Recommending that adolescents and young adults be treated at pediatric hospitals or by pediatric oncologists has practical constraints. Many pediatric oncologists are uncomfortable caring for older adolescents and young adults. Adult oncologists are often unfamiliar and uncomfortable with the detailed pediatric protocols and older patients cannot be registered on pedi-atric cooperative trials because of built in upper age limits. Many of the pediatric protocols are written for young children and not for older adolescents. Pediatric hospitals cannot admit patients over a certain age.

The British have pioneered the solution of treating young adult and adolescent patients at a unique "adolescent oncology unit" (see Chap. 21) [38]. This provides the adolescent with age-specific nursing care, recreation therapy, and peer companionship. It is unknown whether this improves survival. One study showed that patient satisfaction was higher in teenage oncology patients treated in a dedicated teenage cancer unit than in adult or pediatric facilities. Several other centers internationally (in Canada, the United States, and Australia) are establishing clinics or programs that seek to establish local "best practice" for adolescents and young adults. Perhaps it is appropriate to have as a goal, centers and oncologists devoted solely to the care of this group of patients. In the meantime, increased cooperation and communication between pediatric and adult oncologists will facilitate the care of this group of patients.

The goal should not be to have all adolescents seen at pediatric cancer centers - the volume would likely overwhelm the system; however, adolescents with cancer should have access to equal services that provide the same outcomes (survival and quality of survival). To fully understand the issue of access we must more fully understand the outcomes. We should worry that only 30% of adolescents are seen at pediatric centers, if more studies clarify that this adversely affects outcomes. There may be patients (such as those with carcinoma) who are better served at adult institutions. The data needs to be looked at in more detail - by diagnosis, age, and treatment - before recommendations can be made.

Outcome studies must not stop at a binary analysis of which provides better survival (pediatric vs. medical oncology), but must characterize the variables that enable better survival (a certain treatment regimen, or level of supportive care or compliance) so that these can be provided equally to all patients.

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