Pleural mesothelioma progresses through four stages.
Oncologists diagnose cancer and monitor its progress in terms of “stages.” Staging allows doctors to determine to what extent an individual’s cancer has developed and spread. It also allows the oncologist to determine the best course of mesothelioma treatment for the patient.Pleural mesothelioma, the most common form of the disease, is staged in the same manner as most cancers, though a staging system is not yet in place for peritoneal and pericardial mesothelioma, the rarer forms of this aggressive cancer.
Currently, the three systems that are used to stage this disease are the Butchart, TNM, and Brigham systems. Each differs slightly, and which is used may depend on the physician in charge or the facility at which the patient is being treated.
The Butchart System
Butchart is the oldest system in place and is still the most commonly used. This system is based on the extent of primary tumor mass.
TNM System
This system considers three components; the first letter of each forming the name of the system. Doctors using TNM will look at the tumor, lymph nodes, and whether the cancer has metastasized. Like the Butchart system, it is divided into four stages.
Brigham System
The system used least for the diagnosis and staging of mesothelioma is the Brigham System. It addresses the ability to surgically remove the tumor (resectability) and the involvement of the lymph nodes. (Because mesothelioma is often diagnosed in its later stages, surgery is often not an option.) Its stages include:
Treatment by Stage
Treating Stage 1 Mesothelioma
Typically, a patient found to be suffering from Stage 1 mesothelioma will be referred to a surgeon for removal of the tumor. This may be followed up by chemotherapy and/or radiation to be sure all the cancer is eradicated. Again, patients with mesothelioma are rarely found to be in Stage 1 at the time of diagnosis, so surgery is often not an option.
EXTRAPLEURAL PNEUMONECTOMY
This is a surgery that is only offered to those in the early stages of the disease who are in otherwise good physical health. The cancer must not have spread to any other major parts of the body, including the lymph nodes. During this surgery, the affected lung will be removed as well as the pleura (lining of the lung), the diaphragm, and the pericardium (covering of the heart). This is major surgery, necessitating a 2-week or so hospital stay and a 2-month recovery period. It carries about a 6% mortality rate. Patients should understand that this is not a curative surgery but can extend their life significantly. Radiation or chemotherapy may be offered along with the surgery.
PLEURECTOMY
Also a surgery, this procedure removes the pleura and the tissue surrounding it. It requires an approximate 7-day hospital stay and a recovery period of about 2-3 weeks, barring any complications. A pleurectomy is performed only to relieve symptoms, not as a cure.
RADIATION
For those who are not candidates for surgery, radiation will be offered to help control the uncomfortable symptoms of the disease.
CLINICAL TRIALS
A wealth of clinical trials are available to those suffering from mesothelioma. These involve the use of volunteers who are stricken with the disease who will, in turn, test experimental drugs or procedures that are not yet approved by the Food and Drug Administration (FDA). Many volunteers have benefited greatly from participation in clinical trials. Ask your doctor if there are any available for which you fit the criteria.
Treating Stage 2 Mesothelioma
As mesothelioma progresses through the stages, it becomes more difficult to treat. Therefore, those with Stage 2 cancer have fewer options than those with Stage 1 meso. Also, life expectancy for Stage 2 patients goes down because the cancer has spread further.
Surgery may still be recommended in order to remove the primary tumor and the affected lymph nodes. In some cases, patients are already not candidates for surgery and may be prescribed less-invasive treatments. Chemotherapy and/or radiation is usually recommended either post-operatively (to kill any remaining cancer cells) or as the only sources of treatment at this stage.
THORACENTESIS (LUNGS) OR PARACENTESIS (ABDOMEN)
These procedures remove the fluid that has accumulated around the lungs or, in the case of peritoneal mesothelioma, the abdomen. The retention of fluid is a common symptom of mesothelioma. These procedures can be done on an outpatient basis but may require a short hospital stay (possibly overnight) if the patient is high risk.
TRADITIONAL RADIATION OR CHEMOTHERAPY
Either of these procedures is used to reduce symptoms of mesothelioma, such as chest pain or breathing difficulty.
BRACHYTHERAPY
This is a form of radiation therapy that involves implanting small radioactive rods into the tumor or the area around the tumor in hopes of killing cancer cells in that specific area. As the patient may be “radioactive” after the insertion of the rods, a hospital stay may be required and visitors may be limited.
CLINICAL TRIALS
As with Stage 1, there may be clinical trials to help people with Stage 2 mesothelioma.
Treating Stage 3 Mesothelioma
Patients whose mesothelioma has reached Stage 3 generally have a poor prognosis. Unfortunately, the disease is often not diagnosed until it has reached this point, which is why the survival rate is so low in general.
Curative surgery is no longer an option at this point. Instead, chemotherapy and radiation are usually recommended and patients may opt to participate in clinical trials that are testing new drugs and therapies.
However, at Stage 3, treatments are often palliative in nature (i.e., designed to reduce the pain of symptoms rather than treat the disease), and doctors do not expect them to do much to halt the spread of the cancer. Instead, the treatments are designed to keep the patient as comfortable as possible, relieving symptoms of the disease rather than offering an improved prognosis. Chemo, for example, can provide symptomatic relief by shrinking tumors, and surgical procedures like thoracentesis, the removal of fluid around the lungs, can assist with breathing.
Procedures used in treating Stage 3 mesothelioma are similar to those used to treat Stage 2 (see above).
Treatment of Stage 4 Mesothelioma
As this is considered “end stage” cancer, there are few treatment options left at this point and none that offer the potential for cure. The patient is too weak to withstand anything but palliative therapies designed to relieve pain and ease breathing. Treatments like chemotherapy should be carefully considered when recommended as the side effects can be debilitating and little success will result from taking advantage of the treatment at this stage.
Families of the victim should begin to consider end-of-life issues at this point if they have not already done so, including wills and funeral plans.
CHEMOTHERAPY OR RADIATION
Goals for these treatments should be clearly defined so that the patient is not subject to furthering suffering through the use of treatments that may cause serious side effects.
PAIN MEDICATION
Many Stage IV patients and their families describe the pain at this point as unbearable. Don’t hesitate to ask for additional pain medications, if needed.
SUPPORTIVE CARE
Often, those at this stage of the disease enter hospice care as their families are no longer able to care for them nor can they care for themselves. Hospice facilities also offer end-of-life emotional support for the patient’s family and friends.
COUNSELING
In addition to all the treatment options above, doctors may suggest psychotherapy or counseling to help patients and their families deal with the diagnosis of mesothelioma and the impending outcome of the disease.
Sources:1 Cancer Help, UK: The Stages of Mesothelioma.
2 National Cancer Institute: Stages of Mesothelioma
3 American Cancer Society: How is Malignant Mesothelioma Staged?
4 https://www.maacenter.org/mesothelioma/stages/
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