• Treatment & Side Effects

    Following a brain cancer diagnosis, the first question many patients have is “what do I do now?” Our guide outlines the standard treatment options provided for most patients. However, working closely with your doctor, you’ll be able to determine which course of action is right for you.

    There are three standard types of treatment for patients with high-grade gliomas: Surgery, Chemotherapy and Radiation therapy.

    Doctors who specialize in brain tumor surgery are called neurosurgeons. Doctors who deliver radiation therapy are known as radiation oncologists. Neuro-oncologists are doctors who specialize in the medical aspects of care for patients with brain tumors. This includes managing chemotherapy and other drug treatments or medications as may be related to the brain tumor.

    In addition to these standard therapies, medical centers that specialize in brain tumor treatment, such as the Center for Advanced Brain Tumor Treatment (CABTT), give patients the opportunity to participate in research studies called Clinical Trials.

    Two to four weeks after surgery, or as soon as the surgical wound heals, patients begin either radiation therapy or chemotherapy treatment or a combination of these.

    • Surgery
    • Chemotherapy
    • Radiation therapy
    • Alternative Therapy
    • What is naturopathic care?
    • How natural medicine can benefit you:
    • What to expect
    • Clinical Trials
    • What types of trials are there?
    • Drugs
    • Seizures
    • Commonly Used Seizure Medications
    • Side Effects
    • Nausea
    • Fatigue
    • Appetite Changes
    • Constipation
    • Low Blood Counts
    • Infection
    • Bleeding
    • Treatments for brain tumors are intended to achieve the following:
    • Remove as many tumor cells as possible at surgery (however, sometimes only a biopsy can be performed.) Because gliomas invade, or migrate into normal tissue adjacent to the major component of the tumor, it is almost never possible to cure the tumor with surgery.
    • Use radiation and/or chemotherapy to kill as many of the tumor cells left behind at surgery as possible.
    • For those cells still present after these treatments, radiation and chemotherapy can put them into a nondividing, or sleeping, state for a period of time.

    Surgery:

    The amount of tumor that can be safely removed from the brain of a patient is different for each person. It depends mainly on the location of the tumor. For example, a large percentage of the tumor in some brain areas can be removed with very low risk, while in other brain areas, surgery is too dangerous to consider and a biopsy with a small needle is recommended. Brain tumor neurosurgeons make decisions about the benefit and risk of surgery. The goal is for the patient to be the same or better after brain tumor removal. Because of the way gliomas spread into the brain around the tumor, even an aggressive resection will leave some tumor cells behind. An MRI scan is usually performed within 2-3 days after surgery. This MRI serves as a baseline, and all future MRIs are compared to this.

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  • Radiation therapy:

    Most patients undergo a series of radiation treatments starting about two weeks after surgery. Radiation therapy is an important part of the treatment of high-grade gliomas. A doctor who supervises radiation treatments is called a radiation oncologist.

    Before you get started with treatments, you will have a radiation planning session called a simulation. Your daily set up for radiation treatment will be decided during this session. It should be a comfortable position for you, usually with you lying on your back. Either a CT scan or X-ray pictures are taken of your head to use for radiation planning. This is a special scan that is different from other scans that you may have had for diagnosis or seeing the details of your tumor.

    Treatments are given daily, Monday through Friday for about 6 weeks. Each treatment takes only a few minutes and is painless. Patients are seen weekly by the radiation oncologist, and a nurse is available for questions every day.

    An MRI will be performed about 2 to 4 weeks after the end of radiation therapy in order to assess the status of the tumor. Usually this scan will show no change from the MRI performed immediately following surgery, which is good. Some shrinkage is even better. Growth of the tumor during radiation therapy is a sign of a more aggressive tumor.

    Most side effects will be mild and can be easily managed. The common side effects are:

    • Hair loss in the area being treated by radiation. This can sometimes be permanent.
    • Skin redness, dryness, or irritation in the areas exposed to radiation.
    • Fatigue, usually starting the second or third week of treatment. For many, a nap is helpful every afternoon.
    • Nausea does not occur for all patients but can be managed with medication if it occurs.
    • Headaches do not occur often but should be mentioned to your doctor and can usually be managed with standard headache medications. Do not take aspirin or aspirin-containing medications. Tylenol is fine.

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  • Chemotherapy:

    Chemotherapy is helpful in controlling the growth of high-grade gliomas. Several different types of chemotherapy drugs are used. For many high-grade gliomas, radiation and chemotherapy are given at the same time. Generally, the chemotherapy is a drug called temozolomide (Temodar). A small dose is taken each day during the course of radiation. Once radiation is completed, patients take a higher dose of the drug for 5 straight days every 4 weeks. However, decisions are individualized to each patient.

    New treatment plans call for highly personalized drug cocktails. New technologies are now allowing doctors to examine the genes that make-up cancerous brain tumors and in turn, shows the doctor which drugs will have the greatest effect.

    Chemotherapy affects rapidly growing tumor cells but can also harm healthy, fast-growing cells and thus produce side effects. The cells that are most commonly affected are the cells in your bone marrow and gastrointestinal tract. Because of this, some patients:

    • Tire easily because of a low red blood cell count
    • Catch infection easily because of a low white blood cell count
    • Bleed easily from low platelets
    • Have nausea, vomiting or diarrhea

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  • Alternative Therapy:

    What is naturopathic care?

    Naturopathic care combines traditional natural therapies with the latest nutritional, botanical and health science. In the ideal setting, naturopathic physicians work cooperatively with medical oncologists and other medical specialists communicating directly with each patient’s health-care team to be certain that all providers are up-to-date and informed.

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    How natural medicine can benefit you:

    A natural medicine consultation can help in several ways depending on your condition and treatment. It can:

    • Help keep you as strong and healthy as possible during conventional oncology treatment
    • Support your body, including the immune system, in its fight against cancer
    • Help reduce the side effects of some conventional oncology treatments
    • Ensure that you avoid nutritional supple­ments that could interfere with your cancer treatment or worsen side effects
    • Help you develop a cancer-prevention plan after completion of treatment

    In addition to cancer, naturopathic medicine is also used to treat bloating, dyspepsia, diarrhea, constipation, diarrhea, bowel and urinary urgency, fatigue, aller­gies, weight loss, headaches, vaginal dryness, joint aches and pain, sleep disturbance, muscle cramps, restless leg syndrome and skin rashes, among others.

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    What to expect:

    Naturopathic treatments usually focus on a wide range of areas, including clinical nutrition (diet, vitamins, minerals, etc.), botanical medicines such as herbs, lifestyle adjustments, psychological support, mind-body therapies and more. Ideally each treatment plan should be unique and devel­oped with your specific needs in mind.

    If you are receiving conventional treatments such as chemotherapy, radiation therapy, and surgery, natural thera­pies offer the most promising benefits if they do not interfere with your other treatments. With this in mind, your naturopathic treatment plans and related activities should be coordinated directly with your medical oncologist and other members of your health-care team.

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  • Clinical Trials:

    In addition to standard chemotherapy, major research centers conduct studies of new brain tumor treatments. It is advisable to enter a research study if possible, both for reasons of potential personal benefit as well as for the benefit of others in the future. Neuro-oncologists, nurse practitioners, and research nurses can provide detailed information about clinical trials.

    What types of trials are there?

    New chemotherapy and biological agents are evaluated in a standard format called “clinical trials.”

    • A Phase I trial is a small trial, typically with 10 to 12 patients. They are designed to test the toxicity of various doses of a new agent.
    • A Phase II trial is a larger trial involving more patients to assess whether a new agent from the Phase I level can effectively treat a tumor.
    • A Phase III trial is usually a very large trial designed to compare how the new agent, from the Phase I and II level, compares to the best currently available agent(s) treatments.
    • A neoadjuvant trial is a trial looking at an agent that is administered after biopsy or surgery, but prior to irradiation.
    • An adjuvant trial is a trial looking at an agent that is administered immediately after surgery and irradiation.
    • A recurrent (salvage) trial is a trial looking at an agent that is administered at the time of tumor progression or recurrence.

    An excellent resource for currently available clinical trials can be found at:
    www.virtualtrials.com and www.clinicaltrials.gov

    Your oncologist and other medical specialists are a critical resource to help you evaluate clinical trial opportunities as they relate to your unique circumstance.

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  • Drugs:

    Seizures

    Seizures may occur in patients with brain tumors. Seizures are caused by a disruption of the normal flow of electricity in the brain. There are many different types of seizures. The most common types are focal seizures which may involve twitching of the face, arm or leg, or clouding of thought processes without complete loss of consciousness or they may be generalized and involve the total body shaking with complete loss of consciousness.

    How to manage this symptom:

    • During a seizure remain calm. Patients do not suffocate during seizures.
    • Most seizures are brief lasting less than a minute or two.
    • Do not put anything in the patient’s mouth. They will not “swallow” or bite off their tongue.
    • Protect the patient as much as possible from sharp objects or dangerous situations.
    • If vomiting occurs, turn the patient on their side so that the stomach fluid runs out of their mouth so that they do not choke.
    • If seizures occur, talk with your neuro-oncologist about driving, operating equipment, swimming or any other potentially dangerous activity.

    Make sure you take your anti-seizure medication as prescribed.

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    Commonly Used Seizure Medications:

    • Dilantin (phenytoin). The major potential side effects are:
    • Blood levels that are too high can cause clumsiness while walking, much like that of alcohol intoxication
    • Dilantin rashes are very common and can be dangerous – call your provider if this occurs
    • Some patients may feel fatigue (overwhelming tiredness) when taking Dilantin
    • Tegretol (carbamazepine). The major side effects are:
    • Rash, although far more rare than with Dilantin; however, patients who get a rash from Dilantin are more likely to get a rash on Tegretol
    • Low white blood counts
    • Double vision, when levels become toxic
    • Fatigue
    • Depakote (valproic acid). The major side effects are:
    • The most frequent side effect is a mild tremor (shaking) in the hands
    • Rash is far rarer than with Dilantin
    • The liver can be injured by this medication
    • This medication is very harmful to the human fetus and should not be given to pregnant women or nursing mothers
    • Keppra (levetiracetam). The most frequent side effects are:
    • Fatigue, weakness
    • Irritability, anxiety (nervousness)
    • Lamictal (lamotrigine). The most common side effects include:
    • Dizziness, fatigue
    • Balance problems
    • Headaches, double vision

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  • Side Effects:

    Nausea

    Many types of chemotherapy can cause nausea and vomiting. This may last for the day of treatment only or for several days after treatment.

    How to manage this symptom

    • Use your anti-nausea medication as directed by your provider. If it is not helping with your nausea, contact your provider as there are many medications that you can use.
    • Eat 5 to 6 small meals or snacks rather than 3 large meals during the day.
    • Do not force yourself to eat when you are nauseated.
    • Pick foods that have been soothing for you when you have experienced nausea in the past (bland foods, crackers, ginger ale).
    • Do not eat your favorite foods while you are nauseated.
    • Avoid foods that are fatty, fried, very spicy or very sweet when you are nauseated.
    • Avoid strong scented food.
    • Eat foods that are room temperature or cold if the smells from hot food increase your nausea.
    • Have someone else prepare your food if possible.
    • Distract yourself with activities you enjoy.

    When to call your health-care provider

    • If you are nauseated and your anti-nausea medication is not working.
    • If you are vomiting and unable to keep anything down for more than 12 hours.
    • If there is blood or particles that look like coffee grounds in your emesis (vomit).

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    Fatigue

    Fatigue is a feeling of tiredness that can interfere with your normal daily activities. It is common in people receiving treatment for their brain tumor to experience fatigue. There are multiple reasons people experience fatigue while undergoing treatment. These include the tumor itself and/ or the treatments both chemotherapy and radiation which can cause fatigue. Low red blood-cell counts, anemia, can cause fatigue. Poor sleep and poor nutrition can also be factors in fatigue.

    How to manage this symptom

    • Rest is important but too much rest can make you more fatigued. Do not nap for more than an hour.
    • Exercise can improve your fatigue. Keep active by starting slow and gradually increasing your activities.
    • Eat a well-balanced diet with protein and carbohydrates. Make sure you drink a moderate amount of fluids.
    • Relax and decrease stress. Try using meditation, prayer, yoga or guided imagery to help.
    • Conserve your energy by spreading your activities throughout the day. Plan rest breaks and have others help you with household chores and errands. Don’t push yourself to do more than you can manage.
    • Restore your energy by doing activities that you enjoy and make you feel good.
    • Talk with your health care provider about your fatigue

    When to call your health-care provider

    If the patient has a change in their level of consciousness and are difficult to arouse, call your health care provider right away.

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    Appetite Changes

    Appetite changes may happen due to treatment. You may lose your appetite because of nausea, fatigue or depression. You may experience taste changes due to the chemotherapy or medications you are on.

    How to manage these symptoms

    • Eat small meals five to six times a day rather than three large meals.
    • Eat foods high in calories, protein and carbohydrates
    • Butter or oils added to food
    • Cottage cheese, cream cheese muffins, croissants
    • Cream soups or soups with lentils, dried peas or beans
    • Custards, frozen yogurt, ice cream
    • Nuts, seeds and wheat germ
    • Instant breakfast drinks, whole milk, milkshakes, smoothies
    • Liquid meal replacements
    • Peanut butter
    • Beef, chicken, fish
    • Eggs
    • Powdered milk added to foods like pudding, milkshakes
    • Drink milkshakes, smoothies, soup or juice if you do not feel like eating solid foods
    • Limit your fluids right before and during a meal as too much liquid can cause you to feel full
    • Try new and attractively prepared foods to help make a meal more appetizing.
    • Have family or friend help you prepare snacks and meals so you have them handy.
    • Keep active. This can help stimulate your appetite and decrease constipation.
    • If you are experiencing a metallic taste, use plastic forks and spoons and avoid cooking foods in metal pots and pans
    • Cold foods are usually better tolerated than warm or hot foods when your taste is altered

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    Constipation

    Constipation is present when bowel movements become less frequent and stools are hard and dry, becoming difficult to pass. It may make you feel bloated or nauseous. You may feel gassy or have stomach cramps. Constipation can be caused by a side effect of the chemotherapy you are taking or other medications such as pain medication or anti-nausea medication which you are taking.

    How to manage this symptom

    • Eat small frequent meals rather than three large meals
    • Eat low fiber foods. Here are some examples:
    • Chicken, Turkey (without the skin)
    • Potatoes without the skin
    • Bananas
    • Fish
    • White bread
    • Canned fruit (peaches, pears, applesauce)
    • Eggs
    • White rice
    • Clear fruit juice
    • Noodles
    • Asparagus
    • Vegetable juice
    • Cottage cheese
    • Gelatin
    • Saltine crackers
    • Sherbet or sorbet
    • Yogurt (plain or vanilla)
    • Angel food cake
    • Avoid greasy or spicy foods
    • Increase your fluids
    • Avoid drinks that include caffeine, alcohol or milk/ milk products

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    Low Blood Counts

    The bone marrow produces the blood cells that circulate in the arteries, veins and capillaries. White blood cell levels and platelet levels may drop temporarily after each dose of chemotherapy. At the lowest point (called the “nadir”), patients may have an increased risk for infection (with low white blood cells) or bleeding (with low platelets). A low red blood cell count (anemia) is not common with most types of chemotherapy used to treat gliomas. Most of the time patients do not have symptoms related to the presence of low counts. Blood counts are measured by performing a CBC (Complete Blood Count). A CBC may be taken at different times within the chemotherapy cycle and usually within one to two days prior to administration of chemotherapy. The results will help the provider decide if it is safe to give the chemotherapy.

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    Infection

    Common signs of infection include fever (oral temperature over 100.5 degrees), chills, sore throat, shortness of breath, new or worsening cough, abdominal pain, and pain or burning with urination.

    Tips to help prevent infection:

    • Hand washing. Wash your hands frequently particularly after using the bathroom, before cooking or eating, and after touching animals. Have your family wash their hands frequently.
    • Carry hand sanitizer for when you are not near soap and water.
    • Maintain good oral care.
    • Try to avoid people who are sick.
    • Discuss getting the flu shot with your health care provider.

    If your white blood-cell counts become too low (neutropenia) your health care team will give you specific instructions on how to prevent infection and what to do if you are having sign of infection while your counts are low.

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    Bleeding

    Common signs of bleeding include easy bruising of the skin, tiny spots of hemorrhage under the skin (petechia) which look like little red spots, nose bleeds, and bleeding of the gums with brushing teeth.

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