Meet the Experts Recap: Dr. Friedberg on New Frontiers in Surgery

Dr. Joseph FriedbergOver 40 individuals from the meso community joined us Thursday night for our latest Meet the Experts session “New Frontiers in Surgery” with Dr. Joseph Friedberg, a surgeon at the University of Pennsylvania. With an interest in diseases of the pleura, Dr. Friedberg’s surgical protocol involves laser treatments and photodynamic therapy, on which he has published a promising study. During Thursday’s teleconference, Dr. Friedberg explained photodynamic therapy and his surgical treatment process, how it works, and the benefits it may hold for mesothelioma patients.

At the start of the teleconference, Dr. Friedberg explained that photodynamic therapy is a light-based cancer treatment that is minimally toxic, unlike chemotherapy, and not as penetrative as radiation. To administer the therapy, the patient is given a compound similar to chlorophyll, which is used by plants to capture light energy from the sun. The compound enters the patient’s cells, making them very light sensitive and giving them the ability to capture visible light energy. The light energy only penetrates a small distance into the body, which is enough to cause reactions that can kill cancer cells. In a disease such as pleural mesothelioma where, following lung-sparing surgery, microscopic cancer cells generally remain, photodynamic therapy is used to complement or augment surgery in an effort to remove all detectable cancer.

Dr. Friedberg went on to discuss the surgical treatment process for mesothelioma patients at the University of Pennsylvania, but first noted, “All surgery for mesothelioma really remains investigational at this point.” When a new mesothelioma patient goes to UPenn for treatment, a team evaluates their case and determines which type of treatments they qualify for. When a patient is a candidate for surgery, and they decide they want to go this route, Dr. Friedberg notes that they start with surgery followed by photodynamic therapy and then chemotherapy. Most of their patients do not receive radiation treatment.

For pleural mesothelioma patients, Dr. Friedberg performs lung-sparing surgery (as opposed to lung-sacrificing surgery, which is best known as an ‘extrapleural pneumonectomy’ or EPP). In his method, Dr. Friedberg mobilizes the cancer off of the chest wall, diaphragm, and mediastinum, so that the cancer is tethered solely to the lung. The pleural lining is then completely removed from the lung along with the cancer that is connected to it. The median length of stay post-surgery is 13 days with the first 1-3 days spent in the ICU. The photodynamic therapy leaves the patient with light sensitivity that lasts about two weeks and could result in very quick sunburn.

Dr. Friedberg has performed this surgery and treatment process on a few hundred patients, which includes patients with cancers other than mesothelioma. Nonetheless, he notes, “The operation is still in evolution … I’m always trying to think of ways you can make it better and more translatable.”

It is still debatable whether lung-sparing surgery or lung-sacrificing surgery is better for patients. Dr. Friedberg believes that saving the lung allows patients a better quality of life post-surgery. With two lungs, “The patients are doing more; they’re in better shape. They are just more robust.” Additionally, if the mesothelioma reoccurs, “They are typically able to tolerate better and more aggressive treatment.”

As moderator, Mary Hesdorffer, NP, relays the question of a listener who asks, “What is the average lifespan of a surgical patient who goes through a successful surgery?” Dr. Friedberg answers honestly as he states, “This is both the best and the most important, and the least answerable question a patient can ask.” He notes the unpredictable qualities of mesothelioma, as the cancer is not only different from patient to patient, but it also changes character within one patient from one region of the chest cavity to the next.

Dr. Friedberg goes on to explain the questions that arise when a mesothelioma patient is deciding whether or not they should go through with surgery. The patient needs to weigh the benefits and the risks, and also think about lung-sparing or lung-sacrificing surgery. Dr. Friedberg suggests patients ask their surgeons, “What would make you take the lung out and what is the impact of that?” The patient should also make sure the surgeon they speak with will actually be performing their surgery. They should find out who else is on the team, what additional treatments may be necessary, whether or not radiation is needed and why, and so on.

Dr. Friedberg provided a huge amount of information regarding mesothelioma surgery and photodynamic therapy. He discussed who qualifies for his treatment and who will benefit from it, how mesothelioma surgery differs from surgeon to surgeon, what role photodynamic therapy appears to be playing in the treatment process, and much more. We are extremely grateful to Dr. Friedberg for taking part in this Meet the Experts session and providing the community with excellent insight into mesothelioma surgical treatment.

You can listen to the full teleconference on the Meet the Experts page.

UPCOMING MEET THE EXPERTS
The next Meet the Experts session will be held on February 17th at 8PM Eastern with Dr. Valerie Rusch of Memorial Sloan-Kettering Cancer Center. More details will be announced as they become available on the Meet the Experts page.

FROM THE FOUNDATION: Your Questions (and the Doctors’ Answers) from the 2012 Symposium — Part Two

The 2012 Symposium has brought together the best minds in mesothelioma research in order to highlight breakthroughs and options in asbestos cancer and mesothelioma treatment. This year, the Meso Foundation enabled a Live Stream in order to bring the Symposium online and allow you at home to interact.

Here is Part Two of the many questions the meso warriors and survivors sent in through the Live Stream.

Q: How can a patient boost his immune system by over-the-counter drugs?

A: There are many products advertised over the Internet and radio which are intended to boost the immune system. Without exception, they’ are all fraudulent. There is no evidence that any drug will generally boost your immune system.

What you need to do is maintain your health as best as possible by eating well and exercising regularly.

Q: Is there different treatment for someone who has sarcomatoid mesothelioma?

A: Unfortunately, the treatment for sarcoma mesothelioma is poor, and the survivals are poor as well. I know of no institution that has survival rates from diagnosis that exceed one year. Such patients should seek out major medical centers specializing in mesothelioma for experimental trials of new drugs.

Q: Are there any new advances in treatment of peritoneal mesothelioma?

A: There have been important advances in the surgical treatment with removal of known disease, combined with intraperitoneal local and regional chemotherapy given as an outpatient. There are a few centers that specialize in this. I would contact the Meso Foundation’s Nurse Practitioner Mary Hesdorffer at 703-879-3820 or mary@curemeso.org for more information.

Q: Is there any other cause of mesothelioma besides asbestos?

A: High doses of radiation are also known to cause mesothelioma. There may be other causes that have not yet been identified.

Q: To follow up on Sugarbaker comment where chemotherapy gives you one year of life and surgery three years of life.

A: Those comments reflect Dr. Sugarbaker’s feelings, emotions, and hopeful anticipation. You are correct that there is no such study which supports those assertions.

Q: Can MRI be as effective as CT scan for peritoneal mesothelioma follow-up?

A: It often can be more effective, especially in heavier patients with a higher body fat content. Different oncologists prefer different test modalities. CT scan itself is safe in this context and I would let your oncologist decide.

Q: Is there any thoughts among medical professionals that stress or other factors trigger mesothelioma?

A: While we generally think that mesothelioma, like other cancers, is caused by abnormalities in the genetic apparatus, stress and other factors in the patient already diagnosed certainly make matters worse.

Q: If younger patients of being diagnosed are there any thoughts That meso be caused by something other than asbestos.

A: This is not clear yet, but it certainly is a possibility. No cause other than asbestos or ionizing radiation has been identified yet, however.

Q: What is the shortest time from exposure to disease? And how many 911 first responders have been diagnosed with mesothelioma so far?

A: Older statistics suggested that less than 1% of mesothelioma’s had a latency time shorter than 15 years. More recently the estimate of latency time has shortened and may possibly be even less than five years.

I believe that there have been two cases of mesothelioma diagnosed in the 9/11 responders, but whether they were due to 9/11 exposure will never be clarified.

Q: What is the cause of mesotheliomas in young children? Is it a predisposition?

A: The cause in young children may be asbestos, and also may depend upon a genetic predisposition. None of this is really known at this point. There are not enough cases to form an opinion.

Q: Don’t you ever feel bad putting patients on placebo even in the trial?

A: Please understand that when doing a clinical trial the physician is not certain whether the drug will help you or hurt you. Otherwise he/she would not be doing the trial. If the drug is strong and there was a chance that the side effects would be dangerous, detrimental, shorten your life,  then he should have a control group that will get a placebo. If the physician is confident that the drug is likely to help you and there is little chance of it hurting you, then he should not administer a placebo; more to the point, he should not be doing the trial.

Q:  What is the most promising new treatment benefitting meso patients now?

A:  In my opinion, the most promising new treatment benefitting meso patients right now is the advent of lung-sparing surgery for patients with pleural mesothelioma.  There is evidence from multiple centers in the U.S. and around the world that for patients with epithelial pleural mesothelioma that multimodality therapy involving lung-sparing radical pleurectomy in combination with post-operative chemotherapy +/- radiation therapy can engender survival benefits which appear equivalent to those historically provided by extrapleural pneumonectomy (EPP).

Q:  What should you do if you think you have been exposed to asbestos?

A:  Absolutely you should inform your doctor of this information, and your doctor can then initiate, if appropriate, a series of tests to assess whether you have been adversely affected by the asbestos.  It is relatively straightforward to determine if your lung function has been detrimentally affected by the asbestos exposure, as well as to whether you currently have lung cancer or mesothelioma.  What is more complicated is the issue of future screening for development of lung cancer or mesothelioma on the basis of asbestos exposure alone.  As there are no standard screening recommendations, the best option would be to consider enrolling on a clinical trial for screening of those who have been exposed to asbestos.

Q:  What is the percentage of people receiving chemotherapy  after surgical procedure such as EPP or P/D (radical pleurectomy-RP).

A: In general, if patients have not previously received neo-adjuvant (pre-operative) chemotherapy, they should receive adjuvant (post-operative) chemotherapy, as long as they have recovered sufficiently after the surgery to be able to tolerate the treatment.  The recommendation is for 4 (or more) cycles of Pemetrexed and Cisplatin (or Carboplatin).  If patients already have received chemotherapy prior to surgery, there is no standard recommendation for giving additional chemotherapy after EPP/RP, but this is an important topic for future clinical studies.

Q:  Is photodynamic therapy (PDT) available to those who have already had surgery?

A: PDT is not currently available for patients who have had prior EPP or RP/PD, but we are very interested in using this treatment to stimulate immune responses in patients who have had recurrences after definitive surgery.  For patients who have had a prior “diagnostic” surgery for biopsy, pleurodesis, partial pleurectomy, it is still possible for them to undergo RP followed by intraoperative PDT.

Q:  What is being done to educate medical students and/or general practitioners in order for them to diagnose patients in a timely manner.

A:  The best methods are the dissemination of evidence-based knowledge through medical journals, textbooks, and scientifically-based internet based resources, as well as including mesothelioma related topics in medical school curricula and in residency training for general internists and family physicians.

Q: With so few patients, are there other ways than randomized double-blind clinical trials?

A: Clinical trials are rare because they’re very expensive, and pharmaceutical companies do not wish to spend a great deal of money on treatment of a rare cancer.

So that doctors are doing exactly what you say, they are reporting small series of cases individually. Please be assured that if it’s a terrific “standout” treatment appearing in  a small series, it will be quickly tested in the largest and most appropriate series.

UPDATE, July 17, 3:52 p.m. — We discovered these missing questions in our Inbox. We’re bringing them to you today!

Q: Why doesn’t everyone get mesothelioma who has been in contact with asbestos.

A: Many cancers, including mesothelioma are multifactorial, that is, they only appear when an appropriate combination of factors comes together. For example, not everyone who smokes a lot of cigarettes gets lung cancer.

Q: Question what happens when you get only one specialist and have to take what you get?

A: You are a consumer of healthcare. Do not have to “take what you get.” If as a mesothelioma patient, you have seen only one specialist, you should get in touch with MARF to help you chart your course among the different providers, specialists, and institutions, so as to get the best treatment.

 

UPDATE, July 25, 10:37 p.m. — One more question discovered in our Inbox from the 2-012 Symposium…

Q: Is there research into chronic pain?

A: There is a great deal of ongoing research into chronic pain syndromes such as you described. Even if an anatomical cause is not identified, much can be done. Usually opiates such as morphine or fentanyl are needed, supplemented with adjuvant drugs such as gabapentin or baclofen. also very new drugs such as  antibody to the mu receptor and drugs targeting the NMDA receptor will soon be available. Many pain specialists at major medical centers can help.

FROM THE HEADLINES: Photodynamic Therapy Added to Lung-Sparing Surgery Improves Survival for Mesothelioma Patients

The website Medical News Today recently released findings of a new treatment for patients with malignant pleural mesothelioma. The treatment involves PDT (photodynamic therapy) conjunction with lung-sparing surgery. Results look promising in comparison to patients utilizing other mesothelioma treatment options. In this approach, provided the patient can keep both lungs after treatment, patients face better chances in combatting mesothelioma once it returns. Patient are given a photosensitive drug that cancer cells absorb, and then Fiber optics direct light onto the tumor site, which activates the drugs, and destroys the cancerous cells.

Leading this research from the Perelman School of Medicine, University of Pennsylvania, is Dr. Joseph Friedberg, MD. In this battle against mesothelioma, considered one of the most aggressive forms of cancer, Dr. Friedberg has stated, ”While I don’t consider anything short of a cure as a victory against mesothelioma, I am encouraged by our results. Based on our new findings, we are redoubling our clinical and translational research efforts to find a way to further improve and refine this multimodality treatment approach for mesothelioma.” Continue reading “FROM THE HEADLINES: Photodynamic Therapy Added to Lung-Sparing Surgery Improves Survival for Mesothelioma Patients” »