A.L.L.

Spent the morning with pediatric hematologists. Basically their days are spent dealing with sickle-cell anemia and leukemia. Of the blood cancers, the most common is acute lymphocytic leukemia, e.g. ALL.

There was this really smart woman in my med school class who was determined to be a pediatric oncologist. I thought she was crazy. I still do. One of the kids we saw today woke up a few months ago with headaches and some vomiting. Turns out he had a tumor in the back of his brain. They also found it had metastasized down his spinal column and had at some point also settled in one of his hips. The original cancer was found to be from a form of lung cancer that adults usually get from smoking (non-small cell carcinoma).

“Not good,” the kind, crusty oncologist said after he described the basics of the case to me. Of all the people in the world you don’t want to hear ‘not good’ from, I’d put a pediatric oncologist right up there with pilots and exterminators.

An interesting thing I learned about ALL: It has always been the bellweather of pediatric cancer therapy because for decades it has been both the most common leukemia, and the one with the best prognosis. 30 years ago the survival rate was only about 60% (and that was considered good back then). Now it’s over 90% if all the risk factors are minimal. In the 1970’s, there was a big jump from 60 to 80% survival. Why? Because one doc in one hospital found that although they were curing ALL, there was lots of relapse in the CNS (brain and spinal cord), so they started irradiating kids’ brains as part of the ALL therapy. Survival went up, dramatically. The CNS is now regarded as a “sanctuary” site for cancer cells and is usually treated when kids get cancer.

Then survival jumped from the 80’s to the 90% range when docs started realizing that the amount of radiation they were giving was waaay too much and was causing brain tumors and other problems. Today, they rarely use radiation as part of ALL therapy, but they do give chemotherapy intrathecally (directly into the spinal column), and survival is generally really good for these kids.

Not so for this extremely cool 10y old boy with the medullary blastoma. He’s not likely to make it much longer. This is probably not a job I could handle. I’d either become a massive jerk or a slobbering emotional mess. It’s a unique person that can deal with these kids every day for years and still maintain a balanced humanity.

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