Treatments

Different treatments can be used to treat mesothelioma including radiotherapychemotherapy and surgery - you may be suitable for one, two or all three.

Which treatments are recommended for you will depend on the stage of your mesothelioma, in other words how far it has spread, the type of mesothelioma.

Currently there is no cure for mesothelioma but we continually strive to find better treatments to help manage the disease. Patients may therefore be offered the opportunity to enter a clinical trial involving one of these treatments. These trials will hopefully provide us with a much better evidence base for how best to treat the disease in the future.


Radiotherapy

The treatment of mesothelioma will depend on a number of things including the type of mesothelioma, how advanced the disease is, the general health and fitness of the patient and their personal preferences.

There are various treatments that may be recommended for mesothelioma. These include active symptom control, radiotherapy, chemotherapy and surgery. A patient may have just one of these types of treatments or a combination of them.

Radiotherapy is the use of high-energy radiation to kill cancer cells in the body. All the cells in the part of the body being treated have the potential to be affected by the radiotherapy. Normal, healthy cells will to some extent recover.

Radiotherapy is used to treat a particular localised area of the body (for example, an area of the chest where pain is felt). The area being treated is often referred to as the radiotherapy field.

A course of radiotherapy is individually prescribed. The course may involve several doses, usually referred to as fractions, or just a few. The number of fractions required would depend on the amount of tissue that is to be treated.

Radiotherapy can be used in mesothelioma to reduce the size of the tumour to help to relieve symptoms, such as pain or discomfort.

Radiotherapy can also be given to the scar left by a biopsy, drainage tube or operation. This is to help prevent the mesothelioma from spreading into the site as small microscopic deposits may have occurred during the insertion and removal of drains, biopsy needles or surgical instruments.

In mesothelioma small scars are often treated with 3 doses (fractions) of radiotherapy. When treating to relieve symptoms such as pain up to 10 doses (fractions) may be necessary.

Radiotherapy

Before radiotherapy begins

Before treatment begins patients will attend the Radiotherapy Department to plan radiotherapy. Depending on the course of treatment prescribed it may be necessary for X-rays of the area to be treated to be taken by a special machine called a simulator. There may be an interval between this visit to the Radiotherapy Department and the start of the radiotherapy.

 

Radiotherapy sessions

The radiographer will ensure that the patient is comfortable on the couch in the treatment room before starting the session. During treatment the patient will be left alone in the room, but will be able to talk to the radiographer through an intercom and the radiographer will be watching from the next room.

  • Radiotherapy does not make people radioactive – it is safe to be with other people (including children) throughout treatment
  • Patients can eat and drink normally before and after each radiotherapy session
  • Radiotherapy treatments are totally painless (like having an ordinary x-ray)
  • Patients will be asked to remain still during treatment but can breathe normally
  • Each radiotherapy session lasts from a few seconds to several minutes

Radiotherapy side effects

Radiotherapy can cause side effects such as poor appetite, feeling sick, being sick and tiredness. Some patients also experience soreness and itchiness of the skin and difficulty in swallowing. The extent of the side effects does depend on the dose of the radiotherapy, length of treatment and the size of the area being treated.

If receiving radiotherapy is being given to a scar or drain site usually side effects are limited to soreness and itchiness of the skin. However, if a larger area is being treated, skin problems, tiredness, difficulty in swallowing and poor appetite can be experienced. If patients are undergoing an extensive course of radiotherapy it is possible that other organs within the treatment field, such as the heart, liver, spleen and kidneys, will suffer long-term damage, however this is rare.

Once the course of radiotherapy is finished the side effects should gradually disappear.


Chemotherapy

The treatment of mesothelioma will depend on a number of things including the type of mesothelioma, how advanced the disease is, the general health and fitness of the patient and their personal preferences.

There are various treatments that may be recommended for mesothelioma. These include active symptom control, radiotherapy, chemotherapy and surgery. A patient may have just one of these types of treatments or a combination of them.

Chemotherapy can be used to treat mesothelioma. Chemotherapy is the use of anti-cancer (cytotoxic) drugs to destroy cancer cells. They work by disrupting the growth of the cancer cells.

Chemotherapy is used in an attempt to shrink the disease and relieve some of the symptoms it is causing. This may improve quality of life. It is possible it may also help people with mesothelioma to live a little longer, chemotherapy cannot cure mesothelioma.

Chemotherapy may also be given before or after major surgery for mesothelioma to prevent or delay the recurrence of the cancer cells. This is called adjuvant treatment.

The chemotherapy drugs that may be used for the treatment of mesothelioma include Cisplatinum (Platinol), Carboplatin (Paraplatin), Gemcitabine (Gemzar), Pemetrexed (Alimta) and Vinorelbine (Navelbine).

Macmillan Cancer Support's website contains information about individual chemotherapy drugs including how each drug is given and possible side effects that may be experienced with each drug

In mesothelioma there is, as yet, no agreement among experts as to when, if at all, during the course of the illness, to use chemotherapy. It is also unknown which is the best drug or the best combination of drugs to treat this disease.

Chemotherapy - how is it given?

Chemotherapy

Chemotherapy drugs are carried in the bloodstream to the cancer cells and it can be given in a number of ways. These include:

By injection into a vein or through a drip

A fine needle called a cannula will be inserted into a vein, usually in the back of the hand. This procedure is no more painful than any other injection or blood test.

By infusion pump

These are used to give a controlled amount of drug/s into the bloodstream over a number of hours or days. The pumps are compact and can be carried in a bag or on a belt.

By mouth

Some chemotherapy drugs are given as a tablet, capsule or liquid.

Chemotherapy treatment sessions

Before you begin your chemotherapy treatment a nurse will explain what is involved and answer any questions you may have before treatment.

  • You can eat and drink normally on the day of your treatment. However, it is advisable not to have a heavy meal prior to your chemotherapy session
  • Small amounts of alcohol are safe but it is advised that alcohol is avoided for 48 hours after treatment
  • Chemotherapy may be given on a hospital Day Ward (where you visit hospital for a few hours for your treatment) or as an inpatient. Your doctor or nurse will discuss this with you

Chemotherapy side effects

Chemotherapy drugs act on the cancer cells in the body but they also temporarily reduce the number of some of the normal cells in the blood. When the numbers of normal blood cells are lowered you are more at risk of developing infections and may tire easily.

The side effects of chemotherapy drugs differ from drug to drug. Possible side effects include feeling sick, being sick, loss of appetite, loss or thinning of hair, constipation and diarrhoea, sore mouth and fatigue. Before treatment starts, your doctor or nurse will explain the side effects and offer advice about managing these.

As the side effects of chemotherapy can be significant, the benefits of having chemotherapy need to be carefully weighed up against the side effects that may be experienced. Patients are advised to discuss with their oncologist (cancer doctor) about chemotherapy in their individual situation.

Most chemotherapy is given as an outpatient meaning that patients only attend for all or part of a day to have the treatment administered, in addition to this there will be hospital visits at regular intervals to see the oncologist to discuss how treatment is progressing as well as scans to determine whether or not the chemotherapy is helping to control the disease.  It is likely that treatment will be given over a few months.


Surgery

Surgery can have an important role within the treatment of malignant mesothelioma in confirming the diagnosis, assessing the spread of the tumour (stage), removing and reducing the bulk of disease and in the control of symptoms.

Radical surgery

Illustrated image of healthy lung and diseased lung

There are two approaches to surgical resection of malignant pleural mesothelioma: radical and palliative.

Click to download a PDF leaflet on surgery for malignant pleural mesothelioma

The intention of radical surgery is to remove all of the visible tumour. With any cancer type radical surgery is performed with the aim of gaining local control in the area of the tumour, in patients in whom tests have not been able to demonstrate the spread of cancer cells elsewhere in the body. This, of course, cannot be guaranteed, as small deposits of cancer cells may be undetectable.

Radical surgery is appropriate for only a small number of patients since the majority have disease that has already progressed beyond being able to be completely removed, or are not fit enough for surgery. With mesothelioma, although wide margins of normal tissue around the removed cancer are difficult to achieve, the goal of local control can be achieved in some patients.

It is important to remember that, unlike radical surgery in breast, bowel and lung cancers, where it is possible to offer the chance of a cure, this is not the case in mesothelioma. It is very uncommon for patients having radical surgery to gain a cure, in other words never having further problems with mesothelioma.  However, palliative surgery may have an important role in improving and controlling symptoms and maintaining the quality of life.

Radical surgical options

Extrapleural Pneumonectomy (EPP)

EPP was a procedure which gained initial favour amongst some surgeons in the UK and overseas, but it is now less commonly performed. It is the most aggressive surgical option but it is only appropriate for a very small number of patients.  Pre-operative tests must demonstrate that patients have good, adequate lung and heart function before acceptance for surgery. EPP involves removing the entire lung and pleura together with the diaphragm and the side of the pericardium (the sac around the heart) in one piece. After removal of the tumour, the diaphragm and pericardium are reconstructed with artificial patches.

Extended Pleurectomy/Decortication (eP/D)

This procedure is also known as Radical Pleurectomy and Decortication (P/D). With eP/D, the pleura is stripped off the chest wall, but the thickened pleural membrane is peeled off the lung leaving the lung in place. The pericardium and diaphragm are often removed, depending on the extent of the tumour.

eP/D is still, however, a very big operation that is only suitable for patients with sufficient reserves. As the lung remains in place, and it may function better after surgery as it can often now expand more easily, recovery from surgery may be quicker and in the longer term quality of life may be preserved or even improved.

However, compared to EPP, it slightly less likely to remove all the tissue that may contain tumour cells and therefore there is a greater chance of recurrence around the operated lung. In addition, it may not be possible to administer as high a dose of radiotherapy to the chest after the operation, as it may damage the underlying lung.

eP/D may still be useful for patients in whom there is possible spread of the mesothelioma to the lymph glands in the centre of the chest (mediastinum). Not all thoracic surgeons in the UK have experience of this technique and most will usually prefer to operate after a few cycles of chemotherapy have been given.

Palliative surgery

The type of operation depends on whether the lung on the affected side will expand or not. If after drainage of the fluid around the lung (pleural effusion) the lung will expand, then the options are either the insertion of sterile talc around the lung to seal the space between the pleural linings (pleurodesis) or the removal of the bulk of the tumour (pleurectomy). Both these procedures can be performed reliably by keyhole surgery Video Assisted Thoracoscopic Surgery (VATS).

If, however, the lung is encased by tumour and cannot expand after fluid has been drained, then skimming the surface of the lung (decortication) will be required to make it possible for the lung to expand and thereby improve the function of the lung and improve shortness of breath. It is sometimes possible to decorticate the lung by keyhole surgery (VATS), but the majority of surgeons would perform decortication by opening the chest with a large cut made around the back below the shoulder blades, between the ribs this is called a thoracotomy.

Thoracotomy and decortication is a larger procedure reserved for the younger, fitter patients. In the elderly, more infirm patient, a tunnelled, indwelling pleural catheter  (TIPC) can be inserted. This is a permanent drain with a valve that empties the pleural fluid into a vacuum bottle, every few days as required. More information about TIPC can be found in the Controlling Symptoms section.

Referral for surgery

Patients can discuss the appropriateness of surgical treatment with the doctor who is currently caring for them. Not all hospitals are able to offer surgical treatment for mesothelioma. Referral to other hospitals for treatment can be done by the hospital team currently caring for the patient or the GP where this is not feasible. Mesothelioma UK can help to identify the nearest surgical unit, where this is requested.

Conclusion

Surgery is frequently used across the UK to gain a diagnosis and treat pleural effusion. The provision of radical and palliative surgery may vary between parts of the UK and different hospitals. However, not all thoracic surgeons in the UK have experience of radical surgery for malignant pleural Mesothelioma and opinions can differ as to the benefits. It may be necessary for patients to be referred to a specialist centre.