Position Paper on Asbestos of the Italian Society of Occupational Medicine

Our plain-English summary of Position Paper on Asbestos of the Italian Society of Occupational Medicine, by P. Apostoli, P. Boffetta, M. Bovenzi, et al (La Medicina del Lavoro, 2019).

The study

• Authors: P. Apostoli, P. Boffetta, M. Bovenzi, P.L. Cocco, D. Consonni, A. Cristaudo, G. Discalzi, A. Farioli, M. Manno, S. Mattioli, E. Pira, L. Soleo, G. Taino, F.S. Violante, C. Zocchetti
• Journal: La Medicina del Lavoro
• Published: 2019;110(6):459-485
• Type of article: Consensus statement
• Cited by: 9 articles, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

The Position Paper (PP) on asbestos of the Italian Society of Occupational Medicine (SIML) aims at providing a tool to the occupational physician to address current diagnostic criteria and results of epidemiological studies, and their consequences in terms of preventive and evaluation actions for insurance, compensation and litigation. The PP was based on an extensive review of the scientific literature and was compiled by a Working Group comprising researchers who have contributed to the international literature on asbestos-related diseases, as well as occupational physicians with extensive experience in the evaluation of risks and the medical surveillance of workers currently and formerly exposed to asbestos. The PP was drafted and reviewed between 2017 and 2018; its final version was prepared according to the guidelines of AGREE Reporting Checklist. All the members of the Working Group subscribed to the document, which was eventually approved by SIML's Executive Committee. The first section addresses industrial hygiene issues, such as methods for environmental monitoring, advantages and limitations of different microscopy techniques, the potential role of microfibers and approaches for retrospective assessment of exposure, in particular in epidemiological studies. The second section reviews the biological effects of asbestos with particular attention to the diagnostic aspects of asbestosis, pleural changes, mesothelioma and lung cancer. In the following section the criteria of causal attribution are discussed, together with different hypotheses on the form of the risk functions, with a comparison of the opinions prevalent in the literature. In particular, the models of the risk function for mesothelioma were examined, in the light of the hypothesis of an acceleration or anticipation of the events in relation to the dose. The last section discusses topics of immediate relevance for the occupational physician, such as health surveillance of former exposed and of workers currently exposed in remediation activities.

In plain English

This was a position paper of the Italian Society of Occupational Medicine (SIML), not a new study. A working group of researchers and occupational physicians drafted it in 2017-2018 from an extensive literature review. It covered fiber measurement, diagnosis of asbestos diseases, attribution of disease to asbestos, and medical surveillance. It cited INAIL insurance data: 3688 asbestosis cases were reported in 2012-2016, and 1543 were recognized. The paper reported that the Helsinki consensus authors held that 25 fibre/cc-years of cumulative exposure allows a possible lung cancer relative risk of about 2 to be seen in the exposed population. For asbestosis, it described a level around 25 ff/cc-years below which clinically relevant lung fibrosis does not seem to occur. A cited source gave a median mesothelioma latency of about 48 years. The paper set out both sides of the Italian debate on whether higher exposure brings mesothelioma forward. The authors concluded that recent systematic reviews were lacking on several points. For reducing lung cancer deaths, they suggested surveillance of formerly exposed people aged 75 or under with medium-high exposures, meaning exposure begun before 1985.

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: Position paper based on an extensive review of the scientific literature by a working group, approved by the society's executive committee
• Who was studied: No study population. The document was drafted and reviewed between 2017 and 2018 by a working group of researchers and occupational physicians, for occupational physicians in Italy
• Exposure: Asbestos in general. The paper notes that Italian law recognizes six minerals as asbestos: chrysotile (serpentine group) and the amphiboles crocidolite, amosite, tremolite, actinolite and anthophyllite
• Main results:
  • INAIL (Italian national insurer) data cited by the paper: 3688 asbestosis cases were reported in 2012-2016 (over 700 per year on average), of which 1543 were recognized
  • The paper reported that the authors of the Helsinki consensus document considered that a cumulative exposure of 25 fibre/cc-years allows a possible relative risk for lung cancer of about 2 to be detected in the exposed population
  • For asbestosis, the paper described reasonable consensus that risk is a function of cumulative exposure above 100 ff/cc-years
  • For asbestosis, the paper described an exposure threshold of around 25 ff/cc-years, below which a clinically relevant form of lung fibrosis does not seem to be present
  • Citing the Doll and Peto report, the paper described the lung cancer risk function as mainly linear in cumulative exposure, with an excess risk coefficient of the order of 0.01 per ff/cc-year
  • The paper stated that in people exposed to asbestos, relative risks for mesothelioma are often above 20, and excess cases make up the vast majority (over 95%)
  • Citing a referenced source (INAIL mesothelioma register report), the paper gave mesothelioma latency as a median of about 48 years, with a range of 4 to 89 years
  • The paper presented two opposing positions on whether asbestos exposure brings forward (anticipates) mesothelioma: supporters and critics of such a relationship
  • The paper stated that the mechanism by which asbestos causes cancer remains an open question
• The authors' conclusion: The authors concluded that, for important aspects of the risk function, the literature lacks recent systematic reviews conducted with established methods. For the specific aim of reducing lung cancer deaths in formerly exposed people, they suggested as a logical approach surveillance for those with medium-high exposures (in other words, exposures begun before 1985) and aged 75 or under. SIML called for a national law to make protocols uniform.
• Limitations the authors state:
  • The position paper, although commissioned by SIML, was based on the opinion of the experts who took part

Topics

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

Medical terms in this study, explained in our Lexicon: Industrial Hygiene, Mesothelioma, Lung Cancer, Attribution.

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