10.1055/s-0042-124568
The letter of Merget, Feder and Tannapfel to this publication [1] raises significant concern. In the introduction and at the end of their letter they
discredit and misinterpret publications in peer-reviewed journals on the one hand[1] whereas they attribute this behavior to others without any evidence to support their
claims.
It is positively acknowledged, that there is agreement about lack of cut-off value
for fibre burden in the lung for the asbestosis diagnosis. However, this well known
fact, also described in the German guideline for diagnosis and expert opinion of asbestos-related
diseases [2] is not acknowledged either in expert opinions of at least some of the authors of
the letter or other insurance-affiliated physicians as known from court litigation
and an example mentioned in a recent publication [1]. Also statistics of the insurance affiliated so-called German Mesothelioma Registry
[Deutsche Mesotheliomregister] do not support acknowledgement of this well-documented
fact (see below).
The authors of the letter are inconsistent when accepting the Hit and Run Phenomenon
of chrysotile on the one hand and demanding detection of asbestos bodies for the diagnosis
of asbestos-related diseases on the other hand. The same is true for their questioning
of the generally accepted finding that a carefully obtained qualified case history
is the cornerstone of asbestos exposure [3]
[4]. Their cited opinion in a commentary of Cleement et al. 2002 obviously refers to
a situation where the untrained (presumably non-occupational) physician is not able
to take a detailed and reliable case history from patients who are not aware in detail
of their past exposures. For more information on the relevance of a qualified occupational
case history see the afore mentioned publications where it is clearly stated that
a qualified case history provides the best information on exposure to asbestos.
The authors of the letter ignore the cited publication of leading pneumoconiosis pathologists,
namely Hammar and Abraham [5], who convincingly reject the “modification” of the asbestosis definition from CAP-NIOSH
by a group of pathologists headed by V. Roggli. This “modification” proposed by Roggli
et al. is not justified by scientific logic as discussed in [5], has not been validated and has not been endorsed by an independent scientific body
such as NIOSH.
The authors of the letter cite the misleading statement in the Helsinki Criteria that
the Roggli-Pratt modification [6] of the CAP-NIOSH definition of asbestosis [7] represents a reasonable and reproducible scheme. On the contrary, this Roggli-Pratt
modification represents a restrictive new definition that is unsubstantiated by any
scientific evidence. It has to be mentioned that the strong financial affiliations
of V. Roggli were not disclosed when he chaired and significantly influenced the Pathology and biomarker chapter of the Helsinki criteria [1]; for details see below. Asbestosis grade 1 is of highly significant relevance in
compensation issues because of the German medical legal definition of asbestos-related
lung cancer, i. e. of the 25 fibre years threshold in cases without asbestosis or
asbestos-related non-malignant pleural disorders. Contrary to what the authors of
the letter assert, it is obvious from the figures mentioned in the following paragraphs
of this response that non-acceptance of lung cancer as an occupational disease is
frequently due to application of this restrictive and unsound definition of asbestosis.
It should be mentioned that the so-called 1,000 fiber hypothesis, i. e. detection
of 1,000 fibres per cm3 of lung tissue as a prerequisite for acceptance of asbestosis grade 1 originates
from the first head of the Deutsche Mesotheliomregister. It was applied by his successor
and many insurance affiliates, including their lawyers [8]
[9]
[10].
The authors of the letter mention that they identified in about 10 % of their lung
tissue probes minimal asbestosis (asbestosis grade 1). According to the annual report
of the Deutsche Mesotheliomregister in one year (2014) [11] in their examinations of lung tissue probes of 880 subjects with suspected asbestos-related
lung cancer, they diagnosed by means of lung fibre analysis in only 69 cases asbestosis
grade 1 (circa 8 %). What about their expert opinion outcome of the other 92 %? Was
the asbestos exposure as a cause denied in all of them? See also the aforementioned
non-traceable published example. Unfortunately, no detailed information is provided
and no peer-reviewed publication is provided by the authors of the letter, which would
allow any conclusions to be drawn on the remaining 92 % of the cases. Interestingly,
there is a similar relationship between lung cancer cases mainly reported by German
physicians on the one hand and accepted figures by the insurance system on the other
hand (in 2015 there were 4,375 reports, but only 771 accepted cases, i. e. 20 %, and
in 2014 respective figures were 4,343, and 834, respectively, i. e. 17.6 %; [12]). According to international well-based data the figure of asbestos-related lung
cancer is c. 3.5 higher than that of mesothelioma [13], which indicates that the real figure of lung cancer in Germany is to be expected
in the range of 3,500 per year (more than 4 times higher than the accepted figures).
It is only possible to speculate about the influence of the afore mentioned ratio
in the examinations of the Deutsche Mesotheliomregister and the respective expert
opinions on these insurance decisions since no information on that matter is available.
However, it is known that in 2014 there were 1,054 expert opinions (Stellungnahmen)
for asbestos-related lung cancer from the Deutsche Mesotheliomregister.
Another important issue is the differential diagnosis of asbestosis and idiopathic
pulmonary fibrosis (IPF). According to the annual report of the Deutsche Mesotheliomregister
[11] in 2014, 4103 lung tissue probes of 218 subjects with suspected occupational disease
number 4103 (asbestosis and/or asbestos-related plaques/fibrosis) were examined, but
in only 25 of them (11 %) asbestosis grade 1 and in 13 cases asbestosis of higher
grades were diagnosed, a total of 58 out of the 218 examined cases (26.6 %) were described
as suffering from asbestosis and/or benign asbestos-related disorders. Again, no details
are presented for the 73.4 % of the group which were obviously not diagnosed as asbestosis
or an asbestos-related non-malignant pleural disorder. It can be assumed, that figures
of fibre analysis in lung tissue were important for these decisions because out of
the total of 1,038 fibre analyses 158 did not refer to lung cancer cases.
It is true that the presence of pleural plaques favors the existence of asbestosis
rather than that of IPF. However, only approximately 70 % of asbestosis cases show
such changes.
Since asbestosis as well as IPF may exhibit the same UIP pattern, and low counts or
even absence of asbestos bodies (Abraham and Hammar found asbestos cases without detectable
asbestos bodies; personal communication) do not allow reliable differential diagnosis,
other aspects such as the occupational case history and the statistically likelihood
according to epidemiological data have to be considered. As mentioned, asbestosis
is about an order of two more frequently found in asbestos-exposed subjects than IPF
[2]. This is important in decision making of the individual case since only the likelihood
of the causal relationship is relevant according to the legal definition. I’m wondering
why the authors of the letter do not understand this rationale.
Regarding the dose-response relationship in lung cancer caused by asbestos the authors
of the letter claim not to be aware of a dose-response relationship for compensation.
Obviously they are not aware of the health-based scientific evaluation (Wissenschaftliche
Begründung) of the German occupational disease number 4104 where a doubling dose for
lung cancer of 25 fibre years is calculated from several studies with linear dose-response
relations [14]. It should be mentioned that there is evidence for a much lower doubling dose for
lung cancer, namely in the range of four fibre years [15]
[16]
[17].
It seems that the authors of this letter did not read in detail the work shown in
references they cited, since they repeatedly misinterpreted the publications. The
different focuses are already evident in the headings. For example the paper of Woitowitz
[10] refers to the founding, funding and the history of the Deutsche Mesotheliomregister
and its affiliation with and financial support by the German statutory accident insurance
institutions (re. their HVBG/DGUV). The publications by Baur deals with social-legal
aspects and scientific controversies of unsound science [1], ethical issues [18]
[19], and an overview on the current worldwide tragedy and pandemic of asbestos-related
diseases [20]. Of special relevance is the publication by Baur and Woitowitz [21] which presents a review on lung cancer due to occupational agents; they provide
evidence that there is significant underreporting and under-acknowledgement (non-compensation)
of these disorders. Some of the reasons are given above.
The authors of the letter are obviously not willing to accept that scientists’ or
physicians’ affiliation with interest groups is associated with high risk of bias.
This is not only true for the tobacco and pharmaceutical industry, rather it is well
known for any kind of industry, insurance or other interest group affiliation [22]
[23]
[24]
[25]
[26]
[27]
[28]
[29]
[30]. The authors sticking to definitions of asbestosis fibre count requirements in lung
tissue by V. Roggli ignore, that his restrictive asbestosis definition criteria are
not based on scientific knowledge and that he did not disclose his severe conflict
of interests when preparing and publishing these criteria (omitting his obvious COI
in receiving millions of US dollars for testimonies for the asbestos industry and
training of their lawyers, which is documented in several US court reports; a recent
example is from the Circuit Court of the 11th Judicial Circuit Court and for Miami-Dade county, Florida, Case No.08 – 69204 CA
42, where it had to be disclosed that he, among others, was paid for consulting HONEYWELL
INTERNATONAL INC. a well-known defendant in asbestos cases).
It should be mentioned that this identification of shortcomings of current compensation
practice is intended to initiate a broader discussion leading to changes to put in
place an effective and fair compensation system, based on independent scientific evidence
that is free of conflict of interest. Since scientists’ and physicians’ affiliations
with vested interest groups such as the asbestos industry and insurance institutions
have been repeatedly shown to be associated with harmful influence in social health
issues and their burden on society [10]
[18]
[22]
[23]
[30]
[31], there is an urgent need for independency and absence of conflict of interests in
management of the individual case as well as in research and in social-political bodies
in general. The ultimate aim should be timely, effective, preventive measures and
fair independent compensation of victims, such as those suffering from asbestos-related
diseases, based on scientific knowledge, objective soundness and legal definitions.
