Multimodal means using more than one method or mode. Your doctor will probably recommend multimodal mesothelioma treatment options. Treatment of mesothelioma with just surgery or chemotherapy is usually not as effective as multimodal mesothelioma treatment that combines these two options with each other or with other therapeutic options.
What is Multimodal Mesothelioma Treatment?
Multimodal mesothelioma treatment options include surgery plus chemotherapy, chemotherapy plus radiation therapy, or all three of these treatments together. Your multimodal mesothelioma treatment may include cutting edge treatments such as immunotherapy or photodynamic therapy.
In multimodal mesothelioma treatment, one type of treatment is used to make another more effective. This approach to treating mesothelioma has been proven effective in clinical studies and in practice. Average survival times are often longer for those who receive multimodal mesothelioma treatment than for those who receive only one type of treatment.
Preventing Mesothelioma Metastases
For mesothelioma patients, as for many cancer patients, the most dangerous tumors are the metastatic ones. Multimodal treatment is a powerful tool to prevent your mesothelioma from metastasizing.
A mesothelioma diagnosis identifies the original tumor, where the cancer got started. Over time, without treatment, some cancer cells will break away and form new tumors. When these new tumors grow on other organs, your cancer has metastasized. If your pleural mesothelioma metastasizes to your throat, you will have metastasized pleural mesothelioma in your esophagus, not esophageal cancer.
These secondary cancer growths can be more lethal than the original tumors. Preventing metastases is a major focus of multimodal mesothelioma treatment. When your medical team attacks your tumor with two or more cancer therapies, the second treatment will kill many of the cancer cells that managed to survive the first treatment.
The fewer active cancer cells in your body, the smaller the chance that some will migrate to a new spot and create a metastatic tumor. The longer your cancer stays localized, the longer your mesothelioma survival time is likely to be. That’s why most mesothelioma patients receive some form of multimodal mesothelioma treatment.
Neoadjuvant treatments are performed before another treatment to make it more effective. A common type of neoadjuvant therapy is radiation or chemotherapy before surgery. These treatments reduce the size of the tumor and make the surgeon’s job less risky.
Your surgeon will have an easier time removing your tumor once it is shrunk by neoadjuvant therapy and may be able to be complete the operation more quickly. Because time spent under anesthetic is hard on your body, a shorter surgery will improve your recovery time.
Adjuvant treatments are the treatments that happen after another treatment, to amplify the effectiveness of the first treatment. Examples of adjuvant treatments are chemotherapy or radiation after surgery to knock out as many remaining cancer cells as possible. Radiation may also be used as an adjuvant therapy with chemotherapy, when surgery is not an option.
Intraoperative Mesothelioma Treatments
Some types of multimodal mesothelioma treatment take place in the middle of surgery. During surgery, radiation can be directed right at the cancerous cells without having to travel through healthy tissue to reach its target. Photodynamic therapy sheds light (literally) on the tumor during surgery (see below for more details on photodynamic therapy).
Surgery in Multimodal Mesothelioma Treatment
Mesothelioma surgeries can remove much or all of a mesothelioma tumor. Cancer cells are tricky, however. Surgeons can’t always see small nodules of cancerous cells that are not next to the main tumor or tumors. Multimodal mesothelioma treatment kills more cancer cells than surgery alone can remove. Studies have found that trimodality therapy, which follows surgery with both chemotherapy and radiation, can be very effective.
Mesothelioma is caused by free-floating asbestos fibers. When those fibers enter the body, they can cause mesothelioma as well as other diseases. The surgical options are different for each mesothelioma type.
The tiny asbestos fibers are usually inhaled, so almost three quarters of mesothelioma cases are pleural mesothelioma. Pleural mesothelioma is a disease of the pleura, which is the lining or mesothelium that surrounds and protects your lungs.
The second most common type is peritoneal mesothelioma. This form of the disease hits the peritoneum or the lining that encases the organs in your abdomen.
The remaining forms of mesothelioma are extremely rare. Pericardial mesothelioma affects the pericardium or lining around the heart. A primary tumor may form on the pericardium, but it can also be involved in pleural mesothelioma, if the cancer spreads from the nearby pleural tissue. There have been very few reported cases of testicular mesothelioma, which forms in the tunica vaginalis or lining around the testicles. This is an aggressive type of mesothelioma, but is also very treatable with surgery and tends to have the longest survival rate.
Extrapleural Pneumonectomy and Chemotherapy
The first surgery designed primarily for mesothelioma patients was extrapleural pneumonectomy or EPP. This is an intense surgery, requiring many hours in the operating room. The procedure removes the pleura, part of the pericardium, part of the diaphragm, and the lung that is affected by the mesothelioma tumor. After surgery, you will spend about two weeks in the hospital, followed by many weeks of recovery time at home.
Chemotherapy may be used as a neoadjuvant therapy before EPP, to reduce the size of the tumor and make it easier to remove. After surgery, chemotherapy may be used as an adjuvant therapy to increase the effectiveness of the surgical procedure by killing off cancerous cells that the surgery wasn’t able to eliminate.
Pleurectomy/Decortication and Intraoperative Multimodal Mesothelioma Treatment
Pleurectomy/decortication surgery or P/D has become the go-to surgery for pleural mesothelioma patients. Like EPP, this surgery involves removal of the pleura. Your surgeon might remove part of your diaphragm and your pericardium, if it appears the mesothelioma has spread. Instead of removing a lung, however, the decortication part of this procedure is a process of removing visible cancerous or potentially cancerous growths from the surface of your lung while your chest is open during surgery. P/D is a major surgery, but the recovery is easier than for EPP, because you still have two functioning lungs.
In addition to neoadjuvant and adjuvant chemotherapy, surgeons sometimes use either chemotherapy or radiation in the middle of your operation, as an intraoperative multimodal mesothelioma treatment. During surgery, while your doctor has direct access to the area of the tumor, radiation or chemotherapy drugs can be applied directly to the tumor area. Intraoperative treatments have been shown to be highly effective and they are increasingly common.
Cytoreductive Surgery and HIPEC
Peritoneal mesothelioma patients may receive cytoreductive or debulking surgery. The term cytoreduction means to lower the number of cancerous cells in your body. The surgery can only reduce the cancerous growth, not eliminate it, so multimodal mesothelioma treatment is vital with cytoreductive surgery.
Systemic chemotherapy has not proven effective in treating peritoneal mesothelioma. After cytoreductive surgery, you will probably receive a localized chemotherapy treatment called hyperthermic intraperitoneal chemotherapy or HIPEC. Chemotherapy drugs are heated and administered directly into your abdomen through a tube. The heat makes the drugs more effective.
Cytoreductive surgery combined with HIPEC is a common multimodal mesothelioma treatment for peritoneal mesothelioma.
Surgeries for Other Mesothelioma Types
A pericardectomy to remove the affected lining around your heart is the surgical treatment for pericardial mesothelioma. For testicular mesothelioma, surgery to remove the affected testicle is the most common and best first-line treatment. Chemotherapy and possibly radiation can make these therapies more effective.
Chemotherapy in Multimodal Mesothelioma Treatment
Almost every mesothelioma patient receives chemotherapy. At many mesothelioma stages, chemotherapy is an effective treatment for this form of cancer.
Chemotherapy Drug Combinations
Chemotherapy treatments often involve more than one drug. Carboplatin or Cisplatin, platinum-based chemotherapy drugs, are often combined with the enzyme-blocking drug Pemetrexed. Gemcitabine, which targets cells that split rapidly (as cancer cells do), is also used in combination with platinum drugs.
Radiation and Chemotherapy
Surgery is not always an option for mesothelioma patients. Chemotherapy combined with radiation can provide the next best efforts to prolong survival time.
Intrapleural Chemotherapy and HIPEC
HIPEC (hyperthermic Intraperitoneal chemotherapy) is a procedure that washes heated chemotherapy drugs through your abdomen. HIPEC is used in combination with debulking or cytoreductive surgery. Because the drugs are confined to the abdomen, this treatment may have fewer side effects than systemic chemotherapy treatments.
This technique is now also being used for pleural mesothelioma. Intrapleural perfusion of hyperthermic chemotherapy or ITH infuses heated chemotherapy drugs into the pleura or the lining around the lungs. This is a relatively new treatment and is often combined with surgery as a multimodal mesothelioma treatment.
Radiation in Multimodal Mesothelioma Treatment
Mesothelioma radiation therapy is almost exclusively used as part of a multimodal mesothelioma treatment plan. Radiation often increases the effectiveness of chemotherapy and can work as a neoadjuvant or adjuvant treatment with surgery.
There are two types of radiation therapy that you might receive.
External Beam Radiotherapy
External beam radiotherapy or EBRT delivers high intensity, focused x-ray beams that converge on your tumor. EBRT is usually delivered in cycles with multiple treatments in a row over a period of weeks.
Brachytherapy is also called sealed source radiotherapy or internal radiotherapy because small radioactive wires or seeds are inserted directly at the tumor site. This radiation treatment can be very effective because the radiation is placed so close to the target area.
Brachytherapy implants may be put in place temporarily and then removed. Another type of brachytherapy uses implants that stay in place but lose their radioactivity and become harmless over time.
New and Experimental Multimodal Mesothelioma Treatments
There are several new cancer treatments that offer promise for mesothelioma patients. These may be part of your multimodal mesothelioma treatment plan.
Photodynamic therapy or PDT can be used as an intraoperative procedure during mesothelioma surgery or in combination with chemotherapy. It is an innovative treatment that uses light to kill cancer cells.
For this treatment, you will be injected with a photosensitizing chemical that collects in your cancer cells. Then a cable with a light source will be inserted to reach the site of your mesothelioma tumor. The light will activate the chemicals to create a type of oxygen molecule that can eradicate cancer cells.
Doctors can also apply photodynamic therapy during surgery to remove your tumor. The photosensitive chemicals can be applied directly to the tumor site and the correct wavelength of light can be shined on the area.
The most powerful weapon your body has for fighting disease is your own immune system. Immunotherapy harnesses this power by helping your immune cells overcome cancer’s defense mechanisms. Because your immune system can focus on destroying foreign cells and leave healthy cells alone, this type of targeted therapy has the potential for fewer side effects than conventional chemotherapy.
Cancer cells use a variety of techniques to hide from the body’s killer immune cells. By analyzing a biopsy of your cancerous cells, your doctor can tell which trick your tumor is using to evade detection. That will determine which immunotherapy drug will work best for you. Immunotherapy drugs are not effective for every mesothelioma patient.
Chemotherapy and radiation are blunt instruments for attacking cancer. They can be very effective but they also damage some healthy tissue, leading to unpleasant side effects.
Because immunotherapy is new and still somewhat experimental, it is usually deployed as part of a multimodal mesothelioma treatment plan. Immunotherapy combined with traditional chemotherapy or radiation can attack your cancer from multiple directions, wiping out more malignant mesothelioma cells.
All the cells in your body need blood supplied by blood vessels and capillaries to get food and grow. Fast-growing cancer cells are especially hungry for a nourishing blood supply. Angiogenesis is the process of growing blood vessels. Angiogenesis inhibitors are drugs that slow or stop the angiogenesis process around cancerous tumors. Without the flow of blood and nutrients, the tumor begins to starve, enabling the malignant cells to die.
Angiogenesis inhibiting drugs such as Avastin are a promising new front in mesothelioma treatment. Angiogenesis inhibitors can weaken cancer cells, making them more vulnerable to traditional chemotherapy.
Multimodal Mesothelioma Treatment Side Effects
The side effects from multimodal mesothelioma treatment are the same as the side effects for each treatment by itself.
Killing cancer cells is tough work and all mesothelioma cancer treatments have some negative side effects. Your doctor will want to do a thorough check up to make sure you are strong enough to withstand a multimodal mesothelioma treatment.
After surgery, you can expect weakness, fatigue, and some post-surgical pain. You may have a tube in your incision to drain excess fluid for a period of time after surgery. You will need to take care of the incision while it heals to prevent any chance of infection.
During chemotherapy, you may lose your hair and you can feel nauseous, lose your appetite, or have diarrhea. Your doctor may prescribe some additional drugs to help you deal with mesothelioma chemotherapy side effects. If your chemotherapy is administered intravenously, you may have some pain or bleeding at the site where the drugs are injected.
After radiation treatment, you may have some localized pain or a skin rash at the site of the treatment. Radiation is usually not painful while it’s being administered and some people experience very few side effects from this treatment.