Note: Some citations in the text of this section are followed by a level of evidence. The PDQ Pediatric Treatment Editorial Board uses a formal ranking system to help the reader judge the strength of evidence linked to the reported results of a therapeutic strategy. (Refer to the PDQ summary on Levels of Evidence for more information.)
Caregivers of cancer patients are expected to function broadly, providing direct care, assistance with activities of daily living, case management, emotional support, companionship, and medication supervision. Caregivers of cancer patients generally undertake multifaceted responsibilities for tasks such as the following:
Administrative tasks (case management, management of insurance claims, bill payment).
Instrumental tasks (accompanying the cancer patient to medical appointments;...
Three-drug induction therapy using vincristine, corticosteroid (prednisone or dexamethasone), and L-asparaginase in conjunction with intrathecal (IT) therapy, results in complete remission (CR) rates of greater than 95%. For patients presenting with high-risk features, a more intensive induction regimen (four or five agents) may result in improved event-free survival (EFS).[2,3] Such patients generally receive induction therapy that includes an anthracycline (e.g., daunorubicin) in addition to vincristine, prednisone/dexamethasone, plus L-asparaginase. For patients who are at standard risk or low risk of treatment failure, four or more drug induction therapy does not appear necessary for favorable outcome provided that adequate postremission intensification therapy is administered.[2,4,5] The Children's Oncology Group (COG) protocols risk stratify at diagnosis and do not administer anthracycline during induction to patients with National Cancer Institute (NCI) standard-risk precursor B-cell acute lymphoblastic leukemia (ALL). While other groups, such as the Berlin-Frankfurt-Muenster (BFM) Group in Europe, St. Jude Children's Research Hospital (SJCRH), and the Dana-Farber Cancer Institute (DFCI) ALL Consortium, utilize either a four- or five-drug induction for all patients, regardless of presenting features.[6,7,8]
Many current regimens utilize dexamethasone instead of prednisone during remission induction and later phases of therapy. The Children's Cancer Group (CCG) conducted a randomized trial comparing dexamethasone and prednisone in standard-risk ALL patients, and reported that dexamethasone was associated with a superior EFS. Results from another randomized trial conducted by the United Kingdom Medical Research Council (MRC) demonstrated that dexamethasone was associated with a more favorable outcome than prednisolone in all patient subgroups. In the MRC trial, patients who received dexamethasone had a significantly lower incidence of both central nervous system (CNS) and non-CNS relapses than patients who received prednisolone. However, other randomized trials did not confirm an EFS advantage with dexamethasone. It appears that the ratio of dexamethasone to prednisone dose used may influence outcome. Studies in which the dexamethasone to prednisone ratio is 1:5 to 1:7 have shown a better result for dexamethasone, while studies using a 1:10 ratio have shown similar outcomes.
While dexamethasone may be more effective than prednisone, data also suggest that dexamethasone may also be more toxic, especially in the context of more intensive induction regimens and in adolescents. Several reports indicate that dexamethasone may increase the frequency and severity of infections and/or other complications in patients receiving anthracycline-containing induction regimens.[13,14] The increased risk of infection with dexamethasone during the induction phase has not been noted with three-drug induction regimens (vincristine, dexamethasone, and L-asparaginase). Dexamethasone appears to have a greater suppressive effect on short-term linear growth than prednisone, and has been associated with a higher risk of osteonecrosis, especially in adolescent patients.