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Brain Cancer: The ultimate cancer
A brain tumor is a collection or growth of abnormal cells in the brain. Brain tumors in are basically categorized in two types- those which are originally from the brain (primary) and those which have come to the brain from other parts of the body (secondary or metastatic). One feature of primary brain tumors, unlike cancers elsewhere in the body, is that they do not spread beyond the confines of the brain. They usually cause death by growing larger and invading other adjacent structures. One has to remember that the brain is full of important nerves which control everything from vision to breathing. The primary brain tumors are further subdivided in to two subcategories. One group includes the malignant tumors and the other includes the benign tumors. All malignant brain tumors are life threatening because they have an aggressive and invasive nature. The malignant brain tumors are faster growing, tend to invade the nearby structures and can destroy everything in the vicinity. Benign tumors can also grow in the brain. In fact, benign brain tumors are more common than malignant tumors. Even though benign brain cancers are slow growing, it is their location which is most important. Unlike malignant brain tumors, they do not invade nearby tissues but can compress them. Benign brain tumor are life threatening only when they compromises vital structures (e.g., nerves, blood vessels). They may apply pressure on sensitive areas of the brain and can cause loss of vision, speech, or hearing. The other variety of tumors is the secondary or metastatic brain cancers. These tumors have come from somewhere else in the body. Almost any tumor can migrate to the brain, but the most common are lungs, kidney, melanoma and breast. In all such cases, this indicates a very advanced disease and the prognosis is extremely poor. Sometimes, a brain tumor is the first sign of cancer that began elsewhere in your body. Irrespective of the type of tumor in the brain, the major problem with a brain tumor is where in the brain it is growing. Because the brain is confined within a bony skull, there is no where for the mass to grow, and thus the tumor will exert all its affect on the nearby structures including nerves and other sensitive parts of the brain. Of all cancers, brain tumors are a challenge because they grow in the most sensitive part of the body and are confined inside the skull. Treating brain tumors requires skill, judgment, innovative techniques and a multidisciplinary group of physicians.
Incidence and Prevalence
Brain cancer is not uncommon and accounts for at least 15-20 cases per 100,000 people in North America. The cancer is a leading cause of death in adults younger than 35 years. On average 17,000 people develop brain cancer and about 13-15,000 die each year. Overall, 50% of the brain cancers are primary and 50% are secondary or metastatic. Unlike the primary brain tumors, secondary brain cancers are seen in the older individuals. On average about 100,000 metastatic brain cancers occur each year. Brain tumors are common in two age groups, in children under the age of 8 and those over the age of 65. It is very rare that an adult suddenly develops a brain tumor, unless it has spread from somewhere else in the body. Men are more prone to brain tumors than females and of all the ethnic groups; Caucasians have a higher incidence of brain tumors.
Signs and symptoms
The symptoms of any brain tumor primarily depend on where it is located in the brain. The major brain cancer symptoms are due to compression on the surrounding tissues. Depending on where the tumor is growing one may have these brain tumor symptoms: • sudden onset of headaches or a change in the pattern of headaches • frequent and severe headaches • persistent nausea and vomiting • loss of vision or blurring of vision • loss of sensation in the arm of leg • weakness in the arm or leg • Difficulty with walking and balance • Difficulty speaking • New onset of confusion • Change in personality • Change in behavior • Sudden onset of seizures • Difficulty with hearing • Excess or absence of hormones
Despite intensive research and data collection, the cause of brain tumors remains unknown. While there has been some light shed on what the symptoms of brain tumor, there is o definitive cause known and in only a few cases are brain tumors inherited in a family. The familial causes of brain tumors include the following: • Multiple endocrine neoplasia type 1 (pituitary adenoma) • Neurofibromatosis type 2 (brain and spinal cord tumors) • Retinoblastoma (malignant retinal glioma) • Tuberous sclerosis (primary brain tumors) • Von Hippel-Lindau disease (retinal tumor, CNS tumors) Numerous theories have been postulated to what causes brain tumors and claims have been that environmental pollution, exposure to hazardous chemical (vinyl chloride), working in the mining industry and living near a power plant may all be responsible. However, all these are pure speculation and there is no definitive evidence to support any of these statements. There is zero evidence that any prior head injury is the cause of brain tumors. Those patients with a history of cancers of the lung, melanoma, breast, colon, or kidney cancer are at risk for secondary brain cancer.
When to seek medical advice
Most individuals, who have a brain tumor, generally tend to have a headache which is continuous and associated with persistent nausea and vomiting. Some individuals may lose their vision and others may be unable to talk. This may be the first indication that something is not right and one should seek help. Brain tumors are quite rare and many family physicians are not well acquainted with them. So if symptoms occur, one should see a physician right away, because the prognosis is much better in the early stages of the disorder.
In many cases, the initial signs and symptoms may be vague and not arouse suspicion for anything sinister. However, when the symptoms persist, most physicians will suspect a brain tumor. To confirm the diagnosis, the following tests may be required: Neurological exam: The exam will determine if you have developed any neurological deficits. Your hearing, reflexes, balance, speech, ability to swallow, walk, sense touch, pain, balance and concentration will be assessed. This will be the first clue that something is not right. CT scan: This is usually the first test does to determine the presence of a brain mass. The test takes a few minutes and involves the injection of dye. Magnetic resonance imaging (MRI) scan: This is fast becoming the test of choice to determine brain cancers. It produces excellent details about the brain and readily identifies any abnormality. It is a painless test which does not utilize radiation. PET scan: This is a test to confirm what has been seen on an MRI. It is an extremely sensitive test. It is not the first test of choice but can be used to follow the progress of a brain cancer after treatment. PET scan is an expensive test and not readily available everywhere. If there is suspicion that the brain mass may be from somewhere else in the body (lungs, breast, skin), then the physician will order other tests to look for tumors in that part of the body.
Even though all the above tests can reveal that there is a brain mass, the only way to confirm if it is indeed a cancer requires a biopsy. The biopsy usually involves placing a needle in the brain and obtaining a sample. Or sometimes, the surgeon may obtain a biopsy when he explores the patient’s brain. The needle biopsy is obtained by first drilling a hole in the skull (burr hole) and inserting a needle through it. Excellent imaging has allowed needle biopsy to be performed with great safety and minimal risks. All the tissues obtained are examined by the pathologist to determine if it is tumor. Generally, additional testing is done on the tissues to determine the exact type of tumor which may help guide treatment.
The brain is everything. From who we are, what we think, how we see, what we do, speak, brag, cry, walk, run-everything is controlled by the brain. So when a brain tumor occurs on a specific site, one of these sensations is going to be affected. Brain tumors are notorious for invading normal adjacent tissues and causing permanent nerve damage. Frontal lobe: The front part of the brain is important for cognitive skills and learning and memory. It is also concerned with emotions, reasoning, planning, movement, and parts of speech. It is also involved in purposeful acts such as creativity, judgment, problem solving, and planning. Parietal lobe: This part of the brain is concerned with the processing of nerve impulses related to the senses, such as touch, pain, taste, pressure, and temperature. It monitors language functions. Temporal lobe: The temporal lobes are responsible for hearing, memory, meaning, and language. They also play a role in emotion and learning. The temporal lobes are concerned with interpreting and processing auditory stimuli. Occipital lobe: when a tumor is located in the back of the brain, it may affect the vision and can cause blindness. Middle: In the middle of the brain are drainage ducts and when these are blocked, fluid build up can occur. This fluid can be enormous and can alter the shape of the skull and compress large parts of the brain. Because the skull is not compressible, the pressure exerted is enormous and can lead to wide variety of symptoms. Occasionally, some brain tumors may erode into a blood vessel and cause bleeding in the brain. This is usually an emergency and the prognosis in most cases is poor.
The treatment of brain tumors depends greatly on where it is located, how big it is and your overall health. If someone is not in great health, he/she may not be able to tolerate the vigorous treatment. Therapy for all individuals with brain cancer is individualized to offer the best chance of success. The treatment of brain cancer is usually done by a number of specialists which includes a brain surgeon, oncologist and a neurologist. The initial treatment of most brain tumors includes: Steroids: brain cancers generally cause swelling, edema and inflammation. Steroids help to decrease the brain swelling and also diminish the symptoms Nausea and vomiting: Because brain cancers are notorious for causing vomiting, drugs may be required to decrease these symptoms Seizure: Some brain tumors may induce seizures and the drug treatment is required to control the onset of convulsions Shunts: In many cases, the brain tumors block the drainage of brain fluid and this causes a build up of fluid (hydrocephalus). This is usually treated by placing a small plastic tube in the brain cavity and connecting it to the abdomen. This tube will drain the fluid but is only a temporary solution. The tubes do have a tendency to get plugged and often need to be replaced. The specific modality of treatment of brain tumors includes: There are some brain masses which produce minimal symptoms and are not fast growing. Today, our treatment philosophy for these slow growing brain tumors has undergone a 360” revolution. Surgeons now wait and watch tumors which are slow growing and do not cause symptoms- in most cases; this is a better form of treatment than any other therapy. Surgery: Whenever possible, surgery is still the best modality to treat brain cancer. In most cases, the tumor is removed but when the tumor involves adjacent structures the entire cancer can not always be removed. Surgery is usually done after removing part of the skull bone (craniotomy). Surgery is always done under general anesthesia. A saw is used to remove the skull bones and the brain is exposed. The tumor is then localized and delicately removed. All precautions are undertaken to prevent injury to nearby structures. Once the tumor is removed, the skull bone is replaced with a wire. Brain surgery is tedious and recovery is always long. In the majority of individuals, there are always some neural complication(s) because of injury either from the tumor or from the surgery. Radiation: In many cases, radiation is added to surgery to destroy the residual tumor. Radiation therapy is now advanced and can be directed at the tumor selectively. However, some of the brain structures are very sensitive to radiation. The area of the brain which makes hormones is often damaged by radiation therapy. In addition, radiation therapy to the brain can result in loss of concentration, memory loss and poor cognition. Chemotherapy: Frequently, very toxic drugs are given to kill the brain cancer cells. However, these chemicals have a number of side effects and many individuals are unable to tolerate the drugs. To treat brain cancers, a combination of therapies is used. Some brain cancers respond to this combination therapy and some do not. Those cancers which do respond to therapy often disappear for years and may not recur. However, most brain cancers have a habit of coming back and strict follow up is required. Periodic CT scan or MRI are a part of follow up therapy.
Rehabilitation after brain cancer treatment is a very important component of overall treatment. Because the cancer or the treatment significantly affects some part of the body (loss of speech, swallowing, movement, balance, vision, etc), it is extremely important to undergo therapy to regain the lost senses and develop alternate methods of coping. In some cases there may be complete loss of brain function, but with time and patience some recovery may be possible. The types of rehabilitative therapy that are usually offered include: Cognitive rehabilitation can help you cope with or regain lost cognitive abilities. Physical therapy can help you regain lost motor skills or muscle strength. Vocational therapy helps one get back to work or resume the daily living activities. Speech therapy: when speech is affected, intense speech therapy is required for maximum recovery. These therapies are extremely useful in children with brain tumors. Children have a great capacity to regain a lot of their brain function and thus rehabilitative therapy should be started as soon as treatment is completed.
The abysmal results of the last two decades have led to a lot of research and newer therapies to treat brain cancer in a more exact way. The newer advances include: Stereotactic localization: with this technique an MRI maps out the exact location of the tumor and then lasers are used in a more precise way to destroy the cancer. This technique limits injury to surrounding normal tissue and is better tolerated by the patient. Stereotactic radio surgery: This treatment utilizes radiation beams guided in a precise way to the tumor. Called Gamma knife stereotactic radio surgery, the beams are precisely sent to a tumor after the tumor has been exactly localized. Drug-delivering implants: In the last decade, the major impediment to treatment of brain cancers was delivery of drugs specifically to the brain. Todate, advances in technology have allowed for biodegradable wafers containing cancer-fighting drugs which are implanted in the brain during surgery. Gene therapy: This futuristic therapy has been touted to cure everything that affects man. So far, the therapy is still in its infancy and judging by the complications that are associated with it, we are still some years away from this treatment.
Because of the failure of many past treatments, newer clinical trails are now being conducted to determine which treatments are of any benefit. In the last decade numerous drugs have been discovered and numerous combinations of drugs and radiation are presently being evaluated to test their efficacy.
Having any type of tumor is distressing and has a certain emotional toil. A diagnosis of cancer can be overwhelming and very frightening. One should seek help from family, friend and numerous support groups are available. The best way to cope with a diagnosis of brain cancer is know about it so that one can understand and receive the best care.
Complementary and alternative medicine
Because of the failure of conventional medicine to produce good results, many individuals have been seeking health care from alternative healers. These have ranged from taking herbs, nutrients, and even added other complimentary techniques like meditation, yoga, imagery, prayer, massage, relaxation and humor. Many of these alternative care treatments have been available for centuries and in some cultures they are the first treatment of choice. However, scientific assessment of safety, efficacy and mode of action is fragmented or scant for most of these therapies. The major available alternative medicine components are: • Alternative care which includes traditional oriental medicine and homeopathy • Mind-body interventions: yoga, meditation, prayer, imagery, relaxation • Biological therapy: herbs, mistletoe, mushrooms, mega dose vitamins, enzyme therapy, botanicals, nutrients, Saint John’s wort, Ginkgo biloba, Panax Ginseng, Allium sativum (garlic), Piper methysticum (kava) • Manipulative therapy: massage, accupress, acupuncture, manipulation, chiropractic, yoga • Energy Therapies: QiGong, Reiki, Therapeutic touch, distant healing These alternative therapies are the current fads and are a billion dollar business. Many patients are not satisfied by the lack of instant results of conventional medicine and have turned to alternative care in increasing numbers. Each and every one of these therapies offers hope (mostly false) that the cancer will be destroyed by providing a boost to the immune system and that all the pain and side effects will disappear. Every type of diet and nutrient has been recommended as a cure for brain cancer. Some of these include daily consumption of: Whole gran fibers, fruits vegetables and dietary supplements. Mega doses of vitamins AC and E are recommended as a cure for everything. Specialized diets: there are numerous special liquid and solid diets which are purported to improve cancer survival. Most of these specialized diets are dangerous, ineffective and considered sham.
Because there is no scientific data to back up these therapies, one should be cautious. Each and every one of these therapies is expensive and there are lots of stories where desperately ill patients have lost their entire life savings in search for the miracle cure. Talk to your doctor before embarking on any alternative care. Unfortunately, the field of medicine is full of charlatans who take advantage of the ill and week, by making false promises. So be informative and whenever in doubt, seek a second opinion.