1. Mesothelioma Study Day Dr Richard Roope Wessex Clinical Senate and Strategic Networks GP Cancer Lead CRUK & Macmillan GP Mesothelioma Study Day Thursday 19 th September 2013

2. Mesothelioma in Primary Care: Key Facts Signs and Symptoms

3. Mesothelioma Cancer of mesothelial cells 75% pleural mesothelioma 25% peritoneal mesothelioma (does not usually metastasise) Very rare: pericardial mesothelioma outer lining of the testes (testicular mesothelioma). c 90% caused by asbestos exposure Rarely can be related to radiation exposure

4. Mesothelioma <1% of all cancers in UK In 2010: 2543 people diagnosed with Mesothelioma 1 per 12 full time GPs per year – UK average Male:female ratio = 5:1 17 th most common cancer in men (27 th in women) 90% in over 60s

5. Mesothelioma Occupations at risk: joiners and construction workers plumbers electricians boilermakers shipbuilders dockers Family members of the above Proximity to source (factories, scrap yards etc)

6. Mesothelioma Risk seems to be related to: Age of exposure (particularly <30s) Duration of exposure Concentration of exposure

7. Mesothelioma Possible link with SV40 Some people have been found to be exposed to polio vaccines contaminated with SV40 virus between 1955 and 1963 in some countries, including Britain. Kroczynska, B; Cutrone R, Bocchetta M, Yang H, Elmishad A, Vacek P, Ramos-Nino M, Mossman B, Pass H, Carbone M (2006). "Crocidolite asbestos and SV40 are cocarcinogens in human mesothelial cells and in causing mesothelioma in hamsters". PNAS 103 (38): 14128–33. doi:10.1073/pnas.0604544103. PMC 1599923. PMID 16966607"Crocidolite asbestos and SV40 are cocarcinogens in human mesothelial cells and in causing mesothelioma in hamsters" doi10.1073/pnas.0604544103PMC1599923PMID16966607

8. Mesothelioma Latency 10-60 years Rarely less than 20 years typically 35-40 years

9. Mesothelioma

10. Significant geographical variation

11. Mesothelioma

12. From: http://www.hse.gov.uk/statistics/regions/index.htm Male Standardised Mortality Ratios (SMRs) by Local Authority and Unitary Authority 1981 – 2005

13. Mesothelioma Area DeathsSMR Rank in UK Number pa per GP Average years between cases for FT GP Portsmouth UA22733550.283.58 Southampton UA25928280.244.25 Eastleigh118253100.214.74 Havant139243110.204.94 Gosport76240190.205.00 Fareham100208220.175.77 Isle Of Wight UA135175260.156.85 Hampshire867161 0.137.45 Winchester68139530.128.63 New Forest129133480.119.02 Test Valley59130630.119.23 East Hampshire60127650.119.44 Basingstoke And Deane65116760.1010.34 Christchurch331041450.0911.53 Adur341011540.0811.87 UK 100 0.0811.99 Area DeathsSMR Rank in UK Number pa per GP Average years between cases for FT GP UK 100 0.0811.99 Hart30981750.0812.24 Weymouth And Portland31961770.0812.49 East Dorset49921620.0813.04 Worthing52911600.0813.18 Dorset19786 0.0713.95 Crawley32842310.0714.28 West Dorset46832080.0714.45 North Dorset26832570.0714.45 West Sussex31280 0.0714.99 Rushmoor23782850.0715.38 Horsham43782370.0715.38 Arun67762220.0615.78 Chichester44702720.0617.13 Mid Sussex40702750.0617.13 Purbeck12483860.0424.99 Mesothelioma mortality in Great Britain: number of deaths and SMRs for males by area 1981-2005 After: Mesothelioma Mortality in Great Britain: Analyses by Geographical Area and Occupation 2005 http://www.hse.gov.uk/statistics/pdf/mesojune08.pdf

14. Mesothelioma

15. Death rates in past 5 years: Stable in males Increased by 20% in females Expected to peak in 2016 and then fall dramatically www.hse.gov.uk/statistics/causdis/mesothelioma/

16. Mesothelioma After: http://www.hse.gov.uk/research/rrpdf/rr728.pdf

17. Mesothelioma Three main types of asbestos Blue(crocidolite), brown(amosite), white(chrysotile) Gradient of risk: blue>brown>white Blue and brown asbestos are strongly linked with mesothelioma. They have been banned since the late 1980's and cannot be imported into the UK. White asbestos is now also thought to be harmful. The use of all asbestos was banned in 1999 in the UK.

18. Mesothelioma Symptoms In small groups discuss Symptoms of mesothelioma

19. Mesothelioma Symptoms In small groups discuss Symptoms of mesothelioma Rank the top four

20. Mesothelioma

21. Symptoms 79%:Shortness of breath 64%:Pain in the chest, lower back or shoulder 36%:A persistent cough 30%:Losing more than 10% of your weight when not dieting Also: Sweating and fever Difficulty swallowing A hoarse or husky voice Abdominal pain and swelling, nausea, poor appetite, change of bowel pattern (peritoneal mesothelioma).

22. Mesothelioma Signs In small groups discuss Clinical findings

23. Mesothelioma Signs In small groups discuss Clinical findings Consensus as to most frequent finding

24. Mesothelioma

25. Signs 90%:Pleural effusion Also: Clubbing Reduced chest expansion Dull to percussion Reduced or harsh breath sounds

26. Mesothelioma NICE guidance recommends urgent referral for a chest x-ray for people with a history of asbestos exposure with any of the following symptoms: chest pain difficulty breathing unexplained symptoms shoulder pain cough weight loss

27. Mesothelioma NICE guidance recommends urgent referral for a chest x-ray for people with a history of asbestos exposure with any of the following symptoms: chest pain difficulty breathing unexplained symptoms shoulder pain cough weight loss Note: asbestos thought to cause similar numbers of lung cancer (c2000 pa) – though likely to fall quicker than mesothelioma as lung cancer had shorter latency.

28. Any questions?