A busy real estate broker and married mother of three, Susan van der Griend is an optimist by nature, used to making things happen and moving on. When she was diagnosed with melanoma in 2017, she decided to be treated near her home in Connecticut. But a positive outlook didn’t stop the cancer. The disease recurred in four places. She went straight to Memorial Sloan Kettering.
“There’s always somebody working on a new approach to cancer treatment there,” says the 64-year-old.
Susan was given immunotherapy under the care of MSK melanoma medical oncologist Parisa Momtaz. Her cancer seemed to clear. But in 2020, a CT scan showed three new lesions in her brain. “I felt betrayed by my body,” she recalls. “I thought, ‘How could this happen when the cancer had cleared up in the rest of my body?’ My glass is always half full, but this was a setback.”
In the past, news like this was assumed to be the beginning of the end for a patient. But MSK doctors are treating metastatic brain cancer aggressively — and getting good results.
Storming the Fortress
The brain is like a fortress, surrounded by a barrier that protects it from dangerous pathogens. But that same barrier is also what prevents cancer medicines from reaching their target. What’s more, cancer cells can sneak inside, like tiny Trojan horses, by following the cells that are allowed into the brain. The cancer can also express molecules that latch onto the brain’s gatekeeper — like talking their way past security.
But efforts are underway to find the leaks in this barrier, says Adrienne Boire, physician-scientist in MSK’s Human Oncology and Pathogenesis Program. With the help of a liquid biopsy, which is a blood test that can detect DNA from a brain tumor, her lab is also gaining new insight into how brain tumors evolve.
Having this precious DNA gives clinicians the ability to detect hundreds of genes that drive tumor growth. The goal is for doctors to determine the best targeted therapy for a tumor without having to obtain a tissue biopsy from the brain.
These discoveries offer great promise for future therapies, but there is also progress right now. Susan’s cancer has been kept in check by immunotherapy, radiation, and surgery.
Care for the Whole Person
“When a cancer spreads to the brain, it creates enormous challenges, clinically and scientifically, but also psychologically for the patient,” says Viviane Tabar, Chair of the Department of Neurosurgery and Theresa Feng Chair in Neurosurgery.
Dr. Tabar helped establish a new Multidisciplinary Brain Metastasis Clinic that applies a highly efficient team approach for patients like Susan. Experts from many fields study a patient’s case and recommend next steps. To make the experience as easy as possible, they organize appointments — including radiation, if needed — to be done all in one day. This collaborative approach is also offered to patients whose primary oncologist is outside MSK.
Like detectives mining a crime scene, MSK specialists from neurosurgery, radiation oncology, neuroradiology, medical oncology, physical therapy, and more pored over Susan’s case in 2020. They discussed her case at their Brain Metastasis Tumor Board, a newly assembled group of specialists who are focused on treating cancers that spread to the brain.
“She’s in a growing population of patients who have done incredibly well on cancer therapies but have tenacious metastases in the brain,” says neurosurgeon Nelson Moss, the center’s surgical lead.
Kathryn Beal, the tumor board’s lead radiation oncologist, recommended stereotactic radiosurgery for Susan. This high-dose form of radiation was pioneered at MSK. Administered close to Susan’s home at MSK Westchester, the radiation shrunk each tumor, eliminating the activity in two of them.
The third mass was about the size of a walnut, in the part of the brain controlling perception and walking. It was harder to treat and had started to affect her leg function. But Dr. Moss and his colleagues came up with a surgical plan. They also told Susan she could choose to have the tumor monitored over time. The decision was up to her.
“He was very balanced in his approach and clearly pointed out each option. He wasn’t pushing me either way,” she recalls. “He said, ‘This is why I think this is a good idea, but I can understand why you might want to wait.’ But I didn’t want the problem with my leg to persist or get worse.”
In a three-hour procedure, Dr. Moss was able to remove all of the tumor. Susan returned home the very next day. A few weeks later, she had another round of radiation to kill any lingering cancer cells. She has otherwise needed no additional treatment and has regained function in her leg. She checks in with Dr. Moss every three months.
Susan is back at work, with her sunny attitude and sense of humor, despite all she’s endured. When asked if she’d ever considered that melanoma could one day spread to her brain, she replied, “It didn’t even enter my head. Well, I guess it did!”
Dr. Moss is optimistic about Susan’s prognosis and hopeful for other patients like her.
“She and all our patients inspire us to make brain metastasis a condition that can be cured and ultimately prevented,” says Dr. Moss. “We hope that MSK’s Multidisciplinary Brain Metastasis Clinic will bring us closer to that goal.”