Pleural mesothelioma: little evidence, still time to do trials
Saturday, September 25th, 2004.
The Lancet 364, no. 9440 (2004): 1183-5. [Link]
Treasure T, Sedrakyan A.
Cardiothoracic Unit, Guy’s Hospital, London SE1 9RT, UK. Tom.Treasure@ukgateway.net
Abstract
Context: The incidence of malignant pleural mesothelioma is increasing throughout most of the world. This cancer is uniformly fatal, and characterised by progressive breathlessness and unremitting pain in the chest wall. From the onset of symptoms, survival is from a few weeks to a few years. Desperation by patients and doctors has driven a search for effective treatments. Clinical benefits are marginal and evidence of a good quality is lamentably lacking.
Starting Point: David Sugarbaker is the world’s leading proponent of extrapleural pneumonectomy (EPP), an operation in which all the pleura is removed with the lung, pericardium, and diaphragm. He has recently reported the complications of this radical surgery in a series of 496 operations (J Thorac Cardiovasc Surg 2004; 128: 138-46). Although EPP as part of trimodality therapy (preoperative chemotherapy and postoperative radiation) is thought to be the best that can be offered and is regarded as the standard of care for selected patients given the morbidity associated with it, evidence for benefit is needed to justify its wider use.
Where Next? With the increase in the number of cases there is increasing awareness of the disease, leading to earlier diagnosis, and an expectation that something must be done. Survival is short and the treatments on offer are onerous. The only responsible approach from a scientific, compassionate, or economic view (and why not combine all three?) is to find evidence of effectiveness to avoid futile and distressing treatment when possible.
Glossary
- therapy
- any of the measures taken to treat a disease. Unproven therapy is any therapy that has not been scientifically tested and approved. Use of an unproven therapy instead of standard (proven) therapy is called alternative therapy. Some alternative therapies have dangerous or even life-threatening side effects. For others, the main danger is that a patient may lose the opportunity to benefit from standard therapy. Complementary therapy, on the other hand, refers to therapies used in addition to standard therapy. Some complementary therapies may help relieve certain symptoms of cancer, relieve side effects of standard cancer therapy, or improve a patient's sense of well-being. The ACS recommends that patients considering use of any alternative or complementary therapy discuss this with their health care team.
- pleura
- (pler-uh) the membrane around the lungs and lining of the chest cavity. (Pleural mesothelioma.)
- morbidity
- a measure of the new cases of a disease in a population; the number of people who have a disease.
- diagnosis
- identifying a disease by its signs or symptoms, and by using imaging procedures and laboratory findings. The earlier a diagnosis of cancer is made, the better the chance for long-term survival.
- chemotherapy
- (key-mo-THER-uh-pee) treatment with drugs to destroy cancer cells. Chemotherapy is often used with surgery or radiation to treat cancer when the cancer has spread, when it has come back (recurred), or when there is a strong chance that it could recur.
- cancer
- malignancy; a group of diseases typified by abnormal, generally out-of-control, cell growth.
- mesothelioma
- a tumor derived from mesothelial tissue, such as the peritoneum (lining the abdomen) or pleura (lining the lungs). More on mesothelioma.
- extrapleural pneumonectomy
- (EPP) surgery to remove the pleura, diaphragm, pericardium, and entire lung involved with the tumor. You can view a web cast from Brigham and Women's Hospital in Boston of this procedure being done by Dr. David Sugarbaker: see the extrapleural pneumonectomy (EPP) web cast here.
