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Multimodal therapy is a combination of more than one treatment. For cancer and all types of mesothelioma, this usually means some combination of chemotherapy, surgery, and radiation therapy. A multimodal approach may include two of these or all three, used in a strategic way to provide the most effective treatment balanced against patient safety.
The goal of a multimodal approach is to extend the life of the patient and to improve quality of life by shrinking tumors and eliminating them entirely whenever possible. It also involves slowing the progression of the cancer if possible.
Therapies Used in a Multimodal Approach
The three basic strategies for treating cancer may be used alone or in combination. Greater success in treating mesothelioma is seen with combining at least two, if not all three in a trimodal approach. Whether a patient will undergo all three, or the two that are used, depends on health, cancer stage, underlying conditions, and other factors. The three options are chemotherapy, surgery, and radiation therapy:
- Chemotherapy. Chemotherapy uses drugs that kill cancer cells. Many different chemotherapy drugs have been developed and are in use, but most are administered systemically. This means they are injected into the bloodstream through an IV and can circulate through the entire body. The drugs target any cell that grows and divides rapidly, including cancer cells and some healthy cells. Research is underway to develop better strategies for using chemotherapy in a more targeted way, as killing healthy cells produces side effects.
- Surgery. Surgery is one of the best ways to treat mesothelioma, but not all patients are healthy enough to endure it. Surgery involves removing as much cancerous tissue as possible and sometimes removing nearby healthy tissue to prevent or slow the spread of the cancer. Surgery for mesothelioma is often highly invasive. An extrapleural pneumonectomy, for instance, involves removing an entire lung, the pleura, lymph nodes, and part of the diaphragm.
- Radiation therapy. High-energy beams of radiation are used to target and kill cancer cells in radiation therapy. This is most often done externally, with a machine that produces the radiation. It may also be done internally, which is called brachytherapy. A small device is placed inside the body to target the tumor with radiation. Radiation therapy effectively kills cancer cells, but can also cause damage to healthy tissues. New advances in this treatment are helping doctors give higher doses of radiation that are better targeted at tumors and that spare healthy tissue.
Choosing and Ordering Multimodal Treatments
There is no single standard way to administer these treatments in a multimodal approach. Which treatments are used, and the order in which they are used depend on many factors, including the age and overall health of the patient, the location of tumors, the stage of the cancer, the risks associated with the treatments, and how far the cancer has spread throughout the body.
When ordering the treatments for multimodal therapy, doctors have many options. A neoadjuvant therapy is given first, before a primary treatment, to improve the outcome for the primary treatment. The primary therapy is the one likely to be most effective. An adjuvant therapy may be used after a primary therapy to help relieve symptoms or to prevent or delay a recurrence of the cancer.
It is important to use as many approaches as possible, but there are limits. Surgery cannot be used if the cancer has spread too far, for instance. A patient may be too sick to tolerate the side effects of chemotherapy. And, in some cases, the location of the tumor may make radiation impossible. If the tumor is too close to a vital organ, radiation may be too risky.
Examples of Multimodal Therapy
The best option for treating most cancers in most patients is a trimodal approach, using all three options, though this is not possible for all patients. If trimodal treatment is possible, chemotherapy is usually first. This shrinks tumors and gives a surgeon a better chance at removing most of the cancerous tissue. Radiation is then used as the adjuvant therapy to target any cancer cells missed by the previous treatments and to reduce recurrence.
A common problem with mesothelioma is that surgery is not possible. It is almost always the first choice for primary treatment, but many mesothelioma patients are not eligible for surgery because the cancer has spread too far throughout the body. For these patients, a combination of chemotherapy and radiation is the best approach.
While chemotherapy is often used as the neoadjuvant treatment when surgery is the primary therapy, there are situations in which it may be used after surgery. As an adjuvant treatment it is becoming more common for doctors to choose chemotherapy to kill any remaining cancer cells that the surgeon could not see. Radiation therapy is still important as an adjuvant to surgery, especially with new advances that allow doctors to better target tumors and avoid harming healthy tissue. In one study, researchers found that patients had better survival times when one of these advanced types of radiation, called IMRT, was used right after extrapleural pneumonectomy surgery.
An emerging type of treatment may add to the effectiveness of multimodal treatment in the future. Immunotherapy uses the patient’s immune system to attack and kill cancer cells. One immunotherapy drug targets a protein in the immune system that normally prevents it from attacking cancer cells. In one recent study, researchers used a four-modal approach to treating patients: immunotherapy, followed by surgery, followed by chemotherapy, radiation therapy, and more immunotherapy. The patients survived an average of 26 months after treatment.
Multimodal therapy for mesothelioma is standard practice. Whether four, three, or two strategies are used and the order in which they are given depends on the patient and what the medical team thinks will be most effective and safest. The promise for adding immunotherapy treatments to a multimodal approach is positive, but even with all of these options there is still no cure for mesothelioma. Even so, as advances continue, these patients are living longer and suffering from fewer symptoms.
Page Medically Reviewed and Edited by Anne Courtney, AOCNP, DNP
Anne Courtney has a Doctor of Nursing Practice degree and is an Advanced Oncology Certified Nurse Practitioner. She has years of oncology experience working with patients with malignant mesothelioma, as well as other types of cancer. Dr. Courtney currently works at University of Texas LIVESTRONG Cancer Institutes.