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Content on WikiMesothelioma is reviewed prior to publication by three named attorneys at Danziger & De Llano LLP. Dr. Luciano Mutti, MD, PhD, co-author of the European mesothelioma treatment guidelines, serves as the site's Medical Reviewer. See our editorial standards.

Latest Treatment Advances for Mesothelioma

From WikiMesothelioma — Mesothelioma Knowledge Base


Mesothelioma Treatment Landscape 2025-2026
At a Glance
First-line regimens 3 (ASCO 2025)
Best 5-year survival 14% (immunotherapy)
Preferred surgery Pleurectomy/decortication
Germline testing Recommended for all patients
Emerging therapies 5 in advanced trials
Last guideline update March 2025 (ASCO)

Executive Summary

Latest treatment advances for mesothelioma represent the most significant transformation in standard of care in two decades. In March 2025, the American Society of Clinical Oncology (ASCO) published its first guideline update since 2018, reflecting data from 110 peer-reviewed studies and establishing three first-line systemic regimens: platinum-pemetrexed chemotherapy, nivolumab plus ipilimumab immunotherapy, and pembrolizumab plus chemotherapy.[1] Five-year data from the CheckMate 743 trial confirmed durable survival benefit with dual checkpoint blockade, more than doubling the 5-year survival rate versus chemotherapy (14% vs. 6%).[2]

The surgical landscape has shifted decisively toward lung-sparing pleurectomy/decortication (P/D) over the more aggressive extrapleural pneumonectomy (EPP), and the FDA approved pembrolizumab-based chemoimmunotherapy in September 2024.[3] Several novel agents are advancing through the pipeline, including the ADI-PEG 20 (pegargiminase) arginine-depletion therapy, tumor treating fields (TTFields), mesothelin-targeted CAR-T cells, the UV1 telomerase vaccine, and the volrustomig regimen under study in the eVOLVE-Meso phase III trial.

Under ASCO 2025 Recommendation 7.1, all patients with mesothelioma should be offered germline testing (evidence quality High; strength of recommendation Strong).[1] European genetics guidance advises against offering it routinely in isolated mesothelioma.[4] Blood-based liquid biopsy is emerging as a tool for monitoring disease. Patients diagnosed in 2025-2026 have more evidence-based options — and more legal avenues for compensation — than at any point in the disease's history. Families affected by asbestos exposure can pursue trust-fund claims and lawsuits with help from an experienced mesothelioma law firm.

At-a-Glance

The 2025-2026 mesothelioma treatment landscape at a glance:

  • Three first-line regimens — ASCO 2025 recognizes nivolumab+ipilimumab, pembrolizumab+chemotherapy, and platinum-pemetrexed chemotherapy as standard first-line options.[1]
  • 14% five-year survival with immunotherapy — CheckMate 743 reported a 14% five-year overall survival (OS) rate with nivolumab+ipilimumab versus 6% with chemotherapy.[2]
  • Lung-sparing surgery preferred — ASCO recommends pleurectomy/decortication (P/D) over extrapleural pneumonectomy (EPP) when surgery is offered, due to lower operative risk.[1]
  • MARS2 cautioned against routine surgery — the phase III MARS2 trial found extended P/D plus chemotherapy was associated with worse 2-year survival than chemotherapy alone, intensifying debate over patient selection.[5]
  • FDA approved chemoimmunotherapy in 2024 — pembrolizumab plus pemetrexed and platinum was approved September 17, 2024 for unresectable advanced pleural mesothelioma.[3]
  • ADI-PEG 20 improved survival in non-epithelioid disease — pegargiminase added to chemotherapy extended median overall survival to 9.3 vs. 7.7 months (hazard ratio 0.71) in the ATOMIC-Meso trial.[6] The company reported in August 2025 that the biologics license application had entered FDA substantive review.[7]
  • Germline testing — ASCO's 2025 guideline update, Recommendation 7.1, states that all patients with mesothelioma should be offered germline testing (evidence quality High; strength of recommendation Strong).[1] The European BAP1-TPDS consensus advises it should not be offered routinely in isolated mesothelioma.[4] Carriers show roughly 7-fold improved long-term survival.[8]
  • Five emerging therapies in trials — ADI-PEG 20, TTFields, mesothelin CAR-T, the UV1 telomerase vaccine, and volrustomig are advancing through clinical trials.[1]

Key Facts

Measure Finding (Source)
First-line regimens (2025) 3 systemic regimens — nivolumab+ipilimumab, pembrolizumab+chemotherapy, platinum-pemetrexed (ASCO Guideline Update, 2025)[1]
5-year overall survival (OS), immunotherapy 14% vs. 6% chemotherapy — CheckMate 743 five-year follow-up (Scherpereel et al., 2026)[2]
Preferred surgery Pleurectomy/decortication (P/D) over extrapleural pneumonectomy (EPP) — ASCO 2025 (Strong)[1]
MARS2 surgical outcome Extended P/D + chemo worse 2-year OS than chemo alone — MARS2 (Lim, Waller et al., 2024)[5]
FDA chemoimmunotherapy approval September 17, 2024 — pembrolizumab + pemetrexed + platinum (FDA)[3]
ADI-PEG 20 (pegargiminase) Improved survival in non-epithelioid disease — ATOMIC-Meso (Szlosarek et al., 2024)[6]; BLA in FDA substantive review since August 2025[7]
Germline BAP1 mutation survival ~7-fold improved long-term survival vs. sporadic disease — (Baumann et al., 2015)[8]

What are the current first-line treatments for mesothelioma?

The March 2025 ASCO guideline update — the first since 2018 — recognizes three first-line systemic regimens for pleural mesothelioma.[1] The choice among them depends primarily on tumor histology (epithelioid versus non-epithelioid).

  • Nivolumab + ipilimumab — dual immune checkpoint inhibitor (ICI) therapy. Recommended for all patients and the preferred option for non-epithelioid (sarcomatoid or biphasic) disease.
  • Pembrolizumab + pemetrexed + platinum — chemoimmunotherapy approved by the FDA in September 2024; may be offered for epithelioid or non-epithelioid disease.[3]
  • Pemetrexed + platinum (± bevacizumab) — chemotherapy, appropriate for epithelioid disease; ASCO advises that chemotherapy alone should not be offered for non-epithelioid disease unless immunotherapy is contraindicated.

ASCO specifically advises that PD-L1 expression, tumor mutational burden (TMB), and microsatellite instability (MSI) should not be used to guide first-line treatment selection.[1] A detailed breakdown of the landmark immunotherapy data appears on the CheckMate 743 page.

How effective is immunotherapy for mesothelioma?

The CheckMate 743 trial (nivolumab + ipilimumab) established dual checkpoint blockade as a first-line standard of care.[9] In its long-term follow-up, the immunotherapy arm achieved a 14% five-year overall survival (OS) rate versus 6% for chemotherapy — more than double the long-term survival.[2] The benefit was especially pronounced in non-epithelioid disease, the subtype that historically responds poorly to chemotherapy.

Pembrolizumab plus chemotherapy, approved on the basis of the IND.227 trial (a Canadian Cancer Trials Group cooperative-group study), improved overall survival versus chemotherapy alone.[10] The FDA reports a confirmed objective response rate (ORR) of 52% with pembrolizumab plus chemotherapy, versus 29% with chemotherapy alone.[3] For previously treated patients, single-agent immunotherapy (nivolumab) has also demonstrated a survival benefit over placebo. Immunotherapy is now woven into nearly every line of mesothelioma therapy — a fundamental change from the chemotherapy-only era that preceded 2020.

Which surgery is best for mesothelioma — P/D or EPP?

The long-running debate between pleurectomy/decortication (P/D) and extrapleural pneumonectomy (EPP) has shifted decisively toward lung-sparing P/D. ASCO 2025 recommends that, when surgery is offered, lung-sparing options should be the first choice because of lower operative and long-term risk; EPP — which removes the entire lung — should be reserved for highly selected patients at centers of excellence.[1]

ASCO also cautions that surgical cytoreduction should not be offered based on anatomic resectability alone, and should be limited to carefully selected patients with early-stage epithelioid tumors. Patients with sarcomatoid histology should not be offered maximal surgical cytoreduction.[1]

This conservative posture reflects the phase III MARS2 trial, which found that extended P/D plus chemotherapy was associated with worse survival at two years than chemotherapy alone, along with more serious adverse events.[5] High-volume surgical centers have contested how broadly MARS2 applies, arguing that careful patient selection at experienced centers yields far lower operative mortality. The practical takeaway for patients is that surgery is now a selectively applied tool, not a default — and where you are treated matters.

What new mesothelioma treatments are in clinical trials?

Five emerging therapies are advancing through the 2025-2026 pipeline. Each has a dedicated canonical page with full trial data and citations:

  • ADI-PEG 20 (pegargiminase) — an arginine-depletion therapy that starves tumors lacking the enzyme argininosuccinate synthetase 1 (ASS1). In the ATOMIC-Meso trial, adding pegargiminase to chemotherapy improved survival in non-epithelioid disease.[6] The company reported in August 2025 that its biologics license application (BLA) had entered FDA substantive review.[7]
  • Tumor treating fields (TTFields) — the NovoTTF-100L device delivers alternating electric fields to disrupt cancer-cell division; it carries an FDA Humanitarian Device Exemption based on the STELLAR trial.
  • Mesothelin-targeted CAR-T cell therapy — chimeric antigen receptor T cells directed at mesothelin, a protein overexpressed on most mesothelioma tumors, have shown encouraging early-phase activity.
  • UV1 telomerase vaccine — a therapeutic cancer vaccine targeting telomerase, under study in combination with immunotherapy.
  • Volrustomig (eVOLVE-Meso) — a PD-1/CTLA-4 bispecific antibody being evaluated against standard first-line therapy in the AstraZeneca phase III eVOLVE-Meso trial.

ASCO already includes a conditional recommendation for pegargiminase plus chemotherapy in non-epithelioid patients who are not candidates for immunotherapy, signaling how quickly pipeline agents can reach the guideline.[1]

Why does BAP1 genetic testing matter in 2026?

ASCO's 2025 guideline update, Recommendation 7.1, states that all patients with mesothelioma should be offered germline testing (evidence quality High; strength of recommendation Strong).[1] The most important gene is BAP1 (BRCA1-associated protein 1).

European genetics guidance does not agree that every patient should be tested, and the disagreement is between two different kinds of body rather than a misreading by either. The BAP1 tumour predisposition syndrome Delphi consensus records that germline BAP1 genetic testing "should not routinely be offered to all individuals diagnosed with isolated cases of uveal melanoma, mesothelioma, cutaneous melanoma or renal cell carcinoma, but can be considered based on age of onset and other factors such as absence of asbestos exposure or tumour results" — 95% consensus, rated Moderate /weak, the only compound rating in that guideline, which is why the qualifier is easy to drop. The same consensus records at 81% and rated Strong that "the prevalence of germline BAP1 pathogenic variants in individuals with isolated mesothelioma is low (less than 3%)".[4] ASCO is a United States oncology treatment guideline; this is a European clinical-genetics guideline. They address different questions and are cited here as two positions, not one.

The same European guideline describes mesothelioma as "most typically caused by asbestos exposure", and its authors advise that BAP1 carriers avoid occupations with asbestos exposure and be aware of residential exposure during renovations. Its practical focus is surveillance of carriers and predictive testing offered to relatives.[4]

Crucially, mesothelioma patients who carry a germline BAP1 mutation show approximately 7-fold improved long-term survival compared with patients who have sporadic mesothelioma.[8] Carriers also tend to develop disease at a younger age. ASCO recommends that carriers be screened for secondary cancers and that at-risk family members be offered genetic counseling.[1] The BAP1 Gene Mutation in Mesothelioma page covers the science and the legal considerations in depth.

Can a blood test detect or monitor mesothelioma?

Blood-based biomarkers and liquid biopsy are an active area of advance. Soluble mesothelin-related peptides (SMRP), measured by the FDA-cleared MESOMARK assay, remain most useful for monitoring disease response rather than for primary diagnosis. Newer approaches — including circulating tumor DNA (ctDNA) and multi-protein proteomic panels — are being studied for earlier detection in asbestos-exposed populations and for tracking response during treatment.

In the perioperative immunotherapy setting, ctDNA has shown practical value: persistent ctDNA during neoadjuvant therapy has been associated with incomplete surgical resection and shorter progression-free survival (PFS).[1] No blood test yet replaces tissue biopsy for diagnosis, but liquid biopsy is steadily becoming part of how mesothelioma is monitored over time.

How is treatment chosen by mesothelioma stage and type?

Treatment selection in 2025-2026 turns less on anatomic stage alone and more on a combination of histology, fitness, and resectability:

  • Epithelioid, early-stage, fit patients — may be considered for lung-sparing surgery (P/D) at an experienced center, combined with systemic therapy; immunotherapy or chemoimmunotherapy is standard.
  • Non-epithelioid (sarcomatoid/biphasic) disease — nivolumab+ipilimumab is preferred; surgery is generally not recommended for sarcomatoid tumors.
  • Advanced or unresectable disease — systemic immunotherapy or chemoimmunotherapy is the backbone, with emerging agents available through clinical trials.
  • Recurrent disease — second-line immunotherapy or chemotherapy options apply, and trial enrollment is encouraged.

Because the optimal pathway is individualized, patients benefit from evaluation at a specialized mesothelioma center and from understanding the compensation options that can fund travel to such centers and offset the cost of care.

Frequently Asked Questions

What is the most important mesothelioma treatment advance in 2025-2026? The arrival of immunotherapy as a first-line standard. CheckMate 743 showed that nivolumab plus ipilimumab more than doubled five-year survival (14% vs. 6%) compared with chemotherapy, and ASCO's 2025 guideline now lists three first-line regimens.[2][1]

Is surgery still recommended for mesothelioma? Selectively. ASCO 2025 recommends lung-sparing pleurectomy/decortication over extrapleural pneumonectomy and only for carefully selected early-stage epithelioid patients. The MARS2 trial found that adding extended surgery to chemotherapy worsened two-year survival, so patient selection and surgical center experience are critical.[5][1]

What is ADI-PEG 20 and is it FDA-approved? ADI-PEG 20 (pegargiminase) is an arginine-depletion therapy. In the ATOMIC-Meso trial it improved survival in non-epithelioid mesothelioma when added to chemotherapy.[6] It is not FDA-approved. The company reported in August 2025 that its biologics license application had entered FDA substantive review,[7] and it does not appear on FDA's lists of novel drug approvals for 2025 or 2026 (checked September 30, 2026).[11][12]

Should I get genetic testing for mesothelioma? ASCO's 2025 guideline update, Recommendation 7.1, states that all patients with mesothelioma should be offered germline testing (evidence quality High; strength of recommendation Strong).[1] The European BAP1-TPDS consensus advises against offering it routinely in isolated mesothelioma (95% consensus, Moderate /weak).[4] A germline BAP1 mutation is associated with roughly 7-fold better long-term survival.[8] Relatives of carriers should be offered genetic counseling (ASCO Recommendation 7.5).[1]

Can mesothelioma be detected with a blood test? Blood biomarkers such as soluble mesothelin (MESOMARK) are useful for monitoring rather than primary diagnosis. Liquid biopsy approaches like ctDNA are advancing but do not yet replace tissue biopsy. See Liquid Biopsy for Mesothelioma.

Does better treatment affect my legal compensation? Improved survival and new treatments can increase the lifetime medical costs and damages relevant to a claim. An experienced mesothelioma attorney can help document treatment costs and pursue trust-fund claims and lawsuits to recover compensation.

Quick Statistics

  • 3 — first-line systemic regimens recognized by ASCO in 2025.[1]
  • 14% — five-year overall survival with nivolumab+ipilimumab (vs. 6% chemotherapy) in CheckMate 743.[2]
  • 110 — peer-reviewed studies reviewed for the 2025 ASCO guideline update.[1]
  • September 17, 2024 — FDA approval date for pembrolizumab + chemotherapy in pleural mesothelioma.[3]
  • ~7-fold — improved long-term survival for germline BAP1 mutation carriers vs. sporadic mesothelioma.[8]
  • 5 — emerging therapies (ADI-PEG 20, TTFields, CAR-T, UV1 vaccine, volrustomig) in active clinical trials.
  • 2018 → 2025 — years between ASCO's prior mesothelioma guideline and its latest update.[1]
  • Worse — the 2-year survival outcome of adding extended surgery to chemotherapy in the MARS2 trial.[5]

  • Danziger & De Llano — mesothelioma and asbestos-related disease attorneys, covering asbestos bankruptcy trust-fund claims, civil personal-injury and wrongful-death lawsuits, and VA disability claims for veterans.

References

  1. ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 1.13 1.14 1.15 1.16 1.17 1.18 1.19 1.20 1.21 1.22 Kindler HL, Ismaila N, Bazhenova L, Chu Q, et al. Treatment of Pleural Mesothelioma: ASCO Guideline Update. Journal of Clinical Oncology. 2025. PMID 39778125.
  2. ↑ 2.0 2.1 2.2 2.3 2.4 2.5 Scherpereel A, Baas P, Nowak AK, Tsao AS, Fujimoto N, et al. Five-Year Clinical Outcomes With Nivolumab Plus Ipilimumab Versus Chemotherapy as First-Line Treatment for Unresectable Pleural Mesothelioma in CheckMate 743. Journal of Clinical Oncology. 2026. PMID 41734361.
  3. ↑ 3.0 3.1 3.2 3.3 3.4 3.5 U.S. Food and Drug Administration. FDA approves pembrolizumab with chemotherapy for unresectable advanced or metastatic malignant pleural mesothelioma. September 17, 2024.
  4. ↑ 4.0 4.1 4.2 4.3 4.4 Lalloo F, Kulkarni A, Chau C, Nielsen M, Sheaff M, Steele J, et al. Clinical practice guidelines for the diagnosis and surveillance of BAP1 tumour predisposition syndrome. Eur J Hum Genet. 2023;31(11):1261-1269. PMID 37607989. PMC10620132. PubMed
  5. ↑ 5.0 5.1 5.2 5.3 5.4 Lim E, Waller D, Lau K, Steele J, et al. Extended pleurectomy decortication and chemotherapy versus chemotherapy alone for pleural mesothelioma (MARS 2): a phase 3 randomised controlled trial. Lancet Respiratory Medicine. 2024;12(6):457-466. PMID 38740044.
  6. ↑ 6.0 6.1 6.2 6.3 Szlosarek PW, Creelan BC, Sarkodie T, Nolan L, Taylor P, et al. Pegargiminase Plus First-Line Chemotherapy in Patients With Nonepithelioid Pleural Mesothelioma: The ATOMIC-Meso Randomized Clinical Trial. JAMA Oncology. 2024;10(4):475–483. PMID 38358753.
  7. ↑ 7.0 7.1 7.2 7.3 Polaris Group's Biologic License Application (BLA) for Pegargiminase (ADI-PEG 20) has officially entered the FDA substantive review stage, Polaris Group, August 18, 2025
  8. ↑ 8.0 8.1 8.2 8.3 8.4 Baumann F, Flores E, Napolitano A, et al. Mesothelioma patients with germline BAP1 mutations have 7-fold improved long-term survival. Carcinogenesis. 2015. PMID 25380601.
  9. ↑ Baas P, Scherpereel A, Nowak AK, Fujimoto N, Peters S, et al. First-line nivolumab plus ipilimumab in unresectable malignant pleural mesothelioma (CheckMate 743): a multicentre, randomised, open-label, phase 3 trial. The Lancet. 2021;397(10272):375–386. PMID 33485464.
  10. ↑ Chu Q, Perrone F, Greillier L, et al. Pembrolizumab plus chemotherapy versus chemotherapy in untreated advanced pleural mesothelioma in Canada, Italy, and France: a phase 3, open-label, randomised controlled trial. Lancet. 2023;402(10419):2295-2306. PMID: 37931632
  11. ↑ Novel Drug Approvals for 2026, U.S. Food and Drug Administration. Retrieved September 30, 2026.
  12. ↑ Novel Drug Approvals for 2025, U.S. Food and Drug Administration. Retrieved September 30, 2026.
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