A look at brain tumor

"These days, it’s no longer the end of the world, or literally THE end, to have a brain tumor," says Dr. Mayvelyn de Dios-Gose, a neurologist.

Gose knows whereof she speaks, being a member of the steering committee of the newly opened St. Luke’s Comprehensive Brain Tumor Center (CBTC), the first and the only one of its kind in the Philippines. Established under the Institute for Neurosciences, it is involved in the diagnosis and treatment of brain tumor.

Continues Gose, "There are options which the patient and his family can choose from, first for the treatment and management of his ailment, and then to improve the quality of life. I see the doctors’ role as to educate people that brain tumor is not the fearful thing it was in the past. It’s not completely hopeless!"

This is precisely the CBTC’s mission: to diagnose brain and spinal tumors correctly and efficiently by providing state-of-the-art modalities, resources and support necessary for patients and families to meet the challenge of living with such tumors. Thus, its range of services encompasses diagnostic, therapeutic and supportive areas of care, and its aims, as well, to advance the management of brain tumors by presenting the public with a more progressive method of treatment, aided by research, clinical care and support services.

New Developments

Says Gose, "These are exciting times because there are many new developments in the therapeutic management of patients. I have a patient right now who has had a CNS lymphoma for the past five years, whereas before you were only talking of such cases as having only months to live. Now we’re seeing patients of cancer living from three to five years longer than the former one-and-a-half years."

"There was a time when all that was known was cobalt (radiation) therapy. Cobalt beams are wide, so the whole brain area was covered. Now there is the Linear Accelerator, which is a narrow beam that focuses on just the tumor; there is also Stereotactic Radiosurgery. There is the Intensity Modulated Radiation Therapy (IMRT), which conforms to the size and density of the tumor and is even more focused, so the complications are less. IMRT is more precise in avoiding vital structures. But the latest development is the implantation of certain radioactive substances into the tumor itself. The size of a tablet, the implant will try to destroy the tumor.

"And there are now studies on what are called Glial wafers, which are impregnated with chemotherapeutic agents and during surgery, left on the cancer cells to act on them. Viruses are also genetically designed to kill cancer cells," she adds.

The options, admits Gose, may not all end up as success stories, but, she adds, "Hopefully, as science progresses, we will have better prognoses, and more victories. You see, we, doctors, become part of the learning process. We learn from all the patients we take care of. The hope is that in a few more years, we may be able to lick cancer. There are, in fact, complete cures that have been identified with some other cancers, such as Gleevec, which is now a cure for leukemia. It is now being experimented on brain tumors."

Multi-disciplinary team

So what happens when a patient is suspected to have a brain tumor?

Usually, he is referred by his doctor to a specialist. When the patient goes to St. Luke’s CBTC, it is a multi-disciplinary team which will deal with him. Explains Gose, "We have a tumor board made up of specialists in neurology, neurosurgery, medical oncology (adult and pediatric), neuroradiology, nuclear medicine, neuropathology, psychiatry, pain management and nursing. We hold conferences on the case. So the patient has the benefit of several brains working on his diagnosis and treatment."

"We come up with protocols or guidelines for the management of different kinds of tumors, which have gone through the process of research and have been found to have survival or cure rates. There is nothing hit or miss at all," Gose adds.

How does one get a brain tumor?

Head trauma may be one cause. Radioactive waves from wearing headsets, and from exposure to power transmission lines have been suggested, although studies are not conclusive about these. The latest about cellphones is that they don’t cause tumors. There are also such factors as pollution and diet, or lifestyle in general. The thing is that these factors have long-term effects, so you don’t see the consequences right away.

Another cause is age. With the increasing age of the population, we are now seeing more patients with tumors in any part of the body.

Age as risk factor

Why is age a risk factor? Because with age, more errors in cell division and reproduction occur. Gose tells people to maintain a positive attitude toward life because it reflects on your immune system. If you are negative, so are your cells.

Then also, tumors may be primary or secondary. The primary tumor may be in the lungs, but it may travel to the brain. That’s what we call the metastasis or secondary tumor. Or the cancer cells can migrate to the peripheral nerves, the nervous system, of which the spinal cord is part (in fact, they can move to any part of the body).

CBTC doctors also see patients who, while undergoing therapy for their primary cancers, have developed symptoms referable to the nervous system. Say, a patient is being given a chemotherapeutic agent or radiation therapy for lung or breast cancer. This agent can injure nerves which were basically normal to start with.

At the CBTC, Gose is particularly involved in the management of primary and secondary tumors and the complications of therapy of cancers in the brain, spine and nerves. She also recommends diagnostic procedures and therapeutic maneuvers for these cases

But perhaps the greatest irony of Gose’s life and career in medicine is that her youngest daughter, Yasmin, then 27, single and a UP graduate, developed a brain tumor a couple of years ago. It was a crisis that not only drew the family together, but found them calling on their faith for strength to withstand whatever was in store. Yasmin had surgery in the Philippines and then was flown to the United States for IMRT, at the time not yet available here. She improved after that, but now requires regular check-ups just to make sure no cancer cells have remained to regenerate. Happily, where the Goses had to go abroad for such treatment, facilities for IMRT and MRI are now available at St. Luke’s Medical Center. Just as happily, Yasmin has taken up her life again, with an acceptance of her situation that her mother finds admirable.

No to false hopes

"I do not encourage false hopes," Gose says, "I always tell the patient and the family, if and when they are ready to listen, the current treatment and the prognosis. In time, one of the things I have learned is that one does not just go on treating a patient for as long as he is alive. There should be, rather, a monitoring of the quality of life of the patient – if it is already compromised, if the patient is already dependent on support systems for the activities of daily living, and the disease cannot be controlled. As a physician, I am aware of the cycle of cancers, and therefore, try to guide the family into accepting the inevitable, whether it is to place the patient in a special care unit or to move on to the acceptance of death.

"Even when money is not a concern, it might be best for the patient to return home and improve the quality of what is left of his life. Drugs used for the treatment also ravage the body, and you do not want your patient to become so weak or to suffer so much. In short, you don’t just go on giving therapy or treatment because the family says so. You must also be their counselor and tell them how things are early on."

Does she believe in miracles?

Gose acknowledges that there are cases where a tumor seen in an X-ray, CT scan or MRI is found to have disappeared upon surgery or upon further examination. This may happen when the interpretation of the X-ray is not accurate. "We, who do the interpretation, are only human," she says. "We may make mistakes. Which is where the beauty lies in having a multi-disciplinary brain tumor center – because with so many specialists working on one case, there are less chances of error. Then there is what we call the ‘vanishing tumor,’ the primary CNS lymphoma. We use steroids to treat this lymphoma, which then disappears – only to reappear after some time.

"But miracles occur to us on a day-to-day basis. They do not have to be on a grand scale. If your day has been pleasant, if you were able to help someone, if your patient whom you thought would not make it had a good day and probably will have better months ahead, these to me are miracles!"

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Gose was a nurse before she became a doctor, graduating from the UP College of Nursing with BS in Nursing (1966) and MA in Nursing (1968, all units complete, except for thesis).

She obtained her M.D. degree from the University of the East Ramon Magsaysay Medical Center in 1979, became a Fellow of the Brain Foundation of the Philippines on Electroneuroradiologists (1984) and Fellow of the Philippine Neurological Association (PNA), where she was past president.

Today, she is a professor at the UP College of Medicine and St. Luke’s College of Medicine, assistant director for fiscal services at UP-PGH, and a member of the Specialty Board of Examiners of the PNA.