In conjunction with Childhood Cancer Awareness Month, Motherhood Story brings to light this topic so that parents can be more aware. For this, we thank Dr. Eni Juraida, a Consultant Paediatrician and Paediatric Haematologist & Oncologist at Sunway Medical Centre, who generously shared about childhood cancer with us. We appreciate the in-depth information and advise which are incredibly helpful for us mummies to gain some initial insights. Image credit: Dr Eni Juraida Binti Abdul Rahman, Consultant Paediatrician and Paediatric Haematologist & Oncologist, Sunway Medical Centre Q1: Is cancer in children common in Malaysia? Childhood cancers are rare. In the United States, about 11,000 new cases in children aged 0 to 14 years are diagnosed every year. In Malaysia, about 700 to 800 new cases are diagnosed yearly with an incidence rate of 77.4 per million children under 15 years. Yet, childhood cancer continues to rank as the second leading cause of death in children after accidents. According to the Malaysian National Cancer Registry 2012 -2016, the most common cancers among children aged 0 to 14 years are acute leukaemia (39.6%), followed by central nervous system\u00a0tumours (15%) and lymphoma (10%). Whereas for those aged 15 to 24, 22.6% had lymphoma, 15.8% acute leukaemia and 8% bone cancers. Q2: We would like to understand why children get cancer. Can you share with us some of the risk factors and causes of childhood cancer? Unlike adult cancers, the vast majority of childhood cancers have no known cause. Many studies have attempted to identify the causes of childhood cancers, but very few childhood cancers are caused by environmental or lifestyle factors.\u00a0 In general, most childhood cancers are not hereditary, but some cancers such as retinoblastoma are caused by genetics.\u00a0 With regard to risk factors, children with inherited chromosomal abnormalities such as Down syndrome, rare genetic disorders, congenital or acquired immune deficiencies, and infections such as hepatitis B or C have a higher risk of developing cancers.\u00a0 Exposure to radiation whether therapeutic (radiotherapy was previously part of the treatment in acute lymphoblastic leukaemia) or accidental (e.g. the Hiroshima and Nagasaki bombing) is a known risk factor. Image credit: Canva There are\u00a0some studies that suggest that parental exposures (such as smoking) might increase a child\u2019s risk of certain cancers, but more studies are needed to explore these possible links. I always advise parents to stop smoking both for their own sake as well as the child and the rest of the family. For any one child we will not be able to find a cause. Instead of being fixated on the causes of childhood cancer, we should focus more on the treatment. \u00a0 Q3: What are the common types of cancer that develop in children? The most common childhood cancer is acute leukaemia. It accounts for 1\/3 of all childhood cancers. This is followed by central nervous system or brain tumours. Others include lymphoma, rhabdomyosarcomas (which arise from the skeletal muscles), Wilms tumour (which is the most common kidney tumour in children), neuroblastoma (which is usually found in the adrenal gland) and retinoblastoma (which arises from the retinal layer of the eye). Q4: What\u2019s the average age of children diagnosed with cancer? Cancer in children can occur at any age. There is a peak incidence during infancy when neuroblastoma is the most common, and another between the ages of 2 and 4 when leukaemia is the most common. The incidence drops through the school-age years and begins to increase during adolescence. In general, the average age of diagnosis of childhood cancer is 5 years. Q5: How do we detect some early signs of childhood cancer? The signs and symptoms of childhood cancer are nonspecific, and initial recognition can be difficult. It is for this reason that children tend to come in at a late stage. Signs and symptoms of childhood cancer can mimic a variety of childhood disorders. However, if the symptoms persist over time and require multiple clinic visits, it should raise an index of suspicion and needs further looking into. Image credit: Canva Some symptoms that are considered as \u201cred flags\u201d include recurrent fever, pallor, bruising which is related to acute leukaemia, morning headaches particularly if associated with vomiting which indicates brain tumours, and bone pain that wake the child from sleep in cases of bone tumours. Others include any unexplained loss of appetite and weight, deterioration in school performance, pubertal signs that appear too early or alternatively are delayed.\u00a0 \u00a0 An example of a childhood cancer that has visible signs is retinoblastoma. It is a tumour that develops in the eyes. In general, our pupil which is the black part of our eyes appear red in photos taken with a flash. This is the red reflex. However, in patients with retinoblastoma, this reflex appears white because of the tumour growing forward from the retina. Should this occur in your child, it is advisable to consult an ophthalmologist as soon as possible to assess the retina and find out the cause.\u00a0 Q6: What can we do to prevent or reduce the risk of a child getting cancer? This is a difficult question to answer. Because the causes of childhood cancers are generally unknown, it is difficult to institute preventive measures. Similarly, health screening that is practised in adults is not useful in children. The best is an awareness of what are the signs and symptoms of cancer in children. However, this is also not easy. Early symptoms may be difficult to recognise as some of these symptoms may mimic common childhood problems such as infection or injuries. Image credit: Canva However, if a particular symptom such as fever or swelling persist beyond what is usual for an infection or trauma, a consultation with your doctor may be called for. Some symptoms that warrant a clinic visit include persistent or recurrent fever, spontaneous bruising or bleeding from mucus membranes such as gum or nose, looking pale, loss of appetite and weight, and complaints of feeling tired. Early and accurate diagnosis, followed by effective treatment will result in improved outcomes. Q7: What are the long-term or late effects of childhood cancer treatment? Late effects can occur months or years after treatment has ended. The risk of late effects depends on the factors related to the tumour, treatment and patient. Late effects in childhood cancer survivors may affect the following:\u00a0 Image credit: Canva \tGrowth and development: \tPhysical development \tSocial and mental development \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \tIntellectual function\u00a0 \tPsychosocial skills: \tMental health skills such as the ability to make friends and develop relationships \tEducation \tEmployment \tPhysical\/body image \tFertility: \tInfertility \tHealth of offspring \tOrgans dysfunction\u00a0 \tHeart \tLiver \tKidneys \tMusculoskeletal system \tEndocrine\/hormonal system \tCancers: \tRecurrence of cancer \tSecond malignancies Regular follow-ups for life with healthcare professionals is important.\u00a0 During these visits, we emphasise the importance of maintaining a healthy lifestyle including diet and regular exercise and avoidance of factors that will increase the risk of organ damage or development of second cancers such as smoking and consumption of alcohol. Q8: How can parents best explain and talk about cancer with a child, without scaring them? When a child is diagnosed with cancer, parents will go through a host of emotions. Shock, disbelief, denial, anger, guilt fear and anxiety. \u201cWhy did my child get this cancer? How did it happen? There is no history of cancer in my family so can it be something else? Can he\/she take this treatment? Is he\/she going to die?\u201d These are some of the questions frequently asked by parents.\u00a0 Image credit: Canva We will go through these in counselling which may involve a few sessions. Parents are sometimes introduced to other parents whose child has a similar illness, so they can share their experiences. This is very helpful because during this period, there will be a lot of well-meaning friends and relatives giving advice, most of which are obtained second or third hand or more. They are given time to accept the diagnosis and treatment. No treatment will commence without parental consent.\u00a0 I always advise parents to be as truthful to the child as possible. They may experience the same emotions that the parents face. Children who are 5 years old and more need to be told that they have an illness that needs to be treated, that requires frequent hospital visits, and that they need to undergo certain procedures.\u00a0 Part of the treatment will cause them to lose their hair, but parents may emphasise that this is temporary. It may cause them to have a fever, have oral ulcers, and they need to stay off school for a while. These days where practically everything is available on the Internet, kids can easily get information from there. They read the thing that they don\u2019t understand and it scares them. Nothing takes the place of a face-to-face discussion. I advise parents to be as honest as possible, including discussing questions about death with the child.\u00a0 It is important to engage the kids especially the older ones while they are approaching the teenage years. Sometimes treatment stops midway because they refuse to continue. In such cases, we will bring in a child psychologist or psychiatrist. We must not forget the siblings if there are any. Having a child with a chronic illness will disrupt the family routine. Sometimes, siblings are left to care for themselves if they are old enough. They find themselves having to grow up before they are ready. They will also go through emotions such as fear, anger, guilt and jealousy because a lot of attention and preference is given to the affected child. This is something parents have to tackle to the best of their ability. Having extended family support is very helpful. \u00a0 Image credit: Canva Q9: If one parent had cancer, will the child be at an increased risk of cancer? Research shows that children of people with cancer and cancer survivors do not have a higher risk of the disease. However, some cancers can be passed from parents to children through genes. If you have one of these hereditary cancers, the risk may be higher.\u00a0 Q10: Lastly, what is the survival rate of childhood cancer? The treatment of childhood cancer is a multidisciplinary approach that involves paediatric oncologists, paediatric surgeons, radiotherapists and supporting staff such as nurses and physiotherapists. Depending on the type of cancer, the treatment could be only surgery, chemotherapy, radiotherapy or a combination of two or three.\u00a0 Childhood cancer is potentially curable, depending on the type of cancer. Currently, for acute lymphoblastic leukaemia with standard risk features cure rates of more than 90% being achieved in most European and North American centres.\u00a0 Improved survival has also been seen in other types of cancers.\u00a0 This is due to the enrolment of patients in study groups designed to improve cure and reduce side effects, better supportive care including early and timely management of infections, availability of intensive care services, broad-spectrum antibiotics and antifungals, and safe blood and blood products. However, the treatment of childhood cancer is very demanding on the child, family and healthcare providers. Close cooperation is vital to ensure the child receives the optimum treatment.