Sugarbaker: Centralizing Peritoneal Mesothelioma Treatment
September 3, 2020
We’ve come a long way in the treatment of peritoneal mesothelioma cancer over the years, but we’ve still got a long way to go.
I’m asked a lot: What’s wrong with the management of mesothelioma today in the United States, and how could we improve it?
Well, if you look at it from a glass-half-full perspective, there have been a lot of good changes. It used to be these patients would get no treatment at all, except a little systemic chemotherapy, which did nothing for them.
Are we utilizing what’s out there today? To a certain degree, yes. But is it being done optimally? No, it is not. The glass is half full. The treatment is not as good as it could — and should — be.
I’m amazed at how well we’ve done at the Washington Cancer Institute at MedStar Washington Hospital Center because I can remember how things used to be. But we’re the exception.
In our most recent group of 36 surgical patients, we have a 75%, 10-year survival rate. That’s pretty amazing, but I’m treating fewer patients these days.
That success is not being repeated elsewhere like it should be. The expertise and mesothelioma treatment advancements — cytoreductive surgery, HIPEC, long-term care — are not getting to most patients like they should be.
One of the problems is that mesothelioma is such a rare disease. How many places in the country can really handle it optimally? Maybe three or four, but there are 150 cancer centers treating peritoneal surface malignancies that will take on mesothelioma when they really don’t have the experience. That’s a problem.
Centralized Treatment ‘Centers of Excellence’ Are Key
Patients get referred to their local “expert” who may or may not know what he’s doing. He thinks he does, but he doesn’t. You’ve heard the expression, “you don’t know, if you don’t know.” That’s what’s happening too often.
I know a place today treating peritoneal surface malignancies like mesothelioma where nobody is living past six months. That shouldn’t be happening.
In too many places, patients are getting lousy care.
The solution? We need centralization for these rare cancers — centers of excellence. Maybe one on the East Coast, one on the West Coast and one in the Midwest — and allow them to work together, instead of numerous health care systems now vying with each other.
Centralization could make a huge difference with mesothelioma. It would allow us to do the much-needed research that we’re not able to do today with a rare disease. It’s just not happening now, and we have no one championing the issue.
All the time and money are being spent advancing treatment for breast, colon and prostate cancers, which are much more common malignancies.
So the little guy — peritoneal mesothelioma — is really treated poorly. It’s a priority thing, and these rare diseases just don’t score very high.
Mesothelioma Care Should be Handled by Experts
Centralization has made a huge difference in the management of numerous other diseases, such as pancreatic cancer and colorectal cancer.
For example, at MedStar Washington there are a limited number of people who have the tools, and the infrastructure, to do colorectal cancer optimally. No other surgeon will do it now.
The same sort of thing should be happening with peritoneal mesothelioma. Unless you’ve really studied it, don’t do it.
A lot more patients should be getting those great results we got. With centralization, patients would be better selected for mesothelioma surgery, which isn’t happening now. It’s why some patients are getting a lot of treatment, but very little prolongation of survival.
In other words, don’t operate on someone who didn’t have a chance in the first place. Knowledgeable patient selection would be much better at a center of excellence.
There has been a lot of centralization in Europe, and it has worked well. In Sweden, for example, there are only four or five centers in the country that treat all Swedes for peritoneal surface malignancies — only those who can do it optimally.
Our health insurance system now — under the Obamacare rules — is too regionalized. So centers of excellence haven’t happened the way they should in the United States.
I recently talked to a lady with high-grade peritoneal mesothelioma. Her original diagnosis was in 2007, so she’s 13 years out. She’s had another recurrence and is going to need a third operation. She’s in an oil-rich country overseas, and she can go wherever she wants for treatment. That’s good health insurance.