If cancer comes back at any time after a child has been in remission, the term relapse is used. This applies whether the cancer has come back in the same place it was when first diagnosed or if has come back somewhere else in the body. Relapse is always an adverse event and is often viewed as a major setback in the potential for long term cure.
Every child is different and the approach taken to dealing with relapse will vary depending on individual circumstances. However, generally the first thing considered is the severity of the relapse. This is determined by three factors:
1. The type and intensity of initial treatment will reveal something about the resistance of the cancer cells to treatment as well as what is likely to work the second time around. Variables such as prior chemotherapy combinations used, whether radiotherapy has been tried or if intensive approaches such as Bone Marrow Transplantation have been included, all impact on the available options at relapse.
2. The timing of relapse. Generally, the longer it is from initial diagnosis, the more likely it is that a better response to further treatment can be expected. Similarly, if relapse occurs while a child is still receiving chemotherapy, it will usually be more difficult to treat than relapse that occurs after chemotherapy has been completed.
3. The place where the relapse occurs. Options for surgery, radiotherapy and chemotherapy will all be affected by where the relapse occurs. In solid tumours, the relapse may occur in the original site or at one or more sites in the body. Generally, relapse at any one site is better than several. In leukaemia, the most common relapse is in the bone marrow. Sometimes relapse can occur in sites such as the brain and spinal cord, or the testes or lumps in unusual places. The approach to each of these will be different and the chance of achieving further control and possibly cure varies accordingly.
If your child was to relapse, your doctor would discuss the following questions with you:
- What treatment combination can achieve a response after relapse?
- What are the possibilities of achieving a second remission?
- How long is a response or remission likely to last?
- Is cure still a goal and if so how likely is it?
- What side effects are likely to be encountered in the various available approaches?
- What will happen if no anti-cancer treatment is offered and the cancer progresses?
- If cure is only a small possibility, what other treatments are available to control the manifestations of the cancer and improve quality of life?
The decision for each individual child will be determined by both the factual information available from your doctor and also the views and feelings of the family when confronted with this information.
The Range of Options
In general terms, the possibility of cure after relapse is always less than it was at diagnosis. In some situations, the chance of cure after relapse is close to zero. In this case it is important to decide whether to target the treatment to control the disease, with anti-cancer treatment, or to target the treatment to control the symptoms of the cancer. Even when cure cannot be achieved, there may be times when anti-cancer treatment may be offered, because there is a reasonable chance it may slow the growth of the cancer and help improve the quality of life. In other cases, it may be the side effects of the anti-cancer treatment will be too severe with too little benefit to warrant use.
Therapy aimed specifically at relieving discomfort and other symptoms of cancer is called Palliative Care. The emphasis is primarily on maximising the child’s quality of life and controlling the symptoms of the cancer. At Sydney Children’s Hospital, Randwick (SCH) a specialised Palliative Care team helps to provide the highest level of care. Palliative Care can be given even if the patient is still having anti-cancer treatment such as chemotherapy or is receiving experimental therapy.
The other end of the range of options may be to try the most intensive combinations of drugs, radiation, surgery and Bone Marrow Transplantation. Regardless of the intensity and complexity of treatment offered, in most cases if a cure is to be possible, a second remission must first be achieved.
Often, the anti-cancer treatments used in the treatment tend to be more intensive and therefore causes more side effects. Both sides of the equation – the benefits and the risks, need to be carefully weighed up before a decision is reached.
Sometimes new treatments become available for which there is no established experience – these are called experimental treatments and are tested in the context of a ‘clinical trial’. These clinical trials are usually called ‘early phase’ clinical trials and can be Phase I or Phase II. A Phase I study is testing a new drug to assess its safety, determine the right dose level, and to check for side effects. A Phase II study is testing a new drug to see whether it is able to shrink a tumour or delay progression of the tumour.
SCH has established a new Clinical Trials Program to offer new and experimental treatments for children who have relapsed or underwent unsuccessful conventional therapy. You can ask your doctor if any experimental therapies are available or any clinical trials open which may be suitable for your child. Any options would need to be discussed at length with you by your doctor or by a doctor who has expertise in early phase clinical trials.