The stage (extent) of a mesothelioma is an
important factor in determining treatment
options. But other factors, such as whether the
doctor feels the cancer is resectable (all visible
cancer can be removed by surgery), as well
as a person's general health and preferences,
also play a role.
Mesotheliomas can be hard to treat, whether
the cancer is resectable or not. It's very
important that you understand the goal of
treatment before it starts – whether it is to try
to cure the cancer or to help relieve symptoms
– as well as the possible benefits and risks.
This can help you make an informed decision
when looking at your treatment options.
In general, most stage I and some stage II
and III pleural mesotheliomas are potentially
resectable, but there are exceptions. Whether
a tumor is resectable is based on the subtype
(most doctors believe only epithelioid and
mixed/biphasic tumors are potentially
resectable), where it is located, how far it has
grown into nearby tissues, and whether or not
a person is healthy enough to have surgery.
Many patients with resectable pleural
mesothelioma have their cancer removed by
pleurectomy/decortication (P/D) or
extrapleural pneumonectomy (EPP). Surgery
is more likely to result in long-term benefit in
stage I cancers, where there is a better
chance that most or all of the cancer can be
removed. For these early-stage cancers, EPP
may be a good option if it can be done. It
offers the best chance to remove the cancer,
but it is a complex and extensive operation
that can also have major side effects. Patients
with early-stage peritoneal mesotheliomas
might also benefit from surgery. Some
patients can have long remissions after
extensive surgery by experts. Surgery may
still be helpful for later-stage cancers, but the
benefits are more likely to be short term.
Sometimes, the surgeon may think the cancer
is resectable based on imaging tests (such as
CT scans) done before surgery, but once the
operation starts it becomes clear that not all
of the cancer can be removed. In these cases
the surgeon may switch to a less extensive
operation (which is less likely to cause side
effects) or even stop the surgery altogether if
it is not likely to be helpful. Treatment would
then be the same as for unresectable
mesotheliomas (see below).
Doctors are still studying whether giving
chemotherapy before surgery (neoadjuvant
therapy) or giving chemotherapy or radiation
therapy after surgery (adjuvant therapy) is
helpful. Some doctors prefer to give
neoadjuvant chemotherapy, and many
doctors advise adjuvant chemotherapy or
radiation therapy, but not all doctors agree
on what the best course of treatment is.
If you are not healthy enough to have a major
operation, radiation therapy and/or
chemotherapy may be used instead. While
these treatments may shrink or slow the
growth of the cancer for a time, they are not
likely to result in a cure.
If you have symptoms because of fluid
buildup in the chest or abdomen, other
approaches such as thoracentesis/
paracentesis or pleurodesis (described in the
" Surgery" section) may be helpful.
Because these cancers can be hard to treat,
taking part in a clinical trial of a newer form
of treatment may be a reasonable option.
These types of studies are usually done in
large medical centers.
Stage IV mesotheliomas, as well as many
earlier-stage mesotheliomas, can't be
removed completely by surgery either
because of the extent or subtype of the
disease or because a person may not be
healthy enough for an operation.
Chemotherapy and/or radiation therapy may
shrink or slow the growth of the cancer for a
time. But these treatments are very unlikely to
result in a cure and can have their own side
effects. Before starting such treatments, the
goals of treatment should be clear to you and
In people with early-stage mesotheliomas
that are likely to grow slowly and are not
causing any symptoms, watching them closely
at first may be a reasonable option.
Treatment can then be started if there are
signs that the cancer is growing quickly or if it
starts to cause symptoms.