Epidemiology, exposure patterns and survival of malignant mesothelioma in Apulia, Italy (1993-2025): a population-based retrospective registry study

Our plain-English summary of Epidemiology, exposure patterns and survival of malignant mesothelioma in Apulia, Italy (1993-2025): a population-based retrospective registry study, by L. De Maria, D. Cavone, G. Delvecchio, et al (BMJ Open, 2026).

The study

• Authors: L. De Maria, D. Cavone, G. Delvecchio, G. Serio, A. Caputi, S. Sole, G. Aloia, V. Lupariello, A. Pierfelice, A. Sindaco, V. Schino, A. Stufano, L. Vimercati
• Journal: BMJ Open
• Published: 2026;16(10):e120874
• Read it: PubMed · Publisher · Free full text

Abstract

Objectives: To characterise the epidemiology, asbestos-exposure patterns, spatial distribution and survival of malignant mesothelioma in Apulia, Italy.

Design: Population-based retrospective registry study.

Setting: Apulian Regional Mesothelioma Registry, a regional operating centre of the Italian National Mesothelioma Registry.

Participants: All 2281 malignant mesothelioma cases recorded between 1993 and 2025.

Interventions: None.

Primary And Secondary Outcomes: Primary outcomes were case distribution, population-adjusted incidence, asbestos-exposure category and overall survival. Secondary outcomes included temporal trends, municipal patterns, proximity of environmentally exposed cases to the former Fibronit plant in Bari and factors independently associated with mortality.

Results: Overall, 1689 cases (74.0%) occurred in men; mean age at diagnosis was 67.8 years and 2018 cases (88.5%) were pleural. Occupational exposure accounted for 49.8% of cases, environmental exposure for 8.9% and familial exposure for 2.4%. Taranto had the highest municipal annual incidence (7.43 per 100 000), followed by Bari (4.59). Among 112 environmentally exposed Bari cases with reconstructed residential distance, 89.3% lived within 1 km of the former Fibronit plant. Kaplan-Meier median survival was 1.0-year and 5-year survival was 10.1%. Survival improved across diagnostic periods (p<0.001). Older age, male sex and pleural site independently predicted higher mortality.

Conclusions: Mesothelioma in Apulia reflects persistent occupational and environmental consequences of historical asbestos use. Geographical hotspots and poor survival support continued registry surveillance, remediation of contaminated sites and targeted health monitoring of formerly exposed workers and communities.

© Author(s) (or their employer(s)) 2026. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ Group.

In plain English

This population-based retrospective study analysed the 2281 malignant mesothelioma cases recorded by the Apulian Mesothelioma Registry in Italy between 1993 and 2025. Of these, 1689 (74.04%) were men. 2018 (88.46%) were pleural and 239 (10.47%) peritoneal. Occupational asbestos exposure was assigned to 49.8% of cases, environmental exposure to 8.9% and familial exposure to 2.4%. For 29.6%, exposure was still to be defined or not classifiable. Steelworks (141 cases) and the Navy (90) were the leading occupational sectors. Taranto had the highest crude municipal incidence (7.43 cases per 100 000 inhabitants per year), followed by Bari (4.59). Of 112 environmentally exposed Bari cases, 89.3% lived within 1000 m of the former Fibronit asbestos–cement plant. The authors stressed that this describes where cases lived, not risk. Among the 2103 cases with complete diagnosis-year and vital-status data, Kaplan-Meier median survival was 1 year and estimated 5-year survival 10.1%. Survival improved across diagnostic periods. Older age, male sex and pleural site were independently associated with higher mortality; exposure category was not. The authors concluded that mesothelioma in Apulia reflects both occupational and environmental exposures.

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 (regional operating centre of the Italian National Mesothelioma Registry, ReNaM)
• Who was studied: All 2281 incident malignant mesothelioma cases (pleural, peritoneal, pericardial or tunica vaginalis testis) in residents of the Apulia region, Italy, recorded 1993–2025; data extracted June 2025
• Exposure: Asbestos exposure was reconstructed by structured interview. It was classified as occupational (certain, probable, possible) or non-occupational (environmental, domestic/familial, hobby-related), or as unlikely, unknown, to be defined or not classifiable. Environmental cases in Bari were analysed by distance from the former Fibronit asbestos–cement plant. Fibre type was not recorded.
• Main results:
  • 1689 cases (74.04%) occurred in males and 592 (25.95%) in females
  • 2018 cases (88.46%) were pleural and 239 (10.47%) peritoneal
  • Exposure was occupational in 49.8% of cases (n=1135), environmental in 8.9% (n=202) and familial in 2.4% (n=55); 19.9% (n=454) were to be defined and 9.7% (n=222) not classifiable
  • Leading occupational sectors: steelworks (141 cases) and the Navy (90 cases)
  • Highest crude municipal average annual incidence (1997–2024) in Taranto, 7.43 cases per 100 000 inhabitants per year, followed by Bari, 4.59
  • Of 112 environmentally exposed Bari cases with reconstructed distance, 89.3% lived within 1000 m of the former Fibronit plant; the authors state this describes case distribution, not risk
  • Kaplan-Meier analysis was performed on the 2103 cases with complete diagnosis-year and vital-status data
  • Overall Kaplan-Meier median survival was 1 year, with survival measured in complete years (n=2103)
  • Kaplan-Meier 5-year survival was 10.1% (censoring-adjusted, n=2103), compared with 5.17% as a crude proportion of the full cohort
  • 5-year survival was 28.1% for peritoneal versus 7.2% for pleural mesothelioma
  • Survival improved across the four diagnostic periods (log-rank p less than 0.001); the authors report this as a descriptive trend, not evidence of a specific cause
  • In the multivariable Cox model (n=2101), male sex was associated with higher mortality (HR=1.271, 95% CI 1.128 to 1.433). Older age (HR=1.020 per year, 95% CI 1.016 to 1.025) and pleural site (HR=1.621, 95% CI 1.388 to 1.893) were also associated with higher mortality.
  • Exposure category was not an independent predictor of survival (occupational vs non-occupational HR=0.977, 95% CI 0.835 to 1.143, p=0.772)
  • Among peritoneal mesothelioma cases, 74.1% had non-occupational exposures
• The authors' conclusion: The authors concluded that mesothelioma in Apulia shows the dual impact of occupational and environmental exposures. They described the Bari and Taranto hotspots as plausibly related to historical industrial activity, although this was not formally tested.
• Limitations the authors state:
  • Retrospective interview-based exposure reconstruction is susceptible to recall and information bias
  • Incomplete exposure classification was not evenly distributed across periods, so bias in exposure-specific estimates cannot be excluded
  • Municipal incidence rates were crude, not age-standardised, and based on small case counts
  • Distance analysis around Fibronit had no population denominators, so it describes case distribution, not risk
  • The registry lacked stage, comorbidity, smoking and treatment data, so residual confounding in survival models cannot be excluded
  • The proportional-hazards assumption was violated for anatomical site, and more modestly for exposure category
  • Changes in diagnostic practice over 33 years could not be checked
  • Retrospective registry design limits causal inference

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: Epidemiology, Mesothelioma, Overall Survival, Occupational Exposure, Environmental Exposure, Median Overall Survival.

Related studies

• Malignant mesothelioma in construction workers: the Apulia regional mesothelioma register, Southern Italy — L. Vimercati, D. Cavone, et al. (2019)
• Environmental asbestos exposure and mesothelioma cases in Bari, Apulia region, southern Italy: a national interest site for land reclamation — L. Vimercati, D. Cavone, et al. (2018)
• Asbestos exposure and malignant mesothelioma of the tunica vaginalis testis: a systematic review and the experience of the Apulia (southern Italy) mesothelioma register — L. Vimercati, D. Cavone, et al. (2019)
• Epidemiological patterns of asbestos exposure and spatial clusters of incident cases of malignant mesothelioma from the Italian national registry — M. Corfiati, A. Scarselli, et al. (2015)
• Response to the "Letter to the Editor" by Gabor Mezei et al., Comments on Vimercati et al., 2019, "Asbestos exposure and malignant mesothelioma of the tunica vaginalis testis: a systematic review and the experience of the Apulia (Southern Italy) mesothelioma register" — L. Vimercati, D. Cavone, et al. (2019)
• Persistence burden and poor survival of pleural mesothelioma in central Italy, 2013-2022: a population-based study thirty years after asbestos ban — M. Iommi, M. Bonifazi, et al. (2026)

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