Radiation Treatment for Cancer in Children
Guest: Dr. Joseph “Buddy” Jenrette – Radiation Oncology
Host: Dr. Linda Austin – Psychiatry
Dr. Linda Austin: I am Dr. Linda Austin. I am talking today with Dr. Buddy Jenrette who is Chair of Radiation Oncology here at the Medical University of South Carolina. Dr. Jenrette, I know that most oncologists, most radiation oncologists, do not take care of children with tumors. It is a tough area to be involved in. What are some of the most common childhood cancers that you become involved in treating?
Dr. Buddy Jenrette: We take care of a wide variety of childhood cancers in radiation oncology, ranging from brain tumors, which are the most common, to ones that are not so common, Wilm’s Tumor, which used to be a completely fatal cancer in children that arises from the kidney, to bone cancers, to cancers that have really strange names, like rhabdomyosarcoma, which arises from muscles, or ewing's sarcoma which is a cancer that arises usually from bones but, also, it can arise from soft tissues.
Dr. Linda Austin: Are the tumors you see in children different from what you see in adults?
Dr. Buddy Jenrette: Completely, except for the brain tumors. There are some similarities between the two but most of the brain tumors are quite different than the adult tumors and they spread in different ways. One of the most common is called medulloblastoma which spreads throughout the entire cranial-spinal axis, so it travels in the fluid that bathes the brain, from the brain all the way down to the spine. So, we have to treat the whole area when we treat a child with that particular tumor. We never see tumors like breast cancer, prostate cancer, lung cancer, things that are the most common in adults, are never seen in children.
Dr. Linda Austin: Of the brain tumors you treat, which are the most responsive to radiation therapy?
Dr. Buddy Jenrette: I think medulloblastomas overall are probably the most responsive. The problem with the brain tumors, medulloblastomas, is that sometimes they affect really young children. I have patients as young as 6 or 7 months, which is really a tiny child to take care of. We try to avoid radiation until they are 3 years old. So, a lot of times they will be put, at least, on chemotherapy protocols for as long as they can hold out, to see if we can keep the cancer from growing or spreading, and then we introduce the radiation later. We have pretty good results with that.
Dr. Linda Austin: Why do you wait until age 3?
Dr. Buddy Jenrette: The brain seems to go through early maturation at about age 3. The hard-wiring of the brain seems to hook up about that time. Once those connections have been made, they are more difficult to injure. We worry a lot about things like cognitive development, how will someone be able to perform in school, will they even be able to go to school, will they have to go to a special school, will they have speech development, will it be normal, and also hormonal things. Within the brain, there is a tiny gland called the pituitary which controls things like growth, growth of the bones and growth of the body, the thyroid, and other things as well. All of these things can be affected by the treatment of the brain.
Dr. Linda Austin: Does that affect primarily children under the age of 3, or do you worry about these things even in kids over the age of 3?
Dr. Buddy Jenrette: The hormones are affected even in adults. If we treat the brain of an adult, they can have some loss of sexual function because their testosterone or estrogen and progesterone, in females, may be decreased and their thyroid may be decreased, which will cause tiredness. The biggest issue in the children is probably growth hormone. Without growth hormones, the child really will not grow. The nice thing is that, now, in endocrinology, we have replacements for virtually all of these hormones that allow us to replace them so the child will continue to grow and the thyroid will function, the adrenal glands, the testicles, all will continue to mature.
Dr. Linda Austin: In the typical case, let’s say a simpler case, if there is such a thing, of medulloblastoma, how long is the radiation treatment course generally?
Dr. Buddy Jenrette: It takes about six weeks to treat a child with that. With the younger children, they generally have to be treated under general anesthesia each day, which is one of the reasons that most doctors do not have the ability to take care of them. We are very fortunate at MUSC because we have an outstanding anesthesiology department that does offsite, out of the operating room, anesthesia. So, each day, the child comes to us at 7:30 in the morning. They are awakened by their parents, brought to the hospital, and then we put them to sleep for about 20 or 30 minutes. Then, we wake them up and take them to recovery so that they can safely wake up. That is when the day begins for the child. So, it is a hardship on the child. There is nothing worse than a hungry child in the morning. It is hard on the parents as well because there is nothing worse than a hungry child in the morning.
Dr. Linda Austin: How many days a week does a child get that?
Dr. Buddy Jenrette: Five days a week.
Dr. Linda Austin: Five days a week? And you said for six weeks? Is that right?
Dr. Buddy Jenrette: It is usually about 28 to 30 treatments.
Dr. Linda Austin: And what are the response rates for that treatment?
Dr. Buddy Jenrette: Really, very good. We do very well with this disease. About 80 percent of the children are cured now in a disease that used to be completely fatal. Understanding the growth patterns and ways that we can add treatments has really made a huge deal, understanding the surgeries that should be done, and also when chemotherapy should be done, as well as the radiation techniques, have made a big difference.
Dr. Linda Austin: That is quite a statistic. That must be so gratifying to see.
Dr. Buddy Jenrette: It is wonderful.
Dr. Linda Austin: You had mentioned earlier that Wilm’s Tumor, which is a particular type of kidney tumor, is also very responsive.
Dr. Buddy Jenrette: Yes. Back in the 1950s, Wilm’s Tumor was a death notice. There was no cure for it at all. The very earliest papers showing that it would respond to radiation was in about 1952 or 1953. What happened, back in those early days, was we did not know how much treatment to give so we ended up giving a lot; they ended up giving a lot. So, sometimes the treatment was very toxic to the child. They would have curvatures of the spine, all sorts of injuries. We have learned because of clinical trials where physicians team up together to try to do studies in which children are not guinea pigs, they are actually participating in pioneering medical history. They agree, or their parents agree, to enter them into these protocols and that is how we have learned. So, now, Wilm’s Tumor is almost 100 percent curable, even the metastatic disease. If it is metastatic to the lung or other parts of the body, the cure rate is in excess of 80 percent. It is a wonderful turnaround that we have had over the last 50 years.
Dr. Linda Austin: Boy, what a thrill for you in your career, from when you started your career to now, to see that.
Dr. Buddy Jenrette: It is terrific.
Dr. Linda Austin: And to see those first cases that really seemed to turn the corner. Now, you have talked about brain tumors, especially medulloblastoma. You have talked about Wilm’s Tumor, tumor of the kidney. What are some of the other common childhood cancers that you treat?
Dr. Buddy Jenrette: They all have funny names. There is a disease called rhabdomyosarcoma which is a disease that grows out of smooth muscle. It can occur anywhere in the body. A common area is up around the eye and the eye socket. It can actually grow up to the base of the brain. There are tiny holes where nerves go in and out of the brain and it can creep through those little holes along the nerves and can involve their brain. It can occur in the pelvis or in the chest. Each one of them comes with specific problems. We want to preserve organ function when we can. So, we do not like to do amputations of limbs or remove eyes if we can avoid it. We have learned techniques that we can, again, interdigitate the chemotherapy, surgery and radiotherapy together so that we can, with the proper timing, save these things. It is very common to see it around the eye. In earlier years they would have just removed the eye completely, leaving the child completely blind in one eye, but the child had the opportunity to be cured. Now we have the best of both. We can give radiation treatment where it wraps around the eye but spares the eye and can dissolve the tumor under the best circumstances.
Dr. Linda Austin: Very exciting field. I am sure at times it is a very heartbreaking field and then at other times you must see some pretty miraculous, exciting, stuff.
Dr. Buddy Jenrette: It is wonderful working with the families and the children. We get so much hope and strength through their strength. We become so fond of the children and their families too. They are all so endearing. It is hard. It is another reason why many doctors do not like to take care of children with cancer, but I find it one of the most gratifying parts of my career.
Dr. Linda Austin: Good luck in your work. It is so important.
Dr. Buddy Jenrette: Thank you.
Dr. Linda Austin: Dr. Jenrette, thanks for talking with us today.
Dr. Buddy Jenrette: It has been my pleasure.
Dr. Linda Austin: I appreciate it.
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