Once you have been diagnosed with metastasis to the brain, you will meet with your existing medical team and possibly new specialists in neuro-oncology, neurosurgery, neurology, radiology, radiation oncology, medical physics, and pathology. There may be additional experts working with you throughout your treatment journey including rehabilitation specialists, neuropsychologists and psychiatrists, endocrinologists, ophthalmologists, dentists, pharmacists and nutritionists.
Depending on your condition, you may be required to make serious decisions quickly about how to treat your brain metastases. Your medical team can help guide your decision with their experience and knowledge about how your primary cancer reacted to previous treatments.
A second opinion may be considered before undergoing treatment for your metastatic brain tumor(s). Searching local or regional facilities for doctors who specialize in brain mets can help better inform your decision-making process. Please remember that while a second opinion could be important, it could be just as important not to delay treatment.
You may want to start a new journal or notebook for your brain metastases treatment journey. You can write down all your questions and their answers, as well as your schedule for appointments, meetings and treatments, and make note of side effects or other important information. Some patients find it very helpful to keep a detailed schedule of treatment appointments. Having someone with you at your appointments may help to ensure all the information you receive is written down and offers important emotional support.
Treatment Options for Brain Metastasis
The treatment of brain metastases depends on a number of factors including the origin of metastasis and its status (controlled or not), as well as, your health and age.
Other factors affecting treatment recommendations include:
Your treatment team will discuss with you the goals of treatment of your brain metastases, which may include conclusive tissue diagnosis, symptom relief, improved brain function or control of the metastatic brain tumors. In general, possible treatments include chemotherapy, radiation therapy, surgery or a combination of these methods.
If you have any questions or concerns about the treatment that is being recommended, you should seek out more information about the treatment types available and perhaps consider a second opinion.
Tissue Diagnosis
You may have already had a biopsy performed on your secondary brain tumor to verify its origin. If not, this may occur now before treatment is prescribed.
Neurosurgery / Image Guided Surgery (IGS)
Depending on your diagnosis, your doctor may recommend surgery as part of the overall management of your metastatic brain tumors. Surgery has proven to be one of the most effective methods for managing brain cancer [1].
Surgery is typically considered when a number of factors favor removal [2]:
Sophisticated neurosurgical technologies, including precision navigation systems and intraoperative imaging, are available to help decrease morbidity and help lower or eliminate mortality, from surgery. These computer-based systems are designed to help assess a patient case, plan the surgery and actually mirror the real human anatomy on screen—helping to guide the surgeon through important surgical steps during the procedure.
Visit Understand Image Guided Surgery for Brain Metastases to explore the option of having your brain metastases removed using image guided surgery, also known as surgical navigation or neuronavigation.
Surgery may not be considered if your doctors think that your tumor(s) will respond better to radiation therapy. Reasons to choose radiation therapy over surgery include having multiple tumors that are far away from each other or are located in areas of the brain responsible for critical functions, like language or movement.
Radiation Therapy
Radiation therapy (RT), also called radiotherapy, is a common type of treatment for brain metastases. This cancer-fighting, precision-oriented radiation technology can be delivered in different ways, the most common of which is called ‘external beam’ radiation therapy and is given from outside the patient’s body. Doctors use radiation therapy to target tumors with the goal of stopping their growth and destroying the cancer cells, while causing as little damage to the healthy brain tissue as possible.
Radiation can be used to treat brain metastases, to help prevent growth of brain metastases in people newly diagnosed with certain primary cancers, or to help offer relief from symptoms caused by the tumors. This treatment can be delivered in different ways, including whole brain radiation therapy (WBRT), fractionated radiation therapy and stereotactic radiosurgery (SRS).One of the more common treatments for multiple brain metastases is whole brain radiation therapy, even though studies have shown that there may be increased risk of short- and long-term side effects associated with this type of radiation therapy [3-4].
Radiation therapy is typically delivered in a fractionated manner over many appointments.. The fractions, also called sessions, can be delivered once a day, five days a week and can last between two and ten weeks, depending on the type of brain metastases and the goal of the treatment.
Stereotactic radiosurgery (SRS), sometimes called ‘knifeless’ surgery, is an advanced, targeted form of radiation that was originally developed specifically to target tumors in the brain. Patients receive a single high dose of radiation using technology that aims the radiation beams at the targeted tumor, also called a lesion. The radiation beams are delivered from different angles, either via a special helmet or as the system rotates around the patient’s head.
Stereotactic radiosurgery has made one of the most significant impacts on the management of metastatic brain tumors [5-8]. This method has changed the way brain mets patients are treated because it offers a “non-invasive” (non-surgical) option to quickly and effectively control brain metastases. When metastases in the brain are under control, you can focus on fighting your primary cancer—the cancer from which the metastases spread.
Today, patients with brain metastases that originate from certain types of primary cancers can live several years, and potentially experience a high quality of life, after discovery of the first brain metastasis [9-12].
Learn more about radiosurgery for brain metastases in Understand Radiation Therapy for Brain Metastases.
Chemotherapy
Chemotherapy is the use of chemical substances, also called anti-cancer drugs or chemotherapeutic agents, to kill cancer cells. If you are prescribed chemotherapy, you may receive it in the form of pills that you take orally or it may be given intravenously, which means being injected directly into your veins.
Most modern chemotherapy drugs are biologically targeted and not considered “cytotoxic,” meaning they don’t affect all dividing cells in the body, but just tumor cells specifically.
A course of chemotherapy may be given in combination with other types of treatment, like surgery or radiation therapy. If it is used before surgery or radiation therapy, the goal is usually to shrink the tumor to make removal or radiation more effective. This is calledneo-adjuvant therapy. If chemotherapy is used after surgery or radiation therapy, the goal is to destroy any cancer cells that may have been left behind. This is called adjuvant therapy.
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[2] American Brain Tumor Association
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[4] Barani, I. J., Larson, D. a & Berger, M. S. Future directions in treatment of brain metastases. Surg. Neurol. Int. 4, S220–30 (2013).
[5] Kondziolka et al. Stereotactic radiosurgery plus whole brain radiotherapy versus radiotherapy alone for patients with multiple brain metastases. Int J Radiat Oncol Biol Phys. 1999 Sep 1;45(2):427-34.
[6] Andrews et al. Whole brain radiation therapy with or without stereotactic radiosurgery boost for patients with one to three brain metastases: phase III results of the RTOG 9508 randomised trial. Lancet. 2004 May 22;363(9422):1665-72.
[7] Brown et al. Effect of Radiosurgery Alone vs Radiosurgery With Whole Brain Radiation Therapy on Cognitive Function in Patients With 1 to 3 Brain Metastases: A Randomized Clinical Trial. JAMA. 2016 Jul 26;316(4):401-9. doi: 10.1001/jama.2016.9839.
[8] Wolf et al. Toward the complete control of brain metastases using surveillance screening and stereotactic radiosurgery. J Neurosurg. 2017 Feb 17:1-9. doi: 10.3171/2016.10.JNS161036.
[9] Ryberg, M. & Nielsen, D. Prognostic factors and long-term survival in 585 patients with metastatic breast cancer treated with epirubicin-based chemotherapy. Ann. Oncol. 12, 81–87 (2001).
[10] Sledge, G. Should we dream the impossible dream? The meaning of long-term survival in metastatic breast cancer. J. Clin. Oncol. 14, 2191–2193 (1996).
[11] Hamid, N., Chandra, A. & Meyer, C. Multiple brain metastases from malignant melanoma with long-term survival. Br. J. Neurosurg. 18, 552–555 (2004).
[12] Greenberg, P. a et al. Long-term follow-up of patients with complete remission following combination chemotherapy for metastatic breast cancer. J. Clin. Oncol. 14, 2197–205 (1996).
