Two new approaches to the treatment of Mesothelioma have been highlighted in a recent article by Discovery's Edge (Mayo Clinic's Online Research Magazine). The information in this article is very encouraging and provides some insight into the direction of some potential new treatment options.
- Mesothelioma Chemotherapy
- Mesothelioma Radiation Therapy
- Mesothelioma Surgery
- Mesothelioma Immunotherapy
- Mesothelioma Photodynamic Therapy
- Mesothelioma Gene Therapy
- Mesothelioma Alternative Therapy
- Mesothelioma MultiModality Therapy
- Heated Intraoperative Intraperitoneal Chemotherapy
There are numerous options for treatment for a mesothelioma victim. After being diagnosed with mesothelioma, the next step for the physician would be to determine the stage of involvement of mesothelioma. Depending on the staging, this can impact what treatments are available.
Chemotherapy is commonly used to treat mesothelioma. At the most basic level, chemotherapy is merely the attempt to treat a disease process using chemical agents. In mesothelioma patients, the purpose is to use chemicals to kill cancerous cells. Chemotherapy can also be used to describe the use of antineoplastic drugs to treat cancers. Chemotherapy can also refer to the combination of such drugs to create a standard treatment regimen which is cytotoxic, or lethal to the intended cells.
Regardless of the protocol, the goal of chemotherapy is to kill cells as selectively as possible. Typically, the chemical agents in chemotherapy are designed to attack and destroy cells that are rapid dividers, i.e., multiply quickly. This rapid division is a hallmark of most malignant cancers, which allows the drugs to target the cancerous cells. One of the drawbacks, however, is that the chemicals do not discriminate between rapidly dividing cancerous cells, and rapidly dividing healthy cells. Some types of cells in the body which divide rapidly under normal circumstances, and can be affected by chemicals in chemotherapy regimens, include cells in the digestive tract, hair follicles, and bone marrow. This is often the reason why common side effects of chemotherapy include hair loss (alopecia), inflammation of the digestive tract (mucositis), and decreased blood cell production (myelosuppression).
Another method in which chemotherapy drugs can affect cancerous cells is by causing the cell to kill itself. All cells have a pre-programmed lifespan, and also have triggers which may be activated to cause that cell to die. These triggers activate a process called “apoptosis,” which basically means the cell undergoes a programmed death.
Chemotherapy is most effective when it is used in the early stages of cancer, including mesothelioma. This is because at these early stages, the cancerous cells are dividing more rapidly and the cells are usually well-differentiated and uniform. As the tumor grows, the cancerous cells become diffuse and less receptive to the chemotherapy chemicals. In addition, as the tumor grows, the cells at the center do not divide as quickly so the chemicals do not target them. The tumor may also become so dense that the chemicals cannot reach the center of the tumor. New research has also uncovered that in some older cancerous cells, the cell walls have pumps which draw the chemicals out of the cell.
There are three general types of chemotherapy:
- Neoadjuvant Chemotherapy: This type of chemotherapy is designed for cancer patients who are in the initial stages of cancer. It is referred to as pre-operative treatment. The purpose is to reduce the size of the tumor so that other interventions can be made, such as surgery.
- Adjuvant Chemotherapy: This type of chemotherapy is designed for patients who have undergone a surgical resection of a tumor, or have had cancer removed. This type of chemotherapy is often referred to as post-operative chemotherapy. Adjuvant chemotherapy is intended to ensure that any cancerous cells which remain after removal of the primary tumor are destroyed. It is also used to ensure that any cancerous cells which may have spread before surgical intervention, or which were merely missed, are destroyed.
- Palliative Chemotherapy: In some cases, cancer may be far too advanced for chemotherapy, or another type of intervention. The intent of palliative chemotherapy is not cure the cancer, but rather reduce the size of the tumor(s) by as much as possible in an attempt to increase life expectancy.
Before it can be determined what kind of chemotherapy treatment a mesothelioma patient will receive, it must be determined how well the patient can tolerate such treatments. Chemotherapy is what is known as a fractional kill drug. In each treatment, only a fraction of the cancerous cells are killed. This means that chemotherapy must be administered in numerous, successive doses, usually called “rounds.” The determination of the length of those rounds, and their frequency, is usually dependent on the tolerance of the patient.
There are several specific types of chemotherapy treatments which are used for mesothelioma victims. Usually, the chemotherapy drugs are administered in pairs. Types of chemotherapy drugs which may be indicated, include:
- Alimta®: This drug is specifically designed for the treatment of pleural mesothelioma. It carries FDA approval for that purpose, to be used in conjunction with Cisplatin, though it must be taken with vitamin B12 and folic acid as Alimta® interferes with the body’s absorption and use those nutrients. The Alimta®/Cisplatin regimen works by targeting the enzymes which the cancer cells require for DNA replication and cellular division. The patient should also receive an oral steroid which will guard against the development of skin rashes or other potential side effects.
- Cisplatin: This a platinum based chemotherapy drug. It is commonly used with Alimta® in treating mesothelioma. The Alimta®/Cisplatin combination will be administered every 21 days. The typical treatment regimen calls for an IV infusion of Alimta for approximately 10 minutes, followed by intravenous infusion of Cisplatin for approximately 2 hours. This again will depend on the patient’s tolerance of the drug and the staging of the cancer. The specific number of rounds of treatment required will be based on the cancer’s responsiveness to the drugs.
Any one of these drugs, or a combination of drugs, may be used to treat a mesothelioma patient. The determination of which drugs will depend on the type of mesothelioma the patient is suffering from, the stage of the mesothelioma, and the patient’s ability to handle the treatments associated with the drugs. The chance of success of the drugs will also depend on the stage of the mesothelioma, and the patient’s general well-being aside from a cancer diagnosis.
There is an additional treatment, called Heated Chemotherapy, there is mainly indicated for use with peritoneal mesothelioma patients. This involves the administration of heated chemotherapy drugs directly into the peritoneum after surgery to remove tumors.
COMMON SIDE EFFECTS OF CHEMOTHERAPY
Due to the fact that chemotherapy targets cells and either causes their death by damaging them or by triggering their programmed death, there is the potential for side-effects when those drugs attack non-cancerous cells. As most chemotherapy drugs attack rapidly dividing cells, those normal, healthy cells in the body which are rapid dividers can often be targeted as well, causing side-effects which many people have come to associate with chemotherapy. Given that chemotherapeutic drugs seek rapidly dividing cells, those normal, healthy cells which divide the fastest will be the first affected. These include cells in the hair follicles, digestive system, and immune system.
Common side effects include:
- Immuno-Depression/Immunosuppression: This is a weakening of the immune system. This can be a lethal condition because it exposes the body to infections that a healthy person with a normal immune system could fight off. Patients undergoing chemotherapy are warned to avoid potential sources of infection and stay away from people who may be sick, most infections are the result of organisms which always existed in the patient, but until now could be kept at bay by their immune system. If the immune system becomes severely depressed, a patient may be prohibited from continuing chemotherapy until it recovers.
- Myelosuppression: This is a rare side effect which occurs when the bone marrow stem cells of the patient are damaged or destroyed. The bone marrow stem cells are responsible for producing white and red blood cells. The only treatment available for this condition is an autologous bone marrow cell transplant, or an allogenic bone marrow transplant. Autologous bone marrow transplants refers to a procedure where a patient’s own bone marrow cells are extracted, multiplied, and then re-introduced after multiplication. An allogenic bone marrow transplant means the bone marrow cells came from a donor source.
- Fatigue: Cancer, by itself, can lead to fatigue as the body attempts to fight the illness. Chemotherapy drugs can enhance this effect, and leave the patient in an exhausted state. In some cases, anemia can result. In those cases, physicians will administer secondary drugs to boost production of blood, and will administer nutrient supplements or blood transfusions.
- Decrease in Platelets / Bleeding: Due to the fact that chemotherapy kills rapidly dividaing cells, it can have a negative effect on platelet creation and blood creation, both of which are rapidly dividing. Platelets are responsible for coagulation of the blood and a reduced number could result in excessive bleeding or bruising. In some cases, patients will receive transfusions to boost platelet counts, while other patients may have their chemotherapy treatments halted to allow for platelet counts to increase.
- Gastrointestinal Problems: A common side effect associated with chemotherapy treatments are nausea and vomiting. This may also include bouts of diarrhea or constipation. As a result of these conditions, the body may not be able to adequately absorb and utilize nutrients. A patient may become malnourished or dehydrated. A common side effect of this is weight loss. A patient may also be prone to gaining weight, if certain steroid medications are administered or if the patient overeats in an attempt to counteract some of the gastrointestinal side effects. These effects can be limited or resolved by certain medications, called antiemetics. A patient should eat a properly balanced diet, however, and consume plenty of water, clear liquids, or fortified teas to assist the body in processing nutrients.
- Loss of Hair: This is a commonly noted side effect of chemotherapy. As chemotherapy attacks rapidly dividing cells, hair follicles, as some of the most rapidly dividing cells in the body, are often victim to the medication. Hair loss may range from complete hair loss, to a mere thinning of hair. The medication does not destroy the follicles, however, and hair should begin to regrow a short time after the last treatment.
- Heart Damage: Chemotherapy can cause cellular damage to heart muscle, which could impede function, though this side effect is rare.
- Kidney / Liver Damage: Chemotherapy, and its bi-products, can also cause damage to the Kidney and Liver as those materials are processed out. Chemotherapeutic drugs can also direct damage to the cells of the kidney and/or liver resulting in impaired function.
- Damage to Inner Ear: Chemotherapy can also cause damage to the inner ear, which can lead to disorientation, vertigo, or trouble maintaining balance.
- Secondary Neoplasm: In rare cases, a secondary tumor can grow as a result of chemotherapy. These are called secondary neoplasms, and while rare, they are typically an offshoot of the malignant tumor, or can be unrelated tumors.
- Infertility: Certain chemotherapy regimens have the risk of rendering the patient infertile. This side-effect is usually limited to certain classes of drugs, and is usually not a concern for the majority of mesothelioma patients.
- General Side Effects: Some generalized side effects which can be associated with chemotherapy include:
- Cognitive Impairment
- Damaged Fingernails
- Dry Mouth
- Generalized Allergic Reactions
- Generalized Pseudo Allergic Reactions
- Reddened Skin
- Water Retention
The length of time a patient spends on chemotherapy will depend on several factors. These include how well the tumor responds to the chemotherapy, how well the patient is able to tolerate the chemotherapy, and what kind of chemotherapy is being performed. For example, if the tumor is not affected by chemotherapy, it is not likely the patient will remain on the regimen. Similarly, if the side effects are too great, a patient will not typically be kept on the chemotherapy. Additionally, when palliative chemotherapy is prescribed, the purpose to provide an extension of survivability, not a cure to the tumor, and as such, the time frame is dictated by the needs and counsel of the patient and their family.
These questions can be further answered by a mesothelioma specialist after considering the various factors specific to your diagnosis. If you would like to find a mesothelioma specialist near you, please click here. If you would like to find a mesothelioma treatment center near you, please click here. To speak with one of our attorneys for a free, no obligation consultation about the legal remedies available to you, please use or Contact Form, or call us at 1-877-455-6376.
Radiation therapy is generally indicated for patients with non-advanced mesothelioma. Radiation therapy involves sending high-energy radiation, typically directly at the tumor site, in an attempt to shrink the tumor and/or kill the cancerous cells. Typically, the types of radiation used is X-Rays and Gamma Rays, though other types of particles may also be used. It is among the older types of treatments for mesothelioma, and it is not, alone, a curative intervention. Radiation therapy is commonly used as part of a course of chemotherapy and surgical interventions. It is estimated that almost half of all cancer patients will have some type of radiation therapy.
ADMINISTRATION OF RADIATION THERAPY:
The radiation may be introduced in several ways:
- External Beam Radiation Therapy: This type of treatment is just as the name implies. This type of therapy is typically administered as a “photon” beam, applied by a machine. The machine that typically delivers the dose is called a Linear Accelerator (LINAC). The LINAC is able to create incredibly fast moving streams of particles which in turn generates the high-energy radiation needed to treat cancerous cells. This type of treatment will typically be done a daily basis, throughout several weeks, depending on the dose prescribed.
- 3-Dimensional Conformal Radiation Therapy (3D-CRT): This type of radiation therapy is more common than any other type of external beam therapy. Through the use of computer enhanced software, this treatment can administer the proper doses of radiation in a specific, non-typical pattern to treat the desired areas.
- Intensity-Modulated Radiation Therapy (IMRT): This type of radiation therapy involves several hundred tiny devices which shape the radiation. These devices are a called collimators. The effect is the focusing of a single dose of radiation. The collimators can remain fixed, or can move, to allow different doses or intensities of radiation to be applied. This allows for there to be differing doses applied to different areas of the selected area over the course of the same treatment. This type of therapy uses a computer to calculate the areas which are to receive the highest doses, and those with lowest doses. The computer can then direct the doses and angles of the radiation therapy to ensure that those areas which are the least affected do not receive unnecessarily high doses of radiation. A drawback of this type of therapy, however, is that more tissue is treated with radiation than with the 3D-CRT.
- Image-Guided Radiation Therapy (IGRT): This type of treatment uses imaging technology (CT, PET, MRI, etc) on an ongoing basis to provide more focused treatment of the tumor and cancerous cells. Imaging scans are done as the treatment progresses, and the internal computer then calculates the areas which have been effectively treated so that less, if any, radiation is applied to those areas where the tumor or cancerous cells have been eradicated. These scans allow the oncologist to continually evaluate the success of the treatment, and assist in programming the computer for those areas which are still affected.
- Tomotherapy: This is a hybrid type of radiation therapy that combines elements of IGRT and IMRT. A tomotherapy machine contains its’ own scanner and the equipment necessary to create the external beams. This allows for the oncologist to take scans immediately before treatment to assist in directing the doses to treat the tumor and surrounding tissues.
- Sterotactic Radiosurgery (SRS): This is a method of radiation therapy which generates one, or several, extremely high doses of radiation to a tumor. The goal is to be able to target the tumor with pinpoint accuracy so that the tumor receives the highest dose of radiation, and the surrounding areas are spared. Due to this fact, however, this type of radiation therapy is generally only indicated when the tumor is small and well defined. During this type of treatment, due to the fact that high doses of radiation are used and a very small area is being targeted, a patient will typically be immobilized.
- Stereotactic Body Radiation Therapy (SBRT): This is a specific type of radiation therapy that is restricted to small, isolated tumors. Usually, this is an early-stage cancer treatment. This method uses higher doses of radiation but allows the patient fewer sessions of treatment.
- Proton Therapy: This is another delivery mechanism for radiation therapy. The advantage to proton beams over photon beams is that proton beams typically direct their energy at a specific point at the end of the stream. The goal is to reduce the amount of surrounding tissue which receives radiation.
- Electron Beams: This is a type of treatment using a different particle, but does not have the ability to travel deep within the body and is restricted to near-surface or surface tumors. For this reason, mesothelioma patients will not typically be treated in this manner.
- Internal Radiation Therapy (Brachytherapy): This type of treatment is internalized in that radioactive material is placed near the site of the tumor or cancerous cells, if possible. Typically, the radioactive materials, commonly isotopes, are encased in “pellets” or “seeds” which are then inserted in the body at the desired source using needles, catheters or another device. As the materials decay, their radiation naturally causes the damage of the nearby cancerous cells. Eventually, the isotopes will decay, and no further radiation will be released. The “pellet” or “seed” vehicles will not cause any permanent damage to the body and can be left there. This therapy is attractive because it can be placed directly in situ (on site) in the tumor and can yield higher doses of radiation that external beams and can have less damage on surrounding tissue. It can be administered, however, as a high dose treatment, or low dose treatment. Additionally, the placement of the sources of radiation can be permanent (when the “seeds” or “pellets” are left in the body) or temporary (when the “seeds” or “pellets” are removed from the body). Brachytherapy is a common treatment for patients suffering from mesothelioma.
- Interstitial Brachytherapy: In this method, a radioactive source will be physically placed inside the tumor.
- Intracavity Brachytherapy: This method involves placing a radioactive agent in the body cavity near the tumor. In pleural mesothelioma, for example, a radioactive substance may be placed within the pleura near the tumor.
- Systemic Radiation Therapy: This is a secondary type of internalized radiation therapy. This method uses radioactive materials, like radioactive iodine, which are then placed into the blood to travel to the cancerous cells and kill them. Typically, the patient will swallow the substance, or it can be injected directly into the blood stream.
In those instances where a machine will be directing the administration of radiation, a patient will generally have several consults before actually beginning treatment. In these instances, the patient will usually have a CT Scan performed of the affected area of the body so the precise location of the cancer can be pinpointed. Due to the fact that it will be a machine directing the radiation at the cancer, it is crucial that the patient be positioned properly within the machine every time, or radiation will miss the tumor and impact healthy cells.
The patient will typically go through a process called, “simulation,” which involves a dry-run of getting the patient properly positioned for radiation therapy. During this process, the CT Scans (or MRI, PET, Ultrasounds) will be analyzed so that the tumor, and the healthy tissue around it, can be visualized. Because positioning is so crucial, patients will often have body molds, masks, soft restraints or other items crafted to ensure the patient is still. Additionally, patients may have temporary or permanent body marks or tattoos placed on them so they can be put in the same position each time. Radiation therapy will, however, be directed at both the tumor, and a small amount of healthy tissue surrounding the tumor. This is for two reasons:
- To ensure that the entire tumor is treated – the body may move due to breathing during treatment, and the tumor may shift in between treatments as the organs move in the abdominal cavity
- To ensure that any cancerous cells which may have been released from the tumor to the surrounding tissue are also eradicated by the radiation
After this process is completed, the oncologist conducting the treatment will determine the proper dosage. This is largely dependent on the type of cancer, and where it is located. The proper dosage of radiation (measured Grays – Gy = amount of radiation energy which is on average absorbed by a kilogram of normal human tissue) is essential. Certain cancers require higher doses of radiation to be eradicated. Similarly, different tissues of the body respond to levels of radiation in different ways, i.e., some are more sensitive to its effects than others. Partly due to this reason, a patient may only be able to have on radiation treatment in their lifetime. This will depend on the dosage administered, and what the maximum lifetime radiation exposure level for that body part is.
This will also effect the type of radiation therapy which is administered. To determine the proper intervention, an oncologist will consider:
- Type / Size / Location of Cancer
- Tissues near the cancer and their sensitivity to radiation
- How deep the tumor is located / How far must radiation penetrate
- Patient’s Health / Medical History / Associated Conditions
- Other types of Cancer Treatment Patient is Expected to Receive
The effect of radiation therapy is that the radioactive particles damage the cellular DNA of the cancerous cells. The radioactive components will either directly harm the cancerous cells’ DNA, or it will create particles within the cells, called “free radicals,” that will damage the DNA of the cancerous cells. The effect being that cells, cancerous or not, with a damaged DNA structure cannot divide and will die.
There are generally two types of Radiation Therapy:
- Curative Radiation Therapy: In this instance, the intent is to cure the cancerous growth, i.e., kill the tumor and then attendant cancerous cells. It may also be for the purpose of shrinking the tumor so that it can be removed. The focus in curative radiation therapy, however, is to remove the cancer, or reduce it to a size where it can be removed, so that the patient may recover.
- Palliative Radiation Therapy: In some cases, cancer may be far too advanced for radiation therapy, or another type of intervention, to kill the cancer completely or effectuate its removal. The intent of palliative chemotherapy is not cure the cancer, but rather reduce the size of the tumor(s) by as much as possible in an attempt to increase life expectancy. It is also used to reduce the side effects that a tumor may be causing, i.e., pleural mesothelioma may cause intense pain or difficulty breathing, and radiation therapy may be able to shrink the tumors to provide some relief, though radiation therapy will not be able to kill the tumor.
It should be noted that in some types of brachytherapy, where radioactive agents are placed into the patient, the patient is “radioactive.” For temporary placements, the patient will usually remain in the hospital and be shielded, and will not be radioactive when released. In permanent placements of radioactive materials, however, the patient will be radioactive to a certain degree. Though the levels outside the body should be relatively low, many specialists advise these patients to refrain from spending long amounts of time near children or expectant mothers. In those instances where radioactive agents are ingested or injected, bodily fluids may become radioactive and these too should be kept away from children or expectant mothers.
Aside from potential radioactivity, due to the fact that radiation therapy involves the targeting of cancerous cells using low dose radioactive materials, which are introduced into the body, it can also cause damage to otherwise healthy cells. Unlike chemotherapy, radiation is less selective in which cells are actually damaged. This can lead to various side effects. Due to the localized nature of the treatment, however, side effects can usually be monitored. Common side effects include:
- Damage to Salivary Glands
- Diarrhea / Constipation
- Gastrointestinal Distress
- Hair Loss
- Memory Loss
- Nausea / Vomiting
- Secondary Neoplasm
- Skin Irritation
It is more than likely that if you are diagnosed with mesothelioma, you will have some form of surgery. Surgery comes in many variations, however, and can be used for many purposes. While it is true that surgery can be used to diagnose cancer, determine the appropriate stage of cancer, or in some cases to prevent cancer, the focus here is on surgical techniques to treat mesothelioma. To learn more about how mesothelioma is diagnosed or staged using surgical techniques, click here.
Surgery is one of the oldest forms that physicians use for the treatment of cancer. The type of treatment selected will often depend on the stage of mesothelioma the patient is diagnosed with, where it is located, and the type of mesothelial cells present. Another influencing factor will be the goal of the surgery. Surgery for treatment of mesothelioma can generally be classified by the intent or goal of the surgery. In mesothelioma patients, there are typically two goals:
- Curative Intent: This means that the intent of the surgery is to fully remove the cancerous cells, and surrounding tissue, in an attempt to cure the patient of cancer.
- Palliative Intent: This means that the intent of the surgery is lessen the impact the cancer has on the quality of life of the individual. In some cases, where tumors are too advanced or have spread too far, palliative surgery will be indicated to relieve the symptoms some of those tumors are inflicting, i.e., a tumor near the esophagus may be removed or reduced so a patient can swallow without pain.
Depending on the intent of the surgery, the patient may be able to have a number of different procedures done.
In patients with Stage I mesothelioma, the following surgeries may be indicated:
- Pleurectomy and Decortication: A pleurectomy is a procedure which is designed to remove part of the pleura. A decortication means that all or part of the outside surface of a particular organ has been removed. For mesothelioma patients, this procedure is intended to remove the cancerous pleura and the tissue surrounding it. The expected result is not just to remove the cancer, but to allow the lung to expand into that new space and increase lung capacity. This is a common treatment for those suffering from pleural mesothelioma. Many doctors do not view this as a curative treatment, but as palliative treatment.
- Extrapleural Pneumonectomy: This is a procedure that is extremely invasive, and involves both a long, difficult operation and a long recovery period. This is generally reserved for patients who are in otherwise good health, who have been diagnosed at an early stage, and who are suffering from the epithelioid type of mesothelioma. This intervention will involve the surgeon removing the entire lung, and all affiliated tissue and structure, from the side of the body where the pleural mesothelioma is located. This procedure will also remove the membranes surround the heart, lungs and diaphragm. This treatment is generally intended to be curative in nature, but it is only performed at some cancer centers. It carries numerous risks, and numerous common complications and side effects, which include:
- Heart Attack / Failure
- Paralysis of Vocal Cords
- Gastrointestinal Problems
- Lung / Breathing Difficulty
- Empynema – Pus in Pleural Cavity
- Chylothorax – Fatty lymph fluid in chest
- Bronchopleural Fistula – pleura and breathing tubes bond, releasing air
- Organ Failure
These are risks that your doctors or specialist will discuss with you and your family and it will be up to you to weigh the benefits vs. the risks associated with this procedure.
- Cytoreductive Surgery (Debulking Surgery): This is a relatively new process to help those suffering from mesothelioma. It is generally indicated in those situations where a tumor is too involved with the surrounding tissue to allow complete removal. This is generally a two-step procedure. First, a surgeon will remove a portion of the cancer, as much as can be safely removed without adversely affecting healthy tissue. After this is accomplished, directed chemotherapy will be used to treat the physical area of the tumor and the immediate tissue surrounding it. Radiation may alternatively be used to treat the area. Though it is still a new procedure, the intent is usually curative, though it often can produce a palliative result.
- Paracentesis: This is a procedure which is designed to extract fluid from the pleural cavity. The usual goal of this surgery is palliative, and is often prescribed to relieve the pressure caused by a build-up of fluid in the abdominal cavity. This process does not require a large surgical intervention or incision. In the vast majority of cases, a needle will be inserted into the desired area and the fluid will be drained. A physician or surgeon may require diagnostic scanning before the process can commence, to ensure the correct location of the fluid.
- Pericardiocentesis: This is a non-incisional surgical procedure. In certain mesothelioma patients, fluid may build up in the pericardial cavity. In those cases, surgeons may perform a pericardiocentesis to drain that fluid and relieve the pressure around the heart. This is often for palliative reasons, as this fluid build up can cause pain and shortness of breath, among other symptoms. It is typically performed using a small gauge needle and catheter.
- Pleurodesis: A pleurodesis is a procedure designed not to remove fluid, but to prevent the further accumulation. Often, especially in pleural mesothelioma patients, there is a fluid buildup in the pleural cavity. This can cause pain, difficulty breathing or swallowing, and other symptoms. Most patients desire not only to remove that fluid, but to prevent it from coming back. A pleurodesis involves a surgeon opening the pleural cavity and inserting a chemical called talc into the space. This chemical causes irritation which will prevent the further accumulation of pleural fluid. This again is a palliative procedure not designed to remove any cancerous cells, but to alleviate symptoms.
- Thoracentesis: This procedure is similar to a paracentesis. It involves the insertion of a long needle at the end of a syringe to remove fluid accumulation from the pleural cavity. This procedure can be used diagnostically, or palliatively. As buildups of fluid in the pleural cavity (pleural effusions) can cause pain and breathing difficulty, a physician pursuing a palliative goal will attempt to withdraw as much fluid as is possible in an effort to reduce those symptoms.
- Tube Thoracostomy: This is another procedure which is used as a palliative intervention. The goal of this procedure is again to eliminate the side effects caused by the buildup of fluid in the pleural cavity. Unlike the above procedures which involve the mere insertion of a small needle, this procedure inserts a larger tube into the chest cavity to allow the withdrawal of pus, fluid, air, or any other substance which has entered the pleural cavity. The patient will have a collection device attached to the end of the tube outside of the body, and the tube will travel from that device and be inserted in the pleural space. The device will be sealed in such a way as to allow material to flow out of the chest and into the collection area, but not to flow back in. Though it does allow for relief, it is not a permanent treatment and will be removed.
At the most basic level, cancerous cells are not wholly different from other types of cells traveling throughout the body. Generally, we are kept healthy, and free from infection, by our immune system, which contains numerous types of cells, described below, whose sole function is to remove non-normal cells, bacteria, viruses, non-healthy cells, etc. These non-normal bodies are referred to antigens. Our immune system cells recognize most non-normal cells because of markers which all cells carry. Our own cells carry markers that let our immune system killer cells know that they are normal healthy cells. Some cells are recognized instantly as invaders by the immune system. Other cells do not have clearly recognizable markers or tags, or bear markers or tags which our immune system killer cells cannot recognize. Immunotherapy is a process which strives to help those immune cells naturally recognize cancer cells as non-normal, and have the immune system kill them. Vaccinations are an example of immunotherapy. For instance, a vaccination allows our immune system to learn what a harmful cell of polio looks like, and then kill it from that point forward. The reason most diseases and cancers are not naturally removed is because they are unrecognizable to the killer cells. This is part of what immunotherapy seeks to address.
The medical definition of immunotherapy is treating a disease by triggering, magnifying, or decreasing, an autoimmune response. This is also called Biological therapy. Basically, the medical provider is attempting to use the patient’s own immune system in some manner to fight the disease process. Those procedures which trigger or enhance the immune system’s response are referred to as activation immunotherapies. Suppression immunotherapies are those treatments which suppress or redirect an immune system response.
The agents which are used in immunotherapy to achieve these results are called immunomodulators. Immunomodulators often consist of recombinant, synthetic, or natural combinations, typically cytokines. Immunotherapy treatments are often favored by treaters because they have fewer side-effects. The most common immunotherapy for treatments of cancers, like mesothelioma, is a cell based immunotherapy.
Cell Based Immunotherapy
Cell based immunotherapy seeks to trigger the behavior of the cells of the immune system which attack foreign bodies. Immune cells such as lymphocytes, macrophages, dendritic cells, natural killer cells, cytotoxic T lymphocytes, or Killer T Cells, among others, are triggered to attack the tumor. The body naturally recognizes tumors as non-normal cells, but in cases of malignancies, is unable to fight them off. The goal of a mesothelioma patient undergoing immunotherapy would be strengthen the immune responders which would naturally attack those cancerous cells, and increase their quantity and strength to kill the cancer.
A modified method of cell based immunotherapy is autologous immune enhancement therapy (AIET). In this method, a patients own immune system killer cells are taken out of the body. Those cells are then grown in cultures and multiplied. Genetic modifications can be made to increase their selectivity to the particular cancer, increase their resistance to the cancerous cells, and increase their ability to destroy cancer. Typically, this process involves the body’s Natural Killer Cells (NK Cells) and T lymphocytes. Generally, if a patient is receiving chemotherapy, this process will be done after the patients finishes a cycle. The cells, once enhanced and increased in numbers, are then activated for the cancer cells and injected back into the patient’s body. Once there, these cells will attach to the outer wall of the cancerous cell, and deposit bodies into the cancerous cells which will destroy it.
Another type of immunotherapy for cancer patients is T-cell based adoptive immunotherapy (ACT – Adoptive Cell Therapy). This method uses “tumor infiltrating lymphocytes,” which have a natural predilection towards infilitrating and killing cancerous cells and tumors. T-Cells are harvested which are naturally intolerant to the specific cancer, and they are increased in number and made more efficient. They are then replaced into the patient. One method in which this is done involves harvesting the tumor itself. Inside the harvested tumor, there will be killer cells from the patient’s body, which were attempting to kill that tumor. Those cells can be harvested, cultured, modulated and/or enhanced, and then replaced to kill any remaining cancerous cells.
There are other methods of immunotherapy. Medical professionals can synthetically create some types of antibodies to inject into the patient which will “mark” a cancerous cell as non-normal. Once the immune system killer cells recognize the non-normal cell, they will attempt to kill it. Other forms include genetically modifying cancerous cells themselves so that the body will kill them even when they grow. This is still a relatively new area and bears the problem ensuring the previous, unmarked cancer is removed before accomplishing this task, or the patient risks a recurrence of the non-marked cancer.
MESOTHELIOMA AND IMMUNOTHERAPY
These types of therapies are still in their infancy, as it relates to mesothelioma patients. There have been numerous studies performed, and in some cases, they are being studied for their effectiveness on patients. They are not yet considered standard treatments. A mesothelioma patient can, however, seek to be included in clinical trials where these therapies are being tested. Your healthcare provider can assist you, or you can click here for a list of doctors and specialists treating mesothelioma patients and contact their office to see if you qualify.
What is Photodynamic Therapy?
The definition of photodynamic therapy (PDT) is the treatment of cells with particular drugs that activate when exposed to a light source. The intent is that the drug, once activated, will kill the cancerous cells. The active agents in PDT are referred to as “photosynthesizers” or “photosynthesizing agents.” Also necessary is a specialized kind of light. There are many different types of photosynthesizers and each has a specific wavelength of light that it reacts or responds to. The wavelength is determinative of how deep the light can progress into the body before it stops. This becomes important because the determining factor as to which photosynthesizer is used is how deep the cells are which are being targeted. Once that is determined, the correct agents can be selected and placed, and then exposed to the light source. The photosynthesizers, when experiencing the correct wavelength of light, will produce a kind of oxygen that is lethal to nearby cells.
What photosynthesizers are currently used to treat cancer?
Currently, there is one prominent photosynthesizers which has received approval from the FDA to treat cancer. It is an agent called porfimer sodium, brand name Photofrin®. This is approved to treat non-small cell lung cancer and esophageal cancer, in addition to some esophageal lesions.
What is the Light Source?
There are numerous sources which can be used to generate the required light. One of the most common is a laser. The benefit being that laser light can be emitted through attachable fiber optics allowing the light to transmitted directly in the body. The fiber optics can be attached to certain medical objects, including an endoscope, which allows the light to be focused directly on the tumor. Tumors closer to the surface of the body can be exposed to the necessary light through light emitting diodes (LEDs).
How Does PDT Kill Cancer?
The first step is to determine the depth of the tumor and thus which type of light wavelength will be necessary to reach that tumor. Once determined, the appropriate photosynthesizers are chosen. The photosynthesizers are then directly injected into the patient’s bloodstream. The photosynthesizers will be absorbed by numerous different cells in the body, cancerous and non-cancerous. Typically, however, the photosynthesizers will remain in the cancerous cells for a longer period of time than in the non-cancerous cells. It usually takes about 24-72 hours for the photosynthesizers to leave non-cancerous cells. The photosynthesizers will remain in the cancerous cells, however. After the prescribed time period has elapsed, the tumor will be exposed to the light source. The photosynthesizers react to that light, emitting the aforementioned type of oxygen that causes death in the nearby cancer cells.
The photosynthesizers can work in three different ways. The first and most obvious is the emission of that oxygen that directly kills the cancerous cells. Another way in photosynthesizers kill cancer is through some process by which they prevent the tumor from growing blood vessels. Without a supply of blood, the tumor will die. A third way in which photosynthesizers can work is by stimulating the patient’s own immune response to attack the cancerous cells.
Limitations of PDT
Photodynamic therapy’s main limitation is the inability of light to travel deep into tissue. This treatment is usually only effective in surface cancers, or cancers which can be accessed by entering the body cavity to provide the light source directly on the tumor. The reason Photofrin® is able to treat lung cancer is because an endoscope can be used to place the laser light directly into the lungs, onto the tumor. The light sources, as currently configured, can only pass through approximately 1 cm of skin before becoming ineffective and causing the desired reactions of the photosynthesizers. This means that not only would this treatment be ineffective for deep tumors, but it would also be less effective on large tumors as the light source cannot penetrate into the middle of the tumor.
Photodynamic Therapy and Mesothelioma
Photodynamic Therapy is not currently FDA approved as a usual and customary treatment for mesothelioma patients. In some instances, the location of the mesothelioma tumors may prevent the applicability of PDT. But there are currently clinical trials where PDT is being administered to mesothelioma patients in an attempt to determine the effectiveness.
Side Effects of Photodynamic Therapy
The porfimer sodium used as a photosynthesizer can cause some side effects. Most commonly, porfimer sodium causes the eyes and skin to be extra sensitive to light for up to 6 weeks after the administration of the drug. Patients would be encouraged to say out of the sun during those times in addition to synthetic sources of bright lights. PDT, depending on where it is performed, can also cause side effects such as:
- Difficulty Breathing / Pain While Breathing
- Difficulty Swallowing
- Generalized Pain
These side effects are not usually permanent.
WHAT IS A GENE?
Genes are the biological units, located on our chromosomes, and comprised of DNA, which basically dictate our makeup. Humans typically have over 30,000 genes. They determine physical traits about us such as eye or hair color, as well as non-obvious traits such as the oxygenation potential of our blood. Combinations of genes determine other characteristics, such as our stamina. Obviously, though our potential for a certain characteristic is predisposed in some fashion, these predispositions can be overcome due to environmental impacts.
One of a gene’s most important functions is that they contain the blueprints which allow other cells to create certain types of proteins. The type depends on the characteristics of the cell, and the direction provided by the gene. The cells copy the necessary information from genes to make these proteins. A cell can contain numerous different genes, though usually only one is active at a time. After a gene has performed its function, it will likely become inactive. The types of proteins generated by the cell based on the instructions from the genes determine the type of cell and what its abilities and limitations are. If a gene is corrupted, or the cell fails to properly copy the instructions from the gene, a disease can result.
HOW DOES GENE THERAPY WORK
Though the field is still experimental, the theory behind gene therapy is that modifications to genes should allow for changes to the behaviors of cells. There are many different ways in which the manipulation of a gene can cause a certain behavior in cells. Depending on the behavior created, this could benefit a patient suffering from cancer. Currently, gene therapy is undergoing testing in the following ways:
- Gene Replacement: Missing or damaged genes can cause cancer, or a susceptibility to cancer. Replacing missing or damaged genes can rectify that issue.
- Immune System Support: Genes play a role in determining how our immune system fights cancerous cells. In some approaches, genes are inserted into cells that cause them to create certain outside markers. When placed in the body, this causes immune cells to generate these types of cells which then locate and kill cancer cells.
- Cancer Gene Modification: In other studies, experiments are being conducted which modify the genes of cancer cells to make the cancerous cells more susceptible to radiation therapy, chemotherapy, and other types of treatment. In a second variation, a “suicide gene” is placed into the cancerous cells that causes the cancer cells to self-destruct when an appropriate medication is given to the patient. A third way in which cancer genes are being manipulated is to alter the genes in cancer cells which form blood vessels to supply the tumors (anti-angeogenesis). Without this blood supply, the cancer cells die.
Modifying genes in cells is not as simple as it sounds. A person cannot simply place a gene into a cell like putting a quarter into a machine. Rather, something must deliver that gene to the cell and insert the gene into the cell. The delivery vehicle is called a carrier or vector. Most commonly, the carriers are viruses. They can also include non-viral liposomes or other non-viral mechanisms. Viruses are usually the vector of choice due to their proficiency at differentiating between various types of cells and being able to not only select the right cell, but then also inject the material into only that type of cell. The most common vectors include:
- Adenovirus (viral)
- Adeno-associated virus (viral)
- Herpes simplex virus (viral)
- Liposome (non-viral)
- Naked DNA (non-viral)
- Retrovirus (viral)
This process of gene transfer can take place outside the body (ex vivo) or inside the body (in vivo). In outside the body transfer, cells are harvested and exposed to the virus and then reintroduced. In inside the body transfer, the transfer carrier is injected directly into the body.
Gene Therapy and Mesothelioma
The eventual goal for researchers is to apply the lessons of gene therapy and its potential benefits to suffers of malignant mesothelioma. As of yet, the process has not yet been granted federal approval to render this a standard treatment for mesothelioma patients. Mesothelioma patients who are interested, however, may be able to sign up for a clinical trial. There are trials which are testing many of the above mechanisms of gene therapy in conjunction with the effectiveness of the treatment and mesothelioma prognosis. To become part of a clinical trial, you should discuss this with your health care provider, or you can contact a specialist in mesothelioma for further assistance.
To find a list of specialists in mesothelioma near you, please click here. To learn more about ongoing clinical trials, please click here. (Insert clinical trial data!!)
Side Effects of Gene Therapy
There are several potential side effects associated with gene therapy. Additionally, as this is such a new field, some of the potential side effects are not yet known or appreciated. But generally, some side effects which may occur include:
- Secondary Infection: It is possible for the virus carriers to misidentify certain cells. In this case, the viruses would infect healthy cells as opposed to cancerous cells.
- Misplacement: The procedure for transferring the gene into the cell properly is still in its infancy. It is possible that when the gene is placed into the cell, it could be misplaced in the DNA, which could cause the cell to undergo unwanted mutations and could itself cause malignancy.
- Mutation Inheritance: It is further possible that the mutations made to cells using viruses could be passed on to children born after treatment. If the carriers pass the gene modifications into the reproductive cells, any mutation could potentially be passed to offspring.
- Overexpression: This is a term used when too many of the wanted proteins are produced by overactive genes, causing harmful side effects.
- Inflammation / Immune System Reaction
- Virus Transmitted to Patient’s Family / Environment
In many ways, the standard cancer treatments may prove to be effective at treating the tumor, but ineffective at reducing symptoms or improving the quality of life of the patient. This can be exacerbated in mesothelioma patients. For that reason, many cancer and mesothelioma patients will seek alternative means to treat not only the cancer, but to improve their symptoms and quality of life.
Alternative therapies often focus on holistic or non-standard medicinal interventions. Patients should be clear, however, that there is no scientific literature which demonstrates that holistic or alternative medicines are able to cure cancer or put the tumor in remission. This is why many medical providers who condone their patients engaging in these remedies will only agree if that alternative therapy is done in conjunction with standard cancer treatments which have been shown to be effective in the clinical setting.
What each patient chooses, however, is solely up to their own discretion. There are patients who choose not to undergo the standard curative treatments such as radiation, chemotherapy or surgery due to the side-effects that come with those procedures. These patients may prefer to attempt to treat their cancer with alternative remedies with less side effects. Still other patients have decided, either after the failure of standard treatment or after consultation with their medical providers, that continued interventions will not have a curative effect and the side effects may outweigh the potential qualify of life benefits that any further standard treatment can provide. In those instances, many patients have found alternative remedies to offer enhanced quality of life, even without reduction in cancerous cells or tumor size.
Some of the most common alternative therapies include:
- Nutrition Modification: For any cancer patient, and especially those with mesothelioma, their diet should be an important consideration. There are numerous types of foods which have demonstrable benefits to those suffering from cancer. Though it can be difficult for a patient to suffer the side-effects of treatment and the pain associated with cancer, a proper and balanced diet may aide in minimizing that distress. Usually, most specialists have brochures they can share with their patients regarding what foods are beneficial in dealing with the symptoms of cancer and treatment.
- Supplementation: In addition to changing specific foods that a patient may eat, many mesothelioma patients have found benefits to additional vitamins and minerals. Many types of treatments can zap the ability of the body to metabolize certain nutrients from foods, such that a mere change in eating habits can be insufficient to restore those nutrients necessary for proper body function. In those cases, numerous supplements are available which can increase the amounts of vitamins and minerals in the body and can provide relief.
- Accupuncture: Accupunture has been around for thousands of years. The ancient Chinese used acupuncture to assist with the treatment of a variety of ailments. The theory behind acupuncture relied on pressure points and nerves across the body which when properly manipulated could produce physical and/or chemical changes to the body’s composition. Even today, acupuncture is used for everything from smoking cessation to weight loss. There are some patients who have had tremendous success through acupuncture in alleviation many of the painful symptoms associated with mesothelioma and the standard treatment options.
- Holistic Medicine: This is another eastern medical innovation which focuses not just on the body, but on the emotional and spiritual facets of the individual. The guiding philosophy being that a person cannot be physically well, without being spiritually and emotionally well. Thus, holistic treatments focus on treating not just physical symptoms, but also emotional and spiritual symptoms. These types of treatments can provide benefits for some mesothelioma patients as a mesothelioma diagnosis, and the treatment required, do take an emotional and spiritual toll on patients.
- Activity Therapy: Many mesothelioma patients are deprived of the ability to perform the normal activities they once pursued with vigor. Mesothelioma can severely weaken a patient, or reduce their lung capacity such that normal exercise can become too strenuous to perform. In these instances, many patients can receive a needed emotional, spiritual, or physical boost by performing less arduous activities that can enhance their quality of life. Such activities do not require physical exertion and can benefit the overall mental health of the patient.
- Chiropractic Therapy: Pain management is essential element of most mesothelioma therapies. In numerous instances, patients do not receive sufficient relief from pain via their medications and normal treatments. In some instances, it may be beneficial to seek chiropractic help to relieve some of the symptoms caused be mesothelioma or mesothelioma treatment.
- Hypnotherapy: Hypnotherapy can be a useful alternative therapy not to cure mesothelioma, but to assist in pain management. These techniques can assist with relaxation and pain reduction which allow a mesothelioma patient to be able to cope with the day to day stressors of treatment and potential recovery.
There are numerous other types of alternative remedies a mesothelioma patient can try to see what works best for them. Additional alternative therapies include osteopathy, reflexology, meditation, massage, and aromatherapy, among others. A mesothelioma patient should always be guided by engaging in the therapy that provides the best quality of life improvement for them, without aggravating their illness. A process of trial and error may be necessary to settle on the appropriate treatment.
Multimodality Therapy is merely a descriptive term which correlates to the treatment of mesothelioma using multiple different therapeutic techniques. It is known among the specialists treating mesothelioma that the three standard treatment techniques for combating cancer – radiation therapy, surgery, and chemotherapy – do not, by themselves, provide an effect curative strategy to render the patient cancer free. There is an enhanced chance of success, however, when those therapies are combined. Thus, multimodality therapy simply means that two or more of the common curative treatment procedures are combined in an attempt to treat the mesothelioma patient. Often times, the combination will involve cytoreductive surgery or tumor removal surgery, coupled with radiation therapy or chemotherapy applied after to kill the remaining cancerous cells.
The drawbacks of multimodality therapy are that it can be extremely expensive and because a patient is undergoing multiple types of treatments, the patient is exposed to, and can suffer, from the numerous side effects that accompany each procedure. Generally, to undergo extensive multimodality treatments, a patient should be in the early stages of mesothelioma and otherwise be in generally good physical condition.
Heated Intraoperative Intraperitoneal Chemotherapy is a multimodality approach which combines surgery and chemotherapy. This procedure was developed by Dr. Paul Sugarbaker. The procedure begins with surgery to remove as much, if not all, of the tumor as possible. After this is completed, the chemotherapy drugs are heated, and then administered into the cavity where the tumor was located. The chemotherapy durgs are kept in that space for approximately 2 hours, and then are drained. These drugs are usually infused through a port in the chest wall. The added benefits to this treatment are that the heating of the agents allows the chemotherapy drugs to more readily select and enter cancerous cells which increases the efficacy of the treatment.