Malignant Mesothelioma Treatment Therapies
If you have been diagnosed with malignant mesothelioma it is imperative that a ‘specialist’ respiratory physician; and if applicable, an oncologist and thoracic surgeon conversant in asbestos related diseases be consulted.
Malignant mesothelioma is mainly initially diagnosed in one of two areas of the body, in the chest cavity (pleural and/or pericardium), or in the stomach area (peritoneal) – it can be initially diagnosed in both areas, but this is rare. Many people wrongly believe, when talking about malignant pleural mesothelioma (MPM), that it is lung cancer. MPM is a cancer of the lining that surrounds the lung, it is not classed as lung cancer – they are totally different cancers. This is particularly important to understand and remember if you are on social media or are reading media reports – malignant mesothelioma, of any form, is not lung cancer.
This page covers the following:
- Pain Control
- Immunotherapy [including Keytruda]
First and foremost, not everyone who is diagnosed with any of the forms of mesothelioma suffer pain – it is quite common to hear of sufferers who go through their entire journey without suffering any significant short-term or long-term pain. This may be because they have no or little pain, or it may be because what pain they do have is well controlled.
Pain is often equated with Malignant Mesothelioma, in particular Pleural Mesothelioma. In fact it is often pain that unknowingly signals the onslaught that is mesothelioma. For many diagnosed with Pleural Mesothelioma, the first pain experienced is a pain in the back around the lower region of the shoulder blade. Many people believe it is the actual mesothelioma tumours or sheet of tumour masses that are where the pain is coming from, when in fact the pain is caused by the tumours hitting or pressing on a subset of nerves and causing referral pain. Pain can also be caused by tumours restricting room in the pleural cavity and making it hard to breath, or any of a number of other reasons.
Is pain controllable? In the vast majority of cases pain is controllable, the pain control of choice is normally morphine based drugs either given in a tablet, liquid (oral) or intravenous form (needle or drip), or in the form of a patch. Some sufferers cannot handle morphine based drugs, and find it makes them go ‘spacey’ or ‘high’ – an alternative is using methadone based drugs……… this is a genuine alternative drug that doesn’t seem to be readily known or talked about.
An alternative pain controlling treatment option is the possibility of nerve blocking or similar surgery. This is something that should be discussed fully with your either your treating specialist and/or a pain management specialist.
Much the same as a sufferer should look at a specialist oncologist, he or she should also request the services of a pain control specialist to best advise them if pain becomes an issue.
Chemotherapy is the most common treatment for mesothelioma, and is the only form of drug therapy listed for treating malignant mesothelioma, by the relevant authorities, worldwide. Chemotherapy drugs can be given by mouth or injection. Because the medicines travel through the blood stream to the entire body, chemotherapy is considered a body-wide (systemic) treatment.
Chemotherapy may be used to:
- Assist in attempting to keep the cancer from spreading
- Ease symptoms of the cancer
Chemotherapy medicines usually target cells that quickly divide. However, normal cells – including those found in the blood, and the lining of the gastrointestinal tract also divide very quickly. That means chemotherapy can also damage or kill these healthy cells. When this occurs, side effects such as nausea and anaemia can occur. Other side effects that are commonly experienced are fatigue, nerve pain, infection, changing bowel habits and rashes.
The most common chemotherapy drugs used in Australia (and around the world) to treat malignant mesothelioma are:
- *Cisplatin (a platinum based chemotherapy)
- *Carboplatin (a platinum based chemotherapy)
- *Alimta (= pemetrexed)
- Gemcitabine (superseded by Alimta in 2008 as an adjunct to either of the platinum based chemotherapies – but can still be used as an alternative to Alimta – but is not covered by the PBS, and does cost in the low $100s per dose)
*These are the only chemotherapies (or indeed any drug therapies) registered by Australia’s Therapeutic Goods Administration for treating malignant mesothelioma; they are also the only drugs listed on Australia’s PBS (Pharmaceutical Benefits Scheme – commonly called the free list) for treating malignant mesothelioma. This is the case in all countries that have similar authorities and run similar schemes.
They are normally given in combinations of either:
- Cisplatin + Alimta*
- Carboplatin + Alimta*
- Cisplatin + Gemcitabine*
- Carboplatin + Gemcitabine*
- Alimta (can be, and is used as a stand alone last resort therapy)
Note: Cisplatin or Carboplatin given in conjunction with Alimta at 3 week intervals for a course of 4 up to 6 treatments, is the standard 1st line mesothelioma treatment throughout the world. Normally a sufferer will have a Hi Resolution CT scan before either the fourth (4th) or fifth (5th) treatment to see whether or not the chemo is working – before the fourth (4th) treatment is the most common, but this will be a decision the treating oncologist will make depending on a number of factors. Every suffer responds differently to chemotherapy, so it is important you be guided by the specialist treating oncologist.
*These combinations are normally given with a steroid drug called Dexamathasone which is given to aid in alleviating the side effects of the treating chemotherapies.
Generally a sufferer could expect, the side effects of the above chemopherapy treatment combinations, would not be as severe as some other chemopherapy treatments regimes. The main side effects sufferers seem to experience are medium range nausea, constipation and fatigue. Losing hair is not a common or standard side effect. Dexamethasone is normally given to combat the fatigue along with anti-nausea drugs. Your oncologist will also either prescribe or recommend drugs to combat the constipation.
Immunotherapy is a relative new class of drug that is designed to switch on, or re-activate the sufferers own immune system. As with chemotherapy, the medicines travel through the blood stream to the entire body, and therefore are considered a body-wide (systemic) treatment. An important factor with this class of drug is that compared to chemotherapy treatments, in the main sufferers do not report experiencing as many harsh side effects – however, some have had severe adverse side effects. The down side is, being a relative new class of drug, immunotherapies, none have found to be the ‘Holey Grail’ for use in treating mesothelioma.
Please remember, if you are on social media or are reading media reports – malignant mesothelioma, of any form, is not lung cancer.
An Overview of Immunotherapy
Mesothelioma oncologist Dr Tom John says, ‘Physicians should be cautiously optimistic.’
Assoc Prof Tom John is one of the leading mesothelioma clinical oncologists and researchers in Australia. He is based at the Oliver Newton John Cancer Centre in Melbourne, Victoria, Australia. His observations on the new wave of immune checkpoint inhibitors (immunotherapy drugs such as Keytruda) were published in the ASCO Connection magazine 13 October 2016 under the heading: Outlook on Immunotherapy Treatment for Mesothelioma
Extract quoted in part:
“We finally have some drugs that are showing great promise in mesothelioma, but they do not work in everyone,” he said. “We need to temper our enthusiasm so that we can figure out exactly who benefits from these drugs and determine whether there is a way to manipulate the immune response to also help those that don’t benefit.”
More trials are necessary to determine exactly what mechanisms work in different forms of mesothelioma and in other malignancies. “It is important that we generate data and don’t just use immunotherapies on everyone without asking questions. If we can do that, I have no doubt that we will continue to see improvements and hopefully turn mesothelioma into a chronic disease,” he said.
“Clinical trials are the only way of determining the best therapeutic options for patients,” Dr. John said.
There are a number of different immunotherapy drugs seemingly doing similar things, but the one common factor they all have at this stage, is none are approved for treating mesothelioma.
Discussion, mainly animating from social media, about the fact immunotherapies have not been put on the Australian Government’s Pharmaceutical Benefits Scheme (PBS) for treating mesothelioma, seems to be brought up in repetitive cycles. There are a number of very good reasons why they have not been put on the PBS:
- First and foremost the Australian Government’s Therapeutic Goods Administration has not listed any immunotherapies as a treatment for mesothelioma – it is doubtful that any drug company has applied for them to do so.
- Secondly, it is not believed any drug manufacturer has applied for immunotherapy drug to be on the PBS – if the manufacturer does not apply, the government can’t even consider it!
Naturally, we are all hopeful an immunotherapy drug may be found to be a candidate for listing on the PBS. Trials are being conducted in Australia and around the world of combining new generation drugs with existing chemotherapies to try to find the elusive ‘Holy Grail’ for treating malignant mesothelioma.
The Importance of Having an Oncologist Specialising in Mesothelioma
With the rapid changes in the world of possible new treatments being used and trialed, the best way to keep up, is not to ‘Doctor Google’, but to be under the care of an oncologist who is a specialist in the field of malignant mesothelioma and who is up to speed with the latest research.
Radio interview concerning immunotherapy
Take 15 minutes out to listen to this radio interview, Rod Smith, the Bernie Banton Foundation’s former Support Co-ordinator, participated in concerning Keytruda on the 26th May 2016.
Radiotherapy is more commonly used in the treatment of malignant pleural mesothelioma. It may be used as a ‘stand alone’ treatment, or in conjunction with radical surgery, chemotherapy or immunotherapy. It can also be used as palliative treatment to relieve pain issues and the like – this is most common where drug therapies have failed or cease to have an impact.
Radiotherapy is not a body-wide (systemic) treatment, it is a targeted therapy, in other words the treatment is concentrated on one area. Whilst the good thing with this, compared to chemotherapy, is that it is targeting a specific area, rather than spreading toxic substances (chemotherapy) thoughout the entire body – the downside is, whilst it is a targeted treatment, it is at the same time weakening the entire immune system, which may allow or even encourage the mesothelioma cancer to spread.
Radiotherapy can induce severe side effects, including inflammation of lung tissue. Before embarking on a course of radiotherapy, questions should be asked about the likely short and long term side effects.
There are a number of trials around the world currently trialing the use of radiotherapy in conjunction with chemotherapies and/or immunotherapies.
OVERVIEW OF TREATMENT THERAPIES
Unfortunately, chemotherapies are still the only ‘authority’ acknowledged 1st line of treatment for malignant mesothelioma, however with the advent of immunotherapies, whilst, in the main not comprehensively trialed, there are now alternatives that are in some cases showing improvement in the length and quality of life. However, they are not devoid of having, or showing no results, or even negative results – but they are at least another source of providing ‘hope’. The use of radiotherapy has not changed dramatically over the last years, but is now being further looked at in relation to use with other therapies and surgery options.
Supportive Care Options
Supportive Care Options is about maintaining or improving quality of life for sufferers of asbestos or dust related disease, at the same time allowing their loved ones to also have a quality of life during all stages of the disease. It is about working out what support and care options are available, and then putting in place strategies to help sufferers and their loved ones navigate the journey ahead in the best possible way.
Supportive Care Options should be discussed as soon as possible after diagnosis with your treating physician, hospital social worker or other care providers. You should also talk immediately with a specialist asbestos dust litigator regarding possible compensation.