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Chylous effusions are caused by the accumulation of chlye in the thoracic cavity (also known as chylothorax). Chyle is a protein—and calorie—rich fluid with nutritional and immunological functions. It is transported around the body via the lymphatic system, the largest component of which is the thoracic duct. Injury or disruption to the thoracic duct can occur due to trauma, surgery, congenital lymphatic malformations or acquired infiltrative conditions, leading to chylous effusions. As well as causing symptoms, notably breathlessness, chylous effusions can be associated with serious complications, including malnutrition, immunosuppression, and electrolyte disturbances. This article summarizes the potential causes, diagnostic approaches, complications and management options for chylous effusions in adults.

IntroductionMesothelioma is a heterogeneous disease that can be challenging to monitor and prognosticate. ASSESS-meso is a multicentre, prospective, longitudinal observational cohort study of patients with mesothelioma. The primary aim is to describe different clinical phenotypes and investigate predictive and prognostic factors, including biomarkers from blood and pleural fluid. The secondary aim is to provide a resource for future trials and substudies.Methods and analysisWe aim to recruit 700 patients with a histological, cytological or clinicopathological diagnosis of mesothelioma, at any anatomical site (pleural, peritoneal, pericardial, etc). Longitudinal data will be collected, including clinical information, radiological investigations, blood tests and patient-reported outcome measures for breathlessness, chest pain and sweats. Preplanned analyses will use Cox proportional hazards method to evaluate factors associated with survival, linear and logistic regression models to investigate associations with symptoms, and analysis of variance modelling to explore changes in symptoms over time.Ethics and disseminationEthical approval has been granted by the Research Ethics Committee South West—Central Bristol (17-SW-0019) and Health Research Authority (IRAS ID 220360). A study steering committee has been established and results will be published OpenAccess in peer-reviewed journals.Trial registration numberISRCTN: 61861764.

Malignant pleural effusions (MPEs) often cause symptoms, and guidelines recommend early definitive intervention. However, observational data suggest that systemic anticancer treatment (SACT) may control MPE caused by certain pharmacologically sensitive tumors.Is SACT associated with higher rates of MPE resolution in people with pharmacologically sensitive tumors?This was a retrospective analysis of prospectively collected data from an observational cohort study of people diagnosed with MPE from lung, breast, ovarian, and hematologic malignancy between May 11, 2008, and August 6, 2017. MPE resolution (defined as radiologic resolution with removal of drain or catheter and cessation of interventions) was compared in pharmacologically sensitive (high-grade lymphoma, small cell or target-mutation-positive lung cancer, and hormone-receptor-positive breast or ovarian cancer) and nonsensitive (remainder of cohort) tumors, with and without SACT. Secondary outcomes included time to resolution, 3-month resolution rates, and total pleural interventions.Of 280 patients, 127 had sensitive and 153 had nonsensitive tumors. One hundred seventy-one received SACT, and 109 did not. More patients with sensitive tumors achieved MPE resolution than those with nonsensitive tumors (53/127 [41.7%] vs 42/153 [27.5%]; P = .01), and this occurred predominantly after receipt of SACT. However, hematologic malignancies were overrepresented in the sensitive group, with high rates of SACT use and MPE resolution. After adjustment for this and other confounders, no relationship was found among pharmacologic sensitivity, SACT, and MPE resolution (adjusted OR, 1.4; 95% CI, 0.5-4.1). The strongest predictor of MPE resolution was administration of chemical pleurodesis (adjusted OR, 6.2; 95% CI, 3.3-11.7). In sensitive tumors, MPE resolution occurred without chemical pleurodesis in 14 of 52 patients (26.9%; 95% CI, 15.6%-41.1%) after SACT and in 5 of 22 patients (22.7%; 95% CI, 8.2%-47.2%) without SACT.In this observational study, SACT was not associated independently on MPE resolution in pharmacologically sensitive tumors. Randomized trials are required, but with current data, patients with symptomatic MPE should receive early definitive pleural intervention regardless of underlying tumor or intended treatment.

Background: Malignant pleural effusions (MPE) often require multiple pleural interventions. Observational data suggest that systemic anti-cancer therapy (SACT) may effectively control MPE in treatment-sensitive cancers (TSC). Aim: The aim of this study was to determine whether SACT was associated with higher rates of MPE control in patients with TSC. Methods: Patients were identified from a prospective, single-centre, UK-based cohort study between 05/11/08-08/06/17. Cancers classified as TSC are outlined in Table 1. The independent variable was receipt of SACT and the primary outcome control of MPE. Time-to-event analysis was used, adjusted for tumour type, MPE size, non-expandable lung and pleurodesis attempts. Results: 127 eligible patients were identified (Table 1). MPE control occurred more often in patients who received SACT than those who did not (50/112; 44.6% vs 1/15; 6.7%, p=0.005). SACT was an independent predictor of MPE control (adjusted OR 13.1, p=0.045). Other factors associated with MPE control included having lymphoma (OR 5.1, p=0.049) and undergoing pleurodesis (OR 5.3, p=0.001). Discussion: These data suggest that SACT may be an effective first-line treatment of MPE in patients with TSC, particularly lymphoma. Confounding was possible, though, and a randomised trial would determine whether SACT precludes the need for definitive pleural intervention in these patients.

Background Intra-pleural bacteria are effective pleurodesis agents in malignant pleural effusions. However, their relationship with survival is unclear. Objectives We undertook a comprehensive, structured evaluation of survival outcomes in adults with malignant pleural effusions treated with intra-pleural bacterial products. Data sources Medline, Embase, Cochrane library, Clinical Trials Registers and Open Grey. Study eligibility criteria, participants, and interventions Randomised controlled trials and non-randomised comparative studies were included, if the population included adults with malignant pleural effusions. Interventions of interest were any intra-pleural bacterial product, compared with placebo, alternative intra-pleural drug, or no treatment. Survival outcomes were collected. Study appraisal and synthesis methods: Two reviewers independently screened studies for eligibility, assessed papers for risk of bias and extracted data. Narrative synthesis was performed as high heterogeneity between studies precluded meta-analysis. Results 631 studies were identified, of which 14 were included. All were at high or unclear risk of bias in at least one domain. Six studies reported a survival benefit associated with intra-pleural bacterial products, whilst 8 reported no difference. Non-randomised studies and studies published prior to 2000 were more likely to report survival benefits. Limitations There was high heterogeneity between studies, which limited the generalisability of findings. Publication bias may have affected the review as five full-text papers were unobtainable, and survival outcomes were missing in a further five. Conclusions There is a lack of high quality evidence regarding the relationship between intra-pleural bacterial products and survival. Implications of key findings: Well-designed, prospective randomised trials are needed, to determine whether intra-pleural bacterial products can improve survival in pleural malignancy. PROSPERO registration number CRD42017058067.

Background Malignant pleural effusion affects more than 750,000 persons each year across Europe and the United States. Pleurodesis with the administration of talc in hospitalized patients is the most common treatment, but indwelling pleural catheters placed for drainage offer an ambulatory alternative. We examined whether talc administered through an indwelling pleural catheter was more effective at inducing pleurodesis than the use of an indwelling pleural catheter alone. Methods Over a period of 4 years, we recruited patients with malignant pleural effusion at 18 centers in the United Kingdom. After the insertion of an indwelling pleural catheter, patients underwent drainage regularly on an outpatient basis. If there was no evidence of substantial lung entrapment (nonexpandable lung, in which lung expansion and pleural apposition are not possible because of visceral fibrosis or bronchial obstruction) at 10 days, patients were randomly assigned to receive either 4 g of talc slurry or placebo through the indwelling pleural catheter on an outpatient basis. Talc or placebo was administered on a single-blind basis. Follow-up lasted for 70 days. The primary outcome was successful pleurodesis at day 35 after randomization. Results The target of 154 patients undergoing randomization was reached after 584 patients were approached. At day 35, a total of 30 of 69 patients (43%) in the talc group had successful pleurodesis, as compared with 16 of 70 (23%) in the placebo group (hazard ratio, 2.20; 95% confidence interval, 1.23 to 3.92; P = 0.008). No significant between- group differences in effusion size and complexity, number of inpatient days, mortality, or number of adverse events were identified. No significant excess of blockages of the indwelling pleural catheter was noted in the talc group. Conclusions Among patients without substantial lung entrapment, the outpatient administration of talc through an indwelling pleural catheter for the treatment of malignant pleural effusion resulted in a significantly higher chance of pleurodesis at 35 days than an indwelling catheter alone, with no deleterious effects.

Simple Summary Malignant pleural mesothelioma (MPM) is a cancer affecting the covering of the lung (the pleura). This commonly causes a build-up of fluid around the lung, called a pleural effusion. Draining the pleural effusion can improve breathlessness and tests can be performed on the fluid. However, for most patients with MPM, a sample of tissue from the pleura, called a biopsy, is required in addition to make the diagnosis. Sometimes, due to medical conditions, frailty or personal preference, patients may not be able to have a biopsy. This review article discusses additional tests used in this situation to help doctors make a diagnosis of MPM. These techniques include tests on pleural fluid using “immunocytochemistry” methods, biomarkers and scans. Although, without a biopsy, no test in isolation can diagnose MPM, combining information from different types of tests and reviewing results among a specialist team can enable a consensus diagnosis. Abstract For a number of patients presenting with an undiagnosed pleural effusion, frailty, medical co-morbidity or personal choice may preclude the use of pleural biopsy, the gold standard investigation for diagnosis of malignant pleural mesothelioma (MPM). In this review article, we outline the most recent evidence on ancillary diagnostic tests which may be used to support a diagnosis of MPM where histological samples cannot be obtained or where results are non-diagnostic. Immunocytochemical markers, molecular techniques, diagnostic biomarkers and imaging techniques are discussed. No adjunctive test has a sensitivity and specificity profile to support use in isolation; however, correlation of pleural fluid cytology with relevant radiology and supplementary biomarkers can enable an MDT-consensus clinico-radiological-cytological diagnosis to be made where further invasive tests are not possible or not appropriate. Diagnostic challenges surrounding non-epithelioid MPM are recognised, and there is a critical need for reliable and non-invasive investigative tools in this population.

SummaryThe UK has the highest incidence of mesothelioma in the world, but services vary across the country partly due to uneven geographical distribution of cases. The Mesothelioma UK-funded national organisational audit has highlighted challenges in accessing diagnostic procedures such as thoracoscopy, as well as identifying examples of best practice, including access to clinical trials and specialist therapeutic procedures. To ensure equitable and optimal patient care, cancer alliances should have established referral pathways to specialist multidisciplinary team (MDT) services for discussion of all mesothelioma patients.

Malignant pleural mesothelioma is an aggressive malignancy of the pleural surface, predominantly caused by prior asbestos exposure. There is a global epidemic of malignant pleural mesothelioma underway, and incidence rates are predicted to peak in the next few years.This article summarises the epidemiology and pathogenesis of malignant pleural mesothelioma, before describing some key factors in the patient experience and outlining common symptoms. Diagnostic approaches are reviewed, including imaging techniques and the role of various biomarkers. Treatment options are summarised, including the importance of palliative care and methods of controlling pleural effusions. The evidence for chemotherapy, radiotherapy and surgery is reviewed, both in the palliative setting and in the context of trimodality treatment. An algorithm for managing malignant pleural effusion in malignant pleural mesothelioma patients is presented. Finally new treatment developments and novel therapeutic approaches are summarised.

Background and objective: Non-expansile lung (NEL) frequently complicates management of malignant pleural effusion (MPE) and is an important factor in clinical practice and trials. NEL is frequently diagnosed on a single radiographic observation, but neither the inter-observer agreement of this approach nor the prognostic importance of NEL in MPE have been reported. Methods: A multicentre retrospective cohort study was performed in 2 UK pleural centres. NEL was defined as

BackgroundHistorically pleural infection was thought to be associated with longer survival in thoracic malignancies. The aim of this population-based cohort study was to investigate this hypothesis in mesothelioma, using national data from a high incidence country.MethodsCase records for all patients with mesothelioma seen in English hospitals between 01/01/2005 and 31/12/2014 were extracted from Hospital Episode Statistics using International Classification of Diseases Tenth Edition (ICD-10) codes. Episodes of pleural infection were identified. Linked mortality data was obtained from the Office of National Statistics.The primary outcome was all-cause mortality. The explanatory variable was pleural infection. Cox proportional hazards model was used to analyse survival, with pleural infection, chemotherapy and thoracic surgery handled as time-variable co-factors.ResultsOf 22,215 patients with mesothelioma, 512 (2.3%) developed pleural infection at some point in their illness. Overall median survival was 7.0 months (IQR 2.3–16.4). Pleural infection was associated with shorter survival in the immediate post-infection period (up to 30 days – HR 1.81, 95% CI 1.45–2.22) and longer term (>30 days – HR 1.81, 95% CI 1.63–1.99). Other factors associated with increased mortality were age, male gender and being diagnosed as an inpatient. Receiving chemotherapy and being less economically deprived were associated with longer survival.ConclusionPleural infection occurred in 2.3% of people with mesothelioma and was associated with shorter survival. This refutes previous reports suggesting pleural infection may be associated with better outcomes in thoracic malignancy.

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Background Historically pleural infection was thought to be associated with longer survival in lung cancer, and small observational studies have reported a similar trend in mesothelioma. The aim of this population-based cohort study was to investigate whether pleural infection was associated with survival with mesothelioma. Methods Case records for all patients with mesothelioma seen in English hospitals between 01/01/2005 and 1/12/2014 were extracted from Hospital Episode Statistics using International Classification of Diseases Tenth Edition (ICD-10) codes. Episodes of pleural infection were identified. Linked mortality data was obtained from the Office of National Statistics. The primary outcome was all-cause mortality. The explanatory variable was pleural infection. Cox proportional hazards model was used to analyse survival, with pleural infection, chemotherapy and thoracic surgery handled as time-variable co-factors. Findings Of 22 215 patients with mesothelioma, 512 (2.3%) experienced pleural infection. Overall median survival was 7.0 months. Pleural infection was associated with shorter survival in the immediate post-infection period (up to 30 days – HR 1.78, 95% CI 1.44 to 2.19) and longer term (>30 days – HR 1.77, 95% CI 1.60 to 1.96)). Other factors associated with increased mortality were age, male gender, being diagnosed as an inpatient and having documented asbestos exposure or pleural plaques (see table 1). Receiving chemotherapy and being less economically deprived were associated with longer survival. Discussion Pleural infection occurs more frequently in patients with mesothelioma than in the general population and is associated with shorter survival. This refutes previous reports suggesting pleural infection may be associated with better outcomes in malignancy. However, certain prognostic data was unavailable, including patients‘ performance status and tumour histological sub-type, and therefore confounding may have affected this result.

Malignant pleural effusions (MPE) are a common pathology, treated by respiratory physicians and thoracic surgeons alike. In recent years, several well-designed randomized clinical trials have been published that have changed the landscape of MPE management. The European Respiratory Society (ERS) and the European Association for Cardio-Thoracic Surgery (EACTS) established a multidisciplinary collaboration of clinicians with expertise in the management of MPE with the aim of producing a comprehensive review of the scientific literature. Six areas of interest were identified, including the optimum management of symptomatic MPE, management of trapped lung in MPE, management of loculated MPE, prognostic factors in MPE, whether there is a role for oncological therapies prior to intervention for MPE and whether a histological diagnosis is always required in MPE. The literature revealed that talc pleurodesis and indwelling pleural catheters effectively manage the symptoms of MPE. There was limited evidence regarding the management of trapped lung or loculated MPE. The LENT score was identified as a validated tool for predicting survival in MPE, with Brims' prognostic score demonstrating utility in mesothelioma prognostication. There was no evidence to support the use of oncological therapies as an alternative to MPE drainage, and the literature supported the use of tissue biopsy as the gold standard for diagnosis and treatment planning.Management options for malignant pleural effusions have advanced over the past decade, with high-quality randomized trial evidence informing practice in many areas. However, uncertainties remain and further research is required http://ow.ly/rNt730jOxOS.

Primary spontaneous pneumothorax (PSP) recurrence rates vary widely in the published literature, with limited data describing the factors that influence recurrence. The aims of this systematic review were to determine an estimation of PSP recurrence rates and describe risk factors for recurrence.A systematic review was conducted of all studies reporting PSP recurrence. Electronic searches were performed to identify English language publications of randomised trials and observational studies. The population was adults with PSP, who underwent conservative management, pleural aspiration or chest drainage. The outcome of interest was recurrence. Articles were screened and data extracted from eligible studies by two reviewers.Of 3607 identified studies, 29 were eligible for inclusion, comprising 13 548 patients. Pooled 1-year and overall recurrence rates were 29.0% (95% CI 20.9–37.0%) and 32.1% (95% CI 27.0–37.2%), respectively. Female sex was associated with increased recurrence (OR 3.03, 95% CI 1.24–7.41), while smoking cessation was associated with a four-fold decrease in risk (OR 0.26, 95% CI 0.10–0.63). I2 for random effects meta-analysis was 94% (pThis systematic review demonstrates a 32% PSP recurrence rate, with greatest risk in the first year. Female sex was associated with higher risk, suggesting possible sex-specific pathophysiology.

Background Pre-flight risk assessments are currently recommended for all Interstitial Lung Disease (ILD) patients. Hypoxic challenge testing (HCT) can inform regarding the need for supplemental in-flight oxygen but variables which might predict the outcome of HCT and thus guide referral for assessment, are unknown. Methods A retrospective analysis of ILD patients attending for HCT at three tertiary care ILD referral centres was undertaken to investigate the concordance between HCT and existing predictive equations for prediction of in-flight hypoxia. Physiological variables that might predict a hypoxaemic response to HCT were also explored with the aim of developing a practical pre-flight assessment algorithm for ILD patients. Results A total of 106 ILD patients (69 of whom (65%) had Idiopathic Pulmonary Fibrosis (IPF)) underwent HCT. Of these, 54 (51%) patients (of whom 37 (69%) had IPF) failed HCT and were recommended supplemental in-flight oxygen. Existing predictive equations were unable to accurately predict the outcome of HCT. ILD patients who failed HCT had significantly lower resting SpO2, baseline PaO2 reduced walking distance, FEV1, FVC and TLCO, but higher GAP index than those who passed HCT. Conclusions TLCO >50% predicted and PaO2 >9.42 kPa were independent predictors for passing HCT. Using these discriminators, a novel, practical pre-flight algorithm for evaluation of ILD patients is proposed.

Background The ‘trials within cohorts’ (TwiC) design is a pragmatic approach to randomised trials in which trial participants are randomly selected from an existing cohort. The design has multiple potential benefits, including the option of conducting multiple trials within the same cohort. Main text To date, the TwiC design methodology been used in numerous clinical settings but has never been applied to a clinical trial of an investigational medicinal product (CTIMP). We have recently secured the necessary approvals to undertake the first CTIMP using the TwiC design. In this paper, we describe some of the considerations and modifications required to ensure such a trial is compliant with Good Clinical Practice and international clinical trials regulations. We advocate using a two-stage consent process and using the consent stages to explicitly differentiate between trial participants and cohort participants who are providing control data. This distinction ensured compliance but had consequences with respect to costings, recruitment and the trial assessment schedule. Conclusion We have demonstrated that it is possible to secure ethical and regulatory approval for a CTIMP TwiC. By including certain considerations at the trial design stage, we believe this pragmatic and efficient methodology could be utilised in other CTIMPs in future. Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-2432-3) contains supplementary material, which is available to authorized users.

Background Multidisciplinary team meetings are standard care for cancer in the UK and Europe. Professional bodies recommend that mesothelioma cases should be discussed at specialist multidisciplinary team meetings. However, no evidence exists exploring the role of the specialist mesothelioma multidisciplinary team meeting. Objectives To evaluate the clinical activity of 1 specialist mesothelioma multidisciplinary team meeting and to determine how often a definitive diagnosis was made, whether the core requirements of the meeting were met and whether there was any associated benefit or detriment. Design and setting A service evaluation using routinely collected data from 1 specialist mesothelioma multidisciplinary team meeting in a tertiary referral hospital in the South-West of England. Participants All cases discussed between 1/1/2014 and 31/12/2015. Outcome measures The primary outcome measure was whether a definitive diagnosis was made. Secondary outcomes included whether treatment advice was offered, information on clinical trials provided or further investigations suggested. Additional benefits of the multidisciplinary team meeting and time taken from referral to outcome were also collected. Results A definitive diagnosis was reached in 171 of 210 cases discussed (81%). Mesothelioma was diagnosed in 153/210 (73%). Treatment advice was provided for 127 of 171 diagnostic cases (74%) and further investigations suggested for all 35 non-diagnostic cases. 86/210 cases (41%) were invited to participate in a trial, of whom 43/86 (50%) subsequently enrolled. Additional benefits included the avoidance of postmortem examination if the coroner was satisfied with the multidisciplinary team decision. The overall process from referral to outcome dispatch was Conclusions This specialist mesothelioma multidisciplinary team meeting was effective at making diagnoses and providing recommendations for further investigations or treatment. The core requirements of a specialist mesothelioma multidisciplinary team meeting were met. The process was timely, with most outcomes returned within 2 weeks of referral.

A previously fit and well 43-year-old man presented with 8 weeks of worsening breathlessness and a dry cough. He was an ex-smoker of 10 pack-years with no history of asbestos exposure, thoracic radiation or recent trauma. Chest radiograph and CT thorax are shown in figure 1. Pleural aspiration was undertaken and 1.5 L of blood-stained fluid was removed, with symptomatic improvement. The fluid was exudative, with lactose dehydrogenase (LDH) 437U/L (serum 374U/L) and protein 47g/L (serum 77g/L). Infection was excluded by negative microbiological culture and normal inflammatory markers. Cytology revealed numerous red blood cells, scattered lymphocytes and eosinophils, but no malignant cells. Figure 1 (A) Posterior–anterior chest radiograph showing moderate left-sided pleural effusion and an indistinct opacity at the left hilum with mediastinal shift to the right. (B) Coronal CT images showing a round, encapsulated extrapulmonary mass, with cystic areas within in, surrounded by a pleural effusion. (C) Coronal positron emission tomography-CT images demonstrating high SUV uptake within …

Drainage of pleural effusions is often necessary to keep patients symptom free. This article describes two methods of removing pleural fluid and outlines the insertion procedure. Indications, potential complications and post-procedure management are also discussed.

Mesothelioma is an aggressive cancer, for which no curative oncological treatment currently exists. This article outlines the options for managing malignant pleural effusions, describes the developments in chemotherapy over the past 10 years and summarizes the evidence for prophylactic and palliative radiotherapy.

Malignant pleural effusion (MPE) incidence is increasing, and prognosis remains poor. Indwelling pleural catheters (IPCs) relieve symptoms but increase the risk of pleural infection. We reviewed cases of pleural infection in patients with IPCs for MPE from six UK centers between January 1, 2005, and January 31, 2014.Survival in patients with pleural infection was compared with 788 patients with MPE (known as the LENT [pleural fluid lactate dehydrogenase, Eastern Cooperative Oncology Group performance status, serum neutrophil to lymphocyte ratio, and tumor type] cohort) and with national statistics.Of 672 IPCs inserted, 25 (3.7%) became infected. Most patients (20 of 25) had mesothelioma or lung cancer. Median survival in the pleural infection cohort appeared longer than in the LENT cohort, although this result did not achieve significance (386 days vs 132 days; hazard ratio, 0.67; P = .07). Median survival with mesothelioma and pleural infection was twice as long as national estimates for mesothelioma survival (753 days vs365 days) and double the median survival of patients with mesothelioma in the LENT cohort (339 days; 95% CI, nonoverlapping). Survival with lung and breast cancer did not differ significantly between the groups. Sixty-one percent of patients experienced early infection. There was no survival difference between patients with early and late infection (P = .6).This small series of patients with IPCs for MPE suggests pleural infection may be associated with longer survival, particularly in patients with mesothelioma. Results did not achieve significance, and a larger study is needed to explore this relationship further and investigate whether the local immune response, triggered by infection, is able to modulate mesothelioma progression.

Chyle leaks occur when there is interruption to the lymphatic ducts that transport chyle around the body. The loss of this protein-rich, calorie-rich fluid can cause serious complications including dehydration, malnutrition and immunosuppression. Treatment of chyle leaks depends on the underlying cause, which may be surgical, secondary to malignant invasion or the result of a medical condition. Nutritional support is vital and leads to spontaneous leak closure in many cases. Nutritional management options include total bowel rest with parenteral nutrition, enteral feeding with specialized formula, or oral diet with supplementation. At present there is no consensus regarding which approach is superior. In reality, most patients with chyle leaks are managed with a combination or oral and enteral feeding, but further work is needed to clarify the optimum management strategy.

Introduction Malignant pleural mesothelioma (MPM) is an aggressive cancer with a poor prognosis. Treatment options are limited, and pemetrexed and cisplatin chemotherapy is the only intervention shown to extend life. Promising new therapies may provide alternate treatment options in the future. Chemotherapy uptake varies in MPM. Some centres report rates as low as 46% in eligible patients. The aim of this study was to explore the characteristics of patients who declined chemotherapy, and to determine which factors were associated with chemotherapy refusal. Methods Prospective data were collected on all patients diagnosed with MPM in one UK tertiary referral centre. Diagnosis of MPM and eligibility for chemotherapy were determined at the regional MPM multidisciplinary meeting. Patients were followed up until death or censored on 13/7/16. Patient characteristics were compared using chi-squared, Fishers Exact and unpaired T-tests. Kaplan Meier curves were drawn to compare survival between patients who accepted and declined chemotherapy. Logistic regression was used to assess associations between patient characteristics and chemotherapy uptake. Results 200 patients were diagnosed with MPM between 1/3/08 and 8/6/16. 150 (75%) were eligible for chemotherapy. 93/150 (62%) patients received chemotherapy, 46/150 (31%) declined and 11/150 (7.3%) patients did not receive it for other reasons. Patient characteristics are shown in Table 1. The group who declined chemotherapy were older (mean age 74.4 vs 68.4, p The factors associated with chemotherapy refusal were age (regression coefficient 0.144, p Conclusion This is the first study to report the characteristics of MPM patients who declined chemotherapy. Significant differences were seen compared with patients who received chemotherapy. Further research is needed to determine whether similar patterns are seen in other centres. Reasons for refusal were not collected, but the association with age and worse performance status may reflect concerns about chemotherapy toxicity. Qualitative research could explore patients’ reasons for refusing chemotherapy.

Ioannidis et al do not acknowledge the needs or wishes of academic trainees.1 Most F2 doctors care passionately about health care, and ambitious members of the cohort are more likely to channel their efforts into clinical medicine than into academia. Academic …