Our Experts Weigh in on Brain Tumors
May is Brain Tumor Awareness Month, and we’ve asked our proton therapy experts to talk about their latest research in brain tumors. We also bring you a profile on Lia Halasz, MD, who specializes both in brain tumors and ocular melanoma. Our registered dietician, Laura Buono, RD, CSO, CD, CNSC, adds a column on how nutrition guidelines vary based on your own treatment and tumor type.
One of the benefits of a comprehensive research and clinical facility such as Fred Hutchinson Cancer Center is the continuous focus on improving treatment and outcomes for patients with cancer. Two types of brain tumors that our central nervous system (CNS) team is studying are glioblastoma and glioma.
“We have several studies that are looking at radiation in combination with new drugs for glioblastoma,” says Lia Halasz, MD. “That’s because glioblastomas are fairly common and need the most improvement in treatment. We recently closed a trial that looked at increased dose to the tumor using protons or standard photon therapy. We are still waiting for the final results of the study, including those of the participants who received proton therapy.”
Randomized clinical trials are the gold standard researchers use to obtain unbiased data about the benefits and drawbacks of a specific treatment. For example, if a study is comparing two treatment options, patients are randomly assigned to one treatment or the other. Researchers then compare the groups to see which treatment is more effective or has fewer side effects. Bias can occur when a trial's results are affected by human choices or other factors not related to the treatment being tested. It can be hard for patients to risk giving up their treatment choice and enrolling in a randomized trial, but it benefits the patient population in the long run to have definitive answers on treatment. It is always a patient’s decision on whether to take part in a clinical trial.
“A lot of historical knowledge from randomized trials comes from institutions in places like Canada and Germany, where patients are more likely to enroll based on their physicians’ recommendations. In the U.S., people like to make their own choices. For me, after I have presented what we know and don’t know, what’s most important is to support the choice that my patients make,” says Halasz.
Yolanda Tseng, MD, a CNS team member, leads a trial looking at gliomas. “We hope to understand whether proton radiation therapy is associated with lower rates of long-term toxicity compared to photon radiation,” she says. “The goal is to have excellent control over the tumor while minimizing radiation effects on short term memory and processing speed.” Because patients with low-grade gliomas may live for a long time after treatment, the precision of protons may be especially beneficial. This trial is still enrolling.
“There are several scenarios when protons are an especially good option,” says Simon Lo, MB, ChB, FACR, FASTRO, who treats many tumors of the skull base and brain with proton radiation at Fred Hutch. “These include cases when the patient is expected to have a long life expectancy, when the patient needs a higher dose than can be achieved with standard radiation and when the patient has had prior radiation to the brain. Once you’ve irradiated the brain, additional dose to a large area will increase the risk of radiation necrosis. However, with protons, we can still treat the tumor aggressively with reduced risk.”
Jonathan Yang, MD, PhD, pioneered the use of proton therapy in treating leptomeningeal disease (LMD). The benefits have been positive, leading to better survival rates than traditional radiation treatment methods.
“The sooner we diagnose and treat LMD, the better,” explains Yang. “We’ve had many referrals to our proton therapy facility since we started the program. It’s good news that physicians are recognizing symptoms early and considering proton therapy as an option for their patients.”
The integration of Seattle Cancer Care Alliance and Fred Hutchinson Cancer Research Center into Fred Hutchinson Cancer Center has helped our physicians become even better at streamlining and coordinating care. They work together with medical oncologists to provide the standard of care, which for brain and CNS cancers often involves surgery, chemotherapy and radiation therapy. If you’d like more information on CNS cancers or proton therapy, please contact us at info.proton@fredhutch.org.
Everyone’s Disease and Treatment Is Different. Their Nutrition Guidelines Are, Too.
Quarterly Nutrition Column by Laura Buono, Rd, Cso, Cd, Cnsc Fred Hutchinson Cancer Center – Proton Therapy Dietitian
Nutrition recommendations for patients with cancer are not one size fits all. Depending on what type of cancer you have, and what type of treatment you are receiving, your nutrition recommendations will likely be different from someone else's. Dietary recommendations found on social media, in online articles, and from well-meaning friends and family who may have had cancer might not be appropriate for you – and could even be harmful. Some factors that can influence the specific recommendations you receive from a registered dietician may include your type of cancer, type of treatment, expected side effects, other health or medical issues and prognosis. Side effects that can impact eating include appetite changes, bowel changes (constipation or diarrhea), fatigue, dry mouth, mouth sores, swallowing problems and changes in the way foods may taste while being treated.
Surgery, radiation and chemotherapy can make it difficult to eat normally. Surgery to the digestive tract might result in changes in absorption of food, and the need to follow a lower fiber diet. If you have surgery to the head or neck area, it might be difficult to chew or swallow making it necessary to eat only soft foods. With radiation, the part of the body being treated might influence what you can eat. For example, radiation to the chest might cause inflammation to your esophagus which makes swallowing difficult. And with chemotherapy, certain treatments can result in nausea, indigestion, foods tasting unpleasant, and bowel changes making it harder to eat a normal diet.
Getting good nutrition throughout your treatment is essential to promote healing and recovery, while preventing unintentional weight loss. The nutrients we get from food can help with healing our bodies and even reduce treatment-related side effects.
Protein
During your treatment, you might need to change your diet to help with healing, to minimize unintentional weight loss and to build strength. Often, your treatment may require more protein in your diet. Protein helps keep our bodies strong. When we don’t get enough protein, our bodies can break down muscle to get fuel. Some examples of protein-rich foods are fish, chicken, eggs, yogurt, nut butters and legumes. Your dietitian can help you figure out your specific protein needs.
Carbohydrates and Fiber
A diet that is rich in high-fiber plant foods (fruits, vegetables, whole grains, nuts, seeds and legumes) is recommended to provide essential nutrients for healing. These foods contain phytonutrients which are chemicals that have health-promoting compounds. Depending on your cancer type or treatment, you may not be able to eat high-fiber foods because your body might process nutrients differently, and you may not tolerate them well. For example, you might be prescribed a low-fiber diet if you are having diarrhea or if you are producing a lot of gas in your abdomen.
Carbohydrates are your body’s main source of energy. Examples of nutrient-dense carbohydrates include fruits, vegetables, whole grains and legumes. Sweets (like candy, desserts and sugary beverages) contain carbohydrates as well, but these foods usually don’t contain vitamins, minerals and phytonutrients.
Vitamins and Minerals
If you’re able to eat a well-balanced diet, you can get all the nutrients you need from food. Of course, certain treatments might impact your ability to eat a well-balanced diet. Your dietitian can help to ensure that your diet is rich in these essential nutrients, even if your diet is limited. Antioxidants are popular among cancer patients, but antioxidants in supplement form could interfere with treatment. A diet rich in antioxidant plant foods is always encouraged.
No matter what treatment regimen or type of cancer you or your loved one has, nutrition services provided by a registered dietitian (RD) can help by providing strategies to combat common side effects of treatment. Every patient at Fred Hutch has access to nutrition planning throughout their cancer care that matches their specific needs. Ask your care team for a referral.
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Specialist Profile: Dr. Lia Halasz
Lia Halasz, MD, is one of our proton therapy experts at Fred Hutchinson Cancer Center. She focuses both on central nervous system (CNS) tumors and ocular melanoma. Both are relatively rare. In Washington state, about 500 people are diagnosed with a brain or CNS tumor each year, and only 50 are diagnosed with ocular melanoma.
“The ocular melanoma patient community is a strong, tight group, who advocate for advancing treatment options. Because it’s so rare, people find each other on the Internet,” says Halasz.
Fred Hutch recently had our first patient education event, where she spoke about protons as a treatment option and ongoing innovation. The aim of the event was to provide attendees with an overview of ocular melanoma diagnosis, updates in treatment, research and clinical trials, as well as survivorship and integrative medicine information. “It was very well attended, and I even received a sweet thank-you note from a patient afterwards. It can be very gratifying to care for patients with uveal melanoma because proton therapy is a curative treatment.”
It's this curative function in ocular melanoma that strikes a good balance for Halasz, who also treats brain tumors. Halasz treated the first patient at our proton therapy facility in 2013 for a brain tumor. Although she doesn’t think of the two as separate fields – the eye is in the head, after all – the brain is a very different organ. Proton therapy can often be beneficial in treating certain brain tumors, but many of them can’t be “cured” with available therapies. Right now, Halasz and her colleagues are studying whether a novel drug and radiation can improve treatment of glioblastoma, an aggressive type of brain cancer. She is also analyzing the imaging changes seen years after treatment of meningioma – a mostly benign tumor — to see what we can learn about the radiobiological characteristics of proton therapy.
“Brain cancers are inherently trickier, as any damage to part of the brain might result in side effects such as memory loss or physical weakness. The risks must be weighed against the good that radiation can do in controlling the tumor,” says Halasz.
Halasz became interested in brain cancers because it is an area where researchers and physicians constantly improve treatment. "We have a way to go, but being part of the team to end brain cancer is incredibly rewarding," says Halasz. "The brain is such an essential part of a person, making it especially important that we individualize our treatments for each person."
In terms of ocular melanoma, Halasz’ interest grew from her experience at Massachusetts General Hospital's program. She was interested in bringing this technology to the Pacific Northwest and is part of a small team of specialists in proton therapy for ocular melanoma with Ramesh Rengan, MD, PhD, FASTRO, and Jonathan Chen, MD, PhD. Together with the medical physics team, they are developing ways to further improve the precision of proton therapy for eye tumors. They are also looking into other innovations such as clipless treatments and using models in conjunction with imaging to reduce side effects.
If you have questions about proton therapy for CNS tumors or ocular melanoma, please contact us at info.proton@fredhutch.org.
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