The general approach to treating neuroblastoma at Memorial Sloan-Kettering has four areas of emphasis:
Minimize Treatment and Treat Only When Absolutely Necessary
Local or regional neuroblastoma (i.e. non-stage 4) in young children (usually 18 months or younger), and in some older children with stage 1 or 2 disease, can often be cured with surgery alone. After surgery, we generally recommend continued close observation. In infants these tumors can regress without surgery. For patients who have received chemotherapy treatments at other centers, we usually recommend stopping those treatments. Over the past 20 years we have been successful in sparing young children unnecessary toxic treatments.
Minimize Toxic Treatments
For aggressive, high-risk forms of neuroblastoma in which intensive treatment is required, we try to use the fewest rounds of induction chemotherapy possible. An intensive chemotherapy regimen often makes the patient more susceptible to infection, creates complications that can be dangerous to the patient, and may delay other treatments. The goal is to quickly achieve near-complete remission before moving on to subsequent phases of treatment. We have found that a reduction from seven to five in the number of cycles of chemotherapy administered during initial treatment is usually enough to achieve remission. The additional two rounds did not show evidence of improving patients' chances of long-term survival.
We believe that one of the keys to curing high-risk neuroblastoma lies in arming and teaching the body to recognize and kill neuroblastoma cells. That is the idea behind immunotherapeutic treatments such as the 3F8 monoclonal antibodies. 3F8 represents an important part of our post-induction treatment among the 79 percent of patients who are expected to achieve near-complete remission. The goal of immunotherapy, which is a nontoxic treatment, is to prevent relapse by destroying minimal residual disease before it can develop into a detectable tumor or spread to other parts of the body. We have had success with this approach over the past two decades, and we continue to refine these antibody treatments to enhance their effectiveness.
Continue Research to Develop Novel Therapeutics
A key component of our neuroblastoma program is research. We are working to develop new treatments that may help in the fight against neuroblastoma. For example, in addition to the 3F8 antibody that forms the basis of our immunotherapy treatment, another antibody called 8H9 was also conceived and developed in our neuroblastoma laboratory. 8H9 antibody has been very effective in fighting brain metastases. We are also working to better understand how neuroblastoma cells resist treatment so that we can develop more-effective drugs to fight them.
We have built our current treatment protocols around the experience we have gained in treating neuroblastoma patients since the late 1980s. Our earliest protocols were modeled after the treatment for leukemia: generally, a few relatively quick cycles of chemotherapy to achieve remission, followed by what is known as a consolidation regimen to prevent relapse. We found, however, that residual neuroblastoma becomes resistant to conventional chemotherapy and even radiation treatments, making a leukemia-style maintenance treatment ineffective.
Subsequent protocols tested the consolidation portion of the treatment by adding in either bone marrow/stem cell transplant or hot antibodies (liquid radiation carried by antibodies, also known as radiolabeled antibodies). Remission was then maintained with cold (non-radiolabeled) antibodies until the risk period for relapse passed. When the results derived from 20 years of treating patients on these successive protocols at Memorial Sloan-Kettering were examined, 3F8 immunotherapy has achieved long term remissions in the majority of patients without bone marrow or stem cell transplant. Today, except for rare situations, standard stem cell transplant is no longer incorporated in our treatment plans.
While focusing on the development of new treatment methods, we have not forgotten the psychosocial needs of our patients and parents, with particular emphasis on post-treatment quality of life and cancer survivorship issues. The Department of Pediatrics has built a strong child psychiatry and psychology service, as well as a child life support team, to help children and young adults adjust to the complicated treatment plans and treatment environments.
The late effect program will assume an increasingly important role in completing the total care to neuroblastoma survivors as they resume normalcy in their daily lives.