Unrealistically Bleak, Unrealistically Glamorous The book The Fault in Our Stars, which tells the story of 2 teens with cancer, has been on the New York Times best seller list for more than 120 weeks. Earlier this month, the movie of the same name outperformed the latest summer action flick from megastar Tom Cruise in box office receipts during the first weekend of its release. T.F.I.O.S., which is how the book and movie are referred to by many fans, is a huge success financially and culturally. The popularity of the story was achieved despite the fact that it is about seemingly unpromising romantic leads — a girl who lugs around an oxygen tank to aide her breathing after thyroid cancer has spread to her lungs and a boy with an amputated leg from an osteosarcoma. In the book's afterword, the author, John Green, acknowledges that he "cheerfully ignored" input from medical experts "when it suited" his "whims." So what exactly does the success of T.F.I.O.S. mean, if anything, to the world of oncology? Medscape Medical News reached out to a number of American oncologists and reviewed various commentaries online to get a sense of that. Overall, clinicians have praised the exposure brought about by the film, but there have also been some pointed criticisms. The huge popularity of T.F.I.O.S. has "improved awareness culturally about living with cancer," said Suzanne George, MD, clinical director of the Center for Sarcoma and Bone Oncology at the Dana-Farber Cancer Institute in Boston. Dr. George's opinions about T.F.I.O.S. are, in part, shaped by her 11-year-old daughter, who is in the middle of reading the book and will be passing it along to her mother sometime soon. "My daughter told me the other day that 'it's not a book about dying, it's a book about how people with cancer live'," Dr. George reported. Anything that "helps normalize the process and experience of cancer is helpful," Dr. George told Medscape Medical News. That sort of normalization can, perhaps, aide both adults and children when they experience events such as hair loss from chemotherapy, she noted. Author Green, who once worked as an assistant chaplain at a children's hospital in Columbus, Ohio, has seen pediatric cancer close up. But he was inspired to write the novel by a Massachusetts teen he met at a Harry Potter convention and became friends with before she died from her thyroid cancer. T.F.I.O.S. features a 16-year-old girl, Hazel, who also has metastatic thyroid cancer, and a 17-year old boy, Augustus (Gus), who is in remission from osteosarcoma as the story begins. The pair meet in a support group for adolescents with cancer and fall in love. The book is not overwhelmingly laden with medical esoterica, but features a team meeting of Hazel's caregivers, information about the adverse effects of Phalanxifor, the fictional therapy that controls her tumor growth, and ongoing details about one character's palliative chemotherapy. As a film,T.F.I.O.S. joins Love Story as "the great cancer movies" in American culture, said Peter Coccia, MD, Ittner professor and vice-chair of pediatrics at the University of Nebraska Medical Center in Omaha, and chair of the Adolescent and Young Adult (AYA) Oncology Guideline Panel of the National Comprehensive Cancer Network. However, T.F.I.O.S. is different from the 1970s hit in at least 2 obvious ways — both the romantic leads have diagnoses, whereas only 1 did in Love Story, and the new story centers on teens, not adults, Dr. Coccia told Medscape Medical News. He also pointed out that the teens come from stable and supportive backgrounds — not necessarily the norm for young adults with cancer. My major impression is that the story doesn't really deal with many of the real issues. "My major impression is that the story doesn't really deal with many of the real issues that adolescents and young adults face," he said. For instance, both Hazel and Augustus have nuclear families with 2 parents at home, health insurance, and care at "top flight" facilities. "Hazel's mom drops her off at a support group meeting," observed Dr. Coccia. Some young people with cancer do not even have transportation to get to medical appointments or cannot afford them, he pointed out. In fact, as reported by Medscape Medical News, the high cost of cancer care forces many AYA survivors to forgo essential doctor's visits. Even though oncology lumps 2 age groups into the single AYA category, the story of T.F.I.O.S. is "about adolescents, not young adults," Dr. Coccia explained. "The kids who really struggle are those who are out on their own in the world." That group consists of people in their late teens and early 20s. Overall, they are not well-established in work, struggle financially, and have often loosened ties to family. In that regard, T.F.I.O.S.sidesteps a powerful aspect of cancer in young people — economic vulnerability and its fallout, suggested Dr. Coccia. Another oncologist, Lynda Beaupin, MD, from the Roswell Park Cancer Center in Buffalo, New York, is hopeful that the movie will increase awareness "among the general public that 70,000 AYAs are diagnosed with cancer annually" in the United States. "The release of a major motion picture like T.F.I.O.S. brings to light the simple fact that there are AYA cancer patients and survivors among us," she told Medscape Medical News. Dr. Beaupin, who is director of the AYA program at the upstate center, said that she and the patients and survivors in that program are seeing the movie this week in a private viewing at a local theatre. The young adults in the group will "hang out after the movie and chat about it," she added. In addition to the AYA program, Roswell Park runs separate events for young adults that cater to age-specific needs, such as seminars on insurance, intimacy, and nutrition, she reported. Beloved But Also Criticized Green and his signature creation have inspired epic devotion from his fans, who are largely tweens (10- to 12-year-olds) and teens, according to a profile in The New Yorker. But despite reaching great heights in mass culture, T.F.I.O.S. has been criticized for being unrealistically bleak. Outcomes in pediatric cancers are better than portrayed in the story, says Charles Hemenway, MD, PhD, a pediatric oncologist at Loyola University Medical Center in Chicago, in an article in the trade publication HemOnc Today. "It's a dramatic fictional piece of work, so that's fine — poetic license is up to the author, but it deviates from what we typically encounter," Dr. Hemenway is quoted as saying. He was referring to the severity of the cancers afflicting the lead characters, but also to another character, Isaac, a teen in their support group who lost an eye to cancer and is about to have the other surgically removed. The events are especially unlikely, said Dr. Hemenway, because retinoblastoma, the most common of all pediatric cancers, only rarely occurs in teens. Having a recurrence in a second eye necessitating surgery is very improbable, he explained. "For the 3 of them to all be in the same place with such rare forms of cancer is like lighting hitting 3 times. Fortunately, most pediatric cancer patients experience better outcomes," he added. For all childhood cancers combined, the 5-year survival rate has been improving. In 1975 to 1977, the rate was 58.1%; in 1996 to 2003, it increased to 79.6%. This improvement is the result of significant advances in treatment, according to the National Cancer Institute (NCI). Dr. George observed that osteosarcomas were "historically treated with amputation," but that the introduction of chemotherapy in the 1970s changed that. "Chemotherapy clearly improves the cure rate," she said. Now, the combination of surgery (which typically preserves limbs) and multiagent chemotherapy has produced cure rates in teens of about 70%. Some of the other 30% with metastases can still experience cure if the metastases are low in volume, resectable, and limited in number, said Dr. George. As for thyroid cancer, it is "one of the most curable of malignancies," according to an AYA monograph from the NCI. For all types of thyroid cancers, 5-year survival rates are at least 99% in 15- to 29-year-olds. Another critic of the story is a survivor of AYA cancer, who suggests that the celluloid version is unrealistically glamorous. Lauren Sczudlo, who is now 31 years old, says the movie white washes the physical toll that cancer and treatments take on human beings, even spry teens. "How did Hazel maintain that bodacious body? Her daily prescription drug cocktail would almost definitely have included steroids, meaning Hazel would've been a marshmallow waddling on 2 sticks," Sczudlo writes in an essay published earlier this month in The Washington Post. The movie falls short — repeatedly — on a promise from Hazel about depicting cancer accurately. "On the one hand, you can sugar coat it — the way they do in movies and romance novels.... It's just not the truth. This is the truth," the character says. But the truth has never looked so good, counters Sczudlo. "The movie romanticizes sex and impossible standards of beauty in ways that Hazel and Gus would've hated," she writes. Source
