Treatment strategies in childhood cancer☆

Article Outline

• Abstract
• Chemotherapy
• Radiation therapy
• Surgery
• HSCT
• Gene therapy
• Psychosocial impact
• Summary
• References
• Copyright

Abstract 

Strategies for the treatment of childhood cancer have significantly evolved over time. Years ago, surgery was the only option for treating childhood cancer. Now, research has advanced treatment options to include multimodal therapy with chemotherapy, radiation, surgery and hematopoeitic stem cell transplantation. The focus on gene therapy research is also increasing. Pediatric nurses must have a thorough understanding of the treatment for childhood cancer so that as frontline healthcare providers, they give accurate information to patients and their families, deliver appropriate care, and assist with gathering data in support of ongoing research. Copyright 2003, Elsevier Inc. All rights reserved.

Ongoing research and advances in the treatment of childhood cancer have increased the overall likelihood of survival for children diagnosed with malignancies. The goals of therapy are to improve survival while minimizing toxicities and preserving quality of life. Combining modalities of therapy enhances these efforts. For example, the use of surgical interventions combined with chemotherapy has improved survival in children with solid tumors such as osteosarcoma and Wilm's tumor. The use of radiation therapy with chemotherapy increases survival in patients with Hodgkin's disease. Bone marrow transplantation, now commonly referred to as hematopoietic stem cell transplantation (HSCT), is recognized widely as the treatment of choice for many malignant and nonmalignant diseases. Gene therapy is under investigation for the correction of certain defects. Table 1 lists common childhood diseases and treatment options.

Table 1. Treatment Options Of Childhood Malignancies and Diseases

Diagnosis	Chemotherapy	Intrathecal Therapy	Surgery	Radiation	Hematopoeitic Stem Cell Transplant	Research
Lymphoid Leukemia	X	X		CNS+	High risk or relapsed	Vaccine studies
Myeloid Leukemia	X	X		CNS+	High risk or relapsed	Gene therapy; vaccines
Non-Hodgkin's Lymphoma	X			X	"	Gene therapy; vaccines
Hodgkin's	X		X	X	"	Vaccine studies
Neuroblastoma	X		X		Autologous-standard Allogeneic investigational	Vaccine studies
Wilm's Tumor	X		X
Brain Tumors	X		X	X	Autologous-investigational
Osteosarcoma	X		X		Autologous-investigational
Aplastic Anemia	Immunosuppressive therapy				Matched sib first line of tx; or unrelated if failed tx
Metabolic Disorders:					X
Hurler's
Adrenoleukodystrophy
Sickle Cell Disease with history of stroke					Matched sibling allogeneic

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Chemotherapy 

Chemotherapy is the primary treatment modality used to cure many pediatric cancers. Chemotherapy is the use of drugs to destroy cancer cells. The goals for use of chemotherapy include reducing the primary tumor size, destroying cancer cells, and preventing metastases or microscopic spread of disease (Balis, Holcenberg, & Poplack, 1997). This destruction is accomplished by inhibiting cells within the body to divide, which eventually leads to cell death.

Normal cells divide in an orderly fashion proceeding through four phases of cell division. Feedback controls are located within the cell to control the quantity and quality of cell division. Normal cells will stop cell division once contact with other cells occurs, thus limiting the number of cells. Within normal cell division, each phase must be completed before the next phase of division can begin, decreasing the chance for cell mutation. Cancer cells do not exhibit any controlled cell division. They are not inhibited by contact and continue to divide in an unorganized mass. In addition, deletion of some necessary cell components may occur during chaotic cancer cell division leading to cell mutations (Balis, Holcenberg, & Poplack, 1997). Chemotherapy is used to destroy these rapidly dividing and mutating cancer cells by interfering with cell division, causing cell death.

Chemotherapy can be used in several different ways to achieve cancer cell destruction. Chemotherapy drugs can be given in addition to another form of therapy such as radiation or surgery, which is called multimodal therapy. Neoadjuvant chemotherapy is the use of chemotherapy drugs administered before a scheduled surgery to reduce the size of a tumor and increase the chance of a successful surgery. Adjuvant chemotherapy is used on patients who have no evidence of disease after surgery or radiation but are thought to be at a high risk for relapse. Chemotherapy is administered to these individuals to reduce the chance of microscopic spread of disease. Combination chemotherapy is the use of more than one class of drug for treatment. Administering different classes of chemotherapy drugs ensures a greater chance of achieving complete cancer cell destruction and achieving remission.

Chemotherapy can be administered by mouth, subcutaneous or intramuscular injections, intravenously, or intrathecally. The oral route is used when chemotherapy drugs are well absorbed and are nonirritating to the gastrointestinal tract. Subcutaneous and intramuscular injections are used for a slow systemic administration of a chemotherapy drug. This route is often used when chemotherapy agents cannot be tolerated with a fast absorption rate. The intravenous route is the most commonly used route of chemotherapy and may be given intravenously by several methods: intravenous push, intravenous piggyback, or intravenous infusion (Holmes, 1994). Intravenous chemotherapy has specific unique concerns. There is a potential for vein irritation causing a need for frequent venipunctures, a risk for drug extravasation causing skin damage, and a potential for an immediate or delayed drug complication including anaphylactic shock, hypertension, or hypotension (Holmes). Because most chemotherapy drugs cannot cross the blood-brain barrier at therapeutic levels, tumor cells in the central nervous system are not affected by most chemotherapy delivery methods (Balis, Holcenberg, & Poplack, 1997). Intrathecal chemotherapy involves the insertion of a needle into the lumbar region of the spine and administration of drugs to be delivered directly into the central nervous system.

Chemotherapy drugs interfere with all cells undergoing division and cannot distinguish between normal healthy cell division and cancer cell division. Therefore, in addition to cancer cell destruction, many normal cells are destroyed, causing a wide range of side effects. All rapidly dividing cells are affected by chemotherapy, resulting in numerous side effects from healthy cell destruction. The rapidly dividing cells that most likely are to be affected by chemotherapy include blood cells formed in the bone marrow, cells in the digestive tract, cells in the reproductive system, and hair follicles (Balis, Holcenberg, & Poplack, 1997). Certain types of chemotherapy drugs also can damage cells of the heart, kidney, bladder, and lungs. Chemotherapy can reduce the bone marrow's ability to make white blood cells, red blood cells, and platelets. A reduction of white blood cells and platelets typically occurs 7 to 10 days after the administration of many chemotherapy drugs and recovers to normal approximately 21 days after the chemotherapy. It is during this time that patients are susceptible to infections and bleeding episodes. A drop in red blood cells and the development of anemia occurs over a longer time owing to the prolonged life span of a red blood cell. Side effects of the gastrointestinal tract can include nausea, vomiting, diarrhea, constipation, anorexia, pancreatitis, and impaired liver function. Hair loss can occur on all parts of the body including the scalp, face, axilla, arms, legs, and pubic areas.

Chemotherapy may affect sexual organs and functioning of both men and women. Chemotherapy drugs may lower the number of sperm cells, reduce the sperm's motility, or cause other abnormalities. In addition, chemotherapy drugs can damage the ovaries, reducing the amount of hormones produced, causing irregular or suppressed menstrual periods. Damage from chemotherapy may cause sterility or infertility; however, conception still may be possible during chemotherapy (Balis, Holcenberg, & Poplack, 1997). Pregnancy is not recommended during treatment because the chemotherapy drugs may cause birth defects.

To ensure optimal quality of care and patient safety, the Oncology Nurses Society (1988) has recommended that only properly prepared registered nurses administer chemotherapy drugs. Chemotherapy drugs are carcinogens and teratogens that can be absorbed, inhaled, or ingested by anyone handling them (Holmes, 1994). Nurses must be educated to practice safe handling of chemotherapy drugs and bodily waste of the patient to protect themselves, their coworkers, the patient, and the patient's caregivers. Guidelines for safe handling of chemotherapy agents are listed in Table 2.

Table 2. Guidelines for Safe Handling of Chemotherapeutic Agents

Adapted from the Oncology Nurses Society

The nurse administering chemotherapy should have a thorough understanding of the treatment plan and the drugs being given. Treatment plans often are detailed in a protocol. Protocols are created by experienced oncologists who have developed the best treatment modalities for certain types of childhood cancer. The protocol outlines a specific treatment plan in detail and is initiated after the patient's diagnosis is confirmed. A road map is a quick reference to the protocol and outlines the timeframe of specific diagnostic testing and medication that the patient will be receiving. The nurse should have a good understanding of the protocol and have the ability to read and follow the patient's road map. The nurse should confirm that all necessary diagnostic evaluation has been completed and reviewed by the oncologist before the start of the chemotherapy treatment. In addition, the nurse should be able to educate the patient and family members regarding the drug's mechanism of action and side effects.

Nursing care of the patient receiving chemotherapy requires diligent assessment skills and an ongoing, complete analysis of the patient's condition. Patients must be monitored during the chemotherapy infusion to ensure patency of the venous access and to monitor for immediate side effects including anaphylactic reaction or severe nausea and vomiting. Fluid balance including monitoring patient's intake and output and weights must be monitored carefully throughout the hospitalization. Many patients receive a large amount of intravenous fluid during treatment and may retain fluid. After the chemotherapy treatment is completed, nurses must continue to monitor for side effects. Patients may experience fever, mucositis, hematuria, anorexia, persistent nausea, vomiting, or diarrhea. The severity of these side effects must be monitored carefully and reported. Nursing care for patients experiencing side effects from chemotherapy are found in Table 3.

Table 3. Supportive Care for Children Receiving Chemotharpy

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Radiation therapy 

Radiation therapy is the use of ionizing radiation to break apart bonds within a cell causing cell damage and death. This treatment modality for childhood cancer has evolved over the years with technical improvements and clinical investigation. Modern radiation therapy uses imaging data from computed tomography and magnetic resonance imaging scans along with knowledge of clinical tumor biology to deliver precise radiation therapy to target areas (Kun, 1997).

External beam therapy accounts for the majority of radiation treatments in children (Lewis & Levita, 1988). The amount of radiation is determined with consideration of the patient's age, tumor site, tumor size, tumor radiosensitivity, co-existing disease, and the use of other treatment modalities. Specific disease indications for radiation therapy in children include medulloblastoma, germ-cell tumors, Hodgkin's disease, retinoblastoma, Wilm's tumor, Ewing's sarcoma, and sometimes leukemic involvement of the central nervous system. The lowest effective total dose of radiation therapy is calculated and delivered in daily fractions over a period of 3 to 6 weeks. The beams of radiation are arranged toward the tumor site with the lowest possible dose going to the surrounding tissue (Barrett, 1999). Treatment lasts just a few minutes, but it is very important for the child to maintain the necessary position throughout this time period. It may be necessary to sedate younger children to maintain proper positioning. Children younger than 2 or 3 years old may require general anesthesia.

During treatment, radiation beams cannot distinguish between malignant cells and healthy cells. Thus, damage occurs to both cell types causing numerous side effects. Immediate side effects of radiation therapy include transient cutaneous erythema, xerostomia, and fatigue. Delay of the other side effects reflects the survival time of the mature cell population. For example, the differentiated cells of the gastrointestinal mucosa normally live 4 to 7 days. Signs of damage such as nausea, vomiting, and appetite suppression are expressed within this time frame. Radiation therapy's damage to the bone marrow is not evident initially owing to the presence of circulating mature blood cells. However, because the undifferentiated stem cells are destroyed during treatment, a drop in lymphocytes occurs around 5 to 6 days and a drop in neutrophils and platelets occurs in about 2 to 3 weeks. Progressive cutaneous erythema or hyperpigmentation can begin during the second or third week of radiation therapy (Lewis & Levita, 1988). Hair loss is observed only in the field of radiation and begins during the third week of therapy. Hair usually returns 3 to 4 months after radiation therapy is completed; however, this is dose dependent. Hair loss may be permanent in some fields of radiation (Lewis & Levita). Somnolence syndrome, characterized as drowsiness, apathy, and irritability, may be seen after 1 to 2 months of therapy in approximately 50% of the patients who receive cranial radiation (Gaze, 1998). Somnolence syndrome is self-limiting and resolves within a few weeks. Acute side effects require supportive management and should not effect the planned therapy unless changes are severe (Gaze). White matter changes within the central nervous system can occur 3 to 6 months after radiation therapy and can be responsible for permanent learning defects.

Typically, late effects become apparent 6 to 12 months after radiation therapy. These effects are progressive and irreversible. Late effects from radiation therapy can include interstitial lung fibrosis, pericarditis, pericardial effusion, thyroid or pituitary gland dysfunction, hepatic fibrosis, nephritis, small bowel obstruction, and cerebral necrosis (Gaze, 1998). In addition to these life-threatening complications, changes in bone growth are common when young children receive radiation therapy. Radiation of the epiphyseal growth areas of long bones can result in severe reduction of linear growth depending on the age of the child when the treatment was administered (Gaze).

Nursing care of the patient receiving radiation therapy includes monitoring and educating the families for possible side effects. Side effects may consist of nausea, vomiting, diarrhea, fatigue, hair loss, skin changes including erythema or hyperpigmentation, mucositis, xerostomia and possible suppression of white blood cells, red blood cells, and platelets. Nurses must administer appropriate antiemetic therapy, encourage patients to keep skin clean and dry without use of lotion, and encourage good oral hygiene. Nurses should monitor the patient's complete blood count and assess for decreasing values. A list of supportive nursing care is listed in Table 4.

Table 4. Symptom Management for Children Receiving Radiation Therapy

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Surgery 

Before the discovery of chemotherapy and radiation therapy, surgery was the principle treatment of childhood solid tumors. However, only a small percentage of children with localized disease were cured by surgery alone (Andrassy & Hays, 1997). Now a multimodal treatment of chemotherapy, radiation therapy, and surgery is used commonly and has improved significantly the survival rates for children with malignancies. The surgeon has become an integral part of the patient's medical team, combining surgical procedures with chemotherapy and/or radiation therapy to promote cure.

The use of surgical intervention varies widely depending on the child's diagnosis. The uses of surgery include staging often through biopsy procedure, vascular access, excision, and resection (Taylor, Guillou, & Cooke, 1996). Some diseases such as osteosarcoma only can be cured with surgery to remove the local tumor followed by chemotherapy to prevent micrometastasis. However, in other diseases such as lymphoma, all that may be needed is a biopsy examination to confirm the diagnosis and staging of the disease.

Surgery plays an important role in the initial diagnosis of pediatric malignancies. In many cases, diagnosis is confirmed with a biopsy examination of the primary tumor. The biopsy sample may be obtained through a fine-needle aspiration or an open biopsy procedure. Advances in computed tomography imaging techniques have allowed for an increased use of fine-needle aspiration (Andrassy & Hays, 1997). In some cases, an open biopsy procedure still may be preferred to ensure that a representative sample of tumor is obtained. When an open biopsy procedure is required, the tumor size, position, and relationship to surrounding structures are observed. Surgical excision is the treatment of choice when complete removal of the tumor is possible, especially when it will result in improved survival and cure. Resection of the tumor is used in conjunction with chemotherapy and/or radiation therapy.

Surgery also plays an important role in facilitating treatment. Insertion of intravenous catheters is one of the most frequent surgeries performed on children with cancer. Long-term venous access catheters are placed centrally and used for administration of chemotherapy, antibiotics, total parental nutrition, and for acquiring laboratory tests.

Nursing care of the surgical patient involves monitoring for complications from surgery and pain control. The surgical site should be monitored closely for any bleeding or signs of infection. Assessment of pain should be performed by an age-appropriate pain rating scale and adequate analgesics should be provided. If a biopsy procedure was performed, families may be anxiously awaiting results. Nurses should offer support to the family during this stressful period.

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HSCT 

HSCT is a treatment option for malignancies or disorders involving defective bone marrow function. The process of HSCT, formerly referred to as bone marrow transplantation, involves giving patients high doses of chemotherapy and/or radiation therapy to eradicate disease and then rescuing the patient with a source of stem cells. Stem cells are the precursors to red blood cells, white blood cells, and platelets. Stem cell sources for HSCT include bone marrow, peripheral blood, or fetal cord blood. Cancer patients receive higher doses of chemotherapy and/or radiation therapy to kill disease and then are rescued with a stem cell infusion that allows for recovery of healthy bone marrow. Patients with hematologic disorders such as aplastic anemia receive chemotherapy to provide immune suppression and a HSCT to replace the defective marrow.

There are two basic categories of HSCT: autologous and allogeneic transplants. An autologous transplant is when the patient's own peripheral blood, or bone marrow, is given back to the patient as a rescue after administration of high doses of chemotherapy. Allogeneic transplants are performed when another person is used as a stem cell donor. An allogeneic transplant can be from a matched sibling or relative (related transplant). An unrelated donor can be obtained through the National Marrow Donor Program (unrelated transplant). Donors are identified for patients by performing tissue typing, or matching common histocompatibility leukocyte antigens. The process of histocompatibility leukocyte antigen typing involves identifying specific antigens on the surface of leukocytes by using serologic or DNA methods. These antigens are known to influence acceptance of donor cells or cause graft-versus-host disease (GVHD). GVHD occurs when the donor lymphocytes (graft) recognize the patient's tissues (host) as foreign and mounts an immune reaction. The closest histocompatibility leukocyte antigen match carries the least amount of risk for graft rejection or GVHD (Alcoser & Burchett, 1999).

The option of HSCT depends on the patient's disease, disease status, and general physical condition. A patient receives a thorough evaluation before admission that includes diagnostic studies of all major organ functions and viral studies to evaluate exposure to past viral infections. Once the pretransplant evaluation is complete, the patient is admitted to the hospital to begin the transplant process. The patient is admitted a week to 10 days before the day of the stem cell infusion to receive the chemotherapy and/or radiation therapy preparative regimen. In general, a patient may be hospitalized for a minimum of 4 to 6 weeks if there are no complications. Lengthy hospitalizations are related to delayed stem cell engraftment, infectious complications, organ toxicity, or disease relapse.

Side effects of the preparative regimen include nausea, vomiting, diarrhea, severe mucositis, fluid overload, inflammation of the liver, or jaw pain from radiation therapy. At this time, supportive care includes administering antiemetics, analgesics, total parenteral nutrition, blood products, antibiotics, antivirals, antifungals, monitoring for infections, and strict intake and output.

It may take anywhere from 2 to 6 weeks for the new stem cells to engraft and begin producing new blood cells. Once the marrow has engrafted, GVHD becomes a potential risk. Acute GVHD occurs during the first 100 days posttransplant and chronic GVHD occurs anywhere after the first 100 days and up to 2 years later (Whedon, 1997). Symptoms of acute GVHD include diarrhea, skin rash, or elevated liver enzyme levels and inflammation of the liver. Acute GVHD is staged on severity of involvement of the individual organ system and graded by the combination of severity and involved organ systems (Whedon). Stage and grade ranges from one to four with grade four GVHD being the most severe and life threatening. Nursing care of the patient with acute GVHD involves administering the appropriate medications, monitoring strict intake and output, assessing for infection, enforcing strict hygiene, and providing good skin care.

Chronic GVHD occurs anywhere from 100 days to 2 years posttransplant. Symptoms of chronic GVHD include dry eyes, dry mouth, pain with drinking or eating spicy foods, hypopigmentation or hyperpigmentation of the skin, sclerosis or thickening of the skin, joint contractures, arthritis, respiratory difficulty, or pulmonary fibrosis.

Treatment of GVHD involves immune suppression with medications such as steroids, cyclosporine, tacrolimus or mycophenolate. The patient's immune system does not function normally and prophylactic antibiotic therapy and intravenous immunoglobulin are given to prevent infectious complications. If a patient becomes febrile at any time during the period of immune suppression, the patient is admitted to the hospital immediately and started on intravenous antibiotics. Patients also are monitored closely for reactivation of certain viral illnesses such as cytomegalovirus or herpes zoster. A patient's immune system recovers around 1 year posttransplant or after 6 months off immunosuppressive therapy (Alcoser & Burchett, 1999).

Long-term complications of transplant are related to the pretransplant morbidity, medications, radiation therapy, and complications that occur during the transplant process. Long-term side effects include cardiomyopathy, pulmonary fibrosis, renal toxicity and renal failure, dry eye (sicca) syndrome, thyroid dysfunction, growth failure, gonadal failure, amenorrhea, and sterility (Whedon, 1997).

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Gene therapy 

Many years of research have been dedicated to understanding how genetics determines and impacts disease (Brenner, 1997). The use of gene therapy in the treatment of childhood cancer is promising yet complex and still in early phases of clinical application.

Genetic mutations may be inherited or acquired. Hereditary mutations exist in the reproductive cells and are copied every time the body's cells divide. These defects are passed subsequently from generation to generation. Acquired mutations are changes that develop in the DNA of individual cells and passed along only to the direct descendants of those cells. These mutations are the result of errors in cell division or the result of environmental factors such as toxins or radiation (National Institutes of Health, National Cancer Institute, 1997). Some mutations are quiet and have no apparent function, other gene defects result in disease. The origin of cancer arises from mutations that may be hereditary, acquired, or both. These mutations result in the dysfunction of the regulatory function of cell reproduction and growth. Uninhibited growth of cells and invasion of neighboring tissues is characteristic of a malignancy (National Institutes of Health, National Cancer Institute).

Gene therapy currently is being studied in clinical trials for cancer and other diseases. One goal of gene therapy is to correct a gene defect by inserting healthy copies of missing or altered genes (e.g., in the treatment of cystic fibrosis and hemophilia). Another goal is to change the appearance of the cancer to stimulate the immune system cells to attack cancer or increase the resistance of a cell to invasion (Brenner, 1997). Important aspects in the development of gene therapy to treat diseases include identifying the responsible gene, successfully cloning the normal gene, and developing effective methods for inserting the normal gene into a sufficient number of the patient's cells. Certain viruses are altered and used as vectors for inserting the desired gene into a cell's DNA. These are necessary steps to allow the gene expression at a level adequate for treatment of the disease without causing toxicity or interfering with normal cellular function (Hasenauer, 1998).

Gene therapy trials are critically reviewed, evaluated, and regulated by hospital or university review boards, the Food and Drug Administration, and the National Institutes of Health Recombinant DNA Advisory Committee (Hasenauer, 1998). One of the risks associated with gene therapy trials includes altering more than the intended cells, possibly causing cancer or other cell damage. When DNA is injected into a tumor, there is a slight chance that this DNA could be introduced unintentionally into reproductive cells, thereby producing inheritable changes in the cells. Another risk is insertional mutagenesis, whereby a cell's function is unpredictably altered by the inserted gene. Other risks include the possibility that transferred genes could be overexpressed, producing so much of the missing protein as to be harmful (Brenner, 1997). The viral vector could cause inflammation or an immune reaction, or the virus could be transmitted to the patient or other individuals. Stringent preclinical trials are conducted to avoid these risks in humans. General side effects experienced in genetic clinical trials include fever, chills, fatigue, nausea, vomiting, anorexia, pain, swelling and erythema of injection sites, and central nervous system side effects such as headache, meningeal inflammation, and seizures (Hasenauer).

Overall, therapy is well tolerated with minimal symptomatology. Patients are monitored closely during the administration of therapy as well as after administration. As with any cancer therapy, patients are monitored for long-term side effects as well.

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Psychosocial impact 

The diagnosis, treatment, and side effects of therapy can impact the child and caregiver in many ways, both physically and psychologically. Initial reactions to diagnosis include fear of death, confusion, anger, and guilt that caregivers may have in some way neglected or caused their child to become sick. These feelings are recurring feelings throughout the course of therapy, oftentimes brought on by a symptom associated with initial diagnosis, anniversary of certain events, or particular milestone in therapy. Educating the family and child is one of the foremost means of empowering the family through this most difficult time. Explanation of therapy and side effects must be at a developmentally appropriate level for the patient, family, and the siblings. Child life specialists are a valuable resource for the child undergoing cancer therapy and their siblings.

A family's mode of coping and existing family dynamics is challenged with the care and treatment of a child with cancer. One of the caregivers may assume the primary role of home health care provider while the other continues to work to provide for the family. This can place a strain on the family because the primary health caregiver may feel overwhelmed with making daily or sometimes critical decisions in managing the child's illness, and explaining to other family members what is happening to the child. The provider that continues working feels guilt and frustration because they cannot be as involved as they would wish. If there is only one parent or caregiver involved, the strain is much stronger. Additionally, siblings may feel abandoned, jealous, guilty, angry, and frightened. Many times sibling's frustration is reflected in school performance and behavior. Although this may be an understatement of the overall impact of the diagnosis of cancer on the family, it is important to remember that parents, or caregivers, are often torn between meeting the needs of the sick child, their own needs, and those of the rest of the family.

Again, educating the families is crucial in empowering families in an otherwise debilitating experience. It is important to consider the family's level of education when providing care. The staff nurse can begin educating the family and child with cancer by asking for their questions and current understanding of the diagnosis and treatment. Although the nurse should have a basic understanding of the diagnosis, treatment, and side effects, she is not expected to be an expert at the bedside. Because of Internet access, some families are very informed and ask very educated questions. It is appropriate to write down the family's questions and seek answers from the medical team. Many seasoned oncology nurses will attest to the fact that much of what they know about caring for a child with cancer can be attributed to what they learned from the families themselves.

There are many psychologic and emotional aspects to be considered in caring for the child with cancer. The physical and psychological development, education, and growth of a previously healthy child is suddenly and significantly altered. The child must deal with symptoms of their illness, pain, loss of hair, loss of limb or other body changes, nausea, vomiting, mouth sores, infections, surgeries, prolonged hospitalizations, painful procedures, multiple diagnostic studies, venipunctures, and social isolation. Again, it is important to prepare the child for treatment, side effects, and procedures at an age-appropriate level.

Antiemetics are used to control nausea and vomiting. Topical anesthetics can be used for injections, venipunctures, or procedures. Adequate sedation and pain control for painful procedures is very important to minimize trauma, and should be administered safely according to established institutional policy. It is the staff nurse's responsibility to assess each child's pain and tolerance for procedures and advocate the child's needs to the medical staff.

Normalization for each child receiving cancer therapy is an ongoing endeavor. To facilitate school reentry when feasible, it is important to maintain each child's education as much as possible while receiving cancer therapy. The staff nurse should ask each child or caregiver if the child is attending school or enrolled in homebound schooling. The staff nurse should notify the social worker so that homebound schooling may be initiated. Because much of a child's social development occurs in school it is important to facilitate returning to school as soon as therapy allows. Child life specialists and social workers may facilitate a school visit to the child's class to answer classmate's questions and support returning to school. Staff nurses may help provide information and answer questions for teachers and school nurses.

Finally, financial resources that already may be limited are additionally strained and must suddenly include hospital and clinic bills, prescriptions, parking, and meal money, all of which quickly can add up to thousands of dollars. Loss of employment and loss of insurance coverage can be a devastating experience when supporting a family and a child with cancer. Family support systems are invaluable and should be assessed at diagnosis and periodic intervals to provide support and access other available resources. The staff nurse should make a cursory assessment of immediate resources at periodic intervals (e.g., mode of transportation, meal money, employment, available family support), and make a referral to a social worker as soon as possible.

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Summary 

Over the years, there have been many improvements in the treatment of the child with cancer. Survival rates have increased and many children are becoming long-term survivors of cancer. Therapeutic modalities given alone or in combination have increased this survival rate. Chemotherapy is the primary treatment option for many childhood cancers. Treatment with chemotherapy has been improved through the use of clinical trials that have allowed for close monitoring of toxicities and an increased understanding of the different effects of different agents on particular diseases. Improvements in surgical techniques allow for strategic removal of affected organs or limbs while minimizing physical disfigurement. Radiation therapy, alone or in combination with other therapies, is used to minimize disease or reduce the risk for relapse in certain sites.

Many high-risk diseases that have failed to respond to previous therapy now are curable with HSCT. Finally, future directions for gene therapy are being explored actively and the impact on the treatment of childhood cancer soon will be recognized more widely. Clinical trials in the treatment of childhood cancer are an ongoing committed endeavor to improve therapy, minimize toxicities, maintain quality of life, and increase survival. The staff nurse is the primary health care giver and advocate for a child receiving therapy for cancer. This challenge often is met with reward, either by success or new insight. The staff nurse is the link from the science and research to the overall impact on the child and family receiving care.

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