Balkinization  

Saturday, July 28, 2007

The Fairness Doctrine, Part I

JB

Senators Durbin and Kerry have recently raised the possibility of resurrecting the Fairness Doctrine. Senators Thune and Coleman have tried a preemptive strike against it. The right wing of the blogosphere is very much in arms about the issue, fearing that the Democrats are going to reinstate it. There is almost no chance that they will do so in the next two years, and even if they did, President Bush has vowed to veto the bill. Nevertheless, if the Democrats win the White House in 2008 there is an outside chance that the Fairness Doctrine might make a comeback, so I thought I'd say something about it.

The Fairness Doctrine is bad public policy and it should not be revived. That does not necessarily mean that it is unconstitutional, as many critics have charged. In fact it is probably not unconstitutional on its face, but it certainly could be unconstitutional as applied in certain circumstances. In this post, I only want to talk about its policy implications, why it is so easy to evade and why it does little to improve the quality of broadcasting. I'll leave the constitutional arguments to Part II of this series. In Part III I'll suggest what Congress might do if it really wanted to reform our broadcasting system. Critics on the right have charged that the recent attempt by Democrats to resurrect the Fairness Doctrine is an attempt to silence conservative talk radio. If that is so, it is doomed to failure, for reasons I shall describe in a moment.

A bit of history: We have been living without the Fairness Doctrine for about twenty years. The FCC, dominated by Reagan appointees in the 1980s, issued a report in 1985 arguing that the Fairness Doctrine was no longer necessary given the increase in media outlets due in part to cable penetration. The FCC also argued that the doctrine chilled speech and was probably unconstitutional, despite the fact that the Supreme Court upheld aspects of it in 1969 in the Red Lion decision. In any case, the FCC eliminated the Fairness Doctrine in 1987. Congress tried to reestablish it by statute several times in the years that followed, but Presidents Reagan and George H.W. Bush vetoed the bills and their vetoes were sustained.

The Fairness Doctrine, which has its roots in the 1940s, should be distinguished from the Equal Time/Equal Opportunities provisions of the Federal Communications Act, which are statutory. They are part of section 315 of the Federal Communications Act. The equal time/equal opportunities rules require that if a licensee gives the use of broadcast facilities to a qualified candidate for public office, it must give equal time and opportunities to all of the candidate's opponents. If the licensee sells the time to a candidate, it must offer time to the other candidates at the same rate; if it gives away time free, it must offer opponents time for free. There are exceptions for bona fide news events and interviews. The purpose of the Equal Time/Equal Access rules are to prevent broadcast stations from becoming effectively propaganda mouthpieces for particular candidates during election time.

The Fairness Doctrine is both broader and narrower in scope. It is narrower in the sense that it does not require that the licensee actually give the microphone to anyone else, as the equal time provision does. Many people who write about the Fairness Doctrine assume that the Fairness Doctrine requires that licensees let strangers use the station's facilities. That is only true under two sub-doctrines-- the so-called personal attack rules and the political editorializing rules. These are narrowly defined and rarely apply. In general, the Fairness Doctrine does not require this, as long as the licensee covers different points of view. As I'll explain shortly, this feature allows licensees to get around the Fairness Doctrine fairly easily.

The Fairness Doctrine is broader in scope because it applies in many more cases than the Equal Time provisions. The doctrine has (or had) two prongs. The first prong requires broadcast licensees to cover important issues of public concern. The second prong requires licensees to cover contrasting points of view fairly. The first prong was as important to the doctrine as the second. Its goal was to ensure that broadcast licensees did not provide only entertainment, but also contributed to public debate. But in doing so, it had to be an honest broker in its coverage. Originally, under the FCC's Mayflower doctrine, licensees were forbidden from editorializing at all. That prohibition was dropped in the late 1940s and the Fairness Doctrine was adopted as a less restrictive alternative. Henceforth licensees could editorialize if they allowed opportunity for discussion of contrasting perspectives.

By the 1980s, the fairness doctrine had long outlived its usefulness. It is possible that it was good public policy during the period in which there were only a limited number of television stations in each community, although I doubt it. The reason I doubt it was that the fairness doctrine in practice was fairly easy for most licensees to evade and mostly caused them bureaucratic problems.

First, licensees mostly decided for themselves what issues were of public concern. This allowed them to limit the ways in which the doctrine would affect them.

Second, licensees were permitted to decide what "both sides" of the relevant issue were and who would represent those sides. Issues are often multidimensional. Since it would not be possible to cover all aspects of a question, the licensee was given considerable range in choosing what the issue was, what the "reasonable" positions were on an issue, and who would present those positions. Licensees could exclude "extremist" positions or could include them to discredit the side they did not like.

To give only one example, when a reporter covered a controversy, the fairness doctrine did not demand anything more than traditional journalistic neutrality/objectivity. Journalists could present contrasting quotes from sources they themselves chose. Thus, a licensee determined to provide a particular message with respect to an issue could easily frame matters and select spokespersons so as to give a slanted portrayal. They could select only a narrow range of views on a topic and they could pick weak or unsympathetic representatives of positions they did not favor.

Perhaps more to the point, most licensees didn't want to cover public issues very much at all. Rather, they wanted to focus on entertainment and sports, and regarded the Fairness Doctrine as mostly a nuisance.

In practice, the Fairness Doctrine did not pose much of a problem for broadcasters who simply wanted to broadcast entertainment and sports, and whose coverage of contemporary events was broadly and blandly mainstream in their tastes, either liberal or conservative. It was more problematic for a handful of station owners who had a decidedly out of the mainstream point of view and who wanted to use their license to broadcast their views to the exclusion of others. The Fairness Doctrine fit mainstream journalistic practices of objectivity (with all their faults and non-objective elements) like a glove, which was not surprising because the Doctrine was modeled on those developing practices.

What about today, though? The increase in number of media outlets meant that advertiser-driven stations could make money by covering smaller niches and thus appeal to only one side of the political spectrum. This is one reason for the rise of conservative talk radio.

The Fairness Doctrine would probably require a change in formats for conservative talk radio. But it would not necessarily require actual fairness. Nor would it necessarily change the demagogic character of talk radio. Rush Limbaugh might have to invite a series of liberal patsies to give their views, which he could bully, make fun of, or talk past. Or he could offer his account of liberal views, which would no doubt be highly amusing to his audience. A radio version of Fox's Hannity and Colmes would clearly have passed muster under the Fairness Doctrine as the FCC enforced it in the old days, because, after all, there's Colmes, isn't there? It's true that Hannity sometimes treats him as a sidekick, and that he's not very liberal, but he does present contrasting points of view.

Now it's true that, under the Fairness Doctrine, someone like Michael Savage couldn't rant on and on without letting someone get a word in edgewise, but since Savage would be allowed to pick his opponents, it is unlikely that the bottom line message of talk radio would change all that much. It would simply be pitched in a way that preserved a fig leaf of fairness given bureaucratic imperatives from the FCC.

As you can see, given how easy it is to get around the requirements of the Fairness Doctrine, the doctrine is not going to do much to cure the bad behavior we see on the airwaves these days. At most it will cause bureaucratic problems for licensees, and require them to hire a few more personnel. Perhaps it will lead to the hiring of a few liberal patsies and punching bags. So think of it as affirmative action for milquetoasts. But what it won't do is improve the quality of talk radio.

In my next installment, I'll discuss the constitutional arguments for and against the fairness doctrine. It turns out that these arguments are trickier than they might at first seem.

UPDATE: Eugene Volokh has more on the implementation problems with the Fairness Doctrine. He also quotes from Powe and Krattenmaker's study, which, I think, offers the best criticisms of the doctrine as it developed before 1987.

Comments:

With all due respect--I agree that the fairness doctrine should not be reinstituted in its present form, however 91% of talk radio in this country is conservative and 9% is progressive. This huge imbalance is due to corporate support of conservative talk, the likes of which progressive stations receive little because it doesn't support "their" agenda. What ever happened to the airwaves serving the public interest.

Paul
 

The purpose of the Equal Time/Equal Access rules are to prevent broadcast stations from becoming effectively propaganda mouthpieces for particular candidates during election time.

In light of your persuasive argument about the ease of evading the Fairness Doctrine (I was pre-disposed to agree anyway), does the ET/EA rule really work? It seems obvious to me that, as a factual matter, it doesn't. Maybe that's just an enforcement issue, but I suspect it's subject to the same evasions as the Fairness Doctrine.
 

The Fairness Doctrine would not survive review by the current Supreme Court. Neither is it the best we can do with current technology. Under current Supreme Court case law, Congress can create an internet comment space allowing a vibrant public discussion of issues. For details see "A Listener's Free Speech, A Reader's Copyright," forthcoming Hofstra Law Review, now available at http://works.bepress.com/malla_pollack/
 

As they say on talk radio, longtime reader, first-time commenter. Excellent, compelling blog.

I agree that the fairness doctrine probably is bad policy. But when the percentage of conservative vs. liberal talk approaches 100 to zero in many markets, such as this Montana market, and when the few liberals who have the courage to call in to conservative shows are routinely shouted down, then the marketplace of ideas has broken down.

I will read with interest your suggestions in Part 3.
 

Professor Balkin paints a vivid portrait of the fairness doctrine in action, both back in the days and in a nightmarish future. Were it reinstated, Robert Greenwald would quickly amass footage enough for Outfoxed II, though he could equally call it The Sorrow and the Pity II given its length and tone.

I'd add that, given their superior resources and access to (and revolving identity with) regulators, people at rightwing media firms would in no time at all work up a double standard and deluge progressives outlets in nuisance actions.

Glenn Greenwald has a post up on Salon titled "What Beltway media stars mean by 'centrism' and 'extremism.' " It hits home in the same way: the media that give the stars airtime fix the terms of debate in outright disregard of public opinion.

About the last thing we need is a government seal of approval for such issue-framing. To me it is hardly an accident that each restorationist, Kerry and Durbin, has let himself be framed by the right, Kerry as a fake warrior, Durbin as so unpatriotic as to openly wring his hands at the thought that we may be borrowing interrogation techniques from the Nazis.

With friends like this, who needs enemies?

I look forward to Parts II and III. In the meantime I'll plug one of our more visionary senators, Bernie Sanders, who defines the fairness issue in contemporary terms: access, diversity of ownership, and interlocking arrangements.

Sanders notes that UHF frequencies will soon be up for auction and could be made available to wholesalers but won't unless we do something about it. He also calls attention to the iPod's tie-in to AT&T. His article is here: www.commondreams.org/archive/2007/07/27/2820/.
 

I think the Roberts Court would probably strike down the Fairness Doctrine as unconstitutional. One would think this has already been decided by Red Lion Broadcasting Co. v. FCC (1969) (unanimous opinion). But FEDERAL ELECTION COMM’N v. WISCONSIN RIGHT TOLIFE, INC. (2007) indicates Red Lion Broadcasting Co. v. FCC and that line of reasoning is no longer operative.

In Turner Broadcasting System, Inc.. v. F.C.C., (1994) Kennedy, with Scalia concurring, wrote for the court observing that since 1943, minimal scrutiny has been applied to broadcasting regulations. He wrote, "It is true that our cases have permitted more intrusive regulation of broadcast speakers than of speakers in other media." He also cited White saying, "[w]here there are substantially more individuals who want to broadcast than there are frequencies to allocate, it is idle to posit an unabridgeable First Amendment right to broadcast comparable to the right of every individual to speak, write, or publish."

But in FEDERAL ELECTION COMM’N v. WISCONSIN RIGHT TO LIFE, INC, in a case which dealt basically with a broadcasting regulation, the Supreme Court (with the votes of Kennedy and Scalia) ignored cases stretching back to over 60 years ago and applied some form of heightened scrutiny to a broadcasting regulation. I think we can say that the Roberts courts is no longer going to respect those precedents and in fact is willing to effectively overrule them if they get in the way of striking down down certain laws they dislike - although Roberts himself won't so because standard Roberts operating procedure is to not say so.
 

Agreed the Roberts Court (4 neatherthals plus Kennedy) would likely find the Fairness Doctrine unconstitutional (except if television and radio talk shows were 90/10 in favor of "leftists").

But really, where is the evidence for the parade of horribles? The Fairness Doctrine was not attacked in the 1970s and 1980s, when there was a veritiable explosion of political litigation.

I doubt most real world radio and television stations would be sued for airing two diverging points of view, but not a third diverging view. And I doubt that it would be worse under a Fairness Doctrine revival of television and radio than it is now.

So let's try reviving the Fairness Doctrine and see what happens. Maybe Kennedy will swing to the other side and television and radio might improve its balance of political voices.
 

Jack Balkin said in the opening post,
>>>>>Many people who write about the Fairness Doctrine assume that the Fairness Doctrine requires that licensees let strangers use the station's facilities. That is only true under two sub-doctrines-- the so-called personal attack rules and the political editorializing rules. These are narrowly defined and rarely apply. <<<<<<

The "personal attack rule" and the "political editorial rule" were repealed in 2000, whereas the fairness doctrine itself was abandoned in 1987. For details about these two rules and their histories, see this comment on Volokh Conspiracy.

Also, the Red Lion decision does not apply to the fairness doctrine generally but only applies to the personal attack rule and the political editorial rule. The Red Lion decision says,

We need not and do not now ratify every past and future decision by the FCC with regard to programming . . . . . But we do hold that the Congress and the Commission do not violate the First Amendment when they require a radio or television station to give reply time to answer personal attacks and political editorials.

Jack Balkin said,
>>>>>>The equal time/equal opportunities rules [in section 315 of the Federal Communications Act] require that if a licensee gives the use of broadcast facilities to a qualified candidate for public office, it must give equal time and opportunities to all of the candidate's opponents. <<<<<<

There is actually no general "equal time" requirement -- a reference says,

The equal time, or more accurately, the equal opportunity provision of the Communications Act requires radio and television stations and cable systems which originate their own programming to treat legally qualified political candidates equally when it comes to selling or giving away air time. Simply put, a station which sells or gives one minute to Candidate A must sell or give the same amount of time with the same audience potential to all other candidates for the particular office. However, a candidate who can not afford time does not receive free time unless his or her opponent is also given free time. Thus, even with the equal time law, a well funded campaign has a significant advantage in terms of broadcast exposure for the candidate.

However, sometimes "equal time" is required where a candidate's appearance is non-political: ". . .during Ronald Reagan's political campaigns, if a station aired one of his films, it would have been required to offer equal time to Mr. Reagan's opponents."

There appears to be some overlap between (1) the repealed personal attack and political editorial rules and (2) the so-called "equal time/equal opportunity" law, Section 315 of the Federal Communications Act. However, air time was required to be offered for free under the personal attack and political editorial rules, whereas Section 315 of the FCA only requires that all candidates be charged equal amounts (including zero) for air time. Also, those two repealed rules required that the air time be used for rebuttal of a personal attack or political editorial on the same channel -- Section 315 has no such requirement.

Paul said (11:27 AM) --
. . .91% of talk radio in this country is conservative and 9% is progressive. This huge imbalance is due to corporate support of conservative talk, the likes of which progressive stations receive little because it doesn't support "their" agenda.

Good point. Conservative talk show hosts tend to be pro-business in their views about issues concerning the environment, labor, business regulations, business taxes, the fairness doctrine (yes), etc., and I think that explains the radio stations' and commercial sponsors' preference for conservative talk shows.
 

Dan the Man said ( 7:22 PM ) --
>>>>> I think the Roberts Court would probably strike down the Fairness Doctrine as unconstitutional. One would think this has already been decided by Red Lion Broadcasting Co. v. FCC (1969) (unanimous opinion). But FEDERAL ELECTION COMM’N v. WISCONSIN RIGHT TOLIFE, INC. (2007) indicates Red Lion Broadcasting Co. v. FCC and that line of reasoning is no longer operative. <<<<<<

As I pointed out, Red Lion did not rule on the Fairness Doctrine generally but only upheld the two "corollary" or "sub-doctrine" rules, the "political editorial rule" and the "personal attack rule," as constitutional. Red Lion said,

We need not and do not now ratify every past and future decision by the FCC with regard to programming . . . . . But we do hold that the Congress and the Commission do not violate the First Amendment when they require a radio or television station to give reply time to answer personal attacks and political editorials..

The "political editorial" and "personal attack" rules, which were repealed in 2000, are described in this comment on the Volokh Conspiracy blog.

Considering how great the changes have been in the broadcasting industry since Red Lion(1969) -- with the additions of cable TV and satellite radio -- it is doubtful that the courts would consider Red Lion to be binding, anyway.

Also, in Miami Herald Publishing Co. v. Tornillo (1974), the Supreme Court struck down as unconstitutional a Florida "right to reply" law for newspapers that was equivalent to the FCC "political editorial rule." IMO that was really stupid. The Miami Herald decision is discussed in Item #8 in this article on my blog. It is often impossible to predict how the courts are going to rule in specific cases.

BTW, there is another difference between the repealed FCC "personal attack rule" and Section 315 of the Federal Communications Act (47 USC §315): The "personal attack rule" was available to everyone whereas Section 315 is available only to candidates in a public election.
 

Here are some more thoughts --

1. A broad fairness doctrine would be a great burden on broadcasters because of limited air time.

2. It is often difficult or impossible to decide what is "liberal" and what is "conservative."

3. Suppose that a fairness doctrine is in effect and a broadcaster has only "conservative" talk shows and so is required to add "liberal" talk shows. The broadcaster may have to offer free air time for liberal talk shows because the liberals cannot be forced to pay for the time. Then the conservative talk show hosts are going to argue that the liberals ought to pay for air time and that the conservatives should get the free air time.

4. As I said, I think that conservative bias is built into talk radio because conservative show hosts tend to have views that favor big business and the conservative shows are therefore preferred by radio stations and commercial sponsors. This is a real dilemma because the cure may be worse than the disease.

5. It is ironic that the people who make the "let them eat cake" argument that we don't need fairness doctrines for broadcasters and newspapers because people have the alternative of expressing themselves on the Internet are the same people who are in favor of allowing arbitrary censorship of visitors' comments on blogs and other Internet forums. The argument of limited time/space does not apply to the Internet because the space for comments is virtually unlimited.

6. Here are some suggestions for reducing radio talk show bias: (1) Limit consolidation of radio station ownership and (2) require that a certain percentage of call-ins to radio talk shows not be pre-screened.

7. I think that the "personal attack" and "political editorial" rules should be restored in some form.
 

This is weird.

As I pointed out, the Supreme Court ruled in Red Lion (1969) that two corollaries of the Fairness Doctrine, the "political editorial rule" and the "personal attack rule," are constitutional --

We need not and do not now ratify every past and future decision by the FCC with regard to programming . . . . . But we do hold that the Congress and the Commission do not violate the First Amendment when they require a radio or television station to give reply time to answer personal attacks and political editorials.

However, in 2000, the DC Circuit federal court of appeals ordered the FCC to repeal these same two rules! In so ordering, the court suggested that these two rules are unconstitutional (Radio-Television News Directors Association and
National Association of Broadcasters v. FCC
) --

The court is presently asked to order the vacation of the personal attack and political editorial rules adopted by the Federal Communications Commission in 1967 as corollaries to the fairness doctrine, which the Commission abandoned in 1985. . . .

. . . . The court has previously recounted the chronology of events, now exceeding twenty years when in response to a 1980 petition to vacate the rules, nothing happened for long periods of time. See Radio-Television News Dirs. Ass'n v. FCC, 184 F.3d 872 (D.C. Cir. 1999) ("1999 Radio-Television"). The court did, however, acknowledge that the rules "interfere with editorial judgment of professional journalists and entangle the government in day-to-day operations of the media," id. at 881, and "chill at least some speech, and impose at least some burdens on activities at the heart of the First Amendment." Id. at 887. Consequently, the court held that it was incumbent upon the Commission to "explain why the public interest would benefit from rules that raise these policy and constitutional doubts." Id. at 882. (emphasis added)

In December 1999, following the denial of rehearing and rehearing en banc, the court remanded the case to the Commission, stating that the Joint Statement by the two Commissioners in support of the rules was inadequate to permit judicial review. Id. at 881-85. The court instructed the Commission's two-member majority to explain its support of the personal attack and political editorial rules in light of the Commission's conclusion in 1985 that the fairness doctrine was not in the public interest and its decision in 1987 not to enforce the fairness doctrine. Id. at 889. . . . .

. . . . The court has afforded repeated opportunities for the Commission to take final action. Despite its filings suggesting to the court that something would happen, the Commission, once again, has done nothing to cure the deficiencies of which it has been long aware. Of course, the Commission may institute a new rule-making proceeding to determine whether, consistent with constitutional constraints, the public interest requires the personal attack and political editorial rules. These are issues that the court has yet to decide. Nevertheless, extraordinary action by the court is warranted in this case, particularly in view of the fact that the six reasons proffered in support of the rules were all wanting. . . .

. . . . the court hereby recalls its mandate and issues a writ of mandamus directing the Commission immediately to repeal the personal attack and political editorial rules.
(emphasis added)

So the court demanded that the FCC justify its support of the two corollary rules (the personal attack and political editorial rules) in light of the abandonment of the rest of the fairness doctrine in the period 1985-87. But a petition to vacate these two rules was filed in 1980 when the full fairness doctrine was still in effect.

These two rules might be considered to be a side-issue here because what the opponents of conservative talk radio are seeking is a full fairness doctrine, not fairness doctrine lite. However, these two rules are an important part of the story --- for example, in Red Lion, the Supreme Court declined to rule on the full fairness doctrine but only upheld these two rules.
 

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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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