Hidden in plain sight: a narrative review on environmental exposures and the fight against mesothelioma

Mesothelioma remains lethal, with a growing share linked to non-occupational exposure in community settings. This review synthesizes contemporary epidemiology, mechanisms, exposure sources, diagnosis, treatment and public health strategies.

This narrative review was conducted to synthesize heterogeneous evidence addressing environmental and para-occupational asbestos exposure and its relationship to malignant mesothelioma. A structured literature search was performed using PubMed/MEDLINE, Embase, and Web of Science databases for articles published through 2025. Terms related exclusively to occupational exposure were deliberately deprioritized. Studies were eligible for inclusion if they met at least one of the following criteria: (I) epidemiological investigations evaluating non-occupational, environmental, or para-occupational asbestos exposure; (II) mechanistic or toxicological studies elucidating fiber pathogenicity relevant to environmental exposure scenarios; (III) investigations of population clusters associated with naturally occurring or construction-related mineral fibers; (IV) studies assessing environmental remediation, surveillance strategies, or public-health interventions; or (V) clinical investigations reporting data stratified by exposure category. Articles focusing exclusively on occupational exposure without environmental relevance were excluded. Case reports without exposure characterization, editorials without primary data, and studies lacking clear methodological description were also excluded.

Environmental risk arises from naturally occurring asbestos (NOA), legacy building materials, industrial residues and para-occupational transfer into homes. Case mix is shifting toward women, younger patients and peritoneal presentations in geologic or industrial hotspots. Fiber biopersistence drives chronic inflammation, oxidative injury and mesothelial transformation. Systemic therapy now centers on dual checkpoint blockade as a first-line standard, with chemo-immunotherapy and platinum-pemetrexed backbones, and selective use of bevacizumab. Surgery is reserved for candidates in expert centers, favoring lung-sparing pleurectomy and decortication when macroscopic clearance is plausible. Prevention requires total prohibition of new asbestos use, disciplined legacy management, robust enforcement, land-use controls in NOA terrains, and household protections.

Environmental drivers will sustain mesothelioma burden unless exposure pathways are eliminated and legacy sources are controlled. Clinical gains come from immunotherapy, selective surgery and coordinated supportive care, but prevention and earlier detection carry the greatest impact. A unified agenda that couples exposure science with equitable public health action is essential to bend incidence and improve outcomes.