The Case For A Children's Cancer Center
The Tumor Board
Editor's Note: Reports concerning cancer in relation to amputation and prosthetic management were published in the February and April 1966 issues of the ICIB. The present article highlights a number of general points of interest regarding cancer in children. It appeared in Ca, Vol.16, No. 2, March-April 1966, and is reprinted here by permission of the American Cancer Society, Inc.
Cancer constitutes an increasing hazard to life and health during childhood years. Although great strides have been made toward the control of other conditions, cancer is becoming more conspicuous in childhood mortality. Between the ages of one and 15 years, cancer is the leading cause of death from disease, with a rate increase in the last two decades from 5.2 per 100,000 children to 8.1 per 100,000, an increase of some 50%.
From a biological as well as a sociological standpoint, children are not small adults, and their specific needs fully justify the establishment of special facilities for their care. It is our conviction that a child-oriented center devoted to the problem of cancer and allied conditions in children is not only desirable but mandatory.
The primary goals of such a center are threefold: (1) to provide to the community the best possible diagnostic and treatment services for children having or suspected of having cancer; (2) to provide teaching programs for the diagnosis and care of this disease to physicians, medical students, and ancillary personnel; and (3) to develop clinically oriented and basic research programs directed toward the eventual prevention and cure of childhood cancer.
The type and behavior of cancer in children differ widely from that in adults (Table 1 ). In contrast to an over-all cure rate of some 42% in adults, less than 20% of children with cancer are cured. Cancer in children, in more than 65% of the cases, first presents as a generalized disease in which surgical removal is of no avail. Many of these cancers are congenital in type and appear in early infancy, during which time few if any symptoms are presented. For this reason, diagnosis is significantly delayed and cancer is most often recognized late and only after spread has occurred.
Also widely variant from the adult cancer problem is the necessary follow-up care. The number of patient visits for the care of the child and counseling of the parents is estimated to be three times that required of adults. Thus, in spite of the seemingly low statistical incidence of cancer in children, the time and effort expended in the care of a child often exceeds that which is required for an adult.
The use of radiation for cure of cancer in children presents a much more complex problem than it does in adults. The arresting effect of intensive radiation on growth processes and the possibility of genetic changes must always be considered.
Because of the fundamentally different nature of childhood cancer, perplexing diagnostic difficulties are often presented to the clinician and pathologist. It has been our experience, as well as that of others, that a considerable number of diagnostic errors are made by the general pathologist. It is by no means rare for benign conditions in children to be interpreted as malignant, and hence, for the children to receive radical and unnecessary therapy; and conversely, malignant lesions may not be recognized as such at a stage when they are still curable. The pathology department of a large children's hospital recently reported diagnostic errors in 507. of slides of malignant tumors of children submitted to them by general pathologists.
The etiology of cancer in children differs from that usually considered responsible for tumors in adults. For example, aniline dyes, hydrocarbons, and cigarette tars seem unlikely to be related to the genesis of cancer in children under age fifteen. It seems more reasonable to consider that the majority of tumors in children arise before birth, probably as a result of error in organ differentiation during embryonic life. Thus, research oriented toward the pathogenesis of tumors in adults will probably find limited application to children.
We feel that many tumors of children can eventually be conquered. Modern techniques of management have markedly improved the prognosis for several common tumors in this age group. For example, somewhat over 50% of neuroblastomas occurring during the first year of life are now being completely cured. The life span in childhood leukemia has been increased from a median of 50% survival for three months 15 years ago to a current median of over 16 months. Encouraging developments in the elucidation of fundamental mechanisms regulating growth of embryonic tissue afford real hope for practical benefit in the case of tumors derived from such tissues.
The cure of cancer in a child is a particularly significant triumph when one considers the long-term salvage. Those who deal with the problems of children's cancer think in terms of 70-year survival, rather than the 5- to 10-year survival span, which is the mark of successful cancer therapy in adults.
The social problems created by cancer in children are of the utmost importance and constitute a somewhat neglected area in over-all care. The intensive nature of treatment required for a child is often not understood, and extreme delicacy and sensitivity must be exercised in providing such therapy to the innocent child with cancer. Parents of these children are usually young and starting out in life with limited financial resources, thus increasing the severity of the burden of a malignant disease upon the family group. The treatment of the whole family group is an integral part of cancer therapy in children.
To correlate these isolated findings, there exist in this country approximately six centers devoted to the study of cancer in children. There can be little question that a regional Children's Cancer Center, drawing from a wide geographical area, can make a significant clinical and epidemiologic contribution to the solution of this problem.
The highly specialized nature of the problems presented by childhood cancer and its treatment justifies an aggressive attack and its complexity demands the coordinated efforts of many disciplines. This effort can be made with maximum efficiency in a Children's Cancer Center.
The Tumor Board of the Children's Orthopedic Hospital and Medical Center Seattle, Washington: J. Bruce Beckwith, M.D.; Alexander H. Bill, Jr., M.D.; Robert C. Coe, M.D.; S. Allison Creighton, M.D.; Jack M. Docter, M.D.; John R. Hartmann, M.D., and Byron H. Ward, M.D.