Dr. Nicholas Cost
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From an early age, Nick Cost, MD, knew he wanted to be a physician with a focus on kids. And he can’t imagine a career more rewarding than being able to build relationships with his patients and collaborate with colleagues to improve outcomes for kids with kidney cancer. Read about the COG Renal Tumor Committee’s latest research and long-term goals.
Nicholas Cost, MD, decided he wanted to become a physician when he was in elementary school. He was inspired by his mom, a nurse, and watching pediatric providers care for his little sister who was born with complex medical needs.
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“I spent a lot of time after school and weekends at the children’s hospital with my sister while she was inpatient. I knew I wanted to focus my practice on caring for kids,” Dr. Cost says.
During medical school, he was drawn to surgery because he liked that he could have an immediate impact on helping restore a patient’s health. But patient relationships were important to him too. Urological oncology offered a good mix of clinical care and surgery.
Dr. Cost is now the chair of the Children’s Oncology Group (COG) Renal Tumor Committee. He practices at Children’s Hospital Colorado, where he is also the Division Chief for Pediatric Urology.
Can you talk a bit about the different kinds of renal tumors?
About 85% of kids with kidney cancer have a Wilms tumor. It typically occurs in kids under 5 years old. For about 85-90% of those kids, their treatment is successful.
The other 10-15% of pediatric renal cancers are exceptionally rare. These include clear cell carcinoma, congenital mesoblastic nephroma and rhabdoid tumors of the kidney. These cancers are usually what we call embryonic cancers, meaning they actually begin when a child is developing in the womb. So they occur most often in babies and young children.
These tumors happen when a few of the kidney’s cells don’t develop correctly. Over time, the cells grow into a tumor. Some of COG’s renal tumor committee members, Andrew Murphy, MD, Jack Brzezinski, MD, PhD, and Andrew Hong, MD, are doing a lot of work looking into how some of these “missteps” in cell development happen during the very first weeks in utero.
Renal cell carcinomas and anaplastic sarcoma of the kidney happen more often in older children, adolescents, and young adults. Some of these cancers are caused by genetic mutations in the DNA that happen as a kid is growing up.
How are renal cancers treated?
Almost all children with renal cancer will need the kidney that has the tumor in it removed. I’m trained as a urologist and a surgeon, specializing in oncology. So I’m the physician who removes the kidney and the tumor. After patients have recovered from surgery, most will begin chemotherapy and sometimes radiation. For a small number of patients, we’re able to remove their tumor and kidney, and they don’t need any additional cancer treatments. If a tumor has wrapped itself into or around the veins that are connected to the kidney, the patient may need chemotherapy first, to reduce the size of the tumor before surgery.
The more complex treatments happen when the cancer has spread beyond the kidney, usually to the lungs first. Renal cancers also sometimes spread to the liver and bones.
Why do renal tumors often spread to the lungs first?
When blood leaves the kidneys, it goes to a large vein that takes the blood to the heart and then to the lungs. Renal tumors shed some of their cells into the blood that’s going out. And when those cells get to the lungs, they get stuck in tiny blood vessels. Unfortunately, an oxygen-rich environment like the lungs is ideal for tumor growth.
Can you tell us a bit about the renal tumor committee’s new Wilms tumor study that launched in March 2025?
This year, our committee launched one of the most comprehensive studies we’ve ever done. It’s truly an honor to be part of this team. Having all of us connected through COG, working together to design new studies, centralizing our biospecimens and helping each other get through research challenges makes being part of this study extremely rewarding.
Elizabeth Mullen, MD, is leading this study. She is a pediatric oncologist at Boston Children's and the vice chair for the COG Renal Tumor Committee. Similar to some of COG’s other big renal tumor studies, this trial (AREN2231) is working to study biomarkers that we can use to group these cancers into new subtypes of renal tumors.
Within these new groups, we’ll be able to learn more about why some tumors respond well to treatments while others – that appear similar – are better at resisting them. Then we can design even more precise treatment plans for these newly defined subgroups – and ultimately improve outcomes.
The trial is divided into three groups. Kelly Vallance, MD, with Cook Children’s leads the low-risk group. She is looking at ways to expand the group of patients who only need surgery and don’t need chemotherapy.
The standard risk group is led by Nicholas Evageliou, MD, with the Children’s Hospital of Philadelphia. A big goal for the trial is to pinpoint biomarkers that predict who might respond really well to treatment. Dr. Evageliou is also working to identify which patients can potentially move to a lower-risk group. For these patients, we hope to be able to pull back on some of the harsher treatments that have long-term side effects.
The high-risk group – kids whose disease has spread – is studied by Dan Benedetti, MD, Vanderbilt University. Similar to the standard-risk group, researchers are looking at who can benefit from more intense therapy, while also potentially identifying which patients can have a reduction in the intensity and length of therapy and still achieve outstanding cure rates.
How will AREN2231 change long-term outcomes for renal tumor patients?
We’re all excited about the potential to further risk-classify Wilms tumors and develop COG treatment protocols that are more precise to each individual patient.
One of the biggest long-term side effects for kids who have been treated for renal cancer is difficulty with fertility. High doses of chemotherapy or radiation can impact a child's future fertility potential. So, if we can effectively treat these cancers with lower doses of chemotherapy, that would have a big impact on the patients’ survivorship. While our care is always focused on eliminating a child’s cancer, it’s also about preserving their long-term health.
One of COG’s priorities is to look into all cancers – even the rarest. Can you share a bit about how your committee is studying rare renal tumors?
Highly aggressive renal cancers are rare. But they’re equally important to study. One of the reasons I appreciate COG so much is because we don’t have to advocate for studying rare cancers. As long as any child is at risk of dying, our work isn’t done.
Jim Geller, MD with Cincinnati Children’s Hospital is the study chair for AREN1921, which focuses on patients with anaplastic Wilms tumor. These patients go through very aggressive treatments. He is working to understand what it is about these cancers that allows them to grow so quickly and to resist treatment. This is an area where we want to be making a big difference in the next few years.
Another rarity is when patients have tumors on both kidneys. For a long time, we thought that tumors on both kidneys or multiple tumors on the same kidney were the same tumor. They may even look the same under the microscope. But when you dig deeper, they can be very different biologically. Andrew Murphy, MD, Jack Brzezinski, MD, PhD, and Andrew Hong, MD, are together researching how to treat patients with multiple renal tumors and how the cancer’s DNA changes when they’ve spread to another part of the body. Essentially, we’re working toward treating each tumor individually. Treating multiple tumors at the same time is complicated, but putting this into action will be a game-changer for these patients.
One of your research interests is in how chemotherapies affect the urinary tract. Can you tell us a bit about your research and how kids are affected?
As a urologist, I see patients with all kinds of cancers. That’s because a lot of cancer treatments impact the bladder. Sometimes, that side effect gets blown off because a child has just survived a life-threatening illness. But wetting the bed or not being able to urinate is a terrible side effect to experience.
Early on in my career, I took care of a child and the family started making gifts to support my research. Those gifts have really pushed along my ability to build studies and analyze how two of the most common chemotherapies in all pediatric cancer treatment affect the bladder.
We are at the early stages of this study, but we have identified — both with clinic patients and with animal models in the lab — that doxorubicin and vincristine can negatively impact the lower urinary tract’s function. We believe we are close to understanding the mechanisms behind this issue, so the next step will be a targeted prevention and treatment.
As the COG committee chair, what are some of your long-term priorities?
One key priority is always doing the necessary pre-clinical research and early-phase clinical trials. These studies help build a strong foundation for larger studies. I don’t want there to ever be a gap in making major advancements for pediatric renal tumor treatment.
Another thing is building a pipeline for more young physicians to specialize in the care of, and research for, children with renal tumors. This is a really gratifying specialty and like I said, it’s one of the few that offered me the opportunity to do surgery and provide long-term care.
And of course, I think we all would hope for more philanthropic support. We’ve been really fortunate to have some great philanthropic support from the Emma Jordon Kidz Fighting Cancer Foundation and through the COG Foundation. Supporting the COG Foundation makes it possible for COG to do the core work to build a study for our physician-scientists and support them with biostatisticians, lab-based scientists and epidemiologists.
What’s the best part of your job?
Oh, there’s no question there – interacting with patients and the ongoing relationships we build with their families. Every time I get to see a child after surgery and then watch them get better and eventually celebrate the completion of their treatment is special. But the very moment a child goes from being scared about being in the hospital to giving out hugs — that’s truly the best.
During medical school, he was drawn to surgery because he liked that he could have an immediate impact on helping restore a patient’s health. But patient relationships were important to him too. Urological oncology offered a good mix of clinical care and surgery.
Dr. Cost is now the chair of the Children’s Oncology Group (COG) Renal Tumor Committee. He practices at Children’s Hospital Colorado, where he is also the Division Chief for Pediatric Urology.
Can you talk a bit about the different kinds of renal tumors?
About 85% of kids with kidney cancer have a Wilms tumor. It typically occurs in kids under 5 years old. For about 85-90% of those kids, their treatment is successful.
The other 10-15% of pediatric renal cancers are exceptionally rare. These include clear cell carcinoma, congenital mesoblastic nephroma and rhabdoid tumors of the kidney. These cancers are usually what we call embryonic cancers, meaning they actually begin when a child is developing in the womb. So they occur most often in babies and young children.
These tumors happen when a few of the kidney’s cells don’t develop correctly. Over time, the cells grow into a tumor. Some of COG’s renal tumor committee members, Andrew Murphy, MD, Jack Brzezinski, MD, PhD, and Andrew Hong, MD, are doing a lot of work looking into how some of these “missteps” in cell development happen during the very first weeks in utero.
Renal cell carcinomas and anaplastic sarcoma of the kidney happen more often in older children, adolescents, and young adults. Some of these cancers are caused by genetic mutations in the DNA that happen as a kid is growing up.
How are renal cancers treated?
Almost all children with renal cancer will need the kidney that has the tumor in it removed. I’m trained as a urologist and a surgeon, specializing in oncology. So I’m the physician who removes the kidney and the tumor. After patients have recovered from surgery, most will begin chemotherapy and sometimes radiation. For a small number of patients, we’re able to remove their tumor and kidney, and they don’t need any additional cancer treatments. If a tumor has wrapped itself into or around the veins that are connected to the kidney, the patient may need chemotherapy first, to reduce the size of the tumor before surgery.
The more complex treatments happen when the cancer has spread beyond the kidney, usually to the lungs first. Renal cancers also sometimes spread to the liver and bones.
Why do renal tumors often spread to the lungs first?
When blood leaves the kidneys, it goes to a large vein that takes the blood to the heart and then to the lungs. Renal tumors shed some of their cells into the blood that’s going out. And when those cells get to the lungs, they get stuck in tiny blood vessels. Unfortunately, an oxygen-rich environment like the lungs is ideal for tumor growth.
Can you tell us a bit about the renal tumor committee’s new Wilms tumor study that launched in March 2025?
This year, our committee launched one of the most comprehensive studies we’ve ever done. It’s truly an honor to be part of this team. Having all of us connected through COG, working together to design new studies, centralizing our biospecimens and helping each other get through research challenges makes being part of this study extremely rewarding.
Elizabeth Mullen, MD, is leading this study. She is a pediatric oncologist at Boston Children's and the vice chair for the COG Renal Tumor Committee. Similar to some of COG’s other big renal tumor studies, this trial (AREN2231) is working to study biomarkers that we can use to group these cancers into new subtypes of renal tumors.
Within these new groups, we’ll be able to learn more about why some tumors respond well to treatments while others – that appear similar – are better at resisting them. Then we can design even more precise treatment plans for these newly defined subgroups – and ultimately improve outcomes.
The trial is divided into three groups. Kelly Vallance, MD, with Cook Children’s leads the low-risk group. She is looking at ways to expand the group of patients who only need surgery and don’t need chemotherapy.
The standard risk group is led by Nicholas Evageliou, MD, with the Children’s Hospital of Philadelphia. A big goal for the trial is to pinpoint biomarkers that predict who might respond really well to treatment. Dr. Evageliou is also working to identify which patients can potentially move to a lower-risk group. For these patients, we hope to be able to pull back on some of the harsher treatments that have long-term side effects.
The high-risk group – kids whose disease has spread – is studied by Dan Benedetti, MD, Vanderbilt University. Similar to the standard-risk group, researchers are looking at who can benefit from more intense therapy, while also potentially identifying which patients can have a reduction in the intensity and length of therapy and still achieve outstanding cure rates.
How will AREN2231 change long-term outcomes for renal tumor patients?
We’re all excited about the potential to further risk-classify Wilms tumors and develop COG treatment protocols that are more precise to each individual patient.
One of the biggest long-term side effects for kids who have been treated for renal cancer is difficulty with fertility. High doses of chemotherapy or radiation can impact a child's future fertility potential. So, if we can effectively treat these cancers with lower doses of chemotherapy, that would have a big impact on the patients’ survivorship. While our care is always focused on eliminating a child’s cancer, it’s also about preserving their long-term health.
One of COG’s priorities is to look into all cancers – even the rarest. Can you share a bit about how your committee is studying rare renal tumors?
Highly aggressive renal cancers are rare. But they’re equally important to study. One of the reasons I appreciate COG so much is because we don’t have to advocate for studying rare cancers. As long as any child is at risk of dying, our work isn’t done.
Jim Geller, MD with Cincinnati Children’s Hospital is the study chair for AREN1921, which focuses on patients with anaplastic Wilms tumor. These patients go through very aggressive treatments. He is working to understand what it is about these cancers that allows them to grow so quickly and to resist treatment. This is an area where we want to be making a big difference in the next few years.
Another rarity is when patients have tumors on both kidneys. For a long time, we thought that tumors on both kidneys or multiple tumors on the same kidney were the same tumor. They may even look the same under the microscope. But when you dig deeper, they can be very different biologically. Andrew Murphy, MD, Jack Brzezinski, MD, PhD, and Andrew Hong, MD, are together researching how to treat patients with multiple renal tumors and how the cancer’s DNA changes when they’ve spread to another part of the body. Essentially, we’re working toward treating each tumor individually. Treating multiple tumors at the same time is complicated, but putting this into action will be a game-changer for these patients.
One of your research interests is in how chemotherapies affect the urinary tract. Can you tell us a bit about your research and how kids are affected?
As a urologist, I see patients with all kinds of cancers. That’s because a lot of cancer treatments impact the bladder. Sometimes, that side effect gets blown off because a child has just survived a life-threatening illness. But wetting the bed or not being able to urinate is a terrible side effect to experience.
Early on in my career, I took care of a child and the family started making gifts to support my research. Those gifts have really pushed along my ability to build studies and analyze how two of the most common chemotherapies in all pediatric cancer treatment affect the bladder.
We are at the early stages of this study, but we have identified — both with clinic patients and with animal models in the lab — that doxorubicin and vincristine can negatively impact the lower urinary tract’s function. We believe we are close to understanding the mechanisms behind this issue, so the next step will be a targeted prevention and treatment.
As the COG committee chair, what are some of your long-term priorities?
One key priority is always doing the necessary pre-clinical research and early-phase clinical trials. These studies help build a strong foundation for larger studies. I don’t want there to ever be a gap in making major advancements for pediatric renal tumor treatment.
Another thing is building a pipeline for more young physicians to specialize in the care of, and research for, children with renal tumors. This is a really gratifying specialty and like I said, it’s one of the few that offered me the opportunity to do surgery and provide long-term care.
And of course, I think we all would hope for more philanthropic support. We’ve been really fortunate to have some great philanthropic support from the Emma Jordon Kidz Fighting Cancer Foundation and through the COG Foundation. Supporting the COG Foundation makes it possible for COG to do the core work to build a study for our physician-scientists and support them with biostatisticians, lab-based scientists and epidemiologists.
What’s the best part of your job?
Oh, there’s no question there – interacting with patients and the ongoing relationships we build with their families. Every time I get to see a child after surgery and then watch them get better and eventually celebrate the completion of their treatment is special. But the very moment a child goes from being scared about being in the hospital to giving out hugs — that’s truly the best.