Childhood Cancer Warning
Curing cancer in children – early recognition and appropriate treatment is the key.
Cancer is uncommon in the paediatric population with rates of 110-130 per million children per year being reported in Western countries.1 Accurate figures for South Africa have not been published but preliminary reports suggest a prevalence of only 70-80 per million. Poor data collection is likely to be the main reason for this apparent low incidence and may be due to inadequate reporting of newly diagnosed cases to the cancer registry. Another factor is almost certainly failure to diagnose cancer in some children either because they have poor access to health care or primary health care workers do not recognise signs and symptoms of paediatric malignancy.
Advances in survival of children with cancer over the past thirty years have been remarkable. Today approximately 70% of childhood cancers are potentially curable2. This has been achieved by the rational combination of the three important therapeutic modalities – chemotherapy, surgery and radiotherapy and by successive clinical trials comparing the best known therapy with new innovations in treatment. These trials have been conducted by multidisciplinary teams working in paediatric tertiary academic centres and it has been shown repeatedly that this expertise improves the chance and quality of survival.3, 4 This is emphasised in a consensus statement published in 1998 by the American Federation of Clinical Oncologic Societies.5 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”.
South Africa is fortunate in having several paediatric oncology centres with all the necessary expertise. Unfortunately, as in 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 primary care nurse will rarely see a child with cancer. This lack of familiarity with the signs and symptoms of paediatric malignancy makes it easy to understand why the diagnosis may be delayed or missed.
Except for haematological cancers and brain tumours, the principal cancers that affect children are seldom seen in adults. In children deep-seated sarcomas and embryonal tumours are the rule. Many of the well-known classic warning signs of adult cancer apply to carcinomas which are extremely rare in children. Paediatric tumours do not involve epithelial tissues so they do not bleed externally or exfoliate epithelial cells thus 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 the South African Children’s Cancer Study Group (SACCSG) has compiled 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 in appropriate patients and to refer these to a children’s cancer unit as a matter of urgency.
Warning signs for 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 leukaemia, lymphomas and tumours 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 ).
2) Bone pain
- this is not localised to specific area and often wakes the child at night
- a child may develop a limp, or a toddler may become reluctant to bear weight or stop walking
- always investigate backache in a child.
3) Localised lymphadenopathy, when persistent and unexplained
- Beware of: axillary/inguinal/cervical glands which are >2cms, discreet and non-tender, and do not get smaller after 2 week’s treatment with
antibiotics
- “tuberculous” nodes not responding to treatment in 6 weeks
- biopsy these nodes.
- glands in supraclavicular area.
4) Unexplained neurological signs.
These include: - headaches lasting longer than 2 weeks.
- early morning vomiting
- ataxia ( walks unsteadily )
- cranial nerve palsy.
5) An unexplained mass.
- important sites are: abdomen, testes, head and neck and limbs.
- if a young child with abdominal distension is uncooperative, examine under sedation (Vallergan 2mgs/Kg) to be sure that a mass is not present.
6) Persistent unexplained fever, apathy or weight loss.
- first exclude: urinary tract infection.
TB
HIV.
Then consider malignancy.
7) Eye changes.
i.e. - white reflex
- recent onset of squint
- proptosis.
- loss of vision.
- Refer children with these eye changes urgently to a Centre with
an Ophthalmologist.
If you suspect malignancy refer urgently to your nearest secondary hospital or seek advice from a paediatric oncology centre.
References:
1. International Incidence of Childhood Cancer. IARC Scientific Publications No. 144. World Health Organization 1998: (II): 135 and 365 – 371. Editors Parkin DM, Kramarova E, Draper GJ, Masuyer E, Michaels J, Neglia J, Qureshi S, Stiller CA.
2. The evolution of Cancer Care for Children and Adults. Editorial. J Clin Oncol 1998: 16(9); 2904-2905.
3. Kramer S; Meadows AT; Pastore G et al. Influence of place of treatment on diagnosis, treatment, and survival in three pediatric solid tumors. J Clin Oncol. 1984: 2(8); 917-23
4. Stiller CA. Centralisation of treatment and survival rates for cancer. Arch Dis Child 1988: 63(1); 23-30
5. Access to Quality Cancer Care. A Consensus Statement of the American Federation of Clinical Oncologic Societies. J Pediatr Hematol Oncol 1998: 20(4); 279-281.
6. Hammond G D. The Cure of Childhood Cancers. Cancer 1986: 58:2 Suppl; 407-13
South African Children’s Cancer Study Group
EARLY WARNING SIGNS FOR CANCER IN CHILDREN
S: Seek: Medical help early for persistent symptoms.
(persistent means it lasts for longer than a week)
I: Eye: White spot in the eye; new squint; blindness; bulging eyeball.
L: Lump: Abdomen and pelvis, head and neck, limbs, testes, glands.
(the lumps do not get any better despite medication such as
anti-biotics that have been given)
U: Unexplained: Fever for over 2 weeks; loss of weight and appetite; pallor (pale colour); fatigue (gets tired for no reason); easy bruising or bleeding.
A: Aching: Bones, joints, back, and easy fractures.
N: Neurological Signs: Change or deterioration in walking (if a child walked a certain
way and this changes or does not want to walk anymore), balance (looses balance), speech (change in the way the child speaks i.e. may slur words), or behaviour (child’s normal behaviour changes e.g. may become aggressive); regression of milestones (the going backwards of certain milestones in a child’s normal development); early morning vomiting and/or headache for more than a week; enlarging head (the head swells).
This list has been compiled by the South African Children’s Cancer Study Group and is now used throughout the world.