Management and Survival of Pleural Mesothelioma: A Record Linkage Study

Our plain-English summary of Management and Survival of Pleural Mesothelioma: A Record Linkage Study, by G. Carioli, M. Bonifazi, M. Rossi, et al (Respiration; International Review of Thoracic Diseases, 2018).

The study

• Authors: G. Carioli, M. Bonifazi, M. Rossi, A. Zambelli, M. Franchi, C. Zocchetti, S. Gasparini, G. Corrao, C. La Vecchia, E. Negri
• Journal: Respiration; International Review of Thoracic Diseases
• Published: 2018;95(6):405-413
• Cited by: 4 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Background: Pleural mesothelioma (PM) is a rare, highly lethal tumor. A definite consensus on its management has yet to be established.

Objectives: To assess management, overall survival (OS), and their predictors in a cohort of patients from Lombardy, the largest Italian region (about 10 million inhabitants).

Methods: Through a record linkage between Lombardy health care administrative databases, we identified patients diagnosed with PM in 2006-2011 without history of cancer, evaluating their management. OS from PM diagnosis was estimated using the Kaplan-Meier method. Predictors of OS and of treatment were assessed using Cox regression models with time-dependent covariates when appropriate.

Results: Out of 1,326 patients, 754 (56.9%) received treatment for PM: 205 (15.5%) underwent surgery, and 696 (52.5%) used chemotherapy. Surgery was spread across several hospitals, and most patients diagnosed in nonspecialized centers (70%) underwent surgery in the same centers. Age at diagnosis was a strong inverse determinant of surgery. Determinants of receiving chemotherapy were younger age, a more recent first diagnosis, and first diagnosis in a specialized center. OS was 45.4% at 1 year, 24.8% at 2 years, and 9.6% at 5 years (median 11 months). OS decreased with age, and was higher for those who underwent surgery, but not for those treated with chemotherapy.

Conclusions: Management of PM varied widely in clinical practice, and significant predictors of treatment were younger age and recent diagnosis, though a high proportion of patients were not treated. Patients were treated in various hospitals, indicating the importance of concentrating serious rare neoplasms in Comprehensive Cancer Centers (as recognized by the Italian Health Ministry).

© 2018 S. Karger AG, Basel.

In plain English

This record linkage study used health care administrative databases from Lombardy, Italy, to identify 1,326 residents with pleural cancer first diagnosed in 2006 to 2011. Cases were selected to have a high probability of pleural mesothelioma. Surgery was recorded for 205 patients (15.5%), cancer-drug treatment for about 52.5%, and pleurodesis for 35.1%. Older patients had surgery and chemotherapy less often. Chemotherapy was more common with more recent diagnosis and with first diagnosis in a specialized center. There were 1,058 deaths, and median survival was 11 months. Overall survival was 45.4% at 1 year and 9.6% at 5 years: 16.2% at 5 years for patients aged 70 or younger and 4.2% for those over 70. After adjustment, surgery was associated with a lower hazard of death (HR 0.76, 95% CI 0.59 to 0.97), but chemotherapy was not (HR 1.25, 95% CI 1.00 to 1.58). The authors concluded that many patients received neither treatment. They noted that surgery may select patients with a better prognosis, and that the databases held no information on asbestos exposure, tumor stage or subtype.

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 cohort study based on record linkage of regional health care administrative databases
• Who was studied: 1,326 Lombardy (Italy) residents with pleural cancer first diagnosed between 2006 and 2011. Patients were selected to have a high probability of pleural mesothelioma: those with other primary cancers or with metastases outside the lung or thoracic lymph nodes were excluded.
• Exposure: Not an asbestos exposure study. It examined treatments for pleural mesothelioma (surgery, meaning pleurectomy/decortication or extrapleural pneumonectomy; chemotherapy; and pleurodesis) and predictors of treatment and survival. Asbestos exposure data were not available.
• Main results:
  • Of the 205 surgical patients, 144 (10.9% of the cohort) underwent pleurectomy/decortication and 61 (4.6%) extrapleural pneumonectomy.
  • About 52.5% of the cohort had a record of cancer-drug (chemotherapy) administration.
  • Pleurodesis was performed in 35.1% of patients.
  • For surgery, the hazard ratio per 1-year increase in age was 0.96 (95% CI 0.95 to 0.97).
  • For chemotherapy, patients aged over 80 had an HR of 0.08 (95% CI 0.05 to 0.13) compared with those aged 61 to 70.
  • Patients first diagnosed in specialized centers had an HR for receiving chemotherapy of 1.45 (95% CI 1.24 to 1.68) compared with those diagnosed in nonspecialized centers.
  • There were 1,058 deaths in the whole cohort. Median survival was 11 months.
  • Overall survival in the whole cohort was 45.4% at 1 year, 24.8% at 2, 15.9% at 3, 11.7% at 4 and 9.6% at 5 years.
  • Five-year survival was 16.2% in patients aged 70 or younger and 4.2% in those over 70 (p less than 0.0001).
  • Median survival was 17.8 months after pleurectomy/decortication and 25.4 months after extrapleural pneumonectomy.
  • In the adjusted model, the hazard ratio of death was 0.76 (95% CI 0.59 to 0.97) for patients receiving surgery and 1.25 (95% CI 1.00 to 1.58) for chemotherapy.
  • The hazard of death rose with age, from 0.68 (95% CI 0.47 to 0.98) at age 50 or under to 2.51 (95% CI 2.10 to 3.00) over age 80, compared with ages 61 to 70.
  • First diagnosis in a specialized center did not affect the hazard of death.
  • Of the 104 surgical patients first diagnosed in a nonspecialized center, 73.1% had surgery in a nonspecialized center.
  • In a validation check at one Bergamo hospital, 36 of 38 patients included by the selection method (95%) were confirmed mesothelioma cases.
• The authors' conclusion: The authors concluded that surgery and/or chemotherapy were more frequent in younger patients diagnosed more recently, but that many patients received neither. Because patients were treated in many hospitals, they pointed to concentrating rare serious cancers in Comprehensive Cancer Centers.
• Limitations the authors state:
  • No information was available on tumor stage and grade, asbestos exposure, lifestyle or family history.
  • The study could not distinguish epithelioid from other mesothelioma subtypes.
  • Some cases may have been misdiagnosed where no immunohistochemical confirmation was done.
  • True mesothelioma cases with a history of other cancers were excluded. In the validation check, 20 of 30 excluded patients were mesothelioma cases.
  • The better survival seen with surgery may reflect selection of patients with a better baseline prognosis (confounding by indication).
  • The databases were built for administrative purposes, which may cause inaccuracies.

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, Overall Survival, Chemotherapy, Neoplasm.

Related studies

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• Integrating workplace exposure databases for occupational medicine services and epidemiologic studies at a former nuclear weapons facility — A.J. Ruttenber, J.S. McCrea, et al. (2001)
• Survival after conservative (palliative) management of pleural malignant mesothelioma — N. Merritt, C.J. Blewett, et al. (2001)
• Estimation of Occupational Exposure to Asbestos in Italy by the Linkage of Mesothelioma Registry (ReNaM) and National Insurance Archives. Methodology and Results — C. Airoldi, D. Ferrante, et al. (2020)
• Pleural mesotheliomas and asbestos exposure in the pulp and paper industries: a new risk group identified by linkage of official registers — B. Järvholm, H. Malker, et al. (1988)
• High Wilms' tumour gene (WT1) expression and low mitotic count are independent predictors of survival in diffuse peritoneal mesothelioma — A. Scattone, G. Serio, et al. (2012)

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