Multimodal Therapy

Multimodal therapy combines more than one method of cancer treatment. Surgery with chemotherapy and radiation therapy is a common treatment approach for mesothelioma. Experimental treatments, such as immunotherapy and gene therapy, can also be added to the mix.

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Although each individual treatment option can have a positive impact on patients, mesothelioma specialists achieve the best results by combining various treatments that control, remove and kill cancer cells.

Clinical studies have proven this approach improves survival rates for patients healthy enough to qualify for aggressive cancer treatment.

Doctors sometimes use a more specific term for a multimodal treatment plan. “Bimodal therapy” combines two treatments, and “trimodal therapy” combines three treatments.

A multimodal treatment approach usually centers on a major tumor-removing surgery, with chemotherapy and radiation therapy administered before, after or even during the surgery.

  • For peritoneal mesothelioma, cytoreductive abdominal surgery combined with hyperthermic intraperitoneal chemotherapy (HIPEC) is the most effective treatment approach.

  • For pleural mesothelioma, there is no single treatment plan that is clearly better than all the others. It depends on the patient’s specific circumstances and the judgement of their doctors.

Not all mesothelioma patients are candidates for a multimodal approach, and aggressive cancer treatments always come with risks of toxicity or complications.

However, some cancer survivors have lived years beyond their initial prognosis thanks to the coordinated efforts of cancer specialists from different fields.

A 2014 multicenter analysis of 1,365 pleural mesothelioma patients linked multimodal therapy to a higher median survival time.

Treatment Plan

Median Survival Time

Chemotherapy Alone

11.7 months

Surgery with Adjuvant Chemotherapy

19.8 months

Who Is Eligible for Multimodal Treatment?

Dr. David Sugarbaker video on the importance of multimodal therapy for mesothelioma treatment.
Dr. David Sugarbaker, leading mesothelioma expert, explains the importance of multimodal therapy for treating mesothelioma.

A patient’s treatment plan depends on several factors, including the stage and type of the cancer and the health of the patient.

The stage of mesothelioma refers to how far the cancer has advanced and spread throughout the body. Early-stage cancer is small and localized, making it easy to target in therapy.

Late-stage cancer, however, may already be so widespread that trying to completely remove it would do more harm than good to the patient. For late-stage patients, doctors usually recommend less invasive palliative treatments that focus on easing symptoms.

The cell type of a mesothelioma tumor affects how well it responds to treatment. Epithelioid tumors are easier to remove in surgery and more responsive to chemotherapy. Patients with this type of mesothelioma have a greater chance to benefit from multimodal treatment.

Most important, a patient’s medical history and overall health determines their eligibility for different types of treatment.

A 2016 review of 1,625 mesothelioma patients shows only a small proportion received more than one type of treatment.

Treatment Type

Percentage

Chemotherapy or Surgery

44%

Chemotherapy and Surgery

15%

Neither Treatment

41%

Health Factors That Determine Eligibility for Cancer Treatment

  • Surgeons must ensure the patient’s body is strong enough to heal from a major surgical procedure.

  • Oncologists must analyze the patient’s body chemistry to make sure chemotherapy will not be too toxic.

  • Radiologists must check whether the patient has reached the limit for how much radiation they can safely receive.

Many patients are not eligible for aggressive treatment because of health reasons. The high cost of cancer treatments also puts multimodal therapy beyond the reach of many patients.

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Multimodal Treatment Strategies

The treatments used in multimodal therapy fall into three categories. The difference is in the timing of each treatment relative to the others.

  1. Neoadjuvant Therapy

    This is given in the weeks or months before primary therapy. In certain cases, doctors administer chemotherapy before surgery to reduce the size of tumors. This increases the chance of complete removal during surgery.

  2. Primary Therapy

    This is the most potentially effective treatment option. For mesothelioma patients who qualify, this usually means surgery. Surgeons may administer targeted treatments such as intraoperative chemotherapy or photodynamic therapy immediately after tumor removal, before the surgery is finished.

  3. Adjuvant Therapy

    This is given in the weeks or months after primary therapy. It is common for doctors to administer chemotherapy after surgery to kill any cancer cells remaining in the body. Sometimes doctors also try to prevent local cancer recurrence with radiation therapy. They irradiate the empty space left behind by a removed lung, or they direct small doses of radiation along surgical incision sites.

Video of Dr. Fontaine going over multimodal treatment
Dr. Fontaine goes over multimodal treatment, an aggressive treatment strategy

Choosing the Right Treatments

Doctors are still experimenting to find the most effective combination of therapies for pleural mesothelioma treatment. Most specialists recommend a three-pronged approach that combines surgery with adjuvant chemotherapy and radiation therapy.

A 2014 study of 518 patients showed a link between adjuvant therapies and higher survival rates after surgery.

Treatment

1-Year Survival Rate

2-Year Survival Rate

3-Year Survival Rate

Surgery

52%

34%

21%

Surgery and Chemotherapy

56%

29%

17%

Surgery and Radiation

66%

39%

22%

Surgery, Chemotherapy and Radiation

76%

51%

37%

When developing a multimodal treatment strategy, a team of doctors evaluates each case individually. They weigh the risks and benefits of potential treatments based on the patient’s unique situation. The team recommends the combination of treatments that offers the most hopeful outlook.

If the patient responds poorly — or especially well — to any one treatment, the team can adjust the treatment plan moving forward. They may add a more promising treatment option, replace an ineffective one or adjust the dosage of an existing one.

Quick Fact

With surgery alone, it is nearly impossible for doctors to remove all tumors and prevent them from returning later on. To boost results, they can provide chemotherapy or radiation therapy before or after surgery. Dr. David J. Sugarbaker pioneered trimodal mesothelioma therapy while at Brigham & Women’s Hospital. He combined lung-removing surgery, chemotherapy and radiation therapy.

Multimodal Therapy Breakthroughs for Mesothelioma

Questions About Multimodal Therapy?

Our team of Patient Advocates can help you understand your treatment options and find a mesothelioma specialist.

In recent years, mesothelioma specialists have started combining traditional therapies with experimental treatments. New technologies include immunotherapy, gene therapy and photodynamic therapy. For now, novel treatments such as these are only available to patients participating in a clinical trial.

Photodynamic Therapy Extends Survival for Years

A 2017 study published in the Annals of Thoracic Surgery looked at pleural mesothelioma patients treated with a combination of surgery, chemotherapy and photodynamic therapy. The patients had a median survival time of three years, and 19 of the 73 patients in the study lived more than seven years.

The Abramson Cancer Center of the University of Pennsylvania has sponsored an ongoing phase 2 clinical trial of this novel multimodal approach since 2014.

A 2017 study of 73 epithelioid patients also linked a multimodal approach with photodynamic therapy to long median survival times.

Keytruda Shows Promising Results

The immunotherapy drug pembrolizumab has shown effectiveness with mesothelioma patients in clinical trials. Merck & Co. markets it under the brand name Keytruda.

Pembrolizumab shrunk tumors in more than half of mesothelioma patients in a clinical trial under the Merck Access Program. All the patients had previously received chemotherapy.

In 2016, a phase I clinical trial began to test pembrolizumab in a multimodal approach as both a neoadjuvant treatment and an adjuvant treatment. Doctors are combining it with lung-sparring surgery and standard chemotherapy.

WT1 Vaccine a Possible Second-Line Treatment

A novel DNA vaccine designed to improve chances of inducing anti-tumor immunity could become a second-line treatment for mesothelioma. Doctors use second-line treatments when first-line treatments such as chemotherapy stop working.

In 2016, the FDA awarded Fast Track designation to the WT1 cancer vaccine, also known as galinpepimut-S. The immunotherapy agent targets the WT1 protein, which is expressed in high levels in mesothelioma.

Mesothelioma patients in a phase II clinical trial for the WT1 vaccine had a median survival of 24.8 months, compared to just 16.6 months for those receiving a placebo.

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Karen Selby, RN and Patient Advocate at The Mesothelioma Center

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. Read More

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Last Modified May 25, 2018
Sources
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