Patient Going Strong Seven Years Past Brain Metastasis Diagnosis
Published
From the Duke Cancer Institute archives. Content may be out of date.
William Blake, 65, at his second home in the mountains of West Virginia
William Blake, 65, worked for the State of West Virginia for about 35 years in the toll division before taking early retirement in 2007 when he got sick with follicular lymphoma. He was treated at Charleston Area Medical Center (WV) and survived that cancer.
But when Blake was diagnosed four years later with a different type of cancer at the Beckley, WV, Veterans Hospital — metastatic melanoma to the brain — he was referred to Duke.
John Kirkpatrick, MD, PhD, the director of radiation oncology for The Duke Center for Brain and Spine Metastasis at Duke Cancer Institute and clinical director of radiation oncology at DCI, performed an image-guided stereotactic radiosurgery (SRS) procedure on Blake’s two brain lesions — a high-tech non-surgical therapy that delivers precisely-targeted high-dose radiation in one to five treatments, while preserving nearby healthy tissue.
Medical oncologist April Salama, MD, meanwhile, treated Blake with a course of ipilimumab, an immunotherapy that had just been approved that year for the treatment of advanced melanoma. When another lesion appeared in March 2012, Kirkpatrick “disappeared” that one as well.
“The prognosis was “We’ll do what we can, the mets are really small, and we caught it early,”” said Blake, who’s today making the most of his retirement.
While Blake has recently had some small localized melanomas and basal cell carcinomas removed in other areas of his body, there’s been no sign of cancer in his brain for seven years.
Brain metastasis survivor William Blake, 65, is enjoying his retirement, getting away on weekends to his cabin in the West Virginia mountains to read, hike, hunt, and fish, and spending more time with his wife and family and friends.
No Looking Back
Blake considers himself very fortunate. The percentage of patients who survive brain metastases beyond two years is traditionally less than five percent, but Duke is now seeing much better results than that. With treatment advances (primarily in surgery and radiosurgery) that offer excellent local control of brain metastases, coupled with lower rates of toxicity, an increasing number of patients are surviving well beyond that.
“We try to be realistic; I tell patients that there’s a lot of uncertainty with metastatic cancer, which is really one of the most difficult things in dealing with this disease, but that they should not look upon it as a death sentence,” said Kirkpatrick, who can recall a handful of patients with brain metastases who have lived more than a decade. “We don’t want to be Pollyanna, but on the other hand, you know, I’ve told enough people over the years that they will probably live six months to a year, and who very pleasantly surprise me by living a much longer period of time.”
After earning his doctorate in chemical engineering from Rice University in 1978, John Kirkpatrick, MD, PhD, made a career in Texas as an engineer and business manager in the chemical and plastics industry. But in 1995, he enrolled in medical school because he “wanted to do something that was really going to help people.” He found in radiation oncology a way to combine his engineering skills with day-in-day-out patient care. And he hasn’t looked back.
He explained that with each patient case he “plans for the worst and hopes for the best.” He’s seen the best, like William Blake’s case, and the worst.
Brain metastases can cause devastating symptoms that include headaches, seizures, vomiting, weakness, loss of vision, cognitive decline, and personality changes.
“We do our best to protect our patients’ brains by using the right surgery, the right radiation therapy, the right combination of drugs and the right supportive care so that those people are able to have a good quality of life and good cognition for as long as they can,” said Kirkpatrick.
Exponential Growth
Up to 30 to 40 percent of patients with solid tumors today can expect their cancer to metastasize to the brain. That’s because an increasing number of cancer patients are living longer due to better treatments — to the point where their primary cancer has a chance to spread to the brain.
Most common in patients with non-small cell lung cancer, breast cancer, and melanoma, brain metastases are also prevalent in patients with renal cell carcinoma (kidney cancer) and gastrointestinal cancers. However, any cancer can technically spread to the brain.
This rise in brain mets (metastasis) patients nationwide is driving more and more patients to seek treatment at Duke.
“The growth has been incredible. The number of patients being treated with stereotactic radiosurgery has grown 20 to 30 percent each year since 2002; from 10 patients in 2002 to more than 500 annually now,” said Kirkpatrick. “Our brain metastasis program is one of the biggest programs of its kind in the country. Our team of physicians, physicists, radiation therapists, dosimetrists and nurses does a very good job of treating patients really well when they come here — using the best available technology in surgery and radiotherapy — and in some cases bringing new anti-cancer drugs into the picture as well.”
For many people with lung cancer, the disease doesn’t stay confined to the lungs. Up to half of patients with non-small cell lung cancer, and as many as 80 percent of patients with small cell lung cancer, develop brain metastases throughout the course of their illness. These diagnoses can significantly affect quality of life, treatment options, and long-term outcomes.At Duke Cancer Institute (DCI), Laura Alder, MD, deputy director of medical oncology for the Duke Center for Brain and Spine Metastasis, is working to change how patients with brain metastases are represented in clinical research and, ultimately, how they are treated.Alder’s clinical and research career centers on two closely related priorities: lung cancer and brain metastases. After completing her fellowship at Duke, she joined the faculty and became deeply involved in multidisciplinary efforts to improve care for patients whose cancer has spread to the brain or spine.“Brain metastases have a huge impact on a patient’s trajectory,” Alder said. “They affect quality of life, treatment decisions, and outcomes in very meaningful ways.”Clinical trials often represent the most promising treatment option for patients with advanced cancer, offering access to therapies that are not yet widely available. However, Alder notes that trial eligibility criteria have traditionally been narrow.“There’s been a longstanding concern that patients with brain metastases wouldn’t do well on clinical trials or could confound the results,” Alder said. “As a result, many trials exclude these patients entirely.”To address this gap, Alder collaborated with a multidisciplinary group of researchers on a publication focused on improving clinical trial inclusion for patients with lung cancer and brain metastases. The work, published recently in Lung Cancer, builds on decades of research led by Paul Sperduto, MD, PhD, adjunct professor in the Duke Department of Radiation Oncology, who developed the Graded Prognostic Assessment (GPA).The GPA is a validated tool used to estimate survival in patients with brain metastases by accounting for factors such as age, performance status, disease burden, and tumor biology. For non-small cell lung cancer, the tool incorporates modern biomarkers, including genetic driver mutations, which can influence response to targeted immunotherapies.Paired with the eligibility quotient (EQ), which helps estimate conditional survival, these tools paint a more accurate and individualized picture of prognosis, one that challenges outdated assumptions.“What we see is that many of these patients actually have very good overall survival,” Alder said. “Our therapies are better, more precise, and more effective than ever before.”Alder said advances in imaging, MRI surveillance, and radiation techniques, such as stereotactic radiosurgery (SRS), also make it possible to closely monitor and manage brain metastases during treatment. These innovations further support the safe inclusion of these patients in trials.At Duke, efforts to improve clinical trial inclusivity extend beyond a single publication. Through the Duke Center for Brain and Spine Metastasis, clinicians and researchers regularly collaborate with pharmaceutical partners, advocate at national conferences, and engage in ongoing dialogue with industry leaders.“This has been a mission for many of us for years,” Alder said. “At every meeting, every podium, we’re making the case that these patients need to be included because that’s where the unmet need is.”Encouragingly, progress is being made. National organizations such as the American Society of Clinical Oncology (ASCO) and the European Society for Medical Oncology (ESMO), along with the U.S. Food and Drug Administration (FDA), have increasingly emphasized the importance of broader eligibility criteria in cancer trials.Alder hopes the framework outlined in the publication will be used prospectively in future trials, helping demonstrate that inclusion of patients with brain metastases is both safe and beneficial.“Our patients are living longer than ever before,” she says. “They deserve clinical trials that reflect the reality of their disease and give us the data we need to keep making progress.”
For many people with lung cancer, the disease doesn’t stay confined to the lungs. Up to half of patients with non-small cell lung cancer, and as many as 80 percent of patients with small cell lung cancer, develop brain metastases throughout the course of their illness. These diagnoses can significantly affect quality of life, treatment options, and long-term outcomes.At Duke Cancer Institute (DCI), Laura Alder, MD, deputy director of medical oncology for the Duke Center for Brain and Spine Metastasis, is working to change how patients with brain metastases are represented in clinical research and, ultimately, how they are treated.Alder’s clinical and research career centers on two closely related priorities: lung cancer and brain metastases. After completing her fellowship at Duke, she joined the faculty and became deeply involved in multidisciplinary efforts to improve care for patients whose cancer has spread to the brain or spine.“Brain metastases have a huge impact on a patient’s trajectory,” Alder said. “They affect quality of life, treatment decisions, and outcomes in very meaningful ways.”Clinical trials often represent the most promising treatment option for patients with advanced cancer, offering access to therapies that are not yet widely available. However, Alder notes that trial eligibility criteria have traditionally been narrow.“There’s been a longstanding concern that patients with brain metastases wouldn’t do well on clinical trials or could confound the results,” Alder said. “As a result, many trials exclude these patients entirely.”To address this gap, Alder collaborated with a multidisciplinary group of researchers on a publication focused on improving clinical trial inclusion for patients with lung cancer and brain metastases. The work, published recently in Lung Cancer, builds on decades of research led by Paul Sperduto, MD, PhD, adjunct professor in the Duke Department of Radiation Oncology, who developed the Graded Prognostic Assessment (GPA).The GPA is a validated tool used to estimate survival in patients with brain metastases by accounting for factors such as age, performance status, disease burden, and tumor biology. For non-small cell lung cancer, the tool incorporates modern biomarkers, including genetic driver mutations, which can influence response to targeted immunotherapies.Paired with the eligibility quotient (EQ), which helps estimate conditional survival, these tools paint a more accurate and individualized picture of prognosis, one that challenges outdated assumptions.“What we see is that many of these patients actually have very good overall survival,” Alder said. “Our therapies are better, more precise, and more effective than ever before.”Alder said advances in imaging, MRI surveillance, and radiation techniques, such as stereotactic radiosurgery (SRS), also make it possible to closely monitor and manage brain metastases during treatment. These innovations further support the safe inclusion of these patients in trials.At Duke, efforts to improve clinical trial inclusivity extend beyond a single publication. Through the Duke Center for Brain and Spine Metastasis, clinicians and researchers regularly collaborate with pharmaceutical partners, advocate at national conferences, and engage in ongoing dialogue with industry leaders.“This has been a mission for many of us for years,” Alder said. “At every meeting, every podium, we’re making the case that these patients need to be included because that’s where the unmet need is.”Encouragingly, progress is being made. National organizations such as the American Society of Clinical Oncology (ASCO) and the European Society for Medical Oncology (ESMO), along with the U.S. Food and Drug Administration (FDA), have increasingly emphasized the importance of broader eligibility criteria in cancer trials.Alder hopes the framework outlined in the publication will be used prospectively in future trials, helping demonstrate that inclusion of patients with brain metastases is both safe and beneficial.“Our patients are living longer than ever before,” she says. “They deserve clinical trials that reflect the reality of their disease and give us the data we need to keep making progress.”
