1. Pediatric Cancer & Leukemia December 4, 2007

2. Pediatric Oncology  Acute leukemia  Brain tumors  Lymphoma  Neuroblastoma  Wilm’s tumor  Rhabdomyosarcoma  Retinoblastoma  Osteosarcoma  Ewing’s sarcoma

3. What is Leukemia?  Most common childhood malignancy  Acute lymphoblastic leukemia (ALL)  Acute nonlymphoblastic leukemia (ANLL) Acute myelogenous leukemia (AML)

4. Brain Tumors  2 nd most common type of cancer  1200 US cases diagnosed/year  Described in terms of: Metastasis (M stage) Size of tumor (T stage)

5. Brain Tumors  Terminal to curable  Neuropsychological impact varies based on: Location, size, tumor type Type of treatment Disease of complications Patient factors Social factors

6. Medical Treatment  Radiation  Chemotherapy  Surgery  Most cancers considered CURED if no relapse in 5 years.

7. Bone Marrow Transplantation  Aggressive treatment for malignancies Give near-lethal doses of chemotherapy or radiation Replace dead cells with transplanted healthy cells Autologous vs. Allogenic

8. Stages of BMT  Donor search & initial evaluation  Preparative treatment  Bone marrow infusion

9. Stages of BMT  Severe neutropenia  Engraftment Graft-versus-Host disease  Follow-up

10. Phases of Cancer  Diagnosis  Initiation of treatment  Remission or illness stabilization  Completion of medical therapy  Long-term survival and cue vs. Relapse or deterioration  Terminal illness & death  Post-death adjustment of family

11. Diagnosis  Address emotional reaction  Evaluate family understanding  Determine financial resources Financial Social

12. Diagnosis  Communication with others  What to tell the child? 1. Go slowly 2. Encourage questions 3. Convey hope 4. Establish trust 5. Gauge details to developmental ability

13. Treatment  Disruption of life  Complex treatment schedules  Feeling poorly  Reaction of others  Maintain contact with school

14. Treatment  Coping with acute & chronic pain Bone marrow aspirations (BMA) & lumbar punctures (LP) Distraction, relaxation, hypnosis  Anticipatory nausea & vomiting Classical conditioning Relaxation, imagery, distraction

15. Treatment  Parents need to feel some control during the treatment process Helplessness Hopelessness

16. Don’t forget the siblings!  Suggestions for parents Give them time too Choose caregivers carefully Set limits on gifts Allow them to “help out” Answer questions

17. Coping Strategies Adaptive  Positive reframing  Acceptance  Social support  Maintaining objectivity  Active involvement Maladaptive  Denial  Helplessness  Cognitive escape  Behavioral escape

18. Remission or Stabilization  Maintenance chemotherapy  Return to school Social re-entry concerns Academic performance  Role of doubts and fears

19. Completion of Treatment  Emotional reliance on treatment  Weaning from frequent appointments

20. Completion of Treatment  Marital stress  Difficulty with discipline

21. Long-term Survival & Care  Learning & memory problems  Endocrine dysfunction  Emotional outcomes

22. Relapse & Recurrence  Occurs in 40-50% of pediatric oncology patients  May be harder emotionally than initial diagnosis  Re-learn basic info  Experimental treatments, etc.

23. Terminal Illness & Death  Communication issues What do children know about “death?” What do children fear about “death?” How can parents discuss the child’s own death with him/her?

24. Children’s Understanding of Death Ages 3-5Some understanding Ages 6-8Understand that death is irrevocable & universal Ages 9+Recognize cause of death; have mature conception of death

25. Common Fears of Death  Fear of pain  Fear of being alone  Fear of the unknown  Fear of disappointing parents  Fear of leaving others behind

26. Parents Talking to their Children about Death  Concerns Will it lead to difficulty coping after the child’s death? Will it interfere with the child’s sense of hope? Will it impact the child’s medical care?

27. Parents Talking to their Children about Death  What can they say? Answer questions honestly Give the child permission to cry, be angry, or be sad Tell children that adults do not understand death Reassure child that loss is never complete

28. Preparing for Death  Anticipatory grieving  Preparation for death Hospice care

29. After child’s death…  Mourning  Support groups