Interview with Prof. Hana Hrstková: About pediatric oncology and follow-up care

Prof. MUDr. Hana Hrstková, CSc., has extensive experience in the field of pediatrics, especially in pediatric oncology. For many years she was the head of the First Children's Internal Medicine Clinic of the University Hospital Brno. She specializes mainly in hematology, hematooncology and oncology. In addition to the treatment of malignant tumours, she also deals with late effects of oncological therapy and teaching at the Faculty of Medicine of Masaryk University. He has been working at the University Hospital Brno for more than 40 years and this year he will celebrate a significant jubilee.

16 Apr 2024

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In your professional life, you have been mainly involved in paediatric oncology. Can one get used to working with paediatric oncology patients? What does that trigger in you?
It was really challenging for me at first. I admit that the initial encounter with cancer patients brought me a lot of emotional challenges. Over time, however, I discovered a deep meaning and motivation in my work, which allowed me to move forward and overcome my doubts. Of course, at the time it was distressing for me that more cancer patients were dying. Gradually, I learned to accept this fact, knowing that every disease is bad, but there is always some hope of recovery. Although the success rate of treatment was not as high then as it is now, some patients were cured. And when one sees a child overcome his illness, it gives him the right impetus.

Is there any patient from this period that sticks in your mind?
Each patient's story has its own unique value. Some of the children I treated years ago still come back for regular check-ups. It is touching to watch them grow and build their own lives after treatment.

Could you tell me how many patients are cured today compared to when you started?
We are seeing major advances in the diagnosis and treatment of cancer. The revolution in treatment, especially after 1989, has given us access to more effective drugs and therapies. Diagnostic procedures have become much more precise, allowing treatment to be more individualised. When I started in 1968, recovery was seen as something special. After only ten years, we were able to cure about 40 percent of patients with a cancer diagnosis. Today, a lot depends on the type of tumour; for example, for leukaemias, the average is around 90 per cent.

And as for diagnostics?
It used to be simple. For example, if a patient came in with suspected leukaemia, we would do a bone marrow puncture, smear the sample on a slide and within half an hour we would have a diagnosis.
Nowadays, we do a bone marrow puncture, send the sample to a specialised laboratory and then to a molecular genetics laboratory. The diagnosis is thus more time-consuming, but the actual treatment can be more effective because it follows the precise groups determined by the laboratory methodology.

Are there similar types of tumours in children as in adults?
In adults, carcinomas, i.e. cancers, are the most common, whereas in children the most common solid tumours are sarcomas, which have a different origin. For example, skin cancer or colon cancer are not very common in children. Sarcomas are more rapidly progressive, but again much more sensitive to treatment. I would liken the difference between a carcinoma and a sarcoma to the difference between a wolfdog and a wolf.

There is a common perception that cancer in children and young people is more aggressive than in older patients. Is this really true?
This is mainly due to the fact that older people develop different types of tumours that do not grow as quickly. In children in general, the regenerative capacity is enormous.

How do you explain to children that they are sick and what to expect?
In the case of younger patients, we explain everything to the parents first of all. For the older ones, we have to tell them why they are undergoing treatment and what is ahead of them. But we have specialised psychologists who provide help in this area. The fact is that I recently had a 17-year-old patient at a check-up who told me that he didn't know what had happened to him and if I could tell him. That it was never discussed in their home.

Do you tell patients directly what stage their disease is at and what the prognosis is, even if you assume it is not very good?
Yes, we always tell the parents what the state of their child's health is. Of course, they have to be told sensitively and gradually, but they always get the truth. Including what the prognosis is, even if it is rather worse.

What role does psychosomatics play in the treatment?
Taking care of patients' mental health is crucial to the overall success of treatment. Parental support and a positive attitude can greatly influence a child's psychological well-being. When parents are optimistic, they clearly transfer their attitude to their child.

How do you feel about the inclusion of biological treatment?
I often encounter parents demanding biological treatment for their children. They think it is more gentle and its effect is more targeted. But this is not true, biological treatment also has a number of proven side effects. If we judge it to be the best solution, we will use it for treatment, but it is not self-administered.

So what is the difference between biological treatment and chemotherapy?
They are two different methods of treating cancer with different mechanisms of action. Chemotherapy uses chemicals known as cytostatics to destroy rapidly multiplying cells. It therefore affects both cancerous and healthy cells. This can cause a number of side effects such as nausea, fatigue, hair loss, immunosuppression and so on. Conversely, biological therapies are various enzyme inhibitors that enter specific molecular targets in cancer cells and inhibit their growth or destroy them.

When is a patient considered cured?
We do not say that a patient is cured, but that he is a long-term survivor. If he has been well for 5 years, the probability of recurrence decreases significantly. However, in our long-term patients we see an increased incidence of so-called secondary tumours after many years. The drugs that the sick children have received, all cytostatics and radiotherapy, are inherently carcinogenic. This means that they increase the likelihood that a new tumour may appear years later, independent of the original disease.

What about recurrence?
The most serious relapses are usually in leukaemia during treatment or in the first year after treatment. They are very rare within 5 years.

You are currently working on the consequences of treatment for patients who have undergone the disease. What are the most common sequelae you see?
Common treatment sequelae include endocrine problems, gastrointestinal problems and obesity. It is important to note that some complications may not become apparent until many years after treatment.

You've also done a lot of work on nutrition.
In addition to oncology, I have always been involved in general pediatrics, and I was the head of the pediatric clinic. We know that obesity is a risk factor for cardiovascular disease and cancer. Parents whose children have had cancer often tend to keep them in a cotton wool, to protect them. They worry that if their children perhaps play more sports, the disease might come back. I always try to refute that early on.

How do you see the near future in the development of cancer treatment?
In my opinion, further advances in molecular biology will be crucial. This will enable even more detailed classification of individual tumour types, so that treatment can be targeted even more precisely and effectively.

Finally, what else would you like to achieve?
I would like to be able to continue to actively contribute to patient care and support research in the field of pediatric oncology, while maintaining my health and enjoyment of life.

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