Brain Cancer Symptoms, Treatments & More in Singapore
What is Brain Cancer?
Cancer is characterised by uncontrolled growth of abnormal cells in the body that can potentially spread to other areas, according to the National Cancer Institute’s definition.
This term encompasses a broad range of diseases marked by abnormality in cell growth. Due to this uncontrolled proliferation of cells, the formation of a mass known as a tumour may occur. Of these, some tumours may be cancerous and others noncancerous, which do not spread to other body parts.
Brain cancer, specifically, involves the growth of abnormal cells in the brain or spinal cord. It originates from the brain cells themselves and is typically named after the type of tissue from which it arises. Primary brain cancers develop from the cells within the brain and differ fundamentally from secondary brain cancers, which result from cancer cells that have metastasised from other parts of the body to the brain.
These growths disrupt normal brain function, potentially impacting movement, sensory perception, and cognitive abilities, making it crucial to understand their origins and characteristics.
Types of Brain Tumour
Tumours represent an abnormal mass of cells that grow and multiply without the usual controls that regulate cellular life cycles. They can be categorised into two primary groups: benign and malignant.
Benign tumours are those that remain localised, do not spread to other parts of the body, and are generally not considered cancerous. While they might not be life-threatening, their size and location can still cause significant health issues if they compress nearby tissues or organs.
Conversely, malignant tumours are more aggressive and may invade and destroy surrounding healthy tissue. These tumours can also metastasise, meaning they can spread to other parts of the body and initiate new areas of cancer, leading to serious health implications.
In the context of the brain, these distinctions remain relevant. Brain tumours, also known as intracranial tumours, can either be categorised into two main types: benign and malignant, each presenting different growth patterns and health implications.
Benign Brain Tumours
Benign brain tumours are non-cancerous growths that generally grow at a slow pace and have a lower likelihood of recurrence following treatment. However, their location and size can still cause serious symptoms depending on the pressure they exert on sensitive areas of the brain.
Common types of benign brain tumours include:
- Meningioma: Meningioma is the predominant type of benign brain tumour originating from the meninges, the protective membranes encasing the brain and spinal cord. While typically non-cancerous, there are rare instances where meningiomas may exhibit malignant characteristics.
- Schwannoma: A common benign tumour in adults that develops along nerves that provide insulation for nerve cells. Acoustic neuromas, the most prevalent type, form on the eighth cranial nerve, affecting balance and hearing from the brain to the ear. While typically non-invasive, these tumours can lead to complications if they grow and exert pressure on nerves and brain tissue. Schwannomas may also occur along spinal nerves and, less frequently, nerves leading to the limbs.
- Pituitary Adenoma: Originates in the pituitary gland at the base of the brain, affecting hormone production.
- Craniopharyngioma: Often occurring near the pituitary gland, affecting hormonal and visual functions.
- Hemangioblastoma: Appears in the cerebellum, affecting blood vessels.
- Chordomas: These tumours are uncommon, benign tumours known for their slow growth, often originating in areas like the base of the skull or the lower spine. They may also invade nearby bone and exert pressure on adjacent neural tissues despite their benign nature.
- Gangliocytomas, Gangliomas, and Anaplastic Gangliogliomas: Rare tumours that form in neurons (nerve cells).
- Glomus Jugulare: Typically located just under the base of the skull at the top of the jugular vein.
- Pineocytomas: Slow-growing tumours that form in the pineal gland, which secretes the hormone melatonin.
Malignant Brain Tumours
Malignant brain tumours are characterised by their rapid growth and a higher risk of spreading within the brain. These tumours can be life-threatening due to their invasive nature and the complex regions of the brain they may affect.
Types of malignant brain tumours include:
- Gliomas: Including astrocytomas, ependymomas, glioblastomas (GBMs), and oligodendrogliomas. Gliomas develop in glial cells that surround and support nerve cells.
- Astrocytoma: The most frequent type of glioma, originating from astrocytes, star-shaped glial cells that support brain tissue. While they can develop in various brain regions, they are most commonly found in the cerebrum.
- Ependymoma: Often located near the ventricles, developing from ependymal cells.
- Glioblastoma (GBM): Aggressive form of astrocytoma, known for its rapid growth and invasive nature within the brain. Comprising various cell types, including astrocytes and oligodendrocytes, GBM tumours spread quickly to neighbouring tissues, contributing to a challenging prognosis.
- Oligodendroglioma: Begins in cells that create myelin around nerves in the brain.
- Medulloblastoma: The most common cancerous brain tumour in children, fast-growing and located at the base of the skull.
Potential Causes of Brain Cancer
Understanding the causes of brain cancer requires examining how genetic predispositions and environmental influences interact intricately. Do note, however, that the process by which brain tumours develop is highly complex and not entirely understood. For instance, it remains a mystery why some individuals exposed to the same environmental conditions develop brain tumours while others do not.
In general, it is understood that when cell growth regulation fails, cells may uncontrollably divide, forming tumours. These tumours can hinder immune system recognition and produce angiogenesis factors, prompting new blood vessel growth to meet their increased oxygen and nutrient demands. This interplay of genetic faults and environmental factors fuels brain cancer development, highlighting its multifaceted origins.
Several factors could potentially cause brain tumours, including:
1. Genetic Factors
Genetic mutations are thought to play a crucial role in the development of brain tumours. These genetic mutations can either be inherited from parents or arise spontaneously in the body and impact the genes that control cellular growth and division. Typically, these genes are responsible for ensuring that cells grow and divide in an organised way, repair any DNA damage, and initiate cell death if the damage is too extensive. When these genes are altered, cells can start to grow uncontrollably. In some individuals, inherited genetic conditions can predispose them to these mutations, making them more susceptible to developing brain tumours. Conditions such as neurofibromatosis, Von Hippel-Lindau disease, and Li-Fraumeni syndrome are examples where genetic predispositions can lead to tumour formation.
2. Secondary Brain Tumours
Metastatic brain tumours, referred to as secondary brain tumours, develop when cancer cells from primary tumours elsewhere in the body spread to the brain. Cancers frequently spreading to the brain encompass lung cancer, breast cancer, melanoma, and renal cell carcinoma. This metastatic process involves cancer cells breaking away from their original site, travelling through the bloodstream or lymphatic system, and forming new tumours within the brain tissue.
3. Exposure to Radiation
Exposure to ionising radiation is another risk factor thought to cause the development of brain tumours. This can include radiation from medical treatments such as radiotherapy for other cancers and, less commonly, exposure to radiation from environmental sources. Radiation can damage DNA in brain cells and lead to mutations that disrupt normal cell functions and promote tumour growth.
Risk Factors
While the exact cause of most brain tumours remains largely unknown, there are several recognised risk factors that could potentially increase the likelihood of developing a brain tumour.
1. Age
It is thought that the development of a brain tumour generally increases with age. However, certain types of brain tumours, such as medulloblastomas, are more commonly diagnosed in children, indicating that the risk varies not only by age but also by tumour type. In Singapore, between 2016 and 2020, according to the Singapore Cancer Registry Annual Report 2020, brain and central nervous system (CNS) cancers were notably diagnosed among the younger population, with 67 males and 52 females aged 0 to 29 years being diagnosed. Interestingly, brain and CNS cancers are not listed among the top 10 cancers in individuals over 40 years old, indicating a potential influence of age on the types of cancers prevalent in different age groups.
2. Radiation
Although less common, there are also risks associated with radiation exposure from diagnostic imaging, such as CT scans and X-rays of the head. These risks, however, are generally considered small and are usually outweighed by the benefits of accurately diagnosing and treating medical conditions.
3. Genetic Factors
A family history of brain tumours or inherited genetic syndromes such as Turner syndrome can significantly increase an individual’s risk. These conditions are known to affect cellular growth pathways, leading to an increased likelihood of tumour development.
4. Gender
Statistical data shows a slight variation in brain tumour incidence between genders. Some types of brain tumours are more common in males, whereas others may be more prevalent in females. For instance, according to the Singapore Cancer Registry Annual Report 2020, between 2016 and 2020, a total of 105 males between ages 0 and 39 were diagnosed with cancers of the brain and CNS. However, there were only 52 incident cases among females of the same age group, suggesting that biological differences between genders could influence tumour development.
5. Family History
Having a family member with a brain tumour can increase the risk of developing one, especially if the family member has a genetic condition associated with brain tumours. This familial tendency suggests a genetic component to susceptibility, which might be significant in a small percentage of cases.
6. Weakened Immune System
Individuals with compromised immune systems, whether from medical conditions like HIV/AIDS or from medical treatments such as organ transplants, are at an elevated risk for developing various types of tumours, including brain tumours. Since the immune system plays a crucial role in detecting and controlling abnormal cell growth, any impairment could lead to increased tumour formation.
Symptoms of Brain Tumour
Symptoms of brain cancer can vary significantly depending on the tumour’s size, location, and rate of growth. These symptoms could also be caused by the tumour pressing on or damaging nerves or other parts of the brain as it grows.
Common symptoms include:
- Headaches: Often worse in the morning or when changing positions.
- Nausea or Vomiting: Especially if it occurs without other known causes.
- Cognitive Difficulties: Problems with memory, speech, or performing daily activities. There might also be confusion in familiar situations or significant memory lapses.
- Personality or Behavioral Changes: Alterations in mood, personality, or behaviour.
- Weakness or Paralysis: Decreased strength or numbness in part of the body.
- Vision Problems: Blurry vision, double vision, or loss of peripheral vision.
- Hearing Problems: Sudden hearing loss or ringing in the ears.
- Balance Problems: Difficulty with coordination or frequent falls.
- Fatigue: A deep, persistent exhaustion that doesn’t improve with rest.
- Dizziness or Vertigo: A sense of spinning or losing one’s balance
- Seizures: New onset of seizures or an increase in frequency can occur, even in someone who has never had seizures before. While tonic-clonic seizures are dramatic, brain tumours are more likely to cause focal seizures, which might manifest as:
- Feeling detached or “spaced out”
- Sensing familiarity (déjà vu) or unfamiliarity (jamais vu)
- Intense emotions and hallucinations
- Distorted senses like unusual smells or tastes
- Difficulty speaking or understanding speech
- Repetitive movements and sensations of limb enlargement
- Physical sensations like tingling or muscle stiffness
It’s important to note that these symptoms can also indicate other health conditions, so it’s crucial to consult a healthcare professional for a proper diagnosis.
Diagnosing Brain Tumours
Diagnosing brain tumours involves a comprehensive series of tests and procedures designed to identify the presence, type, stage, and specific characteristics of the tumour. Each diagnostic tool contributes uniquely to providing a detailed understanding of the tumour, which is crucial for planning an appropriate treatment approach.
1. Neurological Exam
A neurological exam is typically the first step in the diagnostic process for a suspected brain tumour. During this exam, a cancer specialist or neurologist will test functions controlled by the brain, including vision, hearing, balance, coordination, strength, and reflexes. Difficulty in any of these areas may indicate problems in specific parts of the brain, which helps narrow down the potential locations of a tumour.
2. Imaging Tests
CT Scan: A Computed Tomography (CT) scan is often one of the first imaging tests performed if a brain tumour is suspected. It creates cross-sectional images of the brain, which can show tumours, as well as bleeding, swelling, and other abnormalities.
MRI: Magnetic Resonance Imaging (MRI) uses magnetic fields and radio waves to produce images of the brain. MRIs can distinguish between different types of tissue, which can help with identifying the boundaries between a tumour and normal brain tissue. Special types of MRI scans, like functional MRI, magnetic resonance spectroscopy, and magnetic resonance perfusion, provide additional information about brain activity, the chemical environment within the tumour, and blood flow within the tumour, respectively.
PET Scan: Positron Emission Tomography (PET) scans are less commonly used initially but can be helpful in assessing the atypical metabolic activity of the tumour. In a PET scan, a small amount of radioactive material is injected into the bloodstream, which accumulates in cancer cells. A scanner then detects this material to produce images that highlight areas of high activity, indicative of rapidly dividing cancer cells.
Brain Biopsy: If imaging tests suggest the presence of a tumour, a brain biopsy may be conducted to check if the tumour is malignant. This can be performed as part of surgical removal of the tumour or separately using a needle. A stereotactic needle biopsy involves drilling a small hole in the skull and inserting a needle to extract a tissue sample.
3. Additional Diagnostic Tests
- Spinal Tap: Also known as a lumbar puncture, it involves collecting and examining cerebrospinal fluid (CSF) surrounding the brain and spinal cord to detect cancer cells, bleeding, or other abnormalities.
- Neurocognitive Assessment: This set of tests evaluates the cognitive impacts of the tumour, assessing memory, problem-solving skills, attention spans, and other intellectual functions.
- Neuro-ophthalmological Examination: This examination checks for vision problems that might result from the tumour affecting the optic nerves or pressure on certain parts of the brain.
- Endocrinological Evaluation: Since some brain tumours can affect hormone production, particularly those near or within the pituitary gland, this evaluation assesses hormone levels and endocrine function.
- Blood and Urine Analyses: Typically, it is not directly involved in diagnosing brain and spinal cord tumours. However, they play a crucial role in assessing overall organ function, particularly the liver and kidneys, which is vital before surgical procedures. For patients undergoing chemotherapy, regular blood tests monitor blood counts and gauge the treatment’s impact on systemic health.
Brain Tumour Grading
Grading brain tumours is crucial in assessing their severity by evaluating their cellular properties and growth potential.
The grading system spans from Grade I, indicating the least aggressive tumours, to Grade IV, denoting the most aggressive forms, guiding treatment decisions and prognosis.
1. Grade I Brain Tumour
Grade I brain tumours are considered benign, with cells that appear nearly normal under a microscope. These tumours grow slowly and are the least likely to invade surrounding brain tissue. They are often associated with long-term survival and are more common in children than in adults. Surgical removal of Grade I tumours could lead to a potential for a complete cure.
2. Grade II Brain Tumour
These tumours are also relatively slow-growing but are more likely to behave in a malignant manner compared to Grade I tumours. Under a microscope, the cells of a Grade II tumour appear slightly abnormal. There is a possibility of these tumours invading adjacent normal tissues and recurring, sometimes as a higher grade tumour.
3. Grade III Brain Tumour
Grade III tumours are malignant and characterised by actively reproducing abnormal cells that can infiltrate nearby normal brain tissue. Microscopically, these cells appear significantly abnormal and more aggressive than those in Grade II tumours. Grade III tumours are also prone to recurrence, often returning as more aggressive tumours.
4. Grade IV Brain Tumour
The most aggressive form, Grade IV brain tumours, grow rapidly and spread quickly into nearby brain tissue. These tumours are highly malignant, with cells that look very abnormal under a microscope. They are known for forming new blood vessels to sustain their rapid growth and often have areas of dead cells (necrosis) at their core due to their fast growth outstripping their blood supply.
NOTE: The grade of a brain tumour can sometimes evolve over time; for instance, a lower-grade tumour can transform into a higher grade over time due to genetic changes within the tumour cells. This dynamic nature of brain tumours makes ongoing monitoring essential after initial treatment.
How Brain Tumours Are Graded
Since understanding the grade of a brain tumour is crucial for developing an appropriate cancer treatment plan, pathologists grade brain tumours by examining tissue obtained from a biopsy. The process involves assessing the tumour’s cellular makeup, rate of cell division, and the presence of necrosis and vascular proliferation.
When to See a Doctor?
It is crucial to consult a doctor if you experience symptoms that may suggest a brain tumour, such as persistent headaches, vision problems, seizures, or changes in personality. Early detection is key in managing brain tumours effectively.
Seeing Your Doctor
Make an appointment with your healthcare provider as soon as you notice any concerning symptoms. It’s important to discuss all symptoms, even those that seem minor, as they can provide significant clues about the presence of a tumour.
Tips to Get the Most Out of the Appointment
Prepare for your visit by listing all symptoms, medications, and any prior medical history. You may want to consider having a family member or close friend accompany you for support and to assist in recalling the information discussed.
What Happens During the Appointment
The doctor will likely conduct a neurological exam to assess your reflexes, muscle strength, eye and mouth movement, coordination, and alertness. Based on the initial findings, they may order additional diagnostic tests, such as an MRI or CT scan, to investigate your symptoms further. This comprehensive approach helps ensure proper diagnosis and appropriate treatment planning.
Brain Cancer Treatment Options
Treatment approaches for brain cancer differ depending on the tumour type, size, location, and the patient’s general health. Here are the main treatment modalities available:
Surgery
Often the first line of treatment, surgery aims to remove as much of the tumour as possible. When tumours are located in areas that make them accessible and removable, surgery may potentially improve prognosis by reducing the amount of cancerous tissue.
Radiation Therapy
Harnesses high-energy beams like X-rays or protons to pinpoint and eradicate cancer cells. It’s typically employed post-surgery to eradicate residual cancer cells and can serve as the primary treatment when surgical intervention isn’t feasible.
Chemotherapy
Chemotherapy employs medications to eradicate or inhibit the growth of cancer cells. This treatment method may be administered orally or through intravenous infusion and is often combined with surgery or radiotherapy for comprehensive cancer management. Chemotherapy’s effectiveness depends on the type of brain tumour, as some cancers are more responsive to chemical treatment than others.
Laser Interstitial Thermal Therapy (LITT)
LITT is a less invasive treatment option that uses laser technology to deliver controlled heat directly to a brain tumour. This method is particularly useful for tumours that are hard to reach with traditional surgery or in patients who cannot undergo standard surgery. LITT can target the tumour with minimal damage to surrounding tissues, making it an effective option for reducing tumour mass and managing symptoms caused by tumour pressure.
Investigational Therapies
Research into new treatment options is ongoing, with clinical trials playing a crucial role in brain cancer treatment. Investigational therapies include new drugs, drug combinations, gene therapy, and immunotherapy, which harnesses the body’s immune system to fight cancer.
Each of these treatments can be used alone or in combination, depending on the specific circumstances of the disease. The goal is always to maximise the quality of life and extend survival while minimising the side effects of treatment.
Oncologists at OncoCare with
Clinical Interests in Brain Cancer
Senior Consultant, Medical Oncologist
MBBS (Delhi) – American Board Certified (Int Med) – American Board Certified (Hematology)
American Board Certified (Med Oncology)
Before joining OncoCare Cancer Centre at Mount Elizabeth Hospital, Singapore, Dr Akhil Chopra was a Senior Consultant in Medical Oncology at Johns Hopkins Singapore, Tan Tock Seng Hospital and Adjunct Associate Professor at Lee Kong Chian School of Medicine.
Dr Chopra has experience treating multiple cancer types including breast cancer, lung cancer, cancers of stomach, colon, rectum, liver, prostate, kidney, testicular and bladder, gynaecological cancers such as ovarian and uterine/cervical cancers; as well as Sarcomas and chronic leukaemia’s/multiple myeloma. Besides his clinical and research work, he has been involved in teaching medical students from the Lee Kong Chian School of Medicine as well as medical residents and students from Johns Hopkins University, Baltimore in USA.
- Graduated from Delhi in 2001
- American Board Certified, Internal Medicine
- American Board Certified, Medical Oncology
- American Board Certified, Hematology
- Fellowship Training at Hahnemann University Hospital/Drexel University College of Medicine in Philadelphia, USA
Cancer Specialities: breast cancer, lung cancer, cancers of stomach, colon, rectum, liver, prostate, kidney, testicular and bladder, gynaecological cancers such as ovarian and uterine/cervical cancers
MBBS (Singapore) – M.Med (Singapore) – MRCP (United Kingdom) – FAMS (Medical Oncology)
Dr Tay Miah Hiang, Senior Consultant Medical Oncologist at OncoCare Cancer Centre, was previously consultant at the National Cancer Centre Singapore’s Department of Medical Oncology, and Chairperson of Patient Education & Patient Survivorship programmes. Dr Tay also served on the board of Singapore Children’s Cancer Foundation from 2006 till 2015, and was Chairperson of this foundation from 2011 to 2013, and now serving as advisor. He is an elected member of Singapore Medical Council (SMC) since 2017 till date.
Dr Tay is passionate in contributing to Continuous Medical Education in the region, giving lectures in cancer management to cancer specialists, general practitioners, medical students and patients. He has won numerous awards for his service excellence and humanity contribution to disaster inflicted regions as such as post-Afghanistan war and Sri Lanka after Tsunami.
He has been actively involved in clinical and translational research for many years, in genitourinary (testicular, kidney, bladder, prostate), lung and other cancers. His research work is well published in hormone-refractory prostate cancer involved chemotherapy agents such as docetaxel and carboplatin. Acknowledged as a senior cancer specialist and an authority in prostate cancer in Singapore, he had also published on the use of ketoconazole and as part of a multi-centre clinical trial, the use of abiraterone acetate in metastatic castration-resistant prostate cancer progressing after chemotherapy.
As a pioneer in kidney cancer oncology, he had used sunitinib (Sutent), refametinib in kidney cancer patients when the drugs were coming into clinical practice in Singapore. Recognised as an authority in prostate cancer in Singapore, he had helped developed guidelines for the treatment of prostate cancer in Singapore in 2013 and the management of kidney cancer in Asia at the Asian Oncology Summit 2012.
His significant research work has been published in both local and international journals including Urology, Cancer, and Annals of Oncology. He also wrote chapters in several internationally recognised cancer specialty books such as Comprehensive Textbook of Genitourinary Oncology (3rd Edition), American Cancer Society’s Complete Guide to Prostate Cancer 2006, and Textbook on Urologic Oncology 2004.
Dr Tay is lauded for his experience in treating prostate, kidney, testicular and the bladder, gynaecological cancers such as ovarian and uterine/cervical cancers, gastrointestinal & hepatobiliary cancers, lung cancer, brain tumour. He does not see patients with lymphoma, leukemia and breast cancer.
MEDICAL PROFILE
- Graduated from the National University of Singapore in 1992.
- Obtained Master of Medicine (Internal Medicine) and Membership of the Royal College of Physicians (United Kingdom) in 1999.
- Awarded the Ministry of Health Manpower Development Programme (HMDP) Scholarship to train at Dana Farber Cancer Institute, (Teaching Affiliates of Harvard Medical School), Boston USA 2003.
- Completed the Cancer Medicine and Hematology course at Harvard Medical School, Boston, MA, USA 2003.
- He was the Chairperson of Cancer Education for National Cancer Centre and Dr Tay was also previously the Chairperson and management committee member of Children’s Cancer Foundation. He is an elected member of Singapore Medical Council since 2017.
- In clinical patient care, he was awarded for his professional and genuine care with National Excellent Service Gold Award (EXSA*) in 2006 and Star Award in 2007.
- He has been actively involved in clinical and translational research for many years, in prostate, kidney, lung and other cancers. These have involved international trials of chemotherapy drugs currently in active use and newer targeted therapy. He was principal investigator for more than 10 clinical trials for cancer drug development.
- Research work by Dr Tay has been published in both local and international journals including Urology, Cancer, Annals of Oncology. He also wrote chapters in several international books such as Comprehensive Textbook of Genitourinary Oncology (3rd Edition), American Cancer Society’s Complete Guide to Prostate Cancer 2006, and Textbook on Urologic Oncology 2004.
- With respect to public service, Dr Tay has given talks both locally and overseas. These include the 13th and 15th Malaysian Urological Symposium on management of prostate cancer and renal cell cancer and Urological Conferences held in Singapore in 2004-2007
- With teaching appointments as Clinical Teacher, Faculty of Medicine, National University of Singapore and had been one of the lecturer for the First Singapore Medical Oncology Review Course (2007) involving surgeons, medical oncologists, radiation oncologists and physicians.
- Accredited for Palliative Medicine.
- Clinical interest in lung cancer, cancers of stomach, colon, rectum, liver, prostate, kidney, testicular and the bladder, gynaecological cancers such as ovarian and uterine/cervical cancers, and brain tumour.
- (*) National Excellent Service Award (EXSA) is a national award managed by SPRING Singapore and nine industry lead associations in Singapore. This award recognises the best of the best individuals who have delivered outstanding service in their respective industries. It seeks to develop models for service staff to emulate, create service champions and enhance professionalism in service delivery.
