The main treatments for brain or spinal cord tumours are surgery, radiation therapy and chemotherapy. These may be used alone or in combination. Medicines, such as steroids or anticonvulsants (anti-seizure medicines), may be given to reduce symptoms. There also could be new, experimental treatments or improvements in existing treatments. These are given in clinical trials – your doctor will tell you if you are eligible to join.
The aim of treatment may be to remove the tumour completely, slow its growth, or relieve symptoms by shrinking the tumour and reducing swelling. Your choice of treatment will depend on:
- the type, size, grade, location and genetic make-up of the tumour
- your age, medical history and general state of health
- the types of symptoms you have.
Surgery in the brain or spinal cord is called neurosurgery. Removing all or part of the tumour may allow you to return to leading an active life.
Sometimes the entire tumour can be removed in an operation called a total resection. In other cases, the surgeon may be able to remove only part of the tumour. This is called a partial resection or debulking. Partial removal may be chosen because the tumour is widespread, or near major blood vessels or other important parts of the brain or spinal cord. A partial resection may improve your symptoms by reducing the pressure on your brain.
Sometimes a tumour cannot be removed because it is too close to certain parts of the brain and surgery would cause serious problems. This is called an inoperable or unresectable tumour. Your doctor will talk to you about trying to ease the symptoms with other treatments.
Preparing for surgery
The types of scans used for diagnosing the tumour (e.g. CT, MRI or MRS scans) are often done again when planning surgery.
The surgeon needs to locate the most important areas of the brain to make sure these are not damaged during the operation. A special MRI scan called a functional MRI (fMRI) shows the exact areas of the brain that are used as you speak or move. Brain mapping is another way to find these parts of the brain. A tiny electrode is placed on the outside layer of the brain during the surgery and stimulated with a low dose of electrical current.
Before surgery, talk to your doctor about any medicines you are taking. Some medicines interfere with the anaesthetic used during the operation, so you may need to stop taking them for a while. You may also be advised to stop smoking before surgery.
It is natural to feel anxious before surgery, so talk to your treatment team about your concerns. You can also call Cancer Council 13 11 20 for support and may want to listen to our podcast about overcoming fear, available at cancercouncil.com.au/podcasts.
Types of surgery
Different types of operations may be used for brain and spinal cord tumours. You may already have had a biopsy to remove a sample of tissue or the biopsy may be done at the same time as the surgery to remove the brain tumour.
Craniotomy to remove a brain tumour
This is the most common type of brain tumour operation. A craniotomy removes all or part of the tumour (total or partial resection) and is done under a general anaesthetic. The surgeon removes part of the skull to access the brain. The tumour is then taken out, and the bone and scalp are put back. The surgeon uses small plates and screws to permanently hold the piece of skull in place.
Patients with a high-grade glioma may be given a solution to drink before surgery that makes the tumour glow under ultraviolet light. This may help the surgeon remove as much of the tumour as possible, while avoiding normal brain tissue.
This operation may be recommended if the tumour is near parts of the brain that control speech or movement. All or part of this operation is done with the patient awake (conscious) but relaxed, so they can speak, move and respond. You may be worried that an awake craniotomy will hurt, but the brain itself does not feel pain and local anaesthetic is used to numb surrounding tissues. During the surgery, the surgeon asks the patient to speak or move parts of the body. This helps the surgeon identify and avoid certain parts of the brain. An electrode is also used to stimulate and pinpoint important areas of the brain.
It is now usual for craniotomies to be done using a computer navigation system to guide the surgeon.
The computer uses the results of planning scans to create three-dimensional images of the brain and tumour. During the operation, the computer then monitors the surgical instruments, allowing the surgeon to be very precise.
Surgery that uses computer navigation is known as stereotactic surgery. It is safer, more accurate and requires a smaller cut in the skull than non-computer guided surgery.
Endoscopic transsphenoidal surgery
This surgery is used for tumours near the base of the brain (e.g. pituitary gland tumours). To remove the tumour, the surgeon inserts a long, thin tube with a light and camera (endoscope) through the nose and into the skull at the base of the brain. An ear, nose and throat (ENT) surgeon may assist with this type of surgery.
The most common surgery for spinal cord tumours is called a laminectomy. In this procedure, the surgeon makes an opening through the skin, muscle and a vertebra in the spinal column to remove the tumour that is affecting the spinal cord. You will be given a general anaesthetic for this operation.
For more information on surgery, see Understanding Surgery or call Cancer Council 13 11 20.
After brain or spinal cord surgery
You will be closely monitored for the first 12–24 hours after the operation. The length of your hospital stay will depend on whether you have any problems or side effects following surgery. Your doctor will tell you when you can start regular activities again.
For the first day or two, nurses will regularly check your breathing, pulse, blood pressure, temperature, pupil size, and arm and leg strength and function. You will also be asked questions to assess your level of consciousness. These neurological observations check how your brain and body are recovering from surgery.
You will need to wear pressure stockings on your legs to prevent blood clots from forming while you are recovering from surgery. Tell your doctor or nurse if you have pain or swelling in your legs or suddenly have difficulty breathing.
Spinal cord checks
If you have had an operation on your spinal cord, the nurses will regularly check the movement and sensation in your arms and legs. You may need to lie flat in bed for 2–5 days to allow the wound to heal. A physiotherapist will help you learn how to roll over and how to get out of bed safely so the wound is not damaged.
Headaches and nausea
You may have a headache or nausea after the operation. Both can be treated with medicines.
Bandages and bruising
The dressing on your head may vary from a simple bandaid to bandaging that covers your whole head. Some or all of your head may have been shaved. After surgery to certain parts of the head, your face and eyes may be swollen or bruised - this is normal. It is not usually painful and should ease within about a week.
The surgery may cause a range of short-term or longer-term side effects (see below). Before you can return home, you may require further treatment known as rehabilitation. This may be offered in the same hospital or in a rehabilitation facility.
Some people have a build-up of cerebrospinal fluid in their brain. This is called hydrocephalus and it may occur before surgery as a result of the tumour, but can also happen after surgery. The surgeon may place a long, thin tube called a shunt into your brain to drain out extra fluid. A temporary shunt drains into a bag on the outside of the body. A permanent shunt is completely inside your body. It drains into your abdomen and the fluid is then safely absorbed into the bloodstream.
Side effects of surgery
Surgery to remove a brain tumour can cause swelling that leads to pressure inside the skull (intracranial pressure). Your medical team will monitor this and try to reduce it, but you may still experience side effects such as confusion, speech problems, dizziness, weakness and seizures. You and your family or carers may worry that you aren't recovering well, but the side effects often improve over time. Your doctor will explain that such side effects are normal and give you an idea of how long they will last.
In some cases, people recover fully and can gradually return to their usual activities. In other cases, the tumour position may mean that there are longer-term changes to how you speak, move and think.
A range of therapies can speed up recovery or help you learn to manage any changes. These therapies are known as rehabilitation.
At first, you may have some rehabilitation therapies in the hospital or in a rehabilitation facility. Once you return home, you can continue to access these therapies as an outpatient.
"The most distressing time for me was immediately post op when my side effects were many, varied and quite severe, even though most turned out to be temporary. It was distressing because I wasn't expecting them." – Ian
Radiation therapy (also called radiotherapy) uses radiation, such as x-ray beams, to kill or damage cancer cells. The radiation is targeted at the treatment site to reduce the risk of damage to healthy cells. The treatment itself is painless, though you may experience side effects afterwards.
Before radiation therapy begins, you will go to a planning or simulation appointment to plan the treatment. A radiation therapist will take measurements of your body and do a CT or MRI scan to work out the precise area to be treated. If you are having radiation therapy for a spinal cord tumour, some small tattoos may be marked on your skin to indicate the treatment area. If you are having radiation therapy for a brain tumour, you will probably need to use a face mask or head frame.
Radiation therapy is usually given once daily, from Monday to Friday, for several weeks. However, how often you have the treatment will depend on the size and type of tumour.
Stereotactic radiosurgery (SRS)
Stereotactic radiosurgery (SRS) is a special type of radiation therapy, not a type of surgery, so no cuts are made in the skull. It is used to treat some small brain tumours. A high dose of radiation is targeted precisely at the tumour, with very little reaching surrounding areas of healthy brain tissue.
Radiosurgery may be offered when neurosurgery is not possible or as an alternative to neurosurgery. It is most commonly used for metastatic cancers that have spread to the brain from another part of the body. It is also used for some meningiomas, pituitary tumours, and schwannomas, and is occasionally used for gliomas that have come back after other treatment.
Often, only 1-3 doses of SRS are needed. A treatment session may last between 15 minutes and two hours, depending on the type of radiosurgery given, and you will need to wear a face mask (see below) during the treatment. You will usually be able to return home afterwards.
Stereotactic radiation therapy (SRT)
A stereotactic radiosurgery machine may also be used to deliver a longer course of radiation, particularly for benign brain tumours. This is called stereotactic radiation therapy. The same precise system is used, but multiple small daily treatments are given.
Also known as proton beam therapy, this uses radiation from protons rather than x-rays. Protons are tiny parts of atoms with a positive charge that release most of their radiation within the cancer. This can be important near sensitive areas, such as the brain stem or spinal cord. Special machines, known as cyclotrons and synchrotrons, are used to generate and deliver the protons.
Proton therapy is not yet available in Australia. In specific circumstances, financial assistance may be available from the Australian Government to travel overseas for proton therapy.
Wearing a face mask
For radiation therapy to the brain, a plastic face mask may be made during the planning sessions. This is known as an immobilisation mask. It will help keep your head still and ensure the radiation is targeted at the same area during each session. The mask is made of a tight-fitting mesh, but you will wear it for only about 10 minutes at a time. You can see and breathe through the mask, but it may feel strange and claustrophobic at first. The radiation therapist can suggest ways to help you adjust to the mask, so let them know if it is making you feel anxious or uncomfortable. During treatment, you will lie on a table under a machine called a linear accelerator. Radiation therapy itself is painless.
Side effects of radiation therapy
Radiation therapy side effects generally occur in the treatment area and are usually temporary, but some may be permanent or last for a few months or years.
The side effects vary depending on whether the tumour is in the brain or spinal cord. They may include:
- nausea – often occurs during the course of treatment
- headaches – often occur during the course of treatment
- tiredness or fatigue – worse at the end of treatment, can continue to build after treatment, but usually fades over time
- red, sore, inflamed or flaky skin – may occur in the treatment area, usually happens at the end of treatment and often worsens before improving
- hair loss – may occur in the brain tumour treatment area and may be permanent
- dulled hearing – may occur if fluid builds up in the middle ear
- swallowing problems (dysphagia) – may occur following treatment for spinal cord tumours
- diarrhoea – may occur after treatment for spinal cord tumours.
A small number of adults who have had radiation therapy to the brain have side effects that appear months or years later. These are called late effects and can include symptoms such as poor memory, confusion, personality changes and headaches. Rehabilitation therapies or medicines can help with managing late effects. Young children are more likely to have long-term effects from radiation therapy because their nervous system is still developing, so other treatments are used where possible.
Radiation therapy is usually combined with chemotherapy for the treatment of glioblastomas (grade 4 tumours). Compared with radiation therapy alone, this combination leads to better outcomes.
Radiation therapy that affects the pituitary gland can lead to it producing too much or too little of particular hormones. If this is a risk for you, your treatment team will monitor the hormone levels in your pituitary gland.
See Understanding Radiation Therapy or call Cancer Council 13 11 20 for more information.
Chemotherapy is the use of drugs to treat cancer. The drugs travel through the bloodstream and damage or destroy rapidly dividing cells such as cancer cells, while causing the least possible damage to healthy cells. Healthy fast-growing cells, such as bone marrow cells, may also be affected, leading to side effects (see below).
It can be difficult to treat brain tumours with chemotherapy drugs because the body has a protection system known as the blood–brain barrier. This guards the brain from harmful substances that may be circulating in the blood, such as germs or chemicals. Only certain types of chemotherapy drugs can get through this barrier. Temozolomide is the most commonly prescribed chemotherapy drug for the treatment of brain tumours, although other chemotherapy drugs are also used.
You may be given chemotherapy as capsules or tablets that you swallow, or as a liquid through a drip inserted into your vein (intravenously). Each treatment session is usually followed by a rest period of a few weeks.
Side effects of chemotherapy
The way your body reacts to chemotherapy will be monitored through regular blood tests. Your treatment schedule may change when your doctor sees how you are responding to the drugs.
There are many possible side effects of chemotherapy, depending on the type of drugs you are given. Side effects may include:
- increased risk of infection
- nausea, vomiting or loss of appetite
- tiredness, fatigue and lack of energy
- mouth sores and ulcers, skin rash
- diarrhoea or constipation
- breathlessness due to low levels of red blood cells (anaemia)
- the feeling of pins and needles and numbness (nerve damage
- known as peripheral neuropathy)
- damage to ovaries or testicles, which can make you unable to have children naturally (infertility).
Anticonvulsant medicines may be given to prevent seizures before and after treatments for brain tumours.
It is rare to lose all your hair with the drugs used to treat brain and spinal cord tumours, although in some cases your hair may become thinner.
See Understanding Chemotherapy or call Cancer Council 13 11 20 for more information.
"Several years ago, I'd been having headaches for a couple of weeks and then one day I collapsed at work. I was rushed off for tests and they found a grade 2 oligodendroglioma.
"Within a week, I was having brain surgery. I got over that operation fairly well and didn't need any more treatment at the time.
"Last year, I found out that the tumour had returned and now included a new astrocytoma strain. That was a reality check. It had been nine years since the first tumour, and I guess I'd sort of taken my health for granted.
"I think I was in denial for a while and I wasn't particularly worried about the second operation, but I got more worried as the date came closer. I had no real problems from the surgery, it was textbook healing really, and the surgeon said they had got it all. But then he told me I'd need radiation therapy and chemotherapy, just to mop up any stray cells. That floored me – I hadn't needed it the first time, so I thought I'd escaped it.
"I had six weeks of radiation therapy, followed by six months of oral chemotherapy, and that knocked everything for six. I developed gastritis – that's an inflamed stomach – and had to go on a very bland diet. I lost so much weight and strength, and I was very vague for a while.
"Time has helped, but it has been very gradual. I started off with short walks and short bursts of activity.
"I also talked it all through with my local Cancer Council – that kept me afloat. It's been like an oasis and is still a big part of my life."
Tell your cancer story.
Steroids are made naturally in the body, but they can also be produced artificially and used as drugs. Brain tumours and their treatments can both lead to swelling in the brain. Steroids may help to reduce this swelling, and can be given before, during and after surgery and radiation therapy. The most commonly used steroid for people with brain tumours is dexamethasone.
Side effects depend on the dose and the length of treatment. If you are prescribed steroids for a short period, you may experience increased appetite, weight gain, trouble sleeping, restlessness, mood swings, anxiety and, in rare cases, more serious changes to thought and behaviour. In people with diabetes, steroids can quickly lead to high or unstable blood sugar levels. These shortterm side effects can be managed. Eating before taking steroids decreases the likelihood of the steroids irritating your stomach.
If taken for several months, steroids can cause puffy skin (fluid retention or oedema) in the feet, hands or face; high blood pressure; unstable blood sugar levels; diabetes; muscle weakness; and loss of bone density (osteoporosis). You will also be more likely to get infections. Most side effects are temporary and your doctor may adjust your dose to manage them.
An experienced counsellor, psychologist or psychiatrist can help you manage mood swings or behavioural changes. If you or your family are worried about side effects, talk to your doctor or nurse.
Palliative treatment helps to improve quality of life by treating the symptoms of cancer without trying to cure the disease. It can be used at any stage of advanced cancer. As well as slowing the spread of cancer, palliative treatment can relieve pain and help other symptoms. Treatment may include surgery, radiation therapy, chemotherapy or other medicines.
Palliative treatment is one aspect of palliative care, in which a team of health professionals aim to meet your physical, practical, emotional, spiritual and social needs. Palliative care services can be accessed in the home as well as in a hospital or in residential care. To find out more, call Cancer Council 13 11 20 and ask for free copies of Understanding Palliative Care and Living with Advanced Cancer, or visit your local Cancer Council website.
"My wife Robyn was diagnosed with grade 4 brain cancer when she had just turned 50. After getting a diagnosis like that, you just go into shock for a couple of days, then you start thinking about how things will change, you evaluate your life and what you need to do to help." – Ross
- The main treatments for brain or spinal cord tumours are surgery, radiation therapy and chemotherapy.
- Stereotactic radiosurgery is the most precise form of radiation therapy that is used to treat small tumours with high doses.
- Some tumours can be completely removed in a total resection. Others can only be partly removed (partial resection or debulking).
- Different types of surgery are used for different types of tumours. The most common brain surgery is a craniotomy. A laminectomy removes tumours from the spinal cord.
- Stereotactic surgery is when a computer guides the surgeon so the surgery is more precise.
- Radiation therapy uses targeted radiation, such as x-rays, to kill cancer cells. You will have a planning appointment so the doctor can work out exactly where to direct the radiation. It is rarely used for young children.
- Chemotherapy is the use of drugs to destroy or kill cancer cells. You may be given chemotherapy as tablets, or into a vein (intravenously) via a drip.
- Other treatments include steroids to reduce brain swelling, and anticonvulsants to prevent seizures occurring.
- Treatments may cause short-term and long-term side effects. Talk to your doctors and nurses about managing symptoms and side effects, including whether you will need rehabilitation.
Expert content reviewers:
Dr Brindha Shivalingam, Neurosurgeon, Chris O'Brien Lifehouse, NSW; Conjoint A/Prof Andrew Cole, University of New South Wales, Senior Staff Specialist and Director, Cancer Rehabilitation Service, Greenwich Hospital Rehabilitation Service, and Chief Medical Officer, HammondCare, NSW; Laraine Cross, Senior Clinician, Social Work and Psychosocial Oncology Services, Calvary Mater Newcastle, NSW; Dr Anthony Dowling, Medical Oncologist, St Vincent's Hospital Melbourne, VIC; Kate Fernandez, 13 11 20 Consultant, Cancer Council SA; Ian Gelling, Consumer; Anne King, Cancer Nurse Coordinator Neuro-oncology, WA Cancer and Palliative Care Network, WA; Jodie Nixon, Team Leader Cancer Occupational Therapy, Princess Alexandra Hospital, Brisbane, QLD; Prof Tamara Ownsworth, School of Applied Psychology, Griffith University, QLD; Dr Claire Phillips, Radiation Oncologist, Breast and Neuro-oncology, Peter MacCallum Cancer Centre, VIC.