Multimodal therapy refers to a combination of more than one treatment strategy. For cancer and for 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 the safest option for the patient.
The goal of a multimodal approach to therapy is to extend the life of the patient and to improve the patient’s quality of life. This is done through shrinking tumors and eliminating them entirely whenever possible. It also involves slowing the progression of the disease by slowing or stopping the spread of the cancer if it is possible. To achieve these goals almost always requires multimodal therapy.
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 of them, if not all three in a trimodal approach. Whether or not a patient will undergo all three, or the two that are used, depends on an individual’s health, cancer stage, underlying conditions, and other factors. The three options are chemotherapy, surgery, and radiation therapy:
- Chemotherapy. Chemotherapy is the treatment of cancer with 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 a lot of side effects.
- Surgery. Surgery is considered to be one of the best ways to effectively treat mesothelioma, but not all patients are eligible for it because of health concerns. 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 type of 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 for administering these three or two treatments in a multimodal approach. Which two are used, if all three 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 it comes to ordering the treatments for multimodal therapy, doctors have many options. A neoadjuvant therapy is the treatment that is given first, before a primary treatment. This therapy is supposed to help improve the outcome for the primary treatment. The primary therapy is the one that it is hoped will 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 this may be limited by the patient. 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 sensitive organ, radiation may be too risky.
Examples of Multimodal Therapy
The best option for treating most types of cancer in most patients is a trimodal approach, using all three options available, but this is not necessarily possible for all patients. If trimodal treatment is possible, one of the most common ways to do it is to give a patient chemotherapy first. This shrinks the size of tumors. The primary treatment is often surgery and by shrinking the tumors first, the surgery may be more successful at removing the bulk 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 the chance of a 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 candidates for surgery because the cancer has spread too far throughout the body. For these patients, a combination of chemotherapy and radiation is often the best approach to treatment.
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 very 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 is a treatment strategy that uses the patient’s immune system to attack and kill cancer cells. For example, an immunotherapy drug that is used to treat some types of cancer 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 currently 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 things 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.
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