Mesothelioma

NEW! The Mesothelioma Center at the New York-Presbyterian Hospital and Columbia University is recruiting patients for a new clinical trial on treatment of mesothelioma with targeted radiation an chemotherapy. This multimodality treatment is an innovative approach led by oncologist Dr. Robert Taub. Click here to learn more.

CLINICAL TRIAL BASICS

TRIAL PHASES

ELIGIBILITY

CLINICAL TRIALS AND MEDICARE

• The trial is funded by the National Cancer Institute (NCI), the NCI-Designated Cancer Centers, the NCI-Sponsored Clinical Trials Cooperative Groups or other Federal agencies that fund cancer research.
• The goal of the trial is to diagnose or treat cancer (cancer prevention trials are not covered).

CURRENT CLINICAL TRIALS

• Phase III Study of Suberoylanilide Hydroxamic Acid (SAHA) Versus Placebo in Advanced Malignant Pleural Mesothelioma
  Click here for an abstract of this trial
• NEW! Phase II Study of Eloxatin® Plus Gemcitabine Chemotherapy for Mesothelioma
  Click here for an abstract of this trial
• Phase II Study Using Chemotherapy Followed by Intensity Modulated Radiation Therapy to the Pleura in Patients With Locally Advanced But Unresectable Malignant Pleural Mesothelioma
  Click here for an abstract of this trial
• A Randomized Phase II Study of a Lung-Sparing Combined Modality Protocol for the Treatment of Malignant Pleural Mesothelioma: The Columbia Protocol
  Click here for an abstract of this trial: For health professionals | For patients Click here for the complete protocol from Columbia University Medical Center (PDF file)
  Click here to read the consent form for this trial (PDF file)
  Contact our MW Coordinators toll-free at 1-877-367-6376 to find out if you are eligible.
  Related Trial: Trimodal Lung-Sparing Treatment of Pleural Mesothelioma
  Click here for an abstract of this trial
• Phase II Study Using Chemotherapy Followed by Intensity Modulated Radiation Therapy to the Pleura in Patients With Locally Advanced But Unresectable Malignant Pleural Mesothelioma
  Click here for an abstract of this trial
• Phase II Study of CBP501 + Pemetrexed + Cisplatin in Patients With Malignant Pleural Mesothelioma
  Click here for an abstract of this trial
• Phase II Study of Dasatinib in Patients With Previously Treated Malignant Mesothelioma
  Click here for an abstract of this trial
• Phase II Study of Pazopanib Hydrochloride in Patients With Malignant Pleural Mesothelioma
  Click here for an abstract of this trial
• Phase II Randomized Study of Pemetrexed Disodium Combined With Either Gemcitabine or Carboplatin in Patients With Advanced Malignant Mesothelioma of the Pleura
  Click here for an abstract of this trial
• Phase II Study of AZD2171 in Patients With Unresectable Malignant Pleural Mesothelioma
  Click here for an abstract of this trial
• Phase II Study of Cisplatin, Pemetrexed and Bevacizumab for Untreated Malignant Mesothelioma
  Click here for an abstract of this trial
• Phase II Study of Induction Combination Chemotherapy Comprising Methotrexate, Vinorelbine Ditartrate, and Cisplatin With or Without Surgery and Adjuvant Chemoradiotherapy in Patients With Malignant Pleural Mesothelioma
  Click here for an abstract of this trial
• Phase II Study of PDX101 as Second-Line Therapy in Patients With Unresectable Malignant Pleural Mesothelioma
  Click here for an abstract of this trial
• Phase II Study of Milataxel (TL139) Administered Orally for Malignant Mesothelioma
  Click here for an abstract of this trial
• Phase I/II Study of Carboplatin, Bevacizumab and Pemetrexed in the First-Line Treatment of Patients With Malignant Pleural Mesothelioma
  Click here for an abstract of this trial
• Phase I Study of Extrapleural Pneumonectomy, IHOC Cisplatin and Gemcitabine With Amifostine and Sodium Thiosulfate Cytoprotection for Resectable Malignant Pleural Mesothelioma
  Click here for an abstract of this trial
• Phase I Dose-Escalation Study of Azacitidine In Combination With Temozolomide
  Click here for an abstract of this trial
• Phase I Study of SS1 (dsFv)-PE38 Immunotoxin in Combination With Pemetrexed Disodium and Cisplatin in Patients With Unresectable Maligant Epithelial Mesothelioma
  Click here for an abstract of this trial
• Phase I Study To Find the Best Dose of SU011248 When Given With Pemetrexed, Pemetrexed and Cisplatin Or Premetrexed and Carboplatin In Patients With Advanced Solid Tumors
  Click here for an abstract of this trial
• Phase I Pharmacokinetic, Safety, and Efficacy Effects of Oral LBH589 on Dextromethorphan in Patients With Advanced or Metastatic Non-Small Cell Lung Cancer or Malignant Pleural Mesothelioma
  Click here for an abstract of this trial
• Phase I Study of Erlotinib in Patients With Solid Tumors and Hepatic or Renal Dysfunction
  Click here for an abstract of this trial
• Phase I Study of BMS-690514 in Patients With Advanced or Metastatic Solid Tumors
  Click here for an abstract of this trial
• Phase I Study of Anti-Mesothelin Monoclonal Antibody MORAB-009 in Patinets With Recurrent Advanced Mesothelin-Expressing Tumors
  Click here for an abstract of this trial
• Phase I Study Using Sunitinib Plus Radiation Therapy for Cancer Patients
  Click here for an abstract of this trial
• Phase I Study of Oxaliplatin and Paclitaxel Plus Bevacizumab in Advanced Peritoneal Carcinomatosis
  Click here for an abstract of this trial
• Phase I Study of Cisplatin, Imatinib Mesylate, and Pemetrexed in Malignant Mesothelioma Patients
  Click here for an abstract of this trial
• Phase I Study of Gene Induction Mediated by Sequential Decitabine/Desipeptide Infusion in Subjects With Pulmonary and Pleural Malignancies
  Click here for an abstract of this trial
• Phase I Study of Flavopiridol in Patients With Metastatic or Unresectable Refractory Solid Tumors or Hematologic Malignancies
  Click here for an abstract of this trial
• Phase I Study of Suberoylanilide Hydroxamic Acid in Advanced Solid Tumors
  Click here for an abstract of this trial
• Phase I Study of Gene Therapy for Pleural Malignancies
  Click here for an abstract of this trial
• Phase I Study of MORAb-009 in Subjects With Pancreatic Cancer, Mesothelioma, or Certain Types of Ovarian or Lung Cancer
  Click here for an abstract of this trial
• Phase I Pilot Study of Wilms Tumor-1 Analog Peptide Vaccine and Sargramostim (GM-CSF) in Patients With Acute Myeloid Leukemia, Myelodysplastic Syndromes, Non-Small Cell Lung Cancer, or Mesothelioma
  Click here for an abstract of this trial

• Diagnostic Trials Study of the Use of Breathing Synchronized CT and PET Scans in Radiation Therapy Treatment Planning
  Click here for an abstract of this trial
  Multiple Biomarkers in Undiagnosed Pleural Effusion
  Click here for an abstract of this trial
  Study of the Etanidazole Derivative EF5 for the Detection of Hypoxia and Vascularity in Patients With Intraperitoneal or Pleural Malignancies Treated With Photodynamic Therapy
  Click here for an abstract of this trial

• Supportive Care Trials Phase III Study of Fentanyl Sublingual Spray for Breakthrough Cancer Pain in Patients Who are Opiod Tolerant
  Click here for an abstract of this trial
  

• Biomarker/Laboratory Analysis Trials Study of Early Detection of Mesothelioma Biomarkers in Patients With Asbestos and Vermiculite Exposure
  Click here for an abstract of this trial
  Multiple Biomarkers in Undiagnosed Pleural Effusion
  Click here for an abstract of this trial
  

FURTHER INFORMATION - CLINICAL TRIALS

The National Cancer Institute (NCI) has designated 40 cancer centers throughout the United States as "Comprehensive" centers. These elite centers have been recognized for their focus on scientific excellence and have dedicated themselves to the prevention, treatment and cure of cancer, including malignant mesothelioma. Following is a list of Cancer Centers by state.
For veterans wishing to be treated at a Veterans Health Administration (VA) cancer care facility, click here for a listing by state.

Alabama

Arizona

California

Colorado

Connecticut

District of Columbia

Florida

Illinois

Iowa

Maryland

Massachusetts

Michigan

Minnesota

Missouri

New Hampshire

New Jersey

New York

North Carolina

Ohio

Pennsylvania

Tennessee

Texas

Vermont

Washington

Wisconsin

NATIONAL CANCER INSTITUTE CANCER CENTERS

A diagnosis of mesothelioma brings with it one of the most difficult challenges you or your loved one will ever face. One of the most important things to remember, however, is that there are resources to help with every aspect of care, and that you or your loved one is at the center of the health care team that will provide help in many different forms. Remember also that in addition to your doctor you can also get a second opinion from another physician.

You, the Patient

• Once you know the day and time of your appointment, start a list of questions you want to ask that particular team member. These questions could be about mesothelioma itself, about test results or about treatments you are undergoing or considering. It is also a good idea to write down any symptoms you may be experiencing so that they can be addressed at this time. If there is something you don’t completely understand, ask to have it explained in simpler terms. Above all, don’t be embarrassed to ask questions or request clarifications.
• If possible, take along another person who can take notes, ask additional questions or record your appointment for later review. Sometimes it can be helpful to return home and play back what was discussed.
• Ask for written material or brochures that can help in making treatment or care decisions . These might include information on nutrition, pain management, support groups or hospice or home care.

Nurses

Social Workers

• Oncology social workers specialize in assisting those diagnosed with cancer. Most cancer treatment facilities have certified oncology social workers on staff.
• Clinical social workers specialize in providing services aimed at family therapy and counseling, or counseling for those coping with a serious illness.
• Hospital social workers can help find resources in your local area such as home care, transportation services or support groups, and can also help you understand your diagnosis, your treatments and other care options.

Psychiatrists and Psychologists

• Psychiatrists are medical doctors who specialize in providing psychotherapy and other general psychological services to their patients. They are licensed to prescribe medications such as antidepressants and sleep aids. (Related: concerns about drug addition during cancer treatment.)
• Psychologists can provide many of the same services as a psychiatrist such as counseling for depression, anxiety, etc., however, they are not medical doctors. Most have PhD’s in psychology and counseling.

Nutritionists and Dietitians

Hospice and Home Care

• Hospice care is palliative in nature, and provides comfort care by helping to control a patient’s physical symptoms as well as offering emotional and spiritual support. Although in most cases, care is provided at home, there are also hospice facilities that provide full-time care in a hospital setting. You can discuss the benefits of hospice with your doctor, nurse or social worker.
• Home care provides assistance in the home with daily activities such as bathing, meal preparation or household chores. These services are usually provided by a home health aide, and may or may not be under the supervision of a nurse. Ask your doctor, nurse or social worker for Home Health Care Agencies in your area.

The following physicians are specialists in the treatment of malignant mesothelioma. You will find links to their web sites, when available and to some of their published articles.They are listed in no particular order with no particular endorsement.
Mesothelioma is typically treated by an interdisciplinary team of doctors rather than by a single physician. You may run into professionals called oncologists, thoracic surgeons, and pulmonologists. Glossary of members of a thoracic oncology care team. More on choosing your mesothelioma doctor.

W. Roy Smythe, MD

David C. Rice, M.B., B.Ch., B.A.O.; F.R.C.S.I

David J. Sugarbaker, MD

Lambros Zellos, MD, MPH

Valerie W. Rusch, FACS

Raja M. Flores, MD

Paul H. Sugarbaker, MD, FACS, FRCS

Brian W. Loggie, MD

David L. Bartlett, MD

Claire F. Verschraegen, MD

• Phase I Study of Capecitabine with Cisplatin and Irinotecan in Patients with Advanced Malignancies
• Phase I Study of Intravenous TZT-1027 and Gemcitabine, Administered on Day 1 and Day 8 of a Three Week Course in Patients with Advanced Solid Tumors
• Phase I Study of Flavoperidol in Combination with Gemcitabine and Irinotecan in Patients with Metastatic Cancer

David P. Mason, MD

David M. Jablons, MD

Lary A. Robinson, MD

Craig W. Stevens, MD, PhD

Robert N. Taub, MD

Daniel Sterman, MD

Eric Vallieres, MD

Stephen C. Yang, MD

Mark J. Krasna, MD

David H. Harpole, Jr., MD

Harvey Pass, MD

Gregory P. Kalemkerian, MD

Joseph S. Friedberg, MD

Robert Cameron, MD

Palliative care is a specialized form of care that alleviates pain and other symptoms. Thme goal of palliative medicine is not to prolong life or hasten death, but rather, to keep the patient as comfortable as possible, while offering support to the patient and their family. Palliative care contributes to the quality of life for patients with life-threatening illnesses, such as mesothelioma, at any phase of the disease.
For the patients who are undergoing life-prolonging therapies, palliative care includes symptom management and therapy aimed at restoring function. For the dying patient, it addresses the traditional roles of the hospice movement. During the course of a serious illness, patients and their families should realize that the goals of care can, and do, change, sometimes rapidly. An open line of communication is essential to optimize patient care.

Symptoms Managed through Palliative Care

• Pain
• Shortness of breath
• Fatigue
• Dry Mouth
• Loss of appetite
• Gastrointestinal problems
• Skin problems
• Anxiety/Depression

Pain

Shortness of Breath

Fatigue

• Diminished energy level disproportionate to activity
• Diminished activity associated with physical or intellectual performance
• Diminished motivation; lack of interest in activities
• Exhaustion, apathy, or lethargy
• Generalized tiredness
• Sleep abnormalities
• Irritability, impatience, or changes in mood

Dry Mouth

• Drinking plenty of fluids
• Sucking on ice chips or Vitamin C tablets
• Chewing sugarless gum
• Maintaining good oral hygiene
• Providing humidified air

Loss of Appetite

• Eating smaller, more frequent meals
• Eating high calorie, high protein foods
• Receiving nutritional counseling

Gastrointestinal Problems

Skin Problems

• Dryness may be lessened by adding baby or mineral oil to warm bath water, and by applying moisturizers. It is also important to drink 8-10 glasses of water per day.
• Itching and rash may be lessened by adding baking soda to cool bath water, or by applying a cool, moist cloth to itchy areas. Avoid harsh laundry detergents, and change sheets and towels daily.
• Keep skin clean and dry and check skin daily for pressure sores or ulcers which may become infected.

Anxiety/Depression

New approaches to treat malignant mesothelioma are currently being tested. They often combine traditional treatments or include something entirely new. They include:

• Angiogenesis and Anti-angiogenesis Drugs
  Although progress has been made in the early detection of cancer, and in improved treatment options once cancer is diagnosed, there are still many cancers, including mesothelioma, which can not be cured and remain difficult to treat effectively. In recent years, researchers have learned a great deal about how cancer cells differ from normal cells and, in an effort to find drugs without the potentially severe side effects of chemotherapy, have now discovered drugs which target the tumor itself while sparing the body’s normal cells. One such group are the anti-angiogenesis drugs.
  Learn more about anti-angiogenesis agents in the treatment of mesothelioma.
  
• Immunotherapy, sometimes called biological therapy, uses the body's own immune system to protect itself against disease. Researchers have found that the immune system may be able to recognize the difference between healthy cells and cancer cells, and eliminate those that become cancerous. Immunotherapy is designed to repair, stimulate, or enhance the immune system's natural anticancer function. Substances used in immunotherapy, called biological response modifiers (BRMs) alter the interaction between the body's immune defenses and cancer, thereby improving the body's ability to fight disease. Some BRMs, such as cytokines and antibodies, occur naturally in the body, however, it is now possible to make BRMs in the laboratory that can imitate or influence natural immune response agents. These BRMs may:
  
  • Enhance the immune system to fight cancer cell growth.
  • Eliminate, regulate, or suppress body responses that permit cancer growth.
  • Make cancer cells more susceptible to destruction by the immune system.
  • Alter cancer cell's growth patterns to behave like normal cells.
  • Block or reverse the process that changes a normal cell into a cancer cell.
  • Prevent a cancer cell from spreading to other sites.
  Many BRMs are currently being used in cancer treatment, including interferons, interleukins, tumor necrosis factor, colony-stimulating factors, monoclonal antibodies, and cancer vaccines.
More on immunotherapy for mesothelioma.

• Photodynamic therapy (PDT) is a type of cancer treatment based on the premise that single-celled organisms, if first treated with certain photosensitive drugs, will die when exposed to light at a particular frequency. PDT destroys cancerous cells by using this fixed frequency light to activate photosensitizing drugs which have accumulated in body tissues. In PDT, a photosensitizing drug is administered intravenously. Within a specific time frame (usually a matter of days), the drug selectively concentrates in diseased cells, while rapidly being eliminated from normal cells. The treated cancer cells are then exposed to a laser light chosen for its ability to activate the photosensitizing agent. This laser light is delivered to the cancer site, (in the case of mesothelioma, the pleura), through a fiberoptic device that allows the laser light to be manipulated by the physician. As the agent in the treated cells absorbs the light, an active form of oxygen destroys the surrounding cancer cells. The light exposure must be carefully timed, so that it occurs when most of the photosensitizing drug has left the healthy cells, but is still present in cancerous ones.
  The major side effect of PDT is skin sensitivity. Patients undergoing this type of therapy are usually advised to avoid direct and even indirect sunlight for at least six weeks. Other side effects may include nausea, vomiting, a metallic taste in the mouth, and eye sensitivity to light. These symptoms may sometimes come as a result of the injection of the photosensitizing agent.

• Gene therapy is an approach to treating potentially fatal or disabling diseases by modifying the expression of an individual's genes toward a therapeutic goal. The premise of gene therapy is based on correcting disease at the DNA level and compensating for the abnormal genes. Replacement gene therapy replaces a mutated or missing gene, most often a tumor suppressor gene, with a normal copy of that gene which serves to keep cell growth and division under control. The p53 gene, the most common gene mutated in cancer has become a prime target for gene replacement, and has met with some success in inhibiting cell growth, inhibiting angiogenesis (the development of a tumor's blood supply), and inducing apoptosis (cell death).
  Knockout gene therapy targets the products of oncogenes (a gene that can induce tumor formation) in an effort to render them inactive and reduce cell growth.
  With constantly expanding knowledge of the genes associated with cancer, their functions, and the delivery systems used in administering these genes, gene therapy has a promising future.
  
• Complementary and alternative medicine covers a wide range of healing philosophies that conventional medicine does not commonly accept or make available to its patients. Some of these practices include the use of acupuncture, herbs, homeopathy, therapeutic massage, and Far Eastern medicine to treat health conditions. These therapies may be used alone as an alternative to conventional medicine, or in addition to conventional medicine, in which case they are referred to as complementary. Many are considered holistic, meaning their focus is to treat the whole patient - physically, mentally, emotionally, and spiritually. These treatments are not widely taught as a part of the medical curriculum, are not generally used in hospitals, and, for the most part, are not covered under insurance policies.
  Many cancer patients try various complementary and/or alternative medicine techniques during the course of their treatment, and although they may not work for everyone, some patients benefit by managing their symptoms or side effects. One important caveat, is to discuss any complementary or alternative treatments you may be considering with your doctor to be sure nothing interferes with your conventional care. For instance, dietary supplements such as herbs or vitamins may be "natural", but not necessarily "safe". They may lessen the effectiveness of certain anticancer drugs, or when taken with other drugs or in large doses, may actually cause harm. Since supplements of this nature are not governed by the FDA (Food and Drug Administration), and a prescription is not necessary to purchase, it is up to the consumer to make informed and conscientious decisions regarding their use.
  Your personal physician may be able to advise you about the use of complementary and alternative treatments and therapies, and how they relate to mesothelioma.
  The combinaton of complementary and conventional therapies is sometimes referred to as integrative medicine.
  
• Unconventional methods of cancer treatment make claims that can not be scientifically substantiated. They commonly claim to be effective against cancers that are considered incurable, and tout treatments with relatively few, if any, side effects. The use of these unconventional methods may result in the loss of valuable time and the opportunity to receive potentially effective therapy. It is always important to remain in the care of a qualified physician who uses accepted methods of treatment or who is participating in scientifically designed investigational therapies.

Other new approaches

Radiation therapy, also called radiotherapy, treats cancer by using penetrating beams of high energy or streams of particles called radiation. In treating mesothelioma, radiation may be used aggressively in combination with surgery, or palliatively to control symptoms.
In an aggressive combined modality approach, radiation is used to attack microscopic or residual disease remaining in the chest cavity after extrapleural pnuemonectomy. An example of this is Intensity Modulated Radiation Therapy (IMRT), which uses x-rays of varying intensities in conjunction with computer generated images to deliver targeted radiation directly to cancer cells while reducing the amount of radiation to surrounding healthy tissue. More on Intensity Modulated Radiation Therapy (IMRT).
Used palliatively, radiation can help control metastases (spread) of the tumor along tracks left by invasive procedures such as thoracoscopy, needle biopsy and chest tube drainage, or to control disease symptoms, such as pain or shortness of breath.
An exciting new development in radiation oncology is tomotherapy.
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Chemotherapy is defined as the treatment of cancer using chemical substances. When cancer occurs, abnormal cells continue to divide uncontrolled. Anticancer, or chemotherapy drugs, work to destroy cancer cells by preventing them from multiplying.

Purposes of Chemotherapy

Chemotherapy may be used to achieve different goals, depending on the stage of the cancer at the time of diagnosis and the age and health of the patient. Since chemotherapy for mesothelioma is not considered "curative", the goal is:

• To control the cancer by stopping its spread or slowing its growth.
• To shrink tumors prior to other treatments, such as surgery. This is called neoadjuvant chemotherapy.
• To destroy microscopic disease which may remain after surgery. This is called adjuvant chemotherapy.
• To relieve symptoms, such as pain. This is called palliative chemotherapy, and is given in cases when a drastic reduction in the tumor is not expected.

The most common use for chemotherapy in mesothelioma patients is as an option for those who are not surgical candidates; however, cancer centers are conducting trials using the neoadjuvant approach (giving chemotherapy before surgery). Alimta (pemetrexed) is a drug approved by the Food and Drug Administration (FDA) for use with Cisplatin in the treatment of patients with malignant pleural mesothelioma whose disease is either unresectable or who are not candidates for curative surgery. Alimta is the first drug approval specific to mesothelioma.
The Alimta/Cisplatin chemotherapy regimen is the first Food and Drug Administration (FDA) approved treatment specifically for malignant pleural mesothelioma. This is currently considered the most effective first-line treatment for mesothelioma patients who are not surgical candidates. A multi-targeted antifolate drug, Alimta works by blocking the enzymes necessary for DNA copying and cell division. During the clinical trial process, Alimta/Cisplatin improved median survival for pleural mesothelioma patients by approximately three months over treatment with Cisplatin as a single agent.
As with any medical treatment, it is important to discuss the use of Alimta with your doctor. This conversation should include all pertinent information regarding effectiveness, administration and possible side effects of the drug combination. It is also important to begin vitamin supplementation of B12 by injection during the week prior to treatment (to be repeated every 9 weeks), and folic acid by mouth daily (to be continued until 21 days after the last cycle of Alimta). Additionally, you will be given an oral steroid medication to minimize the risk of skin rash or other possible side effects. Your doctor will have information on the correct dosages of each medication. Be sure to tell your doctor of any other medications you are taking (including non-prescription drugs) so he may be aware of any adverse interactions.
Alimta/Cisplatin is administered to patients on an outpatient basis every 21 days. This cycle of treatment consists of a 10-minute IV infusion of Alimta followed by a 2-hour infusion of Cisplatin. How many cycles of treatment you receive depends on your response to the drug (regression of the tumor or halt to progression of the disease) and the side effects you might experience.
Side effects of Alimta/Cisplatin are mild to moderate for most mesothelioma patients, i.e., nausea, vomiting and fatigue, and can usually be managed by your doctor. For some patients, however, side effects may be debilitating, and may require a decrease in dosage or removal from the program. All potential side effects should be mentioned to your doctor. Never assume any complaint is minor.

Administration of Chemotherapy

The most common way to administer chemotherapy is intravenously, or through a vein. A thin needle is inserted into a vein in the hand or in the lower arm. Intravenous administration of drugs allows for rapid entry into the blood stream. Drugs may also be delivered via catheters and/or ports.

• Catheters are soft, thin, flexible tubes placed into a large vein in the body. They remain in place for as long as they are needed.
• The catheter may sometimes be attached to a port, a small round plastic or metal disc placed under the skin on the chest. Ports also remain in place for as long as necessary.

Intraperitoneal chemotherapy may also be delivered through a catheter or a port. The catheter is inserted through the abdominal wall. Chemotherapy drugs can then be infused directly into the abdominal cavity for treatment of peritoneal mesothelioma. Ports may also be placed under the skin of the abdominal wall and the catheter tunneled between the skin and muscle into the peritoneum.
Frequently asked questions about being a chemotherapy patient.

Side Effects of Chemotherapy

Cancer cells grow and divide more rapidly than normal cells, but some normal cells also multiply quickly, particularly those in the digestive tract, reproduction system, and hair follicles. It is the damage done to normal cells that causes side effects. The type of side effects you might experience and how severe they are, depend on the type of chemotherapy you are receiving, the dosage given and how your own body reacts. Before beginning any chemotherapy treatment, you will be asked to sign a consent form. Before signing the form, be sure your doctor informs you of all the facts regarding the treatment he/she will be administering, including information about the particular drug or combination of drugs to be used, the possible risks or side effects (including nausea and vomiting and peripheral neuropathy), the number of treatments you will receive and how often, and whether it will be given during a hospital stay or on an outpatient basis. More on vomiting and nausea from chemotherapy. More on peripheral neuropathy. More on anti-nausea treatment for chemotherapy patients.
Click here if you are interested in learning more about chemotherapy for mesothelioma and the types of questions you should ask your doctor.

Chemotherapy Schedules

How often you will receive chemotherapy will be determined by your doctor, taking into consideration factors such as the stage of your cancer, the types of drugs you receive, the anticipated toxicities of the drugs and the time necessary for your body to recover from these toxicities. The doctor may also consider whether the goal of the chemotherapy is to control the growth of the cancer, or to ease symptoms associated with the disease.
In general, chemotherapy treatment is administered in "cycles" — a "cycle" being defined as a period of treatment followed by a period of rest. This cycle allows the cancer cells to be attacked by the drugs, and then allows the body's normal cells time to recover. The combination of drugs used, the length of time to administer the drugs, how often they should be repeated and the number of cycles recommended have been analyzed throughly in clinical trials. For mesothelioma patients, the "standard" treatment is a combination of Alimta and cisplatin, administered IV, with a 10 minute infusion of Alimta followed by two hours of cisplatin, given in 21 day cycles. Modifications to this schedule may be made according to what your doctor feels is appropriate in your particular case.
The number of treatment cycles, or the length of time between the beginning and end of chemotherapy may vary, however in general, 3 to 4 cycles of treatment are given before response is evaluated; 2 to 3 cycles are considered a minimum to assess for effectiveness. After response to the treatment has been determined, the following criteria will be used to decide whether chemotherapy should continue:

• If there is shrinkage of the tumor, or the disease is kept stable, chemotherapy may be continued for as long as it can be tolerated and there is no disease progression.
• If there is continued disease progression, chemotherapy will be stopped, and the patient will be given alternative options.

The goal of setting a chemotherapy schedule is to make treatment as effective, timely and trouble-free as possible, but while the drugs are working to kill cancer cells, they may also affect healthy cells causing side effects. One of the most common side effects, and one your doctor will monitor carefully, is a chemotherapy-induced low white blood cell count (neutropenia) which means your immune system is weakened, therefore leaving you more prone to infection. While this side effect is anticipated when someone is undergoing chemotherapy, it can cause delays in your treatment schedule, or changes in the dosage of the drugs you will receive. Click here for more on understanding your blood counts.
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Note to Patients:

Chemotherapy treatment should be a cooperative effort between you and your doctor. The interaction that takes place is important to your health. It will not only help you feel better, but will also address any potential problems with miscommunication.

1. It is necessary for your doctor to be aware of any side effects which may result from your chemotherapy treatment.
   These may include:
   
   
   • Fever of, or greater than 101 degrees
   • Nausea or vomiting
   • Diarrhea or constipation
   • Fatigue
   • Tingling or numbness in the fingers or toes
   • Ringing in the ears
   • Bruises or rashes
   • Sores in the mouth or throat
2. Taking other medication of any kind can alter the effects of chemotherapy or cause undesirable interactions.
   Be sure you report all over-the-counter and prescribed medicines to your doctor. Don’t take aspirin unless it has been approved by your doctor. Ask your pharmacist if aspirin is contained in any drugs you plan to purchase.
3. Take extra care with your daily health.
   Try to maintain a stable weight by eating a healthy diet and drinking plenty of fluids. If your stomach is upset, ask your doctor for helpful hints or work with a nutritionist who can tailor a program to your needs. Brush your teeth after every meal, or if you can’t brush, rinse your mouth thoroughly with water. Stay away from people who have colds or the flu. Chemotherapy can compromise your immune system and lower your resistance to germs. Make sure you keep appointments for blood work – these tests help your doctor monitor your health.
4. Be open about your feelings regarding your treatment.
   It is normal to feel sad, angry or afraid, however, letting these emotions get out of control can be detrimental to your overall well-being. Seek out the help of family, friends, your doctor, a counselor or a support group.
   

Diagnostic Procedures

As previously mentioned in the "Symptoms" section of this website, a diagnosis of mesothelioma from fluid is many times inconclusive. Given this fact, diagnostic surgery becomes a necessary next step in confirming and staging mesothelioma.
Thoracoscopy enables a physician to evaluate the pleural cavity and to conduct multiple tissue biopsies under direct vision. In up to 98% of cases, a definitive diagnosis can be obtained. Often, chemical pleurodesis aimed at relieving the accumulation of fluid in the intrapleural space, can be accomplished during the same procedure. It is also possible to gauge the extent of the tumor, and make a determination of surgical resectability. While less invasive than an open biopsy, it can only be performed on patients where tumor has not obliterated the pleural space.
VATS, or video-assisted thoracic surgery is an alternative to thoracoscopy, although because of its more invasive nature, concerns of tumor seeding increase. By utilizing small incisions, the physician can view the pleural space with the assistance of a camera, and obtain sufficient tissue samples for analysis by a pathologist. Extent of the tumor (i.e., pleural involvement, chest wall invasion) may also determined, and recommendation as to the type of debulking procedure necessary can be made at this time.
Mediastinoscopy is sometimes used as an aid in staging extent of disease when enlarged nodes are seen using imaging techniques.
Laproscopy is used in mesothelioma patients in cases where imaging techniques suggest possible invasion of the tumor through the diaphragm. This information can be important in evaluating a patient for potential pleurectomy or extrapleural pneumonectomy.

Palliative Procedures

Palliative surgical procedures are those which treat a symptom of mesothelioma, without aggressively treating the disease itself.
Chest Tube Drainage and Pleurodesis is considered the most common of palliative treatments. Fluid build-up, or pleural effusion, is most often the first symptom which will prompt mesothelioma patients to seek medical attention. Once this effusion has occurred, it is many times persistent, returning rapidly after initial thoracentesis (draining of the fluid). In order to eliminate this problem, the pleural space must be closed. This is accomplished by use of a talc slurry or other sclerosing agent which produces an adhesion.
Thoracoscopy and Pleurodesis is done in conjunction with VATS using a powdered form of talc versus talc slurry. Both this and chest tube drainage and pleurodesis will be only effective if there is no tumor encasing the lung which restricts its expansion.
Pleuroperitoneal Shunt plays a limited role in palliation for several reasons. It involves placement of a catheter run under the skin from the pleural to the peritoneal cavity. Obstruction of the catheter and possible seeding of the tumor into the abdominal cavity may be concerns.
Pleurectomy, used as a palliative procedure, may be performed where more extensive surgery is not an option. In these cases, it is understood that all visible or gross tumor will not be removed. It is considered the most effective means of controlling pleural effusion in cases where the lung's expansion is restricted by disease.

Potentially Curative Procedures

These procedures are performed with "curative intent". Their goal is removal of all gross disease, with the knowledge that microscopic disease will most likely remain. Adjuvant therapy (another form of treatment in addition to the primary therapy) is typically aimed at eliminating residual disease.
For Pleural Mesothelioma:

• Pleurectomy/Decortication is usually performed on patients with early stage disease (Stage I and selected Stage II), and attempts to remove all gross tumor. If it is found that all tumor can not be removed without removing the lung, this may be done at the same time and is called pneumonectomy.
• Extrapleural Pneumonectomy is considerably more radical than other surgical approaches, and should be carried out by surgeons with great expertise in evaluating patients and performing the procedure itself. (See Finding Specialists.) Because in the past surgery alone has failed to effect a cure, or even to help prolong life for any extended period of time, it is currently being combined with traditional chemotherapy and/or radiation, or other new approaches such as gene therapy, immunotherapy or photodynamic therapy.
  General Patient Selection Criteria for Extrapleural Pneumonectomy
  Extrapleural pneumonectomy is a serious operation, and doctors experienced in this procedure choose their patients carefully. It is up to each individual surgeon to advise the patient on its feasibility and to conduct whatever tests he/she feel are necessary to optimize the patient's chances for survival and recovery. Following is a general list of patient selection criteria. This list may not be all inclusive, and may vary according to the preference of the surgeon.
  
  • Karnofsky Performance Status score of >70. This score relates to what symptoms of disease the patient may be experiencing and how well they are able to conduct their daily activities. Some surgeons may require a higher performance status than others.
  • Adequate renal (kidney) and liver function tests; no significant kidney or liver disease.
  • Normal cardiac function per electrocardiogram and echocardiography.
  • Adequate pulmonary function to tolerate the surgery.
  • Disease limited to the ipsilateral hemithorax (the same side of the chest in which the mesothelioma is located) with no penetration of the diaphragm, extension to the heart or extensive involvement of the chest wall.
  • Age of the patient is taken into consideration, but may not be as important as their overall status.
  Surgeries of this nature should always be done with a complete understanding of the possible benefits and risks involved. If you are considering surgery as a treatment option, speak openly with your doctor about your concerns, and be sure all of your questions are answered to your satisfaction.
  
  

For Peritoneal Mesothelioma:

• Cytoreductive Surgery is aimed at removing all or nearly all of the gross or visible tumor in the peritoneal cavity. In order to treat any remaining cancer cells, Intra-Peritoneal Hyperthermic (heated) Chemotherapy (IPHC) is then delivered to the abdominal cavity. The type of chemotherapy drug used may vary according to the physician’s preference. Click here for more on treatment of peritoneal mesothelioma.

TOP

The treatment program for mesothelioma depends on many factors, including: the stage of the cancer, where the cancer is, how far the cancer has spread, how the cancer cells look under the microscope and the patient’s age and desires.

TIME MATTERS

TRADITIONAL CARE

• Surgery (taking out the cancer)
• Chemotherapy (using drugs to fight the cancer)
• Radiation Therapy (using high-dose x-rays or other high-energy rays to kill cancer cells)

MESOMARK BLOOD TEST