Remission and Recurrence

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Mesothelioma remission and mesothelioma recurrence often go hand in hand. It's the good and bad news reality of this rare and aggressive incurable cancer.

Remission can bring considerable emotional and physical relief, typically following an aggressive treatment regimen that stops tumor growth. It can also inspire real hope for patients and their families.

Unfortunately, the reality is that recurrence follows remission, creating another tug of war, pitting today's best cancer therapies against a relentless disease difficult to control.

What Is Cancer Remission?

Mesothelioma remission means the cancer improved in a measurable way. It marks a major, positive turn in your overall health.

It means you can reduce or temporarily stop treatment. It should make you smile, but it does not mean the fight is over. Cancer care is not black and white. It is usually gray. There is no on/off switch.

Mesothelioma remission typically falls into two categories:

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    Partial Remission

    The cancer is improving significantly. Doctors usually measure it as a percentage. For example, oncologists may tell their patients there's at least a 50 percent reduction in tumor size. Mesothelioma survivors can live for several years in partial remission despite the presence of tumors. It’s something doctors monitor closely. For the patient, it means you can treat the disease as a chronic but manageable condition.

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    Complete Remission

    All evidence of cancer has disappeared. It's rare with mesothelioma and not fully understood fully, but it is possible. A few mesothelioma survivors have lived 10-15 years or more without signs of recurrence. It usually stems from an early diagnosis and an aggressive treatment approach.

Contributing Factors of Mesothelioma Remission

After reviewing case histories, doctors have identified several factors that may contribute to mesothelioma remission. Surgery is the treatment that will most likely lead to prolonged remission, but some patients have noted partial or complete remission with the following therapies:

  • Systemic chemotherapy
  • Immunotherapy
  • Oxygen therapy
  • Significant dietary changes
  • Nutritional supplements

Learn more about what remission means for mesothelioma patients from Karen Selby.

Survivors in Remission

Survivor, Cindy Christopher

Cindy Christopher

Cindy Christopher of New York has been in remission for more than 11 years after undergoing extensive cytoreductive surgery and heated intraperitoneal chemotherapy (HIPEC) for mesothelioma in 2006. Christopher, 65, continues with regular checkups and hasn't seen signs of cancer recurrence. She previously overcame bouts of thyroid and skin cancer. The former teacher and registered nurse returned to work in the garden department at her local Home Depot.

Survivor, Walter Merth

Walter Merth

Walter Merth of Philadelphia attributes the remission of his pleural mesothelioma to the immunotherapy drug Keytruda, which he received at Penn Medicine’s Abramson Cancer Center. He had experienced recurrence of his mesothelioma less than six months after aggressive pleurectomy/decortication surgery. Although the FDA has not yet approved Keytruda as a first-line treatment for mesothelioma, doctors have been using it successfully for certain types of lung cancer. Merth received the drug under a special Patients Access Program.

Survivor, David Knapp

David Knapp

Air Force veteran David Knapp of California has been in partial remission since starting a pemetrexed clinical trial at the Stanford Cancer Institute. Knapp was first diagnosed with pleural mesothelioma and underwent a combination of surgery, radiation and chemotherapy. He has taken a realistic approach to his current condition.

At this point, it’s just a matter of buying some time. And buying time is good. I’ve been pretty darn lucky my whole life.” — David Knapp, Air Force veteran diagnosed with pleural mesothelioma in 2016.

Understanding Remission

Doctors don’t say the word “cured” when it comes to cancers such as mesothelioma because it's an incurable condition. Complete remission does not mean cured.

Dr. Fontaine talks about remission and keeping an eye on the cancer once it is gone.

Patients should continue with checkups despite the absence of symptoms. The follow-up care will include regular blood tests, imaging scans and physical exams.

Even with the latest and best cancer treatments, mesothelioma tumor cells can remain unnoticed in the body. When those cells begin to multiply again — which they usually do at some point after remission — it is called recurrence.

What Is Cancer Recurrence?

Cancer recurrence is typically defined as a return of the cancer after treatment and after an extended period of remission. Meanwhile, cancer progression is when the condition worsens or spreads. The difference between recurrence and progression is often murky with mesothelioma because there is no cure.

Mesothelioma recurrence is impossible to avoid, even after the most aggressive surgery, multimodal treatments and adjuvant follow-up therapy. The recurrence of mesothelioma cancer stems from the disease's tumors, which can spread through the lining of the lungs, heart and abdomen.

The proximity of tumors to vital organs makes it difficult for surgeons to completely eliminate despite the most advanced medical technology. The key is to delay and keep the eventual recurrence under control for as long as possible.

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Treatments to Control Remission

The most common mesothelioma treatments to control remission include the aggressive extrapleural pneumonectomy and the lung-sparing procedure known as the pleurectomy/decortication.

Extrapleural Pneumonectomy (EPP) Surgery

A recent Italian study covering a 20-year period showed that 93 percent of malignant pleural 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.

Doctors Performing Surgery

Another six-year study from Toronto General Hospital followed 60 patients who were healthy enough for the EPP surgery. Their median survival rate was 14 months. However, the five-year postoperative survival rate was only 10 percent.

EPP is an extensive procedure intended to remove the disease fully from the body. It extracts the affected lung and everything around it that could be affected in the future, including the pleura, the lining around the lung, and the pericardium, which is the lining around the heart as well as parts of the diaphragm, which is later rebuilt with prosthetic material.

The multidisciplinary approach also includes chemotherapy and radiation in an effort to eradicate any tumor cells left in the body. Despite those efforts, recurrence normally happens at some point.

Pleurectomy/Decortication (P/D)

There are other, less radical mesothelioma surgeries, including pleurectomy/decortication (P/D), which eliminates fewer cancer cells but is far less taxing on the body, and it 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 [mesothelioma], than being able to kill every last [cancer] cell. If you can do that, you can live a long time with it.” — Thoracic Surgeon Dr. Robert Cameron

Life After Recurrence

Although they remain exceptions, long-time survivors are becoming more common as advancements in treatment continue. David Cutts and Ruth Phillips beat the odds after recurrence in various ways.

Cutts, a former Marine from New Jersey, went more than seven years after his EPP surgery without having a serious recurrence of his mesothelioma. While, Phillips has controlled her mesothelioma for 17 years by using an alternative medicine approach after she rejected the conventional surgical options.

Few have been as fortunate as Cutts and Phillips.

How Does Mesothelioma Recurrence Occur?

Mesothelioma typically recurs when cancer cells survived after surgery or chemotherapy. The cancer then grows again over time. And when it returns, doctors normally define it in three ways.

  1. Local Recurrence

    Tumors return to the same spot or close to where they were originally found.

  2. Regional Recurrence

    Tumors grow in tissues or lymph nodes near the original cancer location.

  3. Distant Recurrence

    Cancer has spread to tissues far from the location of the original cancer.

Fast Fact: A 2009 Toronto study emphasized that high-dose hemithoracic radiation following EPP surgery decreased the rate of local recurrence, although patients still developed distant recurrence in the contralateral chest or abdomen. Induction chemotherapy before EPP helps decrease rate of distant recurrence.

The lengthy latency period between asbestos exposure and first diagnosis is about 10-50 years. That lengthy span allows the cancer plenty of time to spread, which is another reason recurrence is typical with mesothelioma. Early symptoms resemble those of less serious illnesses, which further slows the diagnosis.

Clinical Trials for Recurring Mesothelioma

There are many clinical trials aimed at patients with recurrent mesothelioma. Talk to your doctor to see if you qualify for any of them. Researchers are often looking for patients in which to use agents or procedures not used in their original treatment.

Clinical trials are where the latest experimental treatments are tested. Patients must apply for new physical approaches, biologicals or new chemotherapeutic agents. For example, patients who didn't originally receive chemotherapy can be candidates for cisplatin/pemetrexed or cisplatin/raltitrexed first-line chemotherapy trials for cancer stages 1-3.

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Karen Selby is a registered nurse and a Patient Advocate at The Mesothelioma Center. She worked in several subspecialties within nursing before joining Asbestos.com in 2009.

  1. Ampollini, L; Soltermann, A; Felley-Bosco, E; Lardinois, D; Arni, S; Speck, R F; Weder, W. (2009). Immuno-chemotherapy reduces recurrence of malignant pleural mesothelioma: an experimental setting. European Journal of Cardio-Thoracic Surgery, 35(3):457-462. Retrieved from: http://www.zora.uzh.ch/15839/
  2. National Institutes of Health. Germline BAP1 mutations predispose to malignant mesothelioma. (Aug. 28, 2011). Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3184199/
  3. National Institutes of Health. Tandar, A; Abraham G; Gurka, J; Wendel, M; Stolbach, L. (2001). Recurrent peritoneal mesothelioma with long-delayed recurrence. Abstract. Retrieved from: http://www.ncbi.nlm.nih.gov/pubmed/11500619
  4. Second Surgery for Recurrence of Malignant Pleural Mesothelioma After Extrapleural Pneumonectomy. Leonardo Politii and Giuseppe Borzellino (2009). The Annals of Thoracic Surgery. Retrieved from: http://www.annalsthoracicsurgery.org/home
  5. Tristan D Yan, MoMo Tin, Michael Boyer, Jocelyn McLean, Paul G. Bannon, Brian C. McCaughan. Treatment Failure after Extrapleural Pneumonectomy for Malignant Pleural Mesothelioma. (2009). Retrieved from: http://www.jthoracdis.com/article/view/54/99
  6. Marc de Perrot, Ronald Feld, B.C. John Cho, Andrea Bezjak, Masaki Anraku, Ronald Burkes, Heidi Roberts, Ming S. Tsao, Natasha Leighl, Shaf Keshavjee and Michael R. Johnston. Trimodal Therapy With Induction Chemotherapy Followed by Extrapleural Pneumonectomy and Adjuvant High-Dose Hemithoracic Radiation for Malignant Pleural Mesothelioma. Journal of Clinical Oncology. Retrieved from: http://jco.ascopubs.org/content/27/9/1413.long

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