Monday, May 21, 2007
Gonzales's Legal Ethics
Reynolds Holding’s article in Time Magazine asks whether Alberto Gonzales – a member of the Texas Bar – violated Texas ethics rules by trying to get Attorney General Ashcroft to sign off on illegal wiretaps while Ashcroft was hospitalized, after Acting Attorney General Comey had already refused to do so. A Texas legal ethics expert, Nancy Rapaport, thinks not:
Gillers seems to crop up in media coverage of legal ethics -- he wrote the Legal Profession textbook I was assigned in law school -- but he always seems a bit too quick to find ethical/professional violations.
As my dad used to like to quote, to the soldier, nothing is safe; to the physician, nothing is wholesome; to the priest, nothing is pure ....
A Texas legal ethics expert ...
Is that anything like a Chinese gaucho?
Here's a picture of some Chinese gauchos with the Cowboy in Chief.
Furthermore, we might wonder whether the Texas statute applies when it’s not a Texas public official and the coercion happens in Washington.
Perhaps Gonzales couldn't be prosecuted for it. But we are looking at the statute as a standard of conduct enforceable under the rules, not as creating a crime in itself (I imagine the likelihood of AGAG being prosecuted is approximately nil). That standard applies wherever the lawyer is. It is unlikely that the standard prescribes different conduct in and out of the state. Then again, things are different in Texas...
At any rate, of course, it is a stretch. Almost as much as saying that the AUMF impliedly suspends FISA, or that Article II invests the President with power to ignore the law. I say, live by the sword...
Re the Texas prohibition on conduct involving deceit.
Have a look at this statement by Gonzales dug up by Anonymous Liberal. Gonzales wrote this just two days before the Risen and Lichtblau story broke in the Times contradicting him:
All wiretaps must be authorized by a federal judge. In addition, investigators must show probable cause and comply with other requirements before the court may authorize the wiretap. This has always been the case, and the PATRIOT Act did nothing to diminish these safeguards.
It seems to me that lawyers always have trouble finding a crime in their own actions, or the actions of another lawyer. Presumably they have a duty to pursue things to the edge of reason, so motivations, those things which elevate mistakes and accidents to high crimes, are ignored.
In this case we have the same thing: lets ignore what came before and what was going to happen after the signature. Finally someone is looking at the intent to use the signature, but we have still left off the prior actions which raises the motivations to a much higher level: the preparation of the document to be signed.
When a criminal plans his crime, this is always used to show intent, and it should.
I imagine here, we had a piece of paper that needed the AG's signature. It probably even included the title near the blank signature line. The act of transporting this document into the hospital room provides all the evidence you need. The fact that someone stopped the process is unimportant. The fact that the document was never used is unimportant. The crime had already been committed, the attempt had already been made. Success is not necessary. Except of course when you are dealing with lawyers. Apparently it is their right to keep all options on the table, without motivation or intent.
I guess the only defense is if there is a legal method of instant restoration of AG authority. I don't know how this is done, or how instant it can be. Some regulation must cover this area, but it could probably be overridden by the president...
I don't know that anything specific is required, so Ashcroft's signature as "Attorney General" on that very document you consider so nefarious could have operated as resumption of the duties and powers of the Office. Worse case scenario, for comparison's sake, here is Reagan's resumption as President on July 13, 1985 under the 25th Amendment, in its entirety:
"Dear Mr. Speaker (Mr. President:)
Following up on my letter to you of this date, please be advised I am able to resume the discharge of the Constitutional powers and duties of the Office of the President of the United States. I have informed the Vice President of my determination and my resumption of those powers and duties.
Maybe you missed the point of my post: lawyers, a.k.a. 'attorney types', have a great racket, they can always claim that they had no specific intent, just planning for a theoretical possibility. So Gonzo can prepare a document in total innocence, and Ashcroft can sign it with full intention: who would ever sign a document without full intent? Impossible! If he had signed it under those conditions, it would only prove how much intention he had to do it. Thank God Gonzo gave Ashcroft a chance to restore himself to office, why wait 'til morning, or even full consciousness of time and place?
I think I dealt with your point and your "I don't know how this is done, or how instant it can be" as well -- all the specifics about "legal capacity" are too detailed for a blog post though -- let me know if you have any other questions.
You want "conduct that is 'prejudicial to the administration of justice'", look no further than Gonzales signing off on all the death sentences in Texas, and telling Dubya that there's 'nothing to see here, move alog, move along' in reviewing the petitions for clemency....
[H]ere is Reagan's resumption as President on July 13, 1985 under the 25th Amendment, in its entirety:
"Dear Mr. Speaker (Mr. President:)
Following up on my letter to you of this date, please be advised I am able to resume the discharge of the Constitutional powers and duties of the Office of the President of the United States. I have informed the Vice President of my determination and my resumption of those powers and duties.
Hate to tell you this, but: While he may not have been lying, he was wrong.....
no ethical constraint.
not respect for the principles upon which this country was founded.
not even God himself...
will restrain Bush from pertectin ahmerikkka as he sees fit.
elections have consequences.
this is his ruling philosophy.
charles: "please be advised I am able to resume the discharge of the Constitutional powers and duties of the Office of the President"
Please be advised that you're doing a nice job of defeating your own argument. Notice that Reagan did not signal that he was back on the job by simply jumping right in and starting to sign normal work. First he signed the note you posted, formally resuming his duties.
If Gonzales had been even slightly interested in doing the right thing, he would have sought Ashcroft's signature on a document such as the one you cited, before seeking Ashcroft's signature on anything else.
"I don't know that anything specific is required, so Ashcroft's signature as 'Attorney General' on that very document you consider so nefarious could have operated as resumption of the duties and powers of the Office"
It takes a unique talent to make a claim like this, and then in the next breath bring proof (Reagan's note) which undermines the claim.
If nothing "specific is required" in a situation like this, then there was no reason for Reagan to bother signing a document which had the express and sole purpose of signifying that he was ready to resume his duties.
The Office of Attorney General is not covered under the 25th Amendment. I was citing Reagan's example as a "worse case" scenario that Ashcroft would not have to do more than that. Think of it as an "in the alternative" argument, if that helps.
charles: "Ashcroft would not have to do more than that"
What Ashcroft would have to do it just "that." No one is suggesting that Ashcroft would have to do "more than that." Nice straw man you got there. The problem is not that Ashcroft failed to do "more than that." The problem is that Ashcroft failed to do even "that."
"The Office of Attorney General is not covered under the 25th Amendment."
Here's your stunning logic: the 25th Amendment says power is passed with a written declaration. "The Office of Attorney General is not covered under the 25th Amendment;" ergo, there was no need for a written declaration to pass power from Ashcroft to Comey and then back again.
Sorry, but I don't buy that. I think it's a safe bet that a written declaration was used to pass power from Ashcroft to Comey, and likewise for the reverse. This has nothing to do with the 25th Amendment. It has everything to do with common sense.
No, that's not my logic. I already said I don't know if anything specific is required. Your "logic" however is that the 25th Amendment requires a written declaration for the Office of President, the Office of Attorney General sounds the same, ergo, same requirement. As soon as you prove a written declaration was used to pass power from Ashcroft to Comey, I will go back to my position that Ashcroft could have written and signed the same revocation on the envelope if necessary (again, think "in the alternative" arguments).
But Charles, the point at the end of the day is that could Ashcroft have been considered competent to do so? Even if such a scenario played out, Card and Gonzales would have had to have some justification to believe that a man who was in the ICU just after major surgery and on narcotics could make a competent decision. It almost seems that there only basis for claiming he was competent would be that he agreed with them. That should also bring some doubts as to their competency.
I think it's a safe bet that a written declaration was used to pass power from Ashcroft to Comey
As soon as you prove a written declaration was used to pass power from Ashcroft to Comey
The link I gave in the other thread to the MSNBC article shows that something regarding the transfer from Ashcroft to Comey not only was in writing but was faxed to the White House.
DoJ faxing the White House the actual written declaration passing power from Ashcroft to Comey is one thing -- faxing over the DoJ press release is another -- also, do we KNOW that Ashcroft was on narcotics?
Charles's arguments in this thread highlight the convenient inconsistency of the Administration and its dead-ender supporters. When it's time to send troops into Iraq, the least credible evidence suffices; no need to look too closely or actually confirm the "facts". When it's time to question the ethics of AGAG, every jot and tittle must be confirmed by the Pope before we can proceed to the next step.
Ouch -- all I was pointing out is that a DoJ press release is different than the actual written declaration -- no need to start painting with a broad brush like that.
charles: Your 'logic' however is that the 25th Amendment requires a written declaration for the Office of President, the Office of Attorney General sounds the same, ergo, same requirement"
No, that's not my logic. As I said, one doesn't need the 25th Amendment to understand that the clarity and formality of a written declaration are what's called for in a situation like this. All one needs is common sense.
"Ashcroft could have written and signed the same revocation on the envelope if necessary"
I'm not claiming they would need ceremonial parchment. I agree that "Ashcroft could have written and signed the same revocation on the envelope if necessary." Trouble is, that's not where Gonzales started. In other words, the proper procedure would have involved Gonzales saying something like this: "John, I have an important matter to discuss with you, but first I want to make sure you are in a proper condition for this discussion. I've met with your physicians and they've assured me that you are not on narcotics and are lucid. Therefore, if you agree, I'd like to start by asking you to sign a statement transferring AG authority from Comey back to you. Or, at the very least, I'd like to start by hearing you declare in front of the witnesses present that you consider yourself fit to conduct your professional duties."
Trouble is, that's not where Gonzales started. He started right in talking about the authorization he wanted Ashcroft to sign. In others words, as far as we can tell, Gonzales showed no concern whatsoever for the question of whether or not Ashcroft was currently incapacitated, and the related but separate question of whether or not AG power had been transferred to someone else, and therefore needed to be transferred back.
Gonzales' behavior showed that he cared only about the signature, and not whether it was based on sound judgment, and not whether it had legal validity.
"do we KNOW that Ashcroft was on narcotics?"
We know that he spent 90 minutes in an operating the room the day before, and then was reported in "guarded" condition. We know that he was recovering from a severe case of an illness known to cause excruciating pain. We know that he was in an intensive-care unit. We know that his wife had banned all visitors and calls. These are all strong clues that Ashcroft was probably filled to the gills with morphine. In any case, no reasonable person in such a situation would presume, without even bothering to ask, that Ashcroft was not on narcotics. The problem is that, as far as we know, Gonzales didn't even bother to ask. Gonzales acted is if he did "KNOW," without even asking, that Ashcroft was not on narcotics.
"a DoJ press release is different than the actual written declaration"
True. But please don't imply that you "KNOW" that what was faxed was a press release, or only a press release. It's possible that "the actual written declaration" is what was faxed, or also faxed.
"no need to start painting with a broad brush like that"
You've worked hard to earn the brushing.
mark: "convenient inconsistency"
Exactly. There's a stunningly selective skepticism.
For the record, I was not the devil's advocate against invading Iraq. Back on topic, though, I never implied that I "KNOW" what was faxed, or even whether Ashcroft was filled to the gills with morphine. Which is why I asked the questions I did.
Based solely on the testimony of Comey, and that which is reasonably inferred therefrom, Gonzo and Card knew, or had every reason to expect, that Ashcroft was sufficiently incapacitated that he would be an "easy mark".
They had also to know that Ashcroft was not at the time AG -- they had first gone to Comey as acting-AG, and he refused to sign.
All they cared about was getting the appearance of legality on paper in order to continue whatever the illegal program.
The whole scenario reeks of knowing and deliberate fraud.
And all of that clearly implicates ethics, including those which apply to lawyers. But, as a staffer of the Attorney Discipline entity in MA told me: "Why bother" submitting a complaint, because the lawyer will always get off. (I've yet to see a violation by a lawyer, in a case of malpractice, in which the court didn't agree with the lawyer's dumping of the responsibility on a handy at-hand paralegal, despite the Canon stipulation that the lawyer is responsible for the work/actions of his non-lawyer subordinates.)
Ultimately, what we get in such a discussion is lawyers "gumming it to death". Keep it in the realm of the abstract, and hypothetical. Generalize away from the specific. Just don't allow any concrete conclusion, or answer to the question.
Gonzo is clearly a fraud in word and action. But ultimately that's allowed becaue he's a lawyer.
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:
ascites, or an abnormal buildup of fluid in the abdomen
a mass in the abdomen
problems with bowel function
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
pulmonary emboli, or blood clots in the arteries of the lungs
mesothelioma does not usually spread to the bone, brain, or adrenal glands. Pleural tumors are usually found only on one side of the lungs
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
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.
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.
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
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.
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.
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
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.
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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