Kennedy hand-picked a surgeon who takes on tough operations

By Stephen Smith and Carey Goldberg, Globe Staff

By choosing to have brain surgery at Duke University, Senator Edward M. Kennedy appears to have opted for an aggressive attack on his malignant tumor, by a hand-picked surgeon at a treatment center whose motto is "There is Hope."

Specialists say that Duke is among the top brain tumor centers around the country, and that Kennedy’s neurosurgeon, Dr. Allan H. Friedman, is a renowned leader in the field.

"They have all the pieces," said Dr. John Park, head of surgical neuro-oncology at the National Institute of Neurological Disorders and Stroke. "They have excellent surgery and a wide range of experimental chemotherapies that can be offered after surgery."

A colleague of Friedman's at Duke, Dr. David Reardon, said Friedman pioneered many of the approaches for operating on difficult-to-reach brain tumors. He is especially adroit at removing tumors without causing collateral damage to healthy brain tissue that can rob patients of the ability to speak or move, said Reardon, a neuro-oncologist who was interviewed at the American Society of Clinical Oncology annual meeting in Chicago.

"The advantage with Dr. Allan Friedman, or one of the compelling considerations, is his lifelong commitment to operating on these difficult, very tricky located tumors," said Reardon. "Because of his extensive experience, he typically will operate on tumors that many neurosurgeons are not comfortable operating on. ... It's not something they deal with day in and day out. It certainly is for him."

Cancer specialists not affiliated with Duke echoed Reardon's comments, describing Friedman as charismatic and a maverick.

Specialists also said that Kennedy's level of comfort with Friedman may have been a factor in his decision.

Dr. Howard Fine, chief of the neuro-oncology branch of the Center for Cancer Research at the National Cancer Institute, said there are 10 or 20 top brain tumor centers in the country, including Massachusetts General Hospital.

"And I think what it came down to is where the senator and his staff felt most comfortable," said Fine, who was among cancer doctors that Kennedy and his staff consulted in recent days about the best treatments.

Kennedy’s doctors at Massachusetts General Hospital did not describe surgery as a likely option when they announced last month that he had a malignant glioma on the left side of his brain. In a statement on May 20, they mentioned only radiation and chemotherapy as "the usual course of treatment."

But in recent days, Kennedy and his family conferred with a constellation of top national cancer specialists. Today’s announcement that Kennedy was undergoing surgery at Duke suggested that they had decided that they were willing to incur the risks of surgery in hopes of slowing the tumor's progression.

Successful "resection", or surgical removal, of a brain tumor before radiation or chemotherapy can significantly improve a patient’s outlook, said Dr. Eric T. Wong, co-director of the Brain Tumor Center at Beth Israel Deaconess Medical Center. Ideally, 90 percent of the tumor is removed.

"But obviously, in surgery there are things that can go wrong; patients can have a stroke, infections, bleeding. There are risks of not doing surgery and risks of surgery, and the job is to balance out the risks toward the more favorable scenario." Removing a brain tumor can damage adjacent healthy tissue, causing various forms of disability, depending on the tumor's location.

Along with the usual risks, Kennedy’s surgery was also highly delicate because the area where doctors found the tumor -- in the upper left portion of his brain -- is also an area important for language functions such as speaking and understanding others.

But the three-and-a-half-hour surgery went well, according to a statement released this afternoon by Friedman. "I am pleased to report that Senator Kennedy's surgery was successful and accomplished our goals. Senator Kennedy was awake during the resection, and should therefore experience no permanent neurological effects from the surgery," the statement said.

Because the brain has no nerves that sense pain, Kennedy could be kept awake during the operation. This allows doctors to stimulate spots of the brain with electrodes to be sure they are not about to cut out anything critical.

Before the operation, specialists said, Kennedy’s surgeons likely mapped his brain, probably with a “functional” MRI scanner that could help pinpoint his language center and other spots, such as those that control movement, that must remain unharmed if he is to function well afterward.

Kennedy could spend as little as two days recuperating in the hospital or as long as a week, said Fine of the National Cancer Institute, who was interviewed at the Chicago cancer meeting.

Though brain surgery sounds traumatic, he said, "patients in fact recover quicker, generally speaking, from brain surgery than they do from abdominal or chest surgery." The main reason is that the brain does not feel pain, he said, "so patients are commonly up and around 12 to 24 hours after their surgery," and if they’re feeling comfortable and have no complications, "there’s really no reason to keep them in the hospital."

Fine said that his advice to Kennedy had been to talk to different surgeons and "just find where you feel most comfortable."

"Obviously," he added, "if someone is operating on your brain, you have to have supreme confidence in them. And more than just confidence, you have to have a connection with them. It’s obviously an intimate relationship. You’re putting literally your life in someone’s hands.

"And more than just your life, your functionality, your cognitive abilities, so many things that make you who you are," Fine said. "So you have to be supremely comfortable with this individual. Beyond having a good reputation and being at a good center, it really comes down to personal connections. And I assume the senator made that connection with Dr. Friedman."

Friedman was among cancer specialists who met with Kennedy Friday at Mass. General. The chief of the division of neurosurgery at Duke University Medical Center, the 59-year-old Friedman is a Chicago native who graduated from Purdue University in 1970 and received his medical degree from the University of Illinois in 1974. He was appointed to the faculty at Duke in 1981.

The Kennedy family has a track record of being aggressive in its approach to cancer. For example, after the senator's daughter, Kara, was diagnosed with lung cancer in 2003, she was initially told the tumor was inoperable by doctors at Johns Hopkins University. She then sought treatment at Brigham and Women's Hospital in Boston, where surgery was performed.