As with most solid tumors, doctors turn to surgery, radiation and chemotherapy to manage mesothelioma. When exploring the various treatment options available with your doctor it is important to be informed about the risk and benefits of each one before making a final decision.
Surgery
Only about 1 in 5 patients with metastatic pleural mesothelioma undergo surgery. There are two main surgeries: pleurectomy/decortication, in which the surgeon tries to remove as much of the tumor from around the lung as possible, and the more radical extrapleural pneumonectomy, in which the lung itself is removed.
Much debate exists as to which surgery is more effective, although studies show that most long-term survivors have undergone some form of surgery. Studies have found that pneumonectomy followed by radiation prevents tumor recurrence in the chest in 80 to 85 percent of patients.
However, it is a long, intensive operation with a 55 percent complication rate and a 3 percent risk of death, higher in some institutions. Therefore, this surgery is only performed for patients with a reasonably good prognosis, when it doesn’t appear that the cancer has spread outside the chest.
Patients best suited for pneumonectomy are younger, with the epithelial form of the disease, no obvious lymph node involvement, and are otherwise healthy enough to withstand the rigor of the procedure.
Pleurectomy/decortication has a higher failure rate, with the tumor recurring in the chest cavity 50 to 80 percent of the time. However, that rate may change with improved radiotherapy techniques. The reason for the high recurrence is that it’s difficult to completely remove the tumor without removing the lung.
However, there is no difference in survival rates between the two surgeries. Part of the reason is that the cancer has often spread to other parts of the body by the time it is diagnosed even if it appears to be confined to the chest.
In the end, part of the debate around the value of surgery is whether many patients who undergo surgery do better because the patients offered it are the very patients most likely to do well regardless of treatment, since surgery tends to be offered far more readily to younger, fit patients with earlier stage disease. There is no randomized trial evidence that demonstrates a significant benefit to surgery over non-surgical management of mesothelioma.
Chemotherapy
Chemotherapy, also known as systemic therapy, uses oral or infusion-based medications to kill cancer cells throughout your body. Chemotherapy is used both before and after surgery, as well as in people who do not undergo surgery. Though not curative, it has a proven survival benefit. It is also used in the palliative setting to reduce pain and improve quality of life.
The most commonly used chemotherapy drugs for mesothelioma are cisplatin combined with pemetrexed (Alimta) or raltitrexed (Tomudex). Other combinations include gemcitabine, carboplatin or oxaliplatin.
If you can’t manage combination therapy, your doctor may start on just one drug. Sometimes, your doctor may infuse the medication directly into your chest cavity, a procedure called pleural chemotherapy, or, abdomen, called intraperitoneal chemotherapy. You may also get a second course of chemotherapy, called “second-line” chemotherapy, with pemetrexed or other drugs, raltitrexed plus oxaliplatin, or the triple drug combination of irinotecan, cisplatin and mitomycin.
Radiation
Radiation can be an important part of mesothelioma treatment. The problem is that because the cancer is near the heart and lungs, it’s challenging to provide the kind of high-dose, intensive therapy needed to shrink the tumor. However, a newer option, intensity-modulated radiotherapy (IMRT), which can more accurately target cancer cells and avoid healthy tissue, may provide better results when performed by experienced clinicians.
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