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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.]
Cancer patient denied drug
EDWARD FOSS
02 August 2006 - A terminal cancer patient has been denied the use of an expensive drug which could extend his life - because he smoked many years ago.
John Wallman has been told he will not be supplied with the drug erlotinib, which trades under the name Tarceva, because it would not necessarily be effective in his case.
Health bosses have said the drug is reserved for those “it is most likely to help” and that 68-year-old Mr Wallman does not fit into this category.
But Mr Wallman, who was diagnosed with inoperable lung cancer a year ago, has accused the NHS of placing a restriction on the use of the drug simply as a mechanism for saving money.
And he added that he had been told the drug could extend his life quite significantly, while conceding it was possible it would not work.
“It is at least 15 years since I smoked, possibly longer. And I have been told that because of that, I cannot have this drug,” said Mr Wallman, who lives in Marsham and is being treated at the Norfolk and Norwich University Hospital.
“I do not want to have a go at the hospital, the staff there have been quite wonderful, they have always acted promptly and sympathetically.
“But it is quite clear that this is yet another example of the NHS trying to save money by qualifying the issue of certain drugs.
“The fact that I packed up many years ago counts for nothing.
“This is important to me because withholding treatment will shorten my lifespan.
“I know there are no guarantees, but this drug could potentially give me an extra two or three years.
“Surely having paid into the NHS for over 50 years I have a right to expect treatment without qualifications?”
Hospital spokesman Andrew Stronach said: “It is an expensive drug and one that is reserved for patients it is most likely to help.
“One factor is that it can help people who have a genetic mutation that led them to develop lung cancer without ever having been a smoker but it is less effective if the lung cancer is a result of smoking and not a genetic mutation.
“There are also a number of other chemotherapy drugs suitable for him that are likely to be more effective.”
But Mr Wallman said there was a clear difference between saying the drug would be “less effective” and saying it would be “not effective”.
“The whole issue is the expense and when you are facing what I am facing you want every help you can get.
“I have paid my dues over the years and when you need something back you don't get the help.
“And this isn't only about me, there are lots of people out there with terminal conditions where treatments are available but they simply are not being offered them because of expense.”
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