Recent Study Confirms Effectiveness of Radiation Therapy Following Lung-Sparing Pleurectomy/Decortication Surgery

There has been a long-standing debate over which surgery is more effective for treating malignant pleural mesothelioma (MPM). For many years, a majority of surgeons believed that a radical procedure called Extrapleural Pneumonectomy (EPP), which involves removal of the mesothelioma tumor along with the affected lung, diaphragm and pericardium, was the preferred way of surgically treating MPM. However, in recent years, many surgeons have come to the realization that the Pleurectomy/Decortication (P/D) procedure innovated by UCLA and West Los Angeles VA Medical Center Thoracic Surgeon Dr. Robert Cameron, in which the tumor is removed and the patient is left with a functioning lung, is the more effective and less risky procedure.

For the surgeons that continue to perform EPP despite the mounting studies confirming the effectiveness of lung-sparing P/D, one of the reasons they cite to is the purported inability to effectively deliver radiation to the area following P/D.

The typical protocol following both EPP and P/D is to have patients undergo a series of radiation treatments, typically 25, beginning a month or so after the surgery. The purpose of the radiation treatments is to eradicate the microscopic tumor cells that remain after all visible tumor is removed. It has been the belief of EPP proponents that radiation treatments following P/D are much less effective because of the presence of the lung and related tissues.

A study published in the November edition of the international journal Lung Cancer disproves this theory. Researchers at the Centro di Riferimento Oncologico di Aviano in northern Italy monitored 20 patients with malignant pleural mesothelioma who were given localized high dose radiation therapy following P/D surgery. The patients underwent 25 radiation treatments likely over the course of five weeks. The survival rate in the study was 70 percent at two years and 49 percent at three years or more, with a median survival rate of 33 months. The estimated progression-free survival rate was 68 percent at two years and 46 percent at three years.

The results of this study confirm what proponents of P/D have believed for some time, namely that it is possible to deliver full dose radiation following lung-sparing surgery.

Related Links:

• Lung-Saving P/D vs. Radical EPP
• Debunking the Myths about P/D
• Surgical Choices: Pleurectomy with Decortication

UCLA Now Offering Multi-Disciplinary Clinic Where Patients Can Meet With Surgeon and Oncologist Specializing in Mesothelioma at the Same Consult

Patients who are diagnosed with mesothelioma often feel overwhelmed and stressed. An aggressive tumor has been growing in their body and time is of the essence in order to effectively treat it. But before proceeding with a treatment, many questions need to be answered:

• Am I a candidate for surgery?
• If so, what surgery is best for me (EPP vs. PD)?
• Should I have chemotherapy instead of surgery?
• Should I have chemotherapy AND surgery?
• If so, should I have chemotherapy before or after surgery?
• If chemotherapy, what agents should I receive?

Under typical circumstances, getting reliable answers to these questions which require input from doctors with specialized knowledge in two disciplines, surgery and oncology, can be a difficult and time-consuming process. Furthermore, because of the rarity of the disease, there are many opportunities for misinformation to de-rail the process.

As part of its Comprehensive Mesothelioma Program, which brings together doctors from various specialties in a collaborative “team” approach to treating pleural mesothelioma, UCLA is now offering a weekly multi-disciplinary clinic to help patients avoid the pit-falls, challenges and delays that are often encountered in determining a treatment plan.

Common Pit-Falls, Challenges and Delays

1.  "You’re not a candidate for surgery because the tumor is too diffuse"

Most patients are diagnosed with pleural mesothelioma via a biopsy performed at a local hospital. The surgeon performing the biopsy is often a general surgeon and, even if a thoracic surgeon, does not have significant experience in the diagnosis or treatment of mesothelioma. There are many instances where the surgeon performing the biopsy advises the patient that he or she is not a candidate for surgery because the tumor is too diffuse or has spread over most of the lung. As a result, the patient is referred only to an oncologist and is presented with chemotherapy as the only treatment option.

A similar result occurs where a pulmonologist or oncologist with limited experience treating mesothelioma reviews a CT scan revealing tumor that has spread over most of the lung and determines that the patient is not a candidate for surgery.

Doctors who specialize in the treatment of pleural mesothelioma will explain that mesothelioma is, by its very nature, a diffuse tumor which spreads throughout the thin pleural lining that  surrounds the lung. Most surgeons who specialize in treating the disease will conclude that a person is a candidate for surgery so long as the tumor remains confined to the pleural space (i.e. it has not invaded the lung or the chest wall), even though it is covering much of the lung.

2.  "Reflex" Response: Alimta/Cisplatin Chemotherapy

In 2004, the FDA approved pemetrexed (Alimta) in combination with Cisplatin for the treatment of pleural mesothelioma. Alimta/Cisplatin remains the only FDA approved chemotherapy drug combination for the treatment of mesothelioma. As a result, many general oncologists that are not experienced in treating mesothelioma reflexively prescribe Alimta/Cisplatin without informing patients about other treatment options.

Doctors more experienced in treating mesothelioma are aware that: a) the FDA’s approval of Alimta/Cisplatin was limited to “use with patients who are not eligible for surgery”, b) in pre-approval trials Alimta/Cisplatin showed only a 41% partial response rate and an increased median survival rate of only 2.8 months, with the best results seen in patients with epithelial cell-type, and c) more recent published trial data reveals that a combination of surgery, radiation, and chemotherapy is almost always associated with the longest survival times. 

Alimta/Cisplatin is administered once every three weeks for a total of six rounds. With follow-up CT-scans, the treatment process typically lasts approximately six months. With the limited response and increased survival rates, many physicians believe that this is too much time to “invest” in this particular treatment when other treatment options are available for treating this aggressive disease.

3.  "Tic-Toc" and "Can we talk?"

Even if a patient is fortunate enough to work with knowledgeable doctors who are willing to consider a full range of available non-surgical and surgical treatments, the mere act of seeing doctors from the various specialties can be extremely time-consuming.

Doctors, especially specialists, are very busy and it often takes many weeks to get an appointment. Furthermore, most experienced mesothelioma specialists will want to review all medical records and radiology scans before recommending a treatment. Some will even want to have the biopsy pathology slides re-tested by pathologists they trust in order to get an accurate read on the specific cell-type of the tumor. The burden of collecting and transmitting all of these materials frequently falls on the patient and the patient’s family.

The process of preparing for and seeing various specialists can easily take a couple of months to complete and often results in different opinions and recommendations regarding treatment. For example, an oncologist recommending chemotherapy and a surgeon recommending surgery. While the oncologist and surgeon may be in communication with the pulmonologist or internist that referred the patient, the oncologist and surgeon frequently don’t speak directly to each other. Accordingly, the patient is left to make a very important medical decision in a relative “vacuum.”

Furthermore, once a decision is made and the patient proceeds with the chosen treatment, the specialist’s involvement typically ends once the treatment is completed. The patient then returns to the pulmonologist for the next step, which is often a referral to another specialist—starting the  process all over again!

UCLA’s Multi-Disciplinary Clinic Brings Patients Together With Expert Surgeon and Oncologist to Make “Team” Decisions Regarding Treatment

In furtherance of its team approach to treating mesothelioma, UCLA’s Comprehensive Mesothelioma Program recently began offering a multi-disciplinary clinic where patients can meet with both a thoracic surgeon and an oncologist who specialize in treating pleural mesothelioma.

The multi-disciplinary clinic is offered Wednesdays at the Pacific Thoracic Surgery office located at 10780 Santa Monica Boulevard, Suite 100, in Los Angeles, California. At the clinic, patients are seen in consultation by thoracic surgeon Dr. Robert B. Cameron and oncologist Dr.Olga Olevsky .

Dr. Cameron is the director of UCLA’s Comprehensive Mesothelioma Program, chief of thoracic surgery at the West Los Angeles Veterans’ Administration Medical Center and Scientific Advisor for The Pacific Meso Center. Dr. Cameron has been treating pleural mesothelioma patients for over 20 years, is the innovator of the lung-sparing Pleurectomy/Decortication surgical procedure and is widely recognized as one of the world’s foremost experts in mesothelioma treatment and research.

Dr. Olevsky is a board certified oncologist and the oncology specialist of the UCLA Comprehensive Mesothelioma Program. She is extremely knowledgeable about the various chemotherapy agents which are producing the best results for epithelial, sarcomatoid and bi-phasic cell types of mesothelioma.

At the multi-disciplinary clinic, patients are able to meet with both Dr. Cameron and Dr. Olevsky who work together to customize a treatment plan based on such factors such as the patient’s age and condition and tumor cell type, location and staging. Patients and accompanying family members are welcomed to be part of a thorough open discussion with Dr. Cameron and Dr. Olevsky regarding surgical and chemotherapy options, as well as other treatments such as radiation, cryoablation and immunotherapy offered by the UCLA Comprehensive Mesothelioma Program. The goal is, of course, to take the guesswork and frustration out of a very complex decision making process.

For patients who decide to proceed with the treatment recommended by Dr. Cameron and Dr. Olevsky, both doctors will continue to supervise all aspects of treatment from that point forward. Patients are closely monitored with follow-up examinations every three months and are referred as necessary to other specialists that are part of the Comprehensive Mesothelioma Program.

The patient-centered approach to care provided by UCLA’s multi-disciplinary clinic is aimed to save patients time and anxiety in making informed decisions about mesothelioma treatment, allowing them to proceed with treatment as early as possible and focus on getting well.

For more information about the multi-disciplinary clinic, contact Nurse Savannah Cline of the Pacific Meso Center at (310) 478-4678 or scline@phlbi.org.

Dr. Cameron: "A Blessing"

When Patricia Crawford was initially diagnosed by doctors at Kaiser Permanente, they tried to steer her into having her lung removed using the radical lung-amputating extra-pleural pnuemonectomy (EPP). She was not made aware of the lung-sparing pleurectomy-decortication (P/D) surgery and probably would've consented. But, thanks to the diligence and curiosity of her children, who logged onto the internet and discovered Dr. Robert Cameron, she sought a second opinion.

Undaunted by the lack of a formal referral from Kaiser Permanente, Patricia set up an appointment with Dr. Cameron. She knew that Kaiser's vast bureaucracy would either delay or reject the referral, but time was short. She decided to pay for the consultation herself and worry about coverage later.

Dr. Cameron talked with her extensively about her surgical options. He explained the differences between the EPP, which removed the lung, and the P/D, which spared the lung. He explained to her that the P/D provided the same tumor clearance as the EPP with a lower risk of mortality.

He also explained to her the adjuvant use of radiation as well as immunotherapy and chemotherapy. Patricia ultimately chose to undergo the pleurectomy/decortication at UCLA on January 10, 2008. (For more information on the differences between the EPP and P/D, click here) The doctors at Kaiser, who recommended the EPP, had not even mentioned the PD as an option. Patricia is thankful that she found Dr. Cameron. "He has been a blessing."