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Treatment for mesothelioma

Friday 30 September, 2011

Reviewed: Dr Malcolm Feigen, Senior Radiation Oncologist, Austin Health; Dr Paul Jenkinson, GP; Mary Duffy, Lung Nurse Specialist, Peter MacCallum; Prof Bill Musk, Respiratory Physician; Kathryn Turner, Social Worker, Slater & Gordon Lawyers ; Jane McDermott, Principal, Maurice Blackburn Lawyers; Asbestos Diseases Society of Victoria

Many years of treating cancer patients and testing different treatments in clinical trials has helped doctors know what is likely to work for a particular type and stage of cancer. Your doctor will advise you of the best treatment for your cancer. This will depend on the type of cancer you have, where it is and how far it has spread, your general health, and what you want.

‘Staging' the disease

The tests described on previous pages show whether you have cancer and some can also show whether it has spread. The cancer may have spread into surrounding tissue or to other parts of your body, including your lymph nodes. This is called metastasis or secondary cancer. Knowing if and how far the cancer has spread is called staging the disease. Staging helps your doctors to work out the best treatment plan for you.

‘Staging' is a way of describing whether a cancer has spread, and if so, how far. Stage 1 means it has not spread; Stage 4 means it has spread to distant organs.

The staging system used for pleural mesothelioma is known as the ‘TNM system' (T = tumour, N = lymph nodes, M = metastases).

The TNM System

T	T followed by a number between 1 and 4 shows whether the cancer has spread in the area of the pleura and if so, how far. A higher number after the T (for example, T3 or T4) means it has spread beyond the pleura into tissue around the pleural cavity, or to nearby organs. People with T1 or T2 disease have cancer that is probably confined within the pleura (early stage mesothelioma).
N	N followed by 0 means that there is no spread to lymph nodes near the tumour. N followed by 1 means there is spread to nearby lymph nodes.
M	M followed by 0 means there is no distant metastasis; M1 means there is distant metastasis. Distant metastasis means that there is evidence the cancer has spread away from the area in and around the pleura, for example, to the bones or other organs.

Doctors combine this information to determine the stage of the cancer, from Stage 1 to Stage 4. For example, a pleural mesothelioma staged as T3, N1, M0 (tumour spread beyond the pleura into tissue around the pleural cavity, or to nearby organs, some lymph nodes affected, no metastasis) is a Stage 3 pleural mesothelioma.

There is no standard staging system for peritoneal mesothelioma. If your cancer is staged, doctors tend to use the TNM system described above. Ask your doctor to explain the stage of your cancer in a way you can understand. This will help you to choose the best treatment for your situation.

It can sometimes be confusing to know which treatment is the best to have. Finding out as much as possible about the disease and its treatment helps most people feel more in control of their situation. It allows people to make decisions about their treatment and care that are best for everyone.

As with most types of cancer, the earlier someone is diagnosed, the better the outcome usually is.

Although there is no proven cure for mesothelioma, in the past few years there have been several major advances in treating the disease. These include:

more accurate staging methods
earlier diagnosis
improvements in surgical techniques and post-surgery care
using different chemotherapy combinations
combining chemotherapy with newer treatments
new radiotherapy techniques.

These advances have meant more people have received better symptom relief and possibly survived for longer. The aim of treatment is to make sure you have good quality of life for as long as possible.

All treatments have risks and you should talk these over with your doctor. Different specialists may have different opinions about the right treatment for you.

Treatment for both types of mesothelioma may include a combination of:

surgery
radiotherapy
chemotherapy
supportive care (palliative care).

People diagnosed in the earlier stages may be offered surgery followed by chemotherapy and/or radiotherapy. Surgery can also be used to reduce the size of a tumour, which may help relieve symptoms in people with advanced stage disease.

Chemotherapy and radiotherapy can shrink the mesothelioma and also relieve symptoms such as pain. Research has shown chemotherapy can help prolong life in some people by weeks or months.

Doctors can use palliative care treatments such as medications to help with pain relief and to relieve shortness of breath if you are too unwell for treatment.

Surgery for pleural mesothelioma

There are two operations for pleural mesothelioma:

pleurectomy
extrapleural pneumonectomy.

Both operations are major surgery and not everyone is fit enough to go through with them. Neither has been shown to completely cure mesothelioma. However, some people who have had the operation have done well for several years. The question that still needs an answer is: Does surgery or other forms of treatment (chemotherapy, radiotherapy or other drugs) better control symptoms and help people live longer?

Trials are underway throughout the world to help us get a clearer answer to this. Your specialist is the best person to ask about the likely outcome of the surgery.

Other types of surgery you may hear about are:

decortications of the lung - removal of the outer layer of the lung
wedge excision - removal of a section of the lobe of a lung
pleurodesis - controlling fluid build-up

Pleurectomy

Surgery can be used to completely remove mesothelioma that has not spread outside the pleura. This operation is known as pleurectomy. It involves removing part or all of the pleura and the lung tissue nearby. For many people with pleural mesothelioma this operation can help to control symptoms such as fluid build-up in the chest and relieve pain.

A pleurectomy is a major operation. However, some surgeons use keyhole surgery. If you have keyhole surgery you will have three small wounds, each about 2 cm long. You will need to stay in hospital for about seven days. Full recovery can take several weeks or more.

Extrapleural pneumonectomy

The surgeon may also suggest removing the pleura, diaphragm and the whole lung on the affected side, as well as the tumour. Lymph nodes may also be removed. This operation is known as extrapleural pneumonectomy. This type of surgery is usually done in combination with chemotherapy and radiotherapy to help improve outcomes.

The operation can be difficult to do and it will not help everyone. For a few people, however, it may be worthwhile. If the cancer is found when it's still small, and you're otherwise fit, surgery may help you gain more time and quality life.

The operation carries a risk of serious complications. Your doctor will talk to you in detail about these risks and together you can decide whether or not the risks outweigh the possible benefit for you.

If you decide to have this operation it is usually done by making a cut in the side of your chest (a thoracotomy). The wound will be quite long (about 22 cm). It is important to remember that you will be offered good pain relief methods during this time to cope with the effects of surgery.

You will need to stay in hospital for about two weeks. Full recovery from the operation can take some people several months.

Before and after your operation

Before you can have either of these operations you will need to have some tests to see if you are fit enough to cope with the surgery. Your doctor will explain in detail about each test. You may have already had some of the tests when you were being diagnosed. However, you may need to have them again. You may need:

mediastinoscopy, which is a test to look into the centre of the chest where the heart is (mediastinum) - it can check to see if the mesothelioma has spread into this area. This test requires you to stay overnight in hospital because you need a general anaesthetic.
pleuroscopy on the opposite lung to where the disease has been found, to see if it has spread to the other lung
laparoscopy, to see if there is spread through the diaphragm to the peritoneal cavity
pericardioscopy, which allows doctors to find out if the mesothelioma has spread into the layers covering the heart (pericardium). You will need a general anaesthetic for this test.
PET or CT scans, to help find the size and extent of the mesothelioma
lung function tests, to make sure your lungs are working well enough for you to have the operation
echocardiogram, to find out how strong your heart is and how well it will cope if you have a lung taken out
heart and lung exercise test, to find out how well these organs work during rest and exercise
breathing and leg exercises
blood tests such as full blood count, liver function and others.

You will need to sign a consent form for any operation you have. Your doctor will explain this.

Your medical team will talk to you about what will happen on the day of the operation as well as immediately after. This will include what tubes and drains you may have after the operation and how long you will be in hospital.

Surgery for peritoneal mesothelioma

Surgery is often not an option for people with mesothelioma in the abdomen (peritoneal). However if it is an option, the operation is known as a peritonectomy. This means removing the lining of the abdomen (peritoneum). It's not often possible to remove all the cancer, but surgery may prolong life and can relieve symptoms such as bowel obstruction and pain.

There is a fairly new technique called cytoreductive or ‘debulking' surgery. This is very intensive treatment and only possible in people who are fit and have early stage mesothelioma. It involves reducing the bulk of the cancer using surgery. During the surgery chemotherapy is given into the peritoneal cavity.

Although there has been some success with these treatments they are still considered experimental. For further information ask your doctor or call the Cancer Council Helpline on 13 11 20.

Going home after your operation

During your recovery at home it is important to gently exercise to help build up your strength. Your doctor or physiotherapist will advise you about the best type of exercise. Walking and swimming after the wounds have healed are usually good for most people after this type of operation.

It is likely you will have a community nurse visit you at home for a few weeks after you get home. You may have wounds to dress or need help with bathing. If you have any concerns after you get home, contact the hospital, lung cancer nurse if you have one, or your GP. Make sure you have these numbers before you leave the hospital and keep them handy at all times (by the phone or your bed).

Controlling the fluid build-up (pleurodesis)

Often the first concern with pleural mesothelioma is to prevent or control pleural effusion. This is the build-up of fluid around the lungs. One treatment approach is to put an irritant like surgical talcum powder into the pleural sac. The pleura becomes inflamed and the two layers stick together. This leaves no space for fluid, so the cells stop producing fluid.

This is called pleurodesis. It's often done during thoracoscopy, when the doctor is looking inside the chest with a flexible instrument like a small telescope or after drainage of fluid from your chest with a tube.

Pleurodesis doesn't work for everyone. Removing the pleura will also control fluid build-up, but it's a major operation. Other possibilities include drawing the fluid out gently through a needle.

Sometimes after a pleurodesis the lungs do not fully expand again. If this happens your doctor may put a small tube into the area to help drain the fluid out. This can stay in for a few weeks and will mean you don't have to keep coming to the hospital to have the fluid drained off.

Follow-up care

After the completion of your treatment, you may need to have regular check-ups. Your doctor will decide how often you will need check-ups - everyone is different. Your check-ups will gradually become less frequent if you have no further problems. However, because mesothelioma is often diagnosed in the advanced stages it is likely that you will continue to have regular check-ups or as you need them.

If the cancer comes back, you may need further treatment and it may be different from the first treatment. It is important that you tell your doctor about any new symptoms.

Prognosis

Prognosis means the outlook for your disease and your life expectancy. Most people diagnosed with cancer want to know this information. However, it can be difficult to predict. Statistics are often used to describe a person's prognosis. Statistics are averages based on large numbers of people. They can be confusing! No statistics can tell you what will happen to you.

You and your cancer are unique. However, there are several factors that will affect your outlook such as:

the type of mesothelioma you have
the stage of your cancer (how far it has spread)
the type of treatment you are able to have
your fitness
your age
your overall health.

Some people believe that having a positive outlook will help your prognosis. While this can help many people cope better with their disease and treatment, there is no scientific evidence to prove it will help control or cure cancer or help you live longer. It is hard to find accurate statistics for the individual stages of either type of mesothelioma. This is because it is a rare disease. Also, accurate staging requires biopsies during surgery. Not everyone with mesothelioma will have surgery.

Your specialist is the best person to talk to about your prognosis. They will know your individual situation best and be able to discuss likely outcomes. Remember, doctors are often working from statistics that may be a few years old and there may have been improvements in treatments and survival since then.