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Chemotherapy For Childhood Cancers

Chemotherapy is treatment with anticancer drugs. These drugs can be given orally (pills or liquids) or by injection. There are several types of injections: into a muscle (intramuscular, or IM), into a vein (intravenous, or IV), into an artery (intra-arterial), or into a cavity (intracavitary). Doctors also inject anticancer drugs into the spinal fluid (intrathecal, or IT) to treat brain tumors and to prevent central nervous system disease in leukemia. Often, special devices, such as catheters and pumps, are used to help deliver the drugs.

Insertion of the IV needle may be painful and, once in the vein, the drugs may cause an uncomfortable burning sensation. If the drug leaks from the vein, it may severely burn the skin, so care must be taken to make sure the IV line is securely in place, and the nurse or doctor must act immediately if the needle comes out of the vein.

Injections are generally given by physicians or nurses, but pills may be given at home. Taking chemotherapy pills can sometimes be a problem with younger children, but the tablets can be broken into smaller pieces for swallowing or powdered and mixed with apple sauce, jam, or custard. Older children, particularly adolescents, may wish to be responsible for taking and keeping track of their oral medication(s). However, it is still important for parents to be familiar with the medications and check to be sure they are being taken correctly.

Whether you or your child is responsible, you may want to develop a system for keeping track of when medications are taken. Marking a special calendar is one way of doing this.

Chemotherapy and Its Side Effects

Once in the bloodstream, chemotherapeutic drugs are taken up by cells such as breast cancer that divide rapidly. In the cancer cell, the drugs act by interfering with the duplication and growth of the cell, primarily by preventing it from dividing or depriving it of a substance it requires to function, and the cell is eventually destroyed. Anticancer drugs can affect not only cancer cells but also other rapidly dividing normal cells such as those in the gastrointestinal tract, bone marrow, hair follicles, and reproductive system. Because of this, unwanted side effects of the treatment can and often do occur. Most side effects, however, are temporary.

One common side effect of chemotherapy is the reduction of the bone marrow's ability to produce the normal amount of blood cells. This may put your child at greater risk for anemia (if significantly fewer red blood cells are being produced), bleeding (if production of platelets is down), or infection (if the white cell count, particularly that of the neutrophils, is low). Doctors use colony stimulating factors (CSFs), hormone-like substances that regulate the production and function of blood cells, to promote the growth of infection-fighting white blood cells. Using CSFs lessens the risk of infection in patients with a low white blood cell count as a result of chemotherapy. In general, you or your child should be particularly alert to any signs of infection, bruising, or bleeding and notify your physician if they occur.

Many side effects from anticancer drugs are possible, and the following points are good to keep in mind:

1. Most side effects can be lessened by taking appropriate measures before, during, and after chemotherapy. (See the following section for how to control side effects.)

2. Side effects vary in severity and type from person to person and treatment to treatment. Your child will not necessarily have the same reactions as another child, but it is important for you to be aware of those problems that occur commonly so you can recognize them early.

3. Most side effects are reversible and will improve after the drug is stopped. Some, such as hair loss and bone marrow depression, may lessen or disappear even without discontinuing chemotherapy.

4. Side effects of chemotherapy may be classified as common or uncommon and as acute (immediate) or delayed (days to weeks after chemotherapy).

Common acute side effects:
Nausea and vomiting
Pain and burning at injection site

Less common acute side effects:
Allergic reactions (hives; rash; swelling of eyelids, hands, and feet; shortness of breath)
Drug extravasation (leaking of drug out of vein into skin)

Common delayed side effects:
Hair loss
Mouth soreness and ulcers
Constipation (especially with the drug vincristine)
Bone marrow depression (low blood counts)

Uncommon delayed side effects:
Jaundice (yellow tint to skin and eyes due to liver problems)
Hemorrhagic cystitis (bloody urine due to bladder irritation-especially with the drug cyclophosphamide)
Mental or nervous system changes (lethargy, tiredness, lack of coordination)

Each drug has the potential of producing its own side effects. Your doctor can tell you which ones your child is most likely to experience.

5. Daunorubicin or its chemical cousin, Adriamycin, may cause heart damage if the cumulative dose over time exceeds certain levels. Your physician should keep a careful record of the cumulative dose and should warn you if your child passes the usual limits.

6. Chemotherapy may cause some long-term side effects in several body organs. The physician can tell you more about these in relation to your child's specific care and treatment.

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Controlling the Side Effects From Chemotherapy

Certain side effects, although not dangerous, are bothersome, and you can try to avoid or control some of these through specific measures:

1. Constipation from vincristine: Encourage increased consumption of fluids and roughage (juices, fruits, vegetables, bran cereals) starting the day before injection and continuing for a week. If the child does not have a bowel movement for a considerably longer period of time than is usual, contact your physician. If constipation is a common problem, the regular use of a stool softener may be necessary while the child is on vincristine.

2. Nausea and vomiting: Caused by several drugs, can often be relieved and sometimes prevented by certain medications. Unfortunately, no perfect drug exists to prevent nausea and vomiting. Those that are effective are most helpful if given before chemotherapy. If these symptoms are marked, ask your physician about prescribing medication to counteract them.

3. Heartburn and stomachache from prednisone and dexamethasone: To prevent this, give 1/2 glass of milk or 1 or 2 tablespoons of an antacid with each dose.

4. Mild to severe mouth soreness is caused occasionally by several drugs (e.g., methotrexate, Adriamycin): Good oral hygiene is important during this period. Many people use special mouth rinses to ease the discomfort. (See the discussion of mouth care in "Common Health Issues" for more information.) No particular regimens are known to prevent mouth soreness from occurring.

5. Hair loss from vincristine, Adriamycin, methotrexate, cyclophosphamide, etc.: This will occur in varying degrees in each child, depending on which drugs and which schedule of drugs are received. There is no way to prevent hair loss, short of discontinuing medication. The hair will grow back, but regrowth may take months. The new hair may be different in color and texture. In the interim, emotional stress exists, especially in teenagers. If marked hair loss appears to be occurring, your child may want to consider wearing a wig. The wearing of a wig will not hamper hair regrowth. Caps or scarves may also be worn.

6. Tissue burns from vincristine, daunorubicin, or Adriamycin leaking at the site of injection: Any swelling, redness, or pain occurring during an injection or up to a few days afterward should immediately be brought to the attention of the doctor or nurse. Prompt treatment may be necessary to prevent a severe burn and ulceration of the skin.

7. Hemorrhagic cystitis (irritation and bleeding from the bladder) from cyclophosphamide: The likelihood of this occasional side effect may be reduced by seeing that the drug does not rest in the bladder for a long time. This is best done by giving the drug early in the day and seeing that urination is increased by encouraging your child to drink plenty of fluids throughout the day (thirst cannot be relied on). This will assure elimination of the drug from the bladder. The amount of liquids to be given depends on the child's size, so discuss this with your physician. This complication may occur shortly after the drug is given or show up weeks or months after the patient receives cyclophosphamide, so pink or bloody urine occurring at any time after therapy should be immediately reported to the doctor.

8. Some drugs increase sensitivity to the sun: A complete sunblocking lotion containing PABA (check the product's list of ingredients) should be used to prevent burning.

Finally, it is helpful to discuss with your physician any of the listed side effects and any other changes that you observe in your child.

Information provided by the
National Cancer Institute
National Institutes of Health

Each year, Medical College of Wisconsin physicians care for more than 180,000 patients, representing nearly 500,000 patient visits. Medical College physicians practice at Children's Hospital of Wisconsin, Froedtert Memorial Lutheran Hospital, the Milwaukee VA Medical Center, and many other hospitals and clinics in Milwaukee and southeastern Wisconsin.