A Mind Shift in Brain Tumor Treatment
Changing the gold standard treatment for any disease is rarely a straightforward matter, especially when it runs counter to conventional wisdom. Just ask the folks who figured out that ulcers are caused by bacteria rather than spicy foods. Despite their evidence, it took nearly a decade for most physicians to alter their approach. Neurotologist Howard Francis and several of his colleagues hope their research into the best ways to treat acoustic neuromas won’t take nearly as long to gain widespread acceptance.
Francis’ paper, published in July in The Laryngoscope, looked at how a type of acoustic neuroma known as vestibular schwannomas were treated at Hopkins between 1997 and 2007. The traditional treatment approach, first developed at Hopkins in the 1920s by pioneering surgeons Harvey Cushing and Walter Dandy, had always been to excise the tumor.
“As clinicians, we often acquire and become attached to a particular ‘filter’ through which we see a disease and its management,” says Francis. “My filter led me and others to believe that surgery was the only methodology with which to address acoustic neuromas. We held on to that belief even in the face of growing information suggesting that this benign, slow-growing tumor could, in many instances, be monitored and not treated at all. There was also emerging evidence that stereotactic radiation therapy could play a role in treating some patients.”
More recently, patients have begun acting as a counterbalance, especially older patients who demand that doctors offer less invasive procedures or monitoring options in lieu of surgery.
It appears the surgeons are yielding. Francis’ study of 805 cases found that, over the study period, the proportion of cases managed initially by surgery dropped from 89.5 percent to 68 percent, while monitoring patients with follow-up scanning nearly tripled (from 10.5 percent to 28 percent). Recommendations for radiation, which never occurred at the beginning of the study, jumped to 4 percent by study’s end. Francis says the inescapable conclusion, at least at Hopkins, is “a significant shift in management of vestibular schwannomas over the last decade.”
He sees the trend away from surgery and toward radiation and observation continuing, noting that, from a collaborative viewpoint, nationwide there’s “less emotional schism now between surgeons and radiation therapists.” Using himself as an example, Francis has joined a growing number of skull base surgeons partnering with radiation oncologists to expand the spectrum of therapy available to patients. Surgery continues to be the firstline approach for large tumors and in individuals who desire aggressive management. Stereotactic radiation using the gamma knife “doesn’t eliminate or shrink the tumor, but it slows overall growth,” notes Francis. “It is therefore necessary to monitor the tumor to document growth before administering this treatment. If it isn’t growing, there’s no point in radiating.” Whereas one approach provides a cure, the other offers tumor control, which may be appropriate for smaller growing tumors in older patients.
The study’s findings confirm what Francis called “his hunch.” He had sensed in his own practice a mental shift, where surgery was no longer the automatic “go to” option for small acoustic neuromas. Now with another paper in the works that will look at how long physicians observe vestibular schwannomas before moving on—if at all—to treatment, Francis says, “we are seeing how new information, technology and attitudes are reshaping the gold standard for the benefit of our patients.”
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