Brain and Central Nervous System Cancers
Approximately 1,000 people in Scotland are diagnosed with primary tumours (malignant and non-malignant) of the brain and CNS, each year. Approximately 41% of these cases are malignant brain cancer (excluding meninges, cranial nerves, pituitary gland, craniopharyngeal duct, and pineal gland), of which more than 80% occur in people over the age of 40 years. However, metastatic cancer commonly involves the brain and presents with similar features.
The anatomical location of CNS tumours influences symptoms that include physical, cognitive and psychological components.
Brain tumours are the commonest cause of cancer related death in children and people under 40 years. People with brain tumours typically present with progressive neurological deficit (such as progressive weakness, sensory loss, dysphasia, ataxia), developing over days to weeks. Other signs and symptoms include: seizure disorder; headache with evidence of raised intracranial pressure (such as vomiting and papilloedema); and cognitive or behavioural changes. An adult presenting with new onset seizure disorder of any type has a probability of 2-6% of having a brain tumour, whereas new onset status epilepticus is associated with a probability of 10% or more. A person presenting with chronic daily headache without features of raised intracranial pressure has a very low probability of having a brain tumour.
Spinal cord tumours often cause neurological symptoms including back and neck pain, numbness, and tingling and weakness in the arms or legs. Tumours in the lower part of the spinal cord may cause loss of control of the bladder and bowel. Please refer to the guideline on Malignant Spinal Cord Compression for further guidance.
Emergency (same day) referral
| Headache |
|
Urgent suspicion of cancer referral
- Neurological deficit:
- Progressive neurological deficit (including personality, cognitive or behavioural change) in the absence of previously diagnosed or suspected alternative disorders (such as multiple sclerosis or dementia)
- Seizure:
- Any new seizure
- Seizures which change in character such as post–ictal deficit, headache, increased frequency, etc.
Good practice Points
- Consider urgent investigation/referral for patients with non-migrainous headaches of recent onset, when accompanied by “red flag” features suggestive of raised intra cranial pressure (for example: woken by headache; vomiting; drowsiness), progressive neurological deficit or new seizure disorder
- All NHS Boards have pathways for investigation of headaches which should include primary care direct access to imaging
- If any uncertainty about the presence of papilloedema, the person should be urgently referred to an optometrist for assessment. If there are red-flags suspicious of cancer as detailed above, a simultaneous
urgent suspicion of cancer referral to secondary care should be made. If papilloedema is confirmed, the optometrist should refer directly to secondary care - An urgent, suspicion of cancer pathway should exist in all NHS Boards for optometrists to refer directly to secondary care for people with optic discs suspicious of papilloedema