Moving the Needle on Brain Tumor Treatment

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Inspired by Family

Henry Brem’s parents were Holocaust survivors. They came to New York when they were 20 years old after every member of their respective families had been murdered by the Nazis. They had little education; the Nazis invaded their native Poland when they were both 14. And yet, “they came with a joy to this country in 1949, and a tremendous ambition,” he said.

They had a passion for learning and imbued their four children (two professors of neurosurgery, one a professor of surgery and one a periodontist) with the Jewish ethical values of tikkun olam, or making the world a better place, of love for all of mankind, and of the value of life.

Throughout his career, Brem said his love for family — especially for his wife of 46 years, breast cancer specialist and radiologist Rachel Brem, and their three daughters — has had an enormous impact on the way he thinks about his patients and their families.

In four decades on the Johns Hopkins faculty, Henry Brem has built one of the largest and most distinguished brain tumor research and treatment centers in the world. He has transformed the field of neurosurgery by pioneering the use of navigational imaging, and by inventing and developing Gliadel wafers, which use biodegradable polymers that deliver chemotherapy directly — and with more potent therapeutic impact than systemic chemotherapy — to malignant tumors in the brain.

Brem is the Harvey Cushing Professor of Neurosurgery, director of the Department of Neurosurgery and neurosurgeon-in-chief of The Johns Hopkins Hospital. He is professor of oncology, ophthalmology and biomedical engineering. He has mentored numerous neurosurgeons — at least 20 are chairs of neurosurgery departments around the country. And he resurrected and runs Harvey Cushing’s Hunterian Neurosurgery Laboratory, where he has trained researchers who have gone on to further advance the most promising approaches to treating brain cancer.

Yet, for Brem, it is all “good, but not good enough.” The median survival for glioblastoma has doubled since he joined the Johns Hopkins faculty in 1980, but today it is still less than two years.

In a moving talk he delivered recently as part of CIM’s series of seminars on humanism in medicine, “Research as an Imperative for Clinical Excellence,” the renowned neurosurgeon made a powerful case for the importance of the role of physician-scientist in humanizing medicine — for providing the best available treatment while working persistently in the lab (and sometimes even in Congress to get Medicare to pay for vital new therapies like Gliadel) to pursue the holy grail of more effective treatment.

Overcoming Emptiness

Brem said that he discovered the joys of research as an undergraduate at New York University. The summer after his freshman year, he worked in a molecular biology laboratory while also getting up at 5:30 a.m. to accompany medical residents at Columbia on rounds. He avidly read up on their cases and could often answer questions they couldn’t. So they invited him to join them in the operating room. “It was very exciting to do so,” he says.

He chose neurosurgery because he wanted to have maximum impact on patients’ lives, and he spent his years in medical training mastering neurosurgical medicine and technique. “And I was very nervous,” he said. “I’d wake up early before I operated, I’d restudy the anatomy, the technique.” Brem was delighted and relieved when he quickly built up a large practice, offering his patients “the best that was available in medicine at the time.”

Yet he felt what he described as “a huge emptiness.” Patients were coming great distances with malignant brain tumors, and “we formed these incredible bonds, and then they died.” When he apologized for letting them down, they reassured him. “‘We know that you’re working on making it better… we want to be part of that process.’” So he felt, and continues to feel, a great moral obligation to honor them by finding better treatments.

Promise on the Horizon

When Brem decided to specialize in brain tumors, at least one mentor tried to discourage him. “The FDA had not approved any new therapy for brain tumors in over 20 years, and the median survival [of 9 months] had not changed from Cushing’s time,” Brem said.

But, inspired by his patients, he worked tirelessly to pioneer new therapies and improvements in imaging and surgical techniques. Clinical research led by Brem and other physician-scientists has more than doubled median survival and increased long-term survival. “On the one hand, that’s very satisfying because it shows that with scientific approaches, we could change something that had never been changed before,” he said. “On the other hand, it’s terrible. Twenty months is still dismal.”

Yet his hope is that by persisting in the lab, “we will eventually, with incremental improvements, see this turned into a chronic, manageable disease.” Inspired, for instance, by a glioblastoma patient who has survived for decades without recurrence — possibly because a serious post-operative infection stimulated his immune system — his team at Johns Hopkins has launched clinical trials to test a promising combination of his trademark localized delivery of chemotherapy and an immunotherapy drug.

“It’s not a one-man show like it was in Harvey Cushing’s time,” said Brem as he concluded his talk with a slide emblazoned with a single word: Gratitude. Gratitude, not only for “the privilege I’ve had in working with great people, both as a student and all through my career,” but for the patients “who give me the stimulation to help move the needle forward.”

May 8th, 2024

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Tales of Joy in Geriatrics

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A Golden Career in Geriatrics

As the longtime director of the Johns Hopkins Division of Geriatric Medicine and Gerontology, John Burton promoted the revival of the house call for homebound older patients, as well as a team-based approach to their care, which helped lead to programs like Johns Hopkins Home-Based Medicine (JHOME) and Hospital at Home. He promoted geriatric research and geriatric education across specialties, leading to the Orthopedic–Geriatric Medicine Hip Fracture Service. He was director of the Geriatric Education Center and Consortium, and developed the fellowship program in geriatrics. He won countless awards for his pioneering work, and the Johns Hopkins Health System renamed the Johns Hopkins Care Center the John R. Burton Pavilion in 2003.

During his “Tales of Joy” CIM Seminar, Burton talked about collaborating for 40 years with Johns Hopkins Bayview nurse Jane Marks, now associate director of the Johns Hopkins Geriatric Workforce Enhancement Program. Their demonstration project providing hospital-level care for patients at home — an initiative supported by the John A. Hartford Foundation — became, under the leadership  of geriatrician Bruce Leff, Hospital at Home, an innovation now used in 150 places around the country and in countries around the world. “It was a terrific partnership,” Burton said. “She certainly made me a much better physician.”

“When I think of the words ‘humanizing medicine,’ the image that immediately pops into my head is a picture of John Burton,” says CIM Director David Hellmann, describing the legendary clinician who helped establish and shape the practice of geriatric medicine, not only at Johns Hopkins but across the country.

Now a professor of medicine emeritus, Burton “has had an extraordinary impact on generations of physicians,” said Hellmann in introducing Burton before his recent CIM Seminar, “The Humanization of Medicine: Tales of Joy in Clinical Practice.”

“Caring for patients has been so incredibly rewarding,” said Burton, who for many years served as director of the Johns Hopkins Division of Geriatric Medicine and Gerontology, where he promoted the revival of the house call for homebound older patients (see sidebar box). “I loved every day of it, particularly geriatrics.” He went on to talk about the rich experience of letting patients and colleagues teach him.

The White Coat Story

Burton’s first tale of joy was what he calls “The White Coat Story,” when as a new intern he was told to “cover the geriatrics center…. I’d never heard the term ‘geriatrics,’” he said. But he dutifully reported to the center, albeit with purple dye on his coat because he’d just spilled it on himself doing a gram stain on a patient in the ER.

“So I went to the nurse, who was about my age, and said, ‘I’m Dr. Burton, and I’m here to help you with any problems.’ And she looked at me, frowned and said, ‘Young man, you are not seeing any of my patients. You are not seeing anybody looking like that.’” She told him the head of the institution, Mason Lord, not only always wore a clean, starched white coat, he wore it with a fresh carnation in the lapel “out of respect for the patients.”

“But then she smiled and said, ‘Sit down. You look awful. Let me get you a cup of tea and then we will see my patients together.’ That was my introduction to geriatrics and the humbling experience of how you present yourself to patients,” Burton said.

‘How I Learned to Grow Dahlias’

Burton received a call from a mentor, asking if he could help a vibrant, 88-year-old photographic artist who had given up hope. She had no family and lived alone, except for a caregiver, and she rarely left the hospital bed set up in her living room.

Burton started by making a house call, where he found “her home adorned with the majesty of the photographic artistry she had created” and her bed situated in front of a bay window with a curtain long closed. After the two chatted for a while, he told her he could see better to examine her if they opened the window shade. “Outside was a remarkable garden with a large plot of dahlias,” said Burton. “I told her, ‘I’ve tried to grow dahlias for years and I just can’t do it.’ She lit up. At each visit she taught him a little more about growing the spectacular flowers, saying, “I have a lesson for you.”

At her funeral, the mentor asked:
“‘John, what medicine did you find that gave her those extra four years?’ And we both cried as we talked about dahlias.”

“Caring for patients has been so incredibly rewarding. I loved every day of it, particularly geriatrics.” – John Burton

Learning from a Longtime Secretary of Defense

Former U.S. Secretary of Defense Clark Clifford had advised five U.S. presidents and, at 88, was eager to finish some important writing projects. But his doctors had confined him to his bed, largely due to severe inflammatory heart disease. Burton paid him a house call, and the two soon became “great friends.” Slowly, said Burton, “we were able to get him mobilized a little bit and back to where he could work on his books.”

Clifford even participated in a Grand Rounds presentation with Burton, given before 150 doctors, nurses and students in Carroll Auditorium at Bayview, on how best to treat a patient. “I said, Secretary Clifford, you’ve had a lot of complex experiences with the health care system in recent years. What advice would you give these people here?” recalled Burton. “He thought a minute, and he looked up like he was advising the president in a cabinet meeting.” Then Clifford shared these pearls: “Know your patient well. Ask the patient what they think, and then listen more than you talk. Explain clearly your thinking. Make house calls. Never take a phone call when you’re with a patient.”

“Patients,” said Burton in concluding his talk, “are our best teachers.”

May 8th, 2024

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Paying Tribute to a Visionary Philanthropist

Last fall, the CIM lost one of its most loyal supporters when Charles Salisbury died on October 30, 2023, at the age of 83.

Salisbury enjoyed a highly successful career with global investment management firm T. Rowe Price, where he guided creation of the Fixed Income Division, launched two fixed income funds, and led management of the firm’s large institutional assets, pension funds and endowments.

“Charlie personified the meaning of serving our clients,” says Brian C. Rogers, former Chair and CIO of T. Rowe Price Associates. “He treated the individual investor with the same thoughtfulness and care as he did a billion-dollar client. Over the years, Charlie spent a lot of time on the road telling the T. Rowe Price story; traveling with him wore you down. He never stopped moving.”

While he had many passions, Salisbury’s highest priority was giving back through education and medical philanthropy. “While Charlie dressed with the reserved, elegant and formal manner of a successful business executive, he was beloved for his dry wit, generosity and deep interest in the lives of others,” says CIM Director David Hellmann. “His wisdom, smarts and philanthropy had a profoundly beneficial impact on multiple professors and research programs at Johns Hopkins.”

In 2008, Salisbury funded the Salisbury Family Professorship in Neurosurgery at The Johns Hopkins Hospital, where Henry Brem is director of neurosurgery. “Charlie was an extraordinary visionary and philanthropist,” says Brem. “He had a profound sense of gratitude of the exceptional care that he and his family had received, and dedicated his resources to being sure that such high-level care was available to others and indeed that there would be resources to continue to improve lifesaving medical treatments. He strove through his dedication and philanthropy to make the world a better place for everyone.”

At the CIM, Salisbury was among the among the earliest supporters of the CIM-supported Human Aging Project (HAP), which launched in 2021, when he and his family funded HAP Director Jeremy Walston as a Salisbury Family Foundation CIM Scholar.

“This early seed money from the Salisbury family and other donors has been crucial to the success of HAP,” says Hellmann. “It has allowed our researchers to embark on projects that have subsequently garnered millions of dollars in grant funding from the National Institutes of Health and other funding agencies.” The Salisbury family subsequently went on to support clinician-researchers, including Peter Abadir and Sean Leng, as Salisbury Family CIM/HAP Family Scholars.

Most recently, notes Hellmann, Salisbury’s generous support was key to the establishment of the David B. Hellmann M.D. Endowed Professorship. “I was thrilled to be honored with this endowed chair,” says Hellmann, “and I will forever be grateful to Charlie for believing in me.”

In addition to his wife of 57 years, Edith O’Donovan Gans, Salisbury is survived by two daughters, Anne O’Donovan Staley of Baltimore, Maryland, and Katherine Gans Ryan (Kevin Ryan) of Severna Park, Maryland: two grandchildren, Franklin E.W. Staley Jr. and Josephine O. Staley; and one brother, Thomas Salisbury.

May 8th, 2024

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