Lung Cancer: Symptoms, Diagnosis and Staging - Joshua R. Sonett, MD
What You Need to Know About Lung Cancer That Has Spread to the Brain
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Lung cancer is one of the cancers that’s most likely to spread to the brain. Roughly 10 percent of patients with non-small-cell lung cancer (NSCLC) have brain metastases at their initial diagnosis; as many as 40 percent will eventually develop brain tumors at some stage during their illness, according to a retrospective cohort study published in August 2013 inCurrent Oncology. Unlike brain cancer, which originates in the brain and consists of brain cancer cells, brain metastases from lung cancer occur when cancer cells break off from the original tumor in the lungs and enter the bloodstream or travel through the lymph system to the brain, where they begin to multiply.
While metastatic lung cancer can rarely be cured, improvements in the detection and treatment of brain metastases are allowing people to live longer lives of higher quality. “In just the last three years, we’ve seen a significant shift in the paradigm of how we treat and manage this disease,” says Abigail Berman, MD, an oncologist who specializes in the treatment of lung cancer at the Hospital of the University of Pennsylvania in Philadelphia. “Not only have standard treatments for brain metastases, such as surgery and radiation, gotten better and more precise, but we have newer systemic therapies that can actually target these brain tumors in many patients.”
Recognizing the Signs of Brain Metastases
As metastatic brain tumors grow, they can directly damage brain cells, or they may affect the brain indirectly by compressing parts of the brain or causing swelling and increased pressure within the skull. Early warning signs, however, can be subtle and may easily be attributed to other causes, including chemotherapy, notes Jonathan Goldman, MD, an associate professor in hematology and oncology at the UCLA Jonsson Comprehensive Cancer Center.
Symptoms vary depending on the location of the metastases in the brain, but they often include:
- Nausea or vomiting
- Blurred vision
- Balance problems
- Loss of sensation or weakness along one side of the body
- Difficulty walking
- Loss of coordination (such as reaching for a door handle and missing)
- Speech problems
- Cognitive problems or memory loss
- Personality or behavior changes
If you consistently experience any of these symptoms, it’s important to alert your cancer care team as soon as possible. To diagnose brain metastases, your doctor will most likely perform a neurological exam (which may include checking your vision, hearing, balance, coordination, strength, and reflexes) and order a magnetic resonance imaging (MRI) scan of your head — an MRI can not only detect cancer but precisely identify the location and size of any brain lesions. Other imaging tests your doctor may use include positron emission tomography (PET) and computerized tomography (CT) scans. A biopsy may also be done to confirm a diagnosis and help determine the best course of treatment. During a biopsy, brain tumor tissue is removed (either as part of surgery to remove the tumor or in a procedure in which a small sample is taken with a needle) and then viewed under a microscope to determine whether it’s cancerous and, if it is, whether it’s a primary or metastatic tumor.
How Brain Metastases Are Treated
If diagnosed and treated early, brain metastases usually respond to therapy. Your treatment plan will depend on the size and number of tumors, where they’re located in the brain, the genetic characteristics of the cancer cells, and the extent of disease outside the brain — as well as your overall health. Treatment may include:
Surgery. “For patients with only one or two brain metastases that are easy to access, or a larger tumor that’s causing compressive symptoms, surgery can be very effective,” says Dr. Berman. Surgery, which may involve the complete or partial removal of a tumor to help alleviate symptoms, is typically followed by whole-brain radiation.
Radiation.This type of therapy involves the use of X-rays or other high-energy beams to kill cancer cells. And different methods of radiation are used to treat brain metastases. People with fewer than five lung cancer metastases in the brain may be good candidates for stereotactic radiation, in which advanced imaging and computer guidance are used to deliver large doses of radiation directly to tumors. “This approach can effectively treat metastases with little radiation exposure to other parts of the brain and with minimal side effects,” says Dr. Goldman. If you have many tumors throughout the brain, or a large tumor located deep in the brain, your doctor may recommend whole-brain radiation, in which radiation is applied to the entire brain to kill tumor cells. “This method,” Goldman explains, “treats the whole area but unfortunately comes with more side effects, such as headache, fatigue, nausea, hair loss, and some slowed cognition.”
Systemic therapy.Systemic therapies, which include chemotherapy, targeted therapy, and immunotherapy, involve drugs that travel through the bloodstream to reach cancer cells throughout the body. Because many chemotherapy drugs are unable to cross the blood-brain barrier — a network of capillaries that keeps certain substances from reaching the brain — targeted therapies are the primary systemic form used to treat brain metastases. Targeted therapies can identify and attack specific cancer cells with minimal harm to normal cells. For people with lung cancer cells that have specific mutations (such as EGFR and ALK mutations), these therapies can be highly effective. “Unlike traditional chemotherapies, these drugs are able to cross the blood-brain barrier and treat the brain tumors,” says Berman. “In fact, patients who have very small brain metastases with these mutations may be able to go on a targeted therapy without any need for radiation or surgery.”
If your lung cancer doesn’t carry these specific mutations or has metastasized elsewhere in the body, other systemic therapies, such as immunotherapy (which uses medicine to activate your own immune system to recognize and kill cancer cells) and chemotherapy, may be considered.
Palliative care.This type of specialized medical care, which can include physical therapy, relaxation techniques, exercise, speech therapy, and pain management, is also a key component of treatment for patients with metastatic NSCLC. These complementary approaches can help mitigate the side effects of both the cancer and its treatment and significantly improve quality of life. Information and support for people with lung cancer and their families is available at the Lung Cancer Foundation, the American Cancer Society, and the Global Resource for Advancing Cancer Education (GRACE).
After surgery, radiation, or systemic treatment for brain metastases, your doctor will most likely have an MRI performed to determine how much of the tumor is gone and will continue to follow up with an MRI every few months.
The prognosis for people with NSCLC that’s metastasized to the brain is highly variable, but it’s important to keep in mind that statistics don’t necessarily pertain to your particular situation. While the outlook traditionally was poor for people with NSCLC and brain metastases, advancements in treatment are continually improving survival rates. “We’re now seeing many patients surviving at least two years,” says Berman, “and a few of my patients are alive even five years after diagnosis.”
Clinical trials are regularly being conducted to find ways to improve treatments for people with NSCLC that’s metastasized to the brain — ask your doctor whether you may be a candidate for such a trial.
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