Meet the Team: David W. Andrews, MD
Neurosurgeon "par excellence" and Biotech entrepreneur
Soon after the initial ER visit and the worst imaging series one can ever see, brain cancer patients find themselves in the company of a neurosurgeon.
The choice of a neurosurgeon is absolutely critical. We cannot emphasize this enough!
At MissionGBM, we have gotten to know dozens of worldwide brain cancer patients (and their families) over the past year. Unfortunately, many of the cases that we have seen have started the patient Journey poorly due to misdiagnosis and typing of the tumor (usually in community hospitals by inexperienced neuro-radiologists and pathologists), or inadequately planned and executed neurosurgery. On the latter point, pre-surgical planning is critical. Get this wrong, and the probability of a poor post-surgical outcome significantly increases.
Neurosurgery on complex and dispersed brain tumors is a job that should be reserved only for the top people in the field. Tumors and their accompanying inflammatory surroundings almost always impact vital areas of the brain responsible for speech & language, neuromotor function, cognition and emotion. Thus, the neurosurgery must be carefully planned with state-of-the-art technologies such as fMRI (to map the active areas of brain function) and 3D perfusion MRI to chart the location of key blood vessels. Detailed planning by a skilled neurosurgical team guides the design of the surgical procedure (e.g. awake craniotomy, avoidance of peri-operative cerebral vascular events), and also improves the chance of a good post-surgical outcome.
In the cases that we have seen in which poor surgical outcomes were evident (total aphasia; cerebrovascular events; significant neuromotor deficits), the common thread is that the brain cancer patient and his/her family felt compelled to make a quick decision regarding neurosurgery under circumstances of shock and duress, often in the ER upon initial case presentation.
An Important Message
In most brain cancer initial case presentations, it is not imperative that the patient makes a snap decision regarding neurosurgery while still under duress in the ER.
Generally, the patient can be stabilized and medicines (e.g. dexamethasone, anti-seizure drugs) can be administered to ameliorate the presenting symptoms (seizure, aphasia), thus giving the patient and the care team some valuable time to investigate the neurosurgical options.
Medicine is a business, and like other businesses, must generate revenue to remain in business. In the hospital environment, the reality is that physicians and surgeons often feel real pressure to maximize Relative Value Units (RVUs) associated with procedures, which are the basis for compensation in the majority of doctor employment contracts these days. While delivering the best possible patient care is always the top priority of doctors, a case that presents in the ER with obvious high RVU potential is simply too attractive for the hospital to refer to a competing hospital, even if the presenting hospital is not a Tier 1 facility with an integrated Brain Tumor Center.
Playing the Hand You Have Been Dealt
Julie initially presented in the ER of a very good community hospital in the Princeton, NJ area. Her presenting symptom was rapid onset, severe aphasia - she could not process speech or language, which is a marked departure from her usual capabilities. The cranial imaging in the ER soon revealed that a large GBM tumor was the issue.
Now what?
The ER called for a Neurosurgery consult, and a well-pedigreed neurosurgeon soon appeared in the ER to talk with us. Having a background in hospitals (including in the Department of Surgery), I interviewed the neurosurgeon. While I was reasonably confident that he could likely do the procedure, he did not give me a warm-and-fuzzy feeling with respect the depth and breadth of the recommended preoperative planning. Since it was obvious that Julie had tumor involvement in her speech & language centers and proximal to important cerebrovasulature, his answers represented a non-starter.
OK, so now what?
It was near midnight, and Julie had been in the ER since just after lunch. The ER staff was outstanding, and Julie’s care was excellent under the circumstances. However, we had to make a rapid assessment as to whether emergency neurosurgery was required. The MRI scans showed a 4.5cm primary GBM tumor with a large surrounding edematous field that had caused an 8mm midline shift of her left cerebrum. The images also indicated an imminent threat of brain herniation, which could have easily been fatal. Finally, the imaging indicated that the inferior medial boundary of the tumor was intercalated into the insula and the highly-vascularized lenticulostriate region of her brain near the middle cerebral artery.
So, the scorecard looked like this:
Large, primary GBM tumor
Large inflammatory surrounding edema field causing 8mm midline shift
Incipient brain herniation
Proximity to Broca’s Area, which is vital to speech & language
Involvement of the insula
Extensive involvement of the lenticulostriate region
No brain abscess
Oh, is that all?
And we are in the heart of the Delta wave of COVID…and it’s the middle of the night.
All Roads Lead to David Andrews
First, just breathe.
Second, it helps to have a thought partner to unpack the case and consider options. We are lucky as our daughter Stephanie Rakestraw, MD is a General Surgery resident, who is very experienced with caring for critically ill hospital patients (especially Trauma and Acute Care Surgery). Stephanie and I were on the phone and text messaging with colleagues in an effort to analyze Julie’s immediate options, and to chart out a plan.
In the Philadelphia region, the two principal Brain Tumor Centers are Thomas Jefferson University (TJU) and the Hospital of the University of Pennsylvania (UPenn). We began doing research and gathering recommendations from trusted Surgery colleagues as to the best neurosurgeon for difficult brain tumor cases. One name kept coming up time-after-time: Dr. David W. Andrews.
We worked with the ER staff and Director at the presenting hospital to prepare Julie’s case for emergency transfer to the Jefferson Hospital for Neuroscience (JHN). The On-Call Center at JHN accepted the case around 1:00am, and indicated that Dr. Andrews would take the case. Transfer of Julie’s EMR to JHN resulted in prioritization of her case to the Neuro ICU. Ambulance transfer of Julie from the local hospital ER to the JHN ER was arranged and completed before dawn. I met the ambulance at JHN around 5:30am.
The Symphony Goes to Work
Julie was moved from the JHN ER to the Neuro ICU. Within minutes, a steady stream of Neurosurgery Fellows, Residents, Nurses and Dr. Andrews began to evaluate Julie. All manner of neurological testing was performed and multiple imaging series were conducted. By noon, the JHN team had concluded that Julie did not need immediate neurosurgery, and that the best course to pursue would be (1) reduce the brain inflammation to address the aphasia and risk of herniation; (2) step Julie down to discharge on high dose corticosteroids and anti-seizure medicines; and (3) use the time to thoroughly plan Julie’s neurosurgery in order to perform a maximal safe resection of the GBM tumor while optimally preserving post-surgical function and quality of life.
Bottom Line: Expert assessment and care by a top shelf Neurosurgery team affiliated with an NCI-designated brain tumor center transformed a potential neurological emergency into a well-managed case with the opportunity to carefully plan a neurosurgery.
Dr. Andrews and His Team Plan & Execute the Neurosurgery
Over the next week, Dr. Andrews and his team performed a careful and detailed planning of Julie’s neurosurgery while she remained comfortably at home with her family. The communication from Dr. Andrews and his team was beyond great. Stephanie and I were included in pre-operative consultations of Julie’s fMRI and other imaging data as well as a detailed discussion of the neurosurgical plan and post-operative recovery plan. Owing to the fact that Julie (a) is left-handed* and her speech & language capabilities were clearly bi-hemispheral on the fMRI studies; and (b) the tumor margins were adequate enough to avoid direct resection in Broca’s Area, the decision was made to forego an awake craniotomy, which significantly shortens the operative duration, and generally is better tolerated by the patient.
From imaging, we could see that a Gross Total Resection of Julie’s GBM tumor would be impossible due to the involvement of the lenticulostriate vasculature. Therefore, the surgical planning emphasized maximization of post-surgical function and quality of life.
We cannot emphasize the above point enough, and we thank Dr. Andrews for his thorough discussion of the goals of the neurosurgery. In addition and because Dr. Andrews is a longtime researcher and Biotech entrepreneur in brain cancer, we were able to comprehensively discuss the integration of surgical and post-surgical options into the overall treatment plan for Julie, including the emphasis on preserving as much resected tumor tissue as safely possible in order to enable deep molecular and genetic profiling of Julie’s tumor.
This is why you go to a world class brain tumor center. Good enough is simply not good enough. There is no substitute for the best.
* Fun Fact: Lefties tend to have a much higher probability of bi-hemispheral distribution of speech & language function than righties. We are tempted to quip that this means lefties may have some excuse for talking out of both sides of their mouth.
Epilogue
Over a year after Julie’s neurosurgery, Dr. Andrews and I remain in touch. As a fellow Biotech entrepreneur, I understand and respect Dr. Andrew’s expertise and commitment to advancing brain cancer therapies in a manner that most people cannot. We consider Dr. Andrews to be a key player in the immunotherapy of brain cancers, and we will do everything that we can to assist his career goal of fundamentally transforming the therapeutic options available to brain cancer patients. After all, his goals are well-aligned with our goals at MissionGBM.