Though pleural mesothelioma continues to be one of the most challenging forms of cancer to treat, recent years have seen a significant shift in both the treatments being offered and patient survival. These changes are reflected in newly published guidelines from the National Comprehensive Cancer Network (NCCN). The update, titled “Mesothelioma: Pleural, Version 3.2026,” points to systemic therapy (immunotherapy and/or chemotherapy) as the primary treatment, reserving surgery for a small, carefully selected group.
Mesothelioma Diagnosis Starts with a Biopsy
Mesothelioma is an asbestos-related disease that can appear in the thoracic cavity, the peritoneal cavity, the pericardial cavity, and the testicular cavity. The type that affects the thoracic cavity is called pleural mesothelioma, and it accounts for roughly 85% of all cases, with about 3,000 Americans diagnosed each year.
One of the most difficult aspects of mesothelioma discussed in the new report is that a firm diagnosis requires several tests. The guidelines suggest that doctors combine a chest CT with contrast, fluid analysis, and a pleural biopsy, ideally a thoracoscopic one, and that the pathology report should strongly shape treatment choices. The report also urges that those findings be evaluated by a multidisciplinary team experienced with the disease so that its members can weigh each patient’s best options.
Mesothelioma Immunotherapy Takes the Lead
The new report indicates that mesothelioma patients whose tumors are unresectable now have two preferred first-line options. One is the immunotherapy combination, nivolumab plus ipilimumab. The other is a different immunotherapy drug, pembrolizumab, combined with what had previously been established as the gold standard chemotherapy treatment, pemetrexed. Neither of these approaches requires PD-L1 testing first. In the highly respected CheckMate 743 trial, nivolumab plus ipilimumab produced a median overall survival of 18.1 months, compared with 14.1 months for chemotherapy alone, with the greatest benefit seen in patients whose tumors were either sarcomatoid or biphasic.
Notably, though surgery had previously been recommended for many mesothelioma patients, the guidelines point to two randomized trials that showed that patients who had extrapleural pneumonectomy survived a median of 14.4 months, compared with 19.5 months for those who did not have the operation. The larger MARS2 trial found median survival of 24.8 months with chemotherapy alone, versus 19.3 months when lung-sparing surgery was added. Surgery also brought more serious side effects, poorer quality of life, and higher costs. The report concludes that surgery may still be considered for physically fit patients with stage I epithelioid disease, with pleurectomy/decortication preferred, but that it is no longer recommended as a primary treatment for stage II through IV disease or for sarcomatoid or biphasic subtypes.
The study also notes that mesothelioma patients may benefit from specialized radiation called IMRT and symptom-focused care including draining fluid from around the lung, performing pleurodesis, or placing a catheter to ease breathing.
If you or someone you love has been diagnosed with mesothelioma, continuing improvements to care provide a real reason for hope. For more information, contact the Patient Advocates at Mesothelioma.net at 1-800-692-8608.
