How Is Brain Cancer Treated?

Once the diagnosis of a brain or spine tumor is made, patients and families can be faced with many difficult decisions to make about their treatment options. Factors to consider include the extent of resection (how much of the tumor was removed at surgery), type of tumor and status of important markers like chromosomes or enzymes such as IDH or MGMT, the patient’s ability to function, and age. 

Treatment of the Individual
The most important factor in determining a treatment course is the patient’s wishes and willingness to accept different levels of side effects in order to benefit from the treatment. Your care team’s job is to fully describe treatment options, including the risks and benefits of each. When they recommend a treatment, they will listen to you, respect your decisions and walk the journey with you.

Before recommending treatments, we will need to review records of medical care that you have previously received from any care provider. 

This includes MRI scans, treatment history and full pathology, which may lead a request for our neuropathologist to do a second opinion of the tumor specimen. This review allows us to present the full range of appropriate treatment options for you. Our tumor board, which includes specialists from neurosurgery, neuroradiology, neuropathology, radiation oncology and neuro-oncology, will discuss MRI scans and pathology findings to make recommendations for treatment.

Neurosurgery treatment

Even in the best circumstances, any tumor can be hard to treat. Surgery requires great emotional commitment and time to recover before additional treatments can begin. However, surgery is the single best way to quickly and effectively decrease the number of tumor cells in the body. It also potentially removes the bulky tumor which gets only limited blood flow and, if left in place, would allow tumor cells to hide from radiation and chemotherapy. 

Both radiation therapy and chemotherapies work better if we are treating microscopic tumor cells versus a large tumor. These therapies work less well if we try to shrink a large tumor mass. Other factors that can make a tumor more difficult to treat include limited blood flow to the tumor, tumor cells resting in low-oxygen/low-nutritional environments in the center of the tumor, and a limited ability for chemotherapies to reach all parts of the tumor.

Most importantly, in addition to providing you the best outcome, your surgical team will discuss with you approaches to minimize the risk of your surgery. While surgical risk can never be zero, a skilled and appropriately aggressive neurosurgeon who is equipped with advanced surgical tools can make surgeries as safe as possible. 

Specialized Mapping Tools
The University of Kansas Cancer Center offers advanced techniques and technologies to remove all or as much of the tumor as safely as possible. These include:

  • 3D navigation
    3D navigation is used during neurosurgery, allowing surgeons to precisely pinpoint a location within the brain in all three planes (axial, coronal and saggital). The surgeon can use this throughout the procedure as a map that highlights where the tumor ends and normal brain tissue begins.

  • Functional MRI brain mapping
    When appropriate, we offer functional MRI brain mapping, a technique that allows surgeons to locate specific areas of the brain before surgery so they can determine the best approach to the tumor. The technique helps surgeons avoid critical areas of the brain that control movement, speech and other functions.
  • Awake craniotomy
    In some cases, a craniotomy can be performed while the patient is awake. The patient is awakened from anesthesia after the initial incision is made. The patient is then asked to perform tasks while the surgeon operates close to a critical area. 

Minimally Invasive Neurosurgery
For some patients, minimally invasive neurosurgery techniques can be considered. The neurosurgeon uses an endoscope (a thin tube with a light and camera at the end) to access difficult-to-reach areas of the brain. There are two types of minimally invasive endoscopic procedures:

  • Transventricular endoscopic surgery
    The surgeon guides the endoscope into the ventricular system, which consists of multiple spaces in the brain that are filled with spinal fluid. This procedure can be used to treat hydrocephalus (a buildup of fluid in the brain ventricles), remove certain cysts (like colloid cysts and arachnoid cysts) and remove certain intraventricular tumors.

  • Endonasal endoscopic brain surgery
    The surgeon guides the endoscope through the nose to perform surgery at the skull base. This can be done for pituitary adenoma, certain skull base meningiomas, chordomas, craniopharyngiomas and some malignant tumors, such as esthesioneuroblastoma.

The advantages of endoscopy include lower infection rate, faster recovery and less damage to normal brain tissue. 

Radiation oncology treatment

A radiation oncologist has spent years studying the delivery of radiation for the treatment of tumors, including cancers. While there are a number of different types of radiation, the goal is to damage the tumor cells while sparing surrounding healthy tissue as much as possible. Delivery of radiation has improved greatly over the years to allow  treatment delivery to very precise locations. Many primary and metastatic brain and spine tumors can be effectively treated with radiation to either stop growth or reduce the chance of recurrence. Your radiation oncologist will discuss specific treatment details with you, as well as strategies to minimize side effects.

Stereotactic radiosurgery (SRS) is a specialized form of radiation that delivers a very high dose of radiation to a very precise area in only one or a few treatment sessions. It can very effectively kill tumor cells in the target area and is often used in the treatment of metastatic tumors. In addition to SRS equipment such as the Gamma Knife and Cyber Knife, we offer advanced Novalis Tx™ image-guided radiosurgery at The University of Kansas Cancer Center. We are the region's only hospital to offer this advanced, noninvasive treatment for all types of brain tumors. 

Role of neuro-oncology in treatment

Neuro-oncologists at The University of Kansas Hospital are the principle coordinating physician for cancer care. They work closely with others from neuroradiology, neurosurgery, neuropathology and radiation oncology. This physician will discuss the progress of your care plan, especially if there are changes, with the rest of the treatment team, often at regular tumor board meetings. 

The goal of your neuro-oncologist is to maintain the best quality of life for you and support your family, during the course of treatment, as well as after treatment completion. 

Neuro-oncologists provide ongoing care and management for brain and spine tumors, working closely with the rest of the care team. The most commonly used treatment these specialists offer is chemotherapy or “chemical therapy.” Chemotherapy can essentially refer to any medication. Chemotherapy is the traditional chemical treatment that can come in the form of pills (oral) or infusions (IV). 

These therapies are relatively nonspecific, which means they can affect both cancer cells as well as normal body cells. Unlike surgery or radiation, the advantage of chemotherapy is that it can go almost anywhere in the body attacking cancer cells wherever they may be, even microscopic tumor deposits that can’t be seen with MRI. However, this is also the disadvantage of chemotherapy. 

Targeted therapies 
Targeted therapies entered clinical trials in the past decade. Because this type of therapy targets only specific cells, it delivers a greater impact to the tissue with high levels of these cells while sparing healthy tissue that has low levels or none of these cells. These therapies are currently under investigation as we continue to understand how best to use them alone and in combination.

Historically, significant clinical testing of immunotherapies has provided limited benefits. However, more recently, this area of cancer medicine has made a resurgence. This is due to increased understanding of the immune system’s anti-cancer effect, as well as tumor-caused suppression of the immune system. Generally, immunotherapy works to “teach” the immune system to recognize the markers on tumor cells as targets and attack the tumor in a sustained way. The idea is that this will offer a “safe,” effective and long-lasting effect. A number of different approaches are currently under investigation in clinical trials.

FDA-approved therapeutic transmissible fields technology (Optune®) is available at The University of Kansas Cancer Center. The technology is based on the observation that cell division can be stopped by exposing cancer cells to an alternating electric field. For newly diagnosed patients, Optune is used with the chemotherapy temozolomide (TMZ) after surgery and radiation with TMZ. For recurrent patients, it can be used alone when surgery and radiation treatment options have been exhausted. In a clinical trial, adding Optune to TMZ was proven to delay GBM tumor growth and extend survival in newly diagnosed patients compared with TMZ alone.

Additional neuro-oncology care/supportive care
In addition to cancer treatment, your neuro-oncologist will help you manage your seizure medicine, or if needed, recommend a seizure specialist. Other areas of supportive care can include management of corticosteroids like Dexamethasone, treatment of depression and helping to control other symptoms potentially affecting your quality of life. 

Studies have shown that good control of symptoms such as pain not only improves day-to-day enjoyment of life, but actually can improve survival. Our neuro-oncologists are focused on supporting each patient and their family in getting the best outcomes and quality of life throughout the cancer journey.