In July 2018, NICE issued guideline [NG99] that covers diagnosing, monitoring and managing any type of primary brain tumour or brain metastases in people aged 16 or over. It aims to improve diagnosis and care, including standardising the care, how information and support are provided, and palliative care.
The guideline includes recommendations on:
- investigation of suspected glioma, meningioma, and brain metastases
- management of suspected glioma, meningioma, and brain metastases
- follow-up and supportive care
- neurorehabilitation
- surveillance for late-onset side effects of treatment.
Detailed recommendations are available here.
By explaining the context for need of such guideline, the NICE wrote that it is estimated that there are around 10,000 new cases of primary brain tumours per year. Malignant high-grade gliomas (anaplastic gliomas and glioblastomas) and pre-malignant low-grade gliomas come from the brain tissue glial cells, and make up over 60% of primary brain tumours. Meningiomas make up a further 30%. Although often thought benign, meningiomas can have an acute presentation and are associated with significant long-term neurological morbidity. Because of this, they can behave in a malignant fashion in terms of recurrence and impact.
Over 60% of people with primary brain tumours present at, and are diagnosed by, accident and emergency services rather than from conventional general practitioner or specialist referral. This causes a significant demand on these services. Although primary malignant brain tumours represent only 3% of all cancers, they result in the most life-years lost of any cancer. There is concern that the true incidence of these tumours is rising.
Many different cancer types can spread to the brain, with lung and breast cancers being the most common. More people with systemic cancers are surviving longer and are referred to neuroscience multidisciplinary teams for management of brain metastases. The number of people needing assessment for cranial treatment is now over 10,000 per year in the UK and rising.
The specialist nature of neuro-imaging and the need for complex diagnostic and reductive surgery emphasises the importance of well-organised service delivery by dedicated units.
The singular effects of brain tumours on mental performance (both psychological state and cognitive decline) are a particular challenge to carers and professionals alike, especially in delivering support to people at home. The peak age of presentation of brain cancer is between 65 and 69, and there are concerns that delivery of all services to these older people is suboptimal. There are also concerns that the transition from paediatric to adult units could create a care gap. This would most specifically affects patients who are between 18 and 30 years old.
Survival with malignant brain tumours has remained poor despite some improvements in surgery, radiotherapy and chemotherapy, and a greater understanding of molecular classification. The management of a low-grade glioma that is likely to transform to high grade remains controversial, and presents issues for ongoing care. Follow‑up for people with meningiomas after primary treatment is often long term, and there is variation in both follow‑up and treatments for recurrence.
Conventional whole-brain irradiation as optimal therapy for brain metastases is being challenged by concerns about its effectiveness and toxicity, as well as the availability and immediacy of surgery and stereotactic radiotherapy.