Most mesothelioma patients receive multiple forms of treatment. This is multimodal therapy. The benefits include individually tailored treatment plans and longer life span.
Multimodal Treatment of Mesothelioma
Multimodal treatment is important for every mesothelioma patient. A well-cited review in the European Respiratory Journal states that “it is clear that multimodal therapy is necessary to improve long-term results.” Mesothelioma specialists around the world agree: patients need multiple treatment modalities to reach long-term survival.
“Treatment modality” simply means “mode,” it’s a technical term used often by doctors to talk about the different modes of mesothelioma treatment.
Treatment modalities for mesothelioma include:
- Surgery. When this treatment is combined with one or more other modes, patients have the longest survival times. The type of surgery a doctor chooses depends on your mesothelioma type. It may also vary depending on other treatments you receive.
- Chemotherapy. Always the standard for systemic cancer treatment, chemotherapy is still an important part of mesothelioma treatment. In multimodal treatment, chemo may be given as part of a surgical procedure, radiation or both.
- Radiation. Often used before, during or after surgery. Doctors may also prescribe radiation as part of a multimodal treatment plan for patients who aren’t eligible for surgery.
- Emerging therapies. As researchers reach the limits of traditional treatment modes, they have looked for novel solutions. Emerging therapies could unlock the cure for mesothelioma. Combining emerging and traditional therapies increases this potential.
The Key Component of Multimodal Therapy
Mesothelioma specialists widely support surgery as the best treatment for long-term survival. After surgery, it’s easier for doctors to maintain and treat the remaining cancer.
Surgeries used in multimodal treatment include:
- Extrapleural pneumonectomy (EPP): Lung-removing surgery for pleural mesothelioma patients
- Pleurectomy with decortication (P/D): Lung-sparing surgery with similar survival rates as EPP
- Cytoreductive surgery: Surgical approach used by peritoneal mesothelioma surgeons
Several studies have shown that without a surgical multimodal approach, most patients have a survival time of about 12 months. The multimodal approach can double or triple this survival time.
The type of pleural surgery you receive depends on how your tumors have developed. Nowadays most surgeons are learning the lung-sparing approach. This is largely because of a 2008 study that showed little difference in survival benefits between P/D and EPP. The authors stated that “should be tailored to the extent of disease, patient comorbidities, and type of multimodality therapy planned.”
Multimodal surgical treatment are available in the VA. Veterans are eligible for treatment at one of the 2 VA hospitals that specialize in mesothelioma treatment: the LA and Boston VA Hospitals. The mesothelioma specialists at these centers are the best in the country. Those with VA healthcare can use their benefits to help pay for treatment.
Chemotherapy is often the first treatment a mesothelioma patient gets. Most patients receive a combination of drugs known as Alimta and cisplatin. This drug combination extends survival times by about 3 months. This helps create more time to develop a strong multimodal treatment plan. When combined with surgery, chemotherapy is significantly more effective.
Neoadjuvant and Adjuvant Chemotherapy
Surgical candidates often receive chemotherapy before or after surgery. The neoadjuvant method prescribes chemo before surgery. The adjuvant method prescribes it after. The goal of both methods is simply to make surgery more effective.
One study found that patients who had neoadjuvant chemotherapy and EPP had a median survival of 23 months. This is nearly double the median survival of all mesothelioma patients. The study also reported that, at the time of publishing, 2 patients still showed no signs of mesothelioma more than 38 months after treatment.
It’s unclear whether neoadjuvant or adjuvant is more effective. Patients need a specialist to determine the most effective chemotherapy type.
Many mesothelioma specialists use chemotherapy during surgery. This allows them to use larger doses without the risk of severe side effects because the drugs are injected into the bloodstream. Intraoperative chemotherapy is possible in pleural and peritoneal mesothelioma.
Dr. David Sugarbaker treated 72 patients using intraoperative chemotherapy from 2001 to 2009. He found that patients with the intraoperative chemo had a median survival of 35 months. These patients lived about 1 year longer than the patients who had surgery without intraoperative chemotherapy.
Peritoneal mesothelioma patients receiving intraoperative chemotherapy have even better survival times. A multicenter analysis of HIPEC (heated intraperitoneal chemotherapy) reported a median survival of 53 months. Over half of the patient recorded lived longer than 4 years after their treatment.
Choosing a cancer center that specializes in mesothelioma is the best way to improve your prognosis. A small study by mesothelioma cancer center reported median survival times greater than 8 years in patients who had HIPEC. They accomplished this through surgical experience and patient-tailored treatment.
Radiation is another important mode of treatment for mesothelioma. Radiation is used in both neoadjuvant and adjuvant methods.
Radiation is most commonly used as an adjuvant therapy. The purpose of following surgery with radiation is to prevent tumors from regrowing. A study of adjuvant radiation reported a median survival of 33 months. More than half of the patients who had surgery plus radiation lived even longer.
Though adjuvant radiation is common, the way specialists look at radiation is changing, because of a 2014 study. Mesothelioma specialists reported on a neoadjuvant radiation method that led to an 84% 3-year survival rate, and all patients in that study were in stage 3 or 4 of their disease. To put this in perspective, the average 2-year survival rate is less than 30% for late-stage mesothelioma patients.
The late-stage patients in the neoadjuvant radiation study were part of a trial called SMART. The acronym means “Surgery for Mesothelioma After Radiation Therapy.” Patients receive high doses of radiation shortly before their diseased lung is removed. Doctors are still testing this method, but the outlook for the future is positive.
Radiation plus chemotherapy is also a popular multimodal treatment plan for advanced mesothelioma. These patients are often ineligible for surgery. The addition of radiation to standard chemotherapy can extend survival.
The research on multimodal therapy is overwhelming in favor of combining different modes of treatment. It’s natural that doctors have been testing the combination of 3 modes rather than just 2. If surgery and chemotherapy are so effective, wouldn’t surgery, chemotherapy and radiation be best? The answer seems to be “yes.”
Back in 1999, doctors were already reporting patients who doubled their survival times with trimodal therapy. The method involved neoadjuvant chemotherapy and surgery followed by radiation therapy. The doctors also reported that carefully selected patients had even longer survival times. Those patients had median survival times of more than 4 years.
The research on trimodal therapy shows the survival benefit to surgical candidates. But it also highlights the importance of seeing a specialist. Mesothelioma specialists are familiar with this research and know which modes of treatment are most likely to help you.
The progress of traditional modes of cancer therapy have progressed slowly in mesothelioma treatment. Researchers have struggled to make chemotherapy and radiation more effective, which is why many doctors are turning to newer forms of cancer treatment.
Some emerging treatments used in multimodal therapy include:
- Immunotherapy. This treatment uses the immune system to fight mesothelioma cells in the body. It is beneficial for patients who aren’t responding to chemotherapy and those who aren’t eligible for surgery. It also causes few side effects. Doctors have used immunotherapy as a maintenance treatment after surgery with notable success.
- Gene therapy. Gene therapy, like immunotherapy, uses the body’s own mechanisms to fight mesothelioma. Gene therapy targets mesothelioma cells, leaving healthy cells unharmed. This treatment method is in clinical stages.
- Photodynamic therapy (PDT). This intraoperative treatment has led to survival times of about 3 years in patients with advanced mesothelioma. It involves a special light-activated drug to kill mesothelioma cells, and it’s applied during P/D surgery. It’s unclear for now whether the PDT or P/D was the main reason for success in that study.
Emerging therapies will, in all likelihood, make a major impact on the course of multimodal therapy for mesothelioma.
Getting Multimodal Therapy
Nearly every mesothelioma survivor received multiple modes of treatment. Whether it was intraoperative chemotherapy, neoadjuvant radiation or a combo of chemo and immunotherapy. One thing remains certain, long-term survival is unlikely without multiple forms of treatment.
Key facts about multimodal treatment:
- It leads to longer life expectancy
- Specialists may use different multimodal methods
- It can be aggressive or relaxed
For example, the Boston VA Hospital has mesothelioma specialists who use trimodality treatment while the LA VA Hospital may recommend surgery followed by immunotherapy. Patients ineligible for surgery commonly just receive chemotherapy and radiation. Talk to our VA-accredited representative to discuss your options and benefits now.