Surgical series in mesothelioma: navigating between biases

Our plain-English summary of Surgical series in mesothelioma: navigating between biases, by J. Raskin, P.E. Van Schil, J.P.V. Meerbeeck (Translational Lung Cancer Research, 2023).

The study

• Authors: J. Raskin, P.E. Van Schil, J.P.V. Meerbeeck
• Journal: Translational Lung Cancer Research
• Published: 2023;12(2):184-186
• Type of article: Editorial, Comment
• Cited by: 2 articles, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

In plain English

This was an editorial, not a new study. It commented on Klotz et al.'s study of mesothelioma patients treated with surgery-based therapy at Heidelberg University Hospital, Germany, from 2001 to 2018. In 2013 the hospital switched from extrapleural pleuropneumonectomy (EPP), which removes the lung, to extended pleurectomy/decortication (EPD), which leaves the lung in place except for visibly invaded parts. The authors described three biases in surgical series: selection bias (reporting on the fittest, earliest-stage patients), comparison bias (the right comparison is a similar unoperated patient), and shrinking denominator bias (patients dropping out along the way). In a cited US trial, 57 of 77 patients (74%) starting chemotherapy reached EPP and 40 (52%) finished. They recommended that future retrospective series include matched non-operated patients with comparable prognostic factors, report modern systemic therapy results for them, and analyse all similar patients by intention to treat or clearly show how and why numbers shrank. They wrote that only prospective series can refute the perception that any surgery in mesothelioma is futile by bias. The article did not discuss asbestos and was not externally peer reviewed.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: editorial commenting on another published study; commissioned by the journal and not externally peer reviewed; no new data
• Who was studied: No population of its own. It commented on Klotz et al.'s single-centre series of mesothelioma patients treated at Heidelberg University Hospital, Germany, from 2001 to 2018.
• Main results:
  • The editorial described the Heidelberg change of approach in 2013 from EPP to EPD, a less aggressive procedure in which the lung is left in place except for macroscopically invaded parts.
  • The authors argued that surgical series suffer from selection bias because they report on the best patients. They cited the 1999 Sugarbaker et al. series as an example.
  • The authors described comparison bias: the ideal comparison for a surgical patient is a similar patient who did not get surgery.
  • The authors described shrinking denominator bias, citing a US trimodality trial (not their own study). Of 77 patients who started neoadjuvant chemotherapy, 57 (74%) advanced to EPP and 40 (52%) completed all treatment.
• The authors' conclusion: The authors recommended that future retrospective surgical series include a matched cohort of non-resected patients with prognostic factors as comparable as possible, report results of modern systemic therapy in that cohort, and report an intention-to-treat analysis in all patients with similar characteristics or else clearly show the shrinking denominator with its causes. They stated that only prospective series are able to refute the perception that any surgery in mesothelioma is futile by bias.

Topics

Medical terms in this study, explained in our Lexicon: Mesothelioma.

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