2004 Asbestos Disease Guidelines Ignore Mass References
Screening Abuse 1. American Thoracic Society. Diagnosis and initial management of nonma-
lignant diseases related to asbestos. Am J Respir Crit Care Med 2004;
To the Editor: 170:691–715.
I had hoped that the long-awaited ATS update on diagnosis of 2. Weiss W. Cigarette smoking and small irregular opacities. Br J Ind Med
nonmalignant asbestos diseases (1) would be thorough and point 1991;48:841–844.
3. Dick JA, Morgan WKC, Muir DFC, Reger RB, Sargent N. The signiﬁ-
out the diagnostic abuse of mass asbestos claims. Instead, key cance of irregular opacities on the chest roentgenogram. Chest 1992;
references are omitted and some of the statements seem slanted 102:251–260.
toward supporting these claims. This is unfortunate when one 4. Meyer JD, Islam S, Ducatman AM, McCunney RJ. Prevalence of small
considers the growing evidence that most of these claims are lung opacities in populations unexposed to dusts: a literature analysis.
medically specious. Chest 1997;111:404–410.
The authors provide no reference for their assertion that the 5. Reger RB, Cole WS, Sargent EN, Wheeler PS. Cases of alleged asbestos-
related disease: a radiologic re-evaluation. J Occup Med 1990;32:1088–
difference between 1/0 and 0/1 profusion readings “is generally 1090.
taken to separate ﬁlms that are considered to be positive for 6. Gitlin JN, Cook LL, Linton OW, Garrett-Mayer E. Comparison of “B”
asbestosis from those that are considered to be negative.” It is readers’ interpretations of chest radiographs for asbestos related changes.
well known that a B-reading of 1/0 is nonspeciﬁc and nondiagnos- Acad Radiol 2004;11:843–856.
tic, as it is commonly found in middle-aged smokers and in 7. Janower ML, Berlin L. “B” readers’ radiographic interpretations in asbes-
ex–factory workers never exposed to asbestos (2–4). tos litigation: is something rotten in the courtroom? [editorial] Acad
The authors do not reference their assertion that “the sensitiv- 8. Egilman D. Asbestos screenings. Am J Ind Med 2002;42:163.
ity of the plain chest ﬁlm for identifying asbestosis at a profusion 9. Setter DM, Young KE, Kalish AL. Asbestos: why we have to defend
level of 1/0 has been estimated at or slightly below 90%. The against screened cases. Mealey’s Litigation Report 2003;18:1–16.
corresponding speciﬁcity has been estimated at 93%.” Is this 10. Bernstein DB. Keeping junk science out of asbestos litigation. Pepperdine
information from plaintiff attorney–hired B-readers (PAHP)? Law Rev 2004;31:11–28.
The authors do not acknowledge the fact that most International 11. Brickman L. On the theory class’s theories of asbestos litigation: discon-
nect between scholarship and reality. Pepperdine Law Rev 2004;31:33–
Labour Organization readings by PAHP are overinterpreted 170.
(5–7), or that PAHP are paid more for a positive diagnosis
than a negative one (8). This is crucial information, as it should
invalidate all medical conclusions based on “diagnoses” gener-
ated by PAHP.
Diagnosis and Initial Management of Nonmalignant
The authors provide no explanation of why ATS lowered the
profusion score for diagnosing asbestosis from 1/1 (in 1986) to
Diseases Related to Asbestos
1/0 (“presumptively diagnostic”). To the Editor:
The disclaimer that the 2004 criteria “are intended for the
A recent ofﬁcial statement of the American Thoracic Society
diagnosis of nonmalignant asbestos-related disease in an individ-
(1) contains statements that are not supported by the literature:
ual in a clinical setting for the purpose of managing that person’s
current condition and future health” is naıve at best, disingenu-
¨ 1. “The clinical evaluation…should consider subjective symp-
ous at worst. Just like the 1986 article, the new ATS review will toms as well as objective ﬁndings…” (p. 695). “The diagno-
be quoted in the legal arena. Unwittingly or not, the authors sis of asbestosis is ideally based on an accurate exposure
have published unsupported statements that can (and will) be history, obtained whenever possible directly from the pa-
taken out of context and quoted in court. tient….” (p. 695).
There is (incredibly) no conﬂict of interest statement (CIS) 2. “Plaques are indicators of increased risk for the future
for the authors, yet such a statement is provided in every other development of asbestosis…” (p. 707).
article in the same issue, including letters to the editor and studies 3. “These obstructive ﬁndings may be due to asbestos-induced
where it would be hard to imagine any conﬂict. Furthermore, the small airway disease. Thus, mixed restrictive and obstruc-
web site regarding manuscript submissions indicates that the CIS tive abnormalities do not rule out asbestosis or necessarily
is an ironclad requirement. Is the ATS itself exempt? Consider- imply that asbestos has not caused an obstructive func-
ing the partisanship of asbestos litigation, each author’s experi- tional impairment…” (p. 701). “In general, the magnitude
ence consulting for plaintiff versus the defense sides should have of the asbestos effect on airway function is relatively small.
been spelled out in detail. This effect, by itself, is unlikely to result in functional
I have had the opportunity to examine hundreds of these impairment or the usual symptoms and signs of chronic
mass asbestos claims on behalf of defendants, and am dismayed obstructive pulmonary disease. However, if superimposed
at the lack of scientiﬁc or medical merit for most of them. Solid on another disease process, the additional loss of [lung]
legal and medical discourse is beginning to acknowledge this function due to the asbestos effect might contribute sig-
abuse of diagnosis (6–11). Now, sadly, ATS has squandered a niﬁcantly to increased functional impairment, especially
golden opportunity to publish an above-suspicion review and in persons with low lung function” (p. 708). “Tobacco
champion science and objectivity in the diagnosis of nonmalig- smoking is the predominant cause of airway obstruction
nant asbestos disease. in asbestos-exposed workers who smoke….” (p. 710).
4. “A chest ﬁlm…showing characteristic signs of asbestosis
Conflict of Interest Statement : L.M. has examined mass asbestos claims on behalf
of the Ohio Bureau of Workers’ Compensation and defending companies.
in the presence of a compatible history of exposure is
adequate for diagnosis of the disease: further imaging pro-
Lawrence Martin cedures are not required” (p. 696). “The positive predictive
CWRU School of Medicine value of the minimally abnormal chest ﬁlm alone in making
Cleveland, Ohio the diagnosis of asbestosis may fall below 30% when expo-
666 AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE VOL 171 2005
sure to asbestos has been infrequent and exceed 50% when that asbestos exposure might be clinically signiﬁcant in the pres-
it has been prevalent” (p. 710). ence of low lung function. Dr. Smith writes: “The role of ILO
B-Reader chest X-ray interpretation has recently come into
Many of the statements are conﬂicting or inaccurate. Patient
question.” In point of fact, the B-Reader Program belongs to
histories and subjective symptoms are unreliable, particularly in
NIOSH. It is not an activity of the ILO.
legal proceedings (2). Pleural plaques are evidence of exposure
Although relatively few communications have been received
and do not indicate a greatly increased risk for asbestos-related
to date, it is unreasonable to expect the members of the Commit-
disease in those workers with equal exposure and no radiologi-
tee to provide individual responses to every future correspon-
cally visible plaques (3). The implication that asbestos contrib-
dent. In the interest of anticipating the concerns of others, there-
utes to clinically signiﬁcant COPD is not supportable (4). The
fore, the Committee offers the following broad overview of the
role of the International Labour Organization (ILO) B-reader
chest X-ray interpretation has recently come into question (5, 6).
The key difference between the 1986 criteria and the 2004
Conflict of Interest Statement : D.D.S. has no financial relationship with any asbes- criteria is that the 2004 Guidelines present a more explicit ap-
tos manufacturer or commercial entity but has been an expert witness for the proach to diagnosis based on criteria: the need to establish evidence
defense in asbestos litigation.
for exposure, to identify a disorder compatible with asbestos as
Dorsett D. Smith a cause, exclusion of other causes, and a forceful requirement
University of Washington for assessing impairment in the event that the physician makes
Seattle, Washington a diagnosis of nonmalignant asbestos-related disease. Although
these elements were mentioned in 1986, they were not given the
The 2004 document also broadens the discussion beyond as-
1. American Thoracic Society. Diagnosis and initial management of nonma-
bestosis, which predominated in 1986, and brings the criteria up
lignant diseases related to asbestos. Am J Respir Crit Care Med 2004;170:
691–715. to date with respect to modern methods of imaging, such as
2. Agostoni P, Smith DD, Schoene R, Robertson H, Butler J. Evaluation of HRCT and digital radiography, and clinical evaluation. It also
breathlessness in asbestos workers: results of exercise testing. Am Rev provides guidance to the physician on the initial management of
Respir Dis 1987;135:812–816. the patient once a disease of this type is diagnosed, including what
3. Smith DD. Plaques, cancer and confusion. Chest 1994;105:8–9. to look for and how to follow up such patients. The disease has
4. Smith DD. Does asbestos exposure cause obstructive airways disease? to come ﬁrst, so the identiﬁcation of a disorder that is compatible
[letter] Chest 2004;126:1000.
5. Janower ML, Berlin L. “B” Reader’s radiographic interpretations in asbes-
with asbestos exposure is ﬁrst. Then, the connection to asbestos
tos litigation: is something rotten in the courtroom? Acad Radiol 2004; exposure must be made and other plausible causes ruled out.
11:841–842. The emphasis in the guidelines is on structural change, not
6. Gitlin JN, Cook LL, Linton OW, Garrett-Mayer E. Comparison of “B” functional change, in making the diagnosis. Functional deﬁcit is
readers’ interpretations of chest radiographs for asbestos related changes. not a diagnosis, in the sense of a speciﬁc disease entity, and
Acad Radiol 2004;11:843–856. members of the committee thought that functional changes were
secondary phenomena, too nonspeciﬁc to fulﬁll a criterion but
which may support the diagnosis. A restrictive defect, for exam-
ple, is consistent with asbestosis (and much else) but may not
From the Committee:
be present early on and is not required for the diagnosis. The
The Committee appreciates the opportunity to respond to these asbestos-related disease entity may of course result in impair-
two additional letters. This is also an opportune time to clarify ment, which should then be measured to guide care and track
other issues that may be lost in the detail of the Statement. progression.
Dr. Martin’s letter is entitled “2004 Asbestos disease guide- The document is not a major break with the past. The evi-
lines ignore mass screening abuse,” as if the Statement condoned dence required to meet each criterion has broadened with the
abusive practices. In fact, the Statement favorably cites both a advance of technology but remains conservative in that the em-
2002 white paper from the National Institute of Occupational phasis is on the likelihood of a connection to asbestos and exclud-
Safety and Health and a 2000 resolution by the Association of ing other types of conditions, rather than identifying disease at
Occupational and Environmental Clinics regarding characteris- the very earliest possible moment. The criteria are generally
tics of responsible and ethical screening programs. more speciﬁc than they are sensitive.
Dr. Martin makes two substantive allegations of error by the The Committee prepared these guidelines for the purpose
Committee in his original letter. One involves the interpretation of guiding physicians to the recognition and conﬁrmation of
of 1/0 readings, which the Statement describes, correctly, as nonmalignant asbestos-related disease for the purpose of treat-
“presumptively diagnostic but not unequivocal”: this interpreta- ment and patient care: that was our mandate. The Committee
tion is inherent in the International Labour Organization (ILO) did not formulate the guidelines for other applications and is
Classiﬁcation system. Dr. Martin also requests a reference for not encouraging the use of these guidelines outside of clinical
the statement that the plain chest ﬁlm has a sensitivity of no diagnosis.
more than 90% and a speciﬁcity of about 93% (the source says The Committee welcomes the comments of ATS members
90 to 95%): the reference is number 150, cited in the Statement on the Asbestos Statement. An open forum has been scheduled
on page 710. during the ATS annual International Conference in San Diego
To Dr. Smith, the Committee responds that the passages he for 7:00 to 9:00 pm, Sunday, 22 May 2005.
describes as contradictory simply make reasonable distinctions.
Conflict of Interest Statement : Neither T.L.G. nor any member of his immediate
With respect to occupational and medical histories, the Commit- family or, to his knowledge, extended family have a financial relationship with
tee has made the unexceptional recommendation that a physician any commercial entity that has a substantial interest in asbestos, exposure to
take a history to help guide the diagnosis. With respect to his asbestos liability, or business that would be affected by the Statement of this
comment on pleural plaques, the Committee stands by what was committee. During the period of deliberation of the Committee, he declined to
participate in personally remunerative activities directly related to asbestos, in
written and the evidence cited. With respect to the contribution order to avoid the perception of conflict of interest. During this period, the George
of asbestos exposure to airway obstruction, the Statement says Washington University Medical Faculty Associates received fees for his professional
services in a few cases in which exposure to asbestos could have been an issue, whom have had asbestos exposure; G.R.W. does not have a financial relationship
including a small number of individual cases and cases referred by the U.S. Depart- with any commercial entity that has an interest in the subject of this letter; A.M.
ment of Energy for evaluation (value, less than $7,000). Dr. Guidotti receives a has reviewed medical/scientific aspects of proposed administrative guidelines or
small revenue from royalties derived from books, one of which, Science on the legislation for asbestos-related claims for the American Bar Association in 2002
Witness Stand (2001), contains an appendix discussing asbestos; future sales of receiving no fee, for the Province of British Columbia Workers Compensation
this book are not expected to be affected (value in 2004, less than $200). C.A.B. Board for a fee of Can $150 and for law firms for a standard per-hour fee. He
has never served as an expert for a commercial sponsor in the course of his lectured for the Defense Research Institute for their standard honorarium and for
occupational medical practice; he has served as an expert witness for individuals a symposium on law and medicine for a Federal District Court, receiving no fee.
with asbestos-related disease involved in workers compensation and litigation He is a designated “impartial expert” for the New York State Workers Compensa-
represented by various attorneys and legal firms and has no contractual financial tion Board, receiving their standard fee. He served on a NIOSH expert panel on
relationship with these individuals or their legal representatives with all work the B Reader Program in 2004, receiving no fee. He has reviewed clinical cases
performed on an hourly fee for service basis; D.C. does not have a financial interest for plaintiff and defense law firms and served as an expert witness in three mesothe-
with a commercial entity that has a substantial interest in the subject of the lioma trials in the past three years, the last being 10/2/02. All his publications on
deliberations of the Committee or the manuscript published as the Statement of asbestos-related disease have been supported solely by the academic medical
the Committee. No member of his family has a financial relationship with such centers at which he was employed.
a commercial entity. The following represents disclosure of asbestos-related in-
come for the years 2001 to the present: in 2001 he received $2,750 in consulting Tee L. Guidotti
fees from asbestos plaintiff attorneys and approximately $4,000 from insurers, The George Washington University
Medicare, Medicaid, work compensation and commercial insurers for evaluating Washington, DC
asbestos-exposed individuals in his clinical practice; in 2002 he received $4,600
in consulting fees from plaintiff attorneys and $4,000 from third party payers for Carl A. Brodkin
evaluating asbestos-exposed individuals in his clinical practice; in 2003 he received University of Washington
$2,000 in consulting fees from asbestos plaintiff attorneys and approximately
$3,000 from third party payers for evaluating asbestos exposed individuals in his Seattle, Washington
clinical practice; in 2004, he received $1,225 in consulting fees from plaintiff David Christiani
attorneys and approximately $2,000 from third party payers for evaluating asbes-
tos-exposed individuals in his clinical practice; M.R.H. presented at the White
House and the U.S. Congress on aspects of the Hyde-Ashcroft Asbestosis reform Boston, Massachusetts
bill; his airfare and hotel were paid for by Public Citizen and he received no other
compensation. He wrote a position statement for the Association of Occupational
Michael R. Harbut
and Environmental Clinics which set ethical guidelines for physician participation Wayne State University
in asbestosis screening. In the early 1990s, he participated in an asbestosis screen- Detroit, Michigan
ing program which was associated with investigations from multiple government
agencies. No impropriety or wrongdoing was found. G.H. does not have a financial Gunnar Hillerdal
relationship with a commercial entity that has an interest in the subject of this Karolinska Institute
letter; J.R.B. does not have a financial relationship with a commercial entity that
has an interest in the subject of this letter. He has been an expert witness for
plaintiffs who have filed asbestos-related disease claims, but has not personally John R. Balmes
received remuneration for work on these cases. Remuneration has always gone University of California at San Francisco
to his employer, e.g., Regents of the University of California; P.H. and his employer,
University of California, Los Angeles, have received approximately $10,000 from San Francisco, California
Conwed Corp. for a project and payment for medical consultation and expert Philip Harber
witness services and approximately $7,500 from multiple insurers and attorneys
in 2001–2004; F.H.Y.G. is employed full time jointly by the University of Calgary University of California Los Angeles
where he is a Professor of Pathology & Laboratory Medicine and by Calgary Los Angeles, California
Laboratory Services where he is the Chief of the Autopsy Service for the Calgary
Health Authority. He has not been employed by a commercial entity that has an Francis H. Y. Green
interest in the subject of the statement and does not perform consultant work. University of Calgary
In the past three years, his medical/legal consultations involving claimants in the Calgary, Alberta, Canada
United States have been entirely in the area of black lung compensation and none
of the cases have involved asbestosis. He is also employed infrequently (once or William N. Rom
twice a year) to review potential cases of occupational lung disease for the Alberta New York University
Workmen’s Compensation Board; in the last three years two of these cases have
involved the pathologic diagnosis of asbestosis at autopsy. He is paid for these
New York, New York
opinions at the rate of Can $200 per hour and has also been paid to give lectures Gregory R.Wagner
by commercial sponsors; in the last three years the only sponsorship has been by National Institute for Occupational Safety
the 3M Company to give a talk on the pathology of asthma at the European
Respiratory Symposium in 2002; asbestos was not part of the presentation or and Health
discussion. With Dr. Sam Schurch he has a patent pending on a treatment of Morgantown, West Virginia
asthma involving surfactants and perfluoracarbons and this has no relationship
to asbestos or asbestos-related injuries. He also receives royalties from a textbook Albert Miller
co-edited by Dr. Andrew Churg entitled “The Pathology of Occupational Lung St. Vincent Catholic Medical Center
Disease” published by Williams & Wilkins. This book covers numerous areas of Jamaica, New York
occupational lung disease pathology including asbestosis. However, the chapters
on non-neoplastic and neoplastic lung disease associated with asbestos exposure On behalf of the Ad Hoc Committee to
are entirely authored by Dr. Churg and thus the opinions expressed in this book Update the 1986 ATS Criteria for the
regarding asbestos are largely those of Dr. Churg. He has no stock ownership or
options in any company that would be related the subject of this letter; W.N.R. Diagnosis of Nonmalignant Asbestos-
has a contract with Con Edison to perform CT scans on employees, some of Related Disease