Pediatric Oncology Basics
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Outline
Overview
- Treatment of cancer is about more than destroying cancer cells. It’s also about preserving healthy cells and minimizing the risk for complications associated with treatment
Nursing Points
General
- Pediatric Cancer is rare, but still the leading cause of death in children <15 yrs
- Early detection provides best outcomes
- Average 5 year survival is 80%
- Children are still growing and developing, this may increase their sensitivity to treatment.
- Long-term monitoring is essential with increasing survival rates
Assessment
- Red flag symptoms for individual cancers
- Leukemia
- Nonspecific
- Frequent fevers/infections
- Unexplained bruising
- Bone pain
- Lymphoma
- Nonspecific
- Frequent fevers/infections
- Painless, enlarged lymph nodes
- Brain Tumors
- Headaches upon waking
- Visual disturbances
- Change in coordination
- Neuroblastoma
- Abdominal mass, crosses the midline
- Nephroblastoma
- Abdominal mass, does NOT cross the midline
- Bone Tumors
- Bone pain – “growing pains”
- Limping
- Retinoblastoma
- Cat’s eye reflex (whitish glow in pupil)
- Leukemia
- Nonspecific Symptoms
- Unexplained paleness
- Loss of energy
- Prolonged fever
- Weight loss
- Pallor
Therapeutic Management
- Treatment Options
- Surgery
- Chemotherapy
- Side effects
- Bone Marrow Suppression
- Alopecia
- N/V
- Mucosal Ulcerations
- Side effects
- Steroids
- Side effects
- Moon face
- Mood changes
- Fluid Retention
- Hyperglycemia
- Side effects
- Radiation
- Side Effects- site specific
- Head – cognitive impairment
- Side Effects- site specific
- Bone Marrow Transplant (BMT)
- Bone Marrow Suppression
- Graft vs Host Disease
- Biologic Response Modifiers
- Palliative Care
- Nursing Care
- Monitor the blood work closely
- Absolute Neutrophil Count (ANC) & Platelets
- Initiate neutropenic precautions
- Strict hand washing
- Limit visitation
- No fresh fruits or flowers
- Initiate bleeding precautions
- See Thrombocytopenia lesson
- Monitor for altered nutrition
- Monitor weight
- Assist with oral care
- Rinse mouth with saline
- Avoid lemon, alcohol based mouthwash
- Skin Care
- Radiation
- Avoid lotions
- Use gentle soap
- Avoid sunburn
- BMT
- Minimize pressure over site
- Prevent skin breakdown
- Radiation
- Monitor long-term complications
- Infertility
- Osteoporosis
- Obesity
- Hypertension
- Slowed growth
- Cognitive deficits
- Secondary cancers
- Psychological support
- Provide support for children and families through developmental regressions
- Beads of Courage (video in resources)
- Monitor the blood work closely
Nursing Concepts
- Cellular Regulation
- Infection Control
- Comfort
- Clotting
Patient Education
- Bleeding Precautions
- Infection Precautions
- Oral Hygiene
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Transcript
Hey Guys, in this lesson we are going to talk about the basics of pediatric oncology.
Cancer is considered to be pretty rare in kids but it is still the number one cause of death for <15 year olds. It’s obviously a terrifying diagnosis, but a lot of people aren’t aware of the really incredible research that has taken place in peds oncology. In the last 50 years or so the average survival rate for all cancers has increased from 10% to 80%.
Because of these increasing survival rates long term monitoring is more important than ever. Unlike adults, kids are being given these incredibly toxic therapies while their bodies are still growing and developing. This makes them more sensitive the therapies which means side effects and toxicities a can be more intense and that’s obviously going to impact our nursing care!
One of the most important factors that influences prognosis is if the cancer was detected early, so we’ve got to know the red flags!
We’ll start with the most common pediatric cancer, Leukemia, a cancer of the bone marrow. Symptoms are often nonspecific but a few that should stand out are frequent fevers, bone pain and spontaneous bruising. There’s a lesson on pediatric Leukemia so check it out for more info.
Lymphoma is a cancer of the lymphatic system and again is fairly nonspecific, but non tender swollen lymph nodes are considered a red flag.
Symptoms for brain tumors vary according to tumor location, but common red flags are a headache in the morning when waking up, change in vision and change in coordination.
Neuroblastoma is a solid tumor that grows from neural cells but can be found anywhere in the body. The most common symptom is an abdominal mass that crosses the middle of the abdomen. This is important to note because the Nephroblastoma, which is a renal tumor also presents with an abdominal mass but it does not cross the midline.
Bone cancers like osteosarcoma and Ewing sarcoma tend to present with bone pain or unexplained limping.
Retinoblastoma is a cancer that is in the eye. It usually presents as the whitish glow you see in the photo, which is called the cat’s eye reflex.
I mentioned for both Leukemia and lymphoma that their clinical pictures may be very nonspecific so what do I mean by that? Basically it just means that the symptoms don’t point to anything specific- the cause could be anything. Listed here are some of the most common- pallor, loss of energy, prolonged fever,and weight loss.
Treatment consists of a plan based on the type of cancer it is and a combination of the following
Surgery is used to remove tumors and is the first step for cancers like nephroblastoma. For bone cancers important conversations about limb salvaging vs full amputation will have to be had with families.
Chemo works by killing cells that are rapidly dividing so it’s killing all of those unhealthy, cancerous blast cell,and suppressing marrow, but also killing other cells that rapidly divide, like GI cells and hair.
Steroids also work to suppress the bone marrow. Common short term side effects are a change in appearance- so you get a moon face and fluid retention making the patient look very puffy. Then you can also see pretty intense mood changes which can be really stressful for families.
Radiation is used to shrink tumors and can also be used palliatively for pain relief. Side effects are specific to the site radiated.
Bone Marrow Transplants are used in patients at high risk for relapse or those who have already relapsed. This can be a a very long hospital admission and one the primary goals is to keep the immune system suppressed so the body doesn’t reject the donated marrow.
So let’s think about our nursing care in relation to those methods of treatment. It’s all about 1) minimizing the impact of the bone marrow suppression that is happening 2) monitoring for and treating side effects and toxicities from drugs and radiation and 3) monitoring for long-term problems.
Nursing care for bone marrow suppression is all about preventing infection and bleeding and treating anemia. You’ve got to monitor their blood work really closely- the key blood test is a CBC with Differential because it can tell us what their absolute neutrophil count is.
Interventions you would expect are – neutropenic precautions, bleeding precautions, blood transfusions, platelet transfusion, and antibiotic administration – lots and lots of antibiotics.
In addition to bone marrow suppression patients will also experience a lot of GI discomfort- so nausea, vomiting and mucosal ulcers. These kids don’t want to eat which results in altered nutrition, which leads to weight loss. So we have to monitor their weight and provide oral care. A lot of these kids will end up with an NG tube or G-tube because their appetites are so reduced.
Skin care is especially important for kids getting radiotherapy and BMT. Radiation basically burns and really irritates the skin so no lotions or harsh soaps should be used.
Every chemo drug will have its own side effects and toxicities. Some common toxicities with drugs used for pediatric cancers are neurotoxicities, cardiac toxicities and pulmonary toxicities.
As I mentioned, long term considerations are becoming increasingly more important. The issues to be aware of are related to infertility, bone density, obesity, hypertension, slowed growth, cognitive delays and increased risk for second cancers. They’ll be monitored closely for the rest of their lives because of these potential problems.
I think it goes without saying that psychological support is essential. These kids go through so much. It can be so stressful that it’s pretty common for kids to experience developmental regressions. The most common example being kids who were toilet trained regressing after diagnosis to using diapers again. So be on the lookout for these regressions and be ready to provide support to parents with these.
Your priority nursing concepts for a pediatric patient with cancer are cellular regulation, infection control and comfort.
Alright guys, that’s it for this lesson. Remember our nursing care for the pediatric patient is all about treating and minimizing side effects- both long term and short term.
Your key takeaway points for this lesson are understanding that more children than ever before are surviving cancer so we have to be thinking about long term issues. When kids are being treated they are still growing so their cells are in a more adaptable and vulnerable state, making them more sensitive to toxicities than adults are. Early detection is key for best outcomes- so make sure you know those red flags. Nursing care focuses centers around managing the bone marrow suppression, supporting nutrition and providing emotional support.
That’s it for our lesson covering the basics of pediatric oncology. The content overlaps quite a bit with your adult hem/onc lessons so refer back to those if you need to. Make sure you check out all the resources attached to this lesson. Now, go out and be your best self today. Happy Nursing!
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