Guidelines for Pediatric Cancer Centers

INTRODUCTION

A pediatric cancer center must have the staff and facilities to ensure that the pediatric patient with cancer will receive the best care that is available for his or her diagnosis. The medical staff at such a center is composed of the primary care pediatrician, pediatric medical subspecialists, and pediatric surgical specialists—hematologists/oncologists, surgeons, urologists, neurologists, neurosurgeons, orthopedic surgeons, radiation oncologists, pathologists, child life specialists, and diagnostic radiologists. These physicians and nurse practitioners, pediatric nurses, social workers, pharmacists, nutritionists, and other allied health professionals serve as a multidisciplinary team committed to the care of the child or adolescent with cancer.

In the United States, the oncologic care of the child or adolescent with cancer should be coordinated by a pediatric hematologist/oncologist who is board certified in the subspecialty of pediatric hematology and oncology by the American Board of Pediatrics. Other subspecialists should be similarly board certified when applicable.

Oncologic care should be provided in a pediatric center that has the following personnel, facilities, and capabilities.

ROLE OF CENTERS IN DIAGNOSIS AND TREATMENT

Approximately 12 000 new cases of cancer are diagnosed in children younger than 20 years annually in the United States.^1,2 Cancer remains the second most frequent cause of death, after injury, in children older than 3 months.³

Great progress has been made in the development of successful treatment programs for children and adolescents with cancer. These improvements have been possible because of the availability of pediatric cancer treatment centers with collective expertise in the clinical management of children with cancer and the existence of a network of experienced investigators and allied health professionals who recognize the central importance of randomized clinical trials as the best available method for identifying more successful treatment strategies and who have the resources to evaluate new treatment modalities as they become available.

The importance of comprehensive, multidisciplinary treatment in improving patient outcome in a cost-effective manner has been well documented for children with acute lymphoblastic leukemia,⁴ non–Hodgkin lymphoma,^5,6 brain tumors,^7,8 rhabdomyosarcoma,^5,8 Wilms' tumor,^9,10 and Ewing sarcoma.⁵ Almost 80% of these children can be treated successfully if modern diagnostic and therapeutic approaches are initiated expeditiously.² Early detection, accurate diagnosis, and appropriate treatment depend on a multidisciplinary treatment approach to children and adolescents with cancer, an approach that is uniquely available at a pediatric cancer center. The roles of specialized nursing, pharmacy, rehabilitation, and paramedical personnel and access to increasingly complex equipment and facilities are critical to improving long-term survival and quality of life.

The center-based pediatric hematologist/oncologist is the coordinator for the diagnosis and treatment of most children and adolescents with cancer. Pediatric hematology/oncology is an established specialty with specific training requirements that lead to subspecialty board eligibility. Because most pediatric tumors show a striking response to specific regimens of intensive chemotherapy, pediatric hematologists/oncologists are necessarily resolute in carrying out therapies that can have devastating morbidity and appreciable mortality. For these therapies to be administered safely, a pediatric hematologist/oncologist who is trained and experienced in the management of children and adolescents with cancer and who has extensive knowledge of the relevant drug indications and toxicities must coordinate this care.

The pediatric hematologist/oncologist must be assisted by skilled nurses, social workers, pharmacists, nutritionists, and psychologists who specialize in pediatric oncology. Professional organizations such as the Association of Pediatric Oncology Nurses and Association of Pediatric Oncology Social Workers facilitate the professional growth and education of these individuals. Diagnostic radiologists and radiation oncologists with specific training and interest in pediatric oncology should be available at the pediatric cancer center. Principles of surgery that are unique to childhood tumors have evolved, and in fields such as general (pediatric) surgery, urology, neurology, and orthopedics, the presence of surgeons whose sole (or major) effort is directed toward pediatric oncology has become indispensable in achieving maximum survival.

A pathologist experienced in pediatric oncology is an essential member of the multidisciplinary team at the pediatric cancer center. State-of-the-art diagnosis of many pediatric hematologic malignancies and tumors requires immunochemistry and/or molecular techniques. Because solid tumors in children and adolescents are rare in the experience of most pathologists, an incorrect histologic diagnosis may be given when initial surgical management occurs at a nonspecialized hospital. Ideally, the diagnostic biopsy should be performed at the cancer center, at which the facilities are available to order and obtain all the special studies that would be appropriate and would obviate the need for subjecting the patient to repeat procedures.

PRACTICE OF PEDIATRIC ONCOLOGY OUTSIDE RECOGNIZED CENTERS

The clinical results in children with cancer have been shown to be superior when specialized diagnostic, supportive, and specific care is given at a pediatric cancer center.^4–10 After diagnosis has been established and the treatment plan has been determined by the pediatric cancer center, certain aspects of care may be continued in the office of a primary care pediatrician for selected children. When such a plan for shared treatment is undertaken, it must be with the understanding that the child will be referred back to the pediatric cancer center if complications develop or there is recurrence of the tumor. For many children, the facilities and expertise available at the pediatric cancer center are required for all aspects of therapy. However, it must be emphasized that the primary care pediatrician should retain an important supportive role for the patient with cancer and his or her family, which requires excellent regular communication between the oncologist and the pediatrician.

SUMMARY

On the basis of the effectiveness of pediatric cancer centers in treating children and adolescents with cancer, the American Academy of Pediatrics recommends the following:

• Children and adolescents with newly suspected and/or recurrent malignancy should be referred to a pediatric cancer center for prompt and accurate diagnosis and management.

• Children and adolescents with newly diagnosed and/or recurrent malignancies should have their treatment coordinated by a board-certified pediatric hematologist/oncologist; treatment should be prescribed and initiated at a pediatric cancer center but may be continued at a center not specialized in the care of the pediatric oncology patient under the continuing oversight of the center's multidisciplinary team.

• Multidisciplinary team members should have pediatric expertise within their specialty area.

Section on Hematology/Oncology, 2003–2004

Roger L. Berkow, MD, Chairperson

*James J. Corrigan, MD

*Stephen A. Feig, MD

F. Leonard Johnson, MD

Peter A. Lane, MD

John J. Hutter, Jr, MD

Liaisons

Edwin N. Forman, MD

Childhood Cancer Alliance

Naomi L. Luban, MD

American Association of Blood Banks

Staff

Laura Laskosz, MPH