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Epidemiology of mesothelioma in the 21 century in Europe and the United States, 40 years after restricted/banned asbestos use

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Research has established a strong association between asbestos exposure and malignant mesothelioma, a deadly form of cancer. Since the early 1980's many countries have restricted or banned the production of asbestos, leading to a decline of occupational asbestos exposure in many industrialized countries. However, some countries continue to use asbestos, and worldwide rates of mesothelioma are still increasing. Because of the long latency between exposure and mesothelioma occurrence and the persistence of environmental exposure, incidence rates (IR) may decrease very slowly for several years ahead. In this review, we examine estimates of asbestos consumption before widespread asbestos regulations and the trends in incidence and mortality rates, as well as changes over time for the United States and Europe. In some countries with earlier asbestos restrictions, mesothelioma incidence has been in a modest decline over time. However, asbestos exposure is still a burden worldwide and legislative action is needed to obtain a full ban. The pattern of mesothelioma is shifting from a mostly male disease to a disease that affects females as well in substantial numbers. Studies on unknown sources of asbestos exposure, of other sources of natural exposure to asbestos and asbestos-like fibers, as well as of individual genetic susceptibility to asbestos fibers are needed.
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© Translational lung cancer research. All rights reserved. Transl Lung Cancer Res 2020;9(Suppl 1):S28-S38 | http://dx.doi.org/10.21037/tlcr.2019.11.11
Introduction
Mesothelioma is a rare, but deadly form of cancer, arising
in the mesothelial surfaces (1) in the pleura, peritoneal,
and pericardial cavities; the most common form of
mesothelioma, accounting for 65–70% of all cases, is
malignant pleural mesothelioma followed by peritoneal
(30%) and pericardial mesothelioma (1–2%) (2). There are
three subtypes, according to the histological morphology:
epithelial, sarcomatoid, and biphasic (1).
Mesothelioma has a very poor prognosis with a median
survival from the time of presentation of approximately
9–12 months (3). Despite the introduction of modern
therapeutic interventions, only modest changes in survival
are observed over time (1). There is a well-established
causal relationship between asbestos exposure and
malignant mesothelioma, although the latency period can
be long. Research suggests that the average latency period
is approximately 40 years, although in some cases, it may be
as long as 60–70 years (4-9). The association with asbestos
exposure is especially strong for the pleural site, where
80% of patients report a history of asbestos exposure (2).
Among asbestos highly exposed individuals, the lifetime
risk of mesothelioma can vary from 5–10% to 25% (3,4,10).
Increased knowledge and better regulations since the early
1980’s, with restrictions or bans on production and use of
Review Article
Epidemiology of mesothelioma in the 21st century in Europe and
the United States, 40 years after restricted/banned asbestos use
Naomi Alpert1, Maaike van Gerwen1,2, Emanuela Taioli1,3,4
1Institute for Translational Epidemiology, 2Department of Otolaryngology-Head and Neck Surgery, 3Department of Thoracic Surgery, 4Tisch
Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
Contributions: (I) Conception and design: All authors; (II) Administrative support: All authors; (III) Provision of study materials or patients: None;
(IV) Collection and assembly of data: N Alpert; (V) Data analysis and interpretation: All authors; (VI) Manuscript writing: All authors; (VII) Final
approval of manuscript: All authors.
Correspondence to: Emanuela Taioli, MD, PhD. Icahn School of Medicine at Mount Sinai, One Gustave L Levy Place, Box 1133, New York, NY
10029, USA. Email: Emanuela.Taioli@mountsinai.org.
Abstract: Research has established a strong association between asbestos exposure and malignant
mesothelioma, a deadly form of cancer. Since the early 1980’s many countries have restricted or banned
the production of asbestos, leading to a decline of occupational asbestos exposure in many industrialized
countries. However, some countries continue to use asbestos, and worldwide rates of mesothelioma are still
increasing. Because of the long latency between exposure and mesothelioma occurrence and the persistence
of environmental exposure, incidence rates (IR) may decrease very slowly for several years ahead. In this
review, we examine estimates of asbestos consumption before widespread asbestos regulations and the trends
in incidence and mortality rates, as well as changes over time for the United States and Europe. In some
countries with earlier asbestos restrictions, mesothelioma incidence has been in a modest decline over time.
However, asbestos exposure is still a burden worldwide and legislative action is needed to obtain a full ban.
The pattern of mesothelioma is shifting from a mostly male disease to a disease that affects females as well in
substantial numbers. Studies on unknown sources of asbestos exposure, of other sources of natural exposure
to asbestos and asbestos-like bers, as well as of individual genetic susceptibility to asbestos bers are needed.
Keywords: Carcinogen regulation; environmental exposure; incidence trends; mortality
Submitted Jul 24, 2019. Accepted for publication Nov 07, 2019.
doi: 10.21037/tlcr.2019.11.11
View this article at: http://dx.doi.org/10.21037/tlcr.2019.11.11
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asbestos in many developed countries has led to abatement
of exposure, particularly in the occupational setting. Four
subsequent bans on asbestos between 1973 and 1989 in the
United States (US) resulted in decreased asbestos consumption
and production, followed by a decline of mesothelioma
incidence and mortality rates 20 years later (11). However,
despite bans, people may still be exposed to asbestos, due
to its presence in several structures such as schools or
public buildings, and the construction of residential areas
in close proximity to former asbestos mines, factories,
or soil containing natural asbestos. Thus the disease
burden associated with environmental asbestos exposure
remains difficult to quantify and is understudied (6,7,12).
Furthermore, a ban on the use and production of asbestos
has not been implemented globally; countries that have a
ban instituted it at different points in time (5), making the
estimate of the future mesothelioma risk in the general
population uncertain.
The goal of this report is to provide an overview of
asbestos use, and mesothelioma incidence and mortality
in the US and Europe [defined as the 53 countries in
the European region of the World Health Organization
(WHO)] (13), within the context of changes in asbestos
policies around the world.
Data sources and methods
This report used several publicly available data sources.
Asbestos consumption (calculated as production plus imports
minus exports) was assessed per capita, in 1980 and 2007,
using reports from the United States Geological Survey
(USGS) (14,15), with population estimates compiled by the
World Bank (16). Negative values of asbestos consumption
(reflecting export of storage from previous years) were
treated as zero. Overall and age specific mesothelioma
incidence rates (IR) [2008–2012] were extracted from the
Cancer Incidence in Five Continents Volume XI (CI5 Vol.
XI) data made available by the WHO and the International
Agency for Research on Cancer (IARC) (17). IR over time
were calculated using Surveillance, Epidemiology, and
End Results (SEER) data (18) (US) and WHO C15plus
data (Europe) (17,19), which includes annual incidence of
selected cancers for the longest possible period. For this
analysis, only registries with continuous information from
1980–2012 were included (SEER-9 Registries for the US;
Denmark, France Calvados, France-Doubs, France-Isere,
Germany-Saarland, Iceland, Israel, Italy-Parma, Norway,
Switzerland-Geneva and UK-Scotland for Europe).
Mortality rates were queried from the IARC WHO Cancer
Mortality Database (20). All incident and mortality rates are
age-adjusted to the world standard population (21).
Results
Worldwide bans on asbestos and asbestos consumption
Since the 1970’s, countries have banned asbestos to varying
degrees, with 67 countries worldwide having a total ban, as
of July 15, 2019 (22). Although the US banned some forms
of asbestos in 1973, and attempted to ban most asbestos-
containing products in 1989 through the Toxic Substances
Control Act, the ban was overturned in 1991 (23). To
this day, the US does not have a full nationwide ban on
asbestos. However there are many laws regulating the use of
asbestos at the federal, state, and local level (24). In Europe,
individual regulations banning asbestos were passed from
the 1980’s through the early 2000’s in many countries
(13,22,25,26). Member states of the European Union (EU)
banned five of the six types of asbestos in 1991 (amosite,
crocidolite, anthophyllite, tremolite, and actinolite) and a
ban prohibiting the new use of chrysotile went into effect
on January 1, 2005 (27). Details of asbestos bans, by country
are shown in Table 1 (13,22,25,26).
Previous research (5,13) has defined asbestos
consumption >1 kg/capita/year as “high”, as it corresponded
to a 2.4- and 1.6-fold increase in mesothelioma deaths
among men and women, respectively. Consumption
>2 kg/capita/year was considered “very high”. Data from
1980 (14), before asbestos bans were widely implemented,
show that asbestos consumption was very high in some
parts of Europe, exceeding 5 kg/capita in the former
Soviet Union (estimates for Russian Federation and
Kazakhstan: 9.6 kg/capita), Cyprus (7.4 kg/capita), Germany
(5.6 kg/capita), and former Yugoslavian states (combined
estimates for all former Yugoslav nations: 5.2 kg/capita).
Asbestos consumption for Belgium and Luxembourg
(4.7 kg/capita), Hungary (4.0 kg/capita), Switzerland
(3.3 kg/capita), Italy (3.2 kg/capita), Czech Republic
and Slovakia combined (3.1 kg/capita), Austria
(2.7 kg/capita), Denmark (2.7 kg/capita), Ireland
(2.5 kg/capita), Poland (2.3 kg/capita), France
(2.3 kg/capita), and Portugal (2.04 kg/capita) all exceeded
2 kg/capita, while it exceeded 1 kg/capita in Spain, Greece,
United Kingdom, Netherlands, and Finland. Consumption
in the US was also high at 1.6 kg/capita (Figure 1A), although
it was already in decline from its peak in the early 1970’s (28).
S30 Alpert et al. Epidemiology of mesothelioma in Europe and the US
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Table 1 Asbestos bans and regulations in the United States and Europe
Country Year Description
United States 1973 Ban on spray-applied surfacing asbestos-containing material for fireproofing and insulation
1989 Toxic Substances Control Act bans most asbestos-containing products
1991 Ban overturned, no current nationwide ban
European Union
Austria1990 Ban on chrysotile asbestos
Belgium1998 Ban on chrysotile asbestos is introduced
Bulgaria 2005 Ban on import, production, and use of all asbestos
Croatia 1993 Ban on crocidolite and amosite
2006 Asbestos added to list of prohibited substances, in line with EU regulations, but ban is not thought
to be well enforced
Cyprus2005 Prohibits new use of chrysotile, other forms of asbestos previously banned under EU regulations
Czech Republic1998 Ban on the import of asbestos
2005 Prohibits new use of chrysotile, other forms of asbestos previously banned under EU regulations
Denmark1980 Ban on uses of asbestos, with exceptions
1985 Extends ban to include asbestos cement products, further restrictions in 1986–1988
Estonia2005 Prohibits new use of chrysotile, other forms of asbestos previously banned under EU regulations
Finland1992 Phase-out ban on chrysotile
France1996 Ban on chrysotile
Germany1993 Ban on chrysotile asbestos (minor exemptions), amosite and crocidolite were banned previously
Greece2005 Prohibits new use of chrysotile, other forms of asbestos previously banned under EU regulations
Hungary1988 Ban on amphibole asbestos, with further bans on non-chrysotile asbestos in 1992, 2001, and 2003
2005 Prohibits new use of chrysotile, other forms of asbestos previously banned under EU regulations
Ireland2000 Ban on chrysotile asbestos
Italy1992 Ban on all types of asbestos (with some exceptions until 1994)
Latvia2001 Ban on asbestos (some exemptions)
Lithuania1998 First law restricting asbestos use
2005 Prohibits new use of chrysotile, other forms of asbestos previously banned under EU regulations
Luxembourg2002 Phase out ban on asbestos
Malta2005 Prohibits new use of chrysotile, other forms of asbestos previously banned under EU regulations
Netherlands1991 First in a series of bans on chrysotile
Poland1997 Ban on all asbestos
Portugal2005 Prohibits new use of chrysotile, other forms of asbestos previously banned under EU regulations
Romania 2005 Prohibits new use of chrysotile, other forms of asbestos previously banned under EU regulations
Slovakia2005 Prohibits new use of chrysotile, other forms of asbestos previously banned under EU regulations
Slovenia1996 Ban on production of asbestos cement products
Table 1 (continued)
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Table 1 (continued)
Country Year Description
Spain2002 Phase out ban on asbestos
Sweden1982 First in a series of bans on various uses of asbestos
1986 Ban on use of all asbestos products
United Kingdom1999 Ban on chrysotile asbestos, with minor exceptions
Other European nations
Albania No ban
Andorra No ban
Armenia No ban
Azerbaijan No ban
Belarus No ban
Bosnia and
Herzegovina
No ban
Georgia No ban
Iceland 1983 Ban on all types of asbestos (with exceptions); bans updated in 1996
Israel 1980 Series of restrictions on asbestos, which eventually became a de facto ban
Kazakhstan No ban
Kyrgyzstan No ban
Monaco 2016 Total ban on all forms of asbestos
Montenegro No ban
North Macedonia 2014 Total ban on all forms of asbestos
Norway 1984 Ban on all asbestos
Republic of Moldova No ban
Russian Federation No ban
San Marino No ban
Serbia 2011 Ban on all asbestos
Switzerland 1989 Ban on crocidolite, amosite, and chrysotile
Tajikistan No ban
Turkey 2010 National regulation banning use of all types of asbestos
Turkmenistan No ban
Ukraine 2017 Complete ban on asbestos announced, implementation may be delayed
Uzbekistan No ban
, members of the European Union as of 2005, subject to the directive mandating all member states ban new uses of chrysotile. Other
forms of asbestos were banned in 1991 for EU member states. All member states of the EU, Iceland, Israel, Macedonia, Monaco, Norway,
Serbia, Switzerland, and Turkey have banned the use of all types of asbestos, as of July 15, 2019. EU, European Union.
S32 Alpert et al. Epidemiology of mesothelioma in Europe and the US
© Translational lung cancer research. All rights reserved. Transl Lung Cancer Res 2020;9(Suppl 1):S28-S38 | http://dx.doi.org/10.21037/tlcr.2019.11.11
The most recent available data refer to 2007 (15),
and indicates that asbestos consumption has declined
considerably in most countries in the years since bans were
enacted (or attempted) (Figure 1B). US consumption was
0.003 kg/capita in 2007, while most of the countries in the
EU had decreased to 0 (or nearly 0) kg/capita. Asbestos
consumption remained high or very high in Kazakhstan
(7.0 kg/capita), Kyrgyzstan (4.0 kg/capita), Belarus
(3.5 kg/capita), Uzbekistan (3.2 kg/capita), Russian
Federation (2.0 kg/capita), and Ukraine (1.8 kg/capita).
An advance report from the USGS for 2016 (29)
indicates that consumption has started to decline in Ukraine
(0.4 kg/capita) and Belarus (0.6 kg/capita), although it
remains high or very high in the Russian Federation
(1.6 kg/capita), Kazakhstan (1.4 kg/capita), Kyrgyzstan
(1.1 kg/capita), and Uzbekistan (2.2 kg/capita).
Mesothelioma IR
Research has shown that IR of mesothelioma are lower in
women than in men, and this difference has been attributed
to historical differences in occupational asbestos exposure
(30,31). From 2008 to 2012, the world standardized IR
(WSIR), per 100,000 persons in the US was 0.9 for males
and 0.3 for females. Overall in Europe, the WSIR per
100,000 was 1.7 for males and 0.4 for females. Data is
limited for nations of the former Soviet Union, Russian
Federation and former Yugoslavia, but for those with data,
reported WSIR for males and females were 0.5 and 0.3
(Russian Federation), 1.5 and 0.3 (Croatia), and 1.5 and
0.5 (Slovenia) per 100,000 persons. In some of the other
countries with very high asbestos consumption, WSIR
remain high, particularly for males versus females: 2.0
and 0.4 (Belgium), 2.0 and 0.3 (Switzerland), 1.9 and 0.3
Apparent Consumption
of Asbestos (kg/capita)
Apparent Consumption
of Asbestos (kg/capita)
1 3 5 7 9
1 3 5 7
A
B
Figure 1 Apparent consumption (kg/capita) of asbestos in (A) 1980 and (B) 2007 in the United States and Europe.
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(Denmark), 1.8 and 0.6 (Italy), and 1.6 and 0.3 (Germany)
per 100,000 persons. WSIR are also very high in the
Netherlands (2.8 in males and 0.4 in females), and United
Kingdom (3.4 and 0.6) (Figure 2). As women generally are
less likely to be occupationally exposed, the high WSIR
in females observed in certain countries, such as Italy,
United Kingdom, and Turkey may indicate other sources
of exposure that are difficult to detect, such as higher
levels of environmental exposure. The classification of
environmental, non-occupational exposure to asbestos is
very heterogeneous in the literature and often includes (I)
areas with naturally occurring asbestos, (II) neighborhood
exposure based on residence in close proximity to industrial/
mining sources of asbestos, and (III) household exposure
for family members of occupationally exposed people, of
which the latter two are more specic exposure risk factors
for females (6). Furthermore, a caveat when comparing
data collected in different countries is that there may be
differences in patterns of reporting for mesothelioma,
misclassification in diagnosis, or lack of the medical
resources required to accurately diagnose the disease.
Age related patterns
Mesothelioma is extremely rare in younger subjects,
with a sharp uptick in IR starting between 50–60 years of
age (4). Prior to age 50, the annual WSIR in the US for
males is 0.3 per 100,000 persons, while for females it is
0.2. In Europe, the rates are 0.6 per 100,000 for males
and 0.4 per 100,000 for females for the same age group.
In the US, the IR for males aged 50–54 years is 0.6 per
100,000, while for females it is 0.4 per 100,000. The rate
Figure 2 World standardized incidence rates of mesothelioma in the United States and Europe for (A) men and (B) women, 2008–2012.
Incidence Rate
(per 100,000)
Incidence Rate
(per 100,000)
1 2 3
0.2 0.4 0.6
A
B
S34 Alpert et al. Epidemiology of mesothelioma in Europe and the US
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starts climbing faster in Europe, with an IR of 1.4 per
100,000 for males, and 0.6 per 100,000 for females at age
50–54 years. As people age, this gap across the US and
Europe continues to widen, particularly for males. For
those 80 years, the IRs for males in the US and Europe are
18.9 and 22.8 per 100,000, respectively; for females, it is 3.0
and 3.4 per 100,000 (Figure 3).
Time trends
Given the long latency period of mesothelioma
(approximately 40 years, on average) (4), we may now
just be beginning to see the effects of asbestos bans. In
the US there is no ofcial ban in place, however attempts
were made to ban asbestos as far back as 1973, and as a
result general consumption was lower in 1980 in the US
as compared to Europe. Over time, the IR has started to
decline in the US from 1980–2016, mostly driven by a
decline in the IR for males, while females have mostly held
steady (Figure 4A). In Europe, rates of mesothelioma were
rising sharply in the early 2000’s, and may just now be
beginning to level off (Figure 4B). This may be partly due to
the later introduction of asbestos bans in parts of Europe,
and the higher consumption observed at least 40 years
ago in many geographic areas. As overall rates have slowly
fallen in the US, and risen in Europe, with steady rates for
females, females now make up a larger portion of those with
mesothelioma in the US than in Europe (Figure 4C).
Mesothelioma mortality
Survival rates for mesothelioma are low, with estimated
median survival of 9–12 months (3). Research has shown
that females have significantly better overall survival
(32-34), and speculated reasons include less amount
and duration of exposure (35), more favorable clinical
characteristics (36,37), and protective effects of estrogen
(38,39). For countries in which IR and mortality rates
were available, the ratio of the mortality rate to the IR was
calculated. In almost all cases, this ratio exceeds 0.5, and
in many cases exceeds 0.75, indicating high mortality rates
among those with mesothelioma. Generally, the ratio was
lower for females (Table 2), reflecting the better survival
reported by individual studies for females with all forms of
mesothelioma.
Comment
Although the US recognized the dangers of asbestos
exposure early and in 1973 produced the first asbestos
regulation followed by a complete ban in 1989, the country
currently has no nationwide ban. Many countries in Europe
independently implemented partial or total asbestos bans
in the 1980’s and 1990’s, while member states of the EU
banned most types of asbestos in 1991, with a complete
ban on all remaining types of asbestos in effect starting in
2005. However, many non-EU states implemented bans
Figure 3 Age specic annual incidence rates [2008–2012], for (A) United States and (B) Europe, by gender.
Incidence Rate
(Per 100,000)
Incidence Rate
(Per 100,000)
Age (years) Age (years)
Female Male
0-4
0-4
10-14
10-14
20-24
20-24
30-34
30-34
40-44
40-44
50-54
50-54
60-64
60-64
70-74
70-74
≥80
≥80
20
15
10
5
0
20
15
10
5
0
A B
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later, while some still have no ban in place. The difference
in the timeframe for asbestos ban legislation in the US and
Europe, combined with a latency period of decades between
exposure and mesothelioma partly explains why a slight
decrease in mesothelioma standardized IR is seen in the US,
consistent with previous research (11), while the incidence
has just started to level off in Europe. There is speculation
that the observed decrease in mesothelioma incidence is
slower than projected (40), and that other factors, including
individual genetic susceptibility, could play a role (41).
However, observational data from cancer registries
prove that legislation on asbestos use and production is an
effective way to decrease occupational exposure to asbestos,
and therefore, mesothelioma rates in the general population,
especially in males. Current legislation is insufficient to
address neighborhood asbestos exposure based on residence
in close proximity to industrial/mining sources of asbestos
and household asbestos exposure for family members of
occupationally exposed people, as well as other sources
of environmental exposure. To further decrease risk from
environmental asbestos exposure, legislation for building
in regions with naturally occurring asbestos should be
explored. These results stress the need for a global forum to
urge countries that currently don’t have an asbestos ban to
start implementing appropriate legislation.
One interesting observation is that any change in IR is
mainly caused by a decrease in mesothelioma occurrence
among males, while the IR of mesothelioma for females
remains more stable. This may reflect the fact that
asbestos exposure has shifted from occupational, mostly
present in males, to environmental exposure, and indicates
that current asbestos regulations do not sufficiently
consider all sources of environmental exposure. The male/
female (M/F) ratio has been used as a relatively reliable
surrogate to distinguish environmental from occupational
exposure (6,7), with a M/F ratio approaching one as a sign
Figure 4 World standardized incidence rates (per 100,000) over time, overall and by gender in the (A) United States, and (B) Europe. (C)
Ratio of world standardized incidence rates for females vs. males, over time in the United States and Europe.
WSIR (Per 100,000)
WSIR (Per 100,000)
WSIR Ratio (female vs. male)
Year Year
Year
Female Male Overall
Europe US
1980
1980 1980
1984
1984
1984
1988
1988
1988
1992
1992
1992
1996
1996
1996
2000
2000
2000
2004
2004
2004
2008
2008
2008
2012
2012
2012
2016
2.0
1.5
1.0
0.5
0
2.0
1.5
1.0
0.5
0
0.3
0.2
0.1
A B
C
S36 Alpert et al. Epidemiology of mesothelioma in Europe and the US
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that environmental exposure plays a more important role.
The identification of current sources of environmental
exposure to asbestos and the associated health effects in
the general population remains an important area of future
research, including the identication of geographic areas
where asbestos is naturally present in the environment (42).
The difference in incidence with gender is of special
importance because females with malignant mesothelioma
have a significantly better survival than males, although
the precise reasons for this observation are still uncertain
(32,33). Given the positive effects of legislation on
occupational exposure to asbestos, the next step will be to
shift the focus of research and legislation to environmental
sources of asbestos exposure, in order to target all potential
avenues of asbestos exposure. Because mesothelioma is a
rare but deadly disease, and combined with the changing
landscape of asbestos exposure, mesothelioma registries
capturing mesothelioma cases in real-time are of utmost
importance to investigate the many unanswered scientic
questions. Countries with mesothelioma registries are
able to research and respond to the current scientic and
legislative needs associated with mesothelioma incidence
and mortality.
In conclusion, we report here the status of mesothelioma
epidemiology in the recent years, and observe that asbestos
exposure is still a burden worldwide, and legislative
action is needed to obtain a complete ban. The pattern of
mesothelioma is shifting from a mostly male disease to a
disease that affects females as well in substantial numbers.
Studies on unknown sources of asbestos exposure, of other
sources of natural exposure to asbestos and asbestos-like
fibers, as well as of individual genetic susceptibility to
asbestos bers are needed.
Acknowledgments
Funding: None.
Footnote
Conicts of Interest: The authors have no conicts of interest
to declare.
Ethical Statement: The authors are accountable for all
aspects of the work in ensuring that questions related
to the accuracy or integrity of any part of the work are
Table 2 Ratio of annual world standardized mortality rates to
incidence rates [2008–2012], by country, for males and females
Country Mortality rate to incidence rate ratio [2008–2012]
Male Female
United States 0.89 0.67
Austria 0.82 1.00
Belgium 0.80 0.75
Bulgaria 0.20 0.00
Croatia 0.87 1.00
Cyprus 0.62 0.33
Czech Republic 0.75 0.50
Denmark 0.68 1.00
Estonia 1.00 0.50
France 0.85 0.75
Germany 0.69 0.67
Iceland0.42 1.00
Ireland 0.90 0.50
Israel 0.86 0.50
Italy 0.83 0.67
Latvia 1.00 1.00
Lithuania 1.00 1.00
Malta 0.74 1.00
Netherlands 0.89 0.75
Norway 0.80 0.67
Poland 0.80 0.67
Portugal 0.60
Slovakia 0.29 0.50
Slovenia0.60 0.80
Spain 0.67 1.00
Switzerland 0.90 0.67
United Kingdom 0.88 0.83
, combined incidence rates are available from 2008–2012.
Combined mortality rates are queried from all years available
from 2008–2012 for each country. For some countries, not
all years from 2008–2012 were available. , due to data from
difference sources, some mortality rates exceed incidence
rates for the same time frame. Those ratios are recorded as 1.
Russian Federation, Turkey, Ukraine, and Belarus reported
incidence rates, but no mortality information. Armenia, Finland,
Georgia, Hungary, Kazakhstan, Kyrgyzstan, Luxembourg,
Republic of Moldova, Romania, Serbia, and Sweden, reported
mortality rates, but not incidence information. Albania, Andorra,
Azerbaijan, Bosnia and Herzegovina, Greece, Macedonia,
Monaco, Montenegro, San Marino, Tajikistan, Turkmenistan, and
Uzbekistan reported no mesothelioma information.
S37
Translational Lung Cancer Research, Vol 9, Suppl 1 February 2020
© Translational lung cancer research. All rights reserved. Transl Lung Cancer Res 2020;9(Suppl 1):S28-S38 | http://dx.doi.org/10.21037/tlcr.2019.11.11
appropriately investigated and resolved.
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Cite this article as: Alpert N, van Gerwen M, Taioli E.
Epidemiology of mesothelioma in the 21st century in Europe
and the United States, 40 years after restricted/banned asbestos
use. Transl Lung Cancer Res 2020;9(Suppl 1):S28-S38. doi:
10.21037/tlcr.2019.11.11
... PM is a relatively chemoresistant disease and has a long median survival time (eg, 9-12 months). 1 Although significant improvement has been made in diagnoses and treatments of many malignancies, therapeutic challenges remain in PM. This review aims to enlighten the unmet needs of patients with PM and to emphasize the need for a multidisciplinary treatment and management of PM by increasing the awareness of health care professionals, in general, and oncologists and pulmonologists, in particular. ...
... PM is the most encountered form, which accounts for 65%-70% of all cases, followed by peritoneal mesothelioma (30% of all cases) and pericardial mesothelioma (1%-2% of all cases). 1 Mesothelioma is more common in males than females due to occupational exposure to asbestos. The incidence rate of mesothelioma varies among countries; per 10 0,0 0 0 people, it is 0.9 for males and 0.3 for females in USA, and 1.7 for males and 0.4 for females in Europe. 1 According to the data of the Ministry of Health in Turkey, the incidence has been reported to be around 1 in 10 0,0 0 0 people; however, it is epidemic in some regions (the incidence is 10 0 0 times higher in Karain village in Cappadocia than in other regions). ...
... The incidence rate of mesothelioma varies among countries; per 10 0,0 0 0 people, it is 0.9 for males and 0.3 for females in USA, and 1.7 for males and 0.4 for females in Europe. 1 According to the data of the Ministry of Health in Turkey, the incidence has been reported to be around 1 in 10 0,0 0 0 people; however, it is epidemic in some regions (the incidence is 10 0 0 times higher in Karain village in Cappadocia than in other regions). 2 Asbestos exposure, either occupational or environmental, is the most important risk factor for the development of PM. 3 , 4 The use of asbestos has been banned in many countries, including Turkey, since the 1990s. 1 The relative risk of various occupational exposures has been extensively addressed in the literature. ...
... Trial registration: Not applicable Background Malignant mesothelioma (MM) is a rare and aggressive form of cancer that affects the mesothelial cells of the pleura, peritoneum, pericardium, and tunica vaginalis (1,2). The pleural location has a particularly high relationship with asbestos exposure (3,4). Despite widespread asbestos use bans, mesothelioma incidence is continuously rising (5). ...
... A global ban on the use and manufacturing of asbestos has not yet been put into effect; the countries that have such a ban adopted it at different times, making it di cult to predict the risk of mesothelioma in the general population in the future (4,8). ...
... In Europe, pleural mesothelioma incidence rates are still rising, while certain countries have seen a decline (14,15). In countries where the law banned the use of asbestos was adopted early, studies have indicated a decrease in the incidence and mortality rates of MM, however, in nations where the law's implementation was delayed, these rates have continued to rise (4,(15)(16)(17). ...
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Background Malignant mesothelioma is a rare form of cancer that mostly affects the pleura and has a strong link to asbestos exposure. Greece banned the use of asbestos in 2005, however, the public was already aware of this substance in the 1980s. This research aims to present an overview of Greece's mesothelioma mortality rates (MMR) from 1983 to 2019 by age, gender, and geographic region and to determine whether the actions to ban asbestos impacted these rates. Methods Data were retrieved by the Hellenic Statistical Authority (HAS) from death certificates that mentioned mesothelioma as the cause of death from 1983 to 2019 with details on the residence, gender, and age. Statistical analysis was performed using SPSS 29 software, a one-way ANOVA test followed by post-hoc and Dunnett C test for multiple comparisons or Independent samples T-test for comparison between two subjects. Results Males' MMR and the whole population's MMR reached their highest levels in 2011 (0.86/100000 and 0.52/100000, respectively). In order to look for any potential changes between the first two decades of the 21st century, we compared the mean MMR of each geographic region in Greece between two different 10-year subperiods (2000–2009 and 2010–2019). Except for Epirus, all regions of Greece had elevated regional MMRs, particularly in those with the highest asbestos deposits. Notably, the MMR in Epirus decreased from 0.55/100000 (2000–2009) to 0.38/100000 (2010–2019). After 2011, the MMR for men and the general population stabilized. This stability is important since mesothelioma in men is associated with occupational asbestos exposure. The intriguing discovery of a lower MMR in Epirus emphasizes the need to raise awareness of the condition and implement effective public health measures. Conclusions In Greece, the annual rate for males and the whole population reached its highest level in 2011, which is positive and encouraging and may be a sign that the rate will stabilize during the following years. Moreover, this study showed that the actions made in the 1980s regarding public awareness and surveillance directly impacted the decrease in Epirus rates. Future research, continual awareness, information, and recording are needed to monitor the mesothelioma epidemic. Trial registration Not applicable
... Due to its nature as an occupational disease, a national surveillance system is active with mandatory reporting; for this reason, the National Mesothelioma Register (ReNaM) exists in Italy and maintains records of all cases of MM and asbestos exposure (6). Although the use of asbestos has been banned in Italy for nearly 30 years, there has not yet been a reduction in the incidence of mesothelioma in our country (7), due to the latency between exposure (8) to the mineral and the development of the disease. The most frequent histology is the epithelioid subtype accounting for 70-85% of cases, while the more aggressive sarcomatoid and biphasic forms are rarer (9). ...
... Nevertheless, because of the rarity and serious prognosis of this disease, patient participation in clinical trials should be further encouraged (18). Furthermore, the progressive elimination of asbestos from public and private environments represents a fundamental condition for achieving a continuing reduction in MM incidence (8). In Italy, asbestos was definitively banned in April 1994 (see Law 257/92); nevertheless, the long latency time between the exposure beginning and the onset of the disease, associated with the lengthening of life expectancy, and the improvement of diagnostic techniques, such as modern imaging techniques and advances in immunohistochemical staining, which have contributed to optimized MM diagnosis, have ultimately led to an increase in the incidence of MM in recent years (19,20). ...
... In the literature, the MM trend shows variable rates with a decrease in some countries and stability or an increase in others, always linked to the various actions to remove the use of asbestos in production activities (8,32,33). MM is a typical tumor of the elderly (46.9% of tumors resulted in age 75+ and 31.9% between 65-74 years), but cases diagnosed at a younger age are not uncommon (48 cases <45 years and 147 cases between 45-54 years). It should be noted that pleural mesothelioma at a young age has an M/F ratio of 1.7 while in later ages it is equal to 3:1, while for peritoneal tumors the ratio is almost always 1:3. ...
... In the United States, asbestos bans between 1973 and 1989 have paved the way to a gradual decrease in PM incidence and mortality rates two decades later. In the European Union, the use of asbestos has come to a complete stop in 2005, with national bans having been enforced in several member states well before [7,8]. ...
... Family members of asbestos workers can also be at risk by exposure to fibers brought home on the worker's clothing. While asbestos may not be actively used and marketed, built-in asbestos inside commonly used objects (including pipes, insulation, stoves, heating devices, asbestos sheeting and roofing) may pose a hazard to people in contact with or living near them [8]. ...
... The latency time between asbestos exposure and PM onset can be as long as approximately 40 years on average, although it may extend to 60-70 years. On this basis, it may be hypothesized that although the earliest asbestos bans date back to approximately 50 years ago, we might be just now beginning to see the beneficial effects of such bans on public health [8,11]. A recent article investigating global trends in PM diagnosis from 1990 to 2017 showed that PM incident cases and age-standardized incidence rates have begun to decrease after 20 years of complete asbestos ban, resulting in a lower PM incidence in patients younger than 50 years, paralleled by a higher incidence in patients older than 70 years and in countries with a low socio-demographic index [12]. ...
Article
Full-text available
Pleural mesothelioma (PM) is an aggressive disease that has a strong causal relationship with asbestos exposure and represents a major challenge from both a diagnostic and therapeutic viewpoint. Despite recent improvements in patient care, PM typically carries a poor outcome, especially in advanced stages. Therefore, a timely and effective diagnosis taking advantage of currently available imaging techniques is essential to perform an accurate staging and dictate the most appropriate treatment strategy. Our aim is to provide a brief, but exhaustive and up-to-date overview of the role of multimodal medical imaging in the management of PM.
... Malignant pleural mesothelioma (MPM) is a rare malignancy [1], but the outcome remains poor with less than 5% of 5-year overall survival for all stages [2,3]. It is to date of great oncological concern since it is correlated with significant morbidity and severe symptoms such as pleural effusion, dyspnea, pain, and fatigue [4,5]. ...
... However, while the incidence of mesothelioma × 100,000 persons is decreasing, the overall number of mesotheliomas has not declined significantly, at least not in the USA as the total population is increasing. Presently mesotheliomas are occurring for a combination of several factors: (1) the presence of asbestos in old constructions that in some cases can result in substantial exposure; (2) the development of rural areas containing asbestos and other carcinogenic fibers, which have caused exposure in workers first and residents later [9,[12][13][14] (3) the discovery that 12-16% of mesotheliomas are linked to germline mutations [15-17, 24, 25]; (4) the development and use of radiation therapy in the past decades to treat several malignancies, which may cause mesothelioma years later [22,23,26,27]; (5) in addition, mesothelioma, like most other cancers, affects prevalently old people. The population in industrialized countries is increasing and growing older, and thus the number of people most susceptible to developing mesothelioma is increasing [6]. ...
Article
Full-text available
Mesothelioma is a cancer typically caused by asbestos. Mechanistically, asbestos carcinogenesis has been linked to the asbestos-induced release of HMGB1 from the nucleus to the cytoplasm, where HMGB1 promotes autophagy and cell survival, and to the extracellular space where HMGB1 promotes chronic inflammation and mesothelioma growth. Targeting HMGB1 inhibited asbestos carcinogenesis and the growth of mesothelioma. It is hoped that targeting HMGB1 will be a novel therapeutic strategy that benefits mesothelioma patients. Severe restrictions and/or a complete ban on the use of asbestos were introduced in the 80 and early 90s in the Western world. These measures have proven effective as the incidence of mesothelioma/per 100,000 persons is decreasing in these countries. However, the overall number of mesotheliomas in the Western world has not significantly decreased. There are several reasons for that which are discussed here: (1) the presence of asbestos in old constructions; (2) the development of rural areas containing asbestos or other carcinogenic mineral fibers in the terrain; (3) the discovery of an increasing fraction of mesotheliomas caused by germline genetic mutations of BAP1 and other tumor suppressor genes; (4) mesotheliomas caused by radiation therapy; (5) the overall increase in the population and of the fraction of older people who are much more susceptible to develop all types of cancers, including mesothelioma. In summary, the epidemiology of mesothelioma is changing, the ban on asbestos worked, there are opportunities to help mesothelioma patients especially those who develop in a background of germline mutations and there is the opportunity to prevent a mesothelioma epidemic in the developing world, where the use of asbestos is increasing exponentially. We hope that restrictive measures similar to those introduced in the Western world will soon be introduced in developing countries to prevent a mesothelioma epidemic.
... Asbestin başta malign plevral mezotelyoma [7], asbestozis, ve diğer malign olmayan akciğer ve plevral hastalıklar (plevral plaklar, plevral kalınlaşmalar ve benign plevral efüzyonlar) olmak üzere pek çok sağlık sorununa neden olduğu [7], [8] anlaşıldıktan sonra asbest kullanımını yasaklayıcı yasal düzenlemeler yapılmıştır [9]. Amerika Birleşik Devletleri ve Avrupa ülkelerinde asbest yasaklamaları veya düzenlemeleri incelendiğinde 1973'den sonra çeşitli yasaklamaların başladığını görmekteyiz [10]. Avrupa Komisyonu'nun 1999'da yayınladığı direktifle [11] Avrupa Birliği ülkelerinde asbest liflerinin veya liflerinden üretilen ürünlerin kullanımı ve pazarlanması yasaklanmıştır. ...
Article
Asbest ısı ve elektrik iletkenliği düşük, fiziksel ve kimyasal etkenlere direnci yüksek bir malzeme olduğu için geçmişte inşaat, kimya, petrol, lastik ve plastik, otomotiv ve enerji sektörü gibi birçok alanda kullanılmıştır. Başta asbestozis ve malign plevral mezotelyoma olmak üzere pek çok sağlık sorununa neden olduğu anlaşıldıktan sonra kullanımını yasaklayıcı yasal düzenlemeler yapılmıştır. Fakat geçmişteki yoğun kullanımı nedeniyle günümüzde halen birçok alanda karşımıza çıkmaktadır. Asbestin uygun şekilde sökülmesi ve uzaklaştırılması oldukça önem taşımaktadır. Ülkemizde, çalışanların asbest söküm, yıkım, tamir, bakım, uzaklaştırma çalışmalarında asbest tozuna maruziyetlerinin önlenmesi ve bu maruziyetten doğacak sağlık risklerinden korunması, sınır değerlerin ve diğer özel önlemlerin belirlenmesi amacıyla Asbestle Çalışmalarda Sağlık ve Güvenlik Önlemleri Hakkında Yönetmelik yürürlüğe girmiştir. Yönetmelik, asbest tozuna maruziyet riski bulunan çalışmalarda işverenin risk değerlendirmesi yapmakla yükümlü olduğunu belirtmektedir. Bu çalışmada, L-Tipi Matris yöntemi kullanılarak konutlarda, işyerlerinde, enerji santrallerinde, maden ocaklarında ve benzeri çalışma alanlarında asbest söküm işlerinde karşılaşılabilecek risklerin değerlendirmesi yapılmıştır. Değerlendirme sonucunda karantina kurulumu ve sökümü, asbest sökümü, söküm sonrası hijyen faaliyetleri, atıkların paketlenmesi ve istiflenmesi işleri yüksek riskli işler olarak belirlenmiştir. Söküm sırasında asbest liflerinin çevreye yayılmasını önlemek amacıyla naylon örtü ile tam sızdırmaz tecrit oluşturulmalı ve uygun sağlık ve güvenlik işaretleri yerleştirilmelidir. Asbest söküm işlerinde çalışanların P3 partikül filtreli tam-yüz veya yarım-yüz maske, Kategori III tip 5/6 tek kullanımlık tulum, iş eldiveni ve iş ayakkabısı gibi uygun kişisel koruyucu donanım (KKD) kullanımı sağlamalıdır. KKD kullanımı ve bakımı konularında çalışanlara eğitim verilmesi ayrıca önemlidir. Asbestli atıklar uygun kalınlıkta çift kat naylona konularak ağızları sıkıca kapatılmalı veya uygun daha büyük naylon torbalara konulmalıdır. Üzerlerine asbestli atık olduğunu bildiren işaretlemeler yapıştırılmalıdır. Atıklar çalışma alanı içinde yaşam mahalline uzak bir yerde geçici depolanmalı ve mümkün olan en kısa sürede lisanslı araçlarla lisanslı atık bertaraf tesisine sevk edilmelidir.
... Despite asbestos being banned or controlled for over 40 years, the incidence rate per 100,000 people has been reported at 0.9 for males and 0.3 for females in the USA and 1.7 for males and 0.4 for females in Europe. 1 With an average reported lifespan from diagnosis of 9 to 12 months 1 , it is one of the most aggressive cancers, with platinum and pemetrexed chemotherapy 2 the mainstay systemic treatment for early stage "resectable" disease despite modest impact on survival. With decades of limited progress in systemic treatment for this cohort, surgery to remove all visible disease (macroscopic resection or cytoreduction) is widely offered and uniformly recommended in American guidelines 3,4 , European 5,6 guidelines and international 7 consensus statements as the principal option to improve survival. ...
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Mesothelioma is a cancer arising from mesothelial cells lining the thoracic (pleura) or the abdominal (peritoneum) cavities, and more rarely from transformed mesothelial cells of pericardium or tunica vaginalis testis. The development of mesothelioma has been related to the exposure to carcinogenic mineral fibers, mainly asbestos. Malignant mesothelioma is an aggressive disease with diffuse nature, low median survival, and prolonged latency presenting difficulty in prognosis, diagnosis, and treatment. We here review all these aspects to underline the progress being made in investigation and to emphasise how much work remains to be done to improve prognosis and treatment.
Article
Asbestos is the main cause of malignant mesothelioma. Previous studies have linked asbestos-induced mesothelioma to the release of HMGB1 from the nucleus to the cytoplasm, and from the cytoplasm to the extracellular space. In the cytoplasm, HMGB1 induces autophagy impairing asbestos-induced cell death. Extracellularly, HMGB1 stimulates the secretion of TNFα . Jointly, these two cytokines kick-start a chronic inflammatory process that over time promotes mesothelioma development. Whether the main source of extracellular HMGB1 were the mesothelial cells, the inflammatory cells, or both was unsolved. This information is critical to identify the targets and design preventive/therapeutic strategies to interfere with asbestos-induced mesothelioma. To address this issue, we developed the conditional mesothelial HMGB1-knockout ( Hmgb1 ΔpMeso ) and the conditional myelomonocytic-lineage HMGB1-knockout ( Hmgb1 ΔMylc ) mouse models. We establish here that HMGB1 is mainly produced and released by the mesothelial cells during the early phases of inflammation following asbestos exposure. The release of HMGB1 from mesothelial cells leads to atypical mesothelial hyperplasia, and in some animals, this evolves over the years into mesothelioma. We found that Hmgb1 ΔpMeso , whose mesothelial cells cannot produce HMGB1, show a greatly reduced inflammatory response to asbestos, and their mesothelial cells express and secrete significantly reduced levels of TNFα . Moreover, the tissue microenvironment in areas of asbestos deposits displays an increased fraction of M1-polarized macrophages compared to M2 macrophages. Supporting the biological significance of these findings, Hmgb1 ΔpMeso mice showed a delayed and reduced incidence of mesothelioma and an increased mesothelioma-specific survival. Altogether, our study provides a biological explanation for HMGB1 as a driver of asbestos-induced mesothelioma.
Article
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Although some countries have reduced asbestos consumption and instituted bans, other countries continue to produce and consume asbestos even as asbestos-related deaths mount and the associated societal costs are high. Asbestos production and consumption has declined globally; the number of bans has increased; and the speed at which countries have tapered off consumption has increased. Using country-level data, we study the economic impact of historical changes in the production and use of asbestos. We compare changes in gross domestic product (GDP) following the enactment of asbestos bans. We do not find any significant effect on GDP following an asbestos ban. In a regional case study, we compare changes in GDP and employment with changes in asbestos production. Regional-level data revealed a temporary employment decline at the local level that was then reversed.
Article
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Introduction The epidemiology of gender differences for mesothelioma incidence has been rarely discussed in national case lists. In Italy an epidemiological surveillance system (ReNaM) is working by the means of a national register. Methods Incident malignant mesothelioma (MM) cases in the period 1993 to 2012 were retrieved from ReNaM. Gender ratio by age class, period of diagnosis, diagnostic certainty, morphology and modalities of asbestos exposure has been analysed using exact tests for proportion. Economic activity sectors, jobs and territorial distribution of mesothelioma cases in women have been described and discussed. To perform international comparative analyses, the gender ratio of mesothelioma deaths was calculated by country from the WHO database and the correlation with the mortality rates estimated. Results In the period of study a case list of 21 463 MMs has been registered and the modalities of asbestos exposure have been investigated for 16 458 (76.7%) of them. The gender ratio (F/M) was 0.38 and 0.70 (0.14 and 0.30 for occupationally exposed subjects only) for pleural and peritoneal cases respectively. Occupational exposures for female MM cases occurred in the chemical and plastic industry, and mainly in the non-asbestos textile sector. Gender ratio proved to be inversely correlated with mortality rate among countries. Conclusions The consistent proportion of mesothelioma cases in women in Italy is mainly due to the relevant role of non-occupational asbestos exposures and the historical presence of the female workforce in several industrial settings. Enhancing the awareness of mesothelioma aetiology in women could support the effectiveness of welfare system and prevention policies.
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While the association between exposure to asbestos and malignant mesothelioma (MM), particularly malignant pleural mesothelioma (MPM) has been well established, the health impact of environmental exposure (EE) to asbestos is less studied. This review summarizes the most recent studies on the association between MM and EE to asbestos, in order to identify features associated with EE, and quantify the association with MPM. There were 44 studies from eighteen countries that met our selection criteria, with considerable amount of heterogeneity in study design, the measures for exposure, and health outcomes. The male to female ratio (M:F) was close to or less than 1, and generally lower than the ratio reported when both occupational and environmental exposure types were considered. While recent studies continue to improve our understanding of the types of EE to asbestos still present, challenges remain. We highlighted a few new research directions, such as a need for reliable matrixes to identify common and less recognized environmental exposure types, asbestos biomarker studies specifically focusing on environmental exposures, and research focused on populations and geographic areas that have not been previously studied.
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Background Australia is known to have had one of the highest per-capita asbestos consumption rates, yet there are few contemporary reports on malignant mesothelioma trends. Methods Data on 10 930 people with malignant pleural mesothelioma (MPM) and 640 people with malignant peritoneal mesothelioma diagnosed in Australia during 1982–2009 were analysed. Observed incidence rate trends were quantified. Incidence rates were projected up to 2030 using observed incident cases during 1982–2012. The relative per-decade change in excess mortality during 1999–2009 was estimated. Results During 1982–2009, acceleration in MPM age-standardised incidence rates were highest for women and those aged 75 years and above, with average annual percentage changes of +4.9 (95% CI 3.6 to 6.2) and +7.2 (95% CI 5.4 to 9.0), respectively. Age-standardised incidence rates for men with MPM aged 0–64 years decelerated rapidly during 2003–2009, an average annual percentage change of −5.1% (95% CI −7.6% to −2.5%). Overall, male age-specific MPM incidence rates in the age group of 65–74 year during 2010–2030 are projected to decline with rates projected to increase for older men and women with MPM. There was a statistically significant 16% relative reduction in the excess mortality rate (EMR) up to 5 years postdiagnosis for people diagnosed with malignant pleural and peritoneal mesothelioma combined in 2009 compared with those diagnosed in 1999, an EMR ratio of 0.84 (95% CI 0.77 to 0.92). Conclusions Australia's malignant mesothelioma incidence rates appear to have reached maximum levels but with differences over time by age, gender and tumour location. Improvements over time in survival provide a glimpse of hope for this almost invariably fatal disease.
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Malignant pleural mesothelioma (MPM) is a rare disease with a very poor prognosis. Previous studies have indicated that women experience longer survival compared with men. We analyzed 16 267 eligible patients (21.3% females) in the National Cancer Database to evaluate which clinical factors are independently predictive of longer survival. After adjusting for all covariates, survival was significantly better in females compared with males [HRadj: 0.81, 95% confidence interval (CI): 0.77-0.85]. Other factors significantly associated with better survival were younger age at diagnosis, higher income, lower comorbidity score, epithelial histology, earlier stage and receipt of surgical or medical treatment. After propensity matching, survival was significantly better for females compared with males [hazard ratio (HR): 0.86, 95% CI: 0.80-0.94]. After propensity matching within the epithelial group, survival remained significantly better for females compared with males (HR: 0.85, 95% CI: 0.74-0.97). This study adds information to the known significant gender survival difference in MPM by disentangling the effect of gender from the effect of age and histology, two known independent factors affecting survival. Circulating estrogen, present in young but not older women, and higher expression of the estrogen receptor beta in epithelial mesothelioma have been suggested to play a role in gender survival differences. These findings may lead to exploring new therapeutic options, such as targeting estrogen receptor beta, and considering hormonal therapy including estrogens for patients with otherwise limited prognosis.
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