Oncology in the School System
from School Health Reporter, Winter 2004
Fran Schiavone, RN, MS - School Nurse Consultant at The Children's Hospital School Health Department
Oncology is the branch of medicine treating cancer and benign tumors. Cancer management is multifaceted and ever-changing no matter the specific oncology diagnosis – this is true in adult oncology, as well as pediatric/adolescent oncology. The goal of this article is to help such school personnel as nurses, teachers and para-professional staff gain a better understanding of the challenges presented to a student and his or her family during treatment of an oncology diagnosis. Additionally, this article provides information to school staff about what to understand and do once a student returns to school after a cancer diagnosis.
What is Cancer?
Cancer occurs when the wrong instructions are given to some cells, resulting in an abnormal out-of-control growth of these cells. Malignancy happens when this overgrowth of cells invades normal surrounding organs and tissue. All cancers are not malignant. Metastasis is when the cancer spreads from the primary site to other areas of the body. Benign tumors are non-cancerous growths that do not spread to other parts of the body. Other words used for cancer are tumor, malignancy and abnormal growth.
An exact cause of most childhood cancers is not known, but it is suspected that there are multiple factors. Ongoing organized research studies and clinical trials contribute to continuously improving survival rates. Survival rates also have improved due to combined forms of such therapies as chemotherapy, radiation, surgery and bone marrow transplants. Each treatment plan for a child’s cancer is diagnosis-specific. Individual patient response to treatment further determines the treatment roadmap to provide the best chance for cure with the fewest side effects.
Types of Childhood Cancers
While there are a myriad of cancers, common childhood cancers are described below.
Leukemias are cancers in the blood and bone marrow. With leukemia, the bone marrow produces large numbers of immature non-functional cells or blasts instead of mature functional white cells. There are several different types of leukemias. The most common childhood leukemias are acute lymphoblastic leukemia, acute myeloid leukemia and chronic myelogenous leukemia.
Lymphomas are cancers of the lymph system. The lymphatic system is part of the immune system. It is a network of thin tubes that branch like blood vessels throughout the entire body with clusters of small organs call lymph nodes in the underarms, groin, neck, chest and abdomen. The spleen, thymus, tonsils and bone marrow also are part of this system. The lymph system’s job is to circulate infection-fighting cells called lymphocytes. Lymphoma cancers include Hodgkin’s, which involves the organs, and non-Hodgkins.
Such solid tumors cancers as osteogenic sarcoma, Wilm’s tumor (kidney specific), neuroblastoma and rhabdomyosarcoma can grow in the bone, organs, central nervous system or other tissues in the body.
Types of Oncology Treatments
Once diagnosed with cancer, a number of different treatments may be appropriate, ranging from chemotherapy to surgery.
Chemotherapy uses a group of medicines that kills cancer cells and may damage healthy cells. Chemotherapy slows the production of white-blood cells in the body, which help fight and kill bacteria, fungi and viruses. When on chemotherapy, patients are susceptible and at risk for any form of infection. Blood draw counts are done daily, sometimes twice a day, until the absolute neutrophil count (ANC) reaches 500. ANC is the percentage of segs and bands in the total white-blood cell count. When the ANC is less than 500 the body is unable to fight bacterial infections. Until a count of at least 500, patients are in isolation and may take antibiotics, antifungals and/or antivirals. Patients generally are hospitalized until their ANC is greater than 500 and likely not attending school when they are this profoundly immune-compromised.
Chemotherapy can be administered by mouth, IV (into a vein), IM (as an injection) or IT (intrathecal injection into the spinal canal).
Radiation is the use of high-energy waves to kill rapidly growing cancer cells and may damage healthy cells.
Common surgical procedures include biopsy for diagnosis, removal of solid tumors, placement of central venous line (CVL) and insertion of gastrostomy tube. (GT).
A bone marrow transplant (BMT) is the process of killing off all body cells and replacing healthy bone marrow cells by infusion. This is a very detailed and high-risk treatment.
Side effects
Unfortunately, there are many side effects associated with cancer treatment. These side effects, as well as the consideration that should be given to them in a school setting, are addressed below.
Myelosuppression/Immunosuppression/Bone Marrow suppression – These are terms used to describe a decrease in one or all of the following: the red-blood cell count (RBC), white-blood cell count (WBC) and/or the platelet (PLT) count, which result from chemotherapy or radiation.
Anemia is low red-blood cell or hemoglobin count. The hemoglobin is the part of the red-blood cell that carries oxygen to all organs and tissues. Normal hemoglobin is 12 to 16 and normal hematocrit is 36 to 50. Such anemia symptoms as a pale complexion, easily tiring and lethargy don't usually occur until hemoglobin is below nine. Standard treatment is a blood transfusion.
School consideration: These students may have very limited energy levels. Work with the student and family to decide academic goals, allow for naps and account for the time of the day when the student feels the best. Shortened days and shortened schedules may be needed.
Neutropenia is low white-blood cell count, specifically those white-blood cells called “neutrophils,” which fight bacterial infection. Normal total WBC is 5,000 to 10,000. ANC is less than 500 and at that point, the body is unable to fight off bacterial infections.
School consideration: Report any such signs of infection as fever, sore throat, headache and/or stomach pain to the parents. Remember also to report any illness going around the school to the student’s parents. They can then make a decision as to whether to keep the student at home. Never give a neutropenic child Tylenol or an antipyretic until it is okayed by the doctor. Blood cultures may need to be drawn while the child is febrile. Never give children under 12 years old aspirin. Simple and frequent handwashing is the single best way to prevent the spread of germs from person to person and is a good practice for all school staff and students.
Thrombocytopenia is low platelet count. Platelets help to stop bleeding. Normal range is 150,000 to 300,000. Low PLTs are under 15,000. A child with low PLTs is at risk for severe bleeding.
School considerations: No contact sports. If the student develops any type of bleeding, use first-aid skills and contact parents immediately. Call 911 if the bleeding is profuse and unstoppable. For nosebleeds have student sit with his or her head hung down, pinching the bridge of the nose. An ice pack may be applied to the nose. You may see significant bruising of a child’s skin when he or she has low PLTs; it is likely not due to trauma.
Pneumocystis Pneumonia is a danger to immunosuppressed people who are at risk for developing this very serious and potentially life-threatening pneumonia. This form of pneumonia frequently is presented in a healthy immune system that can easily fight it off. In an immune-compromised person this type of pneumonia is very invasive, spreads quickly and can be very difficult, if not impossible, to treat. Standard treatment is to take Bactrim/Septra, an antibiotic, two consecutive days a week, to prevent pneumonia. Research has shown that this will keep pneumocystis under control in the immune-compromised host.
School considerations: Report any knowledge of bacterial illness going around the school, as well as any change in respiratory condition of the student, such as fever, increased rate of breathing or shortness of breath, to the student’s parents.
Exposure to chicken pox or shingles. Chicken pox and shingles are from the same varicella virus. Shingles is the reactivated form of the varicella virus. Varicella virus lives forever in anyone who has had chicken pox. Untreated chicken pox or shingles can be a very serious and potentially fatal infection for immunosuppressed children and children with cancer receiving chemotherapy. Chicken pox is contagious one day before and six days after the beginning of the rash or until all the pox are crusted over. A child or adult who has never had chicken pox can catch it from an infected person through close contact in just an hour. Shingles usually presents as a localized painful rash of redclustered blisters. The pain may develop before the rash appears. Exposure is the same as for chicken pox.
School considerations: Classroom teachers, parents and school personnel need to be aware of the dangers of chicken pox in any immunocompromised child. A child may be immunocompromised if he or she is a severe asthmatic who is on steroids, a transplant patient or a cancer patient. The parents of these children need immediate notification. If an immunocompromised child is exposed to chicken pox, he or she can receive an injection of V-ZIG (varicella zoster immune globulin) to greatly reduce the chances of this virus becoming serious, but the injection should be given within 72 hours of the exposure for greatest success. Caution must be used to keep children with rashes home until a physician’s statement eliminates chicken pox or shingles as the cause.
Most vaccinations/immunizations are not given during chemotherapy, but can be resumed six to nine months after the completion of chemotherapy. The exception is the flu vaccine, which is recommended for the student and his or her family. Siblings of children on chemotherapy should not receive the (live virus) oral Sabin polio vaccine; they should receive the IM Salk (killed virus) polio vaccination. The live virus is not recommended because it can mutate and spread. Unhealthy immune systems cannot produce cells quickly enough to fight it.
School considerations: The physician’s office can provide an immunization exemption form for lack of immunization secondary to cancer therapy treatment.
Headaches, mouth sores, mouth care, pain and hair loss also are side effects of cancer that need to be considered. Students should be allowed to use the restroom, eat and snack as needed, be permitted provisions for pain control and be allowed to wear wigs, scarves and/or hats to deal with changes in their personal appearance. Nutrition and eating habits may change as food tastes different.
Upon Return To School
The best plan is to involve the school nurse and/or school team in the discharge planning process when the patient leaves the hospital after a new diagnosis. This involvement provides an opportunity for school personnel to meet the medical team and work with the family toward school re-entry and/or continuing education at home.
The outpatient clinic nurse may come to the school or may be available by phone for consultation. The student and family’s emotional, physical, mental and medical state must be considered when developing the plan for the return to school.
Summary
When a student with a cancer returns to school, it can affect the entire school. The team can best support the student and his or her family by acceptance, redefining what is “normal,” decreasing stress at every opportunity and defining the place for academics, sports and socialization at this time in the student’s life. The team also needs to recognize how this illness may affect fellow students and staff.
