Chapter 29: The Child With Cancer Textbook Flashcards
Define the following terms related to cancer
Apoptosis
Oncogenes
Tumor suppressor genes
What does apoptosis mean?
Death of cells
What does oncogenes mean?
Mutated gene that can turn into a / has the potential to turn into cancer cell
What is tumor suppressor genes?
Anti-oncogene
So helps prevent cancer cells from growing
Identify the cardinal symptoms of cancer in children
What are the cardinal symptoms of cancer in children? (8)
Unusual mass or swelling
Unexplained paleness & loss of energy
Sudden tendency to bruise
Persistent, localized pain or limping
Prolonged, unexplained fever/illness
Frequent headaches, often vomit
Sudden eye/vision changes
Excessive, rapid weight loss
Discuss the diagnostic evaluation of children suspected of having cancer, including the history, physical examination, laboratory testing, diagnostic procedures, diagnostic imaging and pathologic evaluation
Notes
Despite dramatic improvements in prognosis, cancer remains a life-threatening, life-altering illness that has a major impact on family life and places significant demands on family strength in coping with informational and support needs.
Nurses should base support of patients and their families on the premises that with clear communication and compassionate care, fear diminishes, hope emerges and the cancer journey feels less overwhelming.
Epidemiology incidence rates
Childhood cancer is rare
The incidence of specific types of childhood cancer varies according to demographic risk factors such as age,sex and race or ethnicity.
Males have a higher risk for cancer than females
Cancer incidence is higher in children from infancy to 4 years old
Mainly being neuroblastoma and retinoblastoma
&
15 to 19 years old being lymphoma and sarcoma
White children have an overall higher incidence of cancer compared to any other race
Etiology
Often most parents ask, how did my child get this and could it have been prevented?
Lifestyle related behaviors are the main factors adults end up with cancer yet there is no real environmental factor that shows a real connection that causes kids to have cancer.
However characteristics like (3) have been found to increase the risk of childhood cancer
Birth weight
Advanced parental age
Congenital anomalies
Etiology part2
Notes
Genomic technology is rapidly advancing understanding the biology of childhood cancer.
The value of this research is the ability to identify subsets of patients whose prognosis is associated with a particular genetic change & help develop new treatment approaches that are precisely tailored to that particular cancer molecular abnormality!!
Prevention
Knowledge of the risk factors that increase likelihood of cancer holds the promise to prevention.
What are some things health care professionals should educate parents specifically about protecting children from cancer that could be caused from outside/external factors? (2)
Second hand smoking / smoking
- lung cancer
- lung cancer is one of the leading cause of cancer death in adults
Exposure to sunlight & tanning
( excess radiation and not having sunscreen on )
- this could lead to skin cancer
Prevention
To provide early detection to other types of cancer, clinicians have historically recommended that your older patients, around adolescents do what ? Male vs female?
Testicular self-examination
Breast self-examination
What is the only vaccine out there that can prevent cancer and what type?
HPV
- cervical cancer
What type of test, usually recommended to females at the age of 21 to do to detect cancer?
Pap smear
( Papanicolaou smear )
What are diagnostic evaluation we might perform in order to evaluate a child with suspected of having cancer?
Complete health history
Review of system
Physical exemption
Laboratory test
Diagnostic imagining
Diagnostic procedures
- ( lumbar puncture, bone marrow aspirate, biopsy )
Surgical pathology
What are some laboratory tests that can help us diagnose and treat children with cancer?
CBC
Serum chemistries
Liver function test
Coagulation studies
Urinalysis
What are some diagnostic procedures we might do to help diagnosis patients with cancer?
LP
Bone marrow biopsy
What are some diagnostic imaging we might do for a patient who might have cancer?
CT scan
MRI
PET
Lastly what is the pathologic and molecular evaluation after all these diagnostic methods we can perform to help determine if a child has cancer or not?
This is also famously known as what as well?
So let’s use biopsy for example
You can take a piece of tissue for sampling in order for it be sent for various biologic or molecular studies that help define the patients risk of relapse or recurrence & allow health care team to adapt correctly
Targeted therapy because we are specifically finding one thing that’s wrong, typically from these exams and being able to identify that small thing that is causing that cancer & we will help have a patient focus care in treating that abnormality with specific treatment
Discuss the major modes of cancer therapy and their indications for use with children, including surgery, chemotherapy, radiotherapy, biologic response modifiers, and bone marrow transplantation
What is treatment modalities mean?
Forms of surgery or treatment that helps treat patients who have cancer
Examples being
Chemotherapy, biotherapy, blood or marrow transplant
What is the main goal behind surgery for cancer in children?
To remove the tumor and restore normal body functioning to the greatest extent possible
Typically for surgery, many children respond well to it when ?
The cancer is localized & encapsulated
( confined to the site of origin )
Generally, the best prognosis is directly related to _____of the tumor because that facilities surgical removal!
Early prognosis
What is radiation therapy?
Notes
( answer question then read this )
Technology has advanced so much that today, it’s been optimized to beneficial effects and minimized many of the undesirable side by sparing normal tissue
Relieve symptoms by shrinking the size of the tumor with a beam that’s aimed precisely at the tumor or abnormal tissue
However, ionizing radiation is cytotoxic in at least 3 different ways, which are?
Damaging the pyrimidine bases cytosine, thymine and uracil needed for the synthesis of nucleic acids
Causing single stranded breaks in DNA
Causing double helical strand breaks in these molecules
There are two forms of damage that can mainly occur from radiation which is?
Lethal damage - cell death
Sublethal damage - injuries to cells
When you think of this lethal and sublethal damage, what side effects do the patient might present when receiving radiation?
Gi upsets
( nausea & vomit )
Alopecia
( hair falling out )
Bone marrow suppression
Chemotherapy is the primary form of what typically in patients who have cancer?
Primary form of treatment
How does chemotherapy work?
By interfering with the function or production of nucleic acid, DNA/RNA
Why are there precautions in administering and handling chemotherapeutic agents?
Because these agents are Vesicants ( sclerosing agents ) that can cause severe cellular damage if even minute amounts of drug infiltrate surrounding tissue
Are we as new grad nurses be able to handle chemo drugs ?
No, only licensed nurses with that verification can because of how toxic it is
Notes
Chemotherapy drugs must be given through a free flowing IV line
Infusion must be immediately stop if any sign of infiltration are spotted
When a patient is receiving chemo with an known anaphylactic potential, like it’s a very common allergy in the chemo, the precautions are to be in the room/observe for at least an 1 hour after the infusion
- have emergency equipment readably available like your oxygen, epinephrine, corticosteroids, bag valve masks etc
What is biologic therapy?
Also known as biotherapy ?
Uses substances made from living organisms, or laboratory produced version of these substances to treat cancer
Lastly another approach is hematopoietic stem cell transplant, others wise known as your bone marrow transplant. What is it?
Truly how it sounds
Blood forming stem cells being given to a patient
What are the two types of HSCT?
( hematopoietic stem cell transplant )
Allogenic
Autologous
What is allogeneic HSCT?
Where cells are obtained from a family member or volunteer donor
What is autologous HSCT?
Cells previously stored from the patient are given back to the patient by IV infusion
What is the overall treatment or function of successful treatment for patients receiving either HSCT?
That the newly transfused cells will begin to produce functioning nonmalignant blood cells.
In essence the recipient accepts a new blood-forming organ
What are the two stem cells locations patients may end up using if they are getting autologous bone marrow transplantation ?
Peripheral stem cells
Steam cells from umbilical cord blood
Autologous transplants use the patients own marrow that was collected from where?
Disease free tissue
Frozen
Autologous bone marrow transplantation has been used to treat? (6)
Neuroblastoma
Hodgkin disease
Non Hodgkin lymphoma
Wilms tumor
Rhandomyosarcoma
Ewing sarcoma
What does apheresis mean?
Involves blood components removed from a patient, separated and then either returned to the bloodstream or replaced with donor blood products
Discuss the following life-threatening oncologic emergencies that may develop in children with cancer as a a result of malignancy or aggressive treatment of the malignancy ;
Tumor lysis syndrome
Hyperleukocytosis
Superior vena cava syndrome
Spinal cord compression
Disseminated Intravascular coagulation ( DIC )
What are the 4 pediatric oncologic emergencies?
Tumor lysis syndrome
Hyperleukocytosis
Superior vena cava syndrome
Spinal cord compression
Complication of therapy
Although great advances have been achieved through current modes of cancer therapy, the successes are not without consequences. Numerous acute side effects are commonly expected with chemotherapy or biotherapy and radiation. Several complications are less frequent but some are very serious
What is tumor lysis syndrome?
Metabolic abnormalities that are the direct result of rapid release of intracellular contents during the lysis of malignant crisis
What are the 4 metabolic abnormalities of tumor lysis syndrome?
Hyperuricemia
Hypocalcemia
Hyperphosphatemia
Hyperkalemia
With the hyperuricemia, what can occur?
The crystallization of uric acid can lead to acute renal failure
Notes
Risk factors for development
High WBC
Large tumor burden
Cancer cell sensitivity to chemo
What are some side effects of acute tumor lysis syndrome? (8)
Flank pain
Lethargy
Nausea
Vomiting
Muscle cramps
Pruritus
Tetany
Seizures
What medication what might we give to prevent acute tumor lysis syndrome?
Allopurinol
What is Hyperleukocytosis?
Peripheral WBC count is greater than 100,000
When you have Hyperleukocytosis what does it lead to? (3)
Capillary obstruction
Micro infarction
Organ dysfunction
What might be the symptoms we see in patients with Hyperleukocytosis ? (2)
Respiratory distress
Cyanosis
Neurologic changes
Altered level of consciousness
Visual disturbances
Agitation
Confusion
Ataxia
Delirium
What is superior vena cava syndrome?
Especially found in which type of cancer?
Space-occupying lesions located in the chest resulting in airway compression & potential repertory failure
Hodgkin lymphoma
What is the second leading of superior vena cava syndrome?
Thrombotic complications of implantable IV devices ; such as central venous catheters and port catheters
What are the symptoms we’d see with these patients of superior vena cava syndrome? (3)
Cyanosis
( face, neck, upper chest )
Distended neck & chest vein
Wheezing
What would be the treatment for these patients with superior vena cava syndrome? (2)
Airway protection and alleviation of respiratory distress
What is spinal cord compression?
Malignancies can invade or impinge on the spinal cord, causing acute symptoms of cord compression
Really in short, tumors that spread to spinal cord
What is the initial manifestation of spinal cord compression?
Back pain
What is disseminated intravascular coagulation?
Abnormal blood clotting ; leaving the child at risk for hemorrhaging
Discuss the various antiemetics drugs and their indications of treating side effects of nausea and vomiting from cancer and it’s treatment
Before I start this chapter what are the 8 most common acute side effects of treatment?
And give me examples on how to treat them as well
Infection
- antibiotics treatment
- hand washing
Hemorrhage
- platelet transfusion
Anemia
- blood transfusions
Nausea & vomiting
- antiemetic medications
Altered nutrition
- physical exam
- diet/ individualized plan
- oral supplements & high protein/ calorie foods
Mucosal ulcerations
- bland soft diet
- soft sponge toothbrush
- avoid lemon/ acidic
Neurologic problems
- physical activity
- increased fiber
- analgesics pain medication
Hemorrhagic cystitis
- fluid intake
- frequent voding
What are the best type of antiemetic drugs for patients?
And why do you think so?
Serotonin receptor blockers
( Zofran )
They don’t produce that EPS side effects that many other antiemetics do
Note
For mild to moderate - phenothiazine
Acute - metoclopramide
However these antiemetics do have eps symptoms ^
- to avoid typically Benadryl ( diphenhydramine ) is usually given in addition to the administration ^^
There has been increasing interest in using cannabis to help aid it, because it also includes pain relieve !
What is the most beneficial regiment for antiemetic control ?
Like what is the steps usually when giving it so patients are at the best state of not feeling nausea? (2)
30mins-1hour before therapy
Regular (like every 4 hours) at Least 24 hours after chemo
Discuss the important of effective pain management in children with cancer undergoing diagnostic and therapeutic produres
Notes
Nurses must be knowledge about the basic pathophysiology of cancer pain and treatment-related side effects.
Nurses must acquire extensive knowledges of non opioid and opioid analgesics, as well as Nonpharmacologic approaches which are used in many pediatric cancer centers
What are your common pain medications we usually see with cancer patients pain? (2)
NSAIDs
Acetaminophen
( codeine, oxycodone, morphine )
Why should we educate parents on the usage of opioids even if they feel that their child might become addicted to it?
The addiction is less likely when proper protocols are in place
However, it’s our job to educate that we should not put restrictions to access in adequate pain control, and if we delay the medication administration, when we do give medication it may not even work
So treat early and manage properly
( of course following protocols & consent forms from parents )
Discuss guidelines related to the safe administration of vaccine to children with cancer or undergoing cancer treatment including recommendations for live attenuated vaccines, varicella vaccination and vaccination of the family
Should a child receiving chemotherapy for cancer receive a live annuated vaccine?
No
What type of vaccination should a child receive who is being treated for cancer and on chemo?
Inactivated vaccines
Can siblings and other family members receive live vaccines and can they be in the same room in the chemo patient child?
Yes
So would a child treated with chemo be able to get the varicella vaccine?
NO!
( it’s live attenuated )
If there is a communicable disease outbreak, what should the chemo child do?
Be put into isolation and hand washing
Let’s say the child gets exposed to the varicella virus and is being treated with chemo, what do we do?
Give antiviral, like acyclovir
Discus the role of the nurse in educating and supporting the family of the child with cancer
Notes
Nurses working with children being treated for cancer have a significant role in helping the family understand the treatment plan, preventing or managing side effects and transitioning to off-treatment and adult focused health care.
- Patient and family education in family centered
- A diagnosis of childhood cancer is overwhelming and the family needs time to process the diagnosis and develop a plan for managing ongoing life demands before they successfully learn to care the child
- Patient and family education should be Inter-professional endeavor with the 3 area of focus : diagnosis & treatment,psychosocial coping and care of the child
- Patient and family education should occur across the continuum of care
- Supportive environment is necessary to optimize learning
Notes
It’s also important to note that care doesn’t just end when the treatment ends, it’s ongoing even after treatment is done
Maybe like hospice care
Or supportive by successful treatment
Define leukemia & distinguish between acute lymphoblastic leukemia and acute myelogenous leukemia
Leukemia !!
What does leukemia mean?
A broad term given to a group of malignant disease of the bone marrows, blood and lymphatic system
What are the two types of leukemia ?
Acute lymphoblastic leukemia (ALL)
acute myelogenous leukemia (AML)
What is the etiology of leukemia?
Mainly found in who though?
The cause Is unknown
Down syndrome, NF1, chromosomal breakage syndromes
What is more common ALL or AML?
ALL
What are the physical clinical manifestations we might see in these patients with leukemia? (12)
Pallor
Fatigue
Anorexia
Fever/infection
Bruising/bleeding
Bone/joint pain
Refusal to walk
Abdominal pain
Headache
Vomit
Visual disturbances
What are the lab findings for leukemia? (6)
WBC ( normal, low, or high, )
Blasts on CBC
Anemia
Thrombocytopenia
Tumor lysis syndrome / DIC
Bone marrow & lumbar results
Notes
Chromosome studies
Children with trisomy 21 have 20x greater risk for developing ALL
Children with more than 50 chromosomes on leukemic cells have best prognosis
Specific translocations of chromosomes on leukemic cells can affect the prognosis
What are the 2 big consequences of leukemia?
Depressed bone marrow function
Spleen, liver, lymph glands show marked infiltration,enlargement and fibrosis
What are the 3 things that come from a depressed bone marrow function in leukemia?
Anemia from decreased RBC
Infection from neutropenia
Bleeding tendencies from decreased platelet production
What are some diagnostic evaluation of leukemia? (4)
History and physical manifestation
Peripheral blood smear
- immature leukocytes
- frequently low blood counts
Lumbar puncture to evaluate central nervous system involment
Bone marrow aspiration/biopsy
What are the 2 things we would find in a peripheral blood smear?
Immature leukocytes
Frequently, low blood counts
What are the 3 therapeutic management of leukemia?
Chemotherapeutic agents
Cranial irradiations ( some cases )
hematopoeitic stem cell transplantation ( HSCT )
What are the 4 phases of therapy for leukemia?
Induction therapy for 4-6weeks
CNS prophylactic therapy is intrathecal chemotherapy
( don’t cross the blood brain barrier )
Intensification (consolidation) therapy to eradicate residual leukemic cells and prevent resistant leukemic clones
Maintained therapy to preserve remission
Notes
Something I mentioned
5 year survival rate - ALL 89%
AML 60%
What is the prognosis of leukemia?
It’s pretty good but if relapse occurs even after the last resort of HSCT, it’s very dismal
Notes
Prognosis for leukemia
Identified factors that can help determine the prognosis
- initial WBC count
- age at the time of the diagnosis
- type of cell involved
- gender
- karyotype analysis
What are some nursing consideration for leukemia ?
Usually specialized nurses
The nursing care related to the regime therapy, so looking at the patient at the whole
Looking for infection, rejection, side effects, planing and implementation
What are the main 3 implementation of leukemia?
Prepare the child and family for procedures
Pain management
Prevent the complication of myelosuppression
What are the 3 points of increased susceptibility to infection?
At the time of diagnosis and relapse
During immunosuppressive therapy
After prolonged antibiotic therapy that predisposes the patient to the growth of a resistant organism
How are we going to help prevent infection?
Hand washing
Contact precautions
Visitor restriction
Protein- nutrition
Planning for home care
What are the 8 drug toxicity for treatment?
Nausea and vomiting
Anorexia
Mucosal ulceration
Neuropathy
Hemorrhagic cystitis
Alopecia
Mood changes
Moon face
What are some things patients are at risked for when diagnosed with leukemia?
Injury related to treatment
Fluid volume deificit
Altered nutrition
Skin integrity
Fear
Lymphomas
What is lymphoma divided into ? (2 groups )
Hodgkin lymphoma
Non Hodgkin lymphoma
What is lymphomas?
Neoplastic disease originating in the lymphoid system; metastasized to non-nodal sites
( like your spleen, liver, bone marrow, lungs and mediastinum )
Who do we normally see Hodgkin disease in?
Who do we normally see non Hodgkin disease in?
15-19 year old
Younger than 14
Accurate clinical staging of the extent of disease is essential for assignment to treatment protocols based on expected prognosis.
What are the 4 staging of Hodgkin lymphoma ?
- Lesions are limited to one lymph node area or only one additional extra lymphatic site such as livers lungs kidney or intestines
- Two or more lymph node designs on the same side or 1 additional lymphatic site or organ
- Lymph nodes region on both side of the diagram are involved with spread
to one extra lymphatic site - Diffuse spread throughout the body to one or more sites with or without involvement of associated lymph nodes
What is the prognosis of Hodgkin lymphoma?
Very well due to the staging processing of the disease
What are the hallmark of Hodgkin disease?
Characterized by a painless engagement of lymph nodes
What are some systemic symptoms for Hodgkin lymphoma ?
Low grade fever
Anorexia
Nausea
Weight loss
Night seats
Pruritis
What are some diagnosis evaluations of Hodgkin disease? (1)
And presence of ?^
CBC - T cells and radiographs
Lymph node biopsy
- presence of reed-sternberg cells
Bone marrow aspiration
What is the 2 treatment for Hodgkin disease?
Irradiation
Chemotherapy
What is the staging of non-Hodgkin lymphoma ? (4)
- Disease limited to one lymph node area or only one additional extra lymphatic site
- Two or more lymph node regions on the same side of the diaphragm or one additional extra lymphatic site or organ one the same side of the diaphragm
- Tumor on both side of abdomen and may have spread to an area or organ next to lymph nodes
- tumor has spread into the organ
Neuroblastoma
Where do majority of tumors develop in Neuroblastoma?
Adrenal gland or retroperitoneal sympathetic chain
- head, neck, chest, pelvis
What are some diagnostic evaluation of neuroblastoma?
Objective is to locate the primary site
Signs and symptoms
Radiologic studies
IVP
Intravenous pyelogram to evaluate renal involvement
Neuroblastoma is also known to be a what?
Silent tumor
Because we can’t palpate first then we notice then until they raise and become really big
What is the treatment of neuroblastoma?
Surgery- remove the tumor
Chemo
Radiation
Bone marrow transplant
Neuroblastoma is a silent tumor. In more than 70% of cases, diagnosis is made after metastasis occurs, with the first sign of caused by involvement in a nonprimsry site.
What clinical manifestation do think these patients will present?
Typically tumor is firm, no tender and irregular mass that crossing midline
However some patients can get headaches, vomit, nausea and even respiratory compromise !!
Typically neuroblastoma has a well prognosis, just be mindful that if removed, spontaneous regression as new cells come and development could result in another release of the issue
