Treatment of Mesothelioma Based on the Extent of the Cancer

The stage (extent) of 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.

Mesothelioma tends to be hard to treat, whether the cancer is resectable or not. It’s best to be treated by a team of doctors who have a lot of experience with mesothelioma. It's also very important that you understand the goal of treatment before it starts – whether it's 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

Most stage I and some stage II and III pleural mesotheliomas are potentially resectable, but there are exceptions. Whether a tumor is resectable is also based on the subtype (most doctors don’t believe that sarcomatoid tumors are helped by resection), where it is in the body, how far it has grown into nearby tissues, and if the person is healthy enough to have surgery.

Many people with resectable pleural mesothelioma have it removed by either pleurectomy/decortication (P/D) or extrapleural pneumonectomy (EPP). Surgery is more likely to have long-term benefits in early-stage cancers, where there's a better chance that most or all of the cancer can be removed. EPP might offer the best chance to remove the cancer, but it's a complex and extensive operation that's more likely to cause complications, and not all patients can tolerate it.

Patients with early-stage peritoneal mesotheliomas might also benefit from surgery to take out as much of the cancer as possible. This may be combined with heated intraperitoneal chemotherapy (HIPEC). Some patients have long remissions after this treatment. (This means the cancer is under control and not growing or spreading.)

Surgery may also be helpful for some later-stage cancers, but the benefits are more likely to last only a short time.

Sometimes, the surgeon may think the cancer is resectable based on imaging tests (like 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 like P/D (which is easier to tolerate) or even stop the surgery altogether if it’s not likely to be helpful. Treatment would then be the same as for unresectable mesotheliomas (see below).

Doctors are still studying whether giving chemotherapy (chemo) before surgery (called neoadjuvant therapy) or giving chemo and/or radiation therapy after surgery (adjuvant therapy) is helpful. Not all doctors agree on the best ways to use these treatments together. Some doctors prefer to give chemo, either before or after surgery. Radiation therapy might be used after surgery, either alone or along with chemo.

If you're not healthy enough to have a major operation, your treatment will be the same as for unresectable mesothelioma (discussed below).

If you have symptoms because of fluid buildup in the chest or abdomen (belly), other approaches such as thoracentesis/paracentesis or pleurodesis may be helpful. (These are described in palliative procedures.)

Because these cancers can be hard to treat, taking part in a clinical trial of a new, and maybe better, treatment may be another 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. This might be because of the extent or subtype of the cancer or because a person isn't healthy enough to have an operation.

Chemo is typically the main treatment for these cancers. It may ease symptoms and shrink or slow the growth of the cancer for a time. Sometimes chemo might be used along with a targeted therapy drug or with a device that creates electric fields in the tumor. Immunotherapy may also be an option for some people. Though these treatments may help people live longer, it’s very unlikely that they will cure these cancers. Before starting treatment, the goals of the treatment should be clear to you and your family.

In people with early-stage mesotheliomas that are likely to grow slowly and aren’t causing any symptoms, watching the cancer 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 new plan for treatment may be a reasonable option.

In many cases, treatment aimed at relieving symptoms and making you more comfortable is a good choice. This could include treatments that prevent or reduce fluid buildup in the body, such as thoracentesis/paracentesis or pleurodesis (described in palliative procedures). Sometimes pleurectomy/decortication can help with breathing and pain in the chest.

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

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 overall health.

In most cases the options will be a lot like those listed above for unresectable mesotheliomas. For example, chemo or radiation therapy might be used to try to shrink or slow the growth of the cancer and to relieve any symptoms. Because recurrent mesothelioma is hard to treat, clinical trials of new types of treatment may be a good option. For more on dealing with cancer that comes back, see Understanding Recurrence.