Radical Surgery: Keep the Lung? Or Let it Go?
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Chart - "Six recent studies on mesothelioma surgery-a toss up?" lists medical research that probes deeply into the issues associated with mesothelioma treatment and survival. Take a look, but don't take comfort that the best and brightest are on the case. Few of these trials are available in the U.S., where research money for mesothelioma is depressingly tight.
Chart - "The mother of all clinical trials?" lists the only randomized clinical trial ever held to test the efficacy of mesothelioma surgery versus non-surgery. Unfortunately, the trial only tests EPP and is only available in the United Kingdom. Chart - "Keep the lung or lose it? A comparison of the PD and the EPP," breaks down the key differences between the two surgeries. Read it closely. Many of us have been taught that PD is "palliative," a word that suggests the operation is hardly worth the effort, like putting a band-aid on a gashed hull. Many of us presumed that the only chance a patient had for a five-year survival was to head to Boston and have his lung amputated. And yet the published data surprisingly shows that in many cases the PD numbers are better than EPP's. In truth, all surgical procedures to date could and should be considered "palliative." Why surgery? Surgery designed to remove all possible tumor-invaded or contaminated tissue is radical surgery. Because mesothelioma is a diffuse tumor, and because surgery itself can spread the cancer cells, in order to eradicate all tumor the surgeon would have to cut out the ribs and intercostal muscles, the pleura, lung, trachea, pericardium, diaphragm, esophagus, superior vena cava, aorta, subclavian artery and vein, nerves, and vertebral bodies. [1] Essentially, whack out everything below the neck and above the gut, and you'll be "cancer free." You'll also be dead.
Both PD and EPP are controversial in that no randomized clinical trial validates either over the other, or even over no treatment at all. The medical benefit of EPP over PD has never been shown, although there are good indications that PD is associated with longer survival. Some surgeons perform both the EPP and the PD. Indeed, Boston is regarded as the home of the EPP, but recently Dr. Sugarbaker's team has been offering the PD as well. How does a "switch hitter" surgeon decide which operation is best? Dr. Harvey Pass of NYU has said he can't really tell until he pops the hood and takes a look inside. Apparently, the more "bulky" a tumor is, the less inclined the surgeon is to do the PD. The problem is that there is no standardized "bulk" threshold, i.e., how heavy and how extensive, questions which can probably only truly be answered if the tumor is cut away from the lung, either intraoperatively via the PD or later after the tumor-encrusted lung has been amputated. As with obscenity, for the bulk-sensitive surgeon, you just know it when you see it. With the advancement of science, the sun usually sets on ultra-aggressive surgeries. Radical surgery for breast cancer, sarcomas, and colonic cancer have all evolved into narrower, meticulous operations. There is reason to believe that mesothelioma surgery will eventually conform to this approach, favoring the meticulous and careful surgery of the PD. Even then, it's clear to this author that, just as not all EPP's are performed with equal skill, neither are all PD surgeries. At a recent MARF conference in Washington, D.C., an oncologist informed the largely patient audience that the PD was a relatively "quick" procedure. I've witnessed three PD's performed at UCLA. From opening to close, each took about ten hours of painstaking and meticulous surgery in order to remove all visible tumor from the chest, while sparing the lung, diaphragm, and pericardium. During one procedure, another surgeon walked in, saw the massive operation, checked his watch, shook his head and half-joked: "I'll bet you could amputate the whole thing and get three of these operations done in the time it takes you to do one." It turns out that this jest hits close to the truth, as Medicare pays a higher reimbursement to the surgeon who does the EPP over the PD. Reminds me of what my journeyman boilermaker used to say back in the summers when I was a helper at the Exxon refinery in Baytown, Texas: "The less you work, the more you get paid." Survival: the golden ring Patients are hesitant to give up a lung, and this ends up being the strongest argument for them to go with PD. The issue of greatest concern to patients, "Will I survive the operation?" falls squarely in the PD camp. The numbers vary between surgeons, but the literature shows that surgical mortality for the PD is substantially less than the EPP (with less physiologic stress as well) [2] , while another study of 384 patients showed deaths from PD at 3%, as compared to 5% for EPP. [3]
In addition, doctors agree that it's only a matter of time before the tumor recurs. Patients tend to like their chances better if they have two lungs instead of just one. And the distinction between whether the tumor recurs "locally" in PD or "distant" with EPP is not terribly important, as the seeding of tumor during surgery makes virtually every body cavity "local." The lawyer should also note that since the asbestos fibers are distributed between the left and right lungs, if the left lung is removed (or vice versa), experience shows that the same pathogenic disease process will often rear its ugly head in the adjoining lung. See Chart H, "Example of data misrepresentation." Bad data can be easily found in the very places that patients most commonly troll for answers. I co-founded the Mesothelioma Applied Research Foundation, but even this highly respected institution sometimes provides questionable data. On its website, MARF has posted a table that purports to correlate the median survival with various treatment modes. Without citing any author, it lists the survival for the PD as 13 months, rather than the correct figure, which is between 19 and 22 months depending on the institution or surgeon who does the surgery. That's how hard this is, and that's how difficult it is to come by reliable data. Buying more quality life Helping a mesothelioma client means more than winnowing out the best survival data. Clients want to know about quality of life. If their ship is going down, and their time is sorely limited, few want to spend precious days, let alone months, going through horrendous recoveries. They want treatment that will allow them the quality of life to enjoy the time left with their families and friends. We were unable to find a single study examining quality of life for different mesothelioma treatments, and even studies that only look at a single treatment modality rarely address quality of life associated with a given procedure. The upcoming UK trial discussed previously is groundbreaking because it also considers quality of life issues associated with EPP v. chemotherapy. Consider doing more for your client than counseling him to leap into the first lifeboat. Helping him ask the tough questions to any doctor pushing a particular treatment benefits everyone. We may want to fixate on statistics and numbers, but clients may rank quality of life "intangibles" as their top priority. It's imperative that the lawyer and the client understand foreseeable complications no matter the therapy, and always have at the ready a back-up plan. Chart : Six recent studies on mesothelioma surgery-a toss up? The following studies attempt to correlate median survival, surgical mortality, and prognostic factors with the PD and EPP.
Chart : The mother of all clinical trials?
Chart : Keep the lung or lose it? A comparison of the PD and the EPP
[1] Aelony Y, Thoracoscopic talc poudrage in malignant pleural effusions: effective pleurodesis despite low pleural pH, Chest, 1998 [2] Cameron R, Extrapleural pneumonectomy is the preferred surgical management in the multimodality therapy of pleural mesothelioma: con argument, Annals of Surgical Oncology, 2006 [3] Ismail-Khan R, Robinson L, Id. *** POSTED ON FEBRUARY 7, 2008 *** |