The Long Road to Diagnosis for Pediatric Cancer Patients

As a pediatric hematology/oncology/BMT RN, I have heard hundreds of stories from patients, parents and caregivers about their journeys to diagnosis. Common threads among all the stories are the numerous misdiagnoses made along the way. Pediatric cancer is rare. In 2021, the estimated incidence is 15,590 children diagnosed with cancer in the United States¹. For comparison's sake, it is estimated that there were 1,898,160 adults diagnosed with cancer in 2021². It is very possible that a nurse or pediatrician in a pediatric primary care office might never come across a patient with a cancer diagnosis. As a result, it can be difficult to keep the possibility of cancer in the differential when looking for a diagnosis. 

When a new patient arrives on the floor, it is common to hear about multiple trips to the pediatrician, urgent care, or the local emergency department. As an RN, one cannot help but wonder if there might have been a missed opportunity to diagnose the child earlier and possibly, start treatment prior to the disease becoming metastatic. Nurses can use their own clinical thinking to help direct the medical team to identify the possibility of a zebra and not a horse. In other words,  the possibility of a cancer diagnosis and not a virus.

Why are child protective services brought into an emergency department or called from a pediatrician’s office prior to having a simple blood test checking for abnormal blood counts or Chemistry values? Is there room for nurses to take part in identifying all diagnoses to be considered? As nurses, having a basic understanding of some of the early signs of the most common childhood cancers could save lives and possibly start treatment earlier in the disease process. 

Here are some of the common signs of childhood cancer

Unusual bruising

A toddler and preschooler might have shins and knees covered with bruises from their unsteady adventures in the world. However, bruising on the cheeks, stomach and upper arms are not common sites for bruises. Although nonaccidental trauma might be the cause of the bruising, alternative reasons should not be completely disregarded.

Petechiae

Small red dots that suddenly appear anywhere on the body can be a sign of a low platelet count. When pushed on, these small spots do not blanch. Sometimes considered a rash, petechiae can show up without any trauma. When a child is upset and forcefully crying or yelling, the petechiae can develop on the face, neck and upper chest. 

Pallor

Sometimes those closest to the patients are unable to recognize changes in skin color as a result of anemia, explaining how parents miss realizing just how pale their child has become over the span of a couple of weeks. However, as a new set of eyes on a child, nurses might be the first to notice just how pale a child’s skin appears. Telltale signs of anemia are very pale gums and lips. Low red blood cell count can leave the lips and gums pale, despite skin tone. 

Vomiting

A child that begins to vomit every morning when they wake up might be demonstrating signs of increased intracranial pressure. While there are many reasons for an increase in intracranial pressure, none of the reasons are normal and a deeper dive into the cause of vomiting is warranted. Vomiting that follows a pattern or specific time of day could help direct the care team to look more closely at increased intracranial pressure and look less towards a simple case of gastroenteritis. 

Constipation

Many kids struggle with constipation in childhood. However, a new symptom of constipation could be an indicator of something, like a mass, blocking part of the bowel. A quick x-ray can help to alleviate concerns about possible bowel obstruction. 

Fortunately, childhood cancer continues to be very rare. However, since nearly 16,000 children are diagnosed with cancer every year, it seems important that the primary care providers leave cancer within the realm of possibility when trying to determine the cause of a child’s illness. 

References

¹Cancer in Children and Adolescents

²Cancer Incidence Projections in the United States Between 2015 and 2050