Mesothelioma patients may receive radiation therapy before, during or after surgery in an effort to shrink tumors, relieve pain and help prevent cancer growth and recurrence. Generally, radiation carries fewer side effects than chemotherapy. This treatment can be used in all stages.
The main goal of radiation therapy is to prevent cancer cells from spreading and improve life expectancy. Doctors use it either in combination with other treatments or alone as a single, palliative therapy to manage symptoms and control spreading.
Oncologists have used radiation as a cancer treatment for decades, but technological advancements make it a much more refined treatment today. Despite its toxicity, well-targeted radiation can work without causing some of the serious side effects that often accompany chemotherapy.
According to a 2016 study from researchers at New York’s Icahn School of Medicine, overall survival at the two- and five-year marks nearly doubled for pleural mesothelioma patients who received radiation therapy, regardless of what other treatments were used.
Radiation therapy can be administered for a variety of reasons to treat patients in different stages of mesothelioma, including:
Improved Survival: When combined with surgery and chemotherapy, radiation can help you live longer by reducing the risk of local recurrence. Some patients live three to five years longer with this approach.
Pain Relief: Radiation therapy alleviates pain by reducing the size of mesothelioma tumors, relieving pressure on the lungs and chest. Approximately 60 percent of mesothelioma patients report relief of symptoms after radiation therapy.
Seeding Prevention: During surgery, microscopic cancer cells can move to new areas. This is known as seeding. Radiation therapy along incision sites is common. Even modest radiation at surgery or drain tube sites can help.
Radiation for mesothelioma can be applied externally and internally. The internal form is called brachytherapy. The external form is called external beam radiation therapy (EBRT).
EBRT is more commonly used for mesothelioma because it has proven more effective. Brachytherapy is used in specialized mesothelioma cancer centers by experts who know which patients will benefit the most.
External beam radiation is noninvasive and involves high-energy rays directly targeting malignant tumors. It’s performed by an experienced radiologist who has considered tumor size, location, staging of the cancer and general health of the patient.
To help lessen the risk of adverse reactions, the radiation machine is guided by computers that deliver specific doses to precise areas, making sure healthy cells are not damaged. The radiation beam conforms to the 3-D shape of the tumor and is emitted in multiple doses. It permits higher radiation doses within the tumor, while minimizing the dose to the surrounding organs and tissues.
The most common and effective type of EBRT for mesothelioma is intensity-modulated radiation therapy. IMRT is an advanced form of three-dimensional conformal radiation therapy that changes the strength of beams in certain areas, allowing it to precisely target tumors while reducing side effects on normal tissue.
EBRT is fast and painless, and each session takes only a few minutes, but setup time — getting you in the right position for treatment — can take longer. Treatments are usually given five days a week for several weeks.
One study reported a 14 percent recurrence rate among mesothelioma patients treated with IMRT compared with a 42 percent recurrence rate among patients treated with conventional radiation.
Brachytherapy is a type of radiation therapy that minimizes any damage to healthy tissues while killing the cancerous cells with a radioactive material implanted in the tumor.
The radioactive material may be placed during surgery or inserted using a hollow tube under a local or general anesthesia with the aid of an imaging scan. Brachytherapy is also applied temporarily to biopsy and surgical scars to prevent cancer spreading.
It has been effective in treating lung cancer when placed into a tumor site, but it is seldom used for the treatment of pleural mesothelioma.
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EBRT is applied at different times for different effects. EBRT as a single treatment can be applied at any time to control pain.
When combined with surgery, EBRT can be applied before, during (intraoperative radiation therapy) or after the procedure.
Radiation delivered before surgery is known as Surgery for Mesothelioma After Radiation Therapy, or SMART. This approach to treatment is a reversal of the traditional protocol (during or after surgery), but it has produced impressive results for mesothelioma patients.
In a 2015 study, specialists at two leading cancer centers in Toronto estimated a median overall survival of 51 months for pleural mesothelioma patients using the SMART approach. Around 66 percent of patients with early-stage epithelioid tumors lived longer than three years.
It takes an experienced multidisciplinary team to safely execute the SMART approach. A high level of radiation is applied to the lung prior to surgery that could be fatal if the lung isn’t subsequently removed. This means that once a patient receives radiation, they must follow through with surgery.
Intraoperative radiation (IORT) is used as part of the surgical procedure. A radiologist applies the beams to the affected areas to help prevent any seeding or spreading of the cancer cells during the operation. A concentrated dose of radiation is delivered to the tumor site immediately after the tumor is removed.
This option may help some patients finish treatment sooner, reducing the need for additional radiation therapy following surgery. Patients who require additional radiation sessions can get a boost from IORT and typically experience fewer complications.
Traditionally, multimodal therapy for mesothelioma begins with chemotherapy followed by surgery and then radiation therapy once the patient recovers from surgery. In this setting, radiation is used to kill cancer cells left behind in surgery. This technique delays or reduces the risk of local recurrence.
About half of early-stage patients with epithelioid mesothelioma can live longer than five years with this treatment.
Most people are not sure what to expect when radiation therapy is applied. In general, patients go through an initial consultation, get imaging scans, and then receive treatment on an outpatient basis — unless they are receiving radiation during surgery. [This could be designed better in a numbered list]
First Appointment: During the consultation visit, you will meet with a radiation oncologist to discuss the best approach for your case. During this initial visit, you might be asked to sign a consent form once you are fully informed of the process and want to proceed with treatment.
Imaging Scans: To ensure accurate and safe application, imaging scans are performed to determine the exact size, shape and location of tumors. The application of radiation is based upon these images to ensure safety.
Treatment Day: A medical professional will explain what you need to do before, during and after treatment. They will help position you and apply protective coverings to prevent radiation exposure to healthy tissue. Radiation is typically applied one or more times a week for several weeks.
Follow-Up Appointment: During follow-up appointments, you will be checked for signs of side effects. Imaging scans will be taken to keep a close watch on how radiation affected the size of your tumors.
Cancer patients often ask if radiation therapy is painful. The good news is radiation therapy is not painful during administration. There’s no need to worry about pain while receiving the treatment.
After treatment, some people may experience skin irritation around the area where radiation is delivered.
Side effects of radiation are most often temporary and are typically more constrained than those of chemotherapy, which can affect the entire body. However, some may also be chronic and appear months or years after the patient finishes treatment.
Most side effects develop as tissue damage accumulates over several sessions of radiation. A single cycle may last up to eight weeks, during which the patient may begin to notice side effects. As treatment progresses, effects are often more severe.
The following are the most common side effects of radiation.
Skin Problems: Radiation-related irritation, known as radiodermatitis, is most common at the point where the radiation beam was focused. It can cause rashes, redness and a tight feeling or swelling. Peeling or darkening of the skin may occur.
Fatigue: It is typically most severe two to four hours after a radiation session. It may also peak between the third and fifth week of treatment as the healing process uses more of the patient’s energy.
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Advanced methods of delivering radiation therapy can help reduce the amount of surrounding tissue exposed to radiation, but some side effects may still occur in the area where the radiation entered the body.
The type of mesothelioma diagnosis can affect how a person’s body will react to radiation therapy.
Receiving radiation treatments to the chest could temporarily intensify symptoms of pleural mesothelioma such as shortness of breath, difficulty swallowing and coughing.
In rare cases, scarring of the lungs, called fibrosis, may occur.
Radiation to the chest can also cause inflammation of the lungs or the lining of the heart, along with damage to the heart muscle, a condition known as cardiac toxicity.
Other rare but major complications can include pleural effusions, collapsed lungs and calcification of the lymph nodes. Researchers show that pleural effusions, if they develop at all, are typically reported within six months of the initial radiation treatment.
While radiation therapy can have a significant impact for someone with pleural mesothelioma, the treatment is more limited for those with the second-most-common disease type, peritoneal mesothelioma. The reason is location.
Peritoneal cancer involves the lining in the abdominal cavity. Radiation is restricted in this area because it can be extremely toxic to the small intestines, liver, kidneys and other organs within that cavity. The only kind of radiation used on peritoneal patients is to prevent cancer spreading to biopsy and surgical scars.
Nausea and vomiting are most common in peritoneal mesothelioma patients who receive radiation to the abdomen and sustain damage to their gastrointestinal tract. These side effects are also common in patients receiving additional mesothelioma treatments, especially chemotherapy.
When radiation is directed at the abdomen, the bladder may be affected by the powerful rays, resulting in bladder irritation. It may be difficult to completely empty your bladder, urinate at normal intervals or control the flow of urine from your bladder when you cough or sneeze. Inflammation in the bladder, known as cystitis, may also occur.
In rare cases, urine may appear bloody or the bladder may begin to cramp or spasm. These side effects may appear within three to five weeks of treatment.
“If you’re not a candidate for surgery, radiotherapy can do almost as well as surgery. And the combination of the two is even better, like 40 percent better, and that’s significant.”
— Dr. Emanuela Taioli, epidemiologist at Mount Sinai Hospital in New York City
Despite recent advancements, a number of experts question the merits of radiation therapy for mesothelioma. These concerns arise from the inconsistent results published in clinical trials and scientific studies on radiation’s effect on mesothelioma.
The decision to include radiation therapy in your treatment plan is up to you and your oncologist. The potential benefits of the therapy might outweigh the risks and side effects. However, you need to discuss the pros and cons thoroughly with your oncologist to make an informed decision.
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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