Expert Point of View: Michael P. Link, MD

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Michael P. Link, MD

“We have had remarkable success in treating patients with cancer. Millions of survivors are a testament to this success. But the ‘cost of cure’ borne by our patients is substantial in terms of diminished quality and quantity of life,” commented the formal discussant of the study ­Michael P. Link, MD, Lydia J. Lee Professor in Pediatric Cancer, Stanford University School of Medicine.

Dr. Link applauded the investigators of the Childhood Cancer Survivor Study for imparting another “important lesson learned from pediatric oncology.” He noted, “There is good news here for children with cancer, but many of the lessons are applicable to all our patients.”

“ASCO Plenary Sessions usually focus on exciting new therapies that have the prospect of adding incrementally to our goal curing cancer. Dr. Armstrong’s presentation allows us to examine another important aspect of cancer care: survivorship,” he said. “It reminds us that cumulative advances have translated into a growing population of cancer survivors, who are the beneficiaries of our past efforts.”

Consequences of Cures

Since 1990, deaths from cancer in the United States have dropped 22% and patients surviving cancer are living longer. Children and young adults cured of cancer have a lifetime ahead of them during which to develop the potential health-related side effects of the therapies that cured them and to suffer their consequences.

Nearly two-thirds of long-term childhood cancer survivors have at least one chronic condition, and in more than one-fourth of cases, it is severe or life-threatening. “We accept this collateral damage, much like we accept that civilian deaths are the regrettable price of winning a war,” Dr. Link commented.

Launched in 1994, the Childhood Cancer Survivor Study has been instrumental in identifying these late effects through a retrospective cohort study. More than 250 peer-reviewed manuscripts and other publications hare “catalogued the price of cure,” he said.

The study has documented that survivors of childhood cancers, compared with national age-adjusted cohorts, have 10-fold excess mortality and 6.4-fold excess second cancers. In addition, these survivors are at increased risk of cardiac, pulmonary, and endocrine diseases, as well as obesity and psychosocial issues.1

Refining Therapies

Challenged with finding ways to reduce these late effects and improve the quality of life of survivors, pediatric oncologists adjusted treatment protocols that would reduce the intensity of treatments for select, good-risk patients. The aim has been to retain the treatment components believed necessary for cure while eliminating those contributing only toxicity.

“The question remained: Did these modifications actually move the needle on the cost of cure? The good news here,” he said, “is there is a statistically and clinically significant decrease over time in all-cause mortality, nonrecurrence mortality, and mortality related to second malignancies and cardiac and pulmonary disease.”

Dr. Armstrong’s study, he continued, “is a gratifying validation of 3 decades of refining therapies to accomplish cures while lowering the cost of cure.”

Treatment stratification will continue to be refined, based on a growing understanding of host and tumor genetics. Meanwhile, he said, oncologists have an obligation to continue to refine therapies to balance efficacy against toxicity. “Cure,” Dr. Link emphasized, “is not enough.” ■

Disclosure: Dr. Link reported no potential conflicts of interest.


1. Mertens AC, Yasui Y, Neglia JP, et al: Late mortality experience in five-year survivors of childhood and adolescent cancer: The Childhood Cancer Survivor Study. J Clin Oncol 19:3163-3172, 2001.


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