The SMART Protocol in Mesothelioma: Challenges and Opportunities for Global Adoption

Announcer:
You’re listening to Project Oncology on ReachMD. On this episode, Dr. John Cho will discuss the current challenges in adopting the SMART protocol for mesothelioma, which he spoke about at the 2025 World Conference on Lung Cancer. Dr. Cho is a radiation oncologist at Princess Margaret Cancer Centre and an Associate Professor in the Department of Radiation Oncology at the University of Toronto. Let’s hear from him now.

Dr. Cho:
So I think one of the first things that we want to do is see whether this protocol can be applied in other different institutions. And what I mean by that is, when we originally published our SMART results, one of the challenges that we noticed was that other centers, if they follow the protocol, their outcomes were not as good as what we were able to achieve here in Toronto. I think I’m a bit spoiled here at Princess Margaret dealing with my surgical colleague, Dr. Marc de Perrot, because he has so much experience doing meso that his outcomes are actually quite good. And if you’re not used to doing these surgeries, I think there is quite a steep learning curve. I think one of the challenges in trying to export this SMART protocol to other centers is to try to get over that steep learning curve before you start seeing more optimal results because this has been tried in other centers, but unfortunately, some of their results were not as encouraging as what we were able to show in ours, and I suspect part of it was the learning curve and the challenges of doing an EPP.

So that’s one of the reasons why I suspect that this protocol hasn’t really been widely adopted. The other challenge is that, for a lot of the thoracic surgeons, the enthusiasm for surgery for mesothelioma has really taken a hit since the publication of several European studies, and specifically, I’m referring to MARS1 and MARS2. So these were some British studies that were done basically to assess the benefit, if any, of EPP in the treatment of meso. And the original MARS1 looked at EPP versus no EPP, and in fact, they were not able to show any advantage of EPP. And in fact, they showed a decrement in one’s outcome, so it may have even harmed oneself. And then MARS2 looked at pleurectomy decortication, which is the other operation that they do for meso where they remove the lining around the lung but keep the lung intact, and when they did MARS2 to see if that conferred any benefit, again, they did not show any benefit in MARS2. Because of that, at least in Europe, a lot of the enthusiasm for surgery for meso has dissipated because of these studies.

And I would say that Toronto is probably one of the very few centers in the world that still believes and still does surgery for meso mainly because our outcomes seem to be better, so that’s why we still believe in EPP. But that’s also part of the challenge: you need to have, I guess, true believers in both camps—the radiation oncology camp and the surgical oncology camp—to have people that are willing to embark upon this protocol because it is a very, very challenging protocol because we’re using very big fields in terms of radiation and that the planning is not straightforward, and the surgery obviously could be very challenging as well.

So there are some challenges in terms of trying to get the SMART protocol adopted worldwide, but I think they’re overcome able in the sense that if we have sufficient buy-in with the surgeons and the radiation oncologists and a good QA review process, I think it’s not just learning the technique; I think the other learning curve is understanding which patients would benefit best from this protocol.

Announcer:
That was Dr. John Cho talking about the current challenges in implementing the SMART protocol for mesothelioma, a topic he presented at the 2025 World Conference on Lung Cancer. To access this and other episodes in our series, visit Project Oncology on ReachMD.com, where you can Be Part of the Knowledge. Thanks for listening!