Managing Mesothelioma Treatment Side Effects
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This document discusses managing side effects of mesothelioma treatments through nutrition. It covers common treatments for mesothelioma like chemotherapy, immunotherapy, radiation, and surgery. Each treatment can cause side effects that impact quality of life. Side effects from chemotherapy include nausea, low blood counts, and neuropathy. Nutrition strategies like eating small, frequent meals can help manage immunotherapy side effects. Radiation side effects include fatigue, and packing portable protein snacks is advised. Surgery side effects involve risks of infection, which nutrition before and after can reduce. Unintended weight loss from treatments can be prevented by meeting calorie and protein needs.
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Managing Mesothelioma Treatment Side Effects
- 1. Today’s Experts: Karen Selby, RN Registered Nurse & Patient Advocate Suzanne Dixon, MPH, MS, RDN Cancer Nutrition Specialist & Registered Dietitian Managing Mesothelioma Treatment Side Effects
- 2. Effectively Managing Side Effects of Mesothelioma Treatment Common mesothelioma treatments: Chemotherapy Immunotherapy Radiation Surgery Each treatment has side effects that can impact quality of life. Side effects can be managed with: Medications Nutrition Diet (877) 925-2216
- 3. Chemo medications: Are given orally or through IV Attack rapidly dividing cells or target cancer cell proteins Used for pleural and peritoneal mesothelioma patients Most common combination for pleural mesothelioma: Cisplatin and pemetrexed (Alimta) Most common for peritoneal mesothelioma: Heated intraperitoneal chemotherapy (HIPEC) 1-Year Survival Rate No chemotherapy: 17% One chemotherapy drug: 35% Two chemotherapy drugs: 64% Chemotherapy for Mesothelioma (877) 925-2216
- 4. Nausea Low blood counts Decreased kidney function Ototoxicity (hearing loss) Blood test abnormalities These occur in more than 30% of all people receiving chemotherapy. Common Side Effects of Chemotherapy (877) 925-2216
- 5. Peripheral neuropathy (weakness/numbness/tingling and pain in the hands and feet) Loss of appetite (anorexia) Metallic taste Mouth sores These occur in 10% to 29% of all people receiving chemotherapy. Common Side Effects of Chemotherapy (cont.) (877) 925-2216
- 6. Using Nutrition to Manage Chemotherapy Side Effects (877) 925-2216
- 7. Experimental treatment Medications given through IV or orally Stimulates immune system to attack cancer Side effects similar to those from chemotherapy, but they are due to autoimmune effects of therapy. Continued, open communication with your medical team is key to managing immunotherapy. What Is Immunotherapy? (877) 925-2216
- 8. Side Effects of Immunotherapy (877) 925-2216
- 9. Small frequent meals and snacks Plenty of protein Flexible with how, when and what you eat Keep food handy Protein-rich foods Using Nutrition to Manage Immunotherapy Side Effects (877) 925-2216
- 10. Avoid strong food smells/strong flavors Add soluble fiber Don’t ignore GI issues or self-treat Communicate symptom changes to doctor Using Nutrition to Manage Immunotherapy Side Effects (cont.) (877) 925-2216
- 11. High-energy radiation from X-rays, gamma rays, neutrons, protons, and other sources to kill cancer cells and shrink tumors Often used in combination with other treatments Can be used alone to manage symptoms and improve quality of life (palliative therapy) What Is Radiation Therapy? (877) 925-2216
- 12. Side Effects of Radiation Therapy (877) 925-2216
- 13. Good nutrition proven to lessen short- and long-term effects of radiotherapy Radiation therapy sessions often occur daily Plan for time away from home to meet your nutrition needs. Pack portable protein. Is food available at your radiation therapy location? Using Nutrition to Manage Radiation Therapy Side Effects (877) 925-2216
- 14. Common pleural mesothelioma surgeries: Extrapleural pneumonectomy (EPP) Pleurectomy/decortication (P/D) Common peritoneal mesothelioma surgeries: Peritonectomy (debulking surgery) HIPEC Treatment (in conjunction with surgery) Eligibility: Typically, only early-stage pleural mesothelioma patients in good physical health are eligible. Nearly 40% of peritoneal mesothelioma patients qualify for tumor-removing surgery. What Surgeries Are Available for Mesothelioma? (877) 925-2216
- 15. Side Effects of Surgery (877) 925-2216
- 16. Enhanced Recovery After Surgery (ERAS) procedures or protocols Oral supplements Immune-nutrition products Other steps to strengthen the body before surgery Good nutrition can reduce the chances of infection and long hospital stays. Using Nutrition to Manage Surgery Side Effects and Risks (877) 925-2216
- 17. Preventing Unintended Weight Loss Not all weight loss is good weight loss. Unintended weight loss can lead to more side effects, poor quality of life and deceased treatment tolerance. If you’re experiencing this, focus on: Calories (Energy) 11.5 to 16 calories per pound of bodyweight per day Example: 200 pounds = 2,300 to 3,200 calories per day Sources: Healthy fats, starchy vegetables, fresh or frozen fruit, grains (877) 925-2216
- 18. Preventing Unintended Weight Loss (cont.) To support tissue rebuilding and prevent further loss, focus on: Protein (Rebuilds Lean Body Tissue) 0.7 g protein per pound bodyweight per day Example: 170 pounds = 119 grams of protein per day Sources: Meat, fish and poultry; dairy and eggs; legumes; nuts, liquid nutritional supplements, protein powder smoothies Protein Distribution Matters (877) 925-2216
- 19. Why Nutrition Matters for Mesothelioma Patients? Mesothelioma negatively affects nutrition and the ability to eat well. Many patients lack access to adequate nutrition care before, during or after a mesothelioma diagnosis. Nutrition gives mesothelioma patients and their loved ones a way to gain control and positively affect their own lives. (877) 925-2216
- 20. Contact Information (877) 925-2216 Karen Selby, RN Registered Nurse & Patient Advocate Email: kselby@asbestos.com Suzanne Dixon, MPH, MS, RDN Registered Dietitian Email: sdixon@asbestos.com 1-877-925-2216
- 21. Sources • Friedberg, J.S. et al. (2019, May 25). A Proposed System Toward Standardizing Surgery-based Treatments for Malignant Pleural Mesothelioma, From the Joint NCI-IASLC-MARF Taskforce. Retrieved from: doi: 10.1016/j.jtho.2019.04.029 • Gomez, D.R. et al. (2019, May 21). The Use of Radiation Therapy for the Treatment of Malignant Pleural Mesothelioma: Expert Opinion from the National Cancer Institute Thoracic Malignancy Steering Committee, International Association for the Study of Lung Cancer, and Mesothelioma Applied Research Foundation. Retrieved from doi: 10.1016/j.jtho.2019.03.030 • MacRae, R.M. et al. (2019, March 31). The role of radiation treatment in pleural mesothelioma: Highlights of the 14th International Conference of the International mesothelioma interest group. Retrieved from: doi: 10.1016/j.lungcan.2019.03.023 • Forde, P.M. (2019, February 14). Use of Immune Checkpoint Inhibitors in Mesothelioma. Retrieved from doi: 10.1007/s11864-019-0613-x • Cancer.org. (2018, November 16). Chemotherapy for Malignant Mesothelioma. Retrieved from: http://www.cancer.org/Cancer/MalignantMesothelioma/DetailedGuide/malignant-mesothelioma-treating- chemotherapy • Johnson, D.B. et al. (2018, October 23). Immune Checkpoint Inhibitor Toxicity in 2018. Retrieved from: doi:10.1001/jama.2018.13995 • Nicholson, B.D. et al. (2018, April 9). Weight loss as a predictor of cancer in primary care: a systematic review and meta-analysis. Retrieved from https://bjgp.org/content/68/670/e311 • Pearce, A. et al. (2017, October 10). Incidence and severity of self-reported chemotherapy side effects in routine care: A prospective cohort study. Retrieved from doi: 10.1371/journal.pone.0184360 (877) 925-2216
- 22. Sources (cont.) • Bakker, E. et al (2017, September). Immunotherapy advances for mesothelioma treatment. Retrieved from: doi: 10.1080/14737140.2017.1358091 • Alley, E.W. (2017, April). Immunotherapy and radiation therapy for malignant pleural mesothelioma. Retrieved from: doi: 10.21037/tlcr.2017.04.01 • Arends, J. et al. (2017, February). ESPEN guidelines on nutrition in cancer patients. Retrieved from: doi: 10.1016/j.clnu.2016.07.015 • Gangadharan, A. (2017, February 4). Protein calorie malnutrition, nutritional intervention and personalized cancer care. Retrieved from: https://doi.org/10.18632/oncotarget.15103 • American Cancer Society. (2018, November 16). Surgery for malignant mesothelioma. Retrieved from: https://www.cancer.org/cancer/malignant-mesothelioma/treating/surgery.html • Beebe-Dimmer, J.L. et al. (2016, October 30). Mesothelioma in the United States: a Surveillance, Epidemiology, and End Results (SEER)–Medicare investigation of treatment patterns and overall survival. Retrieved from: https://www.dovepress.com/mesothelioma-in-the-united-states-a-surveillance- epidemiology-and-end--peer-reviewed-fulltext-article-CLEP • Dogan, M. et al. (2014, October). The clinicopathological characteristics with long-term outcomes in malignant mesothelioma. Retrieved from doi: 10.1007/s12032-014-0232-0 • Loh, K.W. et al. (2012). Unintentional weight loss is the most important indicator of malnutrition among surgical cancer patients. Retrieved from: http://www.njmonline.nl/getpdf.php?id=1222 (877) 925-2216
Editor's Notes
- Karen: Medication (anti-nausea, pain, or maybe a blood transfusion), nutrition and diet changes and “all other” this would be things like alternative choices such as meditation, talk therapy, or art therapy for example. We will touch on Medications or medical management but focus on diet and nutrition today. Medical management is the first part of managing symptoms and addressed by your physician. In addition to that, small changes in how, what and when you eat can make a world of difference in how you feel. Introduce Suzanne.
- Suzanne: A combination of pemetrexed (Alimta) and cisplatin or carboplatin is the first line chemotherapy used to treat pleural mesothelioma. If a patient can’t tolerate these drugs or isn’t eligible to receive them for other health reasons, your doctor has other options to try. HIPEC surgery, also known as heated or hyperthermic intraperitoneal chemotherapy, is the process of heating chemotherapy drugs and delivering them into the abdominal cavity during surgery. This treatment is often combined with cytoreductive surgery and is an effective approach for peritoneal mesothelioma. Transition: Suzanne to Karen: Karen, can you tell us a little bit about some side effects of chemotherapy?
- Karen will describe these symptoms and mention if there are ways to manage medically (just touch on importance of medical mgmt) then: Nausea – Anti-nausea medications such as Compazine, zofran or Anzemet Low blood counts (WBC, RBC and platelets) may be treated by blood or platelet transfusion, or other stimulating agents Erythropoetin or (ESA’s) for RBC Thrombopoetin for low platelets, neupogen to increase WBCs Decreased Kidney function may be temporary and medically managed by altering treatment to a lower dose or less toxic medication, temporary dialysis and sometimes a drug called amifostine may be given to prevent further kidney damage Ototoxicity – can’t be managed by prescription but possibly through altering dosage
- Karen will describe these symptoms and mention if there are ways to manage medically (just touch on importance of medical mgmt) then: Peripheral neuropathy – OTC pain medications such as non-steroidals, anti-inflammatory or prescription pain-medications can be prescribed, Topical treatment such as lidocaine patches and TENS unit which is a form of physical therapy using electro-magnetic energy can be prescribed. For severe cases, certain anti-seizure medications have been known to show relief. Appetite Loss – Medications can by prescribed such as Reglan, or Marinol to increase appetite. Also Steroids can improve appetite as well. Mouth sores – Your physician may suggest anesthetic gels or washes to help with discomfort Transition: Karen to Suzanne: Along with medically managing these symptoms, are there any things you can do nutritionally to address these challenges?
- Suzanne: Briefly discuss a few things a person can do nutritionally to address side effects. Give examples of foods and patterns of eating.Nausea: don’t let stomach get empty, avoid food odors, small/frequent meals and snacks, bland foods, avoid the kitchen Low blood counts & blood test abnormalities: protein, calories to prevent weight loss, fruit juice and sports drinks if blood tests indicate electrolyte abnormalities Decreased kidney fx: plenty of fluids, avoid dehydration, avoid weight loss if possible Ototoxicity & peripheral neuropathy: Less malnutrition = fewer and less severe side effects. If you’re losing weight without trying, talk to your doctor or nurse and ask for referral to dietitianMetallic taste: Avoid metal utensils, good oral hygiene, try unusual or new flavors, use herbs and fruit marinades for meat, chicken, fish Mouth sores: Avoid dry, sharp, sticky foods. Go for bland, non-spicy items. Lubricate food well with gravy, butter or olive oil, avoid very hot/very cold items, time eating to pain med administration, ask doctor for other pain options if yours isn’t working WAIT FOR KAREN to interject before going on to WHAT IS IMMUNOTHERAPY.
- Suzanne: Immunotherapy stimulates a patient’s own immune system in order to attack the cancer cells. In essence, they take the “brakes” off immune cells so they can attack the cancer. Keytruda, Opdivo and Yervoy are the most talked about immunotherapy drugs for pleural mesothelioma right now. Currently, none of these immunotherapy drugs are approved by the FDA for mesothelioma, so many patients access them by participating in clinical trials. Eligibility varies based on the specific trial. Transition: Karen, can you tell us a little bit about some side effects of immunotherapy?
- Karen will describe these symptoms and mention if there are ways to manage medically (just touch on importance of medical mgmt) then: Unfortunately Fatigue can’t be managed by medication OTC non-steroidals can help with body pain or stronger prescription pain medication can be ordered if OTC is not effective enough Diarrhea can typically be managed with a variety of over the counter medications such as Imodium. HOWEVER, diarrhea can be a result of autoimmune colitis, in this case STEROIDS will be prescribed. Low-grade fever can be treated by OTC non-steroidals. If your temp. is greater than 100.5 it’s important to let your doctor know as there may be a concern of something else causing the fever that needs to be addressed. Unfortunately, there is not medical management for SOB other than supplemental oxygen if the physician feels it is warranted. May need steroids if SOB significantly worsens and it’s due to autoimmune reaction in lungs. Nausea – anti immetics either OTC or a physician may prescribe (essentially the same as what we talked about already ) Rash will usually occur the first few weeks after treatment starts. Your doctor will typically suggest topical cortisone first and OTC antihistamines such as benadryl or zyrtec. If this doesn’t relieve the symptoms, steroids such as prednisone and sometimes antibiotics will be prescribed. Headaches - non-steroidal/anti-inflammatory medications are suggested for headaches Weight loss is medically managed the same as with chemo side-effects as discussed earlier. TRANSITION: Karen to Suzanne: “Suzanne, along with medically managing these symptoms are there any things you can do nutritionally to address these challenges?”
- Suzanne: Briefly discuss a few things a person can do nutritionally to address side effects. Stress nutrition to rebuild tissue.NEXT SLIDE – Continuation of this one
- Suzanne: Briefly discuss a few things a person can do nutritionally to address side effects. Stress nutrition to rebuild tissue. WAIT FOR INTERJECTION by Karen before going on to radiation therapy TRANSITION: Suzanne will talk about sticky stuff. Karen to Suzanne: Suzanne, as you know, radiation is another common treatment for mesothelioma. Can you share some insight on it?
- Suzanne: High energy, targeted beams. Everyone is familiar with X-rays to provide images of the inside of the body. Other forms of radiation energy are used to target and destroy cancer cells. Describe how/why palliative use can be beneficial. Used alone or in combination with other treatments. Karen, can you tell us about some of the side effects of radiation therapy?
- Karen will describe these symptoms and mention if there are ways to manage medically (just touch on importance of medical mgmt) then: Skin Problems - Your physician may suggest OTC ointments such as A&D, Eucerin, Aloe vera or Redicare for Skin Irritation/burns Fatigue – as stated previously can’t really be medically treated however your physician will be monitoring blood counts alterations which may contribute to your fatigue Difficulty swallowing may pose concerns of food getting stuck or aspiration (in other words the food going down wrong) There are no medications to help with this unfortunately Shortness of Breath. Again, there are no medical management for this but your physician will be monitoring 02 saturations for possible 02 supplements. Shoulder Stiffness- over the counter options will be suggested by your physician Radiation Pneumonitis may be treated with decongestants, cough suppressants, bronchodilators, or cortico-steroids and oxygen therapy Radiation Fibrosis may be treated very similarly with anti-inflammatory, cortico-steroids or interferon and sometimes hyperbaric oxygen depending on severity. TRANSITION: Karen to Suzanne: Suzanne, are there any things you can do nutritionally to address these challenges?
- Suzanne: Briefly discuss a few things a person can do nutritionally to address side effects. Radiation therapy can be a big time burden. Without planning, it’s very easy to miss important opportunities to eat. Focusing on balanced meals and snacks with protein at every opportunity is helpful. Staying hydrated. Healthy fats (cell healing/rebuilding). Karen: The last modality we're going to talk about is surgery, and I think most of us want surgery if we are eligible for it. Typically, mesothelioma patients have to be diagnosed at an early stage in order to qualify. Suzanne, can you talk a little bit more about surgery for mesothelioma?
- Suzanne: Common pleural mesothelioma surgeries include a extrapleural pneumonectomy (EPP), an aggressive surgery that removes an entire lung, the lining around it, nearby lymph nodes and parts of the pericardium and diaphragm; and a pleurectomy/decortication (P/D), a slightly less aggressive surgery that only removes the pleural lining around the lungs and all visible tumors. Surgeons will scrape the diseased lung rather than remove it. - For peritoneal mesothelioma patients, the most effective treatment for this disease combines a peritonectomy with a HIPEC procedure. - In a peritonectomy, surgeons remove the diseased parts of the peritoneal lining of the abdomen. Then they perform cytoreductive surgery to remove as much cancerous growth as possible from the abdominal cavity. This is also called debulking surgery, and it may involve removing parts of the liver, pancreas, spleen, gall bladder, bowels and stomach.- Hyperthermic intraperitoneal chemotherapy (HIPEC) is given immediately after the debulking phase of the peritonectomy surgery. Mesothelioma specialists pump a heated mixture of chemotherapy drugs directly into the abdominal cavity. They leave it there for up to two hours so it can be absorbed by any remaining cancer cells.- Most patients hope to be eligible for surgery given that it provides the greatest chance at long-term survival. Unfortunately, many pleural mesothelioma patients are not diagnosed until stage 3 or stage 4 when the cancer is too advanced for surgical removal. In addition, eligibility depends on patient health, heart and breathing function, overall strength and function. - Peritoneal patients typically have a better chance of surgery eligibility. In fact, nearly 40% of peritoneal mesothelioma patients qualify for tumor-removing surgery. - Both pleural and peritoneal mesothelioma patients often combine surgery with another form of mesothelioma treatment as well, which can add to the risk of side effects. Suzanne Karen, can you tell us a little bit more about the side effects or complications that can come from surgery?
- Karen will describe these symptoms and mention if there are ways to manage medically (just touch on importance of medical mgmt) then: Although Anesthesia is safe there are many possible side-effects. Most of these sides-effects can be treated medically while still in the hospital. I don’t want to go into great detail all of the possibilities. Bleeding may occur from altered blood counts. Blood and platelet transfusions may be prescribed and also the possibility of a return trip to the operating room if this can’t be controlled. Post-Op infection may occur from 3 days to 30 days after surgery. Depending on severity, oral or IV antibiotics can be given and possibly wound draining and debriding may be warranted. Organ damage can occur to organs, such as the lungs, heart, or kidneys. These problems are very rare but can be life-threatening. They are more likely to happen to people who already have problems with these organs prior to surgery. Depending on the damage, your physician may be able to medically treat this while recovering from surgery. Persistent air leak (pleural) (the lung won’t stay inflated) This means a need for a chest tube post-operatively until the lung can stay inflated on it’s own Blood clots can form in the deep veins of the legs after surgery, especially if a person stays in bed for a long time. Such a clot can become a serious problem if it breaks loose and travels to another part of the body, such as a lung. These are most commonly treated with anticoagulant medication, also called blood thinners. If this doesn’t work, a filter may need to be surgically inserted to prevent the clot from traveling An Enterocutaneus Fistula is primarily an abdominal type concern (for peritoneal mesothelioma patients) and can happen several days after surgery. It is an abnormal connection between two hollow spaces. It can possibly heal over time or may need to be surgically repaired. Bowel leak is another abdominal side effect which most often means returning to the operating room for repair. Medical treatment for weight loss will be the same as other treatments already noted (Marinol or other options to increase appetite), however Suzanne has some great suggestions on ways to manage this nutritionally. Suzanne?
- Suzanne: Discuss specific pre surgery preparation programs now in use to help patients weather surgery.
- Suzanne: These are general guidelines, everyone is different, but this is a good place to start.
- Suzanne: And don’t forget the importance of eating protein in small-to-moderate amounts throughout the day to help the body best utilize these foods. The consumption of a moderate amount of protein at each meal/snack — spread evenly though out the day — is better for helping your body use protein from food to rebuild healthy tissue.
- Suzanne: STOP and hand over to moderator.
- Suzanne: STOP and hand over to moderator.
- Suzanne: STOP and hand over to moderator.