This information is about a chemotherapy treatment for mesothelioma that uses pemetrexed and cisplatin. Mesothelioma is a type of cancer that can affect the lining of the lungs (pleura) or the lining of the abdomen (peritoneum). Pemetrexed and cisplatin is used to treat pleural mesothelioma. If you have any questions you can ask your doctor or nurse at the hospital where you are having your treatment, or speak to one of our cancer support service nurses.

The treatment involves the two chemotherapy drugs pemetrexed, which is also known as Alimta®, and cisplatin.

Pemetrexed and cisplatin treatment can usually be given to you as a day patient. Before your treatment begins, you will need to have a blood test, either on the same day, or a few days beforehand. You will also be seen by a doctor, specialist nurse or pharmacist. If the results of your blood test are normal, the pharmacy will prepare your chemotherapy drugs. This may take a couple of hours.

The nurse will put a thin, flexible tube (cannula) into a vein in your hand or arm. You may find this uncomfortable, or a little painful, but it should not take long. Some people have their chemotherapy given through a thin plastic tube, which is inserted under the skin and into a vein near the collarbone (central line), or passed through a line in the arm (PICC line). A central or PICC line will almost certainly be needed if you have your treatment as an outpatient. Your doctor or nurse will explain more about this to you.

You will be given some anti-sickness (anti-emetic) drugs. These are usually given by injection through the cannula, central or PICC line, which will be connected to a drip (infusion). However, some anti-sickness medicines may be given as tablets.

After the anti-sickness drugs, the chemotherapy drugs are given as follows:

• Pemetrexed (a clear fluid) is given as a drip (infusion) through your cannula or line. The infusion will take about 10–15 minutes. Before the treatment, you will be given steroid tablets to take, as these help to prevent a skin reaction (see Possible side effects).

• Cisplatin (a colourless fluid) is also given as an infusion that takes 30–60 minutes. Before, and after, the cisplatin you will be given plenty of fluid through the drip to keep your kidneys working normally. This may mean that you have to stay in hospital overnight. This is sometimes called pre- and post-hydration.

Once treatment has finished you can go home. The cannula will be removed and you will be given a supply of anti-sickness drugs to take with you. It is important to take these as directed, even if you are not feeling sick. This is because some anti-sickness drugs are much better at preventing sickness than at stopping it once it has started.

Your doctor may use the word 'regimen' (eg the pemetrexed cisplatin regimen) when talking about your chemotherapy. This means the whole plan, or schedule, of your chemotherapy treatment.

The vitamins folic acid and Vitamin B12 (also known as cyanocobalamin) are prescribed for you before your treatment with pemetrexed begins (this vitamin treatment is continued throughout your chemotherapy). It is very important to take folic acid and B12, as they reduce the unwanted effects of pemetrexed without reducing its effectiveness.

Vitamin B12 is injected into a muscle one week before the first treatment, and again after every third treatment with pemetrexed (roughly every nine weeks).

Folic acid can be taken as a tablet. It is usually taken a few days before the first treatment, and then every day until three weeks after treatment with pemetrexed is completed.

On the first day of your treatment, you will be given both the pemetrexed and the cisplatin as infusions (as described above). You will then have a rest with no chemotherapy for 20 days. This completes what is called a cycle of treatment. Each cycle takes three weeks (21 days).

You will start the next cycle of your treatment after the rest period, which will be three weeks after your first injection. Usually six cycles are given over a period of five months. This makes up a course of treatment.

Each person's reaction to chemotherapy is different. Some people have very few side effects, while others may experience more. The side effects described here will not affect everyone who is having this chemotherapy regimen. We have outlined the most common side effects, so that you can be aware of them if they occur. However, we have not included those that are rare and therefore unlikely to affect you. If you notice any effects that you think may be due to the drug, but which are not listed here, please let your nurse or doctor know.

Feeling sick (nausea) and being sick (vomiting) Your doctor can prescribe very effective anti-sickness (anti-emetic) drugs to prevent or reduce nausea and vomiting. If sickness is not controlled, or if it continues, tell your doctor. They can prescribe other anti-sickness drugs that may be more effective. Some anti-sickness drugs may cause constipation. Let your doctor or nurse know if this is a problem.

Lowered resistance to infection Pemetrexed and cisplatin chemotherapy can reduce the production of white blood cells by the bone marrow, making you more prone to infection. This effect can begin seven days after treatment has been given, with your resistance to infection usually reaching its lowest point 10–14 days after chemotherapy. Your blood cells will then increase steadily and will usually have returned to normal levels before your next course of chemotherapy is due.

Contact your doctor, or the hospital, straightaway if:

• your temperature goes above 38ºC (100.5ºF)
• you suddenly feel unwell (even with a normal temperature).

You will have a blood test before having more chemotherapy to make sure that your number of white blood cells has returned to normal. Occasionally, it may be necessary to delay treatment if your number of blood cells (blood count) is still low.

Bruising or bleeding Pemetrexed and cisplatin chemotherapy can reduce the production of platelets (which help the blood to clot). Let your doctor know if you have any unexplained bruising or bleeding.

Anaemia (low number of red blood cells) While having this treatment you may become anaemic. This can make you feel tired and breathless. Let your doctor or nurse know if these are a problem.

Sore mouth and ulcers Your mouth may become sore or you may notice small ulcers during treatment. Drinking plenty of fluids, and cleaning your teeth gently and regularly with a soft toothbrush, can help. Tell your nurse or doctor if you have any of these problems, as they can prescribe special mouthwashes and medicines to help prevent or clear any mouth infection.

Loss of appetite You may lose your appetite during your treatment. A dietitian or specialist nurse at your hospital can give you advice on coping with eating problems.

Diarrhoea This can usually be controlled easily with medicine, but tell your doctor if it is severe or if it continues. It is important to drink plenty of fluids (2–3 litres a day) if you have diarrhoea. If you experience any change in bowel habit, tell your doctor.

Numbness or tingling in hands or feet (peripheral neuropathy) This is due to the effect of cisplatin on your nerves. Tell your doctor if you notice these symptoms. The problem usually improves slowly a few months after treatment is over, although it can be permanent.

Tiredness Many people feel extremely tired (fatigued) during chemotherapy, particularly towards the end of treatment. This is a very common side effect and it is important to try to get as much rest as you need.

Gritty and sore eyes If this happens tell your doctor. They can prescribe soothing eye drops.

Skin changes Pemetrexed can cause a rash, which may be itchy. Your doctor can prescribe medicine to help. To help prevent or reduce skin reactions, the steroid dexamethasone may be given with each treatment. The steroid is usually taken for three days, starting on the day before pemetrexed is given.

Hair loss Hair loss is rare, but your hair may thin. If this occurs it usually begins about 3-4 weeks after starting treatment. It is temporary and your hair will return to normal once the treatment is finished.

Ringing in your ears and hearing loss (tinnitus) This may be caused by cisplatin, as may some loss of ability to hear high-pitched sounds. This usually improves when the treatment is over. However, for a small number of people it can be permanent. Tell your doctor if you notice any loss of hearing or ringing in your ears.

Your kidney function may be affected Usually this does not cause any symptoms and the effect is generally mild. Rarely, it may cause permanent damage to your kidneys if treatment is not stopped. Before each treatment you will have a blood test to check your kidney function. You may be asked to drink more than normal on the day after treatment. It is important to tell your doctor, or chemotherapy nurse, if you are not able to drink enough. Let your doctor or nurse know if you are not passing as much urine as normal.

Strange taste Occasionally during treatment you may experience a strange taste, sometimes described as metallic or bitter. Sucking on a strongly-flavoured sweet or mint can sometimes help to disguise this.

Allergic reaction Signs of an allergic reaction include skin rashes and itching, a high temperature, shivering, redness or darkening of the face, dizziness, headaches, breathlessness, anxiety, and a need to pass urine. You will be monitored for signs of an allergic reaction during the treatment. Tell your doctor or nurse if you have any of these symptoms.

While you are receiving pemetrexed, it is best that you do not use any folic acid supplements other than those prescribed by your cancer specialist. Some multivitamins or food supplements also contain folic acid, so it is best to consult your pharmacist before taking these.

Risk of blood clots Cancer can increase your risk of developing a blood clot (thrombosis), and having chemotherapy may increase this risk further. A blood clot may cause symptoms such as pain, redness and swelling in a leg, or breathlessness and chest pain. Blood clots can be very serious, so it is important to tell your doctor straightaway if you have any of these symptoms. However, most clots can usually be successfully treated by using drugs which thin the blood. Your doctor or nurse can give you more information.

Other medicines These can be harmful to take when you are having chemotherapy. Let your doctor know about any medications you are taking, including non-prescribed drugs such as over-the-counter medications, complementary therapies and herbal drugs.

Leakage into the tissue around the vein If this happens while the chemotherapy is being given, the tissue in that area can be damaged. If you notice any stinging or burning around the vein while the drugs are being given, tell your doctor or nurse immediately.

Fertility Your ability to become pregnant or father a child may be affected by this treatment. It is important to discuss fertility with your doctor before starting treatment.

Contraception It is not advisable to become pregnant or father a child while taking this treatment, as it may harm the developing foetus. It is important to use effective contraception whilst taking this drug, and for some time afterwards. Again, discuss this with your doctor.

This section is based upon our pemetrexed and cisplatin chemotherapy factsheet which has been compiled using information from a number of reliable sources, including:

• Martindale: The Complete Drug Reference (35th edition). Eds. Sweetman et al. Pharmaceutical Press, 2007.
• British National Formulary (54th edition). British Medical Association and Royal Pharmaceutical Society of Great Britain, September 2007.
• The Chemotherapy Source Book (3rd edition). Eds Perry, Lippincott, Williams and Wilkins, 2001.

For further references, please see general bibliography.