By Dr. Ahmad Daher
Medical Director, Neuro-Oncology
Hartford HealthCare Medical Group
Patients with gliomas, the most common cancerous brain tumors, have shown only a modest improvement in survival rate despite diagnostic and therapeutic — surgery, radiation and pharmacotherapy — advancements in oncology over the last three decades.
Here’s a summary of the major therapeutic barriers in treating these tumors, recent advances in overcoming them, the survivorship challenges that brain tumor patients commonly deal with and Hartford HealthCare Cancer Institute’s role in caring for these patients:
Your doctor’s goal is the maximum safe removal of a tumor, with “safe” being the key word. Many studies have shown that the extent of tumor resection affects survival. A tumor within an organ performing critical functions makes complete removal, including a margin around the tumor, difficult without possible risks to normal brain tissue.
But we continue to seek new ways to come closer to a complete resection. Hartford HealthCare neurosurgeons are now certified in using a new new, non-fluorescent dye given to patients a few hours before surgery that helps better identify the tumor’s true margins. As this article is being written, it already has been used successfully on two patients.
Chemotherapy barriers are also related to the location of these tumors. An organ surrounded by a blood-brain barrier that protects the brain from toxins in the blood will limit to some extent delivery of drugs to it. There’s a lot of research on disrupting this barrier to allow for more efficient delivery of drugs, but this challenge has yet to be overcome efficiently and consistently.
Another barrier to chemotherapy success is the changing molecular makeup of the tumor. Many mutations (alterations in the tumor cell’s DNA) are involved in tumor formation.
There are now sophisticated tests to identify mutations in a tumor. These tests help guide drug choice to chemotherapies more specific to the patient’s tumor. This information is also used for clinical-trial enrollment, so having it available early is valuable. We are routinely doing these tests on our patients’ tumor samples to help personalize their therapy and we recently opened such a trial at the Cancer Institute.
Immunotherapy, which treats cancer by stimulating the immune system, is being used more commonly for brain tumor patients. Research into identifying new ways to stimulate the immune system to kill tumor cells (vaccines, viruses, infusion of immune cells activated to fight tumors in the lab) is ongoing. It’s highly promising and, like personalized therapy mentioned above, is the subject of many glioma clinical trials. We are, in fact, opening an immunotherapy trial at Hartford HealthCare Cancer Institute.
A relatively new way to treat gliomas is a device placed externally on the skull to deliver electrical currents at a certain tumor-killing frequency. This concept, known as tumor treating fields, has proven useful with chemoradiation for glioma patients in clinical trials. It requires use of the device most hours of the day, but has almost no side effects aside from mild scalp irritation. It’s FDA-approved in glioma patients, is covered by insurance companies and is offered to all our patients.
Brain Tumor Management
Brain-tumor management involves more than fine-tuning tumor-killing mechanisms. It requires a multidisciplinary approach to anticipate and help alleviate the many burdens the disease presents to patients and their families.
This can happen on multiple levels, whether patient-visit coordination, early rehabilitation, delivery of care closer to home when possible, visiting nurses to provide extra care at home, phone-call reminders for blood draws and starting oral chemotherapy or home blood draws for patients with mobility problems.
Our nurse navigator helps patients with prompt access to providers and other resources throughout their cancer journey. Patients are seen by neuro-oncology specialists while recovering from surgery in the hospital, even before the diagnosis is finalized, to go over some general concepts of therapy. Cases are discussed weekly at our multidisciplinary tumor board meeting attended by neurosurgery, neuro-oncology, radiation oncology, neuro-radiology and neuro-pathology.
Our healthcare system has several hospitals throughout the state, allowing for radiation therapy and/or infusion chemotherapy as close to the patient’s home as possible. We also just started a multidisciplinary clinic for newly diagnosed patients where they are seen by neuro-oncology and neuro-rehabilitation specialists on their first clinic visit appointment. Patients receive a specialized physical therapy assessment and early intervention.
To fully support our patients and families, we have an active brain tumor support group to help provide information and support for our patients. We also have an annual symposium for patients and families, the Fred Cohen Symposium, where a nationally recognized speaker gives an update on research and progress.
While many of the strategies mentioned above have yet to reach their full potential, they and the collaborative multidisciplinary efforts at the Cancer Institute certainly provide beneficial options that only a few years ago were not available to brain tumor patients.