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Multimodal therapy for mesothelioma combines two or more treatments for the best patient outcome. A common combination is surgery with chemotherapy, radiation, or both. Currently, multimodality is thought to be the best choice for most patients.
What Is Multimodal Therapy?
Multimodal therapy refers to a care strategy that involves multiple treatment types. Instead of just one technique, like chemotherapy, treatment teams attack the cancer on multiple fronts.
The standard treatments combined to treat mesothelioma are chemotherapy, surgery, and radiation therapy. Additional treatments doctors may use are immunotherapy, targeted therapy, tumor treating fields, and photodynamic therapy.
Treatment teams look at a patient’s health, cancer stage and location, and other factors to determine the best combination of treatments. For most people, multimodal treatment is more effective and offers a better prognosis than a single treatment alone.
What Are the Benefits of Multimodal Therapy for Mesothelioma?
The primary advantage of using multimodality is that it gives most patients a better outcome. The median survival rate for untreated mesothelioma is just six to nine months. Any treatment extends this, but the patients living the longest receive multimodal treatment, according to several studies:
- A study with 21 patients receiving both chemotherapy and surgery recorded an overall medican survival time of nearly 26 months.
- Another study looked at trimodality involving radiation, chemotherapy, and surgeons. The overal median survival time for these patients was 39.4 months.
What Do the Official Treatment Guidelines Say About Multimodal Therapy?
Several organizations, including the National Comprehensive Cancer Network, issue regularly updated guidelines for treatment based on research:
- Chemotherapy can be used alone in patients who do not qualify for surgery and in combination with surgery for those who are good candidates.
- Some patients may recieve chemotherapy combined with an antiangiogenesis drug.
- Radiation therapy is not recommended as a sole treatment, but can be used as part of a multimodal plan.
The Standard Multimodal Therapies for Mesothelioma
The three most common treatments strategies for cancer are often used in combinations of two or three. Treating mesothelioma with two or more approaches generally has better outcomes, such as extended survival times. The actual choice of treatments depends on multiple individual factors.
- Chemotherapy: Chemotherapy is a treatment that circulates drugs throughout the body or in a specific part of the body. They target and kill fast-growing cells, like cancers. Healthy cells can also be affected, which leads to serious side effects. Researchers are always looking for more targeted drugs that cause minimal damage to healthy cells.
- Surgery: Surgery remains one of the best and most effective ways to treat early-stage mesothelioma. Most advanced patients are not good candidates for surgery because of the inability to remove all of the cancerous tissue. Surgery for pleural and peritoneal 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 with radiation therapy. This is most often delivered externally, with a machine that aims the beam at a specific part of the body with cancer. Brachytherapy is administered internally, using a small device placed inside the body to target the tumor with radiation. Radiation therapy effectively kills cancer cells, but can also cause damage to healthy tissues. Advances in this treatment are helping doctors give higher doses of radiation that are better targeted at tumors.
Multimodality in Peritoneal Mesothelioma
Patients with peritoneal mesothelioma also generally receive multimodal treatment. One of the most effective combinations is cytoreductive surgery to remove the bulk of tumors followed by HIPEC.
HIPEC stands for heated intraperitoneal chemotherapy. It differs from systemic chemotherapy in that it is targeted to the abdomen. After removing tumors during surgery doctors circulate heated chemotherapy drugs throughout the abdominal cavity.
Advances in Multimodal Treatment
Chemotherapy, surgery, and radiation remain the standard therapies for mesothelioma. Researchers continue to study other therapies, innovative treatments that can be added to the traditional multimodality.
Intensity-Modulated Radiation Therapy (IMRT)
Radiation therapy is an important adjuvant to surgery, especially with new advances that allow doctors to target tumors better and avoid harming healthy tissue.
In one study, researchers found that patients may have better survival outcomes when one of these advanced types of radiation, called IMRT, was used right after surgery. IMRT follows the shapes of tumors for more targeted treatment.
In a mouse model study, researchers used nanoparticles loaded with chemotherapy drugs to target tumor receptors better. The study results suggested that using this strategy along with surgery could prolong survival times for mesothelioma patients.
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. Studies have shown that including immunotherapy can be tolerated by mesothelioma patients and extends survival times.
In 2020, the immunotherapy combination of nivolumab with ipilimumab became the first new medication approved for treating mesothelioma in years. Clinical trials with the combination resulted in better overall survival than treatment with chemotherapy.
The drug bevacizumab (Avastin) is an antiangiogenesis medication. It disrupts a tumor’s ability to create new blood vessels. This results in less blood flow to the tumor and slowed or halted growth. Official guidelines now recommend using bevacizumab in combination with chemotherapy for many patients.
While many patients receive two or three treatments, a four-modality approach may be appropriate for some. This usually means using the three standard therapies of surgery, radiation, and chemotherapy as well as immunotherapy.
Studies have found that the combination of four different treatments is both tolerable to most patients and beneficial in terms of survival.
Tumor Treating Fields
Tumor Treating Fields, or TTFields, is a new approved medical device for treating mesothelioma. It uses electric fields at low intensity to kill cancer cells. It is applied outside the body and is non-invasive.
As such a new treatment device, research is limited, especially as a part of multimodality. In clinical trials, researchers used TTFields along with chemotherapy in mesothelioma patients. The median survival time was over 18 months.
Photodynamic therapy is an emerging cancer treatment that uses light to activate targeted anti-tumor drugs. It is a type of targeted treatment that is more precise than systemic chemotherapy.
A study of patients undergoing lung-sparing surgery included photodynamic therapy after the procedure. Chemotherapy often plays the role of cleaning up remaining cancer cells after surgery, but photodynamic therapy may cause fewer side effects.
Researchers found that this combination of surgery and photodynamic therapy improved median survival time. They saw the best results for patients with epithelioid mesothelioma, a cell type that is easier to treat.
How Do Treatment Teams Choose Multimodal Therapies?
There is no single, standard way to administer these treatments in a multimodal approach for every patient. The treatments used, and the order in which they are used, depend on many factors:
- Overall health
- Tumor location and cell type
- The stage of the cancer and metastasis
- Patient preference
The Order of Multimodal Treatments
Therapies used in a multimodal approach are labeled as neoadjuvant, primary, or adjuvant, which describe when and why they are used:
- Neoadjuvant therapies are used before a primary treatment to make that main therapy easier or more successful. For instance, chemotherapy may be used first to shrink tumors so that the primary treatment, surgery, is less extensive and invasive.
- The primary treatment is the main therapy, which is hoped will provide the best outcomes in slowing or stopping tumor growth. In mesothelioma this is usually surgery or chemotherapy.
- Adjuvant therapy is used after the primary treatment to minimize the risk of recurrence or to slow the progression. Radiation may be used after surgery to eliminate any remaining cancer cells, for example.
Talk to Your Doctor
Multimodal therapy for mesothelioma is standard practice. Whether these strategies are used, and the order in which they are given depends on the patient. Talk to your doctor about all of your treatment options.Get Your FREE Mesothelioma Packet
Page Medically Reviewed and Edited by Shanel Bhagwandin DO, MPH
Dr. Shanel Bhagwandin is a surgeon with special training in surgical oncology. In 2019 he joined the team at Jupiter Medical Center in Palm Beach County, Florida as the Medical Director of the Gastrointestinal Surgical Oncology Program. He came to Jupiter from Mount Sinai in New York, where he still holds teaching and leadership positions and where he trained alongside experts in complex surgical oncology. Dr. Bhagwandin came to Jupiter to bring HIPEC, a treatment for peritoneal mesothelioma that is not available everywhere, to the patients in the region. He is board certified in general surgery, surgical oncology gastroenterology, and hepato-pancreato-billiary surgery.