A retrospective study of chest pain in benign asbestos pleural disease

Our plain-English summary of A retrospective study of chest pain in benign asbestos pleural disease, by R.K. Allen, T. Cramond, D. Lennon, et al (Pain Medicine, 2011).

The study

• Authors: R.K. Allen, T. Cramond, D. Lennon, M. Waterhouse
• Journal: Pain Medicine
• Published: 2011;12(9):1303-8
• Cited by: 7 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Abstract

Purpose: The aims of this review were to ascertain the incidence of asbestos-related chest pain at presentation in two groups of patients referred with asbestos diseases and the demographics, comorbidities, and chest computed tomography findings associated with chest pain.

Methods: Medical charts of patients presenting 1995-2008, audited for quality assurance, were chosen at random by data managers. Patients with mesothelioma, lung cancer, and angina were excluded. Rigorous attempts had been taken by the authors to exclude other causes of chest pain.

Results: There were 167 patients who were medicolegal referrals (Group 1) and 115 clinical referrals (Group 2). Although the patients in Group 1 had more severe disease generally than Group 2, the proportion with pain was not significantly different (45.5% and 55.7%, mean duration 4.8 years, range 1-22 years). Group 1 had more severe disease as a rule. However, the proportion with pain in Groups 1 and 2, respectively, was as follows: diffuse pleural thickening (50.8% and 67.6%, P=0.072), pleural plaques (47.0% and 59.7%, P=0.076), folded atelectasis (70.6% and 83.3%, P=1.000), and asbestosis (43.6% and 53.3%, P=0.346). Of all those with folded atelectasis, 73.9% had pain.

Conclusion: Chest pain appears to be much more common in patients with benign asbestos diseases than is currently recognized, particularly in those with folded atelectasis and is not restricted to litigants. Improved recognition of this entity is needed along with practical management guidelines for the general practitioner. Further studies are envisaged by the authors.

Wiley Periodicals, Inc.

In plain English

This retrospective chart review at the Wesley Research Institute, Brisbane, Australia, covered patients with benign asbestos diseases presenting from 1995 to 2008. Group 1 was 167 medicolegal referrals and Group 2 was 115 general practitioner referrals; patients with mesothelioma were excluded. The first author diagnosed asbestos-related chest pain after investigating other causes, and data managers coded the recorded diagnosis. Asbestos type could not be clearly identified in most patients; chrysotile was described as predominant, with some amosite and a minority exposed to crocidolite. Chest pain was recorded in 45.5% (76/167, 95% CI 38.1 to 53.1) of Group 1 and 55.7% (64/115, 95% CI 46.5 to 64.4) of Group 2, not a statistically significant difference (P = 0.094). Of the 23 patients with folded atelectasis, 17 (73.9%) had chest pain. The authors concluded that chest pain appears much more common in benign asbestos diseases than currently recognized, particularly with folded atelectasis. They noted no specific pain questionnaire had been used, and subgroups formed by combinations of the four disease types were too small to be statistically valid.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: Retrospective review of medical charts. Charts were selected by data managers, who coded the cause of chest pain as stated in the records by the first author after investigation of other causes.
• Who was studied: 282 patients with benign asbestos diseases who presented between 1995 and 2008. Group 1 was 167 medicolegal referrals and Group 2 was 115 referrals from general practitioners. 15 patients with mesothelioma were excluded. The overwhelming majority were male (97.6% and 94.8%).
• Exposure: Asbestos exposure, mostly in blue collar or maritime work. In most subjects the fiber type could not be clearly identified. Chrysotile was described as predominant, with some amosite and a minority exposed to crocidolite. Spousal exposure accounted for 5.6% (Group 1) and 5.0% (Group 2).
• Main results:
  • Chest pain was recorded in 45.5% (76/167, 95% CI 38.1 to 53.1) of Group 1 (medicolegal) and 55.7% (64/115, 95% CI 46.5 to 64.4) of Group 2 (general practitioner referred).
  • The overall difference in the proportion with chest pain between the two groups was not statistically significant (P = 0.094).
  • When stratified by disease type, general practitioner referred patients generally had more chest pain, but none of the differences were statistically significant. For Group 1 vs Group 2: pleural plaques 47.0% vs 59.7% (P = 0.076); diffuse pleural thickening 50.8% vs 67.6% (P = 0.072); folded atelectasis 70.6% vs 83.3% (P = 1.000); asbestosis 43.6% vs 53.3% (P = 0.346).
  • Of all patients (both groups) with folded atelectasis, 17/23 (73.9%) had chest pain.
  • Of all patients (both groups) with asbestosis, 60/131 (45.8%) had chest pain. All of them also had some form of pleural disease.
  • Group 1 had more severe disease. Asbestosis was found on CT in 62.7% of medicolegal patients and 34.9% of general practitioner referred patients (P less than 0.001).
  • The mean duration of pain was 4.8 years (standard deviation 4.5 years, range 1 to 22 years). The article does not clearly state whether this refers to Group 1 only or to both groups.
  • At presentation, chest pain had not been treated at all in 69% and had been treated with simple analgesics in 16%. The remainder were treated with opioids and anti-neuropathic medications.
  • Chest pain did not correlate significantly with age, gender, body mass index, occupation, or comorbidities.
• The authors' conclusion: The authors concluded that chest pain appears to be much more common in patients with benign asbestos diseases than is currently recognized, particularly in those with folded atelectasis. They called for prospective studies and basic research.
• Limitations the authors state:
  • No specific pain questionnaire was in use when the patients presented.
  • Patients had numerous combinations of the four main disease types, so the subgroups formed by these combinations were too small to be statistically valid.
  • Asbestosis could not be isolated as a cause of chest pain, because all patients with asbestosis also had pleural disease.
  • The authors were aware the study could be seen as biased in favor of litigants, so they included a non-litigant comparison group.
  • Among Group 1 patients with pain, the severity of the pain could be graded with any accuracy in only 18%.
  • The higher proportion with pain in the general practitioner referred group may reflect that complaints of chest pain were sometimes the reason for referral.
  • Benign asbestos chest pain remains a diagnosis of exclusion until better diagnostic tools exist.

Topics

The National Library of Medicine indexes this study under subjects our site covers: Asbestosis, Pleural plaques and thickening.

Medical terms in this study, explained in our Lexicon: Asbestos-Related Pleural Disease, Mesothelioma, Lung Cancer, Diffuse Pleural Thickening, Pleural Plaques, Atelectasis.

Related studies

• Chest pain in asbestos-exposed individuals with benign pleural and parenchymal disease — S. Mukherjee, N. de Klerk, et al. (2000)
• Chest pain in asbestos and silica-exposed workers — E.K. Park, P.S. Thomas, et al. (2011)
• Chest pain and ST elevation: not always ST-segment-elevation myocardial infarction — S.A. Pyxaras, G. Lardieri, et al. (2010)
• A 70-year-old woman with dyspnea and chest pain — A. Ganesh, M. Flores, et al. (2014)
• Pleurectomy for persistent pain in benign asbestos-related pleural disease — D.I. Fielding, J.L. McKeon, et al. (1995)
• Long-term continuous erector spinae plane block for palliative pain control in a patient with pleural mesothelioma — J. Ramos, P. Peng, et al. (2018)

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