The standard treatments for brain tumors are surgery, radiation therapy, and chemotherapy.

Surgery is the primary form of treatment for brain tumors that lie within the membranes covering the brain or in parts of the brain that can be removed without damaging critical neurological functions. Because a tumor is likely to recur if any tumor cells are left behind, the goal of surgery is to remove the entire tumor whenever possible.

Radiation therapy and chemotherapy are generally used as secondary or adjuvant treatments for tumors that cannot be managed using only surgery. However, radiation and chemotherapy may be used without surgery if the tumor is inoperable.

For more information about brain tumor treatments, see chapter 5 of The Essential Guide to Brain Tumors.

The medications most commonly prescribed for brain tumors are steroids for brain swelling (edema) and anti-epileptic drugs (AEDs) to control seizures.

Steroids (glucocortico-steroids) are drugs that reduce edema (inflammation) in the brain. Steroids can help relieve pre-surgery symptoms, which may increase the time to make treatment decisions. Steroids may be prescribed at diagnosis, or before or after surgery. Common steroids include dexamethasone (Decadron), prednisone, and methylprednisolone. These drugs do not kill tumor cells, but can improve a patient’s condition. Steroids may be taken alone or combined with other forms of treatment. When the swelling is under control, then the dosage is gradually tapered off.

Steroids have a range of short- and long-term side effects. Common short-term side effects include insomnia, facial swelling and flushing, increased appetite, mood swings, and personality changes. Some people who take steroids for a few days or weeks do not experience side effects; others do. Patients should never stop taking steroids without the doctor's knowledge. Instead, discuss possible side effects with the doctor.

AEDs are medications used to control seizures. They are also called anticonvulsants, antiseizure drugs, and epilepsy drugs. A patient may be put on AEDs if he or she experiences a seizure or as a precautionary measure. Some common AEDs are phenytoin (Dilantin), carbamazepine (Tegretol), and valproate (Depakote). The type and amount of medication is based on the level of seizure control needed and the side effects from the medication. A rash is an allergic reaction, and the patient must see a doctor immediately.

If the patient has not experienced seizures or if the person is seizure-free for an extended period of time, the AED may be tapered off. AEDs should never be stopped abruptly.It is important to remember that side effects of these AEDs vary greatly from person to person. If side effects are a serious problem, a doctor may change a patient’s medication. Other AEDs are available, including levetiracetam (Keppra), gabapentin (Neurontin), toiramate (Topomax), lamotrigine (Lamictal), and tiagabine (Gabitril). A patient should ask his or her doctor for more information about these medications.

Many medications will either increase or reduce the effect of AEDs. Some chemotherapy drugs may interact with AEDs and change the effectiveness of either or both drugs. Blood tests and other methods are used to monitor possible drug interactions.

To help your doctors recognize possible drug interactions, keep a list of all medications, including over-the-counter products. Also, keep track of symptoms that may be possible side effects.

Radiation therapy uses high-energy x-rays or other types of ionizing radiation to stop cancer cells from dividing. Radiation therapy may be used when surgery is not advised, for tumors that cannot be completely resected, or after surgery to prevent or delay tumor recurrence. Radiation therapy can stop or slow the growth of inoperable tumors. Use of radiation therapy is avoided in children below the age of three because it damages the developing brain.

Radiation therapy can be delivered by external or internal means. External beam radiation therapy involves linear accelerators and cobalt machines that direct radiation at the tumor from outside the patient's body. Interstitial radiation therapy (brachytherapy) involves surgically implanting radioactive material directly inside the tumor.

Two of the main types of external beam radiation therapy are conventional and stereotactic radiosurgery (SRS).

Conventional radiation therapy delivers radiation to an entire region of the brain. The radiation is fractionated into many small doses and given over a period of time (usually five to seven weeks, excluding weekends). Depending on the location and size of the tumor(s), the treatment can be either focused or whole brain radiation therapy (WBRT). Focused radiation therapy aims x-rays at the tumor and area surrounding it. WBRT aims radiation at the entire brain. WBRT is used to treat multiple tumors and metastatic brain tumors.

Stereotactic radiosurgery (SRS) delivers a single, high dose of radiation in a one-day session. Several types of machines are used to administer radiosurgery: Gamma Knife, Linac, X-Knife, CyberKnife, and cyclotron. In an SRS procedure, a head frame is attached to the skull to hold the head in position (newer methods of SRS may use a mask instead of a head frame). Then CT or MRI scans are taken. With the aid of computer imaging, the location of the tumor is accurately calculated. The radiation is delivered directly to the tumor, often from several different directions. Size and location of the tumor are important eligibility criteria for SRS.

Chemotherapy uses chemicals (drugs) that have a toxic effect on tumor cells as they divide. Chemotherapy is usually taken orally or by injection, and may be given alone or in combination with other treatments. Chemotherapy is given in cycles, which consist of “on” and “off” phases – days of treatment followed by periods of time between treatments. Cycles vary depending on the drug or drugs used. Chemotherapy is usually a secondary therapy. It is also used to delay or replace radiation treatment in young children. A new method to deliver chemotherapy directly to brain tumors is the polymer wafer implant. Biodegradable wafers are saturated with the chemotherapy drug, BCNU. After resection, several wafers are inserted into the tumor cavity and are left there to dissolve over time. In this way, a concentrated dose of BCNU (approximately 100 times higher than that tolerated through IV) is delivered to the tumor site.

There are several chemotherapy drugs prescribed for brain tumors, and they may be delivered in various ways. Chemotherapy drugs taken orally (by mouth) include temozolomide (Temodar), procarbazine (Matulane), and lomustine (CCNU). Chemotherapy given intravenously (by IV, via needle inserted into a vein) includes vincristine (Oncovin or Vincasar PFS), cisplatin (Platinol), carmustine (BCNU, BiCNU), and carboplatin (Paraplatin). BCNU is also given by polymer wafer implant during surgery. Mexotrexate (Rheumatrex or Trexall) may be taken orally, by injection, or intrathecally (injected directly into spinal fluid).

Treating brain tumors with chemotherapy can be difficult. The brain has a defense mechanism called the blood brain barrier, which keeps out harmful substances such as bacteria and chemicals. The blood brain barrier can also prevent some chemotherapy drugs from entering the brain. Temodar is able to pass through the blood brain barrier, while some other drugs are not.

A technique called blood brain barrier disruption can be used to temporarily interrupt the barrier and allow chemotherapy drugs to pass through the blood vessels into the brain. In this procedure, a catheter is fed into the cerebral artery. The drug mannitol is injected into the catheter. Mannitol disrupts the blood brain barrier. While the blood brain barrier is open, chemotherapy is delivered through the catheter. The effects of mannitol wear off after a period of time.

For more information about chemotherapy drugs, see chapter 5 of The Essential Guide to Brain Tumors.

A molecularly targeted therapy is a medication that blocks or inhibits an important cancer molecular abnormality, thus reducing the cancer’s destructive behavior.

Molecular abnormalities are particles of cells that are not normal. For example, these abnormalities control how cancer cells abnormally grow and divide; aggressively spread and invade; survive and live much longer than normal cells; and make new blood vessels (angiogenesis) required for tumor growth. Blocking abnormal molecules can lead to the death of cancer cells.

Molecularly targeted medicines are sometimes called “smart” medicines because of their ability to hone in on tumor cells while sparing healthy cells. The FDA has already approved several promising molecularly targeted therapies, such as Tarceva, Avastin, Iressa, and Gleevec, for patients with other types of cancer. These medicines are now being evaluated in clinical trials for brain tumor patients.

Because these medications are specific to cancer cells, they have fewer side effects than traditional chemotherapy drugs. At some point in the future, doctors may be able to study each patient’s tumor in the laboratory and determine exactly which molecular abnormalities are present. With that information, the molecularly targeted therapy or regimen best suited to patient could be prescribed.

For more information about molecularly targeted therapies, see Search #64, Summer 2005 in our newsletter archive.

Clinical trials are research studies that involve people. The studies are designed to determine the safety and side effects of new therapies, and the effectiveness of new and current treatments. Clinical trials usually undergo three phases before reaching completion. Each phase answers a question about the safety and effectiveness of the treatment being tested.

Phase I trials test a treatment to determine a safe dosage and its side effects. Phase II trials test a treatment for its effectiveness. Phase III trials compare a new treatment against a standard treatment for its effectiveness. If a drug or treatment is showing statistically positive results, the clinical trial may end early, and the drug may be placed on the market more quickly.

Clinical trials follow a treatment plan, or protocol, and are conducted by various institutions such as hospitals, universities and research institutes. A group of patient advocates called the Institutional Review Board (IRB) examines the protocols to make sure they are designed and conducted with appropriate safeguards for the patients. There is an IRB at every institution that is conducting research.

People participate in clinical trials for a number of reasons: to try a new treatment method, to contribute to developing improved treatments, or to help find a cure. If a patient is considering participating in a trial, the trial he or she chooses will depend on the patient’s tumor type, when it was diagnosed, treatments that have already been received, and the patient’s state of health. Most trials have a series of eligibility criteria a patient needs to meet in order to participate.

There are both benefits and drawbacks to consider. It is important to know the possible risks and benefits of the treatment. Being fully knowledgeable about all the logistics, time involvement and potential financial burdens makes the decision a more informed one. It is important for the patient to consider carefully with his or her medical care team and family whether the benefits outweigh the possible risks.

For more information about clinical trials, see Search #62, Winter 2005 and the fact sheet Clinical Trials: How to Get Access.

Complementary medicine is used in addition to standard therapy. Alternative medicine is used instead of standard therapy. A simple definition of CAM is anything people do other than conventional therapies to maintain or achieve good health. Integrative medicine is a combination of conventional medicine with complementary and/or alternative therapies. The goal of CAM is to enable patients to tolerate higher doses of standard therapy at closer intervals with fewer side effects. CAM also aims to increase the qualityu of life both during and after treatment. Acupuncture, visualization, meditation, yoga, and massage therapy are a few of the many CAM therapies available.

It is important to integrate CAM into conventional medicine safely, under the supervision of a CAM health professional. Patients should tell their medical providers about any herbal medicines or nutritional supplements they are taking in order to avoid unsafe herb-drug interactions. Communication between the CAM provider and physician is strongly recommended.

As with any treatment, it is important to get information about results, side effects, cost, drug interactions, and effectiveness, in addition to discussing your options with your doctor or healthcare provider.

For more information about complementary and alternative treatments, see chapter 5 of The Essential Guide to Brain Tumors.