Chapter 06: The Neurosurgery Database and Tissue Bank
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Description
In this Chapter, Dr. Sawaya recounts how the Department established a database to record detailed information about all surgical procedures performed by clinicians. He begins by explaining why it is important to have a volumetric measurement of brain tumors. Dr. Sawaya explains how recording the size of brain tumors resected helped resolve controversy over the surgical treatment of glioblastoma. A 2001 publication of the results has been cited over 7000 times, and Dr. Sawaya explains how the database provided hard numbers about percentages of resection, replacing the vague terms surgeons previously used to determine how much tumor and normal tissue to remove.
Dr. Sawaya next says that a “very amateurish” database was started in June of 1993, but professionalized in 1997, when the Department hired Dr. Dima Suki. He explains how Dr. Suki developed the database and data collection. He describes how data is collected from surgeons about the procedures they perform so the information can be preserved in the database.
Dr. Sawaya explains how fundamental data and data management are in neurosurgery and explains the strict protocols that govern data collection and entering. The Neuroscience database is IRB approved, a very rare designation, he notes. It is also important that Dr. Suki oversees audits of the database and manages any mistakes to maintain database credibility.
Dr. Sawaya next talks about the Department’s tissue bank was developed to preserve tissue samples from each patient treated. He notes the link with personalized therapy, then goes on to explain why tissue is time sensitive, requiring special handling. The Department received funding in 2001 to support handling of tissue samples.
Identifier
SawayaR_01_20130604_C06
Publication Date
6-4-2013
City
Houston, Texas
Interview Session
Topics Covered
The University of Texas MD Anderson Cancer Center - Building the InstitutionBuilding/Transforming the Institution; Research, Care, and Education; On Research and Researchers; Overview; Healing, Hope, and the Promise of Research; Discovery, Creativity and Innovation; Devices, Drugs, Procedures; The Researcher; The Clinician; MD Anderson Impact; Research, Care, and Education; On Research and Researchers
Transcript
Tacey Ann Rosolowski, PhD:
I was reading about the database and the tissue bank, of course, also the upgraded technology. I wonder if you could tell me more about first the database. What were you collecting, and how was it being used?
Raymond Sawaya, MD:
That’s major. I had started a database in Cincinnati, so again it was something I had a lot of interest in back then. And when I moved here, I brought in the person who helped me in Cincinnati, a Chinese person who was a senior and didn’t have a job. So he was working for me in Cincinnati on a grant. So I brought him down here, and he helped me establish the database. Then I hired a Chinese neurosurgeon who could not practice in the US, a young guy by the name of Weiming Shi to do volumetric measurements of brain tumors. That’s something that practically nobody was doing. The technology was available, but it was time consuming, and in Cincinnati I couldn’t do that. I didn’t have the resources. Here I did.
Tacey Ann Rosolowski, PhD:
Why was it important to do that measuring?
Raymond Sawaya, MD:
Because as it turned out, we published a paper in the Journal of Neurosurgery in 2001 showing that the extent of resection of these glioblastomas has a major influence on the survival of patients. That question and that issue had not been resolved ever before. There was a lot of controversy, because it’s so malignant as a tumor that neurosurgeons were stopping their surgery once they got the results that this was the type of tumor they’re dealing with. And for me building this program here, it was crucial that I demonstrate with scientific data that the amount of tumor removed has an influence on the survival of the patients. And that paper today—and I can give you the reference—has been cited over 700 times. And it was published in 2001. So within ten years, this paper has been cited 700 times, which is more than any paper that I’ve ever published in my life, or that many people have published. So it was quite dramatic how important—and it was based on the concept that when we say, “We did a gross total resection—” You may know this term, or partial resection, or sub-total resection. What does it means? It means different things to different people. I said, “You cannot do that.” You have to measure a volume in a computer before surgery, and you have to measure the residual volume after surgery on a computer and have a percent resection. Is it sixty percent? Is it eighty percent? Is it ninety percent? How did it turn out? And that paper, as I said, has received a huge amount of attention. We have shown in that paper that you have to reach ninety-eight percent resection of the visible mass on the MRI scan to influence maximally the survival of patients.
Tacey Ann Rosolowski, PhD:
And just to have the comfort of the system of numbers there so you know what you’re talking about—that’s just incredible.
Raymond Sawaya, MD:
That’s really—and it all started with the idea that I cannot convince anybody by using nondescript terms or terminology. It would not convey—you want science, give me science. Measurements, comfort of numbers is science. But it took a full-time FTE, a full-time employee, whose job was to capture every single scan on every single patient. And so to be able to do that, not only did I hire that person, I bought him a scanner to digitize the images, and I put it in the operating room next to the OR—in the OR next to the operating room where we were working, because this is where the films are.
Tacey Ann Rosolowski, PhD:
So these were in-vivo scans, all of them?
Raymond Sawaya, MD:
All of them.
Tacey Ann Rosolowski, PhD:
All in-vivo scans. Wow.
Raymond Sawaya, MD:
And so he would scan every case before surgery and after surgery—every case. And so in that paper we had 416 glioblastomas. He did that analysis—well, the statistician did the analysis. But he did the volumetric measurements.
Tacey Ann Rosolowski, PhD:
And that’s only a tiny piece of what’s in this database, I’m sure.
Raymond Sawaya, MD:
Only a tiny piece.
Tacey Ann Rosolowski, PhD:
So tell me what else is in this database?
Raymond Sawaya, MD:
So I brought Dr. [Shu Zhi] Wu, who was the gentleman from Cincinnati, with me, and we started this database in June of 1993. And it really was amateurish, because neither he nor I are professional in developing databases. This brings me to 1997, the year after I hired Fred Lang. It was a lucky year for me, because I was able to attract a lovely young lady who had a PhD in epidemiology and biostatistics from the UT School of Public Health here. She was working in the Infectious Disease Department on their database, and there were some issues—it wasn’t a department, it was a section. There were some issues there, in-fighting among faculty, and that pushed her to leave. And there she is.
Tacey Ann Rosolowski, PhD:
And her name?
Raymond Sawaya, MD:
Dima Suki [PhD], Dr. Suki, S-U-K-I. She’s from Lebanon. And Dima is a professional database expert. And she looked at every box, in every field within our database, defined it, specified it. She hired a data coordinator and a data manager. And she went back and collected some additional data from before. She expanded the fields. And then from her recruitment on, it became prospective that we collect that data, we enter it in the computer when patients are here and we’re treating them. We developed a form for surgery that the surgeon fills out on the day of the surgery. These are things that you may not find easily in the patient’s records, because they are either not dictated and—I will tell you right now, one observation that turned out extremely meaningful was to ask the surgeon on the day of the surgery, “When you took that tumor out, did you take it en bloc or did you take it piecemeal?” And we defined what en bloc is—when you go around the tumor and not open the capsule of the tumor. And the idea that I had back then was that if you go into the tumor, then you’re more likely to spill tumor cells. So that was a simple, basic idea or concept that I wanted to capture. As it turned out, and we’ve published several papers on the subject, when you take these tumors piecemeal, you’re much more likely to spread the tumor into the spinal fluid. And we have some strong data on that. And if we didn’t have this database and collecting it the way we did, we would not have been able to find that. And so now that’s another observation that the database is helping us with.
Tacey Ann Rosolowski, PhD:
And a simple question.
Raymond Sawaya, MD:
A simple question. Yeah. That’s the power of collecting data. I think we have to be careful about time, because at 3:30 I have a meeting that I have to be at.
Tacey Ann Rosolowski, PhD:
Okay. I have until 3:30. We can stop ten minutes early. Would that work for you?
Raymond Sawaya, MD:
That’s okay.
Tacey Ann Rosolowski, PhD:
Okay.
Raymond Sawaya, MD:
So with the database, then it became a gold mine. And you will see on the graph where the database is. It’s very, very basic.
Tacey Ann Rosolowski, PhD:
Yes, and then data management just the next tier up.
Raymond Sawaya, MD:
Data management and database are essential. And they’re in the trunk because they feed everything.
Tacey Ann Rosolowski, PhD:
And just for the record, we’re talking about the image of the tree again.
Raymond Sawaya, MD:
Yes. So based on that—you know—we have made that available to all of our trainees, and as I was saying, it is a true gold mine. But they can discover all kinds of things by mining that database.
Tacey Ann Rosolowski, PhD:
Now are the fellows—I’m thinking about the training element, too—are the fellows working on projects that feed that database, as well?
Raymond Sawaya, MD:
Absolutely. But I emphasize that the data in the database is professionally collected. I cannot rely on a resident or a fellow to collect data. They will collect data, but then it has to go through the professionals. And she introduced audits. So she’s not only relying on her staff who are well-trained and well-prepared. She periodically extracts certain data and verifies that what was entered was correct. And we are, if not the only, but one of the rare databases at MD Anderson that are IRB-approved. The Institutional Review Board has given us—well we cannot say accreditation, because I don’t think they use that term. But they have approved us, and they sanctioned us.
Tacey Ann Rosolowski, PhD:
That’s an amazing honor.
Raymond Sawaya, MD:
It is, and that’s because of Dima. She is so professional about how she does things. And if she ever discovered that there was a mistake about a protocol—because all protocols go through her area. Like one time we found that we had a consent from patients to use blood. We had to have each patient on whom we collected blood sign a consent saying that we can use their blood for research. She found, through another area, that some of these patients that had blood drawn, but did not give permission to use their blood—they’ve had their blood used in research. Now there was no harm made to the patient, but it’s against the law. She immediately issued a report and sent it to the IRB. And so that has helped increase her credibility with them.
Tacey Ann Rosolowski, PhD:
Well, I’m getting this image too. I mean, just like the tree—that you’ve got all of these areas that interconnect and that feed each other. And I’m sure that—I hate to use that gross word—synergy. But you know that the whole is greater than the sum of its parts. I mean, it’s evolving, evolving, evolving.
Raymond Sawaya, MD:
That’s very true. And making it a core in the trunk of that tree, again, is helping every program in the department—you know—the spine program has grown. They have their own identity and their own needs and their own discoveries. They benefit from it. The skull-based program, the pituitary program—that’s another area that Dr. McCutcheon developed which is very specific. So all these areas have benefited from this database.
Tacey Ann Rosolowski, PhD:
Now what about the tissue bank? When—
Raymond Sawaya, MD:
The tissue bank—that is an issue that we can talk more about when we talk about the brain tumor program, because there really is—I mean, I will tell you about it for a minute. But we need to come back to it. So the tissue bank was basically started with what is being talked about now a lot, and that is the personalized patient care. And the idea of a tissue bank, meaning you have a specific tissue that belongs to a specific patient—if you discover something in this tissue, and that discovery belongs and relates to that one person. So very early on, the decision was made that every piece of tissue that we removed during surgery must be preserved, sent to Pathology where it belongs. Because the pathologists are the best people to handle that tissue, to divide it, allocate it, freeze it, or give it to different labs.
Tacey Ann Rosolowski, PhD:
I had a fascinating interview with Janet Bruner [MD] [Oral History Interview].
Raymond Sawaya, MD:
Janet has been the original member of the brain tumor program. We can talk more about that when we talk about the brain tumor program as a whole. But because that tissue is so time-sensitive, what do we look at in the tissue? We look at DNA. We look at RNA. We look at enzymes.
Tacey Ann Rosolowski, PhD:
When you say time-sensitive, what exactly does that mean?
Raymond Sawaya, MD:
When you take a piece of tissue outside of the human body—in our case, outside of the brain—and you put it on the table where the scrub nurse is—which is what happens. You take it out piecemeal or otherwise, and it sits on the table while the surgeon is busy protecting the organ. Okay? That tissue is not being oxygenated anymore. The enzymes and the RNA are undergoing degradation. And so I didn’t want that to happen. So what I did is I hired a full-time technician for the pathology lab, for the tissue bank. That person’s job was to go to the OR and get the tissue and not let it sit there forever. And that person is still working with us. Her name is Alicia Ledoux. That program is going, it’s going. We have some enhancements we need to work on that we can talk about later.
Tacey Ann Rosolowski, PhD:
When was the tissue bank initiated?
Raymond Sawaya, MD:
It was initiated—probably the original tissue bank was by Janet Bruner even before I came. But remember the volume at the time was very low, so it wasn’t a big challenge. As I began to grow the program and we have now hundreds and hundreds of samples per year, that’s where—so the funding really for that person was in ‘01, which is when we formed our current model for the brain tumor program. Again, I’ll be happy to go over that history with you. There is an important history to talk about. I know we’re focusing today on neurosurgery mostly, but maybe the second time we get together we can focus on the broader aspect.
Tacey Ann Rosolowski, PhD:
Absolutely. I have plenty of areas we can cover. There’s a lot to cover. And we have to talk about your research, too. I just wanted to make a couple of notes here. Now I’m wondering with—I know that one of your other areas that you were responsible for when you took over the department were the clinical programs—the clinical protocols. I read that somewhere, so maybe I’m not expressing it quite—
Raymond Sawaya, MD:
I’m not sure what you’re referring to, but please tell me.
Recommended Citation
Sawaya, Raymond MD and Rosolowski, Tacey A. PhD, "Chapter 06: The Neurosurgery Database and Tissue Bank" (2013). Interview Chapters. 1542.
https://openworks.mdanderson.org/mchv_interviewchapters/1542
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