NETWORK T H E N E W S L E T T E R O F T H E I N T E R N A T I O N A L N E T W O R K F O R C A N C E R T R E A T M E N T A N D R E S E A R C H Volume 2, Number 4, Spring 2002 — Inside: The Annual Meeting - 7 The INCTR Awards - 11 Case Report - 16 News and Letters - 14 Shaukat Khanum Memorial Cancer Hospital & Research Center - 17 Profile in Cancer Medicine - 20 THE PRESIDENT’S MESSAGE CONTINUING CONSTRUCTION by Ian Magrath Earlier this year, I had the opportunity to visit the magnificent but startlingly unusual church in Barcelona, la Sagrada Familia, designed by the Catalonian architect Antoni Gaudi. Based on the style of a Gothic cathe- dral, the building eschews the classi- cal arches and flying buttresses in fa- vor of an almost surrealistic appear- ance. Irregular curves and unex- pected asymmetries replace the strict proportionality and formal lines that we encounter in most large buildings, whether ancient or modern. In places, the stone seems to have melted and run down the walls like hot wax on a of artists—water (see picture above). In my annual report at INCTR’s An- candle, piling up into strange shapes Gaudi’s towers are pitted with similar, nual Meeting this year, I used la from which human forms represent- cave-like orifices. High up on the Sagrada Familia as a metaphor for the ing saints and apostles emerge. The steep cliffs of the mountain are the growth and development of the most prominent feature of the build- ruins of a Benedictine monastery INCTR. Both are still under construc- ing is the soaring spiral towers—there founded in the 11th century, and its tion, both are rather unique edifices will eventually be 18 of them—in- more recent replacement. The latter which don’t conform to the usual pat- spired, apparently, by Mount houses a black wooden image of the tern, and both have connections to Monserrat, a mass of limestone which Virgin Mary, which, tradition has it, more distant parts of the world. They arises abruptly from a plain some 50 was carved by St Luke. Some would are icons of the larger human family, kilometers to the northeast of say, however, that the famous “Black for which the symbolism of mother Barcelona. The mountain has been Madonnas,” which have been found and child is particularly apt, and in twisted into strange shapes by earth all over southern Europe, are actually spite of their gravity of purpose, movements while numerous caves representations of the Egyptian god- project a certain youthful irreverence. have been sculpted out of the soft dess Isis, who was worshiped by a se- In the case of INCTR, this is essential rock by that most gentle and patient cret sect in Europe for centuries. to the invention and re-invention that 1 NETWORK CANCER IN CHILDREN Group and four of the six local ethical One of the earliest review committees that will need to projects, decided approve the study have already done upon at the first so. INCTR Annual Meet- Acute lymphoblastic leukemia ing, was to address (ALL) has been a longstanding col- the problem of ret- laborative project among INCTR staff inoblastoma, a tumor and several Indian centers, initially via of the eye occurring the National Cancer Institute, in infants, which is Bethesda, but now, through INCTR’s both more prevalent Leukemia Strategy Group. Analysis of in developing coun- 1,048 patients treated between 1990 tries and tends to and 1997 with the same protocol present to treatment (MCP841) at three major centers, the centers very late in its Cancer Institute in Chennai, the Tata course. This leads to Memorial Hospital in Mumbai, and Ian Magrath (left) listens to Dr Indraneel Mittra’s ideas on the deaths of many the ALL India Institute of Medical Sci- cancer control in developing countries such as India. children from retino- ences in Delhi, has been largely com- blastoma—a rare oc- pleted and a manuscript for publica- must constantly go on if the broad currence in more affluent countries. tion is in preparation. These results range of problems faced in develop- In addition to the development of a demonstrate clear differences in the ing countries is to be addressed and questionnaire to identify the causes patient populations being treated at the creative energies of our many col- of late presentation, several members each of these centers as well as dif- laborators, all too often stifled by lack of the Retinoblastoma Strategy ferences in outcome. Surprisingly, uni- of resources, are to be released. Un- Group have initiated national pro- form risk factors that apply to the like la Sagrada Familia, the INCTR was grams designed to bring the impor- populations in all three centers can- not inspired by a natural rock forma- tance of early diagnosis to both the not be defined, and although risk fac- tion, although its efforts may well be doctors who first see the patient, and tors are more similar in Mumbai and likened to the challenge of climbing to the public. Pictures (in the case of Delhi, a careful analysis of the Mumbai to the top of a high mountain: success Brazil, a brief film) of children with data suggests that even in the last is dependent upon a team approach, leukocoria, the white appearance of three years of the study, the propor- a clear purpose, and a well-planned the pupil that occurs shortly after the tions of patients with various clinical overall strategy, although the latter tumor develops within the eye, are characteristics have changed, as have needs to be plastic enough to be bent the mainstay of these campaigns (see the identifiable risk factors. These data and twisted like Gaudi’s limestone, as page 16 ). Protocols for the treatment illustrate several very important the need arises. of advanced disease are presently be- points. First, it cannot be assumed that Since its creation, INCTR’s growth ing designed and we hope that these risk factors (i.e., patient characteristics has been continuous—both with re- will be activated in the next year. associated with prognosis) identified spect to the projects that have been A second tumor that occurs in chil- in one patient population will apply initiated or are in the planning stages, dren and adolescents, osteosarcoma, to another population, even when the and to the evolution of its network. It was also selected for study at the first same treatment protocol is used. Thus, has begun by focusing on the cancers Annual Meeting, in part to explore the application of treatment successful in of women and children. Last year at issues that would arise in conducting one part of the world, or even in an- this time, I spoke of laying the foun- an international clinical trial involving other institution in the same country, dations of INCTR. This year, I’ll discuss inter- and intra-institutional coopera- by no means guarantees success in the continuing construction. tion. The treatment protocol for ad- another. The reasons for this include vanced osteosarcoma has been com- possible differences in the strictness pleted by the Osteosarcoma Strategy of adherence to the treatment 2 M E S S A G E schema and in the ability to support patients through the sometimes life- threatening side effects of treatment, as well as differences in the “biologi- cal profile” of what we think of as the same neoplasm. All neoplasms actu- Limited Many Patients or ally consist of families of neoplasms, Resources Potential Patients the members of which differ to a greater or lesser extent from each other, and which may require a some- CAPACITY ACCESS what different treatment approach. This is illustrated by the marked dif- ferences in the proportion of precur- The basic problem for patients with cancer in developing countries can be sor T and precursor B cell ALLs in each summed up as “poor access to cancer care.” This arises because of the limita- of the three Indian centers. Until re- tions in the capacity to deal with the extant cancer burden resulting from the cently, the ability to precisely charac- relatively small number of well-trained specialists and ancillary health care terize tumors has been limited to personnel, the paucity of well-equipped specialized centers or departments, morphology—in essence, the study and limitations in the family’s financial ability to deal with the added burden of the size, shape and other physical of a diagnosis of cancer, including the cost of diagnosis, treatment and follow- features of the malignant cells (rather up, time off work and transportation. To a large degree, capacity and access like recognizing one’s neighbor by her bear an inverse relationship to each other. Increasing capacity for treatment facial features), and to the study of the and prevention would improve access to care. expression of a small, although in- creasing number of gene products (the proteins responsible for all of the proved ability to predict the response and, of course, between Indian pa- tumors characteristic features, physi- to therapy. Since the pattern of gene tients and patients in other countries. cal and functional). In the last few expression also contains within it the As time goes by, these same tech- years, powerful new methods of iden- modifications caused by the genetic niques will be applied to other tumors. tifying different family members of abnormalities responsible for creat- The work in India will be extended the same tumors (and of course, dis- ing the malignant cell in the first through two additional projects.