Introducing the new BTS guideline: the investigation and management of pleural malignant mesothelioma

Our plain-English summary of Introducing the new BTS guideline: the investigation and management of pleural malignant mesothelioma, by I. Woolhouse, N.A. Maskell (Thorax, 2018).

The study

• Authors: I. Woolhouse, N.A. Maskell
• Journal: Thorax
• Published: 2018;73(3):210-212
• Type of article: Guideline
• Cited by: 8 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Summary of the article

This article introduced the British Thoracic Society (BTS) guideline on the investigation and management of malignant pleural mesothelioma (MPM), published as a supplement in the same issue of Thorax. The authors, who co-chaired the guideline development group, noted that 2535 mesothelioma deaths were reported in the UK in 2012 and that median survival was 9.5 months. The guideline followed the NICE-accredited BTS process, which is based on SIGN methodology and adheres to the AGREE instrument. No biomarker diagnosed MPM consistently with sensitivity and specificity above 90%, so biomarkers were not recommended in isolation as a diagnostic test. A raised mesothelin could, however, assist diagnosis in patients not fit for invasive tests. Based on the MesoVATS and MARS trials, the guideline did not recommend VATS partial pleurectomy for fluid control or extrapleural pneumonectomy for disease control, and it recommended offering suitable patients entry into the MARS-2 trial. Patients with good performance status were to be offered first-line cisplatin and pemetrexed. In the MAPS trial, adding bevacizumab lengthened survival (median 18.8 vs 16.1 months), but bevacizumab was not available in the NHS. After the SMART trial (procedure tract metastases 9/102 vs 16/101; P=0.14), routine prophylactic radiotherapy was not recommended. The authors described ongoing trials, including immunotherapy trials, and stated that the next challenge was implementing the recommendations.

PubMed has no abstract for this study, and the article doesn't print one. We wrote this summary from the full article with the help of AI. It is not the authors' wording.

In plain English

This short article was not a new study. The authors, who co-chaired the British Thoracic Society (BTS) group that wrote a new guideline on malignant pleural mesothelioma, described that guideline and some of the published trials behind it. They noted that 2535 mesothelioma deaths were reported in the UK in 2012, and that median survival in England and Wales was 9.5 months. According to the article, the guideline recommends that biomarkers not be used on their own to diagnose the disease. Based on the MesoVATS and MARS trials, it does not recommend VATS partial pleurectomy for fluid control or extrapleural pneumonectomy for disease control. It recommends cisplatin plus pemetrexed as first treatment for patients with good performance status. In the MAPS trial, adding bevacizumab gave a median survival of 18.8 versus 16.1 months. Citing the SMART trial, the guideline does not recommend routine preventive radiotherapy to chest wall procedure tracts. The article does not discuss asbestos exposure. The authors concluded that the next challenge is putting the recommendations into practice.

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: Editorial-style overview (journal 'Guideline highlights' piece) introducing a new BTS evidence-based clinical guideline; not an original study
• Who was studied: No study population. The guideline concerns patients with malignant pleural mesothelioma in the UK. Background figures: 2535 mesothelioma deaths reported in the UK in 2012.
• Main results:
  • Background figures cited from a national audit for patients in England and Wales: overall median survival 9.5 months, with 1-year survival of 41% and 3-year survival of 12%.
  • The guideline recommends that biomarkers not be offered on their own as a diagnostic test for malignant pleural mesothelioma.
  • In the MesoVATS trial, as described here, VATS partial pleurectomy was not associated with a survival benefit or with benefits to lung function, compared with talc.
  • In the MARS feasibility study, as described here, median survival was 14.4 months (5.3–18.7) in the extrapleural pneumonectomy (EPP) group and 19.5 months in the no-EPP group.
  • The guideline does not recommend VATS partial pleurectomy for fluid control or EPP for disease control.
  • In the MAPS trial, as described here, overall survival was longer in patients given bevacizumab plus pemetrexed and cisplatin than in those given pemetrexed and cisplatin alone: median 18.8 versus 16.1 months, P=0.0167.
  • The guideline recommends first-line cisplatin and pemetrexed for patients with good performance status.
  • In the SMART trial, as described here, procedure tract metastasis rates did not differ between the immediate radiotherapy group (9/102) and the deferred radiotherapy group (16/101), P=0.14.
  • Based on SMART and several smaller studies, the guideline does not recommend routinely offering preventive radiotherapy to chest wall procedure tracts.
• The authors' conclusion: The authors concluded that the immediate challenge is to implement the guideline's key recommendations so that patients receive the best possible evidence-based care.
• Limitations the authors state:
  • The authors note that guidelines can only appraise evidence from published trials.
  • The authors state that there was not enough published data on pembrolizumab to inform the guideline.

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: Malignant Mesothelioma, Pleural Mesothelioma, Thorax, Mesothelioma, Median Survival, Biomarker, Mesothelin, Video-Assisted Thoracoscopic Surgery (VATS).

Related studies

• British Thoracic Society Guideline for the investigation and management of malignant pleural mesothelioma — I. Woolhouse, L. Bishop, et al. (2018)
• 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)
• Guidelines of the French Speaking Society for Chest Medicine for management of malignant pleural mesothelioma — A. Scherpereel, French Speaking Society for Chest Medicine (SPLF) Experts Group (2007)
• Diagnostic surgical pathology in lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines — A.M. Schwartz, M.K. Rezaei (2013)
• Vulvar sarcomas: Short guideline for histopathological recognition and clinical management. Part 2 — A.A. Chokoeva, G. Tchernev, et al. (2015)
• The 2019 ERS/ESTS/EACTS/ESTRO Guidelines on the Management of Patients With Malignant Pleural Mesothelioma — T.A. Gelzinis (2021)

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