As 2021 concludes and 2022 begins, we bring you mesothelioma treatment news directly from clinicians and researchers. Two newly published articles give us a useful overview of the current treatment landscape for mesothelioma. We have read through both articles and have summarized them for you. However, if you are looking for a treatment option for yourself or your loved one, please contact your medical oncologist or our on-staff oncology nurse. Mesothelioma treatment is complex, and each case is different.
The first publication is a commentary penned by Hedy Kindler, MD, University of Chicago Medicine. The article titled “Systemic Therapy for Mesothelioma: Turning the Corner” discusses the currently available systemic therapies for both pleural and peritoneal patients, with emphasis on how new data has affected treatment approaches and treatment protocols prescribed by medical oncologists. The article is freely available in its entirety for those who wish to read it.
The second article titled “New Era for Malignant Pleural Mesothelioma: Updates on Therapeutic Options,” (written by Dr. Anne Tsao, MD, MBA, MD Anderson Cancer Center; Harvey Pass, NYU Langone; Andreas Rimner, MD, Memorial Sloan Kettering Cancer Center; Aaron Mansfield, MD, Mayo Clinic) is an overview of the full spectrum of treatment options for pleural mesothelioma, including surgery, radiation therapy, and certain novel therapies.
Both articles were published in the Journal of Clinical Oncology.
MESOTHELIOMA TREATMENT NEWS
Systemic therapies (chemotherapies, immunotherapies, chemoimmunotherapies, VEGF-inhibitors)
For nearly two decades, the foundation of mesothelioma treatment has been the combination chemotherapy of Alimta (pemetrexed) with a platinum drug such as cisplatin or carboplatin. In 2004, this treatment became standard of care in the first line setting. Recently, bevacizumab, an anti-angiogenesis drug (inhibiting blood vessels around the tumor, also referred to as a VEGF inhibitor) demonstrated an additional survival benefit when combined with the original combination.
The big mesothelioma treatment news occurred in 2020, and into 2021, when for the first time since 2004, a new mesothelioma treatment became approved by the FDA. This new treatment consists of an immunotherapy drug combination, combining nivolumab (brand name Opdivo) with ipilimumab (known by brand name Yervoy). Both agents are checkpoint inhibitors and function by taking the breaks off of the individual patient’s immune system thus allowing it to attack the tumor. While immunotherapy demonstrated a promising improvement in overall survival across all histologies (cellular types of mesothelioma such as epithelioid (least aggressive), sarcomatoid (most aggressive) or byphasic (combination of least and most aggressive)), it benefited non-epithelioid types the most, doubling their median survival when compared with standard chemo.
Currently, several Phase 3 clinical trials are in progress to determine the potential benefits of combining chemotherapy with checkpoint inhibiting immunotherapy. The Phase 2 counterparts of these showed much promise. Most, if not all of these trials, will include genomic analyses that will provide clinicians with detailed information about who benefits most and least from these treatments.
As for novel systemic treatments for mesothelioma, several are currently under examination in early clinical trials. Therapies engineering the patient’s own t cells have seen only limited efficacy, but new and innovative solutions to problems encountered continue to move this field of study forward. Similarly, early studies targeting certain genetic mutations are currently underway.
On the peritoneal mesothelioma side, systemic therapies often extrapolated from data from the more common pleural type. At the moment, a new study for peritoneal mesothelioma is looking into efficacy of chemotherapy with or without immunotherapy prior to surgery.
Surgery
In the United States, surgery is an accepted treatment option for mesothelioma. To qualify for surgery a patient must meet certain criteria in terms of disease stage, overall well-being, and histological type of mesothelioma. Pleurectomy decortication (PD), also known as lung-sparing surgery, is the most frequently performed procedure for pleural mesothelioma. EPP, or extrapleural pneumonectomy, which involved the removal of the entire affected lung is currently only used in conjunction with neoadjuvant radiation therapy (neoadjuvant means that the therapy is prescribed prior to surgery). When undergoing surgery, a patient will often also undergo certain systemic therapies before and/or after surgery to maximize the surgical benefit. Currently, studies are underway to understand if immunotherapy can be beneficial before and/or after surgery.
Surgical approaches for peritoneal mesothelioma are different and follow very different guidelines. Consult this recent MesoTV recording for more information: https://www.curemeso.org/2021/06/16/experts-discuss-peritoneal-mesothelioma-surgery-and-treatment-at-nci/
Radiation therapies
Treatment with radiation is often used to manage mesothelioma, and it’s typically administered in conjunction with surgery. Sometimes, radiation therapy can be used in a palliative setting to ease disease symptoms for the patient.
Tumor treating fields (TTF) device
In 2019, a tumor treating field device received an FDA approval making mesothelioma treatment news, however its efficacy has not yet been demonstrated in a randomized trial. The device was studied in a Phase 2 trial of 80 participants when it compared their outcomes to those of the 2004 chemotherapy combination study. Currently, the device is being tested in non-small-cell lung cancer in conjunction with immunotherapy. It is possible that the newly acquired data will have applicability in mesothelioma.
Overall, while mesothelioma is still a difficult to manage cancer, in 2021-2022, patients have many more treatment options from which to choose when determining a course of treatment with their doctor. While researchers are still seeking answers into which aspects of a cancer’s biology and genetics play a part in determining which treatment options will be effective, this muddy field is slowly providing more clarity.
