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Innovative mesothelioma Treatment for symptoms You’re Going To Want To Try

Innovative mesothelioma Treatment for symptoms You’re Going To Want To Try

Treatment for symptoms

For many people, mesothelioma is diagnosed at an advanced stage, and the main goal of treatment is to manage and control your symptoms. Although there is usually no cure for

mesothelioma, treatment may make you feel better and help you live longer. This is called palliative treatment.

 

It is often assumed that palliative care is only for people at the end of life; however, it is beneficial for people at any stage of a

mesothelioma diagnosis. It does not mean giving up hope – rather it is about living for as long as possible in the most satisfying way you can and managing symptoms as they occur. Early palliative care is sometimes also called supportive care.

 

This chapter describes treatments and strategies for managing some common symptoms of mesothelioma. As you may be experiencing a number of symptoms, you may have a combination of treatments. Keep in mind, however, that you won’t necessarily experience every symptom listed here.

 

If symptoms return after a period of relatively good health, you may be offered a different combination of treatments.

 

 

Breathlessness

Breathlessness is the most common symptom of pleural mesothelioma and is often caused by a build-up of pleural fluid around the lungs. In the earlier stages of pleural mesothelioma, controlling this fluid build-up will improve breathlessness. The level of improvement will depend on how healthy your lungs

 

 

 

 

 

were before you developed pleural mesothelioma, and the level of lung function after surgery. You may also feel breathless because of the cancer itself not allowing the lung to work properly – this is known as a trapped lung.

 

In peritoneal mesothelioma, a build-up of fluid (ascites) can cause the abdomen to swell. This can be painful, but also puts pressure on the diaphragm and can make you feel breathless.

 

Infection or a low level of red blood cells (anaemia) can also cause breathlessness. Your doctor can manage this with medication.

 

Although living with breathlessness can be difficult, there are ways to reduce its impact on your life (see pages 34–35). For some people, there are surgical options to control the build-up of fluid.

 

Ways  to  drain  fluid  around  the  lungs  or  abdomen You may have a procedure to drain the fluid from around the lungs or abdomen. If you have gone to the doctor with symptoms, this may be done before mesothelioma is diagnosed. Sometimes it is done at the same time as the biopsy (see pages 18–21).

 

Pleural tap – Also known as pleurocentesis or thoracentesis, a pleural tap drains fluid from around the lungs. To drain the fluid, your doctor can numb the area with a local anaesthetic and insert  a needle through the skin. An ultrasound scan is used to help the doctor guide the needle to where the fluid is. A pleural tap can also be done when a biopsy is taken during the keyhole surgery called VATS (see pages 19–20).

 

 

 

 

 

 

Peritoneal tap – In peritoneal mesothelioma, fluid that has  built up in the abdomen (ascites) can be drained with a needle guided by ultrasound. This procedure is called a peritoneal tap or paracentesis and may be done while you are still having tests.

 

Ways to control fluid around the lungs

Talc pleurodesis – To prevent fluid building up again in the lining of the lungs, you may have a talc pleurodesis. This is best done when you are having a pleural tap during VATS, but may also be done under local anaesthetic by a respiratory physician.

 

Pleurodesis means closing the pleural space. The doctor inserts sterile talcum powder (talc slurry) into the pleural cavity. The  talc slurry causes an inflammatory reaction that helps to fuse the two layers of the pleura together. After pleurodesis, some people experience a burning pain in the chest for 24–48 hours. This pain can be eased with medication.

 

Talc pleurodesis is sometimes done during the process of diagnosing pleural mesothelioma. If you haven’t already had this procedure, your surgeon may suggest it now.

 

 

 

 

 

VATS  with  pleurectomy  and  pulmonary  decortication  – When fluid is drained and talc pleurodesis is done during VATS, some of the outer lining of the chest wall and lung may also be removed. This is known as parietal pleurectomy (because only the outer pleura is removed) and pulmonary decortication.

 

Open  surgery  (thoracotomy)  with  pleurectomy  and pulmonary decortication – Following VATS and talc pleurodesis, the fluid build-up around the lungs may come back, making you feel breathless again. The surgeon may suggest more extensive surgery called thoracotomy with pleurectomy and pulmonary decortication. This surgery may also be recommended as a first option if the cancer has grown in a way that makes it difficult to perform VATS successfully.

 

Under a general anaesthetic, the surgeon will open the chest by making a cut from the back to the side of the chest, and between the ribs. The pleural fluid is drained and the part of the pleura most affected with cancer is removed. In some cases, all of the pleura may be removed. After this procedure, the anaesthetist inflates the lung and the surgeon closes the chest. Tubes are left in place in the chest for at least 48 hours to drain blood and any air that is leaking from the surface of the lung.

 

Open surgery helps to prevent fluid building up again in most cases. It also makes it easier for the lungs to expand and to transfer oxygen to the blood. Pain can last longer than after VATS, but the improvement in symptoms may make open surgery a worthwhile option if VATS has been unsuccessful or isn’t possible.

 

 

 

 

 

Indwelling pleural catheter – Some people cannot have VATS or open surgery, either because they are too unwell or because the cancer has grown in a way that makes the surgery too difficult. In this case, you may be offered an indwelling pleural catheter (also known as a drain) to help your breathing. This can also be used if the pleural fluid builds up again after pleurodesis.

 

Under local anaesthetic, the specialist will insert a thin tube (the catheter) through the chest wall into the pleural cavity. You can manage the drain at home with the help of a community nurse, family member or friend. When you need to drain the fluid (usually once or twice a week), the catheter can be connected to a bottle.

 

Sometimes with an indwelling pleural catheter, the pleural cavity may close up over time and stop producing fluid. If this occurs, the drain will be removed.

 

Ways to control fluid in the abdomen

Indwelling peritoneal catheter – If fluid keeps building up around the abdomen, a small tube can be inserted to allow fluid to flow out of the body into a bottle. This is known as an indwelling peritoneal catheter or drain and is managed similarly to an indwelling pleural drain (see above).

 

Heated chemotherapy – To control ascites, your doctor may suggest a single dose of heated chemotherapy directly into

the abdomen (HIPEC, see page 54). This can be given during laparoscopy (see page 20), and there is some evidence that it can help prevent fluid building up again.

 

 

 

 

 

 

Improving breathlessness at home

It can be distressing to feel short of breath, but a range of simple strategies and treatments can provide some relief at home.

 

 

 

Treat other conditions

Let your doctor know if you feel breathless. Other

conditions, such as anaemia or a lung infection, may

also make you feel short of breath, and these can often be treated.

Sleep in a chair Use a recliner chair to help you sleep in a more upright position.

 

 

 

 

 

 

Ask about medicines

Talk to your doctor about medicines, such as a low dose of morphine, to manage feelings of distress. Make sure your chest pain is well controlled as pain may stop you breathing deeply.

 

 

Check if equipment could help

Ask your health care team about equipment to manage breathlessness. You may be able to use an oxygen concentrator at home to deliver oxygen to your lungs. For social outings and medical appointments, you can use a portable oxygen cylinder. If you have a cough or wheeze, you may benefit from a nebuliser, a device that delivers medicine into your lungs.

 

 

 

 

 

 

 

 

 

 

Modify  your  movement Some types of gentle exercise can help, but check with your doctor first. A physiotherapist, exercise physiologist and/

or occupational therapist from your treatment centre can explain how to modify your activities to improve breathlessness.

 

 

Relax on a pillow Lean forward on a table with an arm crossed over a pillow to allow your breathing muscles to relax.

 

 

 

 

Explore   options Some people find breathing exercises, acupuncture and meditation helpful. Call 13 11 20 for a copy of Understanding Complementary Therapies, or find it

on your local Cancer Council website.

 

 

 

 

 

 

 

 

 

 

 

Find ways to relax Listen to a relaxation recording or learn other ways to relax. This can allow you to control anxiety and breathe more easily. In some states and territories, Cancer Council offers free relaxation CDs or has the recordings available on

the website.

Create  a  breeze Use a fan to direct a cool stream of air across your face if you experience breathlessness when you are not exerting yourself.

 

 

 

 

 

Difficulty sleeping

Getting a good night’s sleep is important for maintaining your energy levels, reducing fatigue, and improving mood. Difficulty sleeping may be caused by pain, breathlessness, anxiety or depression. Some medicines can also disrupt sleep. If you already had sleep problems before the mesothelioma diagnosis, these can become worse.

 

Talk to your doctor about what might be helpful for you. Your medicines may need adjusting or sleep medication may be an option. There are also a number of strategies that other people with mesothelioma have found helpful (see below).

 

 

 

Getting a better night’s sleep

 

  • Try to do some gentle physical activity every This will help you sleep better. Talk to

a physiotherapist, who can tailor an exercise program, and an occupational therapist, who can suggest equipment to help you move safely. You can also call Cancer Council 13 11 20 for a copy of the Exercise for People Living with Cancer booklet, or download it from your local Cancer Council website.

  • Limit or cut out the use of alcohol, caffeine, nicotine and spicy food.
  • Avoidusing technology, such as television, computers or smartphones, before
  • Establish a regular routine before bed and set up a calm sleeping envir You may find soothing music helpful. Ensure the room is

dark, quiet and a comfortable temperature.

 

 

 

 

 

Fatigue

Fatigue means feeling very tired and lacking energy to carry out day-to-day activities. For people with cancer, it is different from tiredness and does not always go away with rest or sleep. You may lose interest in things that you usually enjoy doing or feel unable to concentrate for very long. Fatigue can influence how you feel about yourself and others, which may affect your close relationships.

 

If fatigue is a problem, talk to your treatment team. Sometimes fatigue can be caused by a low red blood cell count or the side effects of drugs, and can be treated. While you cannot always get rid of fatigue, you can find ways to improve your energy levels.

 

 

 

Managing fatigue

  • Set small, manageable goalsfor the day, and rest before you get too
  • Ask for and accept offers of help with tasks such as shopping, cleaning and gar
  • Plan breaks throughout the day when you are completely still for a An eye pillow can help at these times.
  • Say no to things you really don’t feel like

 

 

  • Leave plenty of time to get to
  • Sit down whenever you
  • Ask your doctor about what sort of exercise would be Even a walk around

the garden or block can boost your energy levels.

  • Eat nutritious food to keep your energy levels
  • Consider acupuncture – some find it helps with

 

 

 

 

 

Lack of appetite and weight loss

Some people stop feeling interested in eating and lose weight even before mesothelioma is diagnosed. These symptoms may be caused by the disease itself, or by nausea, trouble swallowing, changes in taste or smell, breathlessness, abdominal pain, or feeling down.

 

Eating well will help you cope better with day-to-day living, treatment and side effects, and improve your quality of life. A palliative care specialist can help manage symptoms that impact on your appetite or ability to eat. You may also find it useful to talk to a dietitian who is experienced in treating people with cancer. They can provide helpful eating suggestions.

 

 

 

Eating when you have little appetite

 

  • Eat small meals and snacks A large, full plate may put you off eating – try

using a smaller plate with less daunting portions. Likewise, drink from a half-full glass.

  • Eat more of your favourite foods – follow your
  • Tryeating salads or cold foods if hot food smells make you
  • Avoid fatty or sugary These may make you feel sick.
  • Use lemon juice and herbsto add flavour to bland food.
  • Eat moist food such as scrambled Moister food tends to be easier to eat and will cause less irritation if you have a sore mouth.
  • Add ice-cream or fruit to a drink to increase kilojoules and
  • If solid food doesn’t appeal, ask a dietitian about protein drinks or other

 

 

 

 

 

Constipation

Constipation is when your bowel motions and wind are difficult to pass and infrequent. It may be caused by not moving around as much, eating less fibre, or not drinking enough fluids. Strong pain medicines, some anti-nausea medicines and some chemotherapy drugs also cause constipation.

 

Severe constipation accompanied by other symptoms such as abdominal pain and swelling, nausea and vomiting can indicate a blockage in the bowel (bowel obstruction). This occasionally happens with peritoneal mesothelioma, but rarely with pleural mesothelioma. It needs prompt medical attention.

 

 

 

Managing constipation

  • Drink plenty of
  • Eat fresh fruit and vegetables and fibre-rich foods (e.g. prunes) unless your doctor advises
  • Try to exercise every Talk to your doctor or physiotherapist to find the exercise that is right for you.
  • Ask your doctor about medicines for constipation if it’s caused by chemotherapy or other

 

 

  • Try over-the-counter laxatives such as Coloxyl with senna, Duphalac or Movicol, but check the dose with the pharmacist and let your doctor know. Don’t wait too long before starting
  • Call your treatment team or 000 if you have symptoms of a bowel obstruction (described above).
  • Read Cancer Council’s

Nutrition and Cancer booklet.

 

 

 

 

 

Pain

People are naturally fearful of experiencing pain. It’s vital to tell your treatment team if you are in pain. Pain can be a symptom of mesothelioma, but can also be a side effect of treatment.

 

The pain caused by the mesothelioma itself is usually dull and generalised – it can be difficult to say exactly where it is coming from. If the cancer spreads and presses on bones or other organs, it may feel sharp and stabbing. A sharp pain in the chest can also be caused by a blood clot in the lungs (pulmonary embolism), so seek urgent medical attention if the pain is new. Chemotherapy or surgery can injure nerves and cause pain or numbness.

 

Pain medicines – Pain medicines may be mild, like paracetamol; moderate, like codeine; or strong and opioid-based, like morphine. Pain-relieving drugs may be taken as tablets, oral liquids, patches, injections or intravenous infusions. Other drugs may also be prescribed, like non-steroidal anti-inflammatory drugs (NSAIDs) or drugs specifically for nerve pain.

 

To help find the right medicine for you, your doctor may prescribe different drugs, different doses or a combination of drugs.

 

The pain got so severe that I gave in and accepted some morphine. I wondered afterwards why I had resisted. I am pretty much pain-free most of the time and quite alert when I need to be. It has made such a difference to my quality of life.  Jack

 

 

 

 

 

Opioids, such as morphine or oxycodone, are the most common drugs used to control moderate to severe cancer pain. Morphine is available in quick-acting and long-acting forms.

 

Some people feel concerned that they might become addicted to morphine. However, pain specialists believe that this won’t happen  if you take it as prescribed by your doctor to relieve pain. Morphine can be taken for a long time and in increasing doses, if needed. It doesn’t have to be kept for “when the pain gets really bad”. There are now many strong pain medicines that are similar to morphine, so if one does not agree with you, ask your doctor about other options.

 

A small percentage of people have difficulty in controlling

their pain, and may need to try many medical and non-medical methods of relieving it. A palliative care specialist or pain specialist can help find the right combination for you.

 

Procedures  to  manage  fluid  build-up  –  Fluid build-up around the lungs or abdomen can cause pain as well as breathlessness. There are various treatments that can help drain the fluid and try to prevent it building up again. These are described in Breathlessness on pages 29–33.

 

Radiotherapy – This may be used to shrink mesothelioma that is pressing on body parts such as nerves, bones or major blood vessels and causing pain. Sometimes the mesothelioma can grow

through the scar from VATS surgery and produce a lump in the skin. Radiotherapy can reduce the size of the lump and ease any associated pain. See pages 48–50 for more information about radiotherapy.

 

 

 

 

 

Chemotherapy – This can reduce the size of the mesothelioma that is causing the pain. See pages 46–48 for more information.

 

Debulking surgery – If you are well enough and it is technically possible, surgery may be used to remove the part of the mesothelioma causing pain and other symptoms. This is known as debulking surgery.

 

To find out more about managing pain, call Cancer Council 13 11 20 and ask for a copy of Overcoming Cancer Pain, or

download the booklet from your local Cancer Council website.

 

 

 

 

Coping with pain

  • Keep track of your pain ina symptom diary and try to describe it – what the pain

feels like, how intense it is, exactly where it is, where it comes from and travels to, how long it lasts, and if it goes away with a specific pain medicine or with any other therapy, such as a heat pack.

  • Allow a few days for your body to adjust to the dose of pain medicine/morphine and for the drowsiness to impr

 

  • Let your doctor know if you have vivid dreams, nausea or other side effects after taking a strong pain medicine such as Adjusting the dose may help, or you can try other methods of pain relief.
  • Use a laxative regularly to prevent or relieve constipation from pain
  • Take pain medicine regularly as prescribed, even when you’re not in It’s better to stay on top of the pain.

 

 

 

 

 

My husband did not want to accept help from the palliative care people. He said that once they got involved he would not have much longer left to live. But his GP told him about what they do and how much they can help with symptoms and comfort. He agreed to try and now would not be without them.                               Grace

 

 

How palliative care can help

The options described in this chapter are generally considered palliative treatment because their main aim is to improve quality of life by reducing symptoms. Palliative treatment is one aspect of palliative care, in which a team of health professionals aim to meet your physical, practical, emotional, spiritual and social needs. The palliative care team also provides support to families and carers.

 

Contacting the palliative care team soon after diagnosis gives them the opportunity to get to know you, your family and your circumstances. Although other professionals will be responsible for your treatment in the earlier part of your diagnosis, the palliative care team can become involved when needed.

 

Ask the doctor in charge of your medical care about making an appointment with the palliative care team. To find out more about palliative care and advanced cancer, call Cancer Council 13 11 20. You can ask for free copies of the booklets Understanding Palliative Care and Living with Advanced Cancer, or download digital versions from your local Cancer Council website.

 

 

 

 

 

 

Key points

 

 

  • For most people, treatment is given to control symptoms and improve quality of

 

  • Breathlessness caused by fluid build-up is the most common symptom of pleural It can usually be controlled with surgery

– either a type of keyhole surgery called video-assisted thoracoscopic surgery (VATS) or a type of open surgery called thoracotomy.

 

  • An indwelling pleural catheter allows fluid to be drained without The catheter is inserted through the chest wall into the pleural cavity, and can be collected into a bottle.

 

  • Other ways to improve breathlessness include using a fan, leaning forward on a table over a pillow or sleeping in a recliner

 

  • Fluid in the abdomen (ascites) can be controlled with an

indwelling peritoneal catheter or heated chemotherapy.

 

  • Manage fatigue by exploring ways to improve sleep, setting small goals for the day, and resting before you get too

 

  • Try to drink plenty of fluids and eat fresh fruit and vegetables to ease

 

  • While pain is common for people diagnosed with mesothelioma, it can be Strong pain is often treated with opioid-based drugs such as morphine.

 

  • In some cases, radiotherapy, chemotherapy or surgery can be used to manage

 

  • Palliative treatment helps to improve a person’s quality of life by managing It’s best to access it early. You can get in touch with the palliative care team soon after you have been diagnosed.

 

 

Active treatment

 

A range of active treatments are recommended for some people with mesothelioma. These aim to control or cure the cancer and can include chemotherapy, radiotherapy or surgery, which may be used alone or in combination. Trimodality therapy for pleural mesothelioma is a combination of all three (see pages 50–52).

 

Each person with mesothelioma is different and there is no standard treatment path. Your specialist will discuss your treatment options with you, and these will depend on a number of factors including:

  • the location, stage and type of mesothelioma, which helps estimate the likelihood of response to treatment
  • yourage, health and fitness
  • yourfamily circumstances and support
  • whatis most important to you.

 

 

Deciding to pursue active treatment

The active cancer treatments discussed in this chapter help some people to achieve a longer period of control over the disease and improve their quality of life. It is important to realise that most are intensive treatments and they are not suitable for everyone.

 

Even if a particular treatment is recommended, it will be up

to you whether or not to proceed (see Making treatment decisions, pages 27–28). Talk to your treatment team about what is involved and what recovery will be like. You can also call Cancer Council 13 11 20 or talk to one of the mesothelioma support services listed on page 72.

 

 

 

 

 

 

 

Active treatment for pleural mesothelioma

 

Chemotherapy

Chemotherapy treats cancer using drugs known as cytotoxics.

It aims to destroy cancer cells while causing the least possible damage to healthy cells. The main chemotherapy drugs for pleural mesothelioma are pemetrexed in combination with cisplatin

or carboplatin. Research shows this combination can increase survival by a few months more than using a single drug. However, chemotherapy doesn’t work for some people.

 

 

 

 

 

Chemotherapy is usually administered into a vein through a drip (intravenously). The drugs travel through the bloodstream and reach the entire body. This is known as systemic chemotherapy.

 

You will usually have chemotherapy during day visits to your hospital or treatment centre. Each session may last for several hours followed by a rest period of several weeks. Together, the session and rest period are called a cycle. You will probably have up to six cycles. However, the length and timing of the treatment and rest days of each cycle may vary.

 

Side effects of chemotherapy – People react to chemotherapy drugs differently. Some people will have few side effects, while others will have more.

 

The most common side effects of chemotherapy include:

  • tirednessand feeling weak (fatigue)
  • nauseaand/or vomiting
  • bowelproblems (diarrhoea or constipation related to anti-nausea drugs)
  • soreor dry mouth, or small ulcers in the mouth
  • tastechanges and/or loss of appetite
  • increasedrisk of infection (low level of white blood cells) and anaemia (low level of red blood cells)
  • reducedkidney function
  • ringingin the ears (tinnitus)
  • skinchanges
  • numbor tingling hands or feet
  • redand itchy eyes (conjunctivitis).

 

 

 

 

 

 

While hair loss and scalp problems are rare with chemotherapy for mesothelioma, there may be hair thinning. Some people have trouble thinking clearly or experience short-term memory loss

after chemotherapy, but this usually improves once treatment ends.

 

Side effects depend on the type and dose of chemotherapy drugs. Your specialist may prescribe vitamin B12 injections and low-dose folic acid, which have been shown to reduce the side effects of chemotherapy with pemetrexed and cisplatin. You will also be given medicines (such as anti-nausea medicine) to help control any side effects that are likely to occur. If side effects become too difficult to manage, your oncologist can adjust the dose or type of chemotherapy.

 

Call Cancer Council 13 11 20 for a free copy of Understanding Chemotherapy, or visit your local Cancer Council website.

 

Radiotherapy

Also known as radiation therapy, radiotherapy uses radiation, such as x-rays, to kill or damage cancer cells. Radiotherapy may be used at different stages of pleural mesothelioma treatment and in different ways. It can relieve pain or other symptoms caused by tumours (palliative radiotherapy).

 

 

 

 

 

Radiotherapy is also given after chemotherapy and surgery (adjuvant radiotherapy) to help kill remaining cancer cells.

 

Treatment is carefully planned to destroy as many cancer cells as possible while causing the least harm to your normal tissue. The initial appointment to map out the treatment (simulation)

may take a few hours. You will have CT scans of the affected area, and your skin may be marked with a special ink. This makes sure that the radiation is directed at the same place on your body every time you receive radiotherapy. Although the ink is permanent,  the mark is the size of a freckle.

 

Radiotherapy is usually given every day Monday to Friday as an outpatient treatment. A session usually lasts about 20 minutes because the radiation therapists have to set up the equipment and position you, but the treatment itself takes only a few minutes.

The length of the treatment course will vary depending on why you’re having radiotherapy – it might involve 1–10 sessions for up to two weeks for palliative treatment, or longer if radiotherapy is combined with other treatments with the aim of long-term control. Radiotherapy doesn’t hurt and you aren’t radioactive afterwards.

 

Side effects of radiotherapy – Radiotherapy may cause various side effects during treatment or shortly afterwards, but most side effects go away after the treatment stops.

 

Your doctors and nurses will tell you what side effects to expect and how to manage them. The most common side effects are listed on the next page.

 

 

 

 

 

The side effects of radiotherapy vary depending on the area of the body being treated, but can include:

  • fatigue
  • peeling, cracked skin that looks red or sunburnt and may be painful
  • painful swallowing
  • lossof hair in the treatment ar

 

Radiotherapy to the chest area can cause difficulty swallowing and symptoms of reflux for a few days or weeks, sometimes leading

to weight loss. If high doses of radiotherapy are given to the chest area, it may cause permanent changes (fibrosis) in the lung tissue.

 

Call Cancer Council 13 11 20 for a free copy of Understanding Radiotherapy, or visit your local Cancer Council website.

 

Trimodality therapy

Trimodality therapy includes a combination of induction chemotherapy, radical surgery (also called cytoreductive surgery) and radical radiotherapy. The aim of the three phases is to remove as much pleural mesothelioma as possible, stop any remaining mesothelioma cells from growing or spreading, and prolong disease-free living.

 

The benefits of trimodality therapy for pleural mesothelioma are not yet clear. Not all mesothelioma specialists recommend trimodality therapy, and it’s available only in a few specialist

centres. There has not yet been an evidence-based trial comparing the results of trimodality treatment to less intensive treatment.

 

 

 

 

The three phases of trimodality therapy

 

Induction chemotherapy phase

Three cycles of chemotherapy are given to shrink the tumour. A scan then checks the size of the tumour. If it has been reduced, you will have a rest for 4–6 weeks before having surgery. If there is little or no response, you will not have radical surgery.

 

 

 

 

Radical surgery phase

The surgery is usually an extrapleural pneumonectomy (EPP). It removes the affected lung as well as parts of the lining of the heart (pericardium), lining of the chest (parietal pleura) and diaphragm. Lymph nodes in the centre of the chest that drain the lung are also removed. Mesh is used to repair the

pericardium and diaphragm. You’ll stay in hospital for 10–14 days, or longer if complications occur. Once at home, recovery can take 6–8 weeks and then you’ll be able to start radiotherapy.

 

 

 

 

Radical radiotherapy phase

This phase aims to treat the tumour cells that may still be present. Radiotherapy is delivered using intensity-modulated radiation therapy (IMRT). This type of radiotherapy can be accurately shaped around the chest cavity to allow higher doses to be delivered directly to the tumour cells while minimising

the damage to other organs in the chest and abdomen. You will have treatment every day, Monday to Friday, for up to six weeks. The side effects of radiotherapy (see opposite) usually become more intense as treatment progresses. Most people start to feel better 2–3 weeks after treatment ends.

 

 

 

 

 

Who can have trimodality therapy – Only a small number of people with pleural mesothelioma have trimodality therapy each year as it is only suitable for people:

  • with a small amount of pleural mesothelioma at an early stage (T1–T3)
  • withan epithelioid type of pleural mesothelioma
  • whose scans show a good response to chemotherapy before surgery and no signs of pleural mesothelioma progression
  • withno signs of spread into the lymph nodes or any other disease on CT and/or FDG-PET scans
  • who are able to live independently with one lung
  • who are physically fit enough for surger

 

The best person to determine if you will be a suitable candidate for this treatment is the surgeon who would perform the surgery.

 

It is important to ask your surgeon, oncologist and nurse to explain the likely outcome of the surgery for you. An EPP is a major operation, and not everyone wants to go ahead after the risks, benefits and implications of the therapy are explained by their treatment team.

 

Sometimes, despite a person appearing suitable at first, the doctor may decide it is best for them not to continue with trimodality therapy. This might be because:

  • the mesothelioma does not respond well to the chemotherapy
  • testsof specimens taken at surgery show that the cancer is growing quickly or has spread
  • the person has become too tired or un

 

 

 

 

 

Active treatment for peritoneal mesothelioma

 

Peritonectomy

It is possible for some people to have an operation called a peritonectomy (or cytoreductive surgery). During this procedure, a surgeon removes the parts of the peritoneum where the mesothelioma is growing.

 

The aim of peritonectomy is to achieve the complete removal of the cancer to reduce symptoms, improve quality of life and increase life expectancy.

 

Peritonectomy surgery is complex and recovery can take a long time. Whether this surgery is an option for you will depend on a number of factors, including your overall health and fitness, and whether the small bowel is cancer-free.

 

Only a small number of surgeons in Australia perform peritonectomy. It is recommended you seek an opinion from one of these surgeons if considering this surgery. To find one of these surgeons, talk to your treatment team or contact a mesothelioma support organisation (see page 72).

 

 

 

 

 

 

Chemotherapy

Chemotherapy is sometimes used to treat peritoneal mesothelioma. It may be given as a systemic treatment (into the bloodstream)

on its own or before or after surgery. Systemic chemotherapy for peritoneal mesothelioma is similar to that given for pleural mesothelioma (see pages 46–48 for more information).

 

If you have a peritonectomy, you will have chemotherapy directly into the abdomen. This is known as intraperitoneal chemotherapy and may be given in three ways:

 

  • HIPEC – Heatedintraoperative intraperitoneal chemotherapy (HIPEC) may be given as part of peritonectom For this “hot chemotherapy”, the drugs are heated to 42.5°C and inserted into the abdomen for 60–90 minutes during the operation.

 

  • EPIC – Aftersurgery, chemotherapy may be delivered into the abdomen through a thin tub When given soon after surgery as a single course, it is called early postoperative intraperitoneal chemotherapy (EPIC).

 

  • NIPEC – Thereis evidence that receiving a long-term course of normothermic (normal temperature) intraperitoneal chemotherapy (NIPEC) may offer some benefi

 

 

 

 

 

 

Key points

 

 

  • The type of treatment you have will depend on the location, stage and type of mesothelioma, as well as your age, health and

 

  • Active cancer treatment for pleural mesothelioma may include chemotherapy and radiotherapy.

 

  • Chemotherapy for pleural mesothelioma often uses pemetrexed in combination with cisplatin or

 

  • Radiotherapy may be used at different stages of pleural mesothelioma and in different It may be used to relieve pain or

shrink tumours, or given after chemotherapy and surgery to kill remaining cancer cells.

 

  • Some people with pleural mesothelioma may be offered trimodality therapy, with chemotherapy first, followed by major surgery,

and then radiotherapy. The surgery removes the affected lung and parts of the pericardium, parietal

pleura and diaphragm. This is known as an extrapleural pneumonectomy (EPP).

 

  • Active cancer treatment for peritoneal mesothelioma may include surgery and chemotherapy.

 

  • Some people with peritoneal mesothelioma can have a peritonectomy. This major surgery aims to remove all of the cancer by removing parts of the

 

  • Chemotherapy for peritoneal mesothelioma may be systemic (given into the bloodstream)

or intraperitoneal (given directly into the abdomen).

 

  • New trials are testing targeted therapy and immunotherapy

 

 

Living with mesothelioma

 

Life with a mesothelioma diagnosis can present many challenges. Take some time to adjust to the physical and emotional changes, and establish a daily routine that suits you and the symptoms you’re coping with.

 

You are likely to feel a range of emotions about having mesothelioma. Cancer Council’s Emotions and Cancer booklet offers strategies for coping with anxiety, fear, anger and other feelings. You may also have practical concerns, such as how to make a compensation claim for asbestos exposure (see pages 62–67) and what to do about work

(see Cancer Council’s Cancer, Work and You booklet).

 

 

 

 

 

 

 

Finding support

The organisations listed on page 72 can offer support or connect you with other people who have mesothelioma. You can also  call Cancer Council 13 11 20 or visit your local Cancer Council website (see back cover) for information about many aspects of living with cancer.

 

 

Looking after yourself

A mesothelioma diagnosis will cause physical and emotional strain. It’s important to try to look after your wellbeing as much as possible.

 

Nutrition – Healthy food can help you cope with treatment and side effects. A dietitian can help you manage special dietary needs or eating problems, and choose the best foods for your situation.

 

Call Cancer Council 13 11 20 for a free copy of the Nutrition  and Cancer booklet, or download a copy from your local Cancer Council website.

 

Staying active – Physical activity often helps to reduce tiredness, improve circulation and elevate mood. The amount and type of exercise you do depends on what you are used to, how you feel, and your doctor’s advice.

 

Cancer Council’s Exercise for People Living with Cancer booklet provides more information about the benefits of exercise, and outlines simple exercises that you may want to try.

 

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