Medical experts have spent decades investigating different treatment approaches for mesothelioma. After years of studies and research, most doctors recognize that a combination of surgery, chemotherapy and radiation provides the most hope.

The question still left: Which combination is the best?

Dr. Elliot Wakeam and his team at Michigan Medicine may have the answer.

Dr. Wakeam is one of the experts championing SMART for pleural mesothelioma. He’s a thoracic surgeon at Michigan Medicine and an assistant professor at the University of Michigan. Dr. Wakeam’s specialty is mesothelioma, which is why when he recently joined the institution in 2019, he brought with him his belief in SMART.

“This is not being offered anywhere else in the United States,” he said.

 

What Is SMART for Pleural Mesothelioma?

SMART is the acronym for “surgery for mesothelioma after radiation therapy.” SMART utilizes radiation therapy as a “neoadjuvant treatment,” which refers to therapy delivered before an operation. Neoadjuvant treatment can reduce the size of pleural mesothelioma tumors and make surgery more beneficial for patients.

“There are several advantages to SMART,” Dr. Wakeam said in a recent phone interview with Mesothelioma Guide. “The problem with surgery is you’ll get a local recurrence. … That’s where the radiation is key.”

Dr. Wakeam said the radiation therapy “sterilizes” the margins. Accomplishing this is essential to preventing mesothelioma recurrence.

Mesothelioma spreads differently than most other cancers. It consists of many microscopic tumors that grow and replicate at unchecked rates.

Dr. Raja Flores, a thoracic surgeon and mesothelioma expert at Mount Sinai Medical Center in New York, described mesothelioma’s growth process as “like a sheet” or “an avalanche.” It’s not one mass that gets larger.

The tumors grow in size but also duplicate, which is why the disease spreads so fast and often includes tumors separated from the bulk of the cancer. Mesothelioma surgery usually focuses on the centralized tumors but often doesn’t address the ones on the margins. Radiation is the solution to this dilemma.

“The results for that are quite excellent,” Dr. Wakeam said.

 

Benefits of SMART for Pleural Mesothelioma Patients

A 2014 study published in the Journal of Thoracic Oncology showed the early promise of SMART. Doctors used intensity-modulated radiation therapy (IMRT) before extrapleural pneumonectomy (EPP) on 25 patients.

None of the patients had severe complications from radiation therapy. EPP was performed between four and eight days following completed IMRT. The three-year survival for the epithelioid cell subtype group was 84%, which is much better than the general mesothelioma survival rates.

One of the study’s authors, Dr. Marc de Perrot, is a meaningful influence on Dr. Wakeam’s career and efforts. They worked together at the Princess Margaret Cancer Center in Toronto, where Dr. Wakeam learned SMART. He’s a graduate of the institution’s thoracic and lung transplant programs.

“The main mesothelioma surgeon in our hospital was Marc de Perrot,” Dr. Wakeam said. “Then I had Dr. Shaf Keshavjee. Those were my two mentors when it came to learning and understanding mesothelioma.”

At the Princess Margaret Cancer Center, doctors had three-year mesothelioma survival rates of 72% thanks to SMART. The median survival for patients with the epithelioid cell type was 51 months.

Dr. Wakeam said the SMART protocol at Michigan Medical is for patients with either the epithelioid or biphasic cell type. The third cell type, sarcomatoid, is not often considered for aggressive surgery and treatment. Dr. Wakeam said he would consider operating on these patients.

“There is no one-size-fits-all with this, with any of this,” he said.

That statement rang true for the type of surgery he uses in SMART. Traditionally, doctors rely on EPP for pleural mesothelioma. However, this operation involves removing the affected lung. The other pleural mesothelioma surgery is pleurectomy with decortication (P/D), which spares the lung.

“We primarily use EPP, but we also do P/D as well,” Dr. Wakeam said. “We can do both. I would tailor it to the patient. If you’re a young and fit patient, EPP gives you better disease clearance.”

 

Specifics of SMART at Michigan Medicine

Dr. Wakeam and his staff are building a “compact” SMART protocol for people. The plan is to administer five days of radiation therapy, wait five days and then perform surgery.

Following surgery, patients may receive follow-up radiation or chemotherapy to address any remnant tumors found on scans.

“It’s worth thinking about the future directions of where we want to take it at Michigan,” he said of SMART, noting he is considering adding immunotherapy to the protocol.

While this idea is not yet part of Michigan Medicine’s protocol, it’s an example of the always-evolving treatment for mesothelioma. It’s also an example of what people with this cancer should look for in an institution.

“Every patient should be in a protocol of some kind,” Dr. Wakeam said. “Every patient should look for a program where these innovations are happening.”

If you’re a mesothelioma patient seeking treatment, prioritize your search around experts and institutions that have a mesothelioma treatment protocol. Then look for the one tailored to your diagnosis.

We can help you find a hospital or doctor who specializes in this cancer. If you have any questions, reach out to our patient advocate and registered nurse, Jenna Campagna. She’s available via email at jenna@mesotheliomaguide.com.

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Devin Goldan image

About the Writer, Devin Golden

Devin Golden is the content writer for Mesothelioma Guide. He produces mesothelioma-related content on various mediums, including the Mesothelioma Guide website and social media channels. Devin's objective is to translate complex information regarding mesothelioma into informative, easily absorbable content to help patients and their loved ones.

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    Devin Golden

    About the Writer, Devin Golden

    Devin Golden is the content writer for Mesothelioma Guide. He produces mesothelioma-related content on various mediums, including the Mesothelioma Guide website and social media channels. Devin's objective is to translate complex information regarding mesothelioma into informative, easily absorbable content to help patients and their loved ones.