Malignant Mesothelioma: The Challenge Of Treating Pain

By Stephanie L. Whyche

Introduction

Malignant mesothelioma is a cancer of the lining of the chest or abdominal cavity. It is poorly responsive to chemotherapy, and surgical intervention is rarely curative. Treatment of mesothelioma patients, therefore, often focuses on the management of symptoms. The pain that can accompany malignant mesothelioma — especially during the end-stage of the disease — is one of the major challenges facing patients and their doctors.

Malignant mesothelioma, linked strongly to asbestos exposure, is a cancer that arises in the thin, membranous tissue that forms the lining of the chest cavity and lungs. More rarely it starts in the lining of the abdominal cavity. In either case, pain is a chief symptom.

"Mesothelioma is locally invasive and persistent," says Dr. Steven J. Mentzer, a board-certified thoracic surgeon who specializes in malignant diseases and co-directs the Lung Transplant Program at Brigham and Women's Hospital. Controlling pain, Dr. Mentzer says, is difficult. "Most other cancer pain is treated more effectively."

A reported 60 to 90 percent of mesothelioma patients experience pain or shortness of breath as the first symptom of the disease. However, anesthesiologists and other health care workers who specialize in pain control are providing more relief than ever before, thanks to state-of-the-art pain management techniques, including implanting devices which deliver pain-fighting drugs directly to the central nervous system.

"Utilizing epidural anesthetics and catheters is the most effective analgesic pain therapy for the treatment of patients who have pain from mesothelioma," says Dr. Srdjan S. Nedeljkovic, an anesthesiologist at Brigham and Women's Hospital in Massachusetts and Fellowship Education Director at its Pain Management Center. "Our experience," he says, "suggests a greater than 90 percent effectiveness rate . . . with the fewest side effects."

Progressive Symptoms

When malignant mesothelioma originates in the pleural cavity, the first symptom may be a nagging discomfort or mild pain in the chest area or in the back. If it originates in the lining of abdominal cavity, the first symptom is abdominal or pelvic discomfort.

During this initial stage, pain can be eased with over-the-counter analgesics, such as aspirin, acetaminophen (Tylenol) or ibuprofen (Advil, Motrin). Surgery, radiation and chemotherapy are aimed at stopping the spread of the disease and thus easing the pain. But the treatment themselves are not exactly pain-free.

As the disease progresses and destroys soft tissue and nearby nerves, the patient experiences the most discomfort.

"Eventually, when cancer spreads, it grows into the chest wall, muscles and ribs causing destruction and severe pain," Dr. Nedeljkovic says.

The pain changes from mild, general and episodic to severe, localized and chronic as the disease progresses. Severe pain may be unresponsive to oral doses, intravenous infusions, or intramuscular injections of analgesics or narcotics.

Malignant mesothelioma of the abdominal cavity also can lead to bowel obstruction with its own resultant pain, Dr. Mentzer says.

Easing Severe Pain: A Two-Pronged Approach

Doctors, nurses and other health professionals who specialize in easing severe pain, such as the staff at Brigham and Women's Hospital's Pain Management Center, take the pain caused by cancer and other diseases very seriously, Dr. Nedeljkovic says.

Their job, he says, is to bring maximum physical comfort and quality of life to all patients who come to the center, even individuals diagnosed with end-stage malignant mesothelioma.

The program's standards of care closely mirrors "Cancer Pain: Treatment Guidelines for Patients," published by the American Cancer Society and the Comprehensive Cancer Network. To read the guidelines or to order a copy, click here.

A two-pronged program in pain management is used at Brigham and Women's Hospital's Pain Management Center, where each patient is assigned a multidisciplinary team made up of a doctor, psychologist and palliative-care nurse.

An integral part of the program is helping patients and their families better cope with the emotional upheaval and psychological pain wrought by a diagnosis of malignant mesothelioma.

As noted in "Cancer Pain: Treatment Guidelines for Patients," emotional support and professional counseling play a key role in pain management. Improving a patient's mental health can help minimize the fear, anxiety and depression that can make physical pain feel worse.

The health team at Brigham and Women's Pain Management Center evaluates and monitors the psychological and emotional needs of each patient. Care focuses on helping the patient:

The other crucial part of the center's program is evaluating and managing the physical pain of the disease and painful side effects resulting from treatment.

An Effective Treatment Approach: Epidural Implants

If a patient no longer attains relief taking the strongest oral or intravenous analgesic medications, doctors may prescribe a solution containing local anesthetics and opioid analgesics that is delivered epidurally (outside of the dural membrane of the spinal cord, but still within the spinal canal).

The pain-management team surgically implants a thin catheter beneath the skin. Precise doses of the pain-killing mixture are programmed to flow through this tubing into the epidural area of the spinal canal at preset amounts and times. The drugs bind to receptors in the central nervous system and at the level of the nerve roots, blocking pain signals.

"Through this system, regional segmental infusions of narcotics and local anesthetics are delivered to the spine," Dr. Nedeljkovic says.

In addition to controlling pain, the epidural implant reduces the need for in-hospital pain care. By allowing pain to be controlled at home, it offers maximum mobility for patients. Doctors, in conjunction with trained technicians of a private home-health care agency, provide the medication and monitor the ongoing operation of the device.

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