1. 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

2. 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.

3. Cell development

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

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

6. 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.

7. 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.

8. 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)

9. 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

10. 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

11. 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

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

13. 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).

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

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

16. 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

17. 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.

18. 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.

19. 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

20. 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.

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

22. 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.

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

24. WHAT DOES CANCER LOOK LIKE?

25. 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

26. 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

27. Osteosarcoma
Humerus
Distal Femur

28. 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).

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

30. 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.

31. Ginny’s story

32. 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!!!

33. 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.

34. 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

35. 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!

36. 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

37. References cont. ghr.nlm.nih.gov/.../ basics/MitosisMeiosis.jpg