First Person
Stephen E. Sallan, MD
Edited by Saul Wisnia
Dr. Sallan looks at Dario Deane and others with hope.
Since joining the Institute as a young pediatric oncologist in 1973, Dana-Farber Chief of Staff Stephen E. Sallan, MD, has played an important role in the dramatic rise in cure rates for childhood cancers. The success rates for adult patients in the past 20 years, however, especially those in the 15-40 age range, have not risen as quickly as hoped in some cancers, including acute lymphoblastic leukemia. For the past several years, Sallan and colleagues within and beyond the Institute have worked to understand and combat the disparity. Now, as he explains below, a breakthrough may be at hand.
One thing that has always frustrated and perplexed oncologists has been the different survival rates experienced by children and adults with the same types of cancer. Only recently have we to begun to understand the reasons behind them.
Let's say you're a 19-year-old college student home for the summer. You start feeling run down and progressively more tired. You try going to bed at 9:30, but wake up the next morning not rested. When exercising, you feel like you're hitting a brick wall after half your normal workout. You're not eating much, yet you're feeling full. When you finally get around to seeing the doctor, whom are you apt to go see? Well, if you're like most college kids still living with their parents, you're most likely going to see your pediatrician. He sends you to Dana- Farber's Jimmy Fund Clinic to have your bone marrow checked; the doctors there discover you have leukemia and put you on a pediatric chemotherapy protocol.
Now here's a different scenario. Move the calendar up a couple months, when you're back at school. You're feeling weak, tired, and full, and your face is ashen. Your roommate says, "Hey, you better go to Health Services." You see the campus physician, who's an internist [a physician who treats adults], and she examines you, notes that your blood tests are abnormal, and sends you to the regional medical center to have your bone marrow checked. After it comes back with a leukemia diagnosis, they put you on a standard adult chemotherapy treatment plan.
So here you are, the same age with the same disease, same tolerance to drugs, and same prognosis. Everything is the same – except the treatment plan. And here's the unbelievable part: Until recently, if you were on the pediatric plan, you had a 75 percent chance of being cured in two years. If you were on the adult version, your chances dropped to 35-50 percent, depending on your age.
"It has become accepted over the years that adults can't tolerate some forms of chemotherapy as well as kids…"
How can this be? The challenge is that for the past 25 or 30 years, patients in the 16-21 age group have been "common ground" for both internists and pediatricians. As the scenarios show, some teenagers and young adults are seen by their family pediatricians, while others – often those away at school or living on their own – go to internists. Is there something different about the leukemia cell of a 10-year-old compared to a 19-year-old? No. Are 16- to 21-year-olds physiologically different from those 15 and under, or those 22 and over? The answer is probably not.
What's different, however, is the delivery of care. It has become accepted over the years that adults can't tolerate some forms of chemotherapy as well as kids, and so different regimens for treatment have developed between the two groups.
- Next: 'Incredible' discovery
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