Treatment for mesothelioma

Chemotherapy uses drugs to kill or slow the growth of cancer cells while causing the least possible damage to healthy cells. The main chemotherapy drugs for pleural mesothelioma are pemetrexed in combination with cisplatin or carboplatin. Research shows this combination can improve quality of life and increase survival by a few months more than using a single drug.

The goals of chemotherapy are not only to increase length of life but also to shrink the cancer, reduce symptoms and improve quality of life. However, chemotherapy doesn’t work for some people.

Having chemotherapy – Chemotherapy is usually administered into a vein through a drip (intravenously). The drugs travel through the bloodstream and reach the entire body. This is known as systemic chemotherapy. You will usually have chemotherapy during day visits to your hospital or treatment centre. Each session may last for several hours followed by a rest period of several weeks. Together, the session and rest period are called a cycle. You will probably have up to six cycles. However, the length and timing of the treatment and rest days of each cycle may vary.

Side effects of chemotherapy – Most chemotherapy drugs cause side effects. Side effects depend on the type and dose of chemotherapy drugs. Your specialist may prescribe vitamin B12 injections and low-dose folic acid, which have been shown to reduce the side effects of pemetrexed and cisplatin chemotherapy. You will also be given medicines (such as anti-nausea medicine) to help control any side effects that are likely to occur. If side effects become too difficult to manage, your oncologist can adjust the dose or type of chemotherapy.

Common side effects of chemotherapy include:

• tiredness and feeling weak (fatigue)
• nausea and/or vomiting
• bowel problems (diarrhoea or constipation caused by anti-nausea drugs)
• sore or dry mouth, or small ulcers in the mouth
• taste changes and/or loss of appetite
• increased risk of anaemia (low level of red blood cells)
• reduced kidney function
• skin rash
• numb or tingling hands or feet (peripheral neuropathy)
• ringing in the ears (tinnitus) or hearing loss
• red and itchy eyes (conjunctivitis).

Chemotherapy weakens the immune system by lowering the level of white blood cells, making it harder for your body to fight infections. If you have a temperature over 38°C, contact your doctor immediately or go to your nearest hospital emergency department.

While hair loss and scalp problems are rare with chemotherapy for mesothelioma, hair may thin. Some people have trouble thinking clearly or experience short-term memory loss after chemotherapy, but this usually improves once treatment ends.

Download our booklet ‘Understanding Chemotherapy’

Also known as radiotherapy, radiation therapy is the use of targeted radiation to kill or damage cancer cells so they cannot grow, multiply or spread.

Radiation therapy may be used at different stages of pleural mesothelioma treatment and in different ways:

• as palliative treatment to relieve pain or other symptoms caused by tumours and improve quality of life
• after chemotherapy and surgery (adjuvant radiation therapy) to help kill any remaining cancer cells.

Having radiation therapy – Treatment is carefully planned to destroy as many cancer cells as possible while causing the least harm to your normal tissue. The initial appointment to map out the treatment (simulation) may take a few hours. You will have CT scans of the affected area, and your skin may be marked with a special ink. This makes sure that the radiation is directed at the same place on your body every time you receive radiation therapy. Although the ink is permanent, the mark is only the size of a freckle.

Radiation therapy is usually given every day Monday to Friday as an outpatient treatment. A session usually lasts about 20 minutes because the radiation therapists have to set up the equipment and position you, but the treatment itself takes only a few minutes.

The length of the treatment course will vary depending on why you’re having radiation therapy – it might involve 1–10 sessions for up to two weeks for palliative treatment, or longer if radiation therapy is combined with other treatments with the aim of long-term control. Radiation therapy doesn’t hurt and you aren’t radioactive afterwards.

Side effects of radiation therapy – Radiation therapy may cause various side effects during treatment or shortly afterwards, but most side effects go away after the treatment stops. Your doctors and nurses will tell you what side effects to expect and how to manage them.

The side effects of radiation therapy vary depending on the area of the body treated, but can include fatigue; peeling, cracked skin that looks red or sunburnt and may be uncomfortable; painful swallowing; or loss of hair in the treatment area.

Radiation therapy to the chest area can cause difficulty swallowing and symptoms of reflux for a few days or weeks, sometimes leading to weight loss. If high doses of radiation therapy are given to the chest area, it may cause permanent changes (fibrosis) in the lung tissue.

Download our booklet ‘Understanding Radiation Therapy’

Having a combination of chemotherapy, radical surgery and radical radiation therapy to treat mesothelioma is known as trimodality therapy. The aim of having the three types of treatment is to remove as much pleural mesothelioma as possible, and stop any remaining mesothelioma cells from growing or spreading. The most effective combination will depend on your situation.

Trimodality therapy is an intensive treatment. Despite reduced lung capacity afterwards, some people continue to live independently.

Although some studies show promising results, the benefits of trimodality therapy for pleural mesothelioma are not yet clear. There has not yet been an evidence-based trial comparing the results of trimodality therapy to less intensive treatment. Not all mesothelioma specialists recommend trimodality therapy, and it’s available only in a few specialist centres.

The three parts of trimodality therapy

Chemotherapy

• Several cycles of chemotherapy are given to shrink the tumour.
• A scan then checks the size of the tumour. If it has been reduced, you’ll have surgery in 4–6 weeks. If there is little or no response, you will not have radical surgery. Chemotherapy is usually given before surgery, but some people have chemotherapy after surgery

Radical surgery

• This is either an extrapleural pneumonectomy (EPP) or pleurectomy decortication (PD). An EPP removes the whole lung, a PD keeps the lung but removes the outer lining of the pleura (parietal pleura) and any visible tumours. Sometimes a smaller operation removes only part of the parietal pleura. Lymph nodes in the centre of the chest that drain the lung are also removed.
• You’ll stay in hospital for 10–14 days, or longer if complications occur. After 6–8 weeks you’ll be able to start radiation therapy.

Radical radiation therapy

• This aims to treat any tumour cells that may still be present.
• Radiation therapy is delivered using intensity-modulated radiation therapy (IMRT). Because this type of radiation therapy can be accurately shaped around the chest cavity, higher doses can be delivered directly to the tumour cells while minimising the damage to other organs in the chest and abdomen.
• While IMRT is often given after surgery for up to six weeks, in some cases it is given before surgery for only one week. This shorter treatment is experimental, and your radiologist will decide how long you need radiation therapy depending on your circumstances.
• Radiation therapy may cause various side effects, but most get better after treatment ends.

Who can have trimodality therapy – Only a small number of people with pleural mesothelioma have trimodality therapy. It is suitable only for people:

• with a small amount of pleural mesothelioma at an early stage (T1–T3)
• with an epithelioid type of pleural mesothelioma
• whose scans show a good response to chemotherapy before surgery and no signs of pleural mesothelioma progression
• with no signs of spread into the lymph nodes or any other disease on CT and/or FDG-PET scans
• who are able to live independently with one lung
• who are physically fit enough for surgery.

The best person to work out if trimodality therapy may be suitable for you is the surgeon who would perform the surgery. It is important to ask your surgeon, oncologist and nurse to explain the likely outcome of the surgery for you. An EPP or PD is a major operation, and not everyone wants to go ahead after the risks and benefits of the therapy are explained by their treatment team.

When trimodality therapy is not suitable – Sometimes, despite a person appearing suitable for intensive treatment at first, the doctor may need to adjust the treatment plan or they may decide it is best not to continue with trimodality therapy. This might be because:

• the mesothelioma does not respond well to the chemotherapy
• tests of specimens taken at surgery show that the cancer is growing quickly or has spread
• the person has become too tired or unwell.

It is possible for some people with peritoneal mesothelioma that has not spread to have an operation called a peritonectomy. The surgeon removes the parts of the peritoneum where the mesothelioma is growing. The amount of surgery needed will vary between people. Surgery is usually followed by chemotherapy.

Removing as much of the cancer as possible will help reduce symptoms such as abdominal pain and poor appetite. It will also improve quality of life and increase life expectancy.

Peritonectomy surgery is complex and recovery can take a long time. Whether this surgery is an option for you will depend on several factors, including your overall health and fitness, and whether the small bowel is cancer-free.

Only a small number of surgeons in Australia perform this surgery. It is recommended you seek an opinion from one of these surgeons if considering a peritonectomy. To find contact details, talk to your treatment team or contact a mesothelioma support organisation.

Download our booklet ‘Understanding Surgery’

Chemotherapy is sometimes used to treat peritoneal mesothelioma. It may be given as a systemic treatment (into the bloodstream) on its own, or before or after surgery. Systemic chemotherapy for peritoneal mesothelioma is similar to that given for pleural mesothelioma.

Having chemotherapy – If you have a peritonectomy, you will have chemotherapy directly into the abdomen. This is known as intraperitoneal chemotherapy and may be given in several ways:

• HIPEC – Heated intraoperative intraperitoneal chemotherapy (HIPEC) is known as “heated chemotherapy”. It involves heating the drugs to 42.5°C and inserting the solution into the abdomen for 60–90 minutes during the operation.
• EPIC – After surgery, chemotherapy may be delivered into the abdomen through a thin tube. When given soon after surgery as a single course, it is called early postoperative intraperitoneal chemotherapy (EPIC).
• NIPEC – There is evidence that receiving a long-term course of normothermic (normal temperature) intraperitoneal chemotherapy (NIPEC) may offer some benefit.

Download our booklet ‘Understanding Chemotherapy’

Radiation therapy is rarely used for peritoneal mesothelioma as the doses required to the whole abdomen would cause too much damage to surrounding organs. However, it can be used for localised symptoms.

Download our booklet ‘Understanding Radiation Therapy’