NOTE: This section describes a primary brain tumor, which is a tumor that begins in the brain. A primary brain tumor is relatively rare. A secondary brain tumor (also called a brain metastasis) is much more common. This is a tumor that started in another part of the body and spread to the brain. For example, breast cancer that has spread to the brain is still called breast cancer. For information on a secondary brain tumor, refer to Cancer.Net’s Cancer Type section where the tumor began.
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. Cancer begins when cells begin to grow uncontrollably and eventually form a mass, called a tumor. A tumor can be benign (noncancerous) or malignant (cancerous). When a tumor arises in the CNS, it is especially problematic because of the potential effect on a person's thought processes and movements.
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, the largest part of the brain, contains two cerebral hemispheres and is divided into four lobes where specific functions occur:
The frontal lobe, which controls reasoning, emotions, problem-solving, expressive speech and movement
The parietal lobe, which controls the sensations of touch, pressure, pain, temperature, and parts of speech, visual-spatial orientation, and calculation
The temporal lobe, which controls memory, the special senses, such as hearing, and the ability to understand spoken or written words
The occipital lobe, which controls vision
The cerebellum 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, which 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, all the functions controlled by the cerebrum and cerebellum travel through the brain stem to the connections in the body.
The meninges 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.
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.
Grade I or pilocytic astrocytoma is a slow-growing tumor that is most often benign and rarely spreads into nearby tissue. It accounts for about 2% of all brain tumors.
Grade II or low-grade diffuse astrocytoma is a slow-growing tumor that can often spread into nearby tissue and can become a higher grade. It accounts for about 11% of all brain tumors.
Grade III or anaplastic astrocytoma is a malignant tumor that can quickly grow and spread to nearby tissues. It accounts for about 3% of all brain tumors.
Grade IV or glioblastoma multiforme is a very aggressive form of astrocytoma that accounts for about 20% of all brain tumors.
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. For pediatric information, read the Cancer.Net Guide to Ependymoma, Childhood Cancer.
A non-glioma tumor begins in other types of cells in the CNS, and is described as either benign or malignant. Types of non-glioma tumors include:
Meningioma. Meningioma is the most common primary non-glioma brain tumor, making up about 30% of such 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 Cancer.Net Guide to Meningioma for more information.
Acoustic schwannoma. Acoustic schwannoma (also called acoustic neuroma) is a rare tumor that begins in the vestibular nerve (a nerve in the inner ear that helps control balance) and is normally benign.
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 Cancer.Net Guide to Craniopharyngioma, Childhood Cancer.
Medulloblastoma. Medulloblastoma begins in granular cells in the cerebellum. It is most common in children and is most often malignant. Medulloblastomas make up about 2% of all brain tumors. For pediatric information, refer to Cancer.Net’s Guide to Medulloblastoma, Childhood Cancer.
Primary CNS lymphoma. This is a form of lymphoma (cancer that begins in the lymphatic system) that starts in the brain and makes up about 3% of all brain tumors.
Pineal gland and pituitary gland tumors. The pineal gland and pituitary gland are the locations of about 7% of all brain tumors.
About 6% of all brain tumors cannot be assigned an exact type.
In 2008, an estimated 21,810 adults (11,780 men and 10,030 women) in the United States will be diagnosed with primary malignant tumors of the brain and spinal cord. It is estimated that 13,070 deaths (7,420 men and 5,650 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.
Cancer survival statistics should be interpreted with caution. These estimates are based on data from thousands of cases of this type of cancer 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 2008, the National Cancer Institute, and the Central Brain Tumor Registry.
A risk factor is anything that increases a person’s chance of developing cancer. 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 cancer brain tumor, most do not directly cause cancer brain tumor. Some people with several risk factors never develop cancer 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.
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.
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. Black hair dye has also been researched as a potential cause of brain tumors, although the data remain inconclusive at this time.
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. 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. At this time, more research is needed. Because the research is inconclusive, caution should be taken with cell phone use in children while the brain is still developing. The World Health Organization (WHO) recommends limiting cell phone use and promotes the use of a headset for both adults and children.
Race andethnicity. 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. Treatment 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.
Diet (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.
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 symptoms begin.
General symptoms include:
Headaches, which may be severe and may worsen with activity or in the early morning
Seizures
Personality or memory changes
Nausea or vomiting
Vision changes, such as blurred vision
Symptoms that may be specific to the location of the tumor include:
Pressure or headache near the tumor
Loss of balance and difficulty with fine motor skills (cerebellum)
Changes in judgment, including loss of initiative, sluggishness, and muscle weakness or paralysis (frontal lobe of the cerebrum)
Partial or complete loss of vision (occipital lobe or temporal lobe of the cerebrum)
Changes in speech, hearing, memory, or emotional state, such as aggressiveness and problems understanding or retrieving words (frontal and temporal lobe of cerebrum)
Altered perception of touch or pressure, arm or leg weakness on one side of the body, or confusion with left and right sides of the body (frontal or parietal lobe of the cerebrum)
Inability to look upward (pineal tumor)
Lactation and altered menstrual periods in women, and growth in hands and feet in adults (pituitary tumor)
Difficulty swallowing, facial weakness or numbness, or double vision (brain stem)
Doctors use many tests to diagnose a tumor and determine if it has metastasized (spread). Some tests may also determine which treatments may be the most effective. For most types of tumors, a tissue sampling with biopsy or removal of the tumor is the only way to make a definitive diagnosis of a brain tumor. If a biopsy is not possible, the doctor may suggest other tests that will help make a diagnosis. Imaging tests may be used to find out 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:
Age and medical condition
The type of tumor suspected
Severity of symptoms
Previous test results
Most brain tumors are not diagnosed until symptoms appear. The neuro-oncologist (a doctor who specializes in the effects of abnormal tissue in the central nervous system) can use the patient's symptoms as clues to the location of the tumor. In addition to asking the patient for a detailed history and doing a physical examination, an oncologist or neuro-oncologist may order the following tests be done to determine the presence, and perhaps the type or grade, of a brain tumor. The most effective and common way that a tumor is first suspected is 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 cancer comes back after treatment). Imaging is useful, but a sample of the tumor’s tissue is often needed for the final diagnosis. The primary way of determining the type of brain tumor is with a pathology report (laboratory test results) after a biopsy or surgery.
Based on the results of the diagnostic tests and the biopsy, the doctor will recommend treatment options.
Imaging tests. Each radiologic test can provide specific information, but they must be combined with the results of the patient history, physical examination, and neurologic tests. The most common imaging tests used for diagnosing brain tumors include:
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 use of intravaneous (IV) gadolinium-enhanced MRI may help to aid in the diagnosis. This is when the contrast (gadolinium) medium (a special dye) is given to the patient after the regular MRI has been completed, and another series of pictures are taken.
A spinal MRI may be used in diagnosing a tumor on or near the spine.
A functional MRI (fMRI) provides information about the location of specific areas of the brain that are responsible for muscle movement and speech. During the fMRI examination, the patient is asked to perform certain tasks that result in detectable changes in the brain and can be seen on the fMRI image. This test is often used in surgical planning, so the surgeon can avoid damaging the functional area of the brain while removing the tumor.
Magnetic resonance spectroscopy (MRS) is a test using MRI that provides information on the chemical composition of the brain. It has shown usefulness in distinguishing dead (necrotic) tissue caused by previous radiation treatments from new tumor cells in the brain.
A CT scan creates a three-dimensional picture of the inside of the body. A computer then puts these images into a detailed, cross-sectional view that shows any abnormalities or tumors. Sometimes, a contrast medium is injected into the patient’s vein to provide better detail to aid in the diagnosis, particularly if the patient is not able to undergo an MRI (such as if the person has a pacemaker).
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 and absorbed by the organs or tissues being studied. This substance gives off energy that is detected by a scanner, which produces the images.
Because a brain tumor can spread to 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.
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.
Blood tests. Blood tests can detect tumor markers (substances found in higher than normal amounts in the blood, urine, or body tissues of people with certain types of cancer).
Lumbar puncture (spinal tap). A lumbar puncture is a procedure in which a doctor takes a sample of CSF to look for cancer cells, blood, or tumor markers. Doctors generally give an anesthetic to numb the 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.
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. To help see the blood vessels, a contrast medium is injected through a catheter (long, hollow tube), usually placed in the patient’s thigh.
Stereotactic biopsy. In this procedure, a doctor uses computer guidance to insert a needle into a precise location of the tumor and retrieve a tissue sample. 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). Often, a biopsy is performed if surgical removal of the tumor is not possible due to its location or the medical condition of the patient.
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.
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. Primary brain tumors typically do not spread outside of the CNS. Instead, the degree of malignancy is often determined by characteristics of the tumor seen under the microscope. There are six factors to establish the course of brain tumor treatment and determine prognosis (chance of recovery):
Tumor histology. How a tumor looks under a microscope is called tumor histology. A sample of the tumor is removed during surgery or the biopsy for examination.
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:
Mitosis (the number of cells dividing)
Hypercellularity (if the tumor contains large numbers of cells)
Vascular proliferation (if blood vessels in the tumor are growing)
Necrosis (if there is any dead tissue in the tumor)
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. For astrocytoma, the grade is determined by its features, as seen under a microscope, according to the following criteria:
Grade I represents a separate group of tumors. It refers to a juvenile pilocytic astrocytoma (JPA). The term juvenile does not refer to the age of the patient, but rather the type of cell. This is a benign, slow-growing tumor that can typically be cured with surgery. It is different from a low-grade astrocytoma or Grade II glioma, which have a high probability of a recurrence.
A grade II tumor does not have mitosis, vascular proliferation, or necrosis, but exhibits increased cellularity.
A grade III tumor is hypercellular and has mitosis but no vascular proliferation and no necrosis.
A grade IV tumor has vascular proliferation and/or necrosis in addition to the factors common to grade II and III tumors.
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 outcome.
Extent of tumor residual. Resection refers to surgery to remove a tumor, and residual refers to how much of the tumor remains in the body after surgery. Four classifications are used:
Gross total:The entire tumor was removed (microscopic cells may remain).
Subtotal: Large portions of the tumor were removed.
Partial: Only part of the tumor was removed.
Biopsy only: Only a small portion, used for a biopsy, was removed.
The outcome 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).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
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.
Metastatic spread. A tumor that starts in the brain or spinal cord 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. 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, Sixth Edition (2002) published by Springer-Verlag New York, www.springer-ny.com.
The treatment of an adult brain tumor depends on many factors, including the size, location, type, and grade of the tumor, whether it is cancerous, whether it has spread to other parts of the CNS or body, and the person’s age and overall health. People diagnosed with a CNS tumor generally need to seek treatment as soon as possible, because some tumors can grow quickly and cause severe symptoms.
In many cases, a team of doctors will work with the patient to determine the best treatment plan. Successfully treating brain and spinal cord tumors can be challenging. The blood-brain barrier, which normally serves to protect the brain and spinal cord from harmful chemicals entering those structures through the bloodstream, also keeps out many types of potentially beneficial drugs. Surgery can be difficult if the tumor is near a delicate portion of the brain or spinal cord. 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 and enhanced imaging devices to give surgeons more tools to plan and perform the surgery. For a tumor that is near the 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. For some tumor types, the results of the analysis can help in showing 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.
Radiation therapy
Radiation therapy is the use of high-energy x-rays or other particles to kill cancer cells. Doctors may use radiation therapy along with surgery to slow or stop the growth of tumors. Radiation 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 three methods by which stereotactic radiosurgery is performed:
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.
All of these more elaborate techniques are designed 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.
Radiation therapy is usually not recommended for children younger than 5 because of high risk of damage to their developing brains.
Side effects from radiation therapy may include fatigue, mild skin reactions, upset stomach, and loose bowel movements. Most side effects go away soon after treatment is finished.
For more information about radiation therapy, 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.
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.
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. Occasionally, the chemotherapy may come before the radiation therapy. In other situations, the chemotherapy is administered during the radiation therapy. The decision on what sequence to follow is made by the oncologist or neuro-oncologist.
Some drugs are better at going through the blood-brain barrier, and doctors may recommend a single drug or a combination of chemotherapy. 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 and at diagnosis for people with Grade IV astrocytomas.
The latest standard of care for patients with glioblastoma 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.
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.
The medications used to treat cancer are constantly 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 through Cancer.Net's Drug Information Resources, which provides links to searchable drug databases.
Immunotherapy
Immunotherapy (also called biologic 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.
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 manage the symptoms caused by the tumor. Symptom management 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.
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. 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.
To join a clinical trial, patients must complete a learning 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.
Cancer and its treatment can cause a variety of side effects. However, doctors have made major strides in recent years in reducing pain, nausea and vomiting, and other physical side effects of cancer treatments. Many treatments used today are less intensive but as effective as treatments used in the past. 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 cancer, 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 cancer, 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 your doctor about side effects you experiences during and after treatment. For more information on the most common side effects of cancer and different treatments, along with ways to prevent or control them, visit Cancer.Net's section on Managing Side Effects, based on ASCO’s curriculum.
In addition to physical side effects, there may be psychosocial (emotional and social) effects as well. Learn more about the importance of addressing these needs in Cancer.Net’s section on Caring for the Whole Patient.
For more information on late effects or long-term side effects, please read the After Treatment section or talk with your doctor.
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, therefore, your oncologist or neuro-oncologist will determine your 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, and also to evaluate the person’s quality of life. These evaluations could identify certain problems that may benefit from specific therapies, such as speech or occupational therapy, counseling with a social worker, or medications that can help to reduce fatigue or enhance memory. Whenever possible, participation in a support group 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 cancer 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.
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.
Hyperfractionization uses smaller doses of radiation at more frequent intervals.
Gene therapy seeks to replace or repair abnormal genes that are causing or helping tumor growth.
Immunotherapy boosts the body's immune system to attack the tumor, also called biological response modifier (BRM) therapy.
Anti-angiogenesis therapy 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 is a technique to temporarily disrupt the barrier in order to allow chemotherapy to more easily enter the brain from the bloodstream.
Aggressive treatment plans for childhood tumors may include surgery, chemotherapy, and radiation therapy.
New combination therapies may include radiation therapy and chemotherapy with a convection enhanced delivery (CED), which is a new method to infuse drugs and other molecules in the tumor of the brain. Convection enhanced delivery (CED) allows chemotherapy to be delivered more safely and effectively by pumping the drug under pressure directly into the brain. 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.
Regular communication with your doctor is important in making informed decisions about your health care. Consider asking the following questions of your doctor:
What type of brain tumor do I have?
Is the tumor cancerous?
What is the tumor’s grade? What does this mean?
Can you explain my pathology report to me?
Will an experienced neuropathologist review my pathology slides?
What are my treatment options?
What clinical trials are open to me?
How many brain tumors do you treat each year?
What treatment do you recommend? Why?
When should I start treatment?
Should I get a second opinion?
Do you attend expert meetings to discuss complicated tumor cases?
Are there brain tumor centers of excellence that you recommend I contact?
What are the possible side effects of this treatment, both in the short term and the long term?
How will this treatment affect my daily life? Will I be able to work, exercise, and perform my usual activities?
Does your practice include multidisciplinary care?
Who will be part of my health-care team, and what is each person’s role?
Do you work with a social worker that assists people with brain tumors?
What support services are available to me? To my family?
Do you lead or know of a local support group for people with brain tumors?
Do you have reading material that would help me understand my disease?
Who answers medical questions at your office when you are unavailable?
After treatment, what follow-up tests will I need, and how often will I need them?
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