August 4, 2008
On a ‘re-Mission’ to Save Lives
By Liz Szabo
Although Rashida Wilkins is only 18, she has already weathered eight years of cancer therapy, including four brain surgeries, six weeks of radiation and nearly two years of chemotherapy.She knows she should follow her doctors' advice. Yet Wilkins, like many teens with cancer, has at times deliberately stopped taking pills that are vital for her health.
Of all cancer patients, teenagers are the least likely to consistently follow their care plans, says Steve Cole, associate professor at the University of California-Los Angeles School of Medicine.
Unlike smaller children, teens are often responsible for taking their pills, Cole says. But unlike older adults, they may not believe their conditions are really life-threatening. A few weeks or months after these young patients leave the hospital, the threat of cancer may seem distant, while side effects such as acne and weight gain remain painfully visible.
"Teenagers see themselves as invincible," says Karen McKinley, a social worker at Children's Hospital of The King's Daughters in Norfolk, Va., where Wilkins was treated. "They do risky things. They drive fast. They don't want to do anything that makes them look different. And we make them look different. We make them lose their hair. We give them steroids that make them look puffy."
Wilkins, of Norfolk, says she stopped taking daily thyroid medications -- required because radiation damaged her thyroid -- because she felt better. She resumed taking her pills earlier this year -- a few months after she stopped -- after she began feeling run-down.
Teens' reluctance to follow their care plans could partly explain why survival gains for young adults have lagged behind those of other age groups, says Anna Franklin of the Children's Cancer Center at Houston's M.D. Anderson Cancer Center. Other factors also may hurt their survival. Young adults also are less likely to have insurance or to join clinical trials. Their tumors also may be biologically different from more common cancers.
Just keeping track of home medications can be a struggle. Leukemia survivor Taylor Carol, 13, of Dana Point, Calif., takes 50 pills a day.
Cole hopes to focus kids on battling their cancers rather than their doctors and parents. He has been testing a video game, Re-Mission, that teaches them about the importance of following their care plans. The project's modest success illustrates how hard it can be to motivate young patients, Franklin says.
Re-Mission follows the efforts of a microscopic "nanobot" -- inspired by Lara Croft, the buxom heroine of Tomb Raider -- as she tries to annihilate cancer cells. Players win by taking care of their health: swallowing oral chemotherapies; taking stool softeners to prevent bowel perforations; practicing good oral hygiene to prevent mouth sores.
Wilkins, who participated in the Re-Mission study when she was 15, found it easier to learn about cancer from a game than from books. Like many teens with brain cancer, Wilkins has suffered short-term memory loss because of radiation treatments. That can make it challenging to master complex subjects such as cancer, she says. The game also gave Wilkins a chance to share her experience with friends and a younger brother, who quickly began beating her.
Taylor, who played Re-Mission in the hospital, says he imagined blasting the malignant cells in his body: "I felt like I was getting back at those guys who were keeping me from my friends and family."
In the study, published today in Pediatrics, doctors randomly assigned half of patients to play Re-Mission and half to play an alternate video game, Indiana Jones and the Emperor's Tomb.
Re-Mission players were slightly more likely to take all of their prescribed antibiotics, according to the study, which involved 375 patients ages 13 to 29. Re-Mission players took 62% of their doses, while patients playing the alternate game took 53% of prescribed doses.
Researchers also found that Re-Mission players maintained higher levels of chemo in their blood, an indication they were taking their pills. They also had slightly improved their scores in knowledge about cancer.
Yet many never played the games at all. Only 28% played a game for at least one hour a week as requested.
Re-Mission players also didn't report feeling more control of their health, and they didn't claim to adhere more to their treatment plans. That suggests that the game didn't change the way patients see themselves and the world, or make them feel more responsible for their health, says Abraham Bartell, a child and adolescent psychiatrist at New York's Memorial Sloan-Kettering Cancer Center.
Eric Kodish, chairman of the Cleveland Clinic's Department of Bioethics, says researchers are trying other ways to reach young people, such as text messages reminding them to take their medications.
"This is just too important to allow to fall through the cracks," Kodish says.
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