Mesothelioma recurrence is almost impossible to avoid, even after the most aggressive surgery, after a multimodality approach to treatment and after adjuvant follow-up therapy. The recurrence of mesothelioma cancer is likely because of the unique characteristics of this disease, which can spread through the lining of the lungs, heart and abdomen.
The location of tumors so close to organs makes it difficult for doctors to eliminate it completely, even with the most advanced medical technology. The key – and the hope – is to delay the eventual recurrence, keeping it under control for as long as possible.
Cancer recurrence is typically defined as a return of the cancer after treatment and after an extended period when it cannot be detected. Cancer progression is when it gets worse or spreads. The difference between the two is often murky with mesothelioma because there is no proven cure.
In one recent study from Italy covering a 20-year period, 93 percent of the mesothelioma patients who opted to undergo an aggressive extrapleural pneumonectomy (EPP) surgery, later developed tumor recurrence, highlighting the inadequacy of current treatment strategies and underscoring the difficulty of dealing with this disease.
In another study (covering six years) from the Toronto General Hospital that followed 60 patients who were healthy enough for the EPP surgery, the median survival rate was 14 months. The five-year survival rate post-surgery was 10 percent.
EPP is an extensive procedure intended to remove the disease fully from the body, taking both the affected lung along with everything around it that could be affected in the future. It includes removal of the pleura, the lining around the lung, and the pericardium, the lining around the heart, as well as much of the diaphragm, which is rebuilt with prosthetic material.
The multi-disciplinary approach also includes chemotherapy and radiation in an effort to eradicate any disease left in the body. Even with those efforts, recurrence normally happens at some point.
There are other, less radical, surgeries for mesothelioma, including pleurectomy and decortication (P/D), which eliminates fewer cancer cells but is far less taxing physically and preserves a patient's lung.
Sometimes, we get stuck in the concept of having to cure cancer and don't always understand that we can be good at controlling it. It's much more likely to be able to control it (mesothelioma), then being able to kill every last (cancer) cell. If you can do that, you can live a long time with it.Robert Cameron, M.D.
Robert Cameron is one of America's leading mesothelioma surgeons who practices at the Jonsson Comprehensive Cancer Center. He is a proponent of the P/D surgery, preferring it over the EPP. He concedes there likely will be recurrence of mesothelioma but believes in the work to control it within the body.
Although they remain exceptions, long-time survivors are becoming more common as advancements in treatment continue to be made. David Cutts, Ruth Phillips and Larry Davis are three mesothelioma patients who have beaten the odds in various ways.
Cutts, a former Marine from New Jersey, has gone six years since his EPP surgery without having a serious recurrence of his mesothelioma. In Atlanta, Phillips has controlled her mesothelioma for 12 years by using an alternative medicine approach after she rejected the conventional surgical options.
Davis, from South Florida, continues to lead an active lifestyle six years after his original diagnosis of mesothelioma and several setbacks that he has fought off each time.
Few have been as fortunate as those survivors. From the 74 patients who were part of the original study in Italy, eight were healthy enough and opted for a second round of surgery after recurrence. Their median survival rate after the second surgery was 14.5 months. One of the seven lasted 29 months. The conclusion of the research was that a second surgery was viewed as palliative and not curative.
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A recurrent cancer like mesothelioma usually begins again with cancer cells that escaped the first treatment. The cancer then grows again over time. And when it returns, doctors normally define it in three ways.
Tumors return to the same spot or close to where it was originally found.
When tumors grow in tissues or lymph nodes near the original cancer.
Cancer has spread to tissues far from the spot of the original cancer.
The 2009 Toronto study emphasized that the addition of high-dose hemithoracic radiation following an EPP surgery has proved to decrease the rate of local recurrence, although patients still developed distant recurrence in the contralateral chest or abdomen. The induction chemotherapy, before the EPP, has helped decrease the rate of distant recurrence.
One reason recurrence is typical with mesothelioma is the lengthy latency period (10 to 50 years) after an exposure to asbestos fibers, giving it time to spread before a diagnosis is made. Plus, symptoms first resemble those of less-serious illnesses, further slowing the diagnosis.
The NCI has several ongoing clinical trials aimed at patients with recurrent mesothelioma. To qualify for those trials, patients must utilize agents or procedures not used in their original treatment.
Patients must be apply for new physical approaches, biologicals or new chemotherapeutic agents. For example, patients who had not received chemotherapy originally are candidates for cisplatin pemetrexed or cisplatin raltitrexed first-line chemotherapy. There are trials for Stages I, II and III.
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