An aggressive treatment strategy that begins with chemotherapy, followed by surgery, and then radiation is a safe and effective option for many mesothelioma patients, according to a recent study in The Annals of Thoracic Surgery.
Mesothelioma traditionally hasn’t responded well to just one treatment (surgery, chemotherapy, or radiation). In the early 1990s, Dr. David Sugarbaker of the Brigham and Women’s Hospital in Boston reported on the use of combining therapies. When he treated mesothelioma patients with extrapleural pneumonectomy (EPP—surgery to remove the diseased lung, as well as the diaphragm and the membrane covering the heart and lung), followed by chemotherapy and radiation, the results were promising.
Researchers at the Swedish Cancer Institute in Seattle, Washington, tried to replicate this triple-treatment approach, but they found it difficult to deliver chemotherapy after EPP. “Historically when giving chemotherapy after cancer surgery, we like to start doing it within 60 days, at the latest, of the surgery date,” explains Eric Vallières, MD, FRCSC, Surgical Director of the Swedish Cancer Institute’s Lung Cancer Program. “The problem with starting chemotherapy too ‘early,’ i.e., before full patient recovery, is that the chemo is too hard on them and they just quit.”
Instead of delivering chemotherapy after mesothelioma surgery, Dr. Vallières and his team decided to study the effectiveness and safety of beginning the treatment with chemotherapy, followed by surgery and then radiation. The reported study included 55 patients who were treated for mesothelioma between 1997 and 2008.
First, the mesothelioma patients received up to four cycles of chemotherapy (most often a combination of cisplatin and pemetrexed). A few weeks later, patients who were healthy enough had a diagnostic procedure to determine whether they were good candidates for surgery (if the cancer had not spread). A total of 38 patients underwent the entire treatment—induction chemotherapy, then EPP, followed by either external beam radiotherapy (EBRT) or intensity-modulated radiotherapy (IMRT) six to eight weeks later.
Overall, mesothelioma patients who completed chemotherapy, surgery, and radiation survived an average of two years. Patients who received IMRT appear to have a lower risk of cancer recurrence (14.3%) compared with the EBRT group (41.7%). According to the authors, one of the potential advantages of using IMRT is to better target the cancer while sparing nearby organs from radiation exposure.
Based on the results of this study, chemotherapy followed by EPP and radiation seems to be a safe and effective choice for mesothelioma patients. “Our results are definitely good enough for us to continue favoring an induction approach for most of our patients,” Dr. Vallières says.
However, mesothelioma treatments still have a long way to go before they can provide patients with a more favorable outlook. “Personally, I think that we have plateaued, and will maintain the same results until we have better systemic therapy,” according to Dr. Vallières. He says improved chemotherapy or new biologic treatments are needed to improve survival rates.
Source: Buduhan G, Menon S, Aye R, Louie B, Mehta V, Vallières E. Trimodality therapy for malignant pleural mesothelioma. The Annals of Thoracic Surgery. 2009;88:870-876.