Access to comprehensive care and early detection is key to survival in childhood cancers
ccording to the World Health Organisation (WHO) approximately, 400 000 children and adolescents worldwide develop cancer annually. Genetic factors, exposure to radiation, and some infections like the HIV, increase the likelihood of childhood cancers. So, what types of cancers do children develop, and how do they present?
Cancers of bone marrow and blood (leukaemias) are the most common. Others include lymphomas, retinoblastoma, soft tissue sarcoma, and solid tumours, such as neuroblastoma and Wilms tumours. A majority of childhood leukaemias are either acute lymphoblastic leukaemia (ALL) or acute myeloid leukaemia (AML). Common presenting symptoms include musculoskeletal pain, fatigue, anaemia, easy bruising, recurrent infections etc. These symptoms may go unnoticed; hence it is important for physicians to take a detailed history and consider referral to a specialist early if there is any suspicion clinically or on blood tests. Retinoblastoma, a rare cancer in the retina, a layer at the back of the eye, occurs around the age of 2 years in a majority of cases. There is an abnormal white reflection in the pupil (white pupil) usually noticed after a flash photograph is taken. If this is picked up, the child must be referred urgently to an eye specialist. It has a high cure rate. Other signs or symptoms include squint or visual deterioration.
Neuroblastoma, the tumour of nerve cells, is found in children up to 10 years of age. It is also an uncommon cancer that most commonly affects the abdomen and presents as a swelling in the abdomen. Bone pain, weight loss, fever, lack of appetite and liver problems are some of the other features of this tumour. If, as a general physician, you suspect it, then such patients must be referred to a specialist as soon as possible for further review.
Wilms tumour, although rare, is the most common type of kidney tumour in children. It usually starts in one kidney but, in rare cases, involves both kidneys. Symptoms include swollen abdomen, fever, reduced appetite (similar to neuroblastoma) and blood in the urine. Again, in view of clinical suspicion or radiological findings, an urgent referral to a specialist is imperative.
Soft tissue sarcoma are tumours arising in muscle, fat or other soft tissue of the body. In children especially, they can appear as a lump or swelling in the head and neck, groin, abdomen and pelvis, and upper or lower limbs. Cure depends on their location and how early they are identified and treated.
There is a dire need to develop basic health units in Pakistan, as these facilities are patients’ first point of contact with the healthcare system.
The main forms of childhood cancer treatments include surgery, chemotherapy and radiotherapy. Acute lymphoblastic leukaemia, Wilms tumours and retinoblastoma can be successfully treated. Medicines used to treat cancers (chemotherapy) are effective but may cause side effects like tiredness, nausea, reduced appetite, hair loss and hearing loss, anaemia, recurrent infections etc. Undergoing chemotherapy and having adverse effects can be stressful. Such children also find social interactions challenging.
Approximately 7,000-7,500 children (under the age of 18) per year in Pakistan are diagnosed with cancer (ncbi.nlm.nih.org 2020). With the high incidence and prevalence of childhood cancers in low-middle income countries like Pakistan, proper cancer data collection in the form of a cancer registry must be made a priority.
How can early detection of sinister lesions or findings be ensured?
What are the strategies that can help improve patient outcomes? There is a dire need to develop basic health units in Pakistan. These facilities are the patients’ first point of contact with the healthcare system.
Training of doctors in these facilities must focus on taking a thorough history and identifying any risk factors, including a family history of cancer and danger signs for cancers in the young population. Ensure urgent referral to the hospital for further assessment and investigations in suspected cases. Close liaison with hospital doctors/ specialists with the community-based general practitioner/ family physician must be established for monitoring patient progress, follow-ups, any side effects from treatment and any support required for the child or parent.
Cancer nurse practitioners, as part of the multidisciplinary team, can look after several issues like routine immunisation or a child’s nutrition at home, and provide feedback to the primary physician when the child is discharged.
Keeping record of treatment, its completion and regular surveillance can improve mortality rates. Terminally ill children require palliative care that helps provide relief from pain as well as providing support for other physical or emotional symptoms/ needs.
Primary care teams can also be utilised for public awareness and education regarding childhood cancers.
Early detection is key as cure rates in children are higher than in cancers in adults. Access to comprehensive healthcare can help improve survival.
The writer is a family physician