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Victory in cancer cure is not always as sweet as publicized
The manuscript by Kevin R. Krull, PhD, and colleagues in the Journal of Clinical Oncology (Survivors of childhood ALL need continued support for neurocognitive impairments) and the one by Donghao Lu and colleagues in Annals of Oncology provide a sobering perspective to the major advances achieved in curing cancer and, as such, suggest that the term “victory” should be used with caution.
Lu et al invite us to consider some of the immediate ill effects the disease and treatment have on young individuals diagnosed with cancer, whereas Krull and colleagues point to ill effects that can occur decades after diagnosis and treatment.
Both studies are a strong reminder that the “fight against cancer” cannot and should not solely be a fight against a disease, but rather treatment and management of individuals with a disease.
Max J. Coppes
Although common sense suggests that eradication of cancer as a disease is not compatible with life in the vast majority of cases and therefore a vital part of managing a child, adolescent or young adult with cancer, both studies demonstrate the vulnerability of the individual who deals with cancer. As we care for patients with cancer, we can never lose sight of how cancer itself or our interventions affect the individual and his/her family and friends.
Krull et al confirm what has become increasingly clear in the past decade: Cancer cure in pediatric oncology comes with a price for survivors and, as a consequence, society as a whole. It is true, of course, that it takes survivors (success in destroying cancer cells) to find out what, if any, effect treatment has on healthy cells and organs, but recent studies have started to have a sobering effect on oncologists — in particular pediatric oncologists — declaring victory in the “battle against cancer.”
Krull’s study shows that treatment modalities used in acute lymphoblastic leukemia, the most common childhood cancer, can have profound and lasting unintended effects on the central nervous system (CNS), resulting in neurocognitive impairments. In the early days of childhood cancer treatment, routine cranial radiation therapy for the treatment of ALL was introduced when clinicians noted a disproportionate number of relapses occurring in the CNS (and testes for boys) following systemic chemotherapy-only treatments. The addition of cranial radiation certainly led to many more leukemia cures but, over the years, survivors treated with treatment protocols that included cranial radiation therapy displayed in alarming numbers hormonal and CNS complications attributed to radiation. This observation led to the exploration of treatment protocols that did not contain routine cranial radiation therapy for childhood ALL.
As a whole, the new approach — which included the intrathecal administration of chemotherapy agents as a substitute for cranial radiation — demonstrated to be effective and is now considered standard of care. However, chemotherapy agents given systemically and/or intrathecally, used to replace cranial radiation, have turned out to be not without complications, either. Methotrexate, in particular, when given systemically or intrathecally, has shown to cause neurocognitive impairments. Now Krull et al demonstrate that dexamethasone — which, when given systemically, penetrates the CNS better than prednisone and therefore is seen as a more effective anti-leukemia agent — also affects neurocognitive function, independently from methotrexate. Their observation not only suggests that careful long-term monitoring of children cured from their cancer is paramount to ensure a true understanding of their needs as they grow up, but also form an invitation to study the biological factors that determine which patients will experience neurocognitive impairments secondary to treatment and which patients are spared (or are they really?).
Lu’s study suggests that our attention also needs to focus on more immediate unwanted events associated with treating patients with cancer. Given the fact that both cancer and suicide in young adults are relatively rare events, it is unlikely that the described increased risk for suicidal behavior in young adults with cancer would have been revealed if not for the wonderful registries in Sweden and their ability to conduct large population-based studies. As such, the oncology community has been enriched with knowledge that could and should allow oncologists to include yet another dimension of the patient with cancer that requires careful attention during treatment.
The absolute numbers of suicide attempts in the study population analyzed — 136 in 12,669 cancer patients — may not be alarmingly high, but in many ways masks the utter tragedy associated with the 22 deaths due to completed suicides. Although current medical knowledge around many psychiatric disorders remains limited at best, most health care providers still consider suicide preventable, recognizing that intervention is not always successful. It is possible that future developments in the medical field will provide targeted interventionable pathways associated with suicide, but at present, awareness that a vulnerable patient is at risk for suicide provides the best approach to prevent a patient from taking their own life.
Lu and colleagues alert us that young adults with cancer are indeed at increased risk of suicidal behavior. Unfortunately, this study, although providing important information, offers limited practical clues that would allow clinicians to better identify young individuals with cancer at risk for suicide. It is therefore suggested that the mental status of each patient with cancer be carefully assessed and monitored. Given the enormous stress experienced by our patients, any indication that the mental burden is too hard should be taken seriously and professional help offered.
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Max J. Coppes, MD, PhD, MBA, is president of BC Cancer Agency. He also is a HemOnc Today Editorial Board member. He can be reached at BC Cancer Agency, 600 W. 10th Ave., Vancouver BC V5Z 4E6; email: mcoppes@bccancer.bc.ca.
Disclosure: Coppes reports no relevant financial disclosures.