Sunday, 3 October 2010

In India, should we treat children with High Risk Neuroblastoma (HR NB)?

At the outset, let me clarify two things. Firstly, by no means am I advocating not giving treatment to children with HR NB in India. My only purpose is to generate debate and learn from the more experienced and learned clinicians in India who manage children with this cancer. Secondly, every child irrespective of the type of disease or cancer (including HR NB) has a right to palliation including pain relief and this treatment option should not be denied. So, I guess the question I am really asking is "In India, should we treat children with HR NB with a curative intent?"

Around 50% of all children with NB have HR disease (essentially Stage IV i.e. metastatic NB or NB with mycn gene amplification with some caveats for age and histology). A study from the Children's Oncology Group published last month (Yu et al, 2010) reports a 2-year overall survival of 86% and event-free survival of 66% in children with HR NB who were treated with multi-drug induction + stem cell transplantation + isotretinoin + immunotherapy. Prior to the introduction of immunotherapy, the event-free survival in the developed world had plateaued at less than 50%. Thus, this new report of further improvement in outcomes is significant.

This brings me to the situation in India. As far as I am aware, while multi-drug induction (followed by surgery and radiotherapy) is standard treatment for children with HR NB, use of stem cell transplantation is not standard and immunotherapy has not been tried. In such a setting, what are the outcomes of HR NB? It is difficult to answer this question precisely, because assessment of mycn amplification is not standard practice in India either. Outcome of children with Stage IV i.e. metastatic NB can give us some indication, although very few institutes from India have published their outcomes. This includes 3 long term survivors out of 32 children with Stage IV neuroblastomas reported from Thiruvanathapuram (Kusumakumary et al, 1998); 1 out of 27 reported from Chandigarh (Bansal et al, 2008); and 0 out of 38 reported from Mumbai (Bhatnagar et al, 2007, SIOP).

Based on these reported outcomes i.e. less than 10% reported long-term survivors of HR NB, is there an argument for not offering curative treatment to the above group of patients in India? Has anybody reported better outcomes from India?


  1. Dear Raman Deep
    First of all you cannot get good and reliable statistics from India as the follow up technology has not developed in our country. Significance of follow up is not taught to the undergraduate and post graduate students in this country. In a short trial I have been asking question in exam papers and the examinee's replies were hopeless. should you require my views on Follow up I can share them
    Secondly I have seen very clearly that in retinoblastoma annd childhood neuroblastoma , the drug Septilin( Himalaya) has made wonders when given as adjuvant to the standard chemo regimen. I have not seen 5-7 year survivors before after I started getting such response, The randomization thus was out of question and unethical. However the proxy evidence was the similar cases treated by other units in my department SANS Septilin have even progressed and succumbed while on chemotherapy, couple of them were rescued by administration of septilin secretly, much to the dislike of head of that unit.
    Then question comes how do we rationalize the onco sciences and amalgamate our ways with this marvelous "alternative System Ayurveda" for the greater benefit of humanity!!!!!

  2. Will Preventive Oncological Intervention and paediatric Cancer Awareness help prevent the malady and non-curability of these tumours

    The Pediatric Cancer Preventive oncology has not taken off as yet, What we are left is the palliative care options for most of these cases in India. Please read the lines below.
    IN India we wanted Children’s Day a National even should also be observed as Pediatric Cancer Day with Indian perspective in addition to the International day that is in month of Feb.
    For both the days there was total apathy from the side of medical and pediatric oncologists and oncologists as a whole. Why?
    In a novel experimentation a School Cancer Education programme with a 200 page book in Hindi ( title translates as “The story of Cancer Children ought to have been told”) have been a great success to harvest cancer cases inn early stages. So was a short term awareness programme during the pulse polio administration days with the parents who brought their children for vaccination.

    Any taker of lessons from these experiences.?
    It is only after multipronged efforts that Delhi Govt. Has included cancer in their national Rural Health Mission Curriculum. The Central Govt. And rest of the country is yet to follow the suit.

    I always believed in grassroot level works than hifi jing-bangs that have little relevance to the unaffording population of poor pediatric patients that is overwhelmingly

  3. Dear Prof Manoj

    Thank you for your comments. I agree with your observation of the difficulty in getting reliable and complete statistics, particularly on follow-up.

    The comment on Septilin is interesting - I had not heard of it before. Even in the absence of randomization and reliable follow-up statistics, it should be possible to show benefits of septilin in an objective way. I wonder if this has ever been done. I did find an interesting article ( which shows some benefit of Septilin in those with Wilm's tumour and neuroblastoma though it suffers from serious methodological limitations.