Study Shows Peritoneal Mesothelioma Surgery Underutilized
July 28, 2020
The continued underutilization of aggressive surgery for peritoneal mesothelioma is shortening survival time dramatically for patients who could qualify for, and benefit from, the highly effective procedure.
Only a third of those diagnosed with peritoneal mesothelioma are undergoing potentially curative cytoreductive mesothelioma surgery, according to a comprehensive study of the National Cancer Database by researchers at Inova Fairfax Medical Center in Virginia.
Annals of Surgical Oncology published the mesothelioma study earlier this year.
“Patients who have the surgery perform much better than those who do not. Yet most people do not have surgery,” Dr. Timothy Cannon, medical oncologist at Inova Medical Group and study co-author, told The Mesothelioma Center at Asbestos.com. “We’re hoping the study can raise awareness to this paradox.”
The research involved 2,062 adult patients registered with the National Cancer Database who were diagnosed with diffuse malignant peritoneal mesothelioma, a rare and aggressive cancer found within the abdominal cavity.
Survival Advantage for Peritoneal Mesothelioma Is Dramatic
An estimated 400 cases of peritoneal mesothelioma are diagnosed in the United States annually. It is typically caused by long-ago exposure to asbestos.
Inova’s study found that nonsurgical patients had a median overall survival of just 7.1 months, compared to 38.4 months for surgical patients and 41.8 months for those who also added systemic chemotherapy.
The median overall survival soared to 65.9 months for those who underwent surgery that was accompanied by hyperthermic intraperitoneal chemotherapy, also known as HIPEC.
According to the report, only 34% of patients underwent aggressive surgery. Another 15% underwent minimal, partial or palliative surgery.
Although there are some patients diagnosed who don’t qualify for surgery because of overall health reasons, age, or disease progression, those cases are not in the majority.
“There are just not that many patients who have access to a surgeon who is experienced in radical peritoneal surgery,” Cannon said. “And many are working with oncologists who are not aware of the advantages of surgery in this population.”
Some Oncologists Unfamiliar with Peritoneal Mesothelioma
The database did not differentiate the reasoning behind the nonsurgical patients.
“It appears that surgical treatments have significant potential but are underutilized for patients,” the authors wrote. “It is an orphan disease, and a generally nihilistic attitude among physicians prevails.”
The authors speculate that one reason behind the attitude is the association with the more prevalent and tougher to treat pleural mesothelioma, which develops in the thoracic cavity.
Only an estimated one-fourth of pleural mesothelioma patients even qualify for surgery, and median survival is considerably shorter.
Another reason is that most oncologists rarely see a patient with peritoneal mesothelioma and are unfamiliar with its intricacies and successful mesothelioma treatments.
“Multiple studies suggest that physicians who do not specialize in treatment of peritoneal malignancies have limited knowledge about the possibility of complete surgical resection,” the authors wrote.
With HIPEC, Surgery Makes a Significant Difference
A small number of peritoneal specialists have been successful using cytoreductive surgery, a lengthy procedure that removes all visible tumor cells throughout the abdominal cavity, followed by the HIPEC procedure.
HIPEC is designed to kill any tumor cells in the abdominal cavity that evaded the surgeon. It is used at the end of the surgical procedure. It involves heated, high-dose chemotherapy that is circulated throughout the abdominal cavity for up to 90 minutes before it is removed.
The combination, which also is used with other peritoneal malignancies, is only done at select mesothelioma treatment centers across the country. Depending upon the disease involvement, the two procedures can take anywhere from six to 12 hours in the operating room.
Inova Medical Center is one of the specialty centers that treats peritoneal mesothelioma effectively with the surgery and HIPEC combination. Patient advocates at The Mesothelioma Center can help patients find others across the country.
Multiple studies at specialty centers with experience in the disease have demonstrated median survival from 35 to 100 months with the multidisciplinary treatment.
Cannon said that every patient newly diagnosed with peritoneal mesothelioma should be evaluated for the possibility of surgery.
He and his co-authors agree that the formation of a national network of designated treatment centers with the ability to deliver the full spectrum of care would be helpful.
“Surgical resection appears to be the intervention with the greatest potential to positively impact survival in appropriately selected patients,” the study concludes. “Every newly diagnosed patient should be evaluated by a multidisciplinary team that includes a surgeon with expertise.”