Malignant disease is uncommon in children with an average occurrence of 1 in every 1400 children. With a high-government, spending on health care a restructuring of the way nursing care is provided is needed.  A third of these patients develop leukemia, a quarter develops a central nervous system tumor and others develop other kinds of tumors.
Pediatric patients requiring complex care make the situation worse with a shortage of nurses. The strain on the work force is being felt across the board. Delivery of safe, high-quality chemotherapy to the pediatric patient relays on the service being provided in the most appropriate service setting with a capacity and capability to meet the individual patient’s needs. These needs can only be identified through a comprehensive clinical assessment taking into consideration all known complexities of the situation (Dongen et al 1998).
The overall care and management of children with cancer and specifically incorporates systemic therapies used in the treatment of childhood cancers, including leukemia and hematopoietic stem cell transplant services. The management of patients with nonmalignant hematological disorders such as hemophilia, bleeding and thrombotic disorders, and anaplastic anaemia is not of concern here. Risk stratification and a service delineation model are used to better enable safe and effective cancer care for the pediatric patient.
Chemotherapy standards seeks to enable current and future chemotherapy services to meet and monitor safety and quality specifications. The continuous improvement of pediatric care is significant to successful health care delivery. By describing the minimum workforce, infrastructure and support services necessary to deliver this care in an equitable manner it will be more effective. Despite this and the rarity of cancer in children, it remains the most common cause of death in children.
The United Kingdom children’s cancer study group (UKCCSG) was established in 1977 with the goal of establishing clinical trials of children with cancer. This group established collaborations with childhood cancer research group in oxford (CCRG) and the MRC leukemia working party. Improved clinical outcomes have encouraged recruitment of childhood cancer motivating even parents with such cases.
However, UKCCSG was renamed in 2006 to reflect the significance of leukemia therapy into children’s cancer and leukemia group (CCLG). With 22 primary treatment centers, spread across United Kingdom  with the aim of delivering care to paediatric cancer patients all affiliated to the CCLG . Paediatric oncologists take the main role in development and monitoring of clinical trials and this has significantly improved survival figures.
Ensuring access to these 22 PTC enables patients to receive all their therapy in them. Appropriate tertiary services are provide to the patients through share care system where patients undergo the initial diagnosis and treatment in the PTC and only return for complex procedures such as surgery to remove the tumor. Strategic service planning aims to better enable the health system to meet this growing challenge and ensure equity in access to high-quality cancer care as close to home as possible. Pediatricians with further trading in oncology are in charge of chemotherapy in a large district hospital and maintain correspondence with secondary and tertiary physicians. Factors that influence the organization of paediatric chemotherapy services are explained below.
Timely Access, Coordination of Care and Integration
The initial diagnosis should be done on time and the child should then be registered and then integrated in the system through a primary treatment center. Conditions demanding referral to the tertiary centers should be done on time to avert any tragic results. Service providers should have policies guiding the referral process.
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Governance and Legislation
The set laws, responsibilities, practices, policies and procedures established to provide strategic direction manage risks and measure periodically the service provider’s performance to ensure accountable utilization of resources. These significantly influence service delivery of pediatric chemotherapy.
Workforce Availability and Competence
The necessary workforce skills within the health services to support effective delivery of chemotherapy. Specialists and pediatricians with training on oncology should be the ones delivering this therapy in consultation with tertiary physicians. The right combination of skills, attitudes, values and abilities are crucial for the effectiveness.
Chemotherapy Prescription and Provision of Supportive Care
The right treatment plan through a collaborative assessment is vital. Management of physical and psychological symptoms and side effects during the cancer experience from diagnosis through anticancer treatment to post-treatment are necessary. Children as well as their parents need a lot of support during this process.
Comprehensive Patient Assessment and Multi-Disciplinary Care Availability
Routine risk assessments, review and clinical examinations should be done to establish the success of the therapy. Adoption of an integrated team approach to service delivery in which medical, nursing and allied healthcare professionals consider all relevant options and develop collaboratively an individual treatment plan for a specific patient.
Patients Parent Education and Consent
Since histological material is required to confirm the diagnosis and to study prognostic factors In order to define treatment strategy mass screening is necessary. This has to involve the parent being enlightened on the procedures involved and their consent is required.
Safe Handling, Administration and Disposal of Chemotherapy
Severe side effects including multi-organ toxicity, immunosuppressant and infection can occur as a result of the highly toxic drugs used. Chemotherapy should be administered in line with published guidelines and standards for the safe handling and disposal of chemotherapeutic drugs and related waste. The prescribing and dispensing of oral chemotherapy management and administration of systematic therapy is best dispensed in line with published guide lines from recognized paediatric professional bodies.
The Service Capacity to Protectively Isolate Immuno-compromised Patients and Protect Others
The workforce employed to provide chemotherapy services must be credentialed, educated, and assessed as competent according to current Health policies, standards and endorsed guidelines or frameworks. Governance and monitoring of credentials, scope of practice, clinical privileges, education and competency maintenance remain the responsibility of the employing health service. It is anticipated that continuous development of services in-line with the chemotherapy standards will support progress towards a sustainable and robust cancer workforce (World Book, 2007).
Age at Diagnosis.
For survival, different treatments are required at different stages of the disease. Age at diagnosis as well as prognostic factors influence treatment strategies. Patients should be treated using international treatment recommendations. As an example of localized tumors are treated by primary surgery if possible.  In case of unfavorable prognostic factors, adjuvant chemotherapy may be used (National Collaborating Centre for Cancer, 2002).
Care Coordination
Having a diverse health care there is a need to coordinate service delivery in a coherent, logical and timely manner, which is consistent with the Childs specific needs. It is recognized that not all cancers and or cancer treatments present the same level of risk and therefore chemotherapy provision should be delineated within the health regions to ensure that care is provided in an environment that has adequate infrastructure, workforce, resources and support services to provide consistent and sustainable care (Czauderna et al 2005).
Tertiary specialists visit outlying hospitals regularly, running joint clinics with the local team to maintain continuity of care. Small numbers of patients may lead to care which is less than optimal. In spite of lack of evidence for any difference in survival between the smaller and larger centers in the UK, there are moves towards more consolidation, with fewer puts caring for greater numbers of patients.
Delivery of care safely as close as feasible to home has been possible, with many patients benefiting. There is a notion that  shared care model may allow safe local delivery of services under such a system, while continuing to provide a service which concentrates expertise in tertiary centers. In the past the development of structures which would lead to a progressive improvement in the way clinical trials are run for many patients has been real but sadly not for children with cancer. With seven research networks being established, including those for cancer (National Cancer Research Network, NCRN) and for children (Medicines for Children Network, MCRN) (National Collaborating Centre for Cancer, 2002).
There has been lack funding within the NCRN for children, and it has been the view of many networks that pediatric cancer research is well provided for. Similarly, the MCRN specifically excludes research into paediatric cancer. However, guidelines on chemotherapy are strengths. They include: inpatient care by registered medical specialists with credentials in paediatric oncology and additional aligned junior medical staff. Acute paediatric pain management services on-site. Dedicated Standard isolation rooms, at least four single rooms with unsuited and clinical hand-washing facilities (Votroubek &Votroubek, 1997).
A multidisciplinary team, which should include a designated registered medical specialist with credentials in paediatric oncology, senior paediatric oncology registered nurses, a dedicated paediatric oncology pharmacist and allied health professionals with expertise in the area of paediatric oncology . A collocated radiation oncology service with expertise in the care of children.
Documented processes with all lower-level services for the coordination of care, ensuring that care is provided locally in a coordinated manner accreditation for the performance of antilogous bone marrow transplants with relevant national accreditation bodies. Chemotherapy treatment should be evidence based and supported through the implementation of an electronic patient management, decision support and prescribing system (Cai et al 2007).
Chemotherapy has led to considerable improvements in survival for many tumor types. Paediatric tumors typically not carcinomas, often show significant chemo-sensitivity, and the role for chemotherapy is greater in paediatric than in adult practice. Majority of the infrastructure for paediatric cancer clinical trials in the UK comes from the CCLG, itself supported
By a grant from Cancer Research UK, who fund a core facility based in Leicester. Undoubtedly, chemotherapy will remain the mainstay of therapy for many years, but increasingly, stratified therapy delivering intensive therapy to high-risk patients, less intensive therapy to better prognostic groups are being delivered. This is reflected in survival rates. The remarkable success of early studies of Minimal Residual Disease detection in acute lymphoblastic leukemia has led to this being central to current ALL therapy.
Patients who achieve MRD negativity at the end of induction therapy have been demonstrated to have less than 2 percent chance of leukemia relapse at three years: the focus for these patients can therefore be on reducing effect of therapy and improvement of quality of life. A similar approach is being attempted with solid tumors. Individual, investigator-led studies have generally been run without additional funding, based on goodwill between colleagues, but without the ability to run fully to Good Clinical Practice. Faze me and Phase II clinical trials of necessity must usually come with funding from the pharmaceutical manufacturer, and this area has been one of the few beneficiaries in recent years (Czauderna et al 2005).
Recent United States and European legislation (European Paediatric Medicines Regulation EC 1901/2006) designed to enhance access to new drugs for children  allowing an additional period of exclusive use of a given drug, and hence significantly greater profit  has lead to a much improved stream of potential agents. Many paediatric phase 1 and phase 11 studies are run through the Therapeutics Steering Group of the CCLG and the Innovative Therapies for Children with Cancer consortium (ITCC). This latter organization aims to develop novel therapies for paediatric malignancies through clinical and translational research with a phase I and II network of centers operating throughout Europe and Rigorous data for analysis has been available for several years now (Cai et al 2007).
It should be noted that the different service levels address the complexity and risk associated with the delivery of treatments, such as the administration of systemic chemotherapy protocols, which have a significant effect on service complexity. Historically, new drug
Development has rarely seen paediatric trials as necessary. Systemic therapies may be delivered through various routes and each protocol has different requirements for safe.
Delivery, follow-up and supportive care. Children with cancer are surrounded by their family, and the consequences of treatment are felt by all members. As they grow into adults, and will have long and active lives, but for some particularly for children after treatment for primary brain tumors, reintegration may be incomplete. A major goal in the coming years is therefore to reduce the impact of cancer on the family, to reduce long-term effects, and to help the child reintegrate with the world. This will be the greatest thing to reconnect the physical and the psychological.  Paediatric cancer is a small specialty, but the number of survivors into adult life is increasing making it an emerging one (Feigin, 2004).
Bibliography
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Cotterill SJ, Pearson AD, Pritchard J, 2000. Clinical prognostic factors in 1277 patients with             neuroblastoma: results of The European Neuroblastoma Study Group ‘Survey’ 1982-          1992. European  Journal of  Cancer , pp.901-8.
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Votroubek, Wendy &Votroubek, Julie, 1997. Pediatric home care. Jones & Bartlett Learning
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