Treatment of Mesothelioma Based on the Extent of the Cancer
The stage (extent) of a mesothelioma is an important factor in determining treatment options. But other factors, such as whether the doctor feels the cancer is resectable by surgery and person's general health and preferences also play a role.
Mesotheliomas can be hard to treat, no matter what stage of the cancer is. It's very important that you understand the goal of treatment before it starts – whether it is to try to cure the cancer or to help relieve symptoms – as well as the possible benefits and risks. This can help you make an informed decision when looking at your treatment options.
Resectable Mesotheliomas
In general, most stage I and some stage II and III pleural mesotheliomas are potentially resectable, but there are exceptions. Resectability is based not only on the size of the tumor, but also on the subtype (most doctors believe only epithelioid tumors are potentially resectable), where it is located, how far it has grown into nearby tissues, and whether or not a person is healthy enough to have surgery.
Many patients with resectable pleural mesothelioma have their cancer removed by pleurectomy/decortication or extrapleural pneumonectomy (EPP). Surgery is more likely to result in long-term benefit in stage I cancers, where there is a better chance that most or all of the cancer can be removed. For these early stage cancers, EPP may be a good option if it can be done. Patients with peritoneal mesotheliomas in an early stage might also benefit from surgery. Some patients can have long remissions after extensive surgery by experts. Surgery may still be helpful for later stage cancers, but the benefits are more likely to be short term.
Doctors are still studying whether giving chemotherapy before surgery (neoadjuvant therapy) or giving chemotherapy or radiation therapy after surgery (adjuvant therapy) is helpful. Many doctors advise adjuvant therapy, but not all doctors agree on when to use it or what the best course of treatment is.
If you are not healthy enough to tolerate a major operation, radiation therapy and/or chemotherapy may be used instead. While these treatments may shrink or slow the growth or the cancer for a time, they are not likely to result in a cure.
If you have symptoms because of fluid buildup in the chest or abdomen, other approaches such as thoracentesis/paracentesis or pleurodesis (described in the “Surgery” section) may be helpful.
Because these cancers can be hard to treat, taking part in a clinical trial of a newer form of treatment may be a reasonable option. These types of studies are usually done in large medical centers.
Unresectable Mesotheliomas
Stage IV mesotheliomas, as well as many earlier stage mesotheliomas, can't be removed completely by surgery either because of the extent of the disease or because a person may not be able to tolerate an operation. Chemotherapy and/or radiation therapy may shrink or slow the growth of the cancer for a time. But these treatments are very unlikely to result in a cure and can have their own side effects. Before starting such treatments, the goals of treatment should be clear to you and your family.
Because these cancers can be hard to treat, taking part in a clinical trial of a newer form of treatment may be a reasonable option.
In many cases, treatment aimed at relieving symptoms and making you comfortable may be a good choice. This could include treatments that prevent or reduce fluid buildup in the body, which could affect your breathing or ability to take in nutrition.
Pain management is another important aspect of your care. Some minor operations and types of radiation therapy can help relieve pain if needed. Doctors can also prescribe strong pain-relieving drugs. Some people with cancer may hesitate to use opioid drugs (such as morphine) for fear of being sleepy all the time or becoming addicted to them. But many people get very effective pain relief from these medicines without serious side effects. It's very important to let your cancer care team know if you are having pain so that it can be treated effectively.
Recurrent Mesotheliomas
Cancer is called recurrent when it come backs after treatment. Recurrence can be local (in or near the same place it started) or distant (spread to organs such as the brain or liver). Mesotheliomas often come back after the initial treatment. If this happens, further treatment options depend on where the cancer is, what treatments have already been used, and a person's general health. In most cases the options will be similar to those listed above for unresectable mesotheliomas. For example, chemotherapy may be used to try to shrink or slow the growth of the cancer and to relieve any symptoms. Because recurrent cancers can often be hard to treat, clinical trials of new types of treatment may be a good option.
Surgery
Surgery for mesothelioma may be done for 1 of 2 reasons: to try to cure the cancer or to relieve (palliate) pain and other symptoms caused by the tumor.
Surgery to try to cure the cancer is also known as potentially curative surgery. This type of surgery may be an option if you are in otherwise good health and the cancer has not spread too far to be removed completely. Unfortunately, even when the surgeon can remove all of the cancer that can be seen, some cancer cells are often left behind. These cells can grow and divide, causing the cancer to come back some time after surgery. Because of this, not all doctors agree on the exact role of surgery. In most cases it is not likely to cure you but may extend your life. Still, potentially curative surgery is being done in some major cancer centers, and a small number of patients who have had the surgery have had long remissions of their disease.
Palliative surgery may be an option if the tumor has already spread beyond the mesothelium and is difficult to remove completely, or if you are too ill for a more extensive operation. The goal of this surgery is to relieve or prevent symptoms, as opposed to trying to cure the cancer.
Radiation therapy
Radiation therapy uses high-energy x-rays or particles to kill cancer cells. Mesotheliomas are often hard to treat with radiation therapy. They are not usually contained as single, discrete tumors, so aiming radiation at them while avoiding nearby normal tissues is difficult. But new radiation therapy techniques may make this form of treatment more useful.
Uses of Radiation Therapy
Radiation therapy may be used in different ways to treat mesothelioma:
- It can be used after surgery to try to kill any small areas of cancer that could not be seen and removed during surgery. This is called adjuvant radiation therapy.
- Radiation therapy can be used to ease symptoms of mesothelioma such as shortness of breath, pain, bleeding, and trouble swallowing.
Types of Radiation Therapy
There are 2 main types of radiation therapy that can be used to treat mesothelioma:
External beam radiation therapy (EBRT): This type of radiation therapy uses x-rays from a machine outside the patient's body to kill cancer cells. It is the most common form of radiation therapy for mesothelioma. The treatment is much like getting an x-ray, but the radiation is more intense. The procedure itself is painless. Before your treatments start, the medical team will take careful measurements to find the correct angles for aiming the radiation beams and the proper dose of radiation. Each treatment lasts only a few minutes, although the setup time – getting you into place for treatment – usually takes longer. Most often, radiation treatments are given 5 days a week for several weeks.
With newer techniques, doctors can more accurately treat mesotheliomas while reducing the radiation exposure to nearby healthy tissues such as the lungs. This may offer a better chance of increasing the success rate and reducing side effects.
For example, intensity-modulated radiation therapy (IMRT) is an advanced form of 3-dimensional radiation therapy. It uses a computer-driven machine that moves around the patient as it delivers radiation. Along with shaping the radiation beams and aiming them at the tumor from several angles, the intensity (strength) of the beams can be adjusted to limit the dose reaching nearby normal tissues.
Brachytherapy: When a radiation source is placed inside the body, it is called brachytherapy. When this type of radiation therapy is used for mesothelioma, the doctor places radioactive material directly into the chest or the abdomen at the site of the cancer. The radiation given off travels only a very short distance, which limits the potential damage to nearby healthy tissues. Brachytherapy is seldom used for this type of cancer.
Possible side effects
Side effects of external radiation therapy may include fatigue and sunburn-like skin problems and hair loss where the radiation enters the body. These usually go away once treatment is finished. Chest radiation therapy may cause lung damage and lead to trouble breathing and shortness of breath. Abdominal radiation therapy may cause nausea, vomiting, diarrhea, and a loss of appetite.
If radiation therapy is used together with chemotherapy, it may make the side effects of chemotherapy worse.
If you are having any side effects from radiation therapy, talk with your doctor. In most cases there are ways to help control these symptoms.
Clinical Trials
Clinical trials are carefully controlled research studies that are done with patients who volunteer for them. They are done to get a closer look at promising new treatments or procedures. Clinical trials are one way to get state-of-the art cancer treatment. They are the only way for doctors to learn better methods to treat cancer. Still, they are not right for everyone.
If you would like to take part in a clinical trial, you should start by asking your doctor if your clinic or hospital conducts clinical trials. You can also call our clinical trials matching service for a list of clinical trials that meet your medical needs. You can reach this service at 1-800-303-5691 or at www.cancer.org/clinicaltrials. You can also get a list of current clinical trials by calling the National Cancer Institute's Cancer Information Service toll-free at 1-800-4-CANCER (1-800-422-6237) or by visiting the NCI clinical trials Web site at www.cancer.gov/clinicaltrials.
There are requirements you must meet to take part in any clinical trial. If you do qualify for a clinical trial, it is up to you whether or not to enter (enroll in) it.
Complementary and alternative therapies
When you have cancer you are likely to hear about ways to treat your cancer or relieve symptoms that your doctor hasn't mentioned. Everyone from friends and family to Internet groups and Web sites may offer ideas for what might help you. These methods can include vitamins, herbs, and special diets, or other methods such as acupuncture or massage, to name a few.
What exactly are complementary and alternative therapies?
Not everyone uses these terms the same way, and they are used to refer to many different methods, so it can be confusing. We use complementary to refer to treatments that are used along with your regular medical care. Alternative treatments are used instead of a doctor's medical treatment.
Complementary methods: Most complementary treatment methods are not offered as cures for cancer. Mainly, they are used to help you feel better. Some methods that are used along with regular treatment are meditation to reduce stress, acupuncture to help relieve pain, or peppermint tea to relieve nausea. Some complementary methods are known to help, while others have not been tested. Some have been proven not be helpful, and a few have even been found harmful.
Alternative treatments: Alternative treatments may be offered as cancer cures. These treatments have not been proven safe and effective in clinical trials. Some of these methods may pose danger, or have life-threatening side effects. But the biggest danger in most cases is that you may lose the chance to be helped by standard medical treatment. Delays or interruptions in your medical treatments may give the cancer more time to grow and make it less likely that treatment will help.
Finding out more
It is easy to see why people with cancer think about alternative methods. You want to do all you can to fight the cancer, and the idea of a treatment with few or no side effects sounds great. Sometimes medical treatments like chemotherapy can be hard to take, or they may no longer be working. But the truth is that most of these alternative methods have not been tested and proven to work in treating cancer.
As you consider your options, here are 3 important steps you can take:
- Look for "red flags" that suggest fraud. Does the method promise to cure all or most cancers? Are you told not to have regular medical treatments? Is the treatment a "secret" that requires you to visit certain providers or travel to another country?
- Talk to your doctor or nurse about any method you are thinking about using.
- Contact Cancer.org at 1-800-227-2345 to learn more about complementary and alternative methods in general and to find out about the specific methods you are looking at.
Drugs
This is a list of cancer drugs approved by the Food and Drug Administration (FDA) for malignant mesothelioma:
Alimta (Pemetrexed Disodium)
Cisplatin
GEMCITABINE-CISPLATIN
Pemetrexed Disodium
Platinol (Cisplatin)
Platinol-AQ (Cisplatin)
Note: There may be some drugs that used in the the treatment of malignant mesothelioma that are not listed above.
Making Treatment Decisions
After the tumor is found and staged, your cancer care team will discuss your treatment options with you. The main factors in selecting a treatment for mesotheliomas are the size and location of the tumor, whether it has spread to lymph nodes or other organs, and your health and personal preferences.
Because mesothelioma is a rare cancer, it has been hard for doctors to compare the value of different treatments. Only a few large clinical trials of treatments for mesothelioma have been done. In addition, many doctors have little or no experience treating this disease. They usually refer patients with this cancer to specialists who treat large numbers of mesothelioma patients at major medical centers.
You may have different types of doctors on your treatment team, depending on the stage of your cancer and your treatment options. These doctors may include:
- A thoracic surgeon: a doctor who treats diseases of the lungs and chest with surgery.
- A radiation oncologist: a doctor who treats cancer with radiation therapy.
- A medical oncologist: a doctor who treats cancer with medicines such as chemotherapy.
- A pulmonologist: a doctor who specializes in medical treatment of diseases of the lungs.
Many other specialists may be involved in your care as well, including nurse practitioners, nurses, respiratory therapists, social workers, and other health professionals.
Mesothelioma is often hard to treat because it typically does not grow as a single tumor mass. It tends to spread along nearby surfaces, nerves, and blood vessels. This makes it very difficult, except in rare situations, to completely get rid of it with surgery and/or radiation.
Before deciding on a treatment option, it's very important to have an idea of its likely benefits and possible risks. You will probably have many questions about the treatment options suggested. Mesotheliomas are rare, so if time permits it is often a good idea to seek a second opinion from a doctor who has a lot of experience in treating people with these cancers. A second opinion can provide more information and help you feel more confident about the treatment plan that you choose.
Sources: 1 2, 3, 4, 5