Types of Mesothelioma Chemotherapy

There are various types of mesothelioma chemotherapy available to patients. Some are used in conjunction with surgery. Others are used as a standalone treatment when surgery is not an option. The type of chemotherapy used can affect survival.

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Written by Karen Ritter, RN BSN

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Important Facts About Types of Mesothelioma Chemotherapy

  • The most popular and well‑known type of mesothelioma chemotherapy is systemic chemotherapy. Another name is intravenous chemotherapy.
  • Many mesothelioma cancer centers of excellence use intraoperative chemotherapy. This coincides with an aggressive mesothelioma surgery.
  • Other types of chemotherapy revolve around when patients receive other forms of mesothelioma treatment. Neoadjuvant chemotherapy happens before surgery. Adjuvant chemotherapy happens 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 are:

  • Systemic or intravenous chemotherapy
  • Heated intraoperative chemotherapy
  • Dwell chemotherapy

Most patients can receive systemic chemotherapy. Not all patients are eligible for heated intraoperative chemotherapy or dwell chemotherapy.

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 is a type of systemic (intravenous) chemotherapy that delivers the drugs quicker than standard chemotherapy.

Oral delivery of chemotherapy medication is still in experimental stages.

Systemic Chemotherapy (Intravenous Chemotherapy)

Systemic chemotherapy is delivered through an IV into a vein or port. The chemotherapy drugs travel through the bloodstream to stop tumor growth and decrease tumor size.

Systemic chemotherapy can also unfortunately damage healthy tissue and attack the blood cells. This can cause side effects like nausea, vomiting, fatigue and loss of appetite.

Patients usually receive systemic chemotherapy in cycles. For mesothelioma, each cycle lasts 21 days. The number of cycles is determined by the oncologist. The length of a chemotherapy session depends on the treatment center. In most studies, the length is 30‑60 minutes.

Systemic chemotherapy is offered at all mesothelioma cancer centers of excellence in the United States.

Chemotherapy Injection

Chemotherapy injection sends chemotherapy drugs into the body in less time than systemic chemotherapy. The FDA approved injection of pemetrexed for malignant mesothelioma. This is called PEMFEXY.

Chemotherapy injection takes around 10 minutes compared to the 30‑60 minutes for traditional chemotherapy. This is due to the injection being a ready‑to‑dilute formula rather than a bag‑and‑drip delivery method.

It’s unknown how accessible this chemotherapy treatment is for mesothelioma patients. Many cancer centers may prefer systemic chemotherapy.

Heated Intraoperative Chemotherapy (HIOC)

Heated intraoperative chemotherapy, or HIOC for short, is a type of chemoperfusion. Doctors deliver heated liquid chemotherapy drugs into the chest cavity or abdominal cavity. These drugs are delivered immediately after mesothelioma surgery concludes, while the doctors have direct access to the tumors via the open chest or abdomen.

There are two types of HIOC and they are both used with surgery:

  • Hyperthermic intraperitoneal chemotherapy (HIPEC), for peritoneal mesothelioma
  • Hyperthermic intrathoracic chemotherapy (HITHOC), for pleural mesothelioma

Intraoperative chemotherapy is offered at specialized cancer centers offering mesothelioma treatment. A few of the high‑profile centers are:

Dwell Chemotherapy

Dwell chemotherapy is an experimental type of treatment for mesothelioma. It involves infusing chemotherapy directly into the abdominal cavity. Doctors leave the drugs in place for an extended amount of time. The prolonged exposure to the chemotherapy drugs improves their ability to wash tumors and kill cancer cells.

Doctors place two catheters, or ports, in the patient’s body. These ports deliver the drugs directly into the affected area, such as the peritoneal cavity or abdominal cavity. Since the chemotherapy doesn’t travel through the bloodstream, the side effects are limited.

Dwell chemotherapy is limited to clinical trials and specialized cancer centers. We suggest you contact a mesothelioma patient advocate for recommendations on treatment centers.

NIPEC

One type of dwell chemotherapy is normothermic intraperitoneal chemotherapy (NIPEC), primarily used for peritoneal mesothelioma. This is a long‑term type of chemotherapy. Doctors deliver a room‑temperature chemotherapy solution 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 affected area for multiple days. This therapy is different from HIPEC, which involves draining the drugs 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 eight years survival, largely due to dwell 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 to diseased tissue. Transarterial chemotherapy avoids the bloodstream, which limits side effects.

A trial of 72 patients at Moffitt Cancer Center 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. They are 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 sessions last two hours.

Oral Delivery of Chemotherapy

Oral chemotherapy pills are still in testing for malignant mesothelioma. One such medication, olaparib, sold under the brand name Lynparza, treats specific genetic damages.

Mesothelioma involves damaged genes from exposure to asbestos. Olaparib is a poly polymerase enzyme inhibitor. It has three enzymes helping with DNA transcription and repair and can improve cancer cell destruction.

Olaparib is the focus of multiple mesothelioma clinical trials. One of them opened in 2020 at the University of Chicago Medical Center. It is recruiting up to 56 participants.

This type of chemotherapy is limited to clinical trials. It’s not a widely accessible option yet for people with mesothelioma.

When to Use Chemotherapy for Mesothelioma

Doctors and cancer centers have varying views on when to use chemotherapy for mesothelioma. The main options are whether to use chemotherapy before, during or after surgery:

  • The traditional thought is use chemotherapy after surgery (adjuvant chemotherapy)
  • Some doctors may prefer chemotherapy during surgery (intraoperative chemotherapy)
  • A few specialists believe the best approach is chemotherapy before surgery (neoadjuvant chemotherapy)

Neoadjuvant Chemotherapy

Neoadjuvant chemotherapy refers to using the treatment before surgery. It’s primarily for patients with an aggressive cancer (stage 3 or stage 4).

Doctors use neoadjuvant chemotherapy to contain or shrink tumors prior to surgery. This tactic hopefully makes resection easier for the experienced surgeon. It can also “downstage” patients to a more manageable diagnosis.

Intraoperative Chemotherapy

Intraoperative chemotherapy makes the most of direct access to the tumor environment through surgery. Doctors deliver heated liquid chemotherapy to wash the chest or abdomen of standalone tumors in the area.

Intraoperative chemotherapy is an option for both pleural and peritoneal mesothelioma. It can be used with all three aggressive surgeries:

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).

For pleural mesothelioma, the survival stats range from 2‑4 years. One from 2019 had a median survival of 42 months after pleurectomy with decortication.

Adjuvant Chemotherapy

Adjuvant chemotherapy refers to using the treatment after surgery. The goal is to contain what’s left of the disease following the operation. Since mesothelioma grows and spreads as separate tumors, complete resection is near‑impossible. Chemotherapy is an option to control the remaining cancer cells.

Adjuvant chemotherapy includes many types of delivery:

  • Systemic/intravenous chemotherapy
  • Oral chemotherapy
  • Injection
  • Dwell chemotherapy

Many studies report favorable survival stats from systemic chemotherapy after surgery. Memorial Sloan Kettering Cancer Center paired pleurectomy with decortication and systemic chemotherapy. The median survival was 32 months.

Common Questions About Types of Mesothelioma Chemotherapy

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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 chemotherapy; and oral chemotherapy.

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Which type of chemotherapy has the fewest side effects?

Intraoperative chemotherapy and dwell 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.

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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, most cancer centers provide intraoperative chemotherapy along with a surgery.

Sources & Author

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About the Writer, Jenna Campagna, RN

Jenna Campagna is a registered nurse and patient advocate who is passionate about helping mesothelioma patients navigate their health care. She has over seven years of experience working with patients diagnosed with rare diseases including mesothelioma. Jenna is also a member of the Academy of Oncology Nurse & Patient Navigators and her goal is to connect patients to top mesothelioma specialists, treatment facilities, and clinical trials. Through her writing, she aims to simplify the complicated journey through mesothelioma by offering helpful tips and advice.