Mesothelioma
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Mesothelioma
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We're approaching the mesothelioma "epidemic", with the peak meant to be around 2015-ish. And still we have no effective treatment for mesothelioma. Our local oncologists are keen on chemo
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Cat:OpenClinicalForum:8114d353-b41b-4a03-b052-dc009589d5cfDiscussion:6cf950ff-d316-4192-a303-edd8ab663f11
Forums » Open clinical » Respiratory medicine » Mesothelioma
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Mesothelioma
posted at 13/11/2011 9:54 PM GMT
on bmj.com
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Posts: 1177
First: 19/4/2010 Last: 16/5/2013 |
We're approaching the mesothelioma "epidemic", with the peak meant to be around 2015-ish. And still we have no effective treatment for mesothelioma. Our local oncologists are keen on chemotherapy, but our local chest physicians are less enthusiastic. We do agree on extra-thoracic pneumonectomy, as our surgical colleagues now don't take them on. What do you tell your patients with mesothelioma?
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Re: Mesothelioma
posted at 13/11/2011 11:52 PM GMT
on bmj.com
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*Moderator*
Posts: 682
First: 17/11/2008 Last: 19/5/2013 |
I don't know anything about mesothelioma other than what I learnt at medical school and what I googled when a friend of mine;s mother in law died of it- related to exposure from her father's work- washing his shirts dripping with aspestos I think.. I did not realise there was an anticipated epidemic of any sorts -is there any idea how many people would have been exposed to aspestos at the requisite levels.When my friend's mother in law died there were no effective treatments - we looked at trials in the US as you do. Why are surgeons not enthusaistic about pneumonectomy- and why do you think it is an option? |
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Re: Mesothelioma
posted at 14/11/2011 2:32 AM GMT
on bmj.com
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Posts: 2947
First: 10/3/2009 Last: 29/4/2013 |
Australia is leading the world in mesothelioma incidence and we are proud of it. This has been due to years of exemplary incompetence by government and even the medical profession. I think Belgium just pips us at the post but we are doing very well in this field as it is a growth industry. To date I have done over 10,000 medicolegal reports for asbestos victims. We first got wind of the potential dangers of asbestos in the 1930's or even earlier (abestosis) but it was not until the early 1960s that the association between this wonder fibre and mesothelioma was found (in the Cape Province in Sth Africa,, Selikoff et al). However, not to be outdone and as Australia and Africa were once joined, we have lots of blue asbestos called crocidolite as we have lots of crocodiles too. The Wittenoom Gorge in Western Australia was the brain child of a mining magnate called Lang Hancock and it all went ahead despite the warnings of a young English medical officer in the West Australian Health Dept in Perth called Eric Saint who was later my Dean of Medicine. Yes, we have done it well. Most houses pre-1990 here have some asbestos in them. This occupational epidemic will go on for years to come. Yes, we have done it well but now like apostates converted to Catholicism, we are now zealots in the war against asbestos while Canada has a scientific scotoma when it comes to this wonder fibre which brings so much wealth to Quebec and cheap shanties to India. I could say more, but there is probably a limit on notes in this doc2doc requiem.
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Re: Mesothelioma
posted at 14/11/2011 10:27 AM GMT
on bmj.com
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Posts: 1177
First: 19/4/2010 Last: 16/5/2013 |
The issue of how much asbestos is required to give a patient mesothelioma is not entirely clear, and has been the point of argument for many a legal case (I can't admit to the 10,000 cases my learned colleague has done, but I am but a boy). We generally acknowledge that it takes 5 years of daily exposure to asbestos fibres to contract asbestosis. We've seen Mesothelioma is patients with only 2 years of exposure, but we must remember that there is a small proportion of patients who will develop mesothelioma without any asbestos exposure at all. Extra-thoracic pneumonectomy - removal of the lung, both layers of pleura, the diaphragm on that side, and the pericardium - was the great white hope for mesothelioma; the enthusiastic surgeons touting not a cure, but years of disease free time. The procedure has proved to have a huge associated peri-operative mortality, as well as a significant post operative morbidity, with complications, and most importantly, no significant prologation of life expectancy. So the surgeons locally don't want to do it, and we don't tend to ask. That's not to say I wouldn't refer a 50 year old man who is remarkably fit otherwise, but that's not the patient group we see....
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Re: Mesothelioma
posted at 14/11/2011 12:19 PM GMT
on bmj.com
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Posts: 2947
First: 10/3/2009 Last: 29/4/2013 |
I have seen mesothelioma from exposure over a weekend, over the school holidays etc. Surgery is for idealists and those after research grants. Radical horrendoplasties are not good for the patient but they may help the surgeon pay off his Merc faster.
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Re: Mesothelioma
posted at 15/11/2011 12:04 AM GMT
on bmj.com
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Posts: 2947
First: 10/3/2009 Last: 29/4/2013 |
I disagree it takes five years of exposure to get asbestosis. It takes heavy exposure even of shorter duration or moderate exposure over longer duration. Clearance of fibres by the lung varies a lot from person to person. It is not a given you will get asbestosis. Fibre type is also important. I have seen male workers with no asbestosis or even plaques while their wives/partners/mistresses/ concubines have asbestosis from washing his clothes. (Mistresses usually don't wash clothes). Statements like "It is generally agreed that it takes 2 years bla, bla and 5 years bla,bla" sound too much like the words of an opinion from a textbook than from life for my liking. They might say that in their slippers and smoking jackets in their Thoracic Club in London but not at the coal face. As knowledge increases, doubt increases. Goethe.
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Asbestosis vs UIP
posted at 15/11/2011 9:00 AM GMT
on bmj.com
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Posts: 1177
First: 19/4/2010 Last: 16/5/2013 |
The difficulty lies with the difficulty of making the diagnosis of asbestosis, I think. HRCT has helped a great deal, but the appearances of asbestosis are often similar to those of UIP, a common finding in patients of the same age group. Biopsies are not hugely helpful either - the presence of asbestos fibres within the biopsy does not confirm the diagnosis of asbestosis, and the absence of the fibres does not exclude asbestosis. In my experience, during the litigation process, the lawers become quite fixated on the duration of exposure to asbestos fibres. Some 'experts' in the field in my region are firmly of the opinion that daily exposure to asbestos fibres for 5 years is required to develop asbestosis. Some are less rigid. Many cases boil down to the question of whether the appearances are due to UIP in a patient who was exposed to asbestos, or truly due to asbestosis. Does this matter, given the lack of any efficacious treatment for either disease? It matters a deal to the patient's coffers. I am very cautious indeed about writing in any patient's notes that they definitely have asbestosis, particularly if their exposure is less than the 5 years that the lawers and experts tell me is 'required'. A difficult area, I think.
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Re: Mesothelioma
posted at 15/11/2011 10:32 AM GMT
on bmj.com
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Posts: 2947
First: 10/3/2009 Last: 29/4/2013 |
I have little time for so-called experts. As for the magic five years...what a load of cobblers. How about 4.5 years or 4.23 recurring years or how 3.78 years or 2.78889 years of really heavy exposure and how about the individual and how he or she reacts to a fibre or how some live and some die when someone fires a machine gun into a crowd. The world is full of pontificating medical fools who masquerade as expert witnesses. I don't respect them. I have sat through court cases where some expert radiologist for the defendant asbestos company argues about UIP versus asbestosis and even says that asbestosis is UIP when we all know bugger all about what UIP is anyway. There is no histological difference between UIP and asbestosis and any ashed lung of an asbestos worker will have squillions of asbestos fibres per gram (not asbestos bodies which really are neither here nor there). So what? The way we distinguish UIP from asbestosis is based on occupational history but also in the rate of decline of lung function. The former declines to death in 2-5 years and occasionally longer and with finger clubbing manifesting early while the other usually (not always)n has stigmata of asbestos pleural disease as well) and progresses at a glacial rate. In a patient with sufficient asbestos exposure to cause asbestosis who has asbestosis, we should call it as it is unless there are very cogent reasons to the contrary. This is in the occupational thoracic literature as a credo. The earliest feature of asbestosis is basal or axillary velcro end-inspiratory crackles. Defendant doctors can never hear them. You always need HR CT chest with prone lung windows. Without this go away as hypostatic changes make interpretation an inexact talk fest. The earliest radiographic sign is dot-like opacities (peribronchiolar fibrosis) followed by increased septal lines, then reticulation and sometimes ground-glass opacification and only later and sometimes do we see subpleural thick wall cysts which go on to form honey-comb lung (advanced). So go tell me it must be 5.000 years to ten decimal places and pontificate more because the physician lacks the moral fortitude to call a spade a spade. Giving a former workman and his wife some dignity as he dies of this may just be what the doctor ordered. I am no bleeding heart but I am a man of conscience. PS. The NAZI government in 1944 was the first to compensate workers for lung cancer caused by asbestos exposure but that is another subject. The relative risk of lung cancer in patients with asbestosis is considerably higher than the general population in both smokers. ex-smokers and non-smokers. I often observe that the medical profession is more aligned with big business,, government and Das Kapital than I think is honorable. We must not buck the horse of our masters.
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Re: Mesothelioma
posted at 15/11/2011 9:22 PM GMT
on bmj.com
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Posts: 1784
First: 7/3/2009 Last: 18/5/2013 |
We had a factory in Nahariya that worked with asbestos and the workers got sick. They closed the factory and very "cleverly" threw the asbestos near the seashore. Now there are mesotheliomas all over the city especially among those who live nearby. What we can do to ourselves in our stupidity has realy no limit.....
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