Palliative Treatment

Palliative care or supportive care is different than hospice care. Palliative care, aims to relieve symptoms and improve quality of life. Although historically reserved for late-stage mesothelioma patients, recent research shows patients can live longer and better lives if they begin palliative treatment sooner — and even during other forms of active therapy such as during and following surgery, radiation, chemotherapy, or immunotherapy.

While the search for a mesothelioma cure continues, most people who fight the various forms of the disease undergo palliative treatment, which focuses on managing pain and symptoms of the cancer. There are a number of palliative treatment options such as surgery, radiation therapy, chemotherapy and medications. Recommended treatments depend on the stage and the type of cancer diagnosed as well as age and overall health.

The goal of palliative treatment is simple: Relieve pain, reduce symptoms and improve overall quality of life. This type of care was once only given to patients with terminal cancer and a poor prognosis. Studies have again shown that patients with “incurable” cancer can live longer if palliative care interventions are introduced sooner in their treatment.

According to a 2016 study published in Current Medical Research and Opinion, the most common issues addressed in palliative care among mesothelioma patients include:

  • Pain

  • Weakness

  • Difficulty breathing

  • Reduced appetite

  • Poor well-being

Although palliative treatment does not attack the cancer, it has the potential to prolong a patient’s life expectancy by improving the quality of life, overall health, and lessening the impact and frequency of adverse events.

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Pleural Mesothelioma

If aggressive surgery is not recommended for someone with pleural mesothelioma, several palliative treatments can help reduce symptoms and pain. Pleural mesothelioma symptoms generally include coughing, chest pain and shortness of breath. These symptoms result from tumors pressing against vital organs and pleural effusion, a condition marked by a buildup of fluid around the lungs.

Surgery

Two palliative procedures that treat pleural effusion include a pleurodesis and a thoracentesis. Both procedures extract fluid through a tube and relieve pressure on the lungs in the process. A pleurodesis also eliminates the space where fluid can build up by using a talc-like substance to seal the space and is a more permanent fix to the problem, but some pain is felt during recovery.

After either one of these treatments, breathing should become easier and coughing should lessen. In one study, 92 percent of those with a pleural effusion experienced relief from shortness of breath following a pleurodesis that uses talc to seal the pleural space.

Quick Fact

Roughly 60 percent of peritoneal mesothelioma patients are not candidates for surgery

Chemotherapy

Chemotherapy is a palliative treatment option when used as a solo approach. However, chemotherapy can cause side effects such as nausea, fatigue, vomiting, hair loss and lack of appetite. Such side effects are what some patients try to avoid, and this may discourage them from trying chemotherapy. Today, newer palliative interventions can lessen many of those side effects.

After a pleural diagnosis, a combination of the chemotherapy drugs pemetrexed (Alimta) and cisplatin is most often recommended. These chemotherapy drugs have demonstrated the ability to kill cancerous mesothelioma cells, relieve symptoms, improve quality of life and prolong survival in many patients.

Immunotherapy treatments in clinical trials can also offer palliative benefit in cases of pleural mesothelioma. Side effects of such treatments are different but usually manageable.

Radiation Therapy

This treatment is sometimes combined with surgery and chemotherapy to shrink tumors. When used alone, it can shrink tumors growing into the chest wall to effectively relieve chest pain by reducing pressure on the lungs and chest. There are side effects associated with radiation therapy that some patients may wish to avoid, but sometimes the benefits can outweigh the side effects. Such side effects can include skin irritations, fatigue and pulmonary toxicity if a high dosage is used.

Peritoneal Mesothelioma

Roughly 60 percent of peritoneal mesothelioma patients are not candidates for surgery. Instead, doctors recommend a treatment option that reduces symptoms, alleviates pain and improves overall quality of life while avoiding the rigorous recovery that follows surgery. The procedure is called a paracentesis, which removes fluid that has collected in the abdominal cavity, which is a condition known as ascites. This treatment can relieve pain and reduce future complications concerning the bowels, kidneys and other parts of the digestive system caused by that fluid.

The preferred option for those who can undergo surgery is a combination of cytoreductive surgery along with heated chemotherapy in the abdominal cavity. This procedure is highly invasive, although it’s still considered palliative in nature. Cytoreductive surgery, or debulking surgery, is the surgical removal of part of the malignant tumor. This is performed when all of the tumor cannot be removed. After cytoreductive surgery, the effectiveness of chemotherapy is significantly improved.

Although the implementation of chemotherapy following surgery has been successful, it’s not always considered palliative because of the side effects. Radiation is not typically used on peritoneal patients.

Pericardial Mesothelioma

Pericardial mesothelioma is an exceedingly rare type of asbestos cancer, composing around 1 percent of all cases. Because of its rarity, little research is performed to develop treatments that can prolong life expectancy. Treating pericardial mesothelioma is challenging largely because of its proximity to the heart and the risk of complications.

The primary palliative option for this type is a pericardiocentesis. This procedure removes excess fluid in the pericardium, the sac that surrounds the heart. The purpose of a pericardiocentesis is to improve quality of life and reduce symptoms, which can consist of chest pain, coughing, difficulty breathing and an irregular heartbeat. Following a pericardiocentesis, the use of the chemotherapy with medications such as cisplatin, pemetrexed and gemcitabine has been used with a low frequency of complications and may prolong life expectancy.

This form of asbestos cancer is resistant to radiation therapy as a single treatment approach and in combination with chemotherapy. Radiation is difficult to safely administer to the heart lining without harming the heart.

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Medication

Medicine is normally the first option in pain relief. Your doctor will recommend a type and amount of medicine depending on the type and intensity of your pain. If you experience mild discomfort, your doctor may advise you to begin taking an over-the-counter medication such as ibuprofen or acetaminophen (Tylenol). These medicines, which can be bought without a prescription, can help with mild bone and muscle discomfort as well as general aches.

If you have more severe issues, or if you experience breakthrough pain (moments of sharp pain), you may be given a prescription for opioids. Drugs, such as morphine, oxycodone or tramadol, and several others are stronger and can help relieve chronic or intense pain.

Be sure you completely understand the instructions and uses before you begin taking a new medication. Your doctor can answer any questions you may have about new prescriptions. Doctors can also suggest another medication if your current one is not helping you feel better.

Pain Management Techniques

A 2009 study of palliative care for mesothelioma patients, published in Seminars in Thoracic and Cardiovascular Surgery, discovered the most common sources of pain included:

  • Peripheral neuropathy caused by chemotherapy

  • Nerve pain caused by tumors in the chest wall

  • Difficulty breathing caused by pleural effusion or tumor burden

Your doctor may suggest you try certain pain management techniques, many of which you can do in your own home, in addition to pain medication. The techniques that may work for you depend on the type and severity of your discomfort. If you have minor aches, try taking a warm bath or placing a warm washcloth on the bothersome areas. If that doesn’t help, try using ice or cold packs on painful areas.

Additionally, respiratory therapy can improve breathing and lung function in many mesothelioma patients and may lessen breathing pain.

You may also consider using alternative therapies. For example, muscular or superficial discomfort may be eased by a gentle massage or with a topical pain reliever, such as arnica or menthol, and acupuncture can help reduce inflammation.

Cognitive and behavioral techniques work for many cancer patients as well. These tend to focus on the mental aspects of pain.

You can try the following options at home.

  • Relaxation: Deep breathing and relaxing your muscles has helped control discomfort in some patients. In addition to relieving anxiety, these techniques reduce tension, thereby managing some of your pain.

  • Distraction: Changing the focus of your attention can temporarily relieve aches. This is especially helpful when you experience breakthrough pain or when you are waiting for medications to kick in.

  • Visualization: Visualize your discomfort as a color, symbol or object such as a large fire. Then visualize the pain diminishing. For example, imagine slowly putting out the flames with water. Or imagine a color that represents your pain and visualize it slowly turning into a color that feels soothing.

It is important to speak with your doctor before beginning new treatments, especially when your pain management program involves new medicine or potentially strenuous physical activity.

Alternative Options

Some asbestos cancer patients may wish to avoid traditional anticancer treatment and combine palliative care with complementary and alternative medicine (CAM). For example, one of the most impactful decisions a cancer patient can make is electing to improve their diet with the supervision of a dietitian. There have been numerous anecdotal cases where patients have extended their survival by eating the right foods and integrating supplements or healthy lifestyle changes. All cancer patients should consult a nutritionist before making changes to their diet. Cancer patients are often desperate and must be careful not to be taken advantage of by unscrupulous persons peddling “cures” for cash.

Patients often benefit from a combination of traditional options and alternative treatments such as undergoing a pleurodesis and making nutritional changes. Because difficulty breathing is often a symptom of mesothelioma, patients may be able to improve their breathing patterns through respiratory therapy, walking, meditation and yoga.

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Karen Selby, RN

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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Sources
  1. Pass, I., Vogelzang, N., Carbone, M. (2005). Malignant Mesothelioma: Advances in Pathogenesis, Diagnosis, and Transitional Therapies. Springer: New York.
  2. Ed. by O’Byrne, K. and Rusch, V. (2006). Malignant Pleural Mesothelioma. Oxford University Press: New York.
  3. Baldi, Alfonso. (2008). Mesothelioma from Bench Side to Clinic. Nova Science Publishers: New York.
  4. Surgical Oncology Associates. Specialty Section for the Treatment of Peritoneal Mesothelioma. Retrieved from http://www.sugarbakeroncology.com/specialty-section-treatment-peritoneal-mesothelioma/
  5. Abrahm, J. (2009). Palliative care for the patient with mesothelioma. Semin Thorac Cardiovasc Surg., 21(2):164-171. doi: 10.1053/j.semtcvs.2009.06.006
  6. Mercandante, S., Degiovanni, D., & Casucci, A. (2016). Symptom burden in mesothelioma patients admitted to home palliative care. Current Medical Research and Opinion, 32(12):1985-1988. doi: 10.1080/03007995.2016.1226165

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