Patients who are diagnosed with mesothelioma often feel overwhelmed and
stressed. An aggressive tumor has been growing in their body and time
is of the essence in order to effectively treat it. But before proceeding with a
treatment, many questions need to be answered:
- Am I a candidate for surgery?
If so, what surgery is best for me (
- Should I have chemotherapy instead of surgery?
- Should I have chemotherapy AND surgery?
- If so, should I have chemotherapy before or after surgery?
- If chemotherapy, what agents should I receive?
Under typical circumstances, getting reliable answers to these questions
which require input from doctors with specialized knowledge in two disciplines,
surgery and oncology, can be a difficult and time-consuming process. Furthermore,
because of the rarity of the disease, there are many opportunities for
misinformation to de-rail the process.
As part of its
Comprehensive Mesothelioma Program, which brings together doctors from various specialties in a collaborative
“team” approach to treating pleural mesothelioma, UCLA is
now offering a weekly multi-disciplinary clinic to help patients avoid
the pit-falls, challenges and delays that are often encountered in determining
a treatment plan.
Common Pit-Falls, Challenges and Delays
1. "You’re not a candidate for surgery because the tumor is
Most patients are diagnosed with pleural mesothelioma via a biopsy performed
at a local hospital. The surgeon performing the biopsy is often a general
surgeon and, even if a thoracic surgeon, does not have significant experience
in the diagnosis or treatment of mesothelioma. There are many instances
where the surgeon performing the biopsy advises the patient that he or
she is not a candidate for surgery because the tumor is too diffuse or
has spread over most of the lung. As a result, the patient is referred
only to an oncologist and is presented with chemotherapy as the only treatment option.
A similar result occurs where a pulmonologist or oncologist with limited
experience treating mesothelioma reviews a CT scan revealing tumor that
has spread over most of the lung and determines that the patient is not
a candidate for surgery.
Doctors who specialize in the treatment of pleural mesothelioma will explain
that mesothelioma is, by its very nature, a diffuse tumor which spreads
throughout the thin pleural lining that surrounds the lung. Most surgeons
who specialize in treating the disease will conclude that a person is
a candidate for surgery so long as the tumor remains confined to the pleural
space (i.e. it has not invaded the lung or the chest wall), even though
it is covering much of the lung.
2. "Reflex" Response: Alimta/Cisplatin Chemotherapy
In 2004, the FDA approved pemetrexed (
Alimta) in combination with Cisplatin for the treatment of pleural mesothelioma.
Alimta/Cisplatin remains the only FDA approved chemotherapy drug combination
for the treatment of mesothelioma. As a result, many general oncologists
that are not experienced in treating mesothelioma reflexively prescribe
Alimta/Cisplatin without informing patients about other treatment options.
Doctors more experienced in treating mesothelioma are aware that: a) the
FDA’s approval of Alimta/Cisplatin was limited to “use with
patients who are not eligible for surgery”, b) in pre-approval trials
Alimta/Cisplatin showed only a 41% partial response rate and an increased
median survival rate of only 2.8 months, with the best results seen in
patients with epithelial cell-type, and c) more recent published trial
data reveals that a combination of surgery, radiation, and chemotherapy
is almost always associated with the longest survival times.
Alimta/Cisplatin is administered once every three weeks for a total of
six rounds. With follow-up CT-scans, the treatment process typically lasts
approximately six months. With the limited response and increased survival
rates, many physicians believe that this is too much time to “invest”
in this particular treatment when other treatment options are available
for treating this aggressive disease.
3. "Tic-Toc" and "Can we talk?"
Even if a patient is fortunate enough to work with knowledgeable doctors
who are willing to consider a full range of available non-surgical and
surgical treatments, the mere act of seeing doctors from the various specialties
can be extremely time-consuming.
Doctors, especially specialists, are very busy and it often takes many
weeks to get an appointment. Furthermore, most experienced mesothelioma
specialists will want to review all medical records and radiology scans
before recommending a treatment. Some will even want to have the biopsy
pathology slides re-tested by pathologists they trust in order to get
an accurate read on the specific cell-type of the tumor. The burden of
collecting and transmitting all of these materials frequently falls on
the patient and the patient’s family.
The process of preparing for and seeing various specialists can easily
take a couple of months to complete and often results in different opinions
and recommendations regarding treatment. For example, an oncologist recommending
chemotherapy and a surgeon recommending surgery. While the oncologist
and surgeon may be in communication with the pulmonologist or internist
that referred the patient, the oncologist and surgeon frequently don’t
speak directly to each other. Accordingly, the patient is left to make
a very important medical decision in a relative “vacuum.”
Furthermore, once a decision is made and the patient proceeds with the
chosen treatment, the specialist’s involvement typically ends once
the treatment is completed. The patient then returns to the pulmonologist
for the next step, which is often a referral to another specialist—starting
the process all over again!
UCLA’s Multi-Disciplinary Clinic Brings Patients Together With Expert
Surgeon and Oncologist to Make “Team” Decisions Regarding Treatment
In furtherance of its team approach to treating mesothelioma, UCLA’s
Comprehensive Mesothelioma Program recently began offering a multi-disciplinary
clinic where patients can meet with both a thoracic surgeon and an oncologist
who specialize in treating pleural mesothelioma.
The multi-disciplinary clinic is offered Wednesdays at the Pacific Thoracic
Surgery office located at 10780 Santa Monica Boulevard, Suite 100, in
Los Angeles, California. At the clinic, patients are seen in consultation
by thoracic surgeon
Dr. Robert B. Cameron and oncologist
Dr. Cameron is the director of UCLA’s Comprehensive Mesothelioma
Program, chief of thoracic surgery at the West Los Angeles Veterans’
Administration Medical Center and Scientific Advisor for
The Pacific Meso Center. Dr. Cameron has been treating pleural mesothelioma patients for over
20 years, is the innovator of the lung-sparing
Pleurectomy/Decortication surgical procedure and is widely recognized as one of the world’s
foremost experts in mesothelioma treatment and research.
Dr. Olevsky is a board certified oncologist and the oncology specialist
of the UCLA Comprehensive Mesothelioma Program. She is extremely knowledgeable
about the various chemotherapy agents which are producing the best results
for epithelial, sarcomatoid and bi-phasic cell types of mesothelioma.
At the multi-disciplinary clinic, patients are able to meet with both Dr.
Cameron and Dr. Olevsky who work together to customize a treatment plan
based on such factors such as the patient’s age and condition and
tumor cell type, location and staging. Patients and accompanying family
members are welcomed to be part of a thorough open discussion with Dr.
Cameron and Dr. Olevsky regarding surgical and chemotherapy options, as
well as other treatments such as radiation, cryoablation and immunotherapy
offered by the UCLA Comprehensive Mesothelioma Program. The goal is, of
course, to take the guesswork and frustration out of a very complex decision
For patients who decide to proceed with the treatment recommended by Dr.
Cameron and Dr. Olevsky, both doctors will continue to supervise all aspects
of treatment from that point forward. Patients are closely monitored with
follow-up examinations every three months and are referred as necessary
to other specialists that are part of the Comprehensive Mesothelioma Program.
The patient-centered approach to care provided by UCLA’s multi-disciplinary
clinic is aimed to save patients time and anxiety in making informed decisions
about mesothelioma treatment, allowing them to proceed with treatment
as early as possible and focus on getting well.