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Dr Michael M Stevens
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What is cancer in childhood?
Cancer is a group of diseases characterised by uncontrolled multiplication and spread of abnormal cells within the body. There are about 15 types of cancer that occur in children and all are considered fatal if untreated, or if treatment is ineffective.
In 2010, the overall cure rate for childhood cancer is 75%. A new medical sub-specialty has developed to ensure that survivors are properly evaluated for after effects of treatment, provided with rehabilitation, and encouraged to become participants in their own long-term follow-up.
It is important that teachers are familiar with side effects that are likely to occur while a student with cancer is proceeding through planned treatment.
Leukaemia is the most common cancer affecting children. It is a cancer of the blood-forming tissue called bone marrow. A mutation occurs in one developing white blood cell, which begins dividing continuously, producing a huge number of cancerous white cells. These accumulate in the bone marrow, leaving little room for normal blood cell production and eventually threatening the patient’s life.
Symptoms at diagnosis are:
The diagnosis can be confirmed quickly with routine tests on the blood and bone marrow.
Types of leukaemia include:
Acute lymphoblastic leukaemia (ALL) is the most common form of leukaemia occurring in children, and accounts for about one-third
of all childhood cancers. Figure 1 shows typical appearances of bone marrow affected by ALL at diagnosis.
AML is much less common than ALL in children, but more difficult to eradicate and cure. It arises by the same process of mutation occurring in one precursor white blood cell, but in a different type of white cell from that involved in ALL. There are as many as 10 subtypes of AML, some of which require different combinations of chemotherapy, and which have varying outlooks.
Brain tumours are the second most common group of cancers after leukaemia that affect children.
The diagnosis is made by scanning the brain and spine by CAT scans (computerised axial tomography), MRI scans (magnetic resonance imaging), and PET scans (positron emission tomography).
Solid tumours (tumours of other organs or tissues)
Cancer can occur in a number of organs in a child’s body other than the bone marrow and brain. These tumours are collectively called solid tumours. Organs that may be affected include lymph glands (Hodgkin’s disease, non-Hodgkin’s lymphoma), the kidneys (Wilms’ tumour), tissue found in the adrenal glands and also within nerve tissue in the body (neuroblastoma), muscle or connective tissue (rhabdomyosarcoma, primitive neuro-ectodermal tumour), the light-sensitive layer of the eye (retinoblastoma), or bones (osteosarcoma, Ewing’s tumour).
There have been improvements in the use of combined modality treatment and devising more effective combinations of chemotherapy including:
Various treatments are available for the following types of cancer:
Treatment of acute lymphoblastic leukaemia (ALL)
Treatment for ALL begins promptly after diagnosis. The patient must initially remain in hospital, and early therapy involves
administration of a combination of five cancer drugs over five weeks. The patient will frequently be well enough to be discharged
within a week or two of starting treatment, which is then continued on an outpatient basis. The initial treatment almost always
brings the leukaemia under control – this is called inducing a remission. Figure 2 shows a remission bone marrow in ALL.
Download: Treatment of Acute lymphoblastic leukaemia (.pdf 66kB)
Treatment of acute myeloid leukaemia (AML)
Treatment for AML usually involves longer periods of hospitalisation. A stem cell transplant is more often indicated, and is usually performed around six months after diagnosis. The outlook and success rate for children with AML depend mainly on the subtype of AML involved. ALL can be permanently eradicated in about 75% of cases. AML currently has a long-term survival rate of about 60% overall.
Treatment of brain tumours
Because the skull is a closed box, a tumour growing in the brain will cause symptoms of raised pressure soon after it develops (ie in a matter of weeks), particularly if the tumour is increasing quickly in size. A preliminary operation is usually performed on the brain to obtain a small sample of the tumour for diagnosis (this procedure is called a biopsy) and treatment with steroids is commenced.
Download: Treatment of Brain tumours (.pdf 66kB)
Treatment of solid tumours
Treatment depends on identifying the precise nature of the tumour by performing a biopsy, and how far it has spread, which requires tests such as a CT scan, MRI scan, PET scan, bone scan, bone marrow aspirate) searching for detectable spread of the cancer to other organs, especially the lungs, lymph glands, skeleton, and bone marrow.
Download: Treatment of Solid tumours (.pdf 60kB)
Stem cell transplant
A stem cell transplant (previously called a bone marrow transplant) involves a much more intensive course of chemotherapy, sometimes combined with radiation therapy, given over 7–14 days, which is strong enough to eradicate the last remnant of the patient’s cancer, but which also permanently destroys the patient’s bone marrow as an unavoidable side effect.
Download: Stem cell transplant (.pdf 58kB)
Indwelling venous access devices: Central lines and ports
Children receiving routine chemotherapy commonly have an indwelling venous access device inserted surgically at diagnosis to provide convenient access to the bloodstream. This helps with administration of chemotherapy and sampling of blood, with less need for potentially traumatic and distressing needling of veins in the arms and hands. Figure 3 shows a young patient receiving an injection of chemotherapy via her central line.
Download: Indwelling venous access devices (.pdf 95kB)
For some patients, the cancer may recur after a period of apparent improvement or absence (relapse). Recurrence of the cancer after earlier front-line therapy is usually associated with a much poorer outlook. Treatment of patients who have relapsed is often more intensive than the original therapy.
Even for patients who are permanently cured, the original treatment may have important long-term after effects, some of which may adversely affect school performance. In particular, radiation therapy to the brain, administered as part of treatment for leukaemia or brain tumours, may cause impaired concentration and short-term memory in a small but significant proportion of survivors.
Survivors of childhood cancer must be reassessed regularly for the presence of complications for many years after treatment has ceased. This follow-up should be coordinated through the cancer unit responsible for the child’s original treatment, and continued until the survivor becomes a young adult, after which follow-up is transferred to a family practitioner.
Side effects that are commonly experienced by a child on chemotherapy include the following:
Students experience a loss of self-esteem due to:
Referral to the school counsellor or School Learning Support Team may assist in developing a whole school approach to supporting the learning needs of students undergoing chemotherapy.
Chemotherapy reduces temporarily the numbers of blood cells produced in the bone marrow by inadvertently destroying them. The number of normal cells present in a small sample of the patient’s blood is tested regularly and referred to as a blood count. When the count is low the patient can experience a variety of symptoms depending on the levels of the different cells.
There are three main types of cells in blood:
Download: Types of blood cells and the effect of chemotherapy (.pdf 65kB)
Patients receiving chemotherapy, or radiation therapy to the head, experience significant and sometimes near-total loss of hair. Hair begins falling out a few weeks after starting treatment. The hair will grow back eventually, but complete regrowth may not occur satisfactorily until after all treatment is completed. Students may be embarrassed and should be permitted to wear a cap, beanie, or bandana in class. Excellent wigs are available but are not popular with the majority of young patients.
Steroid drugs used in the initial therapy for leukaemia and brain tumours cause excessive appetite, overeating, significant weight gain, and a bloated appearance, which can add to the student’s loss of self-esteem. Changes in behaviour may also occur, including shorter attention span and increased aggression.
Children on chemotherapy frequently experience loss of appetite because the chemotherapy causes nausea and altered taste. Over months of treatment, considerable weight loss may occur. Strategies to help prevent this include careful attention to diet, provision of smaller and attractively served meals, and also tempting nutritious snacks.
An immediate side effect of many cancer drugs is severe nausea, usually accompanied by vomiting. This may persist for several days after the most recent injection. Recently introduced anti-nausea medications, including ondansetron (Zofran) and aprepitant (Emend), provide effective relief and even complete prevention of chemotherapy-induced nausea. The patient may develop anticipatory nausea preceding scheduled treatment. This usually responds well to psychological intervention. Nausea and vomiting may persist for protracted periods (weeks to months) during treatment, and also after completion of planned treatment.
About two weeks after treatment is given, ulcers may appear inside the patient’s mouth. They are not contagious. The patient will have a sore mouth and throat and may not be able to speak or eat easily. Supportive treatment with regular mouth rinses and antifungal drops taken three or four times a day helps mouth ulcers resolve quickly. This treatment is administered by the parent/carer continuously to treat the ulcers and help them resolve quickly. Such treatment would not have to be given during school hours.
Students on chemotherapy are susceptible to viral infections, notably measles and chickenpox. Either of these usually only causes a mild and self-limiting infection in a well student, but they may occasionally be more serious, or even lethal, when contracted by a student on chemotherapy, even though the cancer is under complete control. Previous vaccination against measles, or a previous history of either chickenpox or measles, is helpful in providing some protection, but does not confer complete protection while on chemotherapy.
Download: Students on chemotherapy: preventing exposure to viral infections (.pdf 67kB)