Chemotherapy is a versatile treatment option for pleural and peritoneal mesothelioma patients. Despite the side effects involved in most regimens, more than 70 percent of cancer patients opt to undergo some type of chemotherapy to slow tumor growth, alleviate symptoms or support surgical treatment.
Chemotherapy drugs attack rapidly dividing cells, making them an effective way to kill cancer cells and shrink tumors for many mesothelioma patients.
Although chemotherapy can’t cure mesothelioma on its own, it can alleviate symptoms, improve quality of life and prolong survival. Doctors can also use it in combination with surgery, radiation therapy or a newer technology such as immunotherapy or photodynamic therapy.
With several medications, dosage levels and methods of administration to choose from, cancer specialists can tailor chemotherapy to the circumstances of individual patients, which is why it remains the most common form of treatment for mesothelioma.
No doubt, chemotherapy can be a frightening treatment to consider. Because the drugs attack all rapidly dividing cells in the body, both cancerous and healthy, this treatment often has harsh side effects including hair loss, vomiting, fatigue and fever.
However, according to a 2016 study using data from the Surveillance, Epidemiology and End Results (SEER) database, the potential benefits of chemotherapy for mesothelioma patients are significant.
The median survival time for patients who received chemotherapy treatment was 12 months, compared to just four months for those who did not. Combining two lines of chemotherapy with surgical treatment boosted the median overall survival to 16 months.
Most common treatment for mesothelioma
First-line drug combination is pemetrexed/cisplatin
Given orally or intravenously for pleural mesothelioma
Can be heated and pumped into the abdominal cavity during surgery for peritoneal mesothelioma
For pleural mesothelioma, the most common type of this cancer, chemotherapy drugs are usually injected into a patient’s vein from an IV bag or swallowed in pill form. This type of treatment is called “systemic chemotherapy” because the drugs enter the patient’s bloodstream and affect their entire body.
Systemic chemotherapy drugs are given in cycles, which means the patient receives a dose every few weeks for a certain number of months. An experienced mesothelioma specialist must take into account the cancer stage and cell type as well as the patient’s body chemistry and overall health to determine the appropriate drug combination, dosage, frequency and total number of cycles.
Systemic chemotherapy treatment plans vary from patient to patient, but they fall into three general categories:
Multimodal therapy: For patients with earlier presentations of mesothelioma and who are healthy enough to withstand aggressive cancer treatment, chemotherapy is often combined with other treatments such as surgery and radiation therapy.”Neoadjuvant chemotherapy” reduces tumor size before surgery, and “adjuvant chemotherapy” reduces the risk of recurrence after surgery.
Chemotherapy alone: On its own, chemotherapy can still provide an aggressive approach. After undergoing first-line chemotherapy with the standard drug combination, some patients go on to receive second-line chemotherapy with other drugs as well.
Palliative chemotherapy: Aggressive cancer treatment is not recommended for patients with late-stage cancer or other complicating health conditions, but a milder chemotherapy regimen can relieve mesothelioma symptoms for these patients and increase their quality of life.
Researchers are currently developing ways to target chemotherapy drugs so they kill cancer cells more effectively while leaving healthy cells unharmed. Targeted therapy may improve treatment outcomes and reduce side effects, potentially revolutionizing cancer treatment in the future, but for now, this experimental technology is only available through clinical trials.
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.
You should discuss the decision to start chemotherapy treatment with your medical team and your family. Make sure your diagnosis and blood work has been analyzed by an experienced mesothelioma specialist, and ask your doctors plenty of questions so you fully understand the pros and cons of chemotherapy. Each person can react differently to chemotherapy, but where possible, you do not wish to be surprised by anticipatable side effects.
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 them before they can receive intravenous chemotherapy. Everyone reacts differently to treatment, so make sure you arrange for a ride to and from your first session.
A common chemotherapy trial for mesothelioma will start with three or four courses of treatment, administered approximately every three weeks. After taking your vitals and verifying the dosage, a nurse will supervise each treatment. An intravenous combination chemotherapy treatment typically includes 30 minutes of one drug, then up to two hours of a second drug. Blood tests are often performed during treatment to ensure ideal effectiveness.
Follow-up visits will begin a few weeks after you complete the entire regimen. This is a time to ask more questions, get insight into the treatment and discuss its success or failure and whether more treatments are recommended. Bring along a family member to help with the discussion.
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As an alternative to circulating chemicals in the bloodstream, chemotherapy drugs can be injected directly into the area of the body where the tumors are located. For peritoneal mesothelioma patients, combining this type of chemotherapy with surgery has been established as the best treatment approach.
The hyperthermic intraperitoneal chemotherapy (HIPEC) procedure involves removing as much cancer tissue as possible through surgery and then pumping a heated chemotherapy solution into the abdominal cavity for 60–90 minutes while the patient is still on the operating table.
The high temperature increases the solution’s effectiveness, and the medical staff ensure it is evenly distributed throughout the abdominal cavity by massaging the area before draining and rinsing it out. Because the solution is confined to the abdominal cavity, its side effects are minimal.
In 2009, a multicenter review revealed this multimodal therapy approach had helped hundreds of patients live for years after being diagnosed with peritoneal mesothelioma. Whereas the historical life expectancy for peritoneal mesothelioma is 12 months or less, patients treated with HIPEC had an overall median survival time of 53 months.
“I would do it again, without hesitation,” said mesothelioma survivor Jacob Hess, who was diagnosed in 2010. “The way it was explained to me, it was an excellent option to go along with the surgery. It just made sense. Everyone is different, and nothing is 100 percent certain, but I have to believe that the clean checkups I’ve been getting have a lot to do with the HIPEC.”
A similar type of heated chemotherapy procedure has been tried in the chest cavity for pleural mesothelioma, but there is considerable debate over its effectiveness.
“First-line chemotherapy” offers the approach to treating mesothelioma cancer shown most likely to be of benefit for others who have been treated for mesothelioma. First-line chemotherapy for pleural mesothelioma is typically a combination of pemetrexed (Alimta) and cisplatin, although doctors may use other medications depending on a number of factors.
A single drug can be administered in patients who are not healthy enough to handle a combination, though response rates to single agents have typically been low. Three-drug combinations have not demonstrated better results than two-drug combinations.
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.
Other drugs applied in the treatment of mesothelioma include onconase, methotrexate, vincristine, vinblastine, mitomycin, vinorelbine, epirubicin, cyclophosphamide and ifosfamide.
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.
In addition, 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.
While radiation therapy and surgery typically only affect the site of treatment, the side effects of chemotherapy often affect a patient’s entire body.
Systemic chemotherapy will harm any cells throughout the body that divide quickly. Hair follicles, for example, are among the fastest growing cells, and they are easily damaged during treatment, causing many cancer patients to experience temporary hair loss.
Before considering chemotherapy as a treatment option for mesothelioma, it is important to become familiar with its common side effects.
Fatigue affects nearly all cancer patients who undergo chemotherapy, causing them to consistently feel exhausted.
You can manage mild fatigue by getting adequate sleep, taking short naps and performing regular light exercise. If fatigue makes it hard for you to complete chores or errands, allow friends and relatives to help with easy tasks such as grocery shopping and meal preparation.
If you feel faint, dizzy or short of breath, or if your fatigue results in depression or insomnia, call your doctor. They may need to adjust your treatment.
Nausea and vomiting occur in 70 to 80 percent of chemotherapy patients. These symptoms can occur immediately after the drugs are administered or develop over several days, and they may disappear within hours or last up to a week.
Patients often struggle to maintain a healthy weight while fighting nausea or bouts of vomiting. As an added complication, the symptoms of pleural mesothelioma can also make swallowing food difficult.
It is important to keep hydrated and consume small portions of foods that are easy to digest. You can manage nausea with prescription medications, including palonesetron (Aloxi), aprepitant (Emend) and ondansetron (Zofran).
Chemotherapy drugs can damage cells inside the mouth, causing problems with a patient’s teeth and gums. Patients may also experience painful sores inside the mouth if dental hygiene is poor before treatment.
Seeing a dentist a month before beginning treatment can help prevent sores. A teeth cleaning is a start, but the dentist can also take X-rays to spot any potential problems and give you tips on how to self-treat sore gums and mouth sores.
Chemotherapy drugs often irritate the gastrointestinal tract lining, causing diarrhea and constipation. Peritoneal mesothelioma patients may be more susceptible to these side effects because of cancer-related damage and regular irritation to this part of the body.
You can manage these symptoms with antidiarrheal medications or laxatives, which are available at most drugstores. Simple changes, such as drinking more water and eating more fruits and vegetables, may also help relieve these side effects.
Hair loss is perhaps the most common side effect associated with chemotherapy. Unlike the others, unfortunately, it is not treatable. Because hair is one of the most rapidly dividing healthy cells in our bodies, it is very susceptible to damage from chemotherapy drugs. Some patients choose to wear wigs, and some insurance plans will help defray the costs of purchasing wigs.
Chemotherapy drugs can trigger a drop in blood cell counts several days after the first dose of treatment. A drop in white blood cells (neutropenia) weakens the immune system; a drop in platelets (thrombocytopenia) reduces the blood’s ability to clot, and a drop in red blood cells (anemia) causes fatigue.
Certain side effects of chemotherapy are more serious and should be carefully monitored. These symptoms can indicate a negative reaction to medication or an infection.
Consult a doctor immediately if you experience:
Bloody stool or urine
Fever higher than 100.5 F
Shortness of breath
Patients who experience severe problems from their chemotherapy are encouraged to report them to the U.S. Food and Drug Administration (FDA). Patients can file a report on the FDA website to help researchers more effectively tailor future treatment.
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 emotional side effects.
In fact, up to 25 percent 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 refers to “problems a cancer patient has related to the cost of treatment,” according to the National Cancer Institute. Studies have proven cancer treatment is less effective when patients struggle to afford it, and medical professionals are paying more and 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 treatments with your doctors and their staff.
Karen Selby joined Asbestos.com in 2009. She is a registered nurse with a background in oncology and thoracic surgery and was the director of a tissue bank before becoming a Patient Advocate at The Mesothelioma Center. Karen has assisted surgeons with thoracic surgeries such as lung resections, lung transplants, pneumonectomies, pleurectomies and wedge resections. She is also a member of the Academy of Oncology Nurse & Patient Navigators.
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