Elsevier

Lung Cancer

Volume 83, Issue 2, February 2014, Pages 133-138
Lung Cancer

Review
Radiotherapy for the treatment of pain in malignant pleural mesothelioma: A systematic review

https://doi.org/10.1016/j.lungcan.2013.11.004Get rights and content

Abstract

Radiotherapy is commonly used to treat pain in malignant pleural mesothelioma (MPM). The purpose of this systematic review is to examine the evidence for this practice. Medline (1946–2013), Embase (1974–2013) and Central (The Cochrane Library Issue 9, 2012) databases were searched. Eligible studies met the following criteria: MPM (histological or radiological diagnosis), radiotherapy given with the intent of improving pain, response rates to radiotherapy reported, dose and fractionation reported and the relationship between radiotherapy and pain response explored. All studies had independent review and were graded according to evidence level. Eight studies met the eligibility criteria. Two studies were prospective single arm phase II studies while the remainder were retrospective case series. All were graded as either Level 2 or Level 3 evidence. Due to marked heterogeneity among studies, quantitative synthesis of results was not possible. No high quality evidence currently exists to support radiotherapy in treating pain in MPM. Studies focusing on clear pain endpoints and improving target delineation are needed. Such studies should also use modern radiotherapy techniques and concentrate on dose escalation.

Introduction

In 2009, over 2500 patients were diagnosed with MPM in the UK. The global incidence is not known but has been estimated at 14,200 per year [1]. The most common symptoms in MPM are pain and breathlessness though the reported incidence of pain varies from 25% to 90% [2], [3], [4], [5].

The cause of the pain in MPM is often multifactorial. It may be caused by infiltration of the intercostal nerves by tumour and/or due to surgical procedures (pleural biopsy, thoracotomy etc.) [6]. Furthermore, mesothelioma may also invade bone causing significant pain. Therefore, the pathophysiology of pain in MPM is generally mixed: a combination of bone and neuropathic pain. As a result, patients are often on multiple analgesics such as non steroidal anti inflammatory drugs (NSAIDs), opioids, paracetamol, adjuvant analgesics for neuropathic pain as well as topical agents such as lidocaine patches [7]. Cordotomy is occasionally performed for these patients, however this is not widely available [6], [8]. There is an urgency for patients with MPM to receive optimal pain control.

In terms of oncological interventions for treating pain in MPM, the armamentarium is limited. Surgery, chemotherapy and radiotherapy have all been studied in this disease. Surgical studies have tended to focus on long term tumour control rather than symptom improvement. Chemotherapy studies have generally been disappointing though two studies have shown a survival advantage [9], [10].

Radiotherapy is effective at palliating many symptoms in cancer patients, especially cancer related bone pain [11]. Although precise data on the utilisation of radiotherapy in treating pain in MPM is unknown, it is frequently used for this purpose. However, the evidence supporting its use has not been clearly established [7].

This systematic review examines the evidence supporting the use of radiotherapy in treating pain in patients with MPM.

Section snippets

Materials and methods

Ethical approval was not required for this systematic review. The following databases were searched electronically: Medline (1946–2013), Embase (1974–2013) and CENTRAL (The Cochrane Library Issue 9, 2012). The keywords and search strategy are outlined in Appendix 1. The date of the last literature search was 5th February 2013.

Results

The following number of articles was retrieved: 462 (Medline), 1007 (EMBASE) and 11 (Central). The literature search results are shown in Fig. 1. Following the appraisal process described, eight articles were eligible.

Articles which met the eligibility criteria are shown in Table 1. Key aspects of each study are detailed. It is noted that no patients in any of the studies received pemetrexed based chemotherapy.

Excluded articles are shown in supplementary Table 1; [30], [31], [32], [33], [34],

Discussion

Based on the studies presented in this review, the evidence for radiotherapy in treating pain in mesothelioma ranges from Level 2 to 3 [17]. Therefore, firm recommendations on the role of radiotherapy in the relief of pain in MPM cannot be made. Due to a combination of poor study design and small numbers of patients, none of the studies fully examine the role of radiotherapy in the treatment of pain in MPM. Indeed, in four of the eight studies, assessment of pain response was retrospective and

Conflict of interest statement

No conflict of interest declared.

Acknowledgements

The authors would like to acknowledge grants received from the June Hancock Mesothelioma Research Fund and the Beatson Oncology Centre Fund as well as the work from Ms. K Coltart who helped conduct the literature review.

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