Brain Tumors: Multidisciplinary Approach to Treatment
Guest: Dr. Pierre Giglio - Neurosciences
Host: Dr. Linda Austin – Psychiatry
Dr. Linda Austin: I’m Dr. Linda Austin. I’m interviewing, today, Dr. Pierre Giglio who is Assistant Professor of Neurosciences and director of the medical neuro-oncology group here at the Medical University of South Carolina. Dr. Giglio, I understand that one of the things you’re doing that is so important and unique in this area is developing a team approach to the treatment of brain tumors. Can you talk a little bit about why that’s so important?
Dr. Pierre Giglio: Yes, certainly. One of the unique things about the group here at the university in treating brain and spine tumors is that it has to, certainly, be a multidisciplinary approach. You need, certainly, the surgeons for the initial surgery. You need the medical oncologists, or the neuroncologists, that would be me, to see the patients afterwards. You will need pathology for the interpretation of the tissue after the surgery. And, certainly, you need neuroradiology and radiation oncology to be working all as one unit. We have all these components in place at this point. So, I think that makes us, certainly, very unique in the area in terms of the multidisciplinary approach and having everybody available to treat patients in one program.
Dr. Linda Austin: So, the frustration that so many patients have oftentimes when they get a diagnosis of cancer, or, for that matter, anything, is are my doctors talking to each other? The doctors on your team certainly are all talking together. Now, your area is neuroncology. Can you describe, especially, what your role on the team is?
Dr. Pierre Giglio: The neuroncologist tries to put all the care together for the patient. One misconception is that the neuroncologist is there simply to administer chemotherapy to the patient. In fact, to some extent, he does play the role of a primary care physician for the brain tumor patient. And because care is multidisciplinary, there is a risk for the patient’s care to get fragmented. The neuroncologist has to make sure that the patient’s care gets very well coordinated and streamlined so that all the various aspects follow each other seamlessly. After the surgery, the patient, certainly, gets seen by the radiation oncologist if chemotherapy is needed and, after that, the patient gets follow-up care that he requires. All those aspects have to be taken care of by myself and, of course, the group of nurses in our clinic.
Dr. Linda Austin: So, let’s imagine a patient out in the community is diagnosed by their primary care doctor as having a tumor of the brain, would you be the first person, then, who would see the patient and then coordinate the tests and the studies from that point on?
Dr. Pierre Giglio: That is really what we would like to see happen in practically every case. From then on, I would coordinate care with the other members of the team. That’s correct.
Dr. Linda Austin: I understand you treat a variety of brain tumors. What are some of the different categories that you treat?
Dr. Pierre Giglio: So, certainly, tumors of the brain and spine can start within the brain and the spine. We refer to those as primary brain or primary spine tumors. We also see a fairly large number of patients, however, who have spread of cancer from other parts of the body to the brain and the spine. Those, of course, are secondary or metastatic cancers to the brain and the spine. We see a fair number, also, of complications of cancer affecting the nervous system. A typical one would be nerve damage, for example, or neuropathy from the administration of chemotherapy for other cancers, such a lung cancer or breast cancer.
Dr. Linda Austin: This is a very basic question. I know that sometimes patients are very confused when they hear that they have a brain tumor, so it’s important to underline that not all brain tumors are necessarily cancer but, nonetheless, have to be taken care of. How do you determine what kind of tumor a patient has?
Dr. Pierre Giglio: Clearly, before any treatment recommendations, there has to be, at the very least, a diagnostic biopsy. So, some tissue always has to be examined to determine what type of tumor it is, certainly, whether it started in the brain or came from other parts of the body and whether it is more in the malignant or more benign category. Clearly, the malignant ones need to be treated a little bit more aggressively and more expeditiously than the more benign ones. The benign ones, despite being slow-growing, also have to be followed very carefully and, in some cases, treated because the nervous system is different in that it has very tight confines. Even growth that is slow and slight may result in problems, actually, for these patients as well.
Dr. Linda Austin: The difference, then, being that a benign tumor is not likely to spread elsewhere, but it could still grow and crowd out healthy tissue in the brain, whereas malignant tumors are likely to spread to distant sites?
Dr. Pierre Giglio: The main problem with malignant brain tumors is that they grow very quickly. Their spread to other parts of the body, if they have started in the brain or the spine, is unlikely, so they don’t necessarily follow the same path that cancers in the body follow. They start in the brain. They often stay in the brain. The problem is, though, that they stay in the brain and grow very quickly within the brain. The benign ones, of course, grow more slowly. But, as you stated, they can cause a lot of problems simply by pressure effects over time.
Dr. Linda Austin: With the cancerous brain tumors, how do you go about making a decision about the kind of treatment a patient will have?
Dr. Pierre Giglio: One of the most important aspects, certainly, is the performance of the patient, his general condition, his state of health after the surgery, and so on. The other aspect, of course, is the tissue itself. A lot of these tumors now, the most common type of primary brain tumor is actually treated with a combination of radiation and chemotherapy. As I mentioned earlier, they have to be timed to be given together, and that has to be followed up with more chemotherapy, after that combination. Of course, that brings me, again, to the question of, what is the patient’s condition before treatment is started? Patients who are not doing well medically, of course, will not be expected to tolerate treatment very well. In those cases, we’ll have to hold off until they recover. But, really, for the most malignant brain tumors, the standard of care is chemotherapy and radiation together and then more chemotherapy after that.
Dr. Linda Austin: I have been so amazed by some patients. I’ve worked with some, as a psychiatrist, who have had brain tumors or metastases to the brain. There really has been a lot of progress in this area. There is hope for these patients that there was not, let’s say, 10 years ago.
Dr. Pierre Giglio: That is absolutely correct. I think one of the steps forward has been, certainly, the understanding that chemotherapy can, in fact, make an impact. The two major developments have been, first of all, the development of chemotherapies that make patients less sick than the chemotherapies that were available before. Secondly: the realization that the timing of chemotherapy administration is also important. Those two things have been key.
Looking towards the future, I think the important thing that is happening now is there’s a better understanding of how these tumors develop, and some of that work is being done here at our university. So, fundamentally, of course, the cure will come when we really understand that process completely.
Dr. Linda Austin: In another podcast, I want to talk about some of the research you’re doing in that area. Thank you so much for talking with us today.
Dr. Pierre Giglio: Thank you.
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