Understanding brain tumors: Symptoms, causes, risk factors and treatment

Like every year, International Brain Tumour Awareness Week is being observed from October 26 to November 2, 2024. This initiative was started by the International Brain Tumour Alliance (IBTA) in 2005.

Any form of malignant tumour is dangerous and can't be ignored. It is no different for brain tumours. According to the Asian Heart Institute, Brain Tumour Foundation of India, and other research papers, the number of people affected by brain tumours in India is estimated to be between 40,000 and 50,000 annually. This number includes both adults and children.

Recognising the widespread lack of awareness about brain tumours among the general public, midday.com reached out to Dr Kaustubh Mahajan, Consultant Neurologist, SL Raheja Hospital, Mumbai and Dr. Ravikiran Vutha Consultant Neurosurgery, Apollo Hospital Navi Mumbai to shed some light on brain tumours.

What are the causes of brain tumours?
Vutha: The causes of brain tumours are complex and often elusive, as they can stem from a variety of factors, some of which remain unidentified. Clinically, genetic mutations are a primary cause, where the DNA within brain cells undergoes abnormal changes, leading cells to grow uncontrollably and form a tumour. Some individuals may inherit genetic conditions like neurofibromatosis, Li-Fraumeni syndrome, or Von Hippel-Lindau disease, which increase their risk for brain tumours. Additionally, prolonged exposure to ionising radiation, often from medical treatments like radiotherapy, is linked to a higher risk. For many, the cause remains unknown, making it challenging to implement preventive measures. The lack of clarity on the causes can be emotionally taxing for patients and families, as it leaves them grappling with "why" this happened, underscoring the importance of psychological support in treatment.

Mahajan: There's no definite cause for any particular brain tumour. But usually, we divide them into genetic causes and environmental causes. But most of the tumours, we don't find the cause, in that some environmental causes are mainly related to radiation exposure, like x-ray radiation, atomic radiation, and the one that can be coming from phones or network towers.

Are there different types of brain tumours?
Vutha: Yes, brain tumours are varied and classified into two main categories: primary and secondary. Primary brain tumours originate within the brain itself and include both benign (non-cancerous) and malignant (cancerous) forms. Some common primary types are:
● Gliomas: Including astrocytomas, oligodendrogliomas, and glioblastomas, these arise from glial cells and are often aggressive.
● Meningiomas: Typically benign, these tumours arise from the meninges, the layers surrounding the brain and spinal cord.
● Medulloblastomas: More common in children, these malignant tumours form in the cerebellum and can spread through the cerebrospinal fluid.
Secondary (metastatic) brain tumours originate elsewhere in the body, such as the lungs or breasts, and spread to the brain. This classification informs treatment plans, as benign tumours may only need observation or limited surgery, while malignant tumours often require a multi-faceted approach involving surgery, radiation, and chemotherapy. Each type has unique characteristics and impacts, affecting patients' daily lives in different ways, from cognitive functions to mobility.

Mahajan: The different types of brain tumours are divided basically from where they arise in the brain, and from which cells they arise. There are many different types of cells in the brain, like glial cells, which cause glioma, and meningeal cells, which are the covering of the brain, which cause meningioma. Pneumos are the most common type of brain tumours. Also, we can divide these brain tumours into grades. Where grade 1 and grade 2 are low-grade tumours, called benign or non-cancerous tumours, while grade 3 and grade 4 are high-grade tumours, which can be classified as malignant or cancerous tumours

3. What are the early signs and symptoms of brain tumour?
Vutha: Early symptoms of a brain tumour are often nonspecific, meaning they can be mistaken for more common health issues. Persistent headaches, especially those that worsen upon waking or with coughing and sneezing, are a hallmark sign. Additionally, changes in vision or hearing, unexplained nausea or vomiting, memory lapses, and difficulty with coordination or balance may occur. As the tumour grows and affects specific brain regions, symptoms may intensify, causing muscle weakness, seizures, or speech difficulties. The varied presentation of these symptoms makes it crucial for patients and their loved ones to seek medical evaluation promptly, as early detection can improve outcomes.

Mahajan: Brain tumours usually give signs and symptoms from where they are arising, like which part of the brain they are coming from. In some parts of the brain, like the frontal lobes of the brain, tumours can become very large and people may not come to know, and there will be very subtle signs mild changes in behaviour, irritability without any obvious cause. Then, that can be a sign of a frontal lobe tumour, or sometimes there can be side effects, like cataract issues; there is no obvious cause of that happening, but still, you notice these patients are patients having changes in their behaviour.
● Seizures: When tumours increase in size and press the adjacent normal brain tissue. And then the brain, whatever it is responsible for, that deficit is seen in the patient. So for example, you will get a seizure if the brain tumour is coming from the right side of the brain, then start getting left focal seizures, which are in the left side. Seizures are small jerky movements in one part of the body, which can sometimes increase and involve the whole body.
● Headache: It usually comes last if the brain tumour is really large and it is coming from inside and stretching the covering or obstructing the circulation of the brain or drainage of the blood in the brain. Brain parenchyma is painless. It's only the coverings of the brain when stretched, when you experience pain, or only when the venous system or the drainage system, when stretched or there is a clot, you get pain. If a person is used to having headaches, then suddenly the pattern changes, or it's a different kind of headache, or there is a sudden severity change in the headache. Patterns and decisions, or a new onset headache or early morning headaches, especially which wakes you up from your sleep. So these are what we call red flags and addiction, and neurological signs and symptoms should not be ignored and be immediately shown to a neurologist or a neurosurgeon.
● New neurological deficits: like blurred speech, imbalance, and blindness
● Vomiting: This is very important. Headaches are associated with vomiting. Otherwise common in migraines. But not when it is tumour-related. Usually, the vomiting is not associated with prior nausea. Vomiting and headaches can be classically seen early in the morning when you wake up or when it wakes you up from your sleep, and third, the nausea component before vomiting will not be there.

4. Which age group and gender is most likely to get brain tumours? Are people with a particular type of past health history more vulnerable to it?
Vutha: Brain tumours can affect any age group, but the risk often correlates with age, and certain types are more common in specific demographics. In children, tumours like medulloblastomas are more prevalent, while older adults are at a higher risk for gliomas and meningiomas. Research suggests a slight male predominance in brain tumours overall, although specific tumours like meningiomas occur more frequently in women. Individuals with certain health histories, including those with previous cancer treatments (especially radiation), genetic predispositions, or family histories of brain tumours, may have heightened vulnerability. For these individuals, clinicians often advise regular monitoring, as early signs can otherwise go unnoticed, potentially leading to late-stage diagnosis.

Mahajan: Yes, people who have risk factors for cancer, like smoking or having certain habits like tobacco, then definitely have cancer in the body, which can spread in the brain. Sometimes, the brain tumour is the first symptom, which is the seizures, and then the primary cancer is detected. Sometimes, people who have trauma frequently, like falls, bleeding tendencies in the brain, and an already existing benign tumour can bleed in the brain, which can give rise to symptoms. The cause of brain tumours is not very definite. Many times we cannot find the cause, but radiation, chemical exposures, and cancer, which can be either familial, genetic, or environmental risk factors, like tobacco and smoking. Age groups, again, certain tumours are specific to children, like retinoblastoma, which is present very acutely. Certain tumours are specific to the elderly, like benign tumours which are usually cancerous, but there is no specific rule. And even if it's a benign tumour, it will be very slowly growing, and it will present at an elderly age. So the elderly population is more prone to having tumours.

5. When should a person consult a doctor about a brain tumour? Are timely checkups advisable?
Vutha: Persistent symptoms, particularly those that interfere with daily functioning - such as unrelenting headaches, sudden changes in vision or personality, or unexplained nausea - warrant prompt medical consultation. Delaying evaluation could result in a more advanced diagnosis, complicating treatment. Regular check-ups may not be common for everyone, but individuals with genetic predispositions or those previously exposed to high doses of radiation are encouraged to monitor their health more closely. Early intervention can provide more treatment options and, potentially, a more favourable prognosis, emphasising that timely action can be lifesaving.

Mahajan: If any of these signs and symptoms are there, then definitely one should approach a doctor.
● Headaches: Mainly if it is a headache, change headache pattern or is associated with vomiting.
● Neurological deficit in the form of deep slurring, imbalance, visual symptoms, or any particular hand that is getting weak. Hand weakening, in simple words, is paralysis, many people use the term where your hand starts getting hand or one side of the body starts getting weak, or if it is a sudden thing like suddenly your arm got weak but two minutes back, it was perfectly okay, or when you slept in the night, that time it was okay, but you woke up in the morning, it was weak. This kind of weakness is usually seen in a stroke, but in a tumour-related paralysis, it will usually be over the period, slowly over the weeks, progressing step by step. Initially, it was only the hand and the thumb that were weak. Now the whole hand has got weak. Now the whole arm has gotten weak over a period of weeks.
● Seizures, which can be catapulted, but if it is a focal seizure, then usually some people may miss it.

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6. What is the impact of a brain tumour on a person mentally and physically?
Vutha: The presence of a brain tumour impacts patients profoundly, both physically and psychologically. Physically, depending on the tumour's location and size, individuals may face challenges such as muscle weakness, seizures, loss of coordination, and sensory impairments. These physical effects can lead to decreased mobility and dependence on others for basic tasks, significantly impacting their quality of life. Mentally, the tumour or treatment may induce mood changes, cognitive impairment, memory issues, and emotional distress, creating a sense of isolation. Such challenges underscore the importance of comprehensive care, which includes physical rehabilitation and psychological support, helping patients cope with their altered abilities and emotional turmoil.

Mahajan: The impact of a brain tumour is very huge, not only mentally and physically, but also on the family. The important factor that I would like to address here is that most of the brain tumours are grade 1, or grade 2, which means they are benign, where they must have been sitting for a long time and not causing any problem, and your headaches may be related to something else. So knowing whether the brain tumour is the culprit of your symptoms or it's an incidental finding on the MRI is very important. If this is not sorted out with the neurologist properly, then it is a stigma and it affects the patient mentally so much that the whole quality of life gets ruined. Knowing whether it is the culprit, whether it needs to be treated or not, and what to do for the treatment, all these things have to be sorted out with a neurologist. Sometimes, there are certain tumours that are incidental and which need not be treated but ignored and only monitored on repeated six monthly, one yearly MRIs. And sometimes the person would have grade three and grade four and just by seeing the imaging patterns, we have to do something quickly. So what usually happens in a family, if somebody had a grade one tumours, he says we just kept repeating and nothing happened. And somebody who has a grade three may think he may follow the same pattern. That is not true. So the doctor has to guide them properly and be urgent.

7. What is the severity of a brain tumour?
Vutha: The severity of a brain tumour depends largely on its type, location, and growth rate. Benign tumours like meningiomas may remain stable and asymptomatic for years, while malignant tumours such as glioblastomas grow rapidly and invade surrounding tissues, often leading to significant neurological deficits. If left untreated, brain tumours can severely impair brain function, impacting everything from cognition to vital processes like breathing and heartbeat regulation. Malignant tumours can metastasise to other parts of the body or cause increased intracranial pressure, which, if unchecked, may be fatal. This highlights the urgency for early diagnosis and proactive management to mitigate the potential life-threatening effects.

Mahajan: We divide brain tumours into 4 grades which are Grade 1, 2, 3, 4, and this is a WHO grading. Grade 1 and 2 are low-grade gliomas, anything that is above 2, that is, 3 and 4, are high grade gliomas that will turn out to be malignant, or, in simple words, cancerous. That's why they have to be treated. Grade 1 and Grade 2 turn out to be the same and usually non-cancerous, which can be monitored over time and need not be touched if they are not causing any symptoms. If the symptoms are fixed, then we will usually manage it only with medicines. We may not touch the tumour, we may not operate, but in grade three, grade four, even if it is not causing any symptoms, we have to remove it because over the period, it will increase and cause a lot of harm.

8. What is the post-operation care schedule that people and their families need to follow? Are there any possible side effects they need to be aware of?
Vutha: Post-surgical care is essential for recovery, as it aids in minimising complications and supporting overall health. Rehabilitation therapies, including physical, occupational, and speech therapies, often become part of the recovery routine to help regain lost functions and manage potential side effects like fatigue, weakness, or cognitive challenges. Regular follow-up visits and imaging (CT or MRI scans) are typically advised to monitor for signs of recurrence. Side effects from surgery can include swelling (edema), seizures, or infection, making it crucial for family members to stay informed and vigilant. Emotional support and patience from loved ones are invaluable during this phase, as patients often experience mood changes or frustration with their pace of recovery.

Mahajan: Post-operation, just immediately after the surgery, you will be getting a set of dos and don'ts. Okay. Mainly regarding when to have a proper bath and when to wash your head. So usually, after a brain surgery, the hair is cut. They don't have hair, and the suture site can be sometimes irritating or itching, so instructions like what has to be done for that? What clean has to be applied? All these sets of rules are given. Other than things you have to watch for in a postoperative patient is mainly that Is the headache increasing? Earlier, it was not there. Or any new neurological deficit that was not there now has started to come, like the speech was pretty okay after surgery, but now the speech has started to become slurred or the headache was not there, but now the headache has started. Or an imbalance has started or seizures have started. So anything of this sort, neurologically, uh, new issues have to be watched for and told to be told to the consent physician. The families have to keep a watch on the patient; if the patient has balance issues, especially when the patient gets up and the patient turns, then there should be no falls. Because the patient who's immediately postsurgery has a fall, they can bleed. So, uh, being cautious about how they move around, being there behind them, knowing when the risk of falling is more, like when they get up or when they turn. Taking care of those instances has to be warned earlier by the concerned physician so that these things don't happen. Also, if the patients might have a food pipe for their nutrition, how to feed them through a food pipe, how much amount has to be given, when that amount has to be reduced, and to ensure that there is no already food inside the tummy while giving to the food pipe next time. So all these are trained for the caregivers and attendants of the patient when they are discharged.
● After an operation that a patient would go through, the side effects of the operation are mainly dependent on whether the operation is a surgical operation or a radiation treatment. Usually, when you operate surgically, there can be immediate complications, like bleeding complications. Later complications can be like seizures, which if it happens, you may have to step up the medicines or add some medicine. Radiation can cause late complications like swelling in the brain and cause some neurological issues. Or any new neurological symptoms, for that matter, or any new symptoms that have come after the surgery or radiation have to be informed to the concerned physician. Usually in the first one or three months, you have to be vigilant.

9. Can brain tumours reoccur after treatment?
Vutha: Unfortunately, brain tumours can sometimes recur, particularly malignant types. Factors such as the original tumour's grade, location, and extent of surgical removal influence the likelihood of recurrence. To address this, doctors often implement a comprehensive treatment plan involving surgery, radiation, and chemotherapy to reduce the chances of recurrence. After completing treatment, patients typically undergo regular follow-ups, including imaging studies, to detect any early signs of a tumour returning. Although the risk of recurrence can be emotionally challenging, regular check-ups and vigilant monitoring provide reassurance, allowing doctors to intervene promptly if necessary.

Mahajan: Grade 1 and grade 2 don't grow rapidly, so the recurrence rate is not there. But grade 3 and grade 4, especially grade 4 tumours like glioblastoma, are rapidly growing malignant brain cancer tumour even after removing radiation or even after chemotherapy, and they are likely to regrow. tumours do regrow, especially if they come into the grade three or grade four category.

10. Are there support resources available for patients and their families who have been through the process?
Vutha: Yes, there is an array of resources available to help both patients and their families. Many hospitals offer access to social workers, support groups, and counselling services to assist with the emotional and logistical challenges of a brain tumour diagnosis. National organisations, such as the Brain tumour Foundation, provide educational materials, peer support networks, and assistance with navigating healthcare services. Additionally, online forums and local support groups can provide a sense of community and shared experiences. These resources play a vital role in helping patients and families cope with the emotional impact, manage daily care needs, and find solidarity in the shared journey of healing.

Mahajan: Yes, there are support groups, brain tumour societies, which do counselling, and similar patients with similar problems can meet online or offline.