Nathan Pennell, M.D ., is not convinced that the most aggressive treatment plan for malignant pleural mesothelioma is always the best treatment plan.
Sometimes less is more.
Pennell is a medical oncologist at the Taussig Cancer Center in the Cleveland Clinic, focused on thoracic malignancies, including a special interest in mesothelioma.
His studies have found that the highly-touted trimodality approach, which includes chemotherapy, then surgery, and then radiation, is no guarantee of a better outcome than what a less-taxing regimen could yield.
Fast Fact: Dr. Pennell completed additional training at Harvard School of Public Health in the Program in Clinical Effectiveness
“Studies of patients treated with surgery have shown about the same average overall survival as patients treated palliatively with chemotherapy alone (nine to 12 months),” he wrote in an article for GRACE (Global Resource for Advancing Cancer Education). “The main problem with mesothelioma is that most patients present with advanced disease that has no chance of curative treatment with surgery.”
One of the biggest problems with pleural mesothelioma, caused by exposure to asbestos, is the usually-late diagnosis. The delay allows it to advance through the lining of the chest cavity before treatment even begins. Typical symptoms include a shortness of breath and fluid surrounding the lungs, which can be confused with less-serious illnesses.
“Of course there are case reports, or case series of patients with limited disease who can be aggressively treated with surgery and have lived > five years (most oncologists definition of cure),” he said. “But the reality is that these patients are few and far between.”
Pennell cited a study done by oncologists at the Toronto General Hospital that was published in the Journal of Clinical Oncology in 2009. That study followed 60 mesothelioma patients who qualified for the trimodality therapy over a seven-year period in Toronto, Ontario.
The surgery involved the radical extrapleural pneumonectomy (EPP), which removes an entire lung with the surrounding pleural cavity and pericardium. Only the healthiest of patients could qualify for the surgery.
“The median overall survival for this group was 14 months. To compare, the median survival in the only randomized trial of chemotherapy alone was 12.1 months,” he said.
He did note that surgery-approved patients typically were stronger patients to start. Ten percent of them were alive five years later, while none of the patients who received chemotherapy alone were alive after five years.
“There is a role for surgery in mesothelioma and any advancement that leads to cures in this terrible disease is fantastic, but until this can be applied to a larger percentage of the patients, I think it will remain out of reach for most patients,” he said.
Pennell has been at the Cleveland Clinic since 2008, and his research interests include clinical trials using novel therapies. He graduated from the University of Florida School of Medicine, then went to Boston, where he did his internship and residency at the Brigham & Women’s Hospital and his fellowship at the nearby Dana-Farber Cancer Institute.
It was in Boston, home of the International Mesothelioma Program, where he developed his clinical interest in mesothelioma, a rare cancer that is diagnosed in an estimated 3,000 people annually.
Pennell has authored or co-authored 15 journal articles on a variety of topics including the management of cancer and patient care.
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