154
U N I T 1
Cell and Tissue Function
Unfortunately, there are no early warning signs or
screening tests for cancer in children.
70,71
Prolonged fever,
persistent lymphadenopathy, unexplained weight loss,
growing masses (especially in association with weight
loss), and abnormalities of central nervous system func-
tion should be viewed as warning signs of cancer in chil-
dren. Because these signs and symptoms of cancer are
often similar to those of common childhood diseases,
they are frequently attributed to other causes.
Diagnosis of childhood cancers involves many of the
same methods that are used in adults. Histologic exami-
nation is usually an essential part of the diagnostic pro-
cedure. Accurate disease staging is especially beneficial
in childhood cancers, in which the potential benefits of
treatment must be carefully weighed against potential
long-term treatment effects.
The treatment of childhood cancers is complex and
continuously evolving. It usually involves appropri-
ate multidisciplinary and multimodal therapy, as well
as the evaluation for recurrent disease and late effects
of the disease and therapies used in its treatment. The
treatment program should include specialized teams of
health care providers.
72
Several modalities are frequently used in the treat-
ment of childhood cancer, with chemotherapy being the
most widely used, followed in order of use by surgery,
radiotherapy, and biologic agent therapy. Chemotherapy
is more widely used in treatment of children with cancer
than in adults because children better tolerate the acute
adverse effects, and in general, pediatric tumors are
more responsive to chemotherapy than adult cancers.
Radiation therapy is generally used sparingly in children
because they are more vulnerable to the late adverse
effects. As with care of adults, adequate pain manage-
ment is critical.
Survivors of Childhood Cancers
With improvement in treatment methods, the number
of children who survive childhood cancer is continuing
to increase.
73–76
As a result of cancer treatment, almost
80% of children and adolescents with a diagnosis of
cancer become long-term survivors.
72
Unfortunately,
radiation and chemotherapy may produce late sequelae,
such as impaired growth, neurologic dysfunction, hor-
monal dysfunction, cardiomyopathy, pulmonary fibro-
sis, and risk for second malignancies (Table 7-5). There
is a special risk of second cancers in children with the
retinoblastoma gene. Thus, one of the growing chal-
lenges is providing appropriate health care to survivors
of childhood and adolescent cancers.
Children reaching adulthood after cancer therapy
may have reduced physical stature because of the ther-
apy they received, particularly radiation, which retards
the growth of normal tissues along with cancer tissue.
The younger the age and the higher the radiation dose, the
greater the deviation from normal growth.
There is concern about the effect that CNS radiation
has on cognition and hormones that are controlled by
the hypothalamic-pituitary axis. Children younger than
6 years of age at the time of radiation and those receiving
TABLE 7-5
Long-term Effects of Childhood Cancer Treatment
System
CancerTreatment
Risk
Cardiac
Radiation, chemotherapy (anthracyclines)
Cardiomyopathy, conduction abnormalities,
valve damage, pericarditis, left ventricular
dysfunction
Pulmonary
Radiation, chemotherapy (carmustine,
lomustine, bleomycin)
Reduction in lung volume with exercise
intolerance, restrictive lung disease
Renal/urological
Radiation, chemotherapy (platinums,
ifbsfamide and cyclophosphamide,
cyclosporine A), nephrectomy
Kidney hypertrophy or atrophy, renal
insufficiency or failure, hydronephrosis
Endocrine
Radiation, chemotherapy (alkylating agents)
Pituitary, thyroid, and adrenal dysfunction;
growth failure; ovarian and testicular failure;
delayed secondary sex characteristics;
obesity; infertility
Central nervous system Radiation, intrathecal (injected into
subarachnoid or subdural space)
chemotherapy
Learning disabilities
Musculoskeletal and bone
Radiation, chemotherapy (alkylating agents,
topoisomerase II inhibitors), amputation
Disordored limb growth, disorders of
ambulation and limb use
Hematologic and lymphatic
systems
Radiation, chemotherapy (anthracyclines,
alkylating agents, vinca alkyloids,
antimetabolites), and corticosteroid
medications
Leukemia
Lymphoma
Second malignancy
Radiation, chemotherapy (alkylating agents,
epipodophylotoxins)
Solid tumors, leukemia, lymphoma, brain
tumors
Information from: Schmidt D, Anderson L, Bingen K, et al. Late effects in adult survivors of childhood cancer:
Considerations for the general practitioner. WMJ. 2010;109(2):98–107; and HendersonTO, Friedman DL, Meadows
AT. Childhood cancer survivors:Transition to adult-focused risk-based care. Pediatrics. 2010;126:127–136.
