What are the indications for screening for mesothelioma in individuals with a history of asbestos exposure?

Mesothelioma Screening Is Not Recommended

Screening for mesothelioma is not recommended, even in individuals with documented asbestos exposure, because no screening modality has been proven to improve survival or reduce mortality. 1

Why Screening Is Not Indicated

Lack of Proven Benefit

• Multiple international guidelines explicitly state there is no place for mesothelioma screening (Grade 1B recommendation from the European Respiratory Society/European Society of Thoracic Surgeons). 1
• The NCCN guidelines do not currently recommend screening for malignant pleural mesothelioma despite studying high-risk asbestos-exposed patients. 1
• There is no proof that early discovery of mesothelioma improves survival or quality of life for many months. 1

Imaging Modalities Are Ineffective for Screening

• Low-dose CT scanning has failed as a screening tool: In a cohort of 1,045 asbestos-exposed workers, not a single case of pleural mesothelioma was detected by low-dose CT screening. 1
• While research studies have detected some mesotheliomas with CT screening 2, 3, these were typically advanced cases that would not benefit from earlier detection, and the overall yield remains too low to justify population-based screening.
• PET and MRI are useful for clinical management of known disease but are not applicable for screening purposes. 1

Biomarkers Are Not Suitable for Screening

• Soluble mesothelin-related peptides (SMRP), osteopontin, and other biomarkers have unacceptably high false-positive rates. 1, 4
• In prospective testing of 538 asbestos-exposed individuals, approximately 3% had elevated SMRP levels without mesothelioma, which would result in expensive and potentially harmful investigations for many years. 1
• The low prevalence of mesothelioma means false-positive tests would outnumber true-positive results by several times. 1
• The European Respiratory Society explicitly states these markers should NOT be used as screening tools. 4

What Should Be Done Instead

Surveillance for Asbestos-Related Disease (Not Mesothelioma Screening)

• Persons with documented asbestos exposure and ≥10 years since initial exposure may be monitored with chest radiographs and pulmonary function studies every 3-5 years to identify asbestos-related disease (not specifically mesothelioma). 1
• This surveillance is for detecting asbestosis and other non-malignant asbestos-related conditions, not for cancer screening. 1

Lung Cancer Screening (Different Indication)

• If asbestos-exposed individuals meet standard lung cancer screening criteria (age 50-80, ≥20 pack-year smoking history, currently smoking or quit within 15 years), they should undergo low-dose CT for lung cancer screening, not mesothelioma screening. 5
• This follows the same criteria as for other high-risk populations and is based on lung cancer screening evidence, not mesothelioma detection. 5

Essential Patient Counseling

• Inform asbestos-exposed individuals about the risk of mesothelioma, lung cancer, and other malignancies. 1
• Provide aggressive smoking cessation counseling, as smoking and asbestos exposure synergistically increase lung cancer risk. 1, 6
• Document occupational exposure history for medicolegal and compensation purposes. 1, 6
• Advise patients to seek immediate medical attention if they develop symptoms (dyspnea, chest pain, weight loss). 1

Critical Pitfalls to Avoid

• Do not confuse lung cancer screening with mesothelioma screening: Low-dose CT in asbestos-exposed smokers is for lung cancer detection, not mesothelioma. 5
• Do not order biomarker panels for screening: SMRP and osteopontin testing in asymptomatic individuals leads to false positives and unnecessary workup. 1, 4
• Do not promise that screening will improve outcomes: There is no evidence that early detection changes the natural history of mesothelioma. 1
• Do not use chest X-rays alone for any surveillance: They lack sensitivity for both early mesothelioma and asbestosis. 1, 6