Active treatment

Monday 1 June, 2015

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On this page: Chemotherapy | Radiotherapy | Trimodality therapy | Key points


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 (see below).

Your specialist will discuss suitable treatment options with you. These suggestions will be based their on a number of factors, including the location, stage and type of mesothelioma. Each person with pleural mesothelioma is different, and your age, health and fitness, family circumstances and support will be considered to determine the best treatment options for you.

Although there is no cure for pleural mesothelioma, the active cancer treatments discussed in this section help some people to achieve a longer period of control over the disease and improve prognosis. These treatments differ from palliative treatment, which primarily aims to improve quality of life without extending survival.

Recent advances in treating mesothelioma

In recent years, treatment options for pleural mesothelioma have improved. This includes more accurate diagnostic and staging methods, better surgical techniques and post-surgery care, evidence-based chemotherapy combinations, new radiotherapy techniques and clinical trials. These advances offer hope for improved living. While there is still no standard treatment path for people with pleural mesothelioma, chemotherapy is frequently an important part of treatment.

Chemotherapy

Chemotherapy treats cancer using anti-cancer (cytotoxic) drugs. It aims to destroy cancer cells while causing the least possible damage to healthy cells.

The most commonly used chemotherapy drugs to treat a person with pleural mesothelioma include pemetrexed (Alimta®) with cisplatin or carboplatin. Research shows that this combination can increase survival by a few months and improve quality of life, and is better than receiving a single chemotherapy drug. However, chemotherapy doesn’t work for some people.

Most doctors will recommend that you start chemotherapy when the CT scans show signs of active disease and/or you have developed symptoms. Sometimes your doctor will recommend that you start chemotherapy before symptoms develop further. Talk to your specialist about the best time for you to begin.

Chemotherapy is generally administered into a vein through a drip (intravenously). Each session may last for several hours followed by a rest period of several weeks. This is known as a cycle. You will probably have up to six cycles. However, the length and timing of the treatment and rest days of the cycle may vary.

During the chemotherapy, you will have CT scans to check if the pleural mesothelioma is shrinking. Other scans, such as FDG-PET or FDG-PET-CT, may be used to assess whether the treatment is working and show how active the disease is. Certain blood tests may also show whether the disease is responding to chemotherapy.

For some people, quality of life improves for a while after chemotherapy. If the disease becomes active again, you may be offered additional courses of the same type of chemotherapy. If this is unsuccessful, you may be offered a different chemotherapy drug as ‘second line’ chemotherapy, or an experimental drug. Your medical oncologist will use new information from clinical trials to decide on the best treatment options for you. See taking part in a clinical trial.

Side effects of chemotherapy

People react to chemotherapy differently – some people will have few side effects, while others have more. The side effects depend on the type and dose of drugs you’ve been prescribed. Your doctor may change the dose or type of chemotherapy if necessary.

The most common side effects you may experience include:

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

While hair loss and scalp problems are rare with the pemetrexed and cisplatin or carboplatin combination, there may be hair thinning. Some people have trouble thinking clearly or experience short-term memory loss after chemotherapy, but this usually improves once treatment ends.

You will be given medicines to control any side effects related to the chemotherapy treatment. To find out more, call Cancer Council 13 11 20 to ask for a free copy of Understanding Chemotherapy, or see chemotherapy.

Risk of infection during chemotherapy treatment is common. If you have a temperature over 38oC, contact your doctor immediately or go to your nearest hospital emergency department.

Radiotherapy

Radiotherapy is the use of high-energy x-rays to kill or damage cancer cells. Radiotherapy may be used at different stages of pleural mesothelioma treatment and in different ways. It can relieve pain or other symptoms caused by tumours. Radiotherapy is also given after chemotherapy and surgery (adjuvant radiotherapy) to help kill remaining cancer cells.

Treatment is carefully planned to destroy as many cancer cells as possible while causing the least harm to your normal tissue. To plan your treatment, you will have CT scans of the affected area.

The radiation oncologist may mark your skin with a special ink to make sure the radiation is directed at the same place on your body every time you receive radiotherapy. Although the ink is permanent, the mark is the size of a freckle.

The initial appointment to see the radiation oncologist and set up the machine may take a few hours, but the treatment itself takes only a few minutes. It is usually given Monday to Friday as an outpatient treatment. The length of the treatment course will vary depending on why you’re having radiotherapy – often 2–4 weeks for managing palliative symptoms or 6 weeks for radical radiotherapy.

Radiotherapy does not hurt and you are not radioactive afterwards.

Side effects of radiotherapy

Radiotherapy may cause some side effects during treatment or shortly afterwards, but most side effects go away after the treatment stops. Side effects vary depending on the area of the body being treated, but include tiredness, reddened and peeling skin, painful swallowing and loss of hair in the treatment area.

Radiotherapy to the chest area can cause difficulty swallowing and symptoms of reflux for a few days or weeks. If high doses of radiotherapy are given to the chest area, it may cause permanent changes (fibrosis) in the lung tissue.

Your doctors and nurses will tell you about what side effects to expect from radiotherapy. For more information, call Cancer Council 13 11 20 for a free copy of Understanding Radiotherapy or see radiotherapy.

Trimodality therapy

Trimodality therapy includes a combination of induction chemotherapy, radical surgery and radical radiotherapy. The aim of the three phases is to control the disease for as long as possible.

The benefits of trimodality therapy are not yet clear. Not all mesothelioma specialists recommend trimodality therapy, and it’s available in only a few treatment centres. There has not yet been an evidence-based trial comparing the results of radical trimodality treatment to more limited treatment.

Who can have trimodality therapy

Only a small number of people have trimodality therapy each year as it is only suitable 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 for surgery
  • who want to proceed after the risks, benefits and implications of the therapy are explained by their surgeon, oncologist and thoracic nurse.

Induction chemotherapy phase

Trimodality therapy starts with chemotherapy to shrink the tumour. After three cycles, you will have a scan to check the size of the tumour. If it has been reduced, you will have a rest for 4–6 weeks before having surgery. If there is little or no response, you will continue treatment under supervision of the medical oncologist and you will not have radical surgery.

Radical surgery phase

This can be done in two ways:

Extrapleural pneumonectomy (EPP)

This is a common radical surgical procedure for pleural mesothelioma. It involves removing the tumour along with the pleura, the covering of the heart (pericardium), diaphragm and the whole lung on the affected side. Lymph nodes in the centre of the chest that drain the lung are also removed. Mesh is used to repair the pericardium and diaphragm.

You will need to stay in hospital for 10–14 days to be monitored for any complications and to have physiotherapy. If complications occur, your hospital stay may be extended. Once at home, recovery can take 6–8 weeks and then you’ll be able to start radiotherapy.

Pleurectomy with pulmonary decortication (P/D)

This operation is a more extensive version of the talc pleurodesis procedure used to drain fluid and re-inflate trapped lungs. The aim is to remove all visible pleural mesothelioma from the pleural cavity. This may involve removing all the pleura, depending on the circumstances and what the surgeon decides.

Both types of radical surgery are major operations, and not everyone is fit enough to go through with them. There is no clear evidence for which treatment works best. Ask your treatment team to explain each option and the likely outcome of the surgery.

Radical radiotherapy phase

The aim of the radical radiotherapy phase is to treat the tumour cells in and around the pleural cavity that may still be present after chemotherapy and surgery.

Radiotherapy is delivered using intensity-modulated radiation therapy (IMRT). This type of external beam radiotherapy can be accurately shaped around the chest cavity to allow higher doses to be delivered directly to the tumour cells while reducing the damage to other organs in the chest and abdomen.

If the tissue removed during surgery shows that pleural mesothelioma cells are still present in some areas of the chest, these areas may receive higher x-ray doses than other areas.

Special scans are taken and computers are used to develop an individualised plan of treatment. Radiotherapy usually begins 6–8 weeks after radical surgery. You will have treatment every day on Monday to Friday for six weeks.

Each week the radiation oncologist will examine you, review your blood test results and ask about any side effects. The side effects of radiotherapy usually become more intense as treatment progresses.

Common side effects include nausea, reflux, skin irritation, lethargy, soreness when swallowing, tiredness and exhaustion. Anti-nausea medicines are usually provided from the beginning, but many people find it difficult to eat larger quantities of food, even when they aren’t feeling nauseous.

You will have regular blood tests during radiotherapy to monitor blood counts and liver function. You may need a few days break from the treatment or, rarely, the treatment may be stopped early if your blood count becomes too low. Radiotherapy may temporarily damage liver function, but you will not feel any symptoms. Liver function should return to normal within a few months. Most people start to feel better 2–3 weeks after treatment ends.

Sometimes, despite a person appearing suitable at first, the doctor may decide it is best for them not to continue with trimodality therapy. This might be because the pleural mesothelioma does not respond well to three cycles of chemotherapy, and pathology examination of specimens taken at surgery shows unfavourable grade or that the cancer has spread.

Key points

  • Active cancer treatment for pleural mesothelioma includes chemotherapy and radiotherapy.
  • The type of treatment you have will depend on the location, stage and type of pleural mesothelioma. Your age, health and fitness will also be considered.
  • The most commonly used chemotherapy drugs are pemetrexed (Alimta®) with cisplatin or carboplatin.
  • Studies have shown that treatment with these chemotherapy drugs can increase survival and improve quality of life.
  • Radiotherapy may be used at different stages of pleural mesothelioma and in different ways. It’s often used to relieve pain, and it can be used after chemotherapy and surgery to help kill remaining cancer cells.
  • Some people have a combination of chemotherapy, surgery and radiotherapy. This is called trimodality therapy, and is given in three phases.
  • The first phase consists of three cycles of chemotherapy.
  • The second phase is surgery. You may have an operation called an extrapleural pneumonectomy, which removes the affected lung, along with the diaphragm and a portion of the lining of the heart (pericardium).
  • The other surgical option is pleurectomy/decortication, which removes the pleura and as much disease as possible.
  • The third phase is radiotherapy. This includes intensity- modulated radiation therapy (IMRT), which precisely targets the tumour while sparing other parts of the body from radiation.

Reviewed: Theodora Ahilas, Principal, Maurice Blackburn Lawyers, NSW; Shirley Bare, Support Group Facilitator, Asbestoswise, VIC; Geoffrey Dickin, Consumer; Victoria Keena, Executive Officer, Asbestos Diseases Research Institute, NSW; Angela Kyttaridis, Social Worker, Concord Repatriation General Hospital, NSW; Jocelyn McLean, Mesothelioma Support Coordinator, Asbestos Diseases Research Institute, NSW; Kirsten Mooney, Thoracic Cancer Nurse Coordinator, WA Cancer and Palliative Care Network, Department of Health, WA; Clin/Prof AW Musk AM, Schools of Population Health and Medicine, University of Western Australia, and Physician, Sir Charles Gairdner Hospital, Nedlands, WA; Dr Andrew Penman AM, Consultant, Asbestos Diseases Research Institute, NSW; Tanya Segelov, Partner, Turner Freeman Lawyers, NSW; Roswitha Stegmann, 13 11 20 Consultant, Cancer Council Western Australia, WA; Dr Mo Mo Tin, Staff Specialist Radiation Oncology, Chris O’Brien Lifehouse, NSW; and Prof Nico van Zandwijk, Director of the Asbestos Diseases Research Institute and Professor of Medicine, University of Sydney, NSW.

Updated: 01 Jun, 2015