Jaime Lewis (Host): Meaningful Medicine is a Novant Health podcast, bringing you access to leading doctors who answer questions they wish you would ask. From routine care to rare conditions, our physicians offer tips to navigate medical decisions and build a healthier future. Today I'm sitting down with Neurosurgeon Dr. Rashid Janjua to talk about treating brain tumors. Before we get started, Dr. Janjua, I'd love to know how brain surgery became a passion of yours. What made you decide to become a Neurosurgeon?

Dr. Rashid Janjua: That's a very good question. Thank you so much for taking time to talk to me and talk a little bit more about brain tumors. I wanted to become a brain surgeon, a Neurosurgeon very early on, and during my medical school, that became really a passion when I saw an operation being done for brain tumor.

And then during residency, you get exposure to all sorts of different facets of Neurosurgery. And the one that appealed the most to me was patients who have afflictions of the brain, whether that is with blood vessels or tumors or other problems that might arise, and I found that far more grateful and enjoyable, and I decided to pursue that route and have not looked back and enjoyed it ever since.

Host: So not every brain tumor is cancerous, correct? Can you explain the different types?

Dr. Rashid Janjua: Yes, so whenever anybody gets the information, the news, or a phone call that they have a brain tumor, most people are petrified. If you think about the more common tumors that in our population that might arise, if I ask you a tumor in the body, you would probably not think of brain tumor as the first tumor that comes to mind.

If you talk about people who you've spoken to, people in church, people in your family, people are in your own community, more often than not, it is a lung tumor, prostate tumor, or breast tumor, or a colon tumor. Brain tumor, fortunately, is a very rare occurrence, but when it does occur, people find that very disturbing, because it is in a world that is very much unknown to most people, because you've seen pictures of lungs, you can feel your lungs, you can feel parts of your body, but the brain is a part of your body that you'd never see or never feel.

And so that anxiety is always very provocative and when patients come to me, they usually come with an MRI or a CAT scan and then I get the opportunity to help figure out what the best treatment is. By far, the majority of tumors that I see are benign, non cancerous one, at least in clinic, but unfortunately, a lot of tumors that arise elsewhere in the body, like for example in the lung, as I mentioned, all the other places that I mentioned, and they can spread to the brain, so called metastasizing to the brain, and then it's obviously a different story.

Based upon the story of the patient, the history of the patient, and what the CAT scan or MRI shows, and a composite of all three, it helps us determine whether something is likely cancerous or non cancerous, in other words, malignant or benign.

Host: Okay. Well, I would imagine when somebody is told that they have cancer, it's not just anxiety inducing because it's cancer, but also it's brain cancer, as you mentioned, that's something that just feels scarier. Can you put us in the room? How do you deliver that news and comfort patients during that initial shock?

Dr. Rashid Janjua: I think the most important thing that you have to do with a patient, number one, is to be honest with them. A patient is very vulnerable at the time that they find out that there's something wrong with their brain. And as I said, they're usually petrified. You have to hold their hand, you have to sit close to them, and you have to tell them the truth of what you think is going on.

But at the same time, you have to make sure that you give them hope and you allay their fears, and you tell them what you think needs to happen. Oftentimes, patients, when they hear the news, obviously, they're very worried, and they are emotionally very disturbed, and having family members there is very important, because the more ears can listen in to that conversation, the better it is.

So I think honesty. And speaking in a language that they can understand, as opposed to, you know, medical terminology, is critical, and explaining to them what they can expect. And sometimes, when I do have a sort of, quote unquote, bad news conversation, when I think that it is cancer, then not one conversation, but two or three conversations are needed in order to allow the patient to come to terms with it in as much as they can, and secondly, come up with questions, because in the first visit, they may be so emotionally disturbed that they are not able to ask all the questions, and when they sleep over it, talk with family members, talk with their pastor, talk with the primary care doctor; they may come up with questions that are very helpful to get them prepared for what lies ahead.

Host: What are some of the most common questions you get from patients?

Dr. Rashid Janjua: Well, one of the things that happens with cancerous tumors, obviously people are going to ask, how long do I have to live? That's a very common and very natural question that people ask. And I think it all depends upon what kind of cancer do you think that the patient has. Is it from of the brain itself, or is it a cancer that came from the lung, for example?

Is it a cancer that already was known and they'd discovered because of headaches, because of a seizure, or other reasons that they also had a metastasis, spread to their brain. And I think there are a lot of factors that go into play in being able to answer that question. I think one thing that is important is not to give a time frame the first time you meet the patient, because there are so many unknowns that go into it as you begin the treatment that you don't want to be wrong with that.

You don't want to give them specifically a too short a time frame when they may live for a decade. And I think that it's important to be honest with the patient about that and not withhold the information, yet at the same time be able to shepherd them along in that uncertainty that they may have during the period that we try to figure out what the patient have, have the tissue sent to the pathologist for them to look at under the microscope, but also to determine if it is indeed cancer, what kind of chemotherapy they will need, if they will need radiation therapy, what kind of radiation therapy, what kind of chemotherapy, and most importantly, what is it that we can do for the rest of the cancer and elsewhere in the body, if that's where it came from, so that we treat the entire patient and not just the brain.

Host: Will you share with us a little bit about what goes into developing a treatment plan? I understand there's a lot of planning that goes on with the Novant Health Cancer Institute on the front end. Isn't that correct?

Dr. Rashid Janjua: That is correct. So at Novant Health, what we have championed for our patients is we always put the patient in the middle of every treatment plan. So the plan that would be the right plan for you or me would probably be the wrong one for somebody else. And I think that keeping the patient's needs in mind, keeping the patient's other medical problems in mind, what their wishes are, what their desires are.

Somebody who is 85 has a different outlook than somebody who is 25, and you tailor your treatment based upon that. So what we typically do is that once the diagnosis is made, we, on the neurosurgery side, patients, our team members, the oncology, so cancer treatment side, my partners who give the chemotherapy, those are the oncologists, and doctors and nurse practitioners on the radiation oncology side, the folks who give the radiation treatment, all three of us get together and say, okay, Mr. Johnson, who has X, Y, or Z, here's what will be found. What do you think we should do? And oftentimes we have something called a tumor board. It is a large group of physicians, nurse practitioners, social workers, dieticians, radiologists, many, many specialties get together every other week and we look at the x-rays and CAT scans and MRIs together and we discuss, hey, what do you think Mr. Johnson needs? And then everybody has to give their opinion, and then we come up with a treatment plan that we propose to the patient based upon what we know that, patient's preferences are.

Host: Does every patient require surgery?

Dr. Rashid Janjua: Absolutely not, because oftentimes what I recommend, especially for, if the MRI suggests that it's a non cancerous tumor, then I will oftentimes recommend that we keep an eye on it. So what I will tell them is, hey, let's, we don't think that this is cancer. And I think that we can keep an eye on it.

The only time I recommend surgery as my first option is when I think that it is cancer. If I think it is non cancerous, then why do surgery? And sometimes we actually, from the very beginning, oftentimes, a non cancer patient, we say, well, let's get another MRI or a CAT scan in three months and see if it is growing.

And if it is not growing, we'll keep an eye on it, and in that way, you can just continue with your life without having to have brain surgery.

Host: Well, for those who do need surgery, can you share a little about how technology has improved and maybe even at a higher level, can you explain how many of today's procedures are performed with a minimally invasive approach?

Dr. Rashid Janjua: It all depends upon what the tumor is, where it is, and what the shortest amount of disruption you need to cause. So when we look at a tumor, say for example, pituitary tumors, these are tumors that occur at the bottom of the brain. And classically these tumors have been operated on through the nose.

And what we at Novant Health do is that we do this in conjunction with our ear, nose and throat, partners. And what they do is they take a teeny tiny camera from one nostril up into the brain. And I operate with my instruments through the other nostril, and we do brain surgery through your nose. And so on the outside, you don't see anything at all and you never know that you had surgery other than the symptoms of surgery being headache, and oftentimes you have a little bit of a blood drip from your nose, but you go home the next day. But sometimes there are tumors that are so large in the brain that you cannot do a minimally invasive surgery. And there, it is very important for a couple of things to happen is that you keep from the outside to the inside, you keep the patient's outer appearance intact.

So I will oftentimes do surgery in between the hair so that I don't have to shave their hair so that when the patient has the staples removed, they look just like they did before. That helps with the patient's ability to look in the mirror and see themselves. Women oftentimes care more about their hair than men do, and they spend a lot of money in their hair upkeep. What you don't want is a Neurosurgeon to go in with a razor blade and shave half the head off. And so what we do is we operate in between the hairline so that when the staples come out, they look exactly like they did before surgery. The other thing is, is how big is the bone opening? So in the skull, you have to open the skull in order to get to the brain because your brain is fortunately protected by the bone.

And so when we open the skull, we have to open the skull over the area where the tumor is. So what we don't want to do is make the opening too small in order to be, quote unquote, minimally invasive and not be able to do the job that we need to do. So, for me, the most important thing is that I accomplish the goal that I need to, in other words, remove the tumor. If it is cancerous, get everything out. And the size of the craniotomy as it is called, the opening of the skull, is less important to me than getting my goal accomplished and get the patient back to their family members in a good clinical condition.

Host: What does a typical recovery time look like maybe today versus 20 years ago?

Dr. Rashid Janjua: Yeah, a lot has changed. So, previously, the recovery time, you see, you'd be in the hospital for weeks, and you'd be watched, and we would keep, bring you in the hospital before surgery. Now, you come on the day of surgery, you have the surgery, you stay overnight in the ICU, and the next day you go home. Most patients of mine go home from the ICU, and they get up and walk around, and it's very important for us to get the patient mobilized, to get them on their feet, them used to eating or drinking early enough, because the sooner the patient can be discharged, the better it is for the patient because otherwise in the hospital, you lay in a hospital bed, and that's just not good.

You need to be up and about and be active, and most of the time we accomplish that goal. Even in patients who are senior in age, it is very important, in fact, it is more important for them than for younger people because what you don't want is as an older person to end up in a hospital bed, and then it just becomes harder.

I mean, you can probably remember when you were 18, if not that you're 18, not 18, but when you were much younger, you were able to get over an ailment much quicker than you are now. And I think that as we get older, it is very important to remember that being active is much more important than just laying in a bed in a hospital with the nurse or the doctor doing everything for you.

Host: And that's wonderful. What advice do you have for caregivers?

Dr. Rashid Janjua: I think the most important thing is, for caregivers of patients with brain tumors is to have the most supportive role that you can provide them, the most love that you can give them, the most care you can give them. But one thing that I urge them to do is don't do everything for them. Even though they've had brain surgery, if you go to the kitchen and make them a sandwich and get them a glass of water, or you do everything else for them, they're not going to get up and walk around.

And my goal is for them to be active. So yes, provide all the support. And also be honest with me and our team and tell them, hey, listen, here's what we need at home. Here's how things are not working. Maybe we need home health. We need physical therapy. Here's what I'm noticing. And oftentimes family members can be much more of a sounding board to us, sharing the good and the bad news with us than the patient would.

And I think most patients rely heavily on their family members during the recovery period, but also after that, when they get chemo and radiation, if it is cancer. And I think it's really wonderful. I think it's a great gift to have loving family members and a support system.

Host: Well, thank you, Dr. Janjua, for all this important information and for the work that you do.

Dr. Rashid Janjua: Thank you very much.

Host: Once again, that was Dr. Rashid Janjua. To find a physician, visit NovantHealth.org. and for more health and wellness information from our experts, visit HealthyHeadlines.org. Thanks for joining us.