Combined Modality Treatment in Mesothelioma

A Systemic Literature Review With Treatment Recommendations

Charlotte De Bondt; Ioannis Psallidas; Paul E. Y. Van Schil; Jan P. van Meerbeeck

Disclosures

Transl Lung Cancer Res. 2018;7(5) 

In This Article

Conclusions & Recommendations

Disappointingly, despite previous evidence-based guidelines and recommendations, most patients are still being treated outside of clinical trials. In this review, we found that between 2009 and 2016, only 104 patients were treated in randomized controlled trials. As such, important questions remain unanswered. The role of surgery is still up for debate as even pleurectomy/decortication scores low on the benefit to cost ratio. Novel techniques in RT and CT are promising and should be investigated further, both as monotherapy and as part of combined modality treatment. The optimal sequencing of different modalities has yet to be identified.

Answers to a number of secondary questions have been indirectly obtained from case control series and these issues should therefore not be prioritized for investigation in upcoming trials. Examples are the equivalence of carboplatin to cisplatin when it comes to efficacy, the benefit of adding CT to surgery in improving outcome and the role of advanced precision RT techniques for avoiding toxicity.

We recommend that further reports on multimodality therapy in MPM should unequivocally include an intention-to treat population analysis, report time-to-outcome measurements from day 1 of the first treatment and confer a CONSORT diagram of patient disposition over the different steps of the multimodality protocol.

Furthermore, decisions to step up or down in a combined modality approach should be agreed upon before treatment starts and not ad hoc based on intraoperative or durante treatment findings, obscuring the true effect of each modality.

We emphasize the role of well conducted randomized phase 2 trials including a control group in order to compensate for patient selection bias and to avoid embarking on large phase 3 trials based on immature results in single arm phase 2 trials.

Lastly, it is imperative that good performance patients be referred to high volume expert centers in order to be considered and proposed for the clinical trials necessary to take forward the issue of multimodality treatment on the outcome in MPM.

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