Malignant mesothelioma is a tumour originating from mesothelial cells. 85–95% of mesotheliomas are caused by asbestos exposure. It occurs much more commonly in the chest (malignant pleural mesothelioma) than in the abdomen (peritoneal mesothelioma).

Malignant Mesothelioma

CAA: January 2016

Malignant Mesothelioma Malignant mesothelioma is a tumour originating from mesothelial cells. 85–95% of mesotheliomas are caused by asbestos exposure. It occurs much more commonly in the chest (malignant pleural mesothelioma) than in the abdomen (peritoneal mesothelioma). Rarely mesothelioma arises in the pericardium or tunica vaginalis testis, the membrane surrounding the testicles. The malignant mesothelioma is indicated by yellow arrows, the central pleural effusion is marked with a yellow star. (1) right lung, (2) spine, (3) left lung, (4) ribs, (5) aorta, (6) spleen, (7) left kidney, (8) right kidney, (9) liver. (Image: By Stevenfruitsmaak - self-made, based on Image:Tumor Mesothelioma2.JPG, GFDL, https://commons.wikimedia.org/w/index.php?curid=4069698)

It is accepted by all expert bodies, including the World Health Organisation, that all types of asbestos cause mesothelioma. Crocidolite (blue asbestos) carries the highest risk, amosite (brown asbestos) is almost as dangerous, and chrysotile (white asbestos) the least dangerous. Some of the cases which arise in patients who cannot recall any asbestos exposure probably result from unidentified occupational or domestic exposure. Many cases have occurred in families of workers exposed to asbestos who carried the dust home on their clothes and hair. Other cases probably arise as a result of contamination of the air by asbestos fibres released from asbestos in the environment. A few cases probably occur spontaneously unrelated to any asbestos exposure. Any type of cancer can arise spontaneously as a result of accidental genetic mutations In the UK, there are more than 2000 deaths from mesothelioma each year. Mortality is beginning to decline in younger men but overall is expected to increase by 10-20% over the next 5-10 years, then to fall gradually. Mesothelioma may occur after a small exposure to asbestos but the risk increases with the amount of asbestos exposure. The usual interval between Clydeside Action on Asbestos is a Company Limited by Guarantee with Charitable Status. Company number: 398038 | Scottish Charity Number: SCO17874 Registered Office: 245 High Street, Glasgow, G4 0QR. Tel 0141 552 8852.

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first exposure to asbestos and death from mesothelioma is around 40 (30-50) years but may be as little as 10 years or as much as 60 years or more. The risk of mesothelioma is not affected by smoking.

Presentation and Diagnosis Patients with pleural mesothelioma usually present to their doctor with chest pain and/or breathlessness. Usually there is a pleural effusion (i.e. fluid in the chest cavity) accounting for the breathlessness. They may have a cough, feel tired and generally unwell. Chest X-rays and CT scans often lead to a strong suspicion of mesothelioma. It is necessary to take samples of tissue (a biopsy) from the tumour or fluid from the pleural cavity for examination under the microscope in order to confirm the diagnosis. The samples can often be obtained by passing a special needle through the skin of the chest. This is often done with help from an ultrasound scan or CT scan to make sure the most appropriate area is sampled. These procedures are done under local anaesthesia. Sometimes these methods do not give the diagnosis. It is then necessary to perform a small operation known as a thoracoscopy or pleuroscopy. This is done under general anaesthesia or sometimes under local anaesthesia. It involves small incisions in the chest between the ribs to allow a viewing telescope and forceps to be passed into the chest. The surgeon can see the tumour and take samples from it. When the samples have been obtained the pathologist looks at them under the microscope and performs special stains to identify the tumour as a mesothelioma and to determine the type of mesothelioma. This often takes a week or more. The principal histological varieties are epithelioid, sarcomatoid Clydeside Action on Asbestos is a Company Limited by Guarantee with Charitable Status. Company number: 398038 | Scottish Charity Number: SCO17874 Registered Office: 245 High Street, Glasgow, G4 0QR. Tel 0141 552 8852.

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and mixed. Patients with the epithelioid type tend to survive a little longer. The median survival from presentation is 12–18 months; a few patients with epithelioid tumours survive for more than 5 years. It is important to appreciate that these are average figures and should not be taken as predictions of life expectancy for an individual patient without consideration of the particular circumstances of that patient.

Treatment of Mesothelioma The standard treatment for mesothelioma is often referred to as best supportive care (BSC) or active symptom control (ASC), to highlight the fact that the doctors and nurses will be seeking actively to identify and relieve symptoms of the disease. Increasingly chemotherapy is regarded as part of standard treatment for patients fit enough to receive it. In the earlier stages of pleural mesothelioma there is often a recurrent pleural effusion which causes breathlessness. This is dealt with by pleurodesis which means inducing adhesions between the lung and chest wall. This closes off the pleural space so the effusion cannot reform. It is usually performed by putting sterile talc into the chest through the tube used to drain the fluid. Chest pain is another common problem. Painkilling drugs are usually effective. If pain remains severe despite drugs a minor surgical procedure called cordotomy can be effective. This is done under local anaesthesia and the aim is to disable the pain carrying nerves in the spinal cord. Various other symptoms including sweating, loss of appetite and weight may also be helped by medication.

Surgery for Mesothelioma In some cases it is helpful to remove the pleura from around the lung to help the lung to expand better, a procedure known as pleurectomy (sometimes referred to as decortication). This procedure cannot eliminate the mesothelioma completely and it grows back again.

Clydeside Action on Asbestos is a Company Limited by Guarantee with Charitable Status. Company number: 398038 | Scottish Charity Number: SCO17874 Registered Office: 245 High Street, Glasgow, G4 0QR. Tel 0141 552 8852.

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In highly selected cases with early stage disease more radical surgery called extra-pleural pneumonectomy can be considered. The surgeon attempts to remove the mesothelioma completely, which involves taking out the whole lung and parts of neighbouring structures i.e. the diaphragm which separates the lung from the abdomen and the pericardium, the covering of the heart. Some experienced clinicians report that a few patients enjoy long term survival after this procedure. However, the average survival is no better for patients subjected to radical surgery than for patients treated with chemotherapy.

Radiotherapy for Mesothelioma Some doctors recommend radiotherapy to the chest wall at the sites of chest

drain insertion or a biopsy in order to prevent the mesothelioma growing through the skin. There is some uncertainty as to the effectiveness of this treatment and some doctors do not believe it is worthwhile. There are two main uses of radiotherapy to treat symptoms. One is to treat a chest wall tumour which is forming a lump beneath the skin and which is causing discomfort or pain. Radiotherapy can shrink the lump and alleviate pain. The other is to relieve deeper seated pain which is not responding well to pain relieving drug therapy.

Chemotherapy for Mesothelioma Chemotherapy can prolong survival in patients with mesothelioma. The average gain is around 2 to 3 months. This may not sound very much but the average represents some patients whose mesotheliomas do not respond to therapy who may not live any longer than they would have done without chemotherapy and others whose mesotheliomas respond well and whose survival gain is more than the Clydeside Action on Asbestos is a Company Limited by Guarantee with Charitable Status. Company number: 398038 | Scottish Charity Number: SCO17874 Registered Office: 245 High Street, Glasgow, G4 0QR. Tel 0141 552 8852.

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average of three months. As yet there is no way to predict before treatment starts which mesotheliomas will respond well and which will not. The chemotherapy of first choice is pemetrexed (trade name Alimta) in combination with either cisplatin or carboplatin. The drugs are given through a drip in an arm vein. The treatment is given on an out-patient basis and does not require hospitalization. Usually 4 to 6 cycles are administered at 3 week intervals. A CT scan is performed after every 2 or 3 cycles to assess progress. If the mesothelioma has stayed the same size or shrunk treatment is continued but if the tumour has grown treatment is discontinued. The treatment is generally well tolerated and can help symptoms of the illness as well as prolong survival. However, some patients do not tolerate it well in which case it is discontinued. Side effects are usually not severe but can include sore mouth and eyes, tiredness and sickness. There is usually little, if any, hair loss. Another type of chemotherapy used is vinorelbine (trade name Navelbine). This can also relieve symptoms of mesothelioma and it can probably prolong life by an average of 2 months, although the evidence for prolongation of life is less strong than for pemetrexed. This drug has the advantage of being available in tablet form so the treatment can be given without the need for hospital admission. It is usually well tolerated without serious side effects. Vinorelbine can be used as second line therapy in patients who have previously received pemetrexed.

Mesothelioma Research Clinical Trials There is a recently opened randomised trial known as MARS-2 which aims to assess the value of major surgery called extended pleurectomy and decortication, ie stripping of the parietal pleura lining the ribcage, the visceral pleura from around the lung and resection of the diaphragm and pericardium if they are involved by

Clydeside Action on Asbestos is a Company Limited by Guarantee with Charitable Status. Company number: 398038 | Scottish Charity Number: SCO17874 Registered Office: 245 High Street, Glasgow, G4 0QR. Tel 0141 552 8852.

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tumour. Patients are randomly allocated to received standard chemotherapy alone or chemotherapy plus surgery. A recent randomised trial showed significant prolongation of survival by a median of 2.7 months with the addition of bevacizumab to standard chemotherapy with pemetrexed and cisplatin. Bevacizumab is expensive and unlikely to be approved by NICE for the treatment of mesothelioma. Various new biological agents are under investigation. There have been promising response rates in early trials with ADI – PEG and with Pembrolizumab. A randomised trial comparing standard chemotherapy with standard chemotherapy plus ADI – PEG known as the TRAP trial is under way.

Financial help Compensation and Benefits Those who contract mesothelioma generally fall into two categories: • Those that contract mesothelioma as a result of exposure to asbestos while working for a past or current employer • Those who either were not, or cannot demonstrate that they were, exposed to asbestos at work, which may have led to them contracting mesothelioma There are also two main categories of compensation:  State or government compensation in the form of benefits and no fault compensation schemes  Compensation from bringing a legal action against those employers who exposed you to asbestos Please note: In most cases of mesothelioma, it is possible for you to receive both benefits and a lump-sum payment from the government and then go on to receive civil damages. However, the DWP may recover some of those Clydeside Action on Asbestos is a Company Limited by Guarantee with Charitable Status. Company number: 398038 | Scottish Charity Number: SCO17874 Registered Office: 245 High Street, Glasgow, G4 0QR. Tel 0141 552 8852.

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benefits and any lump-sum payment from your civil/personal injury compensation.

Exposed to Asbestos at Work? State (government) benefits If you contracted mesothelioma at work, you may be entitled to Industrial Injuries Disablement Benefit. You may also be entitled to benefits such as Personal Independence Payment or Attendance Allowance regardless of how you came in to contact with asbestos. In addition, you may qualify for other state benefits depending on your circumstances.

Industrial Injuries Disablement Benefit The UK Government currently categorises mesothelioma as a prescribed disease for the purposes of claiming Industrial Injuries Disablement Benefit (IIDB). Each disease has an allocated Prescribed Disease (PD) number. Mesothelioma is Prescribed Disease D3. To meet the criteria for D3 – Diffuse Mesothelioma (primary neoplasm of the mesothelium of the pleura or of the pericardium or of the peritoneum. A cancer starting in the covering of the lungs or the lining of the abdomen) it is not necessary to demonstrate that you worked directly with asbestos; you need only show that you were employed in a job which led to you being exposed to…. “asbestos, asbestos dust or any admixture of asbestos at a level above that commonly found in the environment at large”. In practice, this could involve any occupation where you may have been exposed to asbestos. For example, it has been accepted that a secretary, who worked in an office building directly opposite a shipyard, contracted mesothelioma as a result of inhaling airborne fibres from the shipyard entering her work environment. Applications for mesothelioma and lung cancer do not normally require a medical examination but you do need confirmation from a medical professional that you have been diagnosed with the disease. Clydeside Action on Asbestos is a Company Limited by Guarantee with Charitable Status. Company number: 398038 | Scottish Charity Number: SCO17874 Registered Office: 245 High Street, Glasgow, G4 0QR. Tel 0141 552 8852.

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State (government) compensation scheme Pneumoconiosis etc. (Workers Compensation) Act 1979 An award of Industrial Injuries Disablement Benefit for mesothelioma may also lead to entitlement to a payment under this workers’ compensation scheme introduced in 1979. Please note: If you are refused a payment under the Pneumoconiosis etc. (Workers Compensation) Act 1979 for mesothelioma, you will automatically be considered for a payment under the Diffuse Mesothelioma Scheme 2008 A payment under the Pneumoconiosis etc. (Workers’ Compensation) Act 1979 may adversely affect any existing entitlement you may already have to other state (government) means-tested benefit such as Universal Credit, Income Support, Pension Credit, Housing Benefit etc.

Civil (personal injury) compensation When you are told, or become aware that you have an asbestos related condition, you will normally have a period of 3 years from that date in which to start a court action for compensation. If you have been diagnosed with an asbestos-related condition, a claim for compensation must be brought within 3 years of the date you first became aware that you had that condition. As the law stands in Scotland, if a claim is not brought within 3 years, you may be time-barred from bringing a claim. Any employer who can be shown to have materially contributed to your asbestos related condition and who acted negligently may be liable to pay Clydeside Action on Asbestos is a Company Limited by Guarantee with Charitable Status. Company number: 398038 | Scottish Charity Number: SCO17874 Registered Office: 245 High Street, Glasgow, G4 0QR. Tel 0141 552 8852.

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damages. Even if the employer has ceased trading, action can still be taken if an employer’s liability insurers can be traced.

What if I can’t trace an employer or insurer? Diffuse Mesothelioma Payment Scheme (DMPS) 2014 You may be able to claim if all of the following apply: • you were diagnosed with diffuse mesothelioma on or after 25 July 2012 • your mesothelioma was caused by exposure to asbestos when working in the UK • you can’t trace the employer that exposed you to asbestos, or their insurers • you haven’t made a civil claim against any employer or insurer • you haven’t received damages or a specified payment for mesothelioma and you’re not eligible to a specified payment.

Not Exposed to Asbestos at Work? State (government) compensation & benefits If you did not contract mesothelioma as a result of exposure to asbestos at work you will not qualify for Industrial Injuries Disablement Benefit. However, you may be entitled to benefits such as Personal Independence Payment or Attendance Allowance. You may also be entitled to other state benefits depending on your circumstances. As well as entitlement to state benefits, you may be eligible for a lumpsum payment under the Diffuse Mesothelioma Scheme 2008.

Diffuse Mesothelioma Scheme 2008 Prior to 2008, there was no entitlement to state compensation for those diagnosed with mesothelioma unless they could show that they had contracted the disease at work. This new scheme therefore covers for the first time those who contracted mesothelioma from domestic or environmental exposure to asbestos. Clydeside Action on Asbestos is a Company Limited by Guarantee with Charitable Status. Company number: 398038 | Scottish Charity Number: SCO17874 Registered Office: 245 High Street, Glasgow, G4 0QR. Tel 0141 552 8852.

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A payment under the Diffuse Mesothelioma Scheme 2008 may adversely affect any existing entitlement you may already have to other state (government) means-tested benefit such as Universal Credit, Income Support, Pension Credit, Housing Benefit etc. We strongly advise you to contact us before applying

Not Exposed to Asbestos at Work? Civil (personal injury) compensation When you are told, or become aware that you have an asbestos related condition, you will normally have a period of 3 years from that date in which to start a court action for compensation. It is possible, in some circumstances, for you to pursue a civil/personal injury claim for compensation even if you have never been exposed to asbestos at work. For example, if you were a married woman and your husband worked in an asbestos polluted environment, like the shipyards, it could be possible that you contracted mesothelioma from washing your husband’s work clothes. In this scenario, it may be possible for you to bring a claim for damages. In order to determine whether a claim is possible, you will require the services of a specialist personal injury solicitor.

Source: www.clydesideactiononasbestos.org.uk © CAA. 2016. All rights reserved. Clydeside Action on Asbestos is a Company Limited by Guarantee with Charitable Status. Company number: 398038 | Scottish Charity Number: SCO17874 Registered Office: 245 High Street, Glasgow, G4 0QR. Tel 0141 552 8852.

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