Among the many challenges of managing malignant pleural mesothelioma (MPM) is reliably assessing the response of the disease to our treatment. We don’t want to discard a treatment that is effective, nor do we want to have patients continue on a treatment that isn’t helpful but is causing significant side effects. In oncology, we typically grade our work by comparing an imaging study like a computerized tomography (CT) scan of the chest done after 2-3 cycles of systemic therapy (usually covering a 6-9 week interval) to a baseline scan performed prior to the start of treatment. As you’d suspect, significant tumor shrinkage is good, while growth is bad, and stable disease is somewhere in between. Typically, we want to continue our treatment in the absence of significant progression or prohibitive side effects.

So why is it so difficult to measure response in MPM? Unlike most solid tumors, MPM doesn’t typically appear on scans as a well circumscribed sphere that can be easily measured. Instead, it appears as a rind around the lung, often with irregular contours, sometimes areas of benign plaques from asbestos exposure, and collections of pleural fluid filling the cavity between the outside of the lung and the inner chest wall. Patients who have undergone a palliative pleurodesis, an intervention in which there is deliberate inflammation within the pleural space in order to cause scarring and close off that space (and thereby prevent fluid from filling there), will typically have marked thickening in that area that represents inflammation and scarring (the desired effect of the pleurodesis) that can be remarkably difficult to distinguish from active cancer.

There are various ways to contend with the challenges of measuring response to treatment for MPM. First, metabolic/functional imaging with positron emission tomography (PET) scanning along with fused CT images is often employed, as it can be instructive to see the level of metabolic activity decrease or increase as an indicator of response or progression, respectively, particularly when the thickness of the rind of tissue thought to represent MPM is not obviously increasing or decreasing in thickness. It is worth noting, however, that a pleurodesis is also expected to transiently increase PET activity in the pleural space in the weeks and perhaps even months after this procedure is performed, so it is necessary to be cautious about interpreting changes in PET uptake that have developed following a pleurodesis. Another clue can come from changes in a patient’s symptoms: many patients with MPM will experience chest wall pain from their underlying disease, and changes in a patient’s symptoms are another helpful indicator of the direction that the cancer is moving in when imaging is notoriously ambiguous. Finally, a blood test such as levels of soluble mesothelin-related proteins (MSRP) can potentially serve as a serum-based indicator that the cancer is responding or progressing.

Ideally, we would hope to have a test for assessing treatment response in MPM that is widely available and well validated. We are limited in the relative infrequency of the disease, with patients treated in a wide range of settings with varied levels of expertise in interpreting imaging results that are often ambiguous and complex. In this setting, it is often necessary to accept greater ambiguity, to be pleased to see an absence of convincing progression, and to utilize additional clues such as the trajectory of a patient’s cancer-related symptoms and potentially serum-based testing such as MSRP levels to provide greater direction as we do our best to make good judgments about the value of the treatment being administered.

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 Nutrition is an important part of preventing and fighting cancer. When cancer patients focus on nutrition, they build their natural defenses and fight disease naturally. Even vitamin C therapy is being considered as a way to fight cancer. Though the treatment is experimental, it shows how advanced the body is in repairing itself with nutrients it needs. Especially with rare cancers like mesothelioma, treatments may be limited so consider how these nutritional changes or inclusions can help to fight cancer.

Studies have shown that a diet high in antioxidants can help to fight and prevent cancer. Antioxidants fight free radicals and protect cells from damage. Antioxidants can be obtained through fruits and vegetables. The most effective antioxidants include lycopene, beta-carotene, vitamin C, vitamin E, and vitamin A.

It is recommended for people suffering from cancer to eat plenty of green leafy vegetables. Kale, collard greens, mixed greens and spinach are recommended for fighting cancer. If arthritis is also an issue, collard greens and kale are better choices than spinach, which is not recommended for people suffering from arthritis. Water retention may occur near joints such as knees and ankles. Carrots, tomatoes, oranges, pumpkin, corn, broccoli, nuts, mangos and soybean oil are recommended for cancer.

Tea, especially green tea, is thought to be effective in preventing and controlling cancer, but the American Cancer Institute does not recommend tea. Caffeine may be the reason why. The polyphenol compounds and catechins are antioxidants that are suspected to be effective in cancer prevention. The studies have been inconclusive, but there is strong evidence that leads experts to believe that the tea can be effective in healing cancer.

Garlic is suspected to reduce the risk of developing cancer in the gastrointestinal tract, but the extent to which it helps is unknown. Garlic helps with numerous ailments in addition to cancer prevention. If high cholesterol is a problem, garlic will help to lower the levels, and it also prevents colds from developing.

Nutrition is important for any patient who is fighting cancer. Without proper nutrition, cancer patients will feel fatigue and may develop aches and pains that they would not otherwise. Cancer patients should work with their physicians to develop the proper regimen because there are so many things that could negatively affect cancer.

A new study from the MD Anderson Cancer Center in Houston found that patients who go to public hospitals for lung cancer care get less effective treatments than those who go to expensive cancer-oriented hospitals. The study also showed that patients who receive their care from public hospitals were nine times more likely to have severe symptoms when they check in for treatment than those who attend cancer centers such as MD Anderson.

The study examined the care in two Houston public hospitals, one Miami public hospital, and MD Anderson, one of the most respected cancer care centers in the world. Dr. Charles Cleeland, the study’s author, said that the disparity of care between public hospitals and cancer centers has existed “for the last couple of decades”. He also noted that lung cancer care “is less well managed” for patients who are poor, unemployed, members of minority groups or those that have little to no health insurance.

The number of public hospital patients experiencing symptoms before admitting themselves for care was nearly double that of cancer center patients. The study, which followed the patients’ progress for two months, showed major differences in the quality of care between the cancer center and the public hospitals. Dr. Cleeland said that patients in public hospitals that were displaying symptoms were “not being corrected”.

Dr. Cleeland also noted that the reasons for the differences in care between public hospitals and well-known cancer centers are “very complex”. “I don’t think it’s the intention of those caring for those folks,” he said. However, he did cite that the lack of access to technical resources or cancer specialists for those underserved patients might be some of the reasons behind the disparity.

A similar study conducted at the University of North Carolina found that African Americans are less likely than Caucasian patients to opt for surgery to remove lung tumors. Surgical tumor removal is often the most effective treatment in the early stages of the disease. Dr. Samuel Cykert, the UNC study’s author, attributed the differences to “unintended biases in physicians”. Dr. Cykert mentioned that doctors who work with underserved patients “would be less apt to recommend surgery” than they would for patients who could afford the procedure.

“Advocating for oneself is very important,” Dr. Cykert said. “Being passive is bad.”

The two doctors do agree on treating symptoms early, rather than allowing them to worsen before seeking help. Dr. Cleeland stressed that doctors, nurses and other health care professionals need to help patients with the symptoms of their lung cancer as much as with treating the cancer itself.

“I think we need to strategize about how to help them (underserved patients)”, he said. “This (study) is characterizing their experience.”

According to public health officials, 62 out of every 100,000 adults will be diagnosed with lung cancer each year. Underserved patients are more likely to engage in cigarette smoking, the primary cause of lung cancer in America, and are also more likely to die from lung cancer.

Sources:

http://www.reuters.com/article/2011/06/20/us-lung-cancer-patients-idUSTRE75J6Y320110620

One of the many mesothelioma community members on Facebook posted a question today about a clinical trial being conducted at the Mesothelioma Center, located at New York-Presbyterian Hospital. MyMeso discussed this clinical trial in a July post. The clinical trial is a program of targeted radiation and chemotherapy protocol for pleural mesothelioma, which is a cancer of the lung’s lining almost always caused by asbestos. In response to the Facebook thread, meso survivor and awareness advocate (read: warrior) Debbie Brewer, who many of you know from her story and updates here (thanks Debbie!), mentioned a similar study currently ongoing in Australia.

Debbie provided a link to a story published in November 2009 by ABC News that outlines the work of specialists at Austin Health Centre in Victoria. The treatment, spearheaded by Dr. Malcolm Feigen, a radiation oncologist at the Centre, uses high doses of radiotherapy, concentrated on specific areas of the lining of the lungs to target mesothelioma tumors.

According to the ABC report, 13 patients participated in a pilot program to test this new targeted radiotherapy treatment. Most had some surgery prior to the radiotherapy treatment, and some also had chemotherapy before or after the treatment, although Dr. Feigen believes the patients showed the most benefit primarily as a result of the radiotherapy regimen.

Participants in the U.S. clinical trial at the Mesothelioma Center receive a multi-modality therapy that incorporates surgery, chemotherapy and radiation therapy in combination.

Listen to the interview with Dr. Feigen about the Australian research, which was broadcast on ABC’s AM morning current affairs program.

Among the most interesting discussions at the recent International Symposium on Malignant Mesothelioma, held in Washington, D.C., June 25-27, was a panel discussion about the challenges of finding treatment once a patient is diagnosed with mesothelioma. The panel featured physicians from three of the leading programs in treating peritoneal mesothelioma, Dr. Paul Sugarbaker, Dr. H. Richard Alexander, and Dr. John Chabot.

Peritoneal mesothelioma affects the lining of the abdomen, and makes up about 10-15 percent of all mesothelioma diagnoses. The more common form of mesothelioma is pleural, which affects the lining of the chest and lungs. All mesothelioma is linked to asbestos exposure.

The current “best practice” for the treatment of mesothelioma is a multi-modality approach, which is a combination of surgery and chemotherapy, along with immunotherapy.

“It’s a sequence of treatments that make sense,” Dr. Chabot explained.

However, Dr. Sugarbaker pointed out, only a small fraction of mesothelioma patients receive multimodality treatment.

“So many more things could be done to manage the treatment of this rare disorder,” Dr. Sugarbaker said. “We should have accumulated many thousands of data points on people with peritoneal mesothelioma. Unfortunately, a majority of patients in the U.S. do not get to a treatment center.”

There are still only a handful of treatment centers that specialize in mesothelioma, and even then there are distinctions in the treatment of peritoneal or pleural mesothelioma that narrows the field even further. Also, there are not a large number of physicians currently treating mesothelioma, and no established surgical training programs specifically for this field to develop more doctors experienced in mesothelioma treatment.

Awareness also is still an issue. Many patients are diagnosed too late for effective treatment.

Even if awareness is high and a patient is diagnosed early enough to be a viable candidate for successful mesothelioma treatment, the logistics of receiving treatment can be difficult. Most of the centers for mesothelioma treatment are located on the East Coast. There is one on the West Coast, but almost no options in the Midwest or other areas of the country. Treatment is usually extended over many months, making it necessary for patients to relocate to be near a treatment center if they are not lucky enough to live nearby.

“People often move and rent temporary housing. People live in trailers,” Dr. Chabot said. “More advocacy is needed to provide patient and family support for treatment. The travel issues for people who need treatment are huge.”

The Mesothelioma Applied Research Foundation, which sponsors the annual Meso Symposium, is laying the groundwork to facilitate discussions and establish a collaborative strategy, simply by bringing together the experts in this field. There is an emphasis now on forming a consortium to establish a new standard of care, and to try to combine the knowledge of the existing research and treatment centers, and to expand access to that research and treatment.

But, the experts acknowledge, there is still much to do.

Tags: asbestos, Dr. H. Richard Alexander, Dr. John Chabot, Dr. Paul Sugarbaker, mesothelioma, Mesothelioma Applied Research Foundation, multimodality treatment, research, treatment, Washington

This entry was posted on Monday, July 13th, 2009 at 2:48 pm and is filed under Events, News, Research/Treatment. You can follow any responses to this entry through the RSS 2.0 feed. You can leave a response, or trackback from your own site.

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The American Association for Cancer Research (AACR) has selected Charles L. Sawyers, M.D., as its 2012-2013 President-Elect. Sawyers is chair of the Human Oncology and Pathogenesis Program at Memorial Sloan-Kettering Cancer Center (MSKCC), one of the leading medical facilities in the United States treating mesothelioma, a deadly cancer linked to asbestos exposure. Founded in 1907, the American Association for Cancer Research (AACR) is the world’s first and largest professional organization dedicated to advancing cancer research and its mission to prevent and cure cancer.

Sawyers also is a Howard Hughes Medical Institute investigator, and a professor in the Cell and Developmental Biology Program and the Department of Medicine at the Joan & Sanford Weill Graduate School of Medical Sciences of Cornell University. He will become president-elect of AACR at the organization’s annual meeting in Chicago, Ill., on April 2, 2012, and will become president of the organization in April 2013.

In a news release from AACR, Dr. Sawyers says, “I am deeply honored to serve as president-elect of the AACR. We are in the midst of a transformative decade in cancer research, with many new therapies emerging from our work that are improving the lives of cancer patients around the world. Yet we are at risk of failing to realize this full vision due to the economic challenges faced by our nation. Now is not the time to cut our investment in cancer research. I will work with the outstanding staff of the AACR to get this important message to the leadership in Washington.”

His own research efforts are currently centered on investigating the signaling pathways that drive the growth of cancer cells, with an eye toward designing new treatment options for patients.

According to its website, MSKCC offers a team of specialists, including surgeons, medical oncologists, radiation oncologists pathologists and other scientists to work together to treat mesothelioma, particularly malignant pleural mesothelioma, which affects the lining of the lungs. Working together, this group of physicians and researchers can determine the best course of treatment for each individual patient. Additionally, MSKCC offers emotional support programs and counseling for mesothelioma patients and their families, and conducts ongoing clinical trials in an effort to find new solutions, and hope for a cure for this deadly disease.

Sources:
American Association for Cancer Research
Memorial Sloan-Kettering Cancer Center