Mesothelioma Treatment

Important Facts About Mesothelioma Treatment

• The best approach in most cases for mesothelioma treatment is multimodal. This means doctors use a combination of different therapies before or after surgery.
• Surgery, chemotherapy and radiation are the primary treatments for mesothelioma. Only intravenous chemotherapy has received FDA approval.
• Optune Lua (NovoTTF-100L) received FDA approval in May 2019 for cases where surgery isn’t an option.
• Two immunotherapy drugs (Opdivo and Yervoy) were approved as a pair in October 2020 for cases ineligible for surgery.
• Other emerging mesothelioma treatment options include: virotherapy, gene therapy, proton radiation therapy and other targeted therapies.

What Are the Top Options for Mesothelioma Treatment?

Most doctors rely on surgery, chemotherapy and radiation as the main mesothelioma treatment options. There are various types of each method.

Doctors prefer to use a combination of these three. 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 treatment’s intent is to make mesothelioma a chronic illness that 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 different 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 for use on an experimental basis, and usually in combination with chemotherapy.

How to Get Treatment for Mesothelioma

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

Mesothelioma Surgery

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

For pleural mesothelioma, the main surgeries 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. There are noninvasive surgeries intended to 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 tumors. 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.

Extrapleural Pneumonectomy (EPP)

Extrapleural pneumonectomy is the most aggressive mesothelioma surgery. It removes the pleura and the nearby lung. Surgeons may also take out the diaphragm and pericardium.

Doctors are cautious about performing EPP on patients. There is an increased risk of complications during 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 median survival times of around 18 months. Chemotherapy and radiation can boost the survival rates.

Cytoreduction With HIPEC

Cytoreduction is mass debulking (removing) of tumors. Part of the surgery is 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 stomach region. 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’s 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.

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

Those are the two main palliative surgeries, and they’re primarily intended for patients with late-stage mesothelioma.

Mesothelioma Chemotherapy

Chemotherapy is the treatment most associated with cancers like mesothelioma. The therapy is a drug or combination of drugs that look to kill diseased cells in the body.

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 insert the drugs into the body.

Systemic (Intravenous) Chemotherapy

The most well-known is systemic or intravenous chemotherapy, which travels through the bloodstream. Doctors inject the chemotherapy 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 a rising method for mesothelioma. 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 the doctors rock the patient back and forth to bathe the area (thorax or abdomen) in the therapy.

For pleural mesothelioma, the HIOC treatment used is hyperthermic intrathoracic chemotherapy (HITHOC). HITHOC bathes the thorax and lung cavity with chemotherapy. For peritoneal mesothelioma, the HIOC method is hyperthermic intraperitoneal chemotherapy (HIPEC). HIPEC bathes the abdominal cavity with chemotherapy.

Both are 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 various 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.

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

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, which 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, specifically in the tumor site. These waves disrupt cell division and prevent replication. Eventually the cells die without replicating.

Tumor treating fields help treat unresectable cases of malignant mesothelioma. “Unresectable” means the disease isn’t treatable with surgery, which is always the first option for mesothelioma.

NovoTTF-100L/Optune Lua

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

The FDA approved NovoTTF-100L with chemotherapy. The survival rate was around 18 months with these two therapies. This was an improvement of around four months from chemotherapy alone.

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 essentially keep the T-cells awake and alert to notice mesothelioma cells.

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

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

Multimodal Treatment for Mesothelioma

Multimodal treatment means multiple types of therapy are used for a disease. The most common multimodal treatment 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 segments of patients surviving for more than five years.

Emerging Mesothelioma Treatment Options

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

The emerging mesothelioma treatments are:

• Gene therapy
• Virotherapy
• Photodynamic therapy

Mesothelioma Gene Therapy

Gene therapy is another emerging option for mesothelioma. The purpose is to slow this 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 that will 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. As of February 2021, ONCOS-102 is close to FDA approval.

Other types of virotherapy are vehicles transporting immunotherapy or gene therapy drugs into the body. These viruses usually deactivate immediately after delivering the other therapy.

Mesothelioma Photodynamic Therapy

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

Once absorbed, the photosensitizers activate when doctors shine a high-beam light at the disease location. Photodynamic therapy uses aspects of radiation therapy and virotherapy.

This emerging treatment option is only featured in a few clinical studies. One involves small nanotubes that kill cancer cells when absorbed.

Stories of Mesothelioma 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, and 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 mesothelioma treatment can help.