This is the current release of the guideline.

The Evidence-based Series report, initially the full original Guideline, over time will expand to contain new information emerging from their reviewing and updating activities.

Please visit the Cancer Care Ontario Web site  for details on any new evidence that has emerged and implications to the guidelines.

Malignant pleural mesothelioma

To evaluate the role of surgery (pleurectomy or extrapleural pneumonectomy) in the treatment of adults with malignant pleural mesothelioma

Adult patients with diffuse or localized malignant pleural mesothelioma

Literature Search Strategy

MEDLINE and CANCERLIT databases were searched from 1985 through July 2005, using the Medical Subject Headings "mesothelioma/surgery" and "lung neoplasms/surgery" and the keyword or text word "mesothelioma" in combination with "surgery, "pleurectomy," "decortication," "pneumonectomy," and "resection". Similar terms were used to search the Cochrane Library 2002, Issue 4 for additional clinical trials. These terms were then combined with the search terms for the following study designs: practice guidelines, meta-analyses, systematic reviews, randomized controlled trials, and clinical trials. The search was limited to 1985 onwards because the classification and staging of pleural mesothelioma have varied tremendously over time, and it is difficult to compare data from early trials with that of trials that are more recent.

Ongoing clinical trials were identified using the Physician Data Query (PDQ) database at http://www.cancer.gov/search/clinical_trials/ . Relevant articles were selected and reviewed by two reviewers, and the reference lists from these sources were searched for additional trials, as were the reference lists from relevant review articles. The Canadian Medical Association Infobase (http://mdm.ca/cpgsnew/cpgs/index.asp ) and the National Guideline Clearinghouse (http://www.guideline.gov ) were searched for existing evidence-based practice guidelines.

Inclusion Criteria

Articles were selected for inclusion in this systematic review of the evidence if they were:

1. Randomized controlled trials (RCTs), systematic reviews (including meta-analyses or practice guidelines), phase II trials, or prospective or retrospective cohort studies examining the role of surgical resection for malignant pleural mesothelioma
2. Trials reporting clinical or sub-clinical adverse effects on the topics mentioned above

Exclusion Criteria

1. Trials where the majority of patients were being treated for conditions other than malignant pleural mesothelioma
2. Papers published before 1985
3. Abstract publications
4. Letters and editorials describing trial results
5. Papers published in a language other than English

18 studies (eight non-controlled prospective, of which only four were comparative, and 10 retrospective case series) involving both pleurectomy (PL) and extrapleural pneumonectomy (EPP); four studies (two retrospective case series and two including both retrospective and prospective case-series data) examining EPP only; and four prospective non-comparative studies plus eight retrospective case series studies examining PL only were identified.

Not applicable

A statistical synthesis of the evidence was not conducted because no randomized trials involving surgical treatment for mesothelioma were identified and the prospective and retrospective studies included a variety of adjuvant treatments.

The Program in Evidence-based Care (PEBC) reports consist of a comprehensive systematic review of the clinical evidence on a specific cancer care topic, an interpretation of and consensus agreement on that evidence by Disease Site Groups and Guideline Development Groups, the resulting clinical recommendations and an external review by Ontario clinicians in the province for whom the topic is relevant.

Not applicable

A formal cost analysis was not performed and published cost analyses were not reviewed.

A draft evidence summary version of this series was reviewed by Ontario practitioners. Any changes made to the report as a result of practitioner feedback are described in the original report. Practitioner feedback was obtained through a mailed survey of 111 practitioners in Ontario (31 surgeons, 36 medical oncologists, 23 radiation oncologists, 20 respirologists, and 1 hematologist). The survey consisted of items evaluating the methods, results, and interpretive summary. Written comments were invited. The practitioner feedback survey was mailed out on June 5, 2003. Follow up reminders were sent out at two weeks (postcard) and four weeks (complete package mailed again). The Lung Disease Site Group (DSG) reviewed the results of the survey.

The evidence summary report was circulated to members of the Practice Guidelines Coordinating Committee (PGCC) for review and approval. Eight of thirteen members of the PGCC returned ballots. Three PGCC members approved the evidence-based series report as written, and five members approved the report conditional on the Lung Disease Site Group addressing specific concerns.

Because of the lack of sufficient high-quality evidence on the surgical management of mesothelioma, the Lung Cancer Disease Site Group opinion is that:

• The role of surgery in the management of malignant pleural mesothelioma cannot be precisely defined. Specifically, the lack of randomised controlled clinical trials makes it impossible to determine whether the use of extrapleural pneumonectomy or pleurectomy improves the survival of patients with malignant pleural mesothelioma or effectively palliates the symptoms of the disease.
• In patients who undergo surgery, combined with chemotherapy and/or radiotherapy, multivariate analysis shows that longer survival is associated with small, epithelial-type, node-negative pleural mesotheliomas.
• This Evidence Summary is confined to the surgical management of malignant pleural mesothelioma. Please refer to Evidence Summary Report #7-14-1 and the Evidence-based Series #7-14-3, to be released shortly, for opinions on the use of systemic therapy and radiation therapy in this disease.
• There is a need for future studies of the role of surgery in the treatment of mesothelioma to include evaluations of quality of life.

None provided

The recommendations are supported by non-controlled prospective studies (including comparative studies), and retrospective case series.

Care has been taken in the preparation of the information contained in this document. Nonetheless, any person seeking to apply or consult the evidence-based series is expected to use independent medical judgment in the context of individual clinical circumstances or seek out the supervision of a qualified clinician. Cancer Care Ontario makes no representation or guarantees of any kind whatsoever regarding their content or use or application and disclaims any for their application or use in any way.

An implementation strategy was not provided.

Not applicable: The guideline was not adapted from another source.

The Program in Evidence-based Care (PEBC) is a Province of Ontario initiative sponsored by Cancer Care Ontario and the Ontario Ministry of Health and Long-Term Care.

Cancer Care Ontario
Ontario Ministry of Health and Long-Term Care

Provincial Lung Cancer Disease Site Group

For a current list of past and present members, please see the Cancer Care Ontario Web site .

The members of the Lung Disease Site Group (DSG) disclosed potential conflicts of interest relating to the topic of this evidence-based series. No potential conflicts were declared.

This is the current release of the guideline.

The Evidence-based Series report, initially the full original Guideline, over time will expand to contain new information emerging from their reviewing and updating activities.

Please visit the Cancer Care Ontario Web site  for details on any new evidence that has emerged and implications to the guidelines.

Electronic copies: Available in Portable Document Format (PDF) from the Cancer Care Ontario Web site .

The following are available:

• Surgical management of malignant pleural mesothelioma. Evidence-Based Series report. Toronto (ON): Cancer Care Ontario (CCO), 2005 Aug 9. Various p. (Practice guideline; no. 7-14-2: Section 1. Electronic copies: Available in Portable Document Format (PDF) from the Cancer Care Ontario Web site .
• Browman GP, Levine MN, Mohide EA, Hayward RSA, Pritchard KI, Gafni A, et al. The practice guidelines development cycle: a conceptual tool for practice guidelines development and implementation. J Clin Oncol 1995;13(2):502-12.

None available

This summary was completed by ECRI on January 24, 2006. The information was verified by the guideline developer on February 23, 2006.

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions. Please refer to the Copyright and Disclaimer Statements  posted at the Program in Evidence-Based Care section of the Cancer Care Ontario Web site.