Dr. Tom Treasure is a thoracic surgeon at Guy’s Hospital in London, United Kingdom.  At the 8^th International Conference of the International Mesothelioma Interest Group (IMIG) held in Chicago, Illinois from October 19-22, 2006, Dr. Tom Treasure supported one side of a debate on the role of EPP for mesothelioma patients.

Dr. Treasure believes that there is no place for extrapleural pneumonectomy or EPP, the radical surgery to remove the diseased lung for mesothelioma patients, in treatment options.  However, Dr. Treasure acknowledges that there is no definitive evidence that can support EPP surgery or not.  Only a proper trial will show the risks and benefits of the surgery for mesothelioma patients.

The primary resource in support of the EPP comes from Dr. David Sugarbaker.  Evidence from this report is that median survival rate of patients was 51 months (more than four years).  The patients had epitheliod mesothelioma, clear resection margins, and no positive extrapleural nodes.  However, there are several problems with this study.  To begin with, the data is outdated, and it has not been duplicated.  Also, the outcomes and the patients were chosen to be included retrospectively, after surgery.  Patients not fitting the criteria or showing different results were not included in the report.  Also, these findings were based on a trimodal approach.  Patients usually first had chemotherapy, followed by radical surgery and then radical radiotherapy.  Therefore, the study does not solely reflect the benefits of EPP.  Finally, Dr. Treasure questions the intent to publish the paper, suggesting it is nothing more than an advertisement endorsing Dr. Sugarbaker, and a false advertisement at that.

In fact, there is no clear evidence.  Too much “grey literature” exists –trials and pharmaceutical reports have not been reported and therefore skewing the statistics.  Dr. Treasure agrees with the multimodal treatment, and stated that adjuvant therapy is “an absolute requirement for either surgery.” 

Dr. Treasure adheres to Dr. Harvey Pass’ corollary, “Only operate if you can do some good.”  With this as the baseline of all his work, Dr. Treasure firmly believes that only a trial setting will prove the efficacy of an EPP and help doctors determine appropriate treatment paths.  Also, a trial is favorable because in the upcoming years, more patients will be diagnosed with mesothelioma.  As more are diagnosed, doctors must be able to draw upon known effective treatments for patients. Dr. Treasure believes that the MARS trial (Mesothelioma and Radical Surgery) will be able to demonstrate the effectiveness of an EPP.

One group of patients will be offered the trimodal approach—they will undergo chemotherapy, followed by EPP, and finished with radiotherapy.  This group will be compared to another group who will receive the full trimodal therapy without the EPP.  This trial has been accepted ethically through MREC and received scientific approval through CTAAC and NCRI.  It is funded through Cancer Research UK.

Dr. Treasure’s primary question is, “What can be ‘ethical’ in deliberately choosing to remain in uncertainty and thus consistently use treatments that fail to help – or are actively harmful?”  MARS is the first proper trial of EPP and it is designed to give clear results on the benefits and risks of EPP.  Currently, 48 patients have consented to having chemotherapy alone.  Research is ongoing.

Even when the evidence for or against an EPP is known, Dr. Treasure believes that it will still be the primary job of the patient to be well informed.  Patients should be critical of their doctors, know their doctor’s intentions, and decide on a treatment path armed with knowledge.

Learn more about Dr. Tom Treasure at http://www.ctsnet.org/home/ttreasure or on his blog, http://blogs.ctsnet.org/ttreasure/

*** POSTED ON OCTOBER 30, 2006   ***