Mesothelioma Treatment Options

The stage, size, and location of your tumor will determine how it is treated. Treatment options could include surgery, chemotherapy, immunotherapy, radiation therapy, or a combination of any of these, depending on the type and stage of cancer that you have.

For most types of tumors, surgical removal of the visible tumor is considered the treatment that gives the best chance of cure. The decision of whether to use surgery is dependent on the size and location of the tumor and on whether the cancer cells have spread to other parts of the body. If the tumor cells have spread or if some of the tumor could not be removed during surgery, one or more other therapies may then be used as the next best chance to improve survival.

Introduction To Treatment Options:

There are no treatments for mesothelioma that have repeatedly provided a complete response. Any discussion of treatments, therefore, must include a wide variety of approaches, all of which continue to be considered primarily palliative. We will also deal with the post-treatment issues of recovery and coping with after-effects. Also given consideration will be concerns about recurrence and long term prognoses.

Primary Treatments:
As of early 2006, the state-of-the-art treatment for mesothelioma always includes some form of surgery. Either complete resection (if possible) or surgical debulking is a necessity for adjuvant treatments to be maximally effective. Surgery by itself, is not considered optimal and the practice of combining surgery with either chemotherapy, radiation, or both has gained acceptance as the preferred approach. This combination of methods is called multimodality treatment and has shown the most progress of any approach

Even chemotherapy by itself is now rarely administered as a single agent. Chemo protocols usually involve two or more complementary agents, often with widely different targets for each therapy. Assessments of various clinical trials and experience with treatment outcomes that rarely include stable disease have demonstrated that single protocol treatments are much less effective. Single agent protocols are therefore rapidly falling into disfavor.

Multimodality treatments that combine several complementary approaches, i.e. surgery together with either radiation or a combination of chemotherapy agents, are complicated treatments and should only be pursued at a mesothelioma center of excellence. Surgeries like extrapleural pneumonectomy can involve significant risks of mortality and morbidity if performed by a surgical and post-surgical nursing team with limited experience. Experienced medical teams can help to prevent or circumvent these issues.

Whether pleural or peritoneal, surgery offers the greatest chance for success but may include serious, even life-threatening side-effects. Such side effects, depending upon whether the surgery is abdominal or thoracic may include hemorrhage, lung infection, empyema, bronchoplenral fistula, heart arrhythmia, chest pain, abdominal pain, digestive problems, constipation, hemoptysis, nerve damage, pulmonary embolism, pneumothorax, or pneumonitis. The surgery itself may introduce malignant seeding at the site of the incisions. Certain chemotherapies may introduce another, entirely different set of morbidity issues such as neuropathy, loss of appetite, tinitus, hair loss, weight loss, nausea and low blood counts of white and red blood cells.

Despite the risks, treatments available today have made significant progress against the disease and with skillful intervention by experienced mesothelioma specialists the benefits of treatment far outweigh the alternatives. This is true, both in terms of improved quality of life, and in median survival times, which keep growing in leaps and bounds.

The choice of a treatment path is very much dependent upon the type of mesothelioma the staging of the disease and the health of the individual. As an example, a comparison of statistics for the various common treatment options for pleural mesothelioma is shown in the table below:

Treatment

Recommended Stage (c)

Quality of Life QoL (a)

Risk of Morbidity (b)

Median Survival (months)

Supportive Care

3 to 5

1 to 3

6 to 8

Theracoscopic Pleurodesis

all

1 to 3

1 to 2

7 to 9

Pleurectomy

1 to 2

2 to 4

1 to 3

EPP With Intracamitary Chemo

1 & 2

2 to 4

3 to 4

Pleurectomy / Brachytherapy

Multimodal Extrapleural Pneumonectomy (EPP)

1 & 2

2 to 4

3 to 4

13 to 19

Surgery/Photodynamic Therapy

Radiotherapy alone

3 to 4

1 to 2

8 to 15

Single Agent Chemotherapy

3 to 5

3 to 4

1 to 2

6 to 9

Combination Chemotherapy

3 to 5

1 to 2

6 to 16

Treatments and Outcomes For Pleural Meso: Legend: 1=lowest, 5=highest, na=not available.
NOTE: Lower can mean both best and worst. Example: Staging of 1 is best, Quality of Life (QOL) of 1 is worst. Table courtesy Meso Foundation 9/11 Asbestos Risk Assessment.

(a) (b) Author’s view based on 130+ patient interviews. (c) Since surgery is not always possible or desirable, patients tend to be segregated into surgical and other treatment groups by stage. Lower stage patients are more likely to be offered surgery. The options on the left represent treatment choices patients may be offered by their primary physician. Not all patients are able or willing to seek treatment at a mesothelioma center of excellence.