The Hematology/Oncology Division: A diverse, but focused group

Joshua was seven years old when he returned to The Montreal Children’s Hospital (MCH) of the McGill University Health Centre (MUHC) for another surgery. From the time he was a toddler, he had spent a lot of time at the hospital being treated for multiple brain tumours. Now, the tumour was back, pushing on his optic nerve and impacting his vision. Another surgery was scheduled. Thankfully for Joshua, the odds were in his favour.
“The five-year relative survival rate among children for all cancer has improved from about 50 percent to more than 70 percent in the last 20 years,” says Dr. Blair Whittemore, Interim Director of the Hematology/Oncology Division at the MCH of the MUHC. “This improvement in survival is not just a function of better medications. It is also a reflection of the advancement in technology, surgical techniques and training.”
Fortunately for Joshua and other cancer patients, The Montreal Children’s Hospital provides access to the latest treatment options and latest technology, as well as access to world-renowned expertise.

Improving the health and welfare of children
The mission of the Division is to improve the health and welfare of children with hematological/oncological disorders through excellent compassionate clinical care, research and education. This is a tall mandate for any department but especially challenging for one that straddles two clinical disciplines, hematology and oncology. For more than 50 years the Division has been meeting the needs of its young patients. Each year, the Oncology Day Treatment Centre has more than 6,000 patient visits.

’s first pediatric intra-operative magnetic resonance imaging (MRI) system
The Division has 20 team members and benefits from having Canada’s first pediatric intra-operative magnetic resonance imaging (MRI) system. In addition to providing outstanding medical care, the Division is dedicated to ensuring that the psycho-social needs of its young patients are met. The Childhood Cancer Care Program includes psychologists; art, massage and music therapists; psychiatrists; nutritionists; child care workers; social workers; pharmacists; chaplains and specialized nurses. They help coordinate a comprehensive care plan for each child. The Neurosurgery-Oncology Clinic provides continuity of care and follow-up for patients with brain and spinal tumours. This team consists of neurosurgeons, neuro-oncologists and a radiation-oncologist.
As with many departments, nurses play a critical role. “Our nurses are extraordinary in juggling both day-to-day care, and liaising with outpatients,” says Ann Marie Suess, head nurse of the Hematology/Oncology Division. “They work with children in the hospital, in the community, as well as working with CLSCs and organizations such as Leucan to ensure patients and families receive the best possible care. Our nurses’ skills have been recognized through FACT (Foundation for the Accreditation of Cellular Therapy) accreditation. This means they have met requirements which demonstrate their commitment to controlling every aspect that impacts the quality of products and therapeutic care.”
Joshua benefited from the Childhood Cancer Care program and from the Division’s clinical expertise. Because his tumour was in such a vulnerable area, it could only be partially removed. Thanks to the intra-operative MRI, which gives immediate feedback during surgery, the majority of the malignancy was excised. This procedure alleviated the pressure on Joshua’s optic nerve and his vision was spared. The expertise present at the MCH starting with the seasoned neurosurgeons performing the surgery, the anesthesiologists who put the children to sleep through an often lengthy and delicate procedure and the radiologists who are available at all times to help interpret the images and advise on further surgery as needed in real time, make the program unique and a major asset in treating children with brain tumours within this institution.
“The Division is unique and strong,” says Dr. Whittemore. “Each of our teams is well trained, respected and plays very important roles in the management of the family and the patient.”
“We have a great interdisciplinary team that thinks outside the box,” agrees Ms. Suess. “For example we are continually looking for alternative paths that help families cope with the stress of diagnosis, whether it is meditation, pet therapy or helping children focus with personalized stones. Findings from our recent patient satisfaction survey confirm the extraordinary work that all team members do, from the nurses and the physicians to the pharmacists.”  
In treating cancer, research is key
“People think that cancer is one word, one thing,” says Dr. Nada Jabado, a Montreal Children’s Hospital researcher and clinician, who studies brain tumours. “The truth is there are many different cancers. In particular, it is important to note that pediatric cancers are not at all the same as adult malignancies. There are differences in their biology and their responses to treatment.”
Researchers such as Dr. Jabado and her colleagues are investigating why therapies sometimes fail. “We are targeting those tumours which are resistant to treatment or relapse following treatment. This is where basic research has a huge role.”
Her work involves understanding the molecular events and pathways responsible for the formation of pediatric astrocytomas - the most common pediatric brain tumour. “We know tumours undergo cycles of growth. We want to know what is driving this and how to specifically target it with chemotherapy.”
Recently, Dr. Jabado and her colleagues made a major genetic breakthrough that could change the way pediatric cancers are treated in the future. The researchers identified two genetic mutations responsible for up to 40 per cent of glioblastomas in children - a fatal cancer of the brain that is often unresponsive to chemo and radiotherapy treatment.
"This research helps explain the ineffectiveness of conventional treatments against cancer in children and adolescents – we've been failing to hit the right spot," says Dr. Jabado. “It is clear now that glioblastoma in children is due to different molecular mechanisms than those in adults, and should not be treated in the same way. Importantly, we now know where to start focusing our efforts and treatments instead of working in the dark”.
Other MCH researchers, such as Dr. Janusz Rak, are studying the formation of the blood vessels (angiogenesis), which supply tumours. He believes by inhibiting the growth of these vessels, the tumour won’t receive necessary nutrients and will be starved. “This is a new way of treating cancer,” he says. Québec Science readers selected Dr. Rak's research as Discovery of the Year in 2008.

Finding the right drug therapy for kids
Determining the right therapy for various pediatric malignancies is a major challenge, as most drug testing is conducted on adults. According to Dr. Jabado, there are not many initiatives designed to find drugs for children, as clinical testing is difficult. Also, there are not enough children with specific types of cancers to allow trials that will provide statistically meaningful results.

To resolve this challenge, The Montreal Children’s Hospital actively participates in the Children’s Oncology Group (COG). of which it was a founding member some 50 years ago. The COG is the world’s largest childhood cancer research organization and presently has more than 200 participating centres, including children’s hospitals, universities, and cancer centres from around the world. By combining the patients enrolled in clinical trials across these various centres, the results become statistically significant. The COG conducts approximately 100 combined research studies at one time. These trials involve studying various cancer treatments, the biology of different cancers, how best to provide supportive care, and survivorship.
“Thanks to the initiatives like the one from COG and other pediatric Canadian or international consortia as well as local initiatives, patients are treated in a more uniform and accurate way,” says Dr. Jabado. “Approximately 85 percent of our cancer patients are enrolled in a clinical research protocol. Their families understand the benefit of participating and the potential of this kind of research.”
When a child is treated on a COG protocol, all the information about the patient’s diagnosis, treatment and results is collected and analyzed. The findings are then published for review by all members of the COG so that rare tumours can be studied far more effectively.

Late-effects and muskulo-skeletal tumours clinics
Spearheaded by Dr, Sharon Abish in the early 1990s, the Division has one of the oldest long-term follow-up clinics in Canada for children who have survived their cancer. While this ensures continuity of care into adulthood for a patient population that is fragile with specific needs, it also improves our knowledge of the type of side effects—or lack of side effects—in the long term for these children. Dr. David Mitchell provides care to patients with a variety of musculoskeletal cancers. These often require intensive chemotherapy and aggressive surgical procedures to achieve long-term remission.

Hematological disorders
In addition to the childhood oncology programs, the Hematology/Oncology Division offers diagnostic and comprehensive treatment for children with non-cancer hematological disorders. Although programs treating disorders such as sickle cell and hemophilia may only see up to 10 new patients a year, they continue to offer support for previously diagnosed children and in some cases, also treat adults. The Montreal Children’s Hospital Thalassemia Clinic is the largest program in Quebec and offers screening for adolescents and education for families.
“As Quebec’s population becomes more international and diverse, we are seeing the demographic of these disorders change,” says Dr. Whittemore. “Previous biases may not hold true and thus it is important to continue to sensitize both our staff and patients.”
The Division also treats patients with thrombocytopenia, anemia, bleeding disorders and immunodeficiency.
A stem cell transplant program is run by Dr. David Mitchell to offer treatment for patients with malignancies, immunodeficiencies and rare metabolic disorders. Autologous, matched-unrelated, sibling, and cord-blood transplantations are all provided.

A diverse service requires extensive training
The Hematology/Oncology Division usually trains between one to three sub-specialty residents a year, under the guidance of Program Director Dr. Adam Fleming.
“Our training program is one of the longer ones,” says Dr. Whittemore. “Following three or four years of pediatric residency training, our physicians must then participate in at least three more years of hematology/oncology instruction.”
In addition to the clinical experience, the residents are encouraged to participate in clinical research protocols and be familiar with the hematology clinical laboratory. This includes an understanding of the blood bank functionalities, review of all the blood tests and smears, and bone marrow exams.
“From A to Z, the Hematology/Oncology Division provides a full range of services,” says Dr. Nada Jabado. “There is no weak link.” 
Happily, patients like Joshua benefit from this. Following his surgery and treatment, he is now back at home, back to living a normal life.