Mesothelioma Treatment Guidelines

Factors Considered in Clinical Guidelines for Treating Mesothelioma

There is no one-size-fits-all treatment for mesothelioma. Experts create treatment guidelines by analyzing multiple clinical studies and finding what works best in specific situations. Mesothelioma treatment guidelines help doctors decide which treatments are best for individual patients based on their specific type of cancer and health status. 

Doctors select mesothelioma treatments for patients after determining the type of mesothelioma, mesothelioma cell type and mesothelioma stage. Additional factors, including age, coexisting conditions and performance status, are also important when determining which treatment options provide the most benefit with the lowest risk of harm.

These factors play a large role in determining the most effective course of treatment. However, they can also limit what treatments and procedures are safe for a patient. 

Performance status is an important measure in deciding cancer treatment options. PS measures a person’s activity level, mobility and how much assistance they need to do everyday tasks. PS ranges from 0 (normal activity) to 4 (bedridden). Doctors must take all of these factors into consideration in deciding on the best treatment strategy.

Guidelines for Accurate Mesothelioma Diagnosis and Staging

Diagnosing mesothelioma can be difficult, but diagnostic guidelines provide recommendations to help doctors make an accurate diagnosis. Recurrent symptoms of fluid buildup in the lungs (pleural effusion) or abdomen (ascites), along with thickening of the pleura or peritoneum, are signs that may indicate mesothelioma.

Diagnosis involves gathering a thorough medical history — including any history of asbestos exposure — and a medical exam, followed by blood tests and imaging. A chest X-ray and chest or abdominal CT scan are necessary to identify possible tumors. If fluid buildup is present, medical professionals should drain it and send it for laboratory analysis. 

The next step is getting a biopsy of suspected mesothelioma tumors. Surgery is the best way to obtain a biopsy, but needle biopsies are possible when surgery is not an option. Doctors send the samples to a pathology lab for analysis to determine whether there are mesothelioma cells and, if so, what kind.

I often help patients go through their pathology report and explain its details. If a patient hasn’t had their biopsy yet and is hesitant, we discuss how knowing mesothelioma type and cell type is imperative in planning treatment.

Danielle DiPietro

Patient Advocate

After making a diagnosis of mesothelioma, doctors must determine the stage. Mesothelioma staging is based on the size and number of tumors, invasion of surrounding tissue, involvement of lymph nodes and whether there are distant metastases. The use of imaging studies — including CT, MRI, PET and ultrasound — can locate signs of mesothelioma throughout the body. Additionally, if a patient is healthy enough for surgery, doctors can explore the chest or abdomen and see the tumors firsthand while conducting biopsies.

The mesothelioma cell type and stage determine which treatments are most effective. Doctors then look at a patient’s overall health and age to decide which of those treatments is best for that individual.

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Latest Guidelines for Treating Mesothelioma

Mesothelioma treatments include chemotherapy, immunotherapy, radiation and surgery. Clinical trials are also an option if the patient qualifies. Multimodal therapy for mesothelioma — using a combination of different treatments — is an essential part of mesothelioma treatment. Depending on the individual patient, they may receive different combinations of these treatments. 

The U.S. Food and Drug Administration approved a new treatment called Tumor Treating Fields  for treating pleural mesothelioma in combination with chemotherapy. TTFields therapy uses electrodes attached to the body to prevent the growth of cancer cells. It can improve survival and can be added to other treatments.

Mesothelioma that is early stage (I through IIIA) and has an epithelioid cell type has the most treatment options. More advanced stage (IIIB or IV), biphasic or sarcomatoid cell types and inoperable tumors limit available options. Supportive care is the recommendation for people who are not healthy enough for treatment.

Treatment recommendations for early-stage epithelioid pleural mesothelioma are surgery and systemic chemotherapy and/or immunotherapy followed by radiation. Systemic chemotherapy and/or immunotherapy are the recommended guidelines for all other stages of pleural mesothelioma. 

Peritoneal mesothelioma treatment recommendations include cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. This may be followed by systemic chemotherapy and/or immunotherapy. Systemic therapy is the recommendation for inoperable tumors, biphasic or sarcomatoid cell type, and peritoneal mesothelioma that has spread to the chest. 

Chemotherapy

Chemotherapy for mesothelioma can be systemic — whole body — or localized to the part of the body where the tumors are, usually the chest or abdomen. Patients receive systemic chemotherapy via an IV line or implanted port. Most systemic chemotherapy treatments for mesothelioma are given once every three weeks for six cycles. 

Systemic mesothelioma chemotherapy drugs include cisplatin, pemetrexed, vinorelbine and gemcitabine.Cisplatin plus pemetrexed may be combined with bevacizumab immunotherapy, and gemcitabine may be combined with ramucirumab. 

In addition to systemic chemotherapy, hyperthermic (heated) intraperitoneal chemotherapy can be an option to treat peritoneal mesothelioma after cytoreductive surgery. HIPEC involves infusing heated chemotherapy drugs directly into the abdominal cavity that typically remain there for 90-110 minutes before being removed. This avoids many systemic chemotherapy side effects. Heated intraperitoneal chemotherapy drugs for peritoneal mesothelioma include cisplatin, doxorubicin, carboplatin and mitomycin.

Immunotherapy

Immunotherapy has become an extremely important tool for treating cancer. Because it doesn’t cause as many side effects as chemotherapy and is better tolerated, it is a viable treatment option for people who are not good candidates for surgery or chemotherapy. It can also be a second-line therapy for mesothelioma when first-line chemotherapy has failed. 

Immunotherapy for mesothelioma helps your immune system target cancer cells and destroy them. While the administration of this systemic treatment is similar to chemotherapy, it has fewer side effects. Patients receive it on days 1 and 22 of a six-week cycle for up to two years. 

Systemic mesothelioma immunotherapy drugs include nivolumab plus ipilimumab (first-line immunotherapy) and atezolizumab plus bevacizumab. This type of therapy can also be an addition to chemotherapy. After chemotherapy, patients typically receive a maintenance dose of immunotherapy once every three weeks. 

Radiation

Radiation for mesothelioma is a first-line treatment along with surgery, chemotherapy and immunotherapy, or it can be palliative care. Its main use is to treat pleural mesothelioma, with occasional uses for peritoneal mesothelioma. Radiation can improve survival, relieve pain and prevent cancer spread by destroying whatever cancer cells remain after primary treatment. For palliative care, radiation can shrink tumors, which can help improve symptoms such as shortness of breath.

Intensity-modulated radiation therapy is the recommendation for pleural mesothelioma, but doctors can also use other three-dimensional radiation therapies. These minimize exposure of healthy tissue to radiation by using lower doses of external beam radiation from multiple angles. Guidelines also allow for using radiation during surgery in some cases. 

For pleural mesothelioma, patients receive radiation therapy daily (Monday through Friday) for five to six weeks after surgery. They may receive palliative radiation for one to two weeks, mostly for tumors in the chest wall and metastasis to bone or the brain.

Surgery

Surgery for mesothelioma involves removing as much of the cancer as possible. It is one of the primary treatments and a recommendation for all types of mesothelioma in people who are healthy enough for it. Some individuals are not candidates for surgery, and some have tumors that cannot be operated on because of their location or other factors. Surgeons do not usually perform surgery if mesothelioma is present in both the abdomen and chest.

There are two aggressive types of pleural mesothelioma surgeries: extrapleural pneumonectomy, and pleurectomy and decortication. EPP involves removing the affected lung and all surrounding tissue that can be safely removed. P/D is less aggressive and spares the lung. Cytoreductive surgery for peritoneal mesothelioma removes as much of each visible tumor as possible. 

Guidelines for Palliative Care and Support for Mesothelioma

Palliative treatment helps relieve symptoms and provide comfort for people who are not candidates for treatment or who do not want treatment. Similar to palliative treatment, supportive care aims to reduce discomfort and side effects of treatment. These therapies help manage pain, nausea and vomiting, and emotional distress. Radiation and surgery can be components of palliative or supportive care as well as procedures such as paracentesis and thoracentesis to drain fluid buildup in the abdomen and lungs.

I find it important when speaking with mesothelioma survivors to explain what palliative treatment is and how patients typically do better integrating it into their care plan early on rather than waiting.

Karen Selby

Patient Advocate

The Mesothelioma Center at Asbestos.com has Patient Advocates who can provide resources to survivors and their families. They work to ensure that you have access to the best care possible. This includes making sure that treatment includes supportive and palliative treatment.

The goal of palliative care is to minimize suffering and improve quality of life. It can be different for each individual based on their personal goals for control of pain and other symptoms. Palliative and supportive care focus on treating the individual, not the disease. This is an essential part of treating mesothelioma.