Is EPP The Answer?

For years in the US the conventional wisdom taught that if you have pleural mesothelioma and you want to survive, you better have your lung taken out.

A new study from the UK has debunked that theory.

Doctors in the UK recently published the preliminary findings from the Mesothelioma and Radical Surgery (MARS) study, a randomized trial in which one group of participants would receive chemotherapy, then extrapleural pneumonectomy (EPP), then radiotherapy. The second group of patients would receive other types of aggressive therapy, but would not receive EPP.

Significantly, the study did not contain an arm for patients to choose or undergo the surgical alternative to the EPP, known as the Pleurectomy/Decortication, which removes the tumor only and spares the lung.

The goal of the trial was to determine whether EPP in conjunction with adjuvant chemotherapy and radiotherapy offered benefits to the patient in terms of life expectancy and quality of life, as compared to other standard therapies. The study also assessed the benefits compared to the surgical risks of morbidity or mortality.

In a nutshell, the MARS trial unambiguously debunked the popular theory that the EPP is the best surgical treatment for pleural mesothelioma patients.

Please read the abstract, as well as the comments by PD pioneer Dr. Robert Cameron of UCLA and the Pacific Meso Center.

Dr. Cameron has been treating mesothelioma patients for over 20 years. He is one of the innovators of the lung-sparing Pleurectomy/Decortication. He has has performed the procedure on over 300 patients in his career. It takes about twice as long as the EPP, is highly tedious, but the results have been worth it in terms of lower patient mortality, above average median survival, and improved quality of life. For more about Dr. Cameron's expertise, click here.

The MARS trial offered up sweet validation of Dr. Cameron's approach -- an approach that has not always endeared him to his pro-EPP surgical colleagues. He writes: "This most recent trial is even more proof that no one suffering from the ravages of mesothelioma should be subjected to the further indignation of a radical, debilitating and useless operation based on "selected" data.”

The take home message: there's no substitute for due diligence. Before consenting to a radical, lung amputating surgery, do your homework. Ask tough questions. And call Dr. Cameron.

December 8, 2010

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."

Dr. Cameron: "He clarified my options in lay terms"

Holger Lochheed is a 70 year-old retired hotel restaurant manager who lives with his wife Lynne in Mesquite, Texas. Holger was diagnosed with malignant pleural mesothelioma two years ago during a routine physical.

Holger recently reviewed a copy of the Pacific Heart, Lung & Blood Institute’s “Patients Road Map”, a brochure written to help mesothelioma patients navigate the many roads before them on their journey to proper diagnosis, treatment and coping with their disease. Here it Holger’s enthusiastic response.

Dear Mr. Caron,

Thank you for your letter and the "Patients Roadmap" brochure.

While the brochure is informative, short and to the point, it lacks the strong emphasis to seek out a specialist as early as possible.

My personal scenario is a case in point. After diagnosis, I was referred to a local Oncologist (a charming gentleman) who gave me 9 months to live and with treatment 3 years. His referral to a Thoracic Surgeon was even bleaker: an immediate operation followed by heavy radiation. Outlook: 2 years and "I'll try to save part of your lung".

Thank God your office referred me to Dr. Cameron. He clarified my options in lay terms.

I chose to do nothing.

So far this decision had stood me in good stead. I feel well and live the good life. Naturally I am under no illusions and know this could change at a moments notice.

Therefore, it is my humble opinion that the publication needs to put a MUCH STRONGER emphasis on the importance of seeking out meso specialists as early as possible.

Kind regards,

Holger Lochheed

The Hunt for A Cure: W&C responds to WSJ article

The Wall Street Journal, which is in the business of putting asbestos trial lawyers out business, contacted me over a year ago. They wanted to run an article about my donations to medical research.

As a journalist myself in college, it didn’t take long for me to figure out their angle. They wanted to show that somehow my practice of sponsoring medical research, as opposed to spending oodles on TV and Google ads, was “fishy” if not “rotten.”

The result of that year long quest appeared today in the crusty WSJ under the byline of reporter Dionne Searcey. The title: “Mesothelioma Doctors, Lawyers Hunt for Valuable Asbestos Cases.” 

Right away you get a feel for the slant. We are “hunters.”  Now, I’ve gotten to know Ms. Searcey fairly well and my guess is she didn’t write the headline.  Contrary to the splenetic anti-lawyer bias of the WSJ’s editorial board,  Ms. Searcey actually went the extra mile to check her facts, question her own biases, and listen to contrary points of view. To her credit, she even previewed with me the accuracy of the quotes she attributed to me and others.  In sum, she has shown a degree of professionalism I did not expect from her employer, and I respect her methods greatly.

But I wanted to clarify just a few points.

First, we wouldn't be in this mess if the asbestos industry hadn’t created it.  Nor would we be fussing about the ethics of sponsoring medical research if the asbestos industry itself had not steadfastly and stupidly refused to clean up their horrific mess.

Second, if the parties responsible for the asbestos cancer mess won’t clean it up, who will? The Federal government has not invested in medical research commensurate with the size of the problem, their responsibility (for Navy vets, meso is a “service connected disability) or their own fault. Meanwhile, the number of people diagnosed with meso is “too small” for Big Pharma to justify any serious investment. The labor unions are broke. If not the patients and their advocates, who will step up? 

Third, if money curries favor, from a strict profits and losses perspective, why hasn’t the asbestos industry donated to research?  A few years ago, Dr. Cameron was invited to speak to 600 asbestos defense lawyers, insurance adjusters and company reps.  He talked about the medical and ethical benefits of sponsoring research. How much did they pony up? Zero. Now, that’s “disgraceful.”

The asbestos industry is notorious for corrupting the medical and scientific literature with false and deceptive articles they paid for designed to prove to juries that asbestos is as benign as mother’s milk. If anyone knows how to curry favor with money, it’s the asbestos industry.

It simply boggles my mind that the industry, after 50 years of wasting tens of billions of dollars on phony research and medical mercenary “experts,” still has yet to see the economic benefits from finding a cure.  Put lawyers like me out of business! Save asbestos-tainted companies from bankruptcy! Spare millions of people agony, misery and death! It makes dollars and sense.

Fourth, the only “stakeholders” that really don’t want to see a cure for mesothelioma are the legions of “bill to kill” defense lawyers. They get paid by the hour. It’s in their economic interest to drag out tedious, life-sucking litigation, as the John Johnson case sadly but clearly demonstrates.

That said, over the past 25 years, I have met several honorable defense lawyers who agree with me that their clients should indeed invest in a cure.  They agree with me that they should find a way to resolve meritorious cases early before racking up thousands and thousands in legal fees. And they agree that it makes no sense at this late date for asbestos defendants to invest in crackpot “experts” to gin up junk science to bamboozle juries, when the money should instead be invested in cleaning up their horrific mess. 

We are quick to forgive in this country.  People, like corporations, make mistakes. What’s unforgivable is the perpetuation of that mistake by stubbornly refusing to own up to it.

Finally, maybe I’m wrong about the “benefits” of keeping meso patients alive. Unfortunately, as long as certain states limit or eliminate the damages available in wrongful death cases, then the bad guys will indeed have an economic incentive to hasten their victim’s demise.  It’s no secret that here in California the asbestos companies generally settle wrongful death claims for far, far less than they do for living claims.  The law encourages this wicked behavior.  In this dark and dusty light, it’s no wonder the bad guys don’t invest in a cure.

My firm’s motto has always been: “Asbestos Lawyers for Life.”  Yes, it’s in my firm’s interest to help my clients live long and prosper.  The day that in this great country we hold in contempt efforts to cure cancer but applaud and reward the cancer creators, well, that’s a day I’d rather put off, and I don’t think I’m alone.

RGW

5/6/13

Hunters for Justice and a Cure for Meso: The John Johnson "Fight Meso" Family, sponsors of the Dana Point Grand Prix

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.

Honoring our Duty to Treat Veterans with Late Onset War-Related Diseases, Worthingtons donate $100,000 to the Pacific Meso Center

LOS ANGELES. As we celebrate the end of the war in Iraq, in which nearly 4,500 US soldiers were killed in action, and over 30,000 were injured, we are mindful of our grateful nation’s duty to medically treat our veterans returning home with war-related disabilities.

Donald Thorp

1946-2003

USN 1964-1985

Mesothelioma, 1999

Historically, while our country has offered valuable medical care to veterans with open and obvious physical injuries, it hasn’t done a great job treating or attempting to treat our veterans afflicted with latent onset injuries, such as asbestos-caused malignant mesothelioma.

Today, to honor our country’s surviving veterans, whether from WWII, the Korean War, the Vietnam War, or more recent conflicts, who were exposed to deadly asbestos fibers, but for whom the US Department of Defense has never funded a treatment program, we are proud to donate $100,000 to the Pacific Meso Center (PMC).


The PMC stands alone as the only medical foundation which is dedicated to both basic science and clinical research on therapies for treating patients with mesothelioma. Of the 3,500 Americans diagnosed with mesothelioma annually, about a third of those patients were exposed to asbestos while serving their country in the armed forces or working as civilians in shipyards which built or repaired naval ships. For over 40 years, these service men and women, many of them heroes, have been dying of this horrible disease and this amounts to ten times the number of deaths as the entire Iraqi war!

Clyde Robison, Sr

USN 1956-1960

Mesothelioma, 2007

Regrettably, despite the clear link between mesothelioma, asbestos, and the US Navy, the DOD has never acknowledged it's duty to care for vets with asbestos diseases. The DOD has invested trillions of dollars over the past three decades in equipping our forces with the most sophisticated weaponry in the world, but it has been inexcusably penurious when it comes to funding programs to help prevent, diagnose or treat vets with service connected asbestos disease, such as mesothelioma.

We salute our front line soldiers, as well as all the doctors, nurses, and personnel within our vast network of Veterans Administration hospitals who daily attempt to treat veterans with asbestos diseases, which can take 20-50 years to manifest after initial asbestos exposures.

Thomas Reed

1950-2007

USCG 1969-1973

Mesothelioma, 2006

Unfortunately, within the colossal VA system, treating meso patients is not a priority. Despite an annual budget of over $132 billion (2012), the VA has neither a research nor a treatment program for vets stricken with war-related mesothelioma. 

One bright spot on treatment front, however, is the work and energy of Dr. Robert Cameron, a thoracic surgeon at the David Geffen School of Medicine at UCLA, who also serves as the Chief of Thoracic Surgery at the VA Medical Center in West Los Angeles and one of the only mesothelioma experts in the VA Medical System.

Dr. Cameron, a scientific advisor for the Pacific Meso Center, has thankfully taken a leadership role in framing the mission to develop a nationwide treatment program for veterans with mesothelioma.

Dr. Cameron commented "we are preparing to ask the VA to live up to its obligations to provide the best medical care for these veterans suffering from mesothelioma by creating a national center of excellence for both research and treatment at the West Los Angeles VA Medical Center where any veteran from across the country can come and be treated with the most advanced medical treatment available worldwide. We not only can but we must finally do this for our veterans." We applaud his interest in this orphan, underfunded disease.



James Hart

1943-2007

USN 1961-1963

Mesothelioma, 2006

Twenty years ago, when we first began representing veterans with mesothelioma, the lack of a federally funded program was perhaps understandable. But, today, the lack of a program is simply negligent. As my client Donald Thorp, a former Navy officer, said in 2000, "We served our country honorably. I cannot accept that our country has not taken responsibility to serve us."

Dr. Cameron recently lectured a large group of asbestos industry lawyers that despite an annual budget of $5 billion, the National Cancer Institute has never funded research on asbestos cancer commensurate with its incidence. He also noted that three promising therapies -- the IL-4 toxin, cryotherapy and stromal cell immunotherapy -- would each require start up funding of $2-3 million, which is a tiny fraction of the financial investment for chemotherapy drugs.

Can the country afford a few million dollars a year for meso research? Yes.  In 2012, our country has budgeted a whopping $1.4 trillion for defense related costs, including $707 billion for the DOD. 

We are hopeful that our donation will spur the PMC to continue to champion its campaign to partner with the DOD and DVA in the creation of a mesothelioma research program for our veterans who, long after their honorable discharge, continue to battle with war-related cancer.

Roger and Ann Worthington
December 16, 2011

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Admiral Elmo Zumwalt

1920-2000

USN 1939-1974

Mesothelioma, 1999

Honoring Admiral Elmo Zumwalt and Remembering the Service Connected Asbestos-Induced Mesothelioma That Killed Him

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Dr. Cameron Proposes IMIG Consensus Statement on the Role of Surgery in Mesothelioma Treatment

Recently several hundred doctors and scientist from all over the world with an interesting in mesothelioma met in Boston to discuss, among other things, the role of surgery in treating meso patients (the "IMIG" group).

Earlier, a paper had been published out of the UK that questioned the merits of extrapleural pneumonectomy (EPP)  as compared to chemotherapy alone (the trial didn't offer pleurectomy/decortication).  The IMIG group pointed out various flaws in the design and operation of the trial.  In particular, the clinical trial, the first of its kind anywhere, had terrible trouble over a period of three years recruiting the 50 patients it needed for a pilot trial. The MARS group's plan was to follow up the pilot study with a full blown and statistical meaningful mega-trial of 670 patients. They never got there. 

Of the 50 meso patients they did recruit, many of those did not complete the arm of the study they started (ie. surgery only or chemo only), or they crossed over (from surgery to chemo, or vice versa) during the trial. 

The MARS authors to their credit did acknowledge this deal-breaker problem. They went so far as to question whether a clincial trial of this kind was ever feasible at all in the real world, where patients simply don't want to be "guniea pigs" even in the greater interests of medical advancement. A clinical trial of this scope has never even been attempted in the US.

In the US, patients have many choices, and it remains "muddy" what the best option is across the board for the "average" meso patient.  Dr. Cameron and Dr. Sugarbaker have publically disagreed over which surgery is "better" - ie. EPP vs Pleurectomy/Decortication. However, both agree today that the role of surgery is to remove as much tumor as you can see (what Dr. Sugarbaker has coined "complete macroscopic resection" (MCR)).  Dr. Cameron has been a long time advocate of pulling up his sleeves and pulling out a much tumor as he can see, without watching the clock, noting that "negative margins" was and always will be a pipedream for a meso surgeon.

I encourage you to read the draft proposal submitted by Dr. Cameron, which is based on an earlier draft proposed by Dr. Sugarbaker.  Although there are stylistic differences, both agree that surgery should be performed along with adjuvant care to attack the unseen tumor cells that remain in the body after surgery.

As Dr. Cameron tactfully writes: "The exact surgical procedure should be based on disease distribution, surgeon preference and experience, and institutional experience and should be performed with a morbidity and mortality consistent with published literature." 

As a patient, before making your decision (e.g., chemo only? What chemo? Surgery? What operation? By whom and where?),  the IMIG Group has also recommended that you follow these important guidelines:

• Pathological diagnosis including histologic subtype should be established by tissue biopsy.
  
• Clinical staging be performed prior to initiation of therapy and should include PET with lymph node sampling and/or MRI as indicated.
• The type of surgery (EPP, P/D, etc) should be based on clinical factors as well as individual surgical judgment and expertise.
• Complete surgical stating should include hilar and mediastinal lymph node removal.

To review a complete text of Dr. Cameron's proposed IMIG consensus statement, please click here.  The IMIG board will review all comments and submit the final approved version for publication in a suitable journal with collective authorship.  Doctors as well as patients need and deserve this kind of up-to-date education. We applaud Dr. Cameron and Dr. Sugarbaker, as well as all the other doctors, who have participated in this project.

RGW

10/16/12

Sarcomatoid Predominant Malignant Pleural Mesothelioma: An Institutional Approach and Experience

As presented by Dr. Robert Cameron at the 11^th International Conference of the International Mesothelioma Interest Group (iMig)  
Boston, MA – September 11-14, 2012

Sarcomatoid-predominant malignant pleural mesothelioma is an especially difficult tumor to control. Thoracic surgeons at UCLA seeking to improve the poor prognosis that comes with this incredibly aggressive cancer looked at the treatment of non-mesothelioma pleural sarcomas, which is typically treated with chemotherapy followed by surgery and radiation.

Doctors identified four patients with sarcomatoid-predominant malignant pleural mesothelioma who had received pre-operative therapy before undergoing the lung-sparing pleurectomy/decortication procedure. Three of these patients utilized Ifosfamide/Adriamycin and one patient Cisplatin/Pemetrexed/ Veglin. Three-fourths of these patients were found to have pathological responses with 80-99% necrosis, or tumor death, which is not often seen with standard Cisplatin and Pemetrexed.

Multimodality approaches that utilize Ifosfamide/Adriamycin seem to be the optimal treatment strategy for sarcomatoid-predominant malignant pleural mesothelioma patients. In addition, patients who originally are not eligible for surgery may become so if they see 80% or higher necrosis and remain free of metastatic growth following chemotherapy. Click here to view this abstract.

Thermal Therapy in the Treatment of Malignant Pleural Mesothelioma

As presented by Dr. Robert Cameron at the 11^th International Conference of the International Mesothelioma Interest Group (iMig)  

Boston, MA – September 11-14, 2012

Thermal therapy has been used in cancer therapy for decades and hyperthermic chemotherapy perfusion, specifically, has been used in the treatment of mesothelioma but without data as to the optimal conditions.

In a study performed at UCLA, doctors sought to define in vitro the most effective strategy for the use of thermal therapy in pleural mesothelioma. They exposed three human mesothelioma cell lines to varying hyper and hyperthermic conditions using either a standard metabolic MTS absorbance assay or a standard clonogenic (which is a microbiology technique for studying the effectiveness of specific agents on the survival and proliferation of cells). Each cell line was then expanded and exposed to varying combination of hyperthermia, hypothermia and/or chemotherapy – using chemotherapy agents cisplatin, gemicitabine, and/or pemetrexed.

Their findings show that thermal therapy appears to be most effective when using hypothermia rather than hyperthermia, and chemotherapy appears to be most effective when using two drug combinations over one individually. Click here to view this abstract. 

The Timing of Chemotherapy in the Multimodality Treatment of Malignant Pleural Mesothelioma

As presented by Dr. Robert Cameron at the 11^th International Conference of the International Mesothelioma Interest Group (iMig)  

Boston, MA – September 11-14, 2012

Chemotherapy used in multimodality treatment of malignant pleural mesothelioma is typically performed within 4-6 weeks prior to or after surgery, and various strategies have been used with regard to the timing of chemotherapy within a multimodality treatment.

Doctors at UCLA identified 121 patients who had undergone the pleurectomy/decorticationsurgery followed by adjuvant radiation therapy and received chemotherapy only after the first recurrence of the disease. The results of receiving delayed chemotherapy were comparable or better to those reported for “trimodality” therapy including the recent MARS trial. These findings suggest that a more rational and conservative approach to multimodality treatment of patients with malignant pleural mesothelioma may be warranted.

Multimodality Therapy is the combination of surgery, radiation, and chemotherapy; and for malignant pleural mesothelioma patients eligible for surgery, is almost always associated with the longest survival rates. Survival of patients who receive this type of treatment varies from 16 to 22 months, depending on the staging, type of surgery, cell type, as well as other factors. Click here to view this abstract.

Percutaneous Outpatient Cryoablation for Localized Recurrent Pleural Mesothelioma Following Lung-sparing Pleurectomy and Decortication Surgery

As presented by Dr. Robert Cameron at the 11^th International Conference of the International Mesothelioma Interest Group (iMig) 

Boston, MA – September 11-14, 2012

Recurrence for patients with malignant pleural mesothelioma is extremely high following surgery, most patients are ineligible for repeat surgery and management of mesothelioma is among the most challenging of cancer therapies. Many of our clients have experienced good results with post-surgery cryoblation therapy. (including Martha Munoz, Patricia Crawford and Sylvia Ramirez) 

Cryoablationfor localized recurrent malignant pleural mesothelioma following surgery can be performed safely as an outpatient procedure. It is a minimally invasive procedure, which uses a needle to target argon gas directly to the tumor killing the cells it touches in a relatively safe and quick manner. It can be performed on multiple lesions at a time and is also a safe and relatively quick method to control pain and improve the patient’s quality of life.

Doctors at UCLA have published a promising study with the International Mesothelioma Interest Group which identifies 24 UCLA patients who have received one or more cryoablation treatments for localized recurrence of malignant pleural mesothelioma following surgery with or without adjuvant therapy. The patients in the study were found to have a minimal morbidity rate of 5.6%, a very high efficacy rate of 95.3%, and an impressive overall survival rate of 36.1 months.

Currently only a handful of centers specialize in the use of cryoablation in the management of mesothelioma, most notably diagnostic radiologists, Dr. Fereidoun Abtin and Dr. Robert Suh at UCLA.

Meso Empowerment Exclusive: Dr. Cameron shares his brilliant insights on breakthrough moments at IMIG Conference in Boston or, Galileo is Smiling

Dr. Robert Cameron
iMig 2012

Dr. Robert Cameron, thoracic surgeon and mesothelioma specialist, was kind enough to provide us with his tweets as he attended the recent IMIG conference in Boston. His “boots on the ground” tweets were simply too compelling to leave alone so we followed up and asked him to elaborate

If you’re reading this, you’re no doubt aware of Dr. Cameron’s pioneering efforts to re-introduce “rationality” to the macho “bigger is better” mentality that unfortunately has tended to dominate meso surgery in the US. Although his pleurectomy/decortication (P/D) model is now becoming not only accepted but strongly endorsed, it wasn’t always this way.

I remember vividly at a meeting among surgeons 12 years ago where his fellow surgeons literally shussed Dr. Cameron when he tried to speak up against powerful, East Coast-driven forces who decreed that their big gnarly “extra-pleural pneumonectomy” (EPP) was as unassailable as a papal decree. For years, Dr. Cameron toiled away, mainly in the dark, while the spotlight remained brightly fixed on the “curative” EPP. But he never lost faith.  Like so many myth busters of lore (Galileo comes to mind), Dr. Cameron’s belief that removing the tumor and sparing the lung was the only rational way.

I can’t speak for Dr. Cameron, but for this cancer warrior, it feels good that his brethren have finally embraced the P/D on which Dr. Cameron based his career and his passion.

Here’s a few of the good doctor’s tweets and the follow up.

Enjoy the read and keep questioning, searching, learning and leaning towards the light.

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IMIG 2012: for the future of treatment of mesothelioma: the future is clearly immunotherapy!

Why is Dr. Cameron so optimistic? Let’s ask.

Dr. Cameron: Although we are only just now learning how to harness the power of immunotherapy, there is already evidence from decades ago that something as simple as stimulation with IL-2 into the pleural space can result in survivals that have rivaled "trimodality therapy" with median survivals as long as 28 months.

Furthermore, the immune system when it does work has been shown in other cancers, such as melanoma and renal cell carcinoma, to eradicate even bulky disease. We are now on a new learning curve with better understanding not only of what it takes to stimulate an immune response but what it takes to reverse the tumor-mediated escape mechanisms present at the actual tumor site. With the accelerated development in this field that has happened over the last few years, we should make good progress in the near future.

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IMIG 2012: Steven Albelda confirms that immunotherapy is a very promising treatment for mesothelioma.

Dr. Steven Albelda
iMig 2012

No need for explantion here. Dr. Cameron’s succinct appraisal speaks for itself. Good news! I remember years ago when I was a director on MARF feeling proud to help sponsor Dr. Abelda’s futuristic benchwork research. Smart guy. Good guy. Glad Dr. A is on the team.

David Sugarbaker: "Can't we all just get along and operate on mesothelioma?"

Funny question, coming from the Pope of the EPP himself who for years dominate the conversation, owned the paradigm, and didn't give much heed to his few naysayers. Let’s face it, we love a title fight between heavyweights, so I couldn’t resist asking Dr. C for his reaction to the EPP’s loudest and most cocksure advocate sudden plea for tolerance. Is Dr. S presuming that surgery, no matter what form it takes, must be bedrock of every treatment regimen for meso?

Dr. Cameron: Despite the continued lack of randomized prospective trials showing exactly what, if any, benefit that surgery offers, Sugarbaker must be feeling the heat of all the mounting data that EPP is not necessary.  In my view, he’s now trying to deflect that argument and avoid controversy by calling on all surgeons regardless of which operation you perform to tell medical oncologists and pulmonologists that surgery forms the cornerstone of treatment.

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IMIG 2012: David Sugarbaker admits that "EPP has no superiority" as an operation over pleurectomy and decortication

Dawgies! Is this one of those “Yes, the earth revolves around the sun” belated acknowledgements? So, Dr. C, why is this such a big deal (picture me feeding the tiger a little red meat).

Dr. Cameron:  “You're kidding right? Most of the posters at this meeting were people trying to do EPPs because they are all under the impression that the "data" shows that it is better.  [Which unfortunately means that for too many ‘get her done’ surgeons with yank-the-lung-it is the earth continues to be the center of the universe….].

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IMIG today: Sugarbaker admitted that he is now doing 2/3 pleurectomies for mesothelioma....a huge change from a few years ago

This is a radical reversal. We asked Dr. C if he knew whether the Titan of Tri-modal had ever publically debunked or disparaged PD for meso?

Dr. Cameron: “I’m not sure he’s ever disparaged the P/D for meso directly but he has said that the only curative operation for the disease was the EPP. “

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Pac Meso Center’s Presentation: "The timing of chemotherapy in the multimodality treatment of malignant pleural mesothelioma" received praise from IMIG.

Congratulations!  To read the abstract of this presentation (by Dr. Cameron), please click here.

Note, it was great to learn that the other surgeon who helped form MARF back in the day (1999), Dr. Harvey Pass, one of the most talented, gifted and intelligent doctors on the planet, complemented the presentation and agreed that chemotherapy may not be such a crucial part of "trimodality" therapy (patient ALWAYS want to avoid chemo; losing their hair, nausea, vomiting, etc.) Thank you Dr. Harvey Pass, one of my heroes in the topsy-turvy turbulent Mesoworld.

Our Presentation: Percutaneous outpatient cryoablation for localized recurrent pleural mesothelioma was likely the highlight of IMIG meeting

This is great news. My law firm is particularly proud of this since cryoablation has been used successfully on several of my meso clients (including Martha Munoz, Patricia Crawford and Sylvia Ramirez) who were relieved and impressed with it’s ease, efficiency and results.

The Pacific Meso Center is currently writing two papers that will be published soon. Consequently, since journals won’t publish anything that’s already been publically circulated, the PMC cannot a this time post it’s powerpoint slides on the internet. Dr. Cameron did however reveal, happily, if not surprisingly, that Dr. Sugarbaker mentioned cryoablation specifically as one of the highlights of info being presented. High praise from the High Priest of Meso! And well should the Big Guy be impressed – preliminary data show that the practice for recurrent patients was effective in 95% of the cases.

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David Sugarbaker TOTALLY BACKS OFF his beloved EPP to "MCR" Macroscopic Complete Resection, which is code for pleurectomy and decortication

We asked Dr. C to flesh out what this means for the typical meso patient. The backstory of course is that Dr. C has always pointed out that total eradication of all tumor is a pipe dream and they only reasonable goal was the removal of all “visible” tumor? (Note to patients – make sure your surgeon is wearing telescopic lens gear).

Dr. Cameron:  Yes, that’s been my common sense approach, but the EPP crowd never embraced this until now. This basically recognizes that what I have said for decades is actually now widely accepted and people like even Dr. Jablons who abandoned P/D for EPP were bowing to peer pressure not acting on data.”

Well, dear readers, hope you enjoyed the ride. It’s been fun. Please drop us a line if you want to learn more. In the meantime, praise hope!

RGW

Sept. 18, 2012

Roger G. Worthington

International Panel of Medical Specialists Convene for First-Ever Medical Symposium Dedicated to Lung-Sparing Therapies for Patients With Malignant Pleural Mesothelioma

The UCLA Mesothelioma Research Program, in conjunction with the Pacific Meso Center, held the 1st International Symposium on Lung-Sparing Therapies for Malignant Pleural Mesothelioma on May 21 in Santa Monica, California. The Law Office of Roger Worthington was proud to co-sponsor this first-ever medical seminar focusing on treatment options for patients with pleural mesothelioma.

In recent years, a growing number of the world’s top mesothelioma experts have questioned the value of a radical surgical procedure known as extrapleural pneumonectomy, or EPP, which involves removal of the pleura-based tumor along with the adjacent lung, lymph nodes, portions of the pericardium and the diaphragm. Despite a 60 percent complication rate, the radical surgery continues to be advocated by a number of leading mesothelioma specialists, including Dr. David Sugarbaker of Brigham and Women’s Hospital/Dana Farber Cancer Institute in Boston.



(left - right) Mr. David Waller, MD, Mr. Tom Treasure, MD and

Dr. Robert Cameron, MD

Led by Dr. Robert Cameron, Director of the UCLA Mesothelioma Research Program and Chief of Thoracic Surgery at the West Los Angeles Veterans’ Administration Medical Center, a wide range of medical specialists reviewed information from a variety of U.S. centers as well as from the recently concluded Mesothelioma And Radical Surgery (MARS) trial from the U.K. The results of this randomized clinical trial were presented by English surgeons, Tom Treasure and David Waller, and clearly demonstrated that radical removal of the lung through EPP holds no advantage over alternative, less radical, lung-sparing therapies.

In a press release issued by the Pacific Meso Center, where Dr. Cameron serves as Scientific Advisor, he commented that, “The information presented at this Symposium makes an incredibly strong statement that surgical removal of the lung for treatment of malignant pleural mesothelioma should no longer be performed anywhere in the world, just like it has been abandoned already in the U.K." Dr. Cameron went on to say that, "Although it's usually hard to get physicians to agree on anything, there was unanimous agreement by the end of the conference that lung-sparing pleurectomy was the preferred surgical procedure if surgery was to be used at all."

The distinguished faculty at this landmark meeting also addressed the role of non-surgical therapies such as cryo and radio frequency ablation, radiation, chemotherapy, immunotherapy, gene therapy and promising future therapies. Dr. Cameron and others described how some of these therapies can be used in the model of treating mesothelioma as a chronic disease once the tumor has been removed through lung-sparing surgery.



Terry and Maryla Latham

One such adjuvant therapy that has only recently been utilized for pleural mesothelioma is cryoablation. UCLA Radiologist Dr. Fereidoun Abtin explained that cryoablation is an outpatient procedure in which compressed argon and helium gas is delivered through 3 mm probes inserted into a tumor to essentially freeze the tumor cells. It can be determined in a matter of a few weeks whether the procedure is successful and, because it is an outpatient treatment with a low incidence of pain, it can be performed many times over a relatively short period. UCLA Medical Center is currently the only institute where cryoablation is being used to treat mesothelioma.

The Symposium also featured a touching presentation from Geraldine Lepore about living with mesothelioma from a family’s perspective, as well as an inspirational speech from mesothelioma survivor Terrence Latham who underwent a lung-sparing pleurectomy in 2010 and credits Dr. Cameron for saving his life.

The Pacific Meso Center plans to release videos of many of the Symposium presentations on its website www.pacificmesocenter.org in the coming weeks.