Systematic review of quality of life following pleurectomy decortication and extrapleural pneumonectomy for malignant pleural mesothelioma

Our plain-English summary of Systematic review of quality of life following pleurectomy decortication and extrapleural pneumonectomy for malignant pleural mesothelioma, by R.M. Schwartz, W. Lieberman-Cribbin, A. Wolf, et al (BMC Cancer, 2018).

The study

• Authors: R.M. Schwartz, W. Lieberman-Cribbin, A. Wolf, R.M. Flores, E. Taioli
• Journal: BMC Cancer
• Published: 2018;18(1):1188
• Type of article: Meta-analysis, Systematic review
• Cited by: 30 articles, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

Background: Few studies have focused on quality of life (QoL) after treatment of malignant pleural mesothelioma (MPM). There are still questions as to which surgical procedure, extrapleural pneumonectomy (EPP) or pleurectomy decortication (P/D) is most effective and results in better survival outcomes, involves fewer complications, and results in better QoL. Here we performed a literature review on MPM patients to assess and compare QoL changes after P/D and EPP.

Methods: Research articles concerning QoL after mesothelioma surgery were identified through May 2018 in Medline. For inclusion, studies were 1) cohort or randomized controlled trials (RCT) design, 2) included standardized QoL instruments, 3) reported QoL measurement after surgery, 4) described the type of surgery performed (EPP or P/D), 5) were written in English. Measures of lung function (FEV1, FVC) and measures from the EORTC-C30 were compared 6 months following surgery with preoperative values.

Results: QoL data was extracted from 17 articles (14 datasets), encompassing 659 patients (102 EPP, 432 P/D); the available evidence was of low quality. While two studies directly compared QoL between the two surgical procedures, additional data was available from one arm of two RCTs, as the RCTs were not comparing EPP and P/D. The remaining data was reported from observational studies. While QoL was still compromised 6 months following surgery, from the limited and low quality data available it would appear that P/D patients had better QoL than EPP patients across all measures. Physical function, social function and global health were better at follow-up for P/D than for EPP, while other indicators such as pain and cough were similar. Forced Expiratory Volume (FEV1) and Forced Vital Capacity (FVC) were reported in one study only, and were higher at follow-up for P/D compared to EPP.

Conclusions: Although the existing evidence is limited and of low quality, it suggests that P/D patients have better QoL than EPP patients following surgery. QoL outcomes should be factored into the choice of surgical procedure for MPM patients, and the possible effects on lung function and QoL should be discussed with patients when presenting surgical treatment options.

In plain English

This was a systematic review of published studies, not a new study of patients. The authors searched PubMed through May 2018 for studies that measured quality of life with standardized questionnaires after surgery for malignant pleural mesothelioma. They compared two operations: extrapleural pneumonectomy (EPP) and pleurectomy decortication (P/D). They included 17 articles covering 14 datasets and 659 patients: 102 in EPP studies, 432 in P/D studies, and the rest in two studies that compared the two operations. No randomized trial compared the two operations directly, and the data could not be pooled. In the P/D studies that used one common questionnaire, physical and social functioning and overall health had not returned to pre-surgery levels at 6 months. In one comparison study of 77 patients, quality of life was more impaired after EPP, and only P/D patients returned to baseline at 12 months. The authors concluded that the limited, low-quality evidence suggests quality of life is better after P/D than after EPP. They noted small study sizes, differing questionnaires, and unaccounted effects of chemotherapy and radiation.

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: systematic review of published studies (cohort studies and randomized controlled trials) reporting quality of life after mesothelioma surgery
• Who was studied: 17 articles and 14 distinct datasets totaling 659 pleural mesothelioma patients. 102 patients were in four EPP datasets, 432 in eight P/D studies, and the remainder in two studies comparing EPP with P/D (77 and 48 patients).
• Exposure: Type of surgery for malignant pleural mesothelioma: extrapleural pneumonectomy (EPP) versus pleurectomy decortication (P/D, including partial, extended and radical pleurectomy in some studies), often combined with chemotherapy and/or radiation. Asbestos exposure was not studied.
• Main results:
  • In P/D studies using the EORTC C30 questionnaire, physical and social functioning and global health had not returned to pre-surgery values at 6 months, and pain was still the main symptom reported.
  • In the Rena study (77 patients with stage I or II mesothelioma: 40 EPP, 37 P/D), both operations led to significant impairment on all EORTC C30 measures at 6 months. Impairment was worse in EPP patients, and only P/D patients returned to baseline at 12 months.
  • In the Ploenes study (25 EPP, 23 P/D patients), lung function was comparable at baseline but significantly worse afterward among EPP patients than P/D patients.
  • Lung function results after P/D differed between studies. In the Rintoul trial, FEV1 rose from 57 to 65.5% and FVC from 60.8 to 69.0% at 6 months after partial pleurectomy. The Tanaka study (22 patients) reported statistically significant decreases in FVC and FEV1 after P/D.
  • In the Treasure feasibility trial (12 EPP patients versus a no-surgery group), median quality of life scores were lower in the EPP group at all time points (for example 33.3 versus 75 at 6 weeks), but none of the differences were statistically significant.
• The authors' conclusion: The authors concluded that, although the evidence is limited and of low quality, it suggests quality of life is better after P/D than after EPP for an extended period following surgery, and that quality of life and lung function effects should be discussed with patients when presenting surgical options.
• Limitations the authors state:
  • No randomized trial compared EPP and P/D. The data came from observational studies or from one arm of two randomized trials.
  • The evidence was of low quality because of small samples, lack of randomization and confounders.
  • Each dataset was small, ranging from 12 to 114 patients.
  • Patients may have been assigned to each operation based on their clinical characteristics, which could themselves affect quality of life (selection bias).
  • The quality of life instruments varied and were often not comparable, so the data could not be statistically pooled.
  • The effects of chemotherapy and radiation on quality of life were not accounted for in the publications.
  • There were more data on P/D than EPP patients, and results might differ with more EPP patients.

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: Systematic Review, Quality of Life, Extrapleural Pneumonectomy (EPP), Pleural Mesothelioma, Mesothelioma, FEV1.

Related studies

• Effects of extended pleurectomy and decortication on quality of life and pulmonary function in patients with malignant pleural mesothelioma — D. Burkholder, D. Hadi, et al. (2015)
• Influence of Pleurectomy and Decortication in Health-Related Quality of Life Among Patients with Malignant Pleural Mesothelioma — W.T. Vigneswaran, D.Y. Kircheva, et al. (2018)
• Quality of Life Is Not Deteriorated After Extrapleural Pneumonectomy vs. (Extended) Pleurectomy/Decortication in Patients With Malignant Pleural Mesothelioma — O. Lauk, M. Patella, et al. (2021)
• Quality of life after radical pleurectomy decortication for malignant pleural mesothelioma — N.M. Mollberg, Y. Vigneswaran, et al. (2012)
• Meta-analysis of survival after pleurectomy decortication versus extrapleural pneumonectomy in mesothelioma — E. Taioli, A.S. Wolf, et al. (2015)
• Short-term outcomes of pleurectomy decortication and extrapleural pneumonectomy in mesothelioma — M. van Gerwen, A. Wolf, et al. (2018)

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