CURING CANCER IN CHILDREN
EARLY DIAGNOSIS AND APPROPRIATE TREATMENT ARE THE KEY
Cancer is uncommon in the pediatric population, with an incidence of 110-130 per million children per year reported in Western countries. Owing to lack of population based registry, accurate estimation of incidence in our country may not be possible. However, it is assumed that approximately 40-50000 new cases of cancer occur in under-14 year of age. Many of these are not diagnosed, either because they have poor access to health care, or because primary health care workers do not recognise signs and symptoms of pediatric malignancy.
Advances in survival of children with cancer over the past 30 years have been remarkable. Today approximately 70% of childhood cancers are potentially curable. Interestingly, this is not because of discovery of new drugs in treatment of childhood cancer, rather it been achieved by the rational combination of the three important therapeutic modalities – chemotherapy, surgery and radiotherapy. This has been achieved through successive clinical trials comparing the best known therapy with new innovations in treatment. These trials have been conducted by multidisciplinary teams working in pediatric tertiary academic centres in North America and Europe, and it has been shown repeatedly that this expertise improves the chance and quality of survival. This is emphasised in a consensus statement published in 1998 by the American Federation of Clinical Oncologic Societies. They also state that “Timely referral for treatment increases the opportunity for optimal outcomes. The interval between the time of diagnosis and Initial treatment should be minimised.”
In India health care facilities are very diverse, ranging from centres having all state of the art facilities and trained medical personnel to centres which do not have even basic infrastructure for diagnosis and treatment of childhood cancer. Like in any other developing countries, late presentation, delays in diagnosis and tardy referral to appropriate treatment centres probably lower the cure rate. There is no doubt that the best chance for cure is the first chance; an unnecessary delay, misdiagnosis, incomplete surgery, or inadequate chemotherapy may adversely affect prognosis, irrespective of subsequent care.
The average general practitioner or pediatrician will rarely see a child with cancer. This lack of familiarity with the signs and symptoms of pediatric malignancy makes it easy to understand why the diagnosis may be delayed or missed.
Case Study#1: 7 year old child presented with history of swelling in the neck, low grade fever and cough for 3 weeks. Physical examination revealed 3×3 cm firm, non tended right sided nodes. Complete blood count was normal. FNAC: reactive hyperplasia. Child received empirically anti-tubercular treatment. After six weeks, nodes were persistent, presuming a diagnosis of multidrug resistant tuberculosis, child was referred to higher centre. Biopsy revealed classical Hodgkin lymphoma.
Message:FNAC is not investigation of choice in pathological lymphadenopathy, specially if reported as reactive. Biopsy MUST be done in all such cases to make an accurate diagnosis.
Case Study 2#:5 year old well looking child consulted local physician for sudden onset of petechie and bruises over trunk and legs. Physical examination was unremarkable without any lymphadenopathy or splenomegaly. CBC showed thrombocytopenia with lymphocytosis. A diagnosis of ITP was made and child was started on steroids. Child got better, bruises disappeared. Presented 3 weeks later with high grade fever and bleeding. CBC revealed hyperleucocytosis with 80% blast.
Message: Leukemia is not always associated with lymphadenopathy or hepatosplenomegaly. All thrombocytopenia in a well child is not ITP. Careful examination of CBC and peripheral smear may help to prevent missing underlying marrow disorder.
Except for haematological cancers and brain tumors, the principal cancers that affect children are seldom seen in adults. In children deep-seated sarcomas and embryonal tumors are the rule. Many of the well-known classic warning signs of adult cancer apply to carcinomas that are extremely rare in children. Pediatric tumors do not involve epithelial tissues so they do not bleed externally or exfoliate epithelial cells; as such screening techniques useful in adults, such as stool blood tests or Pap smears, have no counterparts in children.6 However, there are warning signs and symptoms that should alert the health worker to a possible diagnosis of cancer in children.
To create a greater awareness of these signs we have recommended the following information sheet. We aim to disseminate this widely to primary health care personnel. We trust that this will assist health workers to consider the diagnosis of cancer where appropriate and to refer these patients to a children’s cancer unit as a matter of urgency.
WARNING SIGNS OF CANCER IN CHILDREN
Cancer in children is fairly rare, but is often curable. It is important to make an early diagnosis. For this a high index of suspicion is necessary. The commonest types of cancer in childhood are leukemia, lymphomas and tumors in the brain or abdomen.
Suspect cancer in a child with any of the following features:
1.Pallor plus bleeding (such as purpura, unexplained bruises or persistent oozing from mouth or nose.
3.Localised lymphadenopathy, when persistent and unexplained
4.Unexplained neurological signs
5. An unexplained mass
6.Persistent unexplained fever, apathy or weight loss