Dr. Harvey Pass' comprehensive review of the literature on mesothelioma diagnosis and treatment is a must read, for both doctors and patients alike. The article carefully reviews the diagnostic and therapeutic options for patients from the time of initial symptoms onward. It addresses without bias the pros and cons of the various surgical options, with or without chemotherapy and radiation. I say without "bias" because Dr. Pass to my knowledge is one of the handful of surgeons in the U.S. who does not commit to either pleurectomy/decortication (P/D) or extra pleural pneumonectomy (EPP) prior to opening the chest. In a sense, he let's the tumor decide, and he cannot assess the reach and span of the tumor without actually studying it "up close and personal."

(This article is provided solely to the Mesothelioma Applied Research Foundation (MARF), courtesy of Clinical Lung Cancer, published by the Cancer Information Group located in Dallas Texas, and is copyright protected by the Cancer Information Group.)

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The article raises a number of provocative questions. For example, what will it take to create a nationwide "standard of care" for mesothelioma patients? When can we say that one surgeon's personal "philosophy" with regard to "best" treatment option for particular patient is superior to another surgeon's? If there is no reliable protocol for curing mesothelioma to date, doesn't the language require that we call all options "palliation"?

This is the first article to my knowledge that squarely addresses the question EPP vs P/D? Dr. Pass understands that the tumor is not amenable to a "one size fits all" fix. The procedure must be tailored to the particular patient's extent and bulk of disease. When I talk to patients, those who have attempted to read the literature often speak of "negative margins" post EPP as the holy grail for survival. Dr. Pass reviews the data, most of it from Brigham and Women's Hospital (Dr. Sugarbaker), which shows that about 1/3 of the EPP patients had "margin-free resection," and most of these patients had less bulky disease (stage 1) to start with. He asks"Is it justifiable to spare the functioning lung by performing a parietal pleurectomy instead of EPP if the visceral pleura is minimally involved?"

The answer is that without standards, i.e., criteria for assessing how many tumor sites are involved, their size, etc., the decision to pursue EPP vs P/D is largely one of individual preference or style. Without preoperative guidelines, how does the patient decide? How does he choose the best doctor? How do we know who is "best" -- the doctor with the best reputation, the most publications, the warmest bedside manner? Is cost a factor? In the end, does the patient simply roll the dice? Does he make the choice at all? We need more data -- starting with an update on Dr. Sugarbaker's 1999 article in which he studied the survival of 183 surgery patients.

It is my hope that Dr. Pass updates his excellent review every 6 months or so -- this of course is a lot to ask of a doctor who barely has time to kiss his wife in the morning. The chat rooms are buzzing with rumors and anecdotes about this or that promising new drug or treatment. It would be helpful for patients and doctors to tap into a database that gives us updates on the response and survival rates of new drugs like Alimta, Onconase, Erissa, Sugen, LNDDP, copper chelate, or procedures like intraoperative chemo wash, among others.