Cancer affects more than just the tissue or organ in which a tumor starts — it affects the whole patient. This is as much the case with children as adults, if not more so, and can have greater consequences. With survival rates for childhood cancers constantly on the rise, the long-term effects of cancer care on nearly every organ system are coming under increasing scrutiny, as are ways of reducing those effects.
A multidisciplinary approach to cancer care is the best way to keep cancer treatment’s side effects as low as possible while keeping a patient’s quality of life high, both during and after treatment. In this context, pediatric urologists bring a unique perspective, one that combines techniques that can help a child’s care team evade or alleviate continence and voiding issues during treatment and address options for maintaining urologic, sexual and reproductive function down the road.
Notes talked to Richard S. Lee, MD, director of pediatric urologic oncology for Dana-Farber/Boston Children’s Cancer and Blood Disorders Center and a physician in Boston Children’s Hospital’s Department of Urology, about the expertise a pediatric urologist brings to a multidisciplinary pediatric cancer care team.
Q. What are some of the key aspects of cancer care where a urologist can have an impact?
A. The urologist’s role in the multidisciplinary care of childhood cancer patients is definitely multifaceted. Our goal is to help keep children with cancer as functional as possible in the long term, which is part of treating the whole child and keeping their quality of life as high as possible.
Apart from the care of urologic tumors of children and young adults specifically, such as testicular, kidney or bladder tumors, there four areas a pediatric urologist would focus on:
- bladder function
- kidney function
- sexual function
Q. What expertise can a pediatric urologist offer in the context of cancer?
A. What’s great about collaborating with oncology is that we’ve done a lot of groundbreaking work in pediatric urodynamics, which has taught us how the bladder works in children, how the nerves function and how they can become dysfunctional. While in cancer the insult on the bladder is different from what is seen in benign urology, but the problems can be the same. We can bring all of that expertise into the multidisciplinary care of children with cancer.
For instance, with bladder and sexual function, a lot of what we might do is related to tumors arising around in the pelvis or the spine, and how those tumors may affect the anatomy and the nerve function in that area. Urologists can offer some highly specific testing up front that can reveal whether the tumor is affecting these nerves and help predict how the child will do during and after therapy.
In addition, children with pelvic or lower abdominal tumors often arrive with severe urinary retention, which can cause extreme distress. A urologist can help them get past that acute condition, employ urodynamic or needle EMG testing to get them on a long-term plan during therapy, and help get them back to regular function after therapy.
And we must always remember that some children develop long-term issues from the therapies they’ve received. For instance, urinary incontinence can significantly impact the quality of life. A urologist can help make a child continent again and improve overall function with medical or surgical interventions.
Q. How can a pediatric urologist help address long-term treatment-related concerns about fertility?
A. As part of the multidisciplinary effort, it is very important for the oncologist to discuss fertility with the patient and family. Our role as urologists is to provide additional information and assist in the preservation of fertility whenever feasible.
What can be done depends on the situation and whether a therapy is known to cause infertility. If the patient is a post-pubertal male and is able to provide a semen sample for banking, a urologist doesn’t really need to be involved. If for some reason such a patient is unable to do so, a urologist can offer options like testicular sperm extraction.
The urologist’s goal is to help keep children with cancer as functional as possible in the long term, which is part of treating the whole child and keeping their quality of life as high as possible.
For pre-pubertal boys, there are no standard approaches available for preserving fertility. On an experimental basis, we offer testicular tissue preservation, where we cryopreserve cells from a testicular biopsy in the hope that down the road the technology will become available to mature pre-pubertal cells into viable spermatogonia for IVF.
With girls, it can be challenging. Egg collection and preservation is an option for young women over the age of 17. A very small number of centers offer ovarian tissue preservation for younger or pre-pubertal girls, as it’s still an experimental approach. As with young boys, it’s not yet clear whether it’s possible to derive functional eggs from preserved pre-pubertal ovarian tissue.
Q. When is the right time for a urologist to get involved in the care of a child with cancer?
A. As soon as a child receives a cancer diagnosis that could affect urologic function or later fertility. For instance, at Dana-Farber/Boston Children’s, we are proactive with our services so that we can prevent or better manage the potential urologic implications of cancer therapy, as well as better educate clinicians, parents and patients about those implications.
Q. What does the future hold for the intersection of urology and cancer care?
A. As a basic scientist, I believe that science will revolutionize the way we approach fertility. There may come a day, a ways away, when you don’t need to save sperm or egg cells, but could use cells from another source, such as a skin biopsy, to generate the necessary stem cells.
Surgically, urology has always been a leader in the minimally invasive surgery. Over the last 15 years, we have begun to more aggressively pursue minimally invasive options, including robotic surgery, for pediatric urologic cancers and benign pediatric urology, and I see this as a major opportunity for ongoing advancement.
Lots of new data are coming out of benign urology regarding bladder function and different ways to manipulate it. I think that new therapies for restoring bladder function that arise from these data will be critical for children undergoing cancer treatment.
On the whole, I think that the collaboration has never been better across all facets of the care of children with cancer. And I think that will only improve even more over time.