What to Know About Mesothelioma

  • Q&A with Joseph Friedberg, MD, FACS

    About 3,000 new cases of mesothelioma are diagnosed in the U.S. each year, making it a rare but serious form of cancer caused by exposure to asbestos. Not long ago, a mesothelioma diagnosis came with very little hope. Patients were often told, “there’s not much we can do for you”. While we still have much ground to gain in the fight against mesothelioma, we now have the tools and knowledge to extend and improve the quality of our patients’ lives — and we continue to explore more ways to help them live longer, better lives.

    As the Thoracic Surgeon-in-Chief of Temple University Health System and the Co-director of the Fox Chase - Temple Mesothelioma and Pleural Disease Program, I’ve dedicated my career to finding better treatments for this disease. In this blog, I will answer common questions that I hear from patients and their loved ones about mesothelioma and the innovative therapies that are offered at the Temple Lung Center and Fox Chase Cancer Center. This information may be of much importance to patients newly diagnosed with mesothelioma, as well as those who may be at risk for the disease.

    Q. What is mesothelioma?

    Mesothelioma is a cancer that forms in the lining of certain body cavities. It most commonly occurs in the lining of the chest and lungs (pleural mesothelioma). The second most common mesothelioma occurs in the lining of the abdomen (peritoneal mesothelioma). In rare cases, it can form in the sac around the heart (pericardial mesothelioma) or in tissue that lines the testes (testicular mesothelioma). All these body sites have something in common: They’re lined with mesothelial cells.

    Q. How does mesothelioma affect the lungs?

    The chest is the area most affected by mesothelioma, which disrupts the way the lungs normally work. Every day, fluid exits the lungs and is absorbed by the lining of the chest cavity, called the pleura. Mesothelioma plugs those holes, causing fluid to accumulate and compress the lungs. Or the cancer itself can restrict the lungs and make it hard to breathe.

    Either of these problems can result in shortness of breath, the most common symptom of pleural mesothelioma. Other symptoms include:

    • Pain in the side of the chest or under the rib cage
    • Fatigue
    • Unintended weight loss

    The weight loss may be, in part, a result of early satiety — a feeling of fullness that occurs after eating small amounts of food. This happens because when the fluid in the lungs presses down on the diaphragm (breathing muscles), it also compresses the stomach.

    Q. Who is at risk for mesothelioma?

    Most people who develop mesothelioma have a long history of asbestos exposure. For instance, they might have worked in shipyards, in boiler rooms on Navy ships, in construction, in mining, or in the automotive industry.

    Asbestos is a naturally occurring mineral. Because it resists heat and fire, asbestos was often used in products such as insulation and roofing tiles in buildings until the 1980s. Now we know that asbestos can release tiny, spear-like fibers into the air. When these fibers are inhaled, they work their way through the lungs and lodge in the lining of the lung and chest cavity, causing chronic irritation. This may lead to mesothelioma or other diseases like asbestosis (scarring of the lungs). Peritoneal mesothelioma develops when asbestos fibers are swallowed.

    I also tell my patients that:

    • Mesothelioma takes a long time to develop — usually from 20 to 30 years after their exposures. Until recently, I was still seeing patients who worked around asbestos during World War II.
    • People who lived with someone who worked around asbestos have gotten mesothelioma because the fibers were brought home on the exposed workers’ clothes.
    • Having a history of asbestos exposure doesn’t necessarily mean you’ll get mesothelioma. For example, we know from studies of asbestos miners that only about 10% of them develop mesothelioma. But that is still a lot of people.
    • As with certain other cancers, your genes may increase your chances of getting mesothelioma. In fact, a team led by world-renowned mesothelioma researcher and Fox Chase faculty member Joseph R. Testa, PhD, FACMG discovered the first genetic link to mesothelioma — the BAP1 gene mutation — in families with a history of mesothelioma. I recommend that people with a family history of mesothelioma consider getting screened with imaging tests by a pulmonologist or mesothelioma specialist yearly or even more often. 
    • Researchers at Fox Chase and Temple are working on potential preventive therapies for people at risk of mesothelioma. Our results so far are encouraging.

    Q. How is mesothelioma diagnosed?

    Diagnosis starts with taking a medical history. We ask our patients about the work they did and their current symptoms. If we suspect asbestos exposure, we may order a CT scan. For example, if a patient worked in the shipyards 30 years ago and is now short of breath I would likely order testing.

    A CT scan is a noninvasive test that uses x-rays and computers to make very detailed images. For instance, if we’re looking at the lungs, we may see that they have fluid and that the lining around them is thick and bumpy. In a healthy lung, we usually cannot see this lining at all with a CT scan. Combined with a history of asbestos exposure, we may suspect mesothelioma. In that case, a biopsy would likely come next. During a biopsy, we remove a small piece of tissue to examine under a microscope. We may take the biopsy with an endoscope (a thin tube with an attached camera); a long, thin needle; or surgery.

    Q. What is the life expectancy of someone with mesothelioma?

    Every individual case of cancer is different. Patients with peritoneal mesothelioma can be cured and have a long life expectancy. But without treatment, the average survival rate for pleural mesothelioma is still around 1 year after diagnosis. Mesothelioma of the chest is much more aggressive and still not considered curable. But with treatment, we can extend and improve lives. For certain patients with a subtype of mesothelioma, called epithelioid mesothelioma, the median survival rate is closer to 7 years — which isn’t enough for me. We can always do better.

    Q. How is mesothelioma treated?

    There’s a lot we can do for patients, and the treatments can be tailored to each patient’s unique needs. Here is a brief overview of some treatments for the different types of mesothelioma:

    Pleural mesothelioma. This type is often found at an advanced stage, which makes curative surgery difficult. Instead, many people are treated with systemic chemotherapy and immunotherapy. Radiation and surgery are still considered investigational. However, for a subgroup of patients, we can have a fairly dramatic impact on their survival by combining surgery with standard treatments.

    One of the innovative therapies we offer at Temple is a type of lung-sparing surgery called pleurectomy/decortication. It is an alternative to extrapleural pneumonectomy (EPP), which removes the entire affected lung. With lung-sparing surgery, we remove just part of the affected lung and all the detectable cancer, along with any affected nearby tissues. During the operation, we will often apply chemotherapy drugs to the chest to kill as many remaining cancer cells as we can.

    Sparing the lung can make a big difference in patients’ quality of life. I want my patients to do things like attend their grandchildren’s graduations, take walks, or enjoy working in the garden. Those types of activities are much harder to do if you have only one lung. If lung-sparing surgery isn’t possible — for instance, if the cancer is too extensive to be removed — EPP may be a better option. During EPP, we also remove the pleura, part of the diaphragm, and possibly the sac around the heart (the pericardium). We replace the diaphragm and the pericardium with man-made materials.

    Another way we can improve quality of life: For patients with a lot of fluid compressing their lungs, we can help them breathe better by placing a temporary catheter into the chest that allows them to drain the fluid at home.

    Peritoneal mesothelioma. Surgery called cytoreduction is typically combined with hyperthermic intraperitoneal chemotherapy (HIPEC), in which chemo drugs are delivered directly to the abdomen during surgery. We remove as much of the cancer as possible during the surgery. Fox Chase is one of only a handful of centers in the region that offer HIPEC. As I have said, peritoneal mesothelioma is potentially curative.

    Pericardial mesothelioma. Surgery and chemotherapy are treatment options.

    Testicular mesothelioma. The main treatment is surgery, often with radiation and chemotherapy.

    Q. Who is a candidate for lung-sparing surgery?

    The best candidates are patients with epithelioid mesothelioma, which is about 2 out of 3 pleural mesothelioma patients. Of these, those whose cancer is confined to one side of the chest and who are healthy enough to endure the 10 to 12 hours of major surgery may be candidates.

    Get the help you deserve

    Fox Chase Cancer Center and the Temple Lung Center offer a comprehensive Mesothelioma Program to help ensure that patients with mesothelioma get the personalized care they need and deserve. The team will include thoracic surgeons, medical and radiation oncologists, oncology nurses, pulmonologists, integrative medicine specialists, social workers, and nutrition experts. If you or someone you know has been diagnosed with mesothelioma — or you are at risk for the disease — request an appointment.