Treatment of mesothelioma based on the extent of the cancer

The stage (extent) of a mesothelioma is an important factor in determining treatment options. But other factors, such as whether the doctor feels the cancer is resectable (all visible cancer can be removed by surgery), as well as a person’s general health and preferences, also play a role.

Mesotheliomas can be hard to treat, whether the cancer is resectable or not. It’s very important that you understand the goal of treatment before it starts – whether it is to try to cure the cancer or to help relieve symptoms – as well as the possible benefits and risks. This can help you make an informed decision when looking at your treatment options.

Resectable mesotheliomas

In general, most stage I and some stage II and III pleural mesotheliomas are potentially resectable, but there are exceptions. Whether a tumor is resectable is based on the subtype (most doctors believe only epithelioid and mixed/biphasic tumors are potentially resectable), where it is located, how far it has grown into nearby tissues, and whether or not a person is healthy enough to have surgery.

Many patients with resectable pleural mesothelioma have their cancer removed by pleurectomy/decortication (P/D) or extrapleural pneumonectomy (EPP). Surgery is more likely to result in long-term benefit in stage I cancers, where there is a better chance that most or all of the cancer can be removed. For these early-stage cancers, EPP may be a good option if it can be done. It offers the best chance to remove the cancer, but it is a complex and extensive operation that can also have major side effects. Patients with early-stage peritoneal mesotheliomas might also benefit from surgery. Some patients can have long remissions after extensive surgery by experts. Surgery may still be helpful for later-stage cancers, but the benefits are more likely to be short term.

Sometimes, the surgeon may think the cancer is resectable based on imaging tests (such as CT scans) done before surgery, but once the operation starts it becomes clear that not all of the cancer can be removed. In these cases the surgeon may switch to a less extensive operation (which is less likely to cause side effects) or even stop the surgery altogether if it is not likely to be helpful. Treatment would then be the same as for unresectable mesotheliomas (see below).

Doctors are still studying whether giving chemotherapy before surgery (neoadjuvant therapy) or giving chemotherapy or radiation therapy after surgery (adjuvant therapy) is helpful. Some doctors prefer to give neoadjuvant chemotherapy, and many doctors advise adjuvant chemotherapy or radiation therapy, but not all doctors agree on what the best course of treatment is.

If you are not healthy enough to have a major operation, radiation therapy and/or chemotherapy may be used instead. While these treatments may shrink or slow the growth of the cancer for a time, they are not likely to result in a cure.

If you have symptoms because of fluid buildup in the chest or abdomen, other approaches such as thoracentesis/paracentesis or pleurodesis (described in the “Surgery” section) may be helpful.

Because these cancers can be hard to treat, taking part in a clinical trial of a newer form of treatment may be a reasonable option. These types of studies are usually done in large medical centers.

Unresectable mesotheliomas

Stage IV mesotheliomas, as well as many earlier-stage mesotheliomas, can’t be removed completely by surgery either because of the extent or subtype of the disease or because a person may not be healthy enough for an operation. Chemotherapy and/or radiation therapy may shrink or slow the growth of the cancer for a time. But these treatments are very unlikely to result in a cure and can have their own side effects. Before starting such treatments, the goals of treatment should be clear to you and your family.

In people with early-stage mesotheliomas that are likely to grow slowly and are not causing any symptoms, watching them closely at first may be a reasonable option. Treatment can then be started if there are signs that the cancer is growing quickly or if it starts to cause symptoms.

Because these cancers can be hard to treat, taking part in a clinical trial of a newer form of treatment may be a reasonable option.

In many cases, treatment aimed at relieving symptoms and making you more comfortable may be a good choice. This could include treatments that prevent or reduce fluid buildup in the body, which could affect your breathing or ability to take in nutrition.

Pain management is another important aspect of your care. Some minor operations and types of radiation therapy can help relieve pain if needed. Doctors can also prescribe strong pain-relieving drugs. Some people with cancer may hesitate to use opioid drugs (such as morphine) for fear of being sleepy all the time or becoming addicted to them. But many people get very effective pain relief from these medicines without serious side effects. It’s very important to let your cancer care team know if you are having pain so that it can be treated effectively.

Recurrent mesotheliomas

Cancer is called recurrent when it come backs after treatment. Recurrence can be local (in or near the same place it started) or distant (spread to organs such as the brain or liver). Mesotheliomas often come back after the initial treatment. If this happens, further treatment options depend on where the cancer is, what treatments have already been used, and a person’s general health.

In most cases the options will be similar to those listed above for unresectable mesotheliomas. For example, chemotherapy may be used to try to shrink or slow the growth of the cancer and to relieve any symptoms. Because recurrent cancers can often be hard to treat, clinical trials of new types of treatment may be a good option.