Importance of Dental Hygiene for Mesothelioma Patients

mouth_smallCancer therapies often result in xerostomia (dry mouth), a condition that can lead to increased risk of infection and cavities. Bacteria in the mouth are kept in check by saliva, which is a crucial fist line of defense in maintaining good oral health. When there isn’t enough saliva produced, or the amount available isn’t enough to clear infection-causing bacteria, it is possible to develop sores and excoriated tissue. Dry mouth is also a causative factor of malodorous breath and cavities, as food particles are not cleared away as quickly as they would be in a well-hydrated state.

Symptoms of dry mouth include stringy saliva, cracked or dry lips, difficulty speaking, and a burning sensation. When the mouth becomes too dry, chewing and swallowing are affected and may increase the risk of aspiration pneumonia, a life-threatening condition for at-risk cancer patients.

In mesothelioma patients, xerostomia is most often caused by chemotherapy, but lack of hydration and sometimes radiation can also be the culprits.

Xerostomia can be treated with medications to stimulate the production of saliva or with over-the-counter chewing gum and mouthwashes, depending on the severity.

Scheduling a dentist appointment before initiation of chemotherapy is a good practice to follow in order to identify and correct any dental conditions. Once chemotherapy has begun, patients should  brush 3 to 4 times daily, as vomiting and acid reflux are known to erode dental enamel. During this period, fluid intake should also be increased and gentle flossing should be continued. If platelets become low, patients should discontinue flossing until advised to resume.

It is important for mesothelioma patients to schedule regular dental check-ups. Because some dental interventions should not be performed when a patient is at a high risk for infection or bleeding, patients should inform their dentists if they are receiving chemotherapy treatments.

Update from The American Society of Clinical Oncology (ASCO) Annual Meeting

By Lee Krug, MD, Memorial Sloan-Kettering Cancer Center

ASCO-2013_1The American Society of Clinical Oncology meeting was held from June 1-4 in Chicago. This is the largest oncology meeting each year with around 30,000 attendees from all over the globe who congregate to discuss the latest research in all cancer types. I thought I would summarize a few of the presentations that were made regarding mesothelioma.

Accelerated hypofractionated hemithoracic intensity modulated radiation therapy followed by extrapleural pneumonectomy for malignant pleural mesothelioma (IMRT)

This study was presented by Dr. Marc de Perrot from Toronto, a member of our Science Advisory Board. In this approach, patients with early stage mesothelioma are treated first with high dose radiation over one week, and then, after one week of rest, patients then undergo an extrapleural pneumonectomy (EPP). If patients were found to have mediastinal lymph nodes at the time of surgery, they were planned to get chemotherapy afterward. This was a select group of patients who participated since only 18% of the patients with mesothelioma seen at the center over 4 years were enrolled on this study. Amazingly, the complications after the surgery were not more than expected, though one patient did die of an infection. Furthermore, the survival rates were quite promising; for patients with epithelioid subtype, 85% were predicted to be alive after 3 years. This is a high risk, aggressive treatment modality appropriate for only a select group of patients, and more follow up is needed. However, the excellent survival results are notable.

Randomized phase II study adding axitinib to pemetrexed-cisplatin in patients with malignant pleural mesothelioma

This was a trial conducted at a single institution in the Netherlands.  The researchers were aiming to find a drug that would improve the results of standard Pemetrexed (Alimta) and cisplatin chemotherapy. In this study, another drug called axitinib was added to that chemotherapy combination. Axitinib is an oral drug that blocks the vascular endothelial growth factor receptor (VEGFR) which is responsible for the formation of new blood supply to feed the tumor, which contributes to tumor growth. Patients were placed in two groups, one-third receiving treatment with pemetrexed and cisplatin alone, and two-thirds receiving the same chemotherapy plus axitinib. Patients received three cycle of therapy, and then underwent a pleurectomy (PD). The rate of tumor shrinkage and survival times were no different with the addition of axitinib, but the trial was quite small with only 31 patients in total, so it is difficult to draw definitive conclusions.

Phase I study of cediranib in combination with cisplatin and pemetrexed in chemonaive patients with malignant pleural mesothelioma

Dr. Anne Tsao from MD Anderson (another member of our Science Advisory Board) presented the results of this study on behalf of the Southwest Oncology Group. This study had a similar goal, to find a drug that could be added to standard chemotherapy. Like axitinib, cederinib is a pill that blocks the VEGF receptor, but it also blocks another growth factor called platelet derived growth factor receptor (PDGFR).  This study was designed to determine the side effects of that treatment and find the best dose. Twenty patients received the combination, and two doses of cederinib were tested. Patients received 6 rounds of chemotherapy plus cederinib, and then stayed on cederinib as a maintenance therapy after that. At the higher dose, two patients had severe diarrhea, two had debilitating fatigue, and one had confusion, so the lower dose was chosen for further study. Although the number of patients with tumor shrinkage was not impressive, the time before the cancer grew again was much longer than usual. A larger study is now ongoing in which patients are randomized, some receiving chemotherapy alone and some with chemotherapy plus cederinib.

Sensitivity of malignant mesothelioma lacking Merlin to the FAK inhibitor VS-6063: Evaluation of merlin/NF2 status in clinical samples

One of the genes that is commonly mutated in mesothelioma tumors is NF2 “(neurofibromin 2) This gene makes a protein called Merlin. Merlin sends growth signals inside the cancer cell and one of the proteins it interacts with is focal adhesion kinase (FAK). This abstract reported on experiments in the laboratory. The researchers treated mesothelioma cancer cells and also tumors in mice with a drug that blocks FAK called VS-6063. The treatment worked best in tumor cells that had NF2 mutations supporting their hypothesis. They have used this information to plan a large randomized trial with VS-6063 that is set to start this summer. Patients who have completed initial treatment with chemotherapy will be randomized to receive VS-6063 or placebo, to see if this drug delays the time before the cancer will start to grow again.

FROM THE MESOTHELIOMA APPLIED RESEARCH FOUNDATION’S “MEET THE EXPERTS” SERIES: Introducing a New Clinical Trial with Dr. Julie Brahmer

Tonight, as part of the “Meet the Experts” podcasts presented exclusively by the Meso Foundation, Dr. Julie Brahmer, Associate Professor of Oncology at the Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins Hospital, sat down with Mary Hesdorffer, Nurse Practitioner and Medical Liaison for the Meso Foundation, to discuss her new trial targeting pleural mesothelioma. In her talk “NGR-hTTNF: A New Multi-Center Drug Trial for Pleural Mesothelioma”, Dr. Brahmer discussed a new chemotherapy treatment, designed specifically for pleural mesothelioma patients.

To participate in the trial, one prior treatment regimen is required (for example Alimta and Cisplatin) which usually consists of 4 to 6 treatments. The NGR-hTTNF trial can then be offered in the second line setting. Patients will receive an active chemotherapy agent, and plus or minus the experimental drug NGR-hTTNF. This trial is available worldwide. In the United States, it can be obtained at Johns Hopkins in Baltimore, Maryland, as well as a few others sites in Texas, California, and New York. According to Dr. Brahmer, it consists of a weekly treatment, with the most common side effects resulting in fatigue, nausea, headaches, and generalized weakness. The enrollment process into the NGR-hTTNF trial begins with an appointment with an investigator in trial.

The investigator reviews whether or not the patient is eligible based on treatments already received, the patient’s stage of mesothelioma, and his or her general physical well-being. Following this appointment, the patient must sign the consent form, after which eligibility is finalized through a few additional tests. If patients have responded positively or remain stable, chemotherapy will be discontinued after six cycles and patients will be extended an opportunity to receive NGR-hTTNF as a maintenance therapy. The primary end point of this trial will be to extend survival rates with secondary endpoints of improving quality of life and diminished symptoms of mesothelioma.

Having just returned from the annual Annual Meeting of the American Society for Clinical Oncology (ASCO) conference in Chicago, IL, where another expert from our “Meet the Experts” series — Dr. Lee M. Krug — gave his own summary of the event, Dr. Brahmer feels optimistic and excited about possibilities ahead. “I think a lot of the things we’re learning in lung cancer research may affect patients with mesothelioma,” she states. “There are some therapies being developed that stimulate the immune system, and I hope those types of drugs will have some type of role in combatting mesothelioma, as well.”

Dr. Brahmer’s research and clinical practice focuses on the development of new therapies for the treatment and prevention of lung cancer and mesothelioma. Dr. Brahmer has published several papers in this area of research and is a member of the American Society of Clinical Oncology and the Eastern Cooperative Oncology Group (ECOG) Thoracic Committee and Cancer Prevention Steering Committee. She is one of the founding Board members for the National Lung Cancer Partnership (formerly Women Against Lung Cancer). Within the National Lung Cancer Partnership she currently serves as a member and the Chairman of the Scientific Executive Committee. She serves on the medical advisory board of the Lung Cancer Research Fund and is a former member of the Mesothelioma Applied Research Foundation’s Science Advisory Board.

More information about this trial is available at the Meso Foundation by emailing mary@curemeso.org or by calling (703) 879-3820. If you missed tonight’s “Meet the Experts” presentation, you can replay Dr. Brahmer’s talk and find out more about our other mesothelioma research resources at curemeso.org.