Thursday, September 20, 2012
Kids cured of cancer still have problems
A favorite though sad story of mine that I like to tell my medical students concerns an adolescent I treated for leukemia many years ago. He was extremely bright and was planning a career in mathematics. Years of leukemia treatment had taught us that even though we can “cure” leukemia in the blood and bone marrow, it would come back in the brain and spinal fluid unless we treated those areas also. At that time, once the initial treatment was over, we would then administer radiation therapy to the brain along with chemotherapy into the spinal fluid. These extra treatments are needed because chemotherapy given into the blood doesn’t reach the spinal fluid or brain. And so this young man completed all these treatments and after several months confessed to me that he didn’t feel as competent as he once did in math and perhaps he would try to become a doctor (presumably because it required less brain power). The sad story is he never reached this goal because his leukemia came back and eventually took him away. Now as well as then, most children with acute leukemia are cured – the number is probably greater than 90 percent. My patient recurred because in older children or adolescents the cure rate is much lower. But still, after their treatment these youngsters have problems. One good piece of news is that we have found that we can do without the radiation to the brain by replacing it with lots more chemotherapy into the spinal fluid. In a recent study (Journal of the National Cancer Institute, September 2012) from St. Jude Hospital where much of our childhood leukemia therapy originated, it was found that by avoiding radiation, leukemia survivors retain normal intellectual function. They may have a little problem with attention deficit, but otherwise seem to function normally. This is good news because the treatment given to children with cancer often has devastating effects. Recently, a paper in the Journal of Clinical Oncology (September 20, 2012) highlighted the hormonal effects of treatment. Young men can develop without normal male hormone levels and need boosts of testosterone so they can develop normally. Or, they can end up with too much hormone production and go into puberty at a very early age. Some experience sexual dysfunction and also infertility. Woman can also become infertile. Both groups have trouble with their sex lives. Childhood cancer survivors need lots of help throughout their lives. But, in our dysfunctional health care system, this is often difficult. Even though they can get health insurance, it might be much more costly and the costs of copays and deductibles discourage them from seeking care. It is a lot more expensive to get all the tests needed to follow a cancer survivor than someone without that history. There should be some way to give them a break. These young people have gone through enough. Perhaps “Obamacare” will solve their problem.