the classifier for central nervous system atypical teratoid/rhabdoid tumors reported by Pomeroy et al. (2002) [4]. Thiscould reflect differences in the comparator groups used to buildthe classifiers or could reflect inherent differences in thebiological bases of rhabdoid tumors in these two anatomicalsites. This would be a crucial area for future exploration indeveloping therapies for rhabdoid tumors in cranial and extra-cranial sites.

The NWTSG is to be congratulated on the comprehensivecollection of frozen tumor samples that they organized duringthe NWTSG 5 trial, which provided the resources for this, andmany other, studies to be undertaken. This study illustrates thereality of applyingmolecular biology to the real world of clinicalpractice, with samples being drawn from multiple centers, andpathologists having tomake decisions about which area of tissueto freeze based upon naked eye examination. Together with thestringent RNA quality requirements for expression analysis,nearly 20% of tumors (28/147) were unsuitable for analysis.Clearly, these types of analyses are currently very expensive andalso rely on pathology laboratories having the ability to routinelyfreeze good quality specimens for molecular analysis. It wouldbe good to see the results of these classifiers built intomuchmore

user-friendly and widely applicable tests, such as a small panelof immuno-histochemical markers, or a custom chip that wouldtolerate lowerRNAquality and bemore economically viable. Asfront line therapies for the rarer paediatric renal tumorsimproves, so does the importance of accurate diagnosis.Developing tools that are accurate and economically viable willhelp all children with renal tumors around the world.

REFERENCES

1. Huang C-C, Cutcliffe C, Coffin C, et al. Classification of malignant

pediatric renal tumors by gene expression. Pediatr Blood Cancer

2006;46:728–738.

2. Arroyo MR, Green DM, Perlman EJ, et al. The spectrum of

metanephric adenofibroma and related lesions: Clinicopathologic

study of 25 cases from the National Wilms Tumor Study Group

Pathology Center. Am J Surg Pathol. 2001;25:433–444.

3. Savla J, Chen TT, Schneider NR, et al. Mutations of the hSNF5/INI1

gene in renal rhabdoid tumors with second primary brain tumors.

J Natl Cancer Inst 2000;92:648–650.

4. Pomeroy SL, Tamayo P, Gaasenbeek M, et al. Prediction of central

nervous system embryonal tumor outcome based on gene expres-

sion. Nature 2002;415:436–442.

HIGHLIGHTby Andrea Farkas Patenaude, PhD*

Assessing Adolescents Accurately: Evidence of Needfor the Multi-Disciplinary Pediatric Oncology Clinic

T he article by Hedstrom et al. [1] in this issue examines theconcordance between self-appraisal by 53 Swedish adole-

scents (ages 13–19) who were within 4–8 weeks of diagnosisor relapse with cancer about the level and sources of thephysical and emotional distress they experienced and the rat-ings of these factors by their doctors and nurses. The authorsreport that the doctors were able to adequately identify distressrelated to their patients’ physical symptoms (with the exceptionof mucositis), but missed some types of psychosocial distress,especially worry about missing leisure activities and school.Nurses did better at assessing some of the emotional distresstied to medical symptoms such as round face from steroid useand weight gain, but they also underestimated the adolescentsworry about mucositis, infection, and missing school. Neitherdoctors nor nurses achieved a level of sensitivity or specificitywhich was felt to be acceptable in judging the patients’ anxietyand depression (as measured by standardized scales). While, ingeneral, staff ratings overestimated levels of depression andanxiety, only 56% of self-reported depressed adolescents werecorrectly identified by their doctors and 50% by their nurses.Recognition of anxiety was better, with 75% of self-identifiedadolescents being so identified by their physicians and 60% bytheir nurses. The authors conclude that staff ratings should not

be used to guide use of psychosocial support for patients, butthat ‘‘direct communication’’ with the patient should be usedfor this purpose.

It is reassuring that between the physicians’ and nurses’ratings, most patients’ physical distress was identified. Physicaldistress, after all, iswhat onewould expect themedical staff to befocused on when beginning treatment regimens for adolescentswith cancer. That both physicians and nurses did not register howupset the adolescents were about their mucositis may bebecause, for the medical staff, mucositis is a commonly seenside-effect of treatment which they expect will diminish withoutserious harm to the patient and theymay lose sight of theways inwhich this symptom is both novel and interfering for the patientswith their ability to eat, talk, kiss, feel attractive, etc., allimportant adolescent functions.

� 2006 Wiley-Liss, Inc.DOI 10.1002/pbc.20732

——————Dana-Farber Cancer Institute, Boston, Massachusetts

*Correspondence to: Andrea Farkas Patenaude, Dana-Farber Cancer

Institute, 44 Binney Street, Boston, MA 02115.

E-mail: andrea_patenaude@dfci.harvard.edu

Received 15 November 2005; Accepted 15 November 2005

Highlights 717

The medical staff in this study overestimated the extent towhich their adolescent patients would be focused on worriesabout ‘‘not getting well’’ and underestimated the extent towhichmissing school or leisure activities troubled the adolescents.Again, this likely reflects the natural professional concerns of themedical staff, their worry about getting the patient well. It alsoreflects differences in adult and adolescent development. Adultsare able to abstract and project their concernsmuchmore into thefuture. The medical staff was focused on ‘‘the big picture,’’ theultimate medical outcome, whereas the adolescents judgedprogress by how much their lives were normal again, whichincluded, to largemeasure, the extent towhich theywere back intheir school and social environments. Their focus was muchmore immediately on the present and on whether or not they hadbeen able to re-join their peer group. Recognition of suchdifferences in orientationmay be useful in helping to understandadherence gaps and other problems which may occur as a resultof possible misunderstanding between adolescents and theirmedical care providers.

Over the past decade within pediatric oncology and clinicalmedicine generally, the laudable expectation has developed thatoutcomes of treatment should include not only assessment ofmedical endpoints, but also of quality of life concerns.Nonetheless, within the limited scope of a medical visit with apatient, a month or two into their treatment regimen, there is anecessary focus on physical well-being and limited time toengage the adolescent in a discussion of their emotions. It is notalways easy to get adolescents to talk openly about theirdepression or their worries. Thismay be especially truewhen theadolescents are talking to the doctors and nurses whom they aretrusting to make them well and for whom they may want toappear strong and capable. The findings from this studyunderscore the importance of what has been increasinglyrecognized as the ideal oncology setting, a multi-disciplinaryclinic including physicians, nurses, and mental health providers(psychologists, social workers, and/or psychiatrists) who worktogether to assess and guide the patient through the shoals of

cancer treatment into long-term survivorship (Institute ofMedicine, 2005) [2]. The authors recommend training incommunication skills for the medical staff, provision ofopportunities for adolescent self-report, and psychosocialassessments. All of these suggestions speak to the integral rolemental health professionals can play as part of a pediatriconcology team assessing, triaging, and treating the frequentemotional and psychosocial concomitants of medical treatmentfor childhood cancer. Their professional training is focused onmethods of developing relationships with children and adoles-cents in which the patients emotional, behavioral, and familialissues can be assessed and addressed. Pediatric psycho-oncologists are trained particularly to conduct their assessmentsand treatment of ill children and adolescents within the contextof the cancer clinic, with special attention to the alterationswhich cancer and cancer treatment can effect on self-esteem,depression, cognitive and social functioning, and familyrelationships.

These specialists havewhatmight be considered the luxury ofassessing and working with adolescent cancer patients withouthaving to simultaneously focus on the medical treatment of thechild, though theywork in close harmony with the medical staff,trading important observations about the patients. In such amulti-disciplinary setting, patients can truly receive the attentionof professionalswho are focused on their physical and emotionalneeds and which, together, hopefully results in greater accuracyidentifying those patients in need of additional psychosocialsupport.

REFERENCES

1. HedstromM,Kreuger A, LjungmenG, et al. Accuracy of assessment

of distress, anxiety, and depression by physicians and nurses in

adolescents recently diagnosed with cancer. Pediatr Blood Cancer

2005, [epub ahead of print 12/6/05].

2. Institute ofMedicine. From cancer patient to cancer survivor: Lost in

transition. November 7, 2005.

Pediatr Blood Cancer DOI 10.1002/pbc

718 Patenaude