Multimodal Therapy for Mesothelioma Cancer

Multimodal therapy for mesothelioma treatment combines two or more different treatment types. Researchers have found that using more than one therapy provides better patient outcomes. The most commonly used treatments are chemotherapy, surgery, radiation therapy, and immunotherapy.

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What Is Multimodality Treatment for Mesothelioma?

Multimodal therapy is a combination of two or more different therapies used to increase the effectiveness of malignant mesothelioma treatment. Multimodality is considered the best strategy for extending survival time for mesothelioma patients.

Oncologists usually choose a combination of surgery, chemotherapy, and radiation therapy for treating mesothelioma. More recently, targeted therapy, gene therapy, immunotherapy, and other newer treatments have also been used.

Medical teams choose treatment types and combinations based on each individual patient’s needs. Some patients, for instance, are not good candidates for surgery but benefit from combining chemotherapy with immunotherapy or targeted drugs.

Studies suggest that trimodal therapy is particularly helpful for treating mesothelioma. Trimodal therapy usually involves combining radiation therapy and chemotherapy along with surgery.

What Are the Steps in Multimodal Therapy?

Multimodal therapy for mesothelioma often includes three steps:

1. Neoadjuvant Therapy

The first treatment in a multimodal approach is known as the neoadjuvant therapy. The purpose is usually to shrink the tumor before applying the primary treatment. For example, a patient might receive chemotherapy to make the tumors smaller before surgery.

2. Primary Treatment

The second step is the primary treatment, in which physicians attempt to remove the main tumors and cancerous cells. The primary treatment is usually surgery, but it can also be chemotherapy for those patients who don’t qualify for surgery.

3. Adjuvant Therapy

In many examples of multimodal mesothelioma therapy, the primary treatment is surgery. The adjuvant therapy is typically used to kill cancer cells that the surgeon could not remove. Radiation therapy is a common adjuvant, but it can also be chemotherapy.

Benefits of Multimodal Therapy

Multimodal therapy is the best choice for most mesothelioma patients because the combination of multiple therapies provides better outcomes.

Patients who do not receive treatment after a mesothelioma diagnosis only live an average of six to nine months. Treatment extends life expectancy. According to research, multimodal treatment gives most patients the longest possible life expectancy.

A study of 21 mesothelioma patients undergoing chemotherapy and surgery found that the multimodal approach extended survival time to about 26 months.

One study found that patients with mesothelioma who underwent trimodal treatment—radiation therapy, chemotherapy, and surgery—had a median survival time of nearly 40 months.

How Do Doctors Choose Multimodal Therapies?

While there are treatment guidelines for mesothelioma, no standard approach exists. Every patient is different. The choice of treatments depends on individual factors, like age, patient health, and patient preferences.

Multimodal Treatments by Type of Mesothelioma

The type of mesothelioma is one of the most critical factors in choosing treatments. Pleural mesothelioma, which is the most common type, develops around the lungs. Typical multimodal treatment for pleural mesothelioma is trimodal and includes surgery, chemotherapy, and radiation therapy.

Chemotherapy with immunotherapy drugs is a common approach for patients who cannot undergo surgery.

Peritoneal mesothelioma patients, those with mesothelioma in the abdominal cavity, often benefit from surgery and chemotherapy.

Multimodal Treatments by Mesothelioma Stage

The stage of mesothelioma is another important consideration. It is most important in determining if a patient qualifies for surgery.

If the cancer is too widespread, surgery is not an option. This is known as non-resectable mesothelioma. These patients typically receive a different combination of therapies, like chemotherapy, radiation therapy, and immunotherapy.

What Are the Side Effects of Multimodal Treatment?

Patients undergoing multimodal treatment might experience more side effects. Each individual treatment has the potential to cause unique side effects that range from mild to severe.

Common side effects of chemotherapy include:

• Nausea
• Vomiting
• Lowered immunity
• Hair loss
• Fatigue
• Changes in taste and appetite
• Mouth sores
• Pain

Common side effects and risks of surgery include:

• Bleeding
• Blood clots
• Infection
• Collapsed lung
• Pneumonia
• Organ damage

Common side effects of radiation therapy include:

• Fatigue
• Skin rashes at the treatment site
• Hair loss at the treatment site

Multimodal Treatment for Peritoneal Mesothelioma

Because it is much more common, a lot of treatment research focuses on pleural mesothelioma. Peritoneal mesothelioma is the second most common type of this cancer. It develops in the abdominal cavity.

Peritoneal mesothelioma patients generally have better survival times than pleural mesothelioma patients. One of the main reasons is that they benefit from a special type of multimodal therapy with two steps:

• The therapy begins with cytoreductive surgery, a surgery that aims to remove as much of the cancerous tissue as possible.
• The second step is HIPEC (hyperthermic intraperitoneal chemotherapy). This special kind of chemotherapy is different from the standard systemic type. Doctors heat the chemotherapy drugs and circulate them throughout the abdominal cavity.

Studies have found that patients undergoing cytoreductive surgery with HIPEC can extend their life expectancies by years.

What Are the Newest Treatments Used in Multimodal Therapy?

Most physicians still rely on combinations of radiation, chemotherapy, and surgery. As science progresses, more options are becoming available. Some of the emerging treatments doctors use in multimodal mesothelioma therapy include:

• Immunotherapy is becoming increasingly common in mesothelioma treatment. In fact, a combination of two immunotherapy drugs—nivolumab and ipilimumab—was the first new mesothelioma treatment to be approved in many years. These drugs harness the patient’s immune system to fight cancer. They have been shown to extend survival times in many mesothelioma patients. Pembrolizumab (Keytruda) is another immunotherapy drug with good potential for mesothelioma patients.

• Bevacizumab is another newer medication that is increasingly common in mesothelioma multimodal therapy. This targeted drug is an antiangiogenesis medication. It blocks a tumor’s ability to create blood vessels, reducing blood flow to the tumor. Bevacizumab is now often used in combination with chemotherapy.

• Tumor Treating Fields (TTF) is an approved medical device that delivers low-intensity electric fields at tumors to kill cancer cells. It is non-invasive and can be applied outside the body. As a new device, research is limited but suggests that when combined with chemotherapy, TTF can extend survival time in mesothelioma patients.

• Photodynamic therapy uses light-activated anti-tumor drugs. It is a targeted treatment with greater precision than chemotherapy, and, therefore, fewer side effects. It could help patients undergoing surgery survive longer, but more research is needed.

• Cryotherapy consists of killing cancerous cells by freezing them via a needle. This type of treatment typically eliminates radiation therapy so that patients aren’t exposed to the harmful side effects of radiation.

• The SMART Protocol is a newer multimodal strategy for pleural mesothelioma patients that has shown positive outcomes. It stands for Surgery for Mesothelioma after Radiation Therapy. It does not use any emerging treatment but is a novel protocol. Patients undergo radiation therapy first to shrink tumors. They then undergo surgery. Research has shown that SMART can extend survival times significantly.

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