Melanie Cole, MS (Host): Welcome to AHN Med Talks, an informative resource for physicians across various specialties as we delve into the latest medical insights and best practices, ensuring you stay at the forefront of your field. I'm Melanie Cole. And today we're highlighting the AHN Neuro-Oncology program.

Joining me is Dr. Matthew Shepard. He's a neurosurgeon with the AHN Neuroscience Institute. Dr. Shepard, it's such a pleasure to have you join us today. Let's start by telling viewers, the listeners, what conditions are treated by the AHN Neuro-Oncology Program.

Matthew Shepard, MD: Yeah. No, thank you, Melanie. It's a pleasure to be here and to talk with today. the Allegheny Health Network and the Neurosurgical Oncology Program, we treat patients with a variety of conditions, both benign and malignant brain tumors. Probably some of the more common tumors that we treat are patients with metastatic disease to the brain. These are some of the most commonly diagnosed brain tumors that we see. But there's a whole spectrum of patients with benign tumors such as meningiomas, pituitary adenomas, and of course, aggressive brain tumors such as glioblastoma. These are some of the most common tumors that we treat on a day-to-day basis here.

Melanie Cole, MS: Dr. Shepard, one of the most unique things about your program is the Multidisciplinary Brain Tumor Clinic, where patients are seen by all the providers on the same day to create that comprehensive multidisciplinary treatment plan. Tell us about that.

Matthew Shepard, MD: Yeah. So I think, when patients are diagnosed with a brain tumor, it doesn't matter if it's benign or malignant, this is oftentimes literally the worst day of a patient's life. And so when they come to see us, they don't want to go back and forth to multiple different providers and get in the car and go home and make a whole week out of trying to get a treatment plan, you need to plan kind of all at the same time.

So, one of the things that we developed over the past several years is trying to get all of the integrated providers together in the same clinic so that, when a patient walks in to see us and they see their physician, they're not just seeing the neurosurgeon and the radiation-oncologist and the neuro-oncologist, they're seeing literally all of us at the same time in some circumstances. So, what we found is that this is a way to ensure that our patients get timely treatment, timely diagnoses, and that we also make sure that we're all holding each other to the right standard, which is to really do the best thing for the patients and get them the treatment as quickly and efficiently as possible.

Melanie Cole, MS: That's such a comprehensive approach. And why don't you tell us about some of the latest and most exciting advances right now in use. Why don't you start with the GammaTile brachytherapy?

Matthew Shepard, MD: Yeah, that's a great question. So, we were one of the first centers in Pennsylvania to treat patients with GammaTile brachytherapy for recurrent brain metastases. Brachytherapy, as many of the viewers know, has been used in a multitude of conditions, including prostate cancer and bladder cancer for many decades. But its application and wide use in the brain has not really been utilized until recently.

So, what we've known is that for a variety of conditions, including recurrent glioblastoma and recurrent brain metastases that have previously failed irradiation, when a surgeon goes in and does a further surgical excision of a brain tumor, the tumors have a very high incidence of local recurrence.

I'm going to tell you about the first person that we treated with GammaTile brachytherapy, here at our institution. This was a really nice gentleman who was in his 60s. He had metastatic non-small cell lung cancer, but the only problem was the only area in his whole body where he had any site of disease was in his brain.

When he first came to see me, he had a subcentimeter right occipital brain metastasis that we treated with radiosurgery. Responded well initially, but by six months later had grown. He was having significant symptoms. I removed it. We had a gross total resection, but the tumor came back again. We did more radiation, but the tumor grew still. So, we were 18 months in to his disease course with me and our radiation team. And we were kind of chasing our tails and this was the opportunity for us to say, "Okay, we got to do something different." Going to get this person into remission from his cancer, we can't keep doing the same thing over and over again expecting different results. That's the definition of insanity in some instances.

So, what we did for this gentleman was I went back in, took out his tumor a second time, implanted GammaTile brachytherapy, which are collagen-embedded tiles that have radiation Caesium-131 sources embedded into these tiles. I laid that down at the end of the surgical resection cavity, and he's now two years removed from that procedure, and he still has not had any evidence of local recurrence in that area.

This has really been a game-changer for a lot of patients whose tumors are not following the rule books, not responding to radiation treatment. So, we're currently one of a few centers in the country enrolling patients into a randomized clinical trial, comparing the outcomes of GammaTile brachytherapy to traditional postoperative stereotactic radiosurgery for newly-diagnosed brain metastasis. And we're hoping to expand our clinical portfolio and looking at brachytherapy for patients with newly-diagnosed glioblastomas in the near future as well.

Melanie Cole, MS: What an exciting time in your field, Dr. Shepard. Tell us about Gamma Knife radiosurgery. You mentioned it just a little bit there.

Matthew Shepard, MD: Yeah. Absolutely. At AHN, we're very fortunate that we have a very robust and comprehensive radiosurgical program here. We are one of the busiest radiosurgical treatment centers in the country, treating approximately 300 patients a year with Gamma Knife radiosurgery. Gamma Knife is a non-invasive radiation treatment modality where we can focus multiple radiation sources to a very small target in the brain in order to treat patients with a variety of conditions, including benign and malignant brain tumors.

So, what I tell patients is what we can do is it's kind of like taking a magnifying glass and burning a hole in a leaf with focused sunlight. We're really kind of using positive interference with radiation treatments to treat aggressive brain tumors with high degrees of precision and good results. So, we're able to afford high degrees of local control with radiation treatment. But because of the radiation dose falloff, we're seeing very limited radiation toxicity within the neighboring brain tissue.

Melanie Cole, MS: That's fascinating. Tell us about any research studies overseen by your group. Are you doing anything really exciting you'd like other providers to know about?

Matthew Shepard, MD: Yeah. So, research is one of our main backbones of how we're advancing patient care within the Allegheny Health Network and nationally. We have what I subdivided this in kind of our high level kind of research studies that are probably, you know, five, 10 years down the line from making a major clinical impact on patients. But some of those studies right now include a collaboration with Carnegie Mellon University, using predictive analytics and artificial intelligence to essentially take a look at patients with glioblastomas and look at their preoperative MRI scans and try to find putative hotspots, where they're more likely to have disease recurrence in the future after surgerical excision. The idea of being here, if we can identify areas of non-enhancing tumor that are more likely to recur. Because normally in glioblastoma, we resect the enhancing disease, but we leave a lot of the non-enhancing tumor left behind. That's kind of our current gold standard for gross total resection.

But there's been an emphasis to try to identify other hotspots in the non-enhancing tumor that are more likely to recur in the future. So, that's one of our programs that we're working with CMU currently. We're also leveraging our Moonshot Genomics kind of database within the Cancer Institute. So, many of our patients with benign and malignant brain tumors are now undergoing whole exome sequencing of their tumors and undergoing preoperative and postoperative blood draws to identify biomarkers in the bloodstream to identify novel biomarkers for disease recurrence, and to also identify patients who are more likely to have what we call rapid early progression of their brain tumor after you remove it specifically for glioblastoma.

We're currently heavily involved in multiple radiosurgical Research Foundation projects from the International Radiosurgery Research Foundation. We're leading several of these on CNS lymphoma, meningiomas in patients with metastatic brain tumors.

Melanie Cole, MS: Dr. Shepard, when someone is diagnosed with a brain tumor, as you said, it's worst day of their life. So scary. And even with your multidisciplinary brain tumor clinic and that they get to see everybody kind of in one place, someone has to set that up and that can be one of the most dizzying, confusing, scary times. Tell us about your nurse navigator program and what role they play in helping the patients navigate the dizzying world of going through this kind of treatment.

Matthew Shepard, MD: Yeah. No, you're absolutely right. I mean, at the end of the day, we have to get patients the right care at the right time. And that's really what our nurse navigators are really tremendously helpful for. But they go beyond just scheduling patients. Our current nurse navigator, her name is April DeWeese, she is absolutely fantastic. Every single one of our patients has her phone number. They call her after hours. She gets back to them the next day. And she's really sort of the oil involved in this kind of machine to kind of keep everything running smoothly. She keeps me on track. She keeps my partners on track. And she keeps all of our patients really in the forefront of her mind at all times.

Melanie, this is a story, but one of our patients-- you know, we treat, patients in all walks of life, and there was one young mom who was dealing with a very aggressive brain tumor. And because of that, she couldn't work anymore, and it was the holidays and she couldn't afford Christmas presents for her kids. So, our nurse navigator, she went out of her way to raise money for this patient so she could have Christmas presents to her children.

I think when people come here, yeah, we do a lot of the bells and whistles technology, clinical trials, research. All that's important. But I do think that one of the things that does separate us a lot is that we care. You know, the people that we see on a day-to-day basis, they're our friends, they're our families, they're our neighbors in some capacity. Pittsburgh is a small town. Pennsylvania is a small state in the grand scheme of things. And we really try to get to know all of our patients and try to really get to know everything about them so we can make the right treatment strategy for them. And when we can go out of the way to do something a little bit extra, we try to do that too.

Melanie Cole, MS: Thank you for sharing that story, Dr. Shepard. It really does show what sets you apart, and along those lines, I'd like you to emphasize the patient-directed goals, care and quality of life, because as you were just telling us that story, it's along those same lines, identifying ways of identifying barriers to patients receiving their care, what you said, Pennsylvania is a small state. Pittsburgh is a small city. But there are people outside of that that still have to get into the clinics that are still maybe looking for a televisit. Tell us a little bit about how you work with the patients for the quality of life, because that's really what it's all about.

Matthew Shepard, MD: Yeah. No, that's an excellent point. And I think there's kind of two layers to that question. I think you're right, I mean, we're in a tertiary center in Pittsburgh. And so, yeah, we treat patients from all over the state, all over the county, West Virginia, Maryland even. People have to be able to get here. So to your point, we do take that very seriously. And so, we have philanthropic funds and foundations set up in order to really just pay for people to get a taxi, to get into the car to come see us and get their adjuvant radiation treatment and chemotherapy so that we kind of decrease a lot of the barriers to care.

But to your other point, I think the challenging thing with Neurosurgical-Oncology is if you take an MRI and you show my residents a brain tumor, and you say, "What's the right treatment for this?" I would argue we don't know the right treatment without actually getting to know our patients and knowing what's important to them. And really what a lot of other factors go into making that decision process. And so, a lot of our research and a lot of the things that we're trying to do is directed at identifying physiologic and non-physiologic metrics that are important at dictating the response to treatment, including surgery and radiation treatment.

And then, now that we've identified some of those metrics, we're figuring out ways to improve those metrics for people either with preoperative rehabilitation prior to surgery, Perioperative nutrition consultation, physical medicine rehabilitation integration into our multidisciplinary clinic, for example, and getting a lot of those resources developed so that patients can bounce back from their surgery sooner. And a lot of that comes down to just trying to figure out what is the right level of aggressiveness for each patient, because it's not always going to be surgery. It may very well be, and sometimes it may be newer medication treatments out there or radiation treatments. And so, everyone responds differently and we're trying to figure out exactly for each individual how we can personalize the various treatment options available to them.

Melanie Cole, MS: Such a comprehensive approach. Dr. Shepard, as we get ready to wrap up, what's your vision for the program? How will this care model that you've described here for us today for the AHN Neuro-Oncology Program, how will it change the way patients receive their care? And what would you like to see happen in the future? You're speaking to other providers here. Give them the key takeaways and your vision for this program.

Matthew Shepard, MD: Yeah. So, our vision is to really get everyone at the same table. You know, I think five, 10 years from now, I want multidisciplinary brain tumor clinics, for example, or multidisciplinary oncologic clinics kind of set up across the country and have that sort of be the national standard for how we take care of patients with cancer.

As it pertains to our brain tumor clinic, one of our three to five-year plan is that this is going to be an increasingly integrated program. I talked a lot about surgery, neurosurgeons, radiation-oncologists, neuro-oncologists. We've already started to integrate our supportive care and palliative care team into our clinic as well, so that patients can tolerate their treatments better so that we can have a clear understanding what their goals for the future are and how aggressive we want to be, kind of going into a lot of these complicated decision, clinical algorithms.

And we want to then start really integrating more and more services into these multidisciplinary clinics such as Physical Medicine and Rehabilitation, as I mentioned, Geriatrics, Case Management, Social Work. There's so many issues or there's so many factors that we can't control when a patient's diagnosed with a brain tumor. We can't control what the biology is. We can't control what genetic markers it is. But we can control how we treat them and how we provide the most efficient and tailored care. And I think that's something that we can control and we can continually work to do a better job at that so people can live better and live longer.

Melanie Cole, MS: And that really is what it's all about. Thank you so much, Dr. Shepard, for joining us today and sharing your incredible expertise for other providers And to learn more or to refer a patient to Dr. Shepard, please call 844-MD-REFER, or you can visit ahn.org.

Thank you so much for listening to this edition of AHN Med Talks with the Allegheny Health Network. Thanks so much for joining us today.