Prognostic factors in elderly patients with malignant pleural mesothelioma: results of a multicenter survey

Our plain-English summary of Prognostic factors in elderly patients with malignant pleural mesothelioma: results of a multicenter survey, by G.L. Ceresoli, F. Grosso, P.A. Zucali, et al (British Journal of Cancer, 2014).

The study

• Authors: G.L. Ceresoli, F. Grosso, P.A. Zucali, M. Mencoboni, G. Pasello, C. Ripa, D. Degiovanni, M. Simonelli, A. Bruzzone, C. Dipietrantonj, E. Piccolini, G.D. Beretta, A.G. Favaretto, L. Giordano, A. Santoro, M. Botta
• Journal: British Journal of Cancer
• Published: 2014;111(2):220-6
• Cited by: 30 articles, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

Background: The incidence of malignant pleural mesothelioma (MPM) in elderly patients is increasing. There are no specific guidelines for their management.

Methods: The clinical records of elderly patients (⩾70 years old) with MPM referred from January 2005 to November 2011 to six Italian Centres were reviewed. Age, gender, histology, International Mesothelioma Interest Group (IMIG) stage, Eastern Cooperative Oncology Group Performance Status (ECOG-PS), Charlson Comorbidity Index (CCI) and treatment modalities were analysed and correlated to overall survival (OS).

Results: In total, 241 patients were identified. Charlson Comorbidity Index was ⩾1 in 92 patients (38%). Treatment was multimodality therapy including surgery in 18, chemotherapy alone in 180 (75%) and best supportive care in 43 cases (18%). Chemotherapy was mainly pemetrexed based. Median OS was 11.4 months. Non-epithelioid histology (HR 2.32; 95% CI 1.66-3.23, P<0.001), age ⩾75 years (HR 1.44; 95% CI 1.08-1.93, P=0.014), advanced (III-IV) stage (HR 1.47; 95% CI 1.09-1.98, P=0.011) and CCI⩾1 (HR 1.38; 95% CI 1.02-1.85, P=0.034) were associated to a shorter OS. Treatment with pemetrexed was associated with improved OS (HR 0.40; 95% CI 0.28-0.56, P<0.001).

Conclusions: Non-epithelioid histology, age ⩾75 years, advanced IMIG stage and presence of comorbidities according to CCI were significant prognostic factors in elderly patients with MPM. Treatment with pemetrexed-based chemotherapy was feasible in this setting. Prospective dedicated trials in MPM elderly patients selected according to prognostic factors including comorbidity scales are warranted.

In plain English

This retrospective review covered records of patients aged 70 or older with malignant pleural mesothelioma diagnosed January 2005 to November 2011 at six Italian centres. Of 715 consecutive cases, 241 elderly patients with complete data were included. Asbestos exposure was documented in 80%: occupational in 101 patients and environmental in 91. Most (178) received pemetrexed-based chemotherapy; 43 received supportive care only. Median overall survival was 11.4 months. In the main statistical model, shorter survival was associated with non-epithelioid tumour type (hazard ratio 2.32; 95% CI 1.66 to 3.23), age 75 or older (1.44; 1.08 to 1.93), stage III to IV (1.47; 1.09 to 1.98) and at least one other illness on the Charlson Comorbidity Index (1.38; 1.02 to 1.85). Asbestos exposure was not significantly related to survival in that model (hazard ratio 1.28; 95% CI 0.89 to 1.85). Pemetrexed treatment was associated with longer survival (hazard ratio 0.40; 95% CI 0.28 to 0.56). The authors cautioned that this treatment finding came from a non-randomised retrospective study. They concluded that an invariably nihilistic attitude toward elderly patients should be avoided.

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 multicenter review of clinical records (survey) analysing prognostic factors for overall survival
• Who was studied: 241 patients aged 70 years or older with malignant pleural mesothelioma and complete clinical data, out of 715 consecutive mesothelioma cases diagnosed January 2005 to November 2011 at six Italian centres. Median age was 75 (range 70 to 92), and 64% were male.
• Exposure: Asbestos exposure was taken from clinical records and classified as occupational (101, 42%), environmental (91, 38%), uncertain (19, 8%) or not documented (30, 12%). Fiber types were not reported. Treatments studied were mainly pemetrexed-based chemotherapy, with some multimodality therapy including surgery, or best supportive care.
• Main results:
  • For all 241 patients, median overall survival was 11.4 months. Estimated survival was 48.4% at 1 year (95% CI 41.9 to 54.6%) and 21% at 2 years (95% CI 16.0 to 26.5%).
  • In the multivariate analysis, non-epithelioid histology was associated with shorter overall survival (HR 2.32; 95% CI 1.66 to 3.23, p less than 0.001).
  • In the multivariate analysis, age 75 years or older was associated with shorter overall survival (HR 1.44; 95% CI 1.08 to 1.93, p = 0.014).
  • In the multivariate analysis, advanced (III to IV) IMIG stage was associated with shorter overall survival (HR 1.47; 95% CI 1.09 to 1.98, p = 0.011).
  • In the multivariate analysis, a Charlson Comorbidity Index of 1 or more (92 patients, 38%) was associated with shorter overall survival (HR 1.38; 95% CI 1.02 to 1.85, p = 0.034).
  • Patients aged 80 or older had a median overall survival of 6.7 months, compared with 13.1 months for those under 80 (p less than 0.001).
  • Documented asbestos exposure was linked to shorter survival in the univariate analysis (median 10.4 months for occupational or environmental exposure vs 15.2 months for uncertain or not documented, p = 0.009). It was not significantly related to survival in the multivariate analysis (HR 1.28; 95% CI 0.89 to 1.85, p = 0.183).
  • The 178 patients (74%) who received any pemetrexed-based chemotherapy survived longer than those who did not (median 13.2 vs 4.9 months). In the multivariate analysis, pemetrexed treatment had an HR of 0.40 (95% CI 0.28 to 0.56, p less than 0.001).
  • With first-line chemotherapy, 1 patient had a complete response and 45 a partial response (response rate 23%); 75 had stable disease, giving an overall disease control rate of 61%.
• The authors' conclusion: The authors concluded that non-epithelioid histology, age 75 or older, advanced IMIG stage and comorbidity on the Charlson Index were significant prognostic factors. They stated that pemetrexed-based chemotherapy was strongly correlated with survival, though a retrospective non-randomized evaluation should be treated with great caution. They said an invariably nihilistic attitude toward elderly mesothelioma patients should be avoided, and called for prospective dedicated trials.
• Limitations the authors state:
  • Possible selection: some cases with very poor prognosis may not have been referred to the centres because of very advanced age or poor performance status.
  • The stage finding should be interpreted with caution because the IMIG staging system has known limitations in non-surgical patients.
  • Detailed toxicity data were not available for all patients because the study was retrospective, so toxicity was not analysed.
  • The treatment-related finding comes from a retrospective, non-randomized evaluation and should be considered with great caution.

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: Pleural Mesothelioma, Histology, Mesothelioma, IMIG, Performance Status, Overall Survival, Multimodal Therapy, Chemotherapy.

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