On February 4, 2004 the Food and Drug Administration- FDA- approved cisplatin and pemetrexed also known as Alimta, for the treatment of malignant mesothelioma. Given In conjunction with oral folic acid, vitamin B12 injections, and corticosteroids to reduce skin rashes, it has been the standard of care for the past 14 years. It is the recommended first line treatment for malignant mesothelioma. As progress with research has taught, everyone’s cancer is specific to them, the response, the stage, the cell type, are all factors in the response to chemotherapy. The average life expectancy for patients that receive this treatment regime is 13.3 months, as compared to those who have no treatment. The overall survival time for no treatment is 4 months. Patients should be offered chemotherapy to improve the amount of time they have left, and to improve their quality of life.
Chemotherapy is usually given in cycles, which are usually 3-4 weeks with a rest period between cycles. Systemic chemotherapy is the most common way to deliver these drugs which is an infusion through a vein. Another way of administering chemotherapy drugs is immediately after the tumor has been removed surgically in the operating room, this is called either intrapleural chemotherapy (which is directly into the chest) or intraperitoneal (which is directly into the abdomen). Either of these drugs can be given heated, as the drugs have been found to have the most efficacy at killing microscopic cancer cells. This type of treatment is known as hyper thermic chemotherapy.
The recommended dose of pemetrexed is 500mg and is administered through an IV which takes 10 -15 minutes. If you are a candidate for cisplatin this is usually given within 30 minutes of the conclusion of the pemetrexed dose, which is infused over a few hours.
Cisplatin is a drug that is prescribed to mesothelioma patients which is not very effective alone, but coupled with pemetrexed/Alimta is known to be the chemotherapy agents that provide the most hope. The side effects can include damage to the kidneys, nausea, and loss of appetite, tiredness, hair loss, and increased risk of infection.
It is recommended that patients be offered clinical trials that include different chemotherapeutic medications. Some of the findings from clinical trials involving chemotherapeutic drugs and malignant mesothelioma over the past years have shown promise.
A French Clinical Trial referred to as the MAPS Trial has found that adding bevacizumab to this regime has improved both progression free survival and overall survival for patients with malignant pleural mesothelioma. The bevacizumab was administered on day one of each of 6 -21-day cycles, and then continued as maintenance every three weeks following completion of six cycles of chemotherapy.
Bevacizumab is not recommended for patients who have cardiovascular comorbidity, uncontrollable hypertension, older than 75, or have a bleeding or clotting risk. Patients have to be carefully chosen for this treatment regime. The regimes addition of bevacizumab increased both progression free and overall survival. It is now the standard of care in France. It has not yet been approved by the FDA in the United States.
Another chemotherapeutic agent Raltitrexed used in combination with cisplatin has been found to help overall survival versus cisplatin alone. Raltitrexed is not commercially available in the United States.
Other regimes combinations have been tried with Cisplatin including anthrancyclines (doxorubin, epirubicin) combination of fluorouracil, mitomycin, plus etoposide, and combination of methotrexate plus vinblastine – none have been found to be as effective as the combinations of cisplatin plus pemetrexed or gemcitabine.
No new regimes have been approved since 2004. Research for better chemotherapeutic options is ongoing. In addition ongoing research into immunotherapy is also showing some promising results.
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