A pair of California surgeons say surgery for mesothelioma is rarely worthwhile. They point to what they say are flawed studies on surgical treatment.
One trial they believe was well-conducted seems to show reduced mesothelioma survival after surgery.
Some Background on Surgery for Mesothelioma
Pleural mesothelioma is a cancer of the lining around the lungs. It is an aggressive cancer with no known cure. There are two primary approaches to surgery for mesothelioma. Both types are controversial and the subject of much debate among surgeons.
Extrapleural pneumonectomy (EPP) is a surgical approach that involves removing the pleural membrane, one lung, and part of the diaphragm along with other at-risk tissues. The major difference between EPP and pleurectomy/decortication (P/D) surgery is that P/D leaves the lungs in place.
Both EPP and P/D are major operations with many risks. Some studies suggest that EPP is more risky than P/D but may offer longer survival.
Making Sense of Mesothelioma Surgery Research
The authors of the new article say it is hard to know what to believe. “There is a lack of randomized evidence to support a survival benefit when major surgical resection is included in multi-modality treatment regimens,” they write.
Authors Gavitt Woodard and David Jablons contend that some of the top studies on the subject have serious flaws. As an example, they point to the Surgery for Mesothelioma After Radiation Therapy (SMART) trial. SMART tracked the outcomes of surgery for mesothelioma among patients who had radiotherapy to shrink their tumors first.
Woodard and Jablons say the problem with the SMART trial is that it was limited to the healthiest patients. Only patients with a Performance Status of 0 or 1, meaning cancer did not have a major impact on their activities, could participate.
“This patient population predictably has relatively longer survival times than patients with inoperable advanced disease,” they write.
One trial that the authors support is MARS (Mesothelioma and Radical Surgery). The 2011 MARS trial was a randomized feasibility study. It concluded that EPP was too risky and should be abandoned as a surgery for mesothelioma.
“Critics of the MARS trial cite a high perioperative mortality rate for driving these results, however a similar trial has never been repeated to refute the MARS trial results,” write the authors.
Too Risky for Too Many
Drs. Woodard and Jablons say evidence against surgery for mesothelioma is growing.
Research shows many patients are not good candidates. This includes people with sarcomatoid or biphasic mesothelioma, very old patients, those who have cancer in their lymph nodes, and people with elevated CRP or platelets.
Even in the “ideal candidates”, surgery can cause serious complications and even death. Given these facts, the authors conclude that surgery is of “questionable benefit” to most mesothelioma patients.
Woodard GA and Jablons DM, “Surgery for pleural mesothelioma, when it is indicated and why: arguments against surgery for malignant pleural mesothelioma”, February 2020, Translational Lung Cancer Research, Volume 9, Supplement 1, http://tlcr.amegroups.com/article/view/35964/24353