Ask the Expert: The 'Wait and See' Approach

Why does my surgeon not want to operate on my brain tumour?

When someone is first diagnosed with a brain tumour, there is a natural desire to want to pursue active treatment. As a result, it may seem confusing or counter-intuitive when your surgeon advises you that the best approach at that time is to continue with clinical and imaging-based surveillance and not to undergo an operation – a ‘wait and see’ approach.

The Risks & Benefits

When deciding on treatment of any kind for a newly-diagnosed brain tumour, your doctors must weigh several risks and benefits related to each treatment option. In doing so, they will be able to advise you on what is most appropriate for you at that particular time. They must consider the risk that the tumour poses to you, both at the time as well as in the future if the tumour is not actively treated. They must also consider the risks associated with any intervention (eg: surgery, radiation, chemotherapy) versus the risks of just watching the tumour for the time being. The risks will vary, depending on factors such as:

  • tumour type
  • tumour location
  • tumour size or growth rate
  • patient’s age
  • patient’s general systemic medical condition
  • patient’s symptoms and level of function

Lastly, the health care team will balance these risks against the expected benefits to be gained from treatment. With respect to surgical treatment, benefits that may be achieved depend on the circumstance, and may include:

  • establishing a definitive pathologic diagnosis by examining the tissue directly
  • alleviating neurologic symptoms by reducing or eliminating the pressure exerted on the brain by the tumour
  • reducing the amount of tumour left behind for additional treatments (e.g., radiation and/or chemotherapy) to fight against
  • reducing the number of abnormal tumour cells present that may be at risk of converting to a more aggressive, faster growing tumour in the future
  • reducing the need to stay on certain medications (e.g., steroids)

Your surgeon may suggest a ‘wait and see’ approach for several possible scenarios. Examples when this may be recommended include:

  • the tumour is asymptomatic or incidental (found by accident during investigation for other concerns)
  • the tumour looks typical for a benign or low-grade lesion based on the MRI scan appearance
  • the tumour is either not growing, or growing at such a slow rate that it's not expected to cause you symptoms for some time
  • the tumour is very extensive, and as a result the ability of the surgeon to achieve a meaningful amount of tumour removal is limited, making any benefit outweighed by the risk this would pose to you

If your surgeon suggests a ‘wait and see’ approach, you will likely have ongoing active follow-up and clinical assessment, along with repeat brain imaging to keep an eye on your tumour. This repeat imaging may be at different intervals, between months to years. Your doctor will discuss with you the time interval appropriate for your particular situation.

Will I ever need surgery?

Depending on how your particular tumour behaves, it is possible that your doctor may recommend some type of surgery (biopsy or tumour resection) after a period of initial observation. Each patient’s situation is unique. If things change in a way that they tip the balance between benefit and risk of surgery in favour of operating, your medical team will discuss with you the need to change treatment strategies.

 

Thank you to Dr. Paul Kongkham for sharing his insight and expertise as part of this Ask the Expert Information Sheet.

Dr. Kongkham is an assistant professor of neurosurgery at Toronto Western Hospital (University Health Network) within the Division of Neurosurgery at the University of Toronto, and an affiliate scientist at the Macfeeters-Hamilton Centre for Neuro-Oncology Research (Princess Margaret Cancer Centre). Dr. Kongkham completed his medical training, neurosurgery residency and PhD studies at the University of Toronto. Following this, he undertook a year of clinical neurosurgical fellowship in neurosurgical oncology at the MD Anderson Cancer Center in Houston, Texas, prior to returning to Toronto in 2012. Dr. Kongkham’s clinical and research interests lie in the care of adult patients diagnosed with primary and secondary brain tumours.

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