Clinical prognostic factors in pleural mesothelioma: best supportive care and anti-tumor treatments in a real-life setting

Our plain-English summary of Clinical prognostic factors in pleural mesothelioma: best supportive care and anti-tumor treatments in a real-life setting, by T. Ringgaard Petersen, V. Panou, C. Meristoudis, et al (Acta Oncologica, 2021).

The study

• Authors: T. Ringgaard Petersen, V. Panou, C. Meristoudis, U.M. Weinreich, O.D. Røe
• Journal: Acta Oncologica
• Published: 2021;60(4):521-527
• Cited by: 7 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Background: This study aims to investigate patient- and disease characteristics associated with survival in malignant pleural mesothelioma (MPM) patients with anti-tumor treatment or with best supportive care (BSC).

Materials And Methods: Consecutive MPM cases diagnosed in North Denmark Region from 1972 to 2015 were reevaluated and verified by two pathologists using modern immunohistochemical techniques. Danish registries and hospital records were used to gather patient-, asbestos exposure-, and disease information.

Results: Of the 279 patients, anti-tumor treatment was administered to 184 patients (66.0%). All of those received chemotherapy alone or as part of a multimodal treatment, where pemetrexed was given to 126 (68.5%) patients. Asbestos exposure was documented in 92.5% of all patients. In the treated group, mean age was lower (66 years versus 74 years, p < 0.01), rate of occupational asbestos exposure was higher (74.5 versus 54.7%, p < 0.01), more patients had better performance score (98.4 versus 60%, p < 0.01) and stage was lower (81 versus 63.2%, p < 0.01) compared to the BSC group. Multivariate analysis showed that epithelioid subtype was the only common prognostic factor for OS in both groups. In BSC patients, good PS and female gender was associated with improved OS. Median overall survival (OS) was 17 versus 4 months (p < 0.01), and independently of the histopathological subtype, the median and 2-year survival was higher in the treated versus the BSC group (p < 0.02).

Conclusions: This retrospective study showed that epithelioid subtype is the only independent positive prognostic factor of survival in treated patients with MPM. For BSC patients, the epithelioid subtype, good PS, and female gender were positive prognostic factors, while age and comorbidities were not significant. This study with long-term follow-up of treated and BSC MPM patients can contribute to the clinical stratification of patients. Further validation is appropriate to verify these findings.

In plain English

This retrospective study looked at 279 patients with verified malignant pleural mesothelioma diagnosed in the North Denmark Region from 1972 to 2015 and followed until September 2018. Of these, 184 (66.0%) received anti-tumor treatment, all of it including chemotherapy, and 95 received best supportive care only. Asbestos exposure was documented in 258 patients (92.5%), mostly occupational. Median overall survival was 17 months in the treated group and 4 months in the supportive care group. In treated patients, only the epithelioid tumor subtype was linked to longer survival. In supportive care patients, epithelioid subtype, good performance status and female gender were linked to longer survival. Age, comorbidities and asbestos exposure showed no link with survival in either group. The authors concluded that epithelioid subtype is a strong independent prognostic factor in both groups. They noted that the supportive care group had more patients in poor condition and with advanced disease, so the true effect of treatment is probably more modest. They also noted that the study was retrospective and lacked data on treatment response.

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: Retrospective study of all regional mesothelioma cases, comparing patients given anti-tumor treatment with patients given best supportive care
• Who was studied: 279 patients with verified malignant pleural mesothelioma, selected from 568 patients with a mesothelioma diagnosis in the North Denmark Region, diagnosed 1972 to 2015 and followed until September 2018. 184 were treated and 95 received best supportive care. 10 were alive at data collection.
• Exposure: Asbestos exposure was classified as occupational, environmental, domestic, combinations of those, or no exposure. Occupational meant asbestos-related work such as shipbuilding, isolation, mason, carpenter, blacksmith, electrician, joiner, or work at the Danish Eternit Factory or Aalborg shipyard. Environmental meant living or working within 10,000 meters of asbestos-emitting locations. Domestic meant sharing a residence with an occupationally exposed person. Fiber types were not named. The study also looked at treatments: chemotherapy alone or combined with radiation and/or surgery.
• Main results:
  • Asbestos exposure was documented in 258 of 279 patients (92.5%), most of them with occupational exposure (189 patients, 67.7%).
  • 184 patients (66.0%) received anti-tumor treatment, all including chemotherapy. Pemetrexed-based chemotherapy was given to 126 of them (68.5%).
  • Compared with the best supportive care group, the treated group had a lower mean age (66 versus 74 years, p less than 0.01) and a higher rate of occupational asbestos exposure (74.5 versus 54.7%, p less than 0.01). The treated group also had more patients with good performance status (98.4 versus 60%) and early stage disease (81 versus 63.2%).
  • Median overall survival was 17 months in the treated group versus 4 months in the best supportive care group (p less than 0.01).
  • In the treated group, only epithelioid subtype was associated with better survival (hazard ratio 0.7, 95% CI 0.52 to 0.96, p 0.02). It remained the only significant factor after adjusting for age, gender, stage and comorbidities (p=0.019).
  • In the best supportive care group, multivariate analysis found three factors associated with longer survival: epithelioid subtype (hazard ratio 0.47, 95% CI 0.30 to 0.74), good performance status (hazard ratio 0.58, 95% CI 0.37 to 0.90) and female gender. The hazard ratio for male gender was 1.56 (95% CI 0.99 to 2.47, p 0.05).
  • In the best supportive care group, median survival was five months for epithelioid and two months for non-epithelioid subtypes (p less than 0.001).
  • In the treated group, median survival was 18 months for epithelioid and 17 months for non-epithelioid subtypes (p less than 0.02).
  • 2-year survival in the best supportive care group was 1.6% for epithelioid and 0% for non-epithelioid subtypes. In the treated group it was 33.3% (35 patients) for epithelioid and 24.0% (19 patients) for non-epithelioid subtypes (p less than 0.05).
  • Asbestos exposure had no correlation with overall survival. For occupational exposure the hazard ratio was 1.05 (95% CI 0.58 to 1.90) in the best supportive care group and 0.87 (95% CI 0.41 to 1.87) in the treated group.
  • Age and comorbidities were not associated with overall survival in either group.
• The authors' conclusion: The authors concluded that epithelioid subtype is a strong independent prognostic factor in both best supportive care and treated patients, while age and comorbidities do not seem to be significant factors. They added that treated non-epithelioid patients survived significantly longer than best supportive care patients of any subtype, and that validation in other cohorts is appropriate.
• Limitations the authors state:
  • The authors named the retrospective design and the lack of treatment response data as the main limitations.
  • The best supportive care group had more patients with poor performance status and advanced disease, so the true survival difference due to treatment is probably more modest than observed.
  • The staging system changed over the 40-year study period, so staging information may not be reliable.
  • The accuracy of the comorbidity data may be limited by the retrospective nature of the study.
  • Domestic exposure data for men were available only after 2001, so three men recorded as unexposed before then may have had non-occupational exposure.
  • Only three treated patients had poor performance status, so this factor could not be analyzed in the treated group.
  • Women made up only 14.7% of the treated group and were potentially underrepresented.

Topics

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

Medical terms in this study, explained in our Lexicon: Pleural Mesothelioma, Asbestos Exposure, Chemotherapy, Pemetrexed (Alimta), Multivariate Analysis, Epithelioid, Median Overall Survival.

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