Inside A Stanford Surgeon’s Decision-Making For Pleural Mesothelioma

A big mesothelioma trial rattled the surgical world, and patients are left asking the same question: if surgery might be harmful for some people, when does it still help? We sit down with Dr. Leah Bacchus, a Stanford cardiothoracic surgeon, to translate the MARS 2 trial into practical decision-making for pleural mesothelioma, including why “more aggressive” is not automatically “more effective,” and how quality of life has to stay on the table alongside survival.

We walk through how mesothelioma surgery has shifted over time, from extrapleural pneumonectomy (EPP) toward lung-sparing pleurectomy and decortication, and why even the “less radical” option is still a major undertaking. Dr. Bacchus explains how her team thinks about combining modalities like chemotherapy, immunotherapy, and heated intrathoracic chemotherapy (HITHOC), and why upfront systemic therapy can help reveal tumor biology before anyone commits to a high-risk operation.

Access comes up in a big way. We talk about the Stanford Second Opinion process for virtual, record-based consultations that can help patients outside California get clear answers without immediate travel. Then we look forward, including a promising, less invasive approach Stanford is studying: pressurized aerosol chemotherapy delivered into the pleural space, designed to sit between pure palliation and radical surgery.

If you or someone you love is navigating pleural mesothelioma, listen for the candid framework, the selection criteria, and the hope that comes from a strong multidisciplinary tumor board. Subscribe, share with someone who needs it, and leave a review so more families can find trustworthy guidance.

MESO: The Mesothelioma Podcast is sponsored by Danziger & De Llano, a nationwide mesothelioma law firm with over 30 years of experience and nearly $2 billion recovered for asbestos victims. For a free consultation, visit Dandell.com.

Transcript

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Welcome And Guest Background

SPEAKER_00 0:01

You're listening to Meso, the Misothelioma podcast, where support, education, and outreach come together for families facing mesothelioma.

SPEAKER_02 0:14

Hi, good afternoon. I am so happy you're visiting us today, but we have a special guest, and it's Dr. And help please correct me if I say this incorrect. Bacchus? That's right. Okay. And um if you don't mind, can you tell us um, you know, where you are and and what you do?

SPEAKER_03 0:37

Sure. Thank you for having me. Um my name is uh Leah Bacchus, and I'm a cardiothoracic surgeon um in the subspecialty of general thoracic surgery, uh which basically means a lot of lung cancer. And in this case, the subject is mesothelioma and other cancers related to the um the pleural space or the chest cavity. So I practice uh in California at Stanford Hospital, also at the Palo Alto Um VA hospital, and um here to talk to you all today about mesothelioma.

SPEAKER_02 1:14

Yes. And um, how long did you say you were there? How long have you been where you are now currently?

SPEAKER_03 1:19

I've been here for 11 years.

SPEAKER_02 1:21

11 years. So um my first question is

Surgery Today From Palliation To Pleurectomy

SPEAKER_02 1:25

in the 11 years that you've worked with mesothelioma, um, how has your approach to treating mesothelioma changed since you started your career?

SPEAKER_03 1:36

Uh well, the career, if you will, started before the 11 years. I was at the University of Washington for six years there. Um, but I didn't really start doing uh a ton of mesoces until I came to Stanford. Um and it used to be that it was all just palliation, you know, just uh from the plural standpoint, just dealing with effusions, fluid management, trying to make people feel better as they uh underwent their uh chemotherapy basically. Uh and then uh we started in my in my training, actually, I had been exposed to surgery for mesothelioma, which at that time had already swung away from the slightly more radical extrapleural pneumonectomy, where you remove the pleura and the lung, to a bit more of a conservative approach with the radical pleurectomy and decortication, where you keep the lung in place, but you remove all the pleura that you're able to. Um, and collectively, those are known as cytoreductive surgeries where you remove the bulk of the disease. Um, so we were already moved over towards the radical pleurectomy as opposed to the extra pleural pneumonectomy, which is good. And we had some good data showing that that preserved patients' quality of life. Um that was some advantages to that surgery. Um, but it's still a big surgery. And uh then we had the Mars 2 trial, which came out somewhat recently, uh just a couple years ago, which really said surgery may actually be detrimental to patients, and uh maybe we need to dial back surgery completely and just focus on chemotherapy alone. I think myself and the colleagues that I work with at Stanford have already taken a rather conservative stance in terms of selecting patients for surgery, such that it wasn't just kind of all comers, and every surgery is good for everyone. Um, but we had a much more selective approach. And I think that when you look at some of the data, in fact, the balance of the data on these highly selected patients, that they can do quite well. Um, so we do still offer surgery, but um, we maintain a high level of discernment to try to select patients who are going to do well with it.

SPEAKER_02 3:57

Yeah.

SPEAKER_01 3:58

Your surgery also, your technique, um, and this was somebody else commented about this, is um not only less radical, but also you keep your time down to a couple hours versus some of the other people out there, right? I mean, I mean, some of the people do nine-hour surgeries, right? And I've I've heard that you you try to keep it under two hours, two or three hours. Is that true? Or is that just a rumor?

SPEAKER_03 4:25

No, that's not true. I don't want to put misinformation out there. I mean, it is still a big surgery and it does take kind of all day. It depends on the level of disease, honestly. There's some people who don't have a ton of disease burden, and the operation can be a lot shorter. And then there are those that it's it can be an all-day kind of slug fest. Um, one of the things that extends the operative time for us in our approach is that we also do heated intrathoracic chemotherapy for a V pleural disease, which is analogous to high PEC in the belly for peritoneal disease, but in the chest, it's called high talk. Um, but that happens at the end of a radical

MARS 2, HITHOC, And Treatment Stacking

SPEAKER_03 5:05

operation and adds about another hour and a half-ish to surgery. So we can get that whole circuit set up and do the lavage and then uh finish the operation afterwards. So it does add time, um, but in our hands, we feel that it also adds tremendous benefit with very little added risk to the patient.

SPEAKER_01 5:26

So Mars 2 came out and it changed the world for a lot of people. And I think the medical oncologist thought, hey, I don't want to do surgery anymore. But but have you published your, I'm sure you published your results, right? And um on the mortality rates and benefits of surgery. And um have you have you guys done that at Stanford or worked with another group kind of doing that as well, an answer to Mars 2?

SPEAKER_03 5:50

We have not done that because that's already kind of been done prior to Mars 2, honestly. So Mars 2 kind of uh serves as the uh counter distinction to all the prior published work. Um and the problem, of course, with publishing single institutional series is everyone will say, well, that's just because of your single institution and it's not really applicable across the board, which is true to some extent. Um, but we've done uh analyses where we've looked at pool data to look at see what the benefit is of incrementally over each uh treatment option that we have for patients. And that's what I counsel patients about as well when I see them. If you do nothing, this is what we would expect. If you add chemo uh as plus minus immunotherapy, this is what we would expect. If you add surgery, if on top of surgery, you add high talk or high pec, this is what you expect. So that in my in my opinion, we're trying to stack survivals, you know, six months, another six months, another six months, another year, et cetera, and then circle back to chemo if and when you have a recurrence to try to build up this um uh bank of survival benefit from all the various treatments uh that we have.

unknown 7:07

Yeah.

SPEAKER_01 7:08

I think that if I were a patient, I'd want to know. You're a very confident person. I'm sure you're very good at this and you have great, I'd want to know um, you know, the benefit. I'm sure the medical oncologists say, ah, they don't need a surgery or whatever. But me personally, I'd want it out of my body. And uh I would rather have you, whether it's published or unpublished, you know, put your numbers so I'd know what to expect, right? So personally, no matter what, I'd want it out of my body if I could do the surgery.

SPEAKER_03 7:34

So you know, it's a really interesting um spectrum of people, you know. There are some people who would prefer a minimalist approach and are not very interested in having a very radical, aggressive approach. And then there are those who do, and then there are folks in between that do want more radicality, but it's really not appropriate for them based upon their other medical conditions and whatnot, such that an aggressive surgery wouldn't be safe, wouldn't be prudent for them. Um, but it's all over the spectrum, honestly. And I never push any one thing. Our our job is to guide people and make sure that we lay out the options and then help them as they make the best decision for themselves. Um, because at the end of the day, they're the ones that have to live with it, you know. Um, and we want to do our best to help people, but I also don't subscribe

Access: Second Opinions Without Travel

SPEAKER_03 8:30

to the whole notion of trying to push someone towards any particular treatment versus another.

unknown 8:35

Yeah.

SPEAKER_01 8:36

I think a lot of people would like to hear that. And also I want to make sure we get um get your number out there. You you do consultations with people not even that that are not necessarily in California. That's something you you alluded to before, right? So you do consultations all over the country.

SPEAKER_03 8:53

Yes, we have um a mechanism through Stanford Healthcare called uh Stanford Second Opinion that allows people to basically upload all their data, et cetera. And um, they pay us uh uh, I think it's a few hundred dollars kind of out of pocket, but you don't have it, it bypasses insurance. It doesn't go by way of insurance, so that's not a barrier. Uh obviously can still be a barrier to some people, uh, depending upon their their means, but it does provide an option for folks to get a second opinion that's expedited and smooth, and allows me as a California licensed physician to still be able to provide opinions to patients outside of the state.

SPEAKER_01 9:34

Oh, that's great.

SPEAKER_02 9:35

That's great.

SPEAKER_01 9:36

I think that's that's it's a barrier for a lot of patients that we talk to, just so you know. I mean, they don't want to go to, you know, they may not be able to travel to Boston or whatever. And it's a little bit of a even the mayo, um, a little bit cumbersome sometimes. So it's great that you offer that service.

SPEAKER_03 9:52

So yes, absolutely. Um, and and I think it's nice to be able to refer patients to places that are nearest to home, as you just mentioned. It's such a huge burden to uproot yourself to go and get treatment. And these are not one and done kind of treatment. So it's one thing to go somewhere and travel somewhere for a consultation. Um, sometimes they can take your recommendations back to their home institutions, for instance, if it's about their chemotherapy or immunotherapy regimen, such that they don't have to get treated locally wherever you are. Um, but when it comes to surgery or like radiation, for instance, then those are more prolonged treatments and can be quite um quite a hurdle for patients to um jump on board with that plan outside of their home state.

SPEAKER_02 10:50

Yeah, I I think just uh knowing that I'm not having to travel uh to get a second opinion, um, I I think would be a win-win situation for someone, you know, when they've been diagnosed, because, you know, I mean, they don't really know who to go to for a second opinion, and to have to, like you mentioned, to have to travel and or be able to send it to another um uh doctor to review that is is really big, uh, especially for a lot of the ones, a lot of individuals that have been diagnosed, they don't have the funds to really try do the traveling to for a second opinion. Um they have difficulties with their insurance company, and you know, this you know, 100 or whatever it may be doesn't sound like a whole lot to be able to get a second opinion from another doctor. So that that's awesome.

SPEAKER_01 11:40

Right right before we met you, we I think I mean mentioned this before. We had a 10-year-old boy that uh their family came to us um needing some help, and he had plural meso, and just you know, we were tr struggling to find some place to send him where he didn't have to have ten thousand dollars in a bank account before he went. I mean, literally, I don't know if you've heard of that before, but there were three hospitals that wanted to see him, but they wanted $10,000 to $30,000 up front before they could go there. So had I known this was available, I would have had them contact you. And in the future, I will definitely have them contact you.

SPEAKER_03 12:17

So it's it does make it really nice too from the provider standpoint, because granted, the patient still has to gather all of their documents and images and whatnot, but it makes it easy for us to be able to look at it and provide an opinion expeditiously because of the ways in which they arrange and collate all the information for us. Um, so it's it's a rather streamlined process, and you can actually be very specific. It's to be clear, it's not a video consultation, it's a virtual one. Um, but the um you can be very prescriptive with your questions. I would like to ask the doctor these, you know, 10 questions or whatever. Um so yes, we provide an overview, but also we would be very prescriptive about making sure we address the specific concerns that you have. So it's not, it's more than just generic, it's actually trying to address your specific questions.

SPEAKER_01 13:19

Oh,

Selecting Candidates And Sequencing Therapy

SPEAKER_01 13:20

good, good, good.

SPEAKER_03 13:21

Okay.

SPEAKER_02 13:21

So one of the questions I had was how do you decide if a patient is a good candidate for major surgery surgery like uh EPD or EPP?

SPEAKER_03 13:32

Well, we try to steer clear of the EPP, at least I do personally, as much as possible. Uh-huh. But uh, but any cytoreductive surgery where we're actually removing uh tumor and whatnot is is going to be a big undertaking. Um there are no strict cutoffs with regards to um age per se, but we do take age into consideration. Usually the patients kind of calibrate their enthusiasm for a big operation based on their own age or their physiologic condition. Um, what's your functional status? You know, if you're not ambulant, if you're not like a walking around kind of independently living person, then chances are that's a good barometer of you're not being a good candidate for a radical operation, um, major um heart conditions, major lung conditions, um, or other comorbidities, like for instance, if you have um poor kidney function, then you probably would not be a good candidate for the high tock or high pec because of the a little added burden to your kidneys to um metabolize things.

SPEAKER_02 14:44

Um make a difference there.

SPEAKER_03 14:48

Oh, yes, absolutely. Uh yes, so epithelioid, um, we wouldn't really entertain a radical operation. Occasionally we have people who undergo surgery who we think have epithelioid, and then the final pathology may come back as them having had mixed histology. We try to steer clear of patients with mixed histology, though. Um, but sometimes if it's predominant epithelioid and they otherwise have a good response to their systemic therapy, um, and it's a minority of the tumor, um, then we can consider. But usually any sarcomatoid element is going to be shuttled away from surgery.

SPEAKER_01 15:29

Well, what if they've had a great response to immunotherapy uh and you um and you just see a small amount of tumor? I'm not trying to challenge you here, but would you do it then or no?

SPEAKER_03 15:42

If it's pure sarcomatoid, probably still no. Um, but I wouldn't make that decision unilaterally. That's somebody that we would talk about at our multidisciplinary tumor board, and we'd have our oncologists there weighing in, as well as our uh outside pathology review by our own pathologists, etc. So it wouldn't be a unilateral decision, but I'd say the enthusiasm would be very low, even in that positive scenario. Okay.

SPEAKER_02 16:10

I think I think Dave asked a couple of the questions that I had. So no, that's okay. That's okay. Um so how because and I think you mentioned it too. Um, how is surgery now combined with newer treatments like immunotherapy and high-packs? But you mentioned high-pac earlier. Um so it is is there any other information on that that we could talk about with the combination of the surgery and uh immunotherapies, maybe, or um I guess what are the outcomes that you're seeing when you're combining those um those with uh surgery?

SPEAKER_03 16:50

Um I would say that most people start out with just uh chemotherapy sometimes because these are all epithelioid, the sarcomatoid, they always get immunotherapy to epithelioid kind of plus-minus, depending upon um the preference of that oncologist or if they've the patient has already been treated before, such that immune may wind up being second-line therapy for them. Um so I personally as a surgeon don't uh dictate what sort of systemic therapy that they get. I rely heavily on what my oncology colleagues feel is the most appropriate treatment for that given patient, because that's what they do. Um all of our patients, for the most part, all of my patients wind up getting some systemic therapy up front, though, prior to consideration for surgery. And that's part of that highly selected process. There are surgeons, and in fact, the data are mixed in terms of how important it is to get systemic therapy before surgery. And there are surgeons who would their preference would be to hold all the systemic therapy until after surgery. Um, so you can go either way, but our preference amongst my group has been to treat patients up front with systemic therapy uh to select them better. Uh, if you've got an aggressive tumor that's just growing through all your systemic therapy, then I would be um fool headed to think that I'm gonna go and do a radical operation and that's somehow going to reverse that trend. It's it's not going to. So, really, we're trying to select people whose tumor biology is um favorable such that surgery would still provide some added benefit on top of the systemic therapy that they're getting. They don't have to have had a regression of the tumor, but they definitely don't shouldn't have progressed. If they're progressing, then that's a little bit of a red flag for me. And then sometimes I'll wind up switching to second-line therapy to see if we can again kind of slow things down sufficiently to create a window of opportunity for which surgery would be beneficial for the patient.

SPEAKER_01 19:04

So, a quick question, sorry. Um so how often do you see patients that have the tumor just in the pleura? And if it were in the pleura, would would you still recommend uh will they still go to med oncology and do systemic, or would you want to just to take the the pleura off?

SPEAKER_03 19:22

Um so as a thoracic surgeon, I'm only seeing patients in the with pleural disease for the most part, but I partner with one of my surgical oncology colleagues who treats peritoneal meso. So we do have a few bicavitary patients. Um he treats the peritoneal cavity, I treat the thoracic cavity. That's an even more select group of people that we think that surgery is appropriate for. Um and usually that's an asynchronous presentation, like they started out in one that spread to the other cavity, kind of thing. So we do have bicavitary patients that we um partner on and have uh treated together surgically. Um and I forgot the second part of your question.

SPEAKER_01 20:06

No, I I was just wondering if if the if it was in the pleura, one-sided, you know, one-sided disease and it hadn't spread to the lymph nodes, you didn't think that it did. Would you just take the pleura and and not do the systemic um oncology, the immunotherapy, or would you work?

SPEAKER_03 20:22

There are surgeons who would. Uh, I personally still think that though that patient should be treated. Uh, so that again, I'm trying to select people that have very favorable biology.

SPEAKER_01 20:35

Right.

SPEAKER_03 20:35

Um, so even if they only get a couple of cycles in, I think it's good to do that, not to beat them up too much, because that's one of the downsides, right, of getting chemo before surgery is that now you make people weakened before you're gonna hit them with it with a big operation. Um, but again, I think that's a little bit part of the physiologic challenge that we're I'm aiming for. Um, but I would put it out there that that's not standard, that there are just as many surgeons who would also say, let's just go straight to surgery in the setting of very minimal disease. And that's a patient preference, too. So if the patient says, Um, I really just want to front surgery, and they're otherwise refusing, for lack of a better word, uh, chemotherapy, then we could consider that as well. Right.

unknown 21:23

Right.

SPEAKER_02 21:24

So, what

Pressurized Aerosol Chemo And Clinical Trials

SPEAKER_02 21:25

what exciting clinical trials or emerging technologies are you most hopeful about?

SPEAKER_03 21:32

Well, I am super excited about uh this new thing that we are pioneering at Stanford, uh what called pressurized aerosolized chemotherapy, which is a local treatment. Now, heretofore surgery for mesothelioma was just two different extremes. One is huge radical operation, of which not everyone could qualify for, and the other is pure palation, so just dealing with the fluid. Whether that's a CIDES fluid or if that's plural effusion fluid to just make people feel better, but not actually treating their cancer. This is in between. And it offers a nice thing in between that it doesn't require the radical operation that many people are otherwise kind of signing up for. So there's no cytoreductive surgery, but it's putting aerosolized chemotherapy directly into the pleural space or the peritoneal space to get direct tumor contract contact in the same way that high PEC and high top work, which does palliate the effusion, but also provides this cytotoxic effect where we're actually killing cancer cells. At least we think so. And we think so based upon the fact that the effusions and the fluid tends to go away. So we think that this offers a really nice compromise. And it's but it's more than palliative. So it's still hopeful. It's still trying to kill tumor, it's still trying to reduce the cancer burden and not just palliate and put a band-aid on the symptom, which is the fluid, but really try to actually address the tumor. And so we'd like to study this more. So we have had a handful of patients, more patients with peritoneal, and a handful of patients in the pleural space. And we have this clinical trial that's going to be opening so that we can actually truly measure the potential benefit for people. And we think the risk profile is incredibly low, which is another thing that makes us very excited and enthusiastic about it.

SPEAKER_01 23:45

Yeah, I hadn't heard of that. Are they doing it in the entire right cavity disease? You do it the entire cavity or is it more localized than that?

SPEAKER_03 23:53

The entire pressure.

SPEAKER_01 23:55

Yeah. And then they inflate it and pressurize it, so to speak.

SPEAKER_03 24:00

Well, in the chest, in the chest, as with all lung surgery, the lung is actually deflated. So the lung isn't actually fully inflated. It's deflated on purpose. And there's usually an effusion as part of the criteria for selecting patients as you have an effusion. We evacuate the effusion, and then you're looking at the pleural space. And then basically it's air, it's like a spray uh airbrush sprayer that then um sprays chemotherapy and an aerosol throughout the pleural space, and it only takes about 30 minutes and it's minimally invasive, so there's only two ports, two incisions. Um patients can go home the next day. Um, and we can repeat it as needed, up to three times for studying. So we've had some really encouraging results so far.

SPEAKER_02 24:50

Wow, that's that's awesome. That's a good question. Yeah, that's that's a great answer. We're excited. Um, how critical is a multidisciplinary team? Um, and can you

Team Care, Patient Values, And Hope

SPEAKER_02 25:05

tell me who works along with you in that team?

SPEAKER_03 25:08

So, I mean, for all cancers now, yeah. A multidisciplinary team is the minimum criteria, honestly. There are very few cancers that are treated by a single specialty anymore. And that's just because the treatment landscape for all cancers has gotten tremendously complicated because we have more and more options coming available to people. Mesothelioma is no different. In fact, mesothelioma is more special though, because it's such a rare cancer type. Um, so you really need all hands on deck with people who are accustomed to looking at their pathology, interpreting results, interpreting the imaging, um, and who have the full armamentarium of uh treatment uh options available to um to talk to patients about. So it's I I cannot be emphasized enough.

SPEAKER_02 26:02

Yeah, I mean, I think when when we talk to someone that's recently been diagnosed with mesothelioma, you know, I I try to let them know, listen, you're not gonna have just one doctor talking to you about your situation. You're gonna have a whole team from different parts of you know uh different areas that know um I I basically tell them you have a team taking care of you. Um and if they don't have that, then I definitely want to tell them to go somewhere else. But um, for the most part, they tell me that, yeah, it's it's really I I think that's just I'm so glad that they do that because there's so many areas that that is covered when you're talking to someone with mesothelioma.

SPEAKER_01 26:50

A lot of our patients are in rural areas, so you you know you'd be surprised how many there's no team, right? So having someone like you available and and to meet with is uh is a a blessing.

SPEAKER_02 27:01

So yeah, I I um is there something you would like to share to an individual that's been diagnosed or um uh I just try to keep help alive as much as possible and to kind of um really uh key in to the patient as to what's important to them.

SPEAKER_03 27:22

Um if if being the most aggressive uh is important to them, then we kind of go one route. If being the least aggressive, but that's going to optimize their quality of life right now, today, then that's a different route. And so um trying to provide reassurances, as you said. I think most people are reassured by the fact that it's not a single person making a decision, but there's the collective wisdom of the tumor board and the multidisciplinary team that's being um called bear uh and uh and to come up with recommendations for them. I think most people find that quite reassuring, but at the end of the day, they're actually the ones driving the ship and we can't do anything that they don't want to let us do. And it's a uh I be because it you can be you can feel unmoored, you can feel very um uh um desperate, um sad, uh depressed, every all over the map, right? In terms of emotions that people and their families uh are dealing with with this new diagnosis. So trying to keep that as a central um tenet, I think is important. Um our our role is to help try to guide them through that storm uh and to provide a bit of an anchor so they can feel like they've regained a bit more stability as opposed to just sort of floating around in a sea of uncertainty.

SPEAKER_01 28:57

Right. Quick question for for your clinical trial with this new therapy, are most of the of the uh patients you're enrolling are they in California or do you have anybody outside of California?

SPEAKER_03 29:09

So far it's just been in California.

SPEAKER_02 29:13

We'd love to try to help you get that. So we definitely Yeah, absolutely.

SPEAKER_03 29:17

That would be great if we were able to.

SPEAKER_02 29:19

Right. It's less invasive. I, you know, anytime you know someone doesn't have to go through this um 12-hour surgery and not even knowing whether you'll survive that surgery because of you know the um recovery time is is is just crazy. But um you you you just taught us something which is really important uh for some of the clients that we talk to. So I appreciate your time. And uh I appreciate you actually uh coming out to talk to us about this. Um being able to, you know, uh allow individuals to watch uh and listen to what you have to offer to them. Uh I I am so grateful.

SPEAKER_01 30:04

You have a very soothing voice too. I'm sure that helps with your I don't know if my kids would agree with that, but well maybe it's different when I'm holding home, but so I hear you. Well, it was lovely meeting you and talking to you. And uh we look forward to to working with you over the next few years. So until this disease is coming up.

SPEAKER_02 30:26

Yeah, thank you for your time. I know that uh that you keep pretty busy, so I appreciate you taking some time out with us.

SPEAKER_03 30:33

Yeah, it's my pleasure. My pleasure.

SPEAKER_00 30:35

Have a good day.

SPEAKER_03 30:36

Me too.

SPEAKER_01 30:37

Bye, bye-bye.

SPEAKER_00 30:41

Thank you for listening to Miso, the Misothelioma podcast. For more information, resources, and support, visit our sponsors, Danziger and Diano at dandel.com.