Translational research in hormone-related cancer.

Hormones are implicated in various types of cancer, however, several aspects of steroid activity on carcinogenesis remain elusive. Recent progress has made it possible for us to directly study the biological mechanisms of disease development, including hormone-cancer relationships, from numerous viewpoints, from numerous viewpoints, including genome abnormalities. One tool is comparative genomic hybridization array (aCGH). Furthermore, it is possible to identify the so-called "cancer signature" by gene expression profiling, which provides new information about the role of steroids on carcinogenesis. DNA mutations and gene expression abnormalities may be associated with hormone-related cancer. The recent discovery of microRNA provides new opportunities for understanding the fine regulation of gene expression in cancer cells, and the role of microRNA in the relationship between hormones and cancer. From these experimental models we should be able to rapidly develop translation-to-treatment protocols. The final goal should be to design specific labs on a microchip for prognosis and therapy of individual patients. While in clinical research there is renewed attention to stratification of patients, especially those at high risk.

Health emigration: a challenge in paediatric oncology.

For the past 10 years European states have experienced an increasing flow of emigrating families from developing countries seeking better medical care for their sick children. For Italian paediatricians this has become a new challenge, considering the cultural differences in customs regarding the illness. The onset of a life-threatening disease has a strong impact on the family. The natural bond between the patient and the family must be preserved and strengthened; parents should be encouraged to entertain their child during hospitalization. The inclusion of art therapy may facilitate communication, especially for children of a different language and culture. This approach can help medical staff to understand better both the child's and the parents' anxieties and feelings. This article discusses facets of the now well-known phenomenon of ;health emigration', that is, when a family searches abroad in the hope of finding the most advanced medical treatment possible for their sick child.

Young siblings of children with cancer deserve care and a personalized approach.

The youngest siblings may be both emotionally vulnerable and often neglected members of the family of a childhood cancer patient. The prompt identification of signs of distress in these subjects allows trained caregivers to intervene with personalized, age-appropriate, attention, and care. A narrative approach, based on personalized listening, writings, and spontaneous drawings, can provide the means to elicit markers of psychological maladjustment in even the youngest of siblings. Two exemplary cases are reported to illustrate this approach.

In tribute to Luigi Castagnetta-drawings. A narrative approach for children with cancer.

In troublesome situations, each of us uses verbal communication carefully, at times diminishing our meaning with words of little significance. However, since the need to communicate remains a part of us, body language or other forms of expression are put into use. Inside a hospital a child is always a stranger with regards to the uneasiness that accompanies his/her experience. Because diagnostic and therapeutic ends are the primary concern of the health care professionals, there is often little sign of affection in their impersonal gestures, glances and body language. Graphic and pictorial communication, therefore, hold great importance for sick children since this is an area they have easier access to, and that they cultivate at school and through play. This activity fulfills their innate need to communicate with themselves and with others. Children express themselves through drawings, using them as a stage to dramatize their needs, wishes anxieties, and joys. When in hospital, children are afraid, and they feel embarrassed around strangers and even parents, especially when the parents are speaking with their caregivers. The children are afraid of making a poor impression and of being rejected by adults, of being considered inadequate and untruthful. Their need for truth and for communication unfolds through artistic expression, and this is the basis of art therapy. The opportunity to express themselves through drawings is what makes the ill child his/her won therapeutic agent through a self-healing mechanism. This may be further guided so as to lead to an increase in self-esteem, which in turn will lead to both enhancement of their full expressive possibilities and to positive feedback of their self-image. In addition to verbal language itself, art therapy is the preferred and ideal means to communicate following the rules of "narrative-based medicine", and to understand children. In this study spontaneous drawings of 50 Italian children affected by leukemia or cancer in different stages were evaluated during 2003 at the outpatient clinic of G. Gaslini Children's Hospital. Ages ranged from 4 to 14 years (median 8 years); 27 were males and 23 females. They drew in three situations: spontaneously when they were alone; with play workers; and with the psychologist. Pictures emerging from these settings have proven to be significant and denote the children's perception of the disease, and of their fears and hopes. The children's drawings allowed them to depict their present and future relationship with the disease, with the hospital, and with the environment in general. Their pictures reflected not only their current state of mind, but also past experiences and future prospects. Art therapy proved to be a vitally important means of "narrative" communication for severely sick children in hospital. Thus, collecting and evaluating drawings in an attempt to establish the intellectual, cultural, and emotional status of each child is of paramount importance. To this end, workers have been trained to carefully observe ech child while drawing. Such extremely important collaboration prevents the loss of relevant and vital details. This research confirms our theory that art therapy has to be included in the total care of a severely ill child while in hospital. Drawings accompanied by comments certainly provide a broader approach to better understanding the child's anxiety and feelings.

Randomization, informed consent and physicians' communication skills in pediatric oncology: a delicate balance.

Parents asked to consent to a child's randomization in a pediatric cancer clinical trial are often unprepared to grasp the implications of this scientifically crucial but seemingly unfair process. Physicians must adopt specific communication skills to engage families in open dialogue from the outset in order to elicit truly shared informed consent. Starting from the case of a family with an only child affected by disseminated neuroblastoma, we wish to comment on the problems surfacing in the informed consent process for treatment and research in pediatric oncology that implicate an understanding of bioethical issues and psychological principles. Although the outcome of childhood cancer has improved dramatically over the last 30 years, with overall survival rates now exceeding 70%, there are regretfully still types and stages of cancer carrying a very high risk of death that urgently require new clinical strategies. The response to this need has been the design of experimental protocols that often entail randomized controlled trials (RCT). A large number of these trials concern stage IV neuroblastoma, acute leukemia, rhabdomyosarcoma, and other types of childhood cancers presenting great heterogeneity both in terms of localization and responsiveness to therapy. Most trials for disease relapses also include one or more randomizations. The scientific motivation justifying an RCT is the need to compare and evaluate an innovative protocol (or part thereof) with reference treatment modalities. Nevertheless, the process brings to bear the ethical dilemma of having to weigh the needs of the single afflicted child against the benefit which may ensue for a much larger patient community.

From informed consent to shared consent: a developing process in paediatric oncology.

Little research has been done on consent in clinical management of cancer in children. Many parents think that the informed-consent process is helpful but often confusing; discussions regularly prove more helpful. It can be difficult for parents to understand the notion of randomisation, not to mention the request for consent to this procedure. In this essay, we discuss the clinical problems that arise in the informed-consent process for treatment and research in paediatric oncology and that need an understanding of bioethical issues and psychological principles. We suggest that the process of informed consent is managed as a negotiated shared-consent process, using the problem-based learning method as a guide. Our model provides appropriate and honest information to children and adolescents through easy-to-understand dialogues with the doctor and we propose that medical students and doctors receive specific skills instruction in communications, relational behaviour, and ethics.