Written By: David Statman
Types of Mesothelioma Chemotherapy
There are various types of mesothelioma chemotherapy available to patients. Some are used in combination with surgery, while others are a standalone treatment when surgery is not an option. The specific type of chemotherapy approach can have an impact on overall survival.
Medically Reviewed By
Dr. Stephen Williams
Precision Oncology Scientist
Medically Reviewed By
Dr. Stephen Williams
Precision Oncology Scientist
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Important Facts About Types of Mesothelioma Chemotherapy
- The most popular and well-known type of mesothelioma chemotherapy is systemic chemotherapy. This can be given by intravenous (IV), oral (by mouth), or injection.
- Many mesothelioma cancer centers of excellence incorporate intraoperative chemotherapy as part of aggressive mesothelioma surgery.
- Other types of chemotherapy are used based on when patients receive other mesothelioma treatment. Neoadjuvant chemotherapy is given before surgery, while adjuvant chemotherapy is given after.
What Are the Types of Chemotherapy for Mesothelioma?
The types of mesothelioma chemotherapy differ in how chemotherapy is delivered into the body. The different types of are:
- Systemic chemotherapy – Intravenous, oral, or injectable
- HIPEC – Heated intraperitoneal chemotherapy
- HITHOC – Heated intrathoracic chemotherapy
- NIPEC – Normothermic intraperitoneal chemotherapy
- PIPAC – Pressurized intraperitoneal aerosol chemotherapy
Systemic chemotherapy is the most common form of chemotherapy to treat mesothelioma. Not all patients are candidates for heated intraoperative chemotherapy or other forms of intracavitary (within a body cavity) therapy.
Two other types of chemotherapy are injection and oral delivery. In February 2020, the U.S. Food and Drug Administration (FDA) approved an injection delivery method of the mesothelioma chemotherapy drug pemetrexed. This approach delivers chemotherapy quicker than standard intravenous chemotherapy.
Oral delivery of chemotherapy medication is still in experimental stages.
Systemic Chemotherapy (Intravenous Chemotherapy)
Systemic chemotherapy is often delivered through an IV into a vein or port. The chemotherapy drugs travel through the bloodstream to slow tumor growth, decrease tumor size, and kill cancer cells.
Systemic chemotherapy also can damage healthy tissue and blood cells. This can cause side effects like nausea, vomiting, fatigue, and loss of appetite.
Patients usually receive systemic chemotherapy in cycles: a cycle is made up of treatment days (when chemotherapy is given) and rest periods (no chemotherapy). For mesothelioma, each cycle lasts 21 days. Cycles target the cancer cells at the different growth stages, and the rest periods allow healthy cells to recover.
The patient’s mesothelioma specialist determines the number of cycles depending on the patient’s specific needs. Treatment days can last from 1 hour to several hours depending on the treatment regimen and supplemental infusions that may be needed.
Systemic chemotherapy is offered at all mesothelioma cancer centers of excellence across the United States.
Chemotherapy Injection
Chemotherapy injection requires less time than systemic chemotherapy for cancer-fighting drugs to enter the body. The FDA approved an injectable form of pemetrexed for malignant mesothelioma. The brand name of this injectable chemotherapy is PEMFEXY.
Chemotherapy injections usually take 10 minutes to administer. This is due to the injection being a ready-to-use formula rather than needing to infuse slowly through a drip method with an IV.
Heated Intraoperative Chemotherapy (HIOC)
Heated intraoperative chemotherapy, or HIOC for short, is a type of chemoperfusion used during surgery. Doctors deliver heated liquid chemotherapy drugs directly into the chest cavity or abdominal cavity. These drugs are delivered immediately before mesothelioma surgery concludes, while the doctors have direct access to the tumors within the chest or abdomen.
There are a two types of intraoperative chemotherapy:
- HIPEC – Hyperthermic intraperitoneal chemotherapy, for peritoneal mesothelioma
- HITHOC – Hyperthermic intrathoracic chemotherapy, for pleural mesothelioma
Intraoperative chemotherapy is offered at specialized cancer centers offering mesothelioma treatment. A few of the high-profile centers are:
- Moffitt Cancer Center in Tampa, Florida
- Brigham and Women’s Hospital in Boston, Massachusetts
- Wake Forest Baptist Cancer Center in North Carolina
- Baylor St. Luke’s Medical Center in Houston, Texas
- University of Pittsburgh Medical Center in Pennsylvania
Dwell/Intracavity Chemotherapy: Treatment Delivered into the Chest or Abdomen
Dwell/intracavity chemotherapy infuses chemotherapy directly into the chest or abdominal cavity. Doctors leave the drugs in place for an extended amount of time. Tumors and cancer cells have a prolonged exposure to chemotherapy.
Doctors place two catheters, or ports, in the patient’s body. These ports deliver the drugs directly into the affected area, such as the chest or abdominal cavity. Since the chemotherapy doesn’t travel through the bloodstream, the side effects are limited.
Dwell/intracavity chemotherapy is limited to clinical trials, specialized cancer centers, and select patients. Contact a mesothelioma patient advocate for recommendations on mesothelioma specialists and treatment centers for your specific needs.
Normothermic Intraperitoneal Chemotherapy (NIPEC)
One type of intracavitary chemotherapy is normothermic intraperitoneal chemotherapy (NIPEC), primarily used for peritoneal mesothelioma. This is a long-term treatment approach in which a room-temperature chemotherapy solution is delivered directly into the abdominal cavity.
NIPEC involves leaving ports in the patient’s body following cytoreductive surgery. Doctors deliver the chemotherapy drug paclitaxel through the ports and leave it in the abdominal cavity for multiple days. This therapy is different from HIPEC, which involves heating the chemo solution and draining the drugs out of the body within a couple hours.
NIPEC led to long-term survival in six consecutive cases of peritoneal mesothelioma treated by Dr. Paul Sugarbaker. While he’s now retired, Dr. Sugarbaker was a peritoneal mesothelioma specialist and surgeon. He had six patients in a row reach at least 8 years survival, largely due to intracavity chemotherapy.
“Dwell chemotherapy is very important long-term,” he said in an interview with Mesothelioma Guide. “I’ve used HIPEC several thousand times. I’m aware HIPEC has some huge shortcomings. Number one, it’s only used once. It’s just a single treatment. That’s not the way drugs work. … It’s unlikely that a single dose of cancer chemotherapy will give you a durable response.”
Transarterial Chemoperfusion
Transarterial chemoperfusion delivers high-volume chemotherapy drugs directly into the blood flow going to the tumor. Since the chemotherapy is targeting the tumor, it is avoiding widespread infusion through the body – limiting side effects.
A trial of 72 patients at Moffitt Cancer Center in Tampa, Florida, led to a 70% disease-control rate. The median survival was 28 months from time of diagnosis, and most patients had a stage 3 or stage 4 disease.
Doctors deliver a combination of drugs. In the above study, they used cisplatin, methotrexate and gemcitabine. The drugs were injected into the thoracic artery and possibly the internal mammary artery, which supplies the pleura (where pleural mesothelioma forms) with oxygen-rich blood.
Transarterial chemoperfusion is currently only offered through clinical trials in select research settings and specialized cancer centers.
Oral Delivery of Chemotherapy
Oral chemotherapy pills are in clinical testing for the treatment of malignant mesothelioma. One such medication, olaparib, sold under the brand name Lynparza, treats specific genetic damages.
Mesothelioma is caused when asbestos fibers irritate the body’s cells, leading to genetic changes. These genetic chances cause cells to not die when they should, instead multiplying quickly, which leads to a biological imbalance of too many cells in the area.
Olaparib is a PARP inhibitor (poly ADP-ribose polymerase) that works by blocking an important DNA repairing mechanism found in cancer cells. By inhibiting PARP enzymes, olaparib prevents cells from repairing their DNA, leading to their death.
This type of chemotherapy is limited to clinical trials. It’s not a widely accessible option yet for people with mesothelioma. Clinical trials are ongoing to evaluate the role of PARP inhibitors in mesothelioma.
When to Use Chemotherapy for Mesothelioma
Specialists continue to research and test the most beneficial time to use chemotherapy for mesothelioma. If patients cannot have surgery, then they often receive chemotherapy. This is not likely to prolong their survival more than a few months. The average survival for mesothelioma patients receiving just chemotherapy is 14 months.
The best way to use chemotherapy is before, during, or after surgery.
- Neoadjuvant chemotherapy – Chemotherapy prior to surgery
- Intraoperative chemotherapy – Chemotherapy during surgery
- Adjuvant chemotherapy – Chemotherapy after surgery
Neoadjuvant Chemotherapy
Neoadjuvant chemotherapy is chemotherapy treatment given before surgery. This is a common approach, as it is an initial effort to slow the progression of the disease, start to shrink tumors and kill cancer cells.
Doctors choose neoadjuvant chemotherapy to contain or shrink tumors prior to surgery. This tactic can often make resection easier for the experienced surgeon and provide better overall outcomes.
Intraoperative Chemotherapy
Intraoperative chemotherapy allows specialists to deliver cancer-fighting drugs directly into the tumor environment during surgery. Heating the chemotherapy solution enhances the effectiveness. During this procedure, doctors circulate heated chemotherapy through the chest or abdominal cavity to target cancer cells in the area.
Intraoperative chemotherapy is an option for both of the main types of mesothelioma: pleural mesothelioma and peritoneal mesothelioma. It can be used with all three aggressive surgeries:
For pleural mesothelioma, the average survival for patients who receive intraoperative chemotherapy ranges from 2-4 years. One study from 2019 had a median survival of 42 months (3.5 years) after pleurectomy with decortication.
For peritoneal mesothelioma, intraoperative chemotherapy with surgery can extend patient lives 3-5 years following treatment. Wake Forest Baptist Cancer Center reported a median survival of 40 months (3 years, 4 months).
Intraoperative chemotherapy is not an option for treating the other two types of mesothelioma: pericardial mesothelioma (lining of the heart) and testicular mesothelioma (lining of the testes).
Adjuvant Chemotherapy
Adjuvant chemotherapy is chemotherapy treatment given after surgery. The goal is to kill any cancer cells remaining after surgical removal of visible tumors. Since mesothelioma develops and spreads as separate tumors, complete resection is near-impossible. Chemotherapy is used after surgery to help control the remaining cancer cells, prevent metastatic disease, and possibly achieve remission.
Adjuvant chemotherapy includes many types of delivery:
- Systemic/intravenous chemotherapy
- Oral chemotherapy
- Injection
- Dwell/intracavity chemotherapy
Many studies report favorable survival statistics from systemic chemotherapy after surgery. Memorial Sloan Kettering Cancer Center paired pleurectomy with decortication and systemic chemotherapy. The median survival was 32 months.
Frequently Asked Questions About Types of Mesothelioma Chemotherapy
What are the types of chemotherapy for mesothelioma?
The most popular type of chemotherapy for mesothelioma is systemic chemotherapy. This is also called intravenous chemotherapy. It’s delivered through an IV. Other types are intraoperative chemotherapy, dwell/intracavity chemotherapy, and oral chemotherapy.
Which type of chemotherapy has the fewest side effects?
Intraoperative chemotherapy and dwell/intracavity chemotherapy have the fewest side effects. The drugs avoid the bloodstream and have less of an effect on healthy cells. Systemic chemotherapy has the most side effects but is also the more trusted option in cancer treatment.
When should you take chemotherapy?
Some specialists vary in opinion on when to receive chemotherapy. One option is before surgery (neoadjuvant chemotherapy). Another is after surgery (adjuvant chemotherapy). For peritoneal mesothelioma, many specialists provide intraoperative chemotherapy during surgery.
Sources & Author
- Pemfexy, a Ready-to-Dilute Formulation of Pemetrexed, Gets Final FDA Approval. MPR. Retrieved from:
https://www.empr.com/home/news/pemfexy-a-ready-to-dilute-formulation-of-pemetrexed-gets-final-fda-approval/. Accessed: 02/10/2020. - Pemetrexed Injection. U.S. National Library of Medicine. Retrieved from: https://medlineplus.gov/druginfo/meds/a607043.html. Accessed: 02/10/2020.
- The Role of Neoadjuvant Chemotherapy in Patients With Resectable Malignant Pleural Mesothelioma—An Institutional and National Analysis. Journal of the National Cancer Institute. Retrieved from: https://academic.oup.com/jnci/article/112/11/1118/5721361. Accessed: 06/28/2021.
- Management of Malignant Peritoneal Mesothelioma Using Cytoreductive Surgery and Perioperative Chemotherapy. American Society of Clinical Oncology Journal. Retrieved from: https://ascopubs.org/doi/abs/10.1200/jop.2016.011908. Accessed: 06/28/2021.
- Unusually Favorable Outcome of 6 Consecutive Patients With Diffuse Malignant Peritoneal Mesothelioma Treated With Repeated Doses of Intraperitoneal Paclitaxel. A Case Series. Surgical Oncology. Retrieved from: https://pubmed.ncbi.nlm.nih.gov/32561104/. Accessed: 06/22/2020.
- Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for Peritoneal Surface Malignancy: Experience with 1,000 Patients. US National Library of Medicine National Institutes of Health. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3965636/. Accessed: 11/13/18.
- Hyperthermic intrathoracic chemotherapy (HITHOC) should be included in the guidelines for malignant pleural mesothelioma. Annals of Translational Medicine. Retrieved from: https://atm.amegroups.org/article/view/60185/pdf. Accessed: 01/26/2021.
- Pleurectomy/decortication and hyperthermic intrathoracic chemoperfusion using cisplatin and doxorubicin for malignant pleural mesothelioma. Journal of Thoracic Disease. Retrieved from: https://pubmed.ncbi.nlm.nih.gov/31285889/. Accessed: 07/18/19.
- Transarterial Chemoperfusion: Cisplatin, Methotrexate, Gemcitabine for Unresectable Pleural Mesothelioma. Clinicaltrials.gov. Retrieved from:
https://clinicaltrials.gov/ct2/show/NCT02611037. Accessed: 06/18/2020.
AI Summary of Types of Mesothelioma Chemotherapy
This webpage provides a detailed overview of the different types of chemotherapy used for mesothelioma treatment. Chemotherapy is a common approach to managing mesothelioma, with various methods available depending on the patient's specific condition and treatment plan. The most widely used form is systemic chemotherapy, also known as intravenous chemotherapy, where drugs are delivered directly into the bloodstream through an IV. This method allows the medication to travel throughout the body to target and shrink tumors, but it can also affect healthy tissues and cause side effects such as fatigue, nausea, and loss of appetite. Typically, patients receive chemotherapy in cycles, with each cycle lasting about three weeks, and sessions usually lasting between 30 to 60 minutes.
Other types of chemotherapy are designed to target the tumor more directly or are used around surgical procedures. For example, heated intraoperative chemotherapy, or HIOC, involves applying heated chemotherapy drugs directly into the chest or abdominal cavity during surgery. This is performed immediately after tumor removal to kill remaining cancer cells. This approach is often combined with specific surgeries for pleural or peritoneal mesothelioma. Dwell chemotherapy is a newer, experimental technique where chemotherapy drugs are placed directly into the affected cavity and left in place for extended periods. This method aims to improve treatment effectiveness while reducing side effects. It is mainly used in clinical trials and specialized centers, with some promising results from long-term treatments like normothermic intraperitoneal chemotherapy, which has shown potential for extending patient survival.
Other delivery methods include chemotherapy injections that take less time and oral options that are still in developmental and trial stages. The FDA approved an injectable formulation of pemetrexed in 2020, which allows drugs to be administered more quickly than traditional infusion. The timing of chemotherapy treatment relative to surgery varies, with some protocols administering it before surgery to shrink tumors (neoadjuvant therapy), after surgery to eliminate residual cancer (adjuvant therapy), or during surgery itself. Each approach has its advantages and is tailored to the patient’s disease stage and overall health. Overall, these diverse treatments provide hope and options for individuals battling mesothelioma, with the goal of extending survival and improving quality of life."