The Emerging Field of Neuro-oncology

The complex nature of tumors of the central nervous system (brain and spine) have given rise to a subspecialty known as neuro-oncology. It’s a still relatively new and uncommon discipline, and was not in place at UConn Health until the arrival of Dr. Kevin Becker in the summer of 2019. Dr. Becker joins Carolyn and Chris to explain his role as a neuro-oncologist and the advantages a neuro-oncology program offers both to patients and to the advancement of medicine.

(Dr. Kevin Becker, Carolyn Pennington, Chris DeFrancesco, August 2020)

Transcript

Chris: You have a brain tumor. Now, what? Imagine the fear and uncertainty with hearing those words. Today on the Pulse we talk about it with a specialist, from any emerging discipline.

This is the UConn Health Pulse, a podcast to help you get to know UConn Health and its people a little better, and hopefully leave you with some health information you’ll find useful too.

With Carolyn Pennington. I’m Chris DeFrancesco. Now a few years ago, UConn Health partnered with Duke to establish a brain tumor collaboration to give patients access to the most advanced care and innovative clinical trials. Building on that, UConn Health recently established neuro-oncology program. There are a relative few neuro-oncologists in the region. And one of them is with us today.

Carolyn: Yes. And today we welcome Dr. Kevin Becker, who recently joined UConn Health to establish a neuro-oncology program here. Dr. Becker, thank you for joining us.

Dr. Becker: Thank you so much.

Carolyn: I’m betting a lot of people out there probably don’t know what neuro-oncology is. Can you tell us what is it that you exactly do?

Dr. Becker: Sure. It’s a discipline within neurology and oncology. A lot of the neuro-oncology folks are neurologists trained then in fellowship, although some are medical oncologists who then train in a fellowship for neuro-oncology, the idea behind the discipline, and it’s a relatively new discipline, it’s a discipline where we treat patients with primary brain tumors, tumors of the spinal cord, complications from systemic chemotherapy, and metastatic disease.

Chris: Now what happened before the neuro-oncologist arrives? How does medicine treat brain tumors without a neuro-oncology program or without someone like you to kind of oversee and coordinate?

Dr. Becker: The expertise of neuro-oncology is really second to none. It’s a difficult, very difficult health condition to have, and you really need an expert who’s aware and familiar with tumors of the brain and the spine to treat this. Typically a patient will present with some sort of new symptom, a seizure or headache, or some sort of neurologic deficit. They then will have imaging and something might be found on the MRI. Now, initially if it’s medical physicians who are treating, initially they’ll treat in a very specific, standardized way. However, on the other hand with neuro-oncologists, we actually understand both the quality of the tumor that we’re dealing with, the aggressiveness of what the tumor is, and how to manage that tumor. So we actually see ourselves as sort of quarterbacks for patients with brain tumors.

Carolyn: I was going to say, it sounds like it’s really a team-based approach. I mean, you have to be dealing with a lot of different specialties.

Dr. Becker: Excellent point. I think the most important thing about my job is it’s not a singular person that takes care of these patients. The, the fundamental need is to have a group, a division of people that work together hand in hand, to treat these patients. And that’s absolutely critical. And that includes everything from the neurosurgeons, the radiation oncologist, the neuropathologist, but also mid level providers are important, nurses, palliative care, and even sometimes psychiatry.

Carolyn: Oh really?

Dr. Becker: Oh yeah.

Carolyn: Interesting.

Chris: And that’s to deal with the uncertainty of a diagnosis like this? Or everything that you’re gonna need to go through in order to treat it or manage it?

Dr. Becker: Excellent question. One of the things that makes neuro-oncology somewhat unique is that unlike if you were to have a systemic tumor, a lung cancer or pancreatic tumor or something like that, the problem with tumors of the brain and/or the spine, but mostly the brain, is that oftentimes the patients themselves have lost some level of independence and they’ve lost some level of cognition, and oftentimes there’s a requirement for intense family involvement, intense support. And so maybe to some degree, more than other disciplines within medical oncology there’s a really strong need for a multidisciplinary approach to these patients. And it’s, to be very frank with you, very much I’m treating patients, as much as I treat the patient themself, I’m actually also treating the family members. And the most important thing I do — and I say this when I first meet a patient when I first see them in clinic, usually after their operation and I’m going to discuss the diagnosis with them and then the approach to management — believe it or not what I’m actually doing, not just establishing a relationship with the patient, because that is important obviously, but it’s actually believe it or not establishing relationship with the family.

Unfortunately a lot of these tumors are fatal, and what ends up happening is a lot of these patients end up not being able to make decisions for themselves. So the relationship between the neuro-oncologist and the neuro-oncology team with the family members is absolutely critical and paramount.

Chris: That’s a kind of an underrated portion of patient care that we often hear about what comes to elder care.

Dr. Becker: Yes.

Chris: But here’s another application for it.

Dr. Becker: Absolutely, and I think it’s the very specific thing that makes neuro-oncology unique. I think unlike medical oncology — yes, you do have to support the family as well — but a lot of times at the end of life it’s me talking with the family members. And you want to have a relationship where they know you, they know you personally, they may know my kids, they trust, what you have to say, they trust that you know the patient and that’s absolutely paramount. Because at end of life, these are critical, critical decisions. And it oftentimes is the family members or next of kin that are making these decisions.

There’s an extraordinarily important reason to be cognizant from the moment you meet a patient, of understanding who they are getting to know who they are, the family, but then also quality of life. There’s many different ways to treat patients. All patients have different ideas about what quality of life is. And I think one thing that is somewhat unique to me, and I think there is other oncologists that do it as well, but I do spend a significant period of my time forging relationships with these patients in addition to managing the chemotherapy and the radiation and those kinds of things.

Carolyn: Now you keep saying neuro-oncology is so unique. Like how unique are we talking here? How many are there of you out there?

Dr. Becker: That’s a great question. Certainly in the region, very few. There’s localized areas where there’s higher concentrations, Boston, New York City, that kind of thing, but in between there’s very few, very few. And in Connecticut at this point now there’s only four or five of us that are specific to neuro-oncology. There’s other areas, including north of us in Vermont and New Hampshire — well, New Hampshire does have one, but there’s none in Vermont at all — and Massachusetts, in the Western part of the state, there isn’t any, either.

Chris: Over the course of the first several months you’ve been here, have you observed people coming from relatively far away to seek care from, like you mentioned areas in New England where there’s no such thing as a neuro-oncology program, are people finding their way here? Because of that?

Dr. Becker: Yes, we’re seeing patients coming from both my old practice, down South, in new Haven, as well as we’re seeing patients that come from Massachusetts, Rhode Island and even sometimes New York.

Carolyn: Is a part of that too that some people are interested in clinical trials that we have here?

Dr. Becker: Correct, it is. And at this point, right now, we’re developing this collaboration with Duke, which is going to be a very unique collaboration. At this point, Duke does not collaborate with any other institutions formally. This will be a formal collaboration. And the idea behind that is Henry Friedman, who is at Duke and the director of the brain tumor center, they have a lot of institutional trials that are not available nationwide, including the polio vaccination trial that’s ongoing right now. There was a “60 Minutes” piece on that, as matter of fact. And so we will be getting, in the near future, we’re going to be getting some of those trials that are not going to be available nationwide, whatsoever. They’re not going to be available at other places around the state. It’s only going to be us.

Carolyn: How did that come about? Did you know Dr. Friedman?

Dr. Becker: I knew of Dr. Friedman, actually, Ketan Bulsara, the chief of neurosurgery here at UConn Health, he actually trained down at Duke, knew Dr. Alan Friedman and Henry Friedman very, very well. And that’s how he forged this relationship.

Carolyn: Excellent.

Chris: Can you talk a little bit about what your longterm vision is? You’ve only been here relatively few months, neuro-oncology, new specialty to us at UConn Health. You’re here to kind of get that program up and running. What do you kind of see is your short-term and long-term vision for how that all comes together?

Dr. Becker: I think the first thing to say is long-term and, and what my vision actually for the program is to become a major referral center for innovative clinical trials and specialized neuro-oncology care. And I see that in the setting of a strong group of people that we call ourselves a division. This again, involves multiple, multiple disciplines. And it’s something where, you know, through tumor board, through discussions, formally and informally, we give the best care that we can to these patients.

In the short term, right now really what it is, is actually building the practice itself. Prior to me coming here to UConn Health, there was not a formal neuro-oncology program. It was actually managed by medical oncology, but now that there’s this niche of neurooncology we’re now able at UConn to offer something that has not been available before. And it’s actually a very unique thing, just again, because neuro-oncology is such a specialized field.

Carolyn: Well, it’s great that we have this niche now that’s for sure. But you can treat other things too, right?

Dr. Becker: I do. I’m also, I’m trained as a general neurologist, and I’m certified in general neurology, and then also in neuro-oncology, I’ve had fellowship training. What I do in times where I’m not seeing neuro-oncology patients, I help out with the general neurology program. I see patients there and all types of things, everything from headaches, dementia, post-concussive syndromes and so forth. I’m doing a lot of teaching. I do precepting three times a week. I’m giving lectures. Basically, I’m currently between three different groups. My primary appointment is in neurosurgery, but I am also in neurology as well as the cancer center.

Chris: And just as a distinction, you yourself are not a neurosurgeon, but you are closely tied in to the neurosurgical aspect of care.

Dr. Becker: Very important point. So as a neuro-oncologist, and this is something that is not usually well appreciated by a lot of different folks, but we’re very often involved in pre-surgical planning. I am not a surgeon, but I actually help out very often with the surgeons as to what they will do as far as an approach, whether it’s a biopsy, whether it’s an attempt at a full resection. This also has to do with what’s the neurologic exam, what’s the performance status, and those kinds of things.

Chris: I’d be interested to know, in your experience, not necessarily here at UConn, but when you have people come in with brain tumors or spinal tumors, how old are they generally, or can this strike it pretty much any age? Where do you see most of that?

Dr. Becker: Simply put, it can strike at any age. It can strike in kids, and those are very specific type tumors, and in adults as well. Generally though, the majority of what we see in neuro-oncology, the most common tumor, is a glioblastoma. And that right now, currently throughout the United States, the average age for somebody developing a glioblastoma is approximately 52 to 53. So it’s usually people who were in their middle age. For people with low-grade gliomas, which is another type of brain tumor that’s less aggressive than a glioblastoma, that age is younger. It’s usually in the late 30s to 40s.

Carolyn: Is it usually just due to genetics or is there a reason for these tumors?

Dr. Becker: Outstanding question. So the first thing I will say is, nobody really knows for sure. There is inherited syndromes where you were predisposed to having brain tumors. Secondly, anybody who’s exposed to significant ionizing radiation is at risk for developing brain tumors. And that includes folks like who were at Chernobyl. I had three patients who were from Chernobyl as a matter of fact, who had thyroid cancer and brain tumors. People who have had leukemia as children and then got whole-brain radiation, I’m seeing those folks and they have secondary tumors related to the radiation.

So that’s the group that we generally tend to see. My practice really, for the most part is generally the ages of 30 and up.

Chris: Dr. Kevin Becker, UConn health’s neuro-oncologist, before we let you go, how do people find their way to you? Or just in general, are you the first point of contact for someone who might have a brain or spine tumor, or does it go through a series of other people before they find their way to you? When do you get involved?

Dr. Becker: We get involved in multiple different ways. We get involved both through direct referral from the emergency room. We then also get involved from inpatient consultation after they’ve been to the emergency room. And then we get involved after they’ve had surgery and the neurosurgeons call us and say this is what we’ve got, can you please see this patient in the outpatient setting?

You know, Chris, another thing I’d like to say is, is as much as we talked about brain and spinal cord tumors, I think another very key part of our practice is helping the medical oncologist manage their patients who have metastasis to the central nervous system. And that is something that many of the medical oncologists are able to do that, but we give that added level of expertise. In addition, we oftentimes see patients from the medical oncologist who have complicated neurologic syndromes, syndromes that may or may not be related to their cancer, but that they’re sent to us to evaluate. And that provides an additional support system to them.

Chris: Excellent. Well, Dr. Kevin Becker, it sounds like UConn Health, and Connecticut as a state and new England as a region, is very fortunate to have you here able to offer that care.

That is the time we have for today and for Dr. Kevin Becker from the UConn Health Division of Neurosurgery, the Department of Neurology, and from the Carol and Ray Neag Comprehensive Cancer Center, and probably other things that we’re not mentioning, for Dr. Kevin Becker and Carolyn Pennington, I’m Chris DeFrancesco. Thank you for listening to the UConn Health Pulse. Be sure to subscribe so you can catch us next time, and please share with a friend.