Supportive Care, Complications, and Oncologic Emergencies
Febrile neutropenia
Fever with an absolute neutrophil count under 500 defines this emergency. Obtain cultures and give empiric anti-pseudomonal beta-lactam therapy within 60 minutes; do not wait for results. Add vancomycin for catheter infection or hemodynamic instability, and antifungals for persistent fever after several days.
Drug-specific complications
Anthracyclines cause dose-dependent cardiomyopathy; monitor with echocardiography and use dexrazoxane when indicated. Vincristine causes constipation and peripheral neuropathy and is fatal if given intrathecally. Asparaginase causes pancreatitis, hyperglycemia, and thrombosis. Cisplatin causes hearing loss and nephrotoxicity; audiometry is required. Methotrexate toxicity is rescued with leucovorin, and high-dose regimens require urine alkalinization and level monitoring. Bleomycin causes pulmonary fibrosis.
Infection prophylaxis
Trimethoprim-sulfamethoxazole prevents Pneumocystis jirovecii pneumonia in leukemia and transplant patients. Antifungal prophylaxis is used in high-risk acute myeloid leukemia and after transplant. Live vaccines are avoided during immunosuppression; inactivated vaccines are given but responses may be blunted.
Tumor lysis and leukostasis
Anticipate lysis in bulky, rapidly dividing tumors; hydrate, monitor electrolytes, and use rasburicase or allopurinol. Hyperleukocytosis with leukostasis requires urgent cytoreduction and cautious transfusion.
Rule of thumb
Any child with cancer and a new neurologic deficit, abdominal pain, or fever is an emergency until proven otherwise; the differential includes typhlitis, posterior reversible encephalopathy syndrome, and sepsis.
Trap
A normal total white blood cell count does not exclude neutropenia - calculate the absolute neutrophil count from the differential.
Survivorship, Palliative Care, and Psychosocial and Ethical Issues
Late effects
Survivors need risk-based surveillance. Anthracycline and chest radiation exposure increase cardiomyopathy risk; guidelines recommend periodic echocardiography with dose thresholds. Cranial radiation causes neurocognitive deficits, growth hormone deficiency, and endocrinopathy. Alkylating agents and pelvic radiation impair fertility. Second malignant neoplasms, particularly after radiation and etoposide, require lifelong vigilance. Long-term follow-up guidelines give organ-specific screening schedules.
Survivorship care
A written survivorship care plan summarizing treatment, risks, and recommended screening should be given at the end of therapy and updated over time. School reintegration, educational support, and vocational counseling are essential components of care.
Palliative care
Palliative care is symptom-focused and can begin at diagnosis alongside curative therapy; it improves quality of life and does not shorten survival. At end of life, control pain, dyspnea, and anxiety; support siblings; offer bereavement follow-up. Early goals-of-care conversations prevent crisis decisions.
Ethics and psychosocial
Adolescents can give assent and should participate in decisions, with confidentiality limits explained in advance. Phase I trials are offered when standard therapy is exhausted, with explicit discussion that the primary goal is safety, not benefit. Fertility preservation should be discussed before gonadotoxic therapy: sperm banking is feasible for postpubertal boys, and oocyte or ovarian tissue cryopreservation for girls. Ethical questions include resource allocation, refusal of therapy, and medical futility.
Rule of thumb
Before starting any gonadotoxic or anthracycline therapy, document a fertility discussion and a cardiac baseline.
Trap
Do not assume a survivor is cured and discharged - recurrence risk, cardiac disease, and second cancers persist for decades, and transition to adult care must be deliberate.