TREATMENT OPTIONS

Mesothelioma is a rare and aggressive cancer, and is resistant to many available treatment options. These options are known to offer palliative relief, but currently there is no known cure for mesothelioma.  Recent advances in the study of mesothelioma and the progression of the cancer, however, have led to definite improvements in the effectiveness of the standard therapies.  The results are seen most clearly with the increase in median survival times reported by some classes of mesothelioma patients.

The treatment options for mesothelioma victims will vary depending on several key indicators:   the location and size of the tumor, the extent for which the cancer has spread, the stage of cancer and the overall health of the patient. 

The primary treatment options are similar to those of other cancers.  The three traditional choices that focus on destroying the cancerous cells and preserving the healthy ones are:

•  Surgery - physical removal of the tumor.
•  Chemotherapy - drugs injected, or in pill form, to kill cancer cells.
•  Radiation  - high-dose x-ray beams to destroy cancer cells and shrink tumors.

The final treatment may involve of a combination of therapies. Surgery may be followed up with radiation or chemotherapy to destroy remaining cancerous cells.  Understanding the treatment options and working with your doctor to create the best treatment plan for your needs is a critical step.

TREATMENT OVERVIEW

Localized (Stage 1) Mesothelioma

If the cancer is localized in the chest or abdomen, treatment will most likely be surgery to remove the tumor and the surrounding tissue.  If the cancer is found in a larger part of the pleura, one of the following may be performed: 
Surgery to remove the pleura and the tissue near it to relieve symptoms, with or without radiation therapy after surgery.

• Surgery to remove sections of the pleura, the lung, part of the diaphragm and part of the lining around the heart.
• External beam radiation therapy to relieve symptoms.
• A clinical trial of surgery followed by chemotherapy given inside the chest.
• A clinical trial of surgery, radiation therapy, and/or chemotherapy.

Advanced (Stages II – IV) Mesothelioma

Doctors will often use a process of draining the fluid in the chest or abdomen (thoracentesis or paracentesis) to reduce discomfort. Drugs also may be put into the chest or abdomen to prevent further collection of fluid.  In addition, the following treatment options may be used:

1. Surgery to relieve symptoms.
2. Radiation therapy to relieve symptoms.
3. Chemotherapy.
4. A clinical trial of surgery, radiation therapy, and chemotherapy
5. Chemotherapy given in the chest or abdomen.

SURGERY

There are three primary types of surgical treatments for Mesothelioma:  diagnostic surgery, curative surgery, and palliative surgery.  The disease type and disease stage will determine the type of surgery that will be most effective. Mesothelioma tumors are usually large and difficult to completely remove, so surgery is usually combined with other cancer treatments to ensure the best results in destroying the tumor and providing comfort to the Mesothelioma patient.

Palliative Procedures - treat the symptoms of mesothelioma, providing relief for the patient, without aggressively treating the disease itself.

Chest Tube Drainage and Pleurodesis
The goal of chemical pleurodesis is to cause an irritation between the two layers covering the lung. This irritation causes an obliteration of the space between the layers where the fluid accumulated, and prevents further fluid to be able to accumulate there. There are a variety of agents, which can be used including talc and bleomycin. As the pleural space is closed, fluid drains out of the chest cavity using a chest tube.

Pleuroperitoneal Shunt
Pleuroperitoneal shunting has been used in patients who have failed chemical pleurodesis, chemotherapy, or radiation therapy. Pleuroperitoneal shunting can provide effective palliation in patients with a trapped lung or others who have failed treatment.

Curative Procedures are medical procedures that attempt to remove all gross disease with 'curative intent'. Residual microscopic disease cells are then removed through Adjuvant therapy.  For curative surgery to be effective, it is important that mesothelioma be diagnosed as early as possible.  These procedures are typically used in combination with other treatment options (multi-modal therapy).

Pleurectomy / Decortication
A Pleurectomy / Decortication is a surgical procedure where the pleura, the membrane lining the lungs and chest cavity, is removed, without removing the entire lung. This treatment option is usually performed on patients in the early stages of mesothelioma.

Extra-Pleural Pneumonectomy (EPP)
EPP is the removal of the pleura, diaphragm, pericardium, and the whole lung involved with the tumor. EPP is considered a radical therapy and is not frequently performed by most surgeons, patients are referred to centers specializing in these treatments.

CHEMOTHERAPY

Chemotherapy uses drugs to kill cancer cells.  Chemotherapy may be used as either the primary treatment to treat mesothelioma, or it may be used as part of a multi-modal approach. Chemotherapy is referred to as systemic treatment because the drug is introduced into the patient’s bloodstream and travels throughout the body killing cancer cells. The drugs may be in pill form, or injected into the body through a needle.

In addition to killing cancer cells, chemotherapy drugs work to restrict the uncontrolled spread of abnormal cancer cells - preventing them from dividing and multiplying.

Chemotherapy drugs are targeted to focus on shrinking existing tumors (usually prior to surgery - neoadjuvant therapy), controlling the spread of the cancerous cells, and removing residual cancer cells following surgery (adjuvant therapy).

To effectively treat mesothelioma, multiple drugs may be used in chemotherapy. Researchers and physicians have found that the use of a combination of several chemotherapy drugs offers the most effective treatment. Based on the results of a recent clinical trial, the combination of cisplatin with pemetrexed has become the preferred choice of chemotherapy for malignant pleural mesothelioma. Alimta, the brand name for pemetrexed, was the first drug approved by the U.S. Food and Drug Administration for treatment of patients with malignant pleural mesothelioma. Additional chemotherapy drugs are available, such as bevacizumab, doxorubicin and gemcitabine, and are approved for mesothelioma treatment.

Doctors are studying the effectiveness of putting chemotherapy directly into the chest or abdomen (intracavitary chemotherapy).

RADIATION THERAPY

Radiation therapy, also referred to as radiotherapy, uses high-energy x-rays help to destroy cancer cells and to shrink tumors. The radiation may come from outside the body from a machine (external radiation) or from radioactive materials placed directly in or around cancer cells through thin plastic tubes (internal or implant radiation). Radiation therapy affects the cancer cells only in the treated area.

In pleural mesothelioma, it is difficult to irradiate tumor tissue successfully without injuring nearby organs like the lungs, heart, and liver. However, radiation therapy can be very effective in relieving pain in certain situations. Factors which can impact the use of radiation treatment include the volume of the tumor and how near it is to vital organs.

NON-TRADITIONAL TREATMENTS

Photodynamic Therapy
Photodynamic therapy destroys cancer cells by using the energy from light.  This treatment is most often used to treat skin cancers, and some types of lung cancer.  In the procedure, the patient receives a drug which makes cells sensitive to specific wavelengths of light (photosensitizer ).  The drugs will collect in cancerous cells only. Once the cells have been sensitized, fiber optic cables are placed in the body (usually through open-chest surgery) so that the correct frequency of light can be focused on the tumor. This causes the photosensitizer drug to produce a toxic oxygen molecule which kills the cancer cell.  This treatment is used for localized cancer.

Gene Therapy
This is a new treatment for mesothelioma and is currently only available through clinical trials. This approach allows treatment to target tumors, rather than destroying healthy cells which is the negative of traditional chemotherapy. In gene therapy, cancer is treated by altering genetic defects that allow a tumor to develop.  A “suicide gene” is inserted directly into the tumor, which forces cancer cells to produce substances that cause their death, making the cells sensitive to a normally ineffectual drug.

Immunotherapy
Immunotherapy, or biological therapy, treats cancer by using the body’s own immune system to fight cancer cells. Biological response modifiers (BRMs) is another term used to refer to this treatment. Though not yet obtainable, promising clinical studies are underway for immunotherapy.