STEP 3: Diagnosis, staging and treatment planning

Diagnosis and grading

All patients should undergo:

T1- and T2-weighted fluid-attenuated inversion recovery (FLAIR), T2-weighted and post-contrast T1-weighted MRI, and diffusion-weighted imaging (DWI)
tissue biopsy to reliably diagnose brain cancer:
- The histological diagnosis of brain tumours should be undertaken by a neuropathologist or by an appropriately trained anatomical pathologist with experience in tumour neuropathology.
- Tumours should be classified according to the latest World Health Organization classification of tumours of the central nervous system.

Molecular markers must be identified for an accurate diagnosis.

Grading for high-grade gliomas involves both:

neuroimaging with MRI +/– CT
histological testing.

Genetic testing

The features that suggest a genetic predisposition may include:

early age at onset
multiple primary cancers
a family history of similar or related cancers, neurofibromatosis type 1 or tuberous sclerosis.

If present, these features may indicate that familial genetic testing is appropriate.

Treatment planning

All newly diagnosed patients should be discussed in a multidisciplinary meeting (MDM) within 2 weeks of diagnosis.

However, immediate treatment is often required before a full MDM ratifies details of the management plan (which should include full details of the response assessment).

Research and clinical trials

Consider enrolment where available and appropriate. Search for a trial.

Communication

The lead clinician’s (1) responsibilities include:

discussing a timeframe for diagnosis and treatment options with the patient and/or carer
explaining the role of the multidisciplinary team in treatment planning and ongoing care
providing contact details of a key contact for the patient
encouraging discussion about the diagnosis, prognosis, advance care planning and palliative care while clarifying the patient’s wishes, needs, beliefs and expectations, and their ability to comprehend the communication
providing appropriate information and referral to support services as required
communicating with the patient’s GP about the diagnosis, treatment plan and recommendations from MDMs.

1: Lead clinician – the clinician who is responsible for managing patient care.

The lead clinician may change over time depending on the stage of the care pathway and where care is being provided.

Checklist

Diagnosis confirmed

Grading/molecular profiling conducted

Full histology obtained

Performance status and comorbidities measured and recorded

Patient discussed at an MDM and decisions provided to the patient and/or carer

Clinical trial enrolment considered

Supportive care needs assessment completed and recorded, and referrals to allied health services actioned as required

Patient referred to support services (such as Cancer Council) as required

Treatment costs discussed with the patient and/or carer