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  1. 1. 2004;113;1833-1835Pediatrics Section on Hematology/Oncology Guidelines for Pediatric Cancer Centers located on the World Wide Web at: The online version of this article, along with updated information and services, is rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275. Grove Village, Illinois, 60007. Copyright © 2004 by the American Academy of Pediatrics. All and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk publication, it has been published continuously since 1948. PEDIATRICS is owned, published, PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly by on October 29, 2010www.pediatrics.orgDownloaded from
  2. 2. AMERICAN ACADEMY OF PEDIATRICS POLICY STATEMENT Organizational Principles to Guide and Define the Child Health Care System and/or Improve the Health of All Children Section on Hematology/Oncology Guidelines for Pediatric Cancer Centers ABSTRACT. Since the American Academy of Pediat- rics published guidelines for pediatric cancer centers in 1986 and 1997, significant changes in the delivery of health care have prompted a review of the role of tertiary medical centers in the care of pediatric patients. The potential effect of these changes on the treatment and survival rates of children with cancer led to this revision. The intent of this statement is to delineate personnel and facilities that are essential to provide state-of-the-art care for children and adolescents with cancer. This statement emphasizes the importance of board-certified pediatric hematologists/oncologists, pediatric subspecialty con- sultants, and appropriately qualified pediatric medical subspecialists and pediatric surgical specialists oversee- ing the care of all pediatric and adolescent cancer pa- tients and the need for facilities available only at a ter- tiary center as essential for the initial management and much of the follow-up for pediatric and adolescent can- cer patients. Pediatrics 2004;113:1833–1835; cancer, pedi- atrics, hematology, oncology, cancer center. INTRODUCTION A pediatric cancer center must have the staff and facilities to ensure that the pediatric pa- tient with cancer will receive the best care that is available for his or her diagnosis. The medical staff at such a center is composed of the primary care pediatrician, pediatric medical subspecialists, and pediatric surgical specialists—hematologists/ oncologists, surgeons, urologists, neurologists, neu- rosurgeons, orthopedic surgeons, radiation on- cologists, pathologists, child life specialists, and diagnostic radiologists. These physicians and nurse practitioners, pediatric nurses, social workers, phar- macists, nutritionists, and other allied health profes- sionals serve as a multidisciplinary team committed to the care of the child or adolescent with cancer. In the United States, the oncologic care of the child or adolescent with cancer should be coordinated by a pediatric hematologist/oncologist who is board cer- tified in the subspecialty of pediatric hematology and oncology by the American Board of Pediatrics. Other subspecialists should be similarly board certified when applicable. Oncologic care should be provided in a pediatric center that has the following personnel, facilities, and capabilities. Personnel • Communication with the primary pediatrician, which is essential in the provision of family-cen- tered supportive care • Board-certified pediatric hematologists/oncolo- gists • Pediatric oncology nurses who are certified in che- motherapy, knowledgeable about pediatric proto- cols, and experienced in the management of com- plications of therapy • Board-certified radiologists with specific expertise in the diagnostic imaging of infants, children, and adolescents • Board-certified surgeons with expertise in pediat- ric general surgery • Surgical specialists with pediatric expertise (ie, training and certification, if available) in neurosur- gery, urology, orthopedics, ophthalmology, otolar- yngology, dentistry, and gynecology • A board-certified radiation oncologist trained and experienced in the treatment of infants, children, and adolescents • A board-certified pathologist with special training in the pathology of hematologic malignancies and solid tumors of children and adolescents • Board-certified pediatric subspecialists available to participate actively in all areas of the care of the child with cancer, including anesthesiology, inten- sive care, infectious diseases, cardiology, neurol- ogy, endocrinology and metabolism, genetics, gas- troenterology, child and adolescent psychiatry, nephrology, and pulmonology • Pediatric physical and mental rehabilitation ser- vices including pediatric physiatry • Pediatric (oncology) social worker(s), pediatric psychologists, child life specialists, and access to family support group services • Pediatric nutrition experts with the capability of preparing, administering, and monitoring total parenteral nutrition Facilities • An immediately accessible and fully staffed, on- site pediatric intensive care unit • Up-to-date diagnostic imaging facilities to perform radiography, computed tomography, magnetic resonance imaging, ultrasonography, radionuclide imaging, and angiography; positron-emission to- mography scanning and other emerging technol- ogies are desirable PEDIATRICS (ISSN 0031 4005). Copyright © 2004 by the American Acad- emy of Pediatrics. PEDIATRICS Vol. 113 No. 6 June 2004 1833 by on October 29, 2010www.pediatrics.orgDownloaded from
  3. 3. • Up-to-date radiation-therapy equipment with fa- cilities for treating pediatric patients • A hematopathology laboratory capable of per- forming cell-phenotype analysis using flow cy- tometry, immunohistochemistry, molecular diag- nosis, and cytogenetics and access to blast colony assays and polymerase chain reaction-based meth- odology • Access to hemodialysis and/or hemofiltration and apheresis for collection and storage of hematopoi- etic progenitor cells Capabilities • A clinical chemistry laboratory with the capability to monitor antibiotic and antineoplastic drug lev- els • A blood bank capable of providing a full range of products including irradiated, cytomegalovirus- negative, and leucodepleted blood components • A pharmacy capable of accurate, well-monitored preparation and dispensing of antineoplastic agents and investigational agents • Capability of providing sufficient isolation of pa- tients from airborne pathogens, which could in- clude high-efficiency particulate air (HEPA) filtra- tion or laminar flow and positive/negative pressure rooms • Access to stem cell transplant services • Educational and training programs for health care professionals including the primary care physician • Coordination of services including home health, pain management, palliative, and end-of-life care • A regularly scheduled multidisciplinary pediatric tumor board • An established program designed to provide long- term, multidisciplinary follow-up of successfully treated patients at the original treatment center or by a team of health care professionals who are familiar with the potential adverse effects of treat- ment for childhood cancer • Membership or affiliation with the Children’s On- cology Group to provide access to state-of-the-art clinical trials; availability of support for coordina- tion to track patients’ progress and maintain clin- ical trials data • Capability of providing parent, caregiver, and pa- tient education • Full-time access to translation services to ensure accurate translation and effective communication among all health care professionals and the patient and family • An ongoing program of assessment of care for continuing quality improvement and safety • A formal program for cancer education for the family and instruction on self-management ROLE OF CENTERS IN DIAGNOSIS AND TREATMENT Approximately 12 000 new cases of cancer are di- agnosed in children younger than 20 years annually in the United States.1,2 Cancer remains the second most frequent cause of death, after injury, in children older than 3 months.3 Great progress has been made in the development of successful treatment programs for children and adolescents with cancer. These improvements have been possible because of the availability of pediatric cancer treatment centers with collective expertise in the clinical management of children with cancer and the existence of a network of experienced investiga- tors and allied health professionals who recognize the central importance of randomized clinical trials as the best available method for identifying more successful treatment strategies and who have the resources to evaluate new treatment modalities as they become available. The importance of comprehensive, multidisci- plinary treatment in improving patient outcome in a cost-effective manner has been well documented for children with acute lymphoblastic leukemia,4 non– Hodgkin lymphoma,5,6 brain tumors,7,8 rhabdomyo- sarcoma,5,8 Wilms’ tumor,9,10 and Ewing sarcoma.5 Almost 80% of these children can be treated success- fully if modern diagnostic and therapeutic ap- proaches are initiated expeditiously.2 Early detec- tion, accurate diagnosis, and appropriate treatment depend on a multidisciplinary treatment approach to children and adolescents with cancer, an approach that is uniquely available at a pediatric cancer center. The roles of specialized nursing, pharmacy, rehabil- itation, and paramedical personnel and access to in- creasingly complex equipment and facilities are crit- ical to improving long-term survival and quality of life. The center-based pediatric hematologist/oncolo- gist is the coordinator for the diagnosis and treat- ment of most children and adolescents with cancer. Pediatric hematology/oncology is an established specialty with specific training requirements that lead to subspecialty board eligibility. Because most pediatric tumors show a striking response to specific regimens of intensive chemotherapy, pediatric he- matologists/oncologists are necessarily resolute in carrying out therapies that can have devastating morbidity and appreciable mortality. For these ther- apies to be administered safely, a pediatric hematol- ogist/oncologist who is trained and experienced in the management of children and adolescents with cancer and who has extensive knowledge of the rel- evant drug indications and toxicities must coordi- nate this care. The pediatric hematologist/oncologist must be as- sisted by skilled nurses, social workers, pharmacists, nutritionists, and psychologists who specialize in pe- diatric oncology. Professional organizations such as the Association of Pediatric Oncology Nurses and Association of Pediatric Oncology Social Workers facilitate the professional growth and education of these individuals. Diagnostic radiologists and radia- tion oncologists with specific training and interest in pediatric oncology should be available at the pediat- ric cancer center. Principles of surgery that are unique to childhood tumors have evolved, and in fields such as general (pediatric) surgery, urology, neurology, and orthopedics, the presence of sur- geons whose sole (or major) effort is directed toward pediatric oncology has become indispensable in achieving maximum survival. 1834 GUIDELINES FOR PEDIATRIC CANCER CENTERS by on October 29, 2010www.pediatrics.orgDownloaded from
  4. 4. A pathologist experienced in pediatric oncology is an essential member of the multidisciplinary team at the pediatric cancer center. State-of-the-art diagnosis of many pediatric hematologic malignancies and tu- mors requires immunochemistry and/or molecular techniques. Because solid tumors in children and adolescents are rare in the experience of most pathol- ogists, an incorrect histologic diagnosis may be given when initial surgical management occurs at a non- specialized hospital. Ideally, the diagnostic biopsy should be performed at the cancer center, at which the facilities are available to order and obtain all the special studies that would be appropriate and would obviate the need for subjecting the patient to repeat procedures. PRACTICE OF PEDIATRIC ONCOLOGY OUTSIDE RECOGNIZED CENTERS The clinical results in children with cancer have been shown to be superior when specialized diag- nostic, supportive, and specific care is given at a pediatric cancer center.4–10 After diagnosis has been established and the treatment plan has been deter- mined by the pediatric cancer center, certain aspects of care may be continued in the office of a primary care pediatrician for selected children. When such a plan for shared treatment is undertaken, it must be with the understanding that the child will be referred back to the pediatric cancer center if complications develop or there is recurrence of the tumor. For many children, the facilities and expertise available at the pediatric cancer center are required for all aspects of therapy. However, it must be emphasized that the primary care pediatrician should retain an important supportive role for the patient with cancer and his or her family, which requires excellent reg- ular communication between the oncologist and the pediatrician. SUMMARY On the basis of the effectiveness of pediatric cancer centers in treating children and adolescents with can- cer, the American Academy of Pediatrics recom- mends the following: • Children and adolescents with newly suspected and/or recurrent malignancy should be referred to a pediatric cancer center for prompt and accu- rate diagnosis and management. • Children and adolescents with newly diagnosed and/or recurrent malignancies should have their treatment coordinated by a board-certified pediat- ric hematologist/oncologist; treatment should be prescribed and initiated at a pediatric cancer cen- ter but may be continued at a center not special- ized in the care of the pediatric oncology patient under the continuing oversight of the center’s mul- tidisciplinary team. • Multidisciplinary team members should have pe- diatric expertise within their specialty area. Section on Hematology/Oncology, 2003–2004 Roger L. Berkow, MD, Chairperson *James J. Corrigan, MD *Stephen A. Feig, MD F. Leonard Johnson, MD Peter A. Lane, MD John J. Hutter, Jr, MD Liaisons Edwin N. Forman, MD Childhood Cancer Alliance Naomi L. Luban, MD American Association of Blood Banks Staff Laura Laskosz, MPH *Lead authors REFERENCES 1. Kosary CL, Ries LAG, Miller BA, Hankey BF, Harras A, Edwards BK, eds. SEER Cancer Statistics Review, 1973–1992: Tables and Graphs. Be- thesda, MD: US Department of Health and Human Services, Public Health Service, National Institutes of Health; 1995. DHHS Publication No. NIH 96-2789 2. Bleyer WA. What can be learned about childhood cancer from “Cancer Statistics Review 1973–1988.” Cancer. 1993;71(10 suppl):3229–3236 3. Wegman ME. Annual summary of vital statistics—1993. Pediatrics. 1994; 94:792–803 4. Meadows AT, Kramer S, Hopson R, Lustbader E, Jarrett P, Evans AE. Survival in childhood acute lymphocytic leukemia: effect of protocol and place of treatment. Cancer Invest. 1983;1:49–55 5. Stiller CA. Centralisation of treatment and survival rates for cancer. Arch Dis Child. 1988;63:23–30 6. Wagner HP, Dingeldein-Bettler I, Berchthold W, et al. Childhood NHL in Switzerland: incidence and survival of 120 study and 42 non-study patients. Med Pediatr Oncol. 1995;24:281–286 7. Duffner PK, Cohen ME, Flannery JT. Referral patterns of childhood brain tumors in the state of Connecticut. Cancer. 1982;50:1636–1640 8. Kramer S, Meadows AT, Pastore G, Jarrett P, Bruce D. Influence of place of treatment on diagnosis, treatment, and survival in three pediatric solid tumors. J Clin Oncol. 1984;2:917–923 9. Lennox EL, Stiller CA, Jones PH, Wilson LM. Nephroblastoma: treat- ment during 1970–3 and the effect on survival of inclusion in the first MRC trial. Br Med J. 1979;2(6190):567–569 10. Green DM, Breslow NE, Evans I, et al. The relationship between dose schedule and charges for treatment on National Wilms’ Tumor Study-4. A report from the National Wilms’ Tumor Study Group. J Natl Cancer Inst Monogr. 1995;19:21–25 SELECTED READINGS Bleyer WA. Cancer in older adolescents and young adults: epidemiology, diagnosis, treatment, survival, and importance of clinical trials. Med Pediatr Oncol. 2002;38:1–10 Carter TL, Watt PM, Kumar R, et al. Hemizygous p16 (INK4A) deletion in pediatric acute lymphoblastic leukemia predicts independent risk of relapse. Blood. 2001;97:572–274 Coffin CM, Dehner LP. Pathologic evaluation of pediatric soft tissue tumors. Am J Clin Pathol. 1998;109:S38–S52 Dayton V, Nguyen PL, Jaszcz V. Interpreting flow cytometry for hematologic neoplasms. Am J Clin Pathol. 2000;114:151–153 Gurney JG, Severson RK, Davis S, Robison LL. Incidence of cancer in children in the United States: sex-, race-, and 1-year age-specific rates by histologic type. Cancer. 1995;75:2186–2195 Lo Coco FL, De Santis S, Esposito A, Divona M, Diverio D. Molecular monitoring of hematologic malignancies: current and future issues. Semin Hematol. 2002;39:14–17 Rowley JD. Cytogenetic analysis in leukemia and lymphoma: an introduction. Semin Hematol. 2000;37:315–319 Rowley JD. Molecular genetics in leukemia. Leukemia. 2000;14: 513–517 Shochat SJ, Fremgen AM, Murphy SB, et al. Childhood cancer: patterns of protocol participation in a national survey. CA Cancer J Clin. 2001;51:119–130 All policy statements from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time. AMERICAN ACADEMY OF PEDIATRICS 1835 by on October 29, 2010www.pediatrics.orgDownloaded from
  5. 5. 2004;113;1833-1835Pediatrics Section on Hematology/Oncology Guidelines for Pediatric Cancer Centers & Services Updated Information including high-resolution figures, can be found at: References at: This article cites 16 articles, 5 of which you can access for free Citations les This article has been cited by 5 HighWire-hosted articles: Subspecialty Collections Office Practice following collection(s): This article, along with others on similar topics, appears in the Permissions & Licensing tables) or in its entirety can be found online at: Information about reproducing this article in parts (figures, Reprints Information about ordering reprints can be found online: by on October 29, 2010www.pediatrics.orgDownloaded from