Balkinization  

Saturday, July 07, 2007

Cynicism and Executive Privilege

Guest Blogger

Rob Weiner

Woody Allen once said, “No matter how cynical you are, you can’t keep up.” In its recent assertion of executive privilege, the White House is proving Allen right.
Last week, the White House refused to produce documents to both the Senate and House Judiciary Committees investigating the Justice Department firing of U.S. Attorneys. The White House also barred testimony by former White House Counsel Harriet Miers and Director of Political Affairs Sara Taylor. The Counsel to the President claimed that the interests of the President in confidentiality "far outweigh Congress’s interests in obtaining deliberative White House communications." In support of this decision to block the Congressional investigations into the Department of Justice, the White House relied on--what else?--a legal opinion from the Department of Justice. In fact, the legal position of the White House is so flimsy as to suggest that what is really going on is an effort to run the clock, to exploit the logistical difficulties of enforcing the subpoenas, until Congress gives up, the public loses interest, or the subpoenas expire.

The Justice Department opinion cited by the White House Counsel understates the interests of Congress and overstates those of the President. On the congressional side of the balance, the Department asserts that Congress has no legitimate interest in investigating the firing of U.S. Attorneys because the Constitution gives the President exclusive authority to nominate and remove his appointees. This rationale is weak. Congress is not merely probing the firing of a few prosecutors. It is investigating whether the Administration infected law enforcement decisions with undue political influence. On the reasoning of the Justice Department opinion, Congress lacked a legitimate interest in investigating Watergate because President Nixon had exclusive power to fire Archibald Cox. Indeed, the Department opinion itself is telling evidence of the need for congressional oversight. Usually, the Attorney General signs opinions to the President. He did not sign this one, nor did the Deputy Attorney General. Both were disqualified because their conduct is under review. The Solicitor General therefore had to sign, a sad testament to the condition of the Department.

The opinion also claims that Congress has minimal interests because the Justice Department already provided documents and witnesses. This point, too, is silly. The investigation concerns whether the White House meddled in prosecutorial decisions. Investigators need to scrutinize the meddler. In an investigation of bribery, no one would contend that it was gratuitous to gather evidence from the briber because the bribed official had cooperated with authorities.

As regards the interests of the President, the potency of executive privilege varies for different types of material. Communications directly with the President are at the core of the deliberations the privilege safeguards, and they warrant a high level of protection. Communications among presidential advisers warrant a lower degree protection, and communications by advisers with persons outside the White House, lower still. In addition, communications related to national security receive greater protection than other types. Here, the communications at issue were not with the President and did not pertain to national security. Some were even with members of Congress. Moreover, as regards testimony, the White House asserts that presidential aides do not have to appear before Congress at all, regardless of whether they spoke with the President, other aides, or anyone else.

The opinion also makes much of the White House offer to make aides available for private interviews without transcripts. The Department is correct that both the President and Congress have a duty to accommodate the interests of the other Branch. Therefore, no offer of compromise should be held against either. But what appropriate governmental interest does it serve to deny Congress a transcript of the interview, or to refuse to allow aides to swear to tell the truth? Such conditions, which serve only to obstruct the congressional inquiry, are not legitimate accommodations. These have the hallmarks of a fig leaf -- unacceptable restrictions so that the White House can pretend it is cooperating, while it is in fact courting delay.

Such a tack is possible because of the cumbersome procedures available to enforce a congressional subpoena. Generally, the house of Congress that issued the subpoena must hold someone -- a document custodian, the person refusing to testify, perhaps the White House Counsel -- in contempt of Congress. Either the Sergeant of Arms can lock the individual in a cell in the basement of the House, or Congress can refer the contempt to the U.S. Attorney for the District of Columbia to prosecute. But the U.S. Attorney can decline to prosecute. The Senate may have the additional option of bringing a lawsuit to enforce the subpoena. But even if that option is theoretically available, it requires a resolution of the Senate -- neither easy nor quick -- just to start litigating in the District Court, followed by appeals to the Court of Appeals and the Supreme Court. And if the issue is not resolved before the congressional session ends, the White House may argue that the subpoena has lapsed and that the process must start anew.

These hardball tactics are no way to govern. The President has precious little credibility left. He should not squander it on this fight.

Comments:

Lily Tomlin said the lead-off line, not Woody Allen, and she used the first person.
 

On the congressional side of the balance, the Department asserts that Congress has no legitimate interest in investigating the firing of U.S. Attorneys because the Constitution gives the President exclusive authority to nominate and remove his appointees. This rationale is weak. Congress is not merely probing the firing of a few prosecutors. It is investigating whether the Administration infected law enforcement decisions with undue political influence.

Deciding the priorities of the Justice Department is a political decision on how to delegate finite resources made by the President or his designees. Therefore, there can be no such thing as "undue" political influence in a political decision.

On the reasoning of the Justice Department opinion, Congress lacked a legitimate interest in investigating Watergate because President Nixon had exclusive power to fire Archibald Cox.

This is an silly analogy since this is not a criminal investigation ala Watergate.

Indeed, the Department opinion itself is telling evidence of the need for congressional oversight. Usually, the Attorney General signs opinions to the President. He did not sign this one, nor did the Deputy Attorney General. Both were disqualified because their conduct is under review. The Solicitor General therefore had to sign, a sad testament to the condition of the Department.

No, this is a sad indictment of a Dem Caucus in Congress which has launched 300 investigations in its first 100 days while only managing to pass one of its legislative priorities - the minimum wage. Is there anyone left in the Administration which is not the target of some Dem witch hunt or another?

The opinion also claims that Congress has minimal interests because the Justice Department already provided documents and witnesses. This point, too, is silly. The investigation concerns whether the White House meddled in prosecutorial decisions.

Meddling? The Justice Department works for the President. They will do what he instructs them to do, unless it is illegal. All the fired US Attorneys have testified and none of them claim that they were ordered to do anything illegal. Thus, where is the evidence to justify waiving executive privilege to determine whether the WH did something that no US Attorney has claimed happened?


Investigators need to scrutinize the meddler. In an investigation of bribery, no one would contend that it was gratuitous to gather evidence from the briber because the bribed official had cooperated with authorities.

But what appropriate governmental interest does it serve to deny Congress a transcript of the interview, or to refuse to allow aides to swear to tell the truth? Such conditions, which serve only to obstruct the congressional inquiry, are not legitimate accommodations.

If the Dems in Congress are actually seeking information, then interviews are more than sufficient for that purpose.

However, because the Dems are seeking partisan political theater, they are insisting on televised hearings.

Because the Dems are seeking to destroy members of an opposing administration, they are setting perjury traps by hoping that memories will differ during testimony under oath where there is not even a hint of an underlying crime.

These hardball tactics are no way to govern. The President has precious little credibility left. He should not squander it on this fight.

I agree. The Dems should stop the witch hunts and actually attempt to govern. Congress has even less credibility than this President and should not be squandering what is left.
 

So, Bart, oversight after 6 years of patently obnoxious behavior constitutes a "witchhunt?" For an administration that talks of "accountability" they sure do hate their little piggies being held to the fire. Fortunately, the cynical right has a small, but vocal, contingent of apologists (presumably NOT on the take), to spread disingenous lines parroted straight from RNC talking points memos.

The simple fact remains, irrespective of how you and others operating within the distracting partisan meme wish to play it, the nation has been usurped by an executive who has no regard for a co-equal branch of government and whose every single action is politically calculated one designed to achieve party dominance. As the esteemed Prof. DiIulio observed, the rot starts with Rove and the other "Mayberry Machievellis."

This is no different.
 

Folks, you have to stop feeding the troll. There's only one left here, but you just won't stop passing along the tender vittles of attention.

Please, quit it.

On the quote, I also IDd it as Tomlin, but for all I know Allen wrote the line for her. He was always a great writer.

As for the Executive's actions, depressingly I begin to hope for a volte-face by, let's hypothesize, an HRC executive branch. Yes, the eventual denouement would be very ugly, but perhaps we finally could have a unified, at-long-last moment where even the trolls of this world could unite in beating back the fascists.

It's time, troll-boy. If you don't, try to imagine what's likely to happen. My guess is that you'll find yourself even more offended than I.
 

At this point, I'd just as soon that the President finish squandering the last of his credibility, so that Republicans feel free to cut their last ties to him. It's not like he's going to do anything positive with that crediblity, if he doesn't squander it.
 

Hand-wringing, like tears, is not enough

"Such a tack is possible because of the cumbersome procedures available to enforce a congressional subpoena. Generally, the house of Congress that issued the subpoena must hold someone -- a document custodian, the person refusing to testify, perhaps the White House Counsel -- in contempt of Congress"

What is this?

This inquiry, one into the inner workings of a prosecutorial system that is at the heart of the workings of the republic, is, and is supposed to be a legitimate and important constitutional exercise: It’s the way your framers thought that the processes of government should work.

Who establishes – and can change – these “cumbersome” processes?

It boggles the mind, for example, that doubt might exist after 218 years of Constitutional experience as to whether or not judicial support is available to assist such facially legitimate exercises of constitutional legislative power.

You folks in America are beginning to develop two chronic conditions. The first is, having seen a reform majority countervailing the Administration elected to the Congress you would rather have the opportunity to whine than to act. The second is the self-delusion that the fact that there is still some 14 months of operation left for this governance destroying administration means that hair-tearing and breast-beating is all that can be done.

You are starting to think, and accept,that news conference reprimands of an unresponsive Administration – necessary enough in themselves – are all that can be done.

You are risking turning the slow, grating grind of this Administration towards its conclusion into an excuse for defeatism.

Balkinization is a blog of law professors and others who have the intellect, the insight and the opportunity to examine these "cumbersome" things.

Folks, ya have a duty to identify and others have a duty to amend and effect mechanisms looking to turn congressional oversight into, with respect, a process with at least a remote prospect for effectiveness and success.

Find ways to fix these problems as best they can be fixed, now!

Leave the tears behind.
 

With all deference to Woody Allen and his cynicism, I prefer to dwell on a paraphrase of Archimedes: Build a big enough roost and the chickens will all come home.

I means, of course, impeachment.
 

Der Schatten:

If Bush arrested Nancy Pelosi for a speech she gave in Congress (in direct violation of the Debate Immunity granted her via the Constitution) would you say about her fellow Congressmen complaining that "they sure do hate their little piggies being held to the fire"? I seriously want to know. And, whether you want to believe it or not, I did not get that question straight from any RNC talking points memo.
 

Der Schatten:

If Bush arrested Nancy Pelosi for a speech she gave in Congress (in direct violation of the Debate Immunity granted her via the Constitution) would you say about her fellow Congressmen complaining that "they sure do hate their little piggies being held to the fire"? I seriously want to know. And, whether you want to believe it or not, I did not get that question straight from any RNC talking points memo.

# posted by Charles : 11:14 PM

There is an obvious differnce -- and I'm surprised you failed to note it:

Pelosi would be immune, therefore she could not be legitimately arrested. So it would certainly be proper for Congress to raise hell.

By contrast, I don't know of any member of Busit, et al., who is being arrested for anything, so I guess your effort to beuild some sort of relevant analogy fell apart when WA state pointed out that an apple is not a FL orange.
 

It's called a hypothetical question, JNagarya. Perhaps you missed the posts where people here ARE advocating that the Congress arrest everyone from the President on down -- see "House jail" above -- once you catch up, let me know.
 

Deciding the priorities of the Justice Department is a political decision on how to delegate finite resources made by the President or his designees. Therefore, there can be no such thing as "undue" political influence in a political decision.

Right, so if the next President is a Democrat, and he openly states that his DoJ will be dropping the traditional interests (drugs, terrorism, etc.) and will instead focus only on investigating Republicans and their financial supporters, that won't be an undue political influence, since after all, defining priorities is a political decision?

Or is it only political if you say it out loud?
 

It's called a hypothetical question, JNagarya. Perhaps you missed the posts where people here ARE advocating that the Congress arrest everyone from the President on down -- see "House jail" above -- once you catch up, let me know.

# posted by Charles : 10:53 AM

A hypothetical, to be valid, and honest, should at minimum struggle to find a legitimate premise upon which to rest its feet.

A premise which is false to begin with isn't legitimate. It is Republican.
 

If Bush defenders like Bart want to bash on the Congress for investigating rather than legislating, then how about telling the Republican Senators to stop filibustering everything. They are literally blocking all symbolic legislation.

If Republicans block any effort to make policy, the Democrats are going to focus on process by necessity. It's the fault of dishonest, disingenuous movement conservative Republican partisan hacks, not the Democrats.
 

correction to earlier post, they are blocking all NON-symbolic legislation
 

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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