New ASCO guidelines reinforce role of surgery in mesothelioma treatment
The American Society of Clinical Oncology (ASCO) has updated its guidelines for pleural mesothelioma based on a review of 110 studies from 2016 to 2024. An expert panel of specialists analyzed survival rates, recurrence-free survival and quality of life to develop evidence-based recommendations and concluded surgery is still important for certain patients.
Advancing mesothelioma treatment: the role of surgery and multimodal therapy
Mesothelioma is a rare and aggressive cancer that affects the lining of the lungs, abdomen or heart. It is primarily caused by exposure to asbestos. Symptoms often appear decades after exposure and include shortness of breath, chest pain and fatigue. Because mesothelioma is difficult to treat, doctors use a combination of surgery, chemotherapy and immunotherapy to improve patient outcomes.
Pleural mesothelioma remains one of the toughest thoracic cancers to treat, but advances in surgery and multimodal therapy are helping patients. Despite findings from the MARS 2 trial, which investigated the role of surgery, the ASCO still recommends surgery for select patients. “Surgery remains a viable and beneficial option for patients when carefully selected based on their overall health and disease stage,” said Dr. R. Taylor Ripley, professor in the Michael E. DeBakey Department of Surgery, director of the Mesothelioma Treatment Center and member of Dan L Duncan Comprehensive Cancer Center at Baylor.
The importance of preoperative evaluation
Doctors must determine whether a patient is a good candidate for surgery. “We assess the extent of the disease and the patient’s ability to tolerate surgery,” Ripley said. “This evaluation helps us choose the safest and most effective approach.”
Combining surgery with chemotherapy and immunotherapy
Research suggests that surgery combined with chemotherapy – either before or after the procedure – works better than surgery alone. The sequence of treatments varies by patient. “Some patients benefit from chemotherapy before surgery to shrink the tumor, while others receive it afterward to target remaining cancer cells,” Ripley said.
Immunotherapy before surgery is an option, but experts are unsure about its benefits after surgery. “While immune checkpoint inhibitors before surgery may have promise, we still need more data on its long-term impact,” Ripley said.
Preserving lung function
In most cases, doctors prefer lung-sparing surgery over removing the entire lung. “Preserving the lung whenever possible helps patients maintain their quality of life and reduces risks,” Ripley said. Surgery also can help patients struggling to breathe due to fluid buildup. “For these patients, placing a tube or performing a partial decortication can improve breathing and comfort,” Ripley said.
Mesothelioma subtypes and treatment
ASCO’s updated guidelines emphasize the importance of identifying the specific mesothelioma subtype. “Epithelioid, sarcomatoid and biphasic mesotheliomas behave differently, so we tailor treatment accordingly,” Ripley said. Patients with sarcomatoid or biphasic mesothelioma should receive dual-agent immune checkpoint inhibitors. In contrast, those with epithelioid mesothelioma who are not surgical candidates can receive either chemotherapy or immunotherapy as first-line treatment. A drug targeting blood vessel growth can also be added to chemotherapy in certain cases.
Clinical trials at Baylor College of Medicine
Baylor College of Medicine offers clinical trials for patients seeking new treatment options. The NEMO trial studies two immune checkpoint inhibitors with chemotherapy – or ICIs alone – before surgery, followed by one year of ICIs after surgery. “The NEMO trial is designed to evaluate how immunotherapy affects surgical outcomes and long-term survival,” Ripley said. “We hope these strategies will continue to improve the way we treat mesothelioma.”
For mesothelioma patients, a personalized approach is essential. Ongoing research and advanced surgical techniques are helping doctors improve survival rates and quality of life.
Ripley and his team are currently enrolling mesothelioma patients in the NEMO Trial. For more information or to enroll in the clinical trial, call 713-798-5530.
By Tiffany Harston, senior communications specialist in the Michael E. DeBakey Department of Surgery
