From OncoLog, October 2007, Vol. 52, No. 10
Customized Cancer Care for Kids
by Vickie J. Williams
Childhood cancer, though rare, is the leading cause of disease-related death among children 1 to 14 years old. Leukemias and lymphomas are the most common childhood cancers, followed by brain tumors, neuroblastomas, and sarcomas. Each year, more than 1,200 children receive treatment for these and other malignancies at the Children’s Cancer Hospital, an M. D. Anderson component where clinical care and research are centered on the unique needs of pediatric patients.
“We are different from other children’s hospitals because our efforts focus exclusively on cancer, and we are different from other cancer hospitals because our patients are exclusively children,” said Eugenie Kleinerman, M.D., professor and head of the Children’s Cancer Hospital and the Division of Pediatrics.
The whimsical décor of the Children’s Cancer Hospital is paired with advanced treatments and an active program of scientific discovery. The staff assesses and treats patients at all stages of disease, from infants to those who have survived cancer from childhood into their 20s. As a result of this broad experience, Children’s Cancer Hospital physicians and scientists have developed several anticancer and supportive-care treatments for children and adolescents—contributing to the national 70% cancer cure rate in these populations—and clinical trials of promising treatment regimens are ongoing.
Novel therapies
As an example of the institution’s childhood cancer research, Dr. Kleinerman, Peter Anderson, M.D., Ph.D., professor of pediatrics, and Cynthia Herzog, M.D., associate professor of pediatrics, have launched investigations of the aerosol administration of chemotherapy for pediatric patients. In this approach, patients breathe in anticancer drugs using a hand-held nebulizer much like the ones used in asthma treatment. An ongoing study by Drs. Kleinerman and Anderson involves the use of aerosol-delivered cytokine therapy to treat tumors that have spread to the lungs, such as metastatic Wilms tumor. Dr. Herzog’s study involves the use of aerosol-delivered L9NC with temozolomide for the treatment of relapsed and high-risk Ewing’s sarcoma.
“The goal of aerosol technology is to provide a kid-friendly treatment modality that eliminates the discomfort and inconvenience of intravenous administration and that provides children with a procedure they can learn to do on their own at home,” Dr. Anderson said. Patients are trained to use the nebulizer and a lung-function monitor that records the patient’s pulmonary parameters and transmits the results back to M. D. Anderson for a physician to review. Patients perform the procedure under the supervision of a nurse for an initial period. “This approach appears to be working. Our patients are pleased that they do not have to return to the hospital as often and that they can get back to school faster,” said Dr. Anderson.
As part of the Children’s Cancer Hospital’s expanding research platform, new research endeavors will focus on understanding the genetic alterations in tumors, why tumor cells are resistant to chemotherapy, and the mechanisms that cause learning disabilities in children with brain tumors and neurofibromatosis.
From laboratory to clinic
Many one-time experimental therapies in pediatric oncology developed at M. D. Anderson have since moved into clinical practice. M. D. Anderson researchers designed a limb-salvage perfusion technique that is now used in more than 75% of young patients treated for malignant bone tumors. Other research resulted in the first successful chemotherapy for Wilms tumor; the nation’s first neuroblastoma screening program for infants; and the first clinical trials in the United States of oral antibiotics for treatment of low-risk fever and neutropenia in pediatric patients with cancer, which opened the door for outpatient therapy. The Children’s Cancer Hospital was also among the first centers to use umbilical cord blood for stem cell transplantation.
Among the many anticancer agents developed at the Children’s Cancer Hospital are clofarabine, the first drug approved by the U.S. Food and Drug Administration specifically for the treatment of pediatric leukemia, and liposomal muramyl tripeptide, an immunotherapy that, when combined with chemotherapy, increases cure rates for children with osteosarcoma.
Shared resources
A major benefit of the “hospital within a hospital” structure that M. D. Anderson has adopted for pediatric care is that it fosters adaptation of adult care advances for use in children. “There are only a few large cooperative-group trials in pediatric cancer,” Dr. Kleinerman said. “But M. D. Anderson conducts more clinical trials than any other cancer center in the country. We constantly monitor the results of these trials so we can incorporate therapies into our pediatric care plans as soon as they are proven safe and effective. Our patients are often the first children to have access to these novel treatments and to state-of-the-art diagnostic and therapeutic resources.” Those resources include the new Proton Therapy Center, the BrainSUITE system, and positron emission tomography–computed tomography (PET-CT) fusion imaging technology.
Radiation therapy is used in the treatment of many pediatric cancers, including tumors of the brain and bone and soft-tissue sarcomas. Conventional radiation delivery can damage normal tissues, which can cause long-term side effects in children, including a decrease in bone development and in the growth of soft tissues. In many cases, children who require radiation therapy will now be treated with proton therapy. “With proton therapy, there is a higher likelihood that the radiation can be confined to the primary site, which in many cases translates into improved treatment outcomes and improved quality of life as the child grows into adulthood,” Dr. Kleinerman said.
Brain tumors, which are the most common solid tumors in children, are usually treated surgically. Children with brain tumors benefit from BrainSUITE, a collection of image-guided surgery technologies that enable precise excision of complicated tumors in sensitive areas of the brain. The system provides real-time views of the tumor site during neurosurgery with intraoperative magnetic resonance imaging.
PET-CT fusion imaging improves on the capability of standard CT to detect hard-to-find tumors and is useful in monitoring therapy and communicating treatment decisions to patients and family members. “The high quality of the images produced by PET-CT fusion not only makes it easy to locate an evasive tumor but also provides information on how aggressive the tumor is, which helps us determine the best local-control strategy,” said Dr. Anderson. This technology is particularly useful in the management of solid tumors.
Treating the whole child
But the Children’s Cancer Hospital delivers more than just medical care. “At the foundation of our care plans is our mission to treat the whole child,” Dr. Kleinerman said. “We have created physical spaces and supportive-care programs designed to provide our young patients and their family members with addition to a 26-bed inpatient unit and an outpatient unit, there are primary- and secondary-school classrooms, a library, playrooms, a teen lounge, an indoor recreational area with a basketball goal, a laundry room, and a kitchen.
In addition to their medical needs, pediatric patients also deal with many psychological, emotional, and developmental concerns. “We offer a host of programs designed to help our young patients understand what is happening to them, to adjust to present and inevitable changes, and to prepare for their future,” said Renee Hunte, director of Child Life Services for the Children’s Cancer Hospital. Many of the concerns of pediatric patients mimic those of adult patients, but children also have unique needs. “Across the board, the children’s primary concerns are quality of life and getting back to school, and adolescents experience additional concerns such as body image and relationship concerns,” Hunte said. “Our patients are smart. Even the younger ones will ask pointed questions—Will the treatment hurt? How long will I be in the hospital? How will radiation therapy affect me later in life? Will I die?” The Behavioral Pediatrics team, which consists of social workers, a chaplain, a psychologist, child-life specialists, and teachers, is assigned to each patient. Their goal is to cultivate an environment in which patients can express themselves freely and where questions about treatments, spiritual concerns, and life after cancer can be addressed in confidence and at an appropriate developmental level.
Certified teachers in the hospital’s in-house school program work with a child’s community-based teachers to make sure his or her regular curriculum is followed as closely as possible and that the transition back to the regular school environment after treatment is accomplished smoothly.
“Kids rule, not cancer”
The emphasis on social support services—and the understanding that medical care is only part of what a pediatric patient needs—ties in with the Children’s Cancer Hospital mantra: Kids rule, not cancer. “We know a lot about cancer, but we also know a lot about children,” Dr. Kleinerman said. “And our biggest lesson has been that kids with cancer are still just kids.”
Hotline Consultation Available for Suspected Cancer CasesDifferentiating between the numerous types of cancers, recognizing the various signs and symptoms of the disease, and choosing from the assortment of diagnostic tests and treatment options available can be daunting. The challenge is especially problematic for community physicians who do not encounter the disease routinely and in the case of children. The Children’s Cancer Hospital’s Suspicion of Cancer Program takes some of the challenge out of these tasks by providing community physicians with a telephone consultation and referral service. The Suspicion of Cancer Program is an information hotline that physicians can call during and after regular business hours and on weekends to speak directly with a pediatric oncologist about a case. “The questions vary from very general to very specific,” said Bill Walker, associate administrative director of the Children’s Cancer Hospital at M. D. Anderson. “For example, a physician might want to discuss a patient’s symptoms, get assistance in deciding which diagnostic test is appropriate, or inquire about findings on previous tests. Whatever the concern, the physician does not have to wait until the next day or for the call to be returned—he or she will have an answer right away.” The program’s goal is to support the early detection and treatment of cancer. “Timing is crucial during the initial assessment period,” Mr. Walker said. “The early exchange of important details between the patient’s local health care provider and an M. D. Anderson specialist can facilitate timely and accurate diagnosis and treatment.” Depending on the case and the physician’s particular dilemma, an M. D. Anderson oncologist might recommend that:
A referral can be requested by the physician, patient, or patient’s parent and can typically be scheduled immediately. “We know that with children, it is important that any transition in care—for example, from a local setting to a cancer-center setting—be accomplished in a smooth and speedy fashion,” Mr. Walker said. “Most referral appointments can be scheduled within a day or two.” Eugenie Kleinerman, M.D., professor of pediatrics and head of the Children’s Cancer Hospital and the Division of Pediatrics, said the Suspicion of Cancer Program is in place to give community physicians more options in providing their patients with the best care. “We consider this program a partnership through which we not only contribute to patients’ early diagnosis and make relevant treatment recommendations but also share our knowledge about cancer with community-based physicians,” said Dr. Kleinerman. |
For more information on this topic or for questions about M. D. Anderson’s treatments, programs, or services, call askMDAnderson at (877) MDA-6789.
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