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

Debunking the Myths About P/D

"The Question is, Why Wouldn't a Patient Choose P/D?"

In 1994, Dr. Robert B. Cameron began to develop his specific "radical" lung-sparing pleurectomy and decortication (P/D) surgical procedure as a more rational and less radical alternative to the popular radical extra-pleural pneumonectomy (EPP) surgical procedure for malignant pleural mesothelioma (MPM).

The data show that P/D is much safer than EPP. Surgical mortality (that is, when the patient dies during surgery) for P/D is only 3-4%. For EPP, surgical mortality is 5-7%, or almost twice as high. On top of fatalities, another two-thirds of EPP patients encounter serious surgical complications. Dr. Cameron’s surgical mortality numbers are below 1%.

P/D patients retain the use of both lungs, affording them a better quality of life. EPP patients are left with only one lung. With only on lung, the patient is vulnerable to threats to the remaining lung like infection, pneumonia or pulmonary restriction from prior smoking, asbestos scarring or the unshakeable threat of mesothelioma recurrence.

The only randomized trial for EPP (where the surgeon cannot bias the results through patient selection), revealed that patients who had EPP in fact did worsethan patients who avoided surgery altogether. Studies which have looked at both EPP and P/D reveal that P/D patients survive longer.

With P/D’s superiority overwhelmingly confirmed, the question is then, why wouldn't a patient choose a P/D over EPP? It seems that those clinging to the out-dated notion of performing EPP have tried to answer this question with a series of “myths” about P/D.

Over the coming weeks, Dr. Cameron, as the innovator of the P/D and the surgeon most experienced in performing it, will address in turn each of these "myths".

MYTH #1: “P/D Is Only Appropriate For Very Early Stage Meso.” January 3, 2011

Proponents of the EPP have been known to suggest that “P/D is fine for early-stage cases, but for a BIG tumor you need a BIG surgery.”

It is certainly true that lung-sparing P/D is more appropriate for early-stage cases than EPP. For a patient who is younger with less invasive tumor and a good long-term survival prognosis, there is simply no compelling reason to endure the risks and compromised quality of life associated with a radical lung amputation/EPP.

But just because P/D is more appropriate for early-stage patients does not mean that radical EPP is better for more advanced patients. Statistics reveal that P/D is also better advanced cases of pleural mesothelioma. In fact, many of those who argue that P/D is only appropriate for early-stage meso WILL NOT actually perform EPP for late-stage meso. They understand that EPP is too radical and difficult for late-stage patients and don’t want to harm their published survival statistics. They route their late-stage patients to P/D instead.

As a result, most studies comparing P/D to EPP show patients who were younger (less than 60) and relatively healthy going to EPP, and patients who were older (70 or above) and with more sickness going to P/D. Yet the overall survival for older, more advanced patients who had P/D was still BETTER than the survival for younger, less advanced patients who had EPP.

Click here for more information regarding malignant pleural mesothelioma and Dr. Cameron’s approach to treating the disease.