Brain Cancer (Gliomas)

Glioma is a tumour that occurs in the brain and spinal cord. Gliomas originate from the glial cells which are the supportive cells that surround nerve cells. 

TYPES OF BRAIN CANCER

• Gliomas maybe classified based on the cell of origin: Gliomas originate from glial cells. The glial cells surround neurons (nerve cells) and provide support as well as insulation between them. Glial cells are the most abundant cell types in the central nervous system. Three types of glial cells can produce tumours:

  • Astrocytomas: These begin in cells called astrocytes. Subtypes of astrocytomas include astrocytoma, anaplastic astrocytoma and glioblastoma. 
  • Ependymomas: Ependymomas begin in the ependymal cells found in the brain and spinal cord. These are present in the passageways through which passes a fluid called cerebrospinal fluid. Subtypes include anaplastic ependymoma, myxopapillary ependymoma and subependymoma.
  • Oligodendrogliomas: Oligodendroglioma forms from oligodendrocytes, which are cells in the brain and spinal cord which produce a substance that protects the nerve cells. Subtypes include oligodendroglioma, anaplastic oligodendroglioma and anaplastic oligoastrocytoma.

GRADE BASED CLASSIFICATION OF TUMOURS

The classification of gliomas has a scale which ranges from 1 to 4. The grade reflects the aggressiveness of the tumour. Grade 1 tumours occur mainly in children and tend to have the best prognosis. Grade 2 tumours or low-grade gliomas represent slow-growing tumours which have an intermediate prognosis. Grade 3 or anaplastic tumours and Grade 4 tumours (glioblastoma) are considered high-grade gliomas as they tend to be more aggressive and have the least favourable prognosis. ​

Sources: Mayo Clinic; European Society of Medical Oncology (ESMO)

DIAGNOSTIC TESTS FOR BRAIN CANCER / GLIOMAS

• • Clinical history and examination: A clinician will ask for symptoms such as headache, nausea or vomiting, confusion, a decline in brain function, loss of memory, personality changes, problems with vision, speech difficulties and seizures. During a neurological exam, a doctor examines the patient’s vision, hearing, balance and reflexes.
  • Radiological tests: Magnetic resonance imaging (MRI) - It is often used to help diagnose brain tumours and sometimes uses a dye injected through a vein to better analyse the tumour. There are a number of specialized MRI scans such as functional MRI, perfusion MRI and magnetic resonance spectroscopy that may be performed as well. CT scan- This radiological test is often the first test performed when a brain tumour is suspected. Positron emission tomography (PET) - It is used to test for the spread of cancer to other parts of the body.
  • Biopsy: A sample of tissue is collected to be analysed in the laboratory. Depending on the location of the tumour, the sample may be acquired using a fine needle or as part of an operation to remove the tumour. For tumours that are hard to reach or in sensitive areas of the brain, a stereotactic needle biopsy may be done by drilling a small hole through the skull under CT or MRI guidance, and a thin needle is then inserted to remove the sample. The pathologist examines the physical appearance and growth rate of the tumour and tumour cells.
  • Molecular markers: Cancer comes about due to genetic mutations. There are various genetic and chemical molecules that can help the clinical team choose the right path to treat the glioma, which are known as molecular markers. These may include genetic loss on chromosomes or mutations of specific genes. These markers can help predict the rate of growth and spread of the disease as well as are targets for targeted treatments and are collected and assayed using fluids like blood, serum or the cerebrospinal fluid that surrounds the brain and spinal cord. These are conducted by pathologists or by genetic experts.

TREATMENT OF BRAIN CANCER (GLIOMAS)

The management of cancer depends on various factors, including the stage of the cancer, additional health issues, age etc. Surgery, radiation or chemotherapy may be used.

• • Surgery: Surgical removal has been shown to result in better survival rates. However, in patients in whom radical surgery is expected to lead to loss of neurological function, it is aimed just at removing as much tumour as is safely possible. The tissue removed is usually sent for histopathological and molecular analysis of the tumour. Side effects: Seizures, bleeding, neurological deficits (removal of normal brain tissue leading to side effects), infections, leakage of cerebrospinal fluid (specialised fluid around the brain and spinal cord).
  • Stereotactic and open biopsy: It is performed in patients in whom surgery is not safe due to the tumour location. It may be in an inaccessible region or a region that carries a high-risk damage to critical nervous tissue. A stereotactic biopsy using a CT or MRI is a less invasive way to obtain the tumour sample and an open biopsy is a form of surgery that uses local or general anaesthesia to remove the tissue required for laboratory diagnosis of cancer.
  • Radiotherapy: Radiation uses high-energy beams to kill tumour cells and is administered from a machine outside the body (or external beam radiation). Post-operative radiotherapy is a standard of care for low-grade gliomas and is administered over a number of sessions extending over a couple of weeks. Post-operative radiotherapy is especially considered in the presence of factors which suggest a higher likelihood of tumour recurrence such as tumours larger than 5 cm, patient age over 40 years, depending on the extent and tumour cell characteristic etc. This is also known as Whole brain radiotherapy and affects both the tumour cells and normal nerve cells. Stereotactic radiation therapy is a minimally invasive approach to the treatment of brain tumours. This form of therapy uses thin beams of radiation to destroy only the tumour cells. It requires specialised imaging techniques and computerized planning to precisely focus a high dose of radiation on the brain tumour, while sparing normal tissue. It is associated with lesser side effects than ‘whole brain radiotherapy’. Side effects: Common side effects include fatigue, headaches, scalp irritation, seizures, nausea, and drowsiness.
  • Chemotherapy: Chemotherapy uses drugs to kill tumour cells that may be taken orally or injected into a vein. It is commonly used in combination with radiation therapy to treat gliomas. Side effects: The side effects depend on the type and dose of drugs received. Common side effects include nausea and vomiting, headache, hair loss, fever, and weakness. Some side effects may be managed with medication.
  • Targeted drug therapy: Targeted drug treatments block specific pathways in cancer cells leading to their death. Targeted drug therapy stops the formation of new blood vessels, cutting off blood supply to a tumour and leading to the death of the tumour cells. The medical oncologist will advise the patient regarding the best agent depending on specific patient and tumour characteristics.
  • Alternating Electric Field Therapy: This therapy is sometimes used for brain and spinal cord tumours. Research has suggested that exposing some types of tumour cells to alternating electric fields can interfere with the cells’ ability to grow and spread. These fields are created by a portable device. Side effects: Side effects of the device tend to be minor, and can include skin irritation at the electrode sites, trouble sleeping, mood changes, and a slightly increased risk of headaches and seizures.

Sources: Mayo Clinic; European Society of Medical Oncology (ESMO); Texas Oncology; American Cancer Society

MULTI-DISCIPLINARY TEAM (MDT): Unlike most other diseases, cancer treatment requires an integrated approach from several specialists, each with their own expertise. This team of specialists who would work together on your cancer, is referred to as the Multi-Disciplinary Team (MDT). Many global organisations have recognized the importance of a MDT for cancer treatment, as it improves coordinated care to you, as a patient. Your MDT would include specialists from the following:

• • Medical Oncologist: Specialist that decides the optimum course and agent for chemotherapy
  • Neurosurgeon: A surgeon specialised in operating on conditions related to the brain and spinal cord
  • Neurologist: A medical specialist who is the first point of contact for many patients with brain tumours
  • Radiation Oncologist: Specialist that decides the optimum course and agent for radiotherapy
  • Radiologist: A specialist who interprets MRI, X-rays and CT scans
  • Pathologist: A specialist who studies tissues under the microscope and provides insights regarding cancer cells that help decide treatment
  • Palliative care specialists: Helps patients deal with the physical and psychological symptoms involved with the diagnosis and management of cancer.

Some hospitals that take an organ-based approach to cancer, have a separate department for Central Nervous System (CNS) cancers. These teams comprise of specialists who have dedicated training in cancers occurring in the brain and spinal cord.

TUMOR BOARD: A tumor board is a meeting where a Multi-Disciplinary Team discusses cancer cases and share knowledge. The board’s goal is to determine the best possible cancer treatment and care plan for an individual patient. Having fresh perspectives from other doctors makes it much easier to come up with that plan.

In some hospitals, all cancer cases are discussed at the Tumor Board, while in other hospitals the Tumor Board focuses on cases where a doctor seeks inputs from other specialists on the patient's case. It’s OK to ask your doctor if or why your case was discussed at a tumor board. Or if it wasn’t, why not? In some cases, a patient’s treatment plan is very straightforward using standard treatment guidelines, and the doctor may feel a tumor board review isn’t needed. However, you can request that one be done.

SUPPORT GROUPS: These are offline or online groups that connect patients suffering from cancer. Do find out about a support group around you. The hospital where you are being treated may have a support group that you could join.

Sources:  Mayo Clinic

Choosing your oncologist and hospital is a very important decision, we recommend you make the time to research your options. We profile doctors and hospitals based on their range of services to treat brain cancer. Use our search tools to find a suitable medical provider. You may get in touch with us for any assistance during selection or booking process.  

If you’ve been diagnosed with cancer, you need to find an oncologist to begin your treatment. An oncologist is a doctor who specializes in treating cancer. For brain cancer / Gliomas, you can start by visiting a neurologist or neurosurgeon. Choose someone you are not only confident about but also comfortable with.

TIPS TO FIND AN ONCOLOGIST 

1. 1. Look for Specialists: Look for doctors who treat your specific type of cancer - brain cancer. You may need to work with more than one type of oncologists – surgical, medical or radiation oncologists.
   2. Gather Feedback: Discuss with friends and family, especially those who’ve taken similar treatment before. Online communities are a quick way to get feedback from others who’ve experienced your type of cancer before.
   3. Check the doctor’s credentials: Find out if the doctor has received any advanced training. There may be super-specialists available for Central Nervous System (CNS) cancers, who have received dedicated training on treating brain and spinal cord cancer. If doctor’s credentials are not available easily, you have the right to ask for it from the doctor directly.
   4. Review doctor’s experience: Check how long the doctor has been practicing after completion of formal oncology education. How many patients with your type of cancer – brain cancer – does the doctor see every year? In case of surgeons, studies have proven that higher volumes of surgeries lead to better outcomes.
   5. Find out hospital affiliations: Which hospitals does the doctor practice in? The availability of a multiple types of doctors at the hospital where you get treated is important. Find out what support staff is available at the hospital e.g. dietitian, counselor, home healthcare facilities etc.

TIPS TO FIND A HOSPITAL 

1. 1. Lookout for hospitals with lot of experts: Look for hospitals that offer a multi-disciplinary approach to brain cancer treatment. This means each you receive inputs from many cancer experts. You will be helped by specialists including surgeons, medical oncologists, radiation oncologists, oncology nurses and other supporting staff. Find out if the hospital has a dedicated team for CNS cancers? Does the hospital have Tumor Board reviews – how often are they conducted and will your case be discussed there if you wish?
   2. Work with a major cancer hospital, even if it is far: Most experts in high-volume centers are willing to work with your local doctors. Usually, part of the treatment (for example, surgery) can be executed in the major center and the post-surgery treatment is executed locally.
   3. Research hospital’s CNS Cancer volumes: How many cases of brain cancer are treated in the hospital every year? High volume centers with multiple specialists available for CNS cancers may have better expertise and specialized medical infrastructure required.
   4. Consider Clinical Trials Availability: Ask whether the doctor or hospital has access to clinical trials and if you are eligible for any. Clinical trials are research studies that test new ways to treat cancer that you can be involved with. By being involved, you can help improve treatments and outcomes for future patients.
   5. Insurance Acceptance: Check if the hospital accepts your insurance. Check if the hospital has a desk that can assist you with claims.

Sources: Rogel Cancer Center; Cancer.Net