Children's Cancers: Open Discussion with ZoAnn Dreyer

Last Editorial Review: 10/23/2003

WebMD Live Events Transcript

Do you have a child recently diagnosed with cancer? ZoAnn Dreyer, MD, Medical Director of the Texas Children's Cancer Center Ambulatory Service, will be on hand to field any questions you may have regarding children and cancer.

Event Date: 06/02/2000.

The opinions expressed by Dr. Dreyer are hers and hers alone. If you have questions about your health, you should consult your personal physician. This event is meant for informational purposes only.

Moderator: Good evening all and welcome to WebMD Live! Our guest this evening is ZoAnn Dreyer, MD. Dr. Dreyer is medical director of the Texas Children's Cancer Center Ambulatory Service and Long-Term Survivor Program. Welcome, Dr. Dreyer.

Dr. Dreyer: Hello to anyone that's chatting. I'm happy to answer any general questions about pediatric patients, children with cancer of all ages. For pediatric care doctors, that includes kids up to 20 years old.

Moderator: How prevalent is cancer in children?

Dr. Dreyer: Cancer is not common in children, although it's the second most common cause of death, second to accidents. The incidence rate of kids under 15 is 14 per 100,000 in the U.S. It's pretty rare, certainly, compared to adult cancer.

Moderator: What are the most common types of childhood cancer?

Dr. Dreyer: The most common two things in children are acute lymphoid leukemia (ALL), of which there are probably three cases per 100,000, and brain or central nervous system tumors.

Moderator: What are the survival rates for those most common types?

Dr. Dreyer: The general survival rates for kids with ALL are probably about 65% to 70%, meaning that 65% to 70% of all children with ALL will be cured. Some groups of children with less aggressive disease, younger children, for example, have cure rates as high as nearly 90%. For central nervous system or brain tumors, the cure rates are closer to 50% to 60% overall, with certain groups doing better than others.

Moderator: Have there been any major advancements in cancer treatment for children?

Dr. Dreyer: Huge advances in the last two decades. For example, in 1965 only about 5% of children with ALL were cured. The advances have mainly come from giving better combinations of stronger medicines, and better understanding the particular type of cancer, so that you can actually tailor the treatment for the child, in a sense. There have also been a lot of advances in the direction of the therapies we use, such as how we deliver radiation therapy, and what sort of studies we can do on tumor cells to identify how they will do with different types of chemo (chemotherapy) drugs.

beetneck_WebMD: Are there a lot of clinical trials involving children?

Dr. Dreyer: About 85% of all children in the US with cancer are treated at major children's cancer centers. And most of those will be treated on what we call clinical trials. And clinical trials in pediatric cancer means that we're using therapy designed specifically for a type of disease that's based on the answers to research questions that have been asked in the past, so that children treated today on clinical trials benefit from the information gained from children treated before them. And in that way, we can offer them what is thought to be the very best therapy at the time they are diagnosed.

hankhankhank_WebMD: I have heard a lot of news about new cancer treatments in general. Do these also apply to children or does the article need to state this?

Dr. Dreyer: That's a terrific question. There are new drugs constantly undergoing trial or research specifically aimed at adult cancers. There are oftentimes fewer drugs available for testing in children's cancer, in one sense because there are many more adult cancer patients than children. Along the same lines, drugs that work in adult cancers may not necessarily work for children. So our therapies are quite specific for children, and not the same as an adult with a similar disease. Our cancer center at Texas Children's is actually one of the major centers in the country that works on new cancer drugs for children and that has a variety of investigational drugs available for children who have had recurrence of their disease, and drugs that are oftentimes not available at other centers, or perhaps just a few other centers.

wabe_grb_WebMD: My eight-year-old niece has been diagnosed with adult leukemia. How is that possible?

Dr. Dreyer: There are some types of chronic leukemias that are much more common in adults and quite rare in children, although most of us would not refer to that as an adult cancer. We would simply say it's a rare form of cancer in children.

wabe_grb_WebMD: Can she take the same treatment as an adult?

Dr. Dreyer: Treatment that is used to treat adults with cancer would not generally be the correct treatment for a child with cancer. In a sense, they're almost different diseases, even though they may have a similar name. Statistically, most studies have shown that even teenagers and older adolescents will have better cure rates when treated on treatment protocols designed for children. Some centers treat all patients less than 14 or 15 on children's protocols, and treat all children older than that, on adult protocols. But in fact, most data would suggest that those adolescents will do better on pediatric treatments I think the decision for treatment based on age varies a bit from center to center. For example, it's more common for an 18-year-old with leukemia coming especially from a smaller town to be referred to an adult cancer specialist than to a children's cancer specialist, which may be further away in a bigger city. As a pediatric oncologist, I think we'd agree that it's generally not the best thing for teenagers to be treated without some input from pediatric cancer specialists. Because there are so many more adult cancer doctors, especially in smaller communities, I think that's how many of the older children end up being treated in those centers. One of the unfortunate parts may be that they may not be treated for a pediatric protocol for their age group.

Moderator: What are some qualities to look for when choosing a pediatric oncologist or radiologist?

Dr. Dreyer: I think it's an advantage for that pediatric oncologist to truly be a pediatric oncologist, not a general oncologist who sees some children, but someone who has been trained in the subspecialty of pediatric oncology. Most of us would say it's important that they're certified by the American Board of Oncology as pediatric oncologists because, as most consumers probably know, once you have an MD, you can say you do anything. That's an important point. I think it's also important that the pediatric oncologist has access to a hospital setting that is used to take care of children. Oftentimes the very small community hospitals may not see or take care of many children, so that the extra supportive care a child with cancer needs, perhaps a specialist in pediatric radiotherapy, for an example, or specialist in children's infection, they're oftentimes not available in small community hospitals. Certainly being treated at a facility that's closely connected to a children's hospital or has a children's service, as some adult hospitals do, is an advantage for the patient. I think that the parent of family also needs to feel comfortable that their pediatric oncologist is open with them and answering their questions. As pediatricians, and oncologists, we're well known for spending a lot of time talking with the families and the children. And that's essential. The family and child need to feel comfortable with the doctor that they choose. Most pediatric oncology programs or centers in the country have several different oncologists as part of their group. So if you're in a hospital that you like, and it's in a good location for you, but perhaps the first member of the pediatric oncology group you meet, you're not comfortable with, then you should ask to speak with another member of the group. Most all newly diagnosed children in the country at pediatric cancer centers will be treated with protocols or therapy that is the same as, or similar to that offered in many other children's cancer centers. Which is good, because it generally means the doctor hasn't just thought up a plan for your child, but using therapy based on all of the available research information. There are some very rare cancers in children that we don't have treatment protocols for that are multi-institutional, and in those cases, the oncologist will generally review everything that's available in the literature, and confer with other oncologists about what might be the best for that child, so that no child's treatment is the design of just a single person, which is an advantage.

bobbyjones_WebMD: How can I ensure that my child receives proper pain management?

Dr. Dreyer: None of us want children to have pain. And most big centers that treat children with cancer are quite advanced in how they manage pain. Some cancers have more pain than others. For example, in our center, we have a group of doctors who are pain specialists who help us with children who have extreme or unusual pain to control. Once again, it's important to try to access the people who specialize in that if you need to. Children with cancer shouldn't have constant pain. There are ways to make that better.

bobbyjones_WebMD: How can I get my child to be more expressive about where it hurts?

Dr. Dreyer: One thing that helps us, we have people called child-life specialists, and they do a lot of play therapy with children who are scared. Oftentimes that helps the kids to communicate better. Sometimes, the kids really don't have pain, and the parents are just concerned that that's in fact the truth. So you don't really want to encourage parents to over-react to what they may think is pain, if the child isn't truly complaining. Most kids with cancer who are in remission and simply getting regular treatments don't really have pain. Cancer in children and the way they tolerate the treatment is much, much different than adults. Children are much stronger. And things that would make an adult really sick, children may not become sick from, or complain about at all.

Moderator: Let's talk about the treatment team. Who should a parent expect to make up that team?

Dr. Dreyer: Of course, the oncologist, the cancer specialty nurses, a social worker, the pharmacist, if you're really lucky, the child-life specialist, and an important part of our team here includes our psychologist. We also rely heavily on nurse practitioners.

hankhankhank_WebMD: Do you normally refer your patients to a social worker or a therapist?

Dr. Dreyer: We have social workers as part of our cancer center, and each patient is assigned a social worker from the time they come. The social workers help with all of the extra stress of being in the hospital, help to access financial resources, they help within the family if complications arise within the family relationships, and they're really essential. I think as an oncologist, we think of all the members of the team as being equally important. The social worker and child-life therapist are specialists in areas of taking care of children with cancer that I'm not an expert in. They've been trained in counseling, in family communications, each one of the team members has an area that they are an expert in, which allows us as oncologists, to not just treat the disease, but to treat and support the whole family, as well as the child, which really improves the outcome for everyone.

Moderator: Are there complementary therapies that are targeted towards children?

Dr. Dreyer: There are many centers that incorporate complementary therapies, such as massage, hypnosis, and other behavioral-type therapies, which can be very helpful. With respect to supplements, such as herbs and herbal supplements and vitamins, there are not alternatives that are supplements that replace the cancer therapy, but they may benefit the child in tolerating the cancer therapy. The most important thing a family can do, is if they're interested in exploring some of the herbal or vitamin therapies, they need to discuss it with their oncologist, to be certain the supplements don't counteract the chemo drugs, which some can. And the other risk is that they make the toxicity of the chemo drugs much worse, possibly causing liver damage, or kidney damage, or problems with other major organs. So it's most important to be completely open with the oncologist about what you might like to explore, but I think most would agree that in particular, herbal supplements are not essential to improving the chances for cure. I think that physicians have become much more open to the benefits of some of those types of therapies, and are much more open to considering their importance. There are some centers that rely on hypnosis during painful procedures. Some families that feel strongly that certain forms of massage or acupuncture may strengthen their child. I think as long as it is not a form of therapy that could jeopardize the use of chemo therapy, which you have to include, then they are certainly reasonable to explore, more from the sense of an additional aspect, not a replacement for traditional chemo therapy.

mold28_WebMD: My family has a pretty lengthy history of cancer. What can I do to prevent cancer from hurting my child?

Dr. Dreyer: There are actually a few centers in particular, ours is one, that now have cancer genetic clinics. These clinics are designed to evaluate your family history of cancer, and help identify, if you have, in fact, one of the family cancer syndromes which are now being recognized. And by that I mean, families which have a cancer predisposition based on genetic abnormalities that we can screen for, like some of the breast cancer genes. There are some genetic changes we can screen for now in families where leukemia, brain tumors, and sarcomas are very common. So that cancer genetics has opened up a whole new world for cancer prevention because if you can identify a family at risk, you can intervene for the children, or even the adults, with more aggressive cancer screening and early diagnosis which always improves the chances for cure. It's not necessary for your child to be a patient, or for you to be a patient of a hospital to be evaluated, for example, in our Texas Children's Cancer Genetic Clinic. Families can call from anywhere in the country for appointments and come for evaluations. It's a fascinating new field in cancer.

Moderator: Do we have any idea what causes cancer in children?

Dr. Dreyer: It's a question that researchers throughout the world are working on. Most children's cancers just happen. They aren't linked to high risk behaviors, like smoking. Most of them are not linked to family cancer history. There are a large number of epidemiologists throughout the country who are involved in many different research studies trying to identify causative factors, sometimes which even include looking at patients' tumor samples for the possibility of identifying as yet undescribed  genetic abnormalities. For most children's cancers, we have no cause; we don't know the cause. This will probably change in the next 10 to 20 years as we continue to advance genetic research. One thing I think is really important for people to know about children with cancer is that most children with cancer will be cured. Currently, more than 65% of all children with cancer will be cured, which is a pretty incredible statistic. As cancer doctors, when we say cured, we mean their disease will never come back. Most people don't understand that. The other point, if they're interested on more information on Texas Children's Cancer Center and hospital they can go to  and link into the cancer site, which will include more information on the cancer program, new drug development, all the different areas in childhood cancer.

Moderator: Thank you for being with us today, Dr. Dreyer!

Dr. Dreyer: Again, that's

The opinions expressed by Dr. Dreyer are hers and hers alone. If you have questions about your health, you should consult your personal physician. This event is meant for informational purposes only.

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