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Treatment for pleural mesothelioma
A range of treatments are recommended for some people with mesothelioma. These aim to control the cancer and can include chemotherapy, radiation therapy or surgery, which may be used alone or in combination. The different types of mesothelioma are treated in different ways.
Your specialist will discuss your treatment options with you, and these will depend on several factors including:
- the location, stage and type of mesothelioma, which helps estimate the likelihood of response to treatment
- your age, health and fitness
- your family circumstances and support
- what is most important to you.
Deciding to have treatment
Cancer treatments help control the disease for a longer period of time and improve quality of life for some people. It is important to talk to your treatment team about what each treatment involves, what side effects to expect and what recovery will be like.
While some treatments are not suitable for everyone, even if a particular treatment is recommended, it will be up to you whether or not to proceed.
A range of active cancer treatments are recommended for some people with pleural mesothelioma. These can include chemotherapy, radiotherapy or surgery, or a combination of these treatments called trimodality therapy.
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.
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).
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.
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.
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
- 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
- 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.