If there’s one thing we know about mesothelioma treatment, it’s this: we continue to be challenged to find the most effective way of treating the disease.
Despite years of research since mesothelioma was first identified, it’s still difficult to identify the best approach to treating the disease, says David Rice, MD, a cardiothoracic surgeon and nationally known mesothelioma expert who practices at the MD Anderson Cancer Center in Houston, TX.
The very rareness of the cancer — only about 3,000 people a year are diagnosed in the United States—makes it difficult to run the kind of research studies needed to compare treatments and determine the ideal therapy at each stage of the disease. “There isn’t a lot of evidence-based science in this disease,” Dr. Rice admits. So when his patients ask him what the best treatment is for the disease, he tells them what we tell you in this section, adding that “we don’t have a reliable cure for mesothelioma.” Thus, a major goal of treatment is to reduce pain and suffering and prolong a patient’s life as long as possible while providing them with the highest quality of life possible.
Choosing the right mesothelioma doctor is an important first step in planning for treatment.
There are a number of mesothelioma doctors practicing in specialized clinics throughout the country. Each of these cancer specialists has an acute knowledge of the behavior and pathology of malignant mesothelioma and its treatment. It is likely that if you are diagnosed with mesothelioma, you will be referred by your personal physician to a larger scale comprehensive cancer center.
Important considerations in determining a mesothelioma treatment plan include the cancer stage, primary site affected and cell type. Treatment options also depend on whether the cancer is localized to the chest or has spread to the chest wall, diaphragm, or lymph nodes as well as your age and overall health. Recommended treatment plans will also vary based on available resources and any ongoing clinical trials at the cancer center where you’re being treated. Learn more about finding a doctor here. You should be prepared when you meet with your doctor by being ready to ask these questions.
Conventional treatments for mesothelioma involve surgery, chemotherapy, and radiation therapy.
As with most solid tumors, doctors turn to surgery, radiation and chemotherapy to manage mesothelioma. When exploring the various treatment options available with your doctor it is important to be informed about the risk and benefits of each one before making a final decision.
Only about 1 in 5 patients with metastatic pleural mesothelioma undergo surgery. There are two main surgeries: pleurectomy/decortication, in which the surgeon tries to remove as much of the tumor from around the lung as possible, and the more radical extrapleural pneumonectomy, in which the lung itself is removed.
Much debate exists as to which surgery is more effective, although studies show that most long-term survivors have undergone some form of surgery. Studies have found that pneumonectomy followed by radiation prevents tumor recurrence in the chest in 80 to 85 percent of patients.
However, it is a long, intensive operation with a 55 percent complication rate and a 3 percent risk of death, higher in some institutions. Therefore, this surgery is only performed for patients with a reasonably good prognosis, when it doesn’t appear that the cancer has spread outside the chest.
Patients best suited for pneumonectomy are younger, with the epithelial form of the disease, no obvious lymph node involvement, and are otherwise healthy enough to withstand the rigor of the procedure.
Pleurectomy/decortication has a higher failure rate, with the tumor recurring in the chest cavity 50 to 80 percent of the time. However, that rate may change with improved radiotherapy techniques. The reason for the high recurrence is that it’s difficult to completely remove the tumor without removing the lung.
However, there is no difference in survival rates between the two surgeries. Part of the reason is that the cancer has often spread to other parts of the body by the time it is diagnosed even if it appears to be confined to the chest.
In the end, part of the debate around the value of surgery is whether many patients who undergo surgery do better because the patients offered it are the very patients most likely to do well regardless of treatment, since surgery tends to be offered far more readily to younger, fit patients with earlier stage disease. There is no randomized trial evidence that demonstrates a significant benefit to surgery over non-surgical management of mesothelioma.
Chemotherapy, also known as systemic therapy, uses oral or infusion-based medications to kill cancer cells throughout your body. Chemotherapy is used both before and after surgery, as well as in people who do not undergo surgery. Though not curative, it has a proven survival benefit. It is also used in the palliative setting to reduce pain and improve quality of life.
The most commonly used chemotherapy drugs for mesothelioma are cisplatin combined with pemetrexed (Alimta) or raltitrexed (Tomudex). Other combinations include gemcitabine, carboplatin or oxaliplatin.
If you can’t manage combination therapy, your doctor may start on just one drug. Sometimes, your doctor may infuse the medication directly into your chest cavity, a procedure called pleural chemotherapy, or, abdomen, called intraperitoneal chemotherapy. You may also get a second course of chemotherapy, called “second-line” chemotherapy, with pemetrexed or other drugs, raltitrexed plus oxaliplatin, or the triple drug combination of irinotecan, cisplatin and mitomycin.
Radiation can be an important part of mesothelioma treatment. The problem is that because the cancer is near the heart and lungs, it’s challenging to provide the kind of high-dose, intensive therapy needed to shrink the tumor. However, a newer option, intensity-modulated radiotherapy (IMRT), which can more accurately target cancer cells and avoid healthy tissue, may provide better results when performed by experienced clinicians.
Investigational therapies are being explored through clinical and surgical trials at many of the nation’s top cancer centers. There are more than 50 studies on new therapies for mesothelioma in the U.S. that are looking for volunteers. Researchers are investigating new targeted drugs and chemotherapies, as well as new protocols for giving the medications; immunotherapy, which harnesses the power of the immune system to fight the disease; phototherapy, in which you are injected with a drug that bonds to cancer cells and is activated by high-intensity light; genetic therapies; and novel radiotherapy techniques like tomotherapy to treat the disease. Learn more about participating in a clinical trial here.
At some point, the management of the disease will shift from trying to cure the disease to trying to keep the patient as comfortable as possible for as long as possible. This is the palliative care stage, when many patients enter a hospice program. Hospice care can be provided at a designated hospice facility or in the comfort of a patient’s home by a designated hospice nurse or care provider. The primary goal at this stage is maximizing patient comfort. Medication to help with pain, difficulty breathing, and other symptoms that may be experienced is a mainstay. So is emotional and spiritual support for you and your family.
Alternative therapies for mesothelioma may possibly be helpful to ease side effects of traditional cancer treatment. Complementary and alternative medicine (CAM) includes such therapies as massage, acupuncture, and meditation. They may contribute to your overall management plan, helping you better manage the stress and anxiety of the disease and conventional treatments.