My understanding, having not read the book, is that the tumor and the "HEAD" are the same thing but the first is real and the second was made up to make the movie based on their life more interesting. In the narrative of Barry and Tom's real life Barry has a tumor which may have been a third, undeveloped, twin. There is however also a movie based on the twins' career that footage is taken from for the "documentary". In the movie there is a dramatic element of the "HEAD" which is a much more developed and monstrous version of Barry's actual tumor. The tumor that Barry had would not have been conscious, but it could have affected his personality etc. based on this I don't think there is any way that the tumor could have written the letter. I do think, however, that it was probably the manager who, I believe, had sexual feelings for Barry.
To weigh in on the ending. First of all, it's supposed to be ambiguous and we're not supposed to understand it completely. But it seems to me that the simplest understanding is that when the twins are drawn into the crowd during that last show Tom's guitar is possibly pulled from him and in the general confusion and struggle Barry was struck with the body of the instrument. This may have exacerbated the existing condition with the tumor or his heart, as drug use may have. When the return home with their sister they were out walking, Barry died suddenly and Tom struggled to separate himself but also died. Pretty straight forward and I think that's all we can know for sure from the information we're given. Anything else is speculation.
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