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BTS publish new mesothelioma guideline

The British Thoracic Society has published a new guideline for the investigation and management of malignant pleural mesothelioma (MPM).1

Endorsed by PCRS-UK, the guideline offers recommendations on symptom recognition, management and follow-up of the disease that are relevant for primary care clinicians.

The use of products containing asbestos was banned in the UK in 1999 but mesothelioma takes a long time to develop (often 30-40 years after exposure) and symptoms can be non-specific, especially breathlessness, cough and chest pain.

Key recommendations for primary care:

  • Do not rule out a diagnosis of MPM on the basis of symptoms and examination findings alone.
  • Offer an urgent chest x ray to patients with symptoms as outlined by NICE NG122 (early diagnosis of malignant lung cancers).
  • If the chest x ray result is suggestive of MPM a two week wait suspected cancer pathway is recommended.
  • If the patient has a history of significant asbestos exposure and a normal chest x ray but is symptomatic, this is worth considering for further referral / investigation.

To confirm the diagnosis in secondary care patients should expect:

  • To be offered a CT scan with contrast initially, some will require PET scan or MRI.
  • Biopsies for people with suspected MPM should be reviewed by a pathologist with expertise in the disease and at times a second opinion should be sought.
  • The diagnosis and treatment plan should be established by a multidisciplinary team.

Treatment options:

  • Pleural effusions may be managed with talc or indwelling pleural catheters for symptomatic relief.
  • Some patients may be appropriately treated with cisplatin and pemetrexed.
  • Palliative radiotherapy is recommended for localised pain.
  • Symptom control is important and should be managed in keeping with general palliative care. Early involvement with specialists is advised if patients have problems with symptoms.

Dr Steve Holmes, who represented PCRS-UK on the BTS guideline development group, says: “Primary care clinicians should carefully read the recommendations in this guideline on symptom recognition, management and follow-up of these patients.  The symptoms of MPM can be non specific so primary care clinicians should always be asking themselves when assessing patients complaining of breathlessness, cough and chest pain - what else could it be?’

  1. BTS Guideline for the investigation and management of malignant pleural mesothelioma
  2. Suspected cancer recognition and referral. NICE June 2015 
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