Treatment

Philosophy on Treatment

The mission of the Seattle Cancer Care Alliance Neuro-Oncology Program is to offer the best and most current treatment to patients with brain and spinal cord cancers. This includes offering treatments based on the latest available scientific evidence and clinical research studies. We work toward discovering and implementing new treatments and technologies when caring for our patients and managing their disease.

Neuro-oncology experts in many specialties meet weekly as members of the University of Washington Neuro-Oncology Tumor Board to review patient cases and recommend treatment plans.

The goals for managing brain and spinal cord cancers are to: 

• Remove or destroy the cancer through surgery, radiation, and/or chemotherapy. 
• Relieve symptoms and signs that are due to the cancer pressing on the brain or spinal cord. 
• Improve the overall functioning and quality of life of the patient.

Depending on the type of cancer, treatment may include:

• Surgery
• Radiation
• Chemotherapy
• Biological therapy/Vaccine therapy

The type of treatment for brain and spinal cord cancers depends on many factors including the type of cancer, location of the cancer, overall health of the patient, and the patient’s wants and needs.

Surgery

Surgery is often the first step in treating adult brain and spine cancers. Even for the fastest growing brain cancers, surgery is the first step toward complete treatment. Surgery is done for several reasons:

• To biopsy the cancer to find out the type of cancer, especially if complete removal is not possible to due the location in the brain or spine. In this procedure, a small amount of the cancer is removed and viewed under a microscope by a neuropathologist in order to diagnosis the type of cancer.
• To safely remove the entire visible cancer. 
• Whenever possible, to reduce pressure on the brain or spine caused by the cancer. This may also relieve symptoms caused by the cancer.

For some brain and spine cancers, surgery cures the cancer when it is removed completely. Sometimes it is not possible to remove all of the cancer. Regardless of how much cancer is removed by surgery, radiation therapy and/or chemotherapy treatments may be needed to get rid of invading cancer cells.

Minimally invasive techniques refers to doing surgery through smaller incisions. Endoscopy is a minimally invasive technique that may be used for certain types of brain and spinal cord cancers. The surgeon uses an endoscope for these procedures (a thin flexible tube with an internal light source). Looking through the endoscope, the surgeon can see and remove part(s) of the cancer. There is often less injury to other surrounding tissue with the minimally invasive technique and recovery times are often faster and less painful than with traditional surgery.

Other procedures

There are other types of procedures that may be performed before or during surgery for brain and spinal cord cancers.

• Embolization involves selectively blocking the flow of arterial blood by using pellets or glue to reduce the blood supply to the cancer and permit a safer surgery. After the embolization, surgery is done as soon as possible to avoid re-growth of cancer blood vessels.
• Functional Brain Mapping refers to mapping the parts of the brain to identify important areas such as motor areas, which control movement, somatosensory areas, which control sensation, and language areas, which control speech and understanding verbal communication. The removal of brain cancer is a delicate operation that often needs functional brain mapping. By mapping the brain, the neurosurgeon can find a safe balance between cancer removal and avoiding damage to areas of the brain that affect the patient's quality of life.

UW Medicine’s brain mapping program is the largest and busiest program in the Pacific Northwest. To see a brain mapping procedure, go to UW TV’s Web site and watch the Brain Tumor Surgery program.

• Lasers (Light amplification by stimulated emission of radiation) release a beam of concentrated light energy that can destroy cancerous tissues and are used as a surgical tool.
• Polymer wafer implants Biodegradable wafers containing a chemotherapy drug are placed in the surgical cavity left after a cancer is removed. The wafer dissolves over time. For 4-6 weeks there is a slow release of the chemotherapy directly into the surgical cavity and surrounded brain containing cancer.
• Shunt refers to a piece of flexible tubing that is inserted into a ventricle in the brain and is used to drain excess or blocked cerebrospinal fluid in patients with intracranial pressure.
• Ultrasonic aspiration refers to ultrasound waves that cause vibration which can fragment, or break apart, cancer. The cancer fragments are then removed with suction (aspiration).

Radiation Treatment

Radiation may be performed externally or internally. External radiation treatment is called external beam radiotherapy. Internal radiation treatment is called brachytherapy and uses radioisotopes delivered to the cancer in small “seed” implants. Radiation works by damaging genetic DNA information in the cancer cell and stops cancer cells from being able to divide, grow, and multiply.

• External Beam Radiotherapy is the most common form of radiation therapy and is used to treat most brain and spinal cord cancers. The radiation beam is directed toward the site of the cancer and given fives days a week for two to eight weeks, depending upon the cancer location and type. Radiation treatment is performed using a machine called a linear accelerator or LINAC.

There are several important steps before radiation treatment begins. Your radiation oncologist will determine the volume in brain or spine at risk for having cancer cells. This at risk volume is used to determine the amount of brain or spine that requires radiation. Several different imaging techniques are used to help identify the volumes at risk including MRI, CT scan, PET scan, Angiography, and SPECT scan. The external beam radiation itself can be delivered by several different techniques. Each delivery system has its place in the treatment of brain and spinal cord cancers. The delivery techniques include:

• 3-D conformal radiation delivers radiation directly to and shaped around each target area, typically the cancer and a small surrounding area. This technique is useful when the cancer target is located in the posterior fossa (area near the bottom part of the skull) or near critical brain structures.
• Intensity Modulated Radiation Therapy (IMRT) is a more sophisticated form of 3-D conformal therapy. Different doses of radiation can be delivered to different areas.  Thus, much higher doses of radiation can be delivered to the cancer and surrounding brain receives small doses. This delivery system can be useful to target cancers that are close to critical structures.
• Fractionated Stereotactic LINAC Radiotherapy (FSRT) is a system that allows for a more sophisticated form of radiotherapy. A bite block (a custom-fit piece of plastic held in the mouth) is used to verify patient position from treatment to treatment through the use of cameras in the treatment room. This is similar to a global positioning system (GPS).  Patients are monitored during treatment for movement while the radiation is delivered.
• Stereotactic Radiosurgery is a very sophisticated, single, high-dose radiotherapy technique that can be delivered in several ways with the Leksell Gamma Knife®. A frame is temporarily attached to the patient’s head to prevent movement during the treatment. This frame allows for very accurate targeting of the cancer. If a patient moves during the treatment, the ability to accurately target the cancer is decreased.
• Brachytherapy involves placing radiation seeds or a balloon into the cancer bed during surgery. These implants are placed into the cancer to kill it from the inside out. A high dose of radiation can be delivered directly to the remaining cancer to destroy it.
• Chemotherapy Chemotherapy works by injuring the cancer’s genetic material or DNA, which impairs its ability to divide, multiply, and grow. Most chemotherapy drugs are given through a vein (intravenous) or in a pill taken by mouth. Common pill-form chemotherapies are CCNU (Lomustine), temozolomide (Temodar), procarbazine (Matalan), and etoposide (Toposar). Common intravenous chemotherapies include BCNU (Carmustine), carboplatin (Paraplatin), irinotecan (CPT-11), and cyclophosphamide (Cytoxan). These medications are effective for many brain and spinal cord cancers and are rapidly improving and expanding. 
• Biological therapy/Targeted therapy/Vaccine therapy
  This group of therapies uses proteins like monoclonal antibodies and small molecules to fight cancer cells. A new class of agents called targeted therapies are designed to injure a specific growth-promoting target in cancer.
  Targeted cancer therapies block the growth of cancer cells by using drugs that interfere with signals in cancer cells that permit uncontrolled growth. An example is bevacizumab (Avastin), an intravenous drug that targets cancer blood vessels. Bevacizumab in part converts cancer blood vessels into more normal appearing blood vessels, which aids chemotherapy entry into cancer cells, decreasing leaky blood vessels that result in brain edema, and denying the cancer a source of blood.  Vaccines directed against cancer are a type of targeted therapy. Biological therapies use the body’s immune system to fight cancer.

Managing Brain and Spinal Cord Cancers and the Side Effects of Treatment

The following are common side effects of brain and spinal cord cancer treatment.

Fatigue

Fatigue is often described as feeling tired, weak, exhausted, and worn-out. It is a common side effect of radiation and chemotherapy. Sleep does not always relieve fatigue.

Throughout the day, fatigue can be managed by pacing activities with rest periods. Planning rest periods in advance of feeling fatigue is a good way to manage fatigue. Taking a short nap can help because long naps may interfere with nighttime sleep. Another way to manage fatigue is to ask others for help with activities.

Fatigue can last for a few weeks to many months. It is important to take care of yourself during this time and not be frustrated. Daily exercise can also help manage fatigue. You can take short walks or do more intense activity. Stimulant medicines like amphetamines are sometimes prescribed to help with fatigue. The cause of cancer-related fatigue is not clear. Let your health-care team know you are feeling fatigue so that other causes of fatigue can be evaluated. 

Nausea and Vomiting

Nausea or vomiting can occur with radiation and chemotherapy treatment. There are many medications that can help and are commonly prescribed. Be sure to tell your health-care team if you are having nausea or vomiting so medication can be prescribed for you.

Sometimes avoiding spicy and heavy foods can help. An SCCA nutritionist can give advice on managing nausea and vomiting as well. If you are loosing weight, it might be important for you to take a nutritional supplement. It is important to eat nutritious, well-balanced meals during your treatment. Sometimes it can be helpful to eat several smaller meals throughout the day. It is also healthy to drink plenty of fluids.

Hair Loss

Hair loss may occur with radiation therapy or chemotherapy. Hair loss occurs because radiation and chemotherapy affect all the fast growing cells in your body, which includes cancer cells, and hair cells or follicles. Hair may begin to grow back once chemotherapy treatments have ended. For people receiving radiation treatment, hair often does not grow back. If hair does grow back it may look different either in thickness (usually thinner), color, or texture.  We realize dealing with hair loss can be hard. There are resources that can help with managing hair loss:

• Beauty and Cancer Program at Seattle Cancer Care Alliance and  University of Washington Medical Center This is a free service. To schedule an appointment call (206) 598-3604.
• American Cancer Society has an online catalogue for wigs, hats, and other options for head coverings.
• Retail Shops that can help with hair loss.

Skin Irritation

Your skin can become irritated from exposure to radiation as well as certain kinds of chemotherapy. For example, targeted therapies like Tarceva or Sutent. Avoid lotions that contain alcohol or perfume as this will dry out the skin. A short bath or shower is best. Long baths and hot showers may be irritating and cause dryness to the skin. It is important if you are receiving radiation therapy to use the creams and lotions provided by the treatment team. Regular lotions may cause the skin to be irritated by the radiation. It is important during treatment to protect yourself from sunburn. When you go outdoors, wear a cap or scarf and long sleeves to protect yourself from the sun. Check with your health-care provider to see if you can use a sun screen. 

Short-Term Memory Loss

Some people experience memory loss during or after radiation treatment. This memory loss is usually for events that have happened recently. Long-term memory of years ago does not seem to be affected. Keeping track of things can be helped by using a calendar and a notebook with questions and a to-do list. It is important to let friends, family, and your health-care team know if you are having memory loss.

Seizures

Seizures are often a symptom of brain cancer. Additionally, seizures can occur from the treatments used to treat brain cancer. Seizures occur when there is a burst of uncontrolled electrical activity in the brain. This can occur from the brain cancer or from surrounding normal brain tissue being irritated. If these electrical bursts happen in motor parts of the brain, there may be a burst of uncontrolled muscle activity. This may include muscle contractions of the arms and legs, or loss of consciousness. Seizures are usually treated with medications called anticonvulsants. Side effects of these medications may include drowsiness, rash, and cognitive slowing.

Follow-Up After Treatment

There are many options for follow-up activities after treatment. Be sure to ask you nurse and doctor for suggestions.  They can tell you about options such as support groups. Seattle Cancer Care Alliance offers a survivorship program called MOST (Medical Oncology Survivorship Team). 

More Information

More information about brain cancers and treatment is available to you by clicking here. Information for caregivers can be found on the American Brain Tumor Association Website

December 2007