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Question- Cancer is a scary disease. Why do innocent children get cancers?
Answer– Cancer is an uncontrolled division of cells. In most cases, there is no reason why the cells start dividing fast and why their growth cannot be arrested. Smoking, drinking, pollution, tobacco chewing and viral infections like hepatitis B are some of the common causes of cancer in adults that are not seen in kids. Despite that many children develop cancer. Some children may have faulty genes that can lead to cancer development like Downs syndrome, Li Fraumeni syndrome etc. Viruses like EBV, exposure to chemicals and pesticides, radiation are other plausible causes of cancer in young children.
Question- Can cancer be prevented? Are there any vaccines?
Answer– There are vaccines available for Hepatitis B and HPV which can reduce the chances of liver and cervical cancer respectively. These are caused by viruses. Cancers in other areas and due to other etiologies do not have any vaccines yet. In children, there is very little we can do to prevent cancer. I encourage a healthy life style, regular exercise, fresh foods, avoiding exposure to chemicals/pesticides, artificial food colors and excess exposure to plastics.
Some children need regular screening to detect cancers. Flash photography of young children can pick a abnormal cat eye reflex that can help in early detection of an eye cancer called retinoblastoma. Siblings of children with retinoblastoma should be screened for similar tumors. Children and parents with certain tumor predisposition syndromes should be regularly checked to detect cancer at an early stage.
Question- What are the common type of cancers in children and how do they present?
Answer– Cancers in children can be broadly classified in three types- blood cancers, solid tumors and brain tumors. The most common type of cancer in children is blood cancer or Leukemia. Leukemia can be of various types. The commonest is acute lymphoblastic leukemia or ALL. Leukemias often present with symptoms of progressive paleness of body, tiredness, bluish spots on skin, bone/joint pains, inability to walk, swelling in neck or abdominal distension. These children may have fever for which a cause has not been clearly identified.
Second common type of tumors are brain tumors. These present with headache, early morning forceful vomiting, sudden squint, deviation of mouth, vision disturbances, wobbly gait, slurring of speech, excessive thirst or passing too much urine.
Children can develop abdominal tumors like kidney tumor called Wilms tumor, adrenal tumor called neuroblastoma or a liver tumor called hepatoblastoma. These present with lumps in the abdomen which are often felt by parents while bathing the children or abdominal discomfort or distension.
Swellings over bones (often painless) may point towards bone tumors. Lymphomas are another category of tumors that can be seen in children. They present with swelling in neck or groin, abdominal distension and lumps elsewhere. Some of the lymphomas are very rapidly growing and can double in size within a few days.
One should also suspect cancer in any illness persisting for a 1-2 weeks where a definitive cause has not been identified even after a thorough testing . I often come across children being empirically treated for TB or typhoid without any evidence. Many of them, end up having cancers or other illnesses. It is our duty to look for the exact cause of illness and if not identified, to refer the child to a higher center with better diagnostic and treatment facilities.
Question- Why is early diagnosis of cancer important?
Answer– The outcome of cancer treatment depends on the stage at which we make a diagnosis and initiate therapy. If it’s an early stage cancer, the cure rates are high. If we identify the cancer at an advanced stage or when it has spread to other organs (metastasis), the outcomes are guarded. In blood cancers, the outcome depends on the type, genetic makeup and the WBC count at diagnosis. The outcome is similar for brain tumors too. Late detection of brain tumors complicates their therapy by making the neurosurgery more difficult. Un-resected brain tumors or partially resected brain tumors have poorer outcomes. They may spread to spine and CSF which makes them less amenable to treatment.
Question- How do you treat cancers in children? What is success rates of treatment?
Blood cancers are treated with chemotherapy. Chemotherapy are drugs that kill cancer cells. Average treatment duration for ALL is 2.5 years. The first 6 months of treatment is an intense therapy with frequent visits to hospital, however most of the treatment is given on a day care basis. The remaining 2 years of treatment comprises of oral chemotherapy drugs and hospital visits are limited to once in 2-3 months. Almost 80% of children with ALL are cured. Children who respond poorly or have a very high risk disease or those in whom cancer comes back (relapse) need bone marrow/stem cell transplant.
Most malignant brain tumors require surgery with or without radiation/ chemotherapy. We avoid radiation for children less than 3 years of age. This is to protect their growing brains from long term cognitive sequelae. Some benign brain tumors that are not amenable to surgery may also need chemotherapy due to their elusive location.
Solid tumors like abdominal/ bone/ brain tumors need a multidisciplinary management team. As a general rule, most solid tumors are given chemotherapy to shrink the mass followed by surgery followed by more chemotherapy with or without radiation. Children with bone tumors need expert orthopedic onco surgery to salvage their limbs by using prosthetic implants. Similarly children with retinoblastoma need ocular oncologists to salvage the eye.
A pediatric oncologist, such as myself gives chemotherapy for all cancers and manages the side effects of the drugs. Often pediatric oncologists rope in all the specialists to provide multidisciplinary care to these challenging cases.
Question- What are the common side effects of chemotherapy? How can little children handle chemotherapy?
Answer– Common side effects are nausea, vomiting, mouth ulcers, loss of appetite and hair loss. Blood counts can drop and children may need admission for management of fever. Blood transfusions may be needed. These side effects are temporary and recover in a few days. Parents are very scared of the side effects and I always tell them that these drugs are life saving. We need to worry about the bigger devil, the cancer itself. The benefits of therapy are much more rewarding than the transient but tolerable side effects. Its never an easy conversation but they get the perspective eventually.
Question- What is the long term outcome of children with cancer? Can they go to school, get a good job, get married, have kids?
Answer– Most of the times- YES. Most children are cured. They can live a near normal life. Every child with cancer will have some side effects of cancer or its treatment. But most are transient and children recover fully. They can go to school after their intensive treatment is over and can be rehabilitated into the normal society. Many of these children come to meet in the outpatient with their school medals/ scholarship certificates and awards and it does give a great deal of satisfaction. Its like winning a battle.
We do lose some kids in this journey. Some due to advanced cancers, some due to poor response to treatment and a very few to therapy related side effects. Infections are a major hurdle in a developing country like ours.
Children with brain tumors, bone tumors and those who have undergone stem cell transplants may have long term side effects like infertility, heart disease, second cancers etc. Regular check up, exercise, maintaining weight, vaccination, avoidance of smoking, drinking and substance abuse are some of the methods to curtail these effects.
Question- How hard is it for you as a doctor to manage these children day in and day out? Does it take an emotional toll on you?
Answer– It sure does. We develop an emotional bonding with each family during the many years of treatment course. When these children are cured we are overjoyed for giving them a second chance to a happy life. At other times, we do carry our baggage of tears, pain and suffering. Despite giving our best attempt, we repeatedly question ourselves for failures. Through all these ups and downs, often we are not able to provide 100% dedication to our own families. Most of our time is spent in hospital, counselling sessions and research work…But I guess one has to sacrifice some bit to put a little smile on the beautiful faces of our little cancer warriors. At the end of the day, its worth the personal sacrifice.
Question- Would you like to give a message to parents, children, families going through this difficult journey?
Answer– It is unfortunate that a child who has hardly explored this beautiful world, has to undergo the suffering of cancer and its treatment. But you need to tell yourself everyday that- Hope is like the sun, which, as we journey toward it, casts the shadow of our burden behind us. I want to tell them that this storm too shall pass.
This information is for general guidance and reflects the opinions and experience of the author. It is not intended to replace specialist consultation or provide treatment advice for specific cases.