Lung cancer

UK: First guidelines for the management of mesothelioma

The newly-published British Thoracic Society guideline on the investigation and management of pleural malignant mesothelioma should help reduce “wide and unwarranted variation,” in care, according to the lead author.

Speaking to the limbic, Dr Ian Woolhouse, consultant respiratory physician at Queen Elizabeth Hospital in Birmingham, UK, said the guidelines were the first of its kind to be published in the UK.

He said their need had become clear following data from the 2016 National Mesothelioma Audit that had shown variations in care and outcomes around the UK. “We felt it was important to have a guideline that would standardise care to that of the best,” he said.

For example, around two thirds of mesothelioma patients receive chemotherapy, he said, but “that can vary from in some areas less than a fifth, to in others three quarters, without obvious explanation.”

According to the guidelines patients with good performance status should be offered first line chemotherapy with cisplatin and pemetrexed, plus bevacizumab where licensed (it is not currently licensed in the UK).

“If all units were to adopt this, I think we would see a shift in terms of active treatment rates,” said Dr Woolhouse. He said the guideline committee “would be supportive” of a licence application from the manufacturers of bevacizumab.

The guideline is equally clear about treatments not backed by evidence, in particular radical surgery (extrapleural pneumonectomy or EPP). Trial data showed this treatment “in actual fact appeared to be associated with worse outcomes.”

The guideline does not recommend the use of EPP for disease control, and Dr Woolhouse says surgery should only be offered in the context of a clinical trial.

“I think it’s an important role as a group of experts to protect patients from a treatment that could do more harm than good,” he said.

The decision puts the BTS guideline at odds with the American Society for Clinical Oncology guidelines, published in January, which do recommend EPP surgery for some selected patients, and other surgery more widely.

Dr Woolhouse says it is “difficult to speculate” about why the two guidelines reached different conclusions but said “there may be an issue with surgeons being very attached to performing this procedure and finding it quite difficult to reach a conclusion that it might not be the best procedure to offer to patients.”

The mesothelioma field is changing fast, with several big studies in the pipeline. Dr Woolhouse says “I think we will need to update, probably within five years, particularly the immune-oncology section where we very much hope to be able to recommend some new treatments.”


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