Brain cancer treatment and diagnosis in the United States

Brain cancer treatment in the United States holds unique advantages, including the latest diagnostic equipment, chemotherapy, immunotherapy, stereotactic radiosurgery and high-tech rehabilitation.

Brain cancer is a relatively rare but extremely dangerous malignant disease.

The five-year survival rate for this diagnosis in adults is about 37% (for all stages and cancer types).

About 24,000 Americans are diagnosed with brain cancer every year. It accounts for 86% of all malignant tumors of the central nervous system. This disease is devastating; the growing tumor mass affects well-being, professional and cognitive skills, vision, movement, behavior.

Malignant brain tumors are primary and secondary (metastatic). Primary tumors originate from brain cells (glioblastoma, meningioma, astrocytoma). They differ in the degree of aggressiveness and growth rate. Primary neoplasms are found mainly in children.

Brain tumors are classified according to the degree of malignancy:

⦁ Grade 1 and 2: these are borderline tumors between benign and malignant; at the second degree there are some signs of malignancy, the growth in both cases is slow.
⦁ Grade 3 and 4: tumors have all the signs of malignancy, they grow rapidly and metastasize. Grade 4 tumors (glioblastoma) has a poor prognosis.

Secondary tumors are metastases of another cancer that arise in distant organs and tissues (stomach, lung, colon, skin, breast cancer as well as leukemia – neoplastic meningitis).

Symptoms of brain cancer depend on the tumor size and location:

⦁ Headache
⦁ Convulsive seizures
⦁ Vision and hearing loss
⦁ Sensory symptoms
⦁ Weakness and fatigue
⦁ Nausea and vomiting
⦁ Personality changes
⦁ Memory loss etc.

Best neurology & neurosurgery clinics in America 2018

Surgical resection remains the main approach for the treatment of brain and spinal cord tumors, so choosing the best neurosurgical center is very important step to defeat cancer.

⦁ Mayo Clinic in Rochester, Minnesota
⦁ The John Hopkins Hospital in Baltimore, Maryland
⦁ USCF Medical Center in San Francisco, California
⦁ Cleveland Clinic in Cleveland, Ohio
⦁ New York Presbyterian Hospital Columbia and Cornell
⦁ Massachusetts General Hospital in Boston
⦁ Barnes Jewish Hospital in St. Louis, Missouri
⦁ Northwestern Memorial Hospital in Chicago, Illinois
⦁ University of Michigan Hospital in Ann Arbor
⦁ UCLA Medical Center in Los Angeles, California
⦁ Rush University Medical Center in Chicago, Illinois
⦁ New York Langone Medical Center

These world-famous clinical centers use the best neurosurgical equipment. They maintain the highest surgical standards performing the most complex and risky surgical procedures.

Brain cancer diagnosis in the United States

American doctors extensively use modern 3D imaging techniques and laboratory tests to determine cancer type and choose the best treatment for every patient.

Diagnosis of brain cancer begins with a neurological examination. Neurologist is a qualified specialist in diseases of the central and peripheral nervous system. If the symptoms indicate a brain mass, the doctor will send you for further tests. Imaging techniques (CT, MRI, PET, angiography, myelography) are intended to find out where the neoplasm is located and how cancer spread throughout the body.

But the main role in diagnosis belongs to biopsy, which means total or partial resection of the tumor. The obtained sampled is studied in the laboratory determining histological type of tumor, malignancy level and specific mutations (IDH, MGMT, etc.)

Magnetic resonance imaging (MRI)

Magnetic resonance imaging uses magnetic fields to create detailed images of internal organs and tissues without excessive radiation exposure and health risks.

MRI of the head helps to examine the brain structures in more detail than CT. This information can be used in surgical planning and monitoring disease progression or treatment results. In some cases an MRI of the spine and spinal cord, as well as visualization of distant organs, is required to search for secondary tumors (metastases). The procedure can be performed without a contrast agent, but intravenous administration of gadolinium provides a clearer picture of brain structures. Contrast enhanced MRI has some contraindications, which you need to discuss with your doctor.

US cancer clinics use functional magnetic resonance imaging (fMRI). This technique is intended to determine the location of brain regions responsible for speech, movement and other important functions. fMRI is used by neurosurgeons to assess the risk of damage and neurological deficiency after surgery.

Magnetic resonance spectroscopy (MRS) looks for differences in the brain tissues chemical composition. MRS detects metastases and areas of necrosis after radiation therapy.

Computed Tomography (CT)

Computed tomography creates detailed 3D image of the brain or other organs using focused weak X-rays. Although the radiation dose of cranial CT scan is hundreds of times higher compared to a chest X-ray, the health risk is extremely low. CT detects even subtle cerebral ventricular changes and condition of bone structures.

This technique is used to find tumor masses, cysts and sources of intracranial hemorrhage.

Detailing the image of soft tissue with CT is worse compared to magnetic resonance imaging. On the other hand, computed tomography can be used in cases when MRI is contraindicated because of metal implants. CT is performed with contrast agent or without it.

Positron Emission Tomography (PET)

Positron emission tomography shows the metabolic activity of cells. Before the procedure, the patient is given labeled glucose, which is distributed in the brain and "highlights" the cancer. Typically, PET is combined with computed tomography. This method is called PET / CT.

PET / CT is expensive imaging technique, which is not available in some clinics. The cost of the procedure in the US may exceed $ 6,000. It can be used for monitoring for cancer recurrence.

Cerebral angiography

This technique, also known as arteriography, is a type of X-ray procedure. After injection of the contrast agent into the cerebral arteries, the doctor makes a series of images of the cerebral vascular bed and the tumor itself.

Myelography

If malignant cells are found in the cerebrospinal fluid (CSF), myelography will detect malignancies in the spinal cord. Today this procedure is used relatively rare.

Lumbar puncture

Unlike CT or MRI, lumbar puncture is a painful invasive procedure. During a LP your doctor insert a needle in spinal canal and collect a sample of cerebrospinal fluid with a special syringe. Modern laboratories do wonderful things with this transparent liquid. In few hours specialists calculate different cells and markers, giving your oncologist more data to make decisions.

Brain biopsy

Biopsy (removal of brain tissue sample) may be required in cancer, inflammatory and degenerative diseases of the nervous system. This is the only way to confirm the diagnosis. The pathologist, who examines tissue samples, makes a conclusion about the type of cancer, its aggressiveness and the possibility of treatment with certain drugs (molecular testing). A biopsy can be performed alone or as part of complex surgical procedure.

The cost of removing the brain tumor (craniotomy) in the US may exceed $100,000. A minimally invasive stereotactic biopsy will cost several times cheaper.

Cancer diagnosis may include additional laboratory tests, recording electrical activity of the brain and other additional techniques to make right clinical decisions.

Approximate cost of brain cancer diagnosis in the US:

⦁ Certified neurologist consultation: $500-1000
⦁ Cranial computed tomography scan: $1200-1500
⦁ Positron emission tomography scan: $5500-6500
⦁ Magnetic resonance imaging: $2500-3500
⦁ Lumbar puncture: $3000-6000

The cost can vary greatly depending on the volume and complexity of the procedure, the specifics of your clinical case and the price policy of a particular medical center.

Brain cancer treatment options in the United States

Surgery, chemotherapy, radiotherapy, immunotherapy, and targeted drugs: multidisciplinary team of professionals from different fields of medicine chooses the best for each patient.

⦁ Medical oncologist
⦁ Radiation oncologist
⦁ Neurosurgeon
⦁ Neurologist
⦁ Psychologist
⦁ Pharmacist
⦁ Nutritionist
⦁ Physical therapist

The choice of treatment depends on many factors, including the patient's health, the stage of disease, tumor grade, complications, personal preference and opportunities.

Some neoplasms like glioblastoma grow quickly, demanding immediate medical intervention. Other tumors can remain silent for many years without causing any problems. Over the past decades, American oncology and neurosurgery have changed a lot. Aggressive tumors, which typically meant a death sentence, can now be treated and controlled.

But cancer therapy can be complex, painful, expensive and time-consuming.

One of the main obstacles is the blood-brain barrier, which protects CNS from different foreign substances including medicines. Neurosurgeons have to bypass natural defense line with special devices, such as Ommaya reservoirs or carmustine wafers.

Successful operations on the brain require a lot of surgical experience, high-precision intraoperative imaging, the latest equipment and medicines.

But even the most advanced radiotherapy and chemotherapy techniques can cause serious harm. Each method involves certain health risks. The choice of tactics (surgery, chemotherapy, radiosurgery or expectant management) is always discussed with the patient.

Approximate cost of brain cancer treatment in the United States:

⦁ Open surgery with brain biopsy: $55,000-125,000
⦁ Chemotherapy: up to $100,000 during the first year
⦁ External beam radiation therapy: $15,000 or more
⦁ Stereotactic radiosurgery: about $55,000

The total cost of medical care for brain tumors in the US may exceed $150,000 per year.

Read the information below and ask your doctor about possible alternatives.

Best cancer clinics in America 2018

Sophisticated scanners, experimental medicines, cancer vaccines and advanced treatment protocols.

Modern oncology is continuously moving forward for world leaders:

⦁ MD Anderson Cancer Center in Houston
⦁ Memorial Sloan Kettering Cancer Center in New-York
⦁ Mayo Clinic in Rochester, Minnesota
⦁ Dana-Farber / Brigham & Women’s Cancer Center in Boston
⦁ Cleveland Clinic in Cleveland, Ohio
⦁ The John Hopkins Hospital in Baltimore

Are you looking for the best oncologists of the United States for second opinion?
Do you want to participate in clinical trials?
One of these hospitals may help you to deal with deadly disease.

Surgical treatment

Surgery may have different goals including complete resection of the tumor, biopsy, administration of chemotherapy drugs or relieving symptoms (bypass surgery).

Although neurosurgical treatment is the key, removal of the neoplasm is not always possible. Sometimes cancer invade vital areas, and doctors will have to look for alternative options.

Craniotomy is an opening of the skull. Modern technologies allow performing such procedures not only with general anesthesia, but also in consciousness (locoregional anesthesia).

So called awake craniotomy is used to control some neurological functions. Neurosurgeon checks if important areas are affected during surgery. This approach makes surgery safer. There is nothing to be afraid. Ssafe and reliable regimens of anesthesia 100% guarantee that patient will not feel any pain even in consciousness. This is real medical miracle!

During procedure, your neurosurgeon can install sophisticated devices for chemotherapy that bypass the blood-brain barrier. US clinics use Ommaya reservoirs and biodegradable wafers containing carmustine (Gliadel®).

Typical open surgery lasts 4-8 hours, recovery period may take several weeks.



Sometimes surgery is required only to obtain a tissue sample. Then, minimally invasive intervention under neuronavigation control (stereotactic biopsy) is performed. Stereotactic brain biopsy takes only 2-3 hours, recovery period is much shorter.

Possible complications associated with surgery

Temporary postoperative complications, such as nausea, vomiting, sore throat and pain after intubation, difficulty swallowing, and headache, should pass quickly. Long-term complications are possible as a result of accidental damage to the nerve structures responsible for movement, vision, hearing, memory or even behavior. Among them convulsive attacks, paralysis and paresis, memory loss.

Neurosurgery is always a risk. But US clinics provide the highest quality surgery and postoperative care to minimize the potential negative effects of cancer treatment.

Mayo Clinic in Rochester, MN

According to the US News ranking 2018, Mayo Clinic Cancer Center in Rochester was recognized # 1 in the United States for adult neurology and neurosurgery. This center meets strict NCI requirements. Multidisciplinary approach to the diagnosis and treatment of neuro-oncological diseases is practiced. All kinds of laboratory tests, consultation of the best neurosurgeons, stereotactic radiosurgery (SRS), chemotherapy, targeted therapy – everything is available in this clinical center.

Innovations, professionalism, and glorious history – this is Mayo Clinic.

The Cancer Center is part of SPORE translation research program.This provides access to revolutionary technologies and clinical trials of experimental drugs.

Local doctors are looking for new molecular targets to treat deadly pediatric tumors (such as DIPG and AT/RT). They try to improve awake craniotomy, and discover drugs to regenerate brain tissue after surgical resection or radiotherapy.

Radiation therapy

Brain cancer radiotherapy is based on targeted delivery of controlled radiation doses. Ionizing radiation is harmful for malignant cells, but inevitably causes some damage to healthy tissues.

Radiotherapy is used in the following situations:

⦁ In order kill the remaining cells after surgery
⦁ When surgical removal of the tumor is impossible
⦁ In order to slow the growth of tumor
⦁ To prevent metastases

US clinics use stereotactic radiotherapy (SRT) with computer planning. First, MRI creates a three-dimensional model of the tumor. Second, computer focuses the radiation beams directly on the tumor, keeping the brain safe during this dangerous procedure.

How much radiation to receive today?
What is the total absorbed dose?
How to manage each of the hundreds of emitters?
Powerful computers make radiotherapy more reliable and safe.

Fractionated stereotactic radiotherapy (FSRT) for metastases takes several sessions.

Stereotactic radiosurgery (SRS), also known as Gamma-knife or Cyber-knife, is limited to single session. SRS is extremely accurate method. It is used to destroy small tumors up to 30 mm in diameter. The typical session last 20 minutes (with ultramodern linear accelerators) or several hours (standard Gamma-knife technology).

SRT and SRS are used in neoplasms with clear boundaries; in small inoperable gliomas and hemangioblastomas, meningiomas, pituitary adenomas, acoustic neurinomas, and others.

Because of the very high radiation dose and risk of necrosis, stereotactic radiosurgery is contraindicated in tumors that are located close to vital brain centers.

How long does standard radiation therapy take?

Each procedure, taking from several seconds to several minutes, is called a session (fraction). Standard radiation therapy can take 5-6 weeks for 5 sessions per week. However, there are more convenient treatments involving the delivery of high doses of radiation per session. The total radiation dose and regimen of therapy is choosed individually, depending on the characteristics of your tumor and the heath status.

The first problem is that the sensitivity of cancer to radiation depends on the phase of cell cycle. The second problem is that your healthy cells have to recover between procedures. Radiotherapy is a very complex treatment, which should be performed by experienced doctors.

Possible complications of radiation therapy

Radiation is completely painless. Complications may occur later. Skin burns, ulcers in the mouth, hair loss, change of appetite, nausea, weakness, anemia and frequent infections… These side effects last about 2-4 months after the end of treatment.

The complications depend on the specific treatment (protocol), received dose of radiation. Irradiation of different brain areas may produce different side effects. Contrary to popular belief, patients after external radiation beam therapy (EXBT) are not dangerous. They can safely spend time with relatives including little children.

The long-term effect of radiotherapy is much more serious threat. Despite all precautions, high-energy beams can damage brain (including the pituitary gland) and even eyes.

Among the long-term consequences there are thinking and memory problems , cataracts, hormonal imbalance. In rare cases, new malignant tumors caused by radiation can develop.

Ask your oncologist if radiotherapy benefit outweighs the potential risk.

MD Anderson Cancer Center in Houston, TX

Legendary MD Anderson Cancer Center focuses on personalized treatment of  brain and spinal cord tumors using advanced technologies and experimental drugs. Local scientists discover temozolomide and berubicin, the first-ever chemotherapeutic agent to penetrate the blood-brain barrier. MD Anderson participates in National Cancer Institute’s large-scale translational research  program SPORE.

Today, MD Anderson Cancer Center is one of the best clinics for diagnosis and brain cancer treatment in the United States. More than seven dozen experienced doctors and scientists are working to create therapy for tomorrow that meet your needs.

Brain cancer сhemotherapy

Chemotherapy is used for brain relatively rare. Usually "chemo" is combined with other therapeutic options, such as surgical resection or radiotherapy. Cytotoxic drugs disrupt growth and division of malignant cells, preventing their invasion into adjacent tissues. Unfortunately, "chemo" is dangerous for any rapidly dividing cells, including mucous membranes or fetal cells. Therefore, there is a lot of severe side effects.

The choice of specific chemotherapy, dose and treatment regimen depends on the type of malignancy, the stage of the disease, and the patient’s health.

Chemotherapy alone cannot cure cancer: cytotoxic agent reduce tumors before surgery, prevent relapse after treatment, control further growth of inoperable malignancies. Common medicines used in the US: cisplatin, etoposide, cyclophosphamide, irinotecan, lomustine, carmustine, procarbazine, vincristine, temozolomide and others.

How is chemotherapy delivered to the brain?

Some medicines can be given in tablets or intravenous injections (IV).

But most cytotoxic substances cannot penetrate the blood-brain barrier, so they have to be injected directly into the central nervous system. This is performed intrathecally (into the spinal canal), as well as through a special Ommaya reservoir (intraventricular catheter system) or biodegradable Gliadel wafers.

Ventricular access devices (VAD), such as the Ommaya reservoir, consist of a ventricular catheter and drug-filled reservoir. This device is intended to inject chemotherapeutic agents directly into the brain, and also remove excess cerebrospinal fluid. Some cancer clinics use biodegradable wafers with chemotherapeutic drugs. They are inserted into the brain during craniotomy. For 2 or 3 weeks they dissolve, secreting carmustine.

Brain cancer chemotherapy in the US typically lasts for months.

There is a treatment regimen for each drug and cancer type. Some medications are administered once a week, others for several days at intervals of a couple of weeks. In most cases, you do not need to stay in the hospital.

What are common side effects of chemotherapy?

“Chemo” is a very toxic treatment, because standard medicines suppress healthy cells. Cytotoxic agents disrupt hematopoiesis, immunity, digestion, nerve function.



Here are some of the typical side effects:

⦁ Frequent infections
⦁ Bleeding and bruising
⦁ Anemia and weakness
⦁ Nausea and vomiting
⦁ Indigestion and diarrhea
⦁ Changing food preferences
⦁ Hair loss and thinning
⦁ Skin and nail problems
⦁ Numbness of hands and feet
⦁ Chemo brain phenomenon

During chemotherapy, you should consult a doctor immediately with any suspicious symptoms. A common cold or a minor injury can result in severe complications! Positive results of chemotherapy are assessed by brain imaging: CT or MRI scan should demonstrate expected decrease in tumor size. It means that treatment works.

Corticosteroids

Corticosteroid hormones are often called "steroids". These are highly active natural or synthetic substances with powerful anti-inflammatory action. Do not confuse them with other "steroids" — anabolic hormones that some athletes abuse for non-medical purposes.

Why do we need corticosteroids in neurooncology?

The surgery or irradiation of the central nervous system can cause cerebral edema with increased intracranial pressure. Edema cause severe symptoms, such as seizures, headache, vomiting, faintness and even coma. Corticosteroids suppress inflammation and treat edema, alleviating the symptoms in some patients. Most often, fast-acting and active dexamethasone is used for this purpose.

Usually corticosteroids are administered with short intensive courses. These drugs have a lot of side effects, including supression of immune system, bone loss, and metabolic dysregulation.

Steroids do not treat brain cancer - they only alleviate your symptoms.

Immunotherapy

Brain cancer immunotherapy is a promising option that uses the immune system resources to fight disease. Some methods activate own immunocompetent cells (active immunotherapy), others deliver ready-made cells and antibodies (passive immunotherapy). It would seem that a strong healthy body must cope with foreign cells itself. But cancer is not so simple: malignant cells carry mutations that make it possible to hide from leukocytes. Immunotherapy overcomes these protective barriers to beat cancer.

FDA approved immunotherapy for malignant tumors of skin, breast, lung, prostate. Brain and spinal cord cancer immunotherapy remains experimental and controversial treatment option. One of the most important problems in this area is the blood-brain barrier, which reliably protects our central nervous system from dangerous substances.

Clinical studies conducted in the United States demonstrate that immunotherapeutic drugs, oncolytic viruses and cancer vaccines may prolong life of patients with inoperable tumors for several months, and in some cases for several years. This is real chance for them.

Oncologists successfully combine immunotherapy with other treatments, including chemotherapy and stereotactic radiotherapy.

Targeted therapy

Each tumor cell is unique. Modern cancer treatment is aimed at specific molecules present in each tumor cell. Targeted drugs work differently than the standard "chemo". Less influence on healthy organs and tissues, less toxic effects. Brain cancer targeted therapy in America can cost about $10,000 monthly, which exceeds $100,000 per year of treatment. Although targeted therapy doesn’t play a leading role in neuro-oncology, some medications like bevacizumab (Avastin) and everolimus (Athinitor) may be useful in inoperable brain cancers.

Bevacizumab is an antibody that targets vascular endothelial growth factor (VEGF). This drug stops the growth of blood vessels, limiting the nutrition of a growing tumor. Avastin is useful in relapses of certain tumors after treatment, including glioblastoma.

Everolimus blocks the cellular protein mTOR involved in cell division. The drug controls the growth of inoperable giant cell astrocytes and other agressive malignant tumors.

Our recommendations

Despite the high cost of procedures and medications, brain cancer treatment in the US is one of the best in developed countries. MD Anderson Cancer Center, Cleveland Clinic, Massachusetts General Hospital - these names are well-known far beyond the North American continent.

Here you can try the latest technologies, which are not available in most clinics of Europe or Middle East. High quality of care, comfort and safety standards worth every dollar.

The five-year relative survival in adults with brain cancers exceeds 37%, in children — 75%. These are excellent indicators of cancer care level in America.

© Analytical reviews and oncology news by K. Mokanov: clinical pharmacist and professional medical translator