Interview with Dr. Nalin Gupta: Choosing the Safest Treatment for Pediatric Brain Cancer

Hear an audio interview with UCSF pediatric neurosurgeon Dr. Nalin Gupta discussing how advances in pediatric brain cancers are offering hope for children.

A Team Approach to a Good Outcome

Andrew Schorr:

Pediatric brain tumors are among the most challenging illnesses to treat. Joining us is an expert pediatric neurosurgeon and researcher to explain important advances that are extending survival and offering hope for children. It's all next on Patient Power.

Hello and welcome to Patient Power. I'm Andrew Schorr. This program is sponsored by UCSF Medical Center.

Well, imagine if you're told that your child has a brain tumor. Whether it's malignant or nonmalignant, it is serious business and, quite frankly, overwhelming and terrifying, so you want to get to experts in the field. Well, we have one with us, and that is Dr. Nalin Gupta, who is chief of pediatric neurological surgery at the UCSF Benioff Children's Hospital at UCSF Medical Center in San Francisco.

Dr. Gupta, I know you see it. Families come in, they're just terrified. Help us understand what we're dealing with. And I said earlier, malignant and nonmalignant, it's all serious, isn't it?

Dr. Gupta:

It is serious, and the message that I would like to give to parents and family members is that on one hand this represents a growth or a tumor in a vital part of the body, the brain or spinal cord, and in a child, which can affect that child's personality, their behavior and what they're capable of, so, there are a lot of issues related to just how that child is doing at that time and what impact that will have on the child's life.

The important message, I think, to give, is that often these kinds of tumors in children actually have very good outcomes, meaning that we can either treat these patients by surgery or other kinds of treatment, and a lot of these kids will have excellent survival. Now, that's not true with every type of tumor and that's not true with every kind of tumor in different locations, as well, but overall children do a lot better than adults do.

Andrew Schorr:

That's certainly an encouraging message. Now, help us understand, somebody went to the pediatrician with their child and they were told, oh, it's probably not, it's probably not, and then, lo and behold, it is, and then they come to you. So, when someone comes to a major center like yours, I imagine there is a whole team that gets together to try to assess what is the exact situation for that child.

Dr. Gupta:

That's exactly right. The complexity of treating these tumors comes with the fact that they can arise in different locations in the brain, and, for example, in one extreme, if a tumor is located in an area of the brain that we call noneloquent, meaning an area of the brain that is not actually that important for function, and it's a kind of tumor that we can remove surgically, then those patients will have surgery. We can remove that tumor, it's benign, and these kids are cured. And that's one end of the spectrum.

The other end of the spectrum is tumors that can arise in difficult parts of the brain. We may be able to remove all of it, but there's still a possibility of the tumor returning, and then the difficulty comes in choosing the right therapy that is appropriate for that kind of tumor. That can sometimes be chemotherapy, it can sometimes be radiation therapy, and it can be a combination of those.

And in children, where we have the other variable which plays a big role in our choice of what we do, and that's the age of the patient. So, we actually see brain tumors in little children as well, and so, if you have a 3 year old with a brain tumor the impact of our treatment on that child's development, it's going to be very substantial, and we have to keep that in our discussions or considerations with the group. And that's going to be a very different discussion than if we had a 14 year old or a 15 year old with a tumor in the same location.

Most large medical centers, like ourselves, have groups of individuals, oncologists, radiologists, pathologists, surgeons, who work together and discuss these in a collaborative conference like setting to try and get a consensus. There isn't always a right decision. There isn't always an only decision. The usual situation is that there's a palette of options, and we have to pick the one that we think is going to be acceptable to the family, that's going to minimize the risks and is going to have the best outcome possible.

Personalized Medicine for Brain Tumors

Andrew Schorr:

Now, we are in the age of precision medicine or personalized medicine. You do a lot of research there trying to understand the biology of tumors. How does that come into play in what you recommend as, maybe, a tailored treatment for that particular child?

Dr. Gupta:

Right now, what we use for — and people will hear about this, what's called the standard of care. The standard of care is a course of treatment that's been chosen, or selected, that's been proven to work. In other words, either through history or through clinical trials, we have tested these kinds of treatments, and they've been proven to work.

Right now, the standard of care for virtually all tumors, in fact, probably all tumors in humans, is what we called nonspecific or generalized therapy, meaning that if you have a tumor, lung cancer, breast cancer, you're going to get a choice of treatment that is really directed at all of these tumors as a group. And, for example, if you have a brain tumor in a certain location, you're going to get radiation therapy, you're going to get chemotherapy that we know is going to work for all of these tumors.

What we're testing now is really recognition of the fact that a tumor, the same tumor from one patient to another, is going to differ in certain ways in how they grow the genetics. And you can look at the tumor, it may look the same to the naked eye, but inside it's going to be functioning in a different way. And if you use the same agent, in some situations it will work great and in others it won't.

What we're trying to do, and I'll give you an example of one particular study that is now actually recruiting patients, is we want to test whether this approach of personalizing or tailoring treatment to a specific kind of tumor is actually better than just a generalized therapy. And we have to prove that it’s actually effective, because it's a lot of effort and it's more invasive for the patient, and because we need to get tissue in order to do the study.

There's a kind of tumor that arises in children, that's called a brain stem glioma. It's not surgically resectable because it's wrapped around a key part of the brain called the brain stem. Its outcome unfortunately is among the worst. Most of these kids will die within a couple of years, and we've really made very little progress in this tumor over the last two decades. The study that I'm leading along with Dr. Mark Kieran at the Dana Farber Cancer Institute, on the East Coast, is to take a small piece of this tissue, to examine it using a variety of laboratory tests, pathology tests, and then based on its profile is to treat it in one of four different treatment options tailored to which marker is present. And these are the exact same tumors on the scans and we would expect them to behave the same way, but the idea is to narrow, or provide a focused treatment for that. Is it going to work? We don't know, but this is one of the really first steps in that direction, in this area.

Brain Cancer Survivorship and the Risk of a Second Cancer

Andrew Schorr:

So the discussion with the family is, do we have a trial that we should talk to you about. Here are the treatments we're recommending. What are the short term effects of the treatment that we have to be mindful of? And I also understand that now, as in many cases, not all, children are living longer, you're starting to look at, how do we lower the risk of a second cancer. Tell us about that, too, cancer survivorship, if you will.

Dr. Gupta:

Yeah, so that's arguably one of the biggest challenges we have in the field, and the specific example I'll give you is actually the most common malignant brain tumor in kids, it is called medulloblastoma. It usually happens at the back of the brain. Initial therapy is surgery. Thirty years ago, before radiation was used, even if you took the whole tumor out surgically, almost always, the tumor would come back, and the patient would ultimately succumb to this tumor. And with the advent of radiation therapy, in which the whole brain and spinal cord receives a dose of radiation, the survival of these kids went from zero or nearly zero up to 50, 60 percent, in one step. And you can say well, that's an enormous achievement to reach that point. And by survival, it's really long term cure.

But the downside to that radiation in a child was really twofold. Number one was that this was a developing brain, and that brain was adversely affected — gets adversely affected by the radiation dose, and these kids ended up having a whole host of cognitive, endocrine, hearing difficulties that were permanent. The second issue is that radiation plus additional therapy, like chemotherapy, really has long term effects as well, and they increase the likelihood that you're going to have a second tumor arise, perhaps, decades later. And it's the survivors of these kinds of tumors that we're dealing with and having to treat.

A big focus in the field now is to try to reduce the radiation dose or substitute it with agents that don't cause those same long term effects, but we have to balance that against the simple truth that, even though radiation has negatives, it is for this particular tumor, one of the most effective therapies we have.

Advocating for the Child

Andrew Schorr:

So, Dr. Gupta, you are trying to push the envelope here and do better, and I understand your personal motto is Kids First. What do you mean by that?

Dr. Gupta:

Oh, to me it seems self-evident. I think, though, if you have to articulate it, I would say that you're really trying to put the interests of the child first and foremost. Obviously it's intertwined with the family and the parents in particular and what decisions they make, but sometimes the decision to do something, whether it be either to choose to do something aggressive or to do something, perhaps, not aggressive and let things take their course— it depends on what is right for the child.

The idea is that you choose something that is going to be for the best interests of that child. And sometimes — it gets busy, it gets complicated, and you lose — it's easy to lose focus on what the goal of everything is, and I've certainly been guilty of that, many times. And I think that we still have to keep in mind that this is a person, this is a child, this is a patient, and their interests — we have to be an advocate for their interests, and I think that's what that means.

Progress in Pediatric Brain Tumors

Andrew Schorr:

So, we have different tumor types in different places in the brain, different modalities that come together, but for someone listening and knowing the specific situation they're dealing with needs to be addressed of course, generally, are we moving in the right direction? Are we making progress?

Dr. Gupta:

Absolutely. I think that people tend to think that progress is measured in what we are doing today that we weren't doing yesterday or six months ago, and sometimes progress happens that quickly, and if you look at it in terms of what are we doing now versus six months ago, I think, you can get disillusioned. Oh, my god, we're doing the same as what we were doing last year. But, when I look at just my career or if I look at just, really, even the last 10 years, I think that what we're doing now is a lot more intelligent than what we were doing 10 or 15 years ago. And I think the outcomes of a lot of kids, with these tumors, now, compared to 15, 20 years ago, is markedly different and compared to 40 years ago, is dramatically different.

So, that's not solace for someone who does have a serious condition now, or child that has a serious condition now and we may not be able to say, well, okay, we can figure this out in the next six months, but I think that the path of progress has really been quite remarkable. If you look back over the last 30 or 40 years in diseases that were thought to be basically untreatable, universally fatal, we are able to provide results in long term survivors and very good quality of life for a pretty good number of them.

Andrew Schorr:

And I know when you have children visit you for follow up visits at the medical center and you see they're going on with their life, that must be very gratifying.

Dr. Gupta:

Oh, it is. It's fantastic. We definitely have kids that are now young adults, they're in college, they're doing their own thing. And, I’m not sugar coating it in the sense that some of them have some difficulties related to their initial treatment, but — the long term survivors, really often will make the very best of it.

The other thing that I will say is that kids are remarkably, remarkably adaptable to the things that happen to them, and it's perhaps just a question of that's the way they grow up, and that's what they're used to, but they adapt to those circumstances remarkably well.

Andrew Schorr:

Well, what comes through in this interview, for me, is hope, of course, an evolution of progress, and you're dedication personally, Doctor, to doing what's right for the kids who are your patients. Thank you so much for being with us, Dr. Nalin Gupta. We really appreciate it.

Dr. Gupta:

It's a pleasure. It's a pleasure speaking with your group.

Andrew Schorr:

Well, here we are on Patient Power connecting you with another leading expert which, hopefully, gives you the right information for you and your child.

I'm Andrew Schorr. Thanks for listening. Remember, knowledge can be the best medicine of all.

 

Reviewed by health care specialists at UCSF Benioff Children's Hospital.

This information is for educational purposes only and is not intended to replace the advice of your doctor or health care provider. We encourage you to discuss with your doctor any questions or concerns you may have.

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Phone: (415) 353-2986
Fax: (415) 353-2657

Pediatric Brain Center

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