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Treatment and recovery:
Malignant pleural
mesothelioma
Jocelyn Mclean
Case Manager for Thoracic Surgery
Royal Prince Alfred Hospital, Sydney
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This presentation
 Treatment - management options
 Recovery – well living programme
 Caring for patients, carers and
families during treatment and
management
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Principles of management
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We cannot cure but can offer treatment and care
Main Goals
 Effective palliation
 Prolongation of symptom free survival
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Individual management plan for every patient
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Principles of management
Treatment plan for each patient based on:
Patient Factors
 age
 fitness
 symptoms
 preference
Disease Factors

Histology (epithelioid)

Extent (<T4 & N2)

Rate of progression
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Common presenting
symptoms
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Shortness of breath
Fatigue / lethargy
Weight loss
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Dull chest pain
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Strategy:
– Relieve symptoms
– Control cause of symptoms
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Controlling fluid /obtaining
diagnosis
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Local drainage / indwelling catheter
Pleuroscopy / pleurodesis via slurry
Local biopsy
Thoracoscopy, biopsy, pleurodesis
THIS IS WHAT WE OFFER
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Thoracoscopy
Video Assisted VAT
Leads to
Establish Diagnosis – Biopsy
Control Fluid - Talc Pleurodesis
Maximise lung re-expansion – pleurectomy
Assess for cytoreductive therapy
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Thoracoscopy
Leads to
 Establish Diagnosis
 Talc Pleurodesis
 Assess Suitability
Leads to
Fails (fluid re-accumulates)
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Thoracoscopy
Leads to
 Establish Diagnosis
 Talc Pleurodesis
 Assess Suitability
Leads to
Fails (fluid re-accumulates)
Pleurectomy/Decortication
Or
Simple Drainage
Enables self drainage of fluid when symptomatic
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Thoracoscopy
Leads to
 Establish Diagnosis
 Talc Pleurodesis
 Assess Suitability
Leads to
Fails (fluid re-accumulates)
Pleurectomy/Decortication
or
Simple Drainage
 Assessment for Subsequent
 Radiotherapy &/or
 chemotherapy
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Fluid controlled – what therapy?
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Chemotherapy – pemetrexed / cis (carbo) platin
 3-6+ cycles, regular imaging to assess
effectiveness of treatment
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Radiotherapy – only for symptom control
 In cytoreductive setting
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Cytoreductive treatment - trimodality therapy
 Chemotherapy, radical surgery -EPP, radiotherapy
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Complimentary therapy (s)
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Treatment option - chemotherapy
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Consider chemotherapy
 Pemetrexed / doublet Cistplatin
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Have a consultation and then make a decision
Differing opinions amongst medical teams
No proven correct timing for chemo – measurable
disease, plus or minus - symptomatic,
Ultimate choice is patient
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Treatment option - radiotherapy
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No proven benefit in treating port sites
Benefit in treating symptoms, eg pain, disease
tracking
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Developing roles for XRT being explored overseas
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Has a role in cytoreductive therapy
slide 14 and slide 15 were not included in this version as they contain complex flow diagrams that are too difficult to describe in
an accessible word document.
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Cytoreductive – trimodality therapy
Only offered to suitable patients – numbers are few
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Chemotherapy 3 cycles
 Appears to confer a survival advantage
 Identifies a subset of patients with rampant
disease who are not suitable for radical surgery
 Provides a period of adaptation to the patient
and the family prior to radical surgery
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EPP Extrapleural pneumonectomy
 EPD lung spared or not spared
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IMRT Intensity modulated radiotherapy
 6 -8 weeks post surgery for 6 weeks
slide 17 was not included in this version as it also contains a complex flow diagram that is too difficult to describe in an accessible
word document.
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Care and support
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Patient, carer, family
Begin at time of diagnosis
Information, information
Equitable access to all options for treatment
 Reality – we cannot cure
 Hopefulness – we can treat and support
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Support and Recovery
 Well Living Programme
 Comcare Asbestos Innovation Fund.
 $30,000, over 12 months.
 The Baird Institute (TBI).
 Plan 2012 4 meetings
 2013 “Walking is the best medicine”.
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Goals set at first meeting.
The well living programme needed to:
Meaningful support group for survivors / carers
• Assist survivors and carers to focus on living well
after treatment.
• Address negative aspects of EPP QOL study
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reduced role and social functioning and
• symptoms of fatigue, pain, SOB and insomnia.
• Networking amongst survivors and carers
• Written information for new patients and carers
• Realize potential of group in relation to advocacy.
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Compile resources (computer based DVD, audio etc).
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Gain public recognition for what this group is doing
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Set a group goal
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Actual Programme over 4 meetings
APRIL
 Optimising living with one lung
 Physical and respiratory assessments
 Exploring carer experiences
JUNE
 Physical and respiratory assessments (continuing)
 Understanding resilience: Survivors / carers
 Creating opportunities for self-attention and nurturing –
carers.
 Relating science to the living experience: the role of the
Biobank.
AUGUST
 Physical and respiratory assessments (continuing)]
 Pain management
 Writing – fun with words – patients.
 Music – healing and relaxation – carers..
 Resilience sessions feedback - the living document.
 Eating for Wellbeing - A self management plan.
NOVEMBER Walking is the best medicine – 1.5 Km walk
 Programme in review –
 What has everyone been up too? –
 Goal for 2013- Walk the Sydney City to Surf
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2013 “Walking is the best medicine”.
February
• Goal: to improve the fitness and willingness of
survivors to exercise and have survivors, carers and
others complete a 7 kilometre - the Iron Cove Bay
Run on Sunday 4th August in Sydney.
• An exercise physiologist worked one on one and via
telephone to assist survivors increase their aerobic
and resistance training. They maintained their own
exercise records in the log book provided.
• A number of survivors report improvements in
overall fitness, enjoyment of daily living and
satisfaction with life.
Quality Of Life Results July 2013 of12 Long Term Survivors
(Ranging 3 – 10 Years)
> social and role functioning,
 > global health, physical functionin stable cognitive &
emotional function
< fatigue, breathlessness, and insomnia with smaller
reductions in pain, constipation and appetite loss.
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August 4th - Sunday Morning
6 survivors & 58 carers, family and support staff
participated in the 7 km walk
Participant age range was 2 years to 86 years.
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Patient information
Launched by Her Excellency, The Governor of NSW Marie
Bashir at The Baird Institute Research Conference Dinner on
September 20th 2013
Diagnosis & Treatment
The Journey of a Patient with
Malignant Pleural Mesothelioma
THANK YOU
ONE LUNG WONDERS