Scott Webb (Host): Today, we're going to meet Dr. Gurvinder Kaur. She's a neurosurgeon with Salinas Valley Health. And in addition to telling us about herself, she's going to discuss brain tumors, the current standards of care, and the amazing treatment options that are on the horizon.

 This is Ask the Experts, the podcast from Salinas Valley Health. I'm Scott Webb. Doctor, thanks so much for joining me today. We're going to talk about brain tumors, sure, and the latest research and treatments. But before we get there, I just want to learn a little bit more about you. I don't know many neurosurgeons. So, I'd like to get to know you a little bit and have the audience be able to do that as well. So, just tell us a little bit about yourself, why or when you decided to become a neurosurgeon and so on.

Dr. Gurvinder Kaur: I grew up in Bay Area in San Jose. And I went to a high school there that was a Medical Magnet. So, I got exposed to Medicine very early on in my career. And part of the requirements for that school was to do some volunteer work at medical facilities, including hospitals. So, I ended up at local ER where I happened to see a lot of head trauma, spinal cord injuries. That made me really curious about how those patients are recovering and what effect they will have in their long-term life and how acute care is delivered. So, that led me to pursue neurosciences when I went to college at UCLA. I went to medical school at UCSF where I was fortunate to meet wonderful neurosurgery mentors that really shaped my interest in medicine as well as opened my eyes to different research opportunities there. I did my training at Northwestern in Chicago, where I really focused on Neuro-Oncology. This led me to pursue my fellowship at University of Miami, which is a large tumor cancer center. So, I think that overall my interest sort of got shaped from very young age, but I think oncology sort of became the center of my work, as I saw patients going through long journeys, which is very tumultuous. Brain tumors cause significant morbidity in our patients.

Host: Sure. Yeah, I'm wondering, you know, working there at Salinas Valley Health, maybe you can tell us about that experience. I know there's lots of Spanish speakers, and you and I were kind of talking there before we got rolling here about you trying to brush up and learn Spanish. How's that going?

Dr. Gurvinder Kaur: So, I learned Spanish in high school, but it's been quite a while. So, I am trying to relearn Spanish and we do have a large Spanish population in our area. So, we do currently have translating services, and many of our physicians do speak Spanish. So for our Salinas Valley patients, we want to make sure that they have all the appropriate language services. So, we want to make sure we're breaking the cultural barriers to get our patients access to the best, you know, possible care.

Host: For sure. And I know this next question is a little loaded and certainly broad, and I apologize, but can you tell us about brain tumors? You mentioned what, you know, sort of drew you to Oncology and tumors and things, but I think there's just so much out there in the world that has led us all to think we either know more than we do or we definitely don't know as much as we should. Tell us about brain tumors.

Dr. Gurvinder Kaur: So, brain tumors, like I said, cause significant morbidity and mortality in our patient population, even though they are rare in comparison to common diseases like heart disease. But given the involved central nervous system, it is a tough journey for many of our patients. So, brain tumors come in many forms. So, just to kind of make a generalized sense, there are two different types of brain tumors. One that arise from within the brain tissue, those are called primary brain tumors, and the more common, 80% of the brain tumors, are metastatic brain tumors that come from other parts of the body, including breast cancer, lung cancer, melanoma, where over time they metastasize to the central nervous system and grow there over time because a lot of the chemotherapy drugs, it is harder for them to cross blood-brain barriers, so they tend to escape and grow there.

And in terms of primary brain tumors that arise from within the brain tissue, they could be from the supportive cells called gliomas or from other layering around the brain called meninges. They are benign versus cancerous, so more benign tumors are like meningioma, pituitary tumors that can be watched or, you know, may require surgery if they grow too fast. But a lot of the morbidity comes from the metastatic disease and much more malignant brain cancers.

Host: All right. I'm still with you. I told you before we got rolling, you can use some big words if you need to, but I'm still following you as I'm sure listeners are. Let's talk about the symptoms. And I'm wondering specifically, are the symptoms different from like benign versus cancerous tumors, or are the symptoms basically the same? And maybe you can kind of go through that, you know, how are they similar? How do they differ?

Dr. Gurvinder Kaur: That is correct. So if something is more malignant or cancerous, it tends to be more faster growing. So, those symptoms usually present much quicker and much more aggressive and versus something that is slow-growing-like benign brain tumors. Those can stay dormant in smaller size for a long time before they grow. But the most common symptoms that we see patients present with are headaches, especially morning headaches, followed by nausea, vomiting, seizures, difficulties with speech, vision changes, or just personality changes. So, sometimes these symptoms can look very similar to stroke. But as people come to the hospital, they get a workup. With the imaging studies, we can definitely distinguish between stroke versus a brain tumor.

Host: Yeah. So when should we reach out? I find with a lot of the topics that I cover here, it could be one thing, it could be a thousand things, right? So, you say, okay, well, if you wake up with morning headaches and it's followed by other things like nausea, then it could possibly be a tumor, but it could also maybe just be a headache, right? So when should folks reach out? When do they know it's time to speak with a provider?

Dr. Gurvinder Kaur: I think if symptoms are persistent, particularly headaches that are persistent, you know, headaches are so generalized and they're so common. But I think headaches that often are persistent in the mornings and they're not improving with your local Tylenol, ibuprofen, whatever you're taking, I think it's a time to seek care. Obviously, with symptoms that are like seizures or stroke-like symptoms, weakness, numbness, difficulty talking, I think patients for those obviously go to ER urgently to seek care. But I think it's the mild and moderate symptoms that often kind of delay care for a lot of patients. And your first way to get access in those cases is your primary care doctor, talking with them, discussing that my symptoms are persistent. If they're not getting away, considering imaging modalities because, obviously, MRIs of brain are standard of care in terms of diagnosing for any brain tumor.

Host: Yeah. And as you say, if the symptoms are more stroke-like symptoms, you know, time is brain, get to the ER, skip over contacting your primary, go right to the emergency department, of course. So, let's talk about the treatment of brain tumors. I'm sure it's ever-changing and evolving, probably even for a great neurosurgeon like yourself just to keep up, right? It can be a challenge, but I'm sure we're talking about a combination of surgery, infusion therapy, chemo, and you know, the whole gamut if you will. So, take us through that. What's the latest and greatest when it comes to treating brain tumors?

Dr. Gurvinder Kaur: So, in terms of brain tumors, I think surgery still remains the primary mode of treatment. So, if we can surgically safely remove the tumor, I think we can reduce the tumor burden, but overall long time to treat. And I think adjuvant treatments are very important. So, for all of our brain tumor patients here at Salinas Valley, we take a very multidisciplinary approach that involves a neurosurgeon, a neurologist, oncologist, radiation-oncologist and, of course, their primary care physician.

And the approach is to see if it can be surgically resected safely followed by chemotherapy and radiation. And nowadays, there are many new treatments that are coming up that are more based on the molecular markers. So, our pathologists study those tumors and they send it out to particular companies who are looking for those markers. And based on those markers, whether it's for lung cancer or for primary cancer, we can sort of design treatments for our patients.

In terms of of surgery, you know, it truly depends on the location. There are parts of the brain that are very eloquent, means where your speech is, where your motor and sensory functions are. So, even designing surgery for that area is very different. Often those patient needs awake surgery, which means that we study while they're awake. We study their motor functions, if possible. Particularly for speech, we do have to wake them up in the middle of the case and have them do a bunch of battery of tests while we are trying to resect their tumors.

 After those surgeries, patients often recover for a couple of weeks, and then they end up seeing their oncologist and radiation-oncologist for those treatments. Some for primary brain tumors, some chemotherapies are a pill, which means they are taken by just tab by mouth. Other treatments may involve infusions, and all that is available here at Salinas Valley Health. And we are trying to form associations with local universities, including Stanford and UCSF, where we are trying to enroll some of our patients if they're eligible for clinical trials. So, we're working very closely with their Neuro-Oncology teams as well. So, there are many, many options available.

In terms of very up and coming new treatments from surgery perspective, there is LiTT, which is a laser interstitial thermal therapy, especially tumors that are deep-seated that are not easily accessible to remove, or they're aggressive and they had multiple surgeries in the past and they're now growing back again. We can make a small little incision in the scale and small little drilling of the bone, and we can insert a little probe into that deep-seated tumor and burn it. The burning of that tumor allows, of course, to kill the cell. But also, it allows to break the blood-brain barrier. So, that way, other cancer treatments, including chemotherapies can make it to the brain, and radiation can be a little bit more effective.

And then, of course, in terms of adjuvant treatments, immunotherapy, molecular markers sort of targeted therapy is in process of developing. And ultrasound therapy actually is the most recent one that have come out where with ultrasound waves, you can break the blood-brain barrier around the tumors to make chemotherapy be more effective. So, those are all treatments that are in clinical trial mode, some of them. So, they should be making it down to, you know, standard of care, hopefully very soon.

Host: Yeah. It's really amazing. Often the comparison or analogy is used when I'm speaking with providers is sort of you have tools in a toolbox, right? So, I'm thinking about your toolbox and you kept piling them in there. And I'm like, "You know what? This is good. This is good for patients and their families." As you say, there's this, you know, partnerships and things between Salinas Valley Health and these other institutions and also this great multidisciplinary care, this whole team approach. So, I know we're talking about brain tumors, but it brings a smile to my face because I think about, you know, the folks there, they're in good hands, of course. And you hear the thoughtfulness and the compassion in your voice. But all that said, you know, surgery to remove brain tumors is pretty daunting, right? So, I just want to get a sense from you, how do you talk to patients about that type of surgery and when it is indicated, when it is the right option for them, or if it really is their call? Maybe you could just sort of briefly, you know, peak behind the curtain, if you will, a little bit, just to get a sense of what those conversations are like.

Dr. Gurvinder Kaur: I think those are complex and tough conversations, particularly in aging population. So, I think my goal in those discussions is to truly give my patients all the options and really educate them about what their journey will look like with surgery or without surgery so they can pick the path that works best for them. And sometimes it's very clear cut and sometimes it's very challenging. Given the most aggressive brain tumors, glioma, the median survival even with surgery is about 14 to 18 months with radiation with chemo. So, it's very tough.

I think it's truly patient's personal values, how they want to spend their life I think truly plays a role whether or not they want to pursue surgery. But in most patients, surgery can make a significant benefit in terms of not just improving their lifespan, but also improving their quality of life. I think the goal of surgery is to lift suffering and not cause more because no surgery comes without any risks, right? It has a lot of complications associated with it. So, educating patients about those complications and, if they do occur, how are we going to take care of them? So, sometimes it takes multiple discussions.

Host: I'm sure it does.

Dr. Gurvinder Kaur: Especially with families and caretakers, it's very tough.

Host: And then we discussed earlier, we touched about, you know, the Spanish-speaking population and making sure that everybody is on the same page, everybody understands. And you working hard to not only keep up with the latest treatment options for those with brain tumors, but also you're Spanish and communicating with patients and families. So, as I said, it really does sound like patients are in good hands, always really at Salinas Valley Health. And I just want to give you a chance here at the end, final thoughts, takeaways about tumors, research, treatment options, anything else?

Dr. Gurvinder Kaur: We are really trying to build a comprehensive center here at Salinas Valley Health for our patients. So, that way, patients don't have to travel long distances to get the care they need. We want to offer our community the best resources possible. So, as we're building that up with new imaging protocols, getting patients access to clinical trials, I'm hoping that we continue to grow this program and continue to serve our community.

Host: Yeah. That sounds right to me. It sounds right to my ears. These are complex things you gave us just a sense there of just how delicate the brain is. You make it sound like you're making a sandwich, you know, because you're a neurosurgeon. But for me, I'm like, "Oh my gosh, how do you do that? And how do you not screw that up?" And I'm so glad that we have experts there at Salinas Valley Health like yourself to help folks. So, I really appreciate your time and the education. Thanks so much.

Dr. Gurvinder Kaur: Thank you so much, Scott.

Host: And to listen to more of our podcasts, please visit salinasvalleyhealth.com/podcasts. And if you found this podcast to be helpful, please be sure to tell a friend, neighbor or family member. And subscribe, rate and review this podcast, and check out the entire podcast library for additional topics of interest. This is Ask the Experts from Salinas Valley Health. I'm Scott Webb. Stay well, and we'll talk again next time.