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
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
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
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.