Q&A: Specialist says neuro-oncology needs more awareness, funding, research

Neuro-oncologists must grapple daily with precarious brain tumors that are often masked by common symptoms such as a headache or seizure.

As reported in a Lancet Neurology study funded by the Bill and Melinda Gates Foundation, researchers found that central nervous system cancer incidences and mortality increased between 1990 and 2016. Despite this increase, however, the subspecialty has not received significant additional support or funding.

CNS tumors require highly specialized and complex treatment, making the field of neuro-oncology even more challenging as physicians work to diagnose and treat brain and spinal cord neoplasms.

Healio Neurology spoke with Ashley Love Sumrall, MD, FACP, a section chair of neuro-oncology at the Levine Cancer Institute, about the work of neuro-oncologists and what challenges they experience in their subspecialty.

Healio: What are the main types of cancer that neuro-oncologists treat?

Sumrall: There are over 120 types of primary brain and spinal cord tumors. Some are malignant and some are not. They may affect infants, children or adults. Although nonmalignant tumors are the most commonly seen, neuro-oncologists spend most of their time caring for malignant tumors such as gliomas. Glioblastoma (GBM) is the most common of the high-grade gliomas, representing about 50% of the malignant tumors.

When I went into neuro-oncology, I was amazed at how many different kinds [of cancers] there were. Some are incredibly rare; you may see one in your whole career. The most common thing we see on the nonmalignant side would be a meningioma, which is oftentimes a nonmalignant tumor. Those are often handled by a neurosurgeon, and they don’t need us. That’s your least aggressive tumor.

The most common that we see, unfortunately, is GBM. It’s obviously an incredibly devastating tumor. I’ll often talk to patients about it as a spectrum of disease because we know more about the molecular classification of GBM than ever. We’re a little bit smarter now about what different subtypes will do. But, still, it’s terminal for almost everyone.

Healio: How specialized is the field of neuro-oncology?

Sumrall: We pretty much stick to the brain and spinal cord. And those tumors are both complex in management and classification. As we’ve done more work in tumor profiling, we’ve also learned there are different subtypes. You can predict the severity of the disease or, if you find a rare subtype, you can use a specific therapy for it. By treating only those specific cancers, you can stay as up to date as possible.

While any oncologist can treat brain cancer, there are about 200 neuro-oncologists in the U.S. who have completed additional training in neuro-oncology. Given the complexity of the field (both the scientific and the clinical aspects), we spend most of our time treating patients with cancer that affects the brain and/or spinal cord. In addition to treating cancers that start in the nervous system, we also treat tumors that have spread from other sites, such as breast cancer or lung cancer.

Healio: How often is multidisciplinary treatment used, where neurologists or neurosurgeons may be involved in the care plan?

Sumrall: We work with different subspecialities. When we have patients who come in with a tumor that is causing a difficult seizure disorder, we will often involve the neurologist and epilepsy neurologist. They can do some brain mapping and go into surgery with the surgeon, and the procedure will manage the tumor but also treat the seizures. That’s one of the coolest things that is done in kids and adults. We often treat a simple seizure disorder, but if there’s anything too complicated, we rely on our neurologist to help us. I have some patients with complex headaches, and they will see a headache-trained neurologist to help with that.

In another area, if a patient’s brain tumor is affecting their motor skills, they may have some spasticity and we may need a neurologist to inject Botox (onabotulinum toxin A, Allergan, an AbbVie company)or do a neuromuscular evaluation. Neurologists become subspecialized, also. It has become challenging.

One of my favorite parts of practicing neuro-oncology is the collaborative nature. Each week, our multidisciplinary team meets to review cases. This team includes neurosurgery, neuroradiology, neuropathology, radiation oncology, physiatry, medical oncology, pediatric neuro-oncology, neuropsychology, genetic counselors and nurses.

Healio: What is the breakdown of pediatric vs. adult patients?

Sumrall: I only treat adults and older adolescents. I’m grateful that we have a team of pediatric specialists at our center. Some neuro-oncologists chose to treat children, also. Brain tumors are the most common solid cancer in people 19 years old and younger. Survival for children with brain tumors is better than that for adults.

There are differences in brain tumors in each population. Children can get brain tumors that are very survivable. There is a special subtype that often occurs in patients in their 20s. I have a clinical trial open for that. It is a fascinating tumor.

Healio: What are the main treatment modalities available in neuro-oncology – and have there been any breakthroughs in recent years?

Sumrall: We continue to try new therapies and enroll in clinical trials, but the basic framework of our treatment is unchanged from 2005. First, patients need a maximal safe resection of the tumor if feasible. If malignant, most patients will go on to receive radiation to the brain (and/or spinal cord) and chemotherapy. We also use targeted therapies such as monoclonal antibodies.

In 2011, tumor treating fields were FDA-approved for the treatment of recurrent GBM. We are able to use immunotherapy in a limited fashion for rare tumors such as CNS lymphoma. Otherwise, immunotherapy has been very disappointing for brain and spinal cord tumors. The pandemic has slowed brain cancer research, unfortunately.

Healio: What are the greatest unmet needs in the subspecialty?

Sumrall: We are desperate for more therapies that can cross the blood-brain barrier and get into the nervous system. We have an urgent need for trials for patients with primary and metastatic brain and spinal cord tumors. For years, patients with metastatic brain tumors were excluded from clinical trials. This has finally started to change due to significant advocacy work. We also need more options for supportive care for our patients, including therapies to help with recovery from radiation to the brain and neurocognition. In addition, patients in rural areas need better access to specialists. I am hoping that telehealth will remain available.

Neuro-oncology is often something people don’t understand or appreciate. Traditionally we’ve been left out of funding. We need more money. We need more attention. We need more scientists working on it. It’s very difficult to get these drugs and therapies into the brain and spinal cord, so we need to work on better delivery options for them.

Reference:

GDB 2016 Brain, et al. Lancet Neurol. 2019;doi:10.1016/ S1474-4422(18)30468-X.