This list of frequently asked questions is a starting point for understanding brain tumor treatments. More detailed information can be found in other sections on this website. For instance, we recommend sources to learn about different treatment centers at Resources for Finding Brain Cancer Treatment Centers.
- Which therapies are used to treat brain tumors?
- Which medications are prescribed for brain tumor patients?
- How is surgery used to treat brain tumors?
- What is radiation therapy?
- What is stereotactic radiosurgery?
- What are possible side effects of radiation therapy?
- What is chemotherapy?
- Which chemotherapy drugs are prescribed for brain tumor patients?
- What is molecularly targeted therapy?
- What should I know about clinical trials for brain tumors?
- What is complementary and alternative medicine (CAM) and where can I get information about CAM for brain tumors?
More specific frequently asked questions about treatment
- Can you please explain what "psuedotumor cerebri sine papilledema" is?
- I hear about using molecular information for classifying and treating brain tumors. What does this mean?
- Is it normal to experience fatigue following brain tumor treatment?
- Could you explain to me what the "silent area" means and how symptoms from a brain tumor can affect the functions of the frontal lobe?
- Does hormone replacement therapy contribute to the recurrence of brain tumors?
- Since the surgery I look like the same person, but I have some limitations that are not easily recognized from people who know me. My friends keep asking me if I'm "normal". I feel like I'm disappointing them if I tell them I have some limitations. What should I do?
- I have had nerve pain in my face since surgery. What can I do about this pain?
- My husband has a brain tumor and since he started his chemotherapy he has been extremely tired. What can I do to help him?
- Which therapies are used to treat brain tumors?
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.
Combined treatment approaches are becoming increasingly common. This modality can utilize a range of therapies and drug agents in combination with standard treatment. These additional treatment options are typically available through clinical trials or by the recommendation of the physician. Some therapies include immunotherapy and angiogenesis inhibitors.
- Which medications are prescribed for brain tumor patients?
The medications most commonly prescribed for brain tumors are steroids for brain swelling (edema) and anti-epileptic drugs to control seizures.
Steroids (glucocortico-steroids) are drugs that reduce edema (swelling) 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. Side effects from long-term use of steroids, for example dexamethasone, may include cataracts, osteoporosis, muscle weakeness and diabetes. Patients should never stop taking steroids without the doctor's knowledge. Instead, discuss possible side effects with the doctor.
Anti-epileptic drugs (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), valproate (Depakote), levetiracetam (Keppra), gabapentin (Neurontin), topiramate (Topomax), and lamotrigine (Lamictal). The type and amount of medication is based on the level of seizure control needed and the side effects from the medication. Common side effects may include fatigue, weakness, nausea and lack of balance or coordination. 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.
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.
- How is surgery used to treat brain tumors?
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 buildup of cerebrospinal 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. 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.
Before a definitive diagnosis can be made, a biopsy is usually performed. A biopsy involves taking a small amount of tissue from the tumor through a very thin needle and then examining it. Pathologists will examine the cells and determine the tumor's grade, level of malignancy, and exact type. A biopsy is often 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. You should discuss the risks and benefits of surgery with your medical team.
- What is radiation therapy?
Radiation therapy uses high-energy x-rays or other types of ionizing radiation to stop cancer cells from dividing. It 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. Different forms of radiation are used for specific types and sizes of 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. Two of the main types of external beam radiation therapy are conventional and stereotactic radiosurgery (SRS – see Question 5 below).
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. The radiation is usually administered two to three weeks after surgery and continues for approximately six weeks (excluding weekends), with similar dosages at each visit. 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 primary and metastatic brain tumors.
Interstitial radiation therapy (brachytherapy), an internal form of radiation therapy, involves surgically implanting radioactive material directly inside the tumor.
- What is stereotactic radiosurgery?
Stereotactic radiosurgery (SRS) provides pinpoint precision in the administering of radiation without any invasive surgery. During stereotactic radiation, a single, high dose of radiation is delivered to the tumor, minimizing damage to the surrounding brain tissue. Stereotactic radiosurgery is done on an outpatient basis. Patients typically receive just one treatment , but in some cases doctors may recommend up to five days in a row of the procedure.
In an SRS procedure, a head frame may be attached to the skull to hold the head completely still during the procedure. Some 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, and not everyone is a candidate.
You may hear different names associated with radiosurgery, including Gamma Knife®, LINAC, X-Knife®, Trilogy®, CyberKnife®, and Novalis®. These are the brand names of the equipment that doctors use to provide the treatment. The core principles are the same with each machine, but they use different sources of energy and different methods to target the tumor.
- What are possible side effects of radiation therapy?
Before undergoing treatment, it is important to discuss the risks and benefits of radiation therapy with the medical team. Radiation is tolerated better in older children and adults, although children under the age of four 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.
Short-term side effects of radiation can include fatigue, hair loss, scalp irritation, muffled hearing, and short-term memory loss. These side effects may resolve within two to four weeks of the radiation therapy, although hair loss may be permanent for some people. Long-term side effects can include short term memory loss, radiation necrosis (a build up of dead tumor cells in the brain), or neurological impairments associated with the area of brain most radiated.
- What is chemotherapy?
Chemotherapy uses chemicals (drugs) that have a toxic effect on tumor cells as they divide. The drugs interfere with the normal functioning of the rapidly dividing cells of the tumor to prevent tumor growth. Chemotherapy is usually a secondary therapy. It is usually not used for the treatment of noncancerous brain tumors.
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.
Another way to delivery chemotherapy to the brain is through polymer wafer implants. With this method, biodegradable wafers are saturated with a chemotherapy drug, BCNU, and placed directly inside the tumor cavity at the time of surgery. The wafers are left there to dissolve over a short period of time. In this way, a concentrated dose of BCNU (approximately 100 times higher than that tolerated through IV) can be delivered directly to the tumor site without increasing side effects.
Chemotherapy can decrease the chance of a brain tumor spreading outside the nervous system. Chemotherapy has been particularly effective in treating children with brain tumors that have spread outside the brain to the bone or bone marrow. The use of chemotherapy also helps delay or replace the use of radiation treatment in children, which can be harmful to the developing brain.
- Which chemotherapy drugs are prescribed for brain tumor patients?
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), and carboplatin (Paraplatin). BCNU is also given by polymer wafer implant during surgery. Methotrexate (Rheumatrex or Trexall) may be taken orally, by injection, or intrathecally (injected directly into spinal fluid) for treatment of CNS Lymphoma.
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. Temozolomide is able to pass through the blood brain barrier, while some other drugs are not.
For details about specific chemotherapy drugs, one helpful resource is ChemoCare.com, a website that provides easy-to-understand information about chemotherapy drugs and side effects.
- What is molecularly targeted therapy?
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 aspects 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 for patients with other types of cancer. These medicines are now being evaluated in clinical trials for brain tumor patients. Bevacizumab is one drug in particular that is being extensively evaluated in a number of studies.
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.
- What should I know about clinical trials for brain tumors?
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.
Learn more about clinical trials.
- What is complementary and alternative medicine (CAM) and where can I get information about CAM for brain tumors?
Integrative medicine is the incorporation of complementary therapies derived from ancient healing arts into mainstream medical care. These therapies help patients manage stress, reduce symptoms, improve quality of life and promote a sense of wellness. Complementary therapies are those that are not currently part of conventional medicine, but have demonstrated a favorable risk/benefit ratio to be used as part of supportive care. There are also alternative therapies, those which are promoted to be used in place of standard medical care. Together they are called CAM, for complementary and alternative medicine.
Some different types of complementary therapies include:
- Mind-body interventions: meditation, imagery, relaxation
- Biologically-based treatments: melatonin, herbals, mushrooms, high-dose vitamins, enzyme therapy, botanicals
- Manipulative and body-based approaches: massage, manipulation, chiropractics, yoga
- Energy therapies: Qigong, Reiki, therapeutic touch, distant healing
- Acupuncture
It is important to know that although complementary therapies can be a very helpful part of the overall cancer treatment plan, they can not cure cancer. On the other hand, patients should consider complementary therapies which empower them to take an active part in self care and help them go through cancer treatment. It is important that patients communicate with the health care team about any complementary therapies they are considering, as interactions may occur with standard treatments, such as chemotherapy. As with any treatment approach, it is important to gather information about a complementary therapy's results, side effects, cost, drug interactions, and effectiveness. The best way to take advantage of integrative medicine is to choose practitioners who work and communicate with your regular treatment team.
The National Center for Complementary and Alternative Medicine and the National Cancer Institute have additional information about integrative medicine.
- Can you please explain what "psuedotumor cerebri sine papilledema" is?
Psuedotumor cerebri is also known as benign intracranial hypertension. This syndrome is seen most often in obese adolescent girls and young women. But less commonly, it does occur in men. The chief complaint is headaches, and in some instances, people experience diplopia (double or blurred vision), slight numbness of the face, or dizziness. On physical examination, the person seems quite well. The only abnormal finding is papilledema (swelling or protrusion of the blind spot of the eye caused by edema), which you may not have. Cerebrospinal fluid (CSF) pressure may be high and a CT scan or MRI may show ventricles of normal size. The goal of treatment is to relieve the increased pressure in the head. Treatment options include repeated lumbar punctures to remove the CSF until normal pressure is maintained. Drug therapy is controversial. However, three drugs (Prednisone, Glycerol and Diamox) are treatment options if CSF pressure continues to be elevated and papilledema persists. In persons who do not respond to any of the above treatments - placement of a lumbar shunt may be needed. You are not alone in this diagnosis. People do suffer with this disease because of the health problems associated with the obesity and the headaches.
Top of Page - I hear about using molecular information for classifying and treating brain tumors. What does this mean?
Traditionally, the methods used in the classification and grading of tumors have been to examine the tissue under a microscope and identify characteristics of a specific central nervous system cell type. Grading is based on the level of abnormality such as shape and rate of cell division (i.e. how fast the tumor is growing). This system is useful for predicting overall survival of people with specific types of brain tumors, and historically has been used to help determine the type of treatment to use.
However, it does not provide insight into the molecular makeup of the tumor, and tissue samples that look identical under a microscope might differ significantly in their clinical course. Recently, scientists have begun focusing on differences at the molecular level, even in seemingly similar cell types and grades. Some of these molecular differences have been linked to better prognosis and heightened responsiveness to particular treatments. This has caused a greater interest in testing for some of these specific molecular characteristics. One example is that patients with anaplastic oligodendroglioma who have 1p and 19q chromosomal deletions may respond differently to treatment. Examining a tumor for the chromosomal makeup is now available, though it does require tumor tissue.
Glioblastoma is molecularly diverse with several possible oncogene or tumor suppression gene alterations, and varying patterns of chromosomal gain or loss. This leads to discrepancies in patient survival and may require different treatments. Extensive molecular data is slowly becoming more available that will help separate the molecular subsets within a glioblastoma diagnosis. We are at the beginning. Even though tests may not yet change current treatments, they increase understanding of tumor tissue and may help in future research and the development of targeted therapies.
Top of Page - Is it normal to experience fatigue following brain tumor treatment?
Yes, it is normal to experience fatigue following brain tumor treatment. Brain tumor treatment fatigue is a feeling of tiredness, often more severe than tiredness normally felt from a lack of a good night's sleep. Individuals have described brain tumor fatigue as weakness, exhaustion, lack of energy, sleepiness, drowsiness, confusion, and impatience. Most people have a lack of "pep," and feel a strong desire to stop, rest, and even lie down and sleep. When people experience cancer fatigue, it may affect the way they think. They may have trouble paying attention, reading, watching television, or talking with family members. They may find they may not be able to do all the activities that they used to do. The cause of brain tumor fatigue is not known; however, there are several ways to manage brain tumor treatment fatigue:
* Plan your day so that you have time to rest.
* Take short naps or breaks, rather than one long rest period.
* Eat as well as you can and drink plenty of fluids.
* Take short walks or do light exercise if possible.
* Try easier or shorter versions of activities you enjoy.
* Try activities that are less strenuous, like listening to music or reading.
* Save your energy for the most important things.
* Become comfortable asking others to help with things that you used to be able to do alone.
* Develop consistent sleep habits (go to bed and get up at the same time every day).
If you continue to have problems with brain tumor treatment fatigue, consult your physician or oncology nurse.
Top of Page - Could you explain to me what the "silent area" means and how symptoms from a brain tumor can affect the functions of the frontal lobe?
The right frontal lobe has been considered a "silent area" of the brain because often times people with small tumors in this area do not have any noticeable changes or symptoms. However, if the tumor is large or begins to grow or swelling causing increased intracranial pressure, then symptoms occur. The functions of the frontal lobe include storage of memory, and "executive" functions such as concentration, abstraction in thought, and ability for self-control. There are many connections from the frontal lobe to the other parts of the brain that control vision and automatic functions such as respiration, gastrointestinal activity, and blood pressure. In addition, the posterior or back part of the frontal lobe controls motor function. Formulation of words in the speech process is found in our dominant frontal lobe. Depending on the size and location of the tumor in the frontal lobe, patients may have a collection of symptoms known as "frontal lobe syndrome". These symptoms include behaviors such as inattentiveness, inability to concentrate, emotional instability, indifference, loss of self-restraint, inappropriate social behavior, inability to retain new information, difficulty with abstract thought, as well as the appearance of a quiet or flat persona. A patient may also experience headaches or seizures. If a patient is starting to develop more symptoms or the symptoms have changed, the doctor needs to be called for consideration of further treatment because of possible tumor recurrence and/or swelling. A neuropsychologist should also be contacted for further evaluation and coping measures.
Top of Page - Does hormone replacement therapy contribute to the recurrence of brain tumors?
Hormone replacement therapy (HRT) is the provision of estrogen for women whose natural estrogen decreases during the time of menopause. Female brain tumor patients diagnosed with meningiomas have been concerned about HRT because estrogen has been found in meningiomas. Some patients fear that hormone replacement with estrogen may cause the tumor to recur. Presently, there have been no scientific data on HRT response, the choice to engage or remain on HRT is a point of discussion for each person and one's physician.
Top of Page - Since the surgery I look like the same person, but I have some limitations that are not easily recognized from people who know me. My friends keep asking me if I'm "normal". I feel like I'm disappointing them if I tell them I have some limitations. What should I do?
The symptoms that you are experiencing since surgery are not uncommon. Following brain surgery, many people suffer from short term memory loss, an inability to fully concentrate, and fatigue. It sounds like you understand your limitations and are dealing with them. Many people around you want to believe that everything is back to exactly how things were before the surgery. What was "normal" for you in the past may not be the same now. I suggest that you do not go into detail about the changes that have taken place because it is often hard for people to understand. You may want to explain to them that some things have changed. You may be a little forgetful, and tired, but that you are doing fine. Your friends will know that you are managing and that you are able to cope with your disease. They will feel less guilty about not getting you fully back to "normal".
Top of Page - I have had nerve pain in my face since surgery. What can I do about this pain?
Nerve pain is not terribly common after surgery, but when it occurs it can be very annoying and difficult to relieve. Most physicians will try anticonvulsant medications such as Dilantin or Tegretol to relieve the pain. If the pain continues, there are other means to relieve the pain, such as surgery. However, the best solution is to go to a pain clinic. Most large medical settings have pain clinics to help patients with intractable pain. Pain clinics work with surgeons, anesthesiologists and psychologists. They provide a comprehensive approach on how to relieve or manage post-operative nerve pain.
Top of Page - My husband has a brain tumor and since he started his chemotherapy he has been extremely tired. What can I do to help him?
Ask your doctor to take a red blood cell count to evaluate the causes of fatigue. Fatigue is commonly overlooked side effect for both radiation and chemotherapy. One reason that chemotherapy causes fatigue is because the red blood cell count is low. The red blood cells deliver oxygen to different parts of the body. When they are low or not plentiful, the body is deprived of oxygen. This can result in a condition called anemia, which is the culprit in fatigue. The good news is that anemia can be treated with medications.
There are several ways to cope with cancer related fatigue, and here are some suggestions:
1. Prioritize your activities. Reserve your energy to get the things done that are most important to you.
2. Keep a journal of how you are feeling. It doesn't have to be elaborate, but note your fatigue level at different times of the day. This can help you determine how best to plan your activities according to your energy level.
3. Avoid taking long naps. Take a limited nap during the day, because you want to promote a good nights sleep. Light exercise, such as walking, often decreases fatigue.
4. Don't be afraid to ask for help! If you need help finishing a task, ask for it. This allows you to accomplish things you enjoy and still have time to rest.
5. Utilize the wisdom of other cancer patients. Joining a support group is an excellent way to learn from the experiences of other patients who are coping with cancer related fatigue.
6. Make sure you are getting enough food and water. Cancer treatments can cause appetite loss. Getting enough calories and nutrients helps alleviate fatigue.
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