malignant pleural mesothelioma

• Chest clinic

• Opinion

Surgery in the treatment of malignant pleural mesothelioma: recruitment into trials should be the default position

1. Avijit Datta1,2, 
2. Rhiannon Smith2, 
3. Francesca Fiorentino3, 
4. Tom Treasure4

+Author Affiliations

1. ¹Department of Respiratory Medicine, York Teaching Hospital NHS Foundation Trust, York, UK
2. ²Hull York Medical School, York, UK
3. ³National Heart and Lung Institute, Imperial College London, London, UK
4. ⁴Clinical Operational Research Unit (CORU), University College London, London, UK

1. Correspondence toProfessor Tom Treasure, Department of Mathematics, Clinical Operational Research Unit, University College London (UCL), 4 Taviton Street, London WC1H oBT, UK;tom.treasure@gmail.com

• Received 9 May 2013
• Accepted 16 May 2013
• Published Online First 12 June 2013

Abstract

Background Europe is at the peak of an epidemic of malignant pleural mesothelioma and the burden of disease is likely to continue rising in the large areas of the world where asbestos remains unregulated. Patients with mesothelioma present with thoracic symptoms and radiological changes so respiratory physicians take a leading role in diagnosis and management. Belief that the modest survival times reported after radical surgery, whether alone or as part of multimodal therapy, are longer than they it would have been without surgery relies on data from highly selected, uncontrolled, retrospectively analysed case series. The only randomised study, the Mesothelioma and Radical Surgery (MARS) trial showed no benefit. A simple modelling study of registry patients, described here, shows that an impression of longer survival is eroded when patients who were never candidates for operation on grounds of histology, performance status and age are sequentially excluded from the model.

Conclusion Whenever the question arises `Might an operation help me?' there are two responses that can and should be given. The first is that there is doubt about whether there is any survival or symptomatic benefit from surgery but we know that there is harm. The second is that there are on-going studies, including two randomised trials, which patients should be informed about. The authors suggest that the default position for clinicians should be to encourage recruitment into these trials.