Osteosarcoma, Part 2 — Possible Side Effects, Restrictions, and Implications for School

Possible side effects of surgery on the tumor

Sometimes the original site of the tumor is weakened by the tumor and the surgical procedures needed to remove the tumor and reconstruct the affected limb. If the affected bone is in danger of breaking, the child's activity may be limited from the time of diagnosis until all treatment is completed. The degree and duration of any restriction must be determined individually by the surgeon, in consultation with the oncologist. As noted on the previous page, the extent and duration of any restrictions depend on the exact nature of the reconstruction. For example, if a reconstruction involves replacement bone, which must be permitted to heal, the child might need to avoid vigorous activities for several months.

Chemotherapy

Other physical restrictions might be the result of the chemotherapy treatments, rather than of the cancer itself. The possible side effects depend on the exact medications used and how the child responds to them. These medications may affect the child's ability to produce bone normally, which would make fractures (broken bones) more likely during and after treatment. Due to the increased likelihood of fractures, the patient will need to maintain appropriate nutrition during the course of treatment. Consultation with a nutritionist can help the family provide the proper foods.

Chemotherapy can also affect other processes, notably the production of blood cells. Chemotherapy may result in low blood counts (the number of red blood cells, white blood cells and platelets).

Checking blood sugar levels.
  • Red blood cells contain hemoglobin, carry oxygen throughout the body, and increase energy. If chemotherapy causes these numbers to fall, the patient will become very tired, and the level of activity might need to be restricted. A transfusion of red blood cells is one option to restore normal energy.
  • White blood cells help fight infection in the body. If these numbers drop, the patient will be more likely to catch an infection, and the body will have more difficulty fighting off the infection. In this situation, the patient might need to avoid large crowds, such as malls, football games and grocery stores. If an infection does occur, it must be treated seriously and vigorously. Sometimes the patient must be admitted to the hospital for treatment with IV antibiotics. It is best to avoid infections in the first place. Infections are often carried on the hands by germs and viruses, placed there by coughing, sneezing, and touching any object that is dirty — nearly every surface has germs and viruses on it. The best course of action is to practice thorough and frequent hand washing. That will benefit people getting chemotherapy, and everyone else, as well.
  • Platelets prevent excessive bleeding and bruising. If the number of platelets decrease, the patient will bleed and develop bruises more easily. This might be seen as frequent nosebleeds or the appearance of pinpoint red spots or purplish patches under the skin.

Implications for school

Attending school can be difficult for a young person with osteosarcoma. Many aspects of the disease and its treatment can interfere with school attendance, including surgery, reconstruction, chemotherapy, recovery, and periods when the white blood cell count is very low. During these difficult times, many children must use crutches, a walker or even a wheelchair to get around at school. Support from classmates is critical to ensure that the student remains connected to friends and normal activities. It will take a concerted effort from the school, peers and family to keep life for the student as normal as possible.

Educating peers about osteosarcoma is strongly suggested. Other students are likely to have questions about the child's altered mobility status, hair loss, weight loss, frequent absences and other concerns. These questions are normal and should be expected. If they are not answered honestly, the other children will come up with answers on their own, which will be inaccurate and unhelpful. Teasing and rejection are decreased when classmates understand what their friend is experiencing.

Some students will require physical accomodations.

A student with osteosarcoma will likely have significant absences during treatment. A great deal of flexibility and creativity will be required to enable the student to stay current with classes. Although homebound education is an option, it is recommended only in limited circumstances, such as after very involved reconstruction surgery. If used as the primary educational experience, homebound education interferes with the young person's opportunity for normal social growth. It is useful and appropriate, however, as an adjunct to school attendance. Intermittent homebound education, used as an educational support provided in the home or the hospital, and combined with regular school attendance when the child is able, can provide the greatest academic opportunity for the student with osteosarcoma.

Modifications and accommodations will be necessary, at least temporarily, to create a physical and learning environment that is appropriate for the student with osteosarcoma. These could include:

  • changing desk type to accommodate a wheelchair
  • altering the seating assignment for a child with crutches or a walker to avoid inconveniencing the other students in the class
  • allowing extra time for passage through crowded hallways
  • creating or modifying a Section 504 Plan or an IEP to document the needs of the student

If the status of a student with osteosarcoma changes, the information provided to teachers and classmates should be updated. For example, a recurrence of the disease or metastasis (spread) to another part of the body will likely require different treatment. In this case, the school staff should contact the doctor or hospital school teacher to anticipate the student's needs. Ongoing, effective communication between the family, school and hospital will result in better understanding and better support for the student.

Psychological and social concerns for the student can be significant. Due to the frequency of absences and infections, and the limitations on physical activity, a young person with osteosarcoma likely will feel excluded from normal social interactions. This is a particularly difficult issue during high school. Students might feel abandoned or lost. To encourage healthy psychological, emotional and social adjustment, the school should consider:

  • With the consent of the child and the parents, the school could educate the child's peers about what it means to have osteosarcoma. The hospital school teacher is a good resource for offering a presentation, suggesting materials, or assisting with the education of school personnel or other interested community members. Often, the student will wish to be involved in the educational process, and can provide the most valuable insight into the disease process and implications.
  • Encourage peers to stay in contact with their friend during the inevitable absences. Cards, letters, texts, e-mail and phone calls can bridge the gap between friends when they are apart.
  • This is a wonderful opportunity to teach peers about supporting a friend, showing compassion and other essential life lessons.
  • Identify strong peers to mentor the student upon the return to school. Having someone fill the student in on what was missed in school can be invaluable for a smooth re-entry to school.
  • Help the student find areas of expertise and ways to excel in the school environment. Mentoring support could be included even in the IEP to help the student develop and maintain self-confidence.
  • Include social work or counseling services as part of the IEP. The presence of a trusted individual at school, in whom the student can confide and who can act as an advocate for the student, can be a significant asset. This would afford the student the opportunity to discuss worries about homework, fears about the future, social difficulties and problems with family members; all in a non-threatening setting.

KU Kids Healing Place

During treatment for osteosarcoma, there are many challenges for the child and family. In addition to the essential medical treatments, it is important to care for the psychological, social and spiritual needs of the patient and the family. This type of care, called palliative care, previously had been reserved for only the sickest patients. However, research has demonstrated that palliative care helps maintain normalcy throughout treatment, recovery and life. Today, every child with osteosarcoma receives the benefit of palliative care, along with the family members. The KU Kids Healing Place (KUKHP), through the Department of Pediatrics at the University of Kansas Medical Center, focuses on treating all aspects of the child and family, ensuring that each receives the care needed to maintain psychological, social and spiritual well-being during treatment for osteosarcoma and on into life. The entire treatment team will work to ensure that the needs of the child are recognized and addressed both in the hospital and in the community, including school, sports, worship and activities. KUKHP partners with school professionals, peers, clergy, coaches, scout leaders and many others to ensure that the child continues to grow and achieve in all environments.


For more information

Part 1 — Introduction, Incidence, Symptoms and Treatment

Curesearch
http://www.curesearch.org/

National Library of Medicine/National Institutes of Health
http://www.nlm.nih.gov/medlineplus/ency/article/001302.htm

Contributed by:

Kim Templeton, MD
Professor
Department of Orthopedic Surgery
University of Kansas Medical Center

Kathy Davis, MSEd, PhD
Associate Professor
Project Director, Connected Kansas Kids
Director, KU Kids Healing Place
University of Kansas Medical Center