Tanta University

Faculty of Nursing

Pediatric nursing department

Doctoral Degree

2023-2024

Care of Children
with Cancer
Under supervision
Prof. Dr. Rahma Soliman
Professor of pediatric nursing
Faculty of nursing / Tanta university

Prepared by
Eman Samy Rady
Amany Labib Hegazy
Assistant lecturer of pediatric nursing
Faculty of nursing / Tanta university

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Outlines:

 Introduction
 Definition
 Cancer process and mechanism
 Common causes of cancer
 Sign and symptoms
 Common Types of cancer among children
 Leukemia
 Lymphoma
 Hodgkin disease or Hodgkin's lymphoma
 Non-Hodgkin Lymphoma
 Solid tumors
 Cancers of the Kidney (Wilms tumor)
 Liver Cancers (Hepatoblastoma& Hepatocellular carcinoma)
 Diagnostic evaluation
 Treatment modalities
 The role of the nurse in Pediatric cancer.
 Prevention of cancer among children

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 Introduction
Cancer starts when cells in the body begin to grow out of control. Cells in
nearly any part of the body can become cancer and can spread to other areas of the
body. Childhood cancers are often the result of DNA changes in cells that take
place very early in life, sometimes even before birth. Childhood cancers are not
strongly linked to lifestyle or environmental risk factors. With some exceptions,
childhood cancers tend to respond better to certain treatments, such as
chemotherapy (also called chemo). On the other hand, children (especially very
young children) are more likely to be affected by radiation therapy if it is needed
as part of treatment. Both chemo and radiation therapy can also cause long-term
side effects, so children who have had cancer need careful follow-up for the rest
of their lives.
Definition of cancer
Cancer is the uncontrolled growth of abnormal cells anywhere in a body. The
abnormal cells are termed cancer cells, malignant cells, or tumor cells.
Childhood cancers are malignant diseases that affect children under the age of
18 years.
Path physiology:
Cancer begins when normal cells change and grow uncontrollably. A tumor can
be cancerous or benign. A cancerous tumor is malignant, meaning it can spread to
other parts of the body. A benign tumor means the tumor will not spread. Cancer
cells can also invade (grow into) other tissues. This process is called metastasis. It
happens when the cancer cells get into the bloodstream or lymph vessels of body.

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Possible causes of childhood cancer
The exact cause unknown but there are risk factors include the following:
1. High levels of ionizing radiation.
2. Children with immunodeficiency disorder e.g. AIDS
3. Children with genetic syndromes as children with Down syndrome have an
increased risk of developing leukemia.
4. Dietary factors.
5. Lack of exercise.

Symptoms and Signs:

Cancer can be hard to detect in children. Children with cancer may experience
the following symptoms or signs:
1. Continued, unexplained weight loss.
2. Increased swelling or persistent pain in the bones, joints, back, or legs.
3. Lump or mass, especially in the abdomen, neck, chest, pelvis, or armpits.
4. Constant infections.
5. Nausea that persists or vomiting without nausea.
6. Constant tiredness.
7. Recurring or persistent fevers of unknown origin.

Types of cancer:
A solid tumor is a mass of solid cancer cells that grows in organ systems and can
appear anywhere in the body, like kidney & liver cancer. Liquid tumors, on the
other hand, are cancers that develop in the blood, bone marrow, or lymph nodes,
and include leukemia & lymphoma.

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Leukemia

Leukemia is cancer of the blood. It’s the most common form of cancer in
childhood. When a child has leukemia, the bone marrow makes abnormal blood
cells that don’t mature. The abnormal cells called blast cells. are usually white
blood cells (leukocytes). The bone marrow also makes fewer healthy cells. The
abnormal cells reproduce very quickly. They don’t work the same as healthy cells.
Types of leukemia
Acute lymphocytic leukemia (ALL): start in immature forms of lymphocytes,
which accounts for 75–80% of childhood leukemia.

Acute Myeloid leukemia (AML): start in immature forms of myeloid cells,

which accounts for 20–25% of childhood leukemia.

 AML does not respond to treatment as well as ALL does and children or
adolescents with AML generally have prolonged hospital stays.
 Also, children with AML require a bone marrow or stem cell transplantation
for survival.

Signs and symptoms of leukemia:

1. Anemia (fatigue, pallor, anorexia).

2. Increased bleeding or bruising.
3. frequent or repeated infections.
4. Bone pain.
5. Hepatosplenomegaly.

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Assessment and Diagnosis of leukemia
 Complete blood cell counts with differential: Positive findings: elevated
WBC count, decreased hemoglobin and hematocrit levels and possibly
decreased platelet count.
 Bone marrow biopsy may appear blast cells which confirm the diagnosis.

Treatment for leukemia

Treatment for two types of leukemia consists of three phases occurring over 2 to 3
years.
 The first phase of treatment is called induction and lasts for 4 weeks. In this
phase of treatment, the goal is to induce remission. Remission is indicated
by a reduction of the number of lymphoblasts in the bone marrow.
 The second phase of treatment is termed the consolidation phase. During
this phase, the child receives systemic chemotherapy as well as CNS
prophylaxis to either eradicate leukemic cells in the CNS or prevent CNS
relapse.
 The final phase of treatment is the maintenance phase, Long term, low
dose, single or combination chemotherapy in a patient who has achieved
complete remission, again prevent relapse and eliminate any residual disease.
Nursing management for leukemia

 Nursing management for leukemia focuses on administering chemotherapy as

well as on monitoring for side effects of treatment and complications of
disease.
 Teaching children and families about the treatment regimen and anticipated
side effects is an important part of the nurse's role when caring for a child.

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  The child with leukemia undergoes procedures such as a bone marrow biopsy
and a lumbar puncture. Understand in these procedures in addition to
preparing the child and family for what to expect during procedures is
important.

LYMPHOMA:
Lymphoma is any cancer that starts in the lymphatic system. The lymphatic system
is a network of organs and vessels that moves a clear liquid called lymph around the
body which are part of the body’s immune system. There are 2 kinds of
lymphomas: Hodgkin lymphoma & Non-Hodgkin lymphoma (NHL)

Organs that have lymphoid tissue

Because lymphoid tissue is in many parts of the body, lymphomas can
start almost anywhere.
The major sites of lymphoid tissue
 Lymph nodes (“glands”) in the neck, underarms,
stomach and groin
 Spleen (in the belly)
 Tonsils and adenoids (in the neck)
 Thymus (in the chest behind the breastbone)

Hodgkin disease
• Rare before the age of five years.
• Hodgkin lymphoma is marked by the presence of Reed-Sternberg
lymphocytes.
• Reed-Sternberg: The dominant abnormalities of these cells are their large
size and structure that includes multiple nuclei.
• Hodgkin lymphoma typically begins in the upper body, such as the neck,

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 chest or armpits.

 Non-Hodgkin Lymphoma in Children:

 It is more likely to occur in adolescent (15- 19 years, but it is still rare in

children younger than 3).

 Non-Hodgkin lymphoma may arise in lymph nodes anywhere in the body.

 Affect lymph nodes found deep within the body such as spleen, liver,
bone marrow, thymus and skin.
 Non-Hodgkin lymphoma, Reed-Sternberg are not present.

Staging of Lymphoma:

Stage I indicates that the cancer is located in a single region, usually one lymph
node.
Stage II indicates that the cancer is located in two separate regions, both affected
areas are confined to one side of the diaphragm.

Stage III indicates that the cancer has spread to both sides of the diaphragm.

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 Stage IV indicates diffuse or disseminated involvement of one or more extra
lymphatic organs.

Clinical picture

 Enlarged lymph nodes in the armpits, neck or groin

 Fever

 Unexplained weight loss

 Severe itching

 Ongoing fatigue

Diagnosis of lymphoma
 Clusters of hard lymph nodes are palpable in the child with Hodgkin
lymphoma.
 Palpate the abdomen. The presence of hepatosplenomegaly indicates
advanced disease.
 CT scans of the neck, chest, and pelvis Determines extent of disease.

Treatment of lymphoma
Combination of chemotherapy and radiation therapy.

SOLID TUMORS

Wilms Tumor
Wilms tumor (also called nephroblastoma) is a very malignant type of cancer
that starts in the kidneys. It is the most common type of kidney cancer in children.
Children with this syndrome have about a 30% to 50% chance of having a
Wilms tumor.
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Etiology of Wilms tumor:
 Wilms tumor is thought to arise from the renal mesenchyme as undifferentiated
cells.
 2% of cases there is a family history.
 Genetic mutations are commonly found.

Syndromes linked to Wilms tumor include:

 WAGR syndrome

WAGR stands for the first letters of the physical and mental problems
linked with this syndrome (although not all children have all of them):
 Wilms tumor
 Aniridia (complete or partial lack of the iris [colored area] of the eyes)
 Genitourinary tract abnormalities (defects of the kidneys, urinary tract,
penis, scrotum, clitoris, testicles, or ovaries)
 Mental Retardation

Signs and symptoms of Wilms tumor

 Swelling or a hard mass in the abdomen (belly): This is often the
first sign of a Wilms tumor.
 Fever
 Nausea
 Loss of appetite
 Shortness of breath
 Blood in the urine

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Liver cancers in children
 Hepatoblastoma and hepatocellular carcinoma
The liver is an organ located in the upper right side of the abdomen, protected
by the rib cage. When cells that make up the liver grow without the usual
controls that prevent growth, liver cancer may develop. The two most
common types of liver cancers in children are:

 Hepatoblastoma is a cancer that forms in the tissues of the liver occurs most
frequently in infants or very young children between the ages of 2 months and
3 years. This is the most common kind of cancer of the liver in children.

 Hepatocellular carcinoma (HCC) is the most common type of occurs most

often in children with chronic liver diseases, such as cirrhosis caused by
hepatitis B or hepatitis C infection occurs most frequently in children between
the ages of 10 and 16 years.
 Together hepatoblastoma and HCC account for about 1-2% of cancers in
children.

Symptoms of liver cancer:


Loss of appetite

Weight loss

Vomiting

Stomach pain
Prevention of all cancers among children:

Reducing children's risk of getting many types of cancer later in life by:

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  Helping them adopt a healthy lifestyle with good eating habits and plenty of
exercise to keep a healthy weight.
 Most skin cancers can be prevented if children and teens are protected
from ultraviolet (UV) rays by:

 Cover up with clothing to protect exposed skin.

 Wear a hat to shade the face, head, ears, and neck.

 Put on sunscreen.
 A vaccine to prevent Human papillomavirus (HPV) infections: It protects
against the types of HPV that most often cause cancer.

Diagnostic evaluation for pediatric cancer:

1. Medical history and physical exam

If signs or symptoms suggest child might have leukemia, the doctor

will want to get a thorough medical history, including how long child has
had symptoms and whether or not child has any risk factors.
2. Types of samples

A. Lab tests
- Complete blood count and peripheral blood smear
Changes in the numbers and the appearance of different types of blood cells
often help diagnose.
- Blood chemistry and coagulation tests

B. Bone marrow aspiration and biopsy samples

Bone marrow samples are obtained from 2 tests that are usually done at the
same time:
 Bone marrow aspiration

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  Bone marrow biopsy

c. Kidney biopsy.
3. Cytochemistry: Cells are exposed to chemical stains (dyes) that react with only
some types of cancerous cells.
4. Cytogenetics: Cell’s chromosomes (DNA) are looked at under a microscope.
5. Imaging tests:
A. X-rays: routine chest x-rays may be done if a lung infection is suspected.

B. Computed tomography (CT) scan

This test can help show if any lymph nodes or organs in the body are
enlarged.
C. Magnetic resonance imaging (MRI) scan
Like CT scans, MRI scans make detailed images of soft tissues in the body.
Treatment modalities for paediatric cancer:
Treatment for childhood cancer is based mainly on the type and stage (extent) of
the cancer. The main types of treatment used for childhood cancers are:
 Surgery
 Radiation therapy
 Chemotherapy
 Immunotherapy
 Hematopoietic stem cell transplantation

 Surgery:
 Surgery is the removal of the tumor, either cancerous or noncancerous, and
surrounding tissue during an operation. Many children with a tumor will
need surgery at some point during their treatment.

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  The goal of surgery in cancer therapy is to remove all visible and
microscopic malignant cells when possible. It used to obtain a biopsy, a
sample of the tumor, which examined microscopically for diagnosis.

 Chemotherapy:
 It is the most frequently used treatment modality in pediatric oncology. It is
the use of drugs to kill cancer cells, usually by stopping the cancer cells’
ability to grow and divide.
 Systemic chemotherapy is given by mouth or delivered through the
bloodstream (injected into the vein, muscle, spinal fluid, or under the skin)
to reach cancer cells throughout the body. A patient may receive one drug
at a time or combinations of different drugs at the same time.
Side effects of chemotherapy

General side effects: Many chemo drugs can cause side effects, such as:
 Anemia
 Nausea and vomiting
 Loss of appetite
 Diarrhea
 Constipation
 Hair loss
 Mouth sores
 Mucositis

 Radiation therapy:

 Radiation therapy is used to deliver a therapeutic dose of ionizing radiation

to a tumor with minimal effects to the healthy surrounding tissue. It is the use
of high- energy x-rays or other particles such as photons to kill cancer cells.

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  The most common type of radiation treatment is called external-beam
radiation therapy, which is radiation given from a machine outside the body.

 Immunotherapy:
Immunotherapy (also called biologic therapy) is designed to increase the
body’s natural defenses to fight the cancer.
 Stem cell transplantation:
 Stem cell transplant is a medical procedure in which diseased bone marrow
is replaced by highly specialized cells, called hematopoietic stem cells.
The Role of the Nurse in Pediatric Oncology
1- General management of pain among cancers children:

 The management of children’s cancer pain, beginning at the time of

diagnosis and continuing throughout treatment. Pharmacologic treatment of
pain includes non-opioid analgesics, opioid analgesics and adjuvant
analgesics used together for acute and chronic pain.
2- Care of Side Effects of Treatment

Poor appetite
Cancer and its treatments often cause changes in a child's eating habits and desire
to eat.
 Try to make mealtime fun.
 Offer small meals and snacks throughout the day.
 Let the child eat their favorite foods.

Nausea and Vomiting/Emesis

If the child has nausea and vomiting, here are some things you can do:
 Be sure to encourage him to drink plenty of fluids to prevent dehydration.
 When vomiting has stopped, encourage the child to eat easy-to-digest

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 foods, such as clear liquids.
 Do not give them foods that have a strong odor.

Stomatitis and Mucositis

Sometimes chemotherapy and radiotherapy heavily reduce regeneration of
mucosa which can lead to ulceration or inflammation of mucous membranes in
mouth, throat, and intestines resulting in a dry and sore mucous membrane of the
mouth.
Prophylactic care

 Performing good and consistent oral hygiene during the whole course of
chemotherapy (in hospital as well as at home)
 Consistent oral and dental care is recorded, documented and performed
differently according to guidelines of clinic.
Constipation Prophylactic care
 Fiber-rich nutrition
 Avoidance of food that can cause constipation: white rice white bread.
 The patient needs to drink plentifully.
 As much physical activity as possible

Hair Loss/Alopecia:
Nursing tips concerning hair loss.
 Wash hair with a mild shampoo (e.g. baby shampoo) and dry carefully with
a towel
 Comb hair carefully
 The head should be covered outdoors.

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 Role of nurse Preoperative care
 Nursing intervention
 Ask whether parents have any questions about procedure.
 Confirm that all required consent forms are fully complete.

 Proper hygiene measures

 Bathe child, groom hair.
 Provide mouth care to promote comfort.
 Cleanse operative site according to prescribed method.
 Remove nail polish from fingers and toes.

 Proper preparation for the child

 Label personal articles and clothing document height and weight.
 Remove jewellery, contact lenses.
 Keep children NPO as ordered to prevent aspiration.
 Take and record vital signs.
 Be certain allergies are clearly indicated on chart to decrease risk of adverse
reaction.
 Check laboratory values for any signs of systemic abnormality.
 Check that identification band is securely fastened.

 Role of nurse post operative care

 The nurse should position the child to ensure airway patency.
 Hang IV fluids if ordered.
 Closely monitor all vital signs and oxygen saturation and administer oxygen
as ordered.
 Assess temperature for hypothermia.
 Manage drainage tubes.

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  Promote comfort by administration and antiemetics.

 Nursing intervention for prevention infection

 Uses proper hand washing technique and other standard precautions.
 Check incision regularly for bleeding & signs of infection.
 Change dressing as needed.
 Carry out special wound care such as drain care.

International and national efforts in childhood cancer:

Alliance for Childhood Cancer
 The Alliance for Childhood Cancer, a coalition of 26 national patient
advocacy groups, professional medical societies and scientific organizations
that collaborate on public policy matters supporting childhood cancer
patients and survivors.

International Childhood Cancer Day 2015:

 Is a global collaborative campaign to raise awareness about childhood
cancer, and to express support for children and adolescents with cancer,
 The day promotes increased deeper understanding of issues and challenges
impacting childhood cancer and the survivors.

The National Cancer Institute (NCI)

 It is part of the National Institutes of Health (NIH), which is one of 11
agencies that compose the Department of Health and Human Services (HHS).
The National Cancer Institute coordinates the National Cancer Program, which
conducts and supports research, training, health information dissemination, and
other programs with respect to the cause, diagnosis, prevention, and treatment of
cancer, rehabilitation from cancer, and the continuing care of cancer patients and
the families of cancer patients.

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  57357 Hospital: located in Cairo, Egypt, is one of the biggest hospitals
specialized in children's cancer in the world. Fundraising for the hospital, including
well-attended benefit festivals, started in 1998, with a target date for opening of
December 2003. It eventually opened in 2007.
 500500 hospital

 900900 hospital

New research related to pediatric oncology.

- Effect of Intervention Guidelines on Nurses , Performance Regarding

Prevention and Management of Intravenous Extravasation Chemotherapy
for Children.
The aim of the study was to evaluate nurses, performance regarding prevention
and management of intravenous extravasation chemotherapy for children.

Conclusion: there was a significant improvement in nursing staff performance

in relation to prevention and management of extravasation chemotherapy and
significant reduction in extravasation occurrence in studied children.

Recommendations : In-service training program should be conducted

periodically for teaching the nurses the basic clinical skills.

- Effectiveness of nursing care standard regarding the infection control

precaution of leukemic children.

Aim of the study: It aimed to determine nurses knowledge and performance

regarding infection control measures in caring of leukemic children before ,
immediate and after three months later from the standard.

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 Conclusion: there was an overall improvement in nurses knowledge and
performance after application of the standard.

Recommendations :
--Assigning the nurse who has baccalaureate degree for in-service training
programs to other nurses.
--workshops should be conducted for those nurses to improve their knowledge
and performance related to standard nursing care regarding infection control
measures

Reference:

1. Waldman, E., & Wolfe, J. (2013). Palliative care for children with
cancer. Nature reviews Clinical oncology, 10(2), 100-107.

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2. Atun, R., Bhakta, N., Denburg, A., Frazier, A. L., Friedrich, P., Gupta, S., ... &
Rodriguez-Galindo, C. (2020). Sustainable care for children with cancer: a
Lancet Oncology Commission. The Lancet Oncology, 21(4), e185-e224.

3. Wiener, L., Kazak, A. E., Noll, R. B., Patenaude, A. F., & Kupst, M. J. (2015).
Standards for the psychosocial care of children with cancer and their families:
an introduction to the special issue. Pediatric blood & cancer, 62(S5), S419-
S424.

4. Santo, E. A. R. D. E., Gaíva, M. A. M., Espinosa, M. M., Barbosa, D. A., &

Belasco, A. G. S. (2011). Taking care of children with cancer: evaluation of the
caregivers' burden and quality of life. Revista Latino-Americana de
Enfermagem, 19, 515-522.
5. Bartholdson, C., Lützén, K., Blomgren, K., & Pergert, P. (2015). Experiences of
ethical issues when caring for children with cancer. Cancer nursing, 38(2), 125-
132.

6. Friedrichsdorf, S. J., Postier, A., Dreyfus, J., Osenga, K., Sencer, S., & Wolfe,
J. (2015). Improved quality of life at end of life related to home-based palliative
care in children with cancer. Journal of palliative medicine, 18(2), 143-150.

7. Baker, J. N., Hinds, P. S., Spunt, S. L., Barfield, R. C., Allen, C., Powell, B.
C., ... & Kane, J. R. (2008). Integration of palliative care practices into the
ongoing care of children with cancer: individualized care planning and

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 coordination. Pediatric Clinics of North America, 55(1), 223-250.

8. Bartholdson, C., Lützén, K., Blomgren, K., & Pergert, P. (2015). Experiences of
ethical issues when caring for children with cancer. Cancer nursing, 38(2), 125-
132.
9. Israels, T., Renner, L., Hendricks, M., Hesseling, P., Howard, S., & Molyneux,
E. (2013). SIOP PODC: recommendations for supportive care of children with
cancer in a low‐income setting. Pediatric Blood & Cancer, 60(6), 899-904.

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