According to David Rice, MD, a cardiothoracic surgeon and prominent mesothelioma expert practicing at the University if Texas MD Anderson Cancer Center, Housteon, TX, it is still difficult to identify the best approach for treating this disease.
The rarity os the cancer , with only about 3,000 diagnosed cases a year in the United States, makes it difficult to run the type of research studies required to compare treatments and determine the ideal therapy at each stage of the disease.
“There isn’t a lot of evidence-based science in this disease,” Dr. Rice admitted. When his patients ask him what’s the best treatment for this disease, the only answer he can provide , the same answer we could provide is that ,”We don’t have a reliable cure for this disease.”
Without discovering any reliable cure yet, currently the major goal for the treatment is to reduce the pain and the suffering while also prolong a patient’s life for as long as possible, in which still providing them with the highest quality of life possible.
Throughout the country, numbers of mesothelioma experts practicing in specialized clinics. Each of them has an acute knowledge of the behavior and pathology of malignant mesothelioma and the treatments available. Likely, if you are diagnosed with mesothelioma, you will be referred to a larger scale of comprehensive cancer center.
Some of the factors in determining what treatment plan is suitable includes the cancer stage, primary site afflicted and the cell types. Treatment given also depends on whether the cancer is localized to the chest or it had spreads to the chest wall, diaphragm, or lymph nodes as well as the patient’s age and overall health. In addition, recommended treatment will also vary based on available resources and any ongoing clinical trials at the cancer center where you’re being treated.
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Among the conventional treatments involve surgeries, chemotherapies, and radiation therapies. Doctors turn to these type of treatments as they are common for most solid tumors. Be informed about the risks and benefits of each treatment options available by your doctor before you make the final decision.
So far, only 1 in 5 patients with metastatic pleural mesothelioma undergo surgery. There are two primary surgeries:
- Pleurectomy / decortication: the surgeon tries to remove as much of the tumor from aroudn the lung as possible.
- Extra-pleural pneumonectomy: the lung itself is removed.
There still much debate on deciding which surgery is the most effective, though studies shown that most long-term survivors have at least undergone some form of surgery, and it also shown that pneumonectomy, accompanied by radiation, prevents tumor recurrence in the chest in 80 to 85 percent of patients
Still, it is a long, intentive operation, with a more than half (55%) complication rate and 3% risk of death, and higher in some institutions. Thus, this surgery is only performed for patients with a reasonably good prognosis, in which it doesn’t appear that the cancer has spread outside of the chest area.
Patients best suited for pneumonectomy are:
- Epithelial form of the disease
- No obvious lymph node involvement
- Healthy enough to withstand the rigor of the procedure.
In comparison, pleurectomy/ decortication has a higher failure rate and with the tumor recurring in the cavity almost 50% to 80% of the time. Nonetheless, the rates may change with improved radiotherapy methods. The reason fo such high recurrences is that the difficulty to completely remove the tumor without removing the lungs.
In the end, there is no gap in survival rates between these two types of surgeries. Part of the reason is that the cancer most often has spread to other part of the body by the time it is diagnosed, despite appearing to be confined to the chest.
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Part of the debate around the worth of the surgeries on whether many patients who undergo sugrery do better are because the patients it is offered are the very patients whom most likely to excel regardless of the treatment, as the surgery tends to be offered far more readily to younger and fit patients with an earlier stage of disease. No randomized trial evidence that proves a significant benefit of surgery over noon-surgical management of mesothelioma.
Chemotherapy or systemic therapy, uses oral or infusion-based medication in order to kill cancer cells throughout the whole body. Chemotherapy is used both before and after surgery and for those who do not undergo one. Although not curative, chemotherapy has demonstrated survival benefits and also used to reduce pain and improve quality of life in the palliative setting.
Among the most common drugs used in chemotherapy are Cisplatin combined with Pemetrexed (Alimta) or Raltitrexed ( Tomudex). Besides that, other combinations include Gemcitabine, Carboplatin, or Oxaliplatin.
For some who couldn’t manage combination therapy, their doctors may start with just one drug. At times, their doctors may proceed with pleural chemotherapy, a procedure in which the medication is directly infused into the chest cavity, or intraperitoneal chemotherapy, in which it is the same procedure as the former, except through the abdomen instead of the chest cavity.
If necessary, the patient may also required the second course of the chemotherapy called ‘second-lin’ chemotherapy, with Pemetrexed or other drugs like Raltitrexed plus Oxaliplatin, or even triple drugs combination of Irinotecan, Cisplatin, and Mitomycin.
Radiation, despite being considered complementary treatment, can be a vital part of the mesothelioma treatment. However, since for mesothelioma, the cancer area is near the hear and lungs, it’s quite challenging to provide the needed high-dose, intensive therapy to shrink the tumor. Nevertheless, a recent option, intensity-modulated radiotherapy (IMRT), which can target cancer cells more accurately and avoid health complications, may provide better results when performed by experienced clinicians.
Currently, investigational therapies are being explored and conducted through clinical and surgical trials in many of the nation’s top cancer centers.
In addition, more than 50 studies on new therapies for mesothelioma in the United States looking for volunteer. Researchers are investigating new drugs and chemotherapies in addition to new protocols for giving medication such as :
- Immunotherapy, which harness the immune system’s power to fight diseases
- Phototherapy, which the patient will be injected with a drug that bonds to cancer cells and is activated by high-intensity light
- Genetic therapies
- Common radiotherapies like tomotherapy.
At some level, the management and treatment of the disease will shift from attempting to cure the diseas to trying to keep the patients as comfortable as long as possible.
This is the palliative care stage, when many patients enter a hospice program. Hospice care can be provided at a designated hospice facility or in the comfort of a patient’s home by a designated hospice nurse or care provider. The primary goal at this stage is maximizing patient comfort. Medication to help with pain, difficulty breathing, and other symptoms that may be experienced is a mainstay. So is emotional and spiritual support for you and your family.
Radiotherapy is considered the palliative care stage, in which many patients will enter the hospice program. The program can be conducted at designated hospice facility or in the patient’s home with a designates hospice nurse or care provider. The main goal for this stage is to maximize patient comfort. Emotional and spiritual support for the patient and their family is important as the medications to help endure the pain, the difficulties of breathing, and other symptoms experienced is a mainstay.
Aside from the mentioned treatment, alternative therapies may possibly be helpful to ease the side effects of conventional cancer treatments. Complementary and alternative medicine (CAM), can include therapies such as massage, acupuncture, and meditation, that can contribute to the patient’s overall treatment plan, helping them manage the stress and anxiety of the disease better, also in facing and enduring the conventional treatments.