Chemotherapy for children's cancers
Chemotherapy is the use of anti-cancer (cytotoxic) drugs to destroy cancer cells.
Children usually have a combination of chemotherapy drugs. The number of drugs they have will depend on the type of cancer or leukaemia they have. The doctors will explain to you which drugs are being used and when they’ll be given. The drugs are carried in the blood and can reach cancer cells all over the body.
Chemotherapy drugs affect dividing cells. This includes some normal cells, such as those in the lining of the mouth, the bone marrow, the hair follicles and the digestive system. Healthy cells can repair the damage caused by chemotherapy but cancer cells can’t, so they eventually die.
Chemotherapy can be given in different ways - either as tablets, capsules or liquids that are swallowed, or by injection. There are many technical terms used to describe how the drugs are given. You will see these on your child’s drug chart and on treatment plans (protocols). Common terms are:
intravenous or IV - injection into a vein
oral, PO, O or by mouth - tablets, capsules or a liquid that is swallowed
intramuscular or IM - injection into muscle
subcutaneous or SC - injection under the skin
intrathecal or IT - by lumbar puncture.
Whichever way chemotherapy drugs are given, they are absorbed into the bloodstream and carried around the body so they can reach and destroy cancer cells. This makes chemotherapy especially useful in treating cancers that are likely to spread, or have spread, to other parts of the body.
Chemotherapy has to be planned carefully. It’s usually given as a series of sessions of treatment. Each session destroys some of the cancer cells and will cause some damage to healthy cells. After each treatment, there’s usually a rest period to allow the healthy cells to recover before the next dose. A session of chemotherapy and the rest period is known as a cycle of treatment. A series of cycles make up a course of treatment.
There are many different ways of giving chemotherapy. Sometimes, high doses of the drugs are given intensively over a short period of time, or they may be given as lower doses over a longer period.
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Intravenous chemotherapy is the most common way of giving chemotherapy. It may be given into a vein either through a central line, implantable port or PICC line. These are all tubes that are inserted into a vein and can stay in place for some months or, in some cases, years. They can be used for taking blood as well as giving treatment and other medicines. These devices avoid repeated cannula insertions in children when treatment it needed.
Usually the doctors will suggest which type of line your child should have, although you may be offered a choice. The chemotherapy drugs are usually diluted into a bag of liquid such as salt water (saline) and given as a drip (infusion) through the line.
Sometimes, treatment is given through a thin tube, which is inserted into a vein and then taped firmly to your child’s arm. This is called a cannula. A cannula only stays in place for a few days.
Central lines, implantable ports and PICC lines
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A central line (central venous catheter) is a thin, flexible, plastic tube, that’s inserted into a vein near the collarbone. A central line is often called a Hickman line, after the person who developed it. It's put in under a general anaesthetic. The surgeon makes a small cut into a vein near the collarbone and feeds the tube down until the tip is in one of the large veins near the heart.
The other end of the tube is then tunnelled under the skin and comes out on the front of the chest. A removable bung is attached to the end of the line, which allows samples of blood to be taken or medicines to be injected. It can also be used to give blood or platelet transfusions.
A central line needs to be kept dry while showering or bathing - a plastic dressing can be used for this.
Some tubes don’t come out through the skin. Instead, they end in a reservoir or port that is under the skin below the collarbone, so they aren’t clearly visible. These are known as implantable ports or portacaths.
Implantable ports are put in under a general anaesthetic. A small needle is pushed through the skin into the port to give chemotherapy or take blood. The skin over the port can be numbed beforehand with an anaesthetic cream (such as Ametop® or Emla® cream) or spray (such as Cryogesic®). The needle can stay in place for up to seven days and is secured in place by a dressing.
Occasionally, your doctor may suggest that your child has a long, thin tube put into a vein in the crook of their arm. This is called a peripherally inserted central venous catheter (PICC). It’s put in under local or general anaesthetic. Once in place, the PICC line is taped firmly to your child’s arm to prevent it being pulled out of the vein. It can stay in the vein for many months. A PICC line needs to be kept dry while showering or bathing – a plastic dressing can be used for this.
Looking after a line or implantable port
Before your child goes home, the nurses will show you how to care for the central line, PICC line or implantable port. Make sure you feel confident with this and don’t be afraid to ask any questions. If you have any problems with the line when you’re at home, contact the hospital staff.
Advantages and possible problems with lines and implantable ports
Central lines, implantable ports and PICC lines can stay in place for many months and are a very good way of avoiding the discomfort of repeated injections. However, there are three potential problems that can happen with them: blockage, infection and falling out.
Occasionally, lines or ports may become blocked. This can happen if the tip of the line lies at an odd angle against the wall of the vein. Sometimes the line gets clogged up, even if it has been flushed with liquid regularly. If this happens, drugs can be put into the tube to dissolve the blockage so the line can be used again. Your child may also have a linogram (a special x-ray) to show the position of the tube.
Despite being carefully looked after, some lines or ports become infected. If infection occurs, antibiotics are given. But if these don’t clear the infection, the line may need to be removed and, if necessary, replaced.
Rarely, a central line or PICC line may fall out or move because a child pulls on the tube by accident when they are playing or sleeping. Fortunately, if a tube does fall out, the blood clots quickly and seals up the wall of the vein. Some blood may ooze down the tunnel under the skin where the line was. However, the blood usually clots and seals off the tunnel very quickly. The hospital staff will tell you what to do if this happens.
Rarely some central lines can split or puncture during flushing. If this does happen then a clamp is usually put on straight away to avoid blood leaking and infection. Sometimes split lines can be fixed with a simple puncture repair kit. Other times the central line may need to be replaced.
Side effects of chemotherapy
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Chemotherapy drugs can cause unpleasant side effects. However, these are mostly temporary and there are often ways of controlling or reducing them.
The main areas of the body that are affected are those where normal cells rapidly divide and grow. These include cells in the mouth, the lining of the digestive system, the skin, hair follicles and the bone marrow.
Some common short-term side effects and ways of dealing with them are described here. Different children will be affected by chemotherapy in different ways. Your child will not have all of the side effects described here, but may have some of them. Your child’s doctor or nurse will tell you more about the side effects that are likely to occur during your child's chemotherapy.
Effects on the bone marrow
Low resistance to infection (neutropenia)
Many chemotherapy drugs reduce the production of white blood cells by the bone marrow. This lowers your child’s immunity and makes them more prone to infection. This effect usually begins about seven days after treatment is given. If the chemotherapy is being given every 3-4 weeks, the number of white blood cells usually reaches its lowest point (nadir) about 7-14 days after treatment. The number of blood cells will then increase steadily and usually return to a safe level before the next course of chemotherapy is due.
When the white blood cell count is low, your child may develop an infection. They will be able to overcome most minor infections themselves, but it’s important to contact the hospital straight away if:
your child’s temperature goes above a certain level (staff at the hospital will tell you what this is)
your child suddenly feels unwell, even with a normal temperature
your child becomes shivery.
They will probably need to be admitted to hospital for intravenous antibiotics until the doctors know what type of infection they have.
Your child will have a blood test before having their chemotherapy to make sure their cells have recovered. If the white blood cell count is still too low, treatment may be delayed until it's at a safe level again.
Some infections that would normally cause little trouble may be more difficult for your child’s immune system to cope with. Measles and chickenpox can be particularly serious. If your child is exposed to either of these, or develops these infections, tell the staff at the hospital straight away so that appropriate treatment can be given.
Tiredness or breathlessness
Some chemotherapy drugs lower the number of red blood cells produced by the bone marrow, so your child may become anaemic. This can make them feel very tired and breathless, and look pale. If the number of blood cells is very low, a blood transfusion can be given.
Bruising or bleeding
Some chemotherapy drugs can reduce the production of platelets. These are the cells that help blood to clot. Let the hospital know if your child has any unexplained bruising or bleeding such as nosebleeds, bleeding gums, blood spots or rashes on the skin (petechiae). If the number of platelets is very low, a platelet transfusion can be given.
Effects on the digestive system
Chemotherapy drugs may make your child feel sick (nausea) or in some cases, actually be sick (vomit). However, this can usually be controlled with anti-sickness (anti-emetic) medicines. Tell the doctors if your child's sickness persists - changing the anti-sickness medicine usually helps.
Loss of appetite
Sometimes your child may not feel like eating and they may temporarily lose weight. Try giving them their favourite foods and don’t worry if they keep eating the same thing. Having smaller meals, but eating more often, can also help.
If necessary, they can be fed through a tube passed down their nose into their stomach (nasogastric tube), or through a tube passed through their abdominal wall into the stomach (PEG tube). Sometimes, they may be fed through a central line. Your hospital will tell you more about ways of giving nutrition.
Diarrhoea or constipation
Some drugs can change the way the bowel works, so your child may have diarrhoea or constipation. Let the hospital staff know if constipation becomes a problem, as laxatives can be given to relieve it.
Diarrhoea usually gets better without medication. It’s important for your child to drink plenty of fluids if they have diarrhoea. Occasionally, anti-diarrhoea medicines may be needed. If your child has persistent diarrhoea, please let the hospital know as it is possible that they may become dehydrated.
Some drugs can cause a sore mouth, which may lead to mouth ulcers. Mouth care is very important – the nurses will show you the best way to care for your child’s mouth. The doctor may prescribe mouthwashes or other medicines to help. Any effects on the mouth usually start about 5–10 days after the drugs are given and will clear up within 3–4 weeks after treatment ends.
Chemotherapy can cause taste changes , which may make food taste more salty, bitter or metallic. Your child’s taste will return to normal when chemotherapy treatment finishes.
Effects on skin and hair
Some drugs cause hair loss. In some children, all the hair may fall out, but in others it may just get thinner. Also, hair loss is not restricted to the head but can also affect eyebrows, eyelashes and other body hair. There are lots of ways to deal with hair loss – often children like to wear baseball caps, bandanas, hats or scarves rather than having a wig. However, it is possible for the hospital staff to arrange a wig for your child or refer your child to a hair loss support service.
Usually, hair grows back within a few months of stopping treatment. However, it can sometimes be a different colour or texture. For example, it might come back curly when it used to be straight.
Hair can be an important part of a child’s identity. You may worry about how your child’s different appearance will affect their and your relationships with family and friends. Children and young people may feel less confident and withdraw from social relationships or activities.
It is important that your child knows why their hair will fall out by preparing them for hair loss. The hospital team will be able to advise and help you with this. It may also be beneficial for your child to talk to other children undergoing treatment who have lost their hair.
Some chemotherapy drugs can cause skin rashes or a change in skin colour. The skin may also become more sensitive to chemicals such as chlorine in swimming pools. The hospital staff will tell you whether it’s okay for your child to go swimming during their treatment.
Your child’s skin may become more sensitive to the sun. It’s important to protect your child’s skin by getting them to wear a hat, loose clothing and sunglasses. Use suncream with a high sun protection factor (SPF) on any exposed areas (the doctor may be able to prescribe this).
Kidney, liver or heart damage
Some drugs cause changes in the way the kidneys, liver or heart works. These effects may be long-term. If necessary, your child will have regular tests to check their kidneys, liver and heart are working properly. But many children will not need these tests.
Some drugs can cause feelings of anxiety, restlessness, dizziness, sleeplessness or headaches. Some children may also find it hard to concentrate. Others may have mood swings or feel grumpy and irritable. If your child has any of these side effects, let your doctor know.
The information about children’s cancer was written by the Children’s Cancer and Leukaemia Group (CCLG). It has been reviewed and edited by their publications committee, which includes medical experts from all fields of children’s cancer and care.