The Argument Against Chemotherapy as a Stand-Alone Treatment for Pleural Mesothelioma
Dr. Robert Cameron is a cardiothoracic surgeon and surgical oncologist who specializes in the treatment of malignant pleural mesothelioma. He is the director of the mesothelioma program at the David Geffen School of Medicine at the University of California, Los Angeles (UCLA) and the chief of thoracic surgery at the West Los Angeles Veterans’ Administration Medical Center.
Dr. Cameron has been treating mesothelioma patients for over 20 years. He is the innovator of the lung-sparing Pleurectomy/Decortication surgical procedure for mesothelioma and has performed the procedure on over 300 patients to date. He has also published many articles and is a frequent lecturer on the surgical and multi-modal management of pleural mesothelioma.
In this article, Dr. Cameron expresses his opinion regarding the appropriate role of Alimta/cisplatin chemotherapy in the treatment of patients with malignant pleural mesothelioma.
The Argument Against Chemotherapy as a Stand-Alone Treatment for Pleural Mesothelioma
In 2004, the FDA approved pemetrexed (Alimta®) in combination with cisplatin for the treatment of pleural mesothelioma. To this day, Alimta/cisplatin remains the only FDA approved chemotherapy drug combination for the treatment of mesothelioma.
The Resulting Hype
Following the FDA’s approval, the manufacturer conducted an aggressive marketing campaign of Alimta/cisplatin to general oncologists. This has resulted in the broad acceptance of this chemotherapeutic regimen as the de factostandard of care by general oncologists.
Physicians unfamiliar with mesothelioma who might have previously referred their patients to specialized mesothelioma treatment centers with experienced surgeons, medical and radiation oncologists, and pathologists and with advanced multimodality treatment protocols in place now often refer patients directly to community oncologists for treatment with Alimta/cisplatin alone.
The Limitations of Alimta/Cisplatin
Lost in the hype is the fact that the FDA’s approval is limited to use with patients who are not eligible for surgery (see the FDA approval letter, notice and package insert). Also the fact that, in its Phase III randomized trial, Alimta/cisplatin showed only a 41% partial response rate and an increased median survival rate of only 2.8 months compared to patients treated with cisplatin alone.
The Appropriate Role of Alimta/Cisplatin Chemotherapy
Published trial data show that the combination of surgery, radiation, and chemotherapy is almost always associated with the longest survival times for mesothelioma patients who are eligible for surgery. For this reason, many mesothelioma specialists believe that patients should consider surgery along with other therapies as part of a multimodality approach when the patient is a candidate for surgery.
Surgery can remove gross mesothelioma tumor in up to 85% of patients, equivalent to a complete pathological response, which compares to only a partial clinical response rate of 41% with Alimta/cisplatin alone. Following surgery, adjuvant therapies including chemotherapy and radiation may then be utilized to maintain a clinical remission. Furthermore, maintenance therapies such as immunotherapy, which are intended to continue to suppress microscopic disease and forestall the tumor’s recurrence, may provide even more long-term benefit.
Treating and managing mesothelioma as a chronic illness acknowledges the refractory nature of the disease to all therapies and focuses on coping rather than curing.
Chemotherapy is an important weapon in the treatment of malignant pleural mesothelioma. However, in patients who are otherwise eligible for surgery, it is probably best used in a well-planned multimodality therapy regimen.
The Importance of Obtaining a Surgical Consult Before Starting Alimta/Cisplatin Chemotherapy
Medical oncologists should counsel their mesothelioma patients to consult with a thoracic surgeon who has expertise in mesothelioma surgery, just as surgeons advise their patients to consult with a qualified medical oncologist about the potential benefits of adjuvant chemotherapy and radiation.
Patients who are evaluated and treated in a defined multimodality therapy regimen by a multidisciplinary team of physicians, including surgeons, medical oncologists, and radiation oncologists generally will be the most optimally managed and best served by their physicians.
