Treatment for brain cancer

Surgery in the brain or spinal cord is called neurosurgery. You may have surgery to:

• remove the whole tumour (total resection)
• remove part of the tumour (partial resection or debulking)
• help diagnose a brain tumour (biopsy).

Removing part of the tumour may be considered when the tumour covers a wider area or is near major blood vessels or other important parts of the brain or spinal cord. This may help reduce the pressure on your brain, which will improve some of the symptoms.

When surgery is not possible

Sometimes a tumour cannot be safely removed because it is too close to certain parts of the brain and surgery would cause blindness, speech problems or partial paralysis. This is called an inoperable or unresectable tumour.

Your doctor will talk to you about what other treatments you can have and ways to manage symptoms.

What to expect before surgery

The different scans used to diagnose a brain tumour (such as MRI or CT scans) are often done again to help plan surgery.

To help the surgeon avoid damaging the most important areas of the brain, you may have a type of MRI scan called a functional MRI (fMRI). You will be asked to complete brain exercises during the scan to show the exact areas of the brain that are used as you speak or move. These parts of the brain can also be found during surgery with brain mapping.

Tell your doctor about any blood-thinning or other medicines you are taking. Some medicines interfere with the anaesthetic used  during  the operation, so you may need to stop taking them for a while.

If you smoke, it is important to stop before surgery. Continuing to smoke can increase the risk of complications.

Having surgery to the brain can sound frightening and it is natural to feel anxious beforehand. Talk to your treatment team about your concerns or call Cancer Council 13 11 20 for support.

Types of surgery

Different types of operations may be used to remove brain and spinal cord tumours.

Removing a brain tumour (craniotomy) – This is the most common type of brain tumour operation. A craniotomy removes all or part of the tumour (total or partial resection) and may be done while you are asleep under general anaesthetic.

The surgeon cuts an area of bone from your skull to access the brain and cut out the tumour. The bone is then put back. The surgeon will insert small plates and screws to hold the piece of skull in place.

If you have a high-grade glioma, you may be given a solution to drink before surgery that makes the tumour glow under a special blue light. This may help the surgeon remove as much of the tumour as possible, while avoiding normal brain tissue.

Awake craniotomy – This operation may be recommended if the tumour is near parts of the brain that control speech or movement. All or part of the operation is done while you are awake (conscious) but relaxed, so you can speak, move and respond.

The surgeon asks you to speak or move parts of your body to identify and avoid damaging those parts of the brain. An electrode is also placed on the outside layer of the brain to stimulate and pinpoint important areas of the brain (known as brain mapping).

You may be worried that an awake craniotomy will be painful, but the brain itself does not feel pain and local anaesthetic is used to numb surrounding tissues.

Computer-guided surgery

It is now usual for a craniotomy to be done using a computer system to guide the surgeon. This is known as stereotactic surgery.

The computer uses the results of planning scans to create three‑dimensional images of the brain and tumour.

During the operation, the computer monitors the position of the surgical instruments, allowing the surgeon to be very precise.

Stereotactic surgery is safer, more accurate and requires a smaller cut in the skull than non-computer-guided surgery

Removing a pituitary tumour (endoscopic transsphenoidal surgery) – The most common surgery for tumours near the base of the brain (e.g. pituitary gland tumours) is called endoscopic transsphenoidal surgery. To remove the tumour, the surgeon inserts a long, thin tube with a light and camera (endoscope) through the nose and into the skull at the base of the brain. An ear, nose and throat (ENT) surgeon may assist with this type of surgery. You will be given a general anaesthetic for this operation.

Removing a spinal cord tumour (laminectomy) – The most common surgery for spinal cord tumours is called a laminectomy. In this procedure, the surgeon makes an opening through the skin, muscle and a vertebra in the spinal column to remove the tumour. A laminectomy is usually performed under general anaesthetic.

What to expect after surgery

You will be closely monitored for the first 12–24 hours after the operation. For the first day or two, you will be in the intensive care or high dependency unit. You may stay in hospital for 3–10 days. How long you stay in hospital will depend on whether you have any problems or side effects following surgery.

Checks and observations – Nurses will regularly check your breathing, blood pressure, pulse, temperature, pupil size, and arm and leg strength  and function. You will also be asked questions to assess your level of consciousness. These are called neurological observations. They check how your brain and body are recovering from surgery.

Spinal cord checks – If you have had an operation on your spinal cord, the nurses will regularly check the movement and sensation in your arms and legs. You may need to lie flat in bed for 2–5 days to allow the wound to heal. A physiotherapist will help you learn how to roll over and how to get out of bed safely, so the wound is not damaged.

Pressure stockings – You will need to wear pressure stockings on your legs to prevent blood clots from forming while you are recovering from surgery. Tell your doctor or nurse if you have pain or swelling in your legs or suddenly have difficulty breathing.

Rehabilitation – The surgery may cause a range of short-term or longer-term side effects. Before you can return home, you may need further treatment known as rehabilitation to help you regain your mobility and get back to your daily activities.

Bandages and bruising – The wound will be covered with a dressing, which may vary from a small adhesive pad to bandaging that covers your  head. Some or all of your head may have been shaved. After surgery to some parts of the head, your face and eyes may be swollen or bruised: this is normal. It is not usually painful and should ease in about a week.

Having a shunt – A build-up of cerebrospinal fluid in the brain is called hydrocephalus. It may be caused by the tumour or it can happen after surgery. To drain the extra fluid, you may have a temporary or permanent shunt (a long thin tube placed into your brain). For a temporary shunt (called an external ventricular drain), the tube drains fluid into a bag on the outside of the body. For a permanent shunt, the tube is inserted completely inside your body. It drains into your abdomen and the fluid is absorbed into your bloodstream.

Headaches and nausea – You may have a headache or nausea after the operation. Both can be treated with medicines.

Side effects of surgery

Infection – Although the risk is small, you may develop an infection at the wound site. This can usually be treated with antibiotics. A small number of people may need surgery to have the wound cleaned out.

Bleeding – This is a rare but serious side effect. You’ll have a CT or MRI scan the day after surgery to check for any bleeding or swelling.

Swelling – Surgery can cause swelling in the brain, which increases the pressure inside the skull (intracranial pressure). Your medical team will monitor the swelling and try to reduce it with medicines.

Other side effects – You may continue to feel confused and dizzy, and have speech problems, weakness in parts of the body and seizures. You and your family or carers may be surprised that you may feel worse than before the surgery and worry that you aren’t recovering well. These side effects are normal and often improve with time.

In some cases, people recover fully and can gradually return to their usual activities. In other cases, the tumour position or damage to surrounding brain tissue may mean that there are longer-term changes to how you speak, move and think.

Rehabilitation after surgery

A range of therapies can help speed up your recovery or show you ways to manage any longer-term changes. These therapies are known as rehabilitation. At first, you may have some rehabilitation therapies in the hospital or a rehabilitation facility. Once you return home, you can continue to have these therapies as an outpatient. You may also be given equipment to use at home.

Download our booklet ‘Understanding Surgery’

Also known as radiotherapy, radiation therapy uses a controlled dose of radiation to kill or damage tumour cells in the area being treated. The radiation is usually in the form of x-ray beams.

For gliomas, radiation therapy is typically given after surgery, possibly along with chemotherapy (chemoradiation). Before you start radiation therapy, a radiation therapist will take measurements of your body and do a CT and/or MRI scan to work out the precise area to be treated.

Treatment is carefully planned to do as little harm as possible to the healthy brain tissue near the tumour. Radiation therapy itself is painless, though you may experience some side effects. Your treatment team will discuss these with you before you begin treatment.

If you are having radiation therapy for a brain tumour, you will probably need to wear a special plastic mask over your face. If you are having radiation therapy for a spinal cord tumour, some small marks may be tattooed on your skin to show the treatment area.

How often you have radiation therapy (the treatment course) will depend on the size and type of tumour. Usually it is given once a day, from Monday to Friday, for several weeks. During treatment, you will lie on a table under a machine called a linear accelerator (LINAC). Most machines use imaging scans to check you are in the correct position for treatment. Each daily treatment will last for about 10–15 minutes.

For glioblastomas (grade 4 cancers), radiation therapy is usually combined with chemotherapy. This is called chemoradiation. The chemotherapy drugs make the cancer cells more sensitive to radiation therapy.

Stereotactic radiosurgery (SRS)

Stereotactic radiosurgery (SRS) is a specialised type of radiation therapy, not a type of surgery, and no cuts are made in the skull.

A specialised radiation machine is used to give very precisely targeted radiation to the tumour. Machine types include LINAC, GammaKnife and CyberKnife. They deliver a high dose of radiation to the tumour while the surrounding healthy brain tissue receives very little.

SRS is not suitable for all types of brain tumours. It may be offered when neurosurgery is not possible or as an alternative to neurosurgery. It is most commonly used for cancers that have spread to the brain from another part of the body. It is also used for some meningiomas, pituitary tumours and schwannomas, and is occasionally used for gliomas that have come back after other treatment.

Often, only 1–5 doses of SRS are needed. A treatment session may last between 15 minutes and two hours, depending on the type of radiosurgery given. You will need to wear a special mask or frame during the treatment. You will usually be able to go home afterwards.

Stereotactic radiation therapy (SRT)

A stereotactic radiosurgery machine may also be used to deliver a longer course of radiation, particularly for benign brain tumours. This is called stereotactic radiation therapy. The treatment is given as multiple small daily doses.

Wearing an immobilisation mask

You’ll need to wear a plastic mask during radiation therapy to the brain. This is known as an immobilisation mask. It will help keep your head still and make sure the radiation is targeted at the same area during each session. The mask is made to fit you. It is fixed to the table while the treatment is delivered.

The mask is made of a tight-fitting mesh, but you will wear it for only about 10 minutes at a time. You can see, speak and breathe through the mask, but it may feel strange and confined at first. Tell the radiation therapists if wearing the mask makes you feel anxious. With the support of the  radiation therapy team, many people find that they get used to wearing the mask. The team may suggest you try breathing or relaxation exercises, or you may be offered medicine to help you relax.

Click on image to enlarge

Proton therapy

This uses protons rather than x-ray beams. Protons are tiny parts of atoms with a positive charge. Proton therapy is useful for some types of brain and spinal cord tumours, and tumours near sensitive areas. It is not yet available in Australia (as at mid 2022), but there is funding in special cases to allow Australians to travel overseas for treatment.

Side effects of radiation therapy

Radiation therapy side effects generally occur in the treatment area. They are usually temporary, but some may last for a few months or years, or be permanent. The side effects vary depending on whether the tumour is in the brain or spinal cord. They may include:

• nausea – can occur several hours after treatment
• headaches – can occur during the course of treatment
• tiredness or fatigue – worse at the end of the treatment course; can continue to build after treatment, but usually improves over a month or so
• dry, itchy, red, sore or flaky skin – may occur in the treatment area; usually happens at the end of the treatment course and lasts 1–2 weeks before going away
• hair loss – may occur in a patch in the area of the head receiving treatment; usually temporary but in some cases permanent; if hair grows back, the texture or colour may be different
• dulled hearing – may occur if fluid builds up in the middle ear and may be permanent.

Radiation therapy side effects specific for spinal cord tumours include swallowing problems (dysphagia) if the neck is treated and diarrhoea if the lower spine is treated. Both are temporary.

If any side effects develop, talk to your radiation oncology team. They can suggest ways to manage them.

A small number of adults who have had radiation therapy to the brain have side effects that appear months or years after treatment. These are called late effects and can include symptoms such as poor memory, confusion and headaches. The problems that might develop depend on the part of the brain that was treated.

High-dose radiation to the pituitary gland can cause it to produce too little of some hormones. This can affect body temperature, growth, sleep, weight and appetite. The hormone levels in your pituitary gland will be monitored during and after treatment.

Download our booklet ‘Understanding Radiation Therapy’

Chemotherapy uses drugs to kill or slow the growth of cancer cells. The aim is to destroy cancer cells while causing the least possible damage to healthy cells.

You may have chemotherapy after surgery or radiation therapy. Chemotherapy may also be combined with radiation therapy (chemoradiation). You may be given chemotherapy as capsules or tablets that you swallow (orally), or as a liquid through a drip inserted into your vein (intravenously).

The brain has a structure known as the blood–brain barrier, which helps protect the brain from substances in the blood, such as germs or chemicals, that may injure the brain. Only certain types of chemotherapy drugs can get through this barrier.

Temozolomide is the most commonly prescribed chemotherapy drug for the treatment of glioma brain tumours. It is given as a capsule you take at home for five days in a row, followed by a rest period of a few weeks. This is called a cycle and each cycle lasts for 28 days. You are likely to have 6–12 cycles of temozolomide, though it may continue for longer.

Side effects of chemotherapy

There are many possible side effects of chemotherapy, depending on the type of drugs you are given. Talk to your doctor about ways to reduce or manage any side effects you have. Side effects are mostly mild with temozolomide and may include:

• nausea or vomiting
• tiredness, fatigue and lack of energy
• increased risk of infection
• mouth sores and ulcers
• diarrhoea or constipation
• loss of appetite
• skin rash
• liver damage
• damage to ovaries or testicles, which can make you unable to have children naturally (infertile)
• breathlessness due to low levels of red blood cells (anaemia)
• low levels of platelets (thrombocytopenia), increasing the risk of abnormal bleeding
• reduction in the production of blood cells in the bone marrow; you will usually have regular blood tests to monitor your blood levels.

It is rare to lose all your hair with the chemotherapy drugs used for brain and spinal cord tumours, although in some cases your hair may become thinner or patchy.

Download our booklet ‘Understanding Chemotherapy’

Steroids (also known as corticosteroids) are made naturally in the body, but they can also be produced artificially and used as drugs. Brain tumours and their treatments can both lead to swelling in the brain. Steroids may help to reduce this swelling. They can be given before, during and after surgery and radiation therapy. The most commonly used steroid for people with brain tumours is dexamethasone. It is usually given as a tablet.

Side effects of steroids

The side effects of steroids depend on the dose and length of treatment:

Short-term use – If you are prescribed steroids for a short period, you may experience increased appetite, weight gain, trouble sleeping, restlessness, mood swings, anxiety and, in rare cases, more serious changes to thinking and behaviour. In people who have diabetes, steroids can quickly lead to high or unstable blood sugar levels. These short-term side effects can be managed. Eating before taking steroids can reduce the chance of the steroids irritating your stomach.

Longer-term use – If steroids are taken for several months, they can cause puffy skin (fluid retention or oedema) in the feet, hands or face; high blood pressure; weight gain; unstable blood sugar levels; diabetes; muscle weakness; and loss of bone density (osteoporosis). You will also be more likely to get infections. Your doctor may change your dose to manage any side effects you have. Most side effects will go away when treatment is over.

An experienced counsellor, psychologist or psychiatrist can help you manage any mood swings or behavioural changes. If you or your family are worried about side effects, talk to your doctor or nurse or call Cancer Council 13 11 20.

Palliative treatment helps to improve people’s quality of life by managing the symptoms of cancer without trying to cure the disease. Many people think that palliative treatment is only for people at the end of their life, but it may help at any stage of advanced cancer.

As well as slowing the spread of cancer, palliative treatment can relieve pain and help manage other symptoms. Treatment may include surgery,  radiation therapy, chemotherapy or other medicines or supplements.

Palliative treatment is one aspect of palliative care, in which a team of health professionals aims to meet your physical, emotional, cultural, spiritual and social needs. You can have palliative care services in the home as well as in a hospital or in residential care.

Download our booklet ‘Understanding Palliative Care’

Download our booklet ‘Living with Advanced Cancer’