Australia's first updated mesothelioma guidance in more than a decade recommends routine multidisciplinary care, molecular pathology, and broader access to immunotherapy and clinical trials.
Australia’s first updated national mesothelioma guidelines in 13 years have overhauled recommendations for diagnosing and treating pleural mesothelioma, reflecting major advances in pathology, immunotherapy, and multidisciplinary care.
The consensus guidelines, developed by the Australian Data and Digital Research Institute (ADDRI) with support from the Asbestos and Silica Safety and Eradication Agency and icare, were written by a committee of more than 30 specialists spanning medical oncology, thoracic surgery, respiratory medicine, pathology, radiology, radiation oncology, palliative care, genetics, nursing, general practice, and consumer advocacy.
The committee was chaired by Professor Sonja Klebe and led by ADDRI academic and research director Associate Professor Anthony Linton.
“Outcomes for mesothelioma, an incurable malignancy predominantly impacting the mesothelial surfaces of the lung and chest wall, have traditionally been poor,” they wrote in their foreword to the report.
“A prolonged latency period between exposure and diagnosis and the non-specific nature of presenting symptoms, frequently saw patients test diagnosed at a more advanced stage.
“Furthermore, substantial controversy surrounding surgical interventions and the traditionally chemo-resistant nature of the tumour led to pessimism within the broader medical community, particularly when coupled with the low survival rates.
“However, progress from translational researchers and clinicians has offered hope.”
They said Australia’s first ever guidelines, released in 2013 by the then Asbestos Diseases Research Institute (now the Asbestos and Dust Diseases Research Institute) had reflected the best available evidence for the management of this disease, according to the standards of assessment developed by the National Health and Medical Research Council (NHMRC).
“The 13 years since this publication has seen substantial updates in the approach of clinicians to this malignancy,” Professor Klebe and Professor Linton wrote.
“New standards in histological and radiological diagnosis, shifts in surgical practice, and the identification of novel therapies have introduced greater complexity into the care of patients with mesothelioma, requiring a reassessment of current evidence and how it translates into best practice and optimal outcomes.”
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The document is intended to establish a nationally consistent standard of care for pleural mesothelioma, a disease that continues to disproportionately affect Australians because of decades of widespread asbestos use.
Despite a national asbestos ban introduced more than 20 years ago, Australia still has one of the world’s highest mesothelioma incidence rates, with almost 700 new diagnoses annually and more than 90% of patients having a history of possible or probable asbestos exposure.
The disease’s latency of 20 to 60 years means the burden is expected to continue for decades.
A major focus of the guidelines is reducing delays in diagnosis. They recommend that patients with suspected pleural mesothelioma be referred promptly to centres with expertise in mesothelioma and that diagnosis be made within a multidisciplinary framework involving respiratory physicians, thoracic surgeons, radiologists, pathologists, medical and radiation oncologists, specialist nurses, and palliative care clinicians.
Regular multidisciplinary team review is recommended throughout a patient’s treatment journey rather than only at diagnosis.
The pathology chapter reflects how substantially diagnostic practice has evolved over the past decade. While microscopic assessment remains fundamental, the guidelines recommend incorporating modern immunohistochemistry and molecular testing into routine assessment where appropriate.
Histology and cytology can both establish a diagnosis in selected cases, but tissue biopsy remains important for tumour grading, histological subtyping, and ancillary testing that may influence treatment decisions.
The document also recommends structured synoptic pathology reporting to ensure clinically relevant prognostic and therapeutic information is consistently captured.
Treatment recommendations have also been extensively revised to reflect the emergence of immune checkpoint inhibitors.
Whereas chemotherapy dominated the 2013 guidelines, the updated recommendations incorporate immunotherapy as a standard first-line option for many patients with unresectable pleural mesothelioma while recognising that platinum-pemetrexed chemotherapy remains appropriate for selected patients depending on histological subtype, performance status, and clinical circumstances.
Patients should be considered for clinical trial enrolment whenever feasible, recognising the limited therapeutic options that remain available for this aggressive disease.
The guidelines adopt a more cautious approach to surgery than earlier eras, emphasising that radical procedures should be confined to carefully selected patients managed in experienced centres following multidisciplinary discussion.
They also outline contemporary recommendations for radiotherapy, acknowledging its important role in symptom control and selected multimodality treatment strategies rather than routine radical management.
Supportive care features throughout the document rather than appearing as a separate end-of-life consideration.
The expert panel recommends integrating palliative care from diagnosis, with early management of pain, breathlessness, pleural effusions, nutrition, psychological distress, and advance care planning delivered alongside active anticancer treatment.
The guidelines also recognise the needs of carers and recommend access to specialist mesothelioma nurses, rehabilitation services, and psychosocial support.
Recognising the rarity of mesothelioma and the concentration of expertise in metropolitan centres, the document also addresses inequities in care.
It recommends expanding telehealth, formal referral pathways, and virtual multidisciplinary meetings to improve access for patients living in regional and remote Australia, ensuring geography does not determine treatment options or specialist input.
An entire chapter is dedicated to the medicolegal issues with mesothelioma. The expert panel makes four key recommendations in this regard, including:
- Any patient with mesothelioma should be informed that contacting a lawyer experienced in asbestos-related compensation claims should be undertaken as soon as possible after the diagnosis of a mesothelioma.
- Identification of asbestos exposures in the past by patient, family, or medical practitioners is not a prerequisite for a referral to a legal practitioner.
- Any occupational and non-occupational exposures are important supporting evidence when making asbestos-related compensation claims. This will be explored by the legal team.
- In Australia, cytology and histology diagnosis is not an absolute requirement for an asbestos-related compensation if there is sufficient clinical and radiological evidence of mesothelioma. However, if the exposure to asbestos has occurred in another jurisdiction, expert legal opinion should be sought to explore the requirements for an asbestos-related compensation in that jurisdiction.
The committee identifies several priorities for future research, including biomarkers for earlier diagnosis, molecular profiling to support personalised therapies, improved management of non-epithelioid disease, optimisation of immunotherapy combinations and greater participation in Australian and international clinical trials.
They noted that with treatment options rapidly evolving, the guidelines were intended to provide a framework that can be updated as new evidence emerged.
“Despite a complete ban on asbestos in Australia in 2003, most mesothelioma patients continue to report identifiable exposure to asbestos,” the report concluded.
“All patients should be advised to explore the possibility of compensation early, to avoid losing potential entitlements (which may include non-PBS funded therapy) as legislation varies by state and territory.
“The incidence of mesothelioma in Australia is predicted to remain high for the foreseeable future. Research, together with continuing education, improved awareness and effective clinical networking, should ultimately deliver further tangible improvements in patient outcomes.”
Read the full 61-page report, Guidelines and recommendations for the management of pleural mesothelioma in Australia here.
