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Despite Poor Prognosis, New Treatment Options for Mesothelioma May Extend Life and Decrease Symptoms: Presented at ONS

By Bonnie Darves

PHOENIX, AZ -- November 15, 2005 -- New drug treatment options and recently improved procedures are providing a glimmer of hope for modest improvements in both life expectancy and quality of life for patients with mesothelioma, one of the most challenging cancers that patients can face.

In a presentation here on November 11th at the Oncology Nursing Society's Institutes of Learning (ONS), presenters discussed some recent developments that are helping patients and their families cope with the debilitating effects of the disease.

"Until very recently, life expectancy after diagnosis of mesothelioma was a matter of just a few months. But with new treatment options, surgical procedures and radiation technology, many patients are living longer," said Sue Gardner, MSN, AOCNP, Nurse Practitioner, Lehigh Valley Hospital, Allentown, Pennsylvania, United States.

This aggressive cancer mostly appears in the pleural cavity and mostly affects men.

Ms. Gardner noted that while its incidence is stable in the U.S. -- with 2,000 to 3,000 new diagnoses annually -- it is increasing elsewhere in the world, especially in Third World countries.

Recent advances in pharmacological treatment, notably the new antifolate pemetrexed (Alimpta) in combination with standard platins and gemcitabine have been shown to improve survival and reduce the often severe disease-related symptoms. Response rates to the combination therapy are not high -- about 40% of patients improve on combination regimens compared to single-drug treatment.

Patients who do respond may experience a life expectancy gain of 3 months or longer, a significant amount of time, given that the majority of patients die within 9 months of diagnosis, Ms. Gardner noted.

Co-presenter Marianne Davies, MSN, APRN, Director of Nursing, Yale Cancer Center, New Haven, Connecticut, pointed to several recent developments in both pharmaceutical therapies, surgery and other treatments that are yielding improvements for patients with mesothelioma.

In the drug therapy realm, several recent trials have evaluated various combination regimens and combined drug-surgery treatment. While response rates for single traditional chemotherapy agents have hovered in the 20% to 40% range, newer combination regimens are yielding extended survival and far better symptom control, Ms. Davies noted. In particular, she pointed to the following recent trials:

-- Cisplatin, mytomycin C and vinblastine, the "MVP regimen," which extended survival by 3 months in responders and resulted in a 69% improvement in symptoms, compared to patients on traditional regimens.
-- A phase 2 study in Italy of gemcitabine and carboplatin produced a median response duration of 55 weeks and extended survival to 66 weeks for responders.
-- A trial of combined ifosfamide and interferon-alpha2a, which extended survival to 21 months for some patients who tolerated a 3-dose schedule.
-- A phase 2 trial of vinorelbine and oxaliplatin as a first-line treatment resulted in a mean progression-free survival of 4.7 months and 1-year survival rates of 27%.

In the surgical arena, recent approaches have included exploring possible benefits of radical extrapleural pneumonectomy, and combining aggressive resection surgery and chemotherapy with cisplatin with mitomycin, delivered intraoperatively.

While radiation remains a useful therapeutic option for pain management in patients with advanced disease, it is of limited scope, Ms. Davies noted, because of the unavoidable damage to other organs in the thoracic cavity.

Photodynamic therapy is being used with some success to target superficial tumours on body surfaces and in cavities, with the objective of sparing surrounding tissue.

For oncology nurses, the major challenge is to manage both the severe symptoms of mesothelioma and the treatment-related effects, Ms. Gardner explained. "That's really the difficult issue -- trying to help patients manage both the side effects of treatment and the disease symptoms as they progress," she said.

In the post-surgical phase, patients require oxygen supplementation and aggressive pulmonary care in addition to pain management. For patients who develop the peritoneal form of the cancer, pain management is the mainstay of management after what may be major surgery to debulk tumours.

As their disease progresses, about 95% of patients develop pleural effusions that require management with chest tubes, pleural catheters or shunts. Persistent cough, depression and dyspnea become particularly problematic in the late stages, and require comprehensive direction to caregivers of patients who will be discharged home upon completion of active treatment.

Oxygen supplementation, bronchodilators and steroids are needed frequently to alleviate respiratory symptoms, and opioids are needed in the presence of dyspnea distress.

"It's very important to instruct the family members on the patient's discharge in how to deal with the symptoms," Ms. Gardner said, as many patients wish to remain at home if possible.

The session was supported by Lilly Oncology.

[Presentation title: Mesothelioma: Basics and Beyond.]