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How Does Cancer Stage Affect Mesothelioma Treatment?


The stage of cancer at diagnosis is one of the most important factors affecting cancer treatment plans. In most cases, early-stage cancers have more treatment options, and later-stage cancers have fewer options.

Pleural Mesothelioma Treatments at a Glance

  • All stages: Palliative care can boost quality of life for patients at any stage.
  • Stages 1 – 3: Surgery-based approaches are common. Chemo, immunotherapy and radiation can follow surgery.
  • Stages 3 – 4: Surgery-based approaches are rare but do happen. Immunotherapy and chemo are effective for many patients.

Patients often find disheartening messages that offer little hope for late-stage diagnoses. In many cases, these messages aren’t accurate or helpful. This negative information is too general and doesn’t account for all the factors at play. And it doesn’t recognize that treatment recommendations can change as needed.

Understanding how and why cancer stage affects treatment can offer hope by shedding light on these bleak half-truths. Having medically accurate information may also help patients feel more empowered and supported at a challenging time.

Why Does Cancer Stage Impact Treatment Options?

Cancer stage is a rough measure of the size, location and number of tumors in a patient’s body. Not all cancers use the same staging system. Many indicate how far a cancer has progressed on a scale of 1 to 4. Establishing a stage can help doctors understand if a specific therapy will help.

According to one mesothelioma specialist, surgeons need to answer these questions when making treatment recommendations:

  • Will surgery extend life further than chemo or immunotherapy?
  • Will surgery provide the patient a good quality of life?

The patient’s cancer stage factors into how surgeons answer these questions. Let’s walk through a couple of examples to see how this plays out in the real world.

Stage 1 Example

  • Tumor details: This patient has a single tumor. It is self-contained and located on the outside of the lining around the lung. It is not touching any large blood vessels.
  • Treatment approach: Surgery followed by heated chemo in the chest cavity
  • Reasoning: Surgery has a good chance of success for 2 main reasons. (1) The tumor’s size makes it easier to get the whole thing out. (2) The tumor location means its removal is unlikely to cause serious bleeds or damage to important organs. The heated chemo can come after to help remove tiny cancer cells left behind from surgery. This approach can extend life and boost quality of life.

Stage 4 Example

  • Tumor details: This patient has 2 large and 15 small tumors spread across the chest and belly. The large tumors have grown around important blood vessels.
  • Treatment approach: Systemic (throughout the body) immunotherapy
  • Reasoning: Surgery has a low chance of success for 2 main reasons. (1) The number of tumors is high, making it difficult to get them all out cleanly. (2) Removing the larger tumors could cause life-threatening bleeds. Immunotherapy can still reach these tumors and shrink them. It may even reduce the tumors enough that the patient becomes eligible for surgery at a later date. This approach can extend life and boost quality of life.

The above examples are highly simplified. Doctors consider many factors that are not part of the staging system when recommending treatment. For example, age and overall health can also affect treatment options. This is why patients should not focus too narrowly on stage when thinking about treatment outcomes.

Why Treatment Recommendations Aren't Always Clear-Cut

In official guidelines, treatment decisions can seem black and white. But these are guidelines, not rules. You can keep the following in mind when receiving recommendations:

  • The factors affecting treatment decisions are open to interpretation. This means doctors within the same specialty may disagree about a recommendation.
  • Second opinions are always an option.
  • You only receive treatments you’ve agreed to.

Treatment for Stages 1 – 2 Pleural Mesothelioma

For stages 1 – 2 pleural mesothelioma, treatment is often a surgery-based combination. By using different therapy types, doctors can fight cancer in more than one way. This approach (multimodal treatment) may be the most effective in extending mesothelioma survival.

Many stage 1 and 2 patients undergo surgery followed by some form of chemotherapy. Pleural mesothelioma survivor Heather Von St. James had surgery then 2 kinds of chemo:

  • During surgery: Doctors applied local, heated chemotherapy (HITHOC) in her chest cavity.
  • After surgery: She had traditional systemic (through the bloodstream) chemo.

She also underwent radiation therapy. Patients diagnosed at an earlier stage commonly qualify for treatments similar to Heather’s.

But surgery-based combinations can come with serious side effects, and recovery is not easy. Patients must have certain characteristics, including:

  • Being healthy enough to have a good chance of managing the challenges of treatment and recovery
  • Having limited tumors that surgery can safely remove

If a patient lacks these characteristics, surgery-based treatment may be more harmful than beneficial. Patients who do not qualify for surgery-based approaches still have good treatment options available. And many can receive 2 or more types of non-surgical therapy.

The Role of Palliative Care

Palliative therapy helps maximize quality of life for patients of all cancer stages. It can extend to end-of-life care, but that is not its sole purpose. Palliative therapies can help patients manage treatment side effects and mental health setbacks. This approach can also extend survival.

 

Treatment for Stages 3 – 4 Pleural Mesothelioma

Treatment options for stages 3 – 4 pleural mesothelioma vary. At these stages, some patients qualify for surgery-based options and others do not. Regardless of surgery eligibility, treatment can extend survival and boost quality of life. So patients should discuss their options with a mesothelioma specialist.

Treatment for Stage 3 Pleural Mesothelioma

Stage 3 patients generally have either operable or inoperable tumors. Operable tumors can be treated with surgery-based combination therapies. Inoperable tumors generally qualify for chemotherapy or immunotherapy.

Treatment Spotlight: Immunotherapy May Change Surgery Eligibility

For patients who do not qualify for surgery, immunotherapy may change their eligibility. In a recent inoperable stage 3 case, doctors treated the patient with immune checkpoint inhibitors. This treatment shrunk the tumors enough for the patient to become eligible for surgery. This case shows how helpful non-surgical treatment can be.

Treatment for Stage 4 Pleural Mesothelioma

Stage 4 pleural mesothelioma usually does not qualify for surgery. The tumors are so big and numerous that they likely could not be safely and fully removed. But many patients still undergo combination treatment without surgery. In the past, chemotherapy followed by radiation was a common approach.

In recent years, the combo of Opdivo® (nivolumab) and Yervoy® (ipilimumab) has become a standard option. This regimen of immune checkpoint inhibitors may improve quality of life better than chemo. Many patients also have the option to undergo other therapies after Opdivo and Yervoy.

Even though stage 4 patients may not qualify for surgery, they still have good treatment options. These may include:

Research and drug development advances continue opening new possibilities for treating late-stage pleural mesothelioma.

Treatment for Peritoneal Mesothelioma

Peritoneal and pleural mesothelioma patients have similar treatment options. But peritoneal mesothelioma has a different staging system. Still, treatment recommendations are based on similar factors. Doctors consider whether a surgery-based approach is likely to extend survival better than immunotherapy or chemo.

Many peritoneal mesothelioma patients undergo surgery plus heated chemo in the belly (HIPEC). But immunotherapy is also an option.

What Does This Mean for Mesothelioma Patients?

Many factors go into mesothelioma treatment recommendations. Doctors weigh the cancer stage heavily in these decisions. But stage alone does not determine a patient’s treatment options or prognosis. And surgery-based approaches are not the only effective treatments.