Chapter 25: Childhood Cancer: Treatment & Nursing Care

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Today we are stepping into what is arguably one of the most emotionally charged high -stakes arenas in all of health care.

We are opening up chapter 25 of Wang's Essentials Pediatric Nursing and we are talking about the child with cancer.

It is a heavy topic.

There's just no getting around that.

For a lot of nursing students and even seasoned professionals, this chapter can feel really daunting.

You look at the pages and you just see complex cellular regulation, intense chemotherapy protocols, families in crisis.

But our goal for this deep dive is to take that textbook material and turn it into a living breathing guide for clinical practice.

Exactly.

We want to move from that cellular level right to the outside.

Because when you strip away all the medical jargon, the mission here is pretty clear, isn't it?

It is.

The mission is to demystify pediatric oncology.

It's about ensuring safe, effective care.

But it's also just so deeply rooted in family -centered care.

You cannot treat a child with cancer in a vacuum.

You're treating a whole family unit that has been turned completely upside down.

And I think before we get into the protocols and the drugs, we need to address the elephant in the room.

Caring for a child with cancer, it's got to be one of the toughest challenges in nursing.

It is.

It's emotionally weighty.

But, and this is probably the most important thing to grasp right at the start, the narrative has completely changed.

How so?

If you were a nurse in the 1960s, a childhood cancer diagnosis was essentially a terminal event.

The survival rate was like around 28%.

Wow, only 28%.

And today?

Today, the overall three -year survival rate exceeds 80%.

80%.

That is a massive, massive jump.

So while the disease is still life -threatening and life -altering, the dominant theme now is hope.

We're aiming for a cure.

That is just an incredible statistic to keep in mind, from 28 % to over 80%.

So as we unpack this, we aren't just managing decline, we're fighting for a future.

Precisely.

And while the medical team, the oncologists, are prescribing the regimens to cure the disease, it's the nursing care that sustains the child.

The core focus of this chapter is really on three things.

Cellular regulation,

you know, understanding what's going wrong biologically, family dynamics, because the stress is just unimaginable, and patient and family education.

That last one sounds huge.

It's huge.

Nurses are the translators of this terrifying new world for these families.

And it matters so much because, despite those better survival rates, cancer is still leading cause of death by disease in children past infancy.

That's right.

Accidents are number one overall, but for disease, it's cancer.

So understanding this chapter is critical for, you know, recognizing those early warning signs, managing complications that can kill you faster than the cancer itself, and navigating that long -term survivorship.

So let's start with the basics then.

The epidemiology.

Who is getting childhood cancer?

In the US, we're looking at about 16 ,400 new cases a year in children under 20.

It's considered rare compared to adult cancer, but the impact is just so profound.

What's interesting is the demographic breakdown.

You see these two distinct peaks.

Okay, when are those peaks happening?

So the first is in early childhood infancy to age four.

In this group, you see what are called embryonal tumors,

things like neuroblastoma and retinoblastoma.

Then you have a little bit of a dip, and the second peak hits in adolescence, so ages 15 to 19.

And what are you seeing there?

That's where you see lymphomas and sarcomas, the bone cancers.

So the type of cancer is very much tied to their development.

Absolutely.

And there are gender and racial differences too.

Generally, males have a slightly higher incidence.

White children have higher rates of acute lymphoblastic leukemia.

We call it all -ewing sarcoma and melanoma.

But, you know, survival rates can vary significantly, sometimes due to access to care or different biological subtypes.

Here's the question that I imagine every single parent asks the moment they get that diagnosis.

And it's just a heartbreaking one.

Did I cause this?

That is always the first question.

Did I feed them the wrong things?

Was it the microwave?

Did I let them play near power lines?

And as a nurse, you have to be ready to address this immediately.

You have to bust those myths.

So what's the verdict?

What do we tell them?

The verdict is that lifestyle factors, smoking, diet, environment, which are huge drivers in adult cancer, have little to no effect on childhood cancer.

Really?

Yeah.

I mean, unless the child had high dose radiation or chemotherapy for a previous condition,

environmental roles are really minimal.

That has to be such a relief for parents to hear, but at the same time also frustrating because it feels so random.

It does feel random.

But if we look at table 25 .1 in the text, it breaks down the real risk factors.

And it's mostly genetic or congenital.

For example, children with 21 Down syndrome have a significantly increased risk of leukemia, or you have specific gene mutations like the RB1 gene in retinoblastoma.

And I see the text mentions genomics in these GWA studies.

Right.

Genome wide association studies.

We're moving toward precision medicine.

We're identifying these specific genetic subsets so we can tailor the treatment.

But for the nurse at the bedside, the key takeaway is tell the parents with confidence you did not cause this.

What about prevention then?

If lifestyle doesn't really matter, can we prevent it at all?

Well, primary prevention.

So stopping the cancer before it even starts.

That's really possible in kids because we just don't know the triggers.

But nurses play a huge role in secondary prevention.

Which means what?

Exactly.

Screening and education.

We need to educate on skin cancer awareness because bad sunburns in childhood can lead to melanoma later on.

And the HPV vaccine, vaccinating 11 and 12 year olds, prevents viral associated cancers later in life.

That is active cancer prevention.

Okay.

Let's move to the clinical side.

A child comes in, something isn't right.

How do we get from something's wrong to an actual diagnosis?

It's detective work.

It's a whole process.

History, physical, labs, imaging,

but the labs.

The labs are often the canary in the coal mine, specifically the complete blood count or CBC.

And what are we looking for there on the CBC?

You're looking for a pattern of bone marrow failure.

So you'll see low hemoglobin, so they're anemic, pale, tired, low platelets, so they're bruising easily.

And the white blood cell count can be really tricky.

It might be low, it might be normal, or it could be incredibly high, like over a hundred thousand.

But the key is the cells aren't working properly.

They're immature blasts.

And before you even think about starting chemo, you need to check the organs, right?

Baseline.

Essential.

Absolutely essential.

You need a baseline for liver and kidney function because the drugs we're about to give are toxic.

And you check uric acid levels, which we'll talk about more when we get to oncologic emergencies.

Now the procedures.

This is the really scary stuff for kids.

The lumbar puncture and the bone marrow aspiration.

Can you clarify the difference between those two?

Sure.

A lumbar puncture, or LP, is going into the spinal column.

We do this for two main reasons.

Okay.

One, to see if the cancer has spread to the central nervous system, the CNS.

And two, to inject chemotherapy directly into that space because most IV drugs can't cross the blood brain barrier.

Okay, so that's the LP and the bone marrow.

The bone marrow test is usually done on the back of the hip bone, the iliac crest.

There are two parts to it.

The aspiration pulls out the liquid part of the marrow.

The biopsy takes a solid core of the bone itself.

And you need both.

You need both.

We need to see exactly how crowded the marrow is with cancer cells and to correctly subtype the leukemia.

And this sounds painful.

It is painful, and this is a major nursing priority.

Pain management.

The text really emphasizes that conscious sedation is the standard of care.

We use propofol or fentanyl.

We also use EMLA cream.

That's a topical anesthetic to numb the skin.

But here's the thing.

EMLA only numbs the surface.

Right.

It does not stop the deep bone pain of the needle entering the marrow.

You need systemic sedation for that.

Holding a child down without sedation is just, it's trauma.

Plain and simple.

That is such a crucial point for practice.

Now regarding imaging, there's a phrase in the text that caught my eye.

Image gently.

What does that mean for nurses?

It's a campaign to raise awareness about radiation dose in children.

Kids are way more sensitive to radiation than adults are.

So if we're doing CT scans, we as nurses need to advocate for the lowest effective dose.

Because we don't want to cause a secondary cancer 20 years down the line while we're trying to diagnose this one.

That makes perfect sense.

Okay, so we have a diagnosis.

Now we fight.

The text talks about multimodal therapy.

Right.

It's rarely just one weapon anymore.

It's a combination of surgery, chemotherapy, radiation, and sometimes stem cell transplant.

Let's touch on surgery first.

The trend seems to be changing there too.

It is.

We used to be very radical.

Amputations for bone tumors were standard.

Now because chemotherapy is so effective at shrinking tumors beforehand, surgeons can be much more conservative.

So they can save the limb.

They can do limb salvage procedures.

They remove the tumor and save the leg.

It's a huge deal for quality of life.

And radiation, how does that work?

Radiation kills cells by damaging their DNA,

but you know damages healthy cells in the path too.

So the side effects completely depend on where you aim the beam.

Okay, so if you aim at the gut?

You get nausea and vomiting.

Okay.

If you aim it at the head, you get hair loss and mucositis.

The text highlights proton beam therapy as a real game changer.

It is the new frontier.

It's amazing.

Traditional radiation goes through the tumor and exits out the other side, hitting healthy tissue behind it.

Proton beams stop at the tumor.

There is no exit dose.

So if you were treating a brain tumor, you don't irradiate the heart and lungs that are sitting right behind it.

It spares those vital organs.

That's incredible technology.

But the workhorse is still chemotherapy, right?

And the text mentions a specific regimen, VAC vincristine, doxorubicin, cyclophosphamide.

Why do we mix all these drugs together?

It's strategic.

So cells go through a life cycle.

Some drugs hit the cells when they're dividing.

Some hit them when they're resting.

By combining drugs, we can hit the cancer cells at all these different phases, and we prevent resistance from developing.

It's like a coordinated attack.

Exactly.

It's like attacking a fortress from the front, the back, and the air all at the same time.

But these drugs are dangerous for the nurse, too.

This is a huge nursing alert in the text.

Safety first.

Many of these drugs are vesicans, meaning if they leak out of the vein, they cause severe tissue death, necrosis.

Extravagation is a medical emergency.

You stop that infusion immediately.

And personal protection for the nurse handling them.

Non -negotiable.

Gloves, gown, face shield.

You're handling toxic, hazardous substances.

Nurses have to protect themselves during preparation, administration, and even during disposal of soiled diapers or linens.

Okay, let's move into what I think is the absolute core of this episode.

The side effects.

Because this is where the nurse lives, day in and day out.

You're managing the fallout of the cure.

And the number one enemy is infection.

Infection is the leading cause of death in these kids.

Aside from the cancer itself, it's that serious.

Chemotherapy causes neutropenia, a low neutrophil count.

And neutrophils are the first responders.

They're the body's first responders.

Without them, you are completely defenseless against bacteria.

The text actually has a guideline for calculating the ANC, the absolute neutrophil count.

Can you walk us through that?

Yes.

Okay, nursing students, listen up, because you will do this on exams and you will do this on the floor.

You take the total white blood cell count, the WBC, and you look at the differential.

You add the percentage of segmented neutrophils, which are the mature ones, and the percentage of bands, the baby ones.

Okay, so you add those two percentages together.

Right, and you multiply the total WBC by that combined percentage.

Give us a number.

What's the danger zone?

If the ANC is below 500, that is severe risk,

severe neutropenia.

The child has essentially no functioning immune system.

So if that child spikes a fever.

It is a five alarm fire.

A fever in a neutropenic child is a medical emergency.

You do not wait.

You get cultures, blood, urine, everything, and you start broad spectrum antibiotics immediately.

Immediately.

Within the hour.

Minutes matter because organisms like pseudomonas or E.

coli can kill a neutropenic child in hours.

And we have a helper drug now, right?

GCSF.

Yes, filgrastim.

It's a colony stimulating factor.

It's like a booster shot for the bone marrow to help it recover neutrophils faster.

It just reduces that window of vulnerability.

Okay, next major side effect, hemorrhage.

This is due to low platelets or thrombocytopenia.

Usually we don't see spontaneous internal bleeding until the platelet count is below 20 ,000.

But the nursing care here is incredibly strict.

Like what?

No rectal temperatures, no suppositories.

Why is that so important?

The rectal mucosa is very fragile and full of bacteria.

If you insert a thermometer, you could cause a micro tear.

With no platelets, it bleeds.

With no neutrophils, bacteria from the stool can enter the bloodstream.

Wow.

You can cause sepsis just by taking a temperature.

It's absolutely forbidden.

That's a powerful takeaway.

Okay, note to self, no rectal temps.

What about nausea and vomiting?

That's the one everyone thinks of.

Yeah, and this has improved so much.

It's a different world.

We used to just have basins everywhere.

Now we have the 5 -HT3 antagonists like ondansetron, which is Zofran.

These block the serotonin receptors that trigger vomiting.

And the text mentions a specific rule for giving it.

Yes, this is key.

Do not wait for the child to vomit.

You premedicate 30 minutes to an hour before the chemostats.

You continue it around the clock for at least 24 hours after.

Why is that so critical?

You want to prevent anticipatory vomiting where the brain literally learns to associate the hospital or even the smell of an alcohol swab with being sick and starts to vomit before the drug is even given.

That makes so much sense.

Stop the cycle before it starts.

Now, nutrition.

You have a nauseous kid with a really sore mouth.

How in the world do you get them to eat?

It's what we call the eating battle.

First, you have to manage the mucusitis.

The chemo destroys the lining of the entire GI tract from the mouth down.

You get these painful ulcers.

We use things like magic mouthwash.

But the text gives a good warning.

Avoid lidocaine in young kids because it numbs their gag reflex and they can aspirate.

So what do we feed them?

Anything they will eat.

This is not the time for the balanced diet pyramid.

If they want ice cream for breakfast, they get ice cream for breakfast.

We fortify everything, add butter to their soup,

use full fat yogurt.

Tofu is actually great because it's high protein, but it's soft.

So the goal is just calories.

High calorie, high protein.

And take the pressure off.

Don't make mealtime a fight.

Let's talk about vincristine specifically.

It's a super common drug, but it has some really weird side effects.

Rheotoxicity.

That's the big one.

It affects the nerves.

The most common issue is severe constipation because the nerves in the gut just slow down.

So we give prophylactic stool softeners.

You have to stay ahead of it.

You have to.

And you get foot drop.

The foot just kind of drags because the nerve signal is weak.

Nurses need to watch the child walk.

High top shoes can actually help keep the foot at a right angle.

And what about jaw pain?

Yeah, jaw pain is a weird one, but it's common.

Interestingly, the text mentioned that chewing gum can help work out that pain.

One more specific drug side effect.

Hemorrhagic cystitis.

This is a classic one from cyclophosphamide or ifosfamide.

It irritates the bladder lining, causing it to bleed.

How do you prevent that?

We prevent it with aggressive hydration, usually 1 .5 times their maintenance fluid rate, and a drug called Mesna, which basically coats and protects the bladder lining.

And finally, the really visible side effects,

alopecia and the moon face.

These are huge body image blows, especially for teens.

With alopecia, the hair falls out and clumps.

It's traumatic.

What can we do?

The text suggests cutting the hair short before it starts falling out to minimize the shock.

Use surgical caps to catch the shedding so they don't wake up to a pillow full of hair.

And you have to warn them.

When it grows back, it might be curly or a completely different color.

And the moon face.

That's from high dose steroids.

They get that puffy, cushioned appearance.

It is temporary, but for a teenager, it can be devastating.

We just have to keep reassuring them it will go away when the drugs stop.

Okay, let's shift gears to oncologic emergencies.

These are life or death situations that can happen incredibly fast.

The big one is tumor lysis syndrome or TLS.

Okay, think of it this way.

You give chemo, it works.

It works really well.

It kills millions of cancer cells almost instantly.

Those cells burst open and they dump all of their insides into the bloodstream.

And what's inside a cancer cell?

A ton of uric acid, potassium and phosphate.

It's a toxic soup.

The uric acid crystallizes in the kidneys, which causes acute renal failure.

The high potassium can stop the heart.

So the treatment is actually working too well, too fast.

Exactly.

So prevention is everything.

Hyperhydration to flush the kidneys.

And we give allopurinol, which stops uric acid from being formed.

Or a drug called resburicase, which actually breaks down existing uric acid.

If you see flank pain or sudden lethargy, you have to think TLS.

What about hyperleukocytosis?

That's when the white blood cell count is over a hundred thousand.

The blood becomes thick, almost like sludge.

Wow.

You can clog the tiny capillaries in the brain causing a stroke or in the lungs.

It's an emergency.

You might need an exchange transfusion to literally thin the blood out.

And superior vena cava syndrome.

I've heard of that one.

Yeah, you see this with chest tumors, usually a lymphoma.

Imagine a tumor in the chest pressing on the superior vena cava.

That's the main vein that drains all the blood from the head and neck.

So it gets pinched off?

It gets pinched off.

And the signs are dramatic.

The child's face gets blue and puffy.

The neck veins bulge out.

They can't breathe because the airway is often compressed too.

That sounds terrifying.

It is.

You have to shrink that mass immediately with radiation or chemo to open everything back up.

Okay.

Moving on to a major procedure that we mentioned earlier,

hematopoietic stem cell transplant or HSCT.

Right.

This is the heavy artillery.

When standard chemo just isn't enough, we basically replace the entire blood forming organ.

And there are two main types, right?

Allogeneic, which is from a donor, and autologous, which is from the patient's own cells that were collected and stored earlier.

So what's the process like?

It starts with something called conditioning.

We wipe out the child's own bone marrow and immune system with lethal doses of chemo and sometimes radiation there at absolute zero.

Then we infuse the new stem cells, just like a blood transfusion.

And then we wait.

We wait for them to engraft or set up shop in the bone marrow and start making new cells.

What are the biggest risks during that waiting period?

Well, infection is obvious.

They have no immune system.

But the unique risk with donor transplants is graft versus host disease or GVHD.

What is that?

The new immune system from the donor looks around, sees the child's body as foreign, and attacks it.

It attacks the skin causing a bad rash, the gut causing severe diarrhea, and the liver.

We have to give immunosuppressants to try and control it.

The text mentions a specific family dynamic issue here regarding the donors.

Yes, the donor sibling.

Often a brother or a sister is the best match.

Imagine the psychological burden on that child.

They're told they are the savior.

If the transplant fails or if the sibling dies, the donor child often feels responsible.

It's a huge weight.

Nurses need to support that donor sibling just as much as they support the patient.

That's a really important perspective.

Let's get into the specific cancers now, the big three, starting with the leukemias.

Leukemia is a cancer of the blood -forming tissues.

The bone marrow, which is supposed to be a factory for healthy cells, starts pumping out these useless, immature white blood cells called blasts.

They don't work, but they take up all the space.

Exactly.

They just crowd out the factory.

The healthy cells can't get made.

That's why you get anemia because there are no red cells being made, infection because there are no functional white cells, and bleeding because there are no platelets.

And these blasts can travel.

Right.

They can infiltrate the liver and spleen, causing them to swell up hepatosplenomegaly, or they can hide in what we call sanctuary sites like the CNS or the testes, where chemo has a hard time reaching.

We have all and AML.

What's the main difference?

ALL, or acute lymphoblastic leukemia, is the most common by far.

AML, acute myeloid leukemia, affects a different cell line.

Generally speaking, the prognosis is better for all, especially in kids age one to 10 with a low white count at diagnosis.

The treatment for ALL -L is a marathon, not a sprint.

The text breaks it down into phases.

Can you walk us through those?

Yep.

Phase one is induction.

This lasts four to five weeks.

The goal is simple.

Get into remission.

That means getting the blast count in the marrow under five percent.

This is often when they're the sickest from the chemo.

Okay.

Induction.

What's next?

Phase two is consolidation or intensification.

Here we use different drugs to kill any resistance cells that might have survived induction.

This phase always includes CNS prophylaxis injecting chemo directly into the spine because leukemia loves to hide in the brain.

And then phase three?

Maintenance.

This can last for up to two years.

It's mostly daily oral chemo and weekly methotrexate at home.

And here is a critical, critical fact for nursing education.

What's that?

Adherence must be better than 95 percent.

If a teenager starts skipping their pills because they feel fine, the risk of relapse skyrockets.

The nurse has to drive this point home with the family over and over again.

Ninety -five percent.

That's a high bar over two years.

Okay.

Next up, the lymphomas.

Hodgkin versus non -Hodgkin.

So Hodgkin lymphoma is the classic one with the Ries -Sternberg cells, those big owl eye cells you see under the microscope.

It tends to start in one lymph node and spreads in a very predictable orderly fashion to the next set of nodes.

You'll see a painless, firm, movable node, usually in the neck or collarbone area.

And what are B symptoms?

The text mentions those.

That's a triad of symptoms.

Drenching night sweats, unexplained fever, and significant weight loss.

If you have those, the prognosis is a bit tougher.

But overall, Hodgkin has a very high cure rate, like 95 percent for localized disease.

And non -Hodgkin, how is that different?

It's a completely different beast.

It's diffuse.

It spreads fast and radically through the bloodstream.

It doesn't just stay in the nodes.

It can pop up in the jaw, which is called Burkitt lymphoma, or has a huge mass in the abdomen or chest.

It's a very aggressive cancer that needs aggressive chemo, like yesterday.

Finally, let's talk about brain tumors.

This is the most common solid tumor in kids.

The text says anatomy is destiny here.

It really is.

It all depends on where the tumor is.

60 percent are infertentorial.

That means below the tentorium, the back part of the brain, like the cerebellum or brain center.

And the other 40 percent.

Are supertentorial.

In the top part of the brain, the cerebrum.

So how do the symptoms differ based on that location?

Well, infertentorial tumors affect balance and the flow of cerebral spinal fluid.

So you see a taxia, clumsiness, a weird gait.

You see vomiting that isn't related to food.

You use the first thing in the morning when they get up.

Okay.

And supertentor.

Those cause more top of the brain problems.

Seizures, personality changes, weakness on one side of the body, vision problems.

The nursing care after surgery is extremely specific, especially about positioning.

Yes.

This is a board exam favorite, and it's life or death.

If the surgery was infertentorial, in the back of the head, you keep them flat and positioned on their side.

You do not want to elevate the head of the bed too much.

Okay.

If the surgery was supertentorial, you elevate the head to help drain fluid and reduce pressure.

And there's a big rule about which side to lay them on.

The biggest rule.

If a large tumor was removed, you never place the child on the operative side.

Why not?

What's the risk?

The brain can literally shift into the empty space left by the tumor.

It can cause a massive brain herniation.

You have to keep the brain stable until that space naturally fills with fluid.

It is a critical safety point.

That is absolutely critical.

Before we wrap up, let's just summarize the key signs and symptoms.

The text has a box of cardinal signs.

What should every nurse and really every parent watch for?

It's a list of persistent, unexplained changes.

One, an unusual mass or swelling anywhere on the body.

Two,

unexplained paleness and a real loss of energy.

Three, a sudden tendency to bruise or get little pinpoint red dots.

Four, a persistent localized pain or a link.

This is the one that often gets mistaken for growing pains.

Five, a prolonged fever without a clear source of infection.

Six, frequent headaches, especially with that morning vomiting.

And seven, sudden eye or vision changes.

Like Luca Coria.

That's the white reflection in photos.

Exactly.

Instead of getting red eye in a flash photo, the pupil looks white or yellow.

That is a classic, classic sign of retinal blastoma.

If you see that, it needs an immediate workup.

Okay, we have covered a massive amount of ground today.

From the cellular level to the bedside, from diagnosis all the way through to survivorship.

And that, you know, that leads to a final thought.

Survivorship itself.

We now have over 400 ,000 survivors of childhood cancer in the U .S.

And that is a huge triumph.

But the word cured doesn't mean over.

What do you mean by that?

I mean, these aggressive treatments, the radiation, the chemo, they have late effects.

Years, even decades later.

Things like infertility, secondary cancers, heart damage, growth delays.

So the journey isn't over when the treatment stops?

Not at all.

The nurse's job extends decades past that last dose of chemo.

We have to transition these medical miracles into healthy adults who understand how to manage their unique and complex health history.

It's a lifelong journey and it started on our watch.

A really powerful reminder that our nursing care echoes long after a patient leaves the hospital.

Thank you so much for walking us through this intense but really vital chapter.

My pleasure.

And to all students listening, go look at those charts in the text.

Visualize that ANC calculation.

And just remember, you are the one who sustains the hope.

Thanks for listening to the Dive.

We'll catch you on the next one.