The first preference for treating mesothelioma is surgery.
If you can remove the cancerous tumors in bulk, quickly, then the chances of a long and healthy life increase dramatically.
The issue is doctors use this treatment when possible. The problem is few cases fit the “when possible” distinction.
Since mesothelioma grows so quickly and in a unique manner — many microscopic tumors, some of which spread undetected to distant regions of the body — surgery is often not possible. That leaves secondary therapies, most notably chemotherapy, to maintain the disease and prolong life as much as possible.
The U.S. Food and Drug Administration approved two immunotherapy drugs, Opdivo (nivolumab) and Yervoy (ipilimumab), for mesothelioma in October 2020. Opdivo is the brand name for nivolumab and Yervoy is the brand name for ipilimumab.
Other immunotherapy drugs, such as pembrolizumab (Keytruda) and durvalumab (Imfinzi), are moving through clinical trials.
These immunotherapy drugs are called “immune checkpoint inhibitors.” They take the handcuffs off your body’s immune system, giving it full force to fight malignant mesothelioma.
Immunotherapy for mesothelioma outperforms chemotherapy regularly in studies focused on survival. The difference is usually around four months: 18 months for checkpoint inhibitors and 14 months for chemotherapy. However, immunotherapy is still the “new kid on the block.”
So which therapy do doctors prefer when surgery isn’t an option? We asked a few specialists this question.
Dr. Hassan Khalil is an associate thoracic surgeon at Brigham and Women’s Hospital. He’s also in charge of the Boston VA mesothelioma program.
“I think it’s a hard question to answer. The standard treatment has been chemotherapy. First of all, as a surgeon, I don’t make that determination. I work with a medical oncologist who specializes in mesothelioma.
“The other piece is these tumors are tested for PD-L1, for example, and that helps the oncologist determine if anti-PD-L1 therapy is appropriate or not. That determines if immunotherapy is effective or not. You can’t make a determination ahead of time without knowing the specifics of the tumor and PD-L1. That’s the molecular target for immunotherapy. There might be others down the line.”
Dr. Raja Flores is the director of thoracic surgical oncology at Mount Sinai Medical Center. He’s one of the most experienced mesothelioma specialists in the world.
“I always look at it this way. We have a lot of drugs, whether immunotherapy or chemotherapy, that for mesothelioma don’t do a whole lot. So when patients are trying to decide what drug to use, they should use the one with less side effects. The way I look at it, that’s usually going to be immunotherapy. It’s not like chemotherapy is a grand slam, and it’s not like immunotherapy is a grand slam.
“When we started using the pemetrexed and cisplatin combination compared to cisplatin alone, it’s a difference of three months. … It was such a huge deal. I think that’s what we look at with mesothelioma. When we see differences of 2-5 months, we think it’s a huge deal. It’s better than nothing, but a lot of it depends on the type of tumors you have. … It might not have anything to do with the medication.”
Dr. Marcelo DaSilva is the chief of thoracic surgery at AdventHealth. He previously worked under the tutelage of Dr. Raphael Bueno at Brigham and Women’s Hospital in Boston. He started AdventHealth’s mesothelioma treatment.
“I tell patients they should get standard chemotherapy, which is Alimta and cisplatin. I think all patients should start with at least a few cycles of chemotherapy. Immunotherapy is more like a laser point. Chemotherapy is more broad and we can target most patients. It really depends on the type of tumor and type of cells. Most patients don’t have a target to use immunotherapy.
“… If you’re a surgical candidate, then we can study your tumors better than through a biopsy. Then we can consider immunotherapy.”
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