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:

• A modified linear accelerator is a machine that creates high-energy radiation by using electricity to form a stream of fast-moving subatomic particles.
  
  
• A gamma knife is another form of radiation therapy that concentrates highly focused beams of gamma radiation on the tumor.
  
  
• A cyber knife is a robotic device used in radiation therapy to guide radiation to the tumor target—particularly in the brain, head, and neck regions.

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 radiation therapy 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.

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. 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 faulty genes or proteins that contribute to cancer 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. Learn more about targeted treatments.

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.