Treatment Patterns and Outcomes of Patients With Advanced Pleural Mesothelioma at an Academic Referral Centre

Our plain-English summary of Treatment Patterns and Outcomes of Patients With Advanced Pleural Mesothelioma at an Academic Referral Centre, by S. Schmid, L. Zhan, K. Dietrich, et al (Clinical Lung Cancer, 2022).

The study

• Authors: S. Schmid, L. Zhan, K. Dietrich, K. Khan, M. Chowdhury, M. Herman, D. Patel, F. Zaeimi, N.B. Leighl, A. Sacher, R. Feld, F.A. Shepherd, L. Donahoe, M. de Perrot, B.C.J. Cho, G. Liu, P.A. Bradbury
• Journal: Clinical Lung Cancer
• Published: 2022;23(1):e43-e53
• Cited by: 5 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Background: Overall survival (OS) for malignant pleural mesothelioma (MPM) in vulnerable subgroups remains poorly understood with scarce data available to guide treatment decisions. The study describes real-world detailed treatment patterns and outcomes of patients with advanced MPM overall and specifically in elderly and poor performance status (PS) patients.

Methods: Retrospective chart review was performed for all patients with histologically confirmed MPM seen at University Health Network/Princess Margaret Cancer Centre (UHN-PM).

Results: A total of 667 patients with MPM were identified and 304 advanced-disease MPM (aMPM) patients had continuing care at UHN-PM (UP-cohort). In the UP-cohort, 77% of patients received ≥ one line of systemic treatment. Systemic therapy trial participation was 39%. Patients not treated with systemic therapy (29%) were more likely to be ≥ 75 years and PS ≥ 2. Median OS was 15.3 months (95%CI 13.6-18.3), with longer survival in treated vs. untreated patients (17.4 vs. 10.6 months; P = .01). Longer survival with systemic treatment was seen in patients ≥75 years (12.7 vs. 6.6 months) and patients with poor PS (9.1 vs. 5.9 months). Median progression-free-survival (PFS) and OS for patients treated with second-line therapy was poor (3.0 and 8.9 months, respectively).

Discussion: In our real-world analysis of patients with aMPM treated at an academic referral centre, systemic treatment was given to the majority of patients and benefit was seen even in the elderly and poor PS patients frequently underrepresented in clinical trials. Trial participation was potentially facilitated by the formation of a dedicated multidisciplinary MPM clinic.

Copyright © 2021 Elsevier Inc. All rights reserved.

In plain English

This retrospective chart review covered patients with malignant pleural mesothelioma diagnosed 2006 to 2018 and seen at Princess Margaret Cancer Centre, Toronto. Of 667 patients, 304 with inoperable or advanced disease had ongoing care there. Of these, 88 (29%) received no systemic (drug) treatment. Median overall survival was 15.3 months (95% confidence interval 13.6 to 18.3). It was 17.4 months (14.5 to 20.1) in treated and 10.6 months (7.2 to 14.4) in untreated patients. Among patients aged 75 or older, it was 12.7 months with treatment and 6.6 without. With poor performance status (a measure of daily functioning), it was 9.1 months (7.9 to not reached) in 13 treated patients versus 5.9 months (3.6 to 8.6) untreated. Of the 304, 39% joined drug trials. On second-line treatment, median progression-free survival (time until worsening or death) was 3 months (2.0 to 4.1). Survival did not differ significantly by recorded asbestos exposure; no fiber types were reported. The authors concluded that properly selected elderly and poor-performance-status patients may have improved outcomes with systemic therapy. They noted that treatment was not randomly assigned.

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 single-centre chart review (observational study of treatment patterns and outcomes)
• Who was studied: 667 patients with histologically confirmed malignant pleural mesothelioma diagnosed January 1, 2006 to December 31, 2018 and seen at least once at University Health Network/Princess Margaret Cancer Centre, Toronto, Canada. Of these, 304 patients with inoperable or advanced MPM had ongoing care mainly at the centre (the 'UP-cohort'), and most results apply to this group.
• Exposure: This is not an asbestos exposure study. The factor compared was palliative systemic treatment (most often platinum-pemetrexed chemotherapy, but also other regimens and clinical trial agents) versus no systemic treatment. Asbestos exposure was recorded from charts only as positive or negative, with no fiber types, products, jobs or doses given. It was recorded as positive in 338 of the 490 patients with this information (69%).
• Main results:
  • In all 304 UP-cohort patients, median overall survival was 15.3 months (95% CI 13.6 to 18.3). By tissue type it was 17.5 months for epithelioid, 13.9 months for biphasic and 6.4 months for sarcomatoid (P less than .001).
  • In the UP-cohort, 88 patients (29%) received no systemic treatment and 216 (71%) received first-line palliative chemotherapy.
  • In the UP-cohort, median overall survival was 17.4 months (95% CI 14.5 to 20.1) in patients receiving systemic treatment, versus 10.6 months (95% CI 7.2 to 14.4; P = .01) in patients who never received it.
  • Compared with treated patients, untreated patients were more likely to be aged 75 or older (36% vs. 16%), to have performance status 2 or worse (28% vs 6%), and to have had prior radical surgery (32% vs 18%).
  • Of the 66 UP-cohort patients aged 75 or older, 34 (52%) received systemic therapy. Their unadjusted median overall survival was 12.7 months with systemic chemotherapy versus 6.6 months with observation (P = .01). In younger patients the comparable figures were 17.7 vs. 13.1 months.
  • Of 34 UP-cohort patients with performance status 2 or worse at diagnosis, 13 (38%) received systemic treatment. Median overall survival was 9.1 months (95% CI 7.9 to not reached) in treated patients versus 5.9 months (95% CI 3.6 to 8.6) in untreated patients (P less than .001).
  • Participation in a systemic therapy clinical trial was 39% in the UP-cohort and 12.6% among all patients seen at least once at the centre.
  • Among the 93 UP-cohort patients who received second-line treatment, median progression-free survival was 3 months (95% CI 2.0 to 4.1). Progression-free survival was defined as time from start of treatment to progression, death, or last follow-up. Median overall survival from the start of second-line treatment was 8.9 months (95% CI 5.2 to 10).
  • In the UP-cohort, median overall survival did not differ significantly by recorded previous asbestos exposure (15.3 vs. 13.5 months, P = 0.80). The article does not state which figure belongs to which group.
• The authors' conclusion: The authors concluded that properly selected elderly patients and patients with poor performance status may have improved outcomes with systemic therapy. They also concluded that the relatively high trial enrolment in the UP-cohort shows the potential value of a multidisciplinary MPM clinic.
• Limitations the authors state:
  • Because the study was retrospective, the factors behind treatment decisions could only be inferred.
  • As a single academic centre analysis, the study is prone to referral bias.
  • Response and progression were assessed by the investigators rather than by formal RECIST tumour assessment, which may affect the progression-free survival results.
  • Confounding by indication affects all non-randomized studies.
  • The analyses of patients with poor performance status are limited by small patient numbers.

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, Performance Status, Systemic Therapy, Second-Line Therapy, Clinical Trial.

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• Radiological predictors of complete cytoreduction in 59 patients with peritoneal mesothelioma treated with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy at a UK referral centre — A. Chandramohan, A. Thrower, et al. (2017)
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• Malignant pleural mesothelioma: Treatment patterns and outcomes from the Spanish Lung Cancer Group — J. Remon, E. Nadal, et al. (2020)
• Three Decades of Malignant Pleural Mesothelioma: An Academic Center Experience — A. Nasser, A. Baird, et al. (2021)

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