Neuro-Cognitive Effects of Pediatric Systemic Cancer Management - Essay Example

Neuro-Cognitive Effects of Pediatric Systemic Cancer Management Neuro-Cognitive Effects of Pediatric Systemic Cancer Management Introduction Since the first proposal for treatment of pediatric systemic malignancy by Sidney Farber in 1948, pediatric oncology has evolved in leaps and bounds. Following the landmark work by Farber, this field of oncology has seen extraordinary evolution in pediatric malignancy care, which is reflected in the current 88% rate of malignancy survival among children (Yarbro, Frogge & Goodman 2010, p. 50). Consequently, the number of cancer survivors among children has grown to estimates of over three hundred thousand children. Studies of the long-term effects of systemic malignancy treatment in children have indicated that the treatment has particular adverse impacts that present years following the initial treatment termed as late effects. From the conclusions of the reviewed literature, it becomes clearer that management of childhood systemic malignancies have late effects on them as they grow and develop. This paper will seek to discuss the late effects that result from the management of acute lymphoblastic leukemia and brain tumors on pediatric patients, in this case regarding their neuro-cognitive development. In addition, because the neuro-cognitive deficits resulting from systemic malignancy management will cause psychosocial deficits, these will also be discussed as part of the paper. Finally, the paper will also briefly discuss how these late effects can be managed to improve the lives of the pediatric patients in later life, which is important because it is recognised that survivors of childhood systemic malignancy need follow-up care. The care model for pediatric systemic malignancy patients revolves around a risk-based approach that incorporates risks based on co-morbid health conditions and lifestyle behaviours (Carroll & Finlay 2010, p. 45). Neuro-cognitive Effects of Pediatric Cancer Treatment Deficits in neuro-cognitive function are commonly experienced by survivors of childhood systemic malignancy, manifesting in various domains such as language, visual-spatial skills, verbal memory, psychomotor skills, processing speed, executive functioning, concentration, and attention. While Bottomley & Kassner (2003, p. 129) contend that it has also been found that these deficits manifest across academic performance and intellectual functioning, it is important to note that these deficits are only limited to systemic malignancies like brain tumors and acute lymphoblastic leukemia. From the reading, it is probable that this is mostly caused by treatment directed at the CNS and the irreparable damage caused to a growing CNS, which results in neuro-cognitive deficits in later life for pediatric patients. It is also clear from the research that deficits in the pediatric patient’s neuro-cognitive ability will portend critical implications to their overall capabilities to function, in addition to the manner in which they lead their general life (Wen, Schiff & Quant 2012, p. 39). However, there is further need for research into how the late effects on neuro-cognitive ability interferes with general life quality and the patient’s greater functional capabilities Pediatric systemic malignancy treatment also affects educational progress, which can be attributed to the child’s increasing absence from school, as well as decreased levels of energy (Strojan et al. 2006, p. 79). Additionally, it seems that the use of certain therapies that seek to prevent spread or control systemic malignancy as discussed earlier may be directed at the brain, which will inadvertently affect the child’s future ability to learn. Picking from the complex structure of the brain, especially in children as it continues to develop, there are problems that may not be as apparent until the therapy is completed (Costa 2010, p. 29). However, it does not seem as if most of the literature reviewed with regards to this topic has dealt with the social environment in schools for pediatric systemic malignancy patient survivors with neuro-cognitive deficiencies. Their inability to keep up with their fellow classmates may actually exacerbate their memory, concentration, and attention span deficits. Effects in Pediatric Patients Treated for ALA For acute lymphoblastic leukemia pediatric patients whose systemic malignancy has been managed using radiation, abnormalities found include mineralising micro-angiopathy and leuko-encephalopathy (Buizer, De Sonneville & Veerman 2009, p. 449). The latter condition, which is an abnormality affecting the brain’s white matter, develops after five months of systemic malignancy management, which presents in signs and symptoms including memory loss, slurred speech, ataxia, lethargy, and seizures. In general, the condition’s severity does not correlate with results of academic performance and neuropsychological testing, although there are frequent deficits. Vascular insufficiency and de-myelination are several proposed pathologic mechanisms with the latter explaining why younger people have an enhanced toxic effect incidence (Hayat 2012, p. 56). Vascular insufficiency in the brain may cause an increased probability that the pediatric patient will, on top of getting neuro-cognitive deficiencies, have heightened possibilities of strokes later on in life (Hayat 2012, p. 56). Pediatric patients whose systemic malignancy is managed using radiation have increased incidences of neuro-psychological deficits (Meyle & Gonzáles 2011, p. 95). The results of full-scale and verbal IQ are lower in these pediatric patients than in in-patients and age-matched controls with systemic malignancies. This could be indicative of the fact that their neuro-cognitive functions could be preserved somewhat if their management regime is not too radioactive. Pediatric patients whose systemic malignancy was managed when they were less than seven years of age lose at least thirteen points in their full-scale IQ tests. According to Buizer, De Sonneville & Veerman (2009, p 449), particular deficits are also present in tests concerning concentration and attention, non-verbal memory, spatial-visual functioning and fine motor functioning. The children also have academic difficulties especially in mathematics, with less frequent difficulties in spelling and reading (Buizer et al 2009, p. 449). These results show that the age at which a pediatric patient undergoes systemic malignancy management has a critical impact on their later-life neuro-cognitive functioning. This could be due to the fact that their CNS is less developed. However, from the research findings, it is clear that there is less difficulty with verbal learning and expressive skills of language (Buizer et al 2009, p. 450). Deficits in Neuro-cognition for Brain Tumour Management There have not been many studies on pediatric patients who have survived brain tumours, although those that have indicate neuro-cognitive defect patterns similar to pediatric patients with acute lymphoblastic leukemia. The pediatric patient’s age during the cranial radiation therapy, as well as total dosage of radiation, are the fundamental factors that determine the deficit extent, while these pediatric patients receive increased cranial radiation therapy dosage than those with acute lymphoblastic leukemia (Hewitt et al. 2013, p. 73). Focused attention and working memory deficits reduce the surviving children’s ability to learn, while longer-term follow-up shows that they fall behind their peers academically (Hewitt et al. 2013, p. 73). Pediatric survivors of medulloblastoma, who have been irradiated, show significant deficits with those who have survived over five years after their initial diagnosis having a lower full-scale IQ than ninety do. There are similar patterns to be seen in performance and IQ, as well as in achievement tests regarding mathematics, spelling, and reading with 38% classified as disabled in learning (Schiff et al. 2008, p. 34). Another study by Turner et al (2009, p. 1458) also showed that sixty percent of all children who have medulloblastomas at less than three years have a full-scale IQ below seventy, while ~10% of those treated above three years of age had the same rating for full-scale IQ. In addition, those pediatric patients whose management involved local radiation had relatively higher IQ measurements compared to those with whole-brain irradiation. From these results, it seems that a significant inverse association exists between the volume of the brain irradiated and how the child will function late in terms of intellectual ability. By reviewing this results, it seems that the earlier a pediatric patient’s systemic malignancy is treated, the greater the risk that they will undergo a decline in their intellectual ability (Turner et al 2009, p. 1459). According to Kremer (2013, p. 545), children who receive total brain irradiation during management of their systemic malignancy are especially probable to undergo increased intellectual deficits. While this study may have been carried out with results from five years earlier with changing therapies for the treatment of tumors in the brain, it is illustrative of general principles that underlie neuro-cognitive outcomes in pediatric brain tumor patients. These principles have been validated further by studies utilizing more recent results. Resultant Psychosocial Effects These effects have a profound impact on the psychosocial development and functioning of pediatric patients. According to Jacobs & Pucci (2013, p. 122), because of neuro-cognitive deficits, most pediatric survivors of systemic malignancy have increased difficulties with regard to functioning in society. In addition, it is less likely that they will make it to college, be employed, and get married. Survivors of pediatric malignancy are at risk of psychological issues that stem from cancer diagnosis, treatment, and the physical long-term effects that come with survival. Additionally, insurance issues for the parents, occupational and educational issues lead to complications of the overall life quality (Jacobs & Pucci 2013, p. 122). With respect to psychosocial adaptation, Schneider (2012, p. 55) found that pediatric systemic malignancy survivors suffer more mental health, activity limitation and functional impairment issues. A survey of over three hundred people who survived systemic malignancy in their childhood that compared them with young adult control groups was indicative of the fact that most felt different from their other peers, while at least 70% felt that the differences were more negative than positive (Schneider 2012, p. 55). Self-reports concerning their health status showed that they were more negative compared to their peers, while they also had enhanced worries concerning fertility issues, second cancers, and other late effects. Difficulties in adjustment have also been seen in various areas such as getting into interpersonal relationships and maintaining them. It has also been noted that post-traumatic stress disorder symptoms are prevalent in ~12% of pediatric systemic malignancy survivors (Wallace & Green 2011, p. 61). Survivors in the adolescent stage show fewer tendencies to be anxious, although they also tend to use strategies of avoidance than peers of the same age group when forced to deal with issues of adolescence (Wallace & Green 2011, p. 61). It is also plausible that one of the most critical predictors of the adjustment level for childhood systemic malignancy is maternal coping. Neuro-cognitive problems also lead to psychosocial issues regarding attainment of education. Pediatric patients with systemic malignancy whose illness is managed through radiation therapy, especially for medulloblastoma and acute lymphoblastic leukemia, possess neuro-cognitive deficits, which impact their capabilities regarding performance in spelling, reading and mathematics as well as learning new things. In addition, children survivors with neuro-cognitive issues continue to be absent from school. Pediatric patients with various forms of brain tumours have lower rates of graduating from high school and attending college (Schwartz et al. 2012, p. 41). Following management of their systemic malignancy, pediatric patients also suffer late effects with regard to gaining employment and problems in the workplace, arising from neuro-cognitive problems presenting as psychosocial ones (Strojan et al. 2006, p. 80). There are several reasons why this could occur. Focusing on the neuro-cognitive deficits that result from the management of pediatric systemic malignancy, the biggest reason could be due to the belief that they are considered as risky business investments (Strojan et al. 2006, p. 80) . This is especially so in the military where physical fitness is of utmost importance, which means that any cognitive deficits are taken as weakness and a liability. Therefore, there is a high probability that pediatric cancer survivors will be faced with job discrimination and poor promotion policies. However, according to Turner et al (2009, p. 1461), there does not seem to be any significant difference in the salaries and allowances for survivors compared to their peers in similar conditions. These survivors normally experience issues related to job discrimination and promotion. Nevertheless, it is clear that insurance companies are not willing to extend normal policies to survivors of pediatric systemic malignancies. These manifest through cancellation of policies, new application refusals, extended periods of waiting, and reductions or cancellation of policy. In addition, later on in their adult life, it is possible that those who survived childhood systemic malignancy will be denied health insurance at a higher rate than their siblings (Strojan et al. 2006, p. 81). Management of Neuro-cognitive Issues Long-term care models for survivors of pediatric systemic malignancy should possess enough flexibility to meet the neuro-cognitive needs of older and young adults, adolescents, and young children (Reuter-Rice & Bolick 2012, p. 56). From the late effects discussed in this paper, it is paramount that these care models are sensitive enough in the entire life cycle, especially due to the current lack of a comprehensive and uniform long-term follow-up roadmap. It is important for these models of care to cover the need for health education, psychosocial functioning, risk of late effects development, and financial challenges related to employment and insurance. These care models must build on present cancer centers and community based care centers, probably coming up with combined care centers. Regardless of whether cancer centers and community based care centers work in tandem, health care providers dealing with various specialties will be required to deliver optimal care for survivors of childhood systemic malignancy (Brinkman 2013, p. 274). These should include nurse practitioners, family medicine physicians, adolescent medicine physicians and pediatric oncologists. References Bottomley, SJ & Kassner E 2003, ‘Late effects of childhood cancer therapy’, Journal of Pediatric Nursing, vol. 18, no. 2, pp. 126–133. Brinkman, TM 2013, ‘Suicide ideation and associated mortality in adult survivors of childhood cancer’, Cancer, vol. 120, no. 2, pp. 271–277. Buizer, AI, De Sonneville, LM & Veerman, AJ 2009, ‘Effects of chemotherapy on neuro-cognitive function in children with acute lymphoblastic leukemia: a critical review of the literature’, Pediatric Blood & Cancer, vol. 52, no. 4, pp. 447–454. 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