British Thoracic Society Guideline for the investigation and management of malignant pleural mesothelioma

Our plain-English summary of British Thoracic Society Guideline for the investigation and management of malignant pleural mesothelioma, by I. Woolhouse, L. Bishop, L. Darlison, et al (Thorax, 2018).

The study

• Authors: I. Woolhouse, L. Bishop, L. Darlison, D. De Fonseka, A. Edey, J. Edwards, C. Faivre-Finn, D.A. Fennell, S. Holmes, K.M. Kerr, A. Nakas, T. Peel, N.M. Rahman, M. Slade, J. Steele, S. Tsim, N.A. Maskell
• Journal: Thorax
• Published: 2018;73(Suppl 1):i1-i30
• Type of article: Guideline
• Cited by: 159 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

In plain English

This article is a clinical practice guideline from the British Thoracic Society on investigating and managing malignant pleural mesothelioma (MPM). It is not an original study. The guideline group searched databases in December 2014 and July 2016 for English-language papers and appraised the evidence with standard checklists. It graded each recommendation from A (strongest evidence) to D (case series, expert opinion, or evidence extrapolated from case-control or cohort studies). The authors recommended taking a thorough lifelong occupational history, including exposure through a relative's or partner's job. They also recommended not ruling out MPM on symptoms and examination alone. Both of these were Grade D. They recommended against using biomarkers alone to diagnose MPM (Grade B) or to screen for it (Grade C). They recommended talc or indwelling pleural catheters for symptomatic pleural fluid, and cisplatin with pemetrexed as first-line treatment for patients with good performance status (both Grade A). They recommended against extra-pleural pneumonectomy (Grade B). They recommended offering patients and carers accurate information about compensation (Grade D). The authors acknowledged that there was little high-quality evidence for some questions.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: Clinical practice guideline (British Thoracic Society), based on systematic literature searches, appraisal of evidence with SIGN checklists, and recommendations graded A to D by strength of evidence
• Who was studied: English-language published literature on malignant pleural mesothelioma. Database searches in December 2014 identified 6173 abstracts, and a second search in July 2016 yielded a further 1038 potentially relevant references. Non-pleural mesothelioma was excluded. The guideline is aimed at UK healthcare professionals caring for patients with suspected or proven MPM.
• Exposure: Not an exposure study; the guideline covers diagnosis and treatment. On asbestos, it recommends a lifelong occupational history, including para exposure through relatives' or partners' occupations (Grade D).
• Main results:
  • Grade D, the lowest grade, covers evidence level 3 (non-analytic studies such as case reports and case series), level 4 (expert opinion), or evidence extrapolated from studies rated 2+ (well-conducted case-control or cohort studies).
  • Recommendation: do not rule out MPM on the basis of symptoms and examination findings alone (Grade D).
  • Recommendation: offer contrast CT of the chest as the first cross-sectional imaging test for suspected MPM (Grade D).
  • Recommendation: do not rely on cytology alone to diagnose MPM, except where biopsy is not possible or not required (Grade D).
  • Recommendation: do not offer biomarkers in isolation as a diagnostic test (Grade B).
  • Recommendation: do not offer biomarker testing to screen for MPM (Grade C).
  • Recommendation: offer talc (slurry or poudrage) or indwelling pleural catheters for symptomatic pleural effusion in MPM, informed by patient choice (Grade A).
  • Recommendations on surgery: do not offer extra-pleural pneumonectomy (Grade B), and do not offer extended pleurectomy decortication outside a clinical trial (Grade D).
  • Recommendation: offer first-line cisplatin and pemetrexed to patients with good performance status (WHO 0 to 1) (Grade A).
  • Recommendation: do not offer preoperative or postoperative radiotherapy in MPM (Grade A).
  • Recommendation: offer accurate and understandable information about compensation to patients and carers (Grade D).
• The authors' conclusion: The authors presented the guideline as detailed, evidence-based guidance for investigating suspected MPM and for the care and management of people with proven MPM, set out as graded recommendations and good practice points.
• Limitations the authors state:
  • Little high-quality evidence was expected for some clinical questions, so lower-grade evidence and expert consensus were used.
  • The literature search was limited to English-language papers.
  • Cost-effectiveness was not analysed in detail.
  • The recommendations are a guide and may not suit every situation; clinical judgement is still required.

Topics

The National Library of Medicine indexes this study under subjects our site covers: Mesothelioma.

Medical terms in this study, explained in our Lexicon: Pleural Mesothelioma.

Related studies

• British Thoracic Society study of cryptogenic fibrosing alveolitis: current presentation and initial management. Fibrosing Alveolitis Subcommittee of the Research Committee of the British Thoracic Society — I.D. Johnston, R.J. Prescott, et al. (1997)
• Malignant pleural mesothelioma and the Society of Thoracic Surgeons Database: an analysis of surgical morbidity and mortality — B.M. Burt, R.B. Cameron, et al. (2014)
• A survey of opinions and beliefs concerning surgery for malignant pleural mesothelioma amongst 802 members of the European Association for Cardio-Thoracic Surgery (EACTS), the European Society of Thoracic Surgeons (ESTS) and the Society of Thoracic Surgeons (STS) — T. Treasure, E. Internullo, et al. (2011)
• Guidelines of the European Respiratory Society and the European Society of Thoracic Surgeons for the management of malignant pleural mesothelioma — A. Scherpereel, P. Astoul, et al. (2010)
• Multicenter randomized controlled trial of the management of unresectable malignant mesothelioma proposed by the British Thoracic Society and the British Medical Research Council — D.J. Girling, M.F. Muers, et al. (2002)
• Guidelines for the cytopathologic diagnosis of epithelioid and mixed-type malignant mesothelioma. Complementary statement from the International Mesothelioma Interest Group, also endorsed by the International Academy of Cytology and the Papanicolaou Society of Cytopathology — A. Hjerpe, V. Ascoli, et al. (2015)

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