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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

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.