Leslie Meador, RN, BSN, CPON Children’s Mercy Hospital PEDIATRIC ONCOLOGY Leslie Meador, RN, BSN, CPON Children’s Mercy Hospital Objectives: Review significance of cancer on pediatric health Compare pediatric to adult cancer Discuss means of diagnosing cancer Discuss means of treating cancer Discuss complications of each form of treatment View pathology of malignancies. Illustrate pediatric cancer from patient’s perspective

What is cancer? Normal cells grow and divide, then eventually die. Cancer occurs when the body is unable to regulate cell growth, leading to an overgrowth of abnormal cells.

Cell development

Benign v. Malignant Benign: overgrowth of cells that are NOT cancerous Malignant: overgrowth of cells that ARE cancerous

What is cancer? Cell development Healthy growth Unhealthy growth Normal cells Tumor cells Benign Malignant

Pediatric Oncology Facts In the U.S., cancer remains responsible for more deaths from one year through adolescence than any other disease; more deaths than asthma, diabetes, cystic fibrosis and AIDS combined. Each year in the U.S., approximately 12,500 children and adolescents are diagnosed with cancer. That’s the equivalent of two average size classrooms diagnosed each school day.

Pediatric Oncology Facts In the early 1950s, less than 10 percent of childhood cancer patients could be cured. Today, nearly 80% of children diagnosed with cancer become long-term survivors and the majority of them are considered cured.

Pediatric Oncology Facts Most common childhood cancers: -leukemia (blood) -brain and nervous system -the lymphatic system (lymphoma) -kidneys (Wilm’s tumor) -bones (osteosarcoma & Ewing’s sarcoma) -muscles (rhabdomyosarcoma)

Pediatric v. Adult Frequency Rare: <1% of all cancers Characteristic Pediatric Adult Frequency Rare: <1% of all cancers Common: >99% of all cancers Primary sites Involves TISSUE Involves ORGANS Pathogenesis Genetic alterations Environment & lifestyle Tissue: reticuloendothelial system, CNS, muscle & bone Organs: breast, colon, lung & prostate

Pediatric v. Adult Characteristic Pediatric Adult Screening/ Early detection Small percentage; screening tests are generally not applicable Many can be detected by adhering to screening guidelines Manifestations at diagnosis Metastatic disease ~80% Local or regional disease Treatment Follows protocols as standard Doesn’t always follow a protocol Prognosis 70-90% cure (depending on tumor & stage) <60% cure (depending on tumor & stage) Screening guidelines: mammograms and PAP smears in women, colonoscopy, prostate exam in men, annual physicals

Means of diagnosis Well child check-ups (physical assessment & review of symptoms) Blood tests Radiology exams (x-rays, CT, MRI) Pathology (biopsy of mass) Diagnostic procedures -Bone marrow aspirate -Bone marrow biopsy -Lumbar puncture

Methods for treatment Depends of type and stage of malignancy Includes the following: -Chemotherapy -Radiation -Surgical resection -Stem cell transplantation

Chemotherapy Chemotherapy can be delivered by the bloodstream to reach cancer cells all over the body, or it can be administered directly to specific cancer sites. Chemotherapy can be given through various methods: -intravenously (IV) -intrathecally (IT) -intramuscularly (IM) -subcutaneously (SQ) -orally (PO).

Chemotherapy Works by interfering with the ability of cancer cells to divide and reproduce themselves. Attacks all rapidly dividing cells.

Rapidly dividing cells: Hair Skin Nails Blood cells -Red blood cells -White blood cells -Platelets

Three blood lines Red blood cells: -carry oxygen to surrounding tissues White blood cells: -fight off infection Platelets: -help to prevent excessive bleeding; assists in clot formation

Complications of chemotherapy Anemia (low RBC) Thrombocytopenia (low platelet) Neutropenia (low WBC) INFECTION Hair loss Mouth sores (mucositis) Nausea, vomiting & diarrhea Organ toxicities Review function of RBC, WBC, & Platelets. Discuss implications of each cytopenia.

Radiation Managed by a radiation oncologist The radiation oncology team will precisely measure and mark the radiation “field." This field is established to deliver the maximum radiation to the tumor with the least impact possible on the surrounding tissues. Frequency & duration depends on diagnosis & stage.

Complications of radiation Nausea and vomiting Low blood counts Infection Mouth sores Skin changes (may look and feel like a sunburn) After radiation to the head and spine, other side effects may occur months to years later, including: Problems with growth Hormone production Learning problems

Surgery Can be done initially if tumor is isolated (most common in benign tumors or in brain & kidney tumors). Usually done following a few rounds of chemo. This allows the tumor to shrink, which should allow the surgery to be less invasive.

Complications of Surgery Infection Rupture of tumor – increases risk of later metastasis Delay in other treatments due to time required to heal from surgery.

Stem Cell Transplant Purpose: 1. Remove any remaining diseased cells 2. Clear bone marrow space through ablative therapy (consisting of chemotherapy or chemotherapy+radiation). 3. Replace bone marrow space with healthy stem cells.

Complications of Stem Cell Transplant Organ toxicity Organ failure INFECTION Engraftment Failure Graft v. Host Disease Death

WHAT DOES CANCER LOOK LIKE?

Normal WBC on smear G A E D B H F C Banded Neutrophil B. Lymphocyte Monocyte D. Segmented Neutrophil Eosinophil F. Basophil G. Platelet H: Red blood cell

Acute Lymphocytic Leukemia on smear The WBC's seen here are lymphocytes, but they are blasts--very immature cells with larger nuclei that contain nucleoli. Such lymphocytes are indicative of acute lymphocytic leukemia (ALL). ALL is more common in children than adults. Many cases of ALL in children respond well to treatment, and many are curable. NOTICE THE DECREASED NUMBER OF RBC’s AND THE ABSENCE OF PLATELETS

Osteosarcoma Humerus Distal Femur

Osteosarcoma This femur has a large eccentric tumor mass arising in the metaphyseal region. This is an osteosarcoma (a variant known as parosteal osteogenic sarcoma) of bone. These tumors most often occur in young persons (note that the epiphysis seen at the right is still present).

Brain tumor mass in the high posterior portion of his left parietal lobe

Brain tumor Sagittal MRI of a 6-year-old boy with medulloblastoma. Note a contrast-enhancing tumor (arrow) in the fourth ventricle and hydrocephalus. He had a successful tumor resection followed by radiation therapy and chemotherapy. Hydrocephalus was resolved after the tumor resection. It is now six years after diagnosis, and he has no evidence of disease.

Ginny’s story

WHY this profession? LOVE KIDS!!!!!! Hem/Onc - Increased acuity than med/surg units  mentally challenging each day; pathophysiology is complex in this population Opportunity to INVEST in PEOPLE Develop long-term relations with patients See effects of my efforts over time End of life care Working 3 days/week = Full time!!!

What is my day like? 12 hour shifts; 7am – 7pm Nurse: patient ratio = 1:3 max Manage care for each assigned patient, which may include, but not limited to: medication administration, IVF, chemo (monitoring/managing side effects), blood products, procedures (including sedation) for BMA & LP, bone marrow transplant infusions, monoclonal antibodies, ng placement/feeds, IV access, obtaining & monitoring labs, coordinating with other disciplines (PT/OT, speech therapy, radiology, OR) … being PROACTIVE in patient care, focusing on management while preventing further issues/complications.

And the numbers are … Starting salary: $21.49/hr (CMH in top 5% salary for RN’s in KC area) Shift differentials: 10% evening (3-11:30pm), 15% nights (7p-7a), 10% weekend Specialty differentials: 10% critical care, 5% OR, SDS, PACU, $1.00/hr for approved specialty certifications Up to $3000/year educational assistance

Why Childrens Mercy Hospitals and Clinics? Only pediatric hospital between St. Louis & Denver Competitive salary & benefits MAGNET Designation – reflects nursing satisfaction >50 medical/surgical sections to practice in CMH is expanding throughout KC area to include Urgent Care South & in the Northland, along with clinics in Eastern and Western KC Other professions: APN, PT/OT, Speech Therapy, Musical Therapy, Child Life Specialist, RT, physicians, PA, EMT and more!

References Hooke, M., Kline, N., O’Neill, J., Norville, R., Wilson, K. (2004). (Essentials of Pediatric Oncology: A Core Curriculum ( 2nd ed.) (pp 2-12,57). Glenview, IL: Association of Pediatric Oncology Nurses http://www.cancer.org http://www.childsdoc.org/fall2000/braintumors.asp http://www.curesearch.org/

References cont. ghr.nlm.nih.gov/.../ basics/MitosisMeiosis.jpg http://www.med.harvard.edu/JPNM/TF96_97/Nov4/WriteUp.html http://www-medlib.med.utah.edu/WebPath/HEMEHTML/HEMEIDX.html http://www-medlib.med.utah.edu/WebPath/BONEHTML/BONE001.html