Mesothelioma Treatment Options

The treatment program for mesothelioma depends on many factors, including:

1. The stage of the cancer.

2. Where the cancer is.

3. How far the cancer has spread.

4. How the cancer cells look under the microscope.

5. The patient’s age and desires.

Surgery

Surgery for pleural mesothelioma may be done for 1 of 2 reasons: to relieve pain and discomfort caused by the tumor (called palliation) or to cure.

Palliative surgery is typically done in cases where the tumor has already spread beyond the mesothelium and is difficult to remove completely, or if you are too ill to tolerate a more extensive operation.

Curative surgery is offered if you are in otherwise good health and the tumor is thought to be localized and can be removed completely. Unfortunately, the cancer cells tend to spread into the chest wall, around the heart, over nerves, and the diaphragm. It is often difficult to detect this spread. Because of this, doctors are not clear on the exact role of surgery. It is not likely to cure you but may extend your life. Curative surgery is being done in some cancer centers and a few of the patients who have had the surgery are experiencing long remissions of their disease.

Depending on the stage of a mesothelioma, surgery may be used to remove the cancer and some of the surrounding tissue. Often, however, an operation is not appropriate and you may have only smaller procedures to relieve symptoms.

A thoracentesis, where fluid in the chest is removed by placing a needle into the chest cavity, may be done to make a patient more comfortable. Sometimes talc or drugs that cause scarring may be injected into the chest cavity to try to prevent the fluid from returning. This is called pleurodesis. These techniques are successful in controlling the fluid, at least temporarily, in as many as 90% of patients. Because pleural fluid can compress the lung and cause shortness of breath, these procedures can help you breathe more easily, however, they do not cure the cancer.

In the case of peritoneal mesothelioma, a needle may be inserted into the abdomen to drain the fluid. Similarly, a needle inserted into the pericardium (sac around the heart) can drain pericardial fluid and help relieve circulatory problems. Sometimes the cancer cells spread along the needle path, and a tumor nodule may form under the skin of that area. This concern should not prevent fluid removal, though.

Two surgical procedures may be offered if you have pleural mesothelioma: pleurectomy/decortication and extrapleural pneumonectomy.

Pleurectomy/decortication: Pleurectomy/decortication is usually a palliative procedure (relieves symptoms without curing the cancer) in cases where the entire tumor cannot be removed. This procedure removes the pleura, where the majority of the tumor is located. It can control the build up of fluid improve breathing and decrease pain caused by the cancer.

Extrapleural pneumonectomy: Extrapleural pneumonectomy is a far more extensive operation and is most often used in patients with localized mesothelioma of the epithelioid type, when the surgeon thinks a cure is possible. It is a difficult operation and is done only by surgeons in large specialized medical centers. You should talk with your doctor about an appropriate treatment center nearest to your home. The operation removes the pleura lining the chest wall, diaphragm, pericardium, and the whole lung on the side of the tumor. The diaphragm and the pericardium are then reconstructed with prosthetic material. You must be in overall good health with no other serious illnesses to tolerate the surgery. This operation attempts to remove all or most of the cancer and some surrounding tissues as well.

Surgical treatment of peritoneal mesothelioma is often done either to help relieve symptoms or to remove the tumor from the wall of the abdomen and other digestive organs. As with pleural mesothelioma, these tumors are often too extensive to remove completely. Similar operations can be done to remove a mesothelioma from the pericardium (the sac around the heart).

Surgery for mesothelioma of the tunica vaginalis testis, which occurs in the groin, is also not usually curative. Most of the time surgery is done because the tumor resembles a hernia. The surgeon attempts to treat a suspected hernia and only realizes the diagnosis after the surgery is begun. This kind of mesothelioma can’t be entirely removed.

Chemotherapy

Chemotherapy is the use of drugs for treating cancer. The drugs can be swallowed in pill form or they can be injected by needle into a vein or muscle. Chemotherapy is systemic therapy. This means that the drug enters the bloodstream and circulates throughout the body (through the whole system) to reach and destroy the cancer cells.

To treat mesothelioma, these drugs may also be given intrapleurally (directly into the chest cavity) or intraperitoneally (into the abdominal cavity). Based on the type and stage of mesothelioma, chemotherapy may be given as the primary (main) treatment or as an adjuvant treatment (treatment given in addition to the primary treatment) to surgery. Chemotherapy for this disease is palliative and not curative.

Several chemotherapy drugs have been used to treat mesothelioma. The preferred combination of drugs for now is pemetrexed (Alimta), which is combined with cisplatin. Because pemetrexed interferes with normal metabolism of folic acid and vitamin B12, these must also be given to avoid side effects. Another combination that has a good response rate is cisplatin and gemcitabine. Another option substitutes cisplatin with carboplatin, which causes much less nausea and vomiting.

Other combinations of drugs used to treat mesothelioma include:

• methotrexate and vincristine

• cisplatin, vinblastine and mitomycin

• cisplatin and doxorubicin

• doxorubicin, cyclophosphamide (or ifosfamide), and cisplatin

All the drugs above can be given alone in people who may not be able to tolerate two drugs. Other drugs such as paclitaxel and irinotecan are being studied to determine their effectiveness in treating mesothelioma.

A new, related drug called raltitrexed has also been shown to help patients with mesothelioma when given with cisplatin. Patients who received these drugs lived longer than those who received cisplatin alone.

Chemotherapy drugs kill cancer cells but also damage some normal cells. Therefore, your doctor will pay careful attention to avoiding or minimizing side effects, which depend on the specific drugs, the amount taken, and the length of treatment. Temporary side effects might include nausea and vomiting, loss of appetite, loss of hair, and mouth sores.

Because chemotherapy can damage the blood-producing cells of the bone marrow, patients may have low blood cell counts. This can result in an increased risk of infection (due to a shortage of white blood cells); bleeding or bruising after minor cuts or injuries (due to a shortage of blood; platelets); or fatigue or shortness of breath (due to low red blood cell counts).

Most side effects disappear once treatment is stopped. There are remedies for many of the temporary side effects of chemotherapy. For example, you can be given drugs to prevent or reduce nausea and vomiting. If you experience any side effects, be sure to talk with your doctor.

Radiation Therapy

Radiation therapy is sometimes used as the main treatment of mesothelioma in some patients, especially those whose general health is too poor to undergo surgery. Radiation therapy uses high-energy x-rays to kill cancer cells.

External beam radiation therapy uses radiation delivered from outside the body that is focused on the cancer. This type of radiation therapy is the preferred type to treat mesothelioma. These treatments are much like getting a diagnostic x-ray except for a longer time. A typical course of treatment takes anywhere from 3 to 5 weeks of daily treatments (5 days a week). In general, though, mesothelioma is not helped much by radiotherapy because it is relatively resistant to the effects of radiotherapy. Also, the need to treat a large part of the lung leads to problems with lung damage.

Brachytherapy places radioactive material directly into the chest or the abdomen at the site of the mesothelioma. It is seldom used for this cancer.

Adjuvant radiation therapy can be used in addition to surgery to kill small deposits of cancer that cannot be seen and removed during surgery.

Palliative radiation therapy can also be used to ease symptoms of mesothelioma such as shortness of breath, pain, bleeding, and difficulty swallowing.

Side effects of radiation therapy may include fatigue and mild skin changes that resemble sunburn. Often these side effects are temporary. Radiation may also make the side effects of chemotherapy worse. Chest radiation therapy may cause lung damage and lead to difficulty breathing and shortness of breath. Abdominal radiation therapy may cause nausea, vomiting, and diarrhea. If you are having any of these side effects of radiation therapy, talk with your doctor since there are ways to help control these symptoms.

If fluid collects in the pleural space, radioactive drugs can be put into the space after the fluids are removed. Sometimes they are successful in preventing the fluid from coming back.

Clinical Trials

The purpose of clinical trials: Studies of promising new or experimental treatments in patients are known as clinical trials. A clinical trial is only done when there is some reason to believe that the treatment being studied may be valuable to the patient. Treatments used in clinical trials are often found to have real benefits. Researchers conduct studies of new treatments to answer the following questions:

• Is the treatment helpful?

• How does this new type of treatment work?

• Does it work better than other treatments already available?

• What side effects does the treatment cause?

• Are the side effects greater or less than the standard treatment?

• Do the benefits outweigh the side effects?

• In which patients is the treatment most likely to be helpful?

Types of clinical trials: A treatment is studied in 3 clinical trial phases before it is eligible for approval by the FDA (Food and Drug Administration).

Phase I clinical trials: The purpose of a phase I study is to find the best way to give a new treatment and how much of it can be given safely. The cancer care team watches patients carefully for any harmful side effects. The treatment has been well tested in lab and animal studies, but the side effects in patients are not completely known. Doctors conducting the clinical trial start by giving very low doses of the drug to the first patients and increasing the dose for later groups of patients until side effects appear. Although doctors are hoping to help patients, the main purpose of a phase I study is to test the safety of the drug.

Phase II clinical trials: These are designed to see if the drug works. Patients are given the highest dose that doesn’t cause severe side effects (determined from the phase I study) and are closely observed for an effect on the cancer. The cancer care team also looks for side effects.

Phase III clinical trials: Phase III studies involve large numbers of patients—often several hundred. One group (the control group) will receive the standard (most accepted) treatment. The other groups will receive the new treatment. Usually doctors study only 1 new treatment to see if it works better than the standard treatment, but sometimes they will test 2 or 3. All patients in phase III studies are closely watched. The study will be stopped if the side effects of the new treatment are too severe or if one group has had much better results than the others.

If you are in a clinical trial, you will receive excellent care. You will have a team of experts taking care of you and monitoring your progress very carefully. The study is especially designed to pay close attention to you.

However, there are some risks. No one involved in the study knows in advance whether the treatment will work or exactly what side effects will occur. That is what the study is designed to find out. While most side effects disappear in time, some can be permanent or even life threatening. Keep in mind, though, that even standard treatments have side effects. Depending on many factors, you may decide to enroll in a clinical trial.

Deciding to enter a clinical trial: Enrollment in any clinical trial is completely up to you. Your doctors and nurses will explain the study to you in detail and will give you a form to read and sign indicating your desire to take part. This process is known as giving your informed consent. Even after signing the form and after the clinical trial begins, you are free to leave the study at any time, for any reason. Taking part in the study will not prevent you from getting other medical care you may need.

To find out more about clinical trials, ask your cancer care team. Among the questions you should ask are:

• What is the purpose of the study?

• What kinds of tests and treatments does the study involve?

• What does this treatment do?

• What is likely to happen in my case with, or without, this new treatment?

• What are my other choices and their advantages and disadvantages?

• How could the study affect my daily life?

• What side effects can I expect from the study? Can the side effects be controlled?

• Will I have to be hospitalized? If so, how often and for how long?

• Will the study cost me anything? Will any of the treatment be free?

• If I am harmed as a result of the research, what treatment would I be entitled to?

• What type of long-term follow-up care is part of the study?

• Has the treatment been used to treat other types of cancers?

The American Cancer Society offers a clinical trials matching service for patients, their family, and friends. You can gain access to this service through the ACS cancer information center at 1-800-ACS 2345 or on our Web site at http://clinicaltrials.cancer.org. Based on the information you provide about your cancer type, stage, and previous treatments, our computer can compile a list of clinical trials that match your medical needs. In finding a center most convenient for you, the service can also take into account where you live and whether you are willing to travel.

Complementary and Alternative Therapies

Complementary and alternative therapies are a diverse group of health care practices, systems, and products that are not part of usual medical treatment. They may include products such as vitamins, herbs, or dietary supplements, or procedures such as acupuncture, massage, and a host of other types of treatment. There is a great deal of interest today in complementary and alternative treatments for cancer. Many are now being studied to find out if they are truly helpful to people with cancer.

You may hear about different treatments from family, friends, and others, which may be offered as a way to treat your cancer or to help you feel better. Some of these treatments are harmless in certain situations, while others have been shown to cause harm. Most of them are of unproven benefit.

The American Cancer Society defines complementary medicine or methods as those that are used along with your regular medical care. If these treatments are carefully managed, they may add to your comfort and well-being.

Alternative medicines are defined as those that are used instead of your regular medical care. Some of them have been proven not to be useful or even to be harmful, but are still promoted as “cures.” If you choose to use these alternatives, they may reduce your chance of fighting your cancer by delaying, replacing, or interfering with regular cancer treatment.

Before changing your treatment or adding any of these methods, discuss this openly with your doctor or nurse. Some methods can be safely used along with standard medical treatment. Others, however, can interfere with standard treatment or cause serious side effects. That is why it's important to talk with your doctor.

Treatment of Mesothelioma by Stage

Stage I: Many patients with stage I pleural mesothelioma have their cancer removed by pleurectomy/decortication or extrapleural pneumonectomy, as described in the section How Is Mesothelioma Treated. Patients with peritoneal mesotheliomas in an early stage might also benefit from surgery. The value of adjuvant chemotherapy or radiation therapy (treatments given after surgery) for stage I mesothelioma is being studied. Radiation therapy may be used if your general health is too poor to tolerate a major operation. Some doctors have had success with putting cisplatin into the thoracic space after the surgery. This can also be used in the abdomen for peritoneal mesothelioma.

Stages II, III: Treatment options include palliative and supportive care providing relief of symptoms, such as thoracentesis (to remove fluid accumulation in the chest cavity) along with pleurodesis, paracentesis (removing fluid from the abdomen), operations to remove as much of the tumor as possible in some cases, and radiation therapy or chemotherapy aimed at easing symptoms. Cure is usually not possible for patients in these stages. Enrollment in clinical trials evaluating the newest treatment possibilities in large medical centers should be considered. Some patients can have long remissions after extensive surgery by experts.

Other approaches include putting chemotherapy or radioactive drugs directly into the pleural space or abdominal cavity. This can be done simply with the doctor placing a needle into the pleural space or abdomen after numbing the skin with local anesthetic. Although this only kills some of the cancer cells, it often helps slow down fluid collection.

Stage IV: Because stage IV mesothelioma has spread to distant organs, a cure is not possible. The goals of using any aggressive therapy such as chemotherapy and radiation therapy should be clear to you and your family. You might want to consider enrolling in a clinical trial in a large medical center. These studies evaluate the newest treatment possibilities.

Supportive care may be the best choice, perhaps in the setting of a good hospice program. Pain management is an important aspect of your care. It is important for you to know that drugs are available to effectively treat pain due to mesothelioma. You should not hesitate to request pain medicines or discuss pain control problems with your cancer care team.