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Surgically Based Clinical Trials for High-Grade Gliomas — Bringing the Laboratory to the Operating Room

By Tumor, Tumor SeriesNo Comments

For patients with aggressive, high-grade gliomas, clinical trials offer access to new experimental therapies studied for their effectiveness. Traditionally, clinical trials have been broken into three phases. Phase 1 clinical trials assess the safety of a new treatment. Phase 2 studies involve more patients and evaluate the efficacy of the treatment. Phase 3 studies are designed to compare the novel treatment to a proven treatment to validate its effectiveness further.

While most clinical trials for high-grade glioma patients study systemically administered chemotherapies managed by a neuro-oncologist, some high-grade glioma clinical trials are now surgically based. In these trials, tumor surgery plays more than its usual cytoreductive role. Examples of surgically based clinical trials include:

  • Trials in which biological information is obtained through the surgery;
  • Trials in which a therapy is derived from the surgical tissue; and
  • Trials in which the surgeon delivers a therapy at the time of the procedure.

The first example of obtaining biological information through the surgery consists of phase 0-like “window of opportunity” clinical trials, first in human studies in which a small number of patients are given a drug for a few days before surgery. Blood is drawn regularly before and during the surgery to obtain pharmacokinetic and pharmacodynamic information, which helps determine how quickly a steady-state concentration of the drug within the tumor is achieved under the prescribed dosing regimen. Cerebrospinal fluid is obtained during surgery to determine whether the agent’s intracranial penetration achieves a steady state after a similar time as occurs systemically. Tumor tissue is analyzed to measure drug levels in the enhancing versus non-enhancing tumor, with levels often 3-4 times higher in the former than the latter, underscoring the difficulty of treating the non-enhancing tumor with systemic chemotherapy. Tumor tissue can also be analyzed for levels of the drug’s target protein and its downstream mediators to determine whether the drug affects the intended target in tumor tissue.

The second example of surgically based clinical trials typically involves immunotherapies in which a vaccine is developed from tumor tissue. The vaccine can be peptide-based — in which an immunostimulatory peptide-like heat shock protein is combined with tumor peptides — or a cellular vaccine in which immune cells like dendritic cells taken from the patient are primed with tumor peptides and then returned to the patient to provide antitumor immunity.

The third example involves the surgical administration of cellular, viral or pharmacologic therapies. These can be delivered into craniotomy walls after resection or directly into the tumor without resection. The advantages of delivering the therapy into craniotomy walls include combining the benefit of cytoreductive surgery with the therapeutic injection. In contrast, the disadvantages of delivering the therapy into the craniotomy walls include the reflux of the agents back into the resection cavity. Needle delivery into the tumor avoids reflux into the resection cavity, but reflux up the injection tract or adjacent cavities from previous surgery must be accounted for. The lack of cytoreductive surgery means needle delivery may be best for smaller focal tumors. Needle delivery into the tumor can be accomplished via direct needle delivery or convection-enhanced delivery involving infusion through a catheter along a pressure gradient over hours or days.

Neurosurgeons play a critical role in designing and developing surgically based clinical trials for high-grade glioma patients. Many of these trials have developed from neurosurgeon-scientists’ basic science research in laboratories using preclinical animal models. There is hope that these trials will lead to discoveries that meaningfully impact the prognosis of patients diagnosed with high-grade gliomas in the future.

Editor’s Note: We hope you will share what you learn from our posts. We invite you to join the conversation on Twitter by following @Neurosurgery and @NSTumorSection and using the hashtag #TumorSeries.

Manish K. Aghi, MD, PhD, FAANS
UCSF Dept. of Neurological Surgery
San Francisco, Calif.

December 1, 2022
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Increasing Patient Access to Stereotactic Radiosurgery through Innovation

By Brain Tumor, Tumor, Tumor SeriesNo Comments

Neurosurgery supports and welcomes transparent physician-industry interactions to foster healthy relations and spur innovative device development to benefit patients. Within the specialty of neurosurgery, there are numerous examples of just such benefits, including increased access to stereotactic radiosurgery (SRS). SRS is a treatment that delivers radiation to precise targets in the brain, such as tumors, while minimizing injury to adjacent areas.

As part of the ongoing Neurosurgery Blog Tumor Series, Deborah L. Benzil, MD, FAANS, FACS, interviewed Stefan Vilsmeier, the CEO and founder of Brainlab. Mr. Vilsmeier discusses why he founded the company and how his software and hardware have increased neurosurgical patient access to SRS. Mr. Vilsmeier observed that many institutions created homegrown radiosurgery systems, but there were no commercially available options.

Brainlab created an innovative software and hardware for performing SRS to provide greater treatment access through standardization. Taking it a step further, Brainlab offers the Novalis Circle, a user group to ensure quality, and Novalis Certified Accreditation Program to promote the delivery of radiosurgery at a level of efficacy and safety commensurate with the highest standards of clinical practice.

The interviews are available here and on Neurosurgery Blog’s YouTube channel.

Part I: What is stereotactic radiosurgery?

Part II: Dr. Benzil’s interview with Mr. Vilsmeier

Editor’s Note: Ethical interactions between industry and health care professionals are essential to strengthening patient trust in the health care system. The Open Payments system, also known as the Sunshine Act, is a federal program that collects information about the payments drug and device companies make to physicians and teaching hospitals. The data the Centers for Medicare & Medicaid Services collect is published annually.  

We hope that you will share what you learn from our posts. We invite you to join the conversation on Twitter by following @Neurosurgery and @NSTumorSection and using the hashtag #TumorSeries.

October 27, 2022
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Brain Tumors, Drug Development and Neurosurgeons: Ending the Losing Streak

By Brain Tumor, Tumor, Tumor SeriesNo Comments

For many neurosurgeons, years of training and technical refinement culminate in safely removing a patient’s brain tumor. We dedicate our careers to shepherding people past this inflection point, but the patient journey does not end there. For those with malignant tumors, our surgical heroics are quickly unraveled by tumor recurrence. Theoretically, adjuvant medical therapy should firewall patients against this reality; however, as we all know, no drug today provides much security to brain tumor patients. Our specialty is uniquely positioned to do something about this. Drug development is no longer the sole domain of oncologists, and some of the most impactful drug studies live in our operating rooms.

Conventional clinical trials are exercises in tremendous faith: an educated guess matches a patient to a new drug, followed by months of therapy (and side effects), ending with an MRI that provides, at best, an indirect measure of putative drug effect. For neurosurgical oncologists, Phase 0 and window-of-opportunity clinical trial paradigms offer a different take: brief, presurgical exposure to the experimental therapy, followed by a tumor resection that allows for direct measurement of drug penetration and target modulation in the patient’s own tissue. If the drug proves its worth in the patient’s tumor, the patient can remain on the drug long-term. In other words, safe and rapid quantification of drug effects in the end-user without sacrificing the one commodity all malignant brain tumor patients have in short supply — time.

It was nearly 20 years ago that the Food and Drug Administration last approved a new drug capable of extending high-grade brain tumor patients’ lives. Let that sink in for a moment, and allow yourself to question everything about it. This 20-year losing streak we are all living through is not happening for lack of effort or expertise. We are all aware of the unique challenges facing brain tumor drug development:

  • Poorly-predictive animal models;
  • Unclear tumor driver mutations;
  • Poorly brain-penetrant drugs;
  • Insufficient translational science funding;
  • Small market size; and
  • Patient risks from aggressive treatment.

These realities, and our accompanying track record, suggest that current systems governing oncology drug development should make way for a new paradigm — accelerated early-phase clinical trialing that quickly identifies and prioritizes drugs that deliver on their promise and, with equal analytical ruthlessness, eliminates those that do not.

Understanding the varied dimensions of drug development is a tall order for any specialty. But decades ago, ours made a concerted effort to expand the neurosurgeon-neuroscientist footprint. Today, an entire generation of us are as fluent in the laboratory as in the operating room. Drug development is our next frontier. For neurosurgeons like myself who are engaging in it, each patient’s operation has become a beginning instead of an end.

Editor’s Note: We hope you will share what you learn from our posts. We invite you to join the conversation on Twitter by following @Neurosurgery and @NSTumorSection and using the hashtag #TumorSeries.

Nader Sanai, MD, FAANS
Barrow Neurological Institute
Phoenix, Ariz.

September 6, 2022
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Neurosurgical Oncologists: Pushing the Field Forward

By Neuro-oncology, Tumor, Tumor SeriesNo Comments

The role of neurosurgical oncologists in the laboratory is more important than ever. The emergence of targeted therapies and immunotherapies has shown us that we are at an inflection point for cancer care. We are on the verge of gaining new insights into the causes of cancer and identifying novel pathways and potential new targets. The next-generation research tools available to us now yield unprecedented amounts of data and afford a granularity far beyond what our predecessors could have imagined. While we have historically made substantial contributions to neuro-oncology, our continued participation in the laboratory at this pivotal moment remains crucial.

Today we have access to tissue and can provide unique clinical insights to focus research efforts on the most critical aspects of cancer biology. Furthermore, we can translate our findings from the laboratory to the clinics. In addition to running traditional Phase I, II or III clinical trials with companion correlative studies, concepts like Phase 0 studies are now allowing us to forego mouse and animal studies to explore the mechanism of action of our therapies directly in patients. Phase 0 studies use only a few doses of a new drug in a very small number of people. By design, these studies allow us to examine tissue procured from the operating room and directly study the effects of the drug of interest. Neurosurgical oncologists’ role is central to this process.

Given these basic and translational studies, a team approach is required. While we celebrate being a “triple threat,” neurosurgeons must be careful to avoid practicing and researching in a vacuum — running experiments in isolation risks generating insular findings. The most important questions in oncology require the input of an array of talented individuals with diverse expertise. In addition to working with our colleagues in neuro-oncology, radiation oncology, neuroradiology, neuropathology and biostatistics, among others, we must adopt a culture of diversity, equity and inclusion. Diversity will ensure success. Leadership and learning to work in teams is also a core skill set that needs to be valued and taught to make progress. Our path forward, growth and success depend on this.

It is essential to acknowledge the circumstances that threaten the future of a neurosurgical oncologist. As medicine changes, protected research time is considered more of a luxury as institutions face pressure to consolidate and cut costs. As most compensation models are based on productivity, there is a subsequent bias towards valuing clinical productivity over research accomplishments. In addition, with reduced resident work hours, residents are seeking to augment their clinical experience by doing fellowships during their research years. To ensure that we continue to train neurosurgical oncologists, we must actively promote and value research with a concerted effort to foster the next generation of surgeon-scientists. Research is what will drive the field forward, and we risk sacrificing innovation and progress if we forego this.

National Institutes of Health (NIH) funding has become increasingly challenging to obtain. While neuro-oncologists have successfully received funding, 26% of all R01s awarded to neurosurgeons are in neuro-oncology — the paylines remain in the single digits. As mentioned above, to do more, we need to increase our impact by applying for grants as a multidisciplinary team. As an objective indicator of the magnitude of team science, the highest funded neurosurgery department in 2019 received about $18 million in NIH funding, while the highest funded neurosciences program received about $49 million and the highest internal medicine program received about $216 million in NIH funding.

The awards’ size has not grown even if one successfully obtains funding. We are experiencing the stark reality of dramatically rising research costs in setting fixed grant awards. At a departmental level, with decreasing reimbursements for clinical work, departments have less and less funding to carry over to fund academic efforts. As a result, we need to work creatively with industry and philanthropy to ensure that research output keeps pace with the available technologies.

We live in exciting times — we can gain greater insights into tumors than ever before. Not only are we learning more about tumors, but we are also seeing therapies affecting the natural course of advanced diseases that would, in some cases, have been deemed untreatable only a decade ago. We are now moving towards team science, but in parallel, we are also facing threats, and the classic physician-scientists are becoming endangered. We must continue to protect, value, and participate in research. The lives of our future patients depend on it.

Editor’s Note: We hope you will share what you learn from our posts. We invite you to join the conversation on Twitter by following @Neurosurgery and @NSTumorSection and using the hashtag #TumorSeries.

 

Michael K. Lim, MD
Department of Neurosurgery, Stanford University
Stanford, Calif

July 19, 2022
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Improving the Field of Neurosurgery through Brain Tumor Advocacy

By Brain Tumor, Tumor, Tumor Series, White HouseNo Comments

Working with patient advocates is important for neurosurgeons and neurosurgeons in training. While neurosurgeons help patients through clinical work and conduct innovative research to advance treatment options, advocacy can have an outsized impact on patients across the U.S. Neurosurgeons who participate in patient advocacy gain a better understanding of the priorities of patients, their families and those who care about them.

As a member of the National Brain Tumor Society (NBTS) board of directors, I have had the opportunity to better understand the concerns and priorities of patients dealing with brain tumors and their caregivers. This helps me educate the broader patient population about brain tumor neurosurgery, clinical trials and what my institution offers. NBTS, its Informed in 30 educational program and virtual meetings with brain tumor community members have changed how I communicate with patients, including discussing treatment options and clinical trials. I have learned a great deal about how I can become a better neurosurgeon and think we would all benefit from such education, thus improving our delivery of patient care.

Patient advocacy can do much more than an individual neurosurgeon scientist can to attract research funds to the field. As an individual, I can only apply for so many grants. Patient advocates, tapping into the power of patient stories, can influence lawmakers, friends and families to provide funding for research to benefit the field of neurosurgery and neuro-oncology. NBTS annually disburses approximately $2 million to researchers from across the country. By participating in this process, I can have a hand in steering the direction of not just my lab but that of researchers across the country. In this way, I can encourage rigorous and innovative research that acknowledges the reality of this challenging disease and promote the critical need for neurosurgeons to be involved in clinical trials.

Patient advocate groups like NBTS can have an outsized impact on public policy and, importantly, serve as a platform for patients, caregivers and brain cancer medical providers to have a voice on critical issues facing our cause to ultimately eliminate these diseases and reduce disease burden. While I can call my senator as an individual to advocate for policy changes needed for our field, a group like NBTS has the resources necessary to make long-term relationships with lawmakers across the country, raising the critical needs of their constituents. Like the AANS/CNS Washington Committee, NBTS understands the needs of its volunteers and advocates. They combine the power of all of these individuals to encourage our representatives in Washington to address our concerns.

Every year, NBTS holds the Head To The Hill event (#Head2Hill), where brain tumor patient advocates descend upon Washington, DC, in person or virtually, to present a united front on key issues for the community. While increased federal research funding is a priority every year, directly impacting neurosurgeon-scientists, this year, NBTS also focused on extending telemedicine rules created during the COVID-19 pandemic. I participated in Head to the Hill in May. It was a wonderful experience working side by side with other brain tumor advocates from Georgia on these critical issues. Additionally, through NBTS’s Research Roundtable Program, I have been able to bring expertise to regulatory policy with the Food and Drug Administration in workshops and meetings on clinical trial design and endpoints.

Patient advocacy can also lead to rewarding and one-of-a-kind opportunities in one’s career. An exciting example is my recent opportunity to introduce President Joseph R. Biden, Jr. to unveil the extension of the Cancer Moonshot initiative. This initiative was established in 2016 by then-President Barack Obama to support cancer research and progress in treatment and care.

At its launch, the Cancer Moonshot set forth three ambitious goals: accelerate scientific discovery in cancer, foster greater collaboration, and improve data sharing. On Feb. 2, President Biden announced additional steps to “reignite” the Cancer Moonshot initiative to “ending cancer as we know it” by halving the number of cancer deaths in the U.S. in the next 25 years. Leaders from NBTS had a hand in crafting the initial Cancer Moonshot and sat with me at this prestigious event. Together, I am confident we will make real change for the brain tumor community and someday find a cure and better quality of life for our patients.

I would strongly encourage other neurosurgeons to establish relationships with patient advocates in their fields. My time working with NBTS has been an invaluable tool to improve the patient care that I deliver, improve research in the area of brain tumors and have a direct impact on public policy.

Editor’s Note: We hope that you will share what you learn from our posts. We invite you to join the conversation on Twitter by following @Neurosurgery and @NSTumorSection and using the hashtag #TumorSeries.

Edjah K. E. Nduom, MD, FAANS
Emory University School of Medicine, Department of Neurosurgery
Atlanta, Ga.

May 27, 2022
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Cross-Post: Brain Tumors in Children

By Brain Tumor, Pediatrics, Tumor, Tumor SeriesNo Comments

From time to time on Neurosurgery Blog, you will see us cross-posting pieces from other publications that are worthy of sharing with our readers. Since we are in the middle of our focus series on tumors, we wanted to bring attention to an article published in The New England Journal of Medicine (NEJM) on May 19. Alan R. Cohen, MD, FACS, FAAP, FAANS, discusses recent changes to the classification and management of brain tumors in children. In 2021, the World Health Organization introduced changes in brain tumor taxonomy, emphasizing molecular diagnostic features. These changes reflect the trend of assigning diagnostic categories based on genetic features that, in many cases, drive prognosis and offer potential targets for treatment.

Brain tumors are the leading cause of death from cancer in children. Tumors of the central nervous system (CNS) account for 20% of childhood cancers and are second only to leukemia in frequency. Recent diagnostic and therapeutic advances have improved survival and quality of life for many children with CNS cancers. Sadly, however, the prognosis for many children with brain tumors remains poor.

Click here to read the full NEJM article.

To learn more about Dr. Cohen’s work as a pediatric neurosurgeon and how he uses humor (and Elvis) to bring joy to his patients and their families, check out this oldie but goodie from Good Morning America.

Editor’s Note: We hope that you will share what you learn from our posts. We invite you to join the conversation on Twitter by following @Neurosurgery and @NSTumorSection and using the hashtag #TumorSeries.

Alan R. Cohen, MD, FACS, FAAP, FAANS
Department of Neurosurgery, Johns Hopkins University School of Medicine
Baltimore, Md.

May 23, 2022
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University of Miami Increases Neuro-Oncology Collaboration and Mentorship Through Innovative New Fellowship Program

By Brain Tumor, Tumor, Tumor SeriesNo Comments

Neurosurgery has a long history of mentorship through a trainee’s dedicated time under a more experienced surgeon’s tutelage. Surgical training has long been considered a more advanced form of apprenticeship, mastering a skill under a more experienced practitioner’s guidance. In this tradition, the Sylvester Comprehensive Cancer Center — part of the University of Miami Miller School of Medicine — has launched an International Neuro-oncology Scholars Program (INOSP) that allows neurosurgery trainees to join internationally renowned brain tumor experts in other countries to increase their experience.

The goal is to enhance education and facilitate multi-institutional collaboration. The INOSP program is made possible by a generous gift from a grateful donor family. The plan is to support four traveling rotations each year.

Charles Teo, MD, IFAANS, left, with neurosurgery fellow Daniel Eichberg, MD.

“INOSP represents a unique resource offered to our fellows to visit and learn from world-renowned experts in neurosurgical oncology,” said neurosurgeon Ricardo J. Komotar, MD, FAANS, FACS. He continued, “The goal of the program is to enhance further their neurosurgical training so that they may be able to translate these techniques to our patients. With this international collaboration, we ultimately hope to improve clinical outcomes and enhance surgical education.”

The inaugural recipient of INOSP was neurosurgery fellow Daniel Eichberg, MD, who spent two weeks in Sydney, Australia, learning from highly accomplished neurosurgeons Charles Teo, MD, IFAANS and Michael Sughrue, MD, at Prince of Wales Hospital in Randwick, Australia.

“The opportunity to learn minimally invasive keyhole approaches for complex brain and skull base tumors in one-on-one training sessions from two of the most experienced neurosurgeons in these techniques was a powerful experience and augmented my skillset for cranial neurosurgery,” said Dr. Eichberg.

Dr. Sughrue and Dr. Teo have developed the world’s most advanced technology for mapping the brain’s functional and structural connectivity, which may be markedly abnormal in patients with brain tumors. Providing a better understanding of an individual’s connectome — a map of the brain’s overall connectivity — may critically impact brain tumor surgical outcomes by minimizing postoperative deficits, predicting recovery and maximizing the amount of tumor that can safely be removed during surgery.

Furthermore, this brain mapping technology uses machine learning and artificial intelligence techniques to guide non-invasive transcranial magnetic stimulation (TMS)-based neuro-interventional rehabilitation to improve postoperative brain tumor patients’ strength and speech deficits.

As a result of the international collaboration fostered by INOSP, Sylvester and the University of Miami Department of Neurosurgery will partner with the Sydney team in the Glioma Connectome Project. This endeavor seeks to learn how gliomas cause the brain to reorganize its connectome and initiate a TMS Neuro-interventional Rehabilitation prospective clinical trial.

“Not only are we now able to give our neurosurgical fellows access to additional world-renowned brain tumor experts and each of their unique skills, but we are also seeing that these new international relationships lead to groundbreaking global collaborative research and enhanced clinical trials that will continue to allow us at Sylvester to be able to provide the most advanced and world-class brain tumor treatments possible to our patients,” said program co-director Michael E. Ivan MD, MBS, assistant professor of neurosurgery.

Ashish Shah, MD; Alexis Morell, MD; Ricardo J. Komotar, MD, FAANS, FACS and Christopher A. Sarkiss, MD

Additionally, in 2019, the AANS/CNS Tumor Section, in conjunction with the CNS Foundation, created the International Observership Program, which will allow an Argentinean neurosurgeon to participate as an observer for three months at the University of Miami in the division of surgical neuro-oncology. The rotation focuses on all central nervous system tumors, with participation in clinic, conferences, surgery, and consultations.

Editor’s Note: We hope that you will share what you learn from our posts. We invite you to join the conversation on Twitter by following @Neurosurgery and @NSTumorSection and using the hashtag #TumorSeries.

Ricardo J. Komotar, MD, FAANS, FACS
University of Miami Miller School of Medicine
Miami, Fla.

May 10, 2022
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Socioeconomic Status and Short-term Glioblastoma Survival: Does it Make a Difference?

By Brain Tumor, Tumor, Tumor SeriesNo Comments

The recent COVID-19 pandemic highlighted socioeconomic differences in health care access detrimental to the outcome, including a per capita excess mortality highest among the Black and Latino population. The prognostic role of socioeconomic factors for patients diagnosed with glioblastoma multiforme (GBM) has been hotly debated. GBM is the most common malignant primary brain tumor in adults and affects 3.3 percent of pediatric brain tumor patients. The disease has made headlines in recent years with the diagnosis of high-profile political figures such as President Biden’s son Beau Biden and the late Sens. Ted Kennedy and John McCain. Significant advances in surgical and adjuvant treatments for this disease have had a positive impact on short-term survival. Yet, there is a still-very-low five-year survival rate in adults, around 5.5 percent. As new therapeutic approaches develop, prolonging short-term survival coupled with high quality of life remains a priority when caring for patients with GBM.

Our medical predecessors named the deadliest brain tumor “glioblastoma multiforme” long before the field of molecular biology was established. Yet, they already recognized the complexity of this disease and its heterogeneity by calling it multiforme. We now know that its molecular features are numerous. Different “clusters” of cells with different molecular signatures pose a significant challenge in developing patient-specific therapies even within the same tumor. In addition to differences in each tumor’s molecular signature, other environmental factors might contribute to the speed of disease progression.

 

A recent study collected data from 28,952 patients diagnosed with GBM from the publicly available National Cancer Institute’s Surveillance, Epidemiology, and End Results (SEER) cancer registry. The authors found that socioeconomic status affected overall short-term survival, and patients with higher median household incomes had significantly higher short-term survival. Additionally, patients owning a private insurance plan had lower short-term mortality than those who were Medicaid recipients. When considering the ethnic background, Asian/Pacific Islander patients had the highest short-term survival. Black patients with GBM had the highest mortality due to non-GBM related causes, such as cardiac and stroke events.

The above study also corroborated that Non-Hispanic White (NHW) represented 80 percent of the patients affected by GBM, while they only represent 60 percent of the U.S. population. The higher incidence of GBM in the NHW population corroborates previous studies. Multiple factors can contribute to this discrepancy, including the possibility that this increased percentage is biased by health care access disparities. Other factors that may contribute to such discrepancy could be related to differences in tumor genetics, highlighted by the glioma genome-wide association study (GWAS).

Providing the best care to all patients regardless of ethnic background and socioeconomic status remains a high priority in all medical and surgical disciplines, including neuro-oncology. Moving forward, additional studies are needed to deepen our understanding of the impact on the outcomes of such factors. Further clarifying and identifying differences in health care access, socioeconomic factors, and racial diversities will allow us to develop new and more focused strategies to fight GBM and co-morbid non-GBM related causes of death in our patients.

Editor’s Note: We hope that you will share what you learn from our posts. We invite you to join the conversation on Twitter by following @Neurosurgery and @NSTumorSection and using the hashtag #TumorSeries.

Isabelle M. Germano, MD, MBA, FAANS, FACS
The Mount Sinai Medical Center
New York, NY

March 11, 2022
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Neurosurgical Oncologists as Champions of Diversity, Equity and Inclusion

By DEI, Neuro-oncology, Tumor SeriesNo Comments

Recent events of systemic discrimination have led to national introspection on the importance of tolerance and diversity. The tragic killing of George Floyd in May 2020 was a sentinel event that raised awareness of the pervasive nature of systemic discrimination and served as a significant impetus for positive change. This was a clear reminder that we still face substantial challenges to tolerance and equal treatment for all as a society. It is also a unique opportunity to reflect on our common purpose as humanity.

In the immediate aftermath of Mr. Floyd’s death, many organizations issued statements reaffirming their commitments to promoting and advancing diversity through anti-discriminatory policies and initiatives. On their part, the American Association of Neurological Surgeons (AANS) and the Congress of Neurological Surgeons (CNS) released the following joint statement:

As a profession, we in neurosurgery aim to promote the highest quality of patient care and advance the specialty of neurosurgery and neurosurgical education while espousing the values of integrity, leadership, excellence, and professionalism. As organizations and as a profession, we are committed to inclusion and diversity within our neurosurgical community. As neurosurgeons, we are committed to providing the highest quality of care to all segments of our society. Indeed, our principles are only relevant to the extent they apply to the most disadvantaged in our society.

The Society of Surgical Oncologists (SSO) also released a similar statement:

The Society of Surgical Oncology condemns racism and violence in all forms. We recognize racism as an underpinning to health disparities, and recent events serve as a clarion call to all of us that there is a need to do more than what we do on a daily basis — provide the best cancer care to individual patients regardless of race, ethnicity, gender, sexual orientation, or socioeconomic status.

Diversity requires the core elements of equity and inclusion. Equity requires deliberate, fair and just treatment of our patients and colleagues irrespective of their background. Inclusion requires a conscious effort in thoroughly engaging diverse patients and colleagues in all aspects of the care we deliver and the decisions that govern our care through tolerance. Through equity and inclusion, our colleagues and patients feel respected and valued.

A firm commitment to the core elements of diversity is critical to the impactful delivery of neurosurgical care to society’s most vulnerable members. In treating life-threatening disorders of the nervous system, neurosurgeons can positively impact patients from all works of life. To render the best possible care, neurosurgeons should understand the diverse patient population they serve in the context of race, gender and ethnicity. When we deliver neurosurgical care in an atmosphere of tolerance and understanding, we serve as role models to those who look up to us.

Neurosurgical oncologists are integral to cancer care in the central nervous system, one of the most critical battle lines in the fight against systemic cancer-related morbidity and mortality. Despite advances in oncology, there is still a considerable disparity in cancer care. Racial and ethnic minorities and lower socioeconomic patients are disproportionately impacted by cancer. As part of the multidisciplinary management of diverse patients with central nervous system tumors, neurosurgical oncologists perform surgeries, stereotactic radiosurgery and clinical trials. Therefore, it is imperative for neurosurgical oncologists to incorporate diversity-informed clinical decision-making approaches to positively impact cancer patients who are affected by health disparities. Moreover, neurosurgical oncologists should be mindful of the barriers and challenges to recruiting underrepresented minorities into clinical trials, given historical precedence of mistrust. Identifying, acknowledging and addressing such barriers would undoubtedly enhance participation.

From a workforce perspective, organized neurosurgical oncology should strive to reflect the diverse cancer patient population they serve. Concerted efforts are needed to diversify the pool of neurosurgeons. We should strive to attract, train and mentor neurosurgeons from under-represented groups into the subspecialty of neurosurgical oncology. If we embrace diversity efforts, we should also establish benchmarks to assess progress in this journey. Beyond diversity in its members’ composition in general, neurosurgical oncology should strive to include diverse membership and leadership in committees. Such diversity efforts will strategically position us to address the neurosurgical oncologic needs of a multifaceted society uniformly.

As a profession, we should strive for the ideals of diversity and its associated tenets of equity and inclusion. Neurosurgical oncologists are in a unique position to understand and reduce health disparities. Our patients deserve that from us. We should never forget that our future is only as bright as the future of the patients whom we serve.

Editor’s Note: We hope that you will share what you learn from our posts. We invite you to join the conversation on Twitter by following @Neurosurgery, @AANSDiversity and @NSTumorSection and using the hashtag #TumorSeries.

Arnold B. Etame, MD, PhD, FAANS

Moffitt Cancer Center

Tampa, Fla.

February 2, 2022
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Introduction to Tumor Focus Series: Bringing “Better” to Our Patients in Multiple Ways

By Tumor, Tumor SeriesNo Comments

Neurosurgery has historically been a uniquely wide-ranging and varied specialty. Unlike other specialties that focus on a particular organ system or body region, neurosurgery is quite literally a “head-to-toe” specialty dealing with the brain, spinal cord, peripheral nerves and the other organs intimately related to the nervous system. Neurosurgeons classically had to be experts in a wide variety of surgical procedures and disease processes. As medical knowledge and technology have advanced, neurosurgeons have evolved with medicine to become experts in particular disease processes, leading to a reorganization of neurosurgery into sub-specialty disciplines.

Over the years, the Neurosurgery Blog has partnered with various neurosurgery subspecialty sections to provide an update on the state of the subspecialty, highlight current issues, add to the conversation and portray their concerns to a non-specialized audience. Today’s neurosurgeon must be facile in many different areas — both medical and non-medical. As medical care and health care delivery have grown increasingly complex, neurosurgeons must wear several hats: surgeon, team-member in multi-disciplinary care teams, teacher, scientist and advocate.

We partnered with the AANS/CNS Joint Section on Tumors for the following series of blogs. Under the guidance of Tumor Section chair, Jason P. Sheehan, MD, PhD, FAANS, and AANS/CNS Washington Committee representative, Michael A. Vogelbaum, MD, PhD, FAANS, members of the section came together and produced a sweeping overview of ongoing topics:

  • Arnold B. Etame, MD, FAANS, leads us off with a piece about diversity in neurosurgical oncology. Isabelle M. Germano, MD, FAANS, FACS, then tackles disparities in access to care and outcomes in brain tumor patients.
  • Ricardo J. Komotar, MD, FAANS, FACS, reports on efforts in education and collaboration on an international scale. Edjah E. Nduom, MD, FAANS, speaks to brain tumor advocacy, providing an overview of the outward-looking direction of some of our efforts.
  • Michael Lim, MD, FAANS, and Nader Sanai, MD, FAANS, bring us two pieces highlighting the ability of neurosurgeons to translate discoveries from the lab into patient care and back again and how neurosurgeons contribute to drug development in the increasingly complex fight against brain tumors. These pieces are complemented by an article by Manish K. Aghi, MD, PhD, FAANS, updating the role of neurosurgeons in clinical trials and research in neurosurgical oncology.

Academic publishing, the Journal of Neuro-Oncology, and the dissemination of scientific results, particularly in the era of the COVID-19 pandemic, are at the center of a piece by Dr. Sheehan and Christopher P. Cifarelli, MD, PhD, MMM, FAANS, FACS. Dr. Vogelbaum presents “A Neurosurgical Perspective on Multidisciplinary Care for Patients with Brain Tumors,” emphasizing the team-based nature of neuro-oncology care today.

In the era of a worldwide pandemic and an increasingly complex care delivery environment, neurosurgeons are playing more and more roles in delivering better care to our patients. This is especially true in the field of neurooncology. We hope that these blogs inspire you to join the efforts of this important field. The amount of work that the members of the section and the authors, in particular, put into these issues outside of patient care is astonishing and deserves credit!

Editor’s Note: We hope that you will share what you learn from our posts. We invite you to join the conversation on Twitter by following @Neurosurgery and @NSTumorSection and using the hashtag #TumorSeries.

Clemens M. Schirmer, MD, PhD, FAANS, FAHA
Chair, AANS/CNS Communications and Public Relations Committee
Geisinger
Wilkes Barre, Pa.

January 20, 2022
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