A 48-year-old woman was diagnosed with stage 4 adenocarcinoma of the lung, which soon metastasized to her brain. During treatment and follow-up care for the brain lesion, a tumor was found in her cervical spine.
Although she was asymptomatic, she sought a consultation with the Duke Center for Brain and Spine Metastasis, a new interdisciplinary program that brings together expertise of specialists in the Departments of Orthopaedics, Neurosurgery, Radiation Oncology, Medical Oncology, Interventional Pain, and Palliative Care, and the Duke Cancer Institute to design personalized treatment plans for patients and provide care as a team.
“This patient’s story was sad in several ways,” says C. Rory Goodwin, MD, PhD, a neurosurgeon and spine surgeon who specializes in spinal oncology and consulted with the patient. “Not only was she diagnosed with stage 4 metastatic lung cancer right after having her first child, two of her family members were also diagnosed with lung cancer around the same time and one had recently died.”
The patient wanted to be proactive in treating the tumor, hoping to avoid the numbness, bowel and bladder problems, and paralysis that she knew could eventually arise without treatment. She also wanted to avoid hospital stays and emergency department (ED) visits and preserve her quality of life as much as possible, particularly as a new mother.
“Patients with metastatic spine tumors usually have frequent ED visits due to pain, fractures, paralysis, and other complications,” says Sergio Mendoza-Lattes, MD, a spine surgeon and co-director of the Duke Spine Center, who is also a member of the Brain and Spine Metastasis Program. The majority of pain syndromes are musculoskeletal, of which the spine is the most common location. These emergency visits are usually followed by prolonged hospitalizations and complex care. “At the Brain and Spine Metastasis Program, we work with patients at earlier stages before they have a health care catastrophe that sends them to the ED.”
With the patient’s goals in mind, a tumor board comprising spine surgeons, neurosurgeons, oncologists, pain management specialists, and pathologists discussed the strategy for her treatment. “We agreed that if we could do something relatively small now, we could prevent future problems,” says Goodwin. “She wasn’t having any problems with pain, walking, or function, and our game plan was to keep her in that state.”
Goodwin performed resection and fusion surgery to remove the patient’s tumor and stabilize her spine. Genomic testing was performed to tailor treatment based on her molecular profile—one of the advanced therapies offered through the program. “We look at the mutated entities that are associated with tumor growth, then use systemic therapies to treat the specific cancer, such as osimertinib for treating non-small-cell lung carcinomas,” Goodwin explains.
The patient started radiation therapy two weeks after the surgery, and her care continued to be monitored through the program providers. During one of her follow-up visits she told Goodwin that she was unsure about attending a family wedding because of her health, but he encouraged her to go and enjoy the event.
“I assured her that we had gotten to the tumor early and there was no reason for her to let the disease take over her life. Because we were proactive we’ve already helped her meet the goal of preserving her quality of life,” he says.
Mendoza says there are four key pillars of Duke’s Brain and Spine Metastasis program:
- Early intervention. Seeing patients in the early stages of their diseases can lead to less aggressive surgeries and the use of novel treatment protocols.
- Interdisciplinary approach. The collaborative nature of the program provides multiple perspectives and an array of personalized treatment options which are carefully coordinated by our program’s Patient Navigator, Natalie Ashley.
- Rapid access to care. Patients can often see a specialist within 72 hours, and often same-day or next-day, when they request an appointment. The Patient Navigator ensures continuity of care across disciplines and guides patients through the complex cancer care system.
- Standardization of care. Specialists use standardized scoring systems, protocols, and decision-making algorithms to decide on each patients’ care, and plans are made as a group, instead of being based on an individual specialist’s judgment.
“These principles didn’t exist until the program began, but they now represent a stronghold for Duke that few medical centers can offer,” Mendoza-Lattes says.