Brain TumorLast Updated: August 03, 2011 This section has been reviewed and approved by the Cancer.Net Editorial Board, 01/11 Overview
The brain and spinal column make up the central nervous system (CNS), where all vital functions, including thought, speech, and strength of the body are controlled. When a tumor occurs in the CNS, it is especially problematic because of the possible effect on a person's thought processes or movements. A brain tumor begins when normal cells in the brain change and grow uncontrollably, forming a mass. A tumor can be benign (noncancerous) or malignant (cancerous). In general, primary CNS tumors do not spread outside of the CNS. Malignant brain tumors are further classified using a grade: low, intermediate, or high. More information can be found in Staging. This section describes primary brain tumors, which are tumors that begin in the brain. Secondary brain tumors (also called brain metastases) are much more common than primary tumors. A secondary brain tumor is a cancerous tumor that started in another part of the body (such as the breast, lung, or colon) and then spread to the brain. Learn more about cancer that started elsewhere in the body and spread to the brain by reading about that specific cancer type. Anatomy of the brain The brain is made up of four main parts: the cerebrum, the cerebellum, the brain stem, and the meninges. The cerebrum. This is the largest part of the brain. It contains two cerebral hemispheres and is divided into four lobes where specific functions occur:
The cerebellum. The cerebellum is located at the back part of the brain below the cerebrum. It is responsible for coordination and balance. The brain stem. This is the portion of the brain that connects to the spinal cord, controls involuntary functions essential for life, such as the beating of the heart and breathing. In addition, messages for all the functions controlled by the cerebrum and cerebellum travel through the brain stem to the connections in the body. The meninges. These are the membranes that surround and protect the brain and spinal cord. There are three meningeal layers, called the dura mater, arachnoid, and pia mater. The cerebrospinal fluid (CSF) is made near the center of the brain, in the lateral ventricles, and circulates around the brain and spinal cord between the arachnoid and pia layers. View illustrations of the anatomy of the brain. Types of brain tumors There are more than 100 types of primary brain tumors, and about 6% of all brain tumors cannot be assigned an exact type. For a complete list of the types of brain tumors and how often they are diagnosed, please refer to the Central Brain Tumor Registry of the United States. This section covers brain tumors diagnosed in adults. (Learn about brain tumors in children.) For practical purposes, this section’s coverage is divided into gliomas and non-glioma types of tumors in adults: Gliomas As a group, a glioma is one of the most common types of brain tumor. A glioma is a tumor that grows from a glial cell, which is a supportive cell in the brain. There are two main types of supportive cells: astrocytes and oligodendrocytes. Most gliomas are called either astrocytoma or oligodendroglioma, or a mix of both. A glioma is given a grade (a measure of how much the tumor appears like normal brain tissue) from I to IV (one to four) based how likely they are to grow quickly. A grade I glioma is often considered a benign tumor, while grades II through IV are tumors with an increasing likelihood of growing and spreading quickly and are therefore considered possibly cancerous. Types of gliomas include: Astrocytoma. Astrocytoma is the most common type of glioma and begins in cells called astrocytes in the cerebrum or cerebellum. There are four grades of astrocytoma.
Learn about astrocytoma in children. Oligodendroglioma. Oligodendroglioma is a tumor that develops from cells called oligodendrocytes. These cells are responsible for making the myelin (a substance rich in protein and fatty substances called lipids) that surrounds nerves. Oligodendrogliomas make up about 4% of primary brain tumors and are subclassified as either oligodendrogliomas (considered low grade) or anaplastic oligodendroglioma. Mixed gliomas. A mixed tumor is made up of more than one of the glial cell types and accounts for about 1% of primary brain tumors. Ependymomas. Ependymomas begin in the ependyma (the passageways in the brain where CSF is made and stored) and make up about 2% of primary brain tumors. Learn about ependymoma in children. Brain stem glioma. A brain stem glioma begins in the glial cells in the brain stem. Learn about brain stem glioma in children. Non-glioma tumors As explained above, this section covers non-glioma tumors, which are tumors that arise from cells in the brain that are not glial (supportive) tissue. Types of non-glioma tumors include: Meningioma. Meningioma is the most common primary brain tumor, making up about 30% of all primary brain tumors. It begins in the meninges and is most often noncancerous. Meningioma can cause serious symptoms if it grows and presses on the brain or spinal cord or grows into the brain tissue. Learn more about meningioma. Pineal gland and pituitary gland tumors. About 7% of all brain tumors are located in the pineal gland and pituitary gland. Primary CNS lymphoma. This is a form of lymphoma (cancer that begins in the lymphatic system) that starts in the brain and can spread to the spinal fluid and eyes. It makes up about 3% of all brain tumors. Medulloblastoma. Medulloblastoma begins in granular cells in the cerebellum. It is most common in children and is most often cancerous, often spreading throughout the CNS. Medulloblastomas make up about 2% of all brain tumors. Similar tumors can start in other parts of the brain, frequently in the pineal gland region, and are called primitive neuroectodermal tumors (PNET). Learn about medulloblastoma in children. Craniopharyngioma. Craniopharyngioma is a benign tumor that begins near the pituitary gland located near the base of the brain. These tumors are rare, making up less than 1% of all brain tumors. Learn about craniopharyngioma in children. Acoustic schwannoma. Acoustic schwannoma (also called acoustic neuroma or vestibular schwannomas) is a rare tumor that begins in the vestibular nerve (a nerve in the inner ear that helps control balance) and is typically noncancerous. Find out more about basic cancer terms used in this section. Looking for More of an Overview? If you would like additional introductory information, explore these related items on Cancer.Net:
Or, choose “Next” (below, right) to continue reading this detailed section. To select a specific topic within this section, use the icon panel located on the right side of your screen. Statistics
This year, an estimated 22,340 adults (12,260 men and 10,080 women) in the United States will be diagnosed with primary malignant tumors of the brain and spinal cord. It is estimated that 13,110 adults (7,440 men and 5,670 women) will die from this disease this year. Brain tumors are the tenth most common cause of cancer death in women. About 4,000 children and teens will be diagnosed with a brain or central nervous system tumor this year. More than half of these are in children younger than 15. This section deals with adult brain tumors, learn about brain tumors in children. About 20% to 40% of patients with other types of cancer will have it spread to the brain. The most common primary cancers that spread to the brain are lung, breast, unknown primary, melanoma, and colon cancers. The rest of this section covers primary brain tumors only. Statistics should be interpreted with caution. Estimates are based on data from thousands of people with brain tumors in the United States each year, but the actual risk for a particular individual may differ. It is not possible to tell a person how long he or she will live with a brain tumor. Learn more about understanding statistics. Statistics adapted from the American Cancer Society’s publication, Cancer Facts & Figures 2011, the National Cancer Institute. Medical Illustrations
Risk Factors
A risk factor is anything that increases a person’s chance of developing a brain tumor. Although risk factors can influence the development of a brain tumor, most do not directly cause a brain tumor. Some people with several risk factors never develop a brain tumor, while others with no known risk factors do. However, knowing your risk factors and talking about them with your doctor may help you make more informed lifestyle and health care choices. Most of the time, the cause of a brain tumor is unknown, but the following factors may raise a person’s risk of developing a brain tumor: Age. Brain tumors are more common in children and older adults, although people of any age can develop a brain tumor. Gender. In general, men are more likely than women to develop a brain tumor. However, some specific types of brain tumors, such as meningioma, are more common in women. Home/occupational exposures. Occupational exposures to solvents, pesticides, oil products, rubber, or vinyl chloride may increase the risk of developing a brain tumor, although there is not yet scientific evidence that supports this possible link. Family history. About 5% of brain tumors may be linked to hereditary (genetic) factors or conditions, including Li-Fraumeni syndrome, neurofibromatosis, nevoid basal cell carcinoma syndrome, tuberous sclerosis, Turcot syndrome, and von Hippel-Lindau disease. Scientists have also found “clusters” of brain tumors within some families without a link to these known hereditary conditions, and studies are underway to try to find a cause. Exposure to infections, viruses, and allergens. Infection with the Epstein-Barr virus (EBV) increases the risk of CNS lymphoma; EBV is more commonly known as the virus that causes mononucleosis (sometimes called “mono”). In other research, high levels of a common virus called cytomegalovirus (CMV) have been found in brain tumor tissue; the meaning of this finding is under investigation. Several types of other viruses have been shown to cause brain tumors in research on animals; however, more data are needed to determine if exposure to infections, other viruses, or allergens affect the risk of a brain tumor in people. Electromagnetic fields. Electromagnetic fields, such as energy from power lines or from cell phone use, may or may not increase the risk of developing a brain tumor, as current research has shown conflicting results. The World Health Organization (WHO) recommends limiting cell phone use and promotes the use of a hands-free headset for both adults and children. Race and ethnicity. In the United States, white people are more likely to develop gliomas but less likely to develop meningiomas than black people. Also, people from northern Europe are more than twice as likely to develop a brain tumor as people in Japan. Ionizing radiation. Previous treatment to the brain or head with ionizing radiation (including x-rays) has shown, in some cases, to be a risk factor for a brain tumor. Head injury and seizures. Serious head trauma has long been studied for its relationship to brain tumors. Some studies have shown a link between head trauma and meningioma, but not one between head trauma and glioma. A history of seizures has long been associated with brain tumors, but because a brain tumor can cause seizures, it is not known if seizures increase the risk of brain tumors, if seizures occur as a consequence of the tumor, or if anti-seizure medication increases the risk. N-nitroso compounds. Some studies of diet and vitamin supplementation seem to indicate that dietary N-nitroso compounds may raise the risk of both childhood and adult brain tumors. Dietary N-nitroso compounds are formed in the body from nitrites or nitrates found in some cured meats and from cigarette smoke, and cosmetics. However, additional research is necessary before a definitive link can be established. Exposure to nerve agents. One study has shown that some Gulf War veterans are at increased risk of a brain tumor due to exposure to nerve agents; however, more research is needed before a definitive link can be established. At this time, there are no known ways to prevent a brain tumor. Symptoms and Signs
People with a brain tumor may experience the following symptoms or signs. Sometimes, people with a brain tumor do not show any of these symptoms. Or, these symptoms may be caused by a medical condition that is not a brain tumor. If you are concerned about a symptom or sign on this list, please talk with your doctor. Symptoms of a brain tumor can be general (caused by the pressure of the tumor on the brain or spinal cord) or specific (caused a specific part of the brain not working normally). For many people with a brain tumor, they were diagnosed when they went to the doctor because of certain symptoms. General symptoms include:
Your doctor will ask you questions about the symptoms you are experiencing to help find out the cause of the problem, called a diagnosis. This may include how long you’ve been experiencing the symptom(s) and how often. If a tumor is diagnosed, relieving symptoms and side effects remains an important part of your care and treatment. This may also be called symptom management, palliative care, or supportive care. Be sure to talk with your health care team about symptoms you experience, including any new symptoms or a change in symptoms. Learn more about managing symptoms of a brain tumor in the Treatment section. Diagnosis
Doctors use many tests to diagnose a brain tumor, find out the type of brain tumor, and rarely, find out if it has metastasized (spread). Some tests may also determine which treatments may be the most effective. For most types of tumors, taking a sample of the tumor tissue, either by biopsy (see below) or by removing the entire tumor, is the only way to make a definitive diagnosis of a brain tumor. If this is not possible, the doctor may suggest other tests that will help make a diagnosis. Imaging tests may be used to help determine whether the tumor is a primary brain tumor or if it is another type of cancer from elsewhere in the body that has spread to the brain. Your doctor may consider these factors when choosing a diagnostic test:
Most brain tumors are not diagnosed until after symptoms appear. Often a brain tumor is initially diagnosed by an internist (a doctor who specializes in treating adults) or a neurologist (a doctor who specializes in problems with the brain and central nervous system). To learn more about the brain tumor, an oncologist (a doctor who specializes in cancer) or neuro-oncologist (a doctor who specializes in treating brain tumors) can use the patient's symptoms as clues to the location of the tumor. In addition to asking the patient for a detailed medical history and doing a physical examination, the doctor may recommend the tests described below to determine the presence, and perhaps the type or grade, of a brain tumor. Based on the combined results of the different tests, the doctor will recommend treatment options. Imaging tests The most effective and common tool for diagnosing a brain tumor is the use of a magnetic resonance imaging (MRI) scan, although computed tomography (CT or CAT) scans are also used. A positron emission tomography (PET) scan is generally used to find out more about a tumor while a patient is being treated or if there is a recurrence (the tumor comes back after treatment). Once an imaging scan shows that there is a tumor in the brain, the most common way to determine the type of brain tumor is to look at the results from a sample of tissue (called a pathology report or laboratory test results) after a biopsy or surgery (see below). Each imaging test can provide specific information, but they must be combined with the results of the patient history, physical examination, and neurologic and other tests. The most common imaging tests used for diagnosing a brain tumor include: MRI. An MRI uses magnetic fields, not x-rays, to produce detailed images of the body. MRIs may create more detailed pictures than CT scans (see below) and are the preferred method of diagnosing a brain tumor. The MRI may be of the brain, spinal cord, or both, depending on the type of tumor suspected and the likelihood that it will spread in the CNS. There are different types of MRI, and the results of a neuro-examination, done by the internist or neurologist, helps determine which type of MRI to use.
CT scan. A CT scan creates a three-dimensional picture of the inside of the body with an x-ray machine. A computer then combines these images into a detailed, cross-sectional view that shows any abnormalities or tumors. A CT scan can help find bleeding and enlargement of the fluid-filled spaces in the brain, called ventricles. Changes to bone in the skull can also be seen on a CT scan. Sometimes, a contrast medium (a special dye) is injected into a patient’s vein to provide better detail, particularly if the patient cannot have an MRI (such as if the person has a pacemaker). PET scan. A PET scan is a way to create pictures of organs and tissues inside the body. A small amount of a radioactive substance is injected into a patient’s body. This substance is absorbed mainly by organs and tissues that use the most energy. Because a tumor tends to use energy actively, it absorbs more of the radioactive substance. A scanner then detects this substance to produce images of the inside of the body. Cerebral arteriogram (also called cerebral angiogram). A cerebral arteriogram is an x-ray, or series of x-rays, of the head that shows the arteries in the brain. X-rays are taken after a contrast medium is injected into the main arteries of the patient’s head. Myelogram. Because some specific types of brain tumors can spread to the spinal fluid, other parts of the brain, or the spinal cord, the doctor may order a myelogram to look for metastases. A myelogram uses a dye injected into the CSF that surrounds the spinal cord. The dye shows up on x-ray and can outline the spinal cord to help the doctor look for tumors. This is rarely done; a lumbar puncture (see below) is more common. Lumbar puncture (spinal tap). A lumbar puncture is a procedure in which a doctor takes a sample of CSF to look for tumor cells, blood, or tumor markers. Typically an anesthetic is given to numb the patient’s lower back before the procedure. Tissue sampling/biopsy/surgical removal of a tumor As explained above, imaging tests are useful, but a sample of the tumor’s tissue is typically needed for the final diagnosis. A biopsy is the removal of a small amount of tissue for examination under a microscope and is the only definitive way a brain tumor diagnosis can be made. The sample removed from the biopsy is analyzed by a pathologist (a doctor who specializes in interpreting laboratory tests and evaluating cells, tissues, and organs to diagnose disease). A biopsy can be done as part of surgery to remove the entire tumor or as a separate procedure (if surgical removal of the tumor is not possible because of its location or the health of the patient.) Tumor markers/laboratory tests Laboratory tests can find tumor markers (also called biomarkers), which are substances found in higher than normal amounts in the blood, urine, spinal fluid, plasma or other bodily fluids of people with certain types of cancer. Researchers are examining biomarkers to find ways to diagnose a brain tumor before symptoms begin. Neurological, vision, and hearing tests These tests help determine the suspected tumor’s effects on the brain’s functioning. An eye examination can detect changes to the optic nerve. Neurocognitive assessment This consists of a detailed assessment of all major functions of the brain, such as storage and retrieval of memory, expressive and receptive language abilities, calculation, dexterity, and the overall well-being of the patient. These tests are done by a licensed clinical neuropsychologist, who will write a formal report to be used for comparison with future assessments or to identify specific problems that can be helped through treatment. Electroencephalography (EEG) An EEG is a noninvasive test in which electrodes are attached to a person's scalp to measure electrical activity of the brain. It is used to monitor for possible seizures. Evoked potentials Evoked potentials involve the use of electrodes to measure the electrical activity of nerves and can often detect acoustic schwannoma, a noncancerous brain tumor. This test can be used as a guide during surgical removal of a tumor that is growing around important nerves. Find more about what to expect when having common tests, procedures, and scans. Test results After these diagnostic tests are done, your doctor will review all of the results with you. If the diagnosis is a tumor, these results also help the doctor describe the tumor; this is called staging. Learn more about the first steps to take after diagnosis. Staging
Staging is a way of describing a tumor, such as where it is located, if or where it has spread, and whether it is affecting the functions of other organs in the body. A staging system is used for most other types of cancer. There is a formal staging system for adult brain tumors; however, the grading system described below is always used instead. After a brain tumor has been diagnosed, additional tests will be done to learn more about the tumor. If the tumor is a glial brain tumor, the pathologist will assign a “grade” using a number from I to IV (one to four). The grade indicates how different the tumor cells are from healthy cells, with a higher grade tumor having cells that are the least like healthy cells. The characteristics of the tumor, as seen under the microscope, help determine how cancerous a tumor is. Generally, the lower the grade, the better the prognosis (chance of recovery or long-term control of the tumor). Prognostic factors There are several other factors that help doctors determine the appropriate brain tumor treatment plan and determine prognosis: Tumor histology. As outlined under Diagnosis, a sample of the tumor is removed for analysis. How a tumor looks under a microscope is called tumor histology. Normal brain tissue usually has differentiated tissue (different types of cells grouped together). Brain tissue that is cancerous is usually made up of cells that look more alike. In general, the more differentiated the brain tissue (and the lower the grade), the better the prognosis. To determine histology of a glial tumor, doctors look at several factors including, but not limited to, the following:
The pathologist can determine the type of tumor and its grade. To decide on the best treatment for a brain tumor, both the type and grade of the tumor must be determined. In general, a tumor is referred to by grade. The higher the grade, the more rapidly growing the tumor is. Specifically for glial tumors, the grade is determined by its features, as seen under a microscope, according to the following criteria:
Age of patient. In adults, the age of the patient (as well as his or her level of functioning, called functional status, see below) at the time of diagnosis is one of the most significant predictors of outcome. In general, the younger the adult, the better the prognosis. Extent of tumor residual. Resection is surgery to remove a tumor, and residual refers to how much of the tumor remains in the body after surgery. Four classifications are used:
Prognosis is most favorable when all of the tumor can be surgically removed. Tumor location. A tumor can form in any part of the brain. Some tumor locations cause greater damage than others, and some tumors are harder to treat because of their location than others. Functional neurologic status. The doctor will test how well a patient is able to function and carry out everyday activities by using a functional assessment scale, such as the Karnofsky Performance Scale (KPS), outlined below. A higher score indicates a better functional status. Typically, the better someone is able to walk and care for themselves indicates a better prognosis. 100 Normal, no complaints, no evidence of disease 90 Able to carry on normal activity; minor symptoms of disease 80 Normal activity with effort; some symptoms of disease 70 Cares for self; unable to carry on normal activity or active work 60 Requires occasional assistance but is able to care for needs 50 Requires considerable assistance and frequent medical care 40 Disabled: requires special care and assistance 30 Severely disabled; hospitalization is indicated, but death not imminent 20 Very sick, hospitalization necessary; active treatment necessary 10 Moribund, fatal processes progressing rapidly 0 Dead Metastatic spread. A tumor that starts in the brain or spinal cord, if cancerous, often spreads within the CNS only and rarely metastasizes to other parts of the body in adults. For that reason, with few exceptions, tests looking at the other organs of the body are typically not needed. A tumor that does spread to other parts of the brain or spinal cord is associated with a poorer prognosis. Biogenetic markers. Certain molecular markers found in the tumor tissue can provide information on the tumor’s response to treatment. For instance, for oligodendroglioma, the loss of part of chromosome 1 on the p part of the chromosome, and the loss of part of chromosome 19 on the q part of the chromosome (called 1p and 19q) is associated with a much better response to chemotherapy and more successful treatment. Also, in glioblastoma, the modification of a gene called MGMT appears to be associated with improved responsiveness to treatment and better prognosis, but this is being tested in clinical trials (research studies). Recurrent tumor. A recurrent tumor is one that comes back after treatment. If there is a recurrence, the tumor may need to be graded again using the system above. Currently, the factors listed above are the best indicators of a patient’s prognosis. As discussed in Diagnosis, researchers are currently looking for tumor markers in the tumor tissue that could make a brain tumor easier to diagnose and the staging of an adult brain tumor possible in the future. These tools may someday help doctors analyze the possibility that a brain tumor will grow, develop more effective treatments, and more accurately predict prognosis. Used with permission of the American Joint Committee on Cancer (AJCC), Chicago, Illinois. The original source for this material is the AJCC Cancer Staging Manual, Seventh Edition (2010) published by Springer-Verlag New York, www.cancerstaging.net. Treatment
This section outlines treatments that are the standard of care (the best proven treatments available) for brain tumors. When making treatment plan decisions, patients are also encouraged to consider clinical trials as an option. A clinical trial is a research study to test a new treatment to evaluate whether it is safe, effective, and possibly better than standard treatment. Your doctor can help you review all treatment options. For more information, see the Clinical Trials and Current Research section. Treatment overview In brain tumor care, different types of doctors often work together to create a patient’s overall treatment plan that combines different types of treatment. This is called a multidisciplinary team and can include neuro-oncologists, medical oncologists, radiation oncologists, surgeons, rehabilitation therapists, and other specialists. Descriptions of the most common treatment options for a brain tumor are listed below, including treatments that help manage symptoms. Treatment options and recommendations depend on several factors, including the size, type, and grade of the tumor, if it is putting pressure on vital parts of the brain, whether it has spread to other parts of the CNS or body, possible side effects, and the patient’s preferences and overall health. Some types of brain tumors grow rapidly; other tumors grow slowly. Considering all these factors, your doctor will talk with you about how soon treatment should start after diagnosis. Treatment options may include surgery, radiation therapy, and chemotherapy (each described below). For a benign brain tumor, surgery may be the only treatment needed. Typically, treatment begins with surgery, followed by radiation therapy and chemotherapy if needed. In many situations, the chemotherapy is given at the same time as radiation therapy. Occasionally, the chemotherapy may come before the radiation therapy. Your exact treatment plan will be made by your health care team. Successfully treating brain and spinal cord tumors can be challenging. The body’s blood-brain barrier normally serves to protect the brain and spinal cord from harmful chemicals entering those structures through the bloodstream. However, this barrier also keeps out many types of chemotherapy. Surgery can be difficult if the tumor is near a delicate portion of the brain or spinal cord. Even when the surgeon can completely remove the original tumor, there may be spread from the tumor that is too small to be seen or removed during surgery. And, radiation therapy can damage healthy tissue. However, research in the past two decades has significantly improved the survival rates of people with brain tumors. More refined surgeries, a better understanding of what types of tumors respond to chemotherapy, and more targeted delivery of radiation therapy have resulted in a longer life span and better quality of life for many people diagnosed with a brain tumor. Learn more about making treatment decisions. Managing brain tumor symptoms A brain tumor can cause many symptoms, some of which can be severe. However, they can often be managed with the use of certain medications. At any point during a person’s care, people with a brain tumor can receive supportive care to help prevent or control symptoms, which can improve their comfort and quality of life during treatment. Supportive care for people with a brain tumor includes:
Learn more about palliative care. Surgery Surgery is the removal of the tumor and surrounding tissue during an operation. It is the first treatment most commonly used for a brain tumor and is often the only treatment needed for a noncancerous brain tumor. Removing the tumor can improve neurological symptoms, provide tissue for diagnosis, help make other brain tumor treatments more effective, and, in many instances, improve the prognosis of patients with brain tumors. A neurosurgeon is a doctor who specializes in surgery on the brain and spinal column. Surgery to the brain requires the removal of part of the skull, a procedure called a craniotomy. After the surgeon removes the tumor, the patient's own bone will be used to cover the opening in the skull. There have been rapid advances in surgery for brain tumors, including the use of cortical mapping (which allow doctors to identify certain areas of the brain that control the senses, language, and motor skills) and enhanced imaging devices to give surgeons more tools to plan and perform the surgery. For example, computer-based techniques, such as Image Guided Surgery (IGS), help surgeons map out the location of the tumor very accurately, which can make surgery safer and less invasive. For a tumor that is near the brain’s speech center, it is increasingly common to perform the operation when the patient is awake for part of the surgery; typically, the patient is awakened once the surface of the brain is exposed, and special electrical stimulation techniques are used to locate the speech center and thereby avoid causing damage while removing the tumor. In addition to removing or reducing the size of the brain tumor, surgery can provide a tissue sample for biopsy analysis, as explained in Diagnosis. For some tumor types, the results of this analysis can help determine if chemotherapy or radiation therapy will be useful. In a cancerous tumor, even if the cancer cannot be cured, its removal can relieve symptoms if it is creating pressure on parts of the brain. Learn more about surgery. Radiation therapy Radiation therapy is the use of high-energy x-rays or other particles to kill cancer cells. Doctors may use radiation therapy to slow or stop the growth of the tumor. It is typically given after surgery and possibly along with chemotherapy. A doctor who specializes in giving radiation therapy to treat cancer is called a radiation oncologist. The most common type of radiation treatment is called external-beam radiation therapy, which is radiation given from a machine outside the body. When radiation treatment is given using implants, it is called internal radiation therapy or brachytherapy. A radiation therapy regimen (schedule) usually consists of a specific number of treatments given over a set period of time. External-beam radiation therapy can be directed at the tumor in the following ways: Conventional radiation therapy. The treatment location is determined based on anatomic landmarks and x-rays. In certain situations, such as whole brain radiation therapy for brain metastases, this technique is appropriate. For more precise targeting, different techniques are needed. Three-dimensional conformal radiation therapy (3D-CRT). Using images from CT and MRI scans, a three-dimensional model of the tumor and normal tissue surrounding the tumor is created on a computer. This model can be used to aim the radiation beams directly at the tumor, sparing the normal tissue from high doses of radiation therapy. Intensity modulated radiation therapy (IMRT). IMRT is a type of 3D-CRT (see above) that can more directly target a tumor, further sparing normal tissue from radiation therapy. In IMRT, the radiation beams are broken up into smaller beams and the intensity of each of these smaller beams can be changed. This means that the more intense beams, or the beams giving more radiation, can be directed only at the tumor. Stereotactic radiosurgery. Stereotactic radiosurgery involves delivering a single, high dose of radiation directly to the tumor and not healthy tissues. It works best for a tumor that is only in one area of the brain and certain noncancerous tumors, but is also used for multiple metastatic brain tumors. There are many different types of stereotactic radiosurgery equipment, including:
Fractionated stereotactic radiation therapy. Radiation therapy is delivered with stereotactic precision but divided into small daily fractions over several weeks using a relocatable head frame, in contrast to the one-day radiosurgery. This technique is used for tumors located close to sensitive structures, such as the optic nerves or brain stem. Proton radiation therapy. Proton therapy (also called proton beam therapy) is a type of external-beam radiation therapy that uses protons rather than x-rays. At high energy, protons can destroy cancer cells. Learn more about proton therapy. With these different techniques, doctors are trying to achieve greater precision and reduce radiation exposure to the surrounding normal brain tissue. Depending on the size and location of the tumor, the radiation oncologist may choose any of the above radiation techniques. In certain situations, a combination of two or more techniques is appropriate. Short-term side effects from radiation therapy may include fatigue, mild skin reactions, hair loss, upset stomach, and neurologic symptoms. Most side effects go away soon after treatment is finished. Also, radiation therapy is usually not recommended for children younger than five because of the high risk of damage to their developing brains. Longer term side effects of radiation depend on how much normal tissue received radiation therapy and include memory and hormonal problems and cognitive (thought process) changes, such as difficulty understanding and performing complex tasks. Learn more about radiation therapy on this website, or see the American Society for Therapeutic Radiology and Oncology’s pamphlet, Radiation Therapy for Brain Tumors. Chemotherapy Chemotherapy is the use of drugs to kill cancer cells, usually by stopping the cancer cells’ ability to grow and divide. Systemic chemotherapy is delivered through the bloodstream, to reach cancer cells throughout the body. The goal of chemotherapy can be to destroy cancer cells remaining after surgery, slow a tumor’s growth, or reduce symptoms. As explained above, chemotherapy to treat a brain tumor is typically given after surgery and possibly along with radiation therapy. Chemotherapy is given by a medical oncologist, a doctor who specializes in treating tumors with medication. A chemotherapy regimen (schedule) usually consists of a specific number of cycles given over a set period of time. A patient may receive one drug at a time or combinations of different drugs at the same time. Chemotherapy can be delivered orally (by mouth), intravenously (IV, by vein), or directly into the tumor. IV chemotherapy is either injected directly into a vein or through a thin tube called a catheter, which is a tube temporarily put into a large vein to make injections easier. Some drugs are better at going through the blood-brain barrier, and doctors may recommend a single drug or a combination of drugs. Gliadel wafers are one delivery method for the drug carmustine. Temozolomide (Methazolastone, Temodar) is an oral drug that has also been approved for use in treating people with Grade III tumors that have recurred (come back after original treatment) in combination with radiation therapy, and after surgery in combination with radiation therapy and then continuing after radiation therapy for people with Grade IV astrocytomas. For people with glioblastoma multiforme, the latest standard of care is radiation therapy with daily low-dose temozolomide, followed by monthly doses of temozolomide after radiation therapy for six months to one year. Patients are monitored with brain MRI every two to three months; treatment is stopped after six months to one year or if tumor growth is seen. If the tumor grows during treatment, other treatment options will be considered. Patients often have regular MRIs to monitor their health even if treatment is completed and the tumor has not grown. The side effects of chemotherapy depend on the individual and the dose used, but they can include fatigue, risk of infection, nausea and vomiting, loss of appetite and diarrhea. These side effects usually go away once treatment is finished. Rarely, certain drugs may cause some hearing loss. Others may cause kidney damage. Patients may be given extra fluid intravenously for kidney protection. The doctor may also prescribe corticosteroids to reduce swelling and help to relieve symptoms. Learn more about chemotherapy and preparing for treatment. The medications used to treat cancer are continually being evaluated. Talking with your doctor is often the best way to learn about the medications prescribed for you, their purpose, and their potential side effects or interactions with other medications. Learn more about your prescriptions by using searchable drug databases. Targeted therapy In addition to standard chemotherapy, targeted therapy is a treatment that targets the tumor’s specific genes, proteins, or the tissue environment that contributes to cancer growth and survival. This type of treatment blocks the growth and spread of tumor cells while limiting the damage to normal cells, usually leading to fewer side effects than other cancer medications. Recent studies show that not all tumors have the same targets. To find the most effective treatment, your doctor may run tests to identify the genes, proteins, and other factors in your tumor. As a result, doctors can better match each patient with the most effective treatment whenever possible. In addition, many research studies are taking place now to find out more about specific molecular targets and new treatments directed at them. Learn more about targeted treatments. For a brain tumor, anti-angiogenesis therapy is the type of targeted therapy used. It is focused on stopping angiogenesis, which is the process of making new blood vessels. Because a tumor needs the nutrients found in the blood to grow and spread, the goal of anti-angiogenesis therapies is to “starve” the tumor. Bevacizumab (Avastin) is an anti-angiogenesis therapy used to treat glioblastoma multiforme when prior treatment has not worked. Recurrent brain tumor Once your treatment is complete and there is a remission (absence of symptoms from the tumor; also called “no evidence of disease” or NED), talk with your doctor about the possibility of the tumor returning. Many survivors feel worried or anxious that the tumor will come back. Learn more about coping with this fear. If the tumor does return after the original treatment, it is called a recurrent tumor. It may come back in the same place (called a local recurrence), nearby (regional recurrence), or in another place (distant recurrence). When this occurs, a cycle of testing will begin again to learn as much as possible about the recurrence. After testing is done, you and your doctor will talk about your treatment options. Often the treatment plan will include the therapies described above (such as surgery, radiation therapy, chemotherapy, and targeted therapy) but may be used in a different combination or given at a different pace. Your doctor may also suggest clinical trials that are studying new ways to treat a recurrent brain tumor. There is no single approach to treating a recurrent brain tumor, and your treatment plan will be based on many factors. However, new drugs are being created and tested in clinical trials to treat brain tumors that may help with recurrent tumors. Many of these new drugs are called "small molecules" or "molecularly targeted therapies" because they are small in size (and can therefore be taken by mouth) and/or can attack a specific molecule or target within the brain tumor cells. These new drugs are being tested either alone or in combination with standard chemotherapy. To learn more about clinical trials on brain tumor treatment, please read the section on Current Research. People with recurrent cancer often experience emotions such as disbelief or fear. Patients are encouraged to talk with their health care team about these feelings and ask about support services to help them cope. Learn more about dealing with cancer recurrence. Advanced brain tumor Patients with an advanced brain tumor or, rarely, one that has spread are encouraged to talk with doctors who are experienced in treating an advanced or metastatic tumor, because there can be different opinions about the best treatment plan. Learn more about seeking a second opinion before starting treatment, so you are comfortable with the treatment plan chosen. This discussion may include clinical trials studying new treatments. In addition to treatment to slow, stop or eliminate the tumor (also called disease-directed treatment), an important part of care is relieving a person’s symptoms and side effects with palliative care (see above). It includes supporting the patient with his or her physical, emotional, and social needs. People often receive disease-directed therapy and treatment to ease symptoms at the same time. Sometimes, disease-directed treatment is not successful. This is stressful, and it may be difficult to discuss. However, it is important to have open and honest conversations with your doctor and health care team to express your feelings, preferences, and concerns. The health care team is there to help, and many team members have special skills, experience, and knowledge to support patients and their families. If the patient and caregivers are comfortable with a treatment plan dedicated to maintaining comfort, hospice care is a program in local communities with an emphasis on relieving pain and discomfort and assisting the patient and his or her caregivers. Learn more about hospice care and advanced cancer care planning. Find out more about common terms used during treatment. About Clinical Trials
Doctors and scientists are always looking for better ways to treat patients with a brain tumor. To make scientific advances, doctors create research studies involving people, called clinical trials. Many clinical trials are focused on new treatments, evaluating whether a new treatment is safe, effective, and possibly better than the current (standard) treatment. These types of studies evaluate new drugs, different combinations of existing treatments, new approaches to radiation therapy or surgery, and new methods of treatment. Patients who participate in clinical trials are often among the first to receive new treatments before they are widely available. However, there is no guarantee that the new treatment will be safe, effective, or better than a standard treatment. There are also clinical trials that study new ways to ease symptoms and side effects during treatment and managing the late effects that may occur after treatment. Talk with your doctor about clinical trials regarding side effects. In addition, there are ongoing studies about ways to prevent the disease. Patients decide to participate in clinical trials for many reasons. For some patients, a clinical trial is the best treatment option available. Because standard treatments are not perfect, patients are often willing to face the added uncertainty of a clinical trial in the hope of a better result. Other patients volunteer for clinical trials because they know that these studies are the only way to make progress in treating a brain tumor. Even if they do not benefit directly from the clinical trial, their participation may benefit future patients with a brain tumor. Sometimes people have concerns that, by participating in a clinical trial, they may receive no treatment by being given a placebo or a “sugar pill.” The use of placebos in cancer clinical trials is rare. When a placebo is used in a study, it is done with the full knowledge of the participants or to study the addition of a medication to a standard treatment. Find out more about placebos in cancer clinical trials. To join a clinical trial, patients must participate in a process known as informed consent. During informed consent, the doctor should list all of the patient’s options, so that the person understands how the new treatment differs from the standard treatment. The doctor must also list all of the risks of the new treatment, which may or may not be different than the risks of standard treatment. Finally, the doctor must explain what will be required of each patient in order to participate in the clinical trial, including the number of doctor visits, tests, and the schedule of treatment. Learn more about clinical trials, including patient safety, phases of a clinical trial, deciding to participate in a clinical trial, questions to ask the research team, and links to find clinical trials. For specific topics being studied for brain tumors, learn more in the Current Research section. Patients who participate in a clinical trial may stop participating at any time, for any personal or medical reason. This may include that the new treatment is not working or there are serious side effects. It is important that patients participating in a clinical trial talk with their doctor and researchers about who will be providing their treatment and care during the clinical trial, after the clinical trials ends, and/or if the patient chooses to leave the clinical trial before it ends. Side Effects
Brain tumors and their treatment can cause a variety of side effects. However, doctors have made major strides in recent years in reducing fatigue, pain, nausea and vomiting, infections, and other physical side effects of treatments. Doctors also have many ways to provide relief to patients when such side effects occur. Fear of treatment side effects is common after a diagnosis of a brain tumor, but it may be helpful to know that preventing and controlling side effects is a major focus of your health care team. Before treatment begins, talk with your doctor about possible side effects of the specific treatments you will be receiving. The specific side effects that can occur depend on a variety of factors, including the type of tumor, its location, the individual treatment plan (including the length and dosage of treatment), and your overall health. Common side effects for each treatment option are described in detail within the Treatment section. Ask your doctor which side effects are most likely to happen (and which are not), when side effects are likely to occur, and how they will be addressed by the health care team. Also, be sure to talk with the doctor about side effects you experience during and after treatment. Care of a patient’s symptoms and side effects is an important part of a person’s overall treatment plan; this is called palliative or supportive care. It helps people with any type of brain tumor be as comfortable as possible. Learn more about the most common side effects of a brain tumor and different treatments, along with ways to prevent or control them. Be sure to talk with your doctor about the level of caregiving you may need during treatment and recovery, as family members and friends often play an important role in the care of a person with a brain tumor. Learn more about caregiving. In addition to physical side effects, there may be psychosocial (emotional and social) effects as well. For many patients, a diagnosis of a brain tumor is stressful and can bring difficult emotions. Patients and their families are encouraged to share their feelings with a member of their health care team, who can help with coping strategies. Learn more about the importance of addressing such needs, including concerns about managing the cost of your medical care. A side effect that occurs more than five years after treatment is called a late effect. Treatment of late effects is an important part of survivorship care. Learn more about late effects or long-term side effects by reading the After Treatment section or talking with your doctor. After Treatment
After treatment for a brain tumor ends, talk with your doctor about developing a follow-up care plan. This plan may include regular physical examinations and/or medical tests to monitor your recovery for the coming months and years. Many brain tumors have a high tendency to recur, so people should be routinely monitored for new symptoms with regular MRI scans. The frequency of the follow-up visits and the scans depends on the type of the tumor and other factors, so your health care team will determine your exact schedule. ASCO offers treatment summary forms to help keep track of the treatment you received and develop a survivorship care plan once treatment is completed. As described in previous sections, a brain tumor and its treatments can affect the functioning of the brain, as well as the well-being of the patient. For this reason, it is important for your health care team to evaluate the cognitive abilities of the brain through specialized tests, typically given by a neuropsychologist (a psychologist who has special training in the brain’s capacity and behaviors), and also to evaluate the person’s quality of life. These evaluations could identify situations when specific rehabilitative therapies would be helpful, such as speech therapy, occupational therapy, counseling with a social worker, and/or medications that can help to reduce fatigue or enhance memory. Learn more about rehabilitation. Whenever possible, participation in a support group with other people diagnosed with brain tumors is highly encouraged. People recovering from a brain tumor are encouraged to follow established guidelines for good health, such as maintaining a healthy weight, not smoking, eating a balanced diet, and having recommended health screening tests. Talk with your doctor to develop a plan that is best for your needs. Moderate physical activity can help rebuild your strength and energy level. Your doctor can help you create an appropriate exercise plan based upon your needs, physical abilities, and fitness level. Learn more about the next steps to take in survivorship, including making positive lifestyle changes. Find out more about common terms used after treatment is complete. Current Research
Doctors are working to learn more about brain tumors, ways to prevent them, how to best treat them, and how to provide the best care to people diagnosed with a brain tumor. The following areas of research may include new options for patients through clinical trials. Always talk with your doctor about the diagnostic and treatment options best for you. Enhanced imaging tests. New techniques for imaging scans are being researched. These may help doctors better track the effectiveness of treatment and monitor possible tumor recurrence or growth. Biomarkers. Researchers are examining biomarkers to find better ways to determine the presence of a brain tumor before symptoms begin, using blood or other tests. Biomarkers (also called tumor markers) are substances found in higher than normal amounts in the blood, urine, spinal fluid, plasma or other bodily fluids of people with certain types of tumors. Hyperfractionization. This type of radiation therapy breaks up the total dose of radiation therapy into smaller doses that are given more than once a day. Immunotherapy. Immunotherapy, also called biologic therapy or biological response modifier (BRM) therapy, is designed to boost the body's natural defenses to fight the cancer. It uses materials either made by the body or in a laboratory to bolster, target, or restore immune system function. Different methods are being studied for brain tumors, such as the use of dendritic cells or the use of vaccines aimed against a specific molecule on the surface of the tumor cells. Several methods are currently being tested throughout the country in clinical trials. Targeted therapy. As outlined in Treatment, this type of treatment targets faulty genes or proteins that contribute to cancer growth and development. Research continues regarding the use of therapies for brain tumors that target different pathways that can affect tumor growth, how a tumor spreads, and cell death. Blood-brain barrier disruption. This technique temporarily disrupts the brain’s natural protective barrier in order to allow chemotherapy to more easily enter the brain from the bloodstream. New combination therapies. New combinations may include radiation therapy and chemotherapy with a convection enhanced delivery (CED), which is a method to infuse drugs and other molecules right into the tumor. CED allows chemotherapy to be delivered more safely and effectively by pumping the drug under pressure directly into the tumor cells. The drug links only to receptors located on tumor cells. By targeting the tumor cells, CED helps avoid damage to healthy brain cells and reduces the risk of side effects commonly found with the standard way chemotherapy is given. New drugs and combinations of drugs. Researchers are looking at using drugs currently used for other types of cancer as treatment for a brain tumor. Combinations of drugs being studied for brain tumor treatment include temozolomide and bevacizumab. In addition, combinations of drugs that target different pathways a tumor uses to grow and spread are being explored. Since tumors can develop resistance to chemotherapy, meaning the treatment stops working, another approach is to use a treatment that targets how tumor cells develop resistance. Gene therapy. This type of therapy seeks to replace or repair abnormal genes that are causing or helping tumor growth. Genetic research. Researchers are seeking to learn more about the presence, absence, or mutations of specific genes and how they relate to the risk and growth of brain tumors. In particular, The Cancer Genome Atlas Research Network is a large, ongoing effort by the National Institutes of Health to find out more about the link between genetics and glioblastoma. Recent results include the discovery of three specific genetic mutations not previously linked to glioblastoma; the affected genes are NF1, ERBB2, and PIK3R1; another finding focused on the involvement of the MGMT gene. This information is useful to researchers and may eventually lead to advances in the diagnosis and treatment of this type of brain tumor. Learn more about cancer genome research. Supportive care. Clinical trials are underway to find better ways of reducing symptoms and side effects of current brain tumor treatments, in order to improve patients’ comfort and quality of life. Learn more about common statistical terms used in cancer research. Looking for More about Current Research? If you would like additional information about the latest areas of research regarding brain tumors, explore these related items:
Or, choose “Next” (below, right) to continue reading this detailed section. Questions to Ask the Doctor
Talking often with the doctor is important to make informed decisions about your health care. These suggested questions are a starting point to help you learn more about your care and treatment. You are also encouraged to ask additional questions that are important to you.
Patient Information Resources
In addition to Cancer.Net, there are other sources of information about this type of cancer available online. Cancer.Net maintains a list of national, not-for-profit organizations that may be helpful in finding additional information, services, and support. As always, be sure to talk with your doctor about questions you may have about information you find about this disease. View organizations that offer information on this specific type of cancer. |
