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The process of diagnosis and treatment planning

An Interview with Andrew Seidman, MD, Memorial Sloan-Kettering Cancer Center

Part 3: Diagnosis

 Musa Mayer: Let’s say that you and your patient are both quite concerned about the possibility she may have brain mets.  What would be your next step then?  

Andrew Seidman:  The next step is generally to get an imaging study of the brain.  My imaging study of choice, that has the greatest sensitivity and specificity, is generally an MRI scan of the brain.  Short of that, a CT scan of the head with contrast may often show brain metastases, but can possibly miss some smaller findings that only an MRI would be able to detect.

 

If a brain metastasis is found by imaging, the next step, depending upon the number of lesions and the location of the lesions, is to formulate a treatment approach.  The variables that can influence the approach to the treatment are numerous. They include the number of lesions, the size, whether there is mass effect (swelling), and also what the status of metastases is outside of the brain.  Are they well controlled?  Are they poorly controlled, with rapid progression in other critical organs as well?  So, there’s not one right answer for everybody. 

 MM:  At what point to you involve a radiation oncologist?  

AS: Typically, almost any patient with a diagnosis of brain metastases deserves to see a radiation oncologist.  It’s usually a component of the treatment, but not always.  There are situations with patients with isolated, solitary brain metastases might be best served by a craniotomy (surgery to remove the tumor) but often in that setting, radiation can play a complementary role.  So I involve a radiation oncologist early on.  Typically a radiation oncologist would be called within 24 hours of the diagnosis.  If the patient has any swelling or edema associated with the lesions, then we would institute corticosteroids to offer symptomatic benefit.  In patients who are going to need to undergo whole brain radiation, it’s often useful to have them on corticosteroids, because the radiation itself, in the short term, can actually induce some swelling and edema and steroids are used to help minimize that possibility.  

  

MM: Do you coordinate the care and make sure the different physicians are talking with one another? 

 

That’s a good point.  Typically, it would be the medical oncologist who tends to be the primary cancer care-giver who will call in the troops, so to speak, for the special expertise that’s needed in the management of the case.  So at least in my institution, if a patient needs to be admitted to the hospital, she would be admitted to a medical oncology service.  The radiation oncologist would see the patient as a consultant, and a neurologist would be called in often to do a meticulous and thorough neurological exam, more than most oncologists would do.  If there’s a consideration for surgery, then even a neurosurgeon would be called in.  But generally, the medical oncologist is the “quarterback” of the care. 

 MM: So it would be you who talks to the patient after you’ve heard from the doctors who examined her about their treatment recommendations? 

AS:  Well, the doctors who are being called in to consult will also often discuss what their opinions are about management with the patient.  Certainly, whoever is in the main care-giver role should be able to communicate a clear care plan, having discussed the management with the specialists who are called in.   If there are any mixed messages, if patients are hearing different treatment approaches from different consultants, then yes, it does fall into the lap of the medical oncologist to straighten it out. 

 

If a patient is being seen at one hospital, then they’re likely to be seen only by people called in by the primary care doctor.  But even in one hospital, there are numerous individuals who can walk in and out of the door—attending physicians, fellows, residents, people with different levels of training—and unfortunately there’s a potential to get mixed messages. Also, a complete evaluation when a patient has brain metastases sometimes requires further studies, for example, an MRI of the spine to rule out the possibility of either spinal cord or leptomeningeal involvement.  Sometimes, depending on the symptoms, a complete evaluation might also require other studies, such as a lumbar puncture, or spinal tap, to look at the spinal fluid.  Possibly, if there is seizure activity, even a study like an EEG (electroencephalogram) would be required.

 

So, it can all be very overwhelming, and sometimes the final treatment plan can take days to formulate, depending on the need to do all these other studies. 

 MM: Almost all the patients I interviewed said they experienced a sense of urgency, unless their brain mets were incidental findings and very tiny. Most of them said they felt like they barely had time to absorb what was happening.  

AS:  Yes, definitely. I think that patients often feel a sense of urgency coming from the health care team.  There are certain events that happen to cancer patients in general, and to breast cancer patients specifically, where we don’t like to see the sun rise and set too many times—for example, significant brain metastases that are causing many neurological symptoms.  Generally, we want to try to evaluate the patient, formulate a treatment plan, and institute that treatment plan—depending upon the treatment plan—at times within hours, but more commonly within a few days.  With people who have spinal cord compression, which is a different issue, often one wants to deliver therapy within hours, or at most a day. 

Interview continues in Part 4...