By Lynne Lederman, PhD
As the first pediatric oncologist to be elected president of the American Society of Clinical Oncology, Dr. Link’s career has been heavily influenced by his patients and their families, whom he refers to as his partners and collaborators. Link believes that the collective goal to conquer cancer depends more than ever on partnering within and across specialties, and that pediatric oncology can serve as a model for the future.
Over the 40 years since the National Cancer Act was enacted, the number of cancer survivors has increased, 5-year survival has increased, and patients are living longer with improved quality of life. Moreover, progress in the management of children with cancer is one of the great success stories of modern medicine with dramatic improvement in outcome for almost every category of childhood malignancy. For childhood acute lymphoblastic leukemia (ALL)—the most common childhood cancer, accounting for almost 30% of the cases—5-year survival rate approaches 90%.
The successes in pediatric oncology are due to many factors, such as the responsiveness of tumors to chemotherapy and radiation, pediatric patients are in generally good health with few co-morbidities, and they can withstand and recover from the most intensive therapies. However, this may be changing as more young people develop obesity.
Link said that pediatric oncology pioneered the multi-disciplinary approach to patients. Collaborations among investigators from different specialties facilitated break-through findings and promoted early successes. Clinical trials became the standard of care in pediatric oncology, with the majority of children with cancer in North America participating, and findings from clinical trials were rapidly incorporated into practice. The result of partnerships with laboratory investigators led to the knowledge that pediatric cancers are heterogeneous collections of diseases within organ-specific or morphologic types.
As an example, the ease of obtaining, purifying, and storing leukemic cells facilitated the discovery that ALL is a heterogeneous disease with multiple subsets having different genetic mutations and markedly different prognoses and responses to therapy. This finding is informing the development and use of targeted therapies. However, one consequence of discovering that cancers are so heterogeneous, and therefore like collections of orphan diseases, is the difficulty in accruing sufficient patients to prove efficacy and safety of new agents. In addition, keeping the pharmaceutical industry engaged in pursuing specific targets of interest in increasingly narrow populations is also challenging.
This year, 50 million Americans, almost 15% of the population, had no health insurance, putting them at considerable risk for personal bankruptcy in the event of a serious illness. Twenty-five percent of working adults and 10% of children are uninsured; 25 million non-elderly adults and 35% of children are insured through Medicaid. Data show that the outcome for patients with cancer who are covered by Medicaid is as poor as that for those without insurance and both groups have a worse outcome than those with insurance. Oral targeted agents are available and more are in development, yet their high costs and high copays make them unaffordable for many with insurance. Targeted therapies only work if patients take them, and patients will do so only if they can afford them, Link said.
Another major issue that has emerged over the past few years that poses an increasing threat to the health and welfare of patients is the shortage of generic, sterile, injectable drugs, including anti-cancer agents. Link pointed out that any new-found insight into diseases and their treatment is only as good as the ability to deliver on what is known. During 2011, shortages of 251 drugs were identified, including at least 23 chemotherapy agents. “The current chemotherapy shortage is emblematic of the precarious nature of the path between the discovery and delivery of our most exciting new findings.”
Link also pointed out that there are obstacles to transferring our knowledge to the developing world. Aging populations in low- and middle-income countries account for 85% of the world’s population and will lead to an “anticipated tsunami of cancer cases” that will overwhelm their countries’ resources. Although 80% of children with cancer in resource-rich countries will survive, in resource-poor countries 80% of them will die. At this year’s United Nations’ high level meeting on non-communicable diseases, world leaders committed to speed global progress on cancer and other diseases, and ASCO will be joining in this effort.
Pediatric oncologists have pioneered the concept of survivorship and the issue of long-term consequences of anti-cancer therapy. Children who are cured of their cancer can expect almost an additional 70 years in which to develop and cope with side effects of therapy, and efforts are being made to understand and manage these complications. Link pointed out the value of prevention strategies, including vaccination against hepatitis B to prevent hepatocellular carcinoma and against human papilloma virus (HPV) to prevent cervical cancer and head and neck cancer, as well as counseling on smoking, diet, and sun exposure.
“Our best strategy would move us from the paradigm of diagnose and treat to one of predict and prevent. Here, too, pediatricians may hold the key, since the best opportunity to prevent cancers in adults is proper immunization and life-style counseling of children.”
Although Link bemoans the “businessification” of medicine, including characterization of patients as “customers,” he keeps in mind the philosophy of the physician Francis Peabody, who wrote 85 years ago, “One of the essential qualities of the clinician is interest in humanity, for the secret of the cure of the patient is in caring for the patient.”