Improvements in survival for all childhood cancers combined have increased between the mid-1970s and today, with overall survival approximating 83% and some children with certain diseases approaching or exceeding 90% long-term survival. With these improved outcomes, the focus of research and expectations of patients, parents, and health care providers has increasingly emphasized reducing the burden of cancer and its treatment for these children during treatment, after the completion of treatment, and as adult survivors.
Cancer treatment for children differs in many ways from treatment for adults. Some of the principal differences include the following:
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Intensity. In general, treatment of childhood cancer is more intense. Because the dose-limiting toxicities of most chemotherapy and radiation treatments are generally reached at higher doses, more-intensive chemotherapy and radiation therapy are feasible for children than would be possible for adults.
Toxicity. Some of the toxicities of treatment have a much more significant and lasting effect on children than on adults because of the active development of nearly all organ systems during childhood and adolescence.
Supportive Care. Developmental differences extend to the types of supportive care that children may receive. Medications that represent standards of care for adult cancer supportive care may be contraindicated for children because of adverse toxicities that are associated with specific periods of childhood development.
Fundamental to these differences is the clear recognition that children are not small adults and that even the term children is not all-encompassing. Treatment and supportive care require different approaches across the spectrum from newborn through young adult age groups, and the outcomes of both cancer survivorship (control of disease) and quality of survivorship (impact of toxicities) differ with the age of a child at the time of treatment.
Equally important is the recognition that treatment of childhood cancer inevitably occurs in the context of a family. Frequently, the impact of an adult's cancer treatment focuses on one or two key adults in the cancer patient's life. In childhood cancer, the effects are often felt by more individuals, including one or both parents, one or more siblings who are themselves children or adolescents, grandparents, aunts and uncles, teachers, friends, and other individuals who may be directly involved in the care or life experience of the child. Furthermore, because children are not considered legally competent exclusively on the basis of age, most decisions about cancer treatment are made by proxy. Instead of children making decisions about their own care, their parents or guardians make these decisions for them. The large number of people involved, legal issues related to decision making about minors by others, and ethical concerns about informed consent and assent involving children add extra layers to the complexity of treatment for children.