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Essay on Management Options in Childhood Cancer

Info: 3644 words (15 pages) Nursing Essay
Published: 9th Apr 2021

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A 5-year-old girl presents to the GP with signs and symptoms of a non-specific abdominal tumour. The GP refers on for further investigation to establish a diagnosis. She is an only child; the parents are acrimoniously divorced and share custody. Evaluate the management options that will need to be considered and the potential impact upon the wider family.

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Paediatric cancer is rare- accounting for only 0.5% of cancers in the UK (Children with Cancer UK, 2018). Signs and symptoms of the more common paediatric cancers can be mistaken for more common illnesses meaning that the early warning signs of the tumour can be missed (Aquilino, 2012). In this essay, I will discuss management options and wider considerations using a scenario of a 5-year-old girl (Patient A) presenting with signs and symptoms that lead to a diagnosis of intermediate risk stage 3 Wilms’ tumour (WT) with favourable histology.

According to Children with Cancer UK (2018), WT occur most commonly in children under 5. Typically, the disease is unilateral, but in 5-10% of cases it can present on both kidneys (American Cancer Society, 2018a). There are two different histopathologic types of WT that are recognised: favourable histology, no anaplasia and anaplastic histology, anaplasia present and potentially diffused throughout the tumour. Similarly, anaplastic tumours can be subdivided into focal anaplasia (anaplasia is only present in part of the tumour) and diffuse anaplasia (anaplasia is present throughout the tumour) with the latter of the subdivisions being the more difficult to treat thus affecting the management options available resulting in a poorer prognosis (American Cancer Society, 2018a; Davidoff, 2012).

WT exhibits common symptoms such as a fever or nausea that can be mistaken for a common cold or stomach bug therefore 80% of WT patients present with an abdominal mass (Paulino, 2016). This means it’s more likely that when Patient A presented to the GP it was due to an abdominal mass being felt (Aquilino, 2012). During the assessment, the GP will perform a physical examination where the primary abdominal mass will be palpated (Paulino, 2016). Upon confirmation of a palpable abdominal mass, Patient A would be urgently referred for specialist assessment within 48 hours. (National Institute for Health and Care Excellence, 2017)

The initial imaging method used is ultrasound due to its non-ionising properties but magnetic resonance imaging (MRI) and computed tomography (CT) remain necessary in order to gain adequate information for diagnosis and staging (Lopez and Lorenzo, 2017). Coley (2018) argues that children are at a higher risk of radiation-induced carcinogenesis thus measures are in place to reduce these effects including protocols that limit tube current and overlapping of areas being imaged. According to Pao et al. (2015), it is likely that Patient A will have a biopsy along with a catheter placement ready for neo-adjuvant chemotherapy treatment. They argue that despite most patients with WT being cured, there are significant psychosocial challenges throughout the patient’s journey, involving both the patient and family. In the scenario given, these issues are slightly more complicated as a multidisciplinary approach to better quality of life will involve the parents which, due to an acrimonious divorce, could prove difficult for Patient A’s parents while coming to terms with their child’s diagnosis (Pao et al., 2015). Both Pao et al. (2015) and Feinberg (2014) highlight the guilt and blame parents can feel as a result of watching their child go through painful medical procedures. In Patient A’s case, the parents share custody thus they may not have discussed little, seemingly unimportant, changes in Patient A- such as being feverish- that indicated early stage WT.

According to the Children’s Oncology Group, stage 3 WT means that microscopic or gross residual tumour remains- this could include positive surgery margins, lymph node metastases etc. (Lopez & Lorenzo, 2017). In Patient A’s case, she will receive neo-adjuvant chemotherapy prior to surgery to shrink the tumour. Due to Patient A’s staging being non-metastatic, this will include a 4-week regime involving Vincristine and Actinomycin D prior to surgery (Cancer Research UK, 2017a; Children’s Cancer and Leukaemia Group, 2015). The Children’s Cancer and Leukaemia Group (2015) recommend a needle biopsy before any chemotherapy is undertaken to obtain a histological diagnosis. Similarly, Lopez and Lorenzo (2017) note that the Children’s Oncology Group advocate surgery as the first treatment option instead of neo-adjuvant chemotherapy as the nephrectomy will provide detailed staging and histology that can better inform post-operative treatment. However, this is only possible for tumours that do not extend past the hepatic vein. Feinberg (2014) refers to this stage as the ‘treatment initialisation stage’ where the family start to see the realities of their child’s diagnosis. Pao et al. (2015) supports this by laying out new concerns for parents. In Patient A’s case, her parents’ lives will begin to revolve around her treatment. Her parents share custody, and thus would both have to worry about the cost of travelling to treatment, organising their daily lives around travel including absence from work- their acrimonious divorce could complicate this. At this stage, Patient A’s treatment will have started to disrupt normal activities. She is 5-years-old so she will either be getting ready for school or have already started therefore a disruption of her education at this age is going to have a significant impact on her grades, future goals and aspirations (Pao et al., 2015).

After neo-adjuvant chemotherapy, Patient A will then undergo a nephrectomy to remove the diseased kidney and the surrounding tissues, including the adrenal gland and lymph nodes (Cancer Research UK, 2017b). At this point in treatment Patient A might already be experiencing side effects due to the toxicities of chemotherapy. Hair loss, nausea and fatigue are common side effects of chemotherapy regardless of age (American Cancer Society, 2018b). However, side effects of chemotherapy can be more severe in paediatric cases like Patient A’s due to paediatrics being able to tolerate more intensive treatments (Murusak, 2018). Pao et al. (2015) and Murusak (2018) both discuss the impact of the side effects on the wider family, noting that parents feel more distress throughout treatment as they begin to witness the side effects and invasive nature of treatment. In Patient A’s case, it will be particularly distressing for her parents to cope with this as well as watching her undergo a major operation. Mavrides and Pao (2014) identify two different forms of anxiety experienced by children and highlight how they manifest. The two main forms of anxiety that could affect Patient A during her patient journey are anticipatory anxiety and separation anxiety. They theorise that children can become conditioned to a painful procedure, smell, room etc. This means Patient A could have developed anticipatory anxiety in response to previous diagnostic procedures such as her biopsy meaning she could be experiencing higher levels of anxiety about her surgery. Patient A is in the pre-school development age meaning she is likely to be egocentric and family central- being an only child makes this particularly likely. Mavrides and Pao (2014) highlight that separation anxiety is common in the pre-school aged stage of development thus high anxiety levels could make surgery particularly traumatic for Patient A. However, they suggest that this can be prevented by her parents staying nearby. However, this would depend on a resolution between her parents being agreed upon which could prove difficult.

After surgery, radiotherapy is used to kill any remaining cancer cells. Patient A will receive both post-operative chemotherapy and radiotherapy. Adjuvant chemotherapy and radiotherapy has several indications including histology and spread of disease (Cancer Research UK, 2017a). The Royal College of Radiologists (2016) recommend chemotherapy using vincristine, Actinomycin D and doxorubicin after surgery- the duration and number of drugs is dependent on staging. However, Pritchard-Jones et al. (2015) found that the omission of doxorubicin in the post-operative chemotherapy regime had no effect on 5-year survival rate of patients. Alongside chemotherapy, Patient A will receive flank radiotherapy to the tumour; the Royal College of Radiologists (2016) propose different radiotherapy techniques depending on staging. Due to Patient A’s tumour being Stage 3 and intermediate risk, her recommended prescription is 14.4Gy in 8 fractions of 1.8Gy daily over 1.5 weeks; if disease is found to be present in Patient A’s lymph nodes then a boost prescription of 10.8Gy in 6 fractions of 1.8Gy over 1.5 weeks is recommended. Radiotherapy will cause side effects that Patient A and her parents will have to deal with throughout treatment and later life.

Feinberg (2014) refers to this stage of treatment as the ‘illness stabilisation phase’ where treatment has become part of the family’s everyday life. It is noted by Marcus (2012) that parents of children with cancer are often relatively resilient and alter their roles, responsibilities and family functioning in order to care for their child. By this stage in treatment, it is likely that Patient A’s parents have adjusted their daily lives in order to care for her while on treatment. This could include more open communication so that Patient A’s side effects can be closely monitored and managed accordingly or being absent from work to attend daily treatments (Pao et al., 2015; Sulkers et al., 2015). Sulkers et al. (2015) highlight that poor family function (including single parents) can lead to increased stress and a difficulty with managing and collecting important information for both parents. They argue that these pressures are due to an associated busy or disorganised family life as separated parents; this can be perceived by the parent as poor social support hence it is likely that both parents are going to feel a high level of stress and anxiety throughout Patient A’s journey- from diagnosis to survivorship- due to the unfamiliar and changing parental responsibilities.

The American Cancer Society (2018c) highlights the possible radiotherapy side effects Patient A is likely to experience, including fatigue, diarrhoea and nausea and vomiting. If fatigued, Patient A will still be able to continue some of her normal daily activities, but she may need closer supervision (CureSearch, 2018). Nausea and vomiting are more difficult to manage as persistence of these side effects will involve medication; anti-emetics can be prescribed for nausea and anti-diarrhoeals for diarrhoea (American Cancer Society, 2018d; Cancer Research UK, 2017b). Shared custody means both of her parents will have to inform themselves on the management options and discuss together how best to care for their daughter; this could cause tensions and distress if her parents cannot remain civil under stress.

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Mittal and Kent (2017) discuss late effects of treatment and thus define these as toxicities that are not present at the end of treatment but manifest later. Fertility is a major concern in paediatric radiotherapy due to the potential harm on the child at small doses. Patient A is receiving flank radiotherapy so is at risk for these late effects. Mittal and Kent (2017) indicate that flank radiotherapy does not affect the ovaries but can have an underlying impact on foetus size in later life due to effects on the uterine muscle and vasculature. This is something that Patient A and her partner will have to discuss as she approaches the age at which she wishes to start a family. According to Guerreiro et al. (2018), other late effects include increased risk of renal failure and secondary cancer within the radiation field. They argue that children are more at risk of developing radiation induced late-effects (RILE) but the recent advancements in radiotherapy techniques including intensity modulated radiotherapy (IMRT) using MRI-guided delivery techniques lower the dose to surrounding organs. This in turn reduces the risk of RILE. This would be the ideal treatment plan for Patient A as she will already have psychosocial barriers to overcome during the transition into adolescence and secondary cancers will cause further psychological distress including depression and potentially suicidal thoughts (Mavrides & Pao, 2014). This also eliminates further distress for her parents as they won’t have to cope with the same anxieties about their child going through cancer treatment again. Therefore, MRI-guided IMRT would be the best approach for Patient A’s treatment. However, this is a new technique and healthcare professionals will have to consider the feasibility of this technique for Patient A.

After treatment, the main concern in the family shifts from daily treatment worries to dealing with anxieties of survivorship. Being 5-years-old at the age of diagnosis could have impacted on Patient A’s school work, social functioning and separation anxiety; this could make readjusting to normal life difficult (Marusak, 2018). Similarly, anxiety levels can also increase due to a feeling of being alone without the constant contact with healthcare professionals (Feinberg, 2014; Vetsch et al., 2017). Patient A and/or her parents may receive therapy after treatment in order to cope with the difficulties of survivorship. Easing back into normal life could prove difficult for Patient A’s parents as they might have psychosocial traumas to deal with alongside helping Patient A adjust to survivorship- this may include home-schooling or dealing with psychological late effects such as social anxiety or depression (Mavrides & Pao, 2014). However, periodic follow-up appointments become the only major responsibilities after treatment thus lessening overall anxiety in the family.

In summary, the treatment of WT can have significant psychosocial impacts on both the patient and the parents. A diagnosis of cancer can cause guilt and anxiety in parents as well as anxiety and impaired development for the child. More support systems need to be in place to help parents cope with the psychological distress of caring for their child with cancer including support long-term post-treatment to help the family cope with survivorship (Sulkers et al., 2015)

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