It is estimated that 9-17% of all patients diagnosed with a primary cancer will develop a secondary cancer in the brain. Depending on the size, location and number of tumors, brain metastases can be treated with very effective and aggressive new tools, resulting in an improved prognosis for many patients.
An increasing number of advanced minimally and non invasive treatment options are being “tailored” to meet the needs of the individual patient in the areas of neurosurgery and radiation therapy.
Brainlab is a leading provider of neuronavigation and stereotactic radiosurgery (SRS) technologies that are widely used to assist your doctor during the different treatment phases.
How Brain Metastases develop and promising treatment options
Contents: Brain Metastases: A Documentary
- 1. What are Brain Metastases?
- Hear from patient Brenda Smith about her brain mets and their impact on her life.
- 2. How and why do we develop brain metastases? (3:07)
- Learn which cancers are more likely to penetrate the blood-brain barrier.
- 3. What are potential treatment options? (5:10)
- Understand the challenges associated with chemotherapy for brain metastases.
- 4. Whole Brain Radiation Therapy (6:11)
- Discover the history of conventional treatment.
- 5. Stereotactic Radiosurgery (8:40)
- Appreciate the technology and techniques behind highly precise, tumor-targeted radiation therapy.
- 6. What types of stereotactic radiosurgery exist? (10:22)
- Explore the first-of-its-kind tumor-targeting radiation system.
- 7. Linear Accelerators (12:18)
- Investigate the different types of and benefits to stereotactic radiosurgery systems.
- 8. What is the difference between a frame-based and a frameless treatment? (13:18)
- Discover the pros and cons of both invasive head rings and non-invasive patient immobilization.
- 9. CyberKnife Technology (16:31)
- Learn about this robotic linear accelerator.
- 10. Multileaf Collimator (17:32)
- Find out how technology allows doctors to conform the radiation to match the shape of any tumor.
- 11. Treatment of multiple metastases (19:03)
- Learn about cutting edge technologies for single session treatment of multiple brain metastases.
- 12. Why is it sometimes necessary to perform radiosurgery in more than one session? (21:39)
- Understand how tumors grow and treatment works on larger tumors.
- 13. Why is whole brain radioation therapy still performed today? (24:37)
- Hear about current thinking and the outlook for whole brain radiation.
- 14. As a patient, what can I do to maintain the best quality of life? (26:09)
- See how clinicians are working to turn brain mets into a chronic disease through technology and diligent follow-up.
- 15. Why is it sometimes necessary to perform surgery? (27:09)
- Know the tools we have to effectively treat brain metastases.
- 16. Why is it sometimes necessary to perform surgery AND radiosurgery? (28:20)
- Understand why in some cases the best treatment option is a combined approach.
- 17. How can I select the best and most appropriate care unit? (29:15)
- Learn how to decide on the best and appropriate treatment for you.
- 18. How will the treatment of metastatic brain cancer evolve in the future? (30:25)
- Gain insights into how future innovation in technology will further improve treatment options.
How Brain Metastases develop and promising treatment options
It’s estimated that 9-17% of all patients diagnosed with a primary cancer will develop a secondary cancer in the brain, called metastasis.*
A new and thought-provoking documentary explores the pathology, diagnosis and treatment of brain metastasis through interviews, animations and live treatment footage.
Neurosurgery with Neuronavigation
Open surgery is the most common treatment option for single brain metastases. A craniotomy is performed to remove the tumor or to halt its progress.
Brainlab neuronavigation technology is used to plan and perform open surgery such as tumor resection or brain biopsy with greater precision. Computer-assisted surgery (CAS) works similarly to a car’s navigation system by continuously tracking surgical instruments in relation to the patient’s anatomy. This gives the surgeon additional visual guidance and allows for a more successful and minimally-invasive brain tumor resection or brain biopsy.
Benefits of computer-aided surgery:
- Supports minimally invasive approach
- Avoids critical brain structures
- Reduces risks and hospital stay
For the treatment of single brain metastases, which are often inoperable due to their position and the sensitivity of the surrounding tissue, Brainlab has developed a special radiosurgery treatment system.
Novalis® radiosurgery shapes the cancer-fighting radiation beam around your brain tumor, ensuring that the prescribed treatment dose is delivered to the entire lesion in a one-time treatment or a series of treatments based on your doctor’s recommendation.
Benefits of radiosurgery:
- Frameless non-invasive treatment improves patient comfort
- Treatment typically lasts just minutes
- Reduces recovery times
- Can be performed without hospitalization
Find more information here: Brainlab.org – An educational resource for patients
Find a brain cancer specialist
Discuss the different treatment options with your physician. Ask him/her to present the advantages and disadvantages, as well as the later side effects, of each different treatment option available to you:
- Whole brain radiation
- Stereotactic Radiosurgery (SRS)
- Participation in clinical trials
Getting more help
To support you in the decision process about the best treatment option for your brain metastases, discuss with your family, and also refer to further valuable information sources, such as:
- Self-support groups
- Non-profit organizations
- Written information material
Take the time to be informed; this is your decision and you need to do what is most beneficial and reassuring for you.
Brain Metastases: A Documentary
How They Develop and Promising Treatment Options
What are Brain Metastases?
David Andrews, MD: Cancer. The emperor of all maladies. It is a frightening disease for which currently there’s no cure. However, we are unquestionably in one of the most dynamic and exciting periods of medicine for cancer treatment.
Brenda Vincentz-Smith: I felt that something was a little off with my right breast. It turned out to be breast cancer. I went through seven months of chemotherapy, a mastectomy, radiation. I got to a point where there was no evidence of disease. My oncologist suggested a brain scan, because I hadn’t had that tested since my original PET scan when I was first diagnosed. There were three tumors.
Dwight Heron, MD: A brain metastasis is a collection of cancer cells that have traveled from some part of the body where it started. They cause a lot of swelling and that pressure on the brain and the swelling in the brain causes neurologic symptoms and can actually even cause death if not treated appropriately.
Brenda Vincentz-Smith: My first thought was OK, you know, what’s going to happen next? What’s my quality of life going to be and – actually I was prepared to die.
Veronica Chiang, MD: It’s terrifying. They’re scared that they’re going to die soon. They are scared of the treatments that we might be offering them.
Douglas Kondziolka, MD: We did a study a number of years ago where I took my own patients and I tried to predict how long somebody would live. We shared that data with 17 top people in the world. It was fascinating because what we found is that the doctors really couldn’t pick, at an individual level, who was going to beat the odds and who was going to struggle. Maybe we’re not that good at predicting how long people are going to live.
Veronica Chiang, MD: We’ll find the cure for cancer eventually but in the meantime, you know, we want people to be able to live with their cancer, as opposed to for their cancer.
Dwight Heron, MD: We now have capabilities in radiosurgery to treat tumors that are in deep and inaccessible areas with almost relative impunity. We can do it with such targeted approaches that the side effects are no longer significant.
Douglas Kondziolka, MD: This has revolutionized neurosurgery and radiation oncology because prior to that there was only the options of open surgery or radiation to the whole head, as opposed to precise targets.
David Andrews, MD: The advantage of radiosurgery, by focusing radiation, is sparing the surrounding structures in the brain from radiation injury.
Douglas Kondziolka, MD: Patients are surprising us. They are living longer, they’re beating the odds. We’re seeing things we never saw before.
David Andrews, MD: We have a high confidence that we can eliminate the cancer in the brain and return you to your quality of life and activities of daily living.
How and why do we develop brain metastases?
David Roberge, MD: There are different kinds of brain tumors. It’s important to discriminate between primary brain cancer, which is a tumor that’s born in the brain, and that’s actually pretty rare. And then there’s metastatic brain cancer, which is five times more common. Part of what makes cancer cancer is that it has the ability to spread throughout the body, so the tumor might start in the breast and it gets to a certain size and it develops some mutations and then a cell will split off, get into the blood, and then stop somewhere in the brain and deposit inside the brain and form other tumors and that would be the process of metastasizing.
Orin Bloch, MD: There is a blood-brain barrier and that barrier works very well at keeping toxins and infections and other things floating around through our blood out of the brain. But cancer has developed a mechanism which it can penetrate that barrier and certain cancers in particular are better at penetrating it than others, which is why we tend to see most metastatic tumors from lung cancer, breast cancer, melanoma, and testicular cancer. If you remove one of these metastatic tumors from the brain with surgery and you look at it under a microscope, it looks like the cancer from the original source. So a breast cancer metastasis looks like abnormal breast tissue rather than brain tissue. They are growing into a ball of cells that is the cancer, but they’re not incorporating themselves into the brain. They are unwanted neighbors, if you will.
Douglas Kondziolka, MD: Our goal is to find those tumors early because as the tumors get bigger, the success rates drop. Typically with radiosurgery people have quoted success rates at stopping a brain tumor in the range of 85%, so when we say how do we get that to 95%, to 98%, to 99%? It’s with identifying the tumors earlier and that means getting a periodic brain scan to check, because missing a brain tumor, if it grows, can cause neurologic symptoms that we’d like to avoid.
What are potential treatment options?
Orin Bloch, MD: Typically when you’re diagnosed with metastatic cancer or cancer that’s spreading throughout your body, you’re put on a systemic chemotherapy and this drug is supposed to kill the cancer all over your body wherever it is. But those drugs don’t get into the brain because of the blood-brain barrier.
David Andrews, MD: You want a cancer drug to have a significant impact and if only a fraction of it gets through because of the blood-brain barrier, it makes chemotherapy much more challenging.
Orin Bloch, MD: And so, we have to treat the tumors in the brain as completely separate from the tumors everywhere else in the body.
David Andrews, MD: So the tools that we have before us to treat brain metastases are radiation and surgery.
Douglas Kondziolka, MD: In certain types of situations, certain research protocols, drug therapies are being evaluated and tested. We hope that any drug therapies that are being received are providing benefit to the body, particularly with the goal of preventing new tumors from coming in the future.
Whole Brain Radiation Therapy
Dwight Heron, MD: All brain radiation is as it sounds; We’re treating the entire brain with radiation.
David Roberge, MD: Conventional radiation, the way it’s been given for a long time is that a little bit of radiation is given every day and that’s repeated five days a week up to seven or eight weeks. In that process, there’s a lot of healthy cells that receive the same amount of radiation as the cancer cells, but the healthy cells are better at repairing between the different radiation treatments. So if you give a treatment today and you give another one 24 hours later between those two treatments the healthy cells are repairing at a faster rate than the cancer cells.
Eric Chang, MD: Unfortunately when a patient is diagnosed with brain metastases, there are many more lesions that are not detectable on an MRI or any imaging modality that we have today. They have the potential to grow. Some have referred to this as the “dandelion effect”. When you blow on a dandelion, all these seeds shower an area. It’s not dissimilar to that phenomenon where there is a primary cancer somewhere in the body and therefore there’s a possibility for cancer cells to seed and deposit multiple areas of the brain. So whole brain radiation therapy is used to try to sterilize not just the visible brain metastases but also the microscopic brain metastases that we just can’t see yet.
David Roberge, MD: Radiation has been around for about 100 years and it’s been a really important part of treating cancer. For some people that’s an appropriate treatment but it comes with a lot of side effects. Almost everybody is tired, sometimes really severely tired. You lose your hair. You can get inflammation in your ear, sometimes it leads to hearing loss. It makes people nauseous sometimes. What worries patients the most and what caused us the most concern is it can have an effect on memory, concentration and other brain functioning.
Orin Bloch, MD: Whole brain radiotherapy has a devastating impact on cognition. We’re targeting the areas where new memories are formed, the hippocampus, as well as all of the interconnections between different parts of the brain that are critical for higher-level thought and memory. You can’t expose that much of the brain to toxic radiation and expect to have no consequences. So if we are going to strive for a cure or at least long-term suppression of cancer and keep patients alive for years and years, we really have to think about what their quality of life is going to be and quality of life starts with what’s up here.
Dwight Heron, MD: Now with our modern imaging technology, where we can see really, really small tumors inside the brain, we can actually now avoid whole brain radiation all together and treat those tumors with radiosurgery.
Howard Chandler, MD: Stereotactic radiosurgery is a technique of delivering radiation very specifically to a target inside the head.
Dwight Heron, MD: The concept here is you’re destroying tumors inside the body with frankly the accuracy of the blade of a knife. You’re destroying a tumor deep inside the body, almost like cutting it out, but you’re using a non-invasive way.
David Roberge, MD: The radiosurgery devices are usually accurate to about a millimeter and about a millimeter is about how accurately we can pick out where the tumor is anyways on the MRI or CT scan, so that’s about as accurate as they need to be.
Howard Chandler, MD: It uses multiple beams of radiation that all converge on a single point. What I tell patients is this is very analogous to taking a magnifying glass and a leaf, and if you hold a leaf out into the sun, it won’t spontaneously combust and catch on fire, but if you take a lens and focus that low dose sun power down on the point, it’ll burn a hole in the leaf and so that’s in its essence what stereotactic radiosurgery machines do.
David Roberge, MD: The radiation is coming from all these directions and it’s being concentrated in that one spot. But around that spot there’s not a lot of radiation, so the damage is really focused on the tumor.
David Andrews, MD: Brain metastases are one of the few targets that we treat in the brain that can absolutely disappear with radiation. The tremendous advantage of radiosurgery is it does not interrupt systemic treatment, whereas somebody that’s undergoing standard whole brain radiation must suspend standard treatment.
What types of stereotactic radiosurgery exist?
Douglas Kondziolka, MD: The Gamma Knife is the first hospital-based dedicated radiosurgery system.
Veronica Chiang, MD: The Gamma Knife treatment is a one-day treatment.
Douglas Kondziolka, MD: They’re going to come to the hospital early in the morning. We give them a little sedative. We will clean the skin and I inject some local anesthetic in the forehead and the back of the head prior to placing what I call a guiding device for stereotactic frame. It’s like a halo with little pins that anchor into the head in these numb areas. The patient will wear that during the procedure. The stereotactic frame guiding device prevents head movement. The second thing that the frame does is essentially creates a GPS device for the head so that we know where the tumor is inside the brain mathematically in three dimensional space exactly what that coordinate is.
Dwight Heron, MD: We have 192 sources in a Gamma Knife and they’re all still focused at one point in space.
Douglas Kondziolka, MD: Each of the different radiation devices create this conformal irregularly-shaped plan in different ways. With the Gamma Knife, we use what are isocenters or shots of radiation. Each shot is sort of like a ball and if one wanted to make an irregular shape, you might make a series of balls that mathematically integrates in three dimensions to be that shape. Once that’s done, the group will then choose an amount of radiation that they think is best suited for that tumor in that location in that patient. There’s many factors important including: Did they have radiation before, the size of the tumor, its location, are there any other options should this not work, if there are risks, how would those be managed?
Veronica Chiang, MD: Once the treatment is done, they have the head frame taken off, they get some dressings from the pin sites, a head wrap, and then they go literally right home from there.
David Andrews, MD: Another way to deliver stereotactic radiation is the linear accelerator. It uses accelerated electrons that are channeled into a collision with a heavy metal target and out of this comes high-energy photons.
James Robar, PHD: When they slow down, they actually emit X-Rays, not like the X-Rays that you would use to take a picture of somebody in a chest X-Ray, for example. They’re about 100 times more energetic. These X-Rays are designed to kill cancer cells. Once we had the linear accelerator we had a whole wealth of new tools. We were able to direct radiation beams from different angles and overlap them. We don’t actually have to deliver all the beams at the same time. The biological effect of depositing those is additive, even if we deliver those beams sequentially. We do this quite quickly. We do the whole series of beams and deliver the entire treatment within about 15 minutes to half an hour.
What is the difference between a frame-based and a frameless treatment?
Orin Bloch, MD: Benefit of frame-based radiosurgery is that the patient is held rigidly on the table with the assurance that the patient isn’t moving and that the target is going to be accurately identified. Frameless radiosurgery uses a thermoplastic mask that is custom-molded to the patient by heating this plastic, molding it and then cooling it so that it becomes rigid. It still holds the patient on the table but does still allow about one to two millimeters of micro motion. That’s much more comfortable than being rigidly affixed to the table, but it does introduce the possibility of some error.
Timothy Solberg, PHD: There are frameless technologies track the surface of the patient and use that to then somehow triangulate an internal target that you can´t see.
James Robar, PHD: Optical external surface tracking technology can be quite compatible to various sites, for example, in treating breast cancer. In treating brain tumors, we have the most demanding spatial tolerances of any site within the body. The sensitivity of the technique can be affected by skin color. That skin can move, it can deform, it can stretch and ultimately that’s the limitation of that surface matching approach. One option to accommodate limited precision of surface matching is to actually add a margin around the tumor that we’re treating, but it’s our goal to actually minimize those margins since that expansion equates to knowingly treating healthy brain tissue. If we can imagine for a second a brain metastasis that is 15 millimeters across, if we were to add a margin that is just two millimeters, we would be approximately doubling the volume of the tumor that we would need to treat. What we really would like to do is to have a more direct means of monitoring where the tumor is actually located.
Timothy Solberg, PHD: With an image-guided frameless technique like ExacTrac in real time you actually see where your beam is pointing. So you can constantly monitor the patient if they were to move for some reason, cough, jump, whatever, you know it and you can adapt your treatment to that.
Orin Bloch, MD: When you add imaging and micro motion adjustments into the thermoplastic mask, you really achieve the same level of accuracy as a frame-based system. This can be done through a system such as ExacTrac, that uses in-line X-Ray imaging combined with a robotically moving couch to make minor adjustments in patient position to account for any movement of the patient.
Howard Chandler, MD: In my opinion, treating hundreds of patients with both frame-based and frameless technologies, the patient and provider experience is better with the frameless immobilization. From the patient’s perspective they don’t have to have a painful anesthetic injection, they don’t have to be sedated, they don’t have to have the discomfort of wearing the frame for the entire day of the treatment. They are only immobilized while they’re on the treatment table under treatment delivery.
David Roberge, MD: Then it doesn’t matter if you’re giving one treatment, three treatments, five treatments. You can get the same accuracy, and you can choose the number of treatments that’s best for the patient and their tumor.
Dwight Heron, MD: The CyberKnife is a robotically mounted small linear accelerator that delivers radiation therapy at a much lower dose rate and it does it in a node-based pattern, so it moves from one location to the next location to the next location. Not in a sweeping action. That results frequently in treatment plans that are qualitatively similar, meaning that if I want to deliver 18 Gy to a small tumor, whether it’s the Gamma Knife or the Novalis system or the CyberKnife system, they can all do that. The way the dose is spread out and the way it’s delivered is really the crux of the differences, and the speed, do treatment times are the important part. Much like the Novalis system, the CyberKnife does have stereoscopic imaging that allows us to image the patient and confirm that the patient’s in the right location during the entire course of treatment.
Howard Chandler, MD: The next iteration of beam shaping technology is what’s called a micro multi-leaf collimator. The principle behind it is not all tumors are exactly spherical, so a circular beam can ideally treat a spherical target but if you think of a hot dog, for example, it’s spherical in one view but it’s linear in another view.
James Robar, PHD: And so the multi-leaf collimator allows us to vary these shapes according to the view of the tumor. Because we can’t use magnets to steer X-Rays and we can’t uses lenses like light. What we have to do is simply block the regions where the X-Rays aren’t supposed to go and create an opening where they are supposed to pass through.
Howard Chandler, MD: And so what micro multi-leaf collimators do is use multiple leaves that block part of the beam to shape the beam into the exact beam’s eye view of the tumor, so the edge of the beam is exactly aligned with the edge of the tumor through that view and it can do that on the fly as the beam is moving in an arc of radiation around the tumor.
James Robar, PHD: If we actually control these leaves dynamically, we can vary the intensity of the radiation that’s emitted from the linear accelerator.
Howard Chandler, MD: In my opinion, the development of the micro multi-leaf collimator has been the biggest advance in radiosurgery in my lifetime because it allows more precise and homogenous delivery of the radiation to just the target and so you’re delivering a minimum of radiation to the normal brain tissue around it.
Treatment of multiple metastases
David Andrews, MD: It’s not meaningful if a patient has to have 36 hours of radiosurgery. With marvelous techniques in the linear accelerator, we can perform treatment of ten metastases in no time at all – in half an hour.
Timothy Solberg, PHD: The current mode of practice to treat multiple metastases is to treat one after the other, and you can certainly do that. On a Gamma Knife you would do that conventionally on a linear accelerator, you would treat one after another, and that treatment would take 15 to 20 minutes for each one and so if a patient came in with 12, you could have the patient being treated on the device for three hours, four hours.
David Roberge, MD: That might not matter when it’s two or three tumors, but if we come to a point where we want to treat ten or 15 tumors, it’s really inconvenient to treat them one at a time then and it’s a lot easier to have the technology where they can all be treated at once.
Timothy Solberg, PHD: Historically, treatment planning has been a manual process that’s done with the knowledge and experience of the physicist who’s sitting down at the computer. And you go through this manual, iterative process until you get a plan. Not the best plan, because you know you could probably spend some more time to make a better plan, but you get what’s a clinically acceptable plan and there’s no reason to do that once we have computers that can do this optimization automatically.
James Robar, PHD: New approaches allow us now to treat all of the metastases with a single isocenter and one of those techniques is called volumetric modulated arc therapy. As we are rotating the gantry of the linear accelerator, we can create very complex openings to allow irradiation of all of the metastases. Depending on the orientation of the multi-leaf collimator, it may be challenging to actually create two separate apertures without creating an unwanted region of exposure in between.
New multiple metastases software
James Robar, PHD: Another technique that is gaining popularity takes a different approach in choosing subsets of brain mets to be treated in a single gantry rotation. Let’s imagine a patient who has seven brain metastases. The algorithm would look at that set and decide on maybe three of the seven to be treated in a single gantry arc and then in a second gantry rotation, the algorithm might choose the remaining four and that decision would be based on minimizing the area or amount of normal brain tissue that would have to be exposed.
Why is it sometimes necessary to perform radiosurgery in more than one session?
Dwight Heron, MD: Increasingly, we’re faced with more complicated, complex tumors, larger tumors, and tumors that are in close proximity, they are very close to critical structures, for instance, say the optic chiasm or the brain stem or one of the major cranial nerves. Giving a single fraction would be problematic, it would cause too much of a side effect. And so, the technologies that we have today with our relocatable frame, with our image guidance and our ability to vary the intensity of the radiation beam, has allowed us to give an effective dose of radiation by breaking it up into smaller fractions, something called “hypofractionation”. For instance, for the smallest tumors, we may give 21 or 24 Gy, and that’s a measure of radiation, in a single fraction. But for a tumor that’s say three centimeter, we may give you a much lower dose, which is 16 Gy and that doesn’t make any sense because a bigger tumor will have more cells that need to be killed. So why are we giving a lower dose? It’s because if we try to give 24 Gy to that three centimeter tumor, the side effect, meaning swelling and necrosis, which is dying brain tissue, would be unacceptably high.
David Roberge, MD: In between the treatments, the normal brain can repair. In between the treatments, some areas of the tumor that were more resistant to radiation, maybe because they weren’t getting enough oxygen, can get more oxygen and become more sensitive to radiation.
Dwight Heron, MD: All cells in the body require oxygen and tumors themselves have a higher demand on oxygen consumption just because they’re growing so rapidly. They can actually outgrow their blood supply. And when they outgrow their blood supply, they become what’s called ‘hypoxic’. So there is little oxygen towards the centers of the tumor. Incidentally, by giving a smaller dose of radiation but giving it in multiple fractions we’d get the benefit of having the tumor shrink and then that portion that was hypoxic actually has now more blood supply and as it further shrinks it gets even more blood supply, so the radiation is now more effective because there’s more oxygen around, there’s more free radical to damage the cancer cells and you get a better response to treatment.
David Roberge, MD: For some large tumors, the future might be to be giving three and five treatments as opposed to just one treatment and again, if you have a system that doesn’t rely on screwing something to the patient’s head, then you have that flexibility of what’s best for this tumor. If it’s three treatments, we’ll do three treatments. If it’s one, we’ll give one and the quality and the accuracy will be the same.
Why is whole brain radiation therapy still performed today?
Eric Chang, MD: The whole brain radiotherapy paradigm is very much engrained in many radiation oncologists and this is how it’s been for many years.
David Andrews, MD: Radiation therapy, when not focused, delivers collateral damage to surrounding tissue.
Dwight Heron, MD: Why continue using a technology, a treatment approach, that results in significant, long-term, irreversible side effects of memory loss, dementia, when with a carefully constructed clinical approach of radiosurgery and close and careful follow-up, the outcomes are identical. So it’s unconscionable for me that an insurance company would deny good therapy. In fact, one of the reasons why there’s so much whole brain radiotherapy is that even in the centers that have radiosurgical capability and the staffing, it gets denied.
Eric Chang, MD: For patients receiving radiosurgery upfront, it doesn’t preclude any additional treatment, you can always have whole brain radiation therapy later, if it’s appropriate. My personal opinion is that whole brain radiation therapy will always occupy some role in the management of metastatic brain disease, but I think that it’s role is going to become more and more limited to those patients who have very advanced presentations of brain metastasis.
As a patient, what can I do to maintain the best quality of life?
David Roberge, MD: If you just give someone radiosurgery and you never see them again well, unfortunately it’s about 50/50 that they’ll get new brain metastases and if you don’t follow them, the only reason you’ll see them back is because they’re sick and they’re in the emergency room. But if you see them every few months and you do an MRI, you might find that new metastases when it’s only a few millimeters and you can zap if before it causes any trouble and often the patients, despite having advanced cancer and brain metastases, they’re not going to die from the brain metastases because we can control them by following them and treating them when they’re small.
Douglas Kondziolka, MD: And that’s really part of managing cancer as more of a chronic illness with these periodic tests. It’s been part of the care of the body, PET scans, periodic CT scans, it needs to be part of the care of the brain.
Orin Bloch, MD: If you have a garden and you notice a couple of weeds, you can either go and pull those couple of weeds or you can tear up your entire lawn. There might be two or three other weeds that you didn’t see. If they grow up later, you’ll just pull them out later.
Why is it sometimes necessary to perform surgery?
Orin Bloch, MD: There is no doubt that patients want to avoid surgery. The prospect of having your head cut open and somebody going into your brain is very scary.
Douglas Kondziolka, MD: If the tumor is larger and symptomatic, causing disabling headache or frequent seizures or balance problems and it’s in a location that is suitable for removal, it may be that the recommendation is to surgically take that tumor away and decompress the brain. Now many patients are immediately thankful because when I tell them that this is the fastest way to make them better, that’s good news for them. That’s when we think about surgery. To solve a problem the patient has.
Orin Bloch, MD: As soon as we remove the tumor, that swelling starts to regress, so the patients who have brain metastases removed can feel better the day after their operation. The way we stay minimally invasive is by making small craniotomies just immediately over where we need to be. We’re able to do that in the modern era using something that we call intraoperative neuronavigation. That way we can find the shortest distance from the surface of the skull down to the tumor and make the smallest opening we possibly can.
Why is it sometimes necessary to perform surgery AND radiosurgery?
Orin Bloch, MD: With surgery, we can never guarantee that we removed 100% of the tumor. Sometimes, even when we remove everything we can see on the MRI, we know that there are microscopic cells left behind. The data is very clear on this that patients do better if they receive radiosurgery to the area where we surgically removed a tumor. Treating with radiation before actually doing surgery is really an intriguing idea that is starting to gain some traction. The concept is that if we treat with radiation before we do an operation, we start killing tumor cells with the radiation, so that when we go in there to remove the tumor, much of the tumor is already dead and the cells that get spilled during the operation can’t spread and set up new tumors. When we treat with radiation before surgery, it’s much easier to draw a line around the boundary of the tumor and know exactly what the border between the tumor and the normal brain is.
How can I select the best and most appropriate care unit?
Timothy Solberg, PHD: Radiosurgery is still somewhat new. Twenty years is fairly new. There is a wide variety in the standard of care that you can get.
David Roberge, MD: Radiosurgery has evolved quite a bit and it’s a double-edged sword that radiosurgery, especially for brain metastases, can now be done in relatively small clinics with general radiotherapy equipment and the quality might not be exactly the same in that setting than in a large institution that has a device dedicated to radiosurgery and it’s not easy for a patient or even for myself walking in the door to know is this a quality radiosurgery program.
Timothy Solberg, PHD: Well there is never a guarantee that there’s not going to be a problem. Novalis Certified is the only program in the world that has an independent group come in and look at your program and say yep, you really perform stereotactic radiosurgery at a universally high level from a clinical perspective, from a technical perspective, physics, quality assurance, all of these things. That’s a very valuable indication.
How will the treatment of metastatic brain cancer evolve in the future?
Elizabeth Wilson, CEO: It’s very early on in a movement to really address the treatment of metastatic cancer and metastatic brain, in particular. The importance of a film like this in the American Brain Tumor Association being a part of it is, it really gets back to our mission. If people understand that there is time for them to understand their tumor, that there is time for them to understand that diagnosis, and there is time for them to better understand their treatment options, it’s a better trajectory, it’s a better outcome and I think that that is a mission fulfillment for the organization.
Orin Bloch, MD: If we give treatments that are toxic and cause cognitive decline and those patients won’t be able to enjoy the extra years that we’ve bought them with our new therapies and so when treating cancer patients in the modern era, we really have to consider the quality of life for the time they have left.
Veronica Chiang, MD: We want for people to continue to live, continue to work, continue to do all the things that are meaningful to them.
Dwight Heron, MD: Radiosurgery is an essential component to the next wave of cancer care.
Brenda Vincentz-Smith: I no longer think about dying, you know, I don’t. And that’s I think pretty dramatic.
David Andrews, MD: If we can give you that plateau of survival, imagine what new protocols might be available to you that weren’t available even three years ago, and that provides patients with realistic hope.
Orin Bloch, MD: Technology has evolved to the point where we can treat them quite well and often cure their intracranial disease. Most patients with cancer who have brain metastases are going to find that their ultimate prognosis is really dependent on what’s going on with the cancer in the rest of their body. The future is really bright for these people because our systemic therapies are really progressing and survival is better than it ever has been in the past. I think the future is really going to be changing cancer from a fatal disease to a chronic disease.
*Nayak L, Lee EQ, Wen PY. Epidemiology of brain metastases. Current Oncol Rep., 2012 Feb; 14(1): 48-54.
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