slide 1 - Title slide for professor Nico van Zandwijk
National Asbestos Forum 2013:
Advance in Medical Research on
Asbestos-Related Diseases
Professor Nico van Zandwijk
Asbestos Diseases Research Institute
The University of Sydney
Asbestos Diseases Research Institute
slide 2
Content
• List of Asbestos-Related Diseases
• Epidemiology of Asbestos-Related Diseases
• State of the Art for Diagnosis and Treatment of
Malignant Pleural Mesothelioma
• Unraveling the Genetic Codes of Cancer
• Importance of Disease Markers and Individualization of
Therapy
• Research into Novel (targets for) Treatments for
Asbestos-Related Diseases
• Patient Interviews & Models of Care
slide 3
Asbestos-Related Diseases
•
•
•
•
Asbestosis
Pleural Plaques, Pleural Thickening, Pleural
Effusion
Malignant Mesothelioma
Lung Cancer: two cases for every case of Malignant
Mesothelioma
•
Laryngeal Cancer (area of the voice box)
•
Ovarian Cancer
•
Australia > 2000 cases/year
(difficult to verify those Lung Cancer cases caused
by Asbestos exposure)
slide 4
Combined Effects Tobacco and
Asbestos
Is there a relationship between excess lung cancer risk
and the combination of smoking and asbestos
exposure?
slide 5
Guidelines for Diagnosis and
Treatment of Malignant Pleural
Mesothelioma 2013
• Written for health practitioners
• Consumer version available in early 2014
• 47 experts (including patients, family members)
• Based on the best evidence
• Patient centered / “Primum non Nocere”
• 18,371 references (publications) were checked
• 2304 full text references reviewed
• 1118 references were relevant and scored
• Approved by NHMRC (2-July 2013)
slide 6
ADRI
Guidelines for the Diagnosis and
Treatment of Malignant Pleural
Mesothelioma
Guidelines available
through ADRI website
www.adri.org.au
hard copy or USB stick available today
at the reception desk of the 2013
National Asbestos Forum
slide 7
Epidemiology
(study of patterns, causes, of
disease conditions in defined populations) of
Asbestos-Related Diseases
• Number of Asbestosis patients positively affected by
preventative measures
• Clear effect of preventative measures on the incidence
of Malignant Mesothelioma is yet to be seen (Australia)
• Changing face of Malignant Mesothelioma?
– Data from Western Australia
– Early data from the Australian Mesothelioma
Registry
• Occupational exposure to white asbestos is associated
with a very high risk of Lung Cancer (China)
slide 8
Changing Face of Malignant
Mesothelioma?
• Wall Street Journal of 18-6-2013, 2 page article
• Head & Neck Surgeon, who died from
Malignant Mesothelioma
• Limited exposure to asbestos (cleaning a
boiler) as a boy
Malignant Mesothelioma attributed
to Home Renovation
The potential Hazard of Asbestos in
the Built Environment
Between 1945 and 1960, 25% of all homes in Australia
were clad in asbestos cement. Home renovation is a
popular activity in Australia.
slide 9 has not been included as it only has 2 images that did not have any bearing on this accessible version of the presentation
slide 10
Possible Shifts in Type of
Asbestos Exposure in Western
Australia
There is evidence that an increasing number of
mesothelioma cases were non-occupationally
exposed (Olsen et al, 2012)
Reference: OLSEN ET AL,MJA 2011
slide 11
Malignant Mesothelioma attributed
to Home Renovation
Reference: OLSEN ET AL,MJA 2011
slide 12
Possible Shifts in Type of
Asbestos Exposure in Australia, Pilot
Data
Exposure data on 86 mesothelioma cases in 2011 was
analysed
Reference: Australian Institute of Health and Welfare, Cancer Survival and Prevalence in Australia, 2012
slide 13
What is the Australian Mesothelioma
Registry (AMR)?
 Stand alone database of all mesothelioma cases diagnosed in
Australia from 1-7-2010
 Better understand the exact relationship between asbestos
exposure and mesothelioma (nature and levels of asbestos
exposure that can result in mesothelioma)
 Identify workers (and others) that may be exposed to
potentially dangerous levels of asbestos and prevent that
exposure
 Assist in the development of policies to best deal with asbestos
still present in our environment
 Provide information to assist researchers in undertaking
investigations with the aim of preventing mesothelioma in the
future
slide 14
Malignant Mesothelioma: Diagnosis,
Prognosis and Prediction of Effect of
Therapy
• Diagnosis difficult (expertise of the medical team)
• Poor prognosis but around 25% of patients may
experience survival longer than expected
• Diagnostic Markers (blood): Mesothelin, CEA,
Osteopontin, Fibulin III and microRNA 625-3p
• Accuracy! Large validation studies for Diagnostic Markers
important
• Prognostic Markers: Histologic Subtype, FDG-PET, NLR,
Calretinin, and microRNAs?
• Individualized therapy (in progress) = treatment
proposals on the basis of a combination of markers &
short term culture of mesothelioma cells = Predictive
test (marker)
slide 15
Prognostic and Predictive Factors/Markers
Prognostic
Provides information on outcome
independent of the therapy that is
used
Predictive
Provides information on outcome
with regard to a
specific therapy
slide 16
Treatment of Malignant Pleural
Mesothelioma
• Active control of pleural effusion important
• Chemotherapy with pemetrexed (alimta) and platinum
improves survival (patient selection!)
• Surgery associated with prolonged survival in selected
patients, expertise of the surgical team is of vital
importance
• Combination of surgery, chemotherapy and
radiotherapy may offer benefit in selected groups of
patients, but further research needed
• Radiotherapy insufficiently investigated but effective in
palliation/disease control, advanced technology needed
to avoid excessive toxicity
slide 17
New Avenues for Treatment
• Genetic codes of mesothelioma and lung cancer are
becoming unraveled and Australia (NCARD & ADRI) is
contributing to the international cancer genome
consortium
• Rapid progress in immunotherapy (new methods to
effectively stimulate ‘natural defences’) - Early clinical
trials
• Novel targeted treatment approaches tested - Early
clinical trials
 New molecules/antibodies (Pharma Industry)
 Small messenger protein (microRNA), blocks
experimental tumours (ADRI)
• Goal: transforming a progressive cancer into a chronic
disease
slide 18
Interviews with Patients with
Malignant Pleural Mesothelioma,
their Families and Carers
• Despite having had work related asbestos
exposure, most patients knew little about
mesothelioma prior to receiving their diagnosis
• Patients discussed having had long delays before
receiving a diagnosis, and reported worrying
whether their treatment outcomes would have
been different if they had found out earlier
• Also carers found the delay in receiving a diagnosis
especially difficult
• Patients felt that there was a lack of treatment
options available
• They often felt that they should try treatment for
their families sake, or to feel like they had “done
something”
• Patients wanted more open communication from
doctors
slide 19
Interviews cont’d
• Some of the patients said that doctors should convey
hope (not to be unrealistic about this) and say that they
will be cared for, and their pain will be controlled
• Patients would advise others to seek second opinions
and to stay hopeful and keep a positive attitude
• Carers wanted information about pain management and
palliative care options
• Bad news needs to be broken in a sensitive manner at
an appropriate time, when the family is present with
the patient
slide 20
Interviews cont’d
• Different needs amongst different members of the
family: children would like to know time frames so they
could prepare their own lives (e.g. take time off work,
organise their own children), partners often did not
want to know time frames
• Families were surprised at how quickly the disease
progressed. They also reported feeling very unprepared
for death, particularly in the services and supports
needed for care at home
slide 21
Models of Care
• Individualised Care plan should be developed by a
Multi-disciplinary Team
• The Multidisciplinary Team should work closely with the
patient’s GP
• Importance of Nurse Care Coordinators
• Importance of Expertise of Medical Team (Surgery,
Chemotherapy)
slide 22
Summary 1
• The silent epidemic of asbestos-related diseases affects
more than 2000 Australians every year and it is difficult
to capture it’s exact size
• Careful registration of cases and collection of exposure
data will assist in taking adequate preventative
measures
• There are indications that the face of Malignant
Mesothelioma is changing - more ‘non-occupational’
cases
• Prevention of asbestos exposure is a vitally important Awareness /Education how to safely handle asbestos
slide 23
Summary II
• Evidence Basis for the Diagnosis and Treatment of
Malignant Pleural Mesothelioma has become available
(Guidelines)
• Individualization of Therapy!
• Rapid progress of Medical (Oncological) Research:
Genetic Code & Identification of the Brakes of the
Immune System
• Several Early Clinical Trials ongoing (important to
underline their restrictions)
• Careful listening to patients, family members and carers
• Quality of Life issues increasingly addressed
• Referral of patients to Hospitals with Expertise and
importance of Multidisciplinary Team approaches
slide 24
Thank You!