Treatment patterns among patients with malignant pleural mesothelioma: An Italian, population-based nationwide study

Our plain-English summary of Treatment patterns among patients with malignant pleural mesothelioma: An Italian, population-based nationwide study, by A. Trama, C. Proto, D. Signorelli, et al (Thoracic Cancer, 2020).

The study

• Authors: A. Trama, C. Proto, D. Signorelli, M.C. Garassino, G. Lo Russo, M. Ganzinelli, A. Prelaj, C. Mensi, M. Gangemi, V. Gennaro, E. Chellini, A. Caldarella, I.F. Angelillo, V. Ascoli, C. Pascucci, G. Tagliabue, R. Cusimano, F. Bella, F. Falcini, E. Merler, G. Masanotti, A. Ziino, M. Michiara, G. Gola, C. Storchi, L. Mangone, M.F. Vitale, C. Cirilli, R. Tumino, T. Scuderi, A.C. Fanetti, S. Piffer, M. Tiseo, G. Gatta, L. Botta, LUME study WG
• Journal: Thoracic Cancer
• Published: 2020;11(6):1661-1669
• Cited by: 1 article, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

Background: Malignant pleural mesothelioma (MPM) is a rare cancer with a poor prognosis. Centralization of rare cancer in dedicated centers is recommended to ensure expertise, multidisciplinarity and access to innovation. In Italy, expert centers for MPM have not been identified in all regions. We aimed to describe the treatment patterns among MPM patients across different Italian regions and to identify factors associated with the treatment patterns across the regions.

Methods: We performed an observational study on a random sample of 2026 MPM patients diagnosed in 2003-2008. We included 26 population-based registries covering 70% of the Italian population. To identify factors associated with treatment patterns, across the different regions, we fitted a multinomial logistic regression model adjusted by age, sex, stage, histology and hospital with thoracic surgical department.

Results: MPM patients mostly received chemotherapy alone (41%) or no cancer-directed therapy (36%) especially the older patients. The first course of treatment for MPM patients differed across regions. Patients from Piedmont, Liguria and Campania were more likely to receive no cancer-directed therapy; those living in Tuscany and Sicily were more likely to get surgery; patients from Marche and Lazio were more likely to receive chemotherapy. These differences were not explained by age, sex, stage, histology and availability of a thoracic surgery department.

Conclusions: There is limited expertise available and lack of a network able to maximize the expertise available may contribute to explaining the results of our study. Our findings support the need to ensure the appropriate care of all MPM patients in reorganizing the health care services.

Key Points: Significant findings of the study: MPM patients mostly received chemotherapy alone or no cancer-directed therapy especially the older patients. The first course of treatment for MPM patients differed across Italian regions.

What This Study Adds: Differences in MPM clinical management are not explained by the age, stage, histology nor by the availability of a thoracic surgery department. Limited expertise for MPM contribute to explaining the unequal access to appropriate care for MPM patients in Italy.

© 2020 The Authors. Thoracic Cancer published by China Lung Oncology Group and John Wiley & Sons Australia, Ltd.

In plain English

This population-based study examined the first treatment given to people with malignant pleural mesothelioma in Italy. It used a random sample of 2026 patients diagnosed in 2003–2008, drawn from about 5600 cases recorded by 26 registries covering 70% of the Italian population. The article did not report results on asbestos exposure. Overall, 41% received chemotherapy alone and 36% received no cancer-directed treatment or only best supportive care. Among patients aged 75 or older, 65% received no active treatment. A model compared each treatment with chemotherapy alone, and each region with Lombardy, adjusting for age, sex, stage, histology and on-site thoracic surgery departments. In that model, patients in Piedmont, Liguria and Campania were more likely to be untreated, and those in Tuscany and Sicily to receive surgery plus chemotherapy. An on-site thoracic surgery department was also linked with surgery plus chemotherapy. The authors concluded that limited expertise, and no network to make the most of it, may help explain the regional differences. They lacked information on patients' other illnesses and performance status.

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 observational study using cancer and mesothelioma registry data, with a multinomial logistic regression model
• Who was studied: A representative random sample of 2026 patients with histologically or cytologically confirmed malignant pleural mesothelioma diagnosed 2003–2008. The sample was drawn from about 5600 cases identified by 26 population-based registries in 12 of 21 Italian regions, covering 70% of the Italian population. Cases diagnosed from death certificate or autopsy were excluded. 71% were male, 67% were aged 65 or more, and the average age was 69.
• Exposure: The article reports no results on asbestos exposure. It examined the first course of cancer treatment started within five months of diagnosis: surgery, chemotherapy, radiotherapy, combinations, or no treatment or best supportive care.
• Main results:
  • Of all 2026 patients, 41% (833) received chemotherapy alone and 36% (739) received no treatment or best supportive care. About 46% were diagnosed at stage I–II.
  • Among patients aged 75 or older, 65% did not receive active cancer treatment. In the model, compared with patients aged 65–74, they had a relative risk ratio of 5.32 (95% CI 4.06–6.98) for no treatment or best supportive care rather than chemotherapy alone.
  • 19% of patients received a treatment that included surgery. Among surgically treated patients, extrapleural pneumonectomy, pleurectomy with decortication and pleurectomy were used in 40%, 30% and 24%, respectively.
  • Patients aged 15–54 were more likely than those aged 65–74 to receive surgery alone rather than chemotherapy alone, with a relative risk ratio of 2.35 (95% CI 1.32–4.2).
  • The comparison was with Lombardy and was adjusted for age, sex, stage, histology and thoracic surgery on site. Relative risk ratios for no treatment or best supportive care rather than chemotherapy alone were: Piedmont 1.73 (95% CI 1.23–2.45), Liguria 1.87 (1.23–2.85) and Campania 2.66 (1.68–4.22).
  • Compared with Lombardy, the relative risk ratio for surgery plus chemotherapy rather than chemotherapy alone was 3.98 (95% CI 2.31–6.85) in Tuscany and 2.19 (1.24–3.87) in Sicily. In Lazio it was lower, at 0.35 (0.14–0.87). For surgery alone, the Tuscany and Sicily results were not statistically significant: 1.91 (0.99–3.67) and 1.14 (0.55–2.36).
  • Compared with Lombardy, patients in Marche (relative risk ratio 0.3, 95% CI 0.15–0.59) and Sicily (0.44, 0.26–0.75) were less likely to be untreated than to receive chemotherapy alone.
  • Availability of a thoracic surgery department on site was associated with receiving surgery plus chemotherapy rather than chemotherapy alone, with a relative risk ratio of 2.23 (95% CI 1.43–3.5).
  • Use of chemotherapy alone ranged from about 71% in Trentino-Alto Adige (only 7 cases) to 28% in Campania.
  • Availability of a thoracic surgery department did not fully explain the regional differences in first treatment.
• The authors' conclusion: The authors concluded that limited expertise for a rare cancer such as malignant pleural mesothelioma, and the lack of a network able to make the most of that expertise, may contribute to explaining the regional differences. They also concluded that their findings support the need to ensure appropriate care for all patients when health care services are reorganized.
• Limitations the authors state:
  • No information on comorbidity or performance status, which the authors say matters for interpreting treatment choice.
  • The data could not distinguish patients unsuitable for systemic therapy from untreated patients who were most likely under observation.
  • Possible misclassification of stage because radiologists vary between individuals; stage was missing for about 15% of patients.

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, Prognosis, Histology, Chemotherapy, Thoracic Surgery.

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