Mesothelioma Treatment

Important Facts About Mesothelioma Treatment

• The best approach in most mesothelioma cases is multimodal treatment. This means doctors use a combination of different therapies, such as surgery, chemotherapy, radiation therapy and immunotherapy.
• Surgery, chemotherapy, immunotherapy, tumor treating fields and radiation are the primary options for mesothelioma. Other emerging options include virotherapy, gene therapy and proton radiation therapy.
• Optune Lua (NovoTTF-100L) received FDA approval in May 2019 for cases where surgery isn’t an option. It’s a wearable tumor treating fields device sending electrical waves through the chest.
• Two immunotherapy drugs (Opdivo and Yervoy) were approved as a pair in October 2020 for unresectable cases.

What Are the Top Options for Treatment?

Mesothelioma is treated with drugs, targeted therapies and surgery. Most options for mesothelioma are still investigational. While many aren’t yet approved by the FDA, we’ve listed them for informational purposes to help the reader.

Most doctors rely on surgery, chemotherapy, immunotherapy and radiation as the main options for medical care. There are various types of each.

Doctors prefer to use a combination of these. There’s growing belief in immunotherapy as a substitute for chemotherapy. Another emerging and effective option is tumor treating fields, which is approved when surgery isn’t an option.

Mesothelioma can be treated, although there is no cure for the asbestos cancer. The immediate goal is to remove as much of the cancer as possible and control the disease. Many believe the medical intent is to make mesothelioma a chronic illness patients live with for the remainder of their life.

What Treatments Are Approved for Mesothelioma?

The United States Food and Drug Administration (FDA) has approved three therapies for malignant mesothelioma:

• Chemotherapy (pemetrexed and cisplatin)
• Tumor treating fields (Optune Lua)
• Immunotherapy (Opdivo and Yervoy together, or Keytruda in very specific cases)

Surgery and radiation are allowed on an experimental basis and usually in combination with chemotherapy or immunotherapy.

How to Get Treatment for Mesothelioma

There are three major steps mesothelioma patients should follow for how to receive treatment:

Mesothelioma Surgery

There are three aggressive malignant mesothelioma surgeries. Your type of mesothelioma will dictate which surgery you can have. Your choice in doctor may also determine which surgery you have.

For pleural mesothelioma, the surgery choices are:

• Pleurectomy with decortication
• Extrapleural pneumonectomy

For peritoneal mesothelioma, patients have cytoreduction with heated/hyperthermic intraperitoneal chemotherapy (HIPEC).

Some patients cannot have surgery because their cancer is too widespread in the body. Noninvasive surgery can reduce pain and symptoms. These operations won’t considerably extend survival time but can improve quality of life in the patient’s final months.

Pleurectomy With Decortication (P/D)

Pleurectomy with decortication is a fairly new surgery for pleural mesothelioma. The operation removes the pleura, which is a slim lining between your chest wall and lung cavity. Pleural mesothelioma forms here when asbestos fibers irritate the lining’s cell walls.

By removing the pleura, surgeons can resect a large chunk of tumor. Some may exist on or near the diaphragm and pericardium (sac around your heart). Radical P/D would remove these two areas.

Boosted by chemotherapy and radiation, P/D has shown survival times of 2-3 years. Some specialized centers offer heated intraoperative chemotherapy (HIOC) to kill as many remaining tumor cells as possible after surgery.

Extrapleural Pneumonectomy (EPP)

Extrapleural pneumonectomy is the most aggressive pleural mesothelioma surgery. It removes the pleura, which harbors the cancer, as well as the nearest lung. Surgeons may also take out the diaphragm and pericardium. Similarly to P/D, some cancer centers offer heated intraoperative chemotherapy to kill remaining tumors after surgery is complete.

Doctors are cautious about performing EPP on patients. There is an increased risk of complications with this surgery.

Quality of life is another concern. Patients also may not be healthy enough to live comfortably with just one lung.

Despite these cautions, EPP has a median survival of around 18 months. Chemotherapy and radiation can boost survival chances.

Cytoreduction With HIPEC

Cytoreduction is a debulking surgery. It involves physical removal of tumors.

Part of cytoreductive surgery for peritoneal mesothelioma involves a peritonectomy, which is removal of the peritoneum. This is the thin tissue and fluid lining that surrounds the abdominal cavity. The peritoneum is where peritoneal mesothelioma forms.

HIPEC is a form of heated intraoperative chemotherapy. It’s used immediately after cytoreduction/peritonectomy.

Doctors insert a hot liquid form of the cancer therapy into the belly. This bathes the abdominal cavity in chemotherapy. The intent is to kill any remaining tumors.

One study for cytoreduction with HIPEC showed a median survival time of 38 months. The two-year survival rate is an impressive 70%.

Pain-Relief Surgery

There is at least one noninvasive, pain-relief surgery for each type of mesothelioma. The purpose is to drain the disease site of excess fluid. This relieves pressure against the lungs, chest, stomach or abdominal cavity organs. These palliative procedures are for patients with late-stage mesothelioma.

A thoracentesis, for pleural mesothelioma, removes excess fluid from the pleural space in the chest. A paracentesis, for peritoneal mesothelioma, removes fluid from the peritoneal space in the belly.

When patients need fluid removed often, an indwelling catheter can drain the fluid several times a week at home.

Mesothelioma Chemotherapy

Chemotherapy is a well-known cancer treatment. The therapy is a drug or combination of drugs that look to kill cancer cells.

For mesothelioma, the two FDA-approved chemotherapy drugs are pemetrexed and cisplatin. The FDA allows carboplatin as a substitute for cisplatin.

Other chemotherapy drugs used experimentally for mesothelioma are:

• Gemcitabine
• Vinorelbine
• Doxorubicin

There are several types of chemotherapy. The main differences are how doctors deliver these drugs into the body.

Systemic (Intravenous) Chemotherapy

The most well-known type of chemotherapy is systemic or intravenous chemotherapy, which travels through the bloodstream. Doctors inject the therapy through an IV into the bloodstream. The drugs travel from the injection site to the tumor location.

Systemic chemotherapy is associated with side effects like nausea, fatigue and decreased appetite. The drugs may attack healthy blood cells during the travel through the bloodstream. This can affect patients’ strength and make them feel sick.

Hyperthermic Intraoperative Chemotherapy

Hyperthermic intraoperative chemotherapy, shortened to the acronym HIOC, is another type. Doctors apply chemotherapy directly into the tumor site immediately after surgery.

Doctors use the incision from surgery to deliver hot chemotherapy drugs into the location. The drugs are in liquid form, and for mesothelioma care, the doctors rock the patient back and forth to bathe the area (thorax or abdomen) in the therapy.

HIOC is paired with an aggressive surgery, such as P/D for pleural mesothelioma or cytoreduction/peritonectomy for peritoneal mesothelioma.

Dwell Chemotherapy

Dwell chemotherapy combines different aspects of systemic and intraoperative chemotherapy.

The method sends the drugs through two catheters inserted into the target area. This utilizes aspects of intraoperative chemotherapy.

The drugs remain in the patient’s body for multiple days, exposing tumors to the drugs for an extended amount of time. This is similar to systemic chemotherapy.

Mesothelioma Radiation Therapy

Radiation therapy, also called radiotherapy, delivers high-energy radiation particles at tumors. Doctors use a linear accelerator to send the beams into the body.

Radiation particles disrupt the cancer cells’ DNA and prevent cell division. Eventually, the cells die without further replicating, which can lead to controlling or even eliminating the disease.

Radiation is used for pleural mesothelioma either before or after surgery and chemotherapy. It’s not used for peritoneal mesothelioma due to the organs in the abdominal cavity.

Therapeutic advancements led to new types of radiation therapy. The newest types of radiation are more targeted, reducing the potential damage to healthy tissue.

Mesothelioma doesn’t grow as one distinct tumor but rather many separate tumors. Radiation has many smaller targets rather than one large target, which can lead to hitting healthy tissue with the beams.

Photon (Traditional) Radiation Therapy

Photon radiation therapy is often called external beam radiation. Doctors send photon beams into the disease site.

Photon radiation has the highest risk of affecting healthy tissue.

Intensity-Modulated Radiation Therapy

Intensity-modulated radiation therapy (IMRT) is an advancement of photon radiation. IMRT uses computer programs to send targeted beams at the tumor site from different angles.

This approach reduces damage to healthy tissue and allows for higher doses of radiation particles. In one study, less than 10% of patients had grade 3 or worse lung tissue inflammation (pneumonitis) after IMRT for mesothelioma. Traditional photon radiation has rates up to 25%.

Proton Radiation Therapy

Proton radiation is another advancement to reduce healthy tissue damage and increase doses. This method was created in the 1940s but grew in popularity during the 1990s.

The proton beams stop at the intended target: the tumors. In one study, only 5% of patients had grade 3 pneumonitis. Nearly 90% of patients avoided any mild or severe complications.

Intraoperative Radiation Therapy

Intraoperative radiation therapy, shortened to the acronym IORT, sends radiation into the tumor location quickly after surgery. The purpose is similar to intraoperative chemotherapy.

External beam radiation, like systemic chemotherapy, has side effects. IORT lets doctors use higher doses while avoiding damage to skin or healthy tissue. The distance between the linear accelerator machine and tumor site is much smaller. This keeps the beam’s range tighter.

Tumor Treating Fields for Mesothelioma

Tumor treating fields work similarly to radiation therapy. The fields are electric waves sent through the body. These waves disrupt cell division and prevent replication. Eventually tumor cells die without replicating.

Tumor treating fields help unresectable cases of malignant mesothelioma. “Unresectable” means the disease isn’t treatable with surgery.

NovoTTF-100L/Optune Lua

The FDA approved the NovoTTF-100L System in May 2019 for unresectable cases of pleural mesothelioma. Unresectable cases usually have low survival rates.

The FDA approved NovoTTF-100L with chemotherapy based on the STELLAR clinical trial. The survival rate was around 18 months with these two therapies. This was an improvement of around four months for these patients.

The manufacturer of NovoTTF-100L, Novocure, rebranded the device as “Optune Lua” in 2020. The therapy is offered at more than 70 hospitals spanning 30-plus states.

Mesothelioma Immunotherapy

Immunotherapy boosts the immune system to fight back against mesothelioma and other cancers. Mesothelioma has qualities that subdue the immune system, which either ignores the tumors or isn’t naturally strong enough to stop its spread.

Immunotherapy activates the immune system in various ways:

• Blocking immune-suppressing proteins on cancer cells
• Inspiring an immune system reaction by mimicking a virus
• Redesigning immune system T-cells to fight mesothelioma

Opdivo and Yervoy

The FDA approved Opdivo and Yervoy for malignant mesothelioma in October 2020. Opdivo is the brand name for the generic immunotherapy drug nivolumab. Yervoy is the brand name for ipilimumab. They are approved for unresectable cases of pleural mesothelioma.

Opdivo and Yervoy are both immune checkpoint inhibitors. They block a connection between mesothelioma cells and T-cells that depresses the immune system.

Opdivo and Yervoy improved survival rates for pleural mesothelioma cases by around four months:

• 18 months for Opdivo and Yervoy together
• 14 months for chemotherapy

Keytruda

Keytruda is the brand name for pembrolizumab. It is another immunotherapy drug for mesothelioma. The FDA approved Keytruda during 2020 for specific cases of pleural mesothelioma.

The therapy is specifically for patients with a high count of the cancerous PD-L1 protein.

Multimodal Therapy for Mesothelioma

Multimodal treatment means using multiple types of therapy. The most common multimodal care for mesothelioma is a combination of surgery, chemotherapy and radiation.

Numerous studies have involved a multimodal approach: some combination of surgery, radiation, immunotherapy and chemotherapy. The median survival times are as high as three years, with some patients surviving for more than five years.

Emerging Treatment Options

Researchers and medical experts continue to consider new therapies for mesothelioma. A few show promise for improving life expectancy.

A few of the emerging options are:

• Gene therapy
• Virotherapy
• Photodynamic therapy

Mesothelioma Gene Therapy

Gene therapy slows the cancer’s growth by fixing or disrupting the cancer cells’ DNA. There are a few approaches to gene therapy, each with its own proven benefits:

• Blocking cancerous genes from allowing mesothelioma to grow
• Adding cancer-fighting genes to the body
• Fixing mutated genes

Mesothelioma Virotherapy

Virotherapy delivers a genetically modified virus into the tumor location. The intent is to ignore healthy cells and tissue while focusing on tumors.

Virotherapy may involve sending a virus to kill a tumor. This is called an “oncolytic virus.” An example of this therapy is ONCOS-102, which is a virus that breaks up tumor cells. The virus also elicits an immune response.

Other virotherapy drugs act as vehicles transporting immunotherapy or gene therapy drugs into the body. These viruses usually deactivate after delivering the other therapy.

Mesothelioma Photodynamic Therapy

Photodynamic therapy uses light-sensitive drugs, called photosensitizers, to kill cancer cells internally. The cells absorb the drugs as part of their growth and expansion.

Once absorbed, the photosensitizers activate when doctors shine a high-beam light at them. This therapy is only featured in a few clinical studies.

Stories of Treatment Helping Patients

Treatment extends the lives of mesothelioma patients regularly. A few cases resulted in long-term survival well beyond the initial prognosis.

Alexis K., for instance, has survived for more than a decade with peritoneal mesothelioma. She underwent cytoreduction with HIPEC a few months after her diagnosis. Alexis remains a mesothelioma survivor today.

Jodi Page was diagnosed with pleural mesothelioma in December 1999, more than 20 years ago. She underwent EPP surgery, removing her left lung completely, and is a prime example of how aggressive therapy can help.