For decades, surgery has been an important part of mesothelioma treatment, but it’s also been one of the disease’s biggest challenges. Many surgical procedures are extensive, requiring long operations and lengthy recoveries.
Dr. Leah Backhus is working to change that. In 2025, the Stanford thoracic surgeon performed North America’s first PITAC (pressurized intrathoracic aerosol chemotherapy) procedure for pleural mesothelioma. This minimally invasive technique delivers chemotherapy directly into the chest and may offer another option for patients who can’t undergo more extensive surgery.
Dr. Backhus, who specializes in mesothelioma and lung cancer at Stanford Medicine and the VA Palo Alto Health Care System, has spent her career treating complex chest cancers. In this interview, she explains how PITAC fits into today’s treatment landscape, which patients may benefit, and why she believes surgery continues to play an important role alongside chemotherapy and immunotherapy.
What is PITAC, and how could it help mesothelioma patients?
Historically, surgery for mesothelioma has had a rocky history. Treatment has shifted from very aggressive operations to less extensive surgery and, more recently, toward chemotherapy and immunotherapy.
While immunotherapy has been a tremendous advance, I still believe surgery has a role for carefully selected patients. At Stanford, we’ve used hyperthermic intrathoracic chemotherapy (HITHOC) alongside surgery for several years, and PITAC builds on that experience. Instead of requiring a radical operation, PITAC delivers aerosolized chemotherapy directly into the chest through a minimally invasive procedure.
What makes PITAC different is that it bridges two very different approaches. One option is a major operation that removes as much tumor as possible but requires a long recovery. The other focuses on relieving symptoms by draining fluid or preventing it from returning.
PITAC falls somewhere in the middle. It doesn’t require radical surgery, so the risk is much lower. It also expands the number of patients who may be eligible because they don’t have to be as medically fit. Most patients go home within a day or two, and the procedure delivers chemotherapy directly where the tumor is located while also helping control symptoms.
Who may be a good candidate for PITAC?
We’re still trying to answer that question. At Stanford, we’ve created a PITAC patient registry so we can collect more data, especially on quality of life. We want to make sure the procedure is safe, improves how patients feel, and helps treat the tumor whenever possible.
Right now, the ideal candidate is someone healthy enough to undergo general anesthesia. Ideally, the patient also has a pleural effusion, which creates the space needed to safely perform the procedure.
As we learn more, we’ll have a better understanding of which patients are most likely to benefit.
Can PITAC help reduce pleural effusions?
We think so. Data from Europe suggest PITAC can reduce pleural effusions and decrease the need for repeat drainage procedures.
Another advantage is that PITAC can be repeated if fluid comes back. If it doesn’t return, that’s exactly what we’re hoping for. Because it’s well tolerated, PITAC gives us another option without limiting future treatment choices.
What have you seen so far with safety and recovery?
At Stanford, we’ve only treated two patients so far, so it’s difficult to draw broad conclusions from our own experience. The published studies from Europe have shown a favorable safety profile. Researchers have also found microscopic evidence that tumors are responding to treatment, and the procedure appears to reduce pleural effusions.
The risks are similar to other minimally invasive surgeries, including bleeding and infection. There’s also a potential risk of kidney toxicity, which is something we watch for with HITHOC and hyperthermic intraperitoneal chemotherapy (HIPEC). We haven’t seen that become a problem, but we’re still working with a small number of patients.
How does recovery from PITAC compare with more extensive surgery?
They’re very different experiences. Patients having a radical pleurectomy and decortication (P/D) with HITHOC usually receive chemotherapy beforehand and undergo heart and lung testing to make sure it’s safe to get surgery. After the operation, most people spend about a week in the hospital before beginning a longer recovery.
PITAC is much simpler. Patients still meet with the surgical team beforehand, and traditional chemotherapy may need to be paused for a short time before surgery. The operation itself uses two small incisions. One allows us to place a camera into the chest, while the other is used to drain fluid and deliver the aerosolized chemotherapy.
The chemotherapy portion takes about 30 minutes, and the entire operation usually lasts about an hour to an hour and a half. Most patients stay overnight and go home the next day after the chest tube is removed. If fluid returns later, we can consider repeating the procedure.
How do surgery, chemotherapy, and immunotherapy work together?
Very few cancers today are treated with just one approach. For most patients, multidisciplinary care is the standard since surgery, chemotherapy, immunotherapy, and radiation each have a role depending on the patient’s disease and treatment goals.
Immunotherapy has been a game-changer across many cancers. We’ve also learned that combining treatments often produces better results than relying on any single therapy. Treatment plans will continue to evolve as new therapies become available.
How do you help patients maintain hope during treatment?
We spend a lot of time talking about goals of care because every patient is different. Some people want the most aggressive treatment available, while others prefer a less intensive approach. Our job is to recommend treatments that fit each patient’s goals and preferences.
One of the biggest sources of anxiety is fear of the unknown. I often compare it to shining a flashlight a few steps ahead on a dark road. We can’t illuminate the entire journey because everyone’s path is different, but we can make the next few steps easier to see.
Where can patients learn more about PITAC?
To my knowledge, we’re the only center in North America offering PITAC within the chest. One way to learn whether it’s an option is simply to come to Stanford for an evaluation.
If you’re in California, you can have a consultation through a video visit, so you don’t necessarily have to travel here in person. Stanford also offers a medical second opinion through Stanford Health Care. Patients can submit their medical records, and for a small fee, we can review their information and provide an electronic consultation. That can be arranged with any specialist of your choosing here at Stanford.
Connect With a Mesothelioma Specialist Today
Mesothelioma treatment has changed significantly in recent years, giving patients more options than ever before to improve their survival and ease symptoms.
Working with an experienced specialist can help you understand which treatments may be right for your case, including surgery, immunotherapy, chemotherapy, clinical trials, and newer approaches like PITAC.
Mesothelioma Hope can help connect you with experienced mesothelioma doctors and leading cancer centers across the country. Our Patient Advocates can answer your questions, help you find a specialist, and explain what to expect when seeking a second opinion.
Call (866) 608-8933 or contact us online to speak with a Patient Advocate and get started.
