Brain TumorLast Updated: December 23, 2009 This section has been reviewed and approved by the Cancer.Net Editorial Board, 12/09 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 arises in the CNS, it is especially problematic because of the potential effect on a person's thought processes and movements. A brain tumor begins when cells in the brain begin to grow uncontrollably and eventually form a mass. A tumor can be benign (noncancerous) or malignant (cancerous, meaning it can spread). Malignant brain tumors are further classified using a grade: low, intermediate, or high. More information can be found in Staging/Grading. 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. For cancer that started elsewhere in the body and spread to the brain, learn more information by reading the Cancer Type section where the cancer began. 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, contains two cerebral hemispheres and is divided into four lobes where specific functions occur:
The cerebellum. This is located beneath the cerebrum. 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 produced near the center of the brain, in the lateral ventricles, and circulates around the brain and spinal cord between the arachnoid and pia layers. Types of brain tumors There are more than 100 types of primary brain tumors. For a complete listing of their names and incidence, please refer to the Central Brain Tumor Registry of the United States. This section covers brain tumors diagnosed in adults. (For brain tumors in children, read more about childhood brain tumors in another section of Cancer.Net.) 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 considered the most common type 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 types of supportive cells: astrocytes and oligodendrocytes. Most gliomas are called either astrocytoma or oligodendroglioma, or a mixture 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 on the degree of aggressiveness. A grade I glioma is a benign tumor, while grades II through IV are tumors with an increasing degree of aggressiveness and are therefore considered increasingly cancerous in potential. 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.
For more information on astrocytoma in children, read the guide to Astrocytoma, Childhood Cancer. Oligodendroglioma. Oligodendroglioma is a tumor that develops from cells called oligodendrocytes. These cells are responsible for producing the myelin (a substance rich in protein and lipids [fatty substances]) 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 composed of more than one of the glial cell types and makes up about 1% of primary brain tumors. Ependymomas. Ependymomas begin in the ependyma (the cells that line the passageways in the brain where CSF is made and stored) and make up about 2% of primary brain tumors. These types of tumors develop at the bottom of the brain and canal containing the spinal cord. Although there is no formal staging system for these tumors, they can be divided into supratentorial (in the cerebral portion of the brain) or infratentorial (in the back of the brain) tumors. Ependymomas are most common in children and men and women in their 40s and 50s. For pediatric information, read the Guide to Ependymoma, Childhood Cancer. Brain stem glioma. A brain stem glioma begins in the glial cells in the brain stem. Read guide to Brain Stem Glioma, Childhood Cancer for pediatric information. 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 benign. Meningioma can cause significant symptoms if it grows and presses on the brain or spinal cord or invades into the brain tissue. Read the guide to Meningioma for more information. Pineal gland and pituitary gland tumors. The pineal gland and pituitary gland are the locations of about 7% of all brain tumors. 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 malignant, often spreading throughout the CNS. Medulloblastomas make up about 2% of all brain tumors. Similar tumors can arise in other parts of the brain, frequently in the pineal gland region, and are called Primitive Neuro Ectodermal Tumors (PNET) For pediatric information, refer to guide to Medulloblastoma, Childhood Cancer. 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. For pediatric information, read the guide to Craniopharyngioma, Childhood Cancer. 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 normally benign. Germ cell tumors. Germ cells are special cells in a developing embryo (fetus) that become the testicles in boys and ovaries in girls. Rarely, during development of the embryo, these cells travel to other areas of the body and become cancerous. A germ cell tumor can be benign or malignant. They are often divided into extracranial tumors (occurring in places other than the brain) and extragonadal (occurring outside the reproductive organs). For more pediatric information, read the Guide to Germ Cell Tumors, Childhood Cancers. About 6% of all brain tumors cannot be assigned an exact type. Statistics It is estimated that about 52,000 people will be diagnosed with a primary brain tumor (benign or malignant) each year. In 2009, an estimated 22,070 adults (12,010 men and 10,060 women) in the United States will be diagnosed with primary malignant tumors of the brain and spinal cord. It is estimated that 12,920 deaths (7,330 men and 5,590 women) from this disease will occur this year. Brain tumors are the tenth most common cause of cancer death in women. Metastatic or secondary tumors of the brain will occur in 20% to 40% of patients with cancer. The most common primary cancers that spread to the brain are lung, breast, unknown primary, melanoma, and colon cancers. Survival statistics should be interpreted with caution. Estimates are based on data from thousands of cases of 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. Because the survival statistics are measured in five-year (or sometimes one-year) intervals, they may not represent advances made in the treatment or diagnosis of this cancer. Statistics adapted from the American Cancer Society’s publication, Cancer Facts & Figures 2009, the National Cancer Institute, and the Central Brain Tumor Registry. Find out more about basic cancer terms used in this section. Medical Illustrations
Risk Factors
A risk factor is anything that increases a person’s chance of developing a brain tumor. Some risk factors can be controlled, such as smoking, and some cannot be controlled, such as age and family history. Although risk factors can influence the development of a brain tumor, most do not directly cause cancer 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 communicating them to your doctor may help you make more informed lifestyle and health care choices. In most cases, the cause of a brain tumor is unknown. The following factors may raise a person’s risk of developing a brain tumor: Age. Children and older adults are the two groups most likely to be diagnosed with brain tumors, although a brain tumor can occur at any age. Gender. Men are generally more likely than women to develop gliomas, while women are more likely to have meningiomas. 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 no scientific evidence to date. Family history. About 5% of brain tumor cases 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 are also aware of sporadic “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. 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 experimental animal studies; 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 headset for both adults and children. Race and ethnicity. In the United States, white people have higher rates of gliomas but lower rates of meningiomas than black people. Also, the rate of malignant brain tumors in Japan is less than half the rate found in northern Europe. 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 found in some cured meats, 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, additional research is necessary before a definitive link can be established. At this time, there are no known means of preventing a brain tumor. Symptoms
People with a brain tumor may experience the following symptoms. 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 on this list, please talk with your doctor. Symptoms of a brain tumor can be general (due to the pressure of the tumor on the brain or spinal cord) or specific (due to the interruption of the normal functioning of a specific part of the brain). Typically, a brain tumor is not diagnosed until after symptoms begin. General symptoms include:
Symptoms that may be specific to the location of the tumor include:
Diagnosis
Doctors use many tests to diagnose a brain tumor, determine the type of brain tumor, and learn 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 (called a biopsy) or 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 is the result of spread from another type of cancer in the body. Your doctor may consider these factors when choosing a diagnostic test:
Most brain tumors are not diagnosed until after symptoms appear. The oncologist (a doctor who specializes in cancer) or the neuro-oncologist (a doctor who specializes in diagnosing and 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 order the following tests be done 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. Individual diagnostic tests are described below. 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 gain more information about a tumor while a patient is undergoing treatment or if there is a recurrence (the tumor comes back after treatment). Once an imaging scan shows a tumor is present, the primary way of determining the type of brain tumor is the results of the tissue sampling tests (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 brain tumors include:
Tissue sampling/biopsy/surgical removal of a tumor. As explained above, imaging is 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 cancer 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 after the entire tumor is removed surgically or as a separate procedure (if surgical removal of the tumor is not possible due to its location or the medical condition of the patient.) 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 conducted 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. Tumor markers/laboratory tests. Laboratory tests can detect 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 determine the presence of a brain tumor before symptoms begin. 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. 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. Evoked potentials. Evoked potentials involve the use of electrodes to measure the electrical activity of nerves and can often detect acoustic schwannoma, a benign brain tumor. This test can be used as a guide during surgical removal of a tumor that is growing around important nerves. Learn more about what to expect when having common tests, procedures, and scans. Find out more about common terms used during a diagnosis of cancer. Staging
Staging is a way of describing a tumor, such as where it is located, if or where it has spread, and if it is affecting the functions of other organs in the body. After a brain tumor has been diagnosed, additional tests will be done to learn more about the tumor. There is no formal staging system for adult brain tumors. Instead, once a brain tumor has been diagnosed, the pathologist will perform several tests on a tissue sample of the tumor to learn as much as possible 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 number indicates the degree of abnormality of the tumor cells. The degree of malignancy is often determined by characteristics of the tumor, as seen under the microscope. Generally, the lower the grade, the better the prognosis (chance of recovery or long-term control of the tumor). 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 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 established. In general, a tumor is referred to by grade. The higher the grade, the more rapidly growing the tumor is. Specifically for astrocytoma, 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) 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 due to their location than others. Functional neurologic status. The doctor will test how well a patient is able to function and carry out normal 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. 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). 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 make it possible for doctors to analyze the growth potential of brain tumors, 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
The treatment of an adult brain tumor depends on many factors, including the size, type, and grade of the tumor, where it is located and the pressure it is putting on vital parts of the brain, whether it has spread to other parts of the CNS or body, and the person’s age 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. This section outlines treatments that are the standard of care (the best treatments available) for brain tumors. Patients are also encouraged to consider clinical trials as a treatment option when making treatment plan decisions. A clinical trial is a research study to test a new treatment to prove it is safe, effective, and possibly better than standard treatment. Your doctor can help you review all treatment options. For more information, visit the Clinical Trials section. Overview of brain tumor treatments In many cases, a team of doctors will work with the patient to determine the best treatment plan. This team may include neuro-oncologists, medical oncologists, radiation oncologists, surgeons, rehabilitation therapists, and other specialists. Treatment options may include surgery, radiation therapy, and chemotherapy (each described below). For a benign brain tumor, surgery may be the only treatment needed. For a malignant brain tumor, it is expected that a combination of treatments will be required. Typically, treatment begins with surgery, followed by radiation therapy and chemotherapy. In many situations, the chemotherapy is administered 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 drugs. 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 microscopic spread of the tumor that cannot 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. Surgery Surgery is the first treatment most commonly used for a brain tumor and is often the only treatment needed for a benign brain tumor. 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 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. External-beam radiation therapy can be directed 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 required. Intensity modulated radiation therapy (IMRT). Radiation therapy is delivered with greater intensity or dose to thicker areas of the tumor and with less intensity to thinner areas of the tumor. This is accomplished by placing tiny metal leaves in the beam to reduce the intensity of the beam in order to customize the shape of the dose to the shape of the tumor. Three-dimensional conformal radiation therapy. Based on CT and MRI images, a three-dimensional model of the tumor and normal tissues is created on a computer. Beam size and angles are determined that maximize tumor dose and minimize normal tissue dose. 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 benign 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. Side effects from may include fatigue, mild skin reactions, 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 years of age because of high risk of damage to their developing brains. There are long term side effects that may occur years after treatment. A person may experience cognitive problems, including memory loss and a slow decline in intellectual performance. The extent of these side effects will depend on how much radiation was given and where in the brain. These side effects have become less severe with greater technology and precision in radiation therapy, however you should speak with your radiation therapist from the onset of treatment if you have any questions or concerns about the potential long term side effects of radiation therapy. 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. Systemic chemotherapy is delivered through the bloodstream, targeting cancer cells throughout the body. The goal of chemotherapy can be to destroy cancer cells remaining after surgery, slow the 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. Some people may receive chemotherapy in their doctor's office; others may go to the hospital. A chemotherapy regimen (schedule) usually consists of a specific number of cycles given over a specific time. Chemotherapy can be delivered orally (by mouth), intravenously (IV, by vein), or directly into the tumor cavity. IV chemotherapy is either injected directly into a vein or through a thin tube called a catheter, 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 (BCNU). Temozolomide (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 for people with Grade IV astrocytomas, which are also called glioblastoma multiforme or GBM. For people with glioblastoma, 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 if tumor growth is seen or after six months to one year. If tumor growth does not occur, patients often have regular MRIs scans to monitor their health. The side effects of chemotherapy depend on the individual and the dose used, but 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. It is also important to keep in mind that occasionally a treatment plan can evolve and change over a period of time. Your doctor may need to change the treatment dose or type of treatment if it no longer is proving to be effective. 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 faulty genes or proteins that contribute to tumor growth and development. In May 2009, the U.S. Food and Drug Administration (FDA) approved a targeted therapy called bevacizumab (Avastin) for the treatment of glioblastoma multiforme when prior treatment has not been effective. These drugs may cause serious side effects, although the side effects are usually different than those seen with traditional chemotherapy. For instance, angiogenesis inhibitors are often associated with high blood pressure. Learn more about targeted treatments. Supportive care At any point during a person’s care, people with brain tumors can receive supportive care to help prevent or control symptoms and improve their comfort and quality of life during treatment. Common types of supportive care for people with brain tumors include: Steroids. Steroids occur naturally in the body, but in tiny amounts. They are very powerful anti-inflammatories (drugs that help swelling). Most patients with brain tumors will be prescribed steroids to help relieve swelling of the brain. You will most likely receive steroids when you are first diagnosed, before and after surgery, before and after radiation therapy, and if you have an advanced brain tumor. Steroids have many side effects which include weight gain and water retention, increased appetite, difficulty sleeping, changes in mood, and stomach irritation. After successful treatment for the brain tumor, your doctor may slowly reduce the amount of steroids you need to take over time. Anti-seizure (convulsant) medication. A person with a brain tumor may experience seizures and this type of medication helps to control the frequency of them. Shunt. If fluid begins to build up in the brain, it may become necessary for a surgeon to place a shunt (a device used to bypass or divert fluid from one place to another) to drain the excess fluid. Anti-depressants. Depression can be common in people with brain tumors, but is often undiagnosed. However, this does not mean that all people with brain tumors are depressed. For those who have symptoms of depression, a person’s health care team may decide to prescribe an anti-depressant to help with the symptoms. Learn more about depression. Advanced/recurrent brain tumors If, in spite of initial treatment, the brain tumor does not go into remission (the temporary or permanent disappearance of symptoms) or if it recurs, treatment can still help manage the symptoms caused by the tumor. Symptom management, also called palliative care, is always important since the symptoms of a brain tumor can interfere with quality of life. Currently, no standard treatment exists for most tumors, including glial tumors, at the time of recurrence. This is often the setting where experimental treatments are evaluated in clinical trials. Due to advances in research, new drugs are being created to treat brain 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 orally) 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. Find out more about common terms used during cancer treatment. Clinical Trials Resources
Doctors and scientists are always looking for better ways to treat patients with a brain tumor. A clinical trial is a way to test a new treatment to prove that it is safe, effective, and possibly better than a standard treatment. The clinical trial may be evaluating a new drug, a new combination of existing treatments, a new approach to radiation therapy or surgery, or a new method of treatment or prevention. Patients who participate in clinical trials are 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. 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 finding new drugs and other therapies is 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. 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 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 cancer clinical trials. For specific topics being studied for brain tumors, learn more in the Current Research section. 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 do 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 the person’s overall health. 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 if they do happen. Also, be sure to communicate with the doctor about side effects you experience during and after treatment. Learn more about the most common side effects of cancer and different treatments, along with ways to prevent or control them.This may include information about the best nutrition plan for you during treatment, as well as information about complementary treatments to help relieve symptoms and side effects. Be sure to talk with your doctor about the level of caregiving that you may need during this time, as family caregivers play an important part in the care of people with a brain tumor. Learn more about caregiving. In addition to physical side effects, there may be psychosocial (emotional and social) effects as well. Learn more about the importance of addressing such needs, including concerns about managing the cost of your medical 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. 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 about 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, or medications that can help to reduce fatigue or enhance memory. Learn more about Rehabilitation 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 healthy living after cancer. Find out more about common terms used after cancer treatment is complete. Current Research
Research for brain tumors is ongoing. The following advances may still be under investigation in clinical trials and may not be approved or available at this current time. Always discuss all diagnostic and treatment options with your doctor. The brain tumor developments being explored include the following. Enhanced imaging tests. New techniques for imaging scans are under investigation. 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 under research uses smaller doses at more frequent intervals. 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 applied, such as the use of dendritic cells or the use of vaccines aimed against a specific molecule that is expressed on the surface of the tumor cells. Several studies 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 tumor growth and development. Research continues regarding the use of targeted therapies for brain tumors. Anti-angiogenesis therapy. This is the use of drugs to stop tumors from developing new blood vessels. Without blood vessels feeding the tumor with blood, the tumor cannot grow. 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 conserve healthy brain cells and reduces the risk of side effects commonly found in traditional systemic chemotherapy delivery methods. 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 uncover more about the link between genetics and glioblastoma. In 2008, the first results of this study were announced and included 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 advancements in the diagnosis and treatment of this type of brain tumor. Learn more about cancer genome research. Stem cell research and tumor mitigating cells. Researchers are looking into the possibility of finding the stem cells associated with brain tumors, and tumor mitigation (altering) as a method of potential treatment in the future. More aggressive treatment plans for childhood tumors. As research grows and better treatment techniques are discovered that reduce long-term side effects, the treatment plans for children with brain tumors may include more types of surgery, chemotherapy, and radiation therapy.Questions to Ask the Doctor
Regular communication with your doctor is important in making informed decisions about your health care. Consider asking the following questions of your doctor:
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. |
