In years past, when a person's cancer spread (metastasized) to the brain, the situation looked dim. With cancer, this happens more than you might think: between 20% and 40% of people who have cancer will experience brain metastasis at some point. Brain metastasis is about 10 times more common than cancer that starts first in the brain.
Brain metastasis treatment
While brain metastasis is still a serious condition, there are now more effective treatments and ways of controlling brain metastases. Treatment advances have helped extend survival — a positive development. Longer survival has also made it imperative to preserve brain function and quality of life. Because brain metastasis treatment is so complex, it's important to be treated by a team of doctors who specialize in caring for patients who have these tumors.
"Today, the survival and quality of life of people with brain metastasis is improving due to developments in precision, image-guided radiation, targeted therapies and immunotherapies," said Joseph Bovi, MD, a radiation oncologist who leads the Froedtert & MCW Brain and Spine Tumor Program.
Several years ago, Dr. Bovi, a radiation oncologist who leads our Brain and Spine Tumor Program, and Christopher Schultz, MD, chair of Radiation Oncology within the Froedtert & MCW Cancer Network, came up with the idea of a program to address the unique needs of patients with brain metastases — cancer that started in another part of the body (the primary cancer) and spread to the brain.
To support the Brain Metastases Program and its diverse patient population — people with many different types of primary cancers — Drs. Bovi and Schultz began work on a complicated treatment algorithm to guide treatment decision-making based on a person's original (primary) cancer, how their cancer has responded to previous treatment, the tumor's size and location, as well as other individual factors. The doctors soon realized that because of its overwhelming complexity, this algorithm was not going to work as a "pocket guide."
They turned to UWM's App Brewery for help, and the algorithm became the framework for a mobile app. UWM's App Brewery is a mobile innovation laboratory in which students design, develop, support and host mobile apps for the Milwaukee research community.
Initially, the app was going to be a simple regurgitation of the algorithm. However, Dr. Bovi and developers at the UWM App Brewery began to recognize the need for a tool to help doctors manage treatment for brain metastasis patients in real time, in a secure environment that protects the privacy and security of patients' health information. To meet this challenge, Dr. Bovi secured a grant from the Medical College of Wisconsin Community of Innovators, and app development began. Eighteen months later, the team had developed an app called the Network for the Integrated Management of Brain Metastasis Linking Experts, or NIMBLE — in essence, a virtual tumor board physician can use to consult and collaborate with the specialists of the Brain Metastases Program.
How it works
NIMBLE works on an iPad or desktop computer, but it was also designed to work beautifully on a smartphone — a tool today's physicians embrace for prompt communications. The app is easy to use. It guides the physician user through a form that asks questions based on the patient's number of brain metastases, the primary disease site and specific criteria to arrive at recommended treatment options based on published data. The app even offers a resource section to show the user the evidence base for the decision.
Supporting app inquiries behind the scenes is a team of "super-users" — a team of advanced practice providers experienced in treating brain metastasis patients. These experts review and vet the information physicians have submitted about their patients, adjusting recommended protocols based on a patient's individual condition if needed. They update the protocol recommendation, which activates a chat box. That, in turn, alerts a third group — the virtual tumor board of brain metastasis specialists — to have a conversation about the patient.
Through the chat box, which acts as a sort of i-message, these experts share information (encrypted for patient privacy) that would normally be discussed in a weekly, in-person tumor board. The information can include MRI scans, video, pathology and other information needed to make a treatment decision.
The physician group arrives at a consensus, and makes final recommendations. A fourth group (nurses) activates the final recommendations with the physician who requested the consultation. Finally, the nurses arrange expedited patient tests and appointments as needed.
NIMBLE app expected to be a game-changer for people with brain metastases
The Brain Metastasis Program and the NIMBLE app show promise as game-changers for physicians who need treatment options for their brain metastasis patients.
"With NIMBLE, we're providing faster access to the experts and resources needed to treat brain metastases. Creating the app was central to launching our Brain Metastases Program and addressing the individual complexity of care for these patients. "The NIMBLE app functions as a virtual tumor board that is always available for real-time, doctor-to-doctor discussions," Dr. Bovi said. "With NIMBLE, we will offer data-driven treatment recommendations delivered within hours as opposed to days with references to data and publications that support those recommendations. We expect NIMBLE to make treatment options more accessible and to accelerate the treatment path for patients who need it."
While Dr. Bovi and his team haven't formally published research on the Brain Metastases Program or NIMBLE app, they submitted a paper late in 2019 to an MCW quality symposium. Their preliminary study showed that with the expedited, data-driven approach offered by NIMBLE, they reduced the typical seven to eight day hospital stay for brain metastasis patients to about three days. Usually, such patients require involvement from many specialists, and it takes time for all of them to see patients in the hospital. NIMBLE guidance can help resolve this pause — and lower costs.
The app is the only one of its kind in the U.S. and will be available later in 2020 at no cost to physicians through app stores for iOS and Android platforms. NIMBLE offers unique benefits for brain metastasis patients and their doctors:
- Decreases the wait: Patients and their doctors don't have to wait for the weekly in-person tumor board for a consultation
- Offers immediate recommendations — in hours, not days
- Expands resources for cancer providers caring for a brain metastasis patient
- Provides a more streamlined path to treatment
- Gives a second opinion without having to travel
- Reduces hospital stay: For brain metastasis patients who have been admitted to the hospital, length of stay can be reduced by as much as seven days — no waiting for experts to gather to recommend treatment.