SRS & SBRT - Insights from a Neurosurgeon
A conversation with Isabelle M. Germano, MD, MBA
From an introduction to stereotactic radiosurgery and stereotactic body radiotherapy, current standards and beyond, expert neurosurgeon, Isabelle M. Germano, MD, MBA dives into the details of this promising and precise treatment approach.
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Read the transcript below
Joanne: I’m thrilled to be joined today by Dr. Isabelle Germano. Dr. Germano is a neurosurgeon and tenured professor of neurosurgery, neurology and oncological sciences at the Icahn School of Medicine at Mount Sinai Hospital in New York City . She is also the director of the Comprehensive Brain Tumor Program and the Co-director of the Radiosurgery Program. Dr. Germano has been part of the Novalis Circle Expert Group since 2015. Dr. Germano, thanks so much for taking the time to do this interview with me today. I’m going to go ahead and get started with the first question if that’s okay with you.
Dr. Germano: Thank you for the introduction. It’s a pleasure to be here. And sure, go ahead.
Joanne: Okay. So, the first question is rather general. What is stereotactic radiosurgery or SRS, and what is stereotactic body radiotherapy or SBRT?
Dr. Germano: So, both of them—stereotactic radiosurgery and SBRT—are based on a very precise way to deliver radiation, whereby the radiation goes to the target, and there is minimal spilling over to adjacent tissues. Stereotactic radiosurgery typically refers to one through five fractions given to a lesion within the brain, whereas stereotactic body radiotherapy is used to describe a similar approach for a lesion that is located outside of the brain. So, if you have a lesion in the spine, you can treat it with one through five fractions, and that will be called SBRT. This is totally different than other radiation modalities that also use similar equipment, but then the radiation is not really meant to be focused on the target. It is more widespread to also include the surrounding tissues.
Joanne: Thank you. That’s a really helpful intro to SRS and SBRT. In any case, I wanted to know if there are any challenges associated with SRS and SBRT, and if yes, how can medical practices and hospitals seek to overcome those obstacles?
Dr. Germano: So, the word obstacles is one that I really don’t like very much. I prefer to talk about challenges. I think that when I teach my trainees, fellows and residents about radiosurgery, I like to compare it to flying—I’m not a pilot, but still, I really think that the concept of radiosurgery is like flying a big aircraft. And what does that mean? It means that there’s really no room for errors, and it means that safety is incredibly important. So, clearly, when you fly an airplane, you want to go from point A to point B, that’s the goal. But you want to go from A to B without crashing. So, with radiosurgery and SBRT, it’s the same thing.
You want to treat that patient, but you also need to ensure that there is safety and safety measures are involved. And to me, just like in aviation, one of the most important of the safety aspects is twofold. Number one, that there is a rehearsal. We call it a QA process prior to each case. And number two is that you never fly solo. There is always a co-pilot. And this is why at our institution, we always have a neurosurgeon and a radiation oncologist to do this together. Not because we don’t trust each other. It’s the opposite—because we depend on each other to ensure that safety is there.
Joanne: Why should medical practices and hospitals that don’t have SRS and SBRT tools consider integrating those types of tools into their treatment options?
Dr. Germano: Well, there are many advantages for the patient. I think that—as shown throughout the literature we have published and other centers have published—the cure rate of brain metastasis, spine metastasis with a single fraction or one to five fractions is much higher than when you use external beam radiation. In addition, to have a superior outcome, there is also the aspect for the patient of whether or not that is practical. It’s much easier for a patient to come in only once and have that one treatment than come in five or ten times for conventional treatment.
This is why I think many more hospitals include SRS and SBRT as part of their options. I’ve been part of the team here since 2015, and I can tell you that over the past seven years, I’ve noticed that there has been a growth in hospitals, even small hospitals, that now provide SBRT and SRS as part of their portfolio just because of what we were discussing—because they need to ensure that the patient needs are fulfilled. The patients now are very well educated, and they know what gives the best outcome, and they also care about the practicalities of the treatment.
Joanne: So, actually, you mentioned being part of the Novalis Circle Expert Group. I wanted to dig into that a little bit more. What is your role within Novalis Circle, and why should a medical institution consider becoming Novalis certified?
Dr. Germano: So the concept of the certification, again, if we go back to the comparison with aviation is because we, the people that are endorsing this field, really feel strongly about the safety aspect and the staying up-to-date aspect. So, we felt that if we established a community, a peer-reviewed community that can provide some guidance, some input, it would make the centers feel more comfortable. And perhaps there is also some, you know, strength that is gained by the review. The review is one day onsite and then remote, and there are some comments that are given to each center.
Those comments can really help the center reach the next level or realize that perhaps there has been a slight change in the way in which things have been done over the past three years or so. So, I think that it could really be beneficial for the entire community because ultimately, what we want with SBRT and SRS is to give the best possible treatments to all patients. To me, it doesn’t matter if it’s in my center or in another center, as long as we all feel that the goal is to do the best we can.
Joanne: So, it’s all about kind of moving toward the future, which actually leads me to my last question. Looking back, what are some of the major things that you’ve seen change in the field of neurosurgery and radiosurgery in the last three to five years? And what do you hope to see more of in the future?
Dr. Germano: So, the software has been improving over the years, and the version that we have now it’s clearly much more superior than it used to be two or three years ago—for instance, the possibility of fusing multiple images and the possibility of treating multiple metastases with just one isocenter. I mean, all those are updates and upgrades that the community and industry have been working hand in hand to provide us with, so that ultimately also results in faster and safer treatments.
I think that as we move toward the future, we will see more of those improvements along the lines of software, and really making this even simpler for people that are starting on the learning curve. So, just to go back again to five years ago, or seven years ago, whatever you want. I think that at that time, the centers that were starting really had a pretty steep part of the learning curve. Now that we established a community, now that the software is faster and a little bit more intuitive, I think that that steep part of the learning curve could be much shorter.
Joanne: That sounds really promising and provides a good future outlook. In any case, those were all of my questions for you today. So again, thank you so much for taking the time out of your busy schedule to do this interview and inform everybody and explain SRS and SBRT a little bit more.