There have been impressive surgical, radiotherapeutic, and chemotherapeutic advances in treating cancer. However, the outlook for patients with malignant brain tumors is still dismal. Gene therapy offers hope of replacing defective genes, amplifying the immune response to cancer, and sensitizing tumor cells to systemic therapies (suicide gene therapy). The insertion of the thymidine kinase gene from herpes virus (HSV-TK) into glioma cells can sensitize them to intravenous ganciclovir. Pivotal to the HSV-TK strategy is the "bystander effect," which results in a larger number of tumor cells being killed than those that have been genetically altered. The presence of gap junctions between tumor cells and immunocompetence are required experimentally to observe the "bystander effect." At present, clinical trials using suicide gene therapy in newly diagnosed and recurrent gliomas are underway. Suicide gene therapy faces many challenges in neuro-oncology until p53 gene replacement and immunomodulatory strategies become feasible.