Should Chemotherapy for Mesothelioma Come Before or After Surgery?

Mesothelioma doctors believe that the best approach to treating the aggressive cancer known as mesothelioma is with multiple approaches.

This strategy – called multimodal mesothelioma treatment – uses combinations of surgery, chemotherapy, immunotherapy and radiation therapy. The most popular combination is surgery and chemotherapy.

The remaining question: Should mesothelioma surgery or mesothelioma chemotherapy come first?

A study conducted in Europe attempted to answer this question. The answer? There is no concrete answer and there are benefits to both orders.

 

Purpose of Multimodal Mesothelioma Treatment

Multimodal mesothelioma treatment, such as combining surgery and chemotherapy, aims to attack the disease from multiple fronts to address all aspects of the cancer. Surgery is used to debulk the cancer by removing large amounts of tumors. Chemotherapy, immunotherapy and radiation can kill any hidden cancer cells that are more difficult to take out in an operation.

There are two chemotherapy drugs approved by the FDA for mesothelioma: pemetrexed and cisplatin. These two drugs were approved in 2004.

In 2020, the FDA approved two immunotherapy drugs for mesothelioma: nivolumab (Opdivo) and ipilimumab (Yervoy). Opdivo and Yervoy for mesothelioma are approved for people with an unresectable case of the cancer, which means it cannot be taken out with surgery.

Despite the restrictions of the approval, patients can receive immunotherapy before or after surgery by enrolling in a mesothelioma clinical trial. The same is true for chemotherapy or radiation before or after surgery. There are clinical trials for mesothelioma held regularly at the top mesothelioma cancer centers in the United States.

 

Results of Combining Chemotherapy and Surgery

Doctors in Europe utilized a type of mesothelioma surgery called pleurectomy/decortication (P/D) for this study, which consisted of 64 people with pleural mesothelioma. This type of mesothelioma forms near the lungs, and P/D surgery is a top option to treat it.

P/D surgery removes the lining of the lungs (called the pleura) along with part or all of the diaphragm and the lining of the heart (pericardium).

Half of the people in the study received surgery immediately after diagnosis and before chemotherapy. The other half received surgery later – after chemotherapy.

The results were similar. Both groups had similar risks of mortality and severe side effects from surgery. People receiving surgery first had:

• Median progression-free survival (meaning no signs of the cancer returning or growing) of 10.8 months
• Median overall survival of 27 months (2 years, 3 months)

People receiving chemotherapy first had:

• Median progression-free survival of 8 months
• Median overall survival of 33 months (2 years, 9 months)

Both orders were improvements on usual patient survival. The average survival for people with mesothelioma is 12-16 months. Survival is low because mesothelioma tumors spread quickly and erratically, and surgery often is not a beneficial option for patients diagnosed with an advanced disease.

 

What Should Patients Choose for Mesothelioma Multimodal Treatment?

The results of this study indicate there is no clear “better way” for mesothelioma multimodal treatment. Surgery or chemotherapy can be used first to the benefit of the patient.

Each patient is different and has a unique diagnosis of mesothelioma. They should rely on the expertise of their medical team and specialists to decide the best way to treat their cancer.

The top mesothelioma doctors at prestigious cancer centers will examine all aspects of the diagnosis and case – stage, patient health, primary cell type and the speed of the cancer’s growth – to determine whether it’s best to operate right away or use chemotherapy before surgery.

Mesothelioma Guide will help you or a loved one find one of these experienced mesothelioma doctors. Email our patient advocate and registered nurse, Karen Ritter, at karen@mesotheliomaguide.com to begin the search for your ideal doctor. This is the first step to beginning your treatment journey and finding someone with the expertise needed to fight your unique mesothelioma diagnosis.