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MelanieCole (Host): Welcome to Back To Health, your source for the latest in health, wellness, and medical care. Keeping you informed, so you can make informed healthcare choices for yourself and your whole family. Back To Health features conversations about trending health topics and medical breakthroughs from our team of world-renowned physicians at Weill Cornell. I'm Melanie Cole. And today, we're discussing brain tumor awareness. Joining me is Dr. Rajiv Magge. He's an Assistant Professor of Neurology at Weill Cornell Medical College, a neuro-oncologist at the Weill Cornell Brain Tumor Center and an assistant attending neurologist at New York Presbyterian hospital Weill Cornell Medical Center.

Dr. Magge, I'm so glad to have you joining us today. Before we begin, can you give us a little physiology lesson, a little bit about the brain anatomy to help us understand how a tumor can affect the function of the brain?

Dr. Rajiv Magge: Thank you so much for having me. I really appreciate the opportunity to speak to your audience. Unfortunately, or fortunately, the brain is quite complex. So, the symptoms or signs you might have of any abnormality in the brain is really dependent on where it is. They kind of say that the function really follows location and structure.

There are several lobes in the brain, including the frontal lobe, parietal lobe, occipital lobe, temporal lobe, as well as the cerebellum. And a lesion or any type of pathology in any of these locations can cause different symptoms. So it really depends on where say, so for example, a tumor is, to tell you what symptoms it might cause if any.

MelanieCole (Host): So, this is a scary topic. I mean, we're going to be honest about that. People worry when they get headaches and we're going to talk about symptoms and things, but can you tell us the difference between malignant and benign brain tumors? Are all brain tumors brain cancer?

Dr. Rajiv Magge: No, that's a great question. Brain tumors just represent a mass or growth of abnormal cells in the brain. Generally speaking, most cells in the brain, when it's crowded, they have signals that tell them to stop growing or dividing. Unfortunately, sometimes these cells have a light switch that turns on, in which case, they can keep growing and dividing even when it's crowded. And when you have this abnormal growing population of cells, that can contribute to a tumor. When we talk about malignant tumors, we're talking about tumors that might spread elsewhere. But in many cases, brain tumors are benign, in which case, they can grow slowly even, but will likely not spread anywhere else.

Generally speaking, primary brain tumors, meaning tumors that are rising in the brain itself, don't spread anywhere else in the body. When we talk about secondary brain tumors or brain metastases, those are tumors that have spread from another cancer in the body, such as breast cancer, lung cancer, or melanoma, in which case, sometimes these cells can sneak into the blood and flow up to the brain and then kind of get stuck and start proliferating and growing, in which case, they can create a secondary brain tumor or metastasis.

MelanieCole (Host): Are there any risk factors, Dr. Magge? Is there a genetic component? Are there lifestyle? Are these random? How does that work risk factor-wise?

Dr. Rajiv Magge: In general, there are very few known risk factors that we're aware of that contribute to brain tumors. One of the most common ones is ionizing radiation. And this just isn't radiation from a CAT scan or being around a cell phone tower. We're talking about radiation from a treatment such as patients who had received radiation for another illness to their brain, in which case, that exposure could contribute to abnormal growth in those cells and a tumor.

The other potential risk factor is a familial genetic syndrome, in which case, this is generally rare, but patients whose family might've had a tumor syndrome can inherit a mutation that contributes to multiple tumors. Again, that's generally rare. For the most part, brain tumors are sporadic, meaning they're coming out of nowhere. It's nothing that anyone did to cause it grow. And again, as I mentioned, the main environmental risk factors we're aware of are just Ionizing radiation. And again, secondly, having a genetic syndrome, which is uncommon.

I'll mention that there's no clear association with cell phone use so far that we're aware of causing brain tumors. So I know people in general, including myself, use cell phones and our smartphones all day long. There's no clear correlation, which I know a lot of folks are worried about.

MelanieCole (Host): Well, thank you so much for clearing that up. That's a great point. And we've heard about that for years. And now, on to the signs and symptoms, because I think everyone, you know, we get headaches and right away, if you're certain people like me, it's like, "Oh my God, is that a brain tumor?" Or if your child gets a headache, any of these things, doctor, can you give us some signs and symptoms that are a little bit more of a red flag or a little bit more worrisome because not every headache is a brain tumor, right?

Dr. Rajiv Magge: Exactly. Exactly. For the great majority of folks, headaches are not a sign of a brain tumor. And I just want to clarify that I know a lot of people understandably get worried, but almost 50% of normal people develop headaches, including myself, especially when I don't get my morning coffee.

The main symptoms and signs of any potential tumor, again, it kind of goes along as I mentioned earlier, that the structure and function in the brain go hand in hand. Potential symptoms include headaches, especially headaches in an older person that are new and change in quality, potentially headache that wakes them from sleep. Other things are weakness in any part of the body or sensory loss, speaking trouble, as well as cognitive changes, if there's significant change in memory, or new memory loss, especially with short-term memory. Something that your family might recognize as this is really odd, especially if it developed in a short period of time. Those might be things that are concerning.

Another possibility or symptoms include seizures. That's when a part of the brain is turning off and on in a very regular pattern. Normally, the brain, the neurons are firing really irregularly, so there's not a clear pattern. But sometimes if there's some irritation of the brain such as potentially with a tumor, then that irritation can cause that part of the brain to abnormally turn off and on, and contributing to potential seizure and a seizure could be represented as shaking, a staring spell, but there's a lot of potential semiology or signs of a seizure. So main things we're looking out for are new, severe headaches or change in quality of headaches, seizures, weakness and sensory loss, speaking trouble and cognitive changes.

But in general, if there's anything that concerns you, especially that's something new, you definitely want to talk to your doctor or be evaluated by your primary care doctor or neurologist to make sure that nothing significant is going on.

MelanieCole (Host): So then how do you diagnose it? And thank you for those encouraging words, because I know that that's going to breathe a sigh of relief for people that, you know, get headaches that come and go and such, but what's involved in diagnosis? And if this is diagnosed, should everybody that gets diagnosed with a brain tumor get a second opinion?

Dr. Rajiv Magge: Yeah. So as you mentioned, a lot of folks will have symptoms, especially if they're coming and going, that are not worrisome. But if you have symptoms that don't go away or progressively getting worse, I think that's definitely a reason to be evaluated, especially if it's progressive headache that's not going away and definitely new. In that case, once you're evaluated, you're going to get a good physical exam by your doctors and care providers. And they'll make sure that they're not seeing any clear neurological deficits that might be concerning. If there are potential deficits or if further workup is necessary, one of the best tools we have is neuroimaging and that can be a CAT scan of the head, as well as an MRI of the brain. An MRI can give us a really clear, detailed look at the brain, kind of a real full 3D model of the brain and can tell us if there's any abnormalities or any potential tumor. And other things we look out for are new strokes, anything concerning for inflammation or infection. But for the most part, in patients whose symptoms are not progressive or not too concerning, the MRIs are often clean, but they do give folks some sense of comfort and also knowing that everything's been looked at.

Not everyone who has potential symptoms such as headache needs an MRI. But your doctors, I'm sure you'll be in good hands in terms of deciding whether an MRI is necessary. Depending on the results of an MRI, if there is something of concern, then they might need further workup or management, and that may include a biopsy or a surgical removal of an abnormality to fully understand what it is and what's going on.

MelanieCole (Host): So, as we said before, not every tumor in the brain is cancerous, right? And we've all seen the shows and the medical shows on TV and people have these brain tumors. Can you tell us a little bit about treatment options that are available, and if there's any nonsurgical? And if you do determine that it is cancerous or non-cancerous, does that change the treatment modality?

Dr. Rajiv Magge: That's a great question. So, if there is an abnormality on the brain that's concerning for a tumor, there's certain characteristics we can look at on the MRI that might tell us that it might be one specific pathology versus another. And when I talk about pathology, I'm talking about what the tumor may look like under the microscope. When we talk about tumor, there's a lot of different types and a lot of variability, and that's really dependent on what's the cell of origin, what's that first cell that got activated and had a light switch turn on in it that made it grow and divide in an uncontrolled way. And so, again, as I mentioned earlier, when you have one cell that's growing uncontrollably, it can develop kind of a clone of itself and then you have this population of abnormally growing cells, which is a tumor. But it's all dependent on what's that first cell and there's a lot of different types of brain cells, that if it developed a mutation such as a light switch that turned on in that cell that could make it grow. So there's a lot of different types of tumors, but again, variability in the types of tumors is because of the variability in the specific types of cells that can start growing out of control.

Often, sometimes the best treatment for tumor is potentially surgery. Surgery allows removal of as much of the tumor as possible, and again, as safely as possible. Your surgeons and your doctor will make sure that it's done as safely as possible without giving you any new deficits. So surgery allows removal of the tumor, but it also allows the pathological diagnosis. It allows us to have tissue to give to the pathologist who can look at it under the microscope and assess exactly what type of tumor this is, and that's essentially the gold standard.

As you mentioned, a lot of these tumors are benign and surgery might be the cure. You might take it out and then be done and just follow with MRIs, or may not even need any followup in the future. Some tumors may be more concerning and be higher grade. And when I talk about grading, I'm talking about how abnormal the tumor looks under the microscope. And if you have a higher grade tumor, it may require additional treatment after surgery such as radiation, chemotherapy or other medications. So there's a wide variety of treatment regimens and it's really dependent on what specific tumor this is. There's a lot of variability and a lot of different types of tumors and they all carry different prognoses and outcomes.

MelanieCole (Host): Is there anything exciting you want to share in this field? You can speak about if these are very common or if it's pretty rare, because as we said a few times already, it's really literally, doctor, one of the scariest things when people think about diseases. This is one of those ones, right? This is one of those ones where they say, "Oh, that's the scariest thing." So can you give us a little hope and encouragement? What's going on in the field that's exciting? What do you want the listeners to know about brain tumor awareness so that we can feel relieved and, if we need to, get the best medical care possible from the specialists at Weill Cornell Medicine?

Dr. Rajiv Magge: Yes, that's a great point. In general, brain tumors are quite rare and especially brain cancer, when we're talking about malignant brain tumors that are more aggressive and may spread in the brain, those are very rare. And they're rare across the whole population, but even relatively rare when we talk about other cancers. When we look across cancers, brain cancer again is much less common.

When we talk about brain tumors, secondary brain tumors or brain metastases from other malignancies in the body are much more common than primary brain tumors, which again primary brain tumors are tumors that arose in the brain in the first place. A lot of tumors can be treated very quickly and surgery may be even curative. But even for those tumors, you know, it's understandable a lot of folks are scared and worried even at the potential of having brain cancer. But we've learned a lot more about these tumors and cancers in the past. Just in the last five to 10 years, we know so much more about the etiology and pathogenesis, the biology of how these tumors grow in the first place. We know a lot about what makes them tick and there's been a ton of research and that continues every day going into the best treatments for these tumors. And there's a lot of variability, so there's research in every little pod and every domain of specific type of tumor about what works best. And that includes, again, we know so much about the biology of these tumors, but then we're learning a lot more about how to target that biology and how can we use the body's own immune system to attack these tumors. And there's better drugs and chemotherapies that can get into the brain. There's more targeted treatments that target those light switches that turned on these cells that made them go in the first place. Radiation therapy after surgery is a potential option and the technology for radiation has really made leaps and bounds. It's much better and more accurate in delivering those x-rays to kill cancer cells while not harming the normal brain cells. There's also new research into diet changes such as ketogenic diets in combination with drugs. A ketogenic diet is a very high, fat, low protein, low carbohydrate diet that may make it difficult for cancer cells to grow and come back. A lot of research is going into these things, we don't know definitely, but across the board, we're learning so much about how these tumors grow, but then also ways we can target that growth and prevent them from growing and hopefully kill them. And that includes tumor vaccines and immunotherapy with trying to activate the own body's immune system to attack the tumors, better drugs that get into the brain, targeted treatments, better radiation. So, there's a lot that's being looked at around the world. And I think there's a lot of hope for the future that we're going to find those things, even in the worst case scenarios that can work and maintain patient's good quality of life.

MelanieCole (Host): Wow. What an informative and reassuring podcast this was. You're a great educator. Doctor, thank you so much for joining us today. And Weill Cornell Medicine continues to see our patients in person, as well as through video visits. And you can be confident of the safety of your appointments at Weill Cornell Medicine..

That concludes today's episode of Back To Health. We'd like to invite our audience to download, subscribe, rate, and review Back To Health on Apple Podcast, Spotify and Google Podcast. For more health tips, please visit weillcornell.org and search podcasts. And parents, don't forget to check out our Kids Health Cast. I'm Melanie Cole

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