UK Doctors Question Benefits of EPP Surgery
A group of doctors in the United Kingdom, where asbestos-related disease is peaking, is questioning the wisdom of extrapleural pneumonectomy (EPP) surgery for mesothelioma patients, despite its continued practice at prominent cancer centers in America.
The doctors contend that research supporting the benefits of EPP is badly flawed.
“One more of those surgeries would be one too many,” said Tom Treasure, M.D., thoracic surgeon and researcher at the University College London. “The world has moved away from that surgery, which can be stopped now without a loss.”
Treasure spoke with Asbestos.com about an article he and his peers wrote for the June issue of Thorax, An International Journal of Respiratory Medicine. They believe that patients would be better served by moving into clinical trials and rejecting major surgery for this disease.
EPP is Most Aggressive Option
EPP, which is the most aggressive treatment option for malignant pleural mesothelioma, includes a complete lung resection and removal of the pleural lining around the lung and major parts of the diaphragm.
There is no cure for mesothelioma, a rare but aggressive cancer that is caused by exposure to asbestos. Standard care often includes a combination of surgery, chemotherapy and radiation. Although treatment has improved considerably in recent years, patients still face a grim prognosis.
Thoracic surgeons in the United States have debated for the last several years whether EPP is worth the risks and complications associated with such a major surgery. Some studies have shown it can extend survival time significantly. Some patients are living well beyond five years after an EPP. Others studies suggest it does little to extend patients’ lives.
Joining Treasure in his assessment are Avijit Datta, M.D., and Rhiannon Smith, M.D., from the Department of Respiratory Medicine York Teaching Hospital, and Francesca Fiorentino, M.D., from the National Heart and Lung Institute, Imperial College London.
Their article contends that studies showing longer survival times for surgical patients are misleading because they are not randomized, and only the healthiest patients, with the disease in its earliest stages, become surgical candidates.
Treasure points to the Mesothelioma and Radical Surgery (MARS) trial completed in 2011 that showed no definitive benefits to the radical surgery.
“Those patients who live for three years after surgery, they are the ones who would have survived for three years, anyway,” he said. “These are patients looking for hope, and they want to believe; they are desperate to believe, because they want to live. They want to say, ‘At least I tried.’ There is a need for hope, but that can be overdone. I don’t believe in false hope.”
Clinical Trials a Better Option
Treasure believes that clinical trials, often with promising new therapies, would result in a better quality of life for patients. He believes the medical community should focus more on controlling the cancer instead of trying to surgically remove it.
“There appears to be a place for an approach in which treatment is moderated and in which the primary outcome shifts from survival to giving the patient the best remaining months or years,” the article concludes. “If patients are to be considered for surgery, given the lack of good quality evidence, recruitment into … clinical trials should be considered as the default position by respiratory physicians, surgeons and oncologists.”