Mesothelioma: The environmental cancer that strikes on the job.

As a professor and chief of thoracic surgery at Mount Sinai Hospital, Raja Flores operates on cancers of the chest, mostly lung and esophageal cancer. Over the past 15 years, he has specialized in mesothelioma and sees more than 50 cases annually.

Who's at risk

Mesothelioma is a relatively rare cancer that affects about 3,000 Americans a year. "Mesothelioma is a cancer of the lining of the lung," says Flores. "It starts in one spot, creeps throughout the chest and can give a slow, painful death."

According to the National Cancer Institute, the incidence of mesothelioma has increased during the past 20 years. Environmental exposures account for the vast majority of patients.

"Asbestos exposure is the No. 1 risk factor," says Flores. "That refers to naturally occurring minerals present in many industrial products, like cement, textiles and insulation."

Asbestos can become dangerous when inhaled or swallowed, often during manufacturing. Most sufferers of the disease had exposure to asbestos on the job, where it is a risk for workers like insulators, rescue teams (such as after 9/11) and shipyard crews.

One challenge in fighting mesothelioma is that asbestos exposure is often silent and invisible. "Many people don't even know they've been exposed," says Flores. "There can be a 20- to 30-year latency, so it's years after they're exposed that they see symptoms."

A small portion of people have a genetic predisposition to the disease.

"There are identified cohorts in Montana and Turkey, where clusters in the same family got mesothelioma and other exposed people didn't get it," says Flores, "but for the most part, it's environmental."

Signs and symptoms

There aren't characteristic symptoms for mesothelioma that make it easy to diagnose. "Basically, the warning signs are not specific," says Flores. "People who have asbestos exposure are the main group that needs to be on the alert."

Most patients don't have symptoms of mesothelioma until the disease has started to spread and progressed to stage 3 or 4, he says.

"Shortness of breath is a red flag," says Flores. "That's usually from fluid accumulating in the chest, which can also result from a number of benign ­reasons."

Doctors will usually drain the fluid and often find some cancer cells.

"If the doctor can't explain the fluid accumulation, you have to get a biopsy to make sure it's not mesothelioma," says Flores. Chest pain is an indication that the disease has developed to a higher stage.

Traditional treatment

There is now no cure for mesothelioma, and the prognosis depends on how early it is caught. "Survival really depends on stage," says Flores. "What we're trying to do is help patients live longer with better quality of life."

There are three types of the disease: epitheliod, mixed and sarcomatoid. The type of tumor can determine treatment.

Doctors don't have a consensus about whether surgery is necessary. "One group says surgery, one group says no surgery," says Flores.

"There are certain things we can do to improve the patient's condition, so all patients should see a thoracic surgeon when making their decisions about treatment."

There's also no agreement about which surgical approach works best.

"The two main surgeries are extra-pleural pneumonectomy, which removes the lung, and pleurectomy/decortication, which spares the lung," says Flores. "The goal of surgery is to get rid of tumor bulk and expand the lung while decreasing the pain and gross size of the disease."

Another procedure is chemotherapy, which one randomized control trial found had a survival benefit of three months.

Surgeons can't always tell which surgical approach is best for a patient until they can get a better look at the lung during surgery. "CT scans often downplay the amount of cancer," says Flores. "There's not a standard way of doing these surgeries, which is why going to a surgeon who has a lot of experience is the most important thing."

Research breakthroughs

Mesothelioma care is constantly improving. "It's just been two years since the paper came out that convinced us we could be sparing the lung," says Flores. "That's not a magic bullet, and early
detection is probably the closest thing we have coming down the pike."

Questions for your doctor

If your test results come back positive, ask: "What kind of mesothelioma do I have?"

When you're considering treatment options, ask: "What treatment other than surgery might I benefit from?" Once you've decided on surgery, ask: "Can I have lung-sparing surgery, or do I need to have my lung removed?"

What you can do

See a specialist.

Both the surgeon and radiation specialist should be experts in treating mesothelioma. Ask how many patients they’ve treated and how many surgeries they've done.

Know your family history.

If you have a family member with mesothelioma or asbestos exposure, you should get a CT scan to have a baseline reading so your doctor can watch for changes.

Take precautions when working with asbestos.

The No. 1 rule when working with asbestos is to wear a mask. But another important precaution is being careful with your clothing. "If you have a relative who comes home after a long day of working with
asbestos, be very careful not to inhale it off the clothes," says Flores.

Get informed.

The Mesothelioma Foundation (curemeso.org) has helpful information about how to get treatment and where to find financial support.

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