Validation of death certificates in asbestos workers

Our plain-English summary of Validation of death certificates in asbestos workers, by M.L. Newhouse, J.C. Wagner (British Journal of Industrial Medicine, 1969).

The study

• Authors: M.L. Newhouse, J.C. Wagner
• Journal: British Journal of Industrial Medicine
• Published: 1969;26(4):302-7
• Cited by: 60 articles, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text
• In J-M's library: Johns-Manville's company medical library held a copy (J-M no. 001430).

Abstract

Newhouse, M. L., and Wagner, J. C. (1969).Brit. J. industr. Med.,26, 302-307. Validation of death certificates in asbestos workers. The Registrar General has supplied the certified cause of death of 436 past workers in an asbestos factory. An attempt was made to follow up the 301 (69%) deaths which had occurred in hospital or had been the subject of an inquest or coroner's post-mortem examination. Necropsy reports were obtained for 158 (52%) of this group and histological material was reviewed in 84 (28%). The additional information, particularly that obtained from review of the histology, led to the revision and extension of the diagnosis suggested by the certified cause of death in a number of cases. The incidence of carcinoma of the bronchus had not been grossly underestimated, four additional tumours of this type were identified by scrutiny of the necropsy reports, and a further four by review of histological sections. The incidence of mesothelial tumours was underestimated, endothelioma or mesothelioma was the certified cause of death in four of the series, and a further 15 mesotheliomata were identified by review of histological material. Five patients with pleural mesotheliomata had been certified as dying of carcinoma of the lung or pleura. Ten deaths from peritoneal mesotheliomata had been attributed either to carcinomatosis without mention of a primary tumour or to cancer of the gastro-intestinal tract. Lung sections were submitted for review in 67 of the series; some degree of asbestosis was found in all but seven. Asbestosis graded as either moderate or severe was found in all the confirmed cases of carcinoma of the lung.

In plain English

The authors compared death certificates of past asbestos factory workers with post-mortem (necropsy) reports and a fresh review of tissue slides. Of 436 certificates, they followed up the 301 deaths in hospital or with a coroner's inquiry. They obtained necropsy reports alone for 74, reports plus tissue for 84, and nothing further for 143. Necropsy reports revealed four lung cancers not shown on certificates, and tissue review found four more. Among the 84 deaths with tissue, 19 mesothelial tumours were identified, including two published cases the authors did not review themselves. Five pleural mesotheliomas had been certified as lung cancer. Ten peritoneal mesotheliomas had been certified as other conditions: six as cancer of the pancreas, rectum or gall bladder, three as carcinomatosis and one as tonsil cancer. Asbestosis was found in 60 of 67 men with lung tissue. The authors thought its degree was probably overestimated, as usually only one lung section was available. The authors concluded that certificates had not grossly underestimated lung cancer, but had underestimated mesothelial tumours. They noted that the reviewed deaths were not representative of all deaths among the factory's past workers.

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: Validation study comparing certified causes of death with necropsy reports and review of histological (tissue) material, carried out within a cohort study of factory workers
• Who was studied: 436 deaths among past workers at an asbestos factory. Follow-up was attempted for 301 of them: 215 who died in hospital and 86 who died at a private address but had a coroner's inquest or post-mortem. Many had died in hospitals in the East End of London.
• Exposure: Past employment at an asbestos factory. The article does not name the fiber types or products. The authors note that most of the reviewed workers had been employed there for long periods.
• Main results:
  • Of the 301 deaths followed up, necropsy reports alone were obtained for 74 (24.6%), and necropsy reports plus histological material for review for 84 (27.9%). No further information was obtained for 143.
  • Necropsy-report-only group (74 deaths): four additional lung cancers were found that were not on the certificates.
  • In the group with tissue review (84 deaths), 29 had lung carcinoma on the certificate. Review confirmed bronchial carcinoma in 24, and five were reclassified as pleural mesothelioma.
  • In three deaths where asbestosis was given as the underlying cause (certified causes duodenal ulcer, myocardial fibrosis and bronchopneumonia), bronchial carcinoma was found at necropsy and confirmed on histology.
  • Additional bronchial carcinomas amounted to four (5.4%) in the first group and four (4.7%) in the second group.
  • Across all 436 deaths, mesothelioma or endothelioma appeared on seven certificates. Review of histological material in the 84-death group identified a further 15 mesotheliomas.
  • The 19 mesothelial tumours identified among the 84 deaths with tissue included two previously published cases that the authors did not personally review.
  • Table 5 lists the certified causes of death for the men dying of mesothelial tumours. For the pleural tumours these were endothelioma of pleura (1) and carcinoma of lung (5). For the peritoneal tumours they were mesothelioma or endothelioma of mesentery (3), carcinomatosis (3), carcinoma of pancreas (3), carcinoma of rectum (2), carcinoma of gall bladder (1) and carcinoma of tonsil (1). The authors' text groups seven of these certificates as relating to the gastro-intestinal tract.
  • One man with a peritoneal mesothelioma had carcinoma of the tonsil on his death certificate. He later died from a widespread peritoneal tumour.
  • Of 14 deaths certified as primary gastro-intestinal tumours, seven were reclassified as peritoneal mesothelioma. Of four certified as carcinomatosis without a stated primary tumour, three were reclassified as peritoneal mesothelioma.
  • Among the 84 fully reviewed deaths, a malignant tumour was found in 60 (71%). These were bronchial carcinoma in 28 (33%), mesothelioma in 19 (22%), gastro-intestinal tumour in seven (8.3%) and other tumours in six (7%).
  • Asbestosis was found in 60 of the 67 (90%) deaths with at least one lung section, and was graded moderate or severe in 53. The authors thought the degree of asbestosis, judged from limited tissue, was probably overestimated.
  • As far as the available material showed, all the confirmed bronchial carcinoma cases occurred with marked or moderate asbestosis.
  • In one man aged 52 with severely thickened pleura, expert pathologists were evenly divided on whether the tissue showed mesothelioma. The case was classified as severe asbestosis with gross pleural thickening.
• The authors' conclusion: The authors concluded that death certificates had not grossly underestimated bronchial carcinoma in these workers, but had underestimated mesothelial tumours.
• Limitations the authors state:
  • The deaths with extra information are not representative of all deaths among past workers at the factory.
  • The tissue-review group was heavily weighted by 44 cases from the London Pneumoconiosis Medical Panel. These were men certified with asbestosis in life, or men for whom compensation was thought claimable after death.
  • The deaths investigated were mainly from 1955 to 1964. The authors note this was a period of rising mesothelial tumour incidence, and that information was hard to obtain for deaths before 1955.
  • The degree of asbestosis was judged from limited tissue, usually a single lung section, which probably led to overestimation.

Topics

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

Medical terms in this study, explained in our Lexicon: Death Certificate, Autopsy, Histology, Carcinoma, Bronchus, Mesothelioma, Pleura.

Related studies

• Influence of age at death on accuracy of death certificate disease diagnosis: findings in 475 consecutive deaths of mesothelioma among asbestos insulation workers and asbestos factory workers — I.J. Selikoff (1992)
• Death certificates in epidemiological studies, including occupational hazards: inaccuracies in occupational categories — I.J. Selikoff (1992)
• Recovering missing mesothelioma deaths in death certificates using hospital records — V.S. Santana, E. Algranti, et al. (2018)
• Use of death certificates in epidemiological studies, including occupational hazards: variations in discordance of different asbestos-associated diseases on best evidence ascertainment — I.J. Selikoff, H. Seidman (1992)
• Estimation of the incidence of pleural mesothelioma according to death certificates in France — Y. Iwatsubo, M. Matrat, et al. (2002)
• Use of job-exposure matrix in an occupational analysis of lung and bladder cancers on the basis of death certificates — D. Coggon, B. Pannett, et al. (1984)

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