 December 11, 2001 |
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Brain Tumor Survival Guide5. After surgery, then what?A. Maybe you are cured. Do you need follow-up?Some brain tumors can be cured by surgery. These include acoustic neurinomas, many meningiomas, pituitary adenomas, pinealomas, pilocytic astrocytomas and some others. Nonetheless, you should go for MRI scans every 3-6 months for the first year following surgery and every 1-2 years thereafter to be sure that the tumor is not coming back. Until we know what causes brain tumors in the first place, I wouldn't breathe a sigh of relief when a surgeon tells you "I got it all out, it was benign and you're cured". He or she may believe that and may ultimately prove to be correct. But what if he or she is wrong? Always remember that it is easier and safer to remove a small tumnor than a large one. If your tumor is destined to recur, it would be best if you find this out as soon as possible. B. If you need adjuvant treatment; find an experienced neuro-oncologist and/or radiation oncologist. A radiation oncologist administers radiation therapy. A neuro-oncologist prescribes chemotherapy. A common question:"which is best for treatment of a brain tumor; radiation therapy, chemotherapy or both?" This will depend on the actual type of tumor you have (which is why correct pathology is so important). But even then it's controversial. Nonetheless, you need an experienced physician to guide you. There are many radiation oncologists and many oncologists in the United States. In fact, every medical center has them. Many medical centers also have "excellent equipment". But you have to be careful. What you want is a radiation oncologist with experience in the treatment of brain tumors. And, in many cases a general oncologist will not be as knowledgeable as a neuro-oncologist when it comes to the treatment of brain tumors. A general oncologist treats all types of cancers but many have a limited experience in brain tumors. Neuro-oncologists are neurologists with special expertise in the treatment of brain tumors. They understand and can deal with the neurologic problems that brain tumor patients can have as they undergo a course of treatment Radiation Therapy Many people have questions about radiosurgery(which is also being marketed heavily). Most brain tumors are not really candidates for radiosurgery. Radiosurgery, delivered by the Gamma Knife or a stereotactic LINAC, is best for relatively small circumscribed tumors. Circumscribed means that the boundaries between the tumor and surrounding brain are definite and sharp. Many patients with metastatic tumors are good candidates for radiosurgery. However, the majority of patients with gliomas (glioblastoma, oligodendroglioma, astrocytoma, mixed glioma) are not. These are infiltrating lesions. That means that tumor cells coexist with intact brain tissue. Killing tumor cells with radiosurgery, also kills the brain tissue in which the tumor cells reside. In addition, these tumor cells can be found far beyond the CT and MRI-defined abnormalities on which targeting for radiosurgery is based. Unlike radiosurgery, standard radiation therapy is given not in one single treatment - like radiosurgery- but rather in daily treatments given usually over a six week period in "fractions": part of the total dose given every day 5 days a week for six weeks. There are some new twists such as "conformal" radiation therapy in which the radiation dose is better focused on the MRI or CT-defined abnormality, or fractionated "stereotactic radiosurgery" where the patient's head is fitted in a relocatable brace for each fraction of a course of radiation therapy. There is no evidence as yet that any of these new twists are any better than standard radiation therapy in prolonging the survival of patients with brain tumors. Nonetheless, they sound good, in theory. So if you have radiation therapy, where should you have it? Well, radiation therapy is delivered by a linear accelerator (LINAC). Radiation energy is transmitted by small units of electromagnetic radiation called photons. And photons in Los Angeles, California are no different than photons in Elmira, New York. And the equipment used to deliver those photons is most likely identical. The only difference is the person doing the radiation therapy plan and supervising the therapy. Here you want someone who knows what he or she is doing. You don't want the person who has more experience with, say, the radiation therapy of uterine cancer, treating a brain tumor You want someone with considerable experience with the radiation therapy for brain tumors. In general these people are at large centers that do a lot of brain tumor surgery. Chemotherapy and Protocols If your tumor is the type that is not cured by surgery you will need additional treatment along with close follow-up. This is where things really get confusing. There are many different experimental protocols to treat brain tumors in North America. These feature radiation therapy, perhaps a radiosurgical boost and many varieties of chemotherapy. Which is best? You will soon discover that for any given tumor there will be many different ways to treat it and the "best" will depend on who you talk to and what that institution is doing for that tumor at that time. It will depend on what "protocol" they select. Protocol? That means "experimental". They are placing patients on one type of therapy and comparing how these patients do with some other type of therapy. What do we mean by how these patients "do"? There are only three things the doctors look for: toxicity (side effects and damage) from the treatment, time to recurrence (how long does it take the tumor to come back) and survival (how long do you live on this treatment). Many will also record quality of life measures such as the Karnofsky scale. The goal is to find an effective and safe treatment that will help future patients. If you get lucky there is a chance that the new treatment being studied in the protocol may also help you. Nonetheless, many protocols are pushed by institutions and doctors when there is no scientific evidence that their treatment is significantly better than any of the others. Protocols are now hyped on the internet or in newspapers such as USAToday. In fact, this is basically marketing. Let's face it. If any of these hundreds of different treatments were proven to be significantly better than any of the others, wouldn't everybody be doing it? Wouldn't there be just one treatment regimen instead of many? Fortunately, many academic medical centers are working together in a multicenter group effort trying to find the "best" treatment. |
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