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Amy Armstrong, M.D. (Guest): Hi, I'm Dr. Amy Armstrong and I'm a Pediatric Oncologist at the Washington University Physician Group. And I work at Siteman Kids at the St. Louis Children's Hospital, and I'm a Mom Doc.

Melanie Cole (Host): Hey, welcome to Mom Docs, the podcast from St. Louis Children's Hospital. I'm Melanie Cole. And today we're talking about something no parent wants to hear, but we are talking about children's cancer, and we're going to give you some great and very encouraging information. Dr. Armstrong, it's a pleasure to have you join us today. So, tell us how common cancer in children is. We're always terrified of this as parents. How common is it?

Amy Armstrong, M.D. (Guest): Yeah, of course. And I feel like this is, you know, number one fear of a lot of families across St. Louis, Missouri, and the nation. I would say cancer is common, but not as common as a lot of other childhood ailments; 16,000 kids ages zero to 19 are going to be diagnosed with cancer in the United States each year.

And cancer still unfortunately remains the number one cause of deaths caused by a disease for kids in America. I think the good new is that our overall survival rates continue to increase with new treatment modalities and research efforts. And so now about 80% of kids and adolescents who will be diagnosed with cancer will ultimately survive.

Host: Wow, that is so encouraging. What kinds of cancers are you seeing them most?

Dr. Armstrong: By and far the most common kind of cancer that we'll see are leukemias. And amongst that group would be acute lymphoblastic leukemia. Most common in younger children, but we'll definitely see some in adolescents and then it can go into adulthood as well that some of our adult colleagues will see. After the leukemias and those are a type of blood cancer, other types would be brain tumors or tumors in the spinal cord and then lymphomas. And then I'm a solid tumor physician, which can get a little bit confusing at times. And so that the common types of cancer that I treat, we see them a little bit less often. But definitely there are a huge variety of other diagnoses within kids.

Host: So one of the things, and as a parent, when my kids were little, you know, every bump that shows up, every bruise that shows up, parents are like, oh my God. You know, wondering if that's leukemia, wondering if it's something, right? So do we know why kids get cancer? Is it mostly hereditary? Is it something that is just really random and horrible? And if a child does have cancer, what about the other kids in the family? Are they then at risk? Do we test them? Tell us a little bit about why this happens.

Dr. Armstrong: Yeah, of course. And I feel like you know a lot of our new families, that's the number one question that they always have. You know, why did this happen? Was there something I could have done about it? If we noticed it earlier, would that have changed anything? What I can tell you is that in kids, unlike adults, the majority of the cancers that we see, there's no rhyme or reason for it.

So, there are some type of cancers that are due to genetic mutations, but those are about 10% or so of the diagnoses. So again, the large majority, about 90% are just going to kind of be sporadic. It's not fair. There's nothing that the parents did or missed. These things are going to happen sometimes. And so I think, with every bump and bruise, sure we can all be worried and we can all be scrutinizing our kids day in and day out. But I'd say kids who have cancer, they're going to be pretty sick and I can go through some of the warning signs as well. But I'd say as a parent, you know, we always have that sixth sense.

So, if there's something that just doesn't seem right, I think the first step is always to go to the local pediatrician. I have true accolades for pediatric groups especially within the St. Louis region, because they're really the front gate that's going to tease out what's sick and what's not sick and they'll help kind of guide the workup, and be able to support the families initially. After that, if there are additional concerns or blood work was drawn that showed some abnormalities, that's when these kids will be coming into our emergency rooms or our hospitals or clinic, in order to expedite their workup and diagnosis. But I'd say if your kid, you know, is normally playing has a lot of bruises on the shin, has a nose bleed every now and again, most likely they are just fine. So while we're talking about numbers here, I'd tell you the vast majority of kids are going to go through their life without ever having to worry about a cancer diagnosis.

Host: I love that you keep adding in these encouraging words, because I think that, like you said, every bruise, every bump can really terrify parents. I'd like you to go over some of the warning signs for us, Dr. Armstrong, just so that parents understand the difference between those bruises and bumps and something that really should be seen.

Dr. Armstrong: So, when we go back to again, the most common type of childhood cancer at the leukemias, the kind of warning signs or symptoms that you could see are going to be due to some blood count abnormalities. So, just to be clear, the abnormal cancer cells are white blood cells that are going to be developing in the bone marrow.

I like to say it's kind of like these cells are taking over the car factory and they're making all the cars that they want, but none of the other good cars that are needed on the roads. So, other things like platelets or hemoglobin are going to be a bit lower. And with that, you start to see some of the other signs and symptoms. So, when our platelets are too low, we'll definitely see some easier bruising or bleeding. And when we talk about easy bruising, it's usually in a place in a kid where you wouldn't expect it. So again, we have kids they've all the time, my, my little girl is littered with bruises on her legs. I'm not worried about it, but if I would start to see some bruises on her chest or her face or something that really isn't explained by contact; that's kind of when your little red flag should go up.

When I talk about some easy bleeding, I would say potentially recurrent nosebleeds, sometimes bleeding from the gums, can be an early warning sign. So if you're brushing teeth and all of a sudden you're seeing some blood at that time or when you are flossing, and then other really, you know, less common sites of easy bleeding would be in the urine or in the stool. And then that being said, with cancer that develops in the bone marrow, that's inside of our bones. And so with that, it's going to actually be in a lot of pain. And the main site of the bone marrow is going to be in your lower back and then in your larger bones of the legs and even the arms and things, but kids won't be willing to walk anymore.

So if you have your little three-year-old, who's been running around and all of a sudden wants to be picked up everywhere, isn't willing to kind of put any pressure on their legs. You know, again, that should be kind of another warning sign. Kids can be a little bit sleepier for sure. As that hemoglobin drops, they might look a little paler. They might have a decreased appetite, not want to eat as much. And then fevers are a common presenting sign as well. The fevers can be just explained by the cancer itself. But really, other infections can start to develop that might lead to fevers too. So again, these kids usually come in looking a little sick and having a somewhat concerning history.

So, it's not like all of a sudden, again, that you have one bruise or a bloody nose that, that pops up and you all of a sudden have leukemia. It's usually a couple of week history of things that just seem off. And then when we put the story together, it adds up to the diagnosis that we hit.

Host: That was a very comprehensive answer for parents and parents, I hope you will share this show with your friends and family, because she just gave a really good explanation for all of you parents like me that are terrified all the time things like this. Now, as you're so encouraging Dr. Armstrong, what's exciting in treatments. us a little bit about what's going on in the treatment world for children with cancer.

Dr. Armstrong: Yeah, you know, just to clarify for parents and myself, cause I think about all the time, you know, we live in this world in the hospital where we see really devastating diagnoses and treatment courses and we're there for the families. And it's a huge network here that we provide. But when I go out to my community and I think about my own kids and I'm driving around, you have to think about how many kids that are out there that are going to be just fine. So again, I want to highlight that while the numbers are there, that the large majority of kids are going to make it through without worrying about cancer.

I think nowadays, if you do get that diagnosis, you'd have to learn that the type of chemotherapies that we use, are going to be optimizing cure. So, when I say cure, I mean, getting rid of the cancer completely, and then we're also doing our best to try to minimize what we call toxicities. So toxicities from treatment that can occur kind of during the course of cancer or residual toxicities after the cancer has been treated or cured. So, those are really the two main things that we work hard for as pediatric oncologists to do everything we can to cure your child, but at the same time to get them to a very high quality of life and a good quality of life moving forward too.

So, a lot of that comes from research trials through St. Louis itself, we have some investigator initiated studies that have really done wonders, and we've had a lot of international and national recruits coming to our center to receive certain therapies. We're also part of a big Children's Oncology Group Network. We're also a phase one institution, which means we'll get access to clinical trials and drugs that might not be routinely available to the everyday patient right now. And I'd also say our collaboration with Siteman Cancer Center, so more on the adult side, has really done wonders too.

It's not only given us access to other clinical trials and treatment options, but additional expertise along amongst the medical oncologists, surgical teams, radiation, oncologists, and really, again, it's its a village that is taken to work with a child who has cancer, child or adolescent. And so having, you know, quality team players is really what you'd be looking for as a parent when you're looking for treatment.

Host: And thank you for telling us a little bit about the multidisciplinary care, because that's so important. And one of the things I think parents are most concerned is resilience and how will their kids get through this? When you see kids going through these treatments, and we don't have enough time in these podcasts to talk fertility preservation.

I mean, have you talked about toxicities. There's a lot, but as far as social life and when you hit the adolescence, right. And they're going through these treatments, everything from school to social life, to sports, everything is affected. What you see Dr. Armstrong, tell the parents, what you see as far as kids and their ability to go through these things, the resilience and how you all work together with the families to help them through that.

Dr. Armstrong: Yeah. So I would say that, you know, each kid, each young adult, each adolescent, everyone's different, right? They're coming in with different social ssituation, different background, potentially other different medical diagnoses. And then we're hitting them with a potential cancer diagnosis that requires a lot of care.

And so really our goal is to tailor our approach and our support to the individual patient and family. But I can tell parents kids are more resilient than you'd imagine. It's crazy. I think between a four year old or a 14 year old or an 18 year old, their inner strength and their ability to see the positive sides of things is truly amazing. And so as parents, of course, you're going to take everything to heart and you're going to feel the pain that your child feels, but at the same time, you also want to give them hope, and you can't go home crying every night as they're going through this, they really want to see kind of your spirit as well.

And so a variety of things that we do is figure out where the kids are coming from and how they're managing it. So, as I said, there are a variety of toxicities that could occur with our treatments. But they're not going to occur with everybody. So, I think the first step is to figure out how they're starting to tolerate things, providing the supportive measures and then, you know, we talk a lot about physical health, but I think mental health is equally as important, especially as we get into our adolescent population who is being pulled away a little bit from their social network or is being pulled away from their sports team and is told that they're not going to be able to play for a couple of months, if that, or they might have a major operation, that's going to render them unable to be that star soccer player moving forward in life. And it's okay to feel depressed. It's okay to feel down about these things. And so we have a huge psychological and psychiatric support system here. And then I think as providers, you know, we're somewhat trained to be able to talk through these issues as well.

So, I think the biggest thing is to be honest about what we're facing, to let us know how things are going at home, to not seeing additional medicines or additional therapies as a weakness, but more as a strength that's going to optimize everything that we're doing to get to that ultimate cure or ultimate establishment of quality of life as we're moving through.

Host: As we wrap up, and you've given us a lot to think about today, Dr. Armstrong, where is it that children and adolescents with cancer get treated at St. Louis Children's Hospital and tell parents what you would like them to know about these treatments, about cancer in their children, the hope and encouragement that's out there, and the exciting things that you're doing at St. Louis Children's Hospital.

Dr. Armstrong: Here at St. Louis Children's, we have an entire floor that's devoted to our cancer treatment. So, the ninth floor here in the hospital has our outpatient clinic, our infusion center, and then our inpatient hospital beds as well. That also includes our transplant population.

And so certain types of cancers will have to undergo stem cell transplants. And we have one side of the floor that's devoted to that in addition to other kids can be admitted there. I think the cool thing is, you know, our population here wants to do everything for your kids. And so that's from the nurse, that's the greeter in the clinic, whenever you would check in, that's the staff that's cleaning your room. And so we're all very well versed in making the situation and the experience as child-friendly as possible. Child Life is a huge resource for us. We know that all of this is new and different, especially if this is a kid who really hasn't had a lot of medical problems.

And then all of a sudden is faced with a difficult diagnosis that requires some surgeries, some interventions, and then some treatments that can be a little bit rough. And so our support team is just, I would say ever abundant in order to help with. So that's the ninth floor of St. Louis Children's Hospital. Throughout the whole hospital, we have a lot of other subspecialty providers that are here to help with additional concerns, whether that's from the pediatric ICU team, to our endocrinologists, to our GI doctors, who can help with complications. And then if your child is to receive any type of radiation treatment, they would go just next door over to our pediatric radiation oncology suite, with Dr. Perkins. And I would say that kids are really the VIP over there. They'll treat both adults and kids in the radiation center, but kids are given priority as far as timing of radiation and the kind of the childlike approach that they'll receive as far as making sure that they're comfortable and everything, because we know that it can be scary.

Our pediatric surgeons are throughout the hospital and again, we also collaborate with some adult surgeons through our AYA or adolescent and young adult initiative really optimizing subspecialty surgical care. I'm hoping I'm painting a decent picture. I think we have obviously our emergency room where kids can come through initially and then they'll come up through our hospital, but I'd given our size, our level of expertise and the collaboration that we're able to have with our surrounding centers; I'd really say it's state of the art care that you would receive, not only in St. Louis, but really the Midwest right now. And we would love to help you guys as much as possible.

Host: What great information. Thank you so much, Dr. Armstrong for all the great work you're doing with kids and for joining us today. And for more advice and articles, please check out the Mom Docs website at children'sMD.org. And that concludes another episode of Mom Docs with St. Louis Children's Hospital. For more health tips, follow us on your social channels. And if you found this podcast informative, please share with your friends and family. We're all learning from the experts at St. Louis Children's Hospital together. For Mom Docs and St. Louis Children's Hospital, I'm Melanie Cole.