Ten years ago, a landmark clinical trial in
Canada demonstrated the unequivocal effectiveness of brain surgeries for
treating uncontrolled epilepsy, but since then the procedure has not been
widely adopted—in fact, it is dramatically underutilized according to a new
study from the University of California, San Francisco (UCSF).
The
study, published this month in the journal Neurology, showed that
the number of Americans having the surgery has not changed
in the decade since release of the effectiveness study, though surgical
treatment is now uniformly encouraged by neurology and neurosurgery
professional societies.
The
U.S. Centers for Disease Control and Prevention estimates that 2 million
Americans have epilepsy. Hundreds of thousands of these men, women and children
suffer from uncontrolled seizures, but nationally only a few hundred are
treated surgically each year with UCSF performing about 50 of the operations.
Among
people who do have the operation, the study found, there are significant
disparities by race and insurance status. White patients were more likely to
have surgery than racial minorities, and privately insured patients were more
likely to undergo surgery than those with Medicaid or Medicare.
"As
a medical community, we are not practicing evidence-based medicine with regard
to the treatment of patients who have epilepsy," said Edward Chang, MD,
chief of adult epilepsy surgery in the UCSF Department of Neurological Surgery
and the UCSF Epilepsy Center. "There are a lot of people who are taking
medications and continuing to have seizures even though they can potentially be
seizure-free."
A
MODERN SURGERY FOR AN ANCIENT DISEASE
Epilepsy
has been recognized as an important neurological condition since ancient times
and its name means "seizures" in Greek. It can be inherited or it can
be caused by anything that injures or irritates the brain.
Hippocrates,
the father of western medicine, described it in detail in his writings some
2,500 years ago, and it is believed to have afflicted many famous people
throughout history, including Julius Caesar.
UCSF is
one of the world's leading institutions involved in epilepsy research, with one
of the few medical centers that has top-ranking departments in relevant areas:
neurology, biomedical imaging, and neurosurgery.
Paul
Garcia, MD, director of the clinical epilepsy program and a study co-author,
said that most patients referred to UCSF for surgical evaluation have had
uncontrolled seizures for many years despite trying several medications.
Research
has shown that after the first two medicines fail, it is uncommon for patients
to gain complete seizure control with medical treatment alone. Without control
over their seizures, patients are at risk for physical injuries or even dying.
Furthermore, the seizures often interfere with normal life activities such as
driving, studying and working.
To see
how widely this type of surgery has been used, Chang and neurosurgery resident
Dario Englot, MD, PhD, accessed a national database of all of the surgeries
across the United States for the last 20 years—a timeline centered on the
Canadian study.
They
found that there has been no increase in the 10 years, even as diagnoses of
epilepsy have increased along with the number of hospitalizations for seizures.
Part of
the problem is awareness, both among patients and care providers, Chang said.
New anticonvulsant drugs appear on the market often enough to provide
physicians with new drug combinations for their patients to try.
Brain
surgery can be more daunting than having to swallow fistfuls of pills, even
though surgery is much more effective for many people.
The
problem though is that new medications are not very effective if previous ones
already failed, according to Chang. Epilepsy surgery in the modern era has been
repeatedly shown to be safe and effective.
Also,
many people with epilepsy are not getting the specialty care needed to properly
identify the source of the seizures. The study found a significant trend that
patients are being evaluated less at epilepsy centers and more at community
hospitals often without dedicated epilepsy expertise.
The
result is that some patients may not receive an adequate workup, and in many
cases, the source of the seizures can be very difficult to find without special
expertise. "The success of epilepsy surgery
totally depends upon the accurate localization of seizure onset region,"
Chang said.
The
decade-old Canadian study showed that more than nearly two-thirds of all people
who underwent surgery as part of the study in the 1990s were seizure-free. Fewer
than 10 percent of patients in the study who relied on drugs alone achieved the
same degree of freedom from seizures.
"Even
though this important evidence was published 10 years ago now, we have not seen
increases in the number of patients," Chang said.
"We need to do better."
More
information: The
article, "Epilepsy surgery trends in the United States, 1990-2008" is
authored by Dario J. Englot, David Ouyang, Paul A. Garcia, Nicholas M. Barbaro,
and Edward F. Chang and appears in the journalNeurology. See: http://www.neurolo … 200.abstract
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