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Cancer Medicine :: Brain Tumor Treatmenr

Brain Tumor

Treatment Options

This section outlines treatments that are the standard of care (the best proven treatments available) for brain tumors. When making treatment plan decisions, patients are also encouraged to consider clinical trials as an option. A clinical trial is a research study to test a new treatment to evaluate whether it is safe, effective, and possibly better than standard treatment. Your doctor can help you review all treatment options. 

Treatment overview

In brain tumor care, different types of doctors often work together to create a patient's overall treatment plan that combines different types of treatment. This is called a multidisciplinary team and can include neuro-oncologists, medical oncologists, radiation oncologists, surgeons, rehabilitation therapists, and other specialists.

                         

Descriptions of the most common treatment options for a brain tumor are listed below, including treatments that help manage symptoms. Treatment options and recommendations depend on several factors, including the size, type, and grade of the tumor, if it is putting pressure on vital parts of the brain, whether it has spread to other parts of the CNS or body, possible side effects, and the patient's preferences and overall health. Some types of brain tumors grow rapidly; other tumors grow slowly. Considering all these factors, your doctor will talk with you about how soon treatment should start after diagnosis.

Treatment options may include surgery, radiation therapy, and chemotherapy (each described below). For a benign brain tumor, surgery may be the only treatment needed. Typically, treatment begins with surgery, followed by radiation therapy and chemotherapy if needed. In many situations, chemotherapy is given at the same time as radiation therapy. Occasionally, chemotherapy may be given before the radiation therapy. Your exact treatment plan will be made by your health care team.

Successfully treating brain and spinal cord tumors can be challenging. The body's blood-brain barrier normally serves to protect the brain and spinal cord from harmful chemicals entering those structures through the bloodstream. However, this barrier also keeps out many types of chemotherapy. Surgery can be difficult if the tumor is near a delicate part of the brain or spinal cord. Even when the surgeon can completely remove the original tumor, there may be parts of the tumor remaining that are too small to be seen or removed during surgery. And, radiation therapy can damage healthy tissue.

However, research in the past two decades has significantly improved the survival rates of people with brain tumors. More refined surgeries, a better understanding of what types of tumors respond to chemotherapy, and more targeted delivery of radiation therapy have resulted in a longer life span and better quality of life for many people diagnosed with a brain tumor.

Palliative/supportive care

A brain tumor and its treatment often cause side effects. In addition to treatment to slow, stop, or eliminate the tumor, an important part of care is relieving a person's symptoms and side effects. This approach is called palliative or supportive care, and it includes supporting the patient with his or her physical, emotional, and social needs.

A brain tumor can cause many symptoms, some of which can be severe. However, they can often be managed with the use of certain medications. Supportive care for people with a brain tumor includes:

Pain medications to help manage the pain from headaches, a common symptom of a brain tumor.

Antiseizure medication to help control seizures. There are several types of drugs available, and they are prescribed by your neurologist.

Drugs called corticosteroids are often used to decrease the amount of swelling in the brain.

Palliative care can help a person at any stage of illness. People often receive treatment for the tumor and treatment to ease side effects at the same time. In fact, patients who receive both often have less severe symptoms, better quality of life, and report they are more satisfied with treatment.

Before treatment begins, talk with your health care team about the possible side effects of your specific treatment plan and supportive care options. And during and after treatment, be sure to tell your doctor or another health care team member if you are experiencing a problem, so it is addressed as quickly as possible. 

Surgery

Surgery is the removal of the tumor and surrounding tissue during an operation. It is the first treatment most commonly used for a brain tumor and is often the only treatment needed for a noncancerous brain tumor. Removing the tumor can improve neurological symptoms, provide tissue for diagnosis, help make other brain tumor treatments more effective, and, in many instances, improve the prognosis of patients with brain tumors.

A neurosurgeon is a doctor who specializes in surgery on the brain and spinal column. Surgery to the brain requires the removal of part of the skull, a procedure called a craniotomy. After the surgeon removes the tumor, the patient's own bone will be used to cover the opening in the skull.

There have been rapid advances in surgery for brain tumors, including the use of cortical mapping (which allows doctors to identify certain areas of the brain that control the senses, language, and motor skills) and enhanced imaging devices to give surgeons more tools to plan and perform the surgery. For example, computer-based techniques, such as Image Guided Surgery (IGS), help surgeons map out the location of the tumor very accurately, which can make surgery safer and less invasive. For a tumor that is near the brain's speech center, it is increasingly common to perform the operation when the patient is awake for part of the surgery; typically, the patient is awakened once the surface of the brain is exposed, and special electrical stimulation techniques are used to locate the specific part of the brain that controls speech 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 from the tumor pressing on parts of the brain.

Sometimes, surgery cannot be performed because the tumor is located in a place the surgeon cannot reach or is near a vital structure; these tumors are called inoperable. If the tumor is inoperable, the doctor will recommend other treatment options.

Radiation therapy

Radiation therapy is the use of high-energy x-rays or other particles to kill cancer cells. Doctors may use radiation therapy to slow or stop the growth of the tumor. It is typically given after surgery and possibly along with chemotherapy. A doctor who specializes in giving radiation therapy to treat cancer is called a radiation oncologist. The most common type of radiation treatment is called external-beam radiation therapy, which is radiation given from a machine outside the body. When radiation treatment is given using implants, it is called internal radiation therapy or brachytherapy. A radiation therapy regimen (schedule) usually consists of a specific number of treatments given over a set period of time.

External-beam radiation therapy can be directed at the tumor in the following ways:

Conventional radiation therapy. The treatment location is determined based on anatomic landmarks and x-rays. In certain situations, such as whole brain radiation therapy for brain metastases, this technique is appropriate. For more precise targeting, different techniques are needed. The amount of radiation given depends on the tumor's grade.

Three-dimensional conformal radiation therapy (3D-CRT). Using images from CT and MRI scans, a three-dimensional model of the tumor and normal tissue surrounding the tumor is created on a computer. This model can be used to aim the radiation beams directly at the tumor, sparing the normal tissue from high doses of radiation therapy.

Intensity modulated radiation therapy (IMRT). IMRT is a type of 3D-CRT (see above) that can more directly target a tumor, delivering higher doses of radiation to the tumor while giving less to the surrounding healthy tissue. In IMRT, the radiation beams are broken up into smaller beams and the intensity of each of these smaller beams can be changed. This means that the more intense beams, or the beams giving more radiation, can be directed only at the tumor.

Stereotactic radiosurgery. Stereotactic radiosurgery involves delivering a single, high dose of radiation directly to the tumor and not healthy tissues. It works best for a tumor that is only in one area of the brain and certain noncancerous tumors, but is also used for more than one metastatic brain tumor. 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 given 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. 

With these different techniques, doctors are trying to achieve greater precision and reduce radiation exposure to the surrounding normal brain tissue. Depending on the size and location of the tumor, the radiation oncologist may choose any of the above radiation techniques. In certain situations, a combination of two or more techniques is appropriate.

Short-term side effects from radiation therapy may include fatigue, mild skin reactions, hair loss, upset stomach, and neurologic symptoms. Most side effects go away soon after treatment is finished. Also, radiation therapy is usually not recommended for children younger than five because of the high risk of damage to their developing brains. Longer term side effects of radiation depend on how much normal tissue received radiation therapy and include memory and hormonal problems and cognitive (thought process) changes, such as difficulty understanding and performing complex tasks.

Chemotherapy

Chemotherapy is the use of drugs to kill cancer cells, usually by stopping the cancer cells' ability to grow and divide. Systemic chemotherapy is delivered through the bloodstream to reach cancer cells throughout the body. The goal of chemotherapy can be to destroy cancer cells remaining after surgery, slow a tumor's growth, or reduce symptoms. As explained above, chemotherapy to treat a brain tumor is typically given after surgery and possibly along with radiation therapy.

Chemotherapy is given by a medical oncologist, a doctor who specializes in treating tumors with medication. A chemotherapy regimen (schedule) usually consists of a specific number of cycles given over a set period of time. A patient may receive one drug at a time or combinations of different drugs at the same time.

Chemotherapy can be delivered orally (by mouth), intravenously (IV, by vein), or directly into the tumor. IV chemotherapy is either injected directly into a vein or through a thin tube called a catheter, which is a tube temporarily put into a large vein to make injections easier.

Some drugs are better at going through the blood-brain barrier, and doctors may recommend a single drug or a combination of drugs. Gliadel wafers are one delivery method for the drug carmustine. For people with glioblastoma multiforme, the latest standard of care is radiation therapy with daily low-dose temozolomide (Temodar), followed by monthly doses of temozolomide after radiation therapy for six months to one year. More recently a combination of three drugs, lomustine (CeeNU), procarbazine (Matulane), and vincristine (Oncovin, Vincasar) have been used along with radiation therapy. This newer approach has helped lengthen the lives of patients with grade III oligodendroglioma with a 1p19q co-deletion. Clinical trials on the use of chemotherapy to delay radiation therapy in patients with low grade glioma are also ongoing.

Patients are monitored with brain MRI every two to three months while receiving active treatment. Then, the length of time between MRI scans increases depending on the tumor's grade. Patients often have regular MRIs to monitor their health even if treatment is completed and the tumor has not grown. If the tumor grows during treatment, other treatment options will be considered.

The side effects of chemotherapy depend on the individual and the dose used, but they can include fatigue, risk of infection, nausea and vomiting, loss of appetite and diarrhea. These side effects usually go away once treatment is finished. Rarely, certain drugs may cause some hearing loss. Others may cause kidney damage. Patients may be given extra fluid intravenously for kidney protection. The doctor may also prescribe corticosteroids to reduce swelling and help to relieve symptoms.

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. 

Targeted therapy 

In addition to standard chemotherapy, targeted therapy is a treatment that targets the tumor's specific genes, proteins, or the tissue environment that contributes to cancer growth and survival. This type of treatment blocks the growth and spread of tumor cells while limiting the damage to normal cells.

Recent studies show that not all tumors have the same targets. To find the most effective treatment, your doctor may run tests to identify the genes, proteins, and other factors in your tumor. As a result, doctors can better match each patient with the most effective treatment whenever possible. In addition, many research studies are taking place now to find out more about specific molecular targets and new treatments directed at them. 

For a brain tumor,anti-angiogenesis therapy is the type of targeted therapy used. It is focused on stopping angiogenesis, which is the process of making new blood vessels. Because a tumor needs the nutrients delivered by blood vessels to grow and spread, the goal of anti-angiogenesis therapies is to “starve” the tumor. Bevacizumab (Avastin) is an anti-angiogenesis therapy used to treat glioblastoma multiforme when prior treatment has not worked. Talk with your doctor about possible side effects for a specific medication and how they can be managed.

Recurrent brain tumor

A remission is when the tumor cannot be detected in the body and there are no symptoms. This may also be called “no evidence of disease” or NED.

A remission can be temporary or permanent. This uncertainty leads to many survivors feeling worried or anxious that the tumor will come back. While many remissions are permanent, it's important to talk with your doctor about the possibility of the tumor returning. Understanding the risk of recurrence and the treatment options may help you feel more prepared if the tumor does return. 

If the tumor does return after the original treatment, it is called a recurrent tumor. It may come back in the same place (called a local recurrence), nearby (regional recurrence), or in another place (distant recurrence).

When this occurs, a cycle of testing will begin again to learn as much as possible about the recurrence. After testing is done, you and your doctor will talk about your treatment options. Often the treatment plan will include the therapies described above (such as surgery, radiation therapy, chemotherapy, and targeted therapy) but may be used in a different combination or given at a different pace. Temozolomide has been approved to treat Grade III recurrent tumors. Bevacizumab (see above) may also be used for a recurrent tumor. In addition, alternating electric field therapy is approved by the FDA for patients with recurrent high-grade glioma. Alternating electric field therapy interferes with parts of a cell that are needed for the tumor cells to grow and spread. It is given by placing electrodes that produce an electric field on the outside of a person's head. While this treatment approach has not been shown to increase survival when compared with standard chemotherapy, it causes fewer side effects than chemotherapy. Your doctor may also suggest clinical trials that are studying new ways to treat a recurrent brain tumor.

There is no single approach to treating a recurrent brain tumor, and your treatment plan will be based on many factors. However, new drugs are being created and tested in clinical trials to treat brain tumors that may help with recurrent tumors. Many of these new drugs are called "small molecules" or "molecularly targeted therapies" because they are small in size (and can therefore be taken by mouth) and/or can attack a specific molecule or target within the brain tumor cells. These new drugs are being tested either alone or in combination with standard chemotherapy. 

People with recurrent cancer often experience emotions such as disbelief or fear. Patients are encouraged to talk with their health care team about these feelings and ask about support services to help them cope. 

Advanced brain tumor

Patients with an advanced brain tumor or, rarely, one that has spread are encouraged to talk with doctors who are experienced in treating an advanced or metastatic tumor, because there can be different opinions about the best treatment plan. 

Your health care team may recommend a treatment plan that includes a combination of the treatments discussed above. Supportive care will also be important to help relieve symptoms and side effects.

For many patients, a diagnosis of an advanced brain tumor can be very stressful and, at times, difficult to bear. Patients and their families are encouraged to talk about the way they are feeling with doctors, nurses, social workers, or other members of the health care team. It may also be helpful to talk with other patients, including through a support group.

Side Effects

Fear of treatment side effects is common after a diagnosis of a brain tumor, but it may help to know that preventing and controlling side effects is a major focus of your health care team. This is called palliative or supportive care, and it is an important part of the overall treatment plan, regardless of the stage of disease.

Common side effects from each treatment option for a brain tumor are described in detail within the Treatment section. Side effects depend on a variety of factors, including the type of tumor, the grade, the length and dosage of treatment(s), and your overall health.

Before treatment begins, talk with your doctor about possible side effects of each type of treatment you will be receiving. Ask which side effects are most likely to happen, when they are likely to occur, and what can be done to prevent or relieve them. And, ask about the level of caregiving you may need during treatment and recovery, as family members and friends often play an important role in the care of a person with a brain tumor. 

In addition to physical side effects, there may be psychosocial (emotional and social) effects as well. Patients and their families are encouraged to share their feelings with a member of their health care team who can help with coping strategies. 

During and after treatment, be sure to tell the health care team about the side effects you experience, even if you feel they are not serious. Sometimes, side effects can last beyond the treatment period, called a long-term side effect. A side effect that occurs months or years after treatment is called a late effect. Treatment of both types of effects is an important part of survivorship care. 

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 talk with you about 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 your brain through specialized tests, typically given by a neuropsychologist (a psychologist who has special training in the brain's capacity and behaviors), and also to evaluate your quality of life. These evaluations could identify situations when specific rehabilitative therapies would be helpful, such as speech therapy, occupational therapy, counseling with a social worker, and/or medications that can help to reduce fatigue or enhance memory.

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.

Latest Research

Doctors are working to learn more about brain tumors, ways to prevent them, how to best treat them, and how to provide the best care to people diagnosed with a brain tumor. The following areas of research may include new options for patients through clinical trials. Always talk with your doctor about the diagnostic and treatment options best for you.

Enhanced imaging tests. New techniques for imaging scans are being researched. These may help doctors better track how well treatment is working and watch for 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.

Immunotherapy.  Immunotherapy, also called biologic therapy or biological response modifier (BRM) therapy, is designed to boost the body's natural defenses to fight the cancer. It uses materials either made by the body or in a laboratory to bolster, target, or restore immune system function. Different methods are being studied for brain tumors, such as the use of dendritic cells or the use of vaccines aimed against a specific molecule on the surface of the tumor cells. Several methods are currently being tested in clinical trials.

Targeted therapy. As outlined in Treatment, this type of treatment targets faulty genes or proteins that contribute to cancer growth and development. Research continues on the use of therapies for brain tumors that target the different ways a tumor grows, how a tumor spreads, and cell death.

Blood-brain barrier disruption. This technique temporarily disrupts the brain's natural protective barrier in order to allow chemotherapy to more easily enter the brain from the bloodstream.

New combination therapies.  New combinations may include radiation therapy and chemotherapy with a convection enhanced delivery (CED), which is a method to infuse drugs and other molecules right into the tumor. CED allows chemotherapy to be delivered more safely and effectively by pumping the drug under pressure directly into the tumor cells. The drug links only to receptors located on tumor cells. By targeting the tumor cells, CED helps avoid damage to healthy brain cells and reduces the risk of side effects commonly found with the standard way chemotherapy is given.

New drugs and combinations of drugs. Researchers are looking at using drugs currently used for other types of cancer as treatment for a brain tumor. Combinations of drugs being studied for brain tumor treatment include temozolomide and bevacizumab. In addition, combinations of drugs that target different pathways a tumor uses to grow and spread are being explored. Since tumors can develop resistance to chemotherapy, meaning the treatment stops working, another approach is to use a treatment that targets how tumor cells develop resistance.

Gene therapy. This type of therapy seeks to replace or repair abnormal genes that are causing or helping tumor growth.

Genetic research. Researchers are seeking to learn more about mutations of specific genes and how they relate to the risk and growth of brain tumors. In particular, The Cancer Genome Atlas Research Network is a large, ongoing effort by the National Institutes of Health to find out more about the link between genetics and glioblastoma. Recent results include the discovery of three specific genetic mutations not previously linked to glioblastoma; the affected genes are NF1, ERBB2, and PIK3R1; another finding focused on the involvement of the MGMT gene. This information is useful to researchers and may eventually lead to advances in the diagnosis and treatment of this type of brain tumor. 

Supportive care. Clinical trials are underway to find better ways of reducing symptoms and side effects of current brain tumor treatments, in order to improve patients' comfort and quality of life.

 

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