Thoracic surgeon and mesothelioma specialist Dr. Andrea Wolf likes to use the analogy that you don’t need a randomized trial to know that skydivers with a parachute generally will fare better than those jumping without one.
“Unfortunately, surgery is still an ongoing controversy with mesothelioma, about whether you should have it. I hear that a lot,” Dr. Wolf of Mount Sinai Hospital in New York City told Asbestos.com. “But taking all things into account, we found that surgery didn’t help just a little bit. It helped quite a bit. The truth is, patients can do well with surgery at the right centers today.”
Wolf is the lead author of a new, retrospective analysis that used a 14,228-patient database to evaluate the effectiveness of surgery and survival rates of mesothelioma patients, independent from other potential predictors.
She was joined by four others from Mount Sinai Medical Center, the North Shore-LIJ Cancer Institute and the Hofstra School of Medicine.
Researchers found that surgery alone was associated with longer survival rates, and that radiation did not improve survival unless it was combined with surgery. The database did not include chemotherapy, which is part of standard treatment today.
“There is still too much nihilism around mesothelioma, thinking that there is nothing you can really do, and that nobody should have surgery,” Wolf said. “But this data says otherwise. It would appear that surgery does help a lot of patients.”
The study came from the National Cancer Institute’s Surveillance, Epidemiology and End Results (SEER) database, compiled from 1973 to 2009. Independent predictors of longer survival included younger age, female gender and earlier stage of diagnosis.
“It’s not uncommon for a mesothelioma patient to be told, ‘There is not a lot we can do for you, let’s just try some chemotherapy and see how that does,'” she said. “But what we see here [in this analysis] is that surgery can be a major component to treating this disease.”
According to the data collected, the survival advantage is significant at the one-, three-, and five-year marks. The survival rates with surgery and radiation were 42 percent after one year, 24 percent after three years and 16 percent after five years.
Without surgery, the survival rates dropped to 18 percent after one year, 10 percent after three years and 5 percent after five years.
“There is no randomized trial out there to prove surgery works, but it’s something that a lot of us believe,” she said. “You’re not able to prove surgery helps, but when you see a patient that is alive 10 years out, that sure suggests that it does.”
The most aggressive surgical options for a pleural mesothelioma patient are the extrapleural pneumonectomy (EPP) and the Pleurectomy/decortication (P/D). Both are major operations that are done only at specialty centers like Mount Sinai.
The EPP involves the complete removal of a lung, the lining around the lung and heart, and portions of the diaphragm. The P/D surgery leaves the lung intact, but meticulously removes any visible tumor growth throughout the chest cavity while rebuilding the diaphragm.
In recent years, mesothelioma specialists have begun doing fewer EPP surgeries and more P/D surgeries, believing that the lung-sparing surgery is a better option for the majority of patients.
Although most surgical patients are in their 60s and 70s, mesothelioma patients in their 80s can do well also. Wolf can talk at length about her 88-year-old mesothelioma patient who is three years past surgery and doing well. She has another 83-year-old patient also surviving three years after surgery.
“Patient selection [for surgery] is very important. Who will benefit from it? That’s part of the challenge,” she said. “Age alone should not rule anyone out. Surgery can help. Can you prove it? No. But there’s a lot of data out there now that suggests it can.”