picking a treatment center for stage 2 pleural - what actually separates the good ones

The UCSD response you got is actually a really telling sign. When a center can cite their own volume numbers off the top of their head, that usually means they're tracking outcomes, not just marketing. The MSKCC data from the Flores et al. multimodal study showed pretty clearly that meso patients treated at high-volume centers had meaningfully better outcomes, and "high volume" for this disease is a low bar, maybe 20-30 cases a year at a dedicated thoracic program.

The tumor board question is the one I'd push hardest. Not just "do you have one" but does your specific case go in front of it, and who's in the room. Thoracic surgeon, medical oncologist, radiation oncologist, pulmonologist, pathologist all looking at your imaging together is a different thing than one doc making a call and getting a rubber stamp.

And yeah, the "we handle all thoracic cancers" answer would have made me uncomfortable too. Lung cancer is common enough that a center can do a hundred cases a year and still have seen almost no meso. Those are completely different diseases with different staging logic, different chemo protocols, different surgical philosophy.

On the VA timing, I'd honestly contact the patient advocate office at the VA directly, not just claims. There's a specific pathway for service-connected cancer that can sometimes move faster than the standard claims queue. That said, please talk to your oncologist about the timing question because stage 2 pleural has windows that matter and that's a clinical judgment that has to be yours and your doctor's together, not something to let paperwork decide.

What you noticed about UC San Diego is genuinely significant. The ability to give you specific numbers, specific names, that's not just good PR. In my work I've seen families sit through consultations at big-name hospitals where no one could tell them who would actually be in the room making decisions about their care. The volume question matters because mesothelioma is rare enough that "we treat thoracic cancers" really can mean they've seen three cases in five years.

The tumor board piece you mentioned is something I'd really pay attention to. A center where the surgeon, oncologist, pulmonologist, and palliative team are all looking at your scans together on a regular schedule versus one where those conversations happen in the hallway or by email... that's a real structural difference in how your plan gets made and adjusted.

On the VA timeline, I've sat with patients who waited from October through March before anything moved, and by then the treatment window they'd planned around had shifted. If you have any capacity to go private for this phase, it's worth at least getting that consultation scheduled now so you're not starting from zero if the VA approval does come through late. UCSD Moores specifically has a team that works with patients on exactly this kind of coverage gap.

Journaling what you're feeling about this decision process can help too, not just for clarity but because the anxiety of waiting on bureaucracy while also making treatment decisions is genuinely a lot to carry. If that weight gets heavier, talking to someone in oncology social work can help you sort through what's medical decision-making and what's fear. Those are different things and they deserve different kinds of attention.

What you described with UC San Diego, that they could name the specific oncologist and give you actual case numbers, that's exactly the signal you're looking for. In my experience working with meso patients over the years, the centers that can answer specific questions specifically are almost always the ones doing enough volume to actually know what they're doing with this disease. "We handle all thoracic cancers" tells you nothing.

The tumor board question is real. A center where your oncologist, surgeon, pulmonologist, and rad onc are actually in the same room reviewing your case together versus one where they're emailing each other notes... it changes outcomes. Not dramatically every time, but enough that I've seen it matter. UCSD's Moores Cancer Center does have a multidisciplinary thoracic board and they see enough meso specifically that your case wouldn't be a novelty to them.

On the VA piece, if your claim has been sitting since November you may be able to request a community care authorization in the meantime. I've seen that process move faster when a provider submits documentation that the wait creates clinical risk given staging and treatment timing. Worth asking your VA primary care doc to put that in writing.

The window concern you raised is legitimate and not anxiety talking. Stage 2 and post-pleurectomy, the timing of adjuvant chemo does matter. If this is feeling stuck and heavy beyond just the logistics of it, please don't sit with that alone. A counselor who works specifically with cancer patients can help you sort through the fear that's underneath all these very reasonable practical questions.