Pediatric Cancer Treatment in Delhi, India

• Primary Cancer and Secondary Cancer - The “Primary Cancer” is where the cancer started. In case some cells break away from the primary cancer site and settle in another part of the body, this cancer is then called as “Secondary Cancer” or metastases. The cancer cells can spread locally by entering the bloodstream or lymphatic system. However, secondary cancers are made up of same type of cells as primary cancer.
• Leukemia - Found in the blood and bone marrow, this cancer accounts for one third of all childhood cancers. The common cancers found in children are: Acute Lymphocytic Leukemia (ALL) and Acute Myeloid Leukemia (AML). These cancers can cause fatigue, weight loss, bleeding, joint pain and high fever. As acute leukamias have a tendency to grow quickly, they need immediate medical intervention (chemotherapy).
• Brain and Spinal Cord Tumors - The second most common cancers in children are brain and central nervous system tumors that account for a quarter of all childhood cancers. They commonly occur in lower parts of brain like cerebellum or brain stem. Most common childhood cancer symptoms seen are dizziness, double vision, severe headaches, vomiting, and difficulty in walking or holding things.
• Lymphomas - They start in lymph nodes and lymph tissues and can also affect bone marrow as well as other organs. The most common pediatric cancer symptoms are swollen lymph nodes under neck and armpit, excessive weight loss, and fatigue. 2 types of lymphoma that can occur both in children and adults are:
  • Hodgkin Lymphoma
  • Non-Hodgkin Lymphoma
• Wilms tumor - This tumor accounts for 5% of childhood cancers and is commonly found in children aging 3-4 years. It usually starts in one or both kidneys, causing swelling or lump in the abdomen with symptoms like loss of appetite, nausea and fever.
• Neuroblastoma - This cancer develops in infants and young children. Accounting for about 6% of childhood cancers, neuroblastoma can begin anywhere but starts in the abdomen, and may also cause severe bone pain and fever.
• Bone Cancers - About 3% of childhood cancers are bone cancers that occur in older children and teenagers (though they can develop at any age). Most common types of bone cancers are:
  • Osteosarcoma, which occurs in the areas where the development of bone is quick i.e. long bones in arms or legs. The pain usually becomes severe at night or while doing activity, causing swelling around bone.
  • Ewing Sarcoma is most commonly found in young teenagers. It usually begins in the hip bones, ribs or shoulder bladders or leg bones.

The cancers in children are hard to recognize as the symptoms are common/similar to childhood illnesses or injures. However, if the below-mentioned pediatric cancer symptoms persist, it requires immediate intervention:

• An unusual lump or swelling
• Unexplained paleness and loss of energy
• Easy bruising or bleeding
• An ongoing pain in one area of the body including bones, joints, back
• Limping
• Unexplained fever or illness that doesn’t go away
• Frequent headaches, often with vomiting
• Change or deterioration in walk, balance or speech
• Sudden eye or vision changes including white spot in the eye, new squint, new blindness, bulging eyeball
• Sudden unexplained weight loss

Paediatric oncologists diagnose a child’s cancer by doing tests to identify the specific type of cancer. This is called as “Confirmatory Testing”. Thereafter, a series of tests are done to determine the burden of cancer and where is it located. This is called as “Staging”. For this, several investigations are done like:

• Blood and Urine Tests
• Imaging with ultrasound, MRI, CT scan, PET CT scan
• Bone Marrow examination and lumbar puncture
• Biopsy

To Stage “Solid tumors”, the doctor examines the size of tumor and affected lymph nodes as well as where it has spread.

To Stage “Lymphoma”, the doctor examines the lymph nodes, bone marrow, liver, spleen, lung and the rest of the body. Also, few special tests like genetic testing of tumors are also done to assess the capability of cancer.

It is most important to get the correct diagnosis so that right treatment can be given to the child. Though not all tests are done on children and what is conducted depends on the type of cancer suspected. For most of these tests, the child is sedated so that he/she may not move or feel any pain. The results may take 3-5 days to come back so this is explained to the parents.

Once the diagnosis is confirmed, the oncologists provide detailed counseling to parents. Treatments are available for all childhood cancers, and most children can be cured. The team should ensures that all children are comfortable and free of pain as the treatment of childhood cancer is long and tough. The main types of pediatric cancer treatment options available are:

• Surgery - The tumor is removed by an operation
• Chemotherapy - The medical drugs are given to stop the growth of cancer cells. These are given by:
  • Intravenous ( IV) (drip) : injection into a vein
  • Oral (PO or O) : as syrups, tablets or capsules
  • Intramuscular ( IM) : injection into muscle
  • Subcutaneous ( SC) : injection just under the skin
  • Intrathecal ( IT) : by lumbar puncture

The chemotherapy drugs travel through the bloodstream. As the drugs are carried in the blood, they destroy cancer cells in the body. Therefore, chemotherapy is useful for treating cancers that are generalized, e.g. blood cancers or those cancers that have spread to other parts of the body. Though the chemotherapy drugs destroy the cancer cells completely but they also affect the healthy cells. As a result, chemotherapy is given as a series of treatments in cycles/phases to allow the healthy cells to recover. The chemotherapy drugs can cause side effects as all children may react to it differently.

• Radiotherapy – Radiation is an invisible treatment that requires the use of high energy rays to destroy the cancer cells in one particular area of the body. This treatment is given in daily sessions at the hospital and takes about 10-15 minutes. However, the overall length of treatment depends on the type of tumor and may extend from 2-6 weeks. High doses of radiation are applied to stop the cancer cells from growing, which can kill some healthy cells, causing fatigue, skin changes and loss of appetite.
• Bone Marrow Transplantation- It is a medical procedure done to replace the damaged bone marrow with healthy bone marrow cells. It is useful in certain types of cancer or when the cancer comes back.

As the treatment is quite strong, there may be some side effects. It is important to remember that your child may have only some of these side effects. The oncologists can help the child through some of these treatments and counsel parents that these are a part of treatment, which is ultimately going to cure the child. Below are few side effects:

• Tiredness/Lethargy
• Aches and pains - These may happen all over the body including the jaw and the legs. They can be managed with paracetamol if needed
• Loss of appetite - There may be several reasons that a child may not eat as normal. This could be because of disrupted routine, anxiety, nausea/vomiting or sores/ulcers in the mouth. Your doctor will continuously monitor this and advice appropriately along with input from a dietitian.
• Nausea and vomiting - They may begin immediately after chemotherapy and the effects may last for a variable period of time. Medications are given to decrease the feeling of nausea and vomiting after chemotherapy.
• Diarrhea - It is quite possible that this symptom develops immediately after chemotherapy because of two reasons: Drugs may affect the intestines and due to unhygienic food consumed (fruit juices and coconut water from roadside vendors).
• Sores and ulcers in the mouth and throat - These effects start few days after chemotherapy, hence it is required that the child must have a good oral hygiene. It is important to inform the doctor immediately if the child develops sores or ulcers in the mouth.
• Constipation - This symptom usually appears because of other drugs prescribed with chemotherapy. Please inform the doctor if the child experiences constipation, as it may seem unimportant but constipation can have significant repercussions on the treatment.
• Hair loss - The child can have partial or complete hair loss during treatment. However, there is no proven effective measure to prevent this side effect. Most children will regain their hair within 4-6 months of completion of chemotherapy.
• Low white blood cell counts (leukopenia) with or without infection - This complication usually begins 6-7 days after chemotherapy and last for few days. Low WBC counts may or may not be associated with infection. The first sign of infection is usually fever (≥ 100°F), although some patients can develop severe infection without fever.
• Extravasation - Please inform the doctor if there is a small leakage of chemotherapeutic drug that can cause swelling, pain and ulceration.
• Anemia - It is a symptom that refers to low hemoglobin levels and occurs after several cycles of chemotherapy. There are several other factors that contribute to development of anemia like bleeding, pre-existing malnutrition, heavy or prolonged menses, poor food intake etc. The doctor may decide to give the child blood transfusions to treat this condition or provide iron supplements and other vitamins.

• Beverages Recommended by Experts of Children's Cancer Hospitals :
  • Boiled and cooled water
  • Fresh Fruit juice made at home
  • Canned or packaged juices
• Vegetables to Treat the Childhood Cancer Symptoms:
  • Peeled carrots and cucumbers can be eaten after washing
  • Boiled vegetables
  • Vegetables like tomatoes should be washed and boiled for some time
• Cereals Include in Diet After Childhood Cancer Treatment :
  • Toasted bread and wheat bread
  • Homemade cake and biscuits
  • Cereals like ragi, jowar, wheat, rice and oats
• Fruits After Childhood Cancer Treatments:
  • Skinned fresh fruits like banana, pomegranate, papaya, oranges, water melons and musk melons
  • Smooth thin skinned fruits like chikoo should be peeled and washed well
  • Milk and Milk Products
  • Boiled milk
  • Fresh homemade ice cream, curds and paneer

1. What impact does chemotherapy have on a child's growth and development?

Chemotherapy can temporarily affect a child's growth and development, but most children are able to catch up on their growth after completing the treatment.

2. Is radiation therapy safe for children?

When carefully planned and administered by experienced healthcare professionals, radiation therapy can be safe for children.

3. What are the common types of childhood cancers?

Leukaemia (blood cancer) is the most common type of cancer in children. Other common cancers include Brain tumours, neuroblastoma, lymphoma, Wilms tumour, malignant bone tumour, retinoblastoma and germ cell tumours.

4. What are the side effects of chemotherapy in children?

Chemotherapy kills rapidly dividing cancer cells. As a side effect, it also affects other rapidly dividing cells of the body. Thus, common side effects include hair fall and nail and skin discolouration, which are all temporary and recover completely once treatment is over.

During chemotherapy, the rapidly dividing blood cells are also affected because of which immunity goes very low, and the child is prone to get any kind of infection ranging from a simple viral to a serious bacterial or fungal or rarer infection. Children may need repeated blood and platelet transfusions. There could be an effect on other organs like the liver, kidney and heart, which are monitored closely by the doctor. During chemotherapy, there could be nausea and vomiting, which are easily managed by medications.

But, not all children on chemotherapy will have similar complications. These depend upon the type of cancer, treatment being given, and other factors. All these side effects are usually temporary and settle down once the treatment is over. Your Pediatric Oncology team would guide you more based on the specific diagnosis of the child.

5. Can childhood cancer recur after treatment?

Most childhood cancers are curable. But there is a slight risk of cancer coming back after treatment is completed, which is known as relapse.

6. What is the chance of a cure or complete recovery from cancer in children?

Most cancers in children will get cured if cancer is diagnosed early and treated appropriately by an expert healthcare team with expertise in treating cancers in children.

These children will go on to complete their school, college and have family and professional life like other children.

FAQs Reviewed by Dr. Prachi Jain (Pediatric Oncology), Consultant - Medical Oncology (Hemato - Oncology, Paediatrics), Cancer Care / Oncology, Hematology Oncology, Paediatric (Ped) Oncology, Paediatric (Ped) Hematology, Medical Oncology, Musculoskeletal Oncology, Neuro Oncology on 26-Jun-2023.

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