Pediatric Cancer Genome Project

How cool is this? St. Jude Children's Hospital and the University of Washington School of Medicine in St. Louis have teamed up for the Pediatric Cancer Genome Project, an attempt to map out the genomes of 600 pediatric cancer patients. The more I learn about chemotherapy protocols and all the toxicities that come with them, the more I can't wait for a future where specific tumor mutations or cancer genes can be targeted to treat the disease without causing infertility, cardiomyopathy, immunosupression, extreme nausea, hair loss, etc. Yay!

It'd be great if the cute little 16 month old boy I did a bone marrow aspiration on last week had a better than 25% chance of survival with his Stage 4 Hepatoblastoma. It'd be great if our 19 year old girl just recovering from sepsis and trying to survive her third relapse of ALL could go have fun in college with her boyfriend. It'd be great if our 6 year old boy with Hodgkin's Lymphoma didn't need radiation and could still have kids when he grows up. The future can't get here soon enough!

Haiti

As things continue to fall apart in Haiti post-earthquake, the stark inequalities in health care (and building practices) are painfully obvious. I think I'm particularly sensitive to this right now since I'm in the world of Peds Hem/Onc and the NICU where it is not at all abnormal to spend upwards of a million dollars trying to save one child. I'm not implying that shouldn't be done, how on earth can you deny available treatment to a kid when it might save their life? But just think what that money could do in Haiti...save 10,000 kids or 100,000 kids by giving them vaccines, anti-virals, food. In third world environments, actual health care is only part of the problem...sure you can give people antibiotics, but if they don't have clean water to take them with, you're doomed. The resident on hem/onc is from Pakistan and he was telling us about the one Peds Hem/Onc clinic at their main teaching hospital. They have most of the necessary drugs and can follow the recommended treating protocols, but when the kids are immunosuppressed at all they must keep them in the hospital or the infection rate is just astronomical due to general unsanitary conditions. Health care inequalities are really just one manifestation of overall inequality.

Today was rough...one of the patients I saw on my first day who had a lytic lesion in her leg which we hoped was just a brodie's abscess got her pathology back today and it turns out the lesion is a high grade osteoblastic osteosarcoma. Not good. Then we were consulted on a 5 month old in the NICU with end stage liver failure. She has major coagulopathies since her liver is pretty much nonfunctional and because she's not a candidate for a liver transplant there's really nothing that can be done. Maybe someday soon we'll be able to create new livers in a lab, no problem, but that might just widen the health care gap. At least in the U.S. most kids won't be denied treatment from inability to pay...but sadly for this little girl science just isn't there yet. Then we have our patient who might be a vampire...

I wish I had the training to go and help in Haiti. At least Partners in Health is still relatively intact since it was based in rural areas. I've been rereading Paul Farmer's "Aids and Accusation"...health disasters in Haiti are hardly new, how much can one country take?

What Now?

How do you decide what you want to do for the rest of your life? I know you can change your mind about residency programs (even after you start them, if you must) and certainly any fellowship decisions are still a few years away, but I'm really starting to feel the pressure to make up my mind. This month I'm on my pediatric hematology/oncology ambulatory elective, and it definitely is something I can see myself doing in the future. Not that the elective is everything I hoped it would be...there are three students instead of just one (though they're both friends so it's fun) and there's not all that much for us to do most days. A lot of patients are in the process of being treated so it's hard for students to just jump in and, of course, the chemo protocols are ridiculously complex.

Nevertheless, while I may feel out of place as a student, when I think about what the doctors do all day, their ongoing interactions with patients, their procedures, their research, etc., it certainly seems like something I'd like to be doing long term once I actually know what I'm doing. Fortunately I can still keep my options open...but every day I'm a little more confident in the decision to do a pediatrics residency.

I've certainly seen a range of patients in the last week...from the four month old with the atypical teratoid rhabdoid tumor with an abysmal prognosis (brain tumor + brain surgery + no proven chemo or radiation treatment + young age = bad news) to the 19 year old 3 years out from completion of treatment for Hodgkin's Lymphoma who's doing great. The doctors and nurses are a great support system for patients and families facing a scary treatment and rocky road for the next few years...they offer hope and reassurance. I want to do that. Now if only I could figure out my next few years...