Difficult beginnings—Cancer in infancy

The incidence of cancer in the first year of life, reported in the United States at greater than 230 per million 1, is more than 50% higher than in childhood (0–14 years of age) as a whole 2. Caution has been advised, for numerous reasons, in interpreting successive incidence rates that indicate a recent rise in frequency 1. The distribution of diseases in infancy by incidence differs substantially from that in later childhood; the commonest cancers in infants in the United States (in descending rank order) being neuroblastoma, leukemias, brain tumors and retinoblastoma. It should be recognized that there are notable differences in the racial distribution of these diseases. In the United States for example, neuroblastoma occurs more frequently in whites than in blacks. Moreover, such disparities are described in other parts of the world, as in the lower rank order of neuroblastoma in Taiwan 3. Within developing countries other distributions have been reported, such as the top ranking of retinoblastoma in some areas of India and Pakistan 4. Furthermore, there are also important differences in the biologic characteristics of individual cancers in infants by comparison with older children, as exemplified by the clinical and molecular phenotypes of acute lymphoblastic leukaemia 5. In this symposium the topics of neuroblastoma, leukemias, brain tumors and retinoblastoma were addressed respectively by Dr. Robert Castleberry, Dr. Johann Hitzler and Dr. Lewis Silverman, Dr. Eric Bouffet and Dr. Brenda Gallie. The management of chemotherapy in the very young can be particularly challenging as emphasized by Dr. Gideon Koren. Supportive care of infants with cancer poses additional problems. The issues of nutrition, pain and immunization were discussed by Dr. Paul Pencharz with Mary Barron, Dr. Bonnie Stevens and Dr. Upton Allen, respectively. While the survival prospects overall for children with cancer in the first year of life are poor by comparison with those of older children, one notable exception is that of neuroblastoma 1. But what of other outcome measures? Very little information exists on the health status and health-related quality of life in survivors of cancer in infancy. Given the developmental status of these children and the intensity of therapy to which they are commonly exposed, it is likely that the burden of morbidity in survivors will be high. In addition, the journey from diagnosis through the treatment experience to survivorship can have major adverse effects on families, as described by Dr. Anne Kazak. The occurrence of cancer early in life has provided remarkable insights to the pathogenesis of malignant disease, likely linked to antenatal etiologies as exemplified by tumor suppressor genes 6. The hardship experienced by infants with cancer and their families may be offset somewhat if clinical and laboratory-based investigators take advantage of the learning opportunities provided by these disorders to devise more effective interventions with better therapeutic outcomes based on enhanced understanding of cancers in the very young.

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