The Doctor’s Orders: A Cure
words by eve jacobs / photographs by john emerson
ecalling some of his group’s fabulous success stories brings a quick, bright smile to the face of Richard Drachtman, MD, before his phone rings again — one of maybe 10 or 12 calls needing his attention, right now, during this 45-minute interview. Sick kids don’t wait, at least not in this practice, which deals with some of the sickest, those with cancer and blood disorders. The doctor’s orders — effecting a cure, nothing less, and, of course, ensuring the child’s and family’s trust, safety and comfort during treatment — are carried out here every minute, every day.
Drachtman and his group at The Cancer Institute of New Jersey (CINJ) have about 50 open, ongoing clinical trials at this very moment. “The vast majority of children and adolescents with cancer go into clinical trials,” he explains. “It’s the standard of care.” Nationally, only 4 percent of adults with cancer participate in clinical trials.
Roughly 8,500 children 15 and younger are diagnosed with cancer each year in the U.S. Their most common cancers are the leukemias and lymphomas and tumors of the central and sympathetic nervous systems, soft tissue, bone, and kidney.
The pediatric oncologist, who is interim division chief of pediatric hematology/ oncology at CINJ, has been doing this work for 20 years, and has served as a principal investigator for the Children’s Oncology Group — previously named the Children’s Cancer Study Group — for 10 of those years. This worldwide network of pediatric cancer specialists and programs has been working collaboratively for five decades and has been the model for other cooperative groups. He explains that participating in national pediatric clinical trials is the way to go. For example, there are probably more men with prostate cancer in Essex County, NJ, than children with bone cancer across the country. These low rates of kids’ cancers are a “good thing, certainly,” he says, “but for us it means that no one center would have enough kids with a particular cancer to do a study.”
When Drachtman says that the group treats kids of all ages, that’s exactly what he means. He has delivered the newest care to newborns —“age zero,” he calls them — and infants with cancer, as well as toddlers and rambunctious teens. “Kids have been diagnosed with neuro-blastomas at birth,” he explains. The CINJ Center takes care of “kids” into their 20s, and sometimes to age 30. “Age 21 is an artificial cut-off. We try to bridge the gap,” he says. “A 25-year-old is more like a teen than most patients seen in an adult oncology office.”
The clinical trials test new drugs and new combinations of drugs for malignancies ranging from leukemia to bone cancer, brain to kidney cancer, lymphoma to
sarcoma. The children’s cancer expert proudly tells the stories of Bar Mitzvahs, confirmations, high school and college graduations, and weddings he’s been invited to and attended of once-very-sick young patients who went on to do all of those normal things, and who continue to do well. Keith Pasichow, treated at CINJ as a teen for bone cancer, is now a medical student at Mount Sinai in New York and soon to be married, Drachtman relates, and another patient, once an adolescent with a passion for dancing who was struck with Ewing’s sarcoma, requiring the partial amputation of her leg, now runs a dance studio in South Jersey. “And Flo Carrano, our full-time teacher on the pediatric oncology unit at CINJ, had classic childhood leukemia,” he recalls, “and was in a clinical trial here as a teenager.
“The protocol that cured her is 20 years old. It showed that giving kids an additional strong dose of therapy early on gives cancer a one-two punch in the beginning,” Drachtman states. “These trials from the early ’90s helped us to achieve our current cure rates.” Now as an adult, Carrano teaches kids who, like herself about 15 years ago, are fighting cancer and enrolled in clinical trials. “And Keith is not the only former patient studying to be a doctor,” Drachtman says proudly. “We have
several who have already graduated and gone on to medical careers.” Almost all of them were participants in clinical trials for pediatric cancers and all of them are now healthy.
Cancer is a wicked adversary, but the majority of children with this disease grow into healthy adults, the cancer doctor tells the families of kids who are newly diagnosed. “Those clinical trials of 15 to 20 years ago are the backbone of the therapy that we use now,” he says. “They’ve helped us to achieve our current good results.”
In fact, the team is so good at curing certain kids’ cancers such as Hodgkin’s disease and acute lymphoblastic leukemia that they’ve switched their focus for some of the children. “We’re trying to decrease the therapy in order to decrease the side effects. What is the very lowest dose that we can give for optimal results?” he asks. “That’s what we’re after.”
In February, Drachtman published an article in the Journal of Clinical Oncology outlining a new treatment for children and teens with Hodgkin’s lymphoma, also known as Hodgkin’s disease. “This is for patients who have had at least two rounds of chemo and have relapsed,” he explains. “About 10 percent of Hodgkin’s disease is refractory or not now curable. We have come up with a new combination of drugs that seems to be effective for 80 percent of these kids. In the future, this combination may be able to be moved up to patients who are newly diagnosed.”
Drachtman is currently the vice-chair of another national protocol looking at the possibility of using bortezomib (Velcade) — a drug recently approved for multiple myeloma — for Hodgkin’s disease. The rationale behind the study is that bortezomib (Velcade), a proteasome inhibitor, may stop the growth of cancer cells by blocking some of the enzymes needed for cell growth. Proteasomes are enzymes found in cells, and play a role in regulating cell function and growth.Two other drugs used in chemotherapy for this disease, ifosfamide and vinorelbine, stop the growth of cancer cells either by killing the cells or by stopping them from dividing. Bortezomib may make the two standard drugs more effective by sensitizing cancer cells to the drugs, ultimately resulting in the killing of greater numbers of them.
The cancer doctor continues to dream. His most ambitious vision is that pediatric cancer docs become so good at what they do that they put themselves out of business. “I would be very happy with that,” he says. His short-range goal, however, is to become more proficient at response-based therapy for Hodgkin’s disease, meaning that the chemotherapy regimen would be based on the individual child’s initial response to the first round of drugs. The hope, of course, is that as drug regimens become more tailored to each sick child, cancer cure rates for that small percentage of harder-to-treat malignancies will rise in tandem with the cure rates of the majority.