Asbestos, asbestosis, and cancer: The Helsinki criteria for diagnosis and attribution. Critical need for revision of the 2014 update

Our plain-English summary of Asbestos, asbestosis, and cancer: The Helsinki criteria for diagnosis and attribution. Critical need for revision of the 2014 update, by X. Baur, H.J. Woitowitz, L.T. Budnik, et al (American Journal of Industrial Medicine, 2017).

The study

• Authors: X. Baur, H.J. Woitowitz, L.T. Budnik, D. Egilman, C. Oliver, A. Frank, C.L. Soskolne, P.J. Landrigan, R.A. Lemen
• Journal: American Journal of Industrial Medicine
• Published: 2017;60(5):411-421
• Type of article: Comment
• Cited by: 18 articles, as counted by NIH iCite
• Read it: PubMed · Publisher

Summary of the article

In this commentary, nine authors from Germany, the United States, Canada and Australia set out their concerns about the 2014 update of the Helsinki Criteria for the diagnosis and attribution of asbestos-related diseases and its Consensus Report, particularly the Pathology and Biomarkers section. They listed nine points of contention and discussed each with reference to published literature. They objected that the criteria limited the clinical diagnosis of asbestosis to cases with chest X-ray or tomography findings. They also objected that the criteria equated occupational history with fiber-years of exposure, which physicians generally cannot calculate. A further objection was reliance on counts of asbestos bodies and fibers in lung tissue, which they said grossly underestimate exposure to chrysotile because it is not biopersistent. They also criticised laboratory-specific reference values, criteria implying surgical lung biopsy, low-magnification scanning electron microscopy, the adoption of the 2010 CAP/PPS pathology criteria in place of the 1982 CAP/NIOSH criteria, and the omission of short fibers (<5 μm). They disputed the single figure of 25 fiber-years as the dose that doubles lung cancer risk, citing studies reporting increased risk at lower doses, including a relative risk of 1.90 at 4 fiber-years. The authors concluded that the 2014 criteria would lead to under-diagnosis, under-compensation, unnecessary biopsies and underestimation of chrysotile-induced disease. They pointed to possible bias, including conflicts of interest declared only after publication, and called for formal revision.

PubMed has no abstract for this study, and the article doesn't print one. We wrote this summary from the full article with the help of AI. It is not the authors' wording.

In plain English

This is a commentary, not a new study. The authors critiqued the 2014 update of the Helsinki Criteria for diagnosing asbestos-related disease, and the consensus report that followed. They listed nine points they considered misconceived or in error. They argued that the criteria ignore evidence that abnormal lung function may appear before chest X-ray changes. They argued that counting asbestos bodies or fibers in lung tissue underestimates exposure to chrysotile, which does not persist in the lung, and that lung fiber burden analysis is not standardized and is not yet a diagnostic tool. They also argued that the criteria would push patients toward risky surgical lung biopsies, and that low-magnification scanning electron microscopy misses most chrysotile fibers. In their view, the single figure of 25 fiber-years for a doubling of lung cancer risk ignores studies showing increased risk at lower doses. They objected that a 2010 pathology grading change reclassified grade 1 asbestosis as no asbestosis, and that short fibers were left out. They also pointed to signs of bias in the 2014 report. The authors concluded that unless the criteria are formally revised, asbestos-related diseases will be underdiagnosed and injustice will result.

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: Commentary (critique of a published set of diagnostic criteria); no new data collected
• Who was studied: No study population. The commentary assessed the 2014 Helsinki Criteria for diagnosis and attribution of asbestos-related disease and the 2014 Consensus Report, including its Pathology and Biomarkers section (PBS).
• Exposure: Asbestos in general, with particular attention to chrysotile and to short fibers; also amphiboles (amosite, crocidolite, tremolite, anthophyllite) in cited work
• Main results:
  • The authors argued that limiting the clinical diagnosis of asbestosis to X-ray or CT findings ignores literature showing that abnormal lung function may come before X-ray changes.
  • The authors argued that counting asbestos bodies or fibers in lung tissue grossly underestimates chrysotile dose, because chrysotile is not biopersistent and does not readily form asbestos bodies.
  • The authors argued that occupational history, not fiber burden analysis, is the cornerstone for establishing asbestos exposure.
  • The authors stated that lung fiber burden analysis lacks standardization and is a research method, not yet a diagnostic tool.
  • The authors argued that the criteria imply surgical lung biopsy for some patients with lung fibrosis, an invasive procedure with significant health risks.
  • The authors stated that the low-magnification scanning electron microscopy recommended in the 2014 criteria fails to detect most chrysotile fibers and some crocidolite and other amphibole fibers.
  • The authors criticized the single figure of 25 fiber-years as the dose that doubles lung cancer risk. The 1997 criteria had given a range, and the authors cited studies showing increased risk at much lower cumulative doses and no support for a threshold.
  • Among the studies the authors cited (not this commentary's own data), a Swedish population-based case-referent study by Gustavsson et al reported a relative risk for lung cancer of 1.90 (95% CI 1.32-2.74) at a cumulative dose of 4 fiber-years.
  • The authors objected that the 2010 CAP/PPS pathology criteria adopted in 2014 reclassify what was grade 1 asbestosis as no asbestosis. They held that the 1982 CAP-NIOSH criteria remain the most acceptable.
  • The authors stated that the 2014 criteria ignore short fibers (under 5 micrometers in length) without explanation.
  • The authors stated that several factors point to bias in the 2014 report, including a limited selection of reliance materials and participants with conflicting interests declared after publication.
• The authors' conclusion: The authors concluded that unless the 2014 Helsinki Criteria are formally revised, asbestos-related diseases will be underdiagnosed and injustice will result.

Topics

The National Library of Medicine indexes this study under subjects our site covers: Asbestosis.

Medical terms in this study, explained in our Lexicon: Helsinki Criteria, Attribution, Pathology, Biomarker, Chest X-Ray, Occupational History, Fiber Year, Asbestos Bodies.

Related studies

• Criteria for the diagnosis of asbestosis and considerations in the attribution of lung cancer and mesothelioma to asbestos exposure. Prepared by the Medical Advisory Panel to the Asbestos International Association — (1982)
• Commentary on pathologic diagnosis of asbestosis and critique of the 2010 Asbestosis Committee of the College of American Pathologists (CAP) and Pulmonary Pathology Society's (PPS) update on the diagnostic criteria for pathologic asbestosis — S.P. Hammar, J.L. Abraham (2015)
• Pathology of Asbestosis: An Update of the Diagnostic Criteria Response to a Critique — V. Roggli, A.R. Gibbs, et al. (2016)
• A Critique of Helsinki Criteria for Using Lung Fiber Levels to Determine Causation in Mesothelioma Cases — T. Tran, D. Egilman, et al. (2021)
• Pleural lesions and the ILO classification: the need for a revision — G. Hillerdal (1991)
• Clinical and radiological criteria for the differential diagnosis between asbestosis and idiopathic pulmonary fibrosis: Application in two cases — A. Stufano, A. Scardapane, et al. (2021)

Browse more research in American Journal of Industrial Medicine, or return to medical research.