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.
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Michael K. Lim, MD
Department of Neurosurgery, Stanford University
Stanford, Calif
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.
Arnold B. Etame, MD, PhD, FAANS