A range of active treatments are recommended for some people with mesothelioma. These aim to control or cure the cancer and can include chemotherapy, radiotherapy or surgery, which may be used alone or in combination. Trimodality therapy for pleural mesothelioma is a combination of all three.
Each person with mesothelioma is different and there is no standard treatment path. Your specialist will discuss your treatment options with you, and these will depend on a number of 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 pursue active treatment
The active cancer treatments discussed in this section help some people to achieve a longer period of control over the disease and improve their quality of life. It is important to realise that most are intensive treatments and they are not suitable for everyone.
Even if a particular treatment is recommended, it will be up to you whether or not to proceed (see Making treatment decisions. Talk to your treatment team about what is involved and what recovery will be like. You can also call Cancer Council 13 11 20 or talk to a mesothelioma support service.
Recent advances in treating mesothelioma
Mesothelioma treatment has improved in recent years. There are more accurate ways to diagnose and stage the disease, better surgical techniques and post-surgery care, new evidence-based chemotherapy combinations and new radiotherapy methods.
Clinical trials are testing promising new drug treatments such as immunotherapy and targeted therapy. Immunotherapy slows the growth of cancer or kills cancer cells by altering the body's immune system response. Targeted therapy attacks specific particles within cells that allow cancer to grow and spread.
These newer treatments are still experimental and can be very expensive unless you are part of a clinical trial. Your specialist may suggest that you join a clinical trial for your initial or later treatment.
Active treatment for pleural mesothelioma
Chemotherapy treats cancer using drugs known as cytotoxics. It aims to destroy 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 increase survival by a few months more than using a single drug. However, chemotherapy doesn't work for some people.
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
People react to chemotherapy drugs differently. Some people will have few side effects, while others will have more.
he most common side effects of chemotherapy 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).
Your risk of infection increases during chemotherapy treatment. 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, 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.
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 chemotherapy with pemetrexed and cisplatin. 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.
See Understanding Chemotherapy or call Cancer Council 13 11 20 for more information.
Also known as radiation therapy, radiotherapy uses radiation, such as 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 (palliative radiotherapy).
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. 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 radiotherapy. Although the ink is permanent, the mark is the size of a freckle.
Radiotherapy 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 radiotherapy – it might involve 1–10 sessions for up to two weeks for palliative treatment, or longer if radiotherapy is combined with other treatments with the aim of long-term control. Radiotherapy doesn't hurt and you aren't radioactive afterwards.
Side effects of radiotherapy
Radiotherapy 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 most common side effects are listed below.
The side effects of radiotherapy vary depending on the area of the body being treated, but can include:
- peeling, cracked skin that looks red or sunburnt and may be painful
- painful swallowing
- 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, sometimes leading to weight loss. If high doses of radiotherapy are given to the chest area, it may cause permanent changes (fibrosis) in the lung tissue.
See Understanding Radiotherapy or call Cancer Council 13 11 20 for more information.
Trimodality therapy includes a combination of induction chemotherapy, radical surgery (also called cytoreductive surgery) and radical radiotherapy. The aim of the three phases is to remove as much pleural mesothelioma as possible, stop any remaining mesothelioma cells from growing or spreading, and prolong disease-free living.
The benefits of trimodality therapy for pleural mesothelioma are not yet clear. Not all mesothelioma specialists recommend trimodality therapy, and it's available only in a few specialist centres. There has not yet been an evidence-based trial comparing the results of trimodality treatment to less intensive treatment.
The three phases of trimodality therapy
Induction chemotherapy phase
Three cycles of chemotherapy are given to shrink the tumour. A scan then checks 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 not have radical surgery.
Radical surgery phase
The surgery is usually an extrapleural pneumonectomy (EPP). It removes the affected lung as well as parts of the lining of the heart (pericardium), lining of the chest (parietal pleura) and diaphragm. 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'll stay in hospital for 10–14 days, or longer if complications occur. Once at home, recovery can take 6–8 weeks and then you'll be able to start radiotherapy.
Radical radiotherapy phase
This phase aims to treat the tumour cells that may still be present. Radiotherapy is delivered using intensity-modulated radiation therapy (IMRT). This type of radiotherapy can be accurately shaped around the chest cavity to allow higher doses to be delivered directly to the tumour cells while minimising the damage to other organs in the chest and abdomen. You will have treatment every day, Monday to Friday, for up to six weeks. The side effects of radiotherapy (see below) usually become more intense as treatment progresses. Most people start to feel better 2–3 weeks after treatment ends.
Who can have trimodality therapy
Only a small number of people with pleural mesothelioma 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 enough for surgery.
The best person to determine if you will be a suitable candidate for this treatment 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 is a major operation, and not everyone wants to go ahead after the risks, benefits and implications of the therapy are explained by their treatment team.
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 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.
Active treatment for peritoneal mesothelioma
It is possible for some people to have an operation called a peritonectomy (or cytoreductive surgery). During this procedure, a surgeon removes the parts of the peritoneum where the mesothelioma is growing.
The aim of peritonectomy is to achieve the complete removal of the cancer to reduce symptoms, 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 a number of factors, including your overall health and fitness, and whether the small bowel is cancer-free.
Only a small number of surgeons in Australia perform peritonectomy. It is recommended you seek an opinion from one of these surgeons if considering this surgery. To find one of these surgeons, talk to your treatment team or contact a mesothelioma support organisation.
Radiotherapy is rarely used for peritoneal mesothelioma as the doses required would cause too much damage to the liver, kidneys and other organs in the abdomen.
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.
If you have a peritonectomy, you will have chemotherapy directly into the abdomen. This is known as intraperitoneal chemotherapy and may be given in three ways:
Heated intraoperative intraperitoneal chemotherapy (HIPEC) may be given as part of peritonectomy. For this "hot chemotherapy", the drugs are heated to 42.5°C and inserted into the abdomen for 60–90 minutes during the operation.
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).
There is evidence that receiving a long-term course of normothermic (normal temperature) intraperitoneal chemotherapy (NIPEC) may offer some benefit.
- The type of treatment you have will depend on the location, stage and type of mesothelioma, as well as your age, health and fitness.
- Active cancer treatment for pleural mesothelioma may include chemotherapy and radiotherapy.
- Chemotherapy for pleural mesothelioma often uses pemetrexed in combination with cisplatin or carboplatin.
- Radiotherapy may be used at different stages of pleural mesothelioma and in different ways. It may be used to relieve pain or shrink tumours, or given after chemotherapy and surgery to kill remaining cancer cells.
- Some people with pleural mesothelioma may be offered trimodality therapy, with chemotherapy first, followed by major surgery, and then radiotherapy. The surgery removes the affected lung and parts of the pericardium, parietal pleura and diaphragm. This is known as an extrapleural pneumonectomy (EPP).
- Active cancer treatment for peritoneal mesothelioma may include surgery and chemotherapy.
- Some people with peritoneal mesothelioma can have a peritonectomy. This major surgery aims to remove all of the cancer by removing parts of the peritoneum.
- Chemotherapy for peritoneal mesothelioma may be systemic (given into the bloodstream) or intraperitoneal (given directly into the abdomen).
- New trials are testing targeted therapy and immunotherapy drugs.
Expert content reviewers:
Dr Steven Kao, Medical Oncologist, Chris O'Brien Lifehouse, NSW; Theodora Ahilas, Principal, Maurice Blackburn Lawyers, NSW; Prof David Ball, Director, Lung Service, Peter MacCallum Cancer Centre, VIC; Cely Benchoam, Consumer; Prof Kwun Fong, Thoracic Physician, University of Queensland Thoracic Research Centre, The Prince Charles Hospital, QLD; Victoria Keena, Executive Officer, Asbestos Diseases Research Institute, NSW; Angela Kyttaridis, Social Worker, Concord Repatriation General Hospital, NSW; Dr Judith Lacey, Head of Supportive Care and Integrative Medicine, Chris O'Brien Lifehouse, NSW; Amanda Maple, 13 11 20 Consultant, Cancer Council SA; A/Prof Brian McCaughan, Thoracic Surgeon, Sydney Cardiothoracic Surgeons, Strathfield Private Hospital and University of Sydney, 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; Prof David Morris, University of New South Wales, Department of Surgery, St George Public Hospital, NSW; Rod Smith, Awareness and Support Co-ordinator, Bernie Banton Foundation. We also thank the health professionals, consumers and editorial teams who have worked on previous Cancer Council resources.