Once a mesothelioma diagnosis is reached, the next step is determining what treatments may help. Although it tends to be an aggressive cancer, the right treatments in the right patient can make a difference.
Ongoing research continues to generate new treatments to help patients live longer lives with a higher quality of life. But, what treatment options are available for mesothelioma patients? And how might you go about deciding what’s right for you?
Did you know?
In October 2020, the FDA approved a new immunotherapy treatment for use in mesothelioma patients in the US. It uses a combination of two different antibodies to stimulate the patient’s own immune system to destroy cancer cells. This treatment is currently recommended for patients who have already tried surgery, or who are not candidates for surgery.
What Are The Goals of Mesothelioma Treatment?
For each mesothelioma patient, the first step is deciding what the goal of treatment will be. For some patients, treatment is potentially curative, meaning it’s intended to eliminate the mesothelioma.
The hope is that this treatment will allow the patient to live for many more years, mesothelioma-free. Whether or not this is a realistic possibility depends on the characteristics of the tumor, especially what stage it’s in when it’s found. Epithelioid tumors that are found in stage 1 (before spread to lymph nodes or distant organs) are most likely to respond to potentially curative treatments.
For other patients, treatment is palliative, meaning that its primary aim is to relieve the suffering associated with the disease. For those whose cancer has already spread widely through the body before diagnosis, curative treatment may not be a realistic option.
However, palliative care can help to improve a patient’s quality of life and may buy the patient some extra time. As with any treatment, it’s important to weigh the potential side effects against the potential benefits, to decide whether it’s worth it to undergo a particular treatment.
In general, patients with mesothelioma will be treated by a team of doctors, usually at a cancer center. The team is usually headed by a specialist in oncology, who is known as a medical oncologist.
Depending on the treatments that are chosen, the team may also include a radiation oncologist (who is a specialist in radiation treatment for cancer), a surgeon (who may specialize in a particular type of surgery, such as a thoracic surgeon, who specializes in surgery of the chest), and/or a pulmonologist (who is a specialist in treatments of the lungs) or gastroenterologist (who is a specialist in treatments of the digestive system).
What Are the Types Of Surgery For Mesothelioma?
There are several different surgical options available for mesothelioma. Depending on where the primary tumor is located, the surgical options will be different.
Surgery for Malignant Pleural Mesothelioma
Pleural mesothelioma affects the pleura, which is the membrane around the lungs. This membrane has two layers. One layer is on the outside of the lung, while the other layer is on the inside of the chest wall. Normally, the two layers slide against each other during breathing. Pleural mesothelioma surgery will focus on this area.
Extrapleural Pneumonectomy (EPP)
This is the most aggressive surgical option and is used as a curative procedure. The surgeon removes the lung on the affected side, along with both layers of the pleura, the part of the diaphragm on that side, and sometimes part of the pericardium (the membrane around the heart). The diaphragm is then rebuilt using other muscles so that the patient will still be able to breathe.
For patients whose tumors are found at an early stage, EPP may be able to completely remove the cancer from the body. If successful, this offers a chance of long-term survival. Because this surgery is so invasive, it’s generally only recommended for those with an epithelioid tumor (the type that spreads slowest) that is still localized (stage 1). For other patients, another surgical option may be better.
Pleurectomy/Decortication
This is a less invasive surgery. The surgeon removes the pleura on the affected side but leaves the lung itself in place. In certain cases, part of the diaphragm may also be removed; this is known as an extended or radical pleurectomy/decortication. If surgery is done on the diaphragm, then it will be rebuilt using other tissue.
This procedure may be curative for patients who have small tumors found at a very early stage. For other patients, this is a palliative procedure. It’s intended to remove a large part of the tumor, which can help to address the pain and discomfort associated with the tumor’s growth. It may also buy some time for the patient, by removing the largest part of the tumor.
Debulking
This is the least invasive surgical procedure and is always palliative. The surgeon will remove as much cancerous tissue as possible, to make the patient more comfortable. The surgery will be performed on whichever part of the body has a significant amount of cancerous tissue that is causing symptoms.
The surgeon aims to remove as much cancer as possible while causing as little disruption as possible to the functioning of the remaining tissue. (By contrast, when performing curative surgery for cancer, the surgeon takes “margins” of healthy tissue in case there are some cancer cells in that tissue.)
This is generally performed when the tumor is causing significant pain or other symptoms. Even if the cancer has spread widely to other parts of the body and cannot be cured through surgery alone, debulking can help to make the patient more comfortable.
Thoracostomy and Pleurodesis
Some patients with pleural mesothelioma experience a buildup of fluid or air outside of the lung. This compresses the lungs and leads to shortness of breath. A procedure called thoracostomy can help to remove that fluid or air and allow the lung to expand more fully.
During this procedure, a doctor inserts a plastic tube into the space around the lung, through a small incision in the chest wall. Suction can then be used to drain any fluid or air from this space.
In pleurodesis, medication is delivered through the chest tube. This causes mild irritation and leads to the formation of scar tissue on the outside of the lung, which helps to keep the lung stuck to the chest wall so that it will not collapse again.
Neither of these procedures will remove the cancerous tissue, but they can help to make the patient far more comfortable.
Surgery for Malignant Peritoneal Mesothelioma
For those suffering from mesothelioma of the peritoneum (the membrane surrounding the digestive tract), the surgical options are somewhat different. Rather than surgery of the chest, patients may instead have surgery of the abdomen. One layer of the peritoneum lines the abdominal wall, while the other layer surrounds the digestive organs (such as the intestines).
Cytoreduction
The most common surgical procedure for peritoneal mesothelioma is called cytoreduction. The goal of this surgery is to remove as much of the cancer as possible.
This involves removing the patient’s peritoneum, and sometimes parts of some structures that the peritoneum adheres to (including the uterus, ovaries, and gall bladder). In some cases, parts of the intestine are also removed. Cytoreduction is very often combined with chemotherapy infused into the abdomen (known as heated intraperitoneal chemotherapy, or HIPEC).
This is a very invasive procedure, requiring a hospital stay of approximately two weeks afterward. However, cytoreduction surgery with HIPEC has been successful in helping to extend the lives of patients with peritoneal mesothelioma. In one study, 43.6% of patients who received this therapy were still cancer-free after 7 years.
Debulking
Similar to pleural mesothelioma, debulking surgery can be useful for patients with peritoneal mesothelioma. For this type of surgery, the surgeon will remove as much of the tumor as possible, while removing minimal amounts of healthy tissue.
Radiation Therapy for Mesothelioma
Radiation therapy may be used to help shrink the primary tumor. In almost all cases, the treatment used is external beam radiation therapy (EBRT). For this treatment, beams of radiation are aimed at the body from the outside.
Modern radiation therapy technology aims for multiple beams of radiation from different angles, which meet up directly at the site of the tumor.
This helps to minimize the radiation exposure of the surrounding tissues, while still delivering enough radiation to the tumor to kill the cancer cells.
Other types of radiation therapy do exist, such as those that place radioactive “seeds” into the area of the tumor; however, these are very rarely used in mesothelioma patients.
Chemotherapy for Mesothelioma
Chemotherapy can be useful for many cases of mesothelioma. Very commonly, it’s used in combination with surgery and/or radiation treatments; chemotherapy alone has not shown great results in mesothelioma patients. Adding chemotherapy to another treatment can help to enhance its effectiveness. While surgery or radiation therapy targets cancer cells at the site of a tumor, chemotherapy can help to kill cancer cells that may have traveled away from that site.
Adjuvant Chemotherapy
One option is to give chemotherapy after surgery. This is called adjuvant chemotherapy. After the surgical procedure is complete, the patient will receive chemotherapy drugs through an IV. Several sessions of chemotherapy are generally prescribed. This helps to kill cancer cells that may have escaped the surgery, minimizing the chance that those cells will be able to start growing a new tumor in another part of the body.
Neoadjuvant Chemotherapy
A newer option is to use chemotherapy first, followed by surgery. In this case, the goal is to use chemotherapy to shrink the primary tumor before surgery. This can help to make the tumor smaller and more manageable, which facilitates its removal by the surgeon.
Intrapleural or Intraperitoneal Chemotherapy
In some cases, the chemotherapy is delivered directly to the mesothelium where the cancer originated, rather than being given through an IV. During the surgery, the surgeon first removes whichever tissue is intended for removal.
Next, a solution of chemotherapy drugs is placed into the pleural or peritoneal space. It’s left there for some time and then washed out. As mentioned in the section on surgery, intraperitoneal chemotherapy is almost always used during cytoreduction surgery for peritoneal mesothelioma.
The advantage of this option is that the chemotherapy is preferentially given to the area where most of the cancer cells are likely to be, rather than being given to the entire body. This reduces the toxicity of chemotherapy. Although some of it will still be absorbed into the bloodstream and cause some toxicity, this is much less than when chemotherapy is given through an IV.
Immunotherapy for Mesothelioma
One very promising area of research in mesothelioma treatment, and cancer treatment in general, is called immunotherapy. These treatments aim to stimulate the patient’s immune system to destroy cancer cells throughout the body. Although immunotherapy is a relatively new form of treatment, it’s been showing promise in studies for many different types of malignancies.
The immune system is naturally inclined to react to and destroy cancer cells because they’re different from your healthy cells. Some cancer cells, however, can evade this process. They can be proteins that tell the immune system to ignore them, which allows them to evade detection and continue growing. These proteins are targeted by some immunotherapy drugs.
Another immunotherapy option uses antibodies to stimulate the body’s immune system to kill the cancer cells. In October 2020, two antibody drugs were approved by the FDA for treating certain patients with malignant pleural mesothelioma. The two medications (called nivolumab and ipilimumab) are used together, to treat patients with this cancer who have not responded to surgery or who are not candidates for having it. (The agency is recommending that patients try surgery first if they can.)
In Japan, nivolumab was approved in 2018 to treat certain patients with malignant pleural mesothelioma. In March 2021, the results of a three-year study of this drug were published. The patients’ overall survival rate was 23.5%, which represents a significant improvement.
These very encouraging results are being followed up with additional studies on combining this drug with others, hoping to improve survival rates even further. In the US, researchers will be studying closely the results of treatment with the two immunotherapy drugs together.
Clinical Trials for Mesothelioma
Research into treatments for mesothelioma is ongoing, and many clinical trials are currently underway to test new treatments for this cancer. Researchers are testing new treatments, as well as new combinations of existing treatments.
New immunotherapy Treatments for Mesothelioma
With the recent approval in October 2020 of the new immunotherapy regimen, this form of treatment officially transitioned out of the lab and into the clinic, where it can be more broadly accessed. However, research in this area is ongoing, and various new immunotherapy agents and combinations of these are currently being studied in clinical trials.
Gene Therapy for Mesothelioma
Another promising possibility is gene therapy for mesothelioma. A clinical research trial that started in 2019 is investigating a gene therapy agent that stimulates the body to produce interferon, which is a signaling molecule for the immune system.
High levels of interferon help to cause immune system cells to destroy cancer cells. The study is in phase 3, which is the final step of clinical research; if the study shows that the agent is effective, then it will be eligible to receive FDA approval and become available for clinical use.
How Can You Join a Clinical Trial for Mesothelioma?
For patients and their families who are dealing with this disease, the idea of getting early access to a new therapy is very enticing. Although there are certainly no promises when dealing with experimental treatments, many patients would like the chance to try one of these new therapies.
In general, the only way to get access to an experimental treatment is to join a clinical trial. There’s a lot to think through when you’re deciding whether or not you’d like to do so. For example, patients in a trial are randomized to receive the new therapy under study, or to receive the usual care; not everyone likes the idea of their treatment being randomly selected for them.
Additionally, while many of the new therapies show great promise, we don’t know what the outcomes will be, and there are no guarantees that the new treatments will work better than the old ones.
At the same time, joining a clinical trial has the potential to give you access to a cutting-edge treatment that extends your life. If you’re considering joining a clinical trial, we strongly recommend talking it over with your physician, to discuss the risks and benefits.
If you have considered your options and decided that a clinical trial is right for you, then you’ll need to find out what trials are available and see whether you qualify for any of them. You may need to decide whether you’re willing to travel to participate in a trial.
There Is Hope for Mesothelioma Patients
Although mesothelioma tends to be an aggressive cancer, there is hope for those diagnosed with this malignancy. Currently, available treatments can help many mesothelioma patients, and new research promises to add more options.
Knowing what your options are is your first step. In consultation with your medical team, you’ll make decisions about which treatments are right for you. Your doctors will help guide you toward the best options, but you’re ultimately the one in control of what happens to your own body. You should always feel empowered to ask questions and make your own choices.
Treatment for mesothelioma can be expensive. Health insurance may help, but some patients and their families still struggle to afford the treatments that they need. Many cases of mesothelioma are linked to exposure to asbestos.
If you fall into this group, then you may be entitled to compensation, which will help to ease the financial burden of mesothelioma treatment. To learn more, talk with a lawyer who has extensive experience with mesothelioma cases.
