Real-life treatment practice for malignant pleural mesothelioma in Belgium

Our plain-English summary of Real-life treatment practice for malignant pleural mesothelioma in Belgium, by M. Rosskamp, G. Macq, K. Nackaerts, et al (Lung Cancer, 2018).

The study

• Authors: M. Rosskamp, G. Macq, K. Nackaerts, M. Praet, L. Van Eycken, J.P. Van Meerbeeck, H. De Schutter
• Journal: Lung Cancer
• Published: 2018;125:258-264
• Cited by: 11 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Objectives: Malignant pleural mesothelioma (MPM) is a rare and aggressive cancer, for which treatment is often limited to palliative combination chemotherapy. Multimodality-therapy, including radical surgery, is largely restricted to clinical trials, leaving its benefit currently unclear. This study aimed to get a comprehensive view on real-world MPM treatment at the Belgian population level, to assess survival and to identify prognostic factors.

Materials And Methods: The study period covered the incidence years 2004-2012 (N = 1453). Starting from the Belgian Cancer Registry, additional information regarding patient characteristics, diagnosis and treatment was retrieved from multiple data sources. Adjusted cox proportional-hazard regression models using time-dependent covariates were performed to assess survival in relation to treatment patterns and centre volume.

Results: Sixty-nine percent of patients underwent tumour-directed treatment, mostly cisplatin-pemetrexed chemotherapy. Radical surgery was mainly performed in younger patients with epithelioid subtype. Centre volume, surgery and chemotherapy showed a positive relation with survival in univariable analyses, but only chemotherapy remained significantly relevant in multivariable analyses. Younger patients, females, and epithelioid subtypes also independently had a better survival.

Conclusion: This large population-based study provides insights in MPM treatment practice in Belgium. Centre volume and surgery being related to survival in univariable analyses, only chemotherapy remained prognostic after adjustment.

Copyright © 2018 Elsevier B.V. All rights reserved.

In plain English

This population-based registry study described real-life treatment and survival of malignant pleural mesothelioma in Belgium. It included 1453 patients with histologically confirmed disease diagnosed from 2004 to 2012; 85.4% were men. Sixty-seven (4.6%) had radical surgery; 930 (64.0%) had chemotherapy and/or radiotherapy without radical surgery; 456 (31.4%) had no tumour-directed treatment. Median survival was 12.3 months (95% confidence interval 11.6 to 13.0); 50.8% (48.2 to 53.3) were alive at 1 year, 10.7% (9.1 to 12.3) at 3 years and 3.8% (2.9 to 4.8) at 5 years. Radical surgery, and larger centres among treated patients, were linked to better survival only before adjustment for other factors. Chemotherapy, and epithelioid and biphasic subtypes compared with sarcomatoid, were linked to better survival only in the first year after diagnosis. Younger age and female sex were also linked to better survival. The authors concluded that, of centre volume, surgery and chemotherapy, only chemotherapy remained prognostic after adjustment, only for the first year. They noted that stage was known for only 53.4% of patients and that smoking, employment and trial-enrolment data were unavailable.

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: Population-based retrospective registry study linking the Belgian Cancer Registry with health insurance and other data sources, with survival analysis (Kaplan-Meier and Cox regression with time-dependent treatment variables)
• Who was studied: 1453 patients with histologically confirmed malignant pleural mesothelioma diagnosed in Belgium between 2004 and 2012. 85.4% were male, the median age at diagnosis was 70 years, and 74.5% had the epithelioid subtype.
• Exposure: Asbestos exposure was not studied. The factors examined were treatments (radical surgery, meaning extrapleural pneumonectomy; chemotherapy; long-series radiotherapy), discussion at a multidisciplinary team consult, and treating-centre volume, along with age, sex and tumour subtype.
• Main results:
  • Of 1453 patients, 456 (31.4%) received no tumour-directed treatment. Per Table 1, 67 (4.6%) underwent radical surgery; only 1 of these is listed as 'Surgery only', and the other surgical schemes in the table include chemotherapy. A separate group of 930 (64.0%) received chemotherapy and/or radiotherapy without radical surgery.
  • Cisplatin-pemetrexed was the most frequently used chemotherapy schedule; pemetrexed was used in 81.4% of patients treated with chemotherapy in 2012.
  • In the whole cohort, median survival was 12.3 months (95% CI 11.6 to 13.0). Observed survival was 50.8% [48.2 to 53.3] at 1 year, 10.7% [9.1 to 12.3] at 3 years and 3.8% [2.9 to 4.8] at 5 years.
  • Before adjustment, radical surgery (HR 0.67 [0.51 to 0.87] in the text) was significantly linked to better survival. So was larger centre volume (HR 0.96 [0.92 to 0.99] per 15 patients), in an analysis limited to the 997 patients who received tumour-directed treatment. After adjustment neither was significant (Table 3 adjusted HR: centre size 0.99 [0.95 to 1.03], radical surgery 0.97 [0.70 to 1.35]).
  • In the first year after diagnosis, patients treated with chemotherapy had better survival: unadjusted HR 0.57 [0.49 to 0.67], and adjusted HR 0.69 [0.59 to 0.82] in the text (0.68 [0.58 to 0.81] in Table 3). After the first year the effect was not significant (adjusted HR 1.15 [0.95 to 1.39]).
  • Younger patients and women had better survival. Adjusted HRs: age 1.02 [1.01 to 1.03] per year; males versus females 1.16 [1.00 to 1.35]. In the first year, epithelioid subtype (adjusted HR 0.24 [0.19 to 0.29]) and biphasic subtype (0.54 [0.42 to 0.68]) had better survival than sarcomatoid. After the first year neither was significant (epithelioid 0.81 [0.51 to 1.27]; biphasic 1.16 [0.69 to 1.94]).
  • 150 patients (10.4% of 1447 with sufficient follow-up) survived at least 3 years. These long-term survivors were younger, more often had the epithelioid subtype (96.0% vs 72.1%) and were more often treated (82.0% vs 67.0%).
  • After radical surgery, post-operative mortality was 4.8% at 30 days and 13.4% at 90 days.
• The authors' conclusion: The authors concluded that age, gender and morphology significantly affected survival. Centre volume, surgery and chemotherapy were related to survival in unadjusted analyses, but after adjustment only chemotherapy remained statistically prognostic, and only for the first year after diagnosis.
• Limitations the authors state:
  • Stage was available for only 53.4% of patients, so it was not included in the analyses.
  • Smoking history and employment status were not available from the data sources used.
  • Enrolment in sponsored clinical trials was unknown. Trial chemotherapy may have been missed, which could overestimate the proportion of untreated patients.
  • Treated and untreated patients may differ at baseline, so unmeasured factors can cause confounding by indication. Treatment completion and intention-to-treat analysis could not be assessed.
  • The lack of a significant adjusted effect of radical surgery might reflect the small number of surgically treated patients.
  • The data could not separate curative-intent lung-sparing resections from diagnostic or symptom-relief procedures. The study period also did not cover recent treatment developments.

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, Palliative Care, Chemotherapy, Clinical Trial, Cancer Registry, Cisplatin, Pemetrexed (Alimta), Epithelioid.

Related studies

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• Assessing the completeness and correctness of the registration of malignant mesothelioma in Belgium — M. Rosskamp, H. De Schutter, et al. (2018)
• Systemic treatment in patients with malignant pleural mesothelioma - real life experience — B. Ziółkowska, B. Cybulska-Stopa, et al. (2022)
• Clinical prognostic factors in pleural mesothelioma: best supportive care and anti-tumor treatments in a real-life setting — T. Ringgaard Petersen, V. Panou, et al. (2021)
• Malignant pleural mesothelioma: current concepts in treatment — A. Tsiouris, R.K. Walesby (2007)
• Pemetrexed in the treatment of malignant mesothelioma: results from an expanded access program in Germany — M. Reck, R.A. Stahel, et al. (2010)

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