Obtaining an upper estimate of the survival benefit associated with surgery for mesothelioma

Our plain-English summary of Obtaining an upper estimate of the survival benefit associated with surgery for mesothelioma, by M. Utley, F. Fiorentino, T. Treasure (European Journal of Cardio-thoracic Surgery, 2010).

The study

• Authors: M. Utley, F. Fiorentino, T. Treasure
• Journal: European Journal of Cardio-thoracic Surgery
• Published: 2010;38(3):241-4
• Cited by: 19 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Objective: This study aimed to obtain an upper estimate of any survival benefit conferred by resection in patients with a diagnosis of malignant pleural mesothelioma.

Methods: We analysed published data concerning survival from diagnosis among four groups of patients with mesothelioma, identified by ascending level of intervention: (A) no surgery; (B) thoracotomy but no resection; (C) resection but no adjuvant treatment; and (D) resection as part of multimodality treatment. Mean survival was estimated for each of these four groups. Mean survival was also estimated for all those having resection (groups C and D) and for all those not having a resection (groups A and B).

Results: Mean survival was 16.8, 17.8 and 17 months for those having no surgery, thoracotomy alone and resection with no adjuvant treatment respectively (groups A, B and C) and 32.9 months for those having multimodality treatment (group D). Mean survival was 25.6 months in those who had resection and 17.1 months in those that did not. The survival advantage of any management that included surgical resection was estimated as being no more than 9 months. This is the most optimistic estimate and requires all observed differences in survival to be attributed to the effect of treatment and none to selection for treatment. Furthermore, within this upper estimate is included any benefit from other components of multimodality treatment.

Conclusions: Given the burden of morbidity of resection in the management of pleural mesothelioma, this most optimistic estimate of the magnitude of any survival benefit should be taken into account in any policy decision, in clinical trial proposals and in strategies adopted by clinical teams.

Copyright 2010 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.

In plain English

The authors re-analysed survival curves published in an earlier report by Flores et al. on 945 patients diagnosed with malignant pleural mesothelioma at Memorial Sloan-Kettering Cancer Centre. They could not obtain the original dataset, so they used software to read the curves from the published figures. From these they estimated mean (average) survival from diagnosis for four groups: no surgery, thoracotomy (opening the chest) without resection, resection alone, and resection as part of multimodality treatment with chemotherapy and/or radiotherapy. Estimated mean survival was 16.8, 17.8, 17.0 and 32.9 months respectively. Patients who had resection averaged 25.6 months, compared with 17.1 months for those who did not. The authors estimated that the survival benefit of management including resection was at most 9 months, and noted that this is consistent with no benefit at all. This upper figure assumes that all survival differences came from treatment and none from which patients were selected for it. It also includes any benefit from chemotherapy or radiotherapy. The authors concluded that this estimate should be taken into account in policy decisions, trial proposals and clinical strategies, given the burden of resection.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: Bounding study: secondary analysis of survival curves from a previously published single-institution report, used to obtain an upper estimate of survival benefit
• Who was studied: 945 patients diagnosed with malignant pleural mesothelioma at Memorial Sloan-Kettering Cancer Centre (MSKCC), as reported by Flores et al. Of these, 387 had no surgical exploration, 174 had thoracotomy without resection, and 384 had resection (extra-pleural pneumonectomy or pleurectomy/decortication). Among the 384 resected patients, 177 had no adjuvant treatment. Dates of the original series are not given.
• Exposure: Not asbestos exposure: the comparison was between levels of treatment, namely no surgery, thoracotomy without resection, resection alone, and resection with chemotherapy and/or radiotherapy (multimodality treatment)
• Main results:
  • Estimated mean survival from diagnosis was 16.8 months with no surgery (group A), 17.8 months with thoracotomy alone (group B) and 17.0 months with resection and no adjuvant treatment (group C)
  • Estimated mean survival was 32.9 months for patients who had resection as part of multimodality treatment (group D)
  • Estimated mean survival was 25.6 months for all patients who had resection (groups C and D) and 17.1 months for all who did not (groups A and B)
  • The survival benefit attributable to management including resection was estimated at most 9 months, a figure the authors noted is consistent with no benefit at all
  • The 9-month figure is the most optimistic estimate: it attributes all survival differences to treatment and none to selection, and it includes any benefit from other parts of multimodality treatment
  • The curve-reading software was measured as accurate to 0.3%, which the authors considered sufficient
• The authors' conclusion: The authors concluded that, given the burden of morbidity of resection, this most optimistic estimate of any survival benefit (at most 9 months) should be taken into account in policy decisions, clinical trial proposals and strategies of clinical teams
• Limitations the authors state:
  • The analysis relied on observational data, so survival differences between treatment groups may be entirely due to clinical selection of patients before or at thoracotomy
  • A self-selecting survivor effect: patients must be alive and well enough to receive the second component of multimodality treatment
  • The original dataset could not be obtained, so the data were read from images of the published survival curves
  • The MSKCC report does not allow comparison of extra-pleural pneumonectomy with pleurectomy/decortication

Topics

The National Library of Medicine indexes this study under subjects our site covers: Mesothelioma.

Medical terms in this study, explained in our Lexicon: Mesothelioma, Pleural Mesothelioma, Thoracotomy, Surgical Resection, Clinical Trial.

Related studies

• What is the best approach for surgery of malignant pleural mesothelioma? It is to put our efforts into obtaining trustworthy evidence for practice — T. Treasure (2016)
• Outcomes of Cytoreductive Surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) in patients older than 70 years; survival benefit at considerable morbidity and mortality — K.I. Votanopoulos, N.A. Newman, et al. (2013)
• Repeat cytoreductive surgery and heated intraperitoneal chemotherapy may offer survival benefit for intraperitoneal mesothelioma: a single institution experience — J. Wong, A.L. Koch, et al. (2014)
• Pretreatment serum C-reactive protein levels predict benefit from multimodality treatment including radical surgery in malignant pleural mesothelioma: a retrospective multicenter analysis — B. Ghanim, M.A. Hoda, et al. (2012)
• Predictors of long-term survival following radical surgery for malignant pleural mesothelioma — A. Nakas, D. Waller (2014)
• Treatment factors associated with long-term survival after cytoreductive surgery and regional chemotherapy for patients with malignant peritoneal mesothelioma — H.R. Alexander, D.L. Bartlett, et al. (2013)

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