Adolescents who undergo adult cancer treatment programmes may not do as well as those on paediatric programmes, according to a consultant paediatrician. Anne Dempseyreports
Some adolescents with cancer could be described as the "lost tribe" in terms of treatment protocols, a consultant paediatrician in Crumlin children's hospital has claimed.
Prof Owen Smith says adolescents who, because of their age and/or location, enter an adult cancer treatment programme may do far less well than a peer in a hospital which offers a programme based on a paediatric model.
The two treatment protocols differ substantively, and have different outcomes for leukaemia and some types of lymphoma.
"I call it survival by post code," he says.
Children and adolescents are a tiny proportion of the total population who contract cancer in Ireland annually - about 250-300 out of 26,500. Incidence and mortality rates for child/adolescent cancers are similar to US and Europe, as are current survival rates.
However, Smith, a consultant paediatrician haemotologist, says the Republic will not keep pace, as Britain and France are treating their adolescent cancer patients differently.
"Survival rates are directly linked to clinical trial participation, and in the US and EU, the number of adolescents entered in clinical trials is exquisitely small. The value of such trials is the constant monitoring and ongoing learning they offer," he says.
Leukaemia, lymphoma, brain cancer and sarcomas (tumours of the muscle and bone) make up most adolescent cancers. In particular, Acute Lymphoblastic Lymphoma accounts for one-third of cancers in children and young people. "We can now cure 85-90 per cent of these - a fantastic result," he says.
"Although the same cure rates do not apply to older adolescents and young adults, those treated on paediatric rather than adult protocols have a much better survival rate, the improvement is in the region of 20-30 per cent," he says.
"If there was news of a 5 per cent improvement in survival rate in one of the adult cancers, it would be in all the medical journals, it would be on Morning Ireland, it would have cost billions of dollars in drug development to achieve," argues Smith.
But for this group with this type of leukaemia - I am saying that by simply shifting them across from an adult to a paediatric protocol, we can make this enormous difference in survival rates," he says.
He cites three main differences between adult and paediatric protocols in treating Acute Lymphoblastic Lymphoma. First, the medication is given more frequently and in a more intense form within the paediatric protocol, compared with adult protocols as it is thought a stronger dose is more toxic for adults.
However, Smith says this has been largely disproved, most notably through research carried out at the Dana-Farber Cancer Institute, Boston, which found no increased toxicity in adults receiving the drug asparaginase in more concentrated form. Also, he says, paediatric programmes typically move more quickly from delivering the first tranche of induction medication to delivering second-stage consolidation treatment, which benefits the patient.
Secondly, he says, in the paediatric setting, you have a multidisciplinary team approach which includes patient, parents and family in an inclusive way, not necessarily the case in an adult hospital.
Thirdly, there is the psychosocial factor which indicates that adolescents do best with peers.
"Peer pressure works positively in terms of compliance and in giving a much greater sense of wellbeing," he says.
An eight-bed adolescent cancer unit is due to open at Our Lady's Hospital, Crumlin next year. Not surprisingly, Smith would like it to be the primary unit nationally, with the hope that the designated eight adult cancer hospitals (as proposed in the Cancer Strategy) would each have an adolescent annexe assigned for share care of these patients.
Sixteen-year-old Megan Fiorella, from Shankill, Co Dublin, contracted leukaemia when she was 11.
"I suffer from allergies anyway, and can feel very tired, so at the beginning we put it down to that, but was lucky that we have a very good GP who suspected the symptoms quite quickly," she says.
Megan was lucky too in being treated at Our Lady's Hospital, Crumlin. "I went on Regimen B, quite a high dosage. I suffered badly from side effects. The 'chemo' feels like it is killing you, it is just as bad as the cancer, so you really have to have faith in the doctors.
"Being in a ward with little kids is quite difficult. I was lucky that I had someone my age, Sarah Jane, in the room beside me during my treatment. We're still friends" she says. "Also, people from Canteen, teenagers who have had cancer, come to visit you. It really helped a lot."
Megan got the all-clear two years ago, and still attends Crumlin for regular check- ups.
Tony O'Brien chaired the HSE Management Cancer Control Network and Centres Working Group charged with furthering the development of the National Cancer Control Programme. He says there is broad agreement that a paediatric protocol for some adolescent cancers will produce better outcomes.
"What Owen Smith has done shows the benefits that flow from applying a paediatric protocol to adolescent patients and is a shining example. As a country, we are ahead in paediatric oncology but behind in adult oncology, which could benefit from following the paediatric template, though we still have a long way to go.
"The point that Owen is making to create adolescent-specific environments offering paediatric protocols is based on good evidence. I believe the implementation of the Cancer Control Network creates a very positive context in which to implement this type of change. I am hopeful and supportive," he says.
Prof Owen Smith is organising an international conference which will be held in Dublin on November 1st and 2nd. Entitled Hot Topics in Paediatric/Adolescent Leukaemia and other blood diseases, co-organisers include the Regional Oncology Programme office at St James's Hospital and Trinity College Dublin.