From the Guidelines
The most effective treatment for mesothelioma is a combination of pemetrexed plus platinum-based chemotherapy, which has been shown to improve survival and quality of life in patients with this disease. This recommendation is based on the most recent and highest quality study available, which was published in 2025 1. The study found that pemetrexed plus platinum-based chemotherapy with or without bevacizumab may be offered as a first-line systemic treatment option for patients with epithelioid histology.
Treatment Options
The following treatment options are available for mesothelioma:
- Surgery: pleurectomy/decortication (P/D) or extrapleural pneumonectomy (EPP)
- Chemotherapy: pemetrexed plus platinum-based chemotherapy
- Radiation therapy: often used after surgery or for symptom management
- Immunotherapy: pembrolizumab or nivolumab plus ipilimumab for patients who have progressed after chemotherapy
Chemotherapy Regimens
The standard first-line chemotherapy regimen combines pemetrexed (500 mg/m²) with cisplatin (75 mg/m²) administered intravenously every 3 weeks for 4-6 cycles. Carboplatin may replace cisplatin for patients who cannot tolerate it. Other chemotherapy regimens that may be used include:
- Pemetrexed plus carboplatin
- Gemcitabine plus cisplatin
- Bevacizumab plus pemetrexed plus platinum-based chemotherapy
Patient Selection
Treatment selection depends on the cancer stage, patient's overall health, and mesothelioma type (pleural, peritoneal, etc.). Patients with a poor performance status (PS ≥2) may be offered single-agent palliative chemotherapy or palliative care alone. Patients with a PS of 3 or greater should receive palliative care.
Clinical Trials
Clinical trials may offer access to experimental treatments for patients with limited standard options. Patients should be encouraged to participate in clinical trials to improve treatment outcomes and quality of life. As stated in the 2025 study, systemic therapy (chemotherapy and/or immunotherapy) should be offered to patients with mesothelioma because it improves survival and quality of life 1.
From the Research
Treatment Options for Mesothelioma
The treatment options for mesothelioma include:
- Chemotherapy: Chemotherapy does not appear to prolong the survival of patients with inoperable pleural mesothelioma, and the tumour response rate barely exceeds 20% 2.
- Pemetrexed: Pemetrexed, an antifolate closely related to methotrexate and raltitrexed, has been authorized for use for both conditions 2.
- Cisplatin + Pemetrexed: A combination of cisplatin + pemetrexed seems to provide the best response rates, with a median survival of 12.1 months compared to 9.3 months with cisplatin + placebo 2.
- Vinorelbine: Vinorelbine was moderately active in pemetrexed-pretreated MPM patients, with an acceptable toxicity profile, particularly in patients with ECOG-PS0 and FL-PFS ≥ 6 months 3.
- Bevacizumab: Bevacizumab plus cisplatin/pemetrexed then bevacizumab was well tolerated in Japanese patients with MPM, with a disease control rate of 71.2% 4.
- Gemcitabine and Vinorelbine: The gemcitabine and vinorelbine combination was moderately active and had an acceptable toxicity profile in pemetrexed-pretreated patients with MPM 5.
Second-Line Treatment
Second-line treatment options for mesothelioma include:
- Docetaxel: Docetaxel has been shown to extend survival by about 3 months compared with palliative care in patients with non small cell lung cancer 2.
- Pemetrexed: Pemetrexed cannot replace docetaxel in second-line treatment of non small cell lung cancer 2.
- Vinorelbine: Vinorelbine was given to 34 patients as second-line treatment, with a median progression-free survival of 2.3 months and overall survival of 6.2 months 3.
- Gemcitabine and Vinorelbine: The gemcitabine and vinorelbine combination was moderately active and had an acceptable toxicity profile in pemetrexed-pretreated patients with MPM 5.
Safety and Toxicity
The safety and toxicity of mesothelioma treatments include:
- Pemetrexed: Supplementation with folic acid and vitamin B12 reduces haematological and gastrointestinal complications associated with the antifolate activity of pemetrexed 2.
- Cisplatin + Pemetrexed: The combination of cisplatin + pemetrexed was associated with severe neutropenia, leukopenia, and fatigue in more than 15% of patients 2.
- Vinorelbine: Hematological toxicity was acceptable, with grade 3/4 neutropenia occurring in 5 (8.4%) patients, and there were no cases of febrile neutropenia 3.
- Bevacizumab: Bevacizumab plus cisplatin/pemetrexed then bevacizumab was well tolerated in Japanese patients with MPM, with a disease control rate of 71.2% 4.