Mesothelioma Treatment Guidelines

Factors Considered in Clinical Guidelines for Treating Mesothelioma

The American Society of Clinical Oncology outlines a series of guidelines for physicians treating mesothelioma. These guidelines are evidence-based and derived from clinical trials that highlight proven methods. For example, ASCO guidelines suggest initial diagnosis via thoracentesis followed by thoracoscopic biopsy. If a patient has sarcomatoid histology, the guidelines indicate they should not receive surgery.

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 deciding which treatment options provide the most benefit with the lowest risk of harm.

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

Performance status (PS) is essential in deciding cancer treatment options. It measures a person’s activity level, mobility and how much assistance they need to do everyday tasks. PS ranges from 0 (regular activity) to 4 (bedridden). Doctors must consider all these factors to decide 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, 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 to obtain a biopsy of suspected mesothelioma tumors. Surgery is the best method, but needle biopsies are also 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.

After diagnosing 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. 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 consider a patient’s overall health and age to decide which treatment 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 combines different treatments and is essential to mesothelioma treatment. Depending on the individual patient, they may receive various 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 in its early stage (I through IIIA) and with an epithelioid cell type has the most treatment options. More advanced stages (IIIB or IV), biphasic or sarcomatoid cell types and inoperable tumors limit available options. Supportive care is recommended for people who are not healthy enough for treatment.

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

Peritoneal mesothelioma treatment recommendations include cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. These may be followed by systemic chemotherapy and immunotherapy. Systemic therapy is recommended for inoperable tumors, biphasic or sarcomatoid cell types, 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 (HIPEC) can be an option to treat peritoneal mesothelioma after cytoreductive surgery. HIPEC involves infusing heated chemotherapy drugs directly into the abdominal cavity, which typically remains 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 essential 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 primary use is to treat pleural mesothelioma, with occasional uses for peritoneal mesothelioma. By destroying whatever cancer cells remain after primary treatment, radiation can improve survival, relieve pain, and prevent cancer spread. 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 healthy tissue exposure 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, primarily 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 (EPP) and pleurectomy and decortication (P/D). 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 comfort people who are not candidates for treatment or 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 can procedures such as paracentesis and thoracentesis to drain fluid buildup in the abdomen and lungs.

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, including supportive and palliative treatment.

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

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