Chemotherapy for Malignant Mesothelioma

Chemotherapy (chemo) is treatment with anti-cancer drugs. It's used in many different ways to treat mesothelioma. More studies are needed to find the best drugs and the best way to use chemo. Today, the best results are seen when it's used along with surgery.

If mesothelioma can be treated with surgery, chemo may be given first (before surgery) to try to shrink the cancer and lower the risk that it will spread. This is called neoadjuvant therapy.

Chemo can also be given after surgery to try to kill any cancer cells that were left behind. This type of treatment, called adjuvant therapy, may help delay or help keep the cancer from growing back.

For cancers that can’t be removed with surgery, chemo may be the main treatment (alone or along with radiation therapy). Chemo may shrink the cancer or slow its growth, but it's very unlikely that it will make it go away completely.

How chemotherapy is given

Doctors usually give chemo in cycles, with each period of treatment followed by a rest period to allow the body time to recover. Chemo cycles generally last about 3 to 4 weeks. Chemo is often not recommended for patients in poor health, but advanced age by itself is not a barrier to getting it.

There are 2 main ways chemo can be given to treat mesothelioma.

Systemic chemo

In systemic therapy, chemo is injected into the blood through a vein. The drug goes into the bloodstream and travels throughout the body to reach and destroy the cancer cells wherever they may be.

Intrapleural or intraperitoneal chemo

Chemo drugs can also be put right into the body space where the cancer is – either intrapleurally (into the chest) or intraperitoneally (into the abdomen). This is done with a small catheter (tube) placed through a small cut in the chest or abdominal wall. Chemo drugs given this way are still absorbed into the bloodstream, but the highest concentrations of the drugs go right to where the cancer cells are.

For intrapleural or intraperitoneal chemo, the drugs are sometimes heated before they are put into the body space. This is called hyperthermic chemotherapy. Heating the chemo drugs may help them work better. Sometimes this treatment is given as a single dose in the operating room, right after surgery is done to remove the cancer. This is called heated intraoperative chemotherapy. It's more often used to treat peritoneal cancers, in which case it may be called heated intraperitoneal chemotherapy or HIPEC.

Chemotherapy drugs used for mesothelioma

Many chemo drugs can be used to treat mesothelioma, including:

• Pemetrexed (Alimta^®)
• Cisplatin
• Carboplatin
• Gemcitabine (Gemzar^®)
• Vinorelbine

These are often given as combinations of 2 drugs. But single drugs can be used in people who may not be able to tolerate more than one drug.

When 2 drugs are used, most doctors give pemetrexed and cisplatin. Pemetrexed lowers levels of folic acid and vitamin B12 in the body, so patients get these as well to help avoid certain side effects. Other possible combinations include pemetrexed with carboplatin, or cisplatin with gemcitabine.

The drugs used for HIPEC include:

• Cisplatin plus doxorubicin (most common)
• Paclitaxel
• Pemetrexed

Possible side effects

Chemo drugs attack cells that are dividing quickly, which is why they work against cancer cells. But other cells in the body, such as those in the bone marrow (where new blood cell are made), the lining of the mouth and intestines, and the hair follicles, also divide quickly. These cells are likely to be affected by chemo, which can lead to side effects.

The side effects of chemo depend on the type and dose of drugs given, how they're given, and how long they're used. Common side effects include:

• Hair loss
• Mouth sores
• Loss of appetite
• Nausea and vomiting
• Diarrhea
• Increased chance of infections (from having too few white blood cells)
• Easy bruising or bleeding (from having too few blood platelets)
• Fatigue (from having too few red blood cells)

These side effects usually go away after treatment is finished. There are often ways to lessen these side effects. For example, drugs can be given to help prevent or reduce nausea and vomiting. Be sure to ask your doctor or nurse about medicines to help reduce side effects, and let them know if you have side effects, so they can be managed.

Intrapleural or intraperitoneal chemo tends to cause fewer problems than systemic chemo.

Some drugs can have other side effects. For example, cisplatin and carboplatin can damage nerves (called peripheral neuropathy). This can sometimes lead to hearing loss or symptoms in the hands and feet such as pain, burning or tingling sensations, sensitivity to cold or heat, or weakness. This usually goes away over time once treatment is stopped, but it can last a long time in some people.

Be sure to report any side effects or changes you notice to your medical team so that you can get them treated right away. In some cases, the doses of the drugs may need to be reduced or treatment may need to be delayed or stopped to keep the effects from getting worse.