Rapport with pioneer surgeon leads to the senator's choice

Dr. Allan H. Friedman is Duke's chief of neurosurgery.

For his brain surgery yesterday, Senator Edward M. Kennedy turned to a bold doctor known for his willingness to operate when others might not and to a treatment center at Duke University whose motto is, "There is Hope."

Massachusetts General Hospital, where Kennedy has received care until now, is as expert at treating brain tumors as Duke, cancer specialists said, but the senator was at least partly swayed by a personal connection with the charismatic Dr. Allan H. Friedman.

Duke is among the top brain tumor centers in the country in both research and care, offering a wide array of clinical trials of novel treatments.

"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 damage to adjacent healthy brain tissue that can rob patients of the ability to speak or move, said Reardon, a neuro-oncologist who was interviewed in Chicago at the annual meeting of the nation's leading organization of cancer specialists.

"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."

For Kennedy, the decision was about more than expertise, however. The senator had formed an instant rapport with Friedman during phone conversations and a meeting Friday at Mass. General.

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 Mass. General.

"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.

According to one Kennedy intimate, Friedman and the senator began talking shortly after he was diagnosed with a malignant tumor two weeks ago, as Kennedy, his wife, and former aides were reaching out and talking to elite brain cancer doctors and surgeons across the nation.

Friedman and Kennedy talked multiple times by telephone, the intimate said, and first met last week, all the while forming a bond that continued to get stronger. They were together at the Friday meeting, during which the final decision was made for Kennedy to have the surgery at Duke.

That intimate discounted clinical trials as the reason Kennedy chose Duke, saying that Kennedy may end up participating, but he was drawn to the hospital not by the drugs, but by the doctor, his expertise, and his proposed treatment.

Kennedy's doctors at Mass. General did not describe surgery as a probable option when they announced that he had a malignant glioma. In a statement on May 20, they mentioned only radiation and chemotherapy as "the usual course of treatment."

Kennedy's tumor was located in a region of the brain involved with language and movement, and surgery is typically not recommended if the risk of harm to such sensitive areas is too great.

The fact the senator was willing to have surgery done - and not at Mass. General where he has long received medical care - is a mark of his comfort with Friedman, as well as his desire for aggressive treatment.

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, codirector of the Brain Tumor Center at Beth Israel Deaconess Medical Center. Ideally, 90 percent of the tumor is removed.

Still, the tumor usually grows back eventually, and it's not clear how much surgery extends a patient's life.

Friedman issued a statement yesterday saying the surgery went well and "accomplished our goals."

He did not specify those goals, but "the idea here is to do a maximal, safe tumor removal," said Dr. Mark Gilbert, a neuro-oncologist at M.D. Anderson Cancer Center in Houston.

Kennedy's doctors and relatives declined to provide further information on his surgery.

A secondary goal of the operation may have been to obtain fresh tumor tissue for use in a clinical trial, said Dr. Keith L. Black, chairman of the Cedars-Sinai Medical Center Department of Neurosurgery in Los Angeles. Duke is working on an experimental brain tumor vaccine that takes the patient's own immune defenses and turns them against the tumor. A small Duke-led study presented at the Chicago meeting yesterday described the vaccine as promising, but the authors cautioned that larger studies are needed to confirm the results.

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 meeting of the American Society of Clinical Oncology.

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 described Friedman as "very confident, calm, intelligent."

Friedman, 59, is chief of the division of neurosurgery at Duke University Medical Center. A Chicago native, he graduated from Purdue University in 1970 and received his medical degree from the University of Illinois in 1974.

In 1981, he was appointed to the faculty at Duke.

Jack Walder, of Cary, N.C., said his 25-year-old son, Jason, has visited Duke every year since he was 11 to be screened for a possible recurrence of a medulloblastoma brain tumor. Surgeons at a Long Island hospital removed the tumor when he was 4.

The medical staff at Duke, he said, is uncommonly supportive. The radiation and chemotherapy Jason had after surgery had serious side effects, stunted growth and short-term memory loss.

"Ted couldn't be at any better place," said Walder. "If he was somebody just off the street, he would have gotten the same incredible care."

Jonathan Saltzman of the Globe staff contributed to this report. Smith can be reached at stsmith@globe.com; Goldberg at goldberg@globe.com.