Treatment for Veterans With Mesothelioma
Symptoms like breathlessness and feelings of pain beneath the rib cage may signal the development of tumors. Mesothelioma patients can experience these symptoms when their cancer has already reached an advanced stage. Consequently, doctors typically try to begin treatment as soon as the patient is ready.
The type of treatment you receive generally depends on your overall health, the stage and location of tumors, and the ultimate goals of your cancer treatment plan. Generally, treatment options for mesothelioma patients include variations and/or combinations of surgery, chemotherapy, and radiation. When standard forms of cancer therapy don’t work, targeted therapies and immunotherapy may be effective alternatives.
Veterans can receive mesothelioma treatment at designated cancer treatment centers as well as VA hospitals and clinics. A variety of doctors, nurses, and other healthcare professionals are likewise involved in the treatment of a patient’s mesothelioma, such as dietitians, medical oncologists, oncology nurses, physician assistants, pharmacists, pulmonologists, radiation oncologists, social workers, surgical oncologists, and thoracic surgeons.
How Is Mesothelioma Treated?
In many cases, mesothelioma is diagnosed after the disease has spread from its original location in the lining of the abdominal, lung, and heart cavities. These hard-to-reach sites can make treating advanced mesothelioma difficult. While a cure may not be likely for many patients, modern treatment methods may be able to extend patients’ life expectancy and improve quality of life.
Currently, pleural mesotheliomas (the most easily treated site of this form of cancer) lining the chest cavity containing the lungs may be resected via surgery in most stage I and some stage II and III cancers. Usually, stage IV tumors have spread too far into nearby organs and lymph nodes to be surgically resected.
Often, doctors prescribe chemotherapy and radiation to shrink or kill tumors in patients healthy enough to undergo treatment. When first-line treatments fail to work or stop working, targeted therapy or immunotherapy can also attack cancer cells or make it too hard for them to live.
Surgery has several functions in the diagnosis and treatment of mesothelioma. Surgical procedures can provide curative options as well as palliative ones to patients. Mesothelioma surgery may involve removing large tumors or parts of tissues containing them. Some types can relieve pressure from tumors pressing on airwaves or nerves while others remove built-up fluid.
Types of surgery used to treat mesothelioma include:
- Cytoreductive surgery (with HIPEC)
- Debulking (partial pleurectomy
- Extrapleural pneumonectomy (EPP)
- Pleurectomy/decortication (P/D)
Chemotherapy is a form of treatment that circulates anti-cancer drugs throughout the body or applies them directly to the affected area. For the treatment of mesothelioma, chemotherapy is best used before surgery (to shrink tumors) or afterward (to kill cancer cells too small or too hard to reach through surgery).
When chemotherapy is prescribed via IV drip, it can travel throughout the body – known as systemic chemotherapy. Chemo medication is also heated (to increase its cancer-killing effects) and applied directly to tumors, known as heated intraoperative chemotherapy or hyperthermic intraperitoneal chemotherapy (HIPEC).
Chemo medications approved to treat mesothelioma include:
- Cisplatin with doxorubicin
- Gemcitabine (Gemzar®)
- Paclitaxel (Taxol®)
- Pemetrexed (Alimta®)
In most cases, mesothelioma can be difficult to treat because tumors don’t develop as individual growths. Pointing high-energy X-rays at mesotheliomas may also damage nearby healthy cells. Like chemotherapy, patients may be treated with radiation after surgery to eliminate any remaining cancer cells. As a palliative procedure, radiation may shrink or kill tumors linked to symptoms like bleeding, pain, shortness of breath, or trouble swallowing.
Types of radiation used to treat mesothelioma include:
- External beam radiation therapy (EBRT)
- Stereotactic (Body) Therapy
Targeted therapy is a newer field of mesothelioma treatment medications that target changes in cancer cells. As an emerging form of treatment, targeted therapies may only be prescribed after standard treatments fail. However, targeted therapies typically have fewer and less severe side effects than standard treatments.
Targeted therapy drugs may prevent blood vessels from growing near tumors (purging tumors’ food supply), slow the reproduction of cancer cells, and more to kill mesotheliomas. Some types of targeted therapy are available only in clinical trials. Targeted therapy drugs used to treat mesothelioma include:
- Bevacizumab (Avastin®)
- Nintedanib (Ofev®)
- Ramucirumab (Cyramza®)
Immunotherapy is a form of targeted therapy that boosts the patient’s immune system to detect and attack cancer cells. Because mesotheliomas grow from once normal and healthy cells, immune cells have difficulty recognizing or fighting them. Immunotherapy medications work in different ways to allow the immune system to fight cancer. Some medications include:
- Ipilimumab (Yervoy®)
- Nivolumab (Opdivo®)
- Pembrolizumab (Keytruda®)
Treatment Based on Type of Mesothelioma
As a mesothelioma patient, the treatment you receive is based on the location of your cancer, your prognosis, the purpose of treatment, and how well you’re able to recover from any procedures or medications.
The table below lists the most common routes of treatment based on a range of factors.
|Treatment Category||Mesothelioma Type||Common Treatments|
|By cell type:|
|Epithelioid||Extrapleural pneumonectomy, surgery with chemotherapy and/or radiotherapy, thoracentesis|
|Sarcomatoid||Surgery in early stages; radiation, targeted therapy, and/or immunotherapy in later stages; usually unresponsive to chemotherapy|
|Biphasic||Surgery in early stages; radiation, targeted therapy, and/or immunotherapy in later stages; usually unresponsive to chemotherapy|
|Peritoneal||Chemotherapy, hyperthermic intraperitoneal chemotherapy, paracentesis, peritonectomy, surgery for early-stage cancers|
|Pleural||Bevacizumab targeted therapy; paracentesis; pleurodesis; surgery for most stage I mesotheliomas and some stage II and III tumors using pleurectomy/decortication, extrapleural pneumonectomy, or debulking (partial pleurectomy); thoracentesis|
|Pericardial||Pericardial window, pericardiectomy, pericardiocentesis|
|Tunica vaginalis||Surgery to remove tissues|
|Stages 1 and 2||May be treated with surgery to remove tumors or tissue sections containing mesotheliomas (known as whole or partial organ removal). Chemotherapy or radiation may be used before or after surgery to shrink tumors or kill lingering cancer cells.|
|Stages 3 and 4||Palliative forms of chemotherapy, surgery, radiation, targeted therapy, and immunotherapy are generally used to increase life expectancy and reduce painful symptoms of cancer.|
|Recurrent||If mesotheliomas return after treatment, they are often more difficult to treat. Chemo, radiotherapy, and other palliative treatments may be prescribed or referral to a clinical trial.|
Cost of Treatment
Mesothelioma is a rare form of cancer and, in many cases, treating it can incur substantial medical bills. The cost of mesothelioma treatment can reach hundreds of thousands of dollars. For example, Keytruda (the brand name version of immunotherapy drug pembrolizumab) is listed at a price of over $19,700 for each six-week treatment cycle.
Paying for cancer treatments may require patients and their families or caregivers to seek financial assistance in order to avoid depleting personal savings. Alongside health insurance and medical coverage (including Medicare, TRICARE, VA health benefits, and private programs), a number of legal compensation options are available. Veterans whose mesothelioma can be linked to occupational exposure may file legal claims with asbestos trust funds or seek a financial settlement in court.
Typically, treatment goals are defined as either curative or palliative. While curative therapies aim to eradicate cancer from the patient’s body, palliative options work to make them more comfortable. Thoracentesis is an example of a palliative treatment because it removes fluid accumulating in the chest but does not cure pleural mesothelioma. Pain-relieving medication is another common form of palliative care.
Mesotheliomas can grow in hard-to-treat areas and cause severe pain or difficulty breathing. Studies show that even these side effects can significantly impact patients’ quality of life. Subsequently, doctors recommend some form of palliative treatment to all cancer patients.
New and Emerging Treatments
Though mesothelioma affects a small percentage of cancer patients, its link to occupational disease encourages medical researchers to invest in new treatments. Studies of rare forms of the disease (such as epithelial tumors) and late-stage mesotheliomas continue to test emerging targeted therapy medications.
Current treatment clinical trials for mesothelioma include:
- Adding targeted radiation therapy to surgery and chemotherapy treatment (pemetrexed with cisplatin or carboplatin) for stage I to IIIA malignant pleural mesotheliomas
- Nivolumab and combination chemotherapy before surgery for resectable pleural malignant mesothelioma
- Nivolumab and ipilimumab for peritoneal mesothelioma
- Pembrolizumab (with or without anetumab ravtansine) for Patients with mesothelin-positive pleural mesothelioma
- Surgery, chemotherapy, and intensity modulated radiation therapy for stage I to III pleural mesotheliomas
Alternative and Complementary Therapies
“Alternative” and “complementary” cancer therapies are non-traditional types of treatment that are not intended to cure mesothelioma. Yet, they may be used in conjunction with medical treatment to reduce some painful side effects. Pain-relieving techniques like acupuncture and meditation, for instance, could be useful in controlling some nerve pain.
It is important to discuss any additional forms of cancer therapy with your doctor before beginning. Certain types of complementary therapy can be harmful to some patients.
- Will the VA pay for my mesothelioma treatment? If you are eligible for health and disability benefits from the VA, you may be able to use these resources to cover your treatment.
- What support is available to veterans during treatment? Veterans and their families have a variety of free and low-cost resources to assist with caregiving tasks. Support is available from the VA as well as nonprofit groups like the VFW, American Cancer Society, and more.
- Can I choose to end treatment at any time? Yes. As the patient, you are in control of the direction of your cancer therapy. Oftentimes, patients choose to forego rigorous and painful treatments for the symptom relief provided by hospice care.
- Is hospice care a part of mesothelioma treatment? Hospice is a form of cancer treatment with different goals than curative treatments. In hospice care, treatment focuses on reducing or eliminating painful symptoms that interfere with life.