Understanding clinical decision-making in mesothelioma care: a mixed methods study

Our plain-English summary of Understanding clinical decision-making in mesothelioma care: a mixed methods study, by C. Henshall, P. Dawson, N. Rahman, et al (BMJ Open Respiratory Research, 2022).

The study

• Authors: C. Henshall, P. Dawson, N. Rahman, H. Ball, A. Sundralingam, M. Shahidi, E. McKeown, J. Park, H. Walthall, Z. Davey
• Journal: BMJ Open Respiratory Research
• Published: 2022;9(1)
• Cited by: 4 articles, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

Introduction: Malignant pleural mesothelioma is a rare, incurable cancer arising from previous asbestos exposure; patients have a poor prognosis, with a median survival rate of 8-14 months. Variation in mesothelioma clinical decision-making remains common with a lack of multidisciplinary knowledge sharing, leading to inconsistencies in treatment decisions. The study aimed to explore which factors impacted on clinicians' decision-making in mesothelioma care, with a view to optimising the mesothelioma care pathway.

Methods: This mixed methods study consisted of documentary analysis of local and national guidelines, policies or documents pertaining to mesothelioma care pathways, secondary analysis of mesothelioma patient data, and interviews with clinicians attending lung cancer and/or mesothelioma-specific multidisciplinary team meetings. The study took place at three National Health Service trusts in England. Documentations relating to patients' treatment pathways were collated and reviewed qualitatively. Records of patients with mesothelioma were extracted from hospital patient records and data collected on diagnosis date, treatment, mortality rates, survival postdiagnosis, age and clinical care team. Data were statistically analysed. Interviews with clinicians explored influences on clinical decision-making, including challenges or barriers involved. Data were thematically analysed. The Strengthening the Reporting of Observational Studies in Epidemiology reporting checklist was used.

Results: There were differences in the structure and delivery of mesothelioma treatment and care between trusts. Four main themes were identified: 'collaboration and communication', 'evidence base and knowledge', 'role of the clinician' and 'role of the patient'. Two cross-cutting themes relating to the role of the mesothelioma nurse specialist and the impact of COVID-19 were identified.

Discussion: There is a need to review the structure of mesothelioma multidisciplinary team meetings to ensure patients are reviewed by clinicians with appropriate knowledge, expertise and understanding of how, why and when decisions should be made. There is a need for expert clinicians in mesothelioma care to promote an up-to-date evidence and knowledge base within the wider multidisciplinary team.

© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

In plain English

This mixed methods study examined what shaped clinicians' decisions about care for malignant pleural mesothelioma. It was carried out at three National Health Service trusts in South England between March 2019 and March 2021: one tertiary cancer centre and two district general hospitals. The authors reviewed care-pathway documents, analysed the records of 232 patients treated between August 2014 and August 2019, and interviewed twenty clinicians. Mesothelioma pathways were not always separate from lung cancer pathways. The tertiary centre diagnosed more patients per year than the district hospitals, and a greater proportion of its patients received active treatment and shared care. At one district hospital, DGH2, a greater proportion of patients received best supportive care only or no treatment (34 of 47). Differences between trusts in age at diagnosis, mortality and survival were not statistically significant. Clinicians said the regional mesothelioma team meeting was underused, especially by district hospital staff. Some who saw few patients described feeling hopeless. The suspension of clinical trials during COVID-19 limited treatment options. The authors concluded that mesothelioma team meeting structures need review. They noted that the study covered only one region and a relatively small sample.

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: Mixed methods study: review of care-pathway documents, secondary analysis of patient records, and interviews with clinicians
• Who was studied: Three NHS trusts in South England (one tertiary centre with a cancer centre, two district general hospitals), studied March 2019 to March 2021. The study used records of 232 patients with malignant pleural mesothelioma treated August 2014 to August 2019 and interviewed 20 clinicians who attended lung cancer and/or mesothelioma multidisciplinary team meetings.
• Exposure: Not applicable. The study examined clinical decision-making and care pathways, not asbestos exposure.
• Main results:
  • Care pathways at each trust were clearly defined but not always separate from the lung cancer pathway. Care was led by respiratory teams at the tertiary centre and by oncology teams at the district hospitals.
  • The tertiary centre diagnosed significantly more patients per year (mean 27.8) than either district hospital (means 9.2 and 9.4).
  • Across trusts there were no statistically significant differences in age at diagnosis, in mortality (chi-squared 5.37, p=0.068), or in survival after diagnosis. Overall, 174 of the 232 patients (75.0%) were recorded as deceased.
  • Treatment differed significantly between trusts (chi-squared 15.72, p less than 0.001). A greater proportion of tertiary centre patients received active treatment. At DGH2, a greater proportion received best supportive care only (29 of 47, 61.7%) or no treatment (5 of 47, 10.6%). The corresponding tertiary centre figures were 50 of 139 (36.0%) and 5 of 139 (3.6%).
  • Shared care differed significantly between trusts (chi-squared 84.18, p less than 0.001). It was recorded for 97 of 139 tertiary centre patients (69.8%), compared with 4 of 46 at DGH1 and 4 of 47 at DGH2.
  • Interviews produced four main themes: collaboration and communication, evidence base and knowledge, role of the clinician, and role of the patient. Two further themes ran across these: the mesothelioma nurse specialist and COVID-19.
  • Clinicians described the regional mesothelioma multidisciplinary team meeting as underused and poorly attended, particularly by district hospital clinicians.
  • Some clinicians who saw few mesothelioma patients described feeling hopeless. This contrasted with specialist clinicians who saw patients regularly and described 'therapeutic optimism'.
  • Clinicians reported that the suspension of clinical trials during COVID-19 limited treatment options.
• The authors' conclusion: The authors concluded that mesothelioma multidisciplinary team meeting structures need review, so that patients are reviewed by clinicians with appropriate knowledge and expertise. They also concluded that expert mesothelioma clinicians are needed to share an up-to-date evidence base with the wider team.
• Limitations the authors state:
  • The study covered only one region of England and a relatively small sample, which limits how far the findings can be generalised.
  • District general hospitals and tertiary centres are not directly comparable, which affects interpretation of the patient-record findings.

Topics

The National Library of Medicine indexes this study under subjects our site covers: Mesothelioma.

Medical terms in this study, explained in our Lexicon: Mesothelioma, Pleural Mesothelioma, Asbestos Exposure, Prognosis, Median Survival, Lung Cancer, Multidisciplinary Team, Epidemiology.

Related studies

• Research cost analyses to aid in decision making in the conduct of a large prevention trial, CARET. Carotene and Retinol Efficacy Trial — M.D. Thornquist, N. Urban, et al. (1993)
• Epidemiology: a foundation of environmental decision making — K.C.K. Deener, J.D. Sacks, et al. (2018)
• An integrated multicriteria decision making framework for the selection of waste cement dust filled automotive brake friction composites — T. Singh (2024)
• Understanding the palliative care needs and experiences of people with mesothelioma and their family carers: An integrative systematic review — M. Harrison, C. Gardiner, et al. (2021)
• Sample preparation method for visualization of nanoparticulate captured on mixed cellulose ester filter media by enhanced darkfield microscopy and hyperspectral imaging — N.M. Neu-Baker, A.C. Eastlake, et al. (2019)
• A Novel Clinical Prediction Model for Prognosis in Malignant Pleural Mesothelioma Using Decision Tree Analysis — F.J. Brims, T.M. Meniawy, et al. (2016)

Browse more research in BMJ Open Respiratory Research, or return to medical research.