Comprehensive Programs Address Brain and CNS Metastases
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Central Nervous System Metastases Clinic
Andrew B. Lassman, MD, is Chief, Division of Neuro-Oncology and Co-Director of the Brain Tumor Center at NewYork-Presbyterian/Columbia. Guy M. McKhann II, MD, is Director of Awake Brain Mapping for Tumors and Epilepsy in Columbia’s Department of Neurological Surgery. Catherine A. Shu, MD, is a medical oncologist who specializes in lung and thoracic cancers.
These physicians are key members in the Central Nervous System Metastases Clinic (CNSMets), recently established to coordinate and advance the treatment of brain, leptomeningeal, skull base, spinal cord, and spine metastases. Under the auspices of Columbia’s Division of Neuro-Oncology, CNSMets grew out of the need to organize and focus the complex array of specialist expertise — neurosurgery, neurology, radiation oncology, medical oncology, palliative care, social work, neuro-radiology, neuropathology, molecular pathology, and complementary and alternative medicine among others — to address the many and varied challenges that can accompany brain metastases.
“Patients who have central nervous system — brain or leptomeningeal — metastases often need to see several different specialists on different days in different locations,” says Dr. Lassman. “Many of our patients are frequently dealing with physical disabilities and concurrent cognitive limitations making it difficult to navigate the numerous and varied appointments. Our program makes it logistically easier for patients to obtain care, including rapid access to appointments.”
The CNSMets Clinic utilizes a multidisciplinary and multi-tumor site approach that allows for high level discussion of unique cases and rapid planning of individualized, cutting-edge therapy for each patient.
“I think the key factor in this day and age is finding ways to optimize communication among physicians and with the patient,” says Dr. McKhann. “It is so important for patients with metastatic brain disease to have coordinated, multidisciplinary care where teams of experts are reviewing not just what’s going on in the brain, but what is happening in the body as a whole. Then you can integrate their treatment in the best possible way.”
The CNSMets Clinic takes place every Wednesday afternoon. Patients are first seen by a neuro-oncologist. Cases are then discussed at a multidisciplinary tumor board specifically for brain and spine metastases led by neuro-oncologist Teri N. Kreisl, MD. Dr. Kreisl and representatives from relevant specialties develop a consensus of opinion for a comprehensive treatment plan. Depending on the plan of care, patients may then meet with consultative specialists that same afternoon.
Among the immediate benefits of the tumor board, Dr. Lassman cites the team’s extensive knowledge of Columbia’s many ongoing trials to identify the one that is most appropriate for an individual patient. “This approach, where we are co-located together, can yield additional therapeutic options for the patient,” says Dr. Lassman. “Our goal is to apply new treatments that may lengthen life or improve quality of life. Sometimes that involves using standard technology in a new way. Through the tumor board, clinical trials and other research efforts that, without the tumor board mechanism, may not otherwise have been brought to light, are able to be shared and determined for their appropriateness for the patient.”
For Dr. McKhann and his surgical colleagues, the tumor board optimizes the process of coming to key surgical decisions. “The coordination of therapies with sensitivity in timing helps in the decision-making regarding employing open surgery, the Gamma Knife, often a combination of both, or no surgery at all,” notes Dr. McKhann. “For example, when timed with Gamma Knife procedures, the efficacy of some chemotherapy protocols is enhanced by increasing the permeability of the blood-brain barrier. Sometimes immunotherapy has proven more effective than chemotherapy and can be a factor in delaying or avoiding surgery. It’s also how symptomatic the patient is. If they’re particularly symptomatic, it will push them more towards surgery and away from the Gamma Knife. However, if it’s a single seizure and the patient is otherwise asymptomatic, and we already know this is clearly metastatic disease, then the Gamma Knife is going to make sense.”
“The CNSMets Clinic is a very unique, patient-focused experience that involves all specialties who participate in our tumor board,” says Dr. Shu. “Oftentimes the patient is on site and one or several of us may speak to the patient following our meeting. It makes good sense from the patient’s perspective having information right away from multiple sources. Instead of the patient going to four different clinics, we have four different specialties come directly to the patient. It is a very successful collaboration.”
“Even if I’m not treating the brain, it’s important for me to know what’s going on,” adds Dr. Shu. “For example, do I have to hold their chemotherapy? Are they going to be taken off any systemic steroids? The tumor board helps the medical oncologists stay in the loop about the patient’s brain disease and treatment updates that affect our role.”
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Brain Metastases Clinic
“Today, therapeutic advances are making it possible for patients with cancer to live longer and with better quality of life,” says David M. Nanus, MD, Chief of the Division of Hematology and Medical Oncology at NewYork-Presbyterian/Weill Cornell. “At the same time, however, higher survival rates have also been accompanied by a higher incidence of cancer spreading to the brain. Cancer cells are basically smart. Their goal is to grow, so they’ll find a new environment in which to grow. The brain acts like a sanctuary site for many treatments.”
“The Brain Metastases Clinic at the Weill Cornell Brain and Spine Center is a much-needed program for these patients,” adds Dr. Nanus. “They are provided with access to comprehensive care that promotes their physical and psychological well-being, while addressing the myriad clinical issues, including the toxic side effects of therapy, that accompany this diagnosis.”
The Brain Metastases Clinic provides comprehensive care to patients diagnosed with metastatic brain tumors and leptomeningeal disease. “A brain metastasis is a critical point in a patient’s cancer care,” says neurosurgeon Rohan Ramakrishna, MD, Director of the Brain Metastases Clinic. “I’ve seen the consequences of brain metastases on patients. It’s not the immediate aftermath; it’s what happens months and years following treatment and the problems they can encounter. The consequences of combinations of those therapies often are not managed in a proactive way. For example, patients can suffer chronic pain issues, depression, dementia, neurocognitive and rehabilitation issues, and spiritual concerns related to their own mortality.”
“Our multidisciplinary group includes not only neurosurgery, radiation oncology and medical oncology, but also psycho-oncology, a burgeoning field in this area, as well as palliative care,” continues Dr. Ramakrishna. “We have also incorporated an integrated health program that offers acupuncture, yoga, mindfulness, and meditation. We believe that integrative therapies that address the whole patient should be as important as any of the traditional therapies offered to control the patient’s brain cancer.”
Navigating a large healthcare system is particularly difficult for a patient with brain cancer. “Figuring out which doctor to go to and which appointments to schedule can be overwhelming,” says Dr. Ramakrishna. To that end, the program offers a program coordinator who answers 646-NYP-METS. The goal here is to spare the patient from having to call so many different physicians. The navigator will go through a questionnaire with the patient, determine their availability, and then put together a day of scheduled appointments. It’s concierge medicine that caters to the patient’s needs.”
Research is another component of the program. “Our goal is to study the impact of a comprehensive program like this on the well-being of our patients,” says Dr. Ramakrishna. “We do quality-of-life questionnaires with patients, each of whom is unique with different cancers and different systemic disease. We also plan to study how we can make radiation therapy less toxic on the brain. Neurocognitive decline happens after radiation, but it also happens in patients who have brain mets, period. Learning how to minimize the complications of neurocognitive decline, as a result of not only the disease, but also the therapy, is integral to our research strategy.”
Neuro-oncologist Rajiv S. Magge, MD, believes that the depth of expertise at the Brain Metastases Clinic allows physicians to tackle it from several directions. “Unfortunately, the brain is a place where metastases can potentially be shielded from systemic treatment,” says Dr. Magge. “We’re trying to focus on better treatments that may target metastases in the brain. Newer systemic treatments may get past the blood-brain barrier. These include immunotherapy, which has shown efficacy in treating brain metastases from specific cancers, especially lung cancer and melanoma.”
“With the advent of 3-D cross-sectional imaging and a better understanding of the natural history of cancer, we can focus our treatments more on the tumor deposits themselves,” says Jonathan P.S. Knisely, MD, Medical Director of Stich Radiation Oncology at NewYork-Presbyterian/Weill Cornell, Director of Neuro-Oncology in the Department of Radiation Oncology, and Associate Director of the Brain Tumor Center. “This enables us to minimize the dose of radiation delivered to normal tissue, while greatly increasing the dose of radiation to the tumor deposits.”
“With an MRI scan we can see precisely where a spot or spots are within the brain,” continues Dr. Knisely. “This allows us to map out exactly where the tumor is and where any normal tissues are that you don’t want to have irradiated. We can then treat that very small volume with very high doses of radiation that will often achieve a 95 percent control rate at one year’s time.”
“Managing disease that spreads to the brain is an area of study that is needed more and more today,” says Dr. Nanus. “It used to be that if you wanted to get a new drug for metastatic cancer, nothing was available in clinical trials. But now we have a number of trials that we are opening where there is a cohort specifically for patients with brain metastases.”
Drawing on his neuro-oncology and neurology background, Dr. Magge says, “I would like to be considered a resource — especially for the medical oncologist — to help manage and follow patients with brain metastases. We work with oncologists in coordinating management and helping decide which treatments — systemic therapy, surgery, and/or radiation — may be most effective.”
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