5 Top childhood cancers: A comprehensive guide for parents

Each year, approximately 300,000 cases of childhood cancer are diagnosed around the world. According to the International Agency for Research on Cancer (IARC), top childhood cancers affect 215,000 kids younger than 15 years, and about 85,000 kids aged between 15 and 19 years.

In most developed countries, top childhood cancers affect less than one per cent of the child population. But in developing or underdeveloped nations—where children make up more than half the population—the numbers could be five times more.

“The proportion of children dying from cancer in poorer countries is unacceptably high, especially when we have the example from richer countries as to what can be achieved through access to care,” Dr Christopher Wild, IARC Director, shared in the release.

“Childhood cancer is a public health problem in developing countries, and more resources should be provided to improve diagnosis, treatment, and infrastructure,” he added, and rightfully so.

Fast facts about childhood cancer

As compared to the global adult population, children are affected by several different types of cancers. Before we tell you what these are, here are some facts reported by the IARC report about childhood cancer:

• About half of childhood cancers are related to blood cells (leukemia and lymphoma).
• There are two types of frequent malignant childhood cancer: those of the central nervous system and those that develop from embryonal tissues.
• Some cancers are exclusive to children. These may include neuroblastoma (begins in the adrenal glands) and retinoblastoma (stems from the immature cells of the retina). It may also include nephroblastoma (begins in the kidney).
• Tumors or cancers of the breast, lung, or stomach are usually rare in children.
• Although there have been major advancements in technology, the American Cancer Society (ACS) reveals that top childhood cancers still remain the second cause of death among young children.

5 Top childhood cancers

Incidentally, cancer in childhood can be difficult to identify. That's because fevers, bruises and even common illnesses can often mask the early symptoms. So let's understand each of these top childhood cancers and the warning signs for each.

1. Acute Lymphoblastic Leukemia (ALL)

Leukemia is the cancer of white blood cells (WBC). It occurs when the bone marrow produces an abnormal number of immature white blood cells. These immature WBCs then travel through the bloodstream and overcrowd healthy cells, thereby increasing the chances of infection in the body.

It commonly occurs in kids and teenagers and could either be chronic or acute. It is one of the top childhood cancers, globally. As per data from the American Cancer Society, leukemia accounts for 30 per cent of all types of cancers in children.

As mentioned in our article on childhood leukemia, while the former takes time before it becomes fatal, the latter is a fast-growing cancer.

Types

There are six types of childhood leukemia, as listed below:

• Acute lymphocytic leukemia: Here, the bone marrow creates an unhealthy number of lymphocytes (type of white blood cells).
• Acute myelogenous leukemia: In this type, the cancer starts from the bone marrow where a large number of immature WBCs are produced.
• Hybrid or mixed lineage leukemia: This is a combination of the above two types of leukemia cancers.
• Chronic myelogenous leukemia: While this type of cancer is rare in kids, it is caused by chromosome mutation.
• Chronic lymphocytic leukemia: This type of cancer is extremely rare in kids and mostly occurs in older adults.
• Juvenile myelomonocytic leukemia: This rare type of cancer is neither chronic or acute and affects kids under the age of four.

Symptoms

Some of the common symptoms of leukemia in kids include the following.

• Re-occurring infections
• Frequent bruising and bleeding
• Poor appetite and stomachache
• Breathing troubles
• Swelling in the body
• Joint and bone pain
• Acute anemia

Diagnosis

In order to diagnose leukemia, the healthcare provider may access your child's condition based on either a physical examination, blood test and a bone marrow test.

Treatment

Based on the diagnosis, a cancer patient is given any of the five types of treatments for this disease:

• Chemotherapy: This type of treatment involves the use of a drug or a combination of drugs to treat leukemia, which might be given orally through a pill or an injection.
• Targeted treatment: In this type of leukemia treatment, the immature WBCs are targeted for their specific vulnerabilities. This is identified on the basis of the Leukemia symptoms in kids.
• Radiation therapy: As the name suggests, different types of radiation, including x-ray or even high-energy beams, are used to target and kill growing leukemia cells.
• Biological treatment: This treatment helps the immune system to recognise the growth of leukemia cells in the body and target to destroy them.
• Stem cell transplant: This is also a common procedure to cure cancer. Here, a deceased bone marrow is replaced with one that is healthy.

Remember, childhood leukemia is curable in most cases. So begin by informing yourself about the condition, speak to your doctor about the symptoms and chart out the treatment plan if it is diagnosed.

2. Brain tumor

When there is abnormal cell growth in the brain, it becomes a tumor. This can either be benign (not cancer) or malignant (cancer) and is one of the top childhood cancers.

According to the ACS, "Brain and central nervous system tumors are the second most common cancers in children, making up about 26 per cent of childhood cancers."

The agency also adds that most brain tumors found in children typically start in the lower parts of the brain including the cerebellum or the brain stem.

Types

The American Society of Clinical Oncology lists the various tumors that lead to cancer of the brain or the spinal cord.

• Glial tumors. These are various tumors that develop in the central nervous system from the glial cells. These include Astrocytoma, Oligodendroglioma, Ependymoma, Choroid plexus carcinoma, Oligoastrocytoma, and Glioblastoma.
• Mixed glial neuronal tumors. They are a rare type of tumor that also occur in the central nervous system. These tumours include Ganglioglioma, Desmoplastic infantile ganglioglioma, Pleomorphioc xanthoastrocytoma, and Anaplastic ganglioglioma.
• Neural tumors. Another type of brain tumor or that of the central nervous system is the neural or neuronal tumor. These include Gangliocytoma and Neurocytoma.
• Embryonal tumors. These are tumors that are formed from the embroynic cells that remain in a child's brain after birth. As per the National Cancer Institute, U.S, they spread through the cerebrospinal fluid and include Medulloblastoma and Medulloepithelioma tumours.
• Ependymoblastoma. This is a highly malignant brain tumor of childhood and is usually seen in babies and toddlers or very young children. It includes Atypical Teratoid/Rhabdoid tumors.
• Pineal tumors. These type of tumors occur in the pineal gland and reportedly account for three per cent to eight per cent of the intracranial tumors in kids. The tumors that develop in this type of cancer are called Pineocytoma.

Symptoms

• Constant headaches
• Feeling of dizziness
• Imbalance in the body
• Vision, hearing or speech impairment
• Frequent vomiting
• Lack of concentration
• Memory loss
• Numbness and weakness

Diagnosis of brain tumor

• Physical examination. The healthcare provider may inspect your child to check if he has a bulging fontanelle (soft spot on your baby's head), enlarged eyes, and red reflex in the eye (it shouldn't be there). Plus, a positive Babinski reflex (occurs after the sole of the baby's foot is stroked) and separated sutures are checked.
• Computed Tomography (CT) scan. The computed tomography (CT) scan uses x-ray and creates images of the brain and skull. The three-dimensional models created with this scan can reveal the presence of a tumor. It usually takes about a few seconds to a few minutes.
• Magnetic resonance imaging (MRI). The MRI scan machine uses magnets as well as radio waves to create images of the brain and its surrounding tissues. This helps to locate the brain tumor. The test may last from 30 to 60 minutes.
• Examination of the cerebrospinal fluid. Usually, the doctors will do a lumbar puncture to collect the cerebrospinal fluid from the spinal cord. It can reveal data about proteins as well as sugar content in the body.

Most of these tests are usually done based on the child's age, tumor size, tumor type and location in the central nervous system.

If the tumor is local and benign, it will not spread anywhere else in the body. But if it's malignant, it may spread into other parts. Therefore, a diagnosis using a blood test or physical examination reveals its position and spread.

Treatment

Based on the diagnosis and depending on the type of tumor, a child may be given the following treatments:

• Surgery. A surgery may be done to remove Astrocytoma (glial cell tumor) with the addition of chemotherapy and radiation therapy. Similarly, for Ependymomas (originates from the ependyma tissue of the central nervous system) a surgery is needed along with the two therapies.
• Radiation and chemotherapy. Only surgery cannot remove Medulloblastomas tumor and therefore, one needs these therapies. Similarly, for Brainstem gliomas (cancerous) surgery is not possible because it is usually located deep inside the brain. So radiation is required to reduce the size of the tumor.

In most cases where brain tumor is malignant, treatments can only prolong life. Therefore, the child will need your emotional and physical support to get through the therapies.

3. Neuroblastoma

This type of cancer usually develops due to immature nerve cells. Typically, it begins from the adrenal glands that are located on top of the kidneys. It then slowly develops into malignant tumors that may appear in the abdomen, chest, or even in nerve tissues of the spinal cord.

According to the National Cancer Institute, Neuroblastoma often affects children below the age of five. And while it is believed to begin before birth, it can only be detected after the child begins to show symptoms. Usually, due to its slow growth, doctors are able to diagnose it early.

Types

The American Cancer Society lists the two types of neuroblastomas as follows:

• Ganglioneuroma: This is a benign (non-cancerous) type of tumor. It is made up of nerve sheath cells as well as mature ganglion.
• Ganglioneuroblastoma: This type of tumor has both benign and malignant parts. It has neuroblasts (immature nerve cells) that grow and spread across the autonomic nervous system abnormally. Doctors usually have to study these types of tumours carefully to make sure that there are no malignant cells.

Symptoms

This type of cancer also has its specific type of symptoms:

• Presence of a lump in abdomen, chest, neck and/or pelvis
• Impaired ability to walk
• Blue or purple nodules under the skin
• Bulging eyes with dark circles as well as droopy eyelids
• Body ache, typically in chest, arms and legs
• Diarrhea
• High blood pressure
• Fever and anemia

Sometimes, kids with neuroblastoma don't exhibit any of these symptoms. They may have another illness that is the underlying symptom of this type of cancer. If you are concerned about any of these changes, you must consult a doctor.

Diagnosis of Neuroblastoma

The following diagnostic tests are recommended by the American Society of Clinical Oncology:

• Blood tests: Here, doctors will take complete blood counts (CBC) to find out if the child has anemia (low levels of red blood cells). They can also evaluate liver and kidney function with blood tests. They may also check for blood clots.
• Urine tests: A urine sample is collected to identify tumor markers that a neuroblastoma tumor produces. If your child has this type of cancer, the tumor marker found in the urine will be much higher than normal.
• Biopsy: In a biopsy, the doctors may remove a small part of the tissue from the tumor for examination. A pathologist who will analyse this piece under a microscope can then evaluate the tumor.
• Genetic studies: In some cases, neuroblastoma cell DNA is used to detect changes in the oncogene MYCN. If it is more than 10 copies of gene, it can be a tumor growth.
• Bone marrow aspiration: This method examines the bone marrow. Doctors may take a small tissue sample and its fluid from the pelvic area.
• Other tests: Some other tests to identify this type of cancer is a CT scan, an MRI scan as well as a meta-iodobenzylguanidine (MIBG) scan. The last scan studies the protein that neuroblastoma cells absorb. Additionally, some patients may also need a positron emission tomography (PET) or PET-CT scan. This type of scan creates images of organs and tissues.

Not all children suffering from the neuroblastoma cancer need all these tests. Their use depends on the spread of the tumor and its location, and is completely up to the predisposition of the doctor.

Treatment

Once the diagnosis is complete, a child may need the following treatments:

• Surgery to remove the tumor
• Chemotherapy, in which doctors will give anti-cancer drugs intravenously
• Radiation therapy, in which doctors use powerful rays to remove the tumor
• High-dose chemotherapy or radiation therapy and even stem cell transplant in some cases
• Retinoid therapy, in which the patient is administered with chemicals that are related to vitamin A
• Immunotherapy, wherein medication is given so that the patient's immune system is able to fight off cancer cells

Ideally your doctor will share all the details about the treatment. But as parents, you must be sure of what is happening and why, especially when it comes to cancer treatment.

4. Wilms Tumor or Nephroblastoma

Another one of the top childhood cancers, nephroblastoma accounts for about five per cent of all pediatric cancers. In this type of cancer, immature cells begin to develop in the kidneys of an infant.

Ideally, the kidneys should mature by the time the child turns three or four. But when they don't, they stick together to form a mass of immature cells (Wilms tumor). And, it is also one of the top childhood cancers.

Unfortunately, this tumor is always cancerous.

Types

As per ASCO, there are two types of tumors based on their development in the kidneys:

• Unilateral Wilms tumor: When the tumor develops only in one kidney, it is unilateral. This means the mass of immature cells only affects one of the kidneys.
• Bilateral Wilms tumor: Here, the immature cells spread across both the kidneys. Usually when a child suffers from bilateral Wilms tumor, the immature cells develop in both kidneys simultaneously. Very rarely do doctors find one kidney affected after the other. This makes it quite a deadly childhood cancer.

In addition, Wilms tumor can be of two types based on their appearance. As per the American Cancer Society, the following are the two types:

• Favourable histology: The apex agency notes, "Although the cancer cells in these tumors don’t look quite normal, there is no anaplasia (see next paragraph). More than 9 of 10 Wilms tumors have a favourable histology. The chance of curing children with these tumors is very good."
• Unfavourable histology (anaplastic Wilms tumor): In these types of tumors, the look of the cancer cells varies. Here, the cells' nuclei (the central parts that holds a person's DNA) become large and sometimes distorted. The agency notes, "This is called anaplasia. The more anaplasia a tumor has, the harder it is to cure."

Symptoms

When kids suffer from this type of cancer, their kidneys take a hit. But apart from issues with the urinary tract, here are some other symptoms of one of the top childhood cancers:

• Swelling or lump in and around the belly
• Constant fever
• Pain around the abdomen or in the body in general
• Feeling of nausea
• Very poor appetite

When you notice any of these symptoms in your young child, you must report them to a doctor. Using proper diagnostics that may include the following, early detection is possible.

Diagnosis

The American Cancer Society lists the following diagnostic tests for nephroblastoma:

• Physical examination: Along with your child's medical history, the doctor will also conduct a physical examination. They may question your child about the symptoms and even birth defects and family history related to genitals and the urinary system. During the physical examination, the doctor will check your child's abdomen and may even collect blood and urine samples.
• Imaging tests: If your doctor suspects a nephroblastoma, he might recommend imaging tests. In these tests doctors use sound waves, x-rays, magnetic fields, and radioactive substances to create images of the body's organs.
• Ultrasound (sonogram): An ultrasound will reveal Wilms tumor or any another type of abdominal tumor. This test is easy and gives the doctor a proper view of the kidneys.
• Other tests: Some other tests such as the computed tomography CT scan, the MRI scan, chest x-rays as well as bone scans can show the tumors, if present.
• Kidney biopsy: Although, most of the time an imaging test can reveal the tumor, sometimes it may take a biopsy to understand it.

On the basis of the diagnosis, your doctor will accord a specific treatment to your child.

Treatment

The three primary treatments for Wilms tumor are chemotherapy, surgery, and radiation therapy. Remember, in most cases this is curable. However, you may need to seek immediate medical attention to bring it under control and treat it in time.

Although most children get more than one treatment, there are alternate therapies that some doctors might recommend. As per the ACS, these include "vitamins, herbs, and special diets, or other methods such as acupuncture or massage."

5. Lymphoma

The final one in the list of top childhood cancers that affect the immune system is Lymphoma. It begins in certain cells of the child's immune system.

As per the Roswell Park Comprehensive Cancer Centre, "These cancers affect lymph nodes and lymph tissues, like the tonsils or thymus. They can also affect the bone marrow and other organs, and can cause different symptoms depending on where the cancer is growing."

Types

• Hodgkins lymphoma: This type of lymphoma begins in the white blood cells (lymphocytes). Since the lymph tissue are present in many parts of the body, this type of cancer can start from anywhere. These parts could be the lymph nodes, spleen, bone marrow, thymus, digestive tract and adenoids and tonsils. 
  Hodgkins lymphoma further has four types. But it is Nodular sclerosis Hodgkin lymphoma that actually affects the kids. According to the ACS, this usually starts from the lymph nodes in the neck or the chest area.
• Non-Hodgkin lymphoma: This type of cancer is more likely to occur in young children, than the former. The cancerous cells in this type of cancer grow quickly and intensively. Therefore, they may also need aggressive treatment to control.

Both types have similar symptoms and so only a proper diagnosis can detect them.

Symptoms

The signs that are indicative of lymphoma include the following:

• Swollen lymph nodes, especially in the neck, armpit, or groin areas
• Rapid weight loss
• Constant fever
• Hot flashes or sweat
• Feeling or weakness

Diagnosis

A blood test cannot detect lymphoma. To diagnose this type of childhood cancer, your doctor might recommend the following tests:

• Physical examination: On the basis of the symptoms, the doctor will examine your child's enlarged lymph nodes or spleen. He may even ask questions about his medical history.
• Biopsy: A biopsy can reveal the presence of cancer. So the doctor may take a small part from the lymph node of neck, underarm, or even the groin.
• Other tests: If the doctor detects lymphoma, your child may need some other tests to identify its extent. These include some laboratory tests like CBC, liver and kidney function tests, a CT scan, PET-CT scan, an MRI, and some lung function tests. In addition, there might also be a heart evaluation using the echocardiogram (ECHO) or the multigated acquisition (MUGA) scan.
• Bone marrow aspiration: As stated before, in this test the doctor may take a part of the bone marrow to study the lyphoma cancer, one of the top childhood cancers.

Treatment

If the tests are positive, your child's treatment options include chemotherapy, radiation therapy, immunotherapy, as well as bone marrow transplant.

This type of cancer and its treatments can take a toll on the body. Therefore, the doctor might recommend alternate relaxation therapies. This, in addition to palliative or supportive care for the patient.

The most important thing to remember is that while you cannot do anything about genetic or birth-related cancers, you can work towards creating an environment that is not conducive to childhood cancer.

What to do if your child has cancer

Childhood cancer diagnosis can be devastating for the parents as well as other family members. This condition creates an urgent crisis in a family. And, it also leads to these four scenarios:

• How do you cope when your child is diagnosed with cancer?
• What can you do to help your child cope with cancer?
• How can you help siblings cope with cancer diagnosis?
• What if your child begins to talk about death?

Let's discuss each of these and understand how you can deal with them individually.

1. How do you cope when your child is diagnosed with one of the top childhood cancers?

Nothing can prepare a parent to hear that their kid has a life-threatening illness. Therefore, for most parents the initial days can be a complete blur.

So to begin with, you should know that there are no right or wrong feelings. Some parents are unable to believe it and so they become angry, upset, sad, overwhelmed, fearful, and even anxious. Others may cry. It is all justified.

In order to cope with the initial shock, the American Cancer Society suggests the following:

• Understand the illness and learn more about how it can affect your child. But also, try to learn about the treatments.
• You can also use the support of doctors, nurses, social workers, counselors and psychologists.
• It's crucial to lean on family and friends. Talk to them and let them help you with household chores as you tend to your child.
• Use alternative techniques like yoga and meditation to calm your own self. Keep a journal or do activities that keep anxiety away.
• If you're religious, you can speak with your spiritual gurus and pastors.
• Do not be afraid to open up and discuss this illness and how it is affecting you and your child.
• Take care of yourself by eating right, resting properly and taking breaks. If you don't take care of yourself, your child may blame himself or herself for making you look haggard all the time. So put up a brave face.
• Try to take control of decisions for your kid and express your emotions in a healthy way. Do not shout and scream in front of your child.
• Make sure to answer all of your child's questions.
• Create a new normal. Speak to your employer about your situation and create new routines at home and seek help.

2. What can you do to help your child cope with top childhood cancers?

When you hear of the news, your child's life will change overnight. Instead of the regular school routines, your child may have to incorporate a lot of hospital routines. So the first few weeks can be extremely frightening and stressful.

Your child's reaction to the news may also be similar to that of yours. But the doctors and the cancer teams will help you and your child through the first few weeks of the diagnosis. However, here's what you can do to help your child cope with it:

• Share information about the illness and treatment. Some parents prefer that adults in the family hear the news first and then the child. Other parents may prefer to break the news with the entire family and the child.
• Infants (0-2 years): At this stage, your child will feel secure in the same home routine, even after diagnosis. Your child may need you to be around when the team comes for checkups and tests.
• Toddlers and preschoolers (2-5 years): At this stage, you can tell your child the name of the cancer, along with the treatments and tests involved, as well as how his or her life will change. You will have to reassure your kid that what is happening is not his or her fault.
• School-age children (6-12 years): At this stage, your child might have his or her own understanding of cancer. So you may need to warn your child about missing school activities because of hospitalisation. Again, you will have to reassure your child that this is not happening because of something he or she did.
• Teenagers (13-18 years): With teenagers, it might be easy to convey the information since they can understand more complex details. You can even ask your teen to interact with other cancer patients and social workers to understand how their lives will change.
• Irrespective of age groups, your child can feel better if he or she sees family members dealing with the illness calmly. You must remember that cancer doesn't mean your child has to break off from school and friends. So make sure that your child's inter-personal communications continue as they are.

3. How can you help siblings cope with cancer diagnosis?

Siblings of cancer patients can also feel a tremendous amount of pressure and stress. Since family routines will now change, they may feel overwhelmed, anxious, stressful, and even angry. They may also find it difficult to manage their school and academics.

So here are a few things you can do to help the siblings ease into the situation:

• It helps if the siblings are aware of the illness and you are honest with them about what can possibly happen to their sister or brother.
• You can arrange hospital visits so the siblings can see their brother or sister and meet the hospital team.
• Explain the illness and the treatments so it's not a complete shock when they see their sibling lose hair or become weak and frail.
• Make sure that their routine is as normal as possible and that you reassure them with your love and support.
• If they are infants, you can FaceTime and sing to them, just to let them know you are around. If they are preschoolers, they may throw tantrums. So set the rules as you would normally and explain why you may be sad. For school-going kids, you need to reassure them and help them meet their unwell sibling. You can even ask them to write letters to their sibling. For older teenagers, arrange a tour of the clinic so they can meet the healthcare providers. You can ask them to help out when needed, but not become the primary caretaker of the house, because they need to live their childhood as well.
• In all the cases, you need to monitor the behavior of your children. Too much withdrawal from interpersonal communication, avoiding school, and throwing tantrums on a daily basis are red alerts. This can hamper your spirit as well.
• Set the rules of the house and ask them to be your support system.

4. What if your child begins to talk about death?

Unfortunately, this question is inevitable.Whether it comes from your child who may be suffering or his sibling, the question of death will certainly crop up in conversations.

It is easy to say, "Of course not!" But in many cases, parents know that it's not true. Sometimes even though your child doesn't know anybody with cancer, he or she may think everybody with cancer will die because of what he or she has seen in movies or TV.

You may always approach the cancer care team to understand ways to deal with it. You can also speak to your kid in the following ways:

• "Many children who have one of the top childhood cancers do very well because there are a lot of people who work hard to take good care of them."
• "Yes, sometimes kids do die from some of the top childhood cancers. But we are sure it's not going to happen to you because the doctors have shared with us that they are working on the best treatments for you. If there is any chance, I promise I will honest and share the exact detail with you."
• "Your cancer is complex one to deal with. But we are doing lots of things to make sure that you get better. We may not always know about the future, but there are so many things we can do today to make you feel better. But I promise I will tell you if something comes up."
• "If you are worried about something you should tell me. We can always find a solution to problems when we talk."

If these don't work, you can ask the the cancer team to have a talk with your child.

5 ways to prevent top childhood cancers at home

If you are concerned that cancer may knock on your doors, there are a few things you can do to make sure your kids and your family members are healthy:

• Do not smoke: Smoking is related to various types of cancers including lung, throat, pancreas, larynx, bladder, kidney, and cervix. Mayo Clinic recommends, "Avoiding tobacco—or deciding to stop using it—is one of the most important health decisions you can make. It's also an important part of cancer prevention. If you need help quitting tobacco, ask your doctor about stop-smoking products and other strategies for quitting."
• Eat healthy. Along with saying "no" to junk, refined foods as well as soft drinks, make sure you include a fair amount of healthy foods in your daily diet. So consume green leafy vegetables, fruits, nuts and limit processed meats, to ensure you protect your kids from one of the top childhood cancers.
• Be physically active: There is no shortage of activities that you can do to keep yourself and your family active. Go out for walks, run and cycle or swim if you like. Make sure to ask your kids to include a minimum of 30 minutes of exercise in their daily routine. This will not only keep your heart pumping and your lungs clear, but also help with blood circulation.
• Protect yourself from sun: Yes, applying sunblock is a great idea and one you must not forget. But apart from that, you should avoid mid-day sun, stay in the shade during harsh hot days, and cover any exposed area. These measures can prevent the top childhood cancers from affecting your little ones.
• Get some immunity: If you want to protect your family from any of the top childhood cancers, make sure you protect them from viral infections as well. So get immunization shots fro Hepatitis as well as Human papillomavirus (HPV).

Sources: IARC, American Cancer Society, Roswell Park, American Society of Clinical Oncology

ALSO READ: Clever mom diagnosis child's cancer, thanks to the Internet

(All images courtesy: Wikimedia)

Republished with permission from: theAsianParent Singapore