With quality treatment, Kennedy fought hard and long

By Stephen Smith
Globe Staff / August 26, 2009

E-mail this article

Invalid email address
Invalid email address

Sending your article

Your article has been sent.

  • Email|
  • Print|
  • Reprints|
  • |
Text size +

In those first, terrible days after his diagnosis, US Senator Edward M. Kennedy and his family knew that if they did not act swiftly and aggressively, the malignant tumor infiltrating his brain could kill him in as little as three months. Doctors told them as much.

So the patriarch of the storied political clan, a man who had made health care his legislative cause and his personal crusade, assembled a kitchen cabinet of medical advisers drawn from the high temples of cancer treatment.

He traveled to North Carolina for brain surgery. He took chemotherapy pills. He underwent radiation therapy delivered by a hulking, powerful machine whose acquisition by Massachusetts General Hospital was made possible, in part, by federal money Kennedy and other politicians garnered years earlier, long before a tumor known as a glioblastoma threatened his life.

It was, Kennedy acknowledged in a Newsweek cover story that appeared under his byline in July, “the best medical care money (and a good insurance policy) can buy.’’

The treatment the senator received appears to have extended his life, bestowing precious additional months to spend with his family and to witness glimmers of the health care overhaul he so fervently sought. “From the patient’s point of view, that year is invaluable,’’ said Dr. Keith L. Black, chairman of neurosurgery at Cedars-Sinai Medical Center in Los Angeles. “People can live a lifetime in that year.’’

But, in the end, brain cancer - an implacable, insidious foe - claimed another victim, despite all the privilege and power the senator could bring to the fight. From the frightening seizure in Hyannis Port last year that heralded the tumor’s existence, to the senator’s death Tuesday night, 15 months had passed, a period that mirrors the average life expectancy after diagnosis.

“It is, unfortunately, one of the most devastating forms of cancer,’’ said Dr. Todd Waldman, a neuro-oncology researcher at Georgetown University’s Lombardi Comprehensive Cancer Center in Washington. “Despite aggressive treatment, we are sadly limited in the extent to which we can extend patients’ lives.’’

And, with few exceptions, that is true for the richest patient as well as the poorest, said Dr. Kevin Yao, associate chief of neurosurgical oncology at Tufts Medical Center.

“I see plenty of patients who have limitless access to physicians around the world and access to a variety of different experimental treatments for glioblastoma,’’ Yao said. “And then I also see the other end, patients who have virtually no access and can barely be accepted for pro-bono treatment. I have to say, there’s no clear difference in prognosis in those two subsets of patients.’’

In that sense, Kennedy’s experience illuminates one of the thorniest economic and ethical issues besetting the nation’s health care system. Brain surgery alone can cost $80,000 for patients with a malignancy, one doctor estimated.

“How much is the extra time that we can give a patient worth when we know we cannot produce a cure - especially in terms of a national health care system, which the senator has been such an advocate for?’’ Black said.

In the Newsweek story - largely devoted to the national health care overhaul - Kennedy, whose office released little information about his illness, provided a rare glimpse into his battle with brain cancer.

Treatment typically starts with surgery, and Kennedy wrote that shortly after his diagnosis was confirmed on May 20, 2008, “surgeons at Duke University Medical Center removed part of the tumor.’’

Kennedy’s tumor sat in the left parietal lobe, a region crucial to speaking and understanding speech - two traits indispensable to a man in his professional position. Thus, Black speculated, surgeons probably were reluctant to remove sections of the tumor intertwined with those areas.

A malignant brain tumor is much like a wildfire, always seeking new territory to conquer. Surgery douses only the hottest part of the fire, the part evident on glowing medical scans, but hidden embers remain.

That is why doctors turn to chemotherapy and radiation.

Kennedy’s article recounted that he received “many rounds’’ of chemotherapy and that, at the time of publication, he continued “to receive treatment.’’ A pill called Temozolomide is the standard form of chemotherapy.

In recent months, another drug has entered the medicine cabinet of brain cancer patients: Avastin, first used in advanced colon, lung, and breast cancer. Unlike conventional cancer medication, Avastin starves tumors of the blood they need to flourish, a process called angiogenesis. Federal drug regulators in May approved its use for brain cancer.

But even those drugs are not enough to slow the tumor’s march. The cells that make up a brain tumor are stunningly diverse, meaning no one drug is likely to be a cure.

So patients typically also undergo radiation. Kennedy disclosed in Newsweek that he received proton-beam radiation at Mass. General.

With traditional radiation treatments, a beam enters a patient, disperses, and exits. It hits the targeted tumor but can also cause collateral damage to healthy tissue, an especially important consideration with brain cancer.

Proton-beam therapy, in contrast, is designed to be “much more controllable,’’ said Dr. Jerry Slater, chairman of the Department of Radiation Medicine at Loma Linda University in California.

The actual treatment takes only two to three minutes, but positioning patients to make sure the beam lands on the right spot can take half an hour or longer. For each treatment - and patients typically undergo 25 to 35 sessions - patients don a mask designed exclusively for their head.

At present, just six US medical centers offer proton-beam therapy. Depending on their size, proton treatment facilities are estimated to cost $80 million to $150 million to build and equip.

Whether proton-beam therapy provides an advantage over conventional treatment is a topic of considerable debate. Dr. James Cox, head of radiation oncology at M.D. Anderson Cancer Center in Houston, conceded “the data are not as good as many people would like - they haven’t been gathered in the way that people who are purists like to see them.’’

Specifically, he said, most research has not involved randomly assigning some patients to proton therapy, others to traditional radiation, and then seeing who lives longer. But, Cox said, by looking at sophisticated images of the brain, doctors can see that proton therapy spares healthy tissue, which suggests a reduction in side effects.

Other doctors remain less convinced, arguing there’s not sufficient proof the technique helps more than standard radiation, and, therefore, questioning whether it’s worth the additional cost; proton treatments cost roughly a third more than conventional radiation.

There’s no way to know whether proton therapy extended Kennedy’s life. But there is substantial evidence that, taken together, surgery, chemotherapy, and radiation can turn a prognosis of a few, short months of life into longer than a year.

“What we’ve seen in the last 10 years is a more than doubling of the median survival time, to about 20 months,’’ said Dr. Henry Brem, director of neurosurgery at Johns Hopkins Hospital in Baltimore. “On the other hand, 20 months is still a horrendous disease.’’

Stephen Smith can be reached at