BASIC FACTS ABOUT NON-MALIGNANT BRAIN TUMORS

“Where hope springs eternal”

Pediatric Brain Tumor Foundation® A Resource for Families

Pediatric Brain Tumor Foundation® i Acknowledgements The Pediatric Brain Tumor Foundation® wishes to thank Bridget McCarthy, Ph.D., of the Department of Epidemiology, University of Illinois at Chicago, and Carol Kruchko, President, Central Brain Tumor Registry of the United States, for assistance in preparing this booklet. We also thank Roger McLendon, M.D., Chief, Neuropathology and Surgical Pathology at Duke University Medical Center and Michael Prados, M.D., Director of Transitional Research in Neuro-Oncology and Principal Investigator Brain Tumor Research Center, University of California, San Francisco, for scientific review of this publication.

Sources Statistical and descriptive data in this publication were obtained from the Central Brain Tumor Registry of the United States (CBTRUS, cbtrus.org) and the World Health Organization (WHO) Classification of Tumours of the Central Nervous System.

DISCLAIMER The Pediatric Brain Tumor Foundation® does not render medical advice or professional medical services. Information in this publication is NOT intended to be a substitute for medical care or advice and should not be used for the diagnosis or treatment of a brain tumor or any other health problem. If you have or even suspect you have a problem concerning your health or that of someone else, you should consult with your health care provider. Educational materials provided by the Pediatric Brain Tumor Foundation® are based on current information at the time of publication. Medical research concerning disease and treatments in an ongoing process, however, and you should review all subjects with your doctors and medical institutions to obtain the most up-to-date information available.

COPYRIGHT © 2010 by the Pediatric Brain Tumor Foundation®. First printing 2010. The contents of this publication have been prepared for the exclusive use of the Pediatric Brain Tumor Foundation®. They may not be reproduced in part or in their entirety without the written permission of the PBTF.

Pediatric Brain Tumor Foundation® ii Our Mission • Find the cause of and cure for childhood brain tumors through the support of medical research; • Increase public awareness about the severity and prevalence of childhood brain tumors; • Aid in early detection and treatment of childhood brain tumors; • Support a national database on all primary brain tumors; and • Provide hope and emotional support for the thousands of children and families affected by this life- threatening disease.

ABOUT THE PEDIATRIC BRAIN TUMOR FOUNDATION® The Pediatric Brain Tumor Foundation® (PBTF) was established in 1991 to find the cause of and cure for childhood brain tumors. Our primary source of support is the national Ride for Kids® program, which began in 1984 and has helped make us the world’s largest non-governmental source of funding for childhood brain tumor research. We also offer support programs for families with a child who has been diagnosed with a brain tumor. Our resources include free literature about brain tumors and scholarships for survivors of pediatric brain tumors. A list of our resources can be found on the back cover of this publication.

Pediatric Brain Tumor Foundation® 1 INTRODUCTION Few challenges can compare to dealing with the news that a member of your family has a brain tumor. When the patient is a child, the emotional burden can seem beyond your ability to bear. The experience of thousands of other families, however, proves that it is not. The first step on the path to coming to terms with a pediatric brain tumor, and to restoring control over your family’s life, is to understand as best you can what the child faces. Exactly what kind of tumor is it? Where is the tumor? What are the consequences for the rest of the body? What can be done? What are the prospects for the future? There are hundreds of different tumors known to medical science. Most pose grave risks if left alone, but some can be treated with a high degree of success. Each tumor of the brain presents unique problems of diagnosis and treatment, but the starting point for a parent is always the same: gaining knowledge. This booklet is one in a series produced to help you learn more about the specific tumor that is at the root of your child’s illness. It contains the most recent information drawn from leading scientists and physicians around the world. It is not a substitute for personal consultations with a medical doctor specializing in pediatric brain tumors. The knowledge you gain can help you ask questions, confidently voice your concerns and actively participate as a member of your child’s medical care team. It is important to keep in mind that pediatric brain tumors require specialized treatments best delivered at comprehensive medical centers equipped with departments devoted to cancer and staffed by a multidisciplinary team of specialists. Such a team will include physicians, nurses, social workers, child psychologists, child life specialists and rehabilitation professionals. The care they provide should include education and support services for your family. Medical research has produced incredible advances in recent years, dramatically improving survival rates, life expectancy and treatment options while reducing harmful side effects of what can be difficult courses of treatment. But there is still much we do not know about the causes of childhood brain tumors or the cures. Funding more research, increasing public awareness and aiding in the early detection and treatment of pediatric brain tumors is the mission of the PBTF. Families like yours are at the heart of that mission. If you need further information or other publications, our staff would be happy to take your call. Contact us at 800-253-6530 or [email protected]. Our website is pbtfus.org. 2 Pediatric Brain Tumor Foundation® A FEW BASIC FACTS What causes brain tumors? The short answer is: We don’t know. Researchers believe that inherited and genetic factors may be involved. Environment may also play a part. While science has yielded valuable information, it has yet to produce concrete answers about the causes of most brain tumors. Please go to pbtfus.org to listen to our conference, “Risk Factors and Pediatric Brain Tumors” for more information. In addition, some tumors in the brain can be caused by a cancer that first took hold elsewhere in the body, but they are not the focus of this booklet. Instead, we are dealing with primary tumors that originate in the brain.

What is the difference between benign/ non-malignant and malignant brain tumors? The way medical professionals use language can be confusing to laypeople, and “benign” is a perfect example. Popular usage of the word implies that a tumor is mild or non-threatening, even though there is no such thing as a non-threatening brain tumor. It is more helpful to use the term “non-malignant” to distinguish such growths from malignant tumors. Malignant tumors are composed of cancerous growths, groups of cells that divide and multiply out of control. Malignant brain tumors can shed cancerous cells to other sites in the brain or spinal cord. However, they rarely spread to other parts of the body. They are always life-threatening and the hardest tumors to treat. Non-malignant tumors, by contrast, are not cancerous and they rarely invade the tissues around them. However, any tumor in the brain or spinal cord, which together form the central nervous system (CNS), can grow in size and pose a serious threat. Treatment is essential. The CNS controls behavior, personality, senses, movement, coordination and automatic functions like breathing. Anything that could crowd out vital regions or disrupt the normal functioning of the CNS could cause serious problems, even death. Children are at extra risk from non-malignant tumors because the brain, along with the rest of the body, is still developing. What happens in the early years can have enormous consequences for the rest of the child’s life. In addition, some non-malignant tumors of the brain can turn malignant if they are not removed in time. It is critical to consult with a pediatric neurosurgeon as soon as possible. The good news is that treating non-malignant brain tumors is much easier, for both the patient and the Pediatric Brain Tumor Foundation® 3 treatment team Non-malignant tumors rarely grow back after being removed, or resected. Removal, which usually requires brain surgery, is often aided by well- defined borders between the non-malignant tumor growth and surrounding healthy tissue. The location of the tumor in the brain will determine whether a surgeon can remove the tumor in part or completely. Once the tumor has been removed, most patients will not require the same degree of intensive follow-up treatments that come with malignant tumors. In many cases, the long-term effects are generally mild. Survival rates are typically high for non-malignant tumors, reaching 90 percent or more, depending on the type of tumor. If your doctors diagnose your child with a non- malignant tumor, you may be told it is a Grade I tumor. The grading system is widely used to describe tumors according to the threat they pose. Grade II tumors are also considered non-malignant, but with a significant chance of becoming malignant. Sometimes grading a tumor can be difficult, and experts may make different diagnoses. It is often a good idea to get more than one medical opinion, especially if a tumor has been given an “intermediate” grade. Grade III and IV tumors are malignant and present the most serious risks to health. The “stage” of a tumor is a term applied primarily to malignant cancers, and non-malignant tumors are not usually assigned one.

What is involved in diagnosing a tumor? Recognizing that your child’s illness is something out of the ordinary is the first step on the path to a proper diagnosis. Each type of tumor can produce its own set of symptoms, ranging from headaches, changes in behavior, and drowsiness to nausea, vomiting, blurred or double vision, even seizures. Your doctor will take those symptoms into account when choosing the techniques required to make a proper diagnosis. In most cases, the doctor will employ one or more of several machines that can take three-dimensional images of a patient’s brain without the need for surgery. Among the most common diagnostic techniques is magnetic resonance imaging, or MRI. It uses harmless magnetic waves to scan the brain. A special dye called a contrast agent is injected into the patient to help the scanner distinguish between healthy and abnormal tissues. The patient lies in a car-sized machine, which makes a series of noisy but painless scans. The entire process usually takes less than an hour. Like any photograph, it is important for the patient to remain as still as possible. The presence of a parent, calming music, or a mild sedative can often help. The 4 Pediatric Brain Tumor Foundation® contrast agent is also harmless and is broken down by the body and eliminated soon after the scans. Computerized tomography, also known as CT or CAT technology, is similar in design to MRI systems. It also requires a contrast agent, but uses X-rays instead of magnetic waves. There is a small risk of cancer that comes with exposure to X-rays, which must be weighed against the benefits of the technology, and both should be discussed with your doctor. Like all aspects of medicine, CT techniques, including radiation exposure levels appropriate for children, are constantly being refined. Positron emission tomography comes in two forms, PET or SPECT (for single-photon emission computed tomography). Both record pictures of brain activity. While CT or MRI scanners produce images of what is in the brain, PETs can analyze what those tissues are doing. Patients are first injected with a radioisotope tracer, usually a sugar that emits low levels of radiation as it changes into a stable form. There is no significant risk from the tracer. After a short wait, the machine makes its scans. In many cases, doctors will use both a CT and a PET scan to build a complete picture of what is going on in the brain. Specialists study the images produced by the scans to determine the location and nature of a suspected tumor. Confirming the initial diagnoses may then require a biopsy, or the removal of a small piece of brain tumor tissue. In some cases, all that is needed is a needle; at other times surgery will be necessary. Fortunately, the brain itself does not feel pain, and the procedure is relatively straightforward.

TYPES OF NON-MALIGNANT TUMORS There are dozens of different types of brain tumors known to occur in children. They are usually categorized according to the type of brain cell from which they arose and the part of the brain in which they are found. A few of the more common Grade I pediatric brain tumors are listed below. The list is not comprehensive, but is meant to serve as an exploration of the issues and challenges associated with non-malignant tumors. We recommend reading about all of the tumors, rather than just the one you are researching, because many issues and terms are common to more than one type. Astrocytomas Tumors that involve the star-shaped cells known as astrocytes constitute about half of all pediatric brain tumors. These glial cells connect and support nerves and help repair brain tissue. Recent research has shown that astrocytes have a wider range of roles to play than Pediatric Brain Tumor Foundation® 5 previously thought. Sometimes they even seem to act as nerves themselves, transmitting signals through the brain. One of the most common astrocytomas in children is the pilocytic astrocytoma. “Pilocytic” refers to the fiber-like shape of the cells that make up the tumor. Pilocytic astrocytomas are usually found in the cerebellum – the part of the brain that sits immediately above the spinal cord at the rear of the skull. The cerebellum plays a critical role in integrating information from the senses, coordinating motor control or movement and maintaining balance when performing tasks such as riding a bicycle. More than 80 percent of tumors of the cerebellum are pilocytic astrocytomas. On occasion they appear in other parts of the central nervous system, including near the eye, hypothalamus and fluid-filled cavities known as ventricles. The pressure they may exert on the brain can lead to headaches, nausea, vomiting, irritability, or vision problems. When the tumor appears in the optic pathway of the eyes it is referred to as an optic nerve glioma. Most pilocytic astrocytomas grow slowly and have sharply defined edges. They are therefore easy to remove, if they are not located in an inaccessible region of the brain. If one can’t be removed by surgery, then radiation or chemotherapy may be used. This type of tumor is often called juvenile pilocytic astrocytoma (JPA) because it occurs most commonly in young children. Some experts consider it a “borderline” tumor that can become malignant, but in general, the prognosis for patients is good. When the entire tumor can be removed, survival rates of better 6 Pediatric Brain Tumor Foundation® than 90 percent are typical. For more information about this type of tumor, please see our booklets Basic Facts About Astrocytoma and Basic Facts About Juvenile Pilocytic Astrocytoma. Ependymomas About 6 percent of all childhood tumors of the central nervous system arise from cells that line the ventricles and spinal column, and are known as ependymomas. Most ependymomas in children are malignant and are located in the posterior fossa and the floor of the fourth ventricle. There are two types of the non-malignant ependymomas: myxopapillary ependymoma and subependymoma. Among children, myxopapillary ependymoma is uncommon. It occurs more often in young adults. It is comprised of smooth, sausage-shaped cells, usually in the spinal cord. It is slightly more common in boys than girls. The majority of these tumors are non-malignant and slow growing. At the time of surgery, a small number of these tumors are found to be intact as a bag- like tumor. If the tumor cannot be removed completely, recurrence can occur at the site of the original tumors. Myxopapillary ependymomas typically cause nonspecific symptoms, most commonly low back pain and sometimes lower extremity weakness or bladder problems. A related type of tumor is known as subependymoma, which is also more common in adults than children. They grow slowly, in clusters of glial cells that are often attached to the walls of fluid- filled ventricles in the brain’s cerebrum. The cerebrum is comprised of the familiar folded brain tissue that occupies most of the skull and sits above and in front of the cerebellum. Subependymomas are most often found in the fourth, lateral and third ventricles. Like pilocytic astrocytomas, subependymomas are well-defined groups of cells that can often be completely removed by a surgeon. In many cases, no radiation therapy is required after the operation, although in some rare cases where the tumor regrows, radiation has proven successful. If it is not removed, a subependymoma can eventually cause hydrocephalus, a condition involving a dangerous buildup of excess cerebrospinal fluid (CSF) in the brain. The condition can produce pressure within the skull and enlargement of the head. If not removed in time it can prove fatal. A common method of dealing with hydrocephalus is the insertion of a small tube, known as a shunt, that allows CSF to drain out of the ventricles and into the bloodstream or abdomen, where it is reabsorbed by the

Pediatric Brain Tumor Foundation® 7 body. This is usually a temporary measure, and in some cases a permanent shunt is needed. In other cases, subependymomas can lie dormant, producing no symptoms and remaining undetected throughout a lifetime. It is common for a patient to experience no symptoms of a tumor for many years until hydrocephalus becomes apparent. But even though a tumor itself is non-malignant, its effects can be life- threatening. For more information about malignant ependymomas in general, please see our booklet Basic Facts About Ependymoma. Meninges Frontal lobe Cerebrum

Temporal Lobe Choriod Plexus

Cerebellum Pituitary Gland Brain Stem

Spinal column Spinal Cord

Dura Mater

Choroid plexus papilloma The choroid plexus is a structure in the brain that produces cerebrospinal fluid. Choroid plexus papillomas are typically non-malignant and are most often found in young children, usually no older than 5 or 6. They make up about 3 percent of all pediatric brain tumors and appear more often in boys. In rare circumstances these tumors can be difficult to grade. A choroid plexus papilloma may cause no symptoms as it expands and fills up the ventricle

8 Pediatric Brain Tumor Foundation® because the brain has some ability to compensate for the gradually restricted flow of spinal fluid. Eventually, however, the tumor will likely block the flow of CSF entirely. Loss of CSF circulation presents serious challenges to the brain and its normal functioning, and hydrocephalus or other complications are much more likely if the tumor is left to grow for long. Craniopharyngioma Craniopharyngioma is another slow-growing tumor that usually originates near the pituitary gland at the base of the skull. It develops from ordinarily inactive tissue called the pharyngeal duct. Although the duct was once important to human ancestors and begins to develop before birth, it does not have a function in modern humans and may disappear altogether during childhood. If it doesn’t, however, there is a small chance it will develop into a tumor. Unlike many other non-malignant tumors, craniopharyngiomas have a tendency to spread to surrounding parts of the brain, and may even reappear after surgical removal. They take the form of one or more fluid-filled cysts. They are typically restricted to the base of the brain, but on occasion have been found as far away as the spine. Almost a quarter of all cases of craniopharyngioma occur in children younger than 15. They represent about 4 percent of all childhood tumors. Because of their location, craniopharyngiomas often reach large sizes before being discovered. Often they are more than an inch in diameter by the time symptoms develop. Those symptoms include headaches, poor hormone function, vision problems, a halt in normal growth and delayed puberty. In some cases, treatment with radiation therapy is needed following surgery. Schwannoma Among children, the most frequently diagnosed tumor of the nerves is vestibular schwannoma, a tumor that affects the balance and hearing nerves in the inner ear. It is named after the onion skin-like Schwann cells that wrap around the nerves, and is also known as an acoustic neuroma. When too many Schwann cells are produced, the affected nerve can lose its ability to process signals, leading to dizziness and poor balance, tinnitus (ringing in the ear), and deafness, most often in one ear. If a schwannoma continues to grow, it can also produce facial numbness or paralysis. If left untreated, it may eventually press on the cerebellum and brain stem, a life-threatening condition. Because the early signs are similar to a variety of other middle and inner ear problems, many children

Pediatric Brain Tumor Foundation® 9 with schwannoma are not properly diagnosed quickly. Ear examinations and hearing tests are often not sufficient for a true diagnosis, and only with CT or MRI scans does the tumor become evident. Surgical removal of the abnormal Schwann cells is the usual choice of treatment, particularly if the tumor is still relatively small. In that case, hearing can often be saved. Radiation therapy is used only if the tumor has already damaged nerves that cannot be removed without worsening the patient’s condition. Mixed neuronal-glial tumors Among the more difficult tumors to diagnose without surgery are those that involve both neurons and their supporting glial cells. The most common tumors in this category are gangliogliomas, which can occur in almost any part of the central nervous system, but typically in the temporal lobes and cerebellum. They arise from neurons and astrocytes, and can take a variety of forms. Ganglioglioma tumors are firm, gray masses that may be accompanied by even harder cysts. Although rare in adults, some 10 percent of pediatric brain tumors are gangliogliomas. Specially named variants are recognized and are discussed below. As with many other non-malignant tumors, gangliogliomas grow slowly. They are one of the least aggressive brain tumors, taking years to develop to the point where symptoms, such as headaches, fatigue and seizures, are felt. Once identified, complete removal is the most preferred course of action, after which recurrence is extremely rare. No radiation follow-up therapy is usually required. The hypothalamic hamartoma is a tumor composed of neurons that arise in the base of the brain near the third ventricle in a region known as the hypothalamus. This tumor is associated with early onset of puberty and occasionally other endocrine abnormalities. The desmoplastic infantile ganglioglioma (DIG) can occur in infants as young as 1 year of age and can be quite large. Although DIGs are often first identified as meningiomas because they are attached to the superficial covering of the brain known as the dura, they are also attached to the underlying brain. A second tumor with a very similar microscopic appearance and believed to be related to the DIG is the desmoplastic astrocytoma, a tumor that lacks the neurons of the DIG. Dysembryoplastic neuroepithelial tumors (DNTs) also consist of malfunctioning neurons, astrocytes and the oligodendrocytes that insulate neurons. They occur in the cerebrum, the primary thought control center of the brain. Most arise in the 10 Pediatric Brain Tumor Foundation® temporal lobes and a few in the frontal lobe at some point during the first 19 years of life. Although similar to, and sometimes misdiagnosed as, a ganglioglioma, a DNT has very different consequences. The most frequently described symptom is repeated seizures originating in the temporal lobe, usually beginning before age 10. Like most other non- malignant tumors, however, the prognosis following surgical removal is good. Another tumor composed of malfunctioning neurons and glial cells is the rosette-forming glioneuronal tumor (RGNT), which occurs near the fourth ventricle in children. It can mimic a malignant medulloblastoma (see the booklet Basic Facts about Medulloblastoma/PNET) in both location and microscopic appearance, but it comes with a much better prognosis. Hydrocephalus with headaches, nausea and vomiting are the most common symptoms. Meningioma The membranes that wrap around the central nervous system are collectively known as the meninges. Tumors found on the spider web-like layer that covers the brain are called meningiomas. Just what constitutes a meningioma is still subject to some debate, as several varieties of tumor can arise from the meninges. In addition, it is possible for patients to live for many years without experiencing any symptoms. As a result, their true prevalence is uncertain. When symptoms are apparent they take the form of seizures brought on when the tumor irritates or compresses the brain, as well as facial numbness, loss of hearing, or changes in behavior. Depending on the location of the tumor, it may be possible to cure a child with meningioma through surgical removal. Follow-up radiation therapy is frequently employed if only a portion of the tumor can be excised. About 90 percent of meningiomas are non- malignant, and they recur in less than a tenth of the patients who had the tumor completely removed. Pituitary adenoma The garbanzo bean-shaped pituitary gland regulates many vital functions in the body by releasing hormones. It is located at the base of the brain attached to the hypothalamus. A malfunctioning pituitary can wreak havoc with anyone’s metabolism, and a tumor presents a serious threat. Children are particularly at risk as many of the physical changes they go through require a properly functioning pituitary. The most common non- malignant tumors associated with the gland are known as pituitary adenomas.

Pediatric Brain Tumor Foundation® 11 These tumors can come in many forms, most secreting one or more hormones themselves, although between 25 and 30 percent do not. Both kinds can cause serious damage, however, by compressing the pituitary or preventing it from functioning properly. A long list of symptoms are associated with pituitary adenomas, ranging from headaches, nausea and weakness to seizures and blindness. If the tumor itself secretes a growth hormone, developmental problems for children are likely. Pituitary tumors are among the more challenging to treat. Some tumors are too close to vital regions of the brain for surgery and may require tightly targeted radiation therapy. Even after removal, however, they frequently recur. The most important consideration is to stop the tumor from secreting hormones, which may be possible with hormone therapy. Fortunately, many are relatively easy to remove. If the tumor is small enough, a doctor can excise it through the nose and sinuses, avoiding the need for surgery. Larger tumors may require an incision in the scalp.

SUMMARY The most important thing to remember is that all brain tumors in children present a threat, including non- malignant tumors, sometimes referred to as benign. Each non-malignant tumor presents its own diagnostic and treatment challenges. Many of the tumor types described here can interfere with the production and circulation of cerebral spinal fluid and lead to swelling of the brain. Others make themselves felt by affecting the senses, including vision or hearing. Symptoms may not always suggest a brain tumor, but they can, if left untreated, do significant damage to the brain of the child. Knowledge of how to respond to a specific tumor and which treatments offer the best hope for each child continues to expand. Much work remains before physicians can offer a guarantee of a cure, even when a non-malignant tumor is completely removed. But researchers are getting ever closer, treatments are ever more manageable and survival rates are always increasing. Each new child diagnosed with a brain tumor, has the benefit of all that has been learned about the disease to this point. The likelihood of a complete recovery has never been better.

12 Pediatric Brain Tumor Foundation® CONCLUSION: HOPE FOR TODAY AND TOMORROW By now, you have probably discovered that when you are dealing with a brain tumor or spinal cord tumor, you do not travel in a straight line from beginning to end. Instead, one step forward can be followed by two steps backward, followed by three steps forward, and so on. An attempt to treat one complication may create other problems, which then must be solved. Yet you also experience small triumphs along the way, and you are always aware that a major victory may be just around the corner. As you continue on this difficult journey, we encourage you to ask questions and express your concerns. At the same time, seek out people and places that give you energy and hope. Only when you are nourished can you give of yourself to those who need you. We are making progress. Every study and clinical trial increases our understanding of a tumor's origin and behavior, improving our ability to destroy it. One day, we will leam how to prevent it. And with each advance, more and more children will be able to enjoy a long and productive life. (See back cover for a list of booklets on various types of tumors and audio CDs available to families.)

Pediatric Brain Tumor Foundation® 13 Pediatric Brain Tumor Foundation® Reference Library The following resource literature and audio compact discs are available at no charge to patient families, medical professionals and social services specialists. To place an order, or for information on the availability of these materials in Spanish, call 800-253-6530 or e-mail [email protected]. Brochures 1. Questions for Your Medical Care Team When Your Child Has a Brain Tumor 2. Basic Facts about Pediatric Brain and Spinal Cord Tumors 3. Basic Facts about Medulloblastoma/PNET 4. Basic Facts about Juvenile Pilocytic Astrocytoma 5. Basic Facts about Astrocytoma 6. Basic Facts about Glioma 7. Basic Facts about Ependymoma 8. Basic Facts about Non-Malignant Brain Tumors 9. Basic Facts About Late Effects of Pediatric Brain Tumors and Treatments Informed Parent & Survivor Internet Conference Series (audio CDs) 1. The Importance of a Multidisciplinary Approach to Treating Children with Brain Tumors 2. The Clinical Trials Process 3. School Re-entry Following the Diagnosis and Treatment of Your Child’s Brain Tumor 4. Healing the Family 5. Growth and Development: Endocrine Issues Facing Pediatric Brain Tumor Survivors 6. Post-traumatic Stress: Helping Families Survive Childhood Cancer 7. Sibling Issues: The Impact of Cancer on Healthy Siblings 8. Brothers and Sisters and Brain Tumors: A Child’s Point of View for Coping with Cancer in the Family 9. Combining Curative and Palliative Care for Children with Brain Tumors 10. The Price of Survivorship: Loss and Living 11. Risk Factors and Pediatric Brain Tumors 12. The Role of the Pediatric Oncology Social Worker in Assisting Families 13. Finding Fertility: Parenthood Options and Childhood Cancer Newsletters The Caring Hand (for patient families, caregivers, and medical and social work professionals) The Helping Hand (for Ride for Kids® participants)

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This publication made possible through a generous grant from the Janirve Foundation.