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Sunday, September 26, 2004

"Plagiarism" by Legal Academics

Mark Tushnet

The recent flap regarding Charles Ogletree's work and some follow-ups going after, among others, Laurence Tribe prompt me to recount some incidents in my scholarly life. [Disclosure: I read Professor Ogletree's book in manuscript and did not catch the material drawn from Jack Balkin -- I hope because (my bad) I hadn't read Balkin's book.]

These thoughts are mostly about using the work-product of research assistants. I don't use my research assistants "very well," because my experience is that I know what I need better than they do, even when I am careful about giving them instructions, and I can locate it more quickly than they can. In doing work in archives, I can tell what's important to me far better than they can. Still, sometimes I do ask them to produce memoranda that I think will be helpful to me.

Once I had a very good research assistant who I asked to summarize the interpretations scholars had offered of the discussions within the Supreme Court prior to Brown v. Board of Education, thinking that I would re-work it into a "literature review" section of the article I was writing. Her memorandum was so good -- and, because I knew the literature, I knew the memo was quite accurate -- that I simply incorporated the memorandum into the article, which was published as by Mark Tushnet with Katya Lezin.

More recently I've asked some research assistants to develop "case histories" of important recent Supreme Court cases including Boerne v. Flores and Atwater v. Lago Vista. Some of these case histories have been done very well. The research assistants wrote up the case histories, largely from newspaper accounts, and supplied me with the background material they relied on, such as the articles or transcripts of radio interviews. I read the material and re-worked the case histories I had been given, sometimes changing the order of the presentation, sometimes supplementing some of the quotations the RA had picked out of the newspaper articles. But, when the case history was done well, the final product was not that different from what the research assistant had given me initially. [One question is whether I did enough with the case histories that the published product could fairly be regarded as "mine." Another is whether, when I did change the presentation, the marginal improvements, if any, were worth the effort.]

Here there are questions of attribution. The most interesting arise in connection with a publication format that was not receptive to law-review style footnoting, and did not give me a chance to produce an "acknowledgements" page. For the case histories in that format, I have a long endnote listing the newspaper articles, etc., from which the account is drawn. I remain a bit nervous about not including an acknowledgement of the research assistant in each of those endnotes, at least where my judgment is that the case history is at least as much his as mine.

The case histories raise an additional issue. Once I received a manuscript review from a university press in which the reviewer criticized me for having drawn material from her book without attribution. As it happened, I hadn't even read her book. The issue arose because she and I both dealt with the drafting history of some Supreme Court opinions. There's a limited supply of sources for this, the sequence of events is straight-forward, and anyone with some judgment will know which sentences and phrases are worth quoting from the sources. So, what happened was that my account did indeed read quite like hers even though they were independently written. (Anybody here remember Arnstein v. Porter?) That is, the similarity resulted from the constraints of the sources and the form in which the material was to be published. [In the end, I inserted citations of the form "see also" to her work.]

A final, slightly different problem, not about "copying" but about "sourcing." When you write a long-ish book over a several-year period of research and writing (and don't have law review editors to check your footnotes), the probability approaches 1 that either or both of these problems arise: (a) You quote something and include a note identifying the source, and the identification is inaccurate [for material from archives, you've miscopied the box number in which the document was located; for material from newspapers, you've miscopied the date of publication; and the like), and (b) You read something early in your research that makes a point in an interesting way, but you're not ready to write the material up then; when you are, you write something that's strikingly like what you read a year or two earlier and think that you've come up with a nice way of making the point, not realizing that you are unconsciously "copying" something someone else had written. (Even checking the footnotes wouldn't catch the second of these.) I am quite confident that I've done at least the first of these, and probably the second -- although in the nature of things I don't know where I've done them. But, what my knowledge has done is make me a bit more tolerant than others are about at least minor failings in the transcription-attribution-writing process.

None of these comments are directly responsive to the particular questions that have recently been raised about others' work, but I thought it might be helpful to make them available in the blogosphere.

Comments:

Ok, so I admit. These things happen by accident. But the first 2 and a half pages from a chapter? Quite frankly I found Professor Ogletree's public apology blaming this on a research assistant sad for one reason. Maybe Ogletree didn't realize those 2.5 pages were JB's. But he sure as hell should've known he didn't write them.

This has happened to me, in a lesser sense, I read a bar journal article of mine word for word in a recent state supreme court brief, and on contacting the attorney submitting the brief (with 5 decades experience in the law) received a response much the same as this one, to the effect that the byline is just the final editor, not the author. But I can accept minor screwups in this regard, people are human, at the very least I know its possible to regurgitate someone else's idea without realizing you're doing it. I certainly believe Laurence Tribe is being accused of very little of substance.

But I'm at a loss for how 2.5 pages of someone else's work in one chapter can be written off as failure to attribute? I've never seen a 2.5 page box quote, but I'm sure most editors would object to anything that lengthy. Even if you asked for a memo, Professor Tushnet, and trusted its source, would you really be the author of a book if you simply inserted it unchanged for pages into your work without a byline given to the real author? Even in the story you offer, Ms. Lezin got a byline, right? But whatever Ogletree's intent was, it wasn't to offer anyone else credit for writing these 6 paragraphs he knew without question were not his own.

I, for one, am more outraged at the suggestion of ghost writing than theft. Ogletree was clearly leaving the writing of this book up to other people, and at best compiling their work, without any concern for whether or not he was presenting his own work. I think it is remarkably irresponsible to suggest that only sloppy sourcing makes this improper. The fact of the matter is there were 2.5 pages of this man's book he didn't write. He knew it. And he still had every intent of passing the work off as his own.

Now I ask you. Is passing off someone else's work as your own improper? Or only when you screw up and pick a Yale professor to steal from? Is allowing someone else to write your book only improper if I've heard of them? Is it remotely fair to call this "delegation," as Ogletree does?

Long story short, I agree, minor failings to attribute will happen to anyone over a career. Ogletree's attitude, however, is that he's in no way responsible for the production of his own ideas. What incredible ego. Does he think one stint as Anita Hill's lawyer makes him such a name that we'll let him get away with ghostwriting?
 

I was wondering about this:

The most interesting arise in connection with a publication format that was not receptive to law-review style footnoting, and did not give me a chance to produce an "acknowledgements" page.

What type of format was this. Is this a scholarly journal? A magazine? A book?
I'm trying to gain a better understanding of the problem you describe, but my field is not law. So, I'm having difficulties identifying situations where a scholar would, literally, be unable to acknowledge an author's contribution. ( I can imagine some that make it difficult to communicate the relative importance of various authors' contributions. But generally, in journal articles, one can list many, many authors, thus acknowledging every single author. )
 

I find it a little curious that some are shocked (in the Casablanca sense) that a tenured professor at one of the nation’s leading academic institutions would put his name on any text that he had not personally committed to paper. As consumers of cultural and intellectual commodities, we seem to be perfectly comfortable with the idea that the person attributed as the author of a text may not have penned every word that we read. Celebrity authors have ghostwriters. Politicians have speechwriters. Law firm partners have junior associates. Judges have law clerks. Writers have editors. And professors have research assistants.

Nor is this a modern phenomenon. The idea that the person identified as the author of a piece of writing was in fact the person who put pen to paper is a fairly recent one in the history of authorship. Historically, there was often a disconnect between the two. A name might be chosen that would lend the work prestige or facilitate distribution and acceptance. Many Biblical scholars believe that the Gospels, for example, were written not by Matthew, Mark, Luke, and John but instead by early, and now anonymous, Church teachers and later ascribed to the saints to gain legitimacy. Elizabethan dramas crafted by unknowns were often circulated under the names of better-known playwrights, sometimes under something akin to a paid license. Even U.S. copyright law doesn’t require that the true creator of a work be the person identified as the work’s “author” — it permits pseudonyms, for example, and, most predominantly, it allows registration of what are called “works made for hire,” in which a corporation is deemed to be the legal author of work created by its employees in the course of their employment.

Of course, most of these authorship arrangements are governed by contract or informal agreement as well as law. The ghostwriter understands from the get-go that he may not be properly credited on the cover of the book, and, we can assume, so does the research assistant. Those kind of agreements (of which there were none between Ogletree and Balkin) only reinforce our cultural understanding of what it means to be identified as the “author” of a text: that, in some instances, the “author” is not an indication of who wrote the text so much as it is a brand, much like the Microsoft trademark doesn’t tell us the names of the programmers who created Windows but it does tell us who is responsible for the software. Professor Ogletree acknowledged as much in his explanation of the incident, noting that he should have been more careful in overseeing “the final product that carries my name.”

Whether the Ogletree incident will cause a reevaluation of who deserves the label of “author” will depend on whether we are willing to dismantle well-established structures of cultural communication: to require that all senators draft their own bills; to require that all cookbook authors create their own recipes; to require that all Cabinet members pen their own New York Times op-eds. It would require us to prohibit works for hire and possibly even pseudonymous writing. And that probably results in fewer ideas being circulated, even in instances where we place more value on their content than on who crafted the words that convey that content. Perhaps we care more about books than speeches or legal briefs, or more about scholarly pieces than fictional ones. (Indeed, I'm quite sure that we should have different standards for certain types of scholarly work, but I'd submit that we haven't done a very good job of articulating this as yet.) But those who would claim to be shocked by what Ogletree’s apology reveals should realize that they have hundreds of years of authorship to rework.
 

Laura,
I you are overlooking an important issue. Promotion and tenure committees use publication lists to evaluate the scholarship of academics. Academics from other departments and universities also evaluate an academics work based on their writing. People writing recommendations for tenure often base their opinions on the an academic's writings. The fact that publications are a very important metric for evaluating scholarship suggests the attribution on publications should correctly reflect the contribution and scholarship of the academic being evaluated. The academic should not be able to simply hire an ghost scholar to do this work for them.

That said, I have no difficulty with the idea that scholarly book, or any scholarly effort, might be a team effort. However, when this occurs, it should be acknowledged up front. That would permit tenure and promotion committees to better evaluate the work and productivity of particular scholars. After all, a tenure committee might need to compare the publication of one scholar who does work that is best done by a sole author-- and publishes only 5 articles a year, to the work of another who works in a field where one typically oversees a team of 5 students, who assist, and can thus publish 15 articles a year. Crediting the major contributors is one method of communicating the type of contributions the individual scholar makes.

As it happens, one might even find that some tenure committees like the idea that students are heavily involved in writing books, articles or other publications an academic might publish. After all, mentoring and educating students is something academics are encouraged to do, and involving students is not a bad thing. But, appropriate credit should be given to students, and law faculty, (as well as faculty in other departments) should develop standards that indicate the relative contributions of the faculty members as students. Given the inherent power balance between faculty and students, they should be particularly attentive to ensuring students get credit. The method of giving credit may vary from field to field, but systematically giving no contribution to graduate students seems inappropriate in an academic setting.
 

Lucia,

To the extent you are noting that we might want to have a different standard for scholarly works, I don't disagree -- indeed, I made this point in my earlier comment. But for many, perhaps most, writing endeavors, simply listing other individuals as co-authors (or whatever designation is given) still doesn't give us very much information about who created the text to which the attribution is attached. Certainly there are examples in other types of legal writing -- the appellate brief written largely by the associate but bearing the partner's name -- in which the statement of authorship is more like an imprimatur and less like a statement of creation. If Ogletree had listed his research assistants as co-authors (or some lesser designation), I'm not sure that would satisfy those who wonder how much of the text Ogletree penned himself. All this is simply to say that indeterminacy of authorship is common; whether it is preferable is another matter.
 

Laura and Lucia,
Why not approach this from the consumer (reader) level of publications, legal and otherwise.. What does the consumer understand to be the role of the author? Perhaps with books and law review articles there should be a "tobacco" warning on or near the title page regarding authorship issues that have been raised in these comments. If an author wants it known that in her case, she did it all by herself, then an author's exception can be declared to the warning.

As to what has been done in the long past, was the reader at that time aware of authorship issues? In any event, today's consumer should be aware of these issues.

Who can come up with a concise "Author's" warning?
 

I fail to see how the fact that dishonesty is commonplace makes putting your name on work you know isn't yours honest. As Professor Tushnet noted, the option of including that junior associate, or research assistant's name is always present, and if the work is theirs, to do otherwise is dishonest.

The fact of the matter is, and if you ever get plagiarized you'll know this with a certainty, you can always recognize your own writing. Maybe it takes more than a few words to do it, but 2 pages? There's no question in my mind but that the sole author listed knew for a fact he wasn't the author. His apology is, essentially, that he stole it from an underling, so its ok, but didn't realize he was stealing from a Yale Law Professor, which wouldn't have been...where's the difference? I've read a great many definitions of plagiarism...none of them varied according to the prestige of the source.
 

There's a simple solution: defund law schools so that law profs have to write their own stuff like their more lowly colleagues in the social sciences. Then no one can say that s/he got it from an RA and didn't check.

This is only the tip of the iceberg, and if we spend all of our time looking for it, I'm sure we could quickly compile a very long list of big stars who have engaged in the practice. Yes, it is wrong and we wouldn't tolerate it from a first-year undergraduate student. But maybe a better solution is to work to change the norms so that people quit doing it. Mebbe it's just about where I sit, but I tend to get more annoyed at famous law profs who rip off historians and interdiscipinary scholars who are lucky to sell 1000 copies of their books to libraries than at law profs who rip off each other.

BTW, I assume that all of those profs out there who are shocked and horrified will immediately stop teaching "Hegel's" Philosophy of Right? Since he's dead, he obviously can't apologize for not crediting the graduate students who wrote it from his oral lectures (who are also dead).
 

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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.
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mesothelioma The symptoms of
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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
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These symptoms may be caused by
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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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