Balkinization  

Monday, July 12, 2004

Postponing the Election?

JB

The Bush Administration is now considering contingency plans for postponing the November 2nd, 2004 elections if a terrorist attack should occur in the fall immediately before or on Election Day. Several readers have asked whether this would be constitutional. The short answer is that appropriate legislation passed by Congress could change the day of the election, but there are important constitutional limitations on how this could be done.

Here are a few of the relevant constitutional and legal issues.

The Constitution does not require that elections be held on any particular day. Article II, section 1, cl. 3 states that "[t]he Congress may determine the time of choosing the electors [for President], and the day on which they shall give their votes; which day shall be the same throughout the United States." Article I, section 4, cl. 1 states that "The times, places and manner of holding elections for Senators and Representatives, shall be prescribed in each State by the Legislature thereof; but the Congress may at any time by law make or alter such regulations, except as to the places of choosing Senators." This allows states to set the dates of elections for Congress unless Congress preempts them. Congress has done so in Title 2 sections 1 and 7, and it has chosen the same day for the Presidential election in Title 3 section 1: the first Tuesday after the first Monday in November.

Although Congress may set new dates for elections other than the one it has already chosen, elections for Congress and the President may not be postponed indefinitely past the end of their respective terms, because the Constitution provides that the members of the House are to be chosen "every second year" and members of the Senate serve for "six years." The President, likewise, "shall hold office during the term of four years."

The Twentieth Amendment to the Constitution specifies when the terms of the President and outgoing members of Congress expire, and when new members of Congress and the President are to take office: "The terms of the President and the Vice-President shall end at noon on the 20th day of January, and the terms of Senators and Representatives at noon on the 3rd day of January . . . and the terms of their successors shall then begin."

What happens if elections cannot be held on November 2nd, 2004? Currently the law works as follows: Title 3 section 2 states that "Whenever any State has held an election for the purpose of choosing electors [for President], and has failed to make a choice on the day prescribed by law, the electors may be appointed on a subsequent day in such a manner as the legislature of such State may direct." The law does not specify what happens if no election at all was held. However, one could read the statute together with the Election Clause of Article I, section 4, to imply that individual states have the right to reschedule an election that was never held. But the statutes do not give states the right to postpone an election in advance.

Note however, that the law does not require states to hold new elections for members of the electoral college. The state legislature could pick its own slate of electors, as the Florida legislature tried to do in December 2000. That is a reason for Congress to step in to provide for new popular elections for President.

What about Congressional elections? Well, Title 2, section 8 provides that "[t]he time for holding elections in any State, District, or Territory for a Representative or Delegate to fill a vacancy, whether such vacancy is caused by a failure to elect at the time prescribed by law . . . may be prescribed by the laws of the several States and Territories respectively." This means that the state has the right to schedule new elections for members of the House. Because Title 2 section 1 says that Senators are to be elected at the same time as Representatives, the same rules (presumably) apply to the election of Senators as House members. The Seventeenth Amendment contemplates temporary appointments, or appointments to fill out an existing term of an elected Senator, but it would seem to require elections to fill wholly new Senatorial terms. The bottom line is that if no election is held on November 2nd, 2004, federal law suggests that individual states would be empowered to set their own makeup elections for Congress. But, once again, states have no power to postpone elections in advance.

Under the Elections Clause of Article I, and Article II, section 1, Congress could, if it wanted, pass a new law preempting any makeup dates and setting a new uniform make-up date for the entire country.

Congress could probably also pass a law directing when elections would be held in case of an emergency on Election Day. Could Congress authorize the Department of Homeland Security to cancel a Presidential election and schedule a new date? Article II states that "Congress" (not the Executive) may determine the date of presidential elections; the language of the Election Clause of Article I, is different; it might be more flexible with respect to rescheduling Congressional elections.

How late can Congress postpone the election in case of emergency? One could argue that the Twentieth Amendment even allows Congress to postpone the date of elections past the date when the Presidential term expires, as long as it specifies a procedure to determine who shall be acting President: Section 3 of the Twentieth Amendment states that "If a President shall not have been chosen before the time fixed for the beginning of his term, . . . the Congress may by law provide for the case wherein neither a President elect nor a Vice-President shall have qualified, declaring who shall then act as President, or the manner in which one who is to act shall be selected, and such person shall act accordingly until a President or Vice-President shall have qualified." However, reading this section in conjunction with section 1 of the Twentieth Amendment, it seems fairly clear that Congress cannot cancel elections in order to take advantage of its powers in section 3 to pick a President. Rather, section 3 is for cases of genuine emergency, in which it was simply not possible to schedule an election (or get the electoral college to meet) before January 20th.

I emphasize this because if Congress were to pass a law allowing for rescheduling of an election in case of emergency, there would be strong constitutional reasons to reschedule the election as soon as possible in order to comply with the orderly processes of government.

There are three other points that are important to note.

First, some of the news stories I've seen have suggested that a terrorist attack a few days before an election is a sufficient reason to postpone an election. The claim is that the terror attacks in Madrid "influenced" the parliamentary elections in Spain, and we should not allow the same thing to happen here. I think this logic is faulty: What influenced the election was not simply the terror attacks but the government's manner of handling them; at first government officials tried to suggest that Basque separatists and not Islamic terrorists were responsible. This angered many voters, who then sought to teach the government a lesson.

The fact that a terrorist attack might influence voters one way or the other is not a reason to cancel an election. Lots of things happen before elections that can influence voters. Rather, the reason to postpone an election is that it is simply not possible to conduct the election in a particular jurisdiction, because, for example, there are dead bodies lying everywhere or buildings have been blown up and local services have to be diverted to matters of life and death. The September 11th attacks shut down large parts of New York and diverted essential services. It was no time to have an election. If a terrorist attack occurred on Election Day, it would make sense to postpone the election in the place where the attack occurred, but not everywhere in the country. (Note that under current law, states may pass new legislation rescheduling the election without Congress's intervention). One can imagine situations in which an election would have to be postponed everywhere, but they would be truly terrible situations, ones that effectively brought the entire country to a halt.

Second, it is very important to understand Congress's role in any decision to allow elections to be postponed. There are strong constitutional reasons, whether or not judicially enforceable, for Congress not to allow elections to be postponed or canceled lightly, and certainly not because of a fear that the population will be unduly influenced. We have had regular elections during wartime before, and we have even had regular elections during a Civil War.

Third, and finally, there are important structural reasons why the decision to postpone an election should rest in Congress, and should not be delegated to the Executive, as the Office of Homeland Security has recently suggested. The reason is that the Executive focuses decisionmaking in one person who is a member of one political party, while Congress consists of members of both parties representing all different parts of the country.

There is an enormous temptation for the Executive to overstate the danger in order to keep itself in power and bolster its chances in a postponed election. To be sure, there is also a danger of self-dealing in Congress. Nevertheless, that danger is mitigated by the fact that Congress is not unitary in the same way that the Executive is. If Congress were to consider such legislation, even in an emergency, the need to form a bipartisan consensus would be very strong, and this would help ensure that this very difficult decision was made for the right reasons.


Comments:

There may be filed with Congress a Bill with the title "The Sky May Be Falling, The Sky May Be Falling". Now there is nothing wrong with good planning and preparation for events that might occur. But can we expect good, bipartisan planning just a short few months before the November elections? Perhaps the Republican majority can, with the assistance of Democrats, rush to judgment similar to their granting of open ended war powers to the President that got us into Iraq with a foundation of erroneous information. American voters have a full plate of serious issues to consider over the next several months and discussions of these issues could be diverted by the question of postponing the elections. I wonder what Mr. Dooley would have to say on this subject.
 

Why are emergency plans needed? Suppose there's a terrorist attack on New York at 8AM on election day, or even at noon the day before. There may be good practical reasons not to open polling places in Manhattan (assuming that's where the attack takes place), but those reasons wouldn't apply to the rest of the state -- maybe not even to the other boroughs -- and certainly not to other states. Everyone outside of Manhattan could still vote. As for the votes that couldn't be cast in Manhattan, doesn't Title 3 section 2 already give the state legislature the power to appoint the missing presidential electors?
 

In fact, September 11th *was* an Election Day in New York. Sept. 11th, 2001 was the scheduled date for a local primary election (including, among others, the New York City mayoral primary) that was indeed postponed for a month, with minimal damage to our democratic institutions.
 

Though it did damage individual candidates. A friend of a friend of mine was running for the NY City Council, and spent his budget in the weeks leading up to 11-Sep. When the election was cancelled and postponed for 2 weeks (not a month), he had no money left to campaign with, while his opponent had the resources of a State Assemblyman's office (in which he worked) to continue his campaign.
 

What about martial law? Couldn't the President declare martial law and, based on the war and/or emergency powers granted to him under the Constitution, cancel or postpone elections for so long as martial law remained in place? If so, this would seem to bypass Congressional and state powers to cancel or postpone elections.
 

This idea for postponing a federal election is not about good planning. It is about fear. It is about staging a coup in the name of civil defense. Think of it in these terms: If Tom Ridge were to ask for the authority to postpone a federal election because of a huge death toll on the East or Gulf coasts from a hurricane, he would be laughed out of DC. Right? But by preying on the fear of "terrarists," he can get a bunch of morons and idiots to follow him to the same absurd conclusion. This is not a good idea. It is an idea which should be aborted, immediately.
 

The problems are (1) according to the Washington Post, Homeland Security Department is interested in possibly postponing the presidential election "if it risked being disrupted by terrorism", a risk that is very easy to imagine or cook up and (2) your analysis assumes that the Administration will play by the rules and go to Congress, when recent history forcefully shows that it does not believe itself bound by rules, e.g., the Geneva Convention.
 

There's a lot to be said for debating the issue now and getting some clear rules in place before the fact. Otherwise, suppose we had simulataneous 9/11-scale attacks in NY and LA at 6:00 p.m. Eastern time on Election Day, with early exit polls pointing to a Kerry landslide. Barring an unlikely outbreak of statesmanship, you could end up with a Constitutional crisis that would make Florida look trivial.
 

I should add that giving an Executive-branch appointee discretionary authority to make the postponement call is about the worst imaginable solution. I'd lean more toward the other extreme: do your damndest to run the election as scheduled, but give a bipartisan commission of elder statesman appointed BEFORE THE ELECTION the power to declare a do-over only in areas where significant numbers of people were physically unable to get to the polls and only if re-running the election in those areas could change the outcome. Then make a major push to get the word out that you'd better get to the polls if you possibly can on Election Day because there won't be another chance.
 

This was a very clear analysis. I took the liberty of quoting a couple of your paragraphs and including a pointer to your blog in emails to both Senators and my Congressman opposing any preauthorization. These folks (all Dems) need to be ready to counter any initiative from the Bushites.

John
 

Martial law, you say? Now there's a great idea. Is it possible you're part of the Bush administration?
 

Re the martial law comment above, it is certainly possible that I am with the Bush Administration - but far from it! This concept intrigues me as, apart from the recent Supreme Court ruling concerning writs of habeas corpus, there is very little US law out there to limit the President's ability to wage war and protect the Republic. I would like to see an in depth analysis of the martial law concept (I would do so if I had the time)as it could reveal that the President has a legal out to dispense with the "formalities" proscribed by the Constitution (in which case, as far as I am concerned, it would be time to place the lantern in the bell tower as our forefathers did at the start of this experiment). As part of this analysis, it would be good to see what role the Congress plays (under the Constitution) in providing checks and balances (recognizing that, to date, Congress has reneged on its responsbilites to We The People).
 

Yes, I do believe that Team Chimpy is likely to exploit any possibility of postponing our elections in one way or another.

My opinion only, but it seems delusional to imagine they wouldn't, given the laundry list of the unimaginable we already know they're perfectly happy to do: muscle into power, steal multiple entire Congressional districts by redistricting, expose our own intelligence people for political gain, start an entire war based on obvious lies, endanger our safety by subordinating the fight against Al-Qaeda, treat our own wounded troops as pariahs, claim the right to imprison indefinitely at the president's whim, rationalize torture, try to time the arrest of Bin Laden to sabotage the Democrats, and build their entire freakin' convention around the shameless exploitation of a mass murder.

I can't think of a single damned thing that these people won't try to spin and twist and distort into a political advantage. Right this very minute, it's an uphill fight to make sure the voting machines themselves aren't simply hijacked. And you know perfectly well which side Chimpy is on.

If you truly imagine there's a line they won't cross if they can, you're not paying attention. This is not about democracy for them. It never has been. As Molly Ivins put it so well: They wish not to govern, but to rule.

I mean, what more would we need to see the utterly obvious here? Dick Cheney simply biting large bits out of people every time they disagree with him? "Go fuck yourself" replacing "E pluribus unum" as our national slogan?
 

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mesothelioma Mesotheliomais a form of cancer that is almost always caused by exposure to Asbestos 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 internal chest wall), but it may also occur in the peritoneum (the lining of the abdominal cavity), the heart the pericardium (a sac that surrounds the heart or tunica vaginalis.
Most people who develop
mesothelioma have worked on jobs where they inhaled asbestos particles, or they have been exposed to asbestos dust and fiber in other ways. Washing the clothes of a family member who worked with asbestos can also put a person at risk for developing Mesothelioma Unlike lung cancer, there is no association between mesothelioma and smoking but smoking greatly increases risk of other asbestos induced cancer.Compensation via
Asbestos funds or lawsuits is an important issue in
mesothelioma The symptoms of
mesothelioma include shortness of breath due to pleural effusion (fluid between the lung and the chest wall or chest wall pain, and general symptoms such as weight loss. The diagnosis may be suspected with chest X-ray and CT scan and is confirmed with a biopsy (tissue sample) and microscopic examination. A thoracoscopy inserting a tube with a camera into the chest) can be used to take biopsies. It allows the introduction of substances such as talc to obliterate the pleural space (called pleurodesis, which prevents more fluid from accumulating and pressing on the lung. Despite treatment with chemotherapy, radiation therapy or sometimes surgery, the disease carries a poor prognosis. Research about screening tests for the early detection of mesothelioma is ongoing.
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
mesotheliomaSymptoms 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
fatigue or anemia
wheezing, hoarseness, or cough
blood in the sputum (fluid) coughed up hemoptysis
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
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 incision 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.
There is no universally agreed protocol for screening people who have been exposed to
asbestosScreening tests might diagnose mesothelioma earlier than conventional methods thus improving the survival prospects for patients. The serum osteopontin level might be useful in screening asbestos-exposed people for
mesotheliomaThe 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. Doctors have begun testing the Mesomark assay which measures levels of soluble mesothelin-related proteins (SMRPs) released by diseased mesothelioma cells
Incidence
Although reported incidence rates have increased in the past 20 years, mesothelioma is still a relatively rare cancer. The incidence rate is approximately one per 1,000,000. The highest incidence is found in Britain, Australia and Belgium: 30 per 1,000,000 per year. 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. It has been estimated that incidence may have peaked at 15 per 1,000,000 in the United States in 2004. Incidence is expected to continue increasing in other parts of the world. Mesothelioma occurs more often in men than in women and risk increases with age, but this disease can appear in either men or women at any age. Approximately one fifth to one third of all mesotheliomas are peritoneal.
Between 1940 and 1979, approximately 27.5 million people were occupationally exposed to asbestos in the United States.[ Between 1973 and 1984, there has been a threefold increase in the diagnosis of pleural mesothelioma in Caucasian males. From 1980 to the late 1990s, the death rate from mesothelioma in the USA increased from 2,000 per year to 3,000, 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.
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 Kent brand of cigarettes used
mesothelioma in its filters for the first few years of production in the 1950s and some cases of
mesothelioma have resulted. Smoking modern cigarettes does not appear to increase the risk of mesothelioma.
Some studies suggest that simian virus 40 may act as a cofactor in the development of mesothelioma.
Asbestos was known in antiquity, but it wasn't mined and widely used commercially until 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. Recent findings have shown that a mineral called erionite has been known to cause genetically pre-dispositioned individuals to have malignant mesothelioma rates much higher than those not pre-dispositioned genetically. A study in Cappadocia, Turkey has shown that 3 villiages in Turkey have death rates of 51% attributed to erionite related
mesotheliomaExposure 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.
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 asbestosMany building materials used in both public and domestic premises prior to the banning of
asbestos may contain
asbestos Those performing renovation works or activities may expose themselves to asbestos dust. In the UK use of Chrysotile asbestos was banned at the end of 1999. Brown and blue
asbestos was banned in the UK around 1985. Buildings built or renovated prior to these dates may contain asbestos materials.
For patients with localized disease, and who can tolerate a radical surgery, radiation is often given post-operatively as a consolidative treatment. The entire hemi-thorax is treated with radiation therapy, often given simultaneously with chemotherapy. Delivering radiation and chemotherapy after a radical surgery has led to extended life expectancy in selected patient populations with some patients surviving more than 5 years. As part of a curative approach to
mesothelioma radiotherapy is also commonly applied to the sites of chest drain insertion, in order to prevent growth of the tumor along the track in the chest wall.
Although
mesothelioma is generally resistant to curative treatment with radiotherapy alone, palliative treatment regimens are sometimes used to relieve symptoms arising from tumor growth, such as obstruction of a major blood vessel.
Radiation Therapy when given alone with curative intent has never been shown to improve survival from
mesothelioma The necessary radiation dose to treat mesothelioma that has not been surgically removed would be very toxic.
Chemotherapy is the only treatment for
mesothelioma that has been proven to improve survival in randomised and controlled trials. The landmark study published in 2003 by Vogelzang and colleagues compared cisplatin chemotherapy alone with a combination of cisplatin and pemetrexed (brand name Alimta) chemotherapy) in patients who had not received chemotherapy for malignant pleural mesothelioma previously and were not candidates for more aggressive "curative" surgery. This trial was the first to report a survival advantage from chemotherapy in malignant pleural
mesothelioma showing a statistically significant improvement in median survival from 10 months in the patients treated with cisplatin alone to 13.3 months in the combination pemetrexed group in patients who received supplementation with folate and vitamin B12. Vitamin supplementation was given to most patients in the trial and pemetrexed related side effects were significantly less in patients receiving pemetrexed when they also received daily oral folate 500mcg and intramuscular vitamin B12 1000mcg every 9 weeks compared with patients receiving pemetrexed without vitamin supplementation. The objective response rate increased from 20% in the cisplatin group to 46% in the combination pemetrexed group. Some side effects such as nausea and vomiting, stomatitis, and diarrhoea were more common in the combination pemetrexed group but only affected a minority of patients and overall the combination of pemetrexed and cisplatin was well tolerated when patients received vitamin supplementation; both quality of life and lung function tests improved in the combination pemetrexed group. In February 2004, the United States Food and Drug Administration approved pemetrexed for treatment of malignant pleural mesothelioma. However, there are still unanswered questions about the optimal use of chemotherapy, including when to start treatment, and the optimal number of cycles to give.
Cisplatin in combination with raltitrexed has shown an improvement in survival similar to that reported for pemetrexed in combination with cisplatin, but raltitrexed is no longer commercially available for this indication. For patients unable to tolerate pemetrexed, cisplatin in combination with gemcitabine or vinorelbine is an alternative, although a survival benefit has not been shown for these drugs. For patients in whom cisplatin cannot be used, carboplatin can be substituted but non-randomised data have shown lower response rates and high rates of haematological toxicity for carboplatin-based combinations, albeit with similar survival figures to patients receiving cisplatin.
In January 2009, the United States FDA approved using conventional therapies such as surgery in combination with radiation and or chemotherapy on stage I or II Mesothelioma after research conducted by a nationwide study by Duke University concluded an almost 50 point increase in remission rates.
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.
A procedure known as heated intraoperative intraperitoneal chemotherapy was developed by at the Washington Cancer Institute. 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.

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
mesothelioma tissue surrounding the male internal reproductive organs is called the tunica vaginalis testis. The tunica serosa uteri covers the internal reproductive organs in women.
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.
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 United States each year. Mesothelioma occurs more often in men than in women and risk increases with age, but this disease can appear in either men or women at any age.
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 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.
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. 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 o f asbestosrelated 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.
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
How is
mesotheliomadiagnosed?
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.
How is
mesotheliomatreated?
Treatment for mesothelioma depends on the location of the
cancerthe 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
mesotheliomaThe 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
mesotheliomaa 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.
Stereo Tactic Radiation Therapy also called radiotherapy, involves the use of high-energy rays to kill
cancercells and shrink tumors Radiation therapy affects the
cancercells 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
cancercells are found (internal radiation therapy).
Chemotherapy is the use of anticancer drugs to kill cancer cells throughout the body. Most drugs used to treat
mesotheliomaare 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.
 

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