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Mesothelioma is an aggressive cancer of the lining of the lungs (or abdomen), caused by past exposure to asbestos — often decades earlier. It commonly causes breathlessness, chest pain and tiredness, frequently from fluid building up around the lung. Diagnosis involves scans, fluid sampling and a biopsy, and treatment may combine chemotherapy, immunotherapy, radiotherapy, surgery and measures to ease symptoms. Supportive care and physiotherapy focus on comfort, breathing and quality of life. This page explains mesothelioma and how it is managed.
Malignant pleural mesothelioma is an aggressive malignancy of the pleural mesothelium, caused predominantly by past asbestos exposure. Australia has one of the highest age-standardised incidence rates in the world, reflecting historical asbestos use in mining, construction, shipbuilding and household renovation. The Australian Mesothelioma Registry collects national incidence and exposure data.
Definition
Mesothelioma is a malignant tumour arising from the mesothelial cells lining the pleura (most common), peritoneum, pericardium, or tunica vaginalis. Histological subtypes are epithelioid (most common, best prognosis), sarcomatoid (worst prognosis), and biphasic.
Pathophysiology
Inhaled asbestos fibres deposit in the lower lobe periphery and migrate to the pleura, where they cause chronic inflammation, oxidative stress, DNA damage and immune dysregulation, ultimately leading to malignant transformation of mesothelial cells. Latency from first exposure to clinical presentation is typically 20–50 years.
Australian context
Australia per-capita mesothelioma rates remain among the highest globally. Although the incidence in occupationally exposed cohorts is beginning to decline, the proportion of cases from non-occupational and home renovation exposures is rising. The Australian Mesothelioma Registry reports approximately 700 new diagnoses each year.1
Causes and risk factors
Occupational exposure (asbestos mining, asbestos product manufacture, construction, plumbing, electrical, automotive brake work, shipbuilding, power station maintenance, rail, defence). Non-occupational exposure (home renovation of pre-1990 buildings, take-home exposure from a household member). Environmental exposure (notably former Wittenoom WA residents). Rarely, prior thoracic radiotherapy and genetic predisposition (BAP1 germline mutation).
Symptoms
Insidious onset of dyspnoea (most commonly from pleural effusion), chest wall pain (often dull, deep and progressive), weight loss, fatigue, dry cough, sweats and reduced exercise tolerance. Some patients are identified incidentally on imaging.
Diagnosis
Why diagnosis matters
Definitive diagnosis allows access to multidisciplinary care, clinical trials, and Australian compensation pathways including the Asbestos Injuries Compensation Fund, state dust diseases tribunals, and common-law claims. Early specialist involvement also enables timely palliative care planning.
Imaging
Chest radiograph typically shows unilateral pleural effusion and/or pleural thickening. Contrast-enhanced CT chest is the standard staging investigation, demonstrating circumferential pleural thickening, nodular pleural disease, and reduced hemithorax volume. MRI and PET-CT are used to assess local invasion and metastatic disease in patients being considered for radical treatment.
Pathology
Histological confirmation is required, with adequate tissue for immunohistochemistry to distinguish from metastatic adenocarcinoma. Image-guided pleural biopsy or thoracoscopic biopsy is preferred over pleural fluid cytology alone. BAP1 and MTAP immunohistochemistry are now standard.
Staging
TNM 8th edition (and the forthcoming 9th edition) staging is used. Most patients present with locally advanced disease at diagnosis, limiting the proportion eligible for radical treatment.
Management
Multidisciplinary care
All patients should be discussed at a thoracic oncology MDT with input from thoracic surgery, medical and radiation oncology, respiratory medicine, palliative care, social work, and physiotherapy. Early palliative care involvement is supported by Australian guidelines and improves quality of life.
Surgery
Radical surgery (extended pleurectomy/decortication; rarely extrapleural pneumonectomy) is offered in highly selected fit patients with early-stage epithelioid disease at experienced centres.2 The MARS-2 trial has challenged the long-held view that surgery improves outcomes for many patients, and the role of surgery is now more carefully selected.3
Systemic therapy
First-line systemic therapy is dual immune checkpoint blockade (nivolumab + ipilimumab), supported by the CheckMate 743 trial, particularly for non-epithelioid histology.4 Platinum-pemetrexed chemotherapy remains a standard option, especially for epithelioid disease.5 Subsequent-line therapy includes single-agent immunotherapy and trial enrolment.
Radiotherapy
Palliative radiotherapy is highly effective for chest wall pain, painful biopsy or surgical drain tract sites, and bone metastases. Prophylactic radiotherapy of drain sites is no longer routinely recommended.6
Pleural effusion management
Symptomatic pleural effusion is managed with therapeutic thoracentesis, indwelling pleural catheter (most common in Australian practice), or talc pleurodesis depending on lung re-expansion, life expectancy, and patient preference.7,8 Physiotherapy supports breathing efficiency and mobility around an indwelling catheter.
Medications
Systemic anti-cancer therapy
Immune checkpoint inhibitors (nivolumab + ipilimumab; pembrolizumab), platinum-pemetrexed chemotherapy, bevacizumab in selected patients.
Symptom and supportive medications
Opioids for cancer pain and dyspnoea (titrated, often with breakthrough dosing), anti-emetics, anxiolytics, low-molecular-weight heparin for cancer-associated thrombosis, corticosteroids for selected indications.
Multi-system manifestations
Pain
Chest wall and shoulder pain is the most common and disabling symptom, often requiring multi-modal management (opioids, neuropathic agents, intercostal nerve blocks, radiotherapy, and physiotherapy).
Dyspnoea and trapped lung
Dyspnoea is multi-factorial — pleural effusion, restrictive defect from pleural thickening, trapped lung, and treatment effects. Breathing retraining, hand-held fan, opioids for refractory dyspnoea, and pulmonary rehabilitation principles all have a role.
Cachexia and fatigue
As for other thoracic malignancies — early dietitian referral, structured low-burden exercise, and treatment of contributing factors.
Venous thromboembolism
High incidence in mesothelioma; new dyspnoea or unilateral leg swelling warrants assessment.
Living with mesothelioma
Compensation and legal support
Early referral to a specialist asbestos-disease lawyer is essential. Australian compensation pathways include workers’ compensation (state), common-law claims, the Asbestos Injuries Compensation Fund (former James Hardie workers), and the Defence Personnel scheme. Compensation processes are complex and time-sensitive given prognosis.
Exercise and rehabilitation
Structured supervised exercise, individually prescribed for fluctuating symptom burden and prognosis, improves quality of life and functional capacity.9 Programmes should accommodate indwelling pleural catheters, fatigue, and end-of-life planning.
Nutrition
Cachexia is common and contributes significantly to quality of life and survival. Proactive dietitian involvement, oral nutritional supplements, and protein-prioritised intake should be offered early.
Psychological and family support
A mesothelioma diagnosis brings grief, anger, financial stress, and family disruption. Asbestos Awareness organisations, dust disease support groups, and psycho-oncology referral are valuable. The Asbestos Diseases Research Institute and state-based Asbestos Diseases Foundations are key resources.
Palliative and end-of-life care
Early integration of palliative care, advance care planning, and clear goals-of-care conversations are standard of care.10 Median survival from diagnosis remains 10–14 months, though selected patients with epithelioid histology and immunotherapy response now live considerably longer.
Role of the physiotherapist
The physiotherapist supports function and comfort across the disease course: breathlessness management with breathing techniques, positioning and a handheld fan, gentle exercise to maintain strength and independence, and support around pleural procedures. Care is integrated with the palliative and oncology team.
Warning signs
Part 1 · References
- Australian Institute of Health and Welfare. Mesothelioma in Australia 2023. Canberra: AIHW; 2024.
- Treasure T, Lang-Lazdunski L, Waller D, et al. Extra-pleural pneumonectomy versus no extra-pleural pneumonectomy for patients with malignant pleural mesothelioma: clinical outcomes of the Mesothelioma and Radical Surgery (MARS) randomised feasibility study. Lancet Oncol 2011;12(8):763–772.
- Lim E, Waller D, Lau K, et al. Extended pleurectomy decortication for pleural mesothelioma (MARS 2): a phase 3 randomised controlled trial. Lancet Respir Med 2024;12(6):457–466.
- Baas P, Scherpereel A, Nowak AK, et al. First-line nivolumab plus ipilimumab in unresectable malignant pleural mesothelioma (CheckMate 743): a multicentre, randomised, open-label, phase 3 trial. Lancet 2021;397(10272):375–386.
- Vogelzang NJ, Rusthoven JJ, Symanowski J, et al. Phase III study of pemetrexed in combination with cisplatin versus cisplatin alone in patients with malignant pleural mesothelioma. J Clin Oncol 2003;21(14):2636–2644.
- Clive AO, Taylor H, Dobson L, et al. Prophylactic radiotherapy for the prevention of procedure-tract metastases after surgical and large-bore pleural procedures in malignant pleural mesothelioma (SMART): a multicentre, open-label, phase 3, randomised controlled trial. Lancet Oncol 2016;17(8):1094–1104.
- Davies HE, Mishra EK, Kahan BC, et al. Effect of an indwelling pleural catheter vs chest tube and talc pleurodesis for relieving dyspnea in patients with malignant pleural effusion (TIME2): a randomized controlled trial. JAMA 2012;307(22):2383–2389.
- Rintoul RC, Ritchie AJ, Edwards JG, et al. Efficacy and cost of video-assisted thoracoscopic partial pleurectomy versus talc pleurodesis in patients with malignant pleural mesothelioma (MesoVATS): an open-label, randomised, controlled trial. Lancet 2014;384(9948):1118–1127.
- Peddle-McIntyre CJ, Singh F, Thomas R, Newton RU, Galvão DA, Cavalheri V. Exercise training for advanced lung cancer. Cochrane Database Syst Rev 2019;(2):CD012685.
- Higginson IJ, Bausewein C, Reilly CC, et al. An integrated palliative and respiratory care service for patients with advanced disease and refractory breathlessness: a randomised controlled trial. Lancet Respir Med 2014;2(12):979–987.
References are numbered in citation order (Vancouver/BMJ style) and were current at the time of writing. Guidelines are living documents — verify against the latest version before clinical use.
Supervised exercise, breathing technique and self-management education are the mainstay of cardiorespiratory physiotherapy for this condition.
Clinical evidence
Part 1 covers the same condition without the technical detail. What follows is the evidence base behind it, written for clinicians — the literature, the reasoning and the gaps.
For clinicians: this summary supports clinical reasoning and is not a protocol. Check current guidelines and local policy before applying it, and read it alongside the key references and guidelines directory.
Framing. Pleural mesothelioma is a disease in which the surgical era has closed and the systemic and supportive-care era has opened. MARS 1 and MARS 2 found no survival benefit from radical surgery, and MesoVATS found no survival benefit from VATS partial pleurectomy over talc pleurodesis with more complications — while immunotherapy has improved survival in the unresectable setting.1,2,3,4 Australia has among the highest incidence rates in the world, so this is a disease Australian cardiorespiratory physiotherapists will meet.5
Disease-directed treatment
- Cisplatin plus pemetrexed established the chemotherapy standard, improving survival and quality of life over cisplatin alone.6
- Nivolumab plus ipilimumab improved overall survival versus chemotherapy in first-line unresectable disease (CheckMate 743), with the largest benefit in non-epithelioid histology.4
- Radical surgery is not supported: MARS 1 raised concern about harm from extrapleural pneumonectomy, and MARS 2 found extended pleurectomy–decortication added to chemotherapy did not improve survival.1,2
- Prophylactic irradiation of chest-wall tract sites does not prevent procedure-tract metastasis (PIT trial), so this is no longer routine.7
Effusion, breathlessness and function
- Indwelling pleural catheters and talc pleurodesis relieve breathlessness comparably; catheters reduce hospital days and are preferred where the lung is trapped, which changes what physiotherapy can expect from thoracic expansion work.8
- An integrated breathlessness support service improved breathlessness mastery and patient-reported outcomes in refractory breathlessness from advanced disease; its components are physiotherapy and palliative-care staples.9
- Exercise training in advanced thoracic malignancy is feasible and improves exercise capacity, with the caveat of small trials and high attrition.10
- Trapped lung and progressive chest-wall restriction set a mechanical ceiling that no technique will lift — the goal becomes efficiency, pacing and symptom control rather than restored expansion.8
Physiotherapy implications
- Lead with breathlessness management: hand-held fan, positioning, breathing control with a long relaxed expiration, pacing and energy conservation, plus anxiety management — these are the interventions with the best evidence and the fastest effect.9
- Set expectations about expansion honestly. With trapped lung or extensive pleural encasement, thoracic expansion exercises will not re-expand the lung; use them for comfort and mobility, not as a re-expansion programme.
- Support the indwelling catheter: teach activity and showering around it, keep the shoulder moving, and mobilise rather than treating the drain as a restriction.8
- Treat the chest wall and shoulder actively — tumour-related and post-procedural chest-wall pain is often neuropathic, drives splinting and frozen shoulder, and needs analgesia review alongside range-of-movement work.
- Maintain function with light resistance and walking through chemotherapy and immunotherapy, adjusting for anaemia, neutropenia, fatigue and immune-related adverse events such as pneumonitis or colitis.10
- Escalate rapidly increasing breathlessness (re-accumulated effusion, embolism, pneumonitis), new severe or radicular pain, weight loss, or catheter-site infection.
- Point patients toward entitlements: asbestos-related disease attracts compensation and dust-diseases pathways in Australia, and physiotherapy documentation of functional loss supports those claims.5
Clinical reasoning
- Breathlessness here is usually mechanical (effusion, restriction) or anxiety-amplified rather than a clearance problem; airway clearance has no role unless a coexisting suppurative disease exists.
- Distinguish a re-accumulating effusion (progressive, positional, dull percussion) from progression of restriction — the first is drainable and worth escalating.
- Ask about asbestos exposure history explicitly, including secondary and domestic exposure; it affects diagnosis, compensation and family screening.
- Goals should be measured in what the patient can still do at home, not in walk-test metres alone.
Evidence gaps
- No randomised trial has tested a physiotherapy or rehabilitation intervention specifically in mesothelioma; evidence is borrowed from advanced cancer and pleural-disease populations.9,10
- Optimal exercise prescription during immunotherapy, and safety during immune-related adverse events, is unknown.
- Whether any intervention improves outcomes in trapped-lung physiology has not been studied.
- Rehabilitation needs after the abandonment of radical surgery — a longer non-surgical disease course — are not yet described.2
References for the clinical evidence summary
- Treasure T, Lang-Lazdunski L, Waller D, et al. Extra-pleural pneumonectomy versus no extra-pleural pneumonectomy for patients with malignant pleural mesothelioma: clinical outcomes of the Mesothelioma and Radical Surgery (MARS) randomised feasibility study. Lancet Oncol 2011;12(8):763–772.
- Lim E, Waller D, Lau K, et al. Extended pleurectomy decortication for pleural mesothelioma (MARS 2): a phase 3 randomised controlled trial. Lancet Respir Med 2024;12(6):457–466.
- Rintoul RC, Ritchie AJ, Edwards JG, et al. Efficacy and cost of video-assisted thoracoscopic partial pleurectomy versus talc pleurodesis in patients with malignant pleural mesothelioma (MesoVATS): an open-label, randomised, controlled trial. Lancet 2014;384(9948):1118–1127.
- Baas P, Scherpereel A, Nowak AK, et al. First-line nivolumab plus ipilimumab in unresectable malignant pleural mesothelioma (CheckMate 743): a multicentre, randomised, open-label, phase 3 trial. Lancet 2021;397(10272):375–386.
- Australian Institute of Health and Welfare. Mesothelioma in Australia 2023. Canberra: AIHW; 2024.
- Vogelzang NJ, Rusthoven JJ, Symanowski J, et al. Phase III study of pemetrexed in combination with cisplatin versus cisplatin alone in patients with malignant pleural mesothelioma. J Clin Oncol 2003;21(14):2636–2644.
- Clive AO, Taylor H, Dobson L, et al. Prophylactic radiotherapy for the prevention of procedure-tract metastases after surgical and large-bore pleural procedures in malignant pleural mesothelioma (SMART): a multicentre, open-label, phase 3, randomised controlled trial. Lancet Oncol 2016;17(8):1094–1104.
- Davies HE, Mishra EK, Kahan BC, et al. Effect of an indwelling pleural catheter vs chest tube and talc pleurodesis for relieving dyspnea in patients with malignant pleural effusion (TIME2): a randomized controlled trial. JAMA 2012;307(22):2383–2389.
- Higginson IJ, Bausewein C, Reilly CC, et al. An integrated palliative and respiratory care service for patients with advanced disease and refractory breathlessness: a randomised controlled trial. Lancet Respir Med 2014;2(12):979–987.
- Peddle-McIntyre CJ, Singh F, Thomas R, Newton RU, Galvão DA, Cavalheri V. Exercise training for advanced lung cancer. Cochrane Database Syst Rev 2019;(2):CD012685.
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