Dr. Howard Jack West: What to Expect During Mesothelioma Chemotherapy

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Hi I’m Jack West, Medical Oncologist at Swedish cancer institute in Seattle, Washington. I wanted to talk briefly about the question of what to expect from chemotherapy for mesothelioma. I’m going to focus on the most commonly prescribed and FDA approved regimen for mesothelioma, which is called Cisplatin and Alimta or Pemetrexed. This two-drug combination is given by vein, typically given every three weeks, and it can be a challenging one, and is not something that everyone is ideally suited to receive. Cisplatin has been around for forty years, actually and it is still used even as so many newer drugs have come onto the scene because it just works very well for many kinds of cancer, and specifically for mesothelioma. In contrast Altima, Pemetrexed is a relatively newer drug that was paired with it and was shown to improve survival compared to just Cisplatin alone for patients.

So Cisplatin is given by vein and it has some of the side effects that I think many people think about when you envision chemotherapy. It can cause a good bit of nausea and vomiting, although one of the biggest advances in cancer treatment over the last several decades has been the remarkable improvement in nausea medication that we have available, so that really reduces the risk of it being a severe problem in patients.

As I said the chemo is given by vein typically one day every three weeks, and it’s a long day in the infusion suite. Usually its an outpatient chemo, sometimes given inpatient, but it’s a long day because Cisplatin needs to be given with a lot of fluids, hydration IV, which is essentially just seawater, saline, given before and then after the chemotherapy in order to flush it out and help protect the kidneys as well as possible. Cisplatin can also cause numbness and tingling in the fingers and toes, this is called peripheral neuropathy and it tends to get gradually a little worse over the course of ongoing treatment over many cycles, many months. And it can also cause hearing loss or ringing in the ears called tinnitus, or tinnitus. In contrast, Alimta tends to be very well tolerated; it doesn’t add a lot of additional side effects. It does drop blood counts as most of our conventional chemotherapies do, and with that drop in blood counts there is some pretty much invariable fatigue in people, and it really just varies whether people have a little bit of fatigue for a day or two after, or fatigue that lasts for a week or longer in the three week, so called cycle of time when you’ve completed chemotherapy, blood counts go down over the next ten to fourteen days, and then in the last week before we tend to do chemotherapy again, the blood counts have come up to where it is safe to repeat the chemotherapy.

Pemetrexed or Alimta can also occasionally cause a rash, its not a common finding, and it can also sometimes lead to some transient irritation of the liver as measured by blood tests of liver enzymes that can become elevated, and that means abnormal, when we follow them over time, and we regularly check those blood tests regularly every few weeks while someone is receiving chemotherapy, to make sure their liver and their kidneys are doing okay. Importantly, Alimta and this combination of Cisplatin and Alimta don’t actually cause people to lose hair except in rare cases; it’s really not a regimen that is associated with any appreciable hair loss. So the main issues are really fatigue, sometimes nausea, numbness and tingling that may occur, possibility of hearing loss also relatively uncommon, and sometimes people with decreased blood counts may need a transfusion along the way, but this is something that can be managed.

There are certainly also rarer side effects but the highlights are really the ones that I mentioned. So those are the main points and I will emphasize that the results will vary from patient to patient, and in any one person we really cant know how they’re going to do until you give that first cycle and see how it goes. I regularly see and discuss their side effects with them afterwards and if patients have such a hard time that we’re concerned that the treatment is worse than the disease or just infeasible, we’ll make changes whether its dose reductions or substituting another drug, things like that. Its typical to give about four to at most six cycles of this combination in patients who are not demonstrating progression and are tolerating it well. Beyond that four to six cycle point, it really tends to be a point of diminishing returns where the incremental side effects of ongoing treatment tend to be greater than the incremental benefit of continuing it further.

I hope that that’s a useful general introduction to the concept of chemotherapy that we typically use for mesothelioma. Take care. .

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