Immediate therapy is not always required for mesothelioma. For older patients with incidentally discovered, asymptomatic, and slow-growing disease, active observation is a reasonable clinical strategy. This approach avoids treatment-related toxicity while keeping a close watch on disease progression.
The primary delay in diagnosing mesothelioma isn't lab work, but repeated, non-diagnostic pleural fluid taps. Educating pulmonologists and thoracic surgeons to proceed to a pleural biopsy faster when suspicion is high can significantly shorten the time to diagnosis and treatment.
Contrary to its role in lung cancer, PD-L1 expression does not predict benefit from immunotherapy in mesothelioma. Data from major trials shows similar outcomes regardless of PD-L1 status, leading clinicians to omit this test entirely and streamline treatment decisions.
For patients with very high-burden or symptomatic mesothelioma, clinicians may deviate from standard guidelines. They may choose chemo-immunotherapy to maximize the chance of a rapid response, viewing it as their single best opportunity to control the disease, especially if the patient's condition is precarious.
Frontline treatment selection hinges on histology. Non-epithelioid mesothelioma responds poorly to chemotherapy, making dual immunotherapy (Nivo/Ipi) the clear choice. For epithelioid cases, chemo-immunotherapy is a strong option, especially for symptomatic patients, due to its higher and faster response rate.
Data from the Checkmate 743 trial shows that patients who stopped dual immunotherapy (Nivo/Ipi) due to toxicity can still achieve long-term benefits. A third of these patients had an ongoing response at three years, despite stopping treatment after only four months on average, providing confidence in the regimen.