The National Comprehensive Cancer Network (NCCN) published new guidelines for the treatment of pleural mesothelioma, codifying a marked shift towards systemic treatments such as immunotherapy and chemotherapy and away from surgery.
The new guidelines, authored by a committee led by Dr. James Stevenson of Case Comprehensive Cancer Center, specifically recommended immunotherapy as the first-line treatment in most cases of pleural mesothelioma.
The guidelines also emphasized that surgery should be reserved only for “carefully evaluated” patients, and is no longer recommended as a primary treatment in the vast majority of cases. These shifts reflect recent advancements in mesothelioma treatment made with immunotherapy, and studies such as the MARS2 trial examining the health effects of mesothelioma surgery.
What the New Guidelines Recommend for Mesothelioma
The new NCCN guidelines specifically codify several combinations of immunotherapy medications – either ipilumumab and nivolumab or pembrolizumab along with a platinum-based chemotherapy – as preferred first-line treatments for all three main cell types of pleural mesothelioma.
The combination of ipilimumab and nivolumab – known by the brand names Opdivo and Yervoy – for mesothelioma in 2020, making it the first immunotherapy approved for the treatment of the deadly cancer. Pembrolizumab, also known by the brand name Keytruda, was approved in combination with chemotherapy in 2024.
Although these treatments have only been widely in use for mesothelioma for a few years, they have rapidly become the standard, owing to a number of studies that showed their effectiveness compared to alternative approaches including surgery.
But while surgery has been de-emphasized in the new NCCN guidelines, it by no means will be eliminated entirely. The NCCN still recommends surgical evaluation for certain patients with stage 1 epithelioid mesothelioma, additionally recommending the less invasive pleurectomy/decortication (P/D) procedure as the preferred first choice.
How the New Mesothelioma Guidelines Affect Patients
These new guidelines should prove impactful for mesothelioma patients since they reflect the larger trend away from surgery towards systemic treatments that have proven more effective and have demonstrated better quality of life for patients.
Systemic treatments such as immunotherapy often tend to be more well-tolerated with greater survival rates than surgery when treating mesothelioma, especially more invasive surgeries such as extrapleural pneumonectomy (EPP), where the entire affected lung and surrounding areas are removed.
These new guidelines not only reflect these changing trends, but will influence how physicians treat mesothelioma in the future.
Sources & Author
- NCCN Clinical Practice Guidelines in Oncology, Mesothelioma: Pleural. National Comprehensive Cancer Network. Retrieved from https://www.nccn.org/professionals/physician_gls/pdf/meso_pleural.pdf. Accessed on 09/22/2026.
