You wouldn’t think a pediatric oncology department would be a laughter-filled place, but nurse Sarit David, second-in-command of the inpatient department, says, “People in the department laugh a lot. It’s strange to the outsider, but the department has a lot of laughter. During the horrible times, there are many light moments.
“That’s what makes the team stay. The children are suffering so much. It’s a difficult time. We laugh and cry with them. We love it!”
The Pediatric Oncology Unit at Hadassah University Medical Center in Jerusalem’s Ein Kerem has had its share of controversy, but today, with a new team of 10 doctors and 40 nurses in place, the hospital is once again equipped to handle pediatric cancer and hematological diseases of all kinds.
Some 18 months ago, Prof. Ze’ev Rothstein, general manager of Hadassah
, recruited Dr. Gal Goldstein from Tel Hashomer, Israel’s largest hospital, located in Ramat Gan. Goldstein, who now serves as the head of the Department of Pediatric Hemato-Oncology, together with Prof. Yosef Laver, Pediatric Cancer Center director at Hadassah, went on fill the ranks with experienced, dedicated doctors, completely reinventing the unit. Some of the department’s 40 nurses, including David, stayed on through the transition.
Today, the unit sees 100 new oncology cases a year and treats approximately 200 patients at a time. According to Goldstein, “We can diagnose and treat any kind of cancer in children anytime. We have the ability – in manpower, skills and resources – to treat any type of cancer. With hi-tech cutting-edge technologies, we are having good success directing the right treatment to the right cases.”
One unique case that Goldstein is particularly proud of involved an 18-month-old boy who presented with “a huge mass on his arm.” The team sent the tumor to an overseas lab that discovered the specific gene that caused this tumor. As a result, instead of using chemotherapy, they were able to prescribe a specific drug to treat this specific gene.
“This kid is getting better,” Goldstein enthused. He also cautioned, “Usually we don’t find drugs that interact with a specific pathway of a tumor, and usually we have to use chemotherapy [which is a comparatively low-tech treatment].
“Cancer is more complex than just knowing the genes. We cannot find the specific causative pathway in many tumors,” notes Goldstein.
He explains that in many cancer centers in the United States, every tumor is analyzed, but that takes resources and money that Israel lacks, so only the difficult tumors are sent out for analysis.
To improve care for their patients, the department established a collaboration with the Memorial Sloan Kettering Cancer Center. Sloan Kettering sent a team to Israel to assess the new department. A successful collaboration is moving ahead.
“For instance, we started a protocol in Ewing’s Sarcoma, on which children from Hadassah are receiving the same contemporary protocol as at Sloan Kettering,” explains Goldstein.
HADASSAH INVESTED a lot of energy, time and money to reestablish the department. Much of the credit goes to Goldstein and Laver.
Goldstein was born in Israel, attended Tel Aviv University and earned a bachelor’s degree in biology. He went on to medical school, graduating in 1999. In 2003, he began a fellowship at Sheba Medical Center, Tel Hashomer and rose to a senior faculty position, specializing in pediatric bone marrow transplant. In May 2017, he was recruited to reinvent the department at Hadassah.
Laver is a graduate of the Technion School of Medicine, did his residency in pediatrics at Assaf Harofeh Medical Center and completed a fellowship in New York. He has vast experience in pediatric hemato-oncology, with a special interest in pediatric lymphoma. For many years he worked at different medical institutions in North America, such as Memorial Sloan Kettering Cancer Center and St. Jude’s Children Research Hospital.
Goldstein reflects that pediatric oncology is a “very delicate and emotional field.” When you’re treating a child with cancer, you’re also treating the parents who, understandably, exhibit a great deal of anxiety. Goldstein says that, in this way, what he and his team do is “different from adult oncology.”
Another difference is that of the approximately 30,000 new cases of cancer each year in Israel, only 400 to 500 of them are pediatric cases. On the one hand, that’s something to be happy about. On the other hand, because there are fewer cases, some hi-tech treatments are not commercially viable to develop. With adults, there is more of a financial incentive to develop treatments other than chemotherapy because of the larger demand for those kinds of solutions.
For example, Goldstein explains that the oncology world has understood that when it comes to certain abdominal tumors known as neuroblastomas, there is a target molecule that can be treated in addition to chemotherapy. But because there are so few pediatric abdominal tumors, that alternative treatment was not developed until seven or eight years ago.
For other tumors, there isn’t any specific solution except chemotherapy. The consequence is that many children are left without targeted, hi-tech treatment.
Nevertheless, he notes that in the Western world, 85% of children who have cancer survive. By contrast, only 50% to 60% of adults survive a cancer diagnosis.
THE DEPARTMENT is well positioned to take care of children with different leukemias and solid tumors, as well as brain tumors and a variety of hematology disorders. Dr. Dan Harlev primarily treats children with blood disease such as anemia, white blood cell abnormalities and problems of coagulation (blood clotting) that are not cancer. He also treats cases of kidney or liver tumors, as well lymphomas.
Dr. Sigal Weinreb mainly treats patients with leukemia and lymphoma. Acute Lymphoblastic Leukemia is the most common type of cancer seen in children. Goldstein points out that “in 1960, these children all died.” Today, this type of leukemia is treated with chemotherapy and 85% of the patients are eventually cured.
It’s not an overnight cure. Treating leukemia in children requires six to seven months of intensive outpatient hospital treatment and an additional 18 months of maintenance oral treatment.
Dr. Dror Raviv focuses mainly on solid tumors, which can appear in almost every part of the body. This past summer, Raviv spent three months at Sloan Kettering, enhancing his skills and deepening his knowledge base.
Goldstein explained that tumors in adults generally have some connection to environment. For example, colon cancer in adults is related to dietary choices, melanoma is related to the amount of exposure to the sun and so forth.
“In children,” he continues, “it’s very different. In most of the cases, we do not know what causes cancer in children. Though we suspect genes in many cases, we can find a specific cancer predisposing gene in only 10% to 15% of the pediatric cases. Still, if a child develops cancer, their siblings have a slightly higher risk of also developing cancer.”
Treating children with brain tumors presents a special challenge. Most of these children are being treated by Dr. Rakefet Sidlik-Muskatel and Dr. Hodayah Cohen. Goldstein characterizes brain tumors as a “stepchild in oncology” and explains that the success rate in treating brain tumors is only 60% to 65%, compared to an 85% success rate with leukemia.
“They are solid tumors. They respond worse to chemotherapy. Most chemo doesn’t get into the brain,” he explains. Since it’s very difficult to remove tumors without damaging healthy brain tissue, it’s necessary to have exceptionally skilled brain surgeons.
Goldstein recalls a case where a child came to the department with a brain tumor. After surgery, she needed a specific kind of radiology, so the team referred her to a hospital in Memphis, Tennessee. But that’s rare; Goldstein estimates that only 1% to 2% of cases require a technology not available in Israel.
“Some families prefer to go abroad because they think the care is better there. But it’s important to note that if [the necessary treatment] could be done in Israel, the health funds won’t cover treatment elsewhere.
“In Israel, we can treat as well as other countries,” Goldstein asserts. He also confirms that there are no special risks or anything that distinguishes pediatric cancer care here from the rest of the Western world.
HAVING SUCCESSFULLY rebuilt the department from the ground up, Goldstein says what he’s most proud of is “my team. The medical staff, the nurses, the social workers, the psychologists as well as the special school staff and teachers who do emotional work with the children.”
The medical staff also includes Dr. Ahmed Ashkir, Dr. Tssipi Korenfeld and Dr. Shirley Sayag-Spilberg.
Goldstein is looking forward to much more collaboration with Sloan Kettering, especially in the areas of solid tumors and oncological genetics, which researches cancers that are believed to have a hereditary component. He is also planning to do some fundraising that will allow his department to analyze more tumors and develop more specific treatment protocols.
According to Goldstein, the field of oncology is becoming more complicated every day as more research is conducted and more knowledge is being added.
As he looks back on these tumultuous 18 months, Goldstein has warm memories of the first patient he treated during the department’s earliest days in June 2017. A 13-month-old baby presented at Hadassah University Medical Center on Jerusalem’s Mount Scopus with a mass in her pelvis. When he heard about the case, he got in his car and drove to Mount Scopus to speak with the family. A day later, the girl was admitted to his new department in Ein Kerem. She was treated with four cycles of chemotherapy and today, she is cured.
While Goldstein is focused on cancer research and improving treatment options for his young patients, David spoke about how the team functions as a whole and what kinds of services, beyond medical care, families get.
With 16 years under her belt, David is the most experienced nurse in the department. She elaborated on the day-to-day nature of the work.
“We try to support the children and also the parents. Hospitalization can be very long. We offer much more than just medical care. We have a school here with teachers and volunteers who come and speak with the children and play with them. They are trying to be as close to the children as possible, doing what they can to make them happy, providing them a home environment as much as possible.”
ACCORDING TO David, the school that meets on the hospital’s premises, near the department but outside of it, is officially recognized, and the teachers are employed by the Education Ministry.
Those children who can walk can experience going to school on the hospital grounds. The lessons are crafted for the particular needs of the child. For children not well enough to go to school even in the hospital, teachers will go to their rooms to work with them individually, doing both craft and academic projects.
Some children have computers and cameras that link them to their home school class, allowing them to study together with their peers. David reports that some high school-aged children even take the national bagrut exams from their bedside.
She notes with pride,“The children all study together – Arab, Jewish, Christian – and they study in Hebrew and Arabic. The children get along.”
David also singled out the social workers, who provide much-needed support to the parents of the children on the unit.
Another source of support for parents are the volunteers, who are screened by health-related charitable organizations and help keep the children cheerful and busy. David describes the cooperation between volunteers and the nursing staff. “Nurses tell volunteers what they learn about the children. They know when we and the parents come – and they know when to leave the child alone.”
Other volunteers, both Jewish and Arab, make home-cooked food for parents who spend many long hours on the unit. Parents also have access to hot drinks at no charge, thanks to volunteers.
One special service David mentions is a class that teaches children how to take pills. Some children need to take 10 pills, three times a day, so the staff offers them training, including where to put the pill on the tongue and how to swallow.
“Once a child can take the pills by themselves,” she elaborated, “that gives them the freedom to go home instead of taking the drugs through an IV.”
Hadassah was the first hospital in Israel to use professional medical clowns from the Dream Doctors Project. Today, medical clowns accompany children to some tests or to the operating room, amusing and distracting them.
“The entire team is connected to the children. We love them! We have special ones.” She mentions a sweet five-year-old girl with leukemia. “She entered our hearts. We cried with her and laughed with her. She had her birthday here; we celebrated with her and her parents.”
Her leukemia is in remission for now. “Everyone is so happy to see her when she comes for follow up appointments.”
She also mentions a five-year-old boy who was especially attached to Goldstein. “When he was hospitalized, he loved Dr. Gal! He wanted only Gal to take care of him. ‘I want Dr. Gal! Only Dr. Gal! Not you!’ [In response,] Gal came to offer support and smiles.”
Pediatric oncology patients can be hospitalized for a long period.
“Long-term hospitalization leads to deep connections with parents and children,” David explains, even to the extent that the mother of one of their patients came to the wedding of one of the department’s nurses.
David easily reels off other cases when nurses helped the children connect with what they love and made their dreams come true.
She mentions a child with Down Syndrome who, it was discovered during his treatment for leukemia, loved music. When the staff started playing music for him, as soon as he was well enough, he would dance with the nurses in his room.
Then there was the child who loved the police. The nurses connected him with a real police officer who took him for a ride in an official police car.
Rothstein, the hospital’s general manager, arranged an antique car display for the children as a surprise. That was, “a very emotional day,” says David, “because these children don’t have a lot of happy surprises.
“From my 16 years of experience, we made a big step 18 months ago,” she says proudly. “Now the department can give any kind of treatment to any child. The doctors are experienced. It’s not like the staff is new; they are all experienced from other hospitals.
“The department has had success with a lot of complicated treatments. We have a lot of complicated patients. We treat them all well, with a very professional manner,” she concludes with satisfaction.
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