Surgery for malignant pleural mesothelioma: why we need controlled trials

Our plain-English summary of Surgery for malignant pleural mesothelioma: why we need controlled trials, by T. Treasure, M. Dusmet, F. Fiorentino, et al (European Journal of Cardio-thoracic Surgery, 2014).

The study

• Authors: T. Treasure, M. Dusmet, F. Fiorentino, E. Lim, D. Waller, B. Lees
• Journal: European Journal of Cardio-thoracic Surgery
• Published: 2014;45(4):591-2
• Type of article: Editorial
• Cited by: 5 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Summary of the article

In this editorial, the authors argued that randomized controlled trials (RCTs) are needed to judge whether surgery benefits patients with malignant pleural mesothelioma. They stated that observational follow-up studies can mislead, particularly when patients are highly selected and success is judged on completed treatments rather than intention to treat. They described two analyses of existing data. In the first, of 945 patients, those who had no surgery (387), thoracotomy without resection (174) or resection without further cancer treatment (177) had similar average survival of 17–18 months. The 207 who had multimodal treatment averaged 33 months. The authors said selection could contribute to this difference and that a benefit of surgery was not evident. In the second, 10 of 123 patients (8%) in the Cancer Registry of York Teaching Hospital had extrapleural pneumonectomy. When unoperated patients with sarcomatoid histology, poorer performance status or older age were removed stepwise, the survival gap progressively narrowed. The authors explained that RCTs usually show smaller differences than follow-up studies because all allocated patients are analysed and controls are comparable. They described MARS 2, an RCT comparing extended pleurectomy/decortication (e-P/D) plus platinum-pemetrexed chemotherapy with chemotherapy alone. They noted that the EORTC study, which tests only the timing of e-P/D, cannot show whether e-P/D is effective. They concluded that randomized trials are needed.

PubMed has no abstract for this study, and the article doesn't print one. We wrote this summary from the full article with the help of AI. It is not the authors' wording.

In plain English

This article was an editorial, not a study with its own patient data. It was presented at the 2013 annual meeting of the European Association for Cardio-Thoracic Surgery. The authors argued that surgery for malignant pleural mesothelioma should be tested in randomized controlled trials, because follow-up studies of operated patients can mislead when the patients are highly selected. They described two earlier analyses. In one, by Utley and colleagues, covering 945 mesothelioma patients, three groups had similar average survival of 17–18 months: those with no surgery, those whose chest was opened and closed without the tumor being removed, and those who had removal alone. The 207 of 945 who had multimodal treatment averaged 33 months, which the authors said may partly reflect selection of the best patients. In the other, by Datta and colleagues, 10 of 123 registry patients had extrapleural pneumonectomy. The survival gap narrowed as unoperated patients unlike the operated ones were removed from the comparison step by step. The authors concluded that no benefit was evident in these data and that randomized trials are needed. The editorial did not discuss asbestos exposure.

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: editorial (opinion article discussing earlier analyses and planned trials; no original data)
• Who was studied: No patients were studied in this article. It discusses earlier analyses of mesothelioma patients (945 patients in Utley et al.; 123 patients from the Cancer Registry of York Teaching Hospital in Datta et al.).
• Exposure: Not an exposure study. The editorial concerns surgery for malignant pleural mesothelioma: extrapleural pneumonectomy (EPP) and extended pleurectomy/decortication (e-P/D). Asbestos is not discussed.
• Main results:
  • Earlier analysis by Utley et al., described in the editorial and not this article's own data: of 945 mesothelioma patients, those with no surgery (387), those whose thoracotomy was closed without resection (174) and those with resection without further cancer treatment (177) had similar survival, averaging 17–18 months.
  • In the same earlier analysis, the 207 of 945 patients who had multimodal treatment survived to an average of 33 months. The editorial states that a beneficial effect of surgery is not evident from these results.
  • Earlier analysis by Datta et al., described in the editorial: the patients who had extrapleural pneumonectomy were a selected 8% (10 of 123) of mesothelioma patients in the Cancer Registry of York Teaching Hospital.
  • In the Datta analysis, unoperated patients unlike the operated ones (11 with sarcomatoid histology, 29 with performance status other than 0/1, and 24 older than the oldest operated patient) were removed step by step. As they were removed, the survival gap between the 10 operated patients and the unoperated patients progressively narrowed.
  • The editorial notes that the planned EORTC study cannot show whether e-P/D itself is effective, because all patients in it will have e-P/D and only the timing (immediate or deferred) is being tested.
• The authors' conclusion: The authors concluded that, after scrutiny of the observational data in the two examples, no benefit of surgery was evident, and that randomized trials are needed.
• Limitations the authors state:
  • The authors state that the two analyses of existing data they describe are inconclusive in themselves.

Topics

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

Medical terms in this study, explained in our Lexicon: Pleural Mesothelioma, Thoracotomy, Cancer Registry, Extrapleural Pneumonectomy (EPP), Sarcomatoid, Histology, Performance Status, Pleurectomy/Decortication (P/D).

Related studies

• Beta-carotene supplementation and cancer risk: a systematic review and metaanalysis of randomized controlled trials — N. Druesne-Pecollo, P. Latino-Martel, et al. (2010)
• Need for randomized clinical trials testing targeted therapies in malignant pleural mesothelioma — N. Sobhani, G. Roviello, et al. (2017)
• How successful is lung-preserving radical surgery in the mesothelioma and radical surgery-trial environment? A case-controlled analysis — Y. Shahin, J. Wellham, et al. (2011)
• Surgery in the treatment of malignant pleural mesothelioma: recruitment into trials should be the default position — A. Datta, R. Smith, et al. (2014)
• Surgery for mesothelioma: MARS landing and future missions — T. Treasure (2010)
• Estimating treatment effects from a randomized clinical trial in the presence of a secondary treatment — M. Zhang, Y. Wang (2012)

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