MESOTHELIOMA
Mesothelioma
is a tough cancer
that is usually caused by some exposure to asbestos.
In this disease, malignant (cancerous) cells form in the mesothelium,
a protective lining that covers a lot of the body's internal organs.
Its most common area is the pleura (outer lining of the lungs and chest
cavity), but it may also occur in the peritoneum (the lining of the
abdominal cavity) Most people who get mesothelioma have worked on jobs where they breathed in asbestos particles, or have been exposed to asbestos dust and fibre in other ways, such as by washing the clothes of a family member who handled asbestos, or by home renovation using asbestos cement products. There isn't any association between mesothelioma and smoking.
SIGNS AND SYMPTOMS OF MEOTHELIOMASymptoms of mesothelioma may not appear until 20 to 50 years after exposure to asbestos. Shortness of breath, cough, and pain in the chest due to an accumulation of fluid in the pleural space are often symptoms of pleural mesothelioma . Symptoms of peritoneal mesothelioma include weight loss and cachexia, abdominal
swelling and pain due to ascites (a buildup of fluid in the abdominal
cavity). Other symptoms of peritoneal mesothelioma may include bowel
obstruction, blood clotting abnormalities, anemia, and fever. If the cancer has spread beyond the mesothelium to other parts of the body, symptoms may include pain, trouble swallowing, or swelling of the neck or face. These symptoms may be caused by mesothelioma or by other, less serious conditions. Mesothelioma that affects the pleura can cause these signs and symptoms: * chest
wall pain In severe cases, the person may have many tumor masses. The individual may develop a pneumothorax, or collapse of the lung. The disease may metastasize, or spread, to other parts of the body. Tumors that affect the abdominal cavity often do not cause symptoms until they are at a late stage. Symptoms include: * abdominal
pain In severe cases of the disease, the following signs and symptoms may be present: * blood
clots in the veins, which may cause thrombophlebitis A mesothelioma does not usually spread to the bone, brain, or adrenal glands. Pleural tumors are usually found only on one side of the lungs. DiagnosisDiagnosing mesothelioma is often difficult, because the symptoms are similar to those of a number of other conditions. Diagnosis begins with a review of the patient's medical history. A history of exposure to asbestos may increase clinical suspicion for mesothelioma . A physical examination is performed, followed by chest X-ray and often lung function tests. The X-ray may reveal pleural thickening commonly seen after asbestos exposure and increases suspicion of mesothelioma . A CT (or CAT) scan or an MRI is usually performed. If a large amount of fluid is present, abnormal cells may be detected by cytology if this fluid is aspirated with a syringe. For pleural fluid this is done by a pleural tap or chest drain, in ascites with an paracentesis or ascitic drain and in a pericardial effusion with pericardiocentesis. While absence of malignant cells on cytology does not completely exclude mesothelioma , it makes it much more unlikely, especially if an alternative diagnosis can be made (e.g. tuberculosis, heart failure).
If cytology is positive or a plaque is regarded as suspicious, a biopsy is needed to confirm a diagnosis of mesothelioma . A doctor removes a sample of tissue for examination under a microscope by a histopathologist. A biopsy may be done in different ways, depending on where the abnormal area is located. If the cancer is in the chest, the doctor may perform a thoracoscopy. In this procedure, the doctor makes a small cut through the chest wall and puts a thin, lighted tube called a thoracoscope into the chest between two ribs. Thoracoscopy allows the doctor to look inside the chest and obtain tissue samples. If the cancer
is in the abdomen, the doctor may perform a laparoscopy. To obtain tissue
for examination, the doctor makes a small opening in the abdomen and
inserts a special instrument into the abdominal cavity. If these procedures
do not yield enough tissue, more extensive diagnostic surgery may be
necessary. ScreeningThere is no universally agreed protocol for screening people who have been exposed to asbestos. However some research indicates that the serum osteopontin level might be useful in screening asbestos-exposed people for mesothelioma . The level of soluble mesothelin-related protein is elevated in the serum of about 75% of patients at diagnosis and it has been suggested that it may be useful for screening[3]. StagingOnce the diagnosis is confirmed, the doctor may need to assess the stage to help plan treatment. mesothelioma is described as localized if the cancer is found only on the membrane surface where it originated. It is classified as advanced if it has spread beyond the original membrane surface to other parts of the body, such as the lymph nodes, lungs, chest wall, or abdominal organs. PathophysiologyThe mesothelium consists of a single layer of flattened to cuboidal cells forming the epithelial lining of the serous cavities of the body including the peritoneal, pericardial and pleural cavities. Deposition of asbestos fibres in the parenchyma of the lung may result in the penetration of the visceral pleura from where the fibre can then be carried to the pleural surface, thus leading to the development of malignant mesothelial plaques. The processes leading to the development of peritoneal mesothelioma remain unresolved, although it has been proposed that asbestos fibres from the lung are transported to the abdomen and associated organs via the lymphatic system. Additionally, asbestos fibres may be deposited in the gut after ingestion of sputum contaminated with asbestos fibres. Pleural contamination with asbestos or other mineral fibres has been shown to cause cancer. Long thin asbestos fibers (blue asbestos, amphibole fibers) are more potent carcinogens than "feathery fibers" (chrysotile or white asbestos fibers)[4]. However, there is now evidence that smaller particles may be more dangerous than the larger fibers.[5][6] They remain suspended in the air where they can be inhaled, and may penetrate more easily and deeper into the lungs. "We probably will find out a lot more about the health aspects of asbestos from [the World Trade Center attack], unfortunately," said Dr. Alan Fein, chief of pulmonary and critical-care medicine at North Shore-Long Island Jewish Health System. Dr. Fein has treated several patients for "World Trade Center syndrome" or respiratory ailments from brief exposures of only a day or two near the collapsed buildings.
Mesothelioma development in rats has been demonstrated following intra-pleural inoculation of phosphorylated chrysotile fibres. It has been suggested that in humans, transport of fibres to the pleura is critical to the pathogenesis of mesothelioma . This is supported by the observed recruitment of significant numbers of macrophages and other cells of the immune system to localised lesions of accumulated asbestos fibres in the pleural and peritoneal cavities of rats. These lesions continued to attract and accumulate macrophages as the disease progressed, and cellular changes within the lesion culminated in a morphologically malignant tumour. Experimental evidence suggests that asbestos acts as a complete carcinogen with the development of mesothelioma occurring in sequential stages of initiation and promotion. The molecular mechanisms underlying the malignant transformation of normal mesothelial cells by asbestos fibres remain unclear despite the demonstration of its oncogenic capabilities. However, complete in vitro transformation of normal human mesothelial cells to malignant phenotype following exposure to asbestos fibres has not yet been achieved. In general, asbestos fibres are thought to act through direct physical interactions with the cells of the mesothelium in conjunction with indirect effects following interaction with inflammatory cells such as macrophages. Analysis of the interactions between asbestos fibres and DNA has shown that phagocytosed fibres are able to make contact with chromosomes, often adhering to the chromatin fibres or becoming entangled within the chromosome. This contact between the asbestos fibre and the chromosomes or structural proteins of the spindle apparatus can induce complex abnormalities. The most common abnormality is monosomy of chromosome 22. Other frequent abnormalities include structural rearrangement of 1p, 3p, 9p and 6q chromosome arms. Common gene abnormalities in mesothelioma cell lines include deletion of the tumor suppressor genes: * Neurofibromatosis
type 2 at 22q12 asbestos has also been shown to mediate the entry of foreign DNA into target cells. Incorporation of this foreign DNA may lead to mutations and oncogenesis by several possible mechanisms: * Inactivation
of tumor suppressor genes asbestos fibres have been shown to alter the function and
secretory properties of macrophages, ultimately creating conditions
which favour the development of mesothelioma . Following asbestos phagocytosis, macrophages
generate increased amounts of hydroxyl radicals, which are normal by-products
of cellular anaerobic metabolism. However, these free radicals are also
known clastogenic and membrane-active agents thought to promote asbestos carcinogenicity. These
oxidants can participate in the oncogenic process by directly and indirectly
interacting with DNA, modifying membrane-associated cellular events,
including oncogene activation and perturbation of cellular antioxidant
defences. asbestos
may also possess immunosuppressive properties. For example, chrysotile
fibres have been shown to depress the in vitro proliferation of phytohemagglutinin-stimulated
peripheral blood lymphocytes, suppress natural killer cell lysis and
significantly reduce lymphokine-activated killer (LAK) cell viability
and recovery. Furthermore, genetic alterations in asbestos-activated macrophages may
result in the release of potent mesothelial cell mitogens such as platelet-derived
growth factor (PDGF) and transforming growth factor-ß (TGF-ß) which
in turn, may induce the chronic stimulation and proliferation of mesothelial
cells after injury by asbestos
fibres. EpidemiologyIncidenceAlthough
reported incidence rates have increased in the past 20 years, mesothelioma is still a relatively
rare cancer. The incidence is approximately one per 1,000,000. For comparison,
populations with high levels of smoking can have a lung cancer incidence
of over 1,000 per 1,000,000. Incidence of malignant mesothelioma currently ranges from
about 7 to 40 per 1,000,000 in industrialized Western nations, depending
on the amount of asbestos
exposure of the populations during the past several decades[8]. It has
been estimated that incidence may have peaked at 15 per 1,000,000 in
the
Between 1940 and 1979, approximately 27.5 million people were occupationally exposed to asbestos in the United States.[9] Between 1973 and 1984, there has been a three-fold increase in the diagnosis of pleural mesothelioma in caucasion males. From 1980 to the late 1990s, the rate of deaths from mesothelioma increased from 2,000 to 3,000 a year. in the late 1990se in annual deaths from mesotheiliom, with men four times more likely to acquire it than women. These rates may not be accurate, since it is possible that many cases of mesothelioma are misdiagnosed as adenocarcinoma of the lung, which is difficult to differentiate from mesothelioma . Risk factorsWorking with asbestos is the major risk factor for mesothelioma . A history of asbestos exposure exists in almost all cases. However, mesothelioma has been reported in some individuals without any known exposure to asbestos. In rare cases, mesothelioma has also been associated with irradiation, intrapleural thorium dioxide (Thorotrast), and inhalation of other fibrous silicates, such as erionite. asbestos is the name of a group of minerals that occur naturally
as masses of strong, flexible fibers that can be separated into thin
threads and woven. asbestos has been widely used in many industrial products, including cement, brake
linings, roof shingles, flooring products, textiles, and insulation.
If tiny asbestos
particles float in the air, especially during the manufacturing process,
they may be inhaled or swallowed, and can cause serious health problems.
In addition to mesothelioma , exposure to asbestos
increases the risk of lung cancer, asbestosis
(a noncancerous, chronic lung ailment), and other cancers, such as those
of the larynx and kidney. The combination
of smoking and asbestos
exposure significantly increases a person's risk of developing cancer
of the airways (lung cancer, bronchial carcinoma). The Some studies suggest that simian virus 40 (SV40) may act as a cofactor in the development of mesothelioma [11]. Exposureasbestos has been mined and used commercially since the late 1800s. Its use greatly increased during World War II. Since the early 1940s, millions of American workers have been exposed to asbestos dust. Initially, the risks associated with asbestos exposure were not publicly known. However, an increased risk of developing mesothelioma was later found among shipyard workers, people who work in asbestos mines and mills, producers of asbestos products, workers in the heating and construction industries, and other tradespeople. Today, the U.S. Occupational Safety and Health Administration (OSHA) sets limits for acceptable levels of asbestos exposure in the workplace, and created guidelines for engineering controls and respirators, protective clothing, exposure monitoring, hygiene facilities and practices, warning signs, labeling, recordkeeping, and medical exams. By contrast, the British Government's Health and Safety Executive (HSE) states formally that any threshold for mesothelioma must be at a very low level and it is widely agreed that if any such threshold does exists at all, then it cannot currently be quantified. For practical purposes, therefore, HSE does not assume that any such threshold exists. People who work with asbestos wear personal protective equipment to lower their risk of exposure.
Exposure
to asbestos fibres has been recognised
as an occupational health hazard since the early 1900s. Several epidemiological
studies have associated exposure to asbestos with the development of
lesions such as asbestos
bodies in the sputum, pleural plaques, diffuse pleural thickening, asbestosis, carcinoma of the lung
and larynx, gastrointestinal tumours, and diffuse mesothelioma of the pleura and
peritoneum. The documented presence of asbestos fibres in water supplies and food products has fostered concerns about the possible impact of long-term and, as yet, unknown exposure of the general population to these fibres. Although many authorities consider brief or transient exposure to asbestos fibres as inconsequential and an unlikely risk factor, some epidemiologists claim that there is no risk threshold. Cases of mesothelioma have been found in people whose only exposure was breathing the air through ventilation systems. Other cases had very minimal (3 months or less) direct exposure. Commercial asbestos mining at Wittenoom, Western Australia, occurred between 1945 and 1966. A cohort study of miners employed at the mine reported that while no deaths occurred within the first 10 years after crocidolite exposure, 85 deaths attributable to mesothelioma had occurred by 1985. It is predicted that the number of cases within this study group will reach in excess of 700 by the year 2020. By 1994, 539 reported deaths due to mesothelioma had been reported in Western Australia. Family members and others living with asbestos workers have an increased risk of developing mesothelioma , and possibly other asbestos related diseases. This risk may be the result of exposure to asbestos dust brought home on the clothing and hair of asbestos workers. To reduce the chance of exposing family members to asbestos fibres, asbestos workers are usually required to shower and change their clothing before leaving the workplace. Treatment Treatment of MM using conventional therapies has not proved successful and patients have a median survival time of 6 - 12 months after presentation. The clinical behaviour of the malignancy is affected by several factors including the continuous mesothelial surface of the pleural cavity which favours local metastasis via exfoliated cells, invasion to underlying tissue and other organs within the pleural cavity, and the extremely long latency period between asbestos exposure and development of the disease. Surgery Surgery, either by itself or used in combination with pre- and post-operative adjuvant therapies has proved disappointing with a 5 year survival rate of less than 10%. A pleurectomy/decortication is the most common surgery, in which the lining of the chest is removed. Less common is an extrapleural pneumonectomy (EPP), in which the lung, lining of the inside of the chest, the hemi-diaphragm and the pericardium are removed. RadiationAlthough the tumor is highly resistant to radiotherapy, these regimens are sometimes used to relieve symptoms arising from tumor growth, such as obstruction of a major blood vessel.
Radiotherapy is commonly applied to the sites of chest drain insertion, in order to prevent growth of the tumor along the track in the chest wall. ChemotherapyIn February 2004, the Food and Drug Administration approved pemetrexed (brand name Alimta) for treatment of malignant pleural mesothelioma . Immunotherapy
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or the pericardium (a
sac that envelopes the heart).
| some words on this site are commonly misspelled: mesothlioma
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The first
lawsuit against asbestos
manufacturers was brought in 1929. The parties settled that lawsuit,
and as part of the agreement, the attorneys agreed not to pursue further
cases. It was not until 1960 that an article published by Wagner et
al in 1960 first officially established
mesothelioma as a disease arising from exposure to crocidolite
asbestos[13]. The article referred
to over 30 case studies of people who had suffered from mesothelioma in 
In the town of Wittenoom, asbestos-containing mine waste was used to cover schoolyards and playgrounds. In 1965 an article in the British Journal of Industrial Medicine established that people who lived in the neighbourhoods of asbestos factories and mines, but did not work in them, had contracted mesothelioma .
Despite proof that the dust associated with asbestos mining and milling causes asbestos related disease, mining began at Wittenoom in 1943 and continued until 1966. It is difficult to understand why the mine and mill was allowed to initially open and operate without adequate risk control measures; and why nothing was done to force the owner (CSR) to clean them up, adopt safer work practices or close down their operations.
In 1974 the first public warnings
of the dangers of blue asbestos were published
in a cover story called "Is this Killer in Your Home?"
in
By 1979 the first writs for negligence related to Wittenoom were issued against CSR and its subsidiary ABA, and the asbestos Diseases Society was formed to represent the Wittenoom victims.
External links
* mesothelioma
: Questions and Answers from the National Cancer Institute
* American Cancer Society
* asbestos
Newspaper Archive Free archive of 50,000 newspaper pages dedicated to
asbestos
* Cancer.gov: Malignant mesothelioma
* CancerBACUP: mesothelioma Information Centre
* Medlineplus: mesothelioma
* Worksafe, Western Australia
* US Nat'l Institute for Occupational Safety and Health
Sources
The first
version of this article was adapted from a public domain U.S. National
Cancer Institute fact sheet at http://www.cancer.gov/cancertopics/factsheet/Sites-Types/
mesothelioma
Tumors (and related structures), Cancer, and Oncology
Benign - Premalignant - Carcinoma in situ - Malignant
Topography: Anus - Bladder - Bone - Brain - Breast - Cervix - Colon/rectum - Duodenum - Endometrium - Esophagus - Eye - Gallbladder - Head/Neck - Liver - Larynx - Lung - Mouth - Pancreas - Penis - Prostate - Kidney - Ovaries - Skin - Stomach - Testicles - Thyroid
Morphology: Papilloma/carcinoma - Adenoma/adenocarcinoma - Soft tissue sarcoma - Melanoma - Fibroma/fibrosarcoma - Lipoma/liposarcoma - Leiomyoma/leiomyosarcoma - Rhabdomyoma/rhabdomyosarcoma - mesothelioma - Angioma/angiosarcoma - Osteoma/osteosarcoma - Chondroma/chondrosarcoma - Glioma - Lymphoma/leukemia
Treatment: Chemotherapy - Radiation therapy - Immunotherapy - Experimental cancer treatment
Related structures: Cyst - Dysplasia - Hamartoma - Neoplasia - Nodule - Polyp - Pseudocyst
Misc: Tumor
suppressor genes/oncogenes - Staging/grading - Carcinogenesis/metastasis
- Carcinogen - Research - Paraneoplastic phenomenon - ICD-O - List of
oncology-related terms
Retrieved from "http://en.wikipedia.org/wiki/ mesothelioma "
Categories: Oncology | Pulmonology | Types of cancer
This article is licensed under the GNU Free Documentation License. It uses material from the Wikipedia article " mesothelioma ".
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asbestos (a misapplication of Latin: asbestos "quicklime" from Greek ?sßest??: a, "not" and sbestos, "extinguishable") describes any of a group of minerals that can be fibrous, many of which are metamorphic and are hydrous magnesium silicates. These minerals, together with their occurrences, uses, and associated hazards, have been discussed in detail by Guthrie and Mossman (1993).
The name is derived for its historical use in lamp wicks; the resistance of asbestos to fire has long been exploited for a variety of purposes. asbestos was used in fabrics such as Egyptian burial cloths and Charlemagne's tablecloth (which according to legend, he threw in a fire to clean). asbestos occurs naturally in many forms (see below); it is mined from metamorphic rocks.
When asbestos is used for its resistance to fire or heat, the fibers are often mixed with cement or woven into fabric or mats. asbestos is used in brake shoes and gaskets for its heat resistance, and in the past was used on electric oven and hotplate wiring for its electrical insulation at elevated temperature, and in buildings for its flame-retardant and insulating properties, tensile strength, flexibility, and resistance to chemicals. The inhalation of some kinds of asbestos fibers, however, can cause a number of serious illnesses, including cancer. Many uses of asbestos are banned in many countries.
Types of
asbestos and associated fibres
Chrysotile asbestos
Chrysotile asbestos
asbestos fibers
asbestos fibers
"White"
asbestos
Chrysotile, CAS No. 12001-29-5, is obtained from serpentine rocks.
Chrysotile is the type most often used industrially. There is evidence
that this type of asbestos
is harmful, although not perhaps as harmful as other forms (refer to
UK Health & Safety Commission report asbestos:
Effects on health of exposure to asbestos,
1985). One formula given for Chrysotile is Mg3(Si2O5)(OH)4.
"Brown" asbestos
Amosite, CAS No. 12172-73-5, is a trade name for the amphibole's
belonging to the Cummingtonite - Grunerite solid solution series, commonly
from Africa, named as an acronym from asbestos Mines of South Africa.
One formula given for Amosite is Fe7Si8O22(OH)2. This type of asbestos is highly biohazardous.
"Blue" asbestos
Riebeckite, CAS No. 12001-28-4, also known under the variety name
of Crocidolite, is an amphibole from Africa and
Notes: chrysotile commonly occurs as soft friable fibers. Asbestiform amphibole may also occur as soft friable fibers but some varieties such as amosite are commonly straighter. All forms of asbestos are fibrillar in that they are composed of fibers with widths less than 1 micrometer that occur in bundles and have very long lengths. Amphiboles most commonly occur in nature in a safer nonfibrous form. asbestos with particularly fine fibers is also referred to as "amianthus".
Other asbestos
Other regulated asbestos
minerals, such as tremolite asbestos,
CAS No. 77536-68-6, Ca2Mg5Si8O22(OH)2; actinolite asbestos (or smaragdite), CAS No. 77536-66-4, Ca2(Mg, Fe)5Si8O22(OH)2; and anthophyllite
asbestos,
CAS No. 77536-67-5, (Mg, Fe)7Si8O22(OH)2; are less
commonly used industrially but can still be found in a variety of construction
materials and insulation materials and have been reported in the past
to occur in a few consumer products. Other natural and not currently
regulated asbestos
minerals, such as richterite, Na(CaNa)(Mg,Fe++)5[Si8O22](OH)2, and winchite,
[ ](CaNa)Mg4(Al,Fe3+)Si8O22(OH)2, maybe found as a contaminate in products
such as the vermiculite containing Zonolite insulation manufactured
by W.R. Grace and Company. These forms of asbestos
are no less harmful than chrysotile, amosite, or crocidolite.
In 1989 the United States Environmental Protection Agency (EPA) passed the asbestos Ban and Phase Out Rule which was subsequently overturned in the case of Corrosion Proof Fittings v. U.S. Environmental Protection Agency, 1991. This ruling leaves many consumer product that can still legally contain trace amounts of asbestos. For a clarification of products which legally contain asbestos visit the EPA's clarification statement.[1] Depending on the type of asbestos, the cancer can be worse. It also depends on the amount inhaled. This is a welding occupational hazard.
Uses
Historic usage
Items made of asbestos were held in so great an esteem as to be of equal value with gold; none but emperors and kings had napkins made of it. Supposedly, Charlemagne had a tablecloth made of asbestos. Cleaning an asbestos cloth was simple- it was simply thrown into a fire. Some antiquaries have believed that ancients made shrouds of asbestos, wherein they burnt the bodies of their kings, in order to preserve only their ashes, and prevent their being mixed with those of wood, or other combustible materials commonly used in building funeral pyres.[2]
Others assert that the ancients used asbestos to make perpetual wicks for sepulchral lamps. In more recent centuries, asbestos was indeed used for this purpose. Although asbestos causes skin to itch upon contact, ancient literature indicates that it was prescribed for diseases of the skin, and particularly for the itch. It is possible that they used the term asbestos for alumen plumosum, because the two terms have often been confused throughout history.[2]
asbestos linings were once used in automobile brake pads and shoes. Since the mid-1990s, a majority of brake linings, new or replacement, have been manufactured with Kevlar linings (the same material used in bulletproof vests).
Modern usage
Serpentine group
Chrysotile is the form of
asbestos from the serpentine group that has been used commercially.
In the
* sheetrock taping
* mud and texture coats
* vinyl floor tiles, sheeting, adhesives and ceiling tiles
* plasters and stuccos
* roofing tars, felts, siding, and shingles
* "transite" panels, siding, countertops, and pipes
* acoustical ceilings
* fireproofing
* putty
* caulk
* gaskets
* brake pads and shoes
* clutch plates
* stage curtains
* fire blankets
* interior fire doors
Amphibole group
Amosite and crocidolite were used in many products until the early 1980s. The use of all types of asbestos in the amphibole group was banned in the mid-1980s. These products were mainly:
* Low density
insulation board and ceiling tiles
* asbestos-cement
sheets and pipes for construction, casing for water and electrical/telecommunication
services
* thermal and chemical insulation (i.e., fire rated doors, limpet spray,
lagging and gaskets)
asbestos-related diseases
asbestos as a contaminant
Low levels of asbestos are in the air we breathe and some of the water we drink, including water from natural sources.[4] Studies have shown that members of the general (nonoccupationally exposed) population have tens of thousands to hundreds of thousands of asbestos fibers in each gram of dry lung tissue, which translates into millions of fibers and tens of thousands of asbestos bodies in every person's lungs.[5]
The EPA has proposed a concentration limit of 7 million fibers per liter of drinking water for long fibers (lengths greater than or equal to 5 µm). OSHA (Occupational Safety and Health Administration) has set limits of 100,000 fibers with lengths greater than or equal to 5 µm per cubic meter of workplace air for 8-hour shifts and 40-hour work weeks.[6]
Most respirable asbestos fibers are invisible to the unaided human eye because their size is about 3.0-20.0 µm in length and can be as thin as 0.01 µm. Human hair ranges in size from 17 to 181 µm in width.[7] Fibers ultimately form because when these minerals originally cooled and crystallized, they formed by the polymeric molecules lining up parallel with each other and forming oriented crystal lattices. These crystals thus have three cleavage planes, just as other minerals and gemstones have. But in their case, there are two cleavage planes that are much weaker than the third direction. When sufficient force is applied, they tend to break along their weakest directions, resulting in a linear fragmentation pattern and hence a fibrous form. This fracture process can keep occurring and one larger asbestos fiber can ultimately become the source of hundreds of much thinner and smaller fibers.
As asbestos fibers get smaller and lighter, they more easily become airborne and human respiratory exposures can result. Fibers will eventually settle but may be re-suspended by air currents or other movement.
Friability of an asbestos containing product means that it is so soft and weak in structure that it can be broken with simple finger crushing pressure. Friable materials are of the most initial concern due to their ease of damage. The forces or conditions of usage that come into intimate contact with most non-friable asbestos containing materials are substantially higher than finger pressure. Non-friable asbestos products can release substantial quantities of asbestos fibers into their environments as well.[citation needed]
Diseases
caused by asbestos
asbestos particles
lodged in the lungs.
asbestos particles
lodged in the lungs.
Lung asbestos
bodies after chemical digestion of lung tissue.
Lung asbestos
bodies after chemical digestion of lung tissue.
asbestos fibres
(SEM picture)
asbestos fibres
(SEM picture)
As early
as 1898 the Chief Inspector of Factories of the
The problem with asbestos arises when the fibers become airborne and are inhaled. Because of the size of the fibers, the lungs cannot expel them. [Casarrett & Doull's Toxicology (2001), pp 520-522]
Diseases caused by asbestos include[9][10]:
* asbestosis – A lung disease first found in naval shipyard workers, asbestosis is a scarring of the lung tissue from an acid produced
by the body's attempt to dissolve the fibers.[11] The scarring may eventually become so severe
that the lungs can no longer function. The latency period (the time
it takes for the disease to develop) is often 10-20 years.[citation
needed]
* mesothelioma – A cancer of the mesothelial lining of the lungs
and the chest cavity, the peritoneum (abdominal cavity) or the pericardium
(a sac surrounding the heart). It is believed that mesothelioma is caused by generation of reactive oxygen
species (ROS) by the asbestos
fibers. There is also some evidence to suggest that simian virus 40
(SV40) works together with asbestos
in the development of malignant mesothelioma . asbestos exposure is linked to at
least 50% of patients developing malignant mesothelioma . Malignant mesothelioma has a peak incidence
35-45 years after asbestos
exposure. Median survival for patients with malignant mesothelioma is 11 months. asbestos has a synergistic effect
with tobacco smoking in the causation of pleural mesothelioma .[12]
* Cancer – Lung cancer has been linked to asbestos. asbestos exposure alone can cause lung cancer, but asbestos exposure and tobacco smoking has a synergistic effect, greatly increasing the chances of contracting lung cancer.[13] Cancer of the larynx has been linked to asbestos. Some studies suggest that asbestos exposure is linked to a slightly increased risk of stomach, pharyngeal, and colorectal cancer.[14]
EWG Action
Fund estimates that in the United States, about 9,900 people die each
year of asbestos-related diseases, such
as mesothelioma , asbestosis,
lung cancer, and gastrointestinal cancer.[15]
Other asbestos-related
diseases
* asbestos warts – caused when the sharp fibres lodge in the skin and are overgrown causing benign callus-like growths.
* pleural plaques – discrete fibrous or partially calcified thickened area which can be seen on X-rays of individuals exposed to asbestos. They do not become malignant or cause other lung impairment.
* diffuse pleural thickening – similar to above and can sometimes be associated with asbestosis. Usually no symptoms shown but if extensive can cause lung impairment.
Litigation
Main article: asbestos and the law
asbestos litigation is the longest, most expensive mass tort in U.S.
history, involving more than 6,000 defendants and 600,000 claimants.[16]
Current trends indicate that the rate at which people are diagnosed
with the disease will likely increase through the next decade. Analysts
have estimated that the total costs of asbestos
litigation in the
The volume of the asbestos liability has alarmed the manufacturers and insurance industry. The amounts and method of allocating compensation have been the source of many court cases, and government attempts at resolution of existing and future cases.
Removal
of asbestos
Structures containing asbestos
are marked
Structures containing asbestos
are marked
Many buildings contain asbestos, which was used in spray-applied flame retardant, thermal
system insulation, and in a variety of other materials. asbestos was sometimes
"flocked" above false ceilings, inside technical ducts, and
in many other small spaces where firefighters would have difficulty
gaining access. Structural components like asbestos panels
were also used. In residences, asbestos was often
a component of a type of flocked acoustic ceiling called "popcorn
ceiling", until its production
was banned in the
Depending on how and where asbestos was applied, it might not pose any risk to most users of the building. If the fibers cannot become dislodged, they cannot be inhaled, and thus the asbestos poses no risk.
However, some methods of applying asbestos, particularly flocking, allow asbestos fibers to gradually drop off into the air. asbestos poses hazards to maintenance personnel who have to drill holes in walls for installation of cables or pipes.
Even if the workers are protected, such maintenance operation may release fibers into the air, which may be inhaled by others. Interventions in areas where asbestos is present often have to follow stringent procedures. If removal is to be performed when users are still present in the building, it is usually necessary to relocate some users temporarily. Typically, the part of the building from which asbestos is being removed has to be sealed off in order to prevent contamination of the other areas.
If the building is closed to normal users, it may be necessary to seal it off from outside atmosphere so that no accessible air is contaminated. Examples of asbestos removal enterprises include the Jussieu Campus (begun circa 1996 and still going on as of 2005) and the Tour Montparnasse (in 2005, projected duration was 3 years if the tower was emptied of its users, and 10 years if it was not).
An asbestos-containing building that is to be torn down may have to be sealed, and to have its asbestos safely removed before ordinary demolition can be performed. The asbestos removal may take longer and cost more than the actual demolition. For example, the former seat of parliament of East Germany, the Palast der Republik was stripped of most of its asbestos between 1998 and 2001, before it was finally demolished starting in 2006. The demolition process alone is expected to cost between 20 and 60 million Euros.
Critics of safety regulations
asbestos regulation critics include Junkscience.com author and Fox News columnist Steve Milloy and the asbestos industry.[17] They sometimes argue that the ban does more harm than good and that replacements to asbestos are inferior. An example is the suggestion that the shuttle Challenger exploded because the maker of O-ring putty was pressured by the EPA into ceasing production of asbestos-laden putty. However, scientists point out that the putty used in Challenger's final flight did contain asbestos, and failures in the putty were not responsible for the failure of the O-ring that led to loss of the shuttle.[18][19]
Scott Bass suggests that the World Trade Center towers could still be standing or at least would have stood for longer had a 1971 ban not stopped the completion of the asbestos coating above the 64th floor.[20] This was not mentioned in the National Institute of Standards and Technology's report on the Towers' collapse. Insulation that replaced asbestos is believed to have equivalent fire resistance, and any sort of sprayed-on insulation, including asbestos-based material, would have been removed in large areas by the impact of the planes and subsequent explosion.[21][22][23]
Substitutes for asbestos in construction
Many companies that produced asbestos-cement products that were reinforced with asbestos fibres have developed products incorporating organic fibres. One such product was known as Eternit and another Everite now use Nutec fibres which consist of organic fibres, portland cement and silica.
See also a report by the Australian government, Hazardous Substances-Chrysotile asbestos: Technical Assessment of Alternatives.
See also
* Ambler,
PA
* Asbestine
* asbestos
and the law
* asbestosis
* asbestos,
Quebec
* Brominated flame-retardant
* Eternit
* Fireproofing
* List of minerals
* mesothelioma
* Vermiculite
* Wittenoom, former asbestos
mining town
mesothelioma
From Wikipedia, the free encyclopedia
Jump to: navigation, search
mesothelioma
Classifications and external resources ICD-10 C45
ICD-9 163
ICD-O: 9050-9055
OMIM 156240
DiseasesDB 8074
MedlinePlus 000115
eMedicine med/1457
mesothelioma is a form of cancer that is almost always caused by previous exposure to asbestos.[1] In this disease, malignant cells develop in the mesothelium, a protective lining that covers most of the body's internal organs. Its most common site is the pleura (outer lining of the lungs and chest cavity), but it may also occur in the peritoneum (the lining of the abdominal cavity) or the pericardium (a sac that surrounds the heart).
Most people who develop mesothelioma have worked on jobs where they inhaled asbestos particles, or have been exposed to asbestos dust and fibre in other ways, such as by washing the clothes of a family member who worked with asbestos, or by home renovation using asbestos cement products. There is no association between mesothelioma and smoking.[2]
Signs and symptoms
Symptoms of mesothelioma may not appear until 20 to 50 years after exposure to asbestos. Shortness of breath, cough, and pain in the chest due to an accumulation of fluid in the pleural space are often symptoms of pleural mesothelioma .
Symptoms of peritoneal mesothelioma include weight loss and cachexia, abdominal swelling and pain due to ascites (a buildup of fluid in the abdominal cavity). Other symptoms of peritoneal mesothelioma may include bowel obstruction, blood clotting abnormalities, anemia, and fever. If the cancer has spread beyond the mesothelium to other parts of the body, symptoms may include pain, trouble swallowing, or swelling of the neck or face.
These symptoms may be caused by mesothelioma or by other, less serious conditions.
mesothelioma that affects the pleura can cause these signs and symptoms:
* chest wall pain
* pleural effusion, or fluid surrounding the lung
* shortness of breath
* wheezing, hoarseness, or cough
In severe cases, the person may have many tumor masses. The individual may develop a pneumothorax, or collapse of the lung. The disease may metastasize, or spread, to other parts of the body.
Tumors that affect the abdominal cavity often do not cause symptoms until they are at a late stage. Symptoms include:
* abdominal pain
* ascites, or an abnormal buildup of fluid in the abdomen
* a mass in the abdomen
* problems with bowel function
* weight loss
In severe cases of the disease, the following signs and symptoms may be present:
* blood clots in the veins, which may cause thrombophlebitis
* disseminated intravascular coagulation, a disorder causing severe
bleeding in many body organs
* jaundice, or yellowing of the eyes and skin
* low blood sugar level
* pleural effusion
* pulmonary emboli, or blood clots in the arteries of the lungs
* severe ascites
A mesothelioma does not usually spread to the bone, brain, or adrenal glands. Pleural tumors are usually found only on one side of the lungs.
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Diagnosis
Diagnosing mesothelioma is often difficult, because the symptoms are similar to those of a number of other conditions. Diagnosis begins with a review of the patient's medical history. A history of exposure to asbestos may increase clinical suspicion for mesothelioma . A physical examination is performed, followed by chest X-ray and often lung function tests. The X-ray may reveal pleural thickening commonly seen after asbestos exposure and increases suspicion of mesothelioma . A CT (or CAT) scan or an MRI is usually performed. If a large amount of fluid is present, abnormal cells may be detected by cytology if this fluid is aspirated with a syringe. For pleural fluid this is done by a pleural tap or chest drain, in ascites with an paracentesis or ascitic drain and in a pericardial effusion with pericardiocentesis. While absence of malignant cells on cytology does not completely exclude mesothelioma , it makes it much more unlikely, especially if an alternative diagnosis can be made (e.g. tuberculosis, heart failure).
If cytology is positive or a plaque is regarded as suspicious, a biopsy is needed to confirm a diagnosis of mesothelioma . A doctor removes a sample of tissue for examination under a microscope by a pathologist. A biopsy may be done in different ways, depending on where the abnormal area is located. If the cancer is in the chest, the doctor may perform a thoracoscopy. In this procedure, the doctor makes a small cut through the chest wall and puts a thin, lighted tube called a thoracoscope into the chest between two ribs. Thoracoscopy allows the doctor to look inside the chest and obtain tissue samples.
If the cancer
is in the abdomen, the doctor may perform a laparoscopy. To obtain tissue for examination, the doctor makes a small
opening in the abdomen and inserts a special instrument into the abdominal
cavity. If these procedures
do not yield enough tissue, more extensive diagnostic surgery may be
necessary.
Typical immunohistochemistry results Positive Negative
EMA (epithelial membrane antigen) CEA (carcinoembryonic antigen)
WT1 (Wilms' tumour 1) B72.3
Calretinin MOC-3 1
Mesothelin-1 CD15
Cytokeratin 5/6 Ber-EP4
HBME-1 (human mesothelial cell 1) TTF-1 (thyroid transcription factor-1)
Screening
There is no universally agreed protocol for screening people who have been exposed to asbestos. However some research indicates that the serum osteopontin level might be useful in screening asbestos-exposed people for mesothelioma . The level of soluble mesothelin-related protein is elevated in the serum of about 75% of patients at diagnosis and it has been suggested that it may be useful for screening[3].
Staging
Once the diagnosis is confirmed, the doctor may need to assess the stage to help plan treatment.
mesothelioma is described as localized if the cancer is found only on the membrane surface where it originated. It is classified as advanced if it has spread beyond the original membrane surface to other parts of the body, such as the lymph nodes, lungs, chest wall, or abdominal organs.
Pathophysiology
The mesothelium consists of a single layer of flattened to cuboidal cells forming the epithelial lining of the serous cavities of the body including the peritoneal, pericardial and pleural cavities. Deposition of asbestos fibres in the parenchyma of the lung may result in the penetration of the visceral pleura from where the fibre can then be carried to the pleural surface, thus leading to the development of malignant mesothelial plaques. The processes leading to the development of peritoneal mesothelioma remain unresolved, although it has been proposed that asbestos fibres from the lung are transported to the abdomen and associated organs via the lymphatic system. Additionally, asbestos fibres may be deposited in the gut after ingestion of sputum contaminated with asbestos fibres.
Pleural contamination with asbestos or other mineral fibres has been shown to cause cancer. Long thin asbestos fibers (blue asbestos, amphibole fibers) are more potent carcinogens than "feathery fibers" (chrysotile or white asbestos fibers)[4]. However, there is now evidence that smaller particles may be more dangerous than the larger fibers.[1][2] They remain suspended in the air where they can be inhaled, and may penetrate more easily and deeper into the lungs.
"We probably will find out a lot more about the health aspects of asbestos from [the World Trade Center attack], unfortunately," said Dr. Alan Fein, chief of pulmonary and critical-care medicine at North Shore-Long Island Jewish Health System. Dr. Fein has treated several patients for "World Trade Center syndrome" or respiratory ailments from brief exposures of only a day or two near the collapsed buildings.[3]
mesothelioma development in rats has been demonstrated following intra-pleural inoculation of phosphorylated chrysotile fibres. It has been suggested that in humans, transport of fibres to the pleura is critical to the pathogenesis of mesothelioma . This is supported by the observed recruitment of significant numbers of macrophages and other cells of the immune system to localised lesions of accumulated asbestos fibres in the pleural and peritoneal cavities of rats. These lesions continued to attract and accumulate macrophages as the disease progressed, and cellular changes within the lesion culminated in a morphologically malignant tumour.
Experimental evidence suggests that asbestos acts as a complete carcinogen with the development of mesothelioma occurring in sequential stages of initiation and promotion. The molecular mechanisms underlying the malignant transformation of normal mesothelial cells by asbestos fibres remain unclear despite the demonstration of its oncogenic capabilities.
However, complete in vitro transformation of normal human mesothelial cells to malignant phenotype following exposure to asbestos fibres has not yet been achieved. In general, asbestos fibres are thought to act through direct physical interactions with the cells of the mesothelium in conjunction with indirect effects following interaction with inflammatory cells such as macrophages.
Analysis of the interactions between asbestos fibres and DNA has shown that phagocytosed fibres are able to make contact with chromosomes, often adhering to the chromatin fibres or becoming entangled within the chromosome. This contact between the asbestos fibre and the chromosomes or structural proteins of the spindle apparatus can induce complex abnormalities. The most common abnormality is monosomy of chromosome 22. Other frequent abnormalities include structural rearrangement of 1p, 3p, 9p and 6q chromosome arms.
Common gene abnormalities in mesothelioma cell lines include deletion of the tumor suppressor genes:
* Neurofibromatosis
type 2 at 22q12
* P16INK4A
* P14ARF
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asbestos has also been shown to mediate the entry of foreign DNA into target cells. Incorporation of this foreign DNA may lead to mutations and oncogenesis by several possible mechanisms:
* Inactivation
of tumor suppressor genes
* Activation of oncogenes
* Activation of proto-oncogenes due to incorporation of foreign DNA containing a promoter region
* Activation of DNA repair enzymes, which may be prone to error
* Activation of telomerase
* Prevention of apoptosis
asbestos fibres have been shown to alter the function and secretory properties of macrophages, ultimately creating conditions which favour the development of mesothelioma . Following asbestos phagocytosis, macrophages generate increased amounts of hydroxyl radicals, which are normal by-products of cellular anaerobic metabolism.
However, these free radicals are also known clastogenic and membrane-active agents thought to promote asbestos carcinogenicity. These oxidants can participate in the oncogenic process by directly and indirectly interacting with DNA, modifying membrane-associated cellular events, including oncogene activation and perturbation of cellular antioxidant defences.
asbestos may also possess immunosuppressive properties. For example, chrysotile fibres have been shown to depress the in vitro proliferation of phytohemagglutinin-stimulated peripheral blood lymphocytes, suppress natural killer cell lysis and significantly reduce lymphokine-activated killer (LAK) cell viability and recovery.
Furthermore, genetic alterations in asbestos-activated macrophages may result in the release of potent mesothelial cell mitogens such as platelet-derived growth factor (PDGF) and transforming growth factor-ß (TGF-ß) which in turn, may induce the chronic stimulation and proliferation of mesothelial cells after injury by asbestos fibres.
Epidemiology
Incidence
Although reported incidence rates have increased in the past 20 years, mesothelioma is still a relatively rare cancer. The incidence is approximately one per 1,000,000. For comparison, populations with high levels of smoking can have a lung cancer incidence of over 1,000 per 1,000,000. Incidence of malignant mesothelioma currently ranges from about 7 to 40 per 1,000,000 in industrialized Western nations, depending on the amount of asbestos exposure of the populations during the past several decades[5].
It has been
estimated that incidence may have peaked at 15 per 1,000,000 in the
Between 1940 and 1979, approximately 27.5 million people were occupationally exposed to asbestos in the United States.[4] Between 1973 and 1984, there has been a three-fold increase in the diagnosis of pleural mesothelioma in caucasian males. From 1980 to the late 1990s, the rate of deaths from mesothelioma increased from 2,000 to 3,000 a year.
In the late 1990se in annual deaths from mesotheilioma. [5], with men four times more likely to acquire it than women. These rates may not be accurate, since it is possible that many cases of mesothelioma are misdiagnosed as adenocarcinoma of the lung, which is difficult to differentiate from mesothelioma .
Risk factors
Working with asbestos is the major risk factor for mesothelioma . A history of asbestos exposure exists in almost all cases. However, mesothelioma has been reported in some individuals without any known exposure to asbestos. In rare cases, mesothelioma has also been associated with irradiation, intrapleural thorium dioxide (Thorotrast), and inhalation of other fibrous silicates, such as erionite.
asbestos is the name of a group of minerals that occur naturally as masses of strong, flexible fibers that can be separated into thin threads and woven. asbestos has been widely used in many industrial products, including cement, brake linings, roof shingles, flooring products, textiles, and insulation. If tiny asbestos particles float in the air, especially during the manufacturing process, they may be inhaled or swallowed, and can cause serious health problems. In addition to mesothelioma , exposure to asbestos increases the risk of lung cancer, asbestosis (a noncancerous, chronic lung ailment), and other cancers, such as those of the larynx and kidney.
The combination of smoking
and asbestos exposure significantly increases a person's risk of developing
cancer of the airways (lung cancer, bronchial carcinoma).
The
Some studies suggest that simian virus 40 (SV40) may act as a cofactor in the development of mesothelioma [6].
Exposure
asbestos has been mined and used commercially since the late 1800s. Its use greatly increased during World War II. Since the early 1940s, millions of American workers have been exposed to asbestos dust. Initially, the risks associated with asbestos exposure were not publicly known. However, an increased risk of developing mesothelioma was later found among shipyard workers, people who work in asbestos mines and mills, producers of asbestos products, workers in the heating and construction industries, and other tradespeople.
Today, the U.S. Occupational Safety and Health Administration (OSHA) sets limits for acceptable levels of asbestos exposure in the workplace, and created guidelines for engineering controls and respirators, protective clothing, exposure monitoring, hygiene facilities and practices, warning signs, labeling, recordkeeping, and medical exams.
By contrast, the British Government's Health and Safety Executive (HSE) states formally that any threshold for mesothelioma must be at a very low level and it is widely agreed that if any such threshold does exist at all, then it cannot currently be quantified. For practical purposes, therefore, HSE does not assume that any such threshold exists. People who work with asbestos wear personal protective equipment to lower their risk of exposure.
Exposure to asbestos fibres has been recognised as an occupational health hazard since the early 1900s. Several epidemiological studies have associated exposure to asbestos with the development of lesions such as asbestos bodies in the sputum, pleural plaques, diffuse pleural thickening, asbestosis, carcinoma of the lung and larynx, gastrointestinal tumours, and diffuse mesothelioma of the pleura and peritoneum.
The documented presence of asbestos fibres in water supplies and food products has fostered concerns about the possible impact of long-term and, as yet, unknown exposure of the general population to these fibres. Although many authorities consider brief or transient exposure to asbestos fibres as inconsequential and an unlikely risk factor, some epidemiologists claim that there is no risk threshold. Cases of mesothelioma have been found in people whose only exposure was breathing the air through ventilation systems. Other cases had very minimal (3 months or less) direct exposure.
Commercial asbestos mining at Wittenoom, Western Australia, occurred between 1945 and 1966. A cohort study of miners employed at the mine reported that while no deaths occurred within the first 10 years after crocidolite exposure, 85 deaths attributable to mesothelioma had occurred by 1985. By 1994, 539 reported deaths due to mesothelioma had been reported in Western Australia.
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Family members and others living with asbestos workers have an increased risk of developing mesothelioma , and possibly other asbestos related diseases. This risk may be the result of exposure to asbestos dust brought home on the clothing and hair of asbestos workers. To reduce the chance of exposing family members to asbestos fibres, asbestos workers are usually required to shower and change their clothing before leaving the workplace.
Treatment
Treatment of MM using conventional therapies has not proved successful and patients have a median survival time of 6 - 12 months after presentation. The clinical behaviour of the malignancy is affected by several factors including the continuous mesothelial surface of the pleural cavity which favours local metastasis via exfoliated cells, invasion to underlying tissue and other organs within the pleural cavity, and the extremely long latency period between asbestos exposure and development of the disease.
Surgery for Mesothelioma
Surgery, either by itself or used in combination with pre- and post-operative adjuvant therapies has proved disappointing with a 5 year survival rate of less than 10%. A pleurectomy/decortication is the most common surgery, in which the lining of the chest is removed. Less common is an extrapleural pneumonectomy (EPP), in which the lung, lining of the inside of the chest, the hemi-diaphragm and the pericardium are removed.
Radiation
Although the tumor is highly resistant to radiotherapy, these regimens are sometimes used to relieve symptoms arising from tumor growth, such as obstruction of a major blood vessel.
Radiotherapy is commonly applied to the sites of chest drain insertion, in order to prevent growth of the tumor along the track in the chest wall.
Chemotherapy
In February 2004, the Food and Drug Administration approved pemetrexed (brand name Alimta) for treatment of malignant pleural mesothelioma . Pemetrexed is given in combination with cisplatin. Folic acid is also used to reduce the side-effects of pemetrexed.
Immunotherapy
Treatment regimens involving immunotherapy have yielded variable results. For example, intrapleural inoculation of Bacillus Calmette-Guérin (BCG) in an attempt to boost the immune response, was found to be of no benefit to the patient (while it may benefit patients with bladder cancer). mesothelioma cells proved susceptible to in vitro lysis by LAK cells following activation by interleukin-2 (IL-2), but patients undergoing this particular therapy experienced major side effects.
Indeed, this trial was suspended in view of the unacceptably high levels of IL-2 toxicity and the severity of side effects such as fever and cachexia. Nonetheless, other trials involving interferon alpha have proved more encouraging with 20% of patients experiencing a greater than 50% reduction in tumor mass combined with minimal side effects.
Heated Intraoperative Intraperitoneal Chemotherapy
A procedure known as heated intraoperative intraperitoneal chemotherapy was developed by Paul Sugarbaker at the Washington Cancer Institute[7]. The surgeon removes as much of the tumor as possible followed by the direct administration of a chemotherapy agent, heated to between 40 and 48°C, in the abdomen. The fluid is perfused for 60 to 120 minutes and then drained.
This technique permits the administration of high concentrations of selected drugs into the abdominal and pelvic surfaces. Heating the chemotherapy treatment increases the penetration of the drugs into tissues. Also, heating itself damages the malignant cells more than the normal cells.
Prevention & Expectations
What can
be done to prevent the disease? Since the 1970s, the Environmental Protection
Agency and the Occupational Safety and Health Administration have regulated
the asbestos
industry in the
There are two major types of asbestos: chrysotile and amphibole. It is thought that exposure to the amphibole form is more likely to cause mesothelioma . However, chrysotile has been used more frequently, hence many mesothelioma s are caused by chrysotile.
Removal
is taking place in schools and other public buildings throughout the
What are the long-term effects of the disease? A mesothelioma is a highly aggressive tumor that is generally deadly. Current treatment of malignant mesothelioma is designed to make the person with cancer comfortable. Although long-term survival cannot usually be expected, the case of famed paleontologist Stephen Jay Gould is a noted example.
What are the risks to others? mesothelioma is not contagious and cannot be passed from one person to another. The exposure to the asbestos that caused the cancer occurred many years to several decades before the disease appeared. People who live with asbestos workers have a higher risk of getting this cancer.
Notable people with mesothelioma
* Bob Bellear,
Australian judge, died 2005
* Michael G. Coney, British science fiction writer, died 2005 of mesothelioma
* Paul Gleason, American film and television actor, died 2006 of mesothelioma
* Stephen Jay Gould, American scientist, died 2002 from an unrelated
cancer
* Steve McQueen, American movie actor, died 1980 of mesothelioma
* Mickie Most, British record producer, died 2003 of mesothelioma
* Paul Rudolph, American architect, died 1997 of mesothelioma
* Bruce Vento, American politician, died 2000 of mesothelioma
* Warren Zevon, American rock and roll musician and songwriter, died
2003 of mesothelioma
Legal issues
Main article: asbestos and the law
The first lawsuits against asbestos manufacturers were in 1929. Since then, many lawsuits have been filed against asbestos manufacturers and employers, for neglecting to implement safety measures after the link between asbestos, asbestosis and mesothelioma became known (some reports seem to place this as early as 1898). The liability resulting from the sheer number of lawsuits and people affected has reached billions of dollars. The amounts and method of allocating compensation have been the source of many court cases, and government attempts at resolution of existing and future cases.
History
The first lawsuit against asbestos manufacturers was brought in 1929. The parties settled that lawsuit, and as part of the agreement, the attorneys agreed not to pursue further cases. It was not until 1960 that an article published by Wagner et al in 1960 first officially established mesothelioma as a disease arising from exposure to crocidolite asbestos[8].
The article
referred to over 30 case studies of people who had suffered from mesothelioma in
In the town of Wittenoom, asbestos-containing mine waste was used to cover schoolyards and playgrounds. In 1965 an article in the British Journal of Industrial Medicine established that people who lived in the neighbourhoods of asbestos factories and mines, but did not work in them, had contracted mesothelioma .
Despite proof that the dust associated with asbestos mining and milling causes asbestos related disease, mining began at Wittenoom in 1943 and continued until 1966. It is difficult to understand why the mine and mill was allowed to initially open and operate without adequate risk control measures; and why nothing was done to force the owner (CSR) to clean them up, adopt safer work practices or close down their operations.
In 1974
the first public warnings of the dangers of blue asbestos were published in a cover story called "Is
this Killer in Your Home?" in
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By 1979 the first writs for negligence related to Wittenoom were issued against CSR and its subsidiary ABA, and the asbestos Diseases Society was formed to represent the Wittenoom victims.
Latest Research
1). Eur J Cardiothorac Surg. 2006 Jan;29(1):14-9. Epub 2005 Dec 15.
Multimodality approach in management of malignant pleural mesothelioma . Neragi-Miandoab S.
Thoracic
and Cardiovascular Surgery, Loyola University Medical Center, Chicago, Stritch School of Medicine, Maywood, IL,
Malignant pleural mesothelioma (MPM) is a solid, locally aggressive tumor, which has been closely linked to asbestos exposure. The survival rate without treatment ranges from 4 to 12 months. Response to chemotherapy and radiation is poor, and surgery is the most effective therapy.
There are
currently 3000 new MPM cases per year in the
Single-modality therapy has not been effective in changing the natural history of MPM. As a result, multimodality regimens involving surgery with radiation, chemotherapy, or immunotherapy have been initiated. Multiple modality approach has demonstrated favorable outcome, particularly in patients with epithelial histology, negative resection margins and presence of no metastases to extrapleural lymph nodes.
Cisplatin and mitomycin have demonstrated modest efficacy in management of distant tumor recurrence. Cisplatin and gemcitabine regimen as well as cisplatin/pemetrexed followed by 54 Gy of adjuvant hemithorax radiation have been reported to improve the outcome.
2). Special Issue on mesothelioma : Hematol Oncol Clin North Am. 2005 Dec;19(6):
Several articles, e.g., Gene therapy for malignant pleural mesothelioma , Antiangiogenic therapies for mesothelioma , An overview of chemotherapy for mesothelioma ., Radiotherapy for mesothelioma , Multimodality treatments in the management of malignant pleural mesothelioma : an update, Prognostic factors for mesothelioma . etc
mesothelioma : Questions and Answers
mesothelioma is a rare form of cancer in which malignant (cancerous) cells are found in the mesothelium, a protective sac that covers most of the body’s internal organs. Most people who develop mesothelioma have worked on jobs where they inhaled asbestos particles.
1. What is the mesothelium?
The mesothelium is a membrane that covers and protects most of the internal organs of the body. It is composed of two layers of cells: One layer immediately surrounds the organ; the other forms a sac around it. The mesothelium produces a lubricating fluid that is released between these layers, allowing moving organs (such as the beating heart and the expanding and contracting lungs) to glide easily against adjacent structures.
The mesothelium has different names, depending on its location in the body. The peritoneum is the mesothelial tissue that covers most of the organs in the abdominal cavity. The pleura is the membrane that surrounds the lungs and lines the wall of the chest cavity. The pericardium covers and protects the heart. The mesothelial tissue surrounding the male internal reproductive organs is called the tunica vaginalis testis. The tunica serosa uteri covers the internal reproductive organs in women.
2. What is mesothelioma ?
mesothelioma (cancer of the mesothelium) is a disease in which cells of the mesothelium become abnormal and divide without control or order. They can invade and damage nearby tissues and organs. Cancer cells can also metastasize (spread) from their original site to other parts of the body. Most cases of mesothelioma begin in the pleura or peritoneum.
3. How common is mesothelioma ?
Although
reported incidence rates have increased in the past 20 years, mesothelioma is still a relatively
rare cancer. About 2,000 new cases of mesothelioma are diagnosed in the
4. What are the risk factors for mesothelioma ?
Working with asbestos is the major risk factor for mesothelioma . A history of asbestos exposure at work is reported in about 70 percent to 80 percent of all cases. However, mesothelioma has been reported in some individuals without any known exposure to asbestos.
asbestos is the name of a group of minerals that occur naturally as masses of strong, flexible fibers that can be separated into thin threads and woven. asbestos has been widely used in many industrial products, including cement, brake linings, roof shingles, flooring products, textiles, and insulation. If tiny asbestos particles float in the air, especially during the manufacturing process, they may be inhaled or swallowed, and can cause serious health problems. In addition to mesothelioma , exposure to asbestos increases the risk of lung cancer, asbestosis (a noncancerous, chronic lung ailment), and other cancers, such as those of the larynx and kidney.
Smoking does not appear to increase the risk of mesothelioma . However, the combination of smoking and asbestos exposure significantly increases a person’s risk of developing cancer of the air passageways in the lung.
5. Who is at increased risk for developing mesothelioma ?
asbestos has been mined and used commercially since the late 1800s. Its use greatly increased during World War II. Since the early 1940s, millions of American workers have been exposed to asbestos dust. Initially, the risks associated with asbestos exposure were not known. However, an increased risk of developing mesothelioma was later found among shipyard workers, people who work in asbestos mines and mills, producers of asbestos products, workers in the heating and construction industries, and other tradespeople.
Today, the U.S. Occupational Safety and Health Administration (OSHA) sets limits for acceptable levels of asbestos exposure in the workplace. People who work with asbestos wear personal protective equipment to lower their risk of exposure.
The risk of asbestos-related disease increases with heavier exposure to asbestos and longer exposure time. However, some individuals with only brief exposures have developed mesothelioma . On the other hand, not all workers who are heavily exposed develop asbestos-related diseases.
There is some evidence that family members and others living with asbestos workers have an increased risk of developing mesothelioma , and possibly other asbestos-related diseases. This risk may be the result of exposure to asbestos dust brought home on the clothing and hair of asbestos workers. To reduce the chance of exposing family members to asbestos fibers, asbestos workers are usually required to shower and change their clothing before leaving the workplace.
6. What are the symptoms of mesothelioma ?
Symptoms of mesothelioma may not appear until 30 to 50 years after exposure to asbestos. Shortness of breath and pain in the chest due to an accumulation of fluid in the pleura are often symptoms of pleural mesothelioma . Symptoms of peritoneal mesothelioma include weight loss and abdominal pain and swelling due to a buildup of fluid in the abdomen. Other symptoms of peritoneal mesothelioma may include bowel obstruction, blood clotting abnormalities, anemia, and fever. If the cancer has spread beyond the mesothelium to other parts of the body, symptoms may include pain, trouble swallowing, or swelling of the neck or face.
These symptoms may be caused by mesothelioma or by other, less serious conditions. It is important to see a doctor about any of these symptoms. Only a doctor can make a diagnosis.
7. How is mesothelioma diagnosed?
Diagnosing mesothelioma is often difficult, because the symptoms are similar to those of a number of other conditions. Diagnosis begins with a review of the patient’s medical history, including any history of asbestos exposure. A complete physical examination may be performed, including x-rays of the chest or abdomen and lung function tests. A CT (or CAT) scan or an MRI may also be useful.
A CT scan is a series of detailed pictures of areas inside the body created by a computer linked to an x-ray machine. In an MRI, a powerful magnet linked to a computer is used to make detailed pictures of areas inside the body. These pictures are viewed on a monitor and can also be printed.
A biopsy is needed to confirm a diagnosis of mesothelioma . In a biopsy, a surgeon or a medical oncologist (a doctor who specializes in diagnosing and treating cancer) removes a sample of tissue for examination under a microscope by a pathologist. A biopsy may be done in different ways, depending on where the abnormal area is located.
If the cancer is in the chest, the doctor may perform a thoracoscopy. In this procedure, the doctor makes a small cut through the chest wall and puts a thin, lighted tube called a thoracoscope into the chest between two ribs. Thoracoscopy allows the doctor to look inside the chest and obtain tissue samples. If the cancer is in the abdomen, the doctor may perform a peritoneoscopy. To obtain tissue for examination, the doctor makes a small opening in the abdomen and inserts a special instrument called a peritoneoscope into the abdominal cavity. If these procedures do not yield enough tissue, more extensive diagnostic surgery may be necessary.
If the diagnosis is mesothelioma , the doctor will want to learn the stage (or extent) of the disease. Staging involves more tests in a careful attempt to find out whether the cancer has spread and, if so, to which parts of the body. Knowing the stage of the disease helps the doctor plan treatment.
mesothelioma is described as localized if the cancer is found only on the membrane surface where it originated. It is classified as advanced if it has spread beyond the original membrane surface to other parts of the body, such as the lymph nodes, lungs, chest wall, or abdominal organs.
8. How is mesothelioma treated?
Treatment for mesothelioma depends on the location of the cancer, the stage of the disease, and the patient’s age and general health. Standard treatment options include surgery, radiation therapy, and chemotherapy. Sometimes, these treatments are combined.
* Surgery is a common treatment for mesothelioma . The doctor may remove part of the lining of the chest or abdomen and some of the tissue around it. For cancer of the pleura (pleural mesothelioma ), a lung may be removed in an operation called a pneumonectomy. Sometimes part of the diaphragm, the muscle below the lungs that helps with breathing, is also removed.
* Radiation therapy, also called radiotherapy, involves the use of high-energy rays to kill cancer cells and shrink tumors. Radiation therapy affects the cancer cells only in the treated area. The radiation may come from a machine (external radiation) or from putting materials that produce radiation through thin plastic tubes into the area where the cancer cells are found (internal radiation therapy).
* Chemotherapy is the use of anticancer drugs to kill cancer cells throughout the body. Most drugs used to treat mesothelioma are given by injection into a vein (intravenous, or IV). Doctors are also studying the effectiveness of putting chemotherapy directly into the chest or abdomen (intracavitary chemotherapy).
To relieve symptoms and control pain, the doctor may use a needle or a thin tube to drain fluid that has built up in the chest or abdomen. The procedure for removing fluid from the chest is called thoracentesis. Removal of fluid from the abdomen is called paracentesis. Drugs may be given through a tube in the chest to prevent more fluid from accumulating. Radiation therapy and surgery may also be helpful in relieving symptoms.
9. Are new treatments for mesothelioma being studied?
Yes. Because mesothelioma is very hard to control, the National Cancer Institute (NCI) is sponsoring clinical trials (research studies with people) that are designed to find new treatments and better ways to use current treatments. Before any new treatment can be recommended for general use, doctors conduct clinical trials to find out whether the treatment is safe for patients and effective against the disease. Participation in clinical trials is an important treatment option for many patients with mesothelioma .
People interested in taking part in a clinical trial should talk with their doctor. Information about clinical trials is available from the Cancer Information Service (CIS) (see below) at 1–800–4–CANCER. Information specialists at the CIS use PDQ®, NCI’s cancer information database, to identify and provide detailed information about specific ongoing clinical trials. Patients also have the option of searching for clinical trials on their own. The clinical trials page on the NCI’s Cancer.gov Web site, located at http://www.cancer.gov/clinical_trials on the Internet, provides general information about clinical trials and links to PDQ.
People considering clinical trials may be interested in the NCI booklet Taking Part in Clinical Trials: What Cancer Patients Need To Know. This booklet describes how research studies are carried out and explains their possible benefits and risks. The booklet is available by calling the CIS, or from the NCI Publications Locator Web site at http://www.cancer.gov/publications on the Internet.
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MALIGNANT mesothelioma
What Is Cancer?
Cancer develops when cells in a part of the body begin to grow out of
control. Although there are many kinds of
cancer, they all start because of out-of-control growth of abnormal
cells.
Normal body cells grow, divide, and die in an orderly fashion. During
the early years of a person's life, normal
cells divide more rapidly until the person becomes an adult. After that,
cells in most parts of the body divide
only to replace worn-out or dying cells and to repair injuries.
Because cancer cells continue to grow and divide, they are different
from normal cells. Instead of dying, they
outlive normal cells and continue to form new abnormal cells.
Cancer cells develop because of damage to DNA. This substance is in every cell and directs all
its activities.
Most of the time when DNA becomes damaged the body is able to repair it.
In cancer cells, the damaged DNA
is not repaired. People can inherit damaged DNA, which accounts for inherited cancers. Many times
though, a
person’s DNA becomes damaged by exposure to something in the
environment, like smoking.
Cancer usually forms as a tumor. Some cancers, like leukemia, do
not form tumors. Instead, these cancer cells
involve the blood and blood-forming organs and circulate through other
tissues where they grow.
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Often, cancer cells travel to other parts of the body, where they begin
to grow and replace normal tissue. This
process is called metastasis.
Regardless
of where a cancer may spread, however, it is always named for the
place it began. For instance, breast cancer that spreads to the liver
is still called breast cancer, not liver cancer.
Not all tumors are cancerous. Benign (non-cancerous) tumors do not spread
(metastasize) to other parts of the
body and, with very rare exceptions, are not life threatening.
Different types of cancer can behave very differently. For example,
lung cancer and breast cancer are very
different diseases. They grow at different rates and respond to different
treatments. That is why people with
cancer need treatment that is aimed at their particular kind of cancer.
Cancer is the second leading cause of death in the
third of all women in the
living with cancer or have had cancer. The risk of developing most types
of cancer can be reduced by changes
in a person's lifestyle, for example, by quitting smoking and eating
a better diet. The sooner a cancer is found
and treatment begins, the better are the chances for living for many
years.
What Is Malignant mesothelioma ?
A layer of specialized cells called mesothelial cells lines the chest
cavity, abdominal cavity, and the cavity
around your heart. These cells also cover the outer surface of most
of your internal organs. The tissue formed by
these cells is called mesothelium.
The mesothelium helps protect your organs by producing a special lubricating
fluid that allows organs to move
around. This fluid makes it easier for the lungs to move inside the
chest during breathing. The mesothelium of
Malignant mesothelioma (3 of 43)
the chest is called the pleura and the mesothelium of the abdomen is
known as the peritoneum. The
mesothelium of the "sac-like" space around the heart (pericardial
cavity) is called the pericardium.
Tumors of the mesothelium can be non-cancerous (benign) or cancerous
(malignant). A malignant tumor of the
mesothelium is called a malignant mesothelioma ; however, malignant mesothelioma is often simply called
mesothelioma .
Malignant mesothelioma s are divided into 3 main types:
• epithelioid (50% to 70% are of this type) -- this type
has the best outlook for survival (prognosis)
• sarcomatoid (7% to 20% are of this type)
• mixed/biphasic (20% to 35% are of this type)
Treatment options are the same for all 3 types.
About 75%
of mesothelioma s start in the chest cavity. They are known as pleural
mesothelioma s. Another 10%
to 20% begin in the abdomen. These are called peritoneal mesotheliomas.
Pericardial mesothelioma s start in
the cavity around the heart and are very rare. The covering layer of
the testicles is actually an outpouching of
peritoneum into the scrotum. mesothelioma s that affect this covering
of the testicles can occur but are quite
rare.
It is important
not to confuse malignant mesothelioma
with benign tumors that also start in the mesothelium.
The mesothelium of certain female and male reproductive organs may develop
a type of benign tumor called an
adenomatoid tumor. In men, this non-cancerous tumor often starts in
the epididymis (a small collection of ducts
that carry sperm cells out of the testicle). In women, this tumor may
begin in the fallopian tubes (tubes that
carry eggs from the ovaries to the uterus or womb). Another non-cancerous
tumor that may begin in
mesothelium near female reproductive organs is called benign cystic
mesothelioma .
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A type of benign tumor that used to be called benign fibrous mesothelioma can form in the pleura
surrounding
the lungs. Doctors now know that this tumor actually starts from tissue
under the mesothelium and not from
mesothelial cells. For this reason, the new name of this tumor is solitary
fibrous tumor of the pleura.
This disease
is usually not cancerous, but cancerous forms can occur. A similar disease
starting in the peritoneum is
called solitary fibrous tumor of the peritoneum. The tumors described
in this paragraph are usually removed by
surgery, and there is no need for additional treatment. Only malignant mesothelioma will be discussed
further in
this document.
What Are
the Key Statistics About Malignant mesothelioma ?
mesothelioma is fairly rare. There are an estimated 2,000 to 3,000 new cases of mesothelioma each year in the
stabilized. It may now be decreasing. Most of the past increase in cases,
as well as the recent decrease in cases,
has been in men. The rate, although lower, has been fairly steady for
women. In European countries, the rate of
mesothelioma s is still increasing.
mesothelioma is rare in people under age 55. Its incidence increases
with age. Three-fourths of people with
mesothelioma are
over 65 years old. The disease affects men 5 times more often than women.
mesothelioma is
less common in African Americans than in white Americans.
mesothelioma is a serious disease. By the time the symptoms appear and
cancer is diagnosed, the disease is
often advanced. The average survival time is about 1 year. The 5-year
relative survival rate is around 10%, but
this rate has been slowly improving.
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The 5-year survival rate refers to the percentage of patients who live
at least 5 years after their cancer is
diagnosed. Many of these patients live much longer than 5 years after
diagnosis, and 5-year rates are used to
produce a standard way of discussing prognosis. Five-year relative survival
rates do not include patients dying
of other diseases and are considered to be a more accurate way to describe
the prognosis for patients with a
particular type and stage of cancer.
That means
that relative survival only talks about deaths from
mesothelioma . Of course, 5-year survival rates are based on patients
diagnosed and initially treated more than 5
years ago. They may no longer be accurate. Improvements in treatment
result in a more favorable outlook for
recently diagnosed patients.
What Are
the Risk Factors for Malignant mesothelioma ?
A risk factor is anything that increases your chance of getting a disease
such as cancer. Different cancers have
different risk factors. For example, exposing skin to strong sunlight
is a risk factor for skin cancer. Smoking is a
risk factor for cancers of the lung, mouth, larynx, bladder, kidney,
and several other organs. Individuals exposed
to asbestos
should be encouraged to avoid tobacco exposure because together the
risk for lung cancer is
significantly higher than from smoking without a history of asbestos exposure. But having a
risk factor, or even
several, does not mean that you will get the disease.
asbestos
The main risk factor for developing
mesothelioma is exposure to asbestos. asbestos
refers to a family of fibrous
minerals made of silicate. asbestos
was once used in many products such as insulation, floor tiles, door
gaskets,
soundproofing, roofing, patching compounds, fireproof gloves and ironing
board covers, and even brake pads.
As the link between asbestos
and mesothelioma has
become well known, the use of this material has almost
stopped. Most use stopped after 1989, but it is still used in some products.
Experts have linked this drop in
asbestos use
to the fact that the rate of development of
mesothelioma is no longer increasing.
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Still, up to 8 million Americans may already have been exposed to asbestos. Exposure to asbestos particles
suspended in air and building materials is much less hazardous except
when they are being removed.
Since asbestos
is a naturally occurring mineral, it can also be found in dust and rocks
in certain parts of the
According to the U.S. Environmental Protection Agency, as many as 733,000
schools and public buildings in
the country today contain asbestos
insulation. As many as 10% to 15% of schools in the
contain asbestos
insulation. People who may be at risk for occupational asbestos exposure include some miners,
factory workers, insulation manufacturers, railroad workers, ship builders,
gas mask manufacturers, and
construction workers, particularly those involved with installing insulation.
Several studies have shown that
family members of people exposed to asbestos
at work have an increased risk of developing mesothelioma ,
because asbestos
fibers are carried home on the clothes of the workers.
The incidence rate for mesothelioma
in men is dropping, probably because they are no longer
being exposed
directly to asbestos
in their work. But the incidence rate for mesothelioma in women is steady, which suggests
that they are being exposed in a way that is not directly tied to work,
but more to their environment either at
home or work. One example would be asbestos
in buildings where they work or live. A study from California
also links mesothelioma to
naturally occurring asbestos
deposits in mountains.
Another important point about asbestos
and mesothelioma is
that the risk of mesothelioma
does not drop with
time after exposure to asbestos.
The risk appears to be lifelong and undiminished.
There are 2 main forms of asbestos
-- serpentine and amphiboles.
| some words on this site are commonly misspelled: asbestos, asbesos, asbetos, asbests, asbstos, asestos, abestos, asbestoes, asbestous, asbestas, asbestus, asbestso, asbesots, asbetsos, asbsetos, asebstos, absestos. sabestos, asbesto, sbestos |
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Serpentine fibers are curly and pliable. Chrysotile is the only type
of serpentine fiber and it is the most widely
used form of asbestos.
Amphiboles are thin, rod-like fibers. There are 5 main types —
crocidolite, amosite, anthrophylite, tremolite,
and actinolyte. Amphiboles (particularly crocidolite) are considered
to be the most carcinogenic (cancercausing).
However, even the more commonly used chrysotile fibers are associated
with malignant (cancerous)
mesothelioma s and should be considered dangerous as well.
When asbestos
fibers are inhaled, most are cleared in the nose, throat, trachea (windpipe),
or bronchi (large
breathing tubes of the lungs). Fibers are cleared by sticking to mucus
inside the air passages and being coughed
up or swallowed. The long, thin, fibers are less readily cleared, and
they may reach the ends of the small
airways and penetrate into the pleural lining of the lung and chest
wall. These fibers may then directly injure
mesothelial cells of the pleura, and eventually cause mesothelioma .
asbestos fibers
can also damage cells of the lung and result in asbestosis (formation of scar tissue in the lung),
and/or lung cancer. The risk of lung cancer among people exposed to
asbestos is increased by 7 times,
compared with the general population. Indeed, asbestosis, mesothelioma , and lung cancer are the
3 most
frequent causes of death and disease among people with heavy asbestos exposure. Peritoneal mesothelioma
,
which forms in the abdomen, may result from coughing up and swallowing
inhaled asbestos
fibers. Cancers of
the larynx, pancreas, esophagus, colon, and kidney may also come from
asbestos exposure, but the increased
risk is small.
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The risk of developing a mesothelioma
is related to how much asbestos a person was exposed to
and how long
this exposure lasted. People exposed at an early age, for a long period
of time, and at higher levels are most
likely to develop this cancer. mesothelioma s take a long time to develop.
The time between first exposure to
asbestos and
diagnosis of mesothelioma
is usually between 20 and 50 years.
Radiation
There have been a few published reports of pleural and peritoneal mesothelioma
s that developed following
exposure to thorium dioxide (Thorotrast). This material was used in
the past by doctors for certain x-ray tests.
Because Thorotrast was found to cause cancers, it has not been used
for many years.
Zeolite
This is a silicate mineral, chemically related to asbestos, common in the soil of
the Anatoli region of
Many cases of mesothelioma
have been described in this region and may have been
caused by this mineral.
Tobacco
Although tobacco smoking has not been associated with developing mesothelioma
, the combination of smoking
and asbestos
exposure greatly increases the risk of lung cancer. asbestos workers who also smoke
have a lung
cancer risk 50 to 90 times greater than that of the general population.
More asbestos workers die of lung cancer
than of mesothelioma .
SV40 Virus
Some recent studies have raised the possibility that infection with
simian virus 40 (SV40) might increase the
risk of developing mesothelioma . Some injectable polio vaccines prepared
between 1955 and 1963 were
contaminated with SV40. About 10 to 30 million people were probably
exposed to the virus.
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Intentional infection with SV40 of some laboratory animals, such as
hamsters, causes mesothelioma s to
develop. Researchers also have noticed that SV40 can cause mouse cells
grown in dishes to become cancerous,
and that asbestos
increases the cancer-causing effect of SV40 on these cells. Other researchers
have studied
biopsy specimens of human mesothelioma s and detected SV40 DNA. However, similar fragments of SV40
DNA can also be found in noncancerous human tissues
and some researchers think the SV40 viruses found are
contaminants.
Another study did find SV40 virus in tissues from mesothelioma patients that did
not appear to be contaminants.
In this study, which also looked at tissue from healthy people, the
SV40 virus wasn’t linked to mesothelioma
unless the person was also exposed to asbestos.
The researchers in this study thought the SV40 infection was
not caused by the polio immunization, but occurred naturally as do other
viral infections.
So far, the largest studies addressing this issue in humans have not
found any increased risk for mesothelioma
or other cancers among people who received the contaminated vaccines
as children. But, the peak age range for
diagnosis of mesothelioma
is 50 to 70 years. Some researchers have pointed out
that this issue may remain
unresolved until more of the people accidentally exposed to SV40 between
1955 and 1963 reach that age range.
Research into this important topic is still underway.
A recent study by the Institute of Medicine concluded that we still don’t know whether
SV40 is responsible for
some mesothelioma s and more research needs to be done.
Do We Know What Causes Malignant mesothelioma ?
asbestos exposure
is the main cause of mesothelioma . After these fibers are breathed
in, they travel to the ends
of small air passages and reach the pleura where they damage mesothelial
cells. The damage they cause is
through inflammation and scarring as well as stimulating the growth
of these cells. Finally, they may damage
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DNA and cause changes that result in uncontrolled growth.
In addition, they also cause injury to lung cells that
can result in lung cancer and/or asbestosis
(replacement of lung tissue by scar tissue). If swallowed, these fibers
can reach the abdominal cavity where they have a role in causing peritoneal
mesothelioma .
Researchers are studying exactly how asbestos
causes mesothelial cells to develop into mesothelioma . It is still
not known whether the SV40 virus participates in this process.
Can Malignant mesothelioma Be Prevented?
The best way to prevent mesothelioma
is to prevent or limit your exposure to asbestos in homes, in public
buildings, and at work. People who may be exposed to asbestos at work include miners,
factory workers,
insulation manufacturers, railroad workers, ship builders, gas mask
manufacturers, and construction workers,
particularly those involved with insulation. If there is a possibility
of on-the-job exposure, such as renovating
old buildings, then you should use all protective equipment, work practices,
and safety procedures designed for
working around asbestos.
If you live in an older home, there may be asbestos-containing insulation or other materials.
A knowledgeable
expert can check your home to determine if there is any asbestos and if it poses any risk
of exposure. This may
involve testing the air for asbestos
levels. It is often more dangerous to remove the materials containing
asbestos
than to leave them alone. You may then decide to have the asbestos removed from your home.
You should hire
a qualified contractor to perform this job, to avoid contaminating your
home further or causing any exposure to
the workers. You should not attempt to remove asbestos-containing material yourself.
Can Malignant mesothelioma Be Found Early?
Certain findings on chest x-rays (see the section, “How Is mesothelioma
Diagnosed?”) that suggest asbestos
exposure could prompt the need for further tests or close follow-up.
However, the chest x-ray is not an effective
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test for early detection of
mesothelioma in the general population. One test being
studied is a blood test that
measures the levels in the blood of osteopontin, a protein that is elevated
in people who have lung damage due
to asbestos.
It is even higher if a person develops mesothelioma .
How Is Malignant mesothelioma Diagnosed?
If there is a reason to suspect you may have mesothelioma , your doctor
will use one or more methods to find out
if the disease is present. The first step in diagnosing mesothelioma is recognizing your
symptoms.
Signs and Symptoms of mesothelioma
Early symptoms of mesothelioma s are not specific to the disease. People
often ignore them or mistake them for
common, minor ailments. Most people with mesothelioma have symptoms for only 2 to 3 months
before they
are diagnosed. About one-fourth of people have symptoms for at least
6 months before they are diagnosed.
Over half of patients with pleural
mesothelioma have pain in the lower back or at the side
of the chest. Many
report shortness of breath. A smaller percentage has trouble swallowing,
cough, fever, sweating, fatigue, and
weight loss. Other symptoms include hoarseness, coughing up blood, swelling
of the face and arms, muscle
weakness, and sensory loss.
Symptoms of peritoneal mesothelioma
include abdominal (belly) pain, weight loss, nausea,
and vomiting. There
may also be fluid or a mass in the abdomen.
If you have any of these symptoms and have been exposed to asbestos you should see a doctor
right away.
Medical History and Physical Exam
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A complete medical history (interview) is taken to check for risk factors
and symptoms. This will include
questions to determine if you have been exposed to asbestos.
A physical exam will provide information about signs of mesothelioma and other health problems.
Patients with
pleural mesothelioma s ( mesothelioma s of the chest) often have fluid
in their chest cavity (pleural effusion)
caused by the cancer. Some will have fluid in the abdominal cavity (ascites)
in cases of peritoneal
mesothelioma , or fluid in the pericardium (pericardial effusion) in
cases of pericardial mesothelioma . All these
might be detected during a physical exam. Otherwise they will be found
by imaging studies.
Rarely, mesothelioma can
develop in the groin and look like a hernia.
Imaging Tests
Imaging studies such as x-rays, computed tomography (CT) scans, and
magnetic resonance imaging (MRI)
scans will help determine the location, size, and extent of the cancer.
Chest x-ray: This may show irregular thickening of the pleura, calcium
deposits on the pleura, or fluid in the
pleural space. These findings suggest asbestos
exposure leading to the development of a mesothelioma .
Computed tomography (CT) scan: The CT scan is an x-ray procedure that
produces detailed cross-sectional
images of your body. Instead of taking one picture, like a conventional
x-ray, a CT scanner takes many pictures
as it rotates around you. A computer then combines these pictures into
an image of a slice of your body. The
machine will take pictures of multiple slices of the part of your body
that is being studied.
CT scans are often used to make the initial diagnosis of malignant mesothelioma
, and are helpful in staging the
cancer (determining the extent of its spread).
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Often after the first set of pictures is taken you will receive an intravenous
injection of a "dye" or radiocontrast
agent that helps better outline structures in your body. A second set
of pictures is then taken.
CT scans are more tiring than regular x-rays because they take longer
and you need to lie still on a table while
they are being done. But just like other computerized devices, they
are getting faster and your stay might be
pleasantly short. Also, you might feel a bit confined by the ring you
lie within when the pictures are being
taken.
You will have an IV (intravenous) line through which the contrast "dye"
is injected. The injection can also
cause some flushing (redness and warm feeling). Some people are allergic
and get hives or rarely more serious
reactions like trouble breathing and low blood pressure. Be sure to
tell the doctor if you have ever had a reaction
to any contrast material used for x-rays. You may be asked to drink
1 to 2 pints of a solution of contrast
material. This helps outline the intestine.
Positron emission tomography (PET) scan: In this test, radioactive glucose
(sugar) is injected into your vein.
Because cancers use sugar much faster than normal tissues, the cancerous
tissue takes up the radioactive
material. A scanner can spot the radioactive deposits. This test, which
is still being studied, is useful for telling
whether a thickening of the tissues is cancer or merely scar tissue.
It can also spot spread of the cancer.
Magnetic resonance imaging (MRI) scan: MRI scans use radio waves and strong magnets instead
of x-rays.
The energy from the radio waves is absorbed and then released in a pattern
formed by the type of tissue and by
certain diseases. A computer translates the pattern of radio waves given
off by the tissues into a very detailed
image of parts of the body. Not only does this produce cross sectional
slices of the body like a CT scanner, it
can also produce slices that are parallel with the length of your body.
A contrast material might be injected just
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as with CT scans, but is used less often. Sometimes MRI scans are useful in looking at the diaphragm (the
thin
muscle at the bottom of the lung cage that is responsible for breathing)
where the mesothelioma may
spread.
MRI scans are particularly helpful in examining the
brain and spinal cord. MRI scans are a little more
uncomfortable than CT scans. First, they take longer — often up
to 1 hour. Also, you have to be placed inside a
tube, which is confining and can upset people with claustrophobia (fear
of enclosed places). The machine also
makes a thumping noise that you may find disturbing. Some places will
provide headphones with music to
block this out.
Blood Tests
As mentioned above, blood levels of a protein called osteopontin are
elevated in people with mesothelioma . But
this blood test is probably more useful for following a patient’s
progress during and after treatment. It is not
used to diagnose the disease, although an elevated level may raise suspicions.
Tests of Fluid and Tissue Samples
If you have a pleural effusion (a build up of fluid) a sample of this
fluid can be removed by inserting a needle
into the chest cavity. A similar technique can be used to obtain abdominal
fluid and pericardial fluid. The fluid
is then tested to see its chemical make up and viewed under a microscope
by an expert in diagnosing cancer
(pathologist) to determine whether cancer cells are present. If cancer
cells are present, special tests are needed
to diagnose whether the cancer is a mesothelioma , a lung cancer, or
another type of cancer.
A tissue sample of a pleural or pericardial tumor can be obtained using
a relatively new technique called
thoracoscopy. A thoracoscope (telescope-like instrument connected to
a video camera) is inserted through a
small incision into the chest. Your doctor can see the tumor through
the thoracoscope, and can use special
forceps to take a tissue biopsy. Similarly, laparoscopy can be used
to see and obtain a biopsy of a peritoneal
Malignant mesothelioma (15 of 43) [10/21/2006 2:25:01 AM]
tumor. In this procedure, a flexible tube attached to a video camera
is inserted into the abdominal cavity through
small incisions on the front of the abdomen. Fluid can also be collected
during thoracoscopy or laparoscopy.
The biopsy specimen will be sent to the pathology laboratory where the
pathologist will examine it to determine
if it is cancer.
Surgery, either a thoracotomy (which opens the chest cavity) or a laparotomy
(which opens the abdominal
cavity), allows the surgeon to remove a larger sample of tumor or, sometimes,
to remove the entire tumor.
If you might have pleural mesothelioma , the doctor may also do a bronchoscopy.
In this procedure a flexible
lighted tube is inserted through your mouth, down the trachea, and into
the bronchi to see if there are other
masses in the airway. Small samples of abnormal-appearing tissue can
be removed for testing.
You may also have a mediastinoscopy. A lighted tube is inserted under
the sternum (chest bone) at the level of
the neck and moved down into the chest. Mediastinoscopy allows the surgeon
to view the lymph nodes in this
area and remove samples to check for cancer. Lymph nodes are bean-sized
collections of immune system cells
that help the body fight infections and cancers. Cancers in the lung
often spread to lymph nodes, but
mesothelioma s do this less often. Tests on lymph nodes can give the
doctor information on whether a cancer is
still localized or if it has started to spread, and can help distinguish
lung cancer from mesothelioma .
It is often hard to diagnose
mesothelioma by looking at the cells from the fluid
around the lungs, abdomen, or
heart. It is even hard to diagnose
mesothelioma with tissue from small needle biopsies.
Under the microscope,
mesothelioma can
look like several other types of cancer. For example, pleural mesothelioma may resemble
some types of lung cancer and peritoneal mesothelioma may resemble some cancers of the ovaries.
For this
reason, special laboratory tests are often done to help distinguish mesothelioma from some other cancers.
Malignant mesothelioma (16 of 43) [10/21/2006 2:25:01 AM]
These tests often use special techniques to recognize certain markers
(types of chemicals) contained in
mesothelioma s. One test called immunohistochemistry looks for different
proteins on the surface of the cells. It
can be used to tell if the cancer is a
mesothelioma or a lung cancer, which can appear to start
in the lining of the
chest cavity. A newer test is called DNA microarray analysis. This test actually looks at
genes in the cancers.
mesothelioma s have different gene patterns than other cancers.
The electron microscope can sometimes help diagnose mesothelioma . This
microscope can magnify samples
more than 100 times greater than the light microscope that is generally
used in cancer diagnosis. This more
powerful microscope makes it possible to see the small parts of the
cancer cells that distinguish mesothelioma
from other types of cancer.
How Is Malignant mesothelioma Staged?
Staging is the process of finding out how far the cancer has spread.
Staging of mesothelioma is
based on
imaging studies such as x-rays, CT scans, and MRI scans. The treatment and outlook for patients with
mesothelioma largely
depends on the stage (extent of spread) of their cancer. Since pleural mesothelioma occurs
most frequently and has been studied the most, it is the only mesothelioma for which a staging
classification
exists.
The major staging system has recently been developed by the International
mesothelioma Interest Group and
adopted by the American Joint Committee on Cancer (AJCC). This is a
TNM system, similar to staging systems
used for most other cancers. T stands for tumor (its size and how far
it has spread to nearby organs), N stands
for spread to lymph nodes, and M is for metastasis (spread to distant
organs). In TNM staging, information
about the tumor, lymph nodes, and metastasis is combined in a process
called stage grouping to assign a stage
described by Roman numerals from I to IV.
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T Stages
T1: mesothelioma involves either the right or left pleura lining the
chest. It has only spread to the pleura
covering the lung, with the exception of possibly a few other small
spots.
T2: mesothelioma involves either the right or left pleura lining the
chest and has spread from the lining of the
chest into 1) the outer lining of the lung, 2) the diaphragm, or 3)
into the lung itself.
T3: mesothelioma involves either the right or left pleura lining the
chest and has spread into 1) the first layer of
the chest wall, 2) the fatty part of the mediastinum, 3) a single place
in the chest wall, or 4) the outer covering
layer of the heart.
T4: mesothelioma involves either the right or left pleura lining the
chest and has spread 1) into the chest wall,
either muscle or ribs, 2) through the diaphragm, 3) into any organ contained
in the mediastinum (esophagus,
trachea, thymus, blood vessels), 4) into the spine, 5) across to the
pleura on the other side of the chest, 6)
through the heart lining or into the heart itself, or 7) into the brachial
plexus (nerves leading to the arm).
N Stages
N0: No spread to lymph nodes.
N1: Spread to lymph nodes on the same side of the chest as the mesothelioma
.
N2: Spread to lymph nodes around the point where the windpipe branches
into the left and right bronchi or to
lymph nodes in the space behind the chest bone and in front of the heart
(mediastinum). Affected lymph nodes
are on the same side of the cancerous lung.
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N3: Spread to lymph nodes near the collarbone on either side, to hilar
or mediastinal lymph nodes on the side
opposite the cancerous lung.
M Stages
M0: No spread to distant organs or areas.
M1: The cancer has spread distantly.
Stage Grouping for Pleural mesothelioma
Once the T, N, and M categories have been assigned, this information
is combined (stage grouping) to assign an
overall stage of I, II, III, or IV. Patients with
lower stage numbers have a better prognosis.
Stage I (T1, N0, M0): mesothelioma involves
either the right or left pleura lining the chest. It has only spread
to
the outer lining of the lung in, at most, a few small spots. It has
not spread to the lymph nodes or distant sites.
Stage II (T2, N0, M0): mesothelioma involves
either the right or left pleura lining the chest and has spread from
the lining of the chest into 1) the outer lining of the lung, 2) the
diaphragm, or 3) into the lung itself. It has not
spread to the lymph nodes or distant sites.
Stage III (T1 or 2, N1 or 2, M0 or T3, N0-2, M0): mesothelioma
involves either the right or left pleura lining
the chest and may or may not have spread from the lining of the chest
into 1) the outer lining of the lung, 2) the
diaphragm, 3) into the lung itself and has spread to lymph nodes anywhere
in the chest on the same side as the
tumor, but has not spread to distant sites; OR mesothelioma involves
either the right or left pleura lining the
chest and has spread into 1) the first layer of the chest wall, or 2)
the fatty part of the mediastinum, or 3) a single
place in the chest wall or 4) the outer covering layer of the heart
and may or may not have spread to lymph
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nodes but not as far as to lymph nodes near the collarbone or on the
opposite side of the chest. It has not spread
to distant sites.
Stage IV (T4, any N, M0 or any T, N3, M0 or any T, any N, M1): mesothelioma
involves either the right or left
pleura lining the chest and has spread 1) into the chest wall, either
muscle or ribs, 2) through the diaphragm, 3)
into any organ contained in the mediastinum (esophagus, trachea, thymus,
blood vessels), 4) into the spine, 5)
across to the pleura on the other side of the chest, 6) through the
heart lining or into the heart itself, or 7) into
the brachial plexus (nerves leading to the arm), and may or may not
have spread to lymph nodes anywhere, but
has not spread to distant sites; OR the tumor is of any size, but has
spread to lymph nodes near the collarbone
on either side, to hilar or mediastinal lymph nodes on the side opposite
the cancerous lung but not to distant
sites; OR the mesothelioma
has spread to distant sites.
Other Prognostic Factors
Although stage is an important factor that determines a patient’s
prognosis, other factors should also be
considered. Some of these are poor performance status (for example being
too sick to perform normal tasks of
daily life), chest pain, shortness of breath, weight loss, high levels
of a substance in the blood called LDH, low
red blood cell count, high white blood cell count and others. These
are considered serious factors and most
people with all of these factors usually die within 6 months. Few live
2 years. Most people with none of these
serious factors will live at least one year and have a 40% chance of
living 2 years.
How Is Malignant mesothelioma Treated?
This information represents the views of the doctors and nurses serving
on the American Cancer Society's Cancer Information
Database Editorial Board. These views are based on their interpretation
of studies published in medical journals, as well as their own
professional experience.
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The treatment information in this document is not official policy of
the Society and is not intended as medical advice to replace the
expertise and judgment of your cancer care team. It is intended to help
you and your family make informed decisions, together with
your doctor.
Your doctor may have reasons for suggesting a treatment plan different
from these general treatment options. Don't hesitate to ask
him or her questions about your treatment options.
| some words on this site are commonly misspelled: asbestos, asbesos, asbetos, asbests, asbstos, asestos, abestos, asbestoes, asbestous, asbestas, asbestus, asbestso, asbesots, asbetsos, asbsetos, asebstos. absestos, sabestos, asbesto, sbestos |
Malignant
mesothelioma (21 of 43) [10/21/2006 2:25:01 AM]
If you have mesothelioma , your cancer care team will recommend one
or more treatment options for you to
consider. This is an important decision and you should take time to
think about all of your choices.
In addition to the stage of the cancer, your health and your personal
preferences are factors in deciding on a
treatment plan. Because mesothelioma
is such a rare cancer, it has been difficult for doctors
to compare the
value of different treatments. Only a few large clinical trials have
been reported to date. In addition, most
doctors have little or no experience treating this disease. They usually
refer patients with this cancer to
specialists who treat a large number of
mesothelioma patients in large medical centers.
Another problem with treating
mesothelioma is that it does not grow as a single tumor
mass. It tends to spread
along nearby surfaces, nerves, and blood vessels. Because of this it
is almost impossible, except in rare
situations, to completely get rid of it with surgery, radiation or both.
Because treatment has resulted in modest benefit, you may question the
treatment options suggested. It is often
a good idea to seek a second opinion. A second opinion can provide more
information and help you feel more
confident about the treatment plan that you choose. Also, some insurance
companies require a second opinion
before they will agree to pay for certain treatments.
Surgery
Surgery for pleural mesothelioma
may be done for 1 of 2 reasons: to relieve pain and
discomfort caused by the
tumor (called palliation) or to cure.
Palliative surgery is typically done in cases where the tumor has already
spread beyond the mesothelium and is
difficult to remove completely, or if you are too ill to tolerate a
more extensive operation.
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Curative surgery is offered if you are in otherwise good health and
the tumor is thought to be localized and can
be removed completely. Unfortunately, the cancer cells tend to spread
into the chest wall, around the heart, over
nerves, and the diaphragm. It is often difficult to detect this spread.
Because of this, doctors are not clear on the
exact role of surgery. It is not likely to cure you but may extend your
life. Curative surgery is being done in
some cancer centers and a few of the patients who have had the surgery
are experiencing long remissions of
their disease.
Depending on the stage of a mesothelioma , surgery may be used to remove
the cancer and some of the
surrounding tissue. Often, however, an operation is not appropriate
and you may have only smaller procedures
to relieve symptoms.
A thoracentesis, where fluid in the chest is removed by placing a needle
into the chest cavity, may be done to
make a patient more comfortable. Sometimes talc or drugs that cause
scarring may be injected into the chest
cavity to try to prevent the fluid from returning. This is called pleurodesis.
These techniques are successful in
controlling the fluid, at least temporarily, in as many as 90% of patients.
Because pleural fluid can compress the
lung and cause shortness of breath, these procedures can help you breathe
more easily, however, they do not
cure the cancer.
In the case of peritoneal mesothelioma , a needle may be inserted into
the abdomen to drain the fluid. Similarly,
a needle inserted into the pericardium (sac around the heart) can drain
pericardial fluid and help relieve
circulatory problems. Sometimes the cancer cells spread along the needle
path, and a tumor nodule may form
under the skin of that area. This concern should not prevent fluid removal,
though.
Two surgical procedures may be offered if you have pleural mesothelioma
: pleurectomy/decortication and
extrapleural pneumonectomy.
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Pleurectomy/decortication: Pleurectomy/decortication is usually a palliative
procedure (relieves symptoms
without curing the cancer) in cases where the entire tumor cannot be
removed. This procedure removes the
pleura, where the majority of the tumor is located. It can control the
build up of fluid improve breathing and
decrease pain caused by the cancer.
Extrapleural pneumonectomy: Extrapleural pneumonectomy is a far more
extensive operation and is most
often used in patients with localized
mesothelioma of the epithelioid type, when the surgeon
thinks a cure is
possible. It is a difficult operation and is done only by surgeons in
large specialized medical centers. You should
talk with your doctor about an appropriate treatment center nearest
to your home. The operation removes the
pleura lining the chest wall, diaphragm, pericardium, and the whole
lung on the side of the tumor. The
diaphragm and the pericardium are then reconstructed with prosthetic
material. You must be in overall good
health with no other serious illnesses to tolerate the surgery. This
operation attempts to remove all or most of
the cancer and some surrounding tissues as well.
Surgical treatment of peritoneal
mesothelioma is often done either to help relieve symptoms
or to remove the
tumor from the wall of the abdomen and other digestive organs. As with
pleural mesothelioma , these tumors are
often too extensive to remove completely. Similar operations can be
done to remove a mesothelioma
from the
pericardium (the sac around the heart).
Surgery for mesothelioma of
the tunica vaginalis testis, which occurs in the groin, is also not
usually curative.
Most of the time surgery is done because the tumor resembles a hernia.
The surgeon attempts to treat a
suspected hernia and only realizes the diagnosis after the surgery is
begun. This kind of mesothelioma
can’t be
entirely removed.
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Chemotherapy
Chemotherapy is the use of drugs for treating cancer. The drugs can
be swallowed in pill form or they can be
injected by needle into a vein or muscle. Chemotherapy is systemic therapy.
This means that the drug enters the
bloodstream and circulates throughout the body (through the whole system)
to reach and destroy the cancer
cells.
To treat mesothelioma , these drugs may also be given intrapleurally
(directly into the chest cavity) or
intraperitoneally (into the abdominal cavity). Based on the type and
stage of mesothelioma , chemotherapy may
be given as the primary (main) treatment or as an adjuvant treatment
(treatment given in addition to the primary
treatment) to surgery. Chemotherapy for this disease is palliative and
not curative.
Several chemotherapy drugs have been used to treat mesothelioma . The
preferred combination of drugs for now
is pemetrexed (Alimta), which is combined with cisplatin. Because pemetrexed
interferes with normal
metabolism of folic acid and vitamin B12, these must also be given to
avoid side effects. Another combination
that has a good response rate is cisplatin and gemcitabine. Another
option substitutes cisplatin with carboplatin,
which causes much less nausea and vomiting.
Other combinations of drugs used to treat mesothelioma include:
• methotrexate and vincristine
• cisplatin, vinblastine and mitomycin
• cisplatin and doxorubicin
• doxorubicin, cyclophosphamide (or ifosfamide), and cisplatin
All the drugs above can be given alone in people who may not be able
to tolerate two drugs. Other drugs such
as paclitaxel and irinotecan are being studied to determine their effectiveness
in treating mesothelioma .
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A new, related drug called raltitrexed has also been shown to help patients
with mesothelioma when
given with
cisplatin. Patients who received these drugs lived longer than those
who received cisplatin alone.
Chemotherapy drugs kill cancer cells but also damage some normal cells.
Therefore, your doctor will pay
careful attention to avoiding or minimizing side effects, which depend
on the specific drugs, the amount taken,
and the length of treatment. Temporary side effects might include nausea
and vomiting, loss of appetite, loss of
hair, and mouth sores.
Because chemotherapy can damage the blood-producing cells of the bone
marrow, patients may have low blood
cell counts. This can result in an increased risk of infection (due
to a shortage of white blood cells); bleeding or
bruising after minor cuts or injuries (due to a shortage of blood; platelets);
or fatigue or shortness of breath (due
to low red blood cell counts).
Most side effects disappear once treatment is stopped. There are remedies
for many of the temporary side
effects of chemotherapy. For example, you can be given drugs to prevent
or reduce nausea and vomiting. If you
experience any side effects, be sure to talk with your doctor.
Radiation Therapy
Radiation therapy is sometimes used as the main treatment of mesothelioma in some patients,
especially those
whose general health is too poor to undergo surgery. Radiation therapy
uses high-energy x-rays to kill cancer
cells.
External beam radiation therapy uses radiation delivered from outside
the body that is focused on the cancer.
This type of radiation therapy is the preferred type to treat mesothelioma
. These treatments are much like
getting a diagnostic x-ray except for a longer time. A typical course
of treatment takes anywhere from 3 to 5
Malignant mesothelioma (26 of 43) [10/21/2006 2:25:01 AM]
weeks of daily treatments (5 days a week). In general, though, mesothelioma is not helped much
by
radiotherapy because it is relatively resistant to the effects of radiotherapy.
Also, the need to treat a large part of
the lung leads to problems with lung damage.
Brachytherapy places radioactive material directly into the chest or
the abdomen at the site of the
mesothelioma . It is seldom used for this cancer.
Adjuvant radiation therapy can be used in addition to surgery to kill
small deposits of cancer that cannot be
seen and removed during surgery.
Palliative radiation therapy can also be used to ease symptoms of mesothelioma such as shortness
of breath,
pain, bleeding, and difficulty swallowing.
Side effects of radiation therapy may include fatigue and mild skin
changes that resemble sunburn. Often these
side effects are temporary. Radiation may also make the side effects
of chemotherapy worse. Chest radiation
therapy may cause lung damage and lead to difficulty breathing and shortness
of breath. Abdominal radiation
therapy may cause nausea, vomiting, and diarrhea. If you are having
any of these side effects of radiation
therapy, talk with your doctor since there are ways to help control
these symptoms.
If fluid collects in the pleural space, radioactive drugs can be put
into the space after the fluids are removed.
Sometimes they are successful in preventing the fluid from coming back.
Clinical Trials
The purpose of clinical trials: Studies of promising new or experimental
treatments in patients are known as
clinical trials. A clinical trial is only done when there is some reason
to believe that the treatment being studied
| some words on this site are commonly misspelled: asbestos, asbesos, asbetos, asbests, asbstos, asestos, abestos, asbestoes, asbestous, asbestas, asbestus, asbestso, asbesots, asbetsos, asbsetos, asebstos, absestos, sabestos, asbesto, sbestos |
may be valuable to the patient. Treatments used in clinical trials are
often found to have real benefits.
Researchers conduct studies of new treatments to answer the following
questions:
• Is the treatment helpful?
• How does this new type of treatment work?
• Does it work better than other treatments already available?
• What side effects does the treatment cause?
• Are the side effects greater or less than the standard treatment?
• Do the benefits outweigh the side effects?
• In which patients is the treatment most likely to be helpful?
Types of clinical trials: A treatment is studied in 3 clinical trial
phases before it is eligible for approval by the
FDA (Food and Drug Administration).
Phase I clinical trials: The purpose of a phase I study is to find the
best way to give a new treatment and how
much of it can be given safely. The cancer care team watches patients
carefully for any harmful side effects.
The treatment has been well tested in lab and animal studies, but the
side effects in patients are not completely
known. Doctors conducting the clinical trial start by giving very low
doses of the drug to the first patients and
increasing the dose for later groups of patients until side effects
appear. Although doctors are hoping to help
patients, the main purpose of a phase I study is to test the safety
of the drug.
Phase II clinical trials: These are designed to see if the drug works.
Patients are given the highest dose that
doesn’t cause severe side effects (determined from the phase I
study) and are closely observed for an effect on
the cancer. The cancer care team also looks for side effects.
Phase III clinical trials: Phase III studies involve large numbers of patients—often
several hundred. One group
(the control group) will receive the standard (most accepted) treatment.
The other groups will receive the new
treatment. Usually doctors study only 1 new treatment to see if it works
better than the standard treatment, but
Malignant mesothelioma (28 of 43) [10/21/2006 2:25:01 AM]
sometimes they will test 2 or 3. All patients in phase III studies are closely watched. The study will be
stopped
if the side effects of the new treatment are too severe or if one group
has had much better results than the others.
If you are in a clinical trial, you will receive excellent care. You
will have a team of experts taking care of you
and monitoring your progress very carefully. The study is especially
designed to pay close attention to you.
However, there are some risks. No one involved in the study knows in
advance whether the treatment will work
or exactly what side effects will occur. That is what the study is designed
to find out. While most side effects
disappear in time, some can be permanent or even life threatening. Keep
in mind, though, that even standard
treatments have side effects. Depending on many factors, you may decide
to enroll in a clinical trial.
Deciding to enter a clinical trial: Enrollment in any clinical trial
is completely up to you. Your doctors and
nurses will explain the study to you in detail and will give you a form
to read and sign indicating your desire to
take part. This process is known as giving your informed consent. Even
after signing the form and after the
clinical trial begins, you are free to leave the study at any time,
for any reason. Taking part in the study will not
prevent you from getting other medical care you may need.
To find out more about clinical trials, ask your cancer care team. Among
the questions you should ask are:
• What is the purpose of the study?
• What kinds of tests and treatments does the study involve?
• What does this treatment do?
• What is likely to happen in my case with, or without, this new
treatment?
• What are my other choices and their advantages and disadvantages?
• How could the study affect my daily life?
• What side effects can I expect from the study? Can the side
effects be controlled?
• Will I have to be hospitalized? If so, how often and for how
long?
• Will the study cost me anything? Will any of the treatment be
free?
• If I am harmed as a result of the research, what treatment would
I be entitled to?
• What type of long-term follow-up care is part of the study?
• Has the treatment been used to treat other types of cancers?
Malignant mesothelioma (29 of 43) [10/21/2006 2:25:01 AM]
The American Cancer Society offers a clinical trials matching service
for patients, their family, and friends.
You can gain access to this service through the ACS cancer information center at 1-800-ACS 2345 or on our
Web site at http://clinicaltrials.cancer.org. Based on the information
you provide about your cancer type, stage,
and previous treatments, our computer can compile a list of clinical
trials that match your medical needs. In
finding a center most convenient for you, the service can also take
into account where you live and whether you
are willing to travel.
You can also get a list of current clinical trials by calling the National
Cancer Institute's Cancer Information
Service toll free at 1-800-4-CANCER or by visiting the NCI clinical trials Web site at
www.cancer.gov/clinical_trials/.
Complementary and Alternative Therapies
Complementary and alternative therapies are a diverse group of health
care practices, systems, and products that
are not part of usual medical treatment. They may include products such
as vitamins, herbs, or dietary
supplements, or procedures such as acupuncture, massage, and a host
of other types of treatment. There is a
great deal of interest today in complementary and alternative treatments
for cancer. Many are now being studied
to find out if they are truly helpful to people with cancer.
You may hear about different treatments from family, friends, and others,
which may be offered as a way to
treat your cancer or to help you feel better. Some of these treatments
are harmless in certain situations, while
others have been shown to cause harm. Most of them are of unproven benefit.
The American Cancer Society defines complementary medicine or methods
as those that are used along with
your regular medical care. If these treatments are carefully managed,
they may add to your comfort and wellbeing.
Malignant mesothelioma (30 of 43) [10/21/2006 2:25:01 AM]
Alternative medicines are defined as those that are used instead of
your regular medical care. Some of them
have been proven not to be useful or even to be harmful, but are still
promoted as “cures.” If you choose to use
these alternatives, they may reduce your chance of fighting your cancer
by delaying, replacing, or interfering
with regular cancer treatment.
Before changing your treatment or adding any of these methods, discuss
this openly with your doctor or nurse.
Some methods can be safely used along with standard medical treatment.
Others, however, can interfere with
standard treatment or cause serious side effects. That is why it's important
to talk with your doctor. More
information about specific complementary and alternative therapies used
for cancer is available through our
toll-free number or on our Web site.
Treatment of mesothelioma by Stage
Stage I: Many patients with stage I pleural mesothelioma have their cancer removed by
pleurectomy/decortication or extrapleural pneumonectomy, as described
in the section How Is mesothelioma
Treated. Patients with peritoneal mesothelioma s in an early stage might
also benefit from surgery. The value of
adjuvant chemotherapy or radiation therapy (treatments given after surgery)
for stage I mesothelioma is
being
studied. Radiation therapy may be used if your general health is too
poor to tolerate a major operation. Some
doctors have had success with putting cisplatin into the thoracic space
after the surgery. This can also be used in
the abdomen for peritoneal mesothelioma .
Stages II, III: Treatment options include palliative and supportive
care providing relief of symptoms, such as
thoracentesis (to remove fluid accumulation in the chest cavity) along
with pleurodesis, paracentesis (removing
fluid from the abdomen), operations to remove as much of the tumor as
possible in some cases, and radiation
therapy or chemotherapy aimed at easing symptoms. Cure is usually not
possible for patients in these stages.
| some words on this site are commonly misspelled: asbestos, asbesos, asbetos, asbests, asbstos, asestos, abestos, asbestoes, asbestous, asbestas, asbestus, asbestso, asbesots, asbetsos, asbsetos, asebstos, absestos, sabestos, asbesto, sbestos |
Malignant mesothelioma (31 of 43) [10/21/2006 2:25:01 AM]
Enrollment in clinical trials evaluating the newest treatment possibilities
in large medical centers should be
considered. Some patients can have long remissions after extensive surgery
by experts.
Other approaches include putting chemotherapy or radioactive drugs directly
into the pleural space or
abdominal cavity. This can be done simply with the doctor placing a
needle into the pleural space or abdomen
after numbing the skin with local anesthetic. Although this only kills
some of the cancer cells, it often helps
slow down fluid collection.
Stage IV: Because stage IV
mesothelioma has spread to distant organs, a cure is
not possible. The goals of
using any aggressive therapy such as chemotherapy and radiation therapy
should be clear to you and your
family. You might want to consider enrolling in a clinical trial in
a large medical center. These studies evaluate
the newest treatment possibilities.
Supportive care may be the best choice, perhaps in the setting of a
good hospice program. Pain management is
an important aspect of your care. It is important for you to know that
drugs are available to effectively treat pain
due to mesothelioma . You should not hesitate to request pain medicines
or discuss pain control problems with
your cancer care team.
More Treatment Information
The NCI provides treatment guidelines via its telephone
information center (1-800-4-CANCER) and its Web
site (www.cancer.gov). Detailed guidelines intended for use by cancer
care professionals are also available on
www.cancer.gov.
What Should You Ask Your Doctor About Malignant mesothelioma ?
Malignant mesothelioma (32 of 43) [10/21/2006 2:25:01 AM]
As you cope with cancer and cancer treatment, you need to have honest,
open discussions with your doctor.
You should feel free to ask any question that’s on your mind no
matter how small it might seem. Here are some
questions you might want to ask. Nurses, social workers, and other members
of the treatment team may also be
able to answer many of your questions.
• What kind of mesothelioma
do I have?
• Has my cancer spread beyond the primary site?
• What is the stage of my cancer and what does that mean to me?
• What treatment options do I have?
• What do you recommend and why?
• Based on what you've learned about my cancer, what is my prognosis?
• What risks or side effects are there to the treatments you suggest?
• What are the chances my cancer will come back with these treatment
plans?
• What should I do to be ready for treatment?
In addition to these sample questions, be sure to write down some of
your own. For instance, you might want
more information about recovery times. Or, you may want to ask about
second opinions or about clinical trials
for which you may qualify.
What Happens After Treatment for Malignant mesothelioma ?
Completing treatment can be both stressful and exciting. You will be
relieved to finish treatment, yet it is hard
not to worry about cancer coming back. (When cancer returns, it is called
recurrence.) This is a very common
concern among those who have had cancer.
It may take a while before your confidence in your own recovery begins
to feel real and your fears are
somewhat relieved. Even with no recurrences, people who have had cancer
learn to live with uncertainty.
Follow-up Care
After your treatment is over, it is very important to keep all follow-up
appointments. During these visits, your
doctors will ask about symptoms, do physical exams, and order blood
tests or imaging studies such as CT scans
Malignant mesothelioma (33 of 43) [10/21/2006 2:25:01 AM]
or x-rays. Follow-up is needed to check for cancer recurrence or spread,
as well as possible side effects of
certain treatments. This is the time for you to ask your health care
team any questions you need answered and to
discuss any concerns you might have.
Almost any cancer treatment can have side effects. Some may last for
a few weeks to several months, but others
can be permanent. Don’t hesitate to tell your cancer care team
about any symptoms or side effects that bother
you so they can help you manage them.
It is also important to keep medical insurance. Even though no one wants
to think of their cancer coming back,
it is always a possibility. If it happens, the last thing you want is
to have to worry about paying for treatment.
Many people have been bankrupted by cancer recurrence.
Seeing a New Doctor
At some point after your cancer diagnosis and treatment, you may find
yourself in the office of a new doctor.
Your original doctor may have moved or retired, or you may have moved
or changed doctors for some reason.
It is important that you be able to give your new doctor the exact details
of your diagnosis and treatment. Make
sure you have the following information handy:
• a copy of your pathology report from any biopsy or surgery
• if you had surgery, a copy of your operative report
• if you were hospitalized, a copy of the discharge summary that
every doctor must prepare when patients
are sent home from the hospital
• finally, since some drugs can have long-term side effects, a
list of your drugs, drug doses, and when you
took them
Lifestyle Changes to Consider During and After Treatment
Having cancer and dealing with treatment can be time-consuming and emotionally
draining, but it can also be a
time to look at your life in new ways. Maybe you are thinking about
how to improve your health over the long
term. Some people even begin this process during cancer treatment.
Malignant mesothelioma (34 of 43) [10/21/2006 2:25:01 AM]
Make Healthier Choices
Think about your life before you learned you had cancer. Were there
things you did that might have made you
less healthy? Maybe you drank too much alcohol, or ate more than you
needed, or smoked, or didn’t exercise
very often. Emotionally, maybe you kept your feelings bottled up, or
maybe you let stressful situations go on
too long.
Now is not the time to feel guilty or to blame yourself. However, you
can start making changes today that can
have positive effects for the rest of your life. Not only will you feel
better but you will also be healthier. What
better time than now to take advantage of the motivation you have as
a result of going through a life-changing
experience like having cancer?
You can start by working on those things that you feel most concerned
about. Get help with those that are
harder for you. For instance, if you are thinking about quitting smoking
and need help, call the American
Cancer Society’s Quitline® tobacco cessation program at 1-800-ACS-2345.
.
Diet and Nutrition
Eating right can be a challenge for anyone, but it can get even tougher
during and after cancer treatment. For
instance, treatment often may change your sense of taste. Nausea can
be a problem. You may lose your appetite
for a while and lose weight when you don’t want to. On the other
hand, some people gain weight even without
eating more. This can be frustrating, too.
If you are losing weight or have taste problems during treatment, do
the best you can with eating and remember
that these problems usually improve over time. You may want to ask your
cancer team for a referral to a
dietitian, an expert in nutrition who can give you ideas on how to fight
some of the side effects of your
Malignant mesothelioma (35 of 43) [10/21/2006 2:25:01 AM]
treatment. You may also find it helps to eat small portions every 2
to 3 hours until you feel better and can go
back to a more normal schedule.
One of the best things you can do after treatment is to put healthy
eating habits into place. You will be surprised
at the long-term benefits of some simple changes, like increasing the
variety of healthy foods you eat. Try to eat
5 or more servings of vegetables and fruits each day. Choose whole grain
foods instead of white flour and
sugars. Try to limit meats that are high in fat. Cut back on processed
meats like hot dogs, bologna, and bacon.
Get rid of them altogether if you can. If you drink alcohol, limit yourself
to 1 or 2 drinks a day at the most. And
don't forget to get some type of regular exercise. The combination of
a good diet and regular exercise will help
you maintain a healthy weight and keep you feeling more energetic.
| some words on this site are commonly misspelled: asbestos, asbesos, asbetos, asbests, asbstos, asestos, abestos, asbestoes, asbestous, asbestas, asbestus, asbestso, asbesots, asbetsos, asbsetos, asebstos, absestos, sabestos, asbesto, sbestos |
Rest, Fatigue,
Work, and Exercise
Fatigue is a very common symptom in people being treated for cancer.
This is often not an ordinary type of
tiredness but a “bone-weary” exhaustion that doesn’t
get better with rest. For some, this fatigue lasts a long time
after treatment, and can discourage them from physical activity.
However, exercise can actually help you reduce fatigue. Studies have
shown that patients who follow an
exercise program tailored to their personal needs feel physically and
emotionally improved and can cope better.
If you are ill and need to be on bed rest during treatment, it is normal
to expect your fitness, endurance, and
muscle strength to decline some. Physical therapy can help you maintain
strength and range of motion in your
muscles, which can help fight fatigue and the sense of depression that
sometimes comes with feeling so tired.
Malignant mesothelioma (36 of 43) [10/21/2006 2:25:01 AM]
Any program of physical activity should fit your own situation. An older
person who has never exercised will
not be able to take on the same amount of exercise as a 20-year-old
who plays tennis 3 times a week. If you
haven’t exercised in a few years but can still get around, you
may want to think about taking short walks.
Talk with your health care team before starting, and get their opinion
about your exercise plans. Then, try to get
an exercise buddy so that you’re not doing it alone. Having family
or friends involved when starting a new
exercise program can give you that extra boost of support to keep you
going when the push just isn’t there.
If you are very tired, though, you will need to balance activity with
rest. It is okay to rest when you need to. It is
really hard for some people to allow themselves to do that when they
are used to working all day or taking care
of a household. (For more information about fatigue, please see the
publication, "Cancer Related Fatigue and
Anemia Treatment Guidelines for Patients.")
• Exercise can improve your physical and emotional health.
• It improves your cardiovascular (heart and circulation) fitness.
• It strengthens your muscles.
• It reduces fatigue.
• It lowers anxiety and depression.
• It makes you feel generally happier.
• It helps you feel better about yourself.
And long term, we know that exercise plays a role in preventing some
cancers. The American Cancer Society,
in its guidelines on physical activity for cancer prevention, recommends
that adults take part in at least 1
physical activity for 30 minutes or more on 5 days or more of the week.
Children and teens are encouraged to
try for at least 60 minutes a day of energetic physical activity on
at least 5 days a week.
How About Your Emotional Health?
Malignant mesothelioma (37 of 43) [10/21/2006 2:25:01 AM]
Once your treatment ends, you may find yourself overwhelmed by emotions.
This happens to a lot of people.
You may have been going through so much during treatment that you could
only focus on getting through your
treatment.
Now you may find that you think about the potential of your own death,
or the effect of your cancer on your
family, friends, and career. You may also begin to re-evaluate your
relationship with your spouse or partner.
Unexpected issues may also cause concern -- for instance, as you become
healthier and have fewer doctor visits,
you will see your health care team less often. That can be a source
of anxiety for some.
This is an ideal time to seek out emotional and social support. You
need people you can turn to for strength and
comfort. Support can come in many forms: family, friends, cancer support
groups, church or spiritual groups,
online support communities, or individual counselors.
Almost everyone who has been through cancer can benefit from getting
some type of support. What's best for
you depends on your situation and personality. Some people feel safe
in peer-support groups or education
groups. Others would rather talk in an informal setting, such as church.
Others may feel more at ease talking
one-on-one with a trusted friend or counselor. Whatever your source
of strength or comfort, make sure you have
a place to go with your concerns.
The cancer journey can feel very lonely. It is not necessary or realistic
to go it all by yourself. And your friends
and family may feel shut out if you decide not include them. Let them
in -- and let in anyone else who you feel
may help. If you aren’t sure who can help, call your American
Cancer Society at 1-800-ACS-2345 and we can
put you in touch with an appropriate group or resource.
Malignant mesothelioma (38 of 43) [10/21/2006 2:25:01 AM]
You can’t change the fact that you have had cancer. What you can
change is how you live the rest of your life --
making healthy choices and feeling as well as possible, physically and
emotionally.
What Happens if Treatment Is No Longer Working?
If cancer continues to grow after one kind of treatment, or if it returns,
it is often possible to try another
treatment plan that might still cure the cancer, or at least shrink
the tumors enough to help you live longer and
feel better. On the other hand, when a person has received several different
medical treatments and the cancer
has not been cured, over time the cancer tends to become resistant to
all treatment. At this time it’s important to
weigh the possible limited benefit of a new treatment against the possible
downsides, including continued
doctor visits and treatment side effects.
Everyone has his or her own way of looking at this. Some people may
want to focus on remaining comfortable
during their limited time left.
This is likely to be the most difficult time in your battle with cancer
-- when you have tried everything
medically within reason and it’s just not working anymore. Although
your doctor may offer you new treatment,
you need to consider that at some point, continuing treatment is not
likely to improve your health or change
your prognosis or survival.
If you want to continue treatment to fight your cancer as long as you
can, you still need to consider the odds of
more treatment having any benefit. In many cases, your doctor can estimate
the response rate for the treatment
you are considering. Some people are tempted to try more chemotherapy
or radiation, for example, even when
their doctors say that the odds of benefit are less than 1%. In this
situation, you need to think about and
understand your reasons for choosing this plan.
| some words on this site are commonly misspelled: asbestos, asbesos, asbetos, asbests, asbstos, asestos, abestos, asbestoes, asbestous, asbestas, asbestus, asbestso, asbesots, asbetsos, asbsetos, asebstos, absestos, sabestos, asbesto, sbestos |
Malignant mesothelioma (39 of 43) [10/21/2006 2:25:01 AM]
No matter what you decide to do, it is important that you be as comfortable
as possible. Make sure you are
asking for and getting treatment for any symptoms you might have, such
as pain. This type of treatment is
called “palliative” treatment.
Palliative treatment helps relieve these symptoms, but is not expected
to cure the disease; its main purpose is to
improve your quality of life. Sometimes, the treatments you get to control
your symptoms are similar to the
treatments used to treat cancer. For example, radiation therapy might
be given to help relieve bone pain from
bone metastasis. Or chemotherapy might be given to help shrink a tumor
and keep it from causing a bowel
obstruction. But this is not the same as receiving treatment to try
to cure the cancer.
At some point, you may benefit from hospice care. Most of the time,
this can be given at home. Your cancer
may be causing symptoms or problems that need attention, and hospice
focuses on your comfort. You should
know that receiving hospice care doesn’t mean you can’t
have treatment for the problems caused by your cancer
or other health conditions. It just means that the focus of your care
is on living life as fully as possible and
feeling as well as you can at this difficult stage of your cancer.
Remember also that maintaining hope is important. Your hope for a cure
may not be as bright, but there is still
hope for good times with family and friends -- times that are filled
with happiness and meaning. In a way,
pausing at this time in your cancer treatment is an opportunity to refocus
on the most important things in your
life. This is the time to do some things you’ve always wanted
to do and to stop doing the things you no longer
want to do.
What’s New in Malignant mesothelioma Research and Treatment?
Malignant mesothelioma (40 of 43) [10/21/2006 2:25:01 AM]
There is always research going on in the area of mesothelioma . Scientists
are looking for causes and ways to
prevent mesothelioma . Doctors are working to improve accuracy of diagnosis
and effectiveness of treatment.
Despite recent progress, much remains to be learned about the best way
to treat these cancers.
Causes and Prevention
Much of the research on mesothelioma
has focused on learning exactly how asbestos changes mesothelial cells
and their DNA to cause these cancers. Understanding how these
fibers produce cancer might help us develop
ways to prevent those changes.
The risk of asbestos
in developing mesothelioma
is a definite public health concern. We are continuously
learning more about which fibers can produce cancer, how they cause
these cancers, and what levels of
exposure can be considered safe. Now that we know about the dangers
of asbestos, we can limit or stop
exposure in homes, public buildings, and the workplace. Unfortunately,
regulations protecting workers from
asbestos exposure
are much less stringent in some countries and nonexistent in others.
Research is also underway to clarify the role (if any) of SV40, a virus
that has been linked to mesothelioma
in
some studies.
New Drugs
Because chemotherapy drugs have not been very effective against advanced
mesothelioma , several new
approaches to cancer treatment are now being studied. These include
anti-angiogenesis drugs (which kill
cancers by stopping their blood supply) such as Bevacizumab (Avastin)
and anti-growth factor drugs (which
interfere with substances some cancer cells produce to stimulate their
own growth) such as Erlotinib (Tarceva).
Multimodality Therapy
Malignant mesothelioma (41 of 43) [10/21/2006 2:25:01 AM]
Doctors are always learning more about the best way to treat patients
with mesothelioma s. The roles of surgery,
radiation therapy, and chemotherapy in the treatment of mesothelioma are highly debated.
Treatments that use
some combinations of surgery, radiation therapy, and chemotherapy, called
multimodality therapy, are now
being studied and may provide the most promising option for some patients.
New chemotherapy drugs are
currently being tested in clinical trials, together with other types
of treatment.
Ranpirnase (Onconase) is an enzyme that breaks down RNA and in preliminary
studies has helped some
patients with mesothelioma
to love longer. Larger clinical trials are currently
in progress. Another new drug
being tested in mesothelioma
clinical trials is suberoylanilide hydroxamic acid (vorinostat,
[SAHA]), which
may reduce growth of mesothelioma
cells by inhibiting an enzyme that controls certain
proteins called histones,
which regulate DNA.
Gene Therapy
A new approach to cancer therapy being tested on mesothelioma is gene therapy. One
of these approaches to
treating mesothelioma uses
special viruses that have been modified in the laboratory. The modified
virus is
injected into the pleural space and infects the mesothelioma cells. When this infection
occurs, the virus injects a
gene into the mesothelioma
for interferon-beta, an immune system hormone (cytokine)
that may help activate
immune system cells to attack the cancer.
Additional Resources
More Information From Your American Cancer Society
We have selected some related information that may also be helpful to
you. These materials can be ordered
from our toll-free number 1-800-ACS-2345.
After Diagnosis: A Guide for Patients and Families (also available in
Spanish)
Caring for the Patient with Cancer at Home (also available in Spanish)
Malignant mesothelioma (42 of 43) [10/21/2006 2:25:01 AM]
Pain Control: A Guide for People With Cancer and Their Families (also
available in Spanish)
Surgery (also available in Spanish)
Understanding Radiation Therapy (also available in Spanish)
Chemotherapy (also available in Spanish)
The following books are available from the American Cancer Society.
Call us at 1-800-ACS-2345 to ask about
costs or to place your order.
American Cancer Society’s Guide to Pain Control
Cancer in the Family: Helping Children Cope with a Parent’s Illness
Caregiving: A Step-By-Step Resource for Caring for the Person with Cancer
at Home
National Organizations and Web Sites*
In addition to the American Cancer Society, other sources of patient
information and support include:
Agency for Toxic Substances and Disease Registry
Telephone 1-888-422-8737
Internet Address: www.atsdr.cdc.gov
Environmental Protection Agency
Telephone: 1-202-272-0167
Internet Address: www.epa.gov
National Cancer Institute
Telephone: 1-800-4-CANCER
Internet Address: www.cancer.gov
Occupational Safety and Health Administration
Telephone: 1-800-321-6742
Internet Address: www.osha.gov
*Inclusion on this list does not imply endorsement by the American Cancer
Society
The American Cancer Society is happy to address almost any cancer-related
topic. If you have any more
questions, please call us at 1-800-ACS-2345 at any time, 24 hours a day.
References
Malignant mesothelioma (43 of 43) [10/21/2006 2:25:01 AM]
Aisner J, Belani CP, Aisner SC. Tumors of the pleura and mediastinum.
In: Abeloff MD, Armitage JO, Lichter
AS, Niederhuber JE. Kastan MB, McKenna WG. Clinical Oncology. Philadelphia, PA. Elsevier: 2004: 1745-
1786.
American Joint Committee on Cancer. Pleural mesothelioma . AJCC Cancer
Staging Manual. 6th ed. New
York, New York. Springer: 179-184.
Chahinian AP, Pass HI. Malignant
mesothelioma In: Kufe DW, Pollock RE, Weichselbaum RR,
Bast RC,
Gansler TS, Holland JF, Frei E. Cancer Medicine 6. Hamilton, Ont: BC
Decker; 2003. 1447-1466.
Pan X, Day W, Wang W, et al. Residential proximity to naturally occurring
asbestos and mesothelioma risk in
California. Am J Resp Crit Care. 2005;172:1019-1025.
Pass HI, Vogelzgang NJ, Hahan SM, Carbone M.
Benign and malignant mesothelioma In: DeVita VT, Heilman
S, Rosenberg SA, eds. Cancer: Principles and Practice of Oncology. Philadelphia, PA: Lippincott Williams
&
Wilkins 2005: 1687-1716.
Price B, Ware A. mesothelioma trends in the
End Results program date for 1973-2003.
Robinson BWS, Musk AW, Lake RA. Malignant mesothelioma . Lancet. 2005; 366:397-408.
Robinson BWS, Lake RA. Advances in malignant mesothelioma . N Engl J Med. 2005; 353:1591-1603.
| some words on this site are commonly misspelled: asbestos, asbesos, asbetos, asbests, asbstos, asestos, abestos, asbestoes, asbestous, asbestas, asbestus, asbestso, asbesots, asbetsos, asbsetos, asebstos, absestos, sabestos, asbesto, sbestos |
ATTORNEY:
(also known
simply an attorney or lawyer) in the
The American legal system has a united (or fused) legal profession, and does not draw a distinction between lawyers who plead in court and those who do not. Many other common law jurisdictions, as well as some civil law jurisdictions, have a separation, such as the solicitor and barrister/advocate split in the United Kingdom and the advocate/civil law notary split in France. There is also no delegation of routine work to notaries public or their civil law equivalent.
Comparison: attorney in fact and attorney at law
Broadly speaking, an "attorney" is one who acts on behalf of another person in some capacity. For example, an "attorney-in-fact" is a kind of agent who acts on behalf of another person, typically with respect to business, property, or personal matters, and who does not have to be licensed to practice law or to have any other license from the government. The term "power of attorney" refers to the authority of an attorney-in-fact to act in the name of another person, and to the signed document which is evidence of such authority.
By contrast an attorney at law, or lawyer, is a person trained and licensed to practice law — to represent clients in legal matters (both in and out of court), and to give legal advice. In the United States, the term "attorney," standing alone, is generally intended to have this meaning (and not to mean "attorney in fact").
The term "Attorney General" is used to designate the chief law enforcement officer of a state or other political jurisdiction. The attorney general is a lawyerwho represents the government, prosecutes criminal cases, defends the government from lawsuits against it, and brings civil lawsuits to enforce consumer protection and antitrust laws.
Comparison to older domestic terminology and foreign terminology
In common
law jurisdictions outside the
In earlier
times, some states, as well as the U.S. Supreme Court, maintained a
divided legal profession, as can still be found in the
Some attorneys use the post-nominal "Esq.", the abbreviated form of the word Esquire.
The job of an attorney
Once admitted to practice by the highest court of a state (a function sometimes administered by the state's bar association), an American attorney may file legal pleadings and argue cases in any court in that state (except federal courts, which usually require a separate admission), provide legal advice to clients, and draft important legal documents (such as wills, trusts, deeds, and contracts). American attorneys use the term lawyering to refer to the art of practicing law.
In some states, real estate closings may be performed only by attorneys, even though the attorney's role in a closing may involve primarily notarization of documents and disbursement of settlement funds through an escrow account.
Practicing law can be broadly generalized as:
1. Interviewing
the client and identifying what is their legal matter or dispute;
2. Identifying the discrete legal and factual issues embedded within
the client's larger problem;
3. Researching systematically each issue;
4. Deriving a solution that resolves some, if not all of the issues;
5. Executing it through specific tasks like drafting a contract or filing
a motion with a court.
Most academic legal training is directed to identifying legal issues, researching facts and law, and arguing both the facts and law in favor of either side in any case.
Media images
Contrary to the media image of attorneys, much legal work requires hours of in-depth research in a law library or in an electronic database like Westlaw or LexisNexis. Few television programs and movies accurately portray the long nights surrounded by a pile of books or printouts which form the core of the occupational life of many attorneys. One occasional exception is the television program Law & Order, which sometimes shows the main characters researching at a computer late into the night, always using Westlaw, due to a contract between Westlaw and the show's producers.
Movies and television also do not show the stressful "juggling" aspect of litigation, in that most litigators have many cases in progress at any given time. Each case has deadlines that must be carefully monitored, and court dates which one must not forget to attend. The other side in any case can serve additional motions that will further complicate things. Repeated failures to attend to details—or indeed, even a single mistake, in some instances—can lead to malpractice suits or disbarment.
In litigation,
attorneys spend much time discovering the facts of the case to develop
a "theory of the case" that integrates facts and law in a
way most favorable to their client. The discovery phase of a case sometimes
turns into an unpleasant war of attrition over petty technicalities
although many lawyers believe that civility is
more commonplace in discovery than the unfortunate but well publicized
exceptions. Some attorneys believe approximately 50% to 70% of all funds
spent on legal services in the
In addition, there are a large number of attorneys whose practice specializes in activities that never involve them in litigation, such as writing legal opinions, advising clients, drafting contracts, preparing tax strategies, and preparing and prosecuting filings with government agencies such as the Internal Revenue Service, the Securities and Exchange Commission, and the Patent and Trademark Office. It can be rare for such attorneys to appear in court, and even to wear a suit or a tie, though this reality is all but absent in media depictions of attorneys.
A fair number
of licensed attorneys are unemployed or underemployed, or float from
one temporary assignment to another, doing nothing but poring through
the discovery process. The relatively new phenomenon of many lawyers being unemployed, underemployed,
or paid at relatively low wages is largely a consequence of changes
actively pursued, including by the American Bar Association (ABA), starting
in the 1960s. Many in the profession had determined that legal services
would remain difficult or impossible to attain for the less well-off
unless the supply of lawyers
was increased relative to the demand for legal services. In sharp contrast
with the medical profession and medical schools, the ABA has encouraged the creation and accreditation of
new law schools since that time. As a result, the number of lawyers relative to the total population
has more than doubled in the
Specialization
Many American attorneys limit their practices to specialized fields of law. Often dichotomies are drawn between different types of attorneys, but these are neither fixed nor formal lines. Examples include:
* Litigators
(who sue and defend in court) v. transactional (or "office practice")
attorneys (who draft documents and advise clients, rarely going to court)
* Attorneys in private practice and small firms (who can't afford to
litigate every little issue) v. big firms (who can)
* Plaintiffs' attorneys (individual attorneys and small firms who represent
individuals on contingent fee agreements, such as Jason S. Turchin,
Esq. [1]) v. defendants' attorneys (big firms billing large corporations
by the hour)
* Trial attorneys (who argue the facts, such as Johnnie Cochran) v.
appellate attorneys (who argue the law, such as David Boies)
* Outside counsel (law firms) v. in-house counsel (corporate legal department)
Despite these descriptions, some states sometimes forbid or discourage claims of specialization in particular areas of law unless the attorney has been certified by his or her state bar[2] or state board of legal specialization. Other states allow indirect indications of specialization (in forms of advertisements such as "our practice is limited to . . .") but require that the lawyer state that he or she is not certified by a state board of legal specialization in the advertised practice area. Patent attorneys are allowed to advertise their specialization in all jurisdictions, since registration for patent law is administered by the United States Patent and Trademark Office (USPTO) instead of a state-level body.
Some states grant formal certifications recognizing specialties. In California, for example, bar certification is offered in family law, appellate practice, criminal law, bankruptcy, estate planning, immigration, taxation and workmen's compensation. Any attorney meeting the bar requirements in one of these fields may represent himself as a specialist. Similarly, Texas formally grants certification of specialization in the following fields: administrative law; business bankruptcy law; civil appellate law; civil trial law; consumer bankruptcy law; consumer & commercial law; criminal law; estate planning & probate law; family law; health law; immigration & nationality law; juvenile law; labor & employment law; oil, gas & mineral law; personal injury trial law; real estate law; tax law; and workers' compensation law.[3]
The vast majority of lawyers practicing in a particular field may typically not be certified as specialists in that field (and state board certification is not generally required to practice law in any field). For example, the State Bar of Texas (as of mid 2006) reported 77,056 persons licensed as attorneys in that state (excluding inactive members of the Bar)[1], while the Texas Board of Legal Specialization reported, at about the same time, only 8,303 Texas attorneys who were board certified in any specialty.[4] Indeed, of the 8,303 certified specialists in Texas, the highest number of attorneys certified in one specific field at that time was 1,775 (in personal injury trial law). Despite the relative large number of lawyers that presumably would handle divorce, adoption and child custody matters, Texas reported that of 77,056 attorneys, only 697 in the entire state were certified in family law (which is, arguably, the applicable specialty).
Specialization in patent law is administered by the Office of Enrollment and Discipline of the USPTO, which imposes stringent requirements for applicants to become registered as patent attorneys or patent agents.
About half of American attorneys work solo or in small firms. See law firm. There are also many midsize firms, with anywhere from 50 to 200 attorneys, and since the 1970s, some law firms have merged to form giant "megafirms" with 1,000 attorneys or more.
Control of cases
An American attorney licensed in each applicable court may in a few cases control and argue his or her case at each level of the judiciary through its entire lifecycle. A notable example of this is the Brown v. Board of Education litigation, where the same trial team handled the case from start to finish at the U.S. Supreme Court. However, cases which advance to the appellate level, particularly to the U.S. Supreme Court, are often re-assigned to experienced appellate practitioners or firms.
Education and training
Main article:
Legal education in the
Almost all
The degree
earned by prospective attorneys in the
The content of the J.D./D.Jur. curriculum is substantially the same as for a LL.B. curriculum, except that study for the doctoral level degree builds upon prior undergraduate education whereas the LL.B. is still an undergraduate degree, even in those few countries where it is conferred at graduate level as a second Bachelor's degree. As a professional doctorate, people who hold the J.D./D.Jur. are fully entitled to call themselves "Doctor," though most do not bother. The label "doctor" is an academic tradition, but the tradition in the American legal profession is to call all attorneys "Mr." or "Ms." regardless of their academic qualifications. A litigator with a Ph.D., a M.D., an Ed.D., a Psy.D., as well as a J.D. would still be addressed "Mr." or "Ms." while she or he was making an oral argument before the U.S. Supreme Court.
The LL.M.,
however, continues to be offered in the
Many foreign educated attorneys who have LL.B. degrees come to the United States and obtain an LL.M. degree in comparative law, familiarizing themselves with American common law, from when they then take the bar exam in New York or California, which allows foreign attorneys with such degrees to sit for the test.
The Paul M. Hebert Law Center at Louisiana State University in the
The highest
law degree obtainable in the
The S.J.D. or J.S.D. degree is very rarely awarded, and is generally only sought by attorneys holding exceptional credentials and a desire to enter legal academia. The degree is generally only offered at the very top law schools, which typically accept only 4 or 5 students into their program each year. Admission is limited to those who have achieved their J.D. and LL.M. degrees with distinction. Successful applicants usually have already published significant scholarly legal articles in their proposed area of study, and many have legal teaching experience prior to entering the program.
Law students in court
Some courts allow law students to act as "certified student attorneys" after the satisfactory completion of their first year of law school and the completion of particular second- and third-year courses with subjects such as evidence. Many states allow students to argue in front of a court as a certified legal intern (CLI), provided they meet certain prerequisites, such as requiring the student to have completed at least half of their law education, taken or is taking the law school's ethics class, and they are under the supervision of a qualified and licensed attorney.
This concept
was somewhat misrepresented in the movie Legally Blonde, where the protagonist
Elle argues before a jury. Although Elle was under the supervision of
an attorney, no state would allow a student still completing the first
year of law to argue a case in court. However, it is reminicsent of
"teen court" programs that are expanding around the
Illinois: The 711 license
In Illinois a student currently in good standing who has earned credits that represent at least three-fifths of the credits required for graduation may be eligible for a 711 license (based on Illinois Supreme Court Rule 711). A 711 license allows a student to: (1) Counsel with clients, negotiate in the settlement of claims, and engage in the preparation and drafting of legal instruments. (2) Appear in the trial courts and administrative tribunals subject to the following qualifications: (i) Appearances, pleadings, motions, and other documents to be filed with the court may be prepared by the student or graduate and may be signed by him with the accompanying designation "Senior Law Student" or "Law Graduate" but must also be signed by the supervising member of the bar. (ii) In criminal cases, in which the penalty may be imprisonment, in proceedings challenging sentences of imprisonment, and in civil or criminal contempt proceedings, the student or graduate may participate in pretrial, trial, and posttrial proceedings as an assistant of the supervising member of the bar, who shall be present and responsible for the conduct of the proceedings. (iii) In all other civil and criminal cases the student or graduate may conduct all pretrial, trial, and posttrial proceedings, and the supervising member of the bar need not be present. (3) He/She may prepare briefs, excerpts from the record, abstracts, and other documents filed in courts of review of the State, which may set forth the name of the student or graduate with the accompanying designation "Senior Law Student" or "Law Graduate" but must be filed in the name of the supervising member of the bar.
A JD graduate of the College of Law may qualify for a 711 license if s/he (1) has not yet had an opportunity to take the first Bar examination scheduled after s/he graduates, or (2) has taken the Bar exam but has not received the results, or (3) has taken and passed the Bar examination but has not yet been sworn in as a member of the Illinois bar.
A 711 license is not available for a student working for a private law firm. The license is available for work with (1) a legal aid bureau, legal assistance program, organization or clinic chartered by the State of Illinois or approved by a law school approved by the American Bar Association. (2) the Office of the Public Defender, or (3) a law office of the State or any of its subdivisions.
Unlicensed practice of law
Some states provide criminal penalties for (1) falsely holding oneself out to the public as a lawyer, and (2) the unauthorized practice of law by a non-lawyer.
A person who has a J.D. degree but is not admitted to any bar is not a lawyer, and cannot legally engage in the practice of law. In most states, even the practice of law by an "out-of-state" lawyeris considered the unauthorized practice of law within that state. Exceptions are sometimes made when the out-of-state lawyeris permitted temporarily to practice within the state pro hac vice or in some cases as in-house counsel for corporations.
In addition,
a few areas of law, such as patent law, are mandated by the U.S. Constitution
to be strictly under federal jurisdiction. In this case, state courts
and bar associations are not allowed to restrict the practice of that
field of law, and a patent attorney may freely advise clients as to
patent matters anywhere in the jurisdiction of the
In some jurisdictions, the definition of the practice of law is quite strict; persons have been successfully prosecuted for publishing do-it-yourself will forms and for representing special education children in federal proceedings as specifically allowed by federal law.
Paradoxically, some jurisdictions will allow a non-attorney to sit as a judge, usually in lower courts or in hearings by governmental agencies, even though a non-attorney may not practice before these same courts. This extends to the U.S. Constitution itself, which does not mention any requirement that a U.S. Supreme Court justice or other federal judge be a lawyer, although it appears that no non-lawyer has ever been appointed as a federal judge.
American attorneys' attire
Unlike their counterparts in other common law jurisdictions, American attorneys are not required to wear wigs, robes or any other items of court dress when they appear in court. They are expected to wear contemporary business suits.
The one exception is the United States Solicitor General, who traditionally argues before the U.S. Supreme Court in 19th-century attire, including a "morning coat" with tails.
Attorneys
in the
Alternatives to the practice of law
Because an accredited legal education generally provides a strong understanding of not only the substance of the law, but also an advanced analytical approach to the use and ramifications of the law, many professions, other than the practice of law, promote or require those with legal educations. As a result of overcrowding in the legal profession, the desire to achieve better work/life balance, and disenchantment with the legal profession, many attorneys are leaving the Bar to pursue these other professions that take advantage of the attorney's legal education. In some instances, graduates of law school who either cannot be admitted or who decide not to bother to be admitted to a state bar, enter these various professions.
Alternative careers that seek legally educated employees include:
* Work with
the government as a policy analyst or a legislative drafter (the latter
is sometimes classified as a 'policy analyst' and sometimes as a 'lawyer');
* Work for a publisher of a legal information publication;
* Work in banking, finance, real estate, insurance;
* Work in law enforcement.
In these fields, law degrees are useful (and sometimes mandatory, such as in the case of policy analysts and legislative drafters) qualifications for a job.
See Wikipedia, Attorney at law, http://en.wikipedia.org/wiki/Attorney_at_law (optional description here) (as of Jan. 15, 2007, 07:33 GMT).
A LAWYER
, or legal practitioner, is a person certified to give legal advice who advises clients in legal matters. Some lawyers represent clients in courts of law and in other forms of dispute resolution.
Law is a theoretical and abstract discipline, and working as a lawyerrepresents the practical application of legal theory and knowledge to solve real problems or to advance the interests of those who retain (i.e., hire) lawyers for legal services.
The role of the lawyervaries significantly across legal jurisdictions, and therefore can be treated here in only the most general terms. More information is available in country-specific articles (see below).
The meaning of the word "lawyer" varies slightly between English dialects. In American English, the term is synonymous with licensed attorneys who practice civil or criminal law. For consistency, the narrower definition is generally used throughout this article—in the sense that a lawyerprovides representation and advice, as opposed to deciding cases or writing laws.
In British English, the word "lawyer" is used loosely to refer to a broad variety of law-trained persons. It includes practitioners such as barristers, solicitors, and legal executives; and people who are involved with the law but do not practice it on behalf of individual clients, such as judges, law clerks, and legislators.
In Australian English, the word "lawyer" is used to refer to both barristers and solicitors (whether in private practice or practising as corporate in-house counsel) but not people who do not practice the law.
In Canadian English, the word "lawyer" only refers to individuals who have been called to the bar. They may also be known as "barristers and solicitors", but should not be referred to as "attorneys", as that word has a different meaning under Canadian law.
Responsibilities
In most countries, particularly civil law countries, there has been a tradition of giving many legal tasks to a variety of civil law notaries, clerks, and scriveners.[1] These countries do not have "lawyers" in the American sense, insofar as that term refers to a single type of general-purpose legal services provider;[2] rather, their legal professions consist of a large number of law-trained persons, known as jurists, of which only some are advocates who are licensed to practice in the courts.[3][4] Notably, England, the mother of the common law jurisdictions, emerged from the Dark Ages with similar complexity in its legal professions, but then evolved by the 19th century to a single dichotomy between barristers and solicitors. An equivalent dichotomy developed between advocates and procurators in some civil law countries, though these two types did not always monopolize the practice of law as much as barristers and solicitors, in that they always coexisted with civil law notaries.[5][6][7]
Several countries that originally had two or more legal professions have since fused or united their professions into a single type of lawyer.[8][9][10][11] Most countries in this category are common law countries, though France, a civil law country, merged together its jurists in 1990 and 1991 in response to Anglo-American competition.[12] In countries with fused professions, a lawyeris usually permitted to carry out all or nearly all the responsibilities listed below.
Oral argument in the courts
Arguing a client's case before a judge or jury in a court of law is the traditional province of the barrister.
However,
the boundary between barristers and solicitors has gradually evolved
over time. For example, in
In some countries, litigants have the option of arguing pro se, or on their own behalf. It is common for litigants to appear unrepresented before certain courts like small claims courts; indeed, many such courts do not allow lawyers to speak for their clients, in an effort to save money for all participants in a small case.[14] In other countries, like Venezuela, no one may appear before a judge unless represented by a lawyer.[15] The advantage of the latter regime is that lawyers are familiar with the court's customs and procedures, and make the legal system more efficient for all involved. Unrepresented parties often damage their own credibility or slow the court down as a result of their inexperience.[16][17]
Research and drafting of court papers
Often, lawyers brief a court in writing on the issue in a case before the issue can be orally argued. They may have to perform extensive research into relevant facts and law.
In
In
In some
countries, like
Advocacy (written and oral) in administrative hearings
In most developed countries, the legislature has granted original jurisdiction over highly technical matters to executive branch administrative agencies which oversee such things. As a result, some lawyers have become specialists in administrative law. In a few countries, there is a special category of jurists with a monopoly over this form of advocacy; for example, France formerly had conseil juridiques (who were merged into the main legal profession in 1991).[21] In other countries, like the United States, lawyers have been effectively barred by statute from certain types of administrative hearings in order to preserve their informality.[22]
Client intake and counseling (with regard to pending litigation)
In
Legal advice (with regard to all legal matters)
Legal advice is the application of abstract principles of law to the concrete facts of the client's case in order to advise the client about what they should do next. In many countries, only a properly licensed lawyermay provide legal advice to clients for good consideration, even if no lawsuit is contemplated or is in progress.[26][27][28] Therefore, even conveyancers and corporate in-house counsel must first get a license to practice, though they may actually spend very little of their careers in court. Failure to obey such a rule is the crime of unauthorized practice of law.
In other countries, jurists who hold law degrees are allowed to provide legal advice to individuals or to corporations, and it is irrelevant if they lack a license and cannot appear in court.[29][30] Some countries go further; in England and Wales, there is no general prohibition on the giving of legal advice. Sometimes civil law notaries are allowed to give legal advice, as in Belgium.[31] In many countries, non-jurist accountants may provide what is technically legal advice in tax and accounting matters.[32]
Protecting intellectual property
In virtually all countries, patents, trademarks, industrial designs and other forms of intellectual property must be formally registered with a government agency in order to receive maximum protection under the law. The division of such work among lawyers, licensed non-lawyer jurists/agents, and ordinary clerks or scriveners varies greatly from one country to the next.[33][34]
Negotiating and drafting contracts
In some countries, the negotiating and drafting of contracts is considered to be similar to the provision of legal advice, so that it is subject to the licensing requirement explained above.[35] In others, jurists or notaries may negotiate or draft contracts.[36]
Lawyers in some civil law countries traditionally deprecated "transactional law" or "business law" as beneath them. French law firms developed transactional departments only in the 1990s when they started to lose business to international firms based in the United States and the United Kingdom (where solicitors have always done transactional work).[37]
Conveyancing
Conveyancing is the drafting of the documents necessary for the transfer of real property, such as deeds and mortgages. In some jurisdictions, all real estate transactions must be carried out by a lawyer(or a solicitor where that distinction still exists).[38] Such a monopoly is quite valuable from the lawyer's point of view; historically, conveyancing accounted for about half of English solicitors' income (though this has since changed),[39] and a 1978 study showed that conveyancing "accounts for as much as 80 percent of solicitor-client contact in New South Wales."[40] In most common law jurisdictions outside of the United States, this monopoly arose from an 1804 law[41] that was introduced by William Pitt the Younger as a quid pro quo for the raising of fees on the certification of legal professionals such as barristers, solicitors, attorneys and notaries.[42]
In others,
the use of a lawyeris
optional and banks, title companies, or realtors may be used instead.[43]
In some civil law jurisdictions, real estate transactions are handled
by civil law notaries.[44] In England and
Carrying out the intent of the deceased
In many countries, only lawyers have the legal authority to do drafting of wills, trusts, and any other documents that ensure the efficient disposition of a person's property after death. In some civil law countries this responsibility is handled by civil law notaries.[45]
In the
Prosecution of criminal suspects
In many civil law countries, prosecutors are trained and employed as part of the judiciary; they are law-trained jurists, but may not necessarily be lawyers in the sense that the word is used in the common law world.[47] In common law countries, prosecutors are usually lawyers holding regular licenses who simply happen to work for the government office that files criminal charges against suspects.
Education
Main article: Legal education
In some countries, law is taught by a faculty of law, which is a department of a university's general undergraduate college.[48] Law students in those countries pursue a Bachelor of Laws degree. In some countries it is common or even required for students to earn another bachelor's degree at the same time. Nor is the LL.B the sole obstacle; it is often followed by a series of advanced examinations, apprenticeships, and additional coursework at special government institutes.[49]
In other
countries, particularly the
The methods and quality of legal education vary widely. Some countries require extensive clinical training in the form of apprenticeships or special clinical courses.[51] Others do not, like Venezuela.[52] A few countries prefer to teach through assigned readings of judicial opinions (the casebook method) followed by intense in-class cross-examination by the professor (the Socratic method).[53] Many others have only lectures on highly abstract legal doctrines, which forces young lawyers to figure out how to actually think and write like a lawyerat their first apprenticeship (or job).[54][55][56] Depending upon the country, a typical class size could range from five students in a seminar to five hundred in a giant lecture room. In the United States, law schools maintain small class sizes, and as such, grant admissions on a more limited and competitive basis.[57]
Some students have a preference for full-time law programs,[58] while others often work full- or part-time to pay the tuition and fees of their part-time law programs.[59][60]
Law schools in developing countries share several common problems, such as an overreliance on practicing judges and lawyers who treat teaching as a part-time hobby (and a concomitant scarcity of full-time law professors);[61][62] incompetent faculty with questionable credentials;[63] and textbooks that lag behind the current state of the law by two or three decades.[64][65]
Earning the right to practice law
Main articles: Call to the bar and Admission to the bar
Some jurisdictions grant a "diploma privilege" to certain institutions, so that merely earning a degree or credential from those institutions is the primary qualification for practicing law.[66] Mexico allows anyone with a law degree to practice law.[67] However, in a large number of countries, a law student must pass a bar examination (or a series of such examinations) before receiving a license to practice.[66][68][69] In a handful of U.S. states, one may become an attorney by simply passing the bar examination, without having to attend law school first (though very few people actually become lawyers that way).
Some countries require a formal apprenticeship with an experienced practitioner, while others do not. For example, a few jurisdictions still allow an apprenticeship in place of any kind of formal legal education (though the number of persons who actually become lawyers that way is increasingly rare).[70]
Career structure
U.S. President Abraham Lincoln is a famous example of a lawyer-turned-politician.
U.S. President Abraham Lincoln is a famous example of a lawyer-turned-politician.
The career structure of lawyers varies widely from one country to the next.
Common law/civil law
In most
common law countries, especially those with fused professions, lawyers have many options over the
course of their careers. Besides private practice, they can always aspire
to becoming a prosecutor, government counsel, corporate in-house counsel,
administrative law judge, judge, arbitrator, law professor, or politician.[71]
There are also many non-legal jobs which legal training is good preparation
for, such as corporate executive, government administrator, investment
banker, entrepreneur, or journalist. In developing countries like
In most civil law countries, lawyers generally structure their legal education around their chosen specialty; the boundaries between different types of lawyers are carefully defined and hard to cross. After one earns a law degree, career mobility may be severely constrained. For example, unlike their American counterparts,[73] it is difficult for German judges to leave the bench and become advocates in private practice.[74] Another interesting example is France, where for much of the 20th century, all magistrates were graduates of an elite professional school for judges. Although the French magistracy has begun experimenting with the Anglo-American model of appointing judges from accomplished advocates, the few advocates who have actually joined the bench this way are looked down upon by their colleagues who have taken the traditional route to magistracy.[75]
Specialization
In many countries, lawyers are general practitioners who will take almost any kind of case that walks in the door.[76] In others, there has been a tendency since the start of the 20th century for lawyers to specialize early in their careers.[77][78] In countries where specialization is prevalent, many lawyers specialize in representing one side in one particular area of the law; thus, it is common in the United States to hear of plaintiffs' personal injury attorneys.
Organization
Main article: Law firm
Lawyers in private practice generally work in specialized businesses known as law firms, with the exception of English barristers. The vast majority of law firms worldwide are small businesses that range in size from 1 to 10 lawyers. The United States, with its large number of firms with more than 50 lawyers, is an exception.[79] The United Kingdom and Australia are also exceptions, as the UK, Australia and the U.S. are now home to several firms with more than 1,000 lawyers after a wave of mergers in the late 1990s.
Notably,
barristers in
Professional associations and regulation
Mandatory licensing and membership in professional organizations
In some jurisdictions, either the judiciary[80] or the Ministry of Justice[81] directly supervises the admission, licensing, and regulation of lawyers.
Other jurisdictions, by statute, tradition, or court order, have granted such powers to a professional association which all lawyers must belong to.[82] In the U.S., such associations are known as mandatory, integrated, or unified bar associations. In the Commonwealth of Nations, similar organizations are known as Inns of Court, bar councils or law societies.[83] In civil law countries, comparable organizations are known as Orders of Advocates,[84] Chambers of Advocates,[85] Colleges of Advocates,[86] Faculties of Advocates,[87] or similar names. Generally, a nonmember caught practicing law may be liable for the crime of unauthorized practice of law.[88]
In common law countries with divided legal professions, barristers traditionally belong to the bar council (or an Inn of Court) and solicitors belong to the law society. In the English-speaking world, the largest mandatory professional association of lawyers is the State Bar of California, with 200,000 members.
Some countries
admit and regulate lawyers
at the national level, so that a lawyer, once licensed, can argue cases
in any court in the land. This is common in small countries like
Some countries, like Italy, regulate lawyers at the regional level,[96] and a few, like Belgium, even regulate them at the local level (that is, they are licensed and regulated by the local equivalent of bar associations but can advocate in courts nationwide).[97]
Such geographic limitations can be troublesome for a lawyerwho discovers that his client's cause requires him to litigate in a court beyond the normal geographic scope of his license. Although most courts have special pro hac vice rules for such occasions, the lawyerwill still have to deal with a different set of professional responsibility rules, as well as the possibility of other differences in substantive and procedural law.
Some countries grant licenses to non-resident lawyers, who may then appear regularly on behalf of foreign clients. Others require all lawyers to live in the jurisdiction or to even hold national citizenship as a prerequisite for receiving a license to practice; for example, the Supreme Court of Canada has upheld the constitutionality of a citizenship requirement.[98] In contrast, American citizenship and residency requirements were struck down as unconstitutional by the U.S. Supreme Court in 1973 and 1985, respectively.[99]
Who regulates lawyers
A key difference among countries is whether lawyers should be regulated solely by an independent judiciary and its subordinate institutions (a self-regulating legal profession), or whether lawyers should be subject to supervision by the Ministry of Justice in the executive branch.
In most civil law countries, the government has traditionally exercised tight control over the legal profession in order to ensure a steady supply of loyal judges and bureaucrats. That is, lawyers were expected first and foremost to serve the state, and the availability of counsel for private litigants was an afterthought.[100] Even in civil law countries like Norway which have partially self-regulating professions, the Ministry of Justice is the sole issuer of licenses, and makes its own independent re-evaluation of a lawyer's fitness to practice after a lawyerhas been expelled from the Advocates' Association.[101] Brazil is an unusual exception in that its national Order of Advocates has become a fully self-regulating institution (with direct control over licensing) and has successfully resisted government attempts to place it under the control of the Ministry of Labor.[102][103]
Of all the civil law countries, Communist countries historically went the farthest towards total state control, with all Communist lawyers forced to practice in collectives by the mid-1950s.[104][105]
In contrast, common law lawyers have traditionally regulated themselves through institutions where the influence of non-lawyers, if any, was weak and indirect (despite nominal state control).[106] Such institutions have been traditionally dominated by private practitioners who opposed strong state control of the profession on the grounds that it would endanger the ability of lawyers to zealously and competently advocate their clients' causes in the adversarial system of justice.[107]
However, the concept of the self-regulating profession has been criticized as a sham which serves to legitimize the professional monopoly while protecting the profession from public scrutiny.[108] Disciplinary mechanisms have been astonishingly ineffective, and penalties have been light or nonexistent.[109][110]
Voluntary associations of lawyers
Lawyers are always free to form voluntary associations of their own, apart from any licensing or mandatory membership that may be required by the laws of their jurisdiction. Like their mandatory counterparts, such organizations may exist at all geographic levels.[111][112] In American English, such associations are known as voluntary bar associations.[113] The largest voluntary professional association of lawyers in the English-speaking world is the American Bar Association.
In some
countries, like
Criticism of lawyers
Hostility towards the legal profession is a widespread phenomenon. The legal profession was abolished in Prussia in 1780 and in France in 1789, though both countries eventually realized that their judicial systems could not function efficiently without lawyers.[115] Complaints about too many lawyers were common in both England and the United States in the 1840s[116][117] Germany in the 1910s,[118] and in Australia,[119] Canada,[120] the United States,[121][122][123] and Scotland[124] in the 1980s.
Public distrust of lawyers reached record heights in the United States after the Watergate scandal.[125][123] In the aftermath of Watergate, legal self-help books became popular among those who wished to solve their legal problems without having to deal with lawyers.[126] Lawyer jokes (already a perennial favorite) also soared in popularity in English-speaking North America as a result of Watergate.[127] In 1989, American legal self-help publisher Nolo Press published a 171-page compilation of negative anecdotes about lawyers from throughout human history.[128]
Compensation
Lawyers
are paid for their work in a variety of ways. In private practice, they
may work for an hourly fee according to a billable hour structure, a
contingency fee (usually in cases involving personal injury), or a lump
sum payment if the matter is straightforward. Normally, most lawyers negotiate a written fee agreement up front
and may require a non-refundable retainer in advance. In many countries
there are fee-shifting arrangements by which the loser must pay the
winner's fees and costs; the
Lawyers working directly on the payroll of governments, nonprofits, and corporations usually earn a regular annual salary. Lawyers can also volunteer their labor in the service of worthy causes through an arrangement called pro bono (for the common good). Traditionally such work was performed on behalf of the poor, but in some countries it has now expanded to many other causes like the natural environment.
In some countries, there are legal aid lawyers who specialize in providing legal services to the indigent.[129][130] France and Spain even have formal fee structures by which lawyers are compensated by the government for legal aid cases on a per-case basis.[131] A similar system, though not as extensive or generous, operates in Australia.
In other countries, legal aid specialists are practically nonexistent. This may be because non-lawyers are allowed to provide such services (practice law), as in Norway,[132] or because mandatory fee structures have enabled widespread implementation of affordable legal expense insurance, as in Germany.[133] In Italy, trade unions and political parties provide what can be characterized as legal aid services.[134]
History
The earliest people who could be described as 'lawyers' were probably the orators of ancient Athens (see History of Athens). However, Athenian orators faced serious structural obstacles. First, there was a rule that individuals were supposed to plead their own cases, which was soon bypassed by the increasing tendency of individuals to ask a "friend" for assistance.[135] Fortunately, around the middle of the fourth century BCE, the Athenians disposed of the perfunctory request for a friend.[136] Second, a more serious obstacle, which the Athenian orators never completely overcame, was the rule that no one could take a fee to plead the cause of another. This law was widely disregarded in practice, but was never abolished, which meant that orators could never present themselves as legal professionals or experts.[137] They had to uphold the legal fiction that they were merely an ordinary citizen generously helping out a friend for free, and thus they could never organize into a real profession — with professional associations and titles and all the other pomp and circumstance — like their modern counterparts.[138] Therefore, if one narrows the definition to those men who could practice the legal profession openly and legally, then the first lawyers would have to be the orators of ancient Rome.
A law enacted in 204 BCE barred Roman advocates from taking fees, but the law was widely ignored.[139] The ban on fees was abolished by Emperor Claudius, who legalized advocacy as a profession and allowed the Roman advocates to become the first lawyers who could practice openly — but he also imposed a fee ceiling of 10,000 sesterces.[140] This was apparently not much money; the Satires of Juvenal complain that there was no money in working as an advocate.[141]
Like their Greek contemporaries, early Roman advocates were trained in rhetoric, not law, and the judges before whom they argued were also not law-trained.[142] But very early on, unlike Athens, Rome developed a class of specialists who were learned in the law, known as jurisconsults (iuris consulti).[143] Jurisconsults were wealthy amateurs who dabbled in law as an intellectual hobby; they did not make their primary living from it.[144] They gave legal opinions (responsa) on legal issues to all comers (a practice known as publice respondere).[145] Roman judges and governors would routinely consult with an advisory panel of jurisconsults before rendering a decision, and advocates and ordinary people also went to jurisconsults for legal opinions.[146] Thus, the Romans were the first to have a class of people who spent their days thinking about legal problems, and this is why their law became so "precise, detailed, and technical."[147]
During the Roman Republic and the early Roman Empire, jurisconsults and advocates were unregulated, since the former were amateurs and the latter were technically illegal.[148] Any citizen could call himself an advocate or a legal expert, though whether people believed him would depend upon his personal reputation. This changed once Claudius legalized the legal profession.
By the start of the Byzantine Empire, the legal profession had become well-established, heavily regulated, and highly stratified.[149] The centralization and bureaucratization of the profession was apparently gradual at first, but accelerated during the reign of Emperor Hadrian.[150] At the same time, the jurisconsults went into decline during the imperial period.[151]
In the words of Fritz Schulz: "[B]y the fourth century things had changed in the eastern Empire: advocates now were really lawyers."[152] For example, by the fourth century, advocates had be enrolled on the bar of a court to argue before it, they could only be attached to one court at a time, and there were restrictions (which came and went depending upon who was emperor) on how many advocates could be enrolled at a particular court.[153] By the 380s, advocates were studying law in addition to rhetoric (thus reducing the need for a separate class of jurisconsults); in 460, Emperor Leo imposed a requirement that new advocates seeking admission had to produce testimonials from their teachers; and by the sixth century, a regular course of legal study lasting about four years was required for admission.[154] Claudius's fee ceiling lasted all the way into the Byzantine period, though by then it was measured at 100 solidi.[155] Of course, it was widely evaded, either through demands for maintenance and expenses or a sub rosa barter transaction.[156] The latter was cause for disbarment.[157]
The notaries (tabelliones) appeared in the late Roman Empire. Like their modern-day descendants, the civil law notaries, they were responsible for drafting wills, conveyances, and contracts.[158] They were ubiquitous and most villages had one.[159] In Roman times, notaries were widely considered to be inferior to advocates and jurisconsults.[160] Roman notaries were not law-trained; they were barely literate hacks who wrapped the simplest transactions in mountains of legal jargon, since they were paid by the line.[161]
After the fall of the western Empire and the onset of the Dark Ages, the legal profession of Western Europe collapsed. As James Brundage has explained: "[by 1140], no one in Western Europe could properly be described as a professional lawyeror a professional canonist in anything like the modern sense of the term 'professional.' "[162] However, from 1150 onward, a small but increasing number of men became experts in canon law but only in furtherance of other occupational goals, such as serving the Roman Catholic Church as priests.[163] From 1190 to 1230, however, there was a crucial shift in which some men began to practice canon law as a lifelong profession in itself.[164]
The legal profession's return was marked by the renewed efforts of church and state to regulate it. In 1231 two French councils mandated that lawyers had to swear an oath of admission before practicing before the bishop's courts in their regions, and a similar oath was promulgated by the papal legate in London in 1237.[165] During the same decade, Frederick II, the emperor of the Kingdom of Sicily, imposed a similar oath in his civil courts.[166] By 1250 the a nucleus of a new legal profession had clearly formed.[167] The new trend towards professionalization culminated in a controversial proposal at the second council of Lyon in 1275 that all ecclesiastical courts should require an oath of admission.[168] Although not adopted by the council, it was highly influential in many such courts throughout Europe.[169]
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