This information has been reviewed by:
Dr Kate Drummond, Neurosurgeon, Royal Melbourne Hospital
Dr Peter New, Head, Spinal Rehabilitation Unit, Caulfield General Medical Centre and lecturer, Monash University Departments of Medicine and Epidemiology and Preventative Medicine
Radiosurgery/stereotactic radiotherapy
Steroid therapy for brain tumours
Side effects of steroid therapy
Anticonvulsant therapy for seizures
Complementary and alternative medicines Role of rehabilitationMany years of treating cancer patients and testing different treatments in clinical trials has helped doctors know what is likely to work for a particular type and stage of cancer. Your doctor will advise you on the best treatment for your cancer. This will depend on the type of cancer you have, where it is and how far it has spread, your age and general health, and what you want.
Tumours of the central nervous system may be treated with surgery, radiotherapy, chemotherapy or steroid therapy. These treatments may be used alone or in combination. Prompt treatment may prevent or lessen the effects of brain and spinal cord tumours.
Having diagnosed the type of tumour, the aim of treatment will be to remove or destroy the tumour. If this is not possible, treatment may:
Before your treatment starts, make sure you have discussed it with your doctor. Make sure that you know what to expect, including any risks involved. You may find it helpful to have your partner or a friend or relative with you when you talk to the doctor. You may also find it helpful to write down your questions before your visit.
Each person is different and treatment needs to be planned individually. Most people will have a combination of treatments either at once or over time. Different treatments act on the tumour cells in different ways, so it is often good to combine treatments to achieve the best effect.
Some tumours can be completely removed by surgery. But some are very close to important structures in the brain, or are even growing in amongst normal functioning brain cells. When tumours grow like this, the surgeon may not be able to remove the whole tumour safely and may only remove part of it. This will usually improve your symptoms by reducing the pressure on the rest of the brain or spinal cord. Occasionally, no surgery is possible.
Sometimes, only a small piece of the tumour can be safely taken, to confirm the diagnosis. This is called a biopsy. For some tumours, only a biopsy is necessary.
Whether surgery removes all or only part of the tumour, it often improves a person's condition. This often makes it possible for someone who was seriously ill to lead an active life, at least for a time.
The operation to treat a brain tumour is called a craniotomy. Some of your hair will be shaved off, and you will be given a general anaesthetic. The surgeon cuts and moves aside the skin, then removes a piece of skull above the tumour.
The surgeon will use computer guidance to plan the craniotomy and help with removing the tumour during the operation. The tumour may be in an area of the brain that controls speech or movement. In this case an electric brain stimulator may be used to safely identify these areas.
Sometimes your surgeon will suggest that the operation is performed with you awake, under local anaesthetic. This is called an ‘awake craniotomy'. It means you will have some anaesthetic and be asleep at first, but be awake and alert for the middle part of the operation. The brain does not feel pain). It will seem strange, but you will be able to hear and talk. The surgeon will test that you can talk and move normally during the surgery and will electrically stimulate the brain to identify important structures.This can reduce the risk of damage to the brain and disability after the surgery.
The tumour itself will be removed, the piece of skull replaced, and the skin stitched back in place.
Sometimes the build up of the cerebrospinal fluid in the brain (hydrocephalus) is a problem. If this is the case and particularly if the tumour is in a position that makes it too dangerous to remove, the surgeon may put in a small permanent drain tube, called a shunt. This tube runs from the brain to the chest or abdomen (stomach) under the skin. The shunt will drain the excess fluid from the brain. Sometimes, the hydrocephalus can make a person very ill. In this case, a shunt may be put in first to relieve the symptoms. Then surgery for the brain tumour may follow a week or two later.
The surgeon will remove the whole tumour or as much of it as can be safely removed. The removed tissue can then be examined under the microscope (by a doctor called a pathologist). This is important as it is the only way to determine the type of tumour that you have. You cannot identify the type of tumour for certain using only an MRI or CT scan.
Sometimes the tumour cannot be removed safely so the surgeon does a biopsy in which only a small piece of tissue is removed. This is usually enough for the pathologist to make a diagnosis.
For the first 12 hours or so after the operation, you will be closely observed by a team of doctors and nurses. Your head may be completely bandaged. For the first day, a small tube may drain any excess blood from the operation site into a bottle. You may have other tubes in your arms or into your bladder.
Your face and eyes may be swollen after the operation, but this should go down within about a week. You may have pain in your jaw when chewing or opening your mouth. The length of your stay in hospital will depend on the extent of the operation, and on any treatment you may need afterwards.
The main surgery for spinal cord tumours is a laminectomy. Bone is removed from the spine so your surgeon can reach your spinal cord. It is usually not necessary to replace this bone. The surgeon takes a biopsy or removes the tumour/s affecting the spinal cord. Care is taken to avoid weakening the bones of the spinal column.
After the operation, the medical team will regularly check your pulse, blood pressure, temperature and dressing. They will also check the movement and sensation in your legs. You may have tubes in your arms, bladder and from your wound. You may need to rest flat in bed for three to five days, to allow the wound to heal. You will be turned in bed in a way that avoids twisting your spine and hips. The staff, including a physiotherapist, will teach you how to move to reduce the strain on your spine. Your doctor will tell you when you can start normal activity again.
Radiotherapy treats cancer by using radiation to destroy cancer cells. The radiation can be targeted to cancer sites in your body. Treatment is carefully planned to do as little harm as possible to your normal body tissues. There is no sensation or discomfort, and people are not radioactive after having radiotherapy.
In adults, radiotherapy is often used after surgery for malignant brain tumours and malignant spinal cord tumours. Radiotherapy is sometimes used for benign tumours when surgery cannot remove all of the tumour. The course of radiotherapy you receive will depend on the type and the size of cancer that you have. You may have chemotherapy at the same times as radiotherapy.
In children, radiotherapy to the head is given with particular care, because high doses can slow a child's growth or intellectual development. It is used rarely for children under the age of two or three years for this reason. For some types of childhood tumours, it may be necessary to give radiotherapy to the spine as well as the head.
A plastic mould of the head and shoulders is usually made for people having treatment to an area of the brain. Extra scans will be taken while you wear the mould. This helps treatment to be designed and given accurately.
This type of radiotherapy is used in some cases when the tumour is very small.
The treatment sometimes uses a special stereotactic frame, which is like a ring around your head. It is attached to your skull with sharp pins using local anaesthetic. The frame will prevent your head from moving and enable ‘pin-pointing' of the tumour.
The technique may be used to deliver a very high dose of radiation over a few days which is called radiosurgery. Otherwise the radiation is delivered over a number of weeks (as with usual radiation) and is called stereotactic radiotherapy.
Stereotactic radiotherapy is not available in all centres, although all specialists in brain tumour treatment have access to this service and are aware of the situations where it may be useful. It is not an effective treatment for all types of tumours.
Side effects vary a little from person to person.
Common early side effects of radiotherapy are mild headaches and nausea, which are usually easy to treat with medication. These can come and go during the period of treatment. Most people have tiredness. This may slowly increase during the course of radiation and last a month or so after radiotherapy has finished.
Radiotherapy to your head may cause any hair in the treatment area to fall out. This hair usually grows back slowly, though it may not be as thick as before. Scalp and skin in the treatment area may also become red, dry and tender. Do not use any creams, lotions or soaps without talking to your doctor or radiation therapist first. You also need to check before shaving any affected skin. It is important to keep the affected skin out of the sun,. It is very easily damaged by the sun's rays.
Radiotherapy to the brain will sometimes damage healthy brain tissue or cause swelling of the brain. This is a rare but serious side effect and should be discussed with your doctor. Steroid therapy can help reduce swelling.
A rare side effect of radiotherapy to the spine is damage to the spinal cord, called radiation myelopathy. This sometimes occurs in the months following radiotherapy. It causes an unusual sensation from the neck to the hands or feet. If you notice this, speak to your doctor.
Unfortunately, high dose radiation can affect growth of normal tissues in children. Depending on where the radiation goes, this can slow down bone growth in the spine. The result is the child may not grow as tall. Intellectual development may also be affected. Radiotherapy can also slow a child's growth by affecting the pituitary gland in the brain, which secretes hormones that control growth. These children may need hormone therapy to help them to grow and develop normally.
This is the treatment of cancer with anti-cancer drugs. The aim is to destroy all cancer cells while doing the least possible damage to normal cells. The drugs work by stopping the cancer cells from growing and reproducing themselves. The drugs work by stopping the cancer cells from growing and reproducing themselves.
If you have chemotherapy for your tumour, the doctor will decide on the dose and frequency of the treatment. Each treatment will usually be followed by a rest period of a few weeks. This allows your body to recover from any side effects of the treatment. The number of courses given will depend on the type of cancer, and how well it is responding to the drugs.
You may have chemotherapy through an intravenous drip at the hospital. Usually, you do not need to stay overnight, although you may need to attend for several days in a row.
You may have your chemotherapy in tablet form which you can take at home. Chemotherapy in tablet form is not weaker than intravenous chemotherapy and is one of the commonest types of chemotherapy used. For some types of brain tumour, tablet chemotherapy and radiotherapy are used at the same time.
Some drugs used in chemotherapy can cause side effects. They may include feeling sick (nausea), vomiting, feeling unwell and tired. There can be some thinning or loss of hair from your body or head. Generally, these side effects are temporary and can be prevented or reduced.
Some drugs can cause longer-term or per-manent side effects. Steps will be taken by your doctors to monitor these effects.
Steroid drugs (usually dexamethasone) are used to reduce the swelling that often surrounds brain tumours and the spinal cord. They are used either before or after surgery or radiotherapy. They do not treat the tumour itself but they do help to relieve the swelling and pressure caused by the tumour. Steroids can be used at many stages of treatment, for varying lengths of time. Some people may need to take them for days, others for months.
Do not stop taking steroids suddenly, as this can be dangerous. When it is time to stop taking steroids, the doctor will advise you how to gradually reduce your dose.
If you are having steroid treatment, you should always carry a steroid card (which your doctor or nurse will give you). Steroid cards show the type of steroid you use, and the dose. This is in case you become ill and need medical treatment. The doctor treating you will need to know which medications you are on.
Side effects of steroid therapy
The dose of steroids given will be kept as low as possible to minimise side effects.
Possible side effects are:
These side effects are temporary and will gradually disappear as your steroid dose is reduced. In some people, steroids produce a feeling of wellbeing or even euphoria. After finishing the treatment, it is common to feel a bit low or depressed for a while after you finish your dose. This lasts longer for some people than for others.
Although these side effects can be unpleasant, steroids are often a very important part of your treatment.
Many people with brain tumours require medications called anticonvulsants or antiepileptic drugs. There are many types of these drugs. If you have already had a seizure
(or ‘fit' or ‘convulsion'), they may be used to stop them recurring. Sometimes these drugs are used to stop you from having a seizure if your doctor thinks you are at high risk, even if you have never had one.Anticonvulsant medicines often require regular blood tests to check the levels in the blood. If you are having problems with seizures or with anticonvulsant medications, you may need to see a neurologist who specialises in seizures (also known as a type of epilepsy). Ask your doctor if it is safe to drive.
It's common for people with cancer to seek out complementary and alternative treatments. Many people feel that it gives them a greater sense of control over their illness. They may feel that it's ‘natural' and low-risk, or that they just want to try everything that seems promising.
Complementary therapies include massage, meditation and other relaxation methods. They are used along with medical treatments.
Alternative therapies are unproven remedies which are used instead of medical treatment. They include some herbal and dietary remedies. Some of these have been tested scientifically and found to be not effective or even harmful.
Some complementary therapies are useful in helping people to cope with the challenges of having cancer and cancer treatment. However, some alternative therapies are harmful, especially if:
Be aware that a lot of unproven remedies are advertised on the Internet and else-where without any control or regulation. Before choosing an alternative remedy, discuss it with your doctor or a cancer nurse at the Cancer Council Helpline on 13 11 20.
See the US National Center for Complementary and Alternative Medicines: http://nccam.nih.gov/
The prognosis (or ‘outlook') for tumours of the brain and spinal cord varies. It depends on your age, the type of tumour you have, how much of the tumour can be removed, and how well it responds to radiotherapy or chemotherapy. If you have a benign tumour that is completely removed, total cure is likely.
The rate of growth and spread of malignant tumours also varies. Some types of malignant tumour grow and spread rapidly. Others develop slowly over a number of years. Response to treatments also varies a lot.
After treatment for a brain tumour, some people appear to be completely cured and may live for many years. In many people, however, brain tumours recur (grow again).
Where a cure is not possible, treatment can often relieve symptoms. With treatment it may be possible to lead a good and relatively symptom-free life, sometimes for several years. Recurrence of symptoms after treatment varies from person to person.
All types of brain tumour can occur in children. Some tumours are simple to deal with and easily cured while others are much more difficult to treat and there is less chance of a cure.
While a significant number of children will recover completely, some children whose tumours are cured or controlled for many years will be left with disabilities. These range from mild learning or behaviour problems to severe physical or intellectual disability.
After treatment, you will need regular check-ups. To begin with, these check-ups and scans will occur several times each year, then you will usually need to have a check-up at least once a year. These check-ups are important to make sure there is no reappearance of the original cancer and that a new one does not develop.
After treatment for cancer you may have a range of problems that can be helped by referral to a formal rehabilitation program.
This may be as an inpatient or you may attend a centre-based program from home. The benefits of this program include referral to a range of staff with expertise in helping you regain abilities that may have been lost due to the cancer or treatment, that can be partially reversed.
This may include contact with a rehabilitation specialist, physiotherapist, occupational therapist, dietitian/or psychologist. These people will communicate with your general practitioner and any specialists involved in managing your cancer.
Specific problems that can be ad-dressed by rehabilitation programs in-clude the following:
It is natural to feel anxious about the possibility of further tumour growth. Talking over your concerns with your family and your own doctor can be helpful. The regular check-ups will reassure you that all is well. If there are any problems, they can be found early, when treatment is most likely to be successful.
It can take time before you feel reassured by check-up visits. You will need to rebuild your confidence in your body and in the future.
You may find that you need reassurance from your specialist. This is quite normal. Ask lots of questions if you want to and try to be sure that all your concerns are answered. Remember that you are not alone and that your feelings are normal. Be patient with yourself as you find your way to live with having and having had a tumour.
