Na#onal Asbestos Forum 2013: Advance in Medical Research on Asbestos- Related Diseases

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1 Na#onal Asbestos Forum 2013: Advance in Medical Research on Asbestos- Related Diseases Professor Nico van Zandwijk Asbestos Diseases Research Ins#tute

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 Gene#c Codes of Cancer Importance of Disease Markers and Individualiza#on of Therapy Research into Novel (targets for) Treatments for Asbestos- Related Diseases Pa#ent Interviews & Models of Care

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)

4 Combined Effects Tobacco and Asbestos Is there a rela#onship between excess lung cancer risk and the combina#on of smoking and asbestos exposure? Excess lung cancer risk

5 Guidelines for Diagnosis and Treatment of Malignant Pleural Mesothelioma 2013 Wri]en for health prac##oners Consumer version available in early experts (including pa#ents, family members) Based on the best evidence Pa#ent centered / Primum non Nocere 18,371 references (publica#ons) were checked 2304 full text references reviewed 1118 references were relevant and scored Approved by NHMRC (2- July 2013)

6 Guidelines available through ADRI website hard copy or USB s>ck available today at the recep>on desk of the 2013 Na>onal Asbestos Forum

7 Epidemiology (study of pa]erns, causes, of disease condi#ons in defined popula#ons) of Asbestos- Related Diseases Number of Asbestosis pa#ents posi#vely affected by preventa#ve measures Clear effect of preventa#ve 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 Occupa#onal exposure to white asbestos is associated with a very high risk of Lung Cancer (China)

8 Changing Face of Malignant Mesothelioma? Wall Street Journal of , 2 page ar#cle Head & Neck Surgeon, who died from Malignant Mesothelioma Limited exposure to asbestos (cleaning a boiler) as a boy

9 The poten#al Hazard of Asbestos in the Built Environment Between 1945 and 1960, 25% of all homes in Australia were clad in asbestos cement. Home renova#on is a popular ac#vity in Australia.

10 Possible Shims in Type of Asbestos Exposure in Western Australia There is evidence that an increasing number of mesothelioma cases were non- occupa#onally exposed (Olsen et al, 2012) Home renovators OLSEN ET AL, MJA 2011

11 Malignant Mesothelioma a]ributed to Home Renova#on OLSEN ET AL, MJA 2011

12 Possible Shims in Type of Asbestos Exposure in Australia, Pilot Data Exposure data on 86 mesothelioma cases in 2011 was analysed Types of asbestos exposure, 2011 (n=86) (AMR, 2012) Occupational and non-occupational exposure probable or possible Non-occupational exposure probable or possible Occupational exposure probable or possible Percentage Neither occupational or non-occupational exposure Australian Ins#tute of Health and Welfare, Cancer Survival and Prevalence in Australia, 2012

13 What is the Australian Mesothelioma Registry (AMR)? Stand alone database of all mesothelioma cases diagnosed in Australia from Be]er understand the exact rela#onship between asbestos exposure and mesothelioma (nature and levels of asbestos exposure that can result in mesothelioma) Iden#fy workers (and others) that may be exposed to poten#ally dangerous levels of asbestos and prevent that exposure Assist in the development of policies to best deal with asbestos s#ll present in our environment Provide informa#on to assist researchers in undertaking inves#ga#ons with the aim of preven#ng mesothelioma in the future

14 Malignant Mesothelioma: Diagnosis, Prognosis and Predic#on of Effect of Therapy Diagnosis difficult (exper#se of the medical team) Poor prognosis but around 25% of pa#ents may experience survival longer than expected Diagnos#c Markers (blood): Mesothelin, CEA, Osteopon#n, Fibulin III and microrna 625-3p Accuracy! Large valida#on studies for Diagnos#c Markers important Prognos#c Markers: Histologic Subtype, FDG- PET, NLR, Calre#nin, and micrornas? Individualized therapy (in progress) = treatment proposals on the basis of a combina#on of markers & short term culture of mesothelioma cells = Predic#ve test (marker)

15 Prognos#c and Predic#ve 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

16 Treatment of Malignant Pleural Mesothelioma Ac#ve control of pleural effusion important Chemotherapy with pemetrexed (alimta) and pla#num improves survival (pa#ent selec#on!) Surgery associated with prolonged survival in selected pa#ents, exper#se of the surgical team is of vital importance Combina#on of surgery, chemotherapy and radiotherapy may offer benefit in selected groups of pa#ents, but further research needed Radiotherapy insufficiently inves#gated but effec#ve in pallia#on/ disease control, advanced technology needed to avoid excessive toxicity

17 New Avenues for Treatment Gene#c codes of mesothelioma and lung cancer are becoming unraveled and Australia (NCARD & ADRI) is contribu#ng to the interna#onal cancer genome consor#um Rapid progress in immunotherapy (new methods to effec#vely s#mulate natural defences ) è Early clinical trials Novel targeted treatment approaches tested è Early clinical trials : New molecules/an#bodies (Pharma Industry) : Small messenger protein (microrna), blocks experimental tumours (ADRI) Goal: transforming a progressive cancer into a chronic disease

18 Interviews with Pa#ents with Malignant Pleural Mesothelioma, their Families and Carers Despite having had work related asbestos exposure, most pa#ents knew li]le about mesothelioma prior to receiving their diagnosis Pa#ents 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 Pa#ents felt that there was a lack of treatment op#ons available, They omen felt that they should try treatment for their families sake, or to feel like they had "done something Pa#ents wanted more open communica#on from doctors

19 Interviews cont d Some of the pa#ents said that doctors should convey hope (not to be unrealis#c about this) and say that they will be cared for, and their pain will be controlled Pa#ents would advise others to seek second opinions and to stay hopeful and keep a posi#ve astude Carers wanted informa#on about pain management and pallia#ve care op#ons Bad news needs to be broken in a sensi#ve manner at an appropriate #me, when the family is present with the pa#ent

20 Interviews cont d Different needs amongst different members of the family: children would like to know #me frames so they could prepare their own lives (e.g. take #me off work, organise their own children), partners omen did not want to know #me frames Families were surprised at how quickly the disease progressed. They also reported feeling very unprepared for death, par#cularly in the services and supports needed for care at home

21 Models of Care Individualised Care plan should be developed by a Mul#- disciplinary Team The Mul#disciplinary Team should work closely with the pa#ent s GP Importance of Nurse Care Coordinators Importance of Exper#se of Medical Team (Surgery, Chemotherapy)

22 Summary I 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 registra#on of cases and collec#on of exposure data will assist in taking adequate preventa#ve measures There are indica#ons that the face of Malignant Mesothelioma is changing è more non- occupa#onal cases Preven#on of asbestos exposure is a vitally important è Awareness / Educa#on how to safely handle asbestos

23 Summary II Evidence Basis for the Diagnosis and Treatment of Malignant Pleural Mesothelioma has become available (Guidelines) Individualiza#on of Therapy! Rapid progress of Medical (Oncological) Research: Gene#c Code & Iden#fica#on of the Brakes of the Immune System Several Early Clinical Trials ongoing (important to underline their restric#ons) Careful listening to pa#ents, family members and carers Quality of Life issues increasingly addressed Referral of pa#ents to Hospitals with Exper#se and importance of Mul#disciplinary Team approaches

24 Thank You!

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