Mesothelioma patients and their families are faced with a lot of difficult decisions during the course of the illness, including how to proceed with disease management. In choosing between curative care and palliative care, patients and their medical teams must review the available options and the potential outcomes.
Curative and palliative care have long been associated with life or death, but palliative care today is focused on relieving pain and stress. In fact, both curative care and palliative care can be used simultaneously to enhance a patient’s life. Both types of care are used concurrently with surgery, radiation therapy and chemotherapy.
Curative Care in Mesothelioma
Decades ago, a mesothelioma diagnosis was considered an immediate death sentence. Physicians had few curative-care options. Now, medical researchers are discovering and inventing advanced curative options that allow patients to live longer with the disease. In some cases, medical procedures cure the disease.
After a diagnosis, physicians outline mesothelioma treatment options dependent on a number of different factors, including:
- Type of mesothelioma (pleural, peritoneal, or pericardial)
- Cell type present in mesothelial tumors (epithelioid, sarcomatoid, or biphasic)
- Stage or extend of the cancer’s spread (metastasis)
- Location and size of tumor(s)
- Patient overall age and health
Surgery is an option for two reasons: relieving pain and symptoms (palliative care) and removing the cancer (curative care). Undergoing palliative surgery can significantly improve a patient’s quality of life by decreasing chest pain, making it easier to breathe, and removing fluid from the abdomen. Potentially curative surgery includes the following:
Extrapleural Pneumonectomy (EPP)
For the EPP procedure, the surgeon removes the entire diseased lung and the pleura lining around the diseased lung. The diaphragm, the sac around the heart (pericardium) and the nearby lymph nodes are also removed.
This surgery is extremely difficult and only done by the most skilled surgeons. The procedure is only performed on patients who are generally healthy with good lung function and no concurrent serious illnesses.
The EPP is typically used when physicians consider the disease curable.
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The P/D procedure includes removing the pleura near and on the diseased lung and the diaphragm. No organs are removed. In a different version of the same type of procedure, called the radical or extended P/D, the diaphragm and pericardium are also removed.
A P/D is used in curative procedures as well as palliative surgeries. The procedure helps alleviate fluid buildup in the lungs, relieves pain caused by tumors and can improve breathing functions.
Debulking (also called Partial Pleurectomy)
The purpose of the debulking procedure is to remove as many tumors as possible. When debulking is done as a curative procedure, it is called cytoreduction or cytoreductive surgery.
Debulking is often used to treat peritoneal (abdominal) mesothelioma in conjunction with intraoperative (or intraperitoneal) chemotherapy or heated intraoperative (or intraperitoneal) chemotherapy (HIPEC). For the procedure, the abdominal area is bathed in chemotherapy.
The omentum, or the layer of fat that surrounds the abdominal organs, is removed as part of a curative procedure for peritoneal mesothelioma.
Commonly known as chemo, this drug treatment is given either through a vein (intravenous) or placed directly into the chest or abdominal areas, called intrapleural or intraperitoneal chemo respectively. Direct placement allows the highest concentrations of the medication to go directly to the cancerous tumors.
The first line of chemotherapy for mesothelioma is a pemetrexed (Alimta) and cisplatin combination. Pemetrexed is also used in conjunction with carboplatin and cisplatin is sometimes used with gemcitabine. Physicians determine the best chemotherapy treatments based on individual circumstances.
Chemotherapy works by attacking cancerous cells, which are fast dividing. Since bone marrow, hair follicles and the lining of the intestines and mouth divide quickly, these cells are impacted by chemo as well.
The following common side effects generally dissipate once chemotherapy is discontinued:
- Hair loss
- Mouth sores
- Nausea and vomiting
- Increase infections
- Easier bruising and bleeding
More serious, longer lasting side effects as a result of chemotherapy include the following:
- Nerve damage
- Hearing loss
- Pain, burning and tingling in feet and hands
Radiation directs high-energy X-rays or particles to kill cancer cells and tumors. For mesothelioma, radiation therapy is used to kill cancer that was not removed during surgery (called adjuvant radiation therapy) and to ease symptoms (palliative radiation therapy). Two types of radiation are usually used to treat mesothelioma:
External beam radiation therapy (EBRT)
EBRT, the most commonly used mesothelioma radiation therapy, uses X-rays produced through a linear accelerator (LINAC) machine.
Prior to treatments, clinicians take careful measurements to ensure the radiation beams are directed to the correct area. Each treatment only takes a few minutes.
Intensity-modulated radiation therapy (IMRT), a form of EBRT, can deliver precise doses of radiation to target hard-to-reach tumors.
Also called internal radiation, Brachytherapy is the process of placing radioactive “seeds” in or near tumor sites. It is a highly effective method for treating mesothelioma because it delivers concentrated radiation to targeted areas.
Because of the concentrated doses, Brachytherapy is known to cause less damage to surrounding tissue than EBRT. Each seed is about the size of a grain of rice and is inserted during the intraoperative radiation therapy (IORT) procedure.
Generally, the treatment options are based on the stage of the disease. In many cases, early stage mesothelioma (stages I, II and sometimes III) can be surgically resected, or removed. Cancerous tumors are resectable if their removal won’t damage vital organs and the disease has not spread through the body.
Palliative Care in Mesothelioma
In the past, palliative care meant doctors had given up on patients and there is no hope for wellness. Today, medical professionals have embraced palliative care as a means to a better, more fulfilling life with a disease. Palliative care is not hospice care. Instead, palliative care is aimed at controlling pain and uncomfortable symptoms and improving the quality of life.
Palliative care, sometimes called supportive or comfort care, can be provided alongside curative care or alone. Curative and palliative care are often used interchangeably throughout treatment and may change throughout the progression of the disease. It is not uncommon for patients and their medical providers to abandon curative care entirely in favor of the comfort palliative care provides, especially if curative procedures aren’t helping. Medical professionals say there are several benefits that come with palliative care:
- Provides a holistic approach treating the patient’s mind, body and spirit.
- Improves the quality of life, allowing patients to continue a semblance of normalcy while controlling the disease.
- Controls pain and symptoms such as shortness of breath, nausea and depression
- Provides relief from anxiety.
A 2016 study by the National Cancer Institute found palliative care patients who were undergoing treatment for advanced cancer had “a better quality of life and mood.” The study found patients who received early palliative care were better able to cope with their disease and more likely to discuss long-term care preferences with their providers.
Palliative care for mesothelioma can be several types of treatment including the following:
- Pain management techniques including relaxation and visualization.
- Alternative treatments such as acupuncture and acupressure.
It is important to understand the distinction between palliative and hospice care. Hospice care, like palliative care, is designed to provide comfort to patients living with a disease. Unlike palliative care, however, hospice care is reserved for patients facing a terminal illness with a prognosis of less than six months. Hospice care differs from palliative care in three major ways: diagnosis, affordability, and location.
As mentioned, hospice care is for patients who have been given a prognosis of six months or less. With this comes some added benefits. Patients receiving hospice care can receive their treatment wherever they are living, whether they be at home or an assisted-living facility, while patients receiving palliative care typically receive their treatment in a hospital.
Additionally, patients receiving hospice care will have their medical bills covered by either Medicare, Medicaid, or private insurance; while patients receiving palliative care must pay their medical bills through private insurance or out of pocket if they are uninsured.
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- American Cancer Society. Treating Malignant Mesothelioma. Retrieved from https://www.cancer.org/cancer/malignant-mesothelioma/treating.html
- American Cancer Society. If Treatment of Malignant Mesothelioma Stops Working. Retrieved from https://www.cancer.org/cancer/malignant-mesothelioma/after-treatment/no-longer-working.html
- Cancer Centers of America. Intensity-modulated radiation therapy. Retrieved from http://www.cancercenter.com/treatments/intensity-modulated-radiation-therapy/
- National Cancer Institute. Study Confirms Benefits of Early Palliative Care for Advanced Cancer. Retrieved from https://www.cancer.gov/news-events/cancer-currents-blog/2016/palliative-care-quality