Doctors point to difficult road ahead
Senator Edward M. Kennedy, who built a storied career on Capitol Hill as a warrior, has never faced a foe like this.
What began Saturday as a mysterious seizure turned out to be a deadly brain tumor in the left parietal lobe, an area involved in language, perception, and other higher level mental functions.
Doctors treating Kennedy at Massachusetts General Hospital released few details yesterday about his condition, but cancer specialists in Boston and around the country said that people with his type of tumor live on average less than three years after the diagnosis. Some can live years longer, some less. There is no cure.
"Certainly one of the worst diagnoses that someone can be told is that you have a malignant brain tumor," said Dr. Keith L. Black, chair of the department of neurosurgery at Cedars-Sinai Medical Center in Los Angeles. The brain "is the very essence of who we are."
Though brain tumors affect patients in highly variable ways, one possible consequence with parietal lobe tumors is impaired speech and movement.
In the short term, the diagnosis from Mass. General - malignant glioma - means that Kennedy and his doctors face a series of difficult options. In a statement yesterday, doctors mentioned chemotherapy and radiation as possible treatments that could temporarily beat back the cancer. The doctors might also consider new experimental treatments showing promise in clinical trials.
Some brain cancer patients also undergo surgery that, though it offers no cure, can reduce symptoms.
With treatment, most patients stricken with brain tumors "do well at first and have a good period," said Dr. Carl Heilman, chair man of neurosurgery at Tufts Medical Center. "The tumor is generally well-controlled, and people can live a pretty much normal life.
"The question is: How long does that continue?"
Yesterday, the senator showed no symptoms as he talked, walked, and laughed at the hospital, associates said. He has had no further seizures, his doctors said in a statement.
Those are good signs, said Dr. Eric T. Wong, codirector of the Brain Tumor Center at Beth Israel Deaconess Medical Center.
Malignant glioma is the most common primary brain tumor in adults, striking about 9,000 people a year in the United States.
Kennedy, 76, and his family were told of the tumor late Monday, associates said. The diagnosis amounted to a worst-case scenario among all the possible explanations for the seizure he suffered Saturday morning at the Kennedy compound in Hyannis Port. Only perhaps one in 20 people in Kennedy's age group who first have seizures end up being diagnosed with a brain tumor, said Dr. Steven Schachter, an epilepsy specialist at Beth Israel Deaconess.
A stroke seemed a more likely cause because Kennedy had undergone surgery last October to clean out a plaque-narrowed artery in his neck, which put him at high risk for a stroke. But because of Kennedy's age, once preliminary tests at Mass. General ruled out a stroke as the cause of his seizure, his doctors almost certainly began homing in on a tumor as a leading suspect, specialists not involved with the senator's treatment said.
"With a seizure in an older person," said Dr. Henry Brem, director of neurosurgery at Johns Hopkins School of Medicine in Baltimore, "we like to say it's a brain tumor until proven otherwise." A seizure is often the first symptom of brain cancer.
Doctors almost certainly took sophisticated snapshots of the brain, to aid their diagnosis, typically taken by a magnetic resonance imaging machine. Such scans can show what appear to be growths, but doctors can't know for sure what they're dealing with. In their statement about Kennedy's condition, his physicians said a biopsy was performed on the growth.
Cancerous brain tumors are typically graded on a scale of 1 to 4, with 4 being most serious, specialists said. Kennedy's tumor is described by his doctors as "a malignant glioma," which, by definition, means it is a grade 3 or 4 growth.
After the biopsy results were received, Kennedy's doctors confronted a daunting set of options.
"The first thing that's going to be considered is: Is it an operable brain tumor," said Dr. David Rosenthal, a past president of the American Center Society who is affiliated with Dana-Farber Cancer Institute. "How much normal tissue would you have to take out?"
The statement from the Mass. General team does not mention surgery as an option. That could be telling, outside specialists said.
"If the tumor is invading into the language and the motor areas, then he may not be a candidate for surgery," said Black. Surgeons, Black said, will operate only "if we can get in through a pathway of the brain and remove all the tumor we see on the MRI scan without damaging those critical areas."
The tumor may be near brain areas involved in communication, Wong said, "and Senator Kennedy needs to be able to communicate with his constituents."
Regardless of whether surgery is performed, many patients with brain tumors receive radiation, usually undergoing treatments five days a week for about six weeks.
It cannot eliminate a tumor, said Dr. Patrick Wen, clinical director of the center for neuro-oncology at Dana Farber Cancer Institute, but "it buys time." Radiation treatment leaves some patients fatigued, and some lose hair. Others feel the effects less.
"It hurts just as much as a chest X-ray, which is to say, not at all," Brem said. "We have a lot of patients with malignant gliomas who come into the hospital at 8 o'clock in the morning and they leave by 8:30 and then spend a full day at work" after getting radiation.
Also, Wen said, patients usually undergo chemotherapy in pill form, for as long as six months to a year. He said the pills, called Temodol, were "relatively well tolerated," but they can occasionally cause side effects, such as lowered blood counts, leaving patients tired and susceptible to infections.
Specialists said it is almost certain that sophisticated genetic analyses of Kennedy's tumor will be done to tailor treatments so they are most effective.
There has been some recent progress toward new treatments for malignant gliomas, Wen and others said. One new option still being tested is Avastin, a drug meant to cut off a tumor's blood supply. 