Every year, around 140 people are diagnosed with malignant pleural mesothelioma in Denmark. The disease, which in the majority of cases is due to exposure to asbestos, is extremely serious and rare. Most cases are inoperable, but if the disease has not spread, surgery may be an option. In such cases, the same small group of experts at the Danish Mesothelioma Centre  at Rigshospitalet is always involved. 

In around 15% of patients, it is possible to remove surgically the entire cancerous pleura, and the five-year survival rate among these patients is 32%. ​​

- This is high compared with inoperable cases. And before we began combining surgery with chemotherapy, all cases were considered inoperable, said Jens Benn Sørensen, a consultant.  

 

Since 2006, approx. 200 patients have had their pleura removed by this surgery, and this is one of the greatest advances in lung cancer treatment.​

According to Jens Benn Sørensen and the other major surgeon in Danish malignant pleural mesothelioma treatment since 2000, Jesper Ravn, the good results can be explained by "centralisation".

- The fact that we can operate on a lot of patients means something. All patients without distant metastases are referred to us for surgery and are given chemotherapy before and after surgery, said Jens Benn Sørensen.

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Jesper Ravn agreed:

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- The strong centralisation in Denmark allows us to keep track of every single patient. Just the fact that all the patients have to walk through the same door makes a huge difference, said Jesper Ravn. 

Together with pathologist Eric Santoni-Rugiu, Jesper Ravn and Jens Benn Sørensen have helped assess, operate on and treat all the 186 patients who have undergone successful surgery – complete removal of the cancerous pleura – since 2006. The results showed that 32% of patients are still alive after five years and 10% are still alive after 10 years.​

Jesper Ravn has participated in all the operations since he performed his first operation in 2006. There are always two surgeons present during surgery, and only three other surgeons have participated in total. A surgeon with a permanent assistant performs the surgery. But there is a permanent team consisting of many specialist fields: PET people, pathologists, the anaesthesiologist, nurses in recovery and on the wards, etc. There should be as few people as possible, so that everyone knows what kind of problems these patients may get, and how to address them," he said. 

During surgery, the pleurae are removed, while the lung is preserved. Jesper Ravn compares the surgery with peeling an orange. 

- You must remove both the thick orange peel and the inner fine, white pith. This requires patience, and it's difficult to guarantee that you've removed it all, he said. 

Patients have three rounds of chemotherapy before the operation to remove some of the cancer. After the operation, they have another three rounds of chemotherapy to get rid of any residual cancer cells. 

The first operation took 11 hours, but this was halved already after one year. It is a taxing operation, and not all patients are strong enough to make it.

When you've learned to perform the operation, the great thing is not to overdo it. Don't operate if experience shows that the patient won't benefit," he said.

In addition to Danish patients, the team has also operated on patients from Sweden and Norway, as the lung surgery section at Rigshospitalet is also the Scandinavian centre for treatment of malignant pleural mesothelioma. A total of 25-30 operations are performed annually.​

By far the majority of malignant pleural mesothelioma cases are inoperable – either because the disease has spread, or because the patient is too sick to survive such a comprehensive operation. In Denmark, the five-year survival rate for all patients is 14%. Even though this figure is not very high, it is twice as high as in Sweden, where only 7% are alive after five years according to the most recent data. 

Before the year 2000, there was no treatment whatsoever for patients suffering from malignant pleural mesothelioma. Chemotherapy only began after 2000, and since then surgery for some patients has been introduced, and the five-year survival rate has almost tripled. 

Immunotherapy may be on the way in future, and the same applies to trials of radiation therapy on areas with particular risk of relapse. For an oncologist who has been working on this complex disease for more than two decades, improving treatment for this group of patients is still an intellectual challenge.   

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- Seeing a patient is doing well is amazing. There's little progress, and it's rare. But at least there's progress, and I've experienced significant improvements for patients, including for those who cannot have surgery, but who have many symptoms and much discomfort. For some patients, chemotherapy can shrink the cancer, reduce fluid build-up, and provide a quality of life for much longer than without treatment. This means a lot, said Jens Benn Sørensen.