Mesothelioma Treatment

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Dr. Jeffrey Velotta: What do you feel is the best approach to treating mesothelioma

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I feel that surgery first, followed by chemotherapy, is the best multimodality approach for mesothelioma due to the fact that we know only 20% to 40% of patients will actually have somewhat of a radiologic or clinical response to chemotherapy. So patients that will opt for chemotherapy first--

which is still done in certain places because right now there currently is a clinical trial looking at whether or not to get the chemotherapy prior or after surgery. And we still don't have those results. So in the meantime, it's done depending on what institution you're at.

And so the idea--

why I believe that the chemotherapy--

two reasons, first, is an issue is that 20% to 30% of the time it may be helpful, but it never shrinks it completely. It never gets rid of it.

And then there's a 60% to 80% chance that the tumor will progress and that you missed your window to operate. They're getting sicker on the chemo, and the tumor is growing. And that's a 60% to 80% chance the tumor will progress and grow.

So rather than take that chance, I'd rather get it out first and then have--

and we know that 80% of patients, after we take it out, can still make it to surgery because we do a pleurectomy and decortication. And so it's not as aggressive or not as morbid. So patients will be able to do the chemotherapy afterwards.

It was originally thought that do the chemo first because patients were getting an extrapleural pneumonectomy, and they were never able to make it because they were too sick to get chemotherapy afterwards. So you missed that window. But now that we do pleurectomy decortication, chemo afterwards is better because, like I said, chemo is going to react better to a patient that has less disease in the body.

The other reason why I don't necessarily think it's a great idea to get chemotherapy first is that those patients with symptoms and signs of mesothelioma are already weak. They're already in pain. They're already having a lot of pleural fluid. The chemo doesn't get rid of any of that. It may shrink something a little bit, tiny bit, but it doesn't get the patient clinically better.

So not only does it not help, but these patients are already sick, and then they start to lose even more weight just based on the chemotherapy alone. So those patients are essentially not doing well during that time period. And so what we found in previous studies is that 50% to 65% of patients that get the neoadjuvant or get chemotherapy first never actually make it to surgery. They're too sick to even make it to surgery.

Whereas when you first see them, you catch it early, you haven't had to give them toxic agents or anything, and then we first caught it hopefully early enough, we operate on them first. So I think those are the two big reasons why I really favor the surgery first, followed by chemotherapy afterwards.

At a Glance

Best Treatments for Pleural Mesothelioma

Treatment for pleural mesothelioma, which affects the lining of the lungs and is the most common type of this cancer, typically involves systemic or whole-body therapies. This includes chemo and immunotherapy, often combined with surgery and radiation for patients who qualify. Most specialists recommend combining approaches, known as multimodal treatment, to attack the cancer from multiple angles for the best outcomes.

We’ve ranked the order of these pleural mesothelioma treatments based on what’s best for most people diagnosed with this type of cancer. As an example, specialists say chemotherapy, followed by or combined with immunotherapy, is likely the first and second treatments they consider for people diagnosed with peritoneal mesothelioma.

Chemotherapy

Used Across All Stages and Types

Best for

Before and after surgery as well as when surgery isn’t an option.

What is chemotherapy?

Chemotherapy uses drugs to kill mesothelioma cells throughout your body.

Standard medicines

Alimta (pemetrexed) with cisplatin or carboplatin via IV.

Key stats

• More than 65% of patients on chemo live 3+ years.
• 3X greater survival when combined with other treatments.
• 8 in 10 pleural patients we surveyed received chemotherapy.

What doctors say

“Even if you have surgery, you usually need additional treatment such as chemotherapy… For patients who cannot have surgery, systemic treatment is still important to control the cancer.”

Dr. Hedy Lee Kindler, Associate Vice Chair for Clinical Research at University of Chicago Medicine

What survivors say

“I had a lot of life left to live. I was tired from the chemo, but I wanted to give it one more try. I’d encourage others to do the same.”

Barbara Lapalla, Pleural Mesothelioma Survivor

Continued Learning

Chemotherapy for mesothelioma

Immunotherapy

When Chemo Progresses, Isn’t Tolerated or Needs a Boost

Best for

First-line treatment option for people who can’t have surgery.

What is immunotherapy?

Immunotherapy helps your immune system recognize and attack mesothelioma cells.

Standard medicines

Keytruda (pembrolizumab) with chemo or Opdivo (nivolumab) with Yervoy (ipilimumab).

Key stats

• Clinical trials show 2-year survival of 41% vs. 27% with chemo alone.
• 1 in 3 pleural patients we surveyed received immunotherapy.

What doctors say

“I have personally witnessed the significant impact immunotherapy has had on improving survival for some patients with certain types of mesothelioma.”

Dr. Andrea Wolf, Director of the New York Mesothelioma Program at Mount Sinai

What survivors say

“I tell people today, I’m a walking miracle. They don’t believe in miracles. Then they see me.”

Barbara Lapalla, Pleural Mesothelioma Survivor who receives Keytruda 3 times per week

Continued Learning

Immunotherapy for mesothelioma

Radiation Therapy

Often Combined with Surgery or Chemo

Best for

Tumor control before or after surgery and symptom relief.

What is radiation therapy?

Doctors direct high-energy X-rays or protons at mesothelioma tumors to shrink them and kill cancer cells.

Most common types

External Beam Radiation Therapy or EBRT is the most common type with specific therapies like Intensity-Modulated Radiation Therapy.

Key stats

• Radiation nearly doubles 2-year and 5-year survival rates when combined with other treatments.
• 1 in 3 ppleural patients we surveyed received radiation.

What doctors say

“So when you do mesothelioma surgery… the issue of localized recurrence can occur. And so those patients, we do recommend they undergo either radiation or additional surgical intervention.”

Dr. Jeffrey Velotta, Thoracic surgeon at Kaiser Permanente Oakland Medical Center

What Survivors Say

“Radiation for pleural mesothelioma isn’t fun, but it’s manageable. It took us fully a year to get my SAbR/PULSAR radiation treatment at UT Southwestern in Dallas approved… and I doubt that I would be here without it.”

Michael Cole, Pleural Mesothelioma Survivor

Continued Learning

Radiation therapy for mesothelioma

Surgery

For Select Early-Stage Patients

Best for

Removal of all visible cancer in people with limited disease spread (early-stage) and good overall health.

What is surgery?

Surgery for mesothelioma removes visible tumors and affected tissue.

Most common types

Pleurectomy/decortication, or P/D, and extrapleural pneumonectomy, or EPP, are the primary procedures used for pleural patients.

Key stats

• 24% of early-stage pleural patients lived 5+ years following tumor-removing surgery.
• 7 in 10 pleural patients we surveyed had surgery.

What doctors say

“I feel surgery first, followed by systemic therapy (e.g. chemotherapy, immunotherapy or both) is the best multimodality approach for mesothelioma.”

Dr. Jeffrey Velotta, Thoracic surgeon at Kaiser Permanente Oakland Medical Center

What survivors say

“I believe that the aggressive treatment I had in the beginning was absolutely necessary to give me a chance to be here now, and I am grateful for the decision that we made.”

Michael Cole, Pleural Mesothelioma Survivor

Continued Learning

Mesothelioma surgery options

Why Are These the Best Treatments for Pleural Mesothelioma?

These are the top pleural mesothelioma treatment approaches because they consistently deliver the strongest survival outcomes and quality-of-life improvements across different stages of pleural mesothelioma. Most patients receive a combination of these treatments rather than a single approach, with individual plans customized depending on cancer stage, overall health and personal treatment goals.

How These Treatments Help Pleural Patients

• Chemotherapy: Works for most people regardless of surgical eligibility, shrinking tumors and improving quality of life across all stages.
• Immunotherapy: FDA-approved regimens now offer people who don’t qualify for surgery a median survival of 18 months and 2-year survival rates that are significantly better than with chemo alone. A 2026 study published in the Journal of Clinical Oncology found that using Yervoy and Opdivo as first-line treatment for pleural mesothelioma improved overall survival compared with chemotherapy alone.
• Radiation: Provides precise tumor targeting with modern techniques like IMRT, reducing recurrence from 42% to 14% compared to conventional radiation.
• Surgery: Offers the strongest survival outcomes for eligible patients, particularly when surgery is combined with chemo, radiation, immunotherapy or a combination of these in early-stage disease.

The National Cancer Database shows the greatest survival rates among pleural mesothelioma patients who received surgery and chemo. When combined strategically, these treatments attack cancer from multiple angles and give doctors flexibility to adjust plans as needs change throughout the treatment journey.

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Stories From Pleural Mesothelioma Survivors, Specialists

Pleural mesothelioma survivors, doctors and other experts explain how these treatments have improved their quality of life and extended their life expectancies. Watch as they share their inspirational stories.

Consider these insights when consulting with your doctor. They may help you determine the best treatment for your pleural mesothelioma.

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Sean Marchese, RN: Mesothelioma Radiaton

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Undergoing Mesothelioma Surgery

The first treatment for the mesothelioma was a pleurectomy decortication, which is an operation. They cut through the middle of your back, between your ribs to the almost the middle of your front. It was supposed to be a eight inch incision, but it looks more like twelve. It, they had to remove a rib. They took the cancer that was collected around my the plural, lining of my lung and it was scraped off. I had six lymph nodes cut off. Two of them turned out also positive for mesothelioma. So I was pretty close to the stage where I was still a candidate to have the operation done, because it hadn’t, spread further.

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Sharing My Mesothelioma Surgery Experience

I knew that I would be in the hospital for, you know, at the very least a week. And that I was going to have radiation for five weeks after that. Doctor Cameron said you will probably be in pain for, like, a year. And he said, well, Kim, some patients, when they bend over, they get short of breath. Because I’m probably going to rearrange reconstruct your diaphragm. And so you might have that. You may have coughing. You may have increased flem and secretions. You may have shortness of breath, but you will be able to go back to work. And I said, really. And I said, okay. That sounds great to me. Jeanette came came with me. She stayed in the hospital, and my friend Stacy came. And my husband, Richard, they allowed the three to stay in the hospital room with me. My surgery ended up being about eight hours. I woke up. I remember going in, and I was nervous. You know, I thought, well, what if I don’t wake up? Prior to the surgery, had my will taken care of, my trust. I I kind of wrapped up those kind of legal issues. And, When I woke up, I remember thinking, I made it. I made it. I, you know, I knew that as a nurse, that there was a possibility that I I could maybe not make it through surgery, but I remember saying to my cousin who was there. It was the first face that I call. And I said, oh my gosh, Elaine, you’re here. I I made it. And really, after that, I thought, well, I don’t wanna say I was home free, but I thought, okay. Oh, you’re gonna be fine, Kim.

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What Is Immunotherapy?

[MUSIC PLAYING] So immunotherapy is a new technique that

has been looked at in terms of, it boosts their own immune cells. So the idea is you target a specific protein in the immune system and that will actually enhance the immune cells in your body to go ahead and attack the mesothelioma or cancer cells, specifically. So we normally have normal immune cells that are normally protecting us from infection or for other things, but this, just based on certain pathways that we know are active in cancer, then you boost that activity so that the immune cells will actively try to attack and engulf or eat, as you will, the cancer cells.

And so that's really where immunotherapy is going to be beneficial because it's thought to be a, quote unquote, "more natural way," and not necessarily like chemotherapy, where you're actually giving a toxic substance that will kill and attack and does not have a preference for mesothelioma cells. It has a preference for all cells. And so I think that's where immunotherapy is going to be a nice addition.

Recommendations Among Doctors

In 2025, The Mesothelioma Center surveyed doctors and nurses about their recommendations for pleural mesothelioma treatment approaches. The chart shows that respondents favored chemotherapy plus immunotherapy, which aligns with our ranking of the best treatments.

Best Treatments for Peritoneal Mesothelioma

For eligible peritoneal mesothelioma patients, cytoreductive surgery combined with heated chemo is often the cornerstone of care for this rare cancer that affects the lining of the abdomen. A higher percentage of people qualify for surgery compared to pleural patients. When combined with HIPEC, this approach has produced the longest survival times for peritoneal mesothelioma.

We’ve ranked the order of these peritoneal mesothelioma treatments based on what’s best for most people diagnosed with this type of cancer. For example, specialists agree that cytoreductive surgery combined with HIPEC is likely the first treatment they consider for people diagnosed with peritoneal mesothelioma.

Cytoreductive Surgery + HIPEC

Most Common for Peritoneal Patients Who Can Have Surgery

Best for

Peritoneal patients who are healthy enough for major surgery, with higher eligibility rates than pleural patients.

What is CRS+HIPEC?

As part of the 2-part procedure, surgeons remove all visible tumor tissue, then bathe the abdominal cavity in heated chemotherapy to target any remaining cancer cells.

Standard approach

Cytoreductive surgery removes tumors from abdominal organs and tissues; hyperthermic intraperitoneal chemotherapy or HIPEC immediately follows.

Key Stats

• Achieves 5-year survival rates of 50% to 69% for peritoneal mesothelioma, some achieve 75%.
• 6 in 10 peritoneal patients we surveyed have undergone CRS+HIPEC.

What Doctors Say

“I tell my peritoneal mesothelioma patients, with the good treatment we use now, the median survival can increase years versus the survival rate without treatment.”

Dr. Charles Conway, Director of surgical oncology at the Ridley-Tree Cancer Center

What Survivors Say

“Just as with any surgery, HIPEC has its risks and side effects. Several studies have shown that HIPEC surgery drastically improves life expectancy in about half of the peritoneal mesothelioma patients who have it. As for me, the benefits outweighed the risks!”

Tamron Little, Peritoneal mesothelioma survivor diagnosed in 2007

Continued Learning

Cytoreductive surgery and HIPEC

Chemotherapy

For Patients at Various Treatment Stages and Part of HIPEC

Best for

When surgery isn’t possible, after cancer recurrence or when symptom control is the primary goal.

What is surgery for peritoneal mesothelioma?

Systemic chemo delivered via IV to slow disease progression and manage symptoms.

Standard medicines

Alimta (pemetrexed) with cisplatin or carboplatin, similar to pleural mesothelioma regimens.

Key stats

• Can extend survival and improve quality of life when surgical options are limited.
• 9 in 10 peritoneal patients we surveyed received chemo.

What doctors say

“For patients who cannot have surgery, systemic treatment is still important to control the cancer.”

Dr. Hedy Lee Kindler, Associate vice chair for clinical research at University of Chicago Medicine

What survivors say

“I was given a new chemo cocktail every 21 days for three months. In 2012, I was officially in remission! In disbelief, the doctor performed an exploratory scope, and again, everything was clear. I’ve been in remission ever since.”

Kasie Coleman, Peritoneal survivor diagnosed in 2010

Continued Learning

Chemotherapy for peritoneal mesothelioma

Immunotherapy

Available Through Clinical Trials or Specialist Prescription

Best for

Clinical trial candidates, particularly those with certain tumor characteristics or limited surgical options.

What is immunotherapy for peritoneal mesothelioma?

Immune-based treatments being studied specifically for peritoneal mesothelioma through clinical trials.

Emerging approaches

Checkpoint inhibitors and combination immunotherapy regimens adapted from successful pleural treatments.

Key stats

• Early evidence suggests immunotherapy may benefit select peritoneal patients, with ongoing trials testing effectiveness.
• 1 in 6 peritoneal patients we surveyed participated in immunotherapy clinical trials.

What doctors say

“The combination of [Opdivo] and [cytoreductive surgery] resulted in a long-term survival in this patient with sarcomatoid-predominant peritoneal mesothelioma.”

Dr. Paul Sugarbaker, President of the Foundation for Applied Research in Gastrointestinal Oncology, in a recently published case study

What survivors say

“I can only receive the immunotherapy for 2 years. It will not cure mesothelioma. It will slow it down or put it in a form of remission.”

Tami Pream, Peritoneal mesothelioma survivor diagnosed in 2021

Continued Learning

Explore immunotherapy clinical trials

Why Are These the Best Treatments for Peritoneal Mesothelioma?

Peritoneal mesothelioma requires a different treatment strategy than pleural mesothelioma, with surgery playing a more central role. Cytoreductive surgery with HIPEC has become the gold standard because it directly targets cancer in the abdominal cavity where it develops, achieving 5-year survival rates that far exceed other approaches.

How These Treatments Help Peritoneal Patients

• Chemotherapy: Helps slow disease progression when surgery isn’t possible, or cancer has recurred, and manages symptoms like abdominal pain and fluid buildup.
• Cytoreductive surgery + HIPEC: Combines surgical removal of all visible tumors with targeted heated chemo, offering eligible patients 5-year survival rates of 50% to 69%
• Immunotherapy: Researchers are testing whether immune-based treatments that work for pleural mesothelioma can be adapted to benefit peritoneal patients.

Higher percentages of peritoneal patients qualify for surgery compared to pleural patients because the cancer is usually contained within the abdominal cavity. When patients can undergo cytoreductive surgery with HIPEC, this approach has consistently produced the best long-term outcomes for peritoneal mesothelioma.

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Stories From Peritoneal Mesothelioma Survivors, Specialists

Peritoneal mesothelioma survivors, physicians and medical specialists describe how current treatment options have enhanced patients’ quality of life and contributed to longer life expectancies. Watch as they share their experiences and inspiring stories.

Keep these insights in mind when meeting with your peritoneal mesothelioma specialist. They can help guide your conversation, clarify your options and support you in choosing the most appropriate treatment plan for your peritoneal mesothelioma.

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Multimodal Treatment for All Mesothelioma Types

Most mesothelioma patients receive multimodal treatment, with specific combinations depending on cancer type, stage and overall health. Multimodal therapy combines treatment types to attack mesothelioma from multiple angles. Research shows combining treatments often achieves better outcomes than single-treatment approaches, with the National Cancer Database showing the greatest survival rates among patients who received surgery and chemotherapy. 

Common Multimodal Approaches by Type

• Pleural mesothelioma: Chemotherapy and immunotherapy combination as first-line treatment, with surgery and radiation added for eligible patients.
• Peritoneal mesothelioma: Cytoreductive surgery with HIPEC delivers both surgical removal and heated chemo in one procedure, with systemic chemotherapy added if cancer recurs.
• Pericardial and testicular mesothelioma: Surgery when possible, with chemo or radiation added based on individual circumstances.

The key advantage of multimodal therapy is flexibility. Doctors can adjust treatment plans as your cancer responds and your needs change throughout the treatment journey, combining therapies strategically to maximize effectiveness while managing side effects.

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Palliative Care for All Mesothelioma Types

Palliative care focuses on relieving symptoms and improving the quality of life for mesothelioma patients at any stage. Research shows palliative care can improve quality and length of life when integrated throughout a patient’s treatment journey, not just at the end of life. Palliative procedures and supportive treatments work with curative therapies to manage pain, breathing difficulties and other symptoms.

Common Palliative Approaches by Mesothelioma Type

• Pleural mesothelioma: Thoracentesis is a common palliative approach that removes fluid around the lungs to ease breathing, while pleurodesis prevents fluid from returning.
• Peritoneal mesothelioma: Paracentesis, for example, drains abdominal fluid to reduce swelling and discomfort, with ongoing catheter placement for repeated drainage if needed.
• Pericardial and testicular mesothelioma: Pericardiocentesis removes fluid from around the heart in pericardial cases to improve heart function and reduce chest pain.

Treatments like chemo or radiation can be palliative, improving patient comfort as tumors shrink, pain is reduced and breathing improves. “I don’t think anyone should have to suffer when they don’t have to,” notes Amy Pelegrin, director of hospice care at The Mesothelioma Center. “Your care team can coordinate palliative treatments with your curative therapies to keep you as comfortable and active as possible.”

The Future of Mesothelioma Treatment

Clinical trials are advancing the next generation of mesothelioma treatments. Researchers are testing promising approaches like cancer vaccines that train the immune system to attack tumors, gene therapies that alter cancer cells to stop their growth and specialized viruses that infect and destroy cancer cells while sparing healthy tissue. Many of these emerging treatment options are only accessible through mesothelioma clinical trials, offering patients early access to potentially life-extending treatments.

Several studies focus on combination treatments that build on today’s gold standard therapies to achieve even better results. For example, Ofev, a medication approved for pulmonary fibrosis, is now in phase III trials for pleural mesothelioma. Other trials are exploring a future of treatments combining immunotherapy.

Joining a clinical trial can give you additional treatment options, especially if standard therapies haven’t worked or you’re looking for more aggressive approaches. Your mesothelioma doctor can help determine if a trial may be right for you.

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Dr. Jeffrey Velotta: Specialist’s Take on Future Treatments

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EXPLORE NEW TREATMENTS

Find Active Clinical Trials

Access mesothelioma clinical trials matched to your diagnosis. Get help with eligibility and enrollment.

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How to Find the Best Mesothelioma Treatment for You

Your treatment plan will be customized for your personal health and goals. Finding the right specialist for your specific case is critical. A Patient Advocate personally connects you with mesothelioma experts matched to your diagnosis, navigates insurance coverage, secures financial resources to cover treatment costs and provides information about clinical trials. Your Patient Advocate will guide you from diagnosis through treatment, ensuring you and your loved ones have the support and information needed to make confident decisions about your care.

Questions to Ask Your Mesothelioma Doctor

Bring these questions to your next appointment to help guide treatment decisions and feel more informed about your care. Your answers will help you understand your specific situation and what treatment options make the most sense for you.

1. What type and stage of mesothelioma do I have?
2. Can my cancer be removed with surgery?
3. What treatments do you recommend and why?
4. Am I a candidate for a clinical trial?
5. What side effects should I expect?
6. Should I get a second opinion from a mesothelioma specialist?
7. How will we know if the treatment is working?

Getting clear answers to these questions helps you make confident decisions about your care. Consider bringing a family member or friend to appointments to help remember the information discussed and ask follow-up questions.