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OneThousandOne represents the amount of time, verbally, that it takes to count to one second. In this one second of time, a great thing happened at Nebraska Medicine. In fact, several great things probably happened. A patient was cured, a researcher found the missing link, a nurse treated an injury, a doctor comforted a family or maybe a child just smiled.
MOMENTS IN MEDICINE
Winter | 2014

Keeping Hope Alive

Personalized Brain Cancer Treatment

No one wants to hear the word cancer. But if there is one cancer that you would least like to hear come from your doctor’s mouth, it would probably be brain cancer.

While brain cancer is very rare, affecting less than 1 percent of the population, it also has one of the least favorable outcomes.

Craig Harrison, RN, is very familiar with these facts. Not only is he a nurse, but he often cares for brain cancer patients on the neuro intensive care unit at The Nebraska Medical Center.

Craig Harrison
Craig Harrison

In 2012, when Harrison was just 26 years old, brain cancer became a very intimate part of his life.

Harrison was working in the neuro intensive care unit at The Nebraska Medical Center, doing a little home remodeling on the side and playing golf in his free time. He was planning to go back to school to become a nurse anesthetist and had dreams of having a family of his own and traveling the world. At 26 years old, life was carefree and full of hope.

On a beautiful fall day in September 2012 Harrison met his friends to play golf. The game came to an abrupt end, however, when at the par 3, 2nd hole, Harrison felt a strange sensation pass through his body before falling to the ground.

“All I remember from that point was trying to tell my friends that something wasn’t right, but I was unable to speak to them and unable to move,” recalls Harrison. “The last thing I remember is falling over, and then waking up on my back looking at the bright blue sky above and hearing peoples’ voices telling me that I had had a seizure.”

His friends called 911 and Harrison was taken to The Nebraska Medical Center. After undergoing a series of tests, doctors determined that Harrison had suffered a seizure that they suspected may have been triggered by a primary brain tumor — difficult news to swallow for a 26 year old with a full life ahead of him.

Fear initially engulfed him, Harrison says. But that eventually subsided when he met neuro-oncologist Nicole Shonka, MD, who would lead his treatment and care plan. “I was very comfortable with her from the first time we met and confident in her care,” he says. “She immediately put me at ease and I weighed her advice very heavily in my decisions.”

Nicole Shonka, MD

Dr. Shonka is the only fellowship-trained neuro-oncologist in the state who specializes in brain tumors. An assistant professor in Oncology/Hematology at the University of Nebraska Medical Center (UNMC), she joined the staff in 2010. Dr. Shonka received her medical degree from UNMC where she also completed her residency and general oncology fellowship. Then she went to MD Anderson Cancer Center at the University of Texas where she completed an additional neuro-oncology fellowship. MD Anderson is one of the top cancer centers in the nation and has a highly respected neuro-oncology fellowship — one of a few programs in the country. The program draws from a large population base that allows it to see up to 3,000 primary brain tumors a year. “Receiving training where you can see a large volume of patients exposes you to many more brain tumors, including the rarer ones,” notes Dr. Shonka.

“This is important since brain tumors are so rare. And because there are many nuances in this field, you may not be aware of these unless you have that additional training.”

Neuro-oncologists also have an increased familiarity of the central nervous system and anatomy and how that relates to the patient’s treatment and response. They are trained to read imaging scans and to identify when slight changes in the scans are clinically meaningful and when they are not, she says.

An MRI scan showing Craig Harrison’s brain
tumor

Unlike most neuro-oncologists, Dr. Shonka completed her oncology fellowship first rather than beginning with a neurology fellowship. She believes this has given her a stronger foundation in the treatment and management of cancer, cancer drugs and their side effects.

“I’m more comfortable with thinking outside of the box and in handling a combination of medications that might be daunting to others,” she says.

Brain tumors can be both difficult to diagnose and to treat. There are more than 120 different types of brain tumors that can have varying symptoms ranging from a headache to memory loss or seizures, depending on the tumor’s location in the brain. These symptoms often mimic other neurological conditions. An MRI or CT scan is usually required to screen for the diagnosis. If a tumor diagnosis is confirmed, surgery is required to determine the type and grade of the tumor.

“I’m more comfortable with thinking outside of the box and in handling a combination of medications that might be daunting to others.”
Nicole Shonka, MD

Treatment typically involves surgery followed by radiation therapy and/or chemotherapy. Pseudo-progression and radiation necrosis are two conditions that can develop during cancer treatment that can be misinterpreted by the untrained eye and affect the treatment regimen.

“Glioblastomas (the most common type of brain tumor) often present pseudo-progression the first several months after treatment,” explains Dr. Shonka. “Pseudo-progression is an increase in contrast on the MRI that does not represent true tumor growth but that could easily be misinterpreted by someone unfamiliar with these cancers as evidence that the treatment is uneffective.”

Some patients may also develop radiation necrosis, which also can appear to be additional tumor growth, she says.

Craig Harrison

Adding to the complexity of treating brain tumors is the sensitive real estate that generally surrounds the tumor. “Tumors can affect your eyesight, speech, hearing, memory and can even alter your personality,” says Dr. Shonka. “This can sometimes limit us from even being able to biopsy a tumor.”

After Harrison’s diagnostic tests were completed, Dr. Shonka discussed the results of the tests with him and her thoughts about the type of brain tumor she thought he had. The only way to know for sure, she said, was by undergoing surgery to biopsy the tumor. The surgeon would also remove as much of the tumor as possible at this time. Harrison’s tumor was wrapped around the sensitive areas of the brain that influence speech, a factor that would affect how much of the tumor could be removed.

Neurosurgeon Daniel Surdell, MD, was scheduled to perform the surgery, a surgeon with whom Harrison had worked side-by-side at the medical center. If anything, he knew that he had the best team on his case.

This chart shows the types and relative
frequency of all malignant brain tumors
in adults. Harrison was diagnosed with an
oligodendroglioma, one of the rarest forms

The results of the surgery confirmed Dr. Shonka’s suspicions. Harrison had a 3 cm, golf ball-sized anaplastic oligodendroglioma, a slow-growing brain tumor that usually occurs in young adults. These tumors are frequently located within the frontal, temporal or parietal lobes and cause seizures in a relatively high percentage of patients.

It was a tumor that Dr. Shonka had treated several times before. Not only that, she said new research revealed that the survival rate had jumped from 7.5 years to 15 years or more with a treatment regimen that included both chemotherapy and radiation therapy.

This was promising news when you consider the most common type of brain tumor — glioblastoma — that makes up 50 percent of all malignant brain tumors, has an average survival rate of just 18 months. And there was more good news. Harrison had a mutation that also pointed to a more favorable outcome.

“Craig was in the right place at the right time,” says Dr. Shonka. “A couple of years ago, we would have treated him completely differently. Almost all of the tumor was resected and he had a very good response to chemo and radiation. His outlook is very good.”

Nicole Shonka, MD

Harrison took a 12-week leave of absence from work after surgery during his chemotherapy and radiation treatments. But laying around and feeling sorry for himself was not a part of Harrison’s agenda. To keep himself busy, he started putting in more hours at his friend’s construction business. “I’ve always enjoyed building things and it was a blessing to spend a few hours each day working with my hands while I was recovering from surgery, going through chemo and radiation,” he says. “I helped him with home remodeling projects, roof repairs and we even ‘flipped’ a house. I could work as little or as much as I wanted and it really helped keep me busy and build my stamina.”

While advancements in the treatment of brain cancers have been slow, there has been progress and Dr. Shonka is confident new advancements are just around the corner.

“In the past 10 years, we have developed better chemotherapies for treating brain cancers that have helped improve survival rates for nearly all cancer patients,” says Dr. Shonka. “This is a big step forward because we are very limited in the number of chemotherapies available to treat brain tumors due to the blood brain barrier.”

The blood brain barrier is a semipermeable protective tissue around the brain that maintains a constant and safe environment for the brain by regulating what passes in and out.

Other advances lie in the realm of personalized medicine, in which cancer treatment is based on a person’s unique genetic makeup. In brain cancers, this includes the discovery of molecular markers that can provide both prognostic data — how well a patient will do based on the type of tumor he or she has and predictive data — what therapies will be most effective in treating the tumor. Scientists have also discovered variances in the molecular features of glioblastomas that have allowed scientists to classify the tumors differently. This is spurring the development of personalized therapies based on these classifications.

“We are currently studying certain enzymes which can help predict a patient’s response to therapy or provide us information about their prognosis,” says Dr. Shonka. “This will help us determine what therapies to use and how aggressively to treat a patient.”

Dr. Shonka is involved in several research studies — one is to determine whether certain bio-markers can indicate tumor growth, radiation necrosis or pseudo progression. Another study is looking at how recurrent glioblastomas will respond to continuous chemotherapy with high dose vitamin C.

As Harrison’s energy and stamina returned, he began working half days in the neuro intensive care unit and graduated to full days by July. He continues to work at his friend’s construction business and is back on the golf course perfecting his swing.

“High dose vitamin C has been shown to be toxic to certain tumor cells, including those in glioblastomas, with negligible side effects to other cells,” she says.

Research will reach a new level at The Nebraska Medical Center with the building of the new Fred & Pamela Buffett Cancer Center, which is expected to be open in 2017. A joint project of The Nebraska Medical Center and the University of Nebraska Medical Center, the Fred & Pamela Buffett Cancer Center will include three areas dedicated to cancer: a 10-story, 98-laboratory research tower named the Suzanne and Walter Scott Cancer Research Tower; a seven-story, 108-bed inpatient treatment center named the C.L. Werner Cancer Hospital; and a multidisciplinary outpatient center.

Not only is Harrison helping to spread
more awareness about brain tumors,
but he is using his own experience to
give his life new purpose and to
help others change fear to hope.

“With the new Fred & Pamela Buffett Cancer Center, we will all be housed in greater proximity which I believe will foster more collaboration among clinicians and researchers and should help expedite new advances from basic sciences research to the bedside,” says Dr. Shonka. “From a patient perspective, it will also provide a more patient-friendly environment as patients will be able to have all of their care provided in one building, which is especially important for cancer patients who may be fatigued and lack energy due to treatment.”

As Harrison’s energy and stamina returned, he began working half days in the neuro intensive care unit and graduated to full days by July. He continues to work at his friend’s construction business and is back on the golf course perfecting his swing.

While the words brain tumor are still a little unsettling to Harrison, he now speaks these words with a new purpose and sense of hope.

“I have a new perspective on nursing and taking care of patients who are going through what I have gone through,” he says. “Now I can relate to my patients better and it gives them a sense of ease and provides them hope to see that I’ve been where they are.”

Knowing that he has the best team on his case is also reassuring. “I feel very confident in the team that is helping me battle this brain tumor,” he says. “We have the best treatment team for brain tumors in Nebraska and the surrounding region right here at The Nebraska Medical Center.”

Harrison also started a nonprofit foundation called Save the Brain Campaign to help raise awareness of brain cancer and to increase research. “Being a neuro intensive care nurse and a neuro patient, I didn’t feel that there was any awareness in the community about brain tumors,” he says. “I feel like I’ve been given the opportunity to make something bigger out of this experience. Now I try to promote brain tumor awareness everywhere I go.”

Next article in the Winter | 2014 issue of One Thousand And One:
Leading the Revolution