How is cancer treated?

The treatment your child will receive for their cancer will depend upon what type of cancer your child has. Treatment options will also take into account any risks or side-effects of treatment, length of treatment and where it will take place. Treatment options may also be complicated, so it may be helpful to write any questions for your child's treating team down as you think of them.

A team of health professionals will be involved in planning your child's treatment. These may include medical staff such as doctors, nurses and pharmacists, social workers and psychologists, dietitians and other allied health professionals. This is known as multidisciplinary care and ensures that your all of your child's needs are considered while they have cancer treatment.

In this section, you can find more information about:

some of the treatments that your child might have to treat their cancer
how these treatments work
what side effects they might have
your child's treatment team.

Combinations of treatments are often used to make sure the child has the best chance of being cured.

Also see Making decisions about treatment.

Careful observation

Most children's cancers need active treatment. But sometimes cancer can change and become benign. A benign tumour is a lump of tissue that is not cancer. This is rare, but it can happen.

Children with a benign cancer may not need any specific treatment, but your child’s doctor will closely monitor them. Your child’s doctor will decide if this is a good option.

Careful observation means that the doctors will monitor your child closely, but not recommend any treatment unless the cancer changes or grows. This is because all treatments have side effects. Sometimes, it is better to delay treatment. Some children who are under careful observation may remain well without treatment.

Careful observation involves regular check-ups and tests to check whether the cancer is changing. Tests include those described in How is cancer diagnosed.

Your child will have more tests if:

a test result indicates that the cancer has changed (e.g. the tumour has grown bigger)
your child develops symptoms that they didn’t have when they were diagnosed.

These further tests will help decide if your child should start active treatment, such as:

If it is safe, careful observation can be a good idea. Cancer treatment disrupts your and your child’s life. Careful observation can avoid some of this disruption.

Careful observation is not a good option for cancers that are aggressive or fast growing.

Chemotherapy

Chemotherapy uses medicines to destroy cancer cells. The medicines target fast-growing cells, which include cancer cells. Chemotherapy is used on its own or in combination with other types of treatment.

Although chemotherapy destroys cancer cells, some healthy cells are also damaged. Because of this, many chemotherapy medicines cause side effects (see Side effects of chemotherapy).

Chemotherapy is given in cycles. This allows time for the healthy cells to recover between treatments. Cycles may last 2 to 4 weeks each. Your child will need several cycles of chemotherapy.

Types of chemotherapy

There are many different types of chemotherapy medicines. Most children have combinations of different medicines. This is so the cancer cells don’t become resistant to 1 or 2 medicines – they all work together.

Chemotherapy can be given in different ways, depending on the medicine:

Oral chemotherapy can be taken as pills (tablets, capsules) or liquid. Your child can take this type of chemotherapy by mouth at home.
Intravenous chemotherapy is injected into a vein. This involves inserting a needle into a vein, attaching the chemotherapy medicine to the needle and letting it enter the body slowly. Some chemotherapy treatments take several minutes. Others work better when they are given slowly over a few hours.
Intramuscular chemotherapy is injected straight into a large muscle, such as the thigh or upper arm.
Intra-arterial chemotherapy is injected into an artery that supplies blood to the cancer.
Intraperitoneal chemotherapy is injected into the belly.
Intraventricular/intrathecal chemotherapy is delivered directly into the cerebrospinal fluid through a special device.
Subcutaneous chemotherapy is injected just under the skin, usually in the thigh or belly.

Side effects of chemotherapy

Chemotherapy targets cancer cells, which grow faster than normal cells. This means that some healthy cells are also affected. These include cells that normally grow quickly, such as cells in the hair, blood and in the lining of the mouth.

Your child may experience some side effects because of the effects of chemotherapy on healthy cells. Chemotherapy affects each person differently – your child may experience none, some or many of these side effects:

fatigue
pain or soreness, such as headaches, muscle pain or nerve pain
sores in the throat or mouth
diarrhoea or constipation
nausea and vomiting, and loss of appetite
weight gain or weight loss
hair loss
blood cell disorders, such as low full blood counts, which may result in anaemia, dizziness, shortness of breath and increased chance of infection
nervous system effects, such as tingling, burning or muscle weakness
problems with thinking or memory
organ damage, especially in the long term, such as damage to the heart, kidneys, liver, lungs or reproductive system
increased risk of other cancers in the long term.

Medicines and other treatments can help deal with many of these side effects. Your child’s doctor will discuss these with you. Side effects usually disappear when the treatment finishes.

Some of these side effects seem quite severe, and can be distressing for you and your child. However, the benefits of chemotherapy usually outweigh the risks. Your child’s doctor will discuss the risks and benefits with you.

Radiation Therapy

Radiation therapy (also known as radiotherapy) uses radiation to destroy cancer cells. Radiation damages normal cells as well, but cancer cells are especially sensitive to its effects. This makes radiation therapy a good treatment option for many cancer types.

Radiation therapy can be used:

before surgery, to shrink the tumour and make it easier to remove
after surgery, to destroy any remaining cancer cells
as the main treatment
in combination with surgery, chemotherapy or stem cell transplant
to relieve symptoms caused by the tumour.

Radiation therapy for children is given in a radiation oncology department in an adult hospital located near a children’s hospital. Doctors who specialise in radiation therapy for children will give the treatment to your child. These doctors are called paediatric radiation oncologists and follow international practice.

Radiation therapy typically involves a course of treatment given over many days or weeks. Each treatment is called a fraction. Normally your child will receive 1 fraction each day until the total dose is reached and the course of treatment is completed.

Infants and young children can have radiation therapy although chemotherapy if often used instead, allowing radiation therapy to be given once a child is older.

All radiation therapy aims to concentrate the radiation dose to the tumour very carefully and limit the amount of radiation to other areas of the body.

Types of radiation therapy

The type of radiation therapy your child will have depends on the type and location of the cancer.

External radiation therapy

External radiation therapy (called external beam radiation) uses a machine that delivers a beam of radiation to the tumour. The area that receives the radiation is very exact. This lessens the amount of radiation to surrounding healthy areas.

External radiation therapy does not make your child radioactive.

Your child might have external radiation therapy 5 times per week (with a 2-day weekend rest) and continuing for several weeks. Each fraction (treatment) will take a few minutes. The treatment itself is painless.

In the week or so before radiation treatment begins, you will need to bring your child to the radiation department to plan the treatment (simulation). The session involves placing your child on a treatment bed in a way that is comfortable and can be reproduced for each treatment. Your child will need to lie very still for about 15 minutes. Typically, there is a ‘bean bag’ on the treatment bed that is moulded to the child’s shape. A mask of the head and neck area is made when the tumour is in this area. The mask is worn only for treatment and stays in the radiation department. Both the bean bag and face mask are painless to make and involve no injections or needles.

The treatment team will make every effort to ensure that your child is comfortable during treatment planning and delivery. Play therapists are often part of the team in the radiation department. Very young children may need to have a general anaesthetic to ensure they lie still. Radiation treatment is not painful.

Internal radiation therapy

Radiation therapy can also be given internally and over a very short distance. This is called brachytherapy. It involves giving radiation through a needle, hollow tube (catheter) or another specialised device that has been made in advance. Any needles or catheters are placed in position in the operating theatre at the children’s hospital on the day of radiation treatment, or the day before. A paediatric surgeon works with the paediatric radiation oncologist. Sometimes the devices stay in place for a few days. Depending on the treatment and the dose of radiation, your child may need to stay in the children’s hospital and make a visit to the radiation department once or twice a day for treatment over several days.

Most brachytherapy is delivered in a special room in the radiation department. There is no radiation once the session is finished even though a device may remain inside your child’s body. This is called ‘high dose rate’ brachytherapy.

Occasionally ‘low dose rate’ brachytherapy is used. This means that radioactivity is slowly delivered inside the body over several days. If this is the case, your child’s doctor will discuss this with you in more detail.

Side effects of radiation therapy

The most common side effects of radiation therapy during the course of treatment are:

a skin reaction localised to the radiation site, typically dryness, itchiness or redness. Occasionally there is peeling and rarely blistering (similar to sunburn) when high doses of radiation are needed. Many children have no skin reaction.
Fatigue
Nausea or diarrhoea when the tumour is in the stomach, abdomen or pelvic area

These side effects usually settle within 1 or 2 weeks of the treatment finishing.

Radiation treatment can have longer term side effects. These are very dependent on the part of the body treated and the dose of radiation treatment. Your radiation oncologist will explain these in detail. Radiation treatment is only recommended when the benefit (chance for cure or symptom relief) outweigh the consequences of treatment.

Radiation therapy affects each person differently.

Medicines and other treatments can help deal with many side effects and make your child feel more comfortable. Your child’s doctor will discuss these with you.

Stem cell transplant

A stem cell transplant is also known as a bone marrow transplant. Your child's doctor may recommend this treatment if your child has a blood cancer, such as leukaemia, lymphoma, or high-risk neuroblastoma.

Stem cell transplants involve completely destroying all the blood-forming cells in your child's bone marrow. This includes cancer cells. High-dose chemotherapy or radiation therapy is used for this. Then, all the blood-forming cells are replaced with healthy stem cells. These stem cells will develop into new, healthy bone marrow and produce healthy blood cells.

Stem cell transplants have 4 main phases:

stem cell collection from your child or a donor, which can take 1–2 weeks
chemotherapy and/or radiation therapy, to destroy all the cells in your child's bone marrow, which can take about 1 week
stem cell infusion, which happens in 1 day
recovery, which can take 2–12 weeks, depending on the type of treatment.

A stem cell transplant takes about 4–14 weeks.

Types of stem cell transplant

A stem cell transplant can use either your child’s own stem cells or stem cells from a donor. The choice of whether to use your child’s own cells or stem cells from a donor depends on the type of cancer being treated.

In both types of transplant, the stem cells are given through a vein (intravenously). They will circulate in the body for about 1 day. They will then settle in the bone marrow space and become new bone marrow.

Your child's stem cells

Transplants that use your child's own stem cells are called autologous transplants.

This involves 3 main steps:

Some of your child's stem cells are collected from their blood or bone marrow and frozen for later.
Your child is then given high-dose chemotherapy to destroy their blood-forming cells and any remaining cancer cells.
The frozen stem cells are then returned to their blood to make healthy new stem cells.

Stem cells from a donor

Transplants that use stem cells from a donor are called allogeneic transplants.

This involves 3 main steps:

Another person donates their stem cells to your child. The donor is usually a sibling or other close family member whose tissue type is nearly identical to your child's. Sometimes, an unrelated volunteer donor will match your child's tissue type. In some cases, the stem cells can come from umbilical cord blood collected from unrelated healthy newborn babies.
Your child will have high-dose chemotherapy or radiation therapy to destroy their blood-forming cells.
The donor's stem cells will be given to your child and make healthy stem cells.

Advantages

A transplant from a donor has 2 main advantages:

The doctors are more sure that the new stem cells are all healthy.
A transplant from a donor also creates a ‘new' immune system. This is because the new white blood cells that the transplanted stem cells are making are different from your child's original white blood cells. The ‘new' immune system can continue fighting the cancer even after the radiation therapy and chemotherapy finish. This is called a ‘graft-versus-tumour effect' and works very well with some types of cancer.

Disadvantages

The disadvantage of a transplant from a donor is the risk that the new stem cells will react against your child's body. This is called ‘graft-versus-host disease' (GVHD) and can be very serious. Your child might be given anti-rejection medication for the first few months after the transplant to reduce the risk of GVHD.

The recovery period for a transplant from a donor is usually longer than for a transplant using your child's own stem cells.

Side effects of stem cell transplants

Side effects of stem cell transplants can include:

increased risk of infection – your child will be very prone to infections because the transplant treatment completely destroys their blood-forming cells, and therefore destroys their immune system. The risk of infection is mainly during the first month after the transplant. The infection risk decreases when the new marrow starts making normal numbers of infection-fighting white blood cells.
graft-versus-host disease (GVHD) – this can only happen for children who have received stem cells from a donor. Because the stem cells are from another person, the stem cells may recognise your child's body as ‘foreign' and attack your child's cells. In severe cases, this can be life-threatening. However, in a mild or moderate form, it actually helps to fight the cancer. If necessary, GVHD can be treated with anti-rejection medicines
other side effects as a result of the transplant treatment (see Side effects of chemotherapy and Side effects of radiation therapy).

Cancer treatments affect each person differently – your child may experience none, some or many of these problems.

Medicines and other treatments are available to help deal with many of these side effects. Your child's doctor will discuss these with you.

Some of these side effects seem severe and can be very distressing for you and your child. However, the benefits of stem cell transplants usually outweigh the risks. Your child's doctor will discuss the risks and benefits with you.

Surgery

Surgery is one of the main treatments for children's cancer. Your child might have surgery for a range of reasons, including:

Diagnosis and staging – to help diagnose a tumour, or see how big it is and whether it has spread
First-line treatment – to remove the entire tumour
Combination treatment – to remove as much of the tumour as possible before starting another treatment or to remove any remaining cancer after other treatments
Palliative treatment – to relieve the symptoms of a tumour, especially if it is causing pain.

Doctors will only perform surgery for cancers that involve a lump or tumour. Doctors don’t use surgery for blood cancers, such as leukaemia.

However, a child with any type of cancer, including blood cancer, might have surgery to insert a central line. A central line is also called a venous access device, central venous catheter or portacath. Doctors usually put central lines into a large blood vessel in the chest or upper arm. The device is a small plastic tube that either sticks out of the body or sits just under the skin. It allows medicines, including chemotherapy, to be given intravenously. It can also be used to take blood samples for testing.

Types of surgery

Surgery to remove a tumour usually involves making a large incision the skin. The doctor will remove as much of the tumour as possible. Your child will need to stay in hospital for this type of surgery.

Minimally invasive surgery (also called keyhole surgery) can be used to help make a diagnosis and for treatment. Recovery times are usually shorter than for surgery that requires large cuts, and there is often less pain.

Minimally invasive surgery can only be done in certain parts of the body. The procedure involves making small cuts in the body and inserting plastic or metal tubes called ports. A video camera and instruments can be inserted into the body via the ports so the doctor can see and operate on the tumour and the surrounding tissue. The doctor may use special cauterising devices that can cut out all or part of the cancer.

This type of surgery is called a:

Laparoscopy when it is done in the abdomen (belly), and a
Mediastinoscopy or thorascopy when it is done in the chest.

Another type of surgery, called an endoscopy, uses a tube inserted through a natural body opening such as the mouth, rather than making a cut.

Side effects of surgery

Surgery is almost always done under general anaesthetic so that your child sleeps through it. All childhood cancer centres have specialised teams who make sure your child is comfortable and in minimal pain.

Potential side effects of surgery depend on the type of surgery and how complex the procedure is. During the surgery, potential complications can include:

Bleeding
Infection
Damage to other organs or tissues
Reactions to medicines used during surgery, such as anaesthetics.

Targeted therapy

Targeted therapy includes a range of treatments that target the genes, proteins or tissues that make cancer cells different from normal cells, or that contribute to cancer cell growth. Targeted therapies work differently from standard chemotherapy.

Targeted therapy can include treatments that:

switch off the genes that tell cancer cells to grow
switch on the genes that tell cancer cells to die
deliver toxic substances directly to the cancer cells to destroy them
alter cells within the body, so they destroy cancer cells.

Targeted therapy is a form of personalised medicine. This means the doctors look at your child’s genes, proteins or cell processes, and try to find treatments that will work best. This requires genetic or molecular testing, which is usually done with a blood test or a biopsy. Your child and your child’s cancer need to match a targeted treatment for it to be an option for your child.

Targeted therapies are providing new ways to treat cancer. However, targeted therapies have some limits:

If your child does not have the target gene or protein, the therapy will not work.
If your child does have the target gene or protein, it does not guarantee that the treatment will work.
The cancer may become resistant to the treatment. This means that targeted therapy may work at first but then stop working.

Doctors usually use targeted therapy in combination with other treatments, such as radiation therapy, chemotherapy or surgery. In some cases, targeted therapy is an option after other treatments haven’t worked.

Types of targeted therapy

Targeted therapy includes:

monoclonal antibodies (a type of immunotherapy)
small molecule therapy
chimeric antigen receptor T-cell (CAR-T) therapy (another type of immunotherapy).

Monoclonal antibodies

Monoclonal antibody therapy is a type of immunotherapy. The antibodies attach to a target on the outside of the cancer cell or tissue around the cancer.

Your child will likely get monoclonal antibody therapy intravenously (in a vein).

The therapy may serve different purposes:

The antibody attaches to a cancer cell. It then acts as a ‘flag’ to your child’s own immune system to destroy that cell.
The antibody can block growth receptors on the surface of the cancer cell. Then, substances that make the cancer cell divide cannot reach the cancer cell.
The antibody may have radiation therapy attached to it. This is called radioimmunotherapy. It allows low doses of radiation to be delivered to the cancer cell without affecting healthy cells.
The antibody may have chemotherapy attached to it, which attaches to the cancer cell. Then the chemotherapy is sent to the cancer cells and not to healthy cells.

Small molecule therapies

Small molecule therapies are medicines that block processes that make cancer cells:

grow
survive
spread to other parts of the body.

Small molecule therapies can include targeting specific growth factors.

Your child will likely get their small molecule therapy as a pill to swallow.

Chimeric antigen receptor T-cell (CAR-T) therapy

CAR-T therapy is a term for a type of immunotherapy that changes your child’s own T-cells so they can attack the cancer cells.

Some of your child’s blood will taken and sent to a laboratory. In the laboratory, your child’s cells will be changed so that they have structures called chimeric antigen receptors on the surface. After growing enough of the new cells, they are injected back into your child. In the body, the cells will replicate and grow. The ‘new’ T cells may be able to find and attack the cancer cells.

The T cells are taken and re-injected intravenously (in a vein).

Currently, CAR-T therapy is only used for some forms of acute lymphoblastic leukaemia (ALL).

Side effects of targeted therapy

Although targeted therapy aims to specifically target cancer cells and not healthy cells, it can still have side effects. Children receiving targeted therapy can have problems with:

their skin, hair, nail or eyes
their liver¹
high blood pressure
bleeding, blood clotting or wound healing
their immune system².

Targeted therapies affect each person differently. Your child may experience none, some or many of these problems.

Medicines and other treatments are available to help deal with many of these side effects. Your child’s doctor will discuss these with you.

Some of these side effects seem severe and can be distressing for you and your child. However, the benefits of targeted therapy usually outweigh the risks. Your child’s doctor will discuss the risks and benefits with you.

References

^{1 & 2} https://www.cancer.gov/about-cancer/treatment/types/targeted-therapies/targeted-therapies-fact-sheet

The treatment team

Cancer care for children in Australia is among the best in the world. Your child’s cancer treatment team, a team of doctors and health professionals, is called a multidisciplinary team (MDT). Members of this team are specialists in children’s cancers. These may include medical staff such as doctors, nurses and pharmacists, social workers and psychologists, dietitians and other allied health professionals. They understand the differences between children’s cancer and adult cancer. Each team member brings different skills in managing care to meet the needs of your child and you.

A childhood cancer specialist, called a paediatric oncologist, will lead the team. Other MDT members will depend on the age of your child and their type of disease. The MDT may change over time as your child's needs change.

In addition to paediatric oncologists, the MDT may include:

paediatric surgeons who specialise in operating on children
neurologists who are specialists in diseases affecting the nervous system
radiation oncologists who are specialists in using radiation to treat cancer
radiologists who are specialists in medical imaging
endocrinologists who are specialists in hormones and body development
pathologists who are specialists in laboratory diagnosis
ophthalmologists who are specialists in the eyes and vision
haematologists who are specialists in blood disorders
anaesthetists who are specialists in providing anaesthesia and pain management to patients during operations and procedures
nurses who specialise in caring for children with cancer
paediatricians who specialise in caring for children

Other members of the MDT may include:

dermatologists
plastic surgeons
dieticians
psychologists or psychiatrists
social workers
fertility counsellors
occupational therapists
physiotherapists
educational coordinators
genetic counsellors
dentists
pharmacists
your child’s regular doctor (general practitioner, or GP).

About children’s cancer