An estimated 140,000 to 170,000 patients with common systemic cancers are diagnosed with brain metastasis every year in the United States, particularly patients with breast, lung, kidney and melanoma.
"For many years, oncologists considered brain metastasis as a uniformly fatal condition, and treatments were limited to palliative brain radiation," says Gene Barnett, MD, Director of the Brain Tumor and Neuro-Oncology Center at Cleveland Clinic's Neurological Institute. "Over the last two decades, however, approaches that are more aggressive and accurate have been developed that may lead to a local cure or a sustained control of the disease in some patients."
Nevertheless, Dr. Barnett believes cancer patients with systemic cancers are poorly informed about the risks of developing brain metastasis, its early warning signs and modern therapeutic options available beyond the traditional treatment of whole brain radiation.
"Moreover, we have found there are some physicians who may not be fully aware of new treatment options, or may still be of the mindset that brain metastasis is a uniformly fatal turn in patients with systemic cancers," Dr. Barnett observes.
B-Aware program launches
To address this issue, the Brain Tumor and Neuro-Oncology Center has launched the B-Aware program, to educate and empower patients with information on the risks, symptoms and treatment options that may increase their life-spans and improve quality of life.
"At the same time, we are actively engaged in developing physician awareness," says Dr. Barnett. "To that end, we officially announced the B-Aware initiative before physicians who attended the International Symposium on Long-Term Control of Secondary Central Nervous System Malignancies held this past spring in Cleveland."
The Brain Tumor and Neuro-Oncology Center is collaborating with the American Cancer Society to promote the B-Aware program on its website. "The program is unique because it is believed to be the first initiative of its kind to directly educate cancer patients about the health issues of brain metastasis," Dr. Barnett says.
Understanding the symptoms
In addition to the risks, cancer patients also should know about the common symptoms that may indicate brain metastasis. Many of the symptoms are similar to those of an acute stroke. However, the symptoms for brain metastasis typically manifest gradually as opposed to suddenly during a stroke. Common symptoms include problems with vision, numbness, weakness, difficulty with balance, speaking or memory problems, headaches that are generally progressive and seizures.
"When patients experience the onset of any of these symptoms, particularly when the symptoms begin to become more frequent, prolonged or become worse, they should see their oncologist immediately," Dr. Barnett says. "Aggressive therapies may improve outcomes when brain metastasis is diagnosed in its early stages."
At Cleveland Clinic, a multidisciplinary team of physicians evaluates each patient and recommends an individualized course of treatment that is most likely to produce an optimal outcome.
"Traditional treatments such as whole brain radiation and glucocorticoids still play important roles in the treatment of brain metastasis," says Dr. Barnett. "However, for many patients, whole brain radiation is inadequate to achieve sustained control and quality. In fact, it may be best reserved for later use as opposed to being used as a first line of treatment in some cases."
Aggressive treatments work
Alternatively, research has shown that aggressive treatments such as minimal access surgery and radiosurgery can help an appreciable number of patients to survive up to five years, and in some cases, up to 10 years.
At the Brain Tumor and Neuro-Oncology Center, for example, neurosurgeons commonly utilize aggressive therapies such as minimal access procedures to extract metastatic tumors. For patients with new or recurrent metastatic tumors following radiotherapy, surgery in conjunction with the placement of carmustine wafers in the tumor cavity, or radiosurgery to the tumor cavity may preclude local recurrence.
In addition, the Brain Tumor and Neuro-Oncology Center's Gamma Knife uses state-of-the-art stereotactic radiosurgery to treat metastatic tumors. Lesions are typically small (<3 cm at presentation) and spherical, which displace rather than infiltrate the brain. Results from radiosurgery appear comparable to those achieved by surgery with radiotherapy, and allow for effective treatment even for surgically inaccessible secondary brain tumors.
A recent multi-centered randomized trial showed that radiosurgery in addition to whole-brain radiotherapy led to improved survival or enhanced quality of life for patients with one or more metastatic brain tumors, respectively. In addition, radiosurgery may reduce the chance of leptomeningeal spread as a result of surgery for certain types of tumors.
Other treatment options
In some cases, chemotherapy may be a treatment option. For example, patients who have systemic breast cancer and brain metastases with lesions that are estrogen-receptor positive may respond to high doses of Tamoxifen, which can compensate for the medication's limited penetration to the brain. What's more, temozolomide - an orally administered methylating agent - effectively penetrates the brain and may be considered for selected patients.
"Often times, by applying a combination of these aggressive therapies, we are able to control brain metastasis for an extended period of time for patients and improve their quality of life," concludes Dr. Barnett.
To learn more about the B-Aware program, please visit, http://my.clevelandclinic.org/brain_tumor/patients/baware.aspx.
To refer patients, please call Specialty Services Access Line at 216.738.5439, 7 a.m. - 11 p.m., seven days a week. After 11 p.m., please call 216.444.2000 and ask for neuro-oncology staff or the chief neurosurgical or neurological resident on call. For pediatric patients, ask for the chief of pediatric neurological resident on call.
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