Treatment
Many people with brain tumors want to take an active part in making decisions about their medical care. They want to learn all they can about their disease and their treatment choices. However, shock and stress after a diagnosis of a brain tumor can make it hard to think of everything to ask the doctor. It often helps to make a list of questions before an appointment. To help remember what the doctor says, patients may take notes or ask whether they may use a tape recorder. Some also want to have a family member or friend with them when they talk to the doctor-to take part in the discussion, to take notes, or just to listen.
The doctor may refer the patient to a specialist, or the patient may ask for a referral. Specialists who treat brain tumors include
neurosurgeons,
neurooncologists,
medical oncologists, and
radiation oncologists. The patient may be referred to other health care professionals who work together as a team. The medical team may include a
nurse,
dietitian,
mental health counselor,
social worker,
physical therapist,
occupational therapist, and
speech therapist. Children may need tutors to help with schoolwork. (The section on "Rehabilitation" has more information about therapists and tutors.)
Treatment Options Surgery Surgery is usually the first line of treatment for a brain tumor, with a goal of removing as much visible tumor as possible. Surgeons define an operable, or resectable, tumor as one that can be removed without causing severe damage to surrounding, healthy brain tissue. Surgery is also used to relieve the build-up of cerebro-spinal fluid, the fluid that bathes the brain, which can result from the growth of a tumor. A craniotomy is the most common type of surgery and it involves the removal of a piece of the bone of the skull so that access to the tumor is possible. After surgery, the bone is replaced. Intraoperative Magnetic Resonance Imaging (MRI) surgery is also another possibility. This type of surgery is less invasive and more accurate. It also allows tumors to be more precisely targeted and removed. This treatment is not available for all brain tumors and specific criteria must be met. Before a definitive diagnosis can be made, a biopsy is usually performed. A biopsy involves take a small amount of tissue from the tumor, through a very thin needle, and then examining it. Pathologists will examine the cells and determine its grade, level of malignancy and exact type of tumor. Sometimes a biopsy will be performed during the actual surgical procedure. New surgical techniques and tools allow for the precise and safe removal of tumors from many parts of the brain. Surgery may be followed by radiation and/or chemotherapy. The risks and benefits of surgery should be discussed with you by your medical team. Radiation Therapy and Radiosurgery Radiation plays a central role in the successful treatment of many brain tumors, both benign and malignant. After surgery, any remaining tumor cells can be treated and controlled with radiation, often reducing their size and rate of growth. Radiation also helps to prevent or delay the recurrence of tumors. Additionally, radiation has proven to be extremely helpful in treating inoperable tumors. There are different forms of radiation used for specific types and sizes of tumors. Traditional radiation therapy, or conventional radiation, is composed of either high energy x or gamma rays designed to destroy brain tumor cells. This type of radiation is usually administered one to two weeks after surgery and continues for approximately 6 weeks, with similar dosages at each visit. Stereotactic radiosurgery, another form of radiation, provides pinpoint precision in the administering of radiation, without any invasive surgery. During stereotactic radiosurgery, a single, high dose of radiation is delivered to the tumor, minimizing damage to the surrounding brain tissue. Gamma Knife, adapted linear accelerator and cyclotron are all methods of stereotactic radiosurgery that vary slightly in how they provide radiation. Stereotactic radiosurgery has been helpful in treating small tumors located deep within the brain. It is becoming the treatment of choice in patients with many small metastatic brain tumors. The risks and benefits of radiation therapy should be discussed with you by your medical team, before you undergo treatment. Radiation is tolerated better in older children and adults. Children usually do not receive radiation because of the severe cognitive effects it can have on the young, developing brain. Side effects may vary, depending on the dose of the radiation, the length of treatment and the location and size of the brain tumor. Large, aggressive brain tumors usually require a more intense dose of radiation, which may increase side effects. Short term side effects of radiation can include fatigue, hair loss, scalp irritation and muffled hearing. These side effects may resolve within two to four weeks of radiation therapy. Hair loss may be permanent, depending on the length and dose of radiation. Long term side effects can include short term memory loss, cognitive difficulties and radiation necrosis. Chemotherapy Chemotherapy consists of a series of drugs that interfere with the normal functioning of the rapidly dividing cells of the tumor. This prevents the tumor from growing. Most of these chemotherapy drugs are given in combination so that they are most effective. Research is being conducted to determine the best combination of chemotherapy drugs to combat brain tumors. Some chemotherapy drugs are injected directly into the bloodstream while others can be taken by pill, at home. The biggest challenge for effectively treating brain tumors with chemotherapy is the blood-brain barrier. This barrier, which is a network of blood vessels and cells, protects the brain from any foreign, harmful agents. The barrier can also block chemotherapy drugs from effectively reaching the brain and targeting the brain tumor. Researchers are testing drugs that may break through this barrier. Another way to deliver chemotherapy to the brain is through interstitial chemotherapy. With this method, doctors implant chemotherapy-soaked wafers directly into the brain after surgery. This helps to increase the dose of the drugs without increasing side effects. Chemotherapy has been particularly effective in treating children with brain tumors that have spread outside the brain to the bone or bone marrow. Chemotherapy can decrease the chance of a brain tumor spreading outside the nervous system. The use of chemotherapy also helps to delay or prevent the use of radiation in children, which can be very harmful to the developing brain. Chemotherapy is usually not used for the treatment of benign brain tumors.
Interstitial Brachytherapy This technique involves a surgical procedure that implants radioactive seeds directly into the brain tumor, where they remain for a period of time. This allows the seeds to target tumor cells. Though interstitial brachytherapy is not usually a first line of treatment for brain tumors, it can be used when standard therapy is not effective or if there is a recurrence of a brain tumor. Interstitial brachytherapy has largely been replaced by stereotactic surgery, which is non-invasive while still delivering a large amount of radiation to a small area. Immunotherapy This treatment attempts to make the body's immune system more effective in finding and destroying cancer cells. Using immunotherapy, different techniques are used to boost the immune system. The first approach employs natural proteins, called interferons, which are created by the immune system and are toxic to many different types of tumor cells. Lymphocytes, are cells that are able to fight cancer and can be grown in a laboratory and injected directly back into the tumor, to increase the body's immune response. Lastly, a tumor vaccine can be created from brain tumor cells that are removed, modified and then transferred back to the patient. A tumor vaccine can create a strong immune system response against the tumor. Immunotherapy treatment is currently being investigated and researched. It is often used after standard therapy has failed to produce a response. Gene Therapy The goal of gene therapy is to destroy tumor cells and shrink the size of a brain tumor. Though it is still experimental, gene therapy can be effective for both adults and children diagnosed with malignant tumors who have not responded to standard treatments such as surgery and radiation. Many clinical trials are currently underway that are studying gene therapy and its effectiveness with adult and pediatric brain tumors. Each gene carries specific instructions for the proper functioning of each cell within your body. Genes also contain information that makes the necessary proteins for proper cell growth and destruction. Through a series of processes, genes can become abnormal and may cause certain diseases, such as brain tumors. Researchers are now trying to repair these damaged genes using gene therapy. Two methods of gene therapy are used to treat brain tumors. The first method involves a gene called the suicide gene, which is introduced into the tumor through a weakened virus. The tumor cells then become sensitive to a specific drug that destroys the genetically treated cells of the tumor. The second method involves an immune enhancer gene which is introduced into the tumor and causes an immune response against the patient's own tumor. There are certain risks associated with gene therapy. Discuss gene therapy with your medical team to determine if it is the right option for you. Angiogenesis Inhibitors Angiogenesis is defined as the growth of new blood vessels. Brain tumors simply cannot grow without these blood vessels to provide them with nourishment. Angiogenesis inhibitors are a group of drugs that interfere with the growth of blood vessels. The aim is to starve tumors of the nutrients and oxygen they need to grow. The anti-angiogenesis drugs that are currently under investigation are thalidomide, TNP-470, platelet factor 4, interferon and endostatin. |
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Preparing for Treatment
The doctor can describe treatment choices and discuss the results expected with each treatment option. The doctor and patient can work together to develop a treatment plan that fits the patient's needs.
Treatment depends on a number of factors, including the type, location, size, and grade of the tumor. For some types of brain cancer, the doctor also needs to know whether cancer cells were found in the cerebrospinal fluid.
These are some questions a person may want to ask the doctor before treatment begins: What type of brain tumor do I have? Is it benign or malignant? What is the grade of the tumor? What are my treatment choices? Which do you recommend for me? Why? What are the benefits of each kind of treatment? What are the risks and possible side effects of each treatment? What is the treatment likely to cost? How will treatment affect my normal activities? Would a clinical trial (research study) be appropriate for me? Can you help me find one?
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People do not need to ask all of their questions or understand all of the answers at one time. They will have other chances to ask the doctor to explain things that are not clear and to ask for more information.
Methods of Treatment
People with brain tumors have several treatment options. Depending on the tumor type and stage, patients may be treated with surgery, radiation therapy, or chemotherapy. Some patients receive a combination of treatments.
In addition, at any stage of disease, patients may have treatment to control pain and other symptoms of the cancer, to relieve the side effects of therapy, and to ease emotional problems. This kind of treatment is called symptom management, supportive care, or palliative care.
The doctor is the best person to describe the treatment choices and discuss the expected results.
A patient may want to talk to the doctor about taking part in a clinical trial, which is a research study of new treatment methods. The section on "The Promise of Cancer Research" has more information about clinical trials.
Surgery is the usual treatment for most brain tumors. Surgery to open the skull is called a craniotomy. It is performed under general anesthesia. Before surgery begins, the scalp is shaved. The surgeon then makes an incision in the scalp and uses a special type of saw to remove a piece of bone from the skull. After removing part or all of the tumor, the surgeon covers the opening in the skull with that piece of bone or with a piece of metal or fabric. The surgeon then closes the incision in the scalp.
These are some questions a person may want to ask the doctor before having surgery: How will I feel after the operation? What will you do for me if I have pain? How long will I be in the hospital? Will I have any long-term effects? Will my hair grow back? Are there any side effects from using metal or fabric to replace the bone in the skull? When can I get back to my normal activities? What is my chance of a full recovery?
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Sometimes surgery is not possible. If the tumor is in the brain stem or certain other areas, the surgeon may not be able to remove the tumor without damaging normal brain tissue. Patients who cannot have surgery may receive radiation or other treatment.
Radiation therapy (also called radiotherapy) uses high-energy rays to kill tumor cells. The radiation may come from x-rays, gamma rays, or protons. A large machine aims radiation at the tumor and the tissue close to it. Sometimes the radiation may be directed to the entire brain or to the spinal cord.
Radiation therapy usually follows surgery. The radiation kills tumor cells that may remain in the area. Sometimes, patients who cannot have surgery have radiation therapy instead.
The patient goes to a hospital or clinic for radiation therapy. The treatment schedule depends on the type and size of the tumor and the age of the patient. Each treatment lasts only a few minutes.
Doctors take steps to protect the healthy tissue around the brain tumor:
Fractionation-Radiation therapy usually is given five days a week for several weeks. Giving the total dose of radiation over an extended period helps to protect healthy tissue in the area of the tumor.
Hyperfractionation-The patient gets smaller doses of radiation two or three times a day instead of a larger amount once a day.
Stereotactic radiation therapy-Narrow beams of radiation are directed at the tumor from different angles. For this procedure, the patient wears a rigid head frame. An MRI or CT scan creates pictures of the tumor's exact location. The doctor uses a computer to decide on the dose of radiation needed, as well as the sizes and angles of the radiation beams. The therapy may be given during a single visit or over several visits.
3-dimensional conformal radiation therapy-A computer creates a 3-dimensional image of the tumor and nearby brain tissue. The doctor aims multiple radiation beams to the exact shape of the tumor. The precise focus of the radiation beams protects normal brain tissue.
Proton beam radiation therapy-The source of radiation is protons rather than x-rays. The doctor aims the proton beams at the tumor. Protons can pass through healthy tissue without damaging it.
These are some questions a person may want to ask the doctor before having radiation therapy: Why do I need this treatment? When will the treatments begin? When will they end? How will I feel during therapy? Are there side effects? What can I do to take care of myself during therapy? How will we know if the radiation is working? Will I be able to continue my normal activities during treatment?
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Chemotherapy, the use of drugs to kill cancer cells, is sometimes used to treat brain tumors. The drugs may be given by mouth or by injection. Either way, the drugs enter the bloodstream and travel throughout the body. The drugs are usually given in cycles so that a recovery period follows each treatment period.
Chemotherapy may be given in an outpatient part of the hospital, at the doctor's office, or at home. Rarely, the patient may need to stay in the hospital.
Children are more likely than adults to have chemotherapy. However, adults may have chemotherapy after surgery and radiation therapy.
For some patients with recurrent cancer of the brain, the surgeon removes the tumor and implants several wafers that contain chemotherapy. Each wafer is about the size of a dime. Over several weeks, the wafers dissolve, releasing the drug into the brain. The drug kills cancer cells.
Patients may want to ask these questions about chemotherapy: Why do I need this treatment? What will it do? Will I have side effects? What can I do about them? When will treatment start? When will it end? How often will I need checkups?
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Side Effects of Treatment Because treatment may damage healthy cells and tissues, unwanted side effects are common. These side effects depend on many factors, including the location of the tumor and the type and extent of the treatment. Side effects may not be the same for each person, and they may even change from one treatment session to the next. Before treatment starts, the health care team will explain possible side effects and suggest ways to help the patient manage them.
The NCI provides helpful booklets about cancer treatments and coping with side effects, such as Radiation Therapy and You, Chemotherapy and You, and Eating Hints for Cancer Patients. See the sections "National Cancer Institute Information Resources" and "National Cancer Institute Booklets" for other sources of information about side effects.
Surgery
Patients often have a headache or are uncomfortable for the first few days after surgery. However, medicine can usually control their pain. Patients should feel free to discuss pain relief with the doctor or nurse.
It is also common for patients to feel tired or weak. The length of time it takes to recover from an operation varies for each patient.
Other, less common, problems may occur. Cerebrospinal fluid or blood may build up in the brain. This swelling is called edema. The health care team monitors the patient for signs of these problems. The patient may receive steroids to help relieve swelling. A second surgery may be needed to drain the fluid. The surgeon may place a long, thin tube (shunt) in a ventricle of the brain. The tube is threaded under the skin to another part of the body, usually the abdomen. Excess fluid is carried from the brain and drained into the abdomen. Sometimes the fluid is drained into the heart instead.
Infection is another problem that may develop after surgery. If this happens, the health care team gives the patient an antibiotic.
Brain surgery may damage normal tissue. Brain damage can be a serious problem. The patient may have problems thinking, seeing, or speaking. The patient also may have personality changes or seizures. Most of these problems lessen or disappear with time. But sometimes damage to the brain is permanent. The patient may need physical therapy, speech therapy, or occupational therapy.
Radiation Therapy
Some patients have nausea for several hours after treatment. The health care team can suggest ways to help patients cope with this problem. Radiation therapy also may cause patients to become very tired as treatment continues. Resting is important, but doctors usually advise patients to try to stay as active as they can.
In addition, radiation therapy commonly causes hair loss. Hair usually grows back within a few months. Radiation therapy also may affect the skin in the treated area. The scalp and ears may become red, dry, and tender. The health care team can suggest ways to relieve these problems.
Sometimes radiation therapy causes brain tissue to swell. Patients may get a headache or feel pressure. The health care team watches for signs of this problem. They can provide medicine to reduce the discomfort.
Radiation sometimes kills healthy brain tissue. This side effect is called radiation necrosis. Necrosis can cause headaches, seizures, or even the patient's death.
In children, radiation may damage the pituitary gland and other areas of the brain. This could cause learning problems or slow down growth and development. In addition, radiation during childhood increases the risk of secondary tumors later in life. Researchers are studying whether chemotherapy may be used instead of radiation therapy in young children with brain tumors.
Side effects may be worse if chemotherapy and radiation therapy are given at the same time. The doctor can suggest ways to ease these problems.
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| Chemotherapy The side effects of chemotherapy depend mainly on the drugs that are used. The most common side effects include fever and chills, nausea and vomiting, loss of appetite, and weakness. Some side effects may be relieved with medicine. Patients who receive an implant (a wafer) that contains a drug are monitored by the health care team for signs of infection after surgery. An infection can be treated with an antibiotic. |
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