Pediatric Oncology : Past, Present and Future

Each of us needs to realize the enormity of the debt we owe to the past, so that we can be proud of who we are in the present and can work for a better life for our children who are yet to come ~ Maya Angelou

Though pediatric cancers account for a small proportion of all cancers, their psycho-social impact is much greater. Compared to adult cancers, the disruption to family life and functioning is usually felt more for children wherein it often evokes greater sympathy as well. In the 1970’s, the advent of combination therapies brought about specialized care for patients with differing needs and increased survival of children with cancer. Prior to that time caring for a child with cancer was usually of short duration and focused on helping the child and family face the inevitable death. Since 1973, and with the NCI driven co-operative group trials in the US, there has been a steady increase in the five year survival rate. With modern treatment childhood cancers have cure rates of more than 80% in the developed world. Globally, these achievements are not as significant because 80% of the world’s children live in low- middle-income countries, where cure rates range from 20-40%.

Pediatric oncology as a specialty was virtually non-existent in the early 1980s in India. Most children were treated, often unsuccessfully, by adult oncologists in a few cancer centers or by self-trained pediatricians in medical colleges. There was lack of good quality pediatric cancer units (PCU) and multidisciplinary or protocol based care. There were only a handful of pediatric oncologists, who were usually trained abroad. The first dedicated pediatric cancer unit was started in Tata Memorial Hospital in 1985. In a nationwide survey of pediatric oncology services in 1988, 50% of cancer centers had adult oncologists treating children, only 10% had trained pediatric oncologists, and less than 15% had dedicated beds for pediatric patients or facilities for platelet transfusion. In the non-government sector, Rajiv Gandhi Cancer Institute and Research Centre lead the way in establishing the first private dedicated pediatric oncology unit in the country in 1998. Today it boasts of one of the best state-of the art comprehensive childhood cancer facilities at par with its western counterparts.

While advancements in chemotherapy, radiotherapy, organ and limb preserving surgeries have had a remarkable impact on the overall survival of children afflicted with cancer over the past few decades, pediatric malignancies continue to be a leading cause of death by disease in people younger than 20 years of age. In addition, many patients that survive into adolescence and beyond often do so with a host of debilitating treatment-related side effects that can permanently impact their quality of life. Immunotherapies are an emerging form of treatment that are designed to help the patient’s immune system eradicate cancerous cells while mitigating many of the unfortunate sequelae associated with conventional therapies. Numerous forms of immunotherapy have shown promising results in adult malignancies, paving the way for their implementation against various types of childhood cancers. The landscape of pediatric cancer has seen a dramatic shift in the past few years with the evolving role of immunotherapy. Tremendous efforts have been made in defining the genetic landscape of childhood cancers and this has fuelled initiatives to develop pediatric cancer-specific therapies and to provide guidance and direction for precision medicine treatment of individual patients. “Future match-making”, is a recent term coined for this process.

Hence the future of pediatric oncology will be influenced by changes in drug design and treatment strategy, with genomic medicine and molecular-based diagnostics and therapeutics playing increasingly important roles. Incorporating these techniques into new response-directed treatment algorithms will be crucial as personalized medicine and molecular-targeted, tumor-specific therapies gain acceptance for the treatment of children with cancer.

It is our responsibility to ensure that all children and adolescents with cancer benefit equally from this progress. Indeed, studies have documented disturbing racial/ethnic disparities in cancer incidence and survival rates. And, unfortunately, our youngest are not shielded from this harsh reality. In September 2018 WHO announced a new effort – the WHO Global Initiative on Childhood Cancer – with the aim of reaching at least a 60% survival rate for children with cancer by 2030, thereby saving an additional one million lives. India is committed to this initiative. This new target represents a doubling of the global cure rate for children with cancer. Hence we need accurate registration of childhood cancer cases and studies that allow us to better understand the relative contribution of the factors that cause disparities, as well as finding ways to help remedy disparities at the institutional and community level. It also means supporting research to identify biological factors that contribute to disparities.

Dr. Gauri Kapoor MD, PhD (Guest Editor)
Director Pediatric Hematology, Oncology & BMT
Medical Director, Rajiv Gandhi Cancer Institute and Research Centre, Niti Bagh