Chemotherapy is a common treatment for malignant mesothelioma, used to kill the cancer cells and prevent them from multiplying. Mesothelioma chemotherapy can be used alone or in combination with surgery. Researchers continue to study the effectiveness of new applications and chemotherapy drugs.
There are many chemotherapy drugs used for the treatment of mesothelioma cancer, though the standard first-line treatment is cisplatin or carboplatin with pemetrexed. Newer studies have shown success in combining chemotherapy and immunotherapy drugs, and surgery with a heated chemotherapy called HIPEC has become a popular treatment for peritoneal mesothelioma.
How Chemotherapy Treats Mesothelioma
Chemotherapy uses chemicals to kill cancer cells and prevent them from multiplying, halting metastasis, or the spreading of cancer. There are two methods of administering chemotherapy, which are often used as part of a multimodal treatment in combination with surgery and/or radiation therapy. When used prior to surgery, treatment is referred to as neoadjuvant chemotherapy, and when used after, is called adjuvant chemotherapy.
Systemic chemotherapy is given intravenously (through an IV) or in pill form. It then travels throughout the bloodstream to reach the entire body. As a result, fast-growing cells such as hair cells and healthy blood cells are also killed along with cancer cells, and this type of chemotherapy has the most treatment side effects.
Intraoperative chemotherapy is administered during surgery and is applied directly to the area where mesothelioma tumors have formed. With direct application, this type of chemotherapy doesn’t affect the entire body. As a result, intraoperative chemotherapy typically has fewer side effects than systemic chemotherapy.
First- and Second-Line Chemotherapy
Chemotherapy can be referred to as first-line, second-line or third-line, based on the order that it’s given and effectiveness. The preferred first-line chemotherapy treatment for mesothelioma is a combination of platinum-based cisplatin or carboplatin and pemetrexed. If patients are unresponsive to first-line cancer treatment, physicians will likely advise a second-line treatment option, which can vary from case to case.
Types of Mesothelioma Chemotherapy
Case studies continue to analyze the efficacy of different types of chemotherapy drugs and systemic chemotherapy applications, while also taking into account mesothelioma type, cell type, patient characteristics and staging.
Mesothelioma Chemotherapy Drugs
Oncologists will determine what chemotherapy drug is best for the patient, taking a variety of factors into consideration, including side effects. Chemotherapy drugs and dosage may be changed if the patient doesn’t respond well to treatment.
Pemetrexed, brand name Alimta, is one of the most common chemotherapy drugs used to treat mesothelioma and other cancers like lung cancer. Typically, it’s used in combination with a platinum-based drug like cisplatin or carboplatin. The drug is injected for administration and patients are often given corticosteroids, vitamin B9 (folic acid) and B12 supplements to combat common side effects. This has been shown to extend patient life expectancies by up to several months in many cases.
Cisplatin is a platinum-based chemotherapy drug, commonly used alongside pemetrexed, that is administered through an IV. Studies have shown that this combination can extend average patient survival to 12.1 months, compared to 9.3 months when used alone. In many cases, cisplatin is used on patients with tumors that cannot be surgically removed.
Carboplatin is another platinum-based drug, derived from cisplatin in the 1980s. It has not yet gained approval from the U.S. Food and Drug Administration (FDA) for the treatment of mesothelioma, but has for other cancers like breast cancer and ovarian cancer. Carboplatin typically has less side effects than cisplatin, and therefore may be a better option for some patients.
Gemcitabine, brand name Gemzar, is a less common chemotherapy drug that has been relatively effective in mesothelioma chemotherapy trials. This chemotherapy drug has been used as a first-line treatment in combination with a platinum-based drug, but has also been used as a second-line treatment option for patients not responding to other drugs.
Ranpirnase, brand name Onconase, was granted orphan drug status by the FDA in 2007, meaning it was developed specifically for treatment of a rare disease. Ranpirnase is an enzyme that has been shown in clinical trials to effectively kill mesothelioma cells by breaking down their RNA. This chemotherapy drug is unique in that it solely targets cancer cells without harming healthy cells, significantly reducing potential side effects.
Vinorelbine, brand name Navelbine, is a less common chemotherapy drug that is primarily used to treat non-small cell lung cancer, but has shown to be somewhat effective in treating mesothelioma. This drug triggers apoptosis, or programmed cell death, in cancer cells. According to the National Comprehensive Cancer Network (NCCN), vinorelbine can be used as a first- or second-line treatment for mesothelioma, thought it has not yet been FDA approved.
Mesothelioma Intraoperative Chemotherapy Types
Intraoperative chemotherapy is still being heavily studied through mesothelioma research. However, two types have shown success, including intrapleural chemotherapy and intraperitoneal chemotherapy (HIPEC).
Studies have shown that intrapleural chemotherapy can greatly improve symptoms and quality of life for malignant pleural mesothelioma patients by treating pleural effusion. Pleural effusion is fluid buildup around the lungs, which can cause a series of symptoms like difficulty breathing and chest pain. During the intrapleural chemotherapy procedure, fluid is typically removed from the pleural cavity (pleurodesis) through a test tube, which then inserts chemotherapy medication. The medication causes the lung to stick to the pleural lining, closing the pleural space and allowing the lungs to expand, which then improves breathing and reduces pain.
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Hyperthermic Intraperitoneal Chemotherapy (HIPEC)
HIPEC has shown much success in treatment plans for peritoneal mesothelioma. This type of treatment is typically performed after surgeries like a peritonectomy or cytoreductive surgery to remove affected parts of the abdomen and tumors. A heated chemotherapy solution, usually at 100 – 103 degrees, is pumped into the abdominal cavity, where it circulates for 1.5 – 2 hours, reaching all exposed areas to kill any cancer cells that may not have been removed during surgery.
As a targeted treatment, HIPEC doesn’t affect other areas of the body and often has fewer side effects than systemic chemotherapy. It has also been shown to greatly extend life expectancies for some patients. For example, in one recent study of 42 patients, cytoreductive surgery combined with HIPEC demonstrated a 5-year survival rate of 44%. Another 58 patients treated with intraperitoneal chemotherapy (EPIC) and HIPEC demonstrated a 5-year survival rate of 52%. Of 29 patients treated with HIPEC, EPIC and normothermic intraperitoneal chemotherapy (NIPEC), the 5-year survival was 75%.
Chemotherapy Side Effects
Mesothelioma patients may face many adverse side effects to mesothelioma treatment. Most side effects subside when treatment concludes, though in some cases may last for years after.
- Chemo brain: Patients may experience memory loss or inability to focus and multitask. This is often improved with exercise, a healthy diet, establishing routines and memory exercises.
- Hair loss: Many chemotherapy drugs target fast-growing healthy cells, including hair cells, causing hair loss.
- Low blood cell counts: As chemotherapy targets fast-growing cells, it can also kill red blood cells and white blood cells, lowering the body’s immune response and reducing the flow of oxygen throughout the body. This may lead to the potential for infection, easy bruising and bleeding and fatigue.
- Mouth sores: Mouth sores, also referred to as mucositis, are caused by an inflammatory reaction of the mucous lining of the gastrointestinal tract. They can also affect chewing, swallowing and taste, and can be managed with pain medication.
- Nausea/vomiting: As chemotherapy drugs circulate through the bloodstream, they can cause nausea and vomiting. Anti-nausea medication is typically administered.
It’s crucial for patients to report chemotherapy side effects to their physician for many reasons. There may be other chemotherapy drugs with less side effects available, side effects may offer insight into the efficacy of the chemotherapy and there may be palliative options available to offer relief and a higher quality of life to patients undergoing treatment.
Author: Linda Molinari
Editor in Chief, Mesothelioma Cancer AllianceRead about Linda
Reviewer: Annette Charlevois
Patient Support CoordinatorRead about Annette
American Cancer Society. Chemotherapy for Malignant Mesothelioma. Updated February 2016.
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Sugarbaker PH and Chang D. Long-term regional chemotherapy for patients with epithelial malignant peritoneal mesothelioma results in improved survival. European Journal of Surgical Oncology. July 2017;43(7):1228-1235. doi: 10.1016/j.ejso.2017.01.009
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