Occupational asbestos exposure how to deal with suspected

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					                        Annals of Oncology Advance Access published February 24, 2006

                                                                                                                                           Annals of Oncology
original article                                                                                                                  doi:10.1093/annonc/mdl021

Occupational asbestos exposure: how to deal with
suspected mesothelioma cases—the Dutch approach
P. Baas1*, N. van ’t Hullenaar2, J. Wagenaar3, J. P. G. Kaajan4, M. Koolen5, M. Schrijver6,
N. Schlosser7 & J. A. Burgers1
 Department of Thoracic Oncology, The Netherlands Cancer Institute, Amsterdam; 2Department of Pulmonology, Bernhoven Clinic, Veghel; 3Pulmonologist, Huizen;
 Department of Pulmonology, Deventer Hospital, Deventer; 5Department of Pulmonology, Academic Medical Center, Amsterdam; 6Department of Pulmonology,
Gemini Hospital, Den Helder; 7Department of Pulmonology, Central Military Hospital, Utrecht, The Netherlands

Received 18 December 2005; revised 11 January 2006; accepted 12 January 2006

Introduction: Patients with asbestos-related diseases, such as malignant mesothelioma (MM), are not uniformly

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treated in Europe when they apply for compensation. In The Netherlands, the Institute of Asbestos Victims (IAV) acts
on behalf of patients with a malignant mesothelioma. In the majority of cases, the diagnosis is clear but in some,
uncertainty remains. In these cases a specialist opinion of the Mesothelioma Group of the Dutch Thoracic Society
(DTS) is required. The process of data handling and final outcome for these patients is discussed and compared with
the situation in other European countries.
Materials and methods: Dutch patients with a possible malignant mesothelioma and occupational exposure to
asbestos presented their cases to the IAV. In 10% of the cases, pathological confirmation of a malignant mesothelioma
could not be obtained. These cases were presented to the Mesothelioma Group to obtain a clinical diagnosis based

on clinical reports, occupational history, X-ray examination and other factors. Each case was reviewed by three

independent pulmonologists experienced in MM. The majority view was binding for acceptance or rejection of the
Results: In the period January 2000 until May 2005, the IAV received 1747 cases for compensation. In 161 cases no
definitive diagnosis could be made on pathology and were presented to the Mesothelioma Group. Of these cases, 117
(73%) were considered to be compatible with the clinical diagnosis malignant pleural mesothelioma. Forty-four cases
(27%) were rejected. In 75% of the cases (112 of 150), the conclusion of the three independent specialists was
unanimous; in 11 cases one specialist refrained from a diagnosis. The median time from request to submission of the
report was 34 days (range 1–185 days).
Conclusions: Compared with other European countries, this approach, as determined by the IAV and Mesothelioma
Group of the DTS, is an effective and rapid way to investigate claims of patients with a possible occupationally related
malignant mesothelioma.
Key words: malignant pleural mesothelioma, asbestos claims, asbestos victims

introduction                                                                     forbids the handling of crocidolite (blue asbestos). Due to
                                                                                 economical and political issues, it was not until 1993 that a final
The asbestos industry has grown throughout the 20th century,                     prohibition on the use, disposal and transport of all forms of
first in Western Europe and during the last decades in the third                  asbestos was issued. In other European countries, comparable
world. It was not until the publication of Wagner et al. in 1960                 regulations were taken over during the same period. However, it
that it became clear that there is a causal relationship between                 took until 1 January 2005 before a general prohibition was
occupational exposure to asbestos and the development of                         implemented in Europe. It is therefore expected that between
malignant mesothelioma [1]. Since that time it has taken many                    2005 and 2040, no less than half a million people will die from
years in Europe to restrict the manufacturing and transport of                   asbestos-related diseases in Europe.
asbestos and to control the demolition of buildings containing                     From 1945 to 1995, approximately 340 000 people in The
asbestos. For example, the first asbestos restriction law in The                  Netherlands have had occupational exposure to asbestos.
Netherlands was issued by the Dutch government in 1977; this                     Approximately 10 000 of these people worked in the primary
                                                                                 asbestos industry and were involved in handling of materials
*Correspondence to: P. Baas, Department of Thoracic Oncology, The Netherlands
Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands.           containing asbestos. Even since the last legislation, civilians
Tel: +31-205122958; Fax: +31-205122572; E-mail:                    continue to be exposed to asbestos in the environment.

ª 2006 European Society for Medical Oncology
original article                                                                                                                                    Annals of Oncology

incidence                                                                                  application to the IAV
In The Netherlands, approximately 350 new patients are                                     Patients and their relatives can apply to the IAV for
diagnosed each year with malignant mesothelioma (Figure 1).                                reimbursement. The IAV will collect the relevant medical
Epidemiological surveys suggest that the incidence will increase                           information and obtain an occupational history (by
until 2015, with a maximum of approximately 500 cases per year                             interviewing the patient, if alive, or relatives or former
[2, 3]. Due to the long latency period between exposure and the                            colleagues if the patient is deceased). Histo-pathological
development of the disease, which can last up to 40 years, it is                           material will be requested from the local hospital and, when
expected that approximately 18 000 people will die from this                               available, it will be reviewed by pathologists from The
disease in The Netherlands over the next 40 years.                                         Netherlands Mesothelioma Panel. If the diagnosis of
                                                                                           a malignant mesothelioma is confirmed, the IAV will decide that
occupational disease and compensation by the                                               the patients or their relatives are entitled to compensation.
Institute of Asbestos Victims                                                              In cases where the diagnosis cannot be confirmed, the
                                                                                           application is turned down.
Malignant mesothelioma is considered one of the occupational
diseases in The Netherlands. When a patient is diagnosed with
a malignant mesothelioma and the patient has had occupational                              unconfirmed cases
exposure to asbestos in the past, he is entitled to financial                               The Netherlands Mesothelioma Panel cannot review all cases
compensation. In general, the symptoms of the disease and the                              presented to the IAV. Tumour biopsies may not be representative
advanced age and limited lifespan (8–14 months) of these                                   or available, for example when no diagnostic procedures have

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patients rule out full, time-consuming, legal procedures.                                  been performed due to the poor condition or death of the patient.
   In November 1998, an agreement was made between the                                     In such unclassified cases, the IAV requests the Mesothelioma
ministry of justice, social security, trade unions and the asbestos                        Group of the DTS to intervene. This group consists of 12
victims to ensure that future claims would be handled in a swift                           pulmonologists, who are specialized in the diagnosis and
and socially acceptable way. For that purpose the Institute of                             treatment of malignant mesothelioma. All available material on
Asbestos Victims (IAV) was founded. Its primary task is to                                 these unclassified cases, including radiological examinations, is
support patients in this process, to provide cash advances and to                          sent to three independent panel members. Based on available
organize a short track protocol to select patients who are entitled                        information, each specialist must decide whether the diagnosis
to additional compensation. In the latter case, it is assumed that                         of malignant mesothelioma is considered probable or has to be
the previous employer or his insurance company has a legal                                 rejected. In this paper we have analysed our experience with
responsibility. One of the most important tasks is to help the                             this procedure over the first 5 years.
patient to determine where and when the asbestos exposure has
taken place and which employer is responsible. This approach
safeguards the victims from unwanted, time-consuming and                                   materials and methods
expensive legal procedures. This arrangement only applies to                               Figure 2 shows the process diagram of the protocol which was followed.
patients with a mesothelioma, or their relatives, when                                     Patient information, medical records and radiology charts are sent to
occupational exposure to asbestos has occurred. It is therefore                            a central office, where they are checked for completeness. If necessary,
essential to obtain a definite diagnosis of malignant                                       additional information is requested from the hospital where the patient was
mesothelioma. Unfortunately it is not always possible to obtain                            first examined. By random assignment, three independent members of the
representative tumour material for diagnosis.                                              Mesothelioma Group are asked to give their expert opinion. None of these
                                                                                           may have been involved in the initial diagnostic procedures or treatment of
                                                                                           the patient. The specialists are required to report in writing to the central
                                  Mesothelioma mortality men
                                                                                           office whether they consider the case compatible with a malignant
                                  Mesothelioma mortality female
                                                                                           mesothelioma. After reviewing a case, the patient data and radiological
400                                                                                        material are sent to the next specialist, who is not informed of the decision of
                                                                                           the previous specialist. When at least two of the three specialists report either
                                                                                           a positive or negative conclusion, the IAV is notified of the final outcome.
300                                                                                        There is no additional discussion about cases during the decision process.
                                                                                              In this study, all cases presented to the Mesothelioma Group have been
                                                                                           analysed and compared with the total number of patients who applied for
200                                                                                        reimbursement at the IAV. Finally, the conclusions of the different
                                                                                           specialists in each case were matched and the quality and duration of
150                                                                                        processing the cases was analysed. The data consisted of birth date, race, sex,
100                                                                                        occupational history, smoking history, radiology examinations, diagnostic
                                                                                           procedures and dates of received requests, date of reply, completeness of the
 50                                                                                        available data and results of the reviewing specialists.










Figure 1. Mesothelioma mortality in The Netherlands 1997–2002                              Between January 2000 and April 2005 a total of 1747 patients
(source: Netherlands National Institute of Statistics).                                    applied to the IAV for compensation. Of these, 126 cases were

2 | Baas et al.
Annals of Oncology                                                                                              original article
                                                                     Application to

                                                                  Collection of data,
                                                                  Request to NMP

                                 Diagnosis                            No diagnosis                        Alternative
                                Mesothelioma                                                              diagnosis

                                                                   Evaluation by MG

                                                             positive             negative

                                reimbursement                                                         No reimbursement

Figure 2. Flow diagram of the protocol. Patients first present their case to the IAV (Institute for Asbestos Victims) who collect data and pathology specimen

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which are sent to the NMP (Netherlands Mesothelioma Panel) for pathologic evaluation. When no diagnosis can be made based on the available histological
or cytological specimen all available data are sent to the Mesothelioma Group (MG).

still in analysis during the evaluation of our study. In 161 cases              and often a very long process. Unfortunately, many patients die
insufficient pathology data were available to make a diagnosis.                  during the procedure.
These cases were presented to the Mesothelioma Group. At the                       Comparison with other countries indicates that there are
time of review, most of the patients (>50%) had already died,                   many differences in the response to patients who request
ruling out further diagnostic procedures. In four of the 160                    financial compensation for occupational diseases (Table 1). In
cases, additional information was obtained from the primary                     Germany, the claimant has much fewer possibilities compared
hospital. Over 72% of the patients were aged 62–80 years at the                 with other countries. In most of the cases, the burden of proof
time of application. Only 9% were younger than 60 years.                        lies with the patient and his family. In Belgium, the situation is
   The median duration of the handling process was 34 days                      comparable with the Dutch situation as long as the disease is
(range 1–185). In two cases the procedure took over 5 months:                   recognised as occupationally contracted. In the UK and in
one of these was due to postal failure, the other was due to the                The Netherlands there is a general damage award, which covers
lack of radiographic images.                                                    the ‘pain, suffering and loss of amenity’, while additional
   The diagnosis of probable mesothelioma was accepted in 117                   compensation can be given for the loss of income or pension.
cases (73%) and rejected in 44 cases (27%). There was no bias                      In The Netherlands, the Institute of Asbestos Victims was
from any of the panel members for a positive or negative                        founded in 2000 to overcome most of the problems of patients
scoring. The diagnosis was confirmed when two or three of                        with asbestos-related diseases. A covenant was made between
the specialists decided in favour of a mesothelioma; it was                     involved groups: the government, industries, insurance
rejected when two or three decided against the diagnosis. In 112                companies, unions and patients group representatives. This
out of the 161 cases, the decision was concordant; in 38 cases                  approach has proven to be successful and is transparent for all
one of the panel members came to a discordant conclusion.                       parties (
In 11 cases, a specialist refrained from a conclusion, stating that                In over 90% of the cases, the collaboration between the IAV
the available material was insufficient to draw conclusions from.                and The Netherlands Mesothelioma Panel results in a diagnosis.
In total, there was a discordance of 24% (38 of 161 cases).                     For the remaining 10%, an independent judgement is required.
                                                                                For these cases, the IAV and the Mesothelioma Group have
                                                                                agreed that a binding, clinical diagnosis would be made based on
                                                                                all information available. Our analyses show that in
discussion                                                                      approximately 75% of the patients, the suspicion of
For many years, industries, insurance companies and                             mesothelioma was confirmed based on expert opinion. In 25%
governments have been reluctant to acknowledge their                            of the cases, however, the diagnosis was rejected on the basis of
responsibility for asbestos-related diseases. Of these diseases,                available material. In these particular cases, another diagnosis
mesothelioma is a well recognized entity with a dismal                          was considered more appropriate.
prognosis. In general, the patients are elderly males in poor                      In this set-up, we deliberately chose three independent
condition and deprived of financial compensation. In many                        specialists to judge the material before coming to a conclusion.
cases, their appeal to the court is superannuated; even if it is                We hoped that the experience of these specialists would
accepted, the claimant has to prove the asbestos exposure in the                guarantee a fair decision. Due to the nature of these incomplete
past. This all leads to a heavy psychological burden. In addition,              cases, we refrained from a joint review committee such as The
taking legal action as an individual is a cumbersome, expensive                 Netherlands Mesothelioma Panel of pathologists.

                                                                                                                      doi:10.1093/annonc/mdl021 | 3
                                                                                                                                                                                                                               original article
4 | Baas et al.

                  Table 1. Guidelines for financial reimbursement for patients with occupational asbestos exposure

                                                    Belgium                 France                    Germany                   Italy                 Netherlands              Switzerland           UK
                  Institution (year of              FBZ, Fonds voor de      FIVA (2002) and           Berufsgenos-senschaften   INAIL, National       Instituut Asbest         SUVA, Swiss           Consumer Protection
                    foundation)                       beroepsziekten          Federation Francais       (1894)c                   Institute for         Slachtoffers (1998)e     national Accident     Act (1987) Financial
                                                      (1964)a                          ´
                                                                              de Societe                                          Labour accidentsd                              Insurance Fund        Services Compensation
                                                                              d’Assuradeursb                                                                                     (1984)f               Schemeg
                  Occupational exposure             Yes                     Yes                       Yes                       Yes                   Yes                      Yes >50%              Yes
                  Environmental exposure            No                      No                        No                        Limited               Yes                      No                    Yes
                  Proof of exposure lies with       Claimant                Claimant (‡5 year         Claimant                  Claimant (fibre        Defendant                Defendant             Claimant
                    defendant or claimant                                     exposure)                                           count required)
                  Personal legal action possible    Yes                     Yes                       Yes                       Yes                   Yes                      Yes                   Yes
                  Group action possible             Unknown                 Unknown                   No                        Unknown               Unknown                  Unknown               Yes
                  Time allowed for filing claims     No limitation           40 years                  30 years                  No limitation         >30 yearsh               No limitation         ‘Long-stop limitation’
                    from exposure
                  Time allowed for filing            No limitation           No limitation             3 years                   No limitation         No limitations           No limitation         Open
                    claims from onset of
                    the disease
                  Reimbursement amount              50% of yearly           FIVA e4000                Open                      Age dependent         e15 882 to               40–80 000 SFR         £100 000– open
                    (commonly cited                   income                  Courts e45 000                                                            e55 000 and              and additional        (age dependent)
                    amounts)                                                  FFSA open                                                                 additional costs         costs
                    For the IAS a time limitation of 30 years is set; for cases beyond 30 years legal action is required.

                                                                                                                                                                                                                                    Annals of Oncology
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Annals of Oncology                                                                                       original article
   It is remarkable that in 78% of the cases all panel members            We conclude that this protocol of a financial reimbursement
came to the same decision. As the amount of available data              for patients with suspected malignant mesothelioma that have
differs widely between cases, this percentage is considered             a proven occupational exposure to asbestos, is quite unique
acceptable. Only one specialist made discordant judgements in           compared with other European countries. It also allows the
eight out of the 38 cases he reviewed (data not shown). This            IAV to provide clarity about the diagnosis in an acceptable
judgement, however, was both positive and negative. The                 time frame.
median time of 34 days to achieve a conclusion is mainly caused
by the administrative issues, checking of the completeness of
data and the transport of the material to the different specialists.    acknowledgements
As soon as two identical conclusions were sent to the central
                                                                        We thank Mr M. A. van der Woude, director of the IAV, for
office, the final conclusion was sent out to the IAV. It is expected
                                                                        supplying us with data on the submitted cases. We also thank
that progress in digitalisation of images and patient record files
                                                                        our colleagues of the Mesothelioma Group who were involved
will lead to a faster handling of the cases.
                                                                        in the judgements of the cases: Hugo Schouwink, Jan van
   Despite the awareness of reimbursement protocols for
                                                                        Meerbeeck, Ed van Hezik, Wim Strankinga and Youke Tan.
patients with mesothelioma, a significant percentage of patients
still do not have a diagnosis of their pleural disease. In part, this
is due to the reluctance of doctors to perform invasive                 references
investigations in elderly patients, or patients where significant

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co-morbidity exists and only limited therapeutic options are            1. Wagner JC, Sleggs CA, Marchand P. Diffuse pleural mesothelioma and
                                                                           asbestos exposure in the North Western Cape Province. Br J Ind Med 1960;
                                                                           17: 260–271.
   We consider it of great social relevance to take an active
                                                                        2. Peto J, Decarli A, La Vecchia C et al. The European mesothelioma epidemic.
attitude to obtain the diagnosis and occupational history for this         Br J Cancer 1999; 79: 666–672.
group of patients. Not only the specialist, but also the general        3. Segura O, Burdorf A, Looman C. Update of predictions of mortality from
practitioner can help to improve this process by referring                 pleural mesothelioma in The Netherlands. Occup Environ Med 2003; 60:
patients early for diagnostic procedures.                                  50–55.

                                                                                                               doi:10.1093/annonc/mdl021 | 5

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