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How Is Chemotherapy Used to Treat Mesothelioma?

Chemotherapy, commonly known as “chemo,” is used to treat mesothelioma and its symptoms by controlling tumor growth. These medications travel through the blood until they reach the area of the body with mesothelioma cancer.  

The treatment kills the fast-growing cancer cells that create tumors. It can shrink tumors and prevent or limit new tumor formation. By restricting tumor growth, chemotherapy helps mesothelioma patients live longer.

Chemotherapy also reduces mesothelioma symptoms such as chest pain and difficulty breathing by shrinking tumors pressing against the lungs and chest wall.

How chemotherapy drugs work against mesothelioma cancer

Although chemotherapy can’t cure mesothelioma, it can alleviate symptoms, improve quality of life and prolong survival. Doctors may also combine chemo with surgeryradiation therapy or emerging treatments such as Tumor Treating Fields or immunotherapy.

How Chemotherapy Drugs Are Administered

Cancer specialists can tailor chemotherapy to the circumstances of individual patients. This therapy remains the most common treatment for mesothelioma because it involves several medications, dosage levels and administration methods. Doctors can deliver chemotherapy through an intravenous line into the blood or as a heated wash during surgery. 

Systemic Chemotherapy

During a systemic mesothelioma chemotherapy regimen, doctors or nurses administer the drugs through an IV line in a vein or a port. The medication circulates throughout the entire body, which exposes healthy and cancerous cells to chemotherapy. 

This delivery method may cause more side effects, but it is less invasive than receiving heated chemotherapy during surgery. 

Doctors may administer systemic chemotherapy alone, which is the most common treatment for all types of mesothelioma malignancy, or in combination with other therapies.

Intraoperative Chemotherapy

Surgeons deliver intraoperative chemotherapy during surgery when the cancer site is open and exposed. This technique requires warming the chemotherapy, using a pump to rinse the cancer site with the medication, and a drain to remove the fluid. 

Depending on the mesothelioma type, doctors may refer to this procedure as intrapleural or intraperitoneal chemotherapy. 

Applying chemotherapy during surgery targets the tumor directly and protects healthy areas of the body from chemotherapy exposure, which reduces the risk of side effects.

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For more than 15 years, our Patients Advocates have connected patients with innovators in chemotherapy for mesothelioma patients.

Chemotherapy in a Multimodal Treatment Plan

Doctors sometimes combine chemotherapy for mesothelioma with other treatments such as surgery and radiation therapy. This approach is called multimodal therapy, and it offers a better chance at long-term survival.

By combining multiple therapies, there is a lower risk that cancer can avoid or resist treatment. Patients eligible for multimodal treatment plans tend to have a mesothelioma diagnosis in the early stage or are healthy enough to withstand aggressive cancer treatment.

Doctors use the following terms to describe the best times for delivering chemotherapy for mesothelioma:

  • Neoadjuvant chemotherapy is a systemic IV medication that helps shrink tumors before surgery and makes them more accessible for surgeons to remove.
  • Intraoperative chemotherapy requires a heated pump device to warm chemotherapy and directly treat cancer cells in a local area during surgery.
  • Adjuvant chemotherapy is a systemic IV treatment delivered after surgery to prevent cancer from regrowing or recurring in the same area.

Intraoperative chemotherapy is only available at top cancer centers, while systemic or IV chemotherapy is widely accessible at hospitals and other medical facilities.

Chemotherapy drugs administered during surgery are heated to cause blood vessels to expand, increasing effectiveness. Combining surgery with intraperitoneal chemotherapy has proved to be the most successful approach for extending peritoneal mesothelioma patient survival.

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Tumor Treating Fields for Mesothelioma

Tumor Treating Fields for pleural mesothelioma uses electrical fields to limit cancer growth. The treatment travels through adhesive pads attached to the skin. Doctors prescribe the therapy alongside chemotherapy. 

Patients use a battery-powered device to administer treatment throughout the day. When combined with chemotherapy, the electrical fields prevent growth in cancer cells. Patients report skin irritation as the most common side effect.

HITHOC

A type of heated chemotherapy procedure, called hyperthermic intrathoracic chemotherapy (HITHOC), has been used in the chest cavity for pleural mesothelioma. Mesothelioma patients with pleural disease in the early stages may be eligible for this procedure, which usually follows pleurectomy and decortication surgery. 

There is currently debate over HITHOC’s effectiveness. In a 2017 study, Italian researchers noted that 79% of patients who received HITHOC survived at least one year after surgery, and 45% were alive two years after surgery. By comparison, the median 1-year survival rate for pleural mesothelioma is approximately 73%. 

HIPEC

The hyperthermic intraperitoneal chemotherapy (HIPEC) procedure involves removing as much cancer tissue as possible through surgery. Afterward, the surgical team pumps a heated chemotherapy solution into the abdominal cavity for 60 to 90 minutes while the patient is still on the operating table.

Mesothelioma patients must have the peritoneal variant to be eligible for HIPEC. Recovery can take several months, but the medication’s side effects are minimal because the solution remains within the abdominal cavity.

According to a 2020 study published in the American Journal of Surgical Pathology, 77.8% of peritoneal mesothelioma patients treated with cytoreductive surgery and heated chemotherapy at MD Anderson Cancer Center in Houston survived longer than five years.

What to Expect During Chemotherapy Treatment

Your oncologist will determine the appropriate chemo drugs, dosage and frequency based on your cancer type and stage. Doctors prescribe chemotherapy at regular intervals called cycles. 

For mesothelioma patients, treatment cycles are typically two chemotherapy drugs every three to four weeks. These breaks in treatment allow healthy cells to recover from the effects of chemotherapy.

Your chemotherapy schedule may change based on your response to the treatment. If you develop concerning side effects, your doctor may recommend delaying or skipping a cycle.

3 Tips Before Starting Chemotherapy

  1. Research the drugs your doctor is recommending and all known side effects.
  2. Write down all questions you have about chemotherapy to ask your oncologist.
  3. Discuss alternatives with your oncologist. Is a lower dosage a possibility? What’s the backup plan if it doesn’t work or if the drug is too harsh?
Emily Ward
Pleural Mesothelioma Survivor and Retired Nurse

The Chemotherapy Process

While chemotherapy procedures always differ from patient to patient, here’s a typical timeline of what to expect from your first consultation to the end of treatment.

1. Consultation

Discuss the decision to start chemo for mesothelioma with your medical team and your family. Make sure an experienced mesothelioma specialist has reviewed your mesothelioma tests and blood work, and ask your doctors plenty of questions so you fully understand the pros and cons of chemotherapy.

2. Preparation

Doctors often prescribe drugs ahead of time to reduce chemotherapy side effects. Many patients will need to have a port, catheter or pump inserted in a large vein before receiving systemic chemotherapy. You may also need a dental visit to check for signs of disease that could interfere with chemotherapy. 

Drink plenty of liquids to avoid dehydration. Eat a light meal before treatment. Get enough sleep to arrive well-rested, and plan for a ride to and from your sessions.

3. Treatment

Doctors start with three or four cycles of mesothelioma chemotherapy, administered approximately every three weeks. After taking your vitals and verifying the dosage, a nurse will supervise each treatment. Treatment typically includes 30 minutes of one drug, then up to two hours of a second drug.

If you experience side effects while on treatment, discuss managing them with your oncologist. You may need a prescription for medication to ease any side effects during your treatment cycles. Ask family and friends to help you at home and work. Extreme fatigue often follows chemotherapy treatment, and you may need their assistance for daily duties.

4. Post-Treatment

Follow-up visits will begin a few weeks after you complete the entire regimen. You can ask more questions at these visits, get insight into the treatment, discuss its success or failure and whether there is a need for more treatments. Bring a family member to help with the discussion.

How to Prepare for Chemo Treatment

It’s unlikely you’ll feel entirely prepared for your first chemotherapy treatment, and not knowing how you’ll react to the medication can be frightening. Gathering your thoughts beforehand and making a plan is an excellent way to prevent feeling overwhelmed during your initial visit.

There’s no right or wrong way to prepare for chemo treatment. It’s okay to ask your family and friends for help and advice. The medical staff at your treatment center is also ready to answer any questions or concerns you may have. Researching your mesothelioma chemo drugs beforehand can go a long way toward helping you feel prepared and confident.

Understanding more about the process can help you prepare for chemotherapy treatment:

  • Preliminary Testing: You will undergo blood and heart tests to ensure your body can tolerate chemotherapy.
  • Port Placement: Systemic chemotherapy must be delivered through a port, catheter or pump surgically placed into a large vein.
  • Dental Checkup: You may need a dental visit to check for signs of infection. Proper treatment of dental infections reduces risk of complications during chemotherapy.
  • Expect Side Effects: Discuss managing possible chemotherapy side effects with your oncologist. You may need to pick up prescriptions that treat side effects before your first treatment.
  • Ask for Assistance: Ask family and friends to help you at home and work. Extreme fatigue often follows chemotherapy treatment, and you may need their assistance for daily duties.
  • Get Ready for Treatment: Drink plenty of liquids to avoid dehydration. Eat a light meal before treatment. Get enough sleep to arrive well-rested, and plan for a ride to and from your appointments
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Chemotherapy Drugs for Mesothelioma

Mesothelioma doctors currently use or have tested several chemotherapy drugs for treating mesothelioma. Individual mesothelioma chemotherapy drugs act in different ways, and each has benefits and drawbacks. 

Patients with a new diagnosis receive mesothelioma chemotherapy drugs designed for first-line treatment. These medications work best in patients with no prior cancer therapy. Patients with recurring cancer receive different chemotherapy medications.

Most Common Mesothelioma Chemo Drugs

The most popular combination of mesothelioma chemotherapy medications is cisplatin and pemetrexed, which has the brand name Alimta. Research shows this is the best choice for first-line mesothelioma chemotherapy treatment. 

Some of the most common chemotherapy drugs are:

Clinical trials for mesothelioma show that tumors respond better to a combination of two chemotherapy drugs compared to just one medication. Adding a third drug has not proven more effective, so mesothelioma chemotherapy almost always involves two drugs.

The drug combinations used for first- and second-line chemotherapy are also effective during intraoperative heated chemotherapy. More research has been done on different drugs for hyperthermic intraperitoneal chemotherapy (HIPEC) than hyperthermic intrathoracic chemotherapy (HITHOC). Nearly all of the following drugs have been tested for HIPEC, but research on drugs for HITHOC is limited to cisplatin, doxorubicin and mitomycin C.

Heated Chemotherapy Drugs

Common heated intraoperative chemotherapy drugs include:

  • Cisplatin
  • Carboplatin
  • Pemetrexed (Alimta)
  • Doxorubicin
  • Mitomycin C
  • Gemcitabine
  • Paclitaxel

Depending on allergies, cancer cell type and medical history, your doctor may choose other chemotherapy drugs or combinations.

If cancer starts growing again after you complete first-line treatment, your doctor may prescribe different drug combinations for another regimen, called second-line chemotherapy. These drugs may include Alimta with carboplatin or gemcitabine with cisplatin.

First-Line Chemotherapy Drugs for Mesothelioma

First-line chemotherapy delivers the most effective drugs for mesothelioma based on decades of research. First-line chemotherapy for pleural mesothelioma is a combination of pemetrexed (Alimta) and cisplatin. Doctors may use other medications if a patient has certain health conditions.

The pemetrexed/cisplatin combination is likely to continue as the standard, first-line treatment regimen for patients with inoperable pleural mesothelioma, according to a 2014 study at the Shizuoka Cancer Center and Juntendo University in Japan.

Second-Line Chemotherapy Drugs

If first-line chemotherapy fails to demonstrate positive results, doctors may prescribe second-line chemotherapy. A second round of chemotherapy may involve a similar approach to the initial treatment or a completely different combination of medications.

Sometimes a second-line drug will be substituted for one of the standard mesothelioma drugs in the first round to reduce the combination’s toxicity for the patient. Carboplatin may be substituted for cisplatin, and gemcitabine or doxorubicin may be substituted for pemetrexed.

Side Effects of Chemotherapy

While chemotherapy is the most effective treatment for malignant mesothelioma, side effects are common and some can be severe. Patients should monitor their health closely for adverse reactions. 

Common side effects include:

  • Fatigue: Exhaustion, sometimes lasting throughout the day, impacts nearly all chemotherapy patients. For some, fatigue can result in depression or insomnia. Call your doctor if you experience these effects. 
  • Nausea and Vomiting: Between 70% and 80% of chemotherapy patients experience these symptoms.  They may occur during drug administration or several days later and can last hours or up to a week. 
  • Diarrhea and Constipation: Chemotherapy often irritates the gastrointestinal tract lining. Peritoneal mesothelioma patients may be more susceptible because of cancer-related damage and chronic irritation to the abdomen.
  • Mouth Sores: Chemotherapy drugs can damage cells inside the mouth, causing problems with a patient’s teeth and gums that can also include painful sores.
  • Hair Loss: Because hair is one of the most rapidly dividing healthy cells in our bodies, it’s very susceptible to damage from chemotherapy. Hair loss is perhaps the most common side effect associated with chemotherapy drugs. 
  • Chemo Brain: Many chemotherapy patients experience varying degrees of cognitive impairment, ranging from mild to severe. Chemo brain can be short-lived in some patients, while others may experience symptoms for years. 
  • Low Blood Counts: Chemotherapy can trigger a decrease in blood cell counts several days after the first dose. This decline can cause a weakened immune system, fatigue and a diminishing of blood’s ability to clot.

Catching side effects soon, combined with rapid treatment, makes them easier to control and prevents them from becoming more severe. Although rare, some specific side effects of chemo for mesothelioma are more severe and require careful monitoring. 

These symptoms can indicate an infection or an adverse reaction to a medication. Consult a doctor immediately if you experience any of these symptoms.

Rare side effects include:
  • Bloody stool or urine
  • Fever higher than 100.5 degrees F
  • Unexplained bruising
  • Shortness of breath
  • Intense headaches

Patients who experience severe problems from their chemotherapy are encouraged to report them to the U.S. Food and Drug Administration. Cancer centers can help patients file a report on the FDA website to help researchers develop safer treatments in the future.

Managing Chemotherapy Side Effects

Typically side effects can be managed to help patients be more comfortable. Be mindful of your treatment’s impact on quality of life. Your mesothelioma specialist can adjust therapy to your individual needs. 

3 Tips for Managing Side Effects:
  1. Pemetrexed lowers folic acid and B12 levels in the body. Asking your doctor about supplements may help keep levels regular and prevent side effects.
  2. Keep a journal of any new or changing side effects as you experience them. Record the date, intensity and any remedies that help.
  3. Don’t try to “tough out” any side effects for fear of missing a chemo cycle. Overall health is vital for preventing complications and tolerating long-term chemotherapy.

Nausea and vomiting, for example, might be managed with over-the-counter solutions. For more severe symptoms, your doctor may prescribe medications, including palonosetron (Aloxi), aprepitant (Emend) and ondansetron (Zofran).

Other medications such as antibiotics or corticosteroids may be required for issues like low blood counts. Chemotherapy’s reduction of white blood cells (neutropenia) weakens the immune system. A reduction of platelets (thrombocytopenia) lowers blood’s ability to clot. A drop in red blood cells (anemia) causes fatigue.

You may also be referred to additional specialists. A nutritionist can help plan a diet rich in nutrients with easily-digested foods to help combat fatigue and digestive side effects. A dental hygienist, for example, can help manage mouth sores.  

A palliative care specialist may also be recommended. These doctors are experts at managing side effects and controlling cancer symptoms, including pain.

Mental and Financial Impact of Chemotherapy

Some physical side effects, such as hair loss and fluctuations in weight, can cause mesothelioma patients to struggle with self-esteem, leading to depression and other mental and emotional side effects.

Up to 25% of cancer patients report feeling depressed during and after treatment. Counselors, support groups, antidepressant medications and meditation can help patients manage these psychological effects of chemotherapy.

Another little-known side effect is financial toxicity, which the National Cancer Institute defines as “problems a cancer patient has related to the cost of treatment.” Studies have proven cancer treatment is less effective when patients struggle to afford it, and medical professionals are paying more attention to this issue. Many cancer patients must rely on financial assistance during treatment, and mesothelioma patients are no exception.

Do not be reluctant to discuss any problems that you are experiencing during chemotherapy treatment with your doctors and their staff. They may be able to recommend options for financial assistance such as treatment grants, Social Security Disability Insurance, VA claims, asbestos trust fund claims and mesothelioma claims.

Common Questions About Chemotherapy for Mesothelioma Patients

Is chemotherapy effective for pleural and peritoneal mesothelioma patients?

The most effective treatment for all forms of mesothelioma involves a combination of chemotherapy with another modality. In pleural mesothelioma, the combination of chemotherapy drugs pemetrexed (Alimta) and cisplatin, when given after surgery, has been successful in extending survival. For peritoneal mesothelioma, patients who are eligible for surgery undergo a heated chemotherapy treatment applied during the operation.

How does chemotherapy impact mesothelioma life expectancy?

Factors affecting mesothelioma life expectancy include a patient’s diagnosis, eligibility for treatment and overall health. In a 2019 study, patients who received chemotherapy alone survived an average of 9.5 months. Median survival for patients who received a combination of surgery and chemotherapy was 12.2 months. Median life expectancy without any treatment is seven months.

How long is chemotherapy for mesothelioma?

Mesothelioma chemotherapy doses are administered approximately once every 21 days, or every three to four weeks. First-line chemotherapy treatment usually includes six doses, which means it may take a little longer than four months to complete chemotherapy treatment for mesothelioma.

Does chemotherapy shrink mesothelioma?

Some mesothelioma tumors shrink in size in response to chemotherapy. This happens as a result of the chemotherapy drugs causing cancer cells to die. In addition to shrinking tumors, chemotherapy has the potential to limit new cancer growth and reduce the chance of spreading.

Why does chemotherapy cause side effects?

Chemotherapy drugs kill cells that replicate rapidly, which is a hallmark of cancer cells. Other quickly replicating cells include cells that make up hair, the mouth and digestive tract. Chemotherapy targets these cells, and that’s why it causes side effects such as hair loss, mouth sores and nausea.

What are the alternatives to chemotherapy for mesothelioma treatment?

Mesothelioma treatment options, besides chemotherapy, include surgery, radiation, Tumor Treating Fields and therapies available through clinical research trials. Some patients choose to supplement their care with complementary medicine such as yoga, massage therapy and nutritional counseling. These can improve symptoms and outcomes of conventional treatments.

Is chemotherapy worth it?

Chemotherapy can be a long and challenging process for patients living with mesothelioma and their loved ones. However, mesothelioma survivors across the nation share countless stories of the fulfilling lives they’ve led with the extra time allowed thanks to chemotherapy.


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