Can you imagine learning that you have a brain tumor — and then having your doctor suggest that the best course of treatment may be to just leave it there? Is learning that only half of these turn out to be malignant enough to help you feel comfortable?
I’m not just posing an academic question. An estimated 11,000 American adults learn that they have noncancerous brain tumors each year, and, in many cases, doctors believe that it may be safer to leave them intact than to remove all or part of them.
Researchers report that this happens more often nowadays. Tumors are increasingly being flagged as “incidental findings” when imaging tests such as MRI and CT scans are done to track down other problems (for instance, to determine whether a seemingly minor head injury has caused concussion). About 2% of the time, the scan that answers one pressing question ends up posing another: What to do about this brain tumor you didn’t know you had?
It’s hard, on the one hand, to imagine a more frightening prospect than undergoing brain surgery. On the other hand, though, the idea of taking a “wait and see” approach to treatment of a brain tumor is equally discomfiting. I’m not sure how I’d feel in such a situation, so I called Keith Black, MD, chairman of the department of neurosurgery and director of the Maxine Dunitz Neurosurgical Institute at Cedars-Sinai Medical Center in Los Angeles. His take:Wait-and-see is a valid option — but you have to understand the pros and cons before you make that decision.
Acknowledging that this can be a tough call emotionally, Dr. Black presented the rationale behind it. The types of brain tumors found this way often are benign, primary tumors — and, contrary to what the name suggests, that’s statistically a far more promising diagnosis than a secondary tumor. Secondary tumors are so-called because they originate from cancer elsewhere in the body (for instance, the breast, colon or lungs) that has spread to the brain. An estimated 100,000 secondary tumors are diagnosed in adults in the US each year, and they’re always malignant. Primary tumors of the brain, on the other hand, are far less common — about 22,000 are identified in the US each year, and typically only half are malignant.
The most common benign brain tumors are meningiomas, which originate in the brain’s protective covering… pituitary tumors, which grow out of the pituitary gland… and neuromas, arising from the nerves exiting or entering the brain. Tumors can affect other cells in the brain, as well, but they’re rare compared with these three.
According to Dr. Black, it’s actually a good thing to discover a brain tumor accidentally. “If we can intervene when the tumor is small, the risk of having a complication from the treatment is lower,” he said.
Dr. Black said that there are three basic treatment options for patients with benign primary brain tumors. From the least to the most involved, these are…
Wait and see.A valid treatment decision because it lets the doctor (and patient) judge how quickly the tumor is growing and whether it’s likely to cause problems.
Pro: Benign brain tumors tend to grow slowly, sometimes slowly enough that treatment may never be necessary.
Con: Some tumors look benign on scans but actually are malignant. Also, if a tumor grows and triggers changes in the brain that result in, say, a seizure disorder, there’s a chance that the damage may be irreversible.
Stereotactic radiosurgery(a variety of different technologies, including Gamma Knife, proton beam and CyberKnife). These are outpatient procedures using high-intensity radiation broken into multiple beams to destroy the tumor cells while sparing surrounding healthy tissue.
Pro: Requiring no incision, these are typically onetime treatments enabling patients to immediately resume normal life. “With many benign primary tumors, this treatment can provide patients with a cure,” says Dr. Black.
Cons: All radiation treatments increase a patient’s lifetime risk for cancer, and in a small percentage (about one in 5,000 cases) the radiation from this treatment actually can cause a benign tumor to become malignant. Also, there is some risk of swelling from the radiation in the area surrounding the tumor, which can pose dangers as well.
Surgical removal.This is obviously the most invasive approach, requiring the patient to be hospitalized for several days, with full recovery taking a few weeks, depending on the size and location of the tumor. The smaller the tumor, the lower the risks posed by surgery, generally speaking.
Pro: If the entire tumor is removed, the chance for recurrence is low (the lifetime risk is estimated between 3% and 5%).
Con: This is brain surgery. Not only are there all the usual risks of surgery — bleeding, infection, reaction to anesthesia — but also a small (but real) chance of a problem during surgery that leaves the patient with a permanent neurological deficit.
In addition to understanding the pluses and minuses of the various treatments, Dr. Black emphasized that it is vital to seek out a neurosurgeon who specializesin brain tumors. Many people don’t realize that the majority of neurosurgeons actually focus on disorders of the spine, such as back and neck pain and ruptured disks, he explained. While there are roughly 3,500 neurosurgeons in the US, only a few hundred specialize in brain tumors. You may need to travel to find such an expert, depending on where you live — according to Dr. Black, these specialists are typically found at major cancer centers and university hospitals.
Since this particular medical decision is so fraught, Dr. Black suggested asking the surgeon to examine the actual scans together with you (most would do this anyway, he said). It’s smart to have a family member there to help process this information, too.
“A picture is worth 1,000 words,” said Dr. Black. “With a brain tumor, if you can see it, you have a better appreciation for what it is, what it’s near, and what’s at risk if it happens to grow.” It’s a tough decision under the best of circumstances, so it is important to do all you can to arrive at the best possible one for you.
