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Diagnosis and initial management of nonmalignant diseases related to asbestos - reply.
Guidotti TL; Brodkin CA; Christiani D; Harbut MR; Hillerdal G; Balmes JR; Harber P; Green FHY; Rom WN; Wagner GR; Miller A
Am J Respir Crit Care Med 2005 Mar; 171(5):528-530
We thank our correspondents for their interest and for articulating the ideals that we strove to follow in writing the Statement (1). We offer one clarification before addressing their individual points: The Statement was never intended to be a comprehensive review of the literature on asbestos, a task that would require years and multiple volumes. It is what its title describes: an update of the clinical criteria for making the diagnosis of nonmalignant asbestos-related disease. Where a dispute, controversy, or uncertainty affect clinical management, it is discussed; otherwise, we cite the reference that was most relevant. Ghio and Roggli suggest that the Statement does not recognize confounding by cigarette smoking in the radiographic presentation of small opacities and may lead to misdiagnosis. We direct their attention to page 700, column 1, paragraph 3, where we address this issue. Given that the criteria require evidence for nontrivial exposure to asbestos, the limited effect of even relatively heavy cigarette smoking on the profusion of small opacities (at most one minor category ), and the criterion requiring exclusion of alternative diagnoses, misdiagnosis is unlikely in practice. Weill and Weill make one general and two specific points. The general point is that nonmalignant asbestos-related disease is a marker of risk for lung cancer. The Committee agrees and this point is emphasized in the introduction to the Statement and throughout, specifically with respect to management of the patient after the diagnosis is made. The Statement was not written, nor intended to review, causation of malignant disease. The first specific point is the observation that pleural plaques are an independent marker of risk for lung cancer, which Weill and Weill dispute, relying on the work of Weiss (3, 4).Weiss wrote in his 1993 paper: "...whether pleural disease in workers exposed to asbestos is a marker for increased risk of lung cancer compared with the answer of pleural disease in exposed workers ... is not the question considered in this review" (4). It is, however, the essential question addressed in the Statement. The 1997 review by Hillerdal and Henderson cited in the Statement examines 10 studies and comes to a different conclusion than that of Weiss (3, 4), a conclusion that has since been confirmed by the findings of Karjalainen and colleagues (5) in a 1999 study not then available to Weiss. A new study that also confirms this finding has been published (6). The Committee believed that clinicians should be aware of this association, which is now supported by a substantial body of evidence. On the other hand, the Committee did not address the reported association between pleural plaques and coronary artery disease, which requires confirmation and does not lead to an obvious recommendation for management at this time (7). Weill and Weill actually appear to agree with the Committee on the association of chronic airway disease and asbestos exposure on almost every point. They do raise the question of whether these changes are of clinical importance and allege that the Statement makes "strong assertions" about the clinical implications of these changes. In fact, the Committee was careful to describe the magnitude of the asbestos effect on airway function as "relatively small" and provided supporting documentation demonstrating that the asbestos effect, in isolation, is quite limited. The possibility of clinically significant impairment is suggested only when the asbestos effect is "superimposed on another disease process... in persons with low levels of lung function," and as a possible factor in accelerated loss of lung function observed among asbestos-exposed workers. The alert reader may detect a disproportion between the particular objections raised by the correspondents and the blanket denunciations of the Statement, and by extension the Society itself, in the closing paragraphs of both letters. We invite Weill and Weill, as well as Ghio and Roggli and any others who may be interested, to provide the Committee with the "point-by-point rebuttal" they propose in their letter. The Committee is prepared to discuss these issues in a suitable ATS forum and is planning such an opportunity for the 2005 Annual Meeting.
Asbestosis; Asbestos-dust; Diseases; Respiratory-system-disorders; Pulmonary-system-disorders; Pulmonary-cancer; Lung-cancer; Cigarette-smoking
Issue of Publication
American Journal of Respiratory and Critical Care Medicine
Page last reviewed: September 2, 2020
Content source: National Institute for Occupational Safety and Health Education and Information Division