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Multimodal Therapy: The Kitchen Sink Approach

Since there is no silver bullet, doctors have combined different treatments, hoping that the mixture of therapies will provide a lifeboat. Multimodal therapy, which uses surgery as the bedrock and adds chemotherapy or immunotherapy with radiation, is associated with longer survival in younger, early stage mesothelioma patients.

Multimodal therapy based on surgery appeals to common sense and to the approach with other cancers: extract the monster from the chest, and then blast all remaining traces with radiation or drugs. It also appeals to thoracic surgeons, who make their living cutting. Just when it seems like the lifeboat choice is getting clearer, though - at least we know we need surgery-new issues arise, buffeting the boat harder than ever.

The three surgical options are talc pleurodesis (TP), pleurectomy / decortication (PD), and extrapleural pneumonectomy (EPP). That much is easily said. But here's the kicker: "There are no randomized studies comparing these techniques [TP, PD, EPP] and results are generally found in retrospective series that often used different staging systems, further confounding comparisons." The effect of surgery on mesothelioma is unclear because there has never been a randomized, controlled clinical trial to determine whether PD or EPP improves the survival of patients or even effectively palliates the symptoms of the disease. To compare techniques and decide which one is better, there must be a trial that randomly assigns some patients to a treatment group, and others to a nontreatment group. This is the only way to answer the question, "How much better is this than that?"

It's important to understand what these experts are saying: because you can't reliably compare patients, and you can't reliably compare treatments versus non-treatments, you therefore can't reliably compare outcomes. An educated guess at best, a roll of the dice at worst.

But which guess is best? Multimodal therapy is associated with increased survival, and most patients with early stage, lymph node negative tumors will seriously consider surgery. At this point, the lawyer as patient-advocatecan help.

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