Peritoneal mesothelioma patients are neglecting surgery as a therapeutic option – for a variety of reasons – and needlessly losing out on years of survival time, a recently published study from the Medical College of Wisconsin shows.
Even though the benefits are clear, surgery is not being performed on 62 percent of peritoneal patients, according to the study using 1973 to 2010 data from the Surveillance, Epidemiology and End Results (SEER) database.
The Annals of Surgical Oncology published the study in its May journal.
“It’s unfortunate, but you can see the missed opportunity here,” said Kiran Turaga, M.D., one of the study’s co-authors and assistant professor in the division of surgical oncology at the Medical College of Wisconsin. “It’s a reason to raise awareness. Surgery is a really good option – most patients can benefit – but I think too often, it’s not being offered or recommended.”
The SEER data consisted of 1,591 peritoneal patients with a median age of 74, most of whom had metastatic disease. The overall survival rate of those who underwent cytoreductive surgery was an average of 20 months, compared to just four months for those who did not have surgery.
Recent advancements in surgery and other therapeutic options have improved everyone’s survival rate. Surgical patients, for example, had an overall survival rate of only 15 months from 1991 to 1995, but they survived an average of 38 months from 2006 to 2010.
While the most recent time period reflected a survival rate that more than doubled, the percentage of patients going without surgery remained almost the same. It was 55.8 percent from 1991 to 1995 and 56.8 percent from 2006 to 2010.
The latest surgical procedures involve a combination of radical resection of the tumor, along with hyperthermic intraperitoneal chemoperfusion (HIPEC), which is a heated chemotherapy bath of the abdominal area.
Peritoneal, which attacks the thin membrane around the abdomen, is a less common form of mesothelioma, which strikes an estimated 3,000 Americans annually. Less than a third of those patients are diagnosed with peritoneal. The majority of the cases are pleural, which starts in the lining around the lungs.
The SEER database was not specific regarding why patients were not having surgery, leaving much of it to speculation.
“The reason for this practice pattern could be varied, including nihilism for disease or treatment, misinformation, host of disease characteristics precluding therapy or data collection bias,” the authors wrote.
Turaga told Asbestos.com that perhaps some patients are too weak or just refused surgery, “but it could be the fact there wasn’t the proper facility available to do it.”
“My bias is that most patients are not referred to a specialty center, where they would see someone who could talk about all the options,” Turaga said. “Many medical oncologists out there today don’t know enough about it [peritoneal mesothelioma], and just tell a patient, the surgery is not worth it.”
Turaga also said it is rare when a pleural patient comes to Medical College of Wisconsin and is not offered at least limited surgery to increase their chances of survival. Without surgery today, the prognosis with peritoneal remains poor, typically between 6-12 months.
“The majority of patients who come to us end up getting surgery,” Turaga said. “The bottom line is that patients who undergo surgery can end up living a long time.”
When separating the patients in the study by limited/regional disease indicators, the SEER study shows that patients with radical surgery had an overall survival rate of 40 months, but only 27 months with limited surgery and 13 months with no surgery.
The authors also detailed a separate, multi-institutional study involving 405 patients with peritoneal mesothelioma, and those results were even more encouraging for surgical patients. Patients who had both cytoreductive surgery and HIPEC had an overall survival rate of 53 months. There was a five-year survival rate of 47 percent.
There was considerable disparity, though, based on the tumor histology, which was not reported in the SEER data. Patients with epithelial peritoneal mesothelioma who had surgery and HIPEC had a median survival of 63 months. Those with either biphasic or sarcomatoid mesothelioma, with comparable surgery and HIPEC, averaged only 16 months.
“It’s not surprising that survival time is greatly improved with surgery,” Turaga said. “It’s disappointing that more patients are not being given that option.”