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When Diana Menendez was diagnosed with Hodgkin's disease in 1968 at age 8, doctors weren't sure they could cure her. So they hit her cancer with everything they had: high-dose radiation and four years of chemotherapy.
The treatments worked; her Hodgkin's disease disappeared.
But the side effects of treatment plague her still. Radiation scarred her lungs, and she is often short of breath. At 21, Menendez was diagnosed with thyroid cancer, another result of the radiation. At 33, doctors found bladder cancer caused by the chemotherapy. Menendez lost not only her bladder, but also her uterus and ovaries. Then, last year, at age 43, she was diagnosed with kidney cancer.
''I was devastated,'' Menendez says. ''I cried for two days.''
Yet Menendez says she is luckier than some cancer survivors. Cancer therapy did not prevent her from having four children. ''I'm so fortunate that doctors saved my life,'' says Menendez, of Pearland, Texas. ''But now I have a lot of other problems to deal with.''
Like Menendez, patients who survive Hodgkin's disease -- a cancer of the lymph nodes and related organs -- often have complications years after doctors pronounce them cured. About 7,880 Americans a year are diagnosed with the disease, and more than 1,300 die from it, according to the American Cancer Society. Up to 15% of cases involve children 16 and younger.
Survivors are at increased risk for heart disease, and radiation can damage bones and muscles so that youngsters do not grow normally. Twenty years after treatment, Hodgkin's patients are more likely to die from the ''late effects'' of chemotherapy and radiation than from a recurrence of the original cancer.
Yet cancer therapy has changed drastically since Menendez was first diagnosed. Although doctors now use smaller doses of chemotherapy and radiation, they now cure more than 90% of children with Hodgkin's. Overall, nearly two-thirds of cancer patients in the USA live at least five years.
Less toxic treatments
As therapies help children with Hodgkin's live longer, doctors also are working to make treatment less toxic. Their goal is not just to save lives, but to help children stay healthy and disease-free for decades.
* In July, a study in The New England Journal of Medicine showed that a drug called dexrazoxane may protect children's hearts from damage caused by a class of chemotherapy medications called anthracyclines. Doctors are still testing the drug to make sure that it doesn't also protect tumor cells.
* This week, doctors published a study in The Lancet suggesting that children with Wilms' tumor, a rare kidney cancer, survive about as well with four weeks of chemotherapy after surgery as with 18 weeks.
* A study presented Tuesday at the annual meeting of the American Society for Therapeutic Radiology and Oncology in Atlanta illustrates the challenges of making cancer therapy more gentle.
In that study, German doctors presented research showing that some pediatric Hodgkin's patients may not need radiation. Children whose tumors disappeared completely after chemotherapy did not undergo radiation, says Ursula Rhl, chief of radiation oncology at Moabit Hospital in Berlin and an author of the report.
For ''low-risk'' patients -- whose bodies had only small amounts of cancer -- skipping radiation did not hurt their survival. Nearly five years later, 97% of all the children in the study are still alive. But not all patients fared the same. Children with more advanced cancers who bypassed radiation were more likely to relapse -- and require additional therapy.
Combination of approaches
Sarah Donaldson, a professor of radiation oncology at Stanford University School of Medicine who was not involved in the German study, says relatively few Hodgkin's patients fall into the ''low risk'' category, and most children will still require radiation.
It's important to treat cancers aggressively the first time, because tumors that return are harder to treat, doctors say. ''They have a potentially lethal disease, so the challenge is not to back off therapy too far,'' says Marshall Lichtman, executive vice president for research and medical programs at the Leukemia and Lymphoma Society. Researchers may need to follow these children for at least a decade, he says.
Doctors are developing less toxic approaches to cancers. About 80% of children with acute lymphoblastic leukemia no longer undergo radiation, says James Nachman, professor of pediatrics at the University of Chicago.
Doctors also have learned that high doses of two drugs used to treat Hodgkin's, cyclophosphamide and procarbazine, cause sterility in boys, Nachman says. In an effort to preserve boys' fertility, he and his group have lowered the dose of cyclophosphamide and have eliminated procarbazine. They also use smaller doses of two other drugs used in Hodgkin's: doxorubicin, which can damage the heart, and bleomycin, which can hurt the lungs.
''We're trying to mix and match chemotherapy drugs but not rely on any one drug in high doses,'' Nachman says. ''We want to be as gentle as we possibly can.''
Amy Boykin says she didn't worry much about side effects when she was diagnosed with Hodgkin's four years ago, at age 18. Now she wonders whether she will be able to have kids.
''My main goal at that time was to get better,'' says Boykin, a student at the State University of West Georgia. ''I didn't care how they did it. But at the same time, I wondered, 'If I get through this, what's going to be around the corner?' ''
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