Annals of Oncology Advance Access originally published online on February 24, 2006
Annals of Oncology 2006 17(5):848-852; doi:10.1093/annonc/mdl021
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© 2006 European Society for Medical Oncology
Occupational asbestos exposure: how to deal with suspected mesothelioma cases—the Dutch approach
1 Department of Thoracic Oncology, The Netherlands Cancer Institute, Amsterdam; 2 Department of Pulmonology, Bernhoven Clinic, Veghel; 3 Pulmonologist, Huizen; 4 Department of Pulmonology, Deventer Hospital, Deventer; 5 Department of Pulmonology, Academic Medical Center, Amsterdam; 6 Department of Pulmonology, Gemini Hospital, Den Helder; 7 Department of Pulmonology, Central Military Hospital, Utrecht, The Netherlands
* Correspondence to: P. Baas, Department of Thoracic Oncology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands. Tel: +31-205122958; Fax: +31-205122572; E-mail: p.baas{at}nki.nl
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Abstract |
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Introduction: Patients with asbestos-related diseases, such as malignant mesothelioma (MM), are not uniformly treated in Europe when they apply for compensation. In The Netherlands, the Institute of Asbestos Victims (IAV) acts on behalf of patients with a malignant mesothelioma. In the majority of cases, the diagnosis is clear but in some, uncertainty remains. In these cases a specialist opinion of the Mesothelioma Group of the Dutch Thoracic Society (DTS) is required. The process of data handling and final outcome for these patients is discussed and compared with the situation in other European countries.
Materials and methods: Dutch patients with a possible malignant mesothelioma and occupational exposure to asbestos presented their cases to the IAV. In 10% of the cases, pathological confirmation of a malignant mesothelioma could not be obtained. These cases were presented to the Mesothelioma Group to obtain a clinical diagnosis based on clinical reports, occupational history, X-ray examination and other factors. Each case was reviewed by three independent pulmonologists experienced in MM. The majority view was binding for acceptance or rejection of the diagnosis.
Results: In the period January 2000 until May 2005, the IAV received 1747 cases for compensation. In 161 cases no definitive diagnosis could be made on pathology and were presented to the Mesothelioma Group. Of these cases, 117 (73%) were considered to be compatible with the clinical diagnosis malignant pleural mesothelioma. Forty-four cases (27%) were rejected. In 75% of the cases (112 of 150), the conclusion of the three independent specialists was unanimous; in 11 cases one specialist refrained from a diagnosis. The median time from request to submission of the report was 34 days (range 1–185 days).
Conclusions: Compared with other European countries, this approach, as determined by the IAV and Mesothelioma Group of the DTS, is an effective and rapid way to investigate claims of patients with a possible occupationally related malignant mesothelioma.
Key words: malignant pleural mesothelioma, asbestos claims, asbestos victims
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introduction |
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The asbestos industry has grown throughout the 20th century, first in Western Europe and during the last decades in the third world. It was not until the publication of Wagner et al. in 1960 that it became clear that there is a causal relationship between occupational exposure to asbestos and the development of malignant mesothelioma [1
]. Since that time it has taken many years in Europe to restrict the manufacturing and transport of asbestos and to control the demolition of buildings containing asbestos. For example, the first asbestos restriction law in The Netherlands was issued by the Dutch government in 1977; this forbids the handling of crocidolite (blue asbestos). Due to economical and political issues, it was not until 1993 that a final prohibition on the use, disposal and transport of all forms of asbestos was issued. In other European countries, comparable regulations were taken over during the same period. However, it took until 1 January 2005 before a general prohibition was implemented in Europe. It is therefore expected that between 2005 and 2040, no less than half a million people will die from asbestos-related diseases in Europe. From 1945 to 1995, approximately 340 000 people in The Netherlands have had occupational exposure to asbestos. Approximately 10 000 of these people worked in the primary asbestos industry and were involved in handling of materials containing asbestos. Even since the last legislation, civilians continue to be exposed to asbestos in the environment.
incidence
In The Netherlands, approximately 350 new patients are diagnosed each year with malignant mesothelioma (Figure 1). Epidemiological surveys suggest that the incidence will increase until 2015, with a maximum of approximately 500 cases per year [2, 3]. Due to the long latency period between exposure and the development of the disease, which can last up to 40 years, it is expected that approximately 18 000 people will die from this disease in The Netherlands over the next 40 years.
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occupational disease and compensation by the Institute of Asbestos Victims
Malignant mesothelioma is considered one of the occupational diseases in The Netherlands. When a patient is diagnosed with a malignant mesothelioma and the patient has had occupational exposure to asbestos in the past, he is entitled to financial compensation. In general, the symptoms of the disease and the advanced age and limited lifespan (8–14 months) of these patients rule out full, time-consuming, legal procedures.
In November 1998, an agreement was made between the ministry of justice, social security, trade unions and the asbestos victims to ensure that future claims would be handled in a swift and socially acceptable way. For that purpose the Institute of Asbestos Victims (IAV) was founded. Its primary task is to support patients in this process, to provide cash advances and to organize a short track protocol to select patients who are entitled to additional compensation. In the latter case, it is assumed that the previous employer or his insurance company has a legal responsibility. One of the most important tasks is to help the patient to determine where and when the asbestos exposure has taken place and which employer is responsible. This approach safeguards the victims from unwanted, time-consuming and expensive legal procedures. This arrangement only applies to patients with a mesothelioma, or their relatives, when occupational exposure to asbestos has occurred. It is therefore essential to obtain a definite diagnosis of malignant mesothelioma. Unfortunately it is not always possible to obtain representative tumour material for diagnosis.
application to the IAV
Patients and their relatives can apply to the IAV for reimbursement. The IAV will collect the relevant medical information and obtain an occupational history (by interviewing the patient, if alive, or relatives or former colleagues if the patient is deceased). Histo-pathological material will be requested from the local hospital and, when available, it will be reviewed by pathologists from The Netherlands Mesothelioma Panel. If the diagnosis of a malignant mesothelioma is confirmed, the IAV will decide that the patients or their relatives are entitled to compensation. In cases where the diagnosis cannot be confirmed, the application is turned down.
unconfirmed cases
The Netherlands Mesothelioma Panel cannot review all cases presented to the IAV. Tumour biopsies may not be representative or available, for example when no diagnostic procedures have been performed due to the poor condition or death of the patient. In such unclassified cases, the IAV requests the Mesothelioma Group of the DTS to intervene. This group consists of 12 pulmonologists, who are specialized in the diagnosis and treatment of malignant mesothelioma. All available material on these unclassified cases, including radiological examinations, is sent to three independent panel members. Based on available information, each specialist must decide whether the diagnosis of malignant mesothelioma is considered probable or has to be rejected. In this paper we have analysed our experience with this procedure over the first 5 years.
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materials and methods |
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Figure 2 shows the process diagram of the protocol which was followed. Patient information, medical records and radiology charts are sent to a central office, where they are checked for completeness. If necessary, additional information is requested from the hospital where the patient was first examined. By random assignment, three independent members of the Mesothelioma Group are asked to give their expert opinion. None of these may have been involved in the initial diagnostic procedures or treatment of the patient. The specialists are required to report in writing to the central office whether they consider the case compatible with a malignant mesothelioma. After reviewing a case, the patient data and radiological material are sent to the next specialist, who is not informed of the decision of the previous specialist. When at least two of the three specialists report either a positive or negative conclusion, the IAV is notified of the final outcome. There is no additional discussion about cases during the decision process.
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In this study, all cases presented to the Mesothelioma Group have been analysed and compared with the total number of patients who applied for reimbursement at the IAV. Finally, the conclusions of the different specialists in each case were matched and the quality and duration of processing the cases was analysed. The data consisted of birth date, race, sex, occupational history, smoking history, radiology examinations, diagnostic procedures and dates of received requests, date of reply, completeness of the available data and results of the reviewing specialists.
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results |
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Between January 2000 and April 2005 a total of 1747 patients applied to the IAV for compensation. Of these, 126 cases were still in analysis during the evaluation of our study. In 161 cases insufficient pathology data were available to make a diagnosis. These cases were presented to the Mesothelioma Group. At the time of review, most of the patients (>50%) had already died, ruling out further diagnostic procedures. In four of the 160 cases, additional information was obtained from the primary hospital. Over 72% of the patients were aged 62–80 years at the time of application. Only 9% were younger than 60 years.
The median duration of the handling process was 34 days (range 1–185). In two cases the procedure took over 5 months: one of these was due to postal failure, the other was due to the lack of radiographic images.
The diagnosis of probable mesothelioma was accepted in 117 cases (73%) and rejected in 44 cases (27%). There was no bias from any of the panel members for a positive or negative scoring. The diagnosis was confirmed when two or three of the specialists decided in favour of a mesothelioma; it was rejected when two or three decided against the diagnosis. In 112 out of the 161 cases, the decision was concordant; in 38 cases one of the panel members came to a discordant conclusion. In 11 cases, a specialist refrained from a conclusion, stating that the available material was insufficient to draw conclusions from. In total, there was a discordance of 24% (38 of 161 cases).
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discussion |
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For many years, industries, insurance companies and governments have been reluctant to acknowledge their responsibility for asbestos-related diseases. Of these diseases, mesothelioma is a well recognized entity with a dismal prognosis. In general, the patients are elderly males in poor condition and deprived of financial compensation. In many cases, their appeal to the court is superannuated; even if it is accepted, the claimant has to prove the asbestos exposure in the past. This all leads to a heavy psychological burden. In addition, taking legal action as an individual is a cumbersome, expensive and often a very long process. Unfortunately, many patients die during the procedure.
Comparison with other countries indicates that there are many differences in the response to patients who request financial compensation for occupational diseases (Table 1). In Germany, the claimant has much fewer possibilities compared with other countries. In most of the cases, the burden of proof lies with the patient and his family. In Belgium, the situation is comparable with the Dutch situation as long as the disease is recognised as occupationally contracted. In the UK and in The Netherlands there is a general damage award, which covers the ‘pain, suffering and loss of amenity’, while additional compensation can be given for the loss of income or pension.
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In The Netherlands, the Institute of Asbestos Victims was founded in 2000 to overcome most of the problems of patients with asbestos-related diseases. A covenant was made between involved groups: the government, industries, insurance companies, unions and patients group representatives. This approach has proven to be successful and is transparent for all parties (http://www.asbestslachtoffers.nl/pages/welkom.html).
In over 90% of the cases, the collaboration between the IAV and The Netherlands Mesothelioma Panel results in a diagnosis. For the remaining 10%, an independent judgement is required. For these cases, the IAV and the Mesothelioma Group have agreed that a binding, clinical diagnosis would be made based on all information available. Our analyses show that in approximately 75% of the patients, the suspicion of mesothelioma was confirmed based on expert opinion. In 25% of the cases, however, the diagnosis was rejected on the basis of available material. In these particular cases, another diagnosis was considered more appropriate.
In this set-up, we deliberately chose three independent specialists to judge the material before coming to a conclusion. We hoped that the experience of these specialists would guarantee a fair decision. Due to the nature of these incomplete cases, we refrained from a joint review committee such as The Netherlands Mesothelioma Panel of pathologists.
It is remarkable that in 78% of the cases all panel members came to the same decision. As the amount of available data differs widely between cases, this percentage is considered acceptable. Only one specialist made discordant judgements in eight out of the 38 cases he reviewed (data not shown). This judgement, however, was both positive and negative. The median time of 34 days to achieve a conclusion is mainly caused by the administrative issues, checking of the completeness of data and the transport of the material to the different specialists. As soon as two identical conclusions were sent to the central office, the final conclusion was sent out to the IAV. It is expected that progress in digitalisation of images and patient record files will lead to a faster handling of the cases.
Despite the awareness of reimbursement protocols for patients with mesothelioma, a significant percentage of patients still do not have a diagnosis of their pleural disease. In part, this is due to the reluctance of doctors to perform invasive investigations in elderly patients, or patients where significant co-morbidity exists and only limited therapeutic options are available.
We consider it of great social relevance to take an active attitude to obtain the diagnosis and occupational history for this group of patients. Not only the specialist, but also the general practitioner can help to improve this process by referring patients early for diagnostic procedures.
We conclude that this protocol of a financial reimbursement for patients with suspected malignant mesothelioma that have a proven occupational exposure to asbestos, is quite unique compared with other European countries. It also allows the IAV to provide clarity about the diagnosis in an acceptable time frame.
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Acknowledgements |
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We thank Mr M. A. van der Woude, director of the IAV, for supplying us with data on the submitted cases. We also thank our colleagues of the Mesothelioma Group who were involved in the judgements of the cases: Hugo Schouwink, Jan van Meerbeeck, Ed van Hezik, Wim Strankinga and Youke Tan.
Received for publication December 18, 2005. Revision received January 11, 2006. Accepted for publication January 12, 2006.
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References |
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TopAbstractintroductionmaterials and methodsresultsdiscussionReferences |
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1. Wagner JC, Sleggs CA, Marchand P. Diffuse pleural mesothelioma and asbestos exposure in the North Western Cape Province. Br J Ind Med 1960; 17: 260–271.[Medline]
2. Peto J, Decarli A, La Vecchia C et al. The European mesothelioma epidemic. Br J Cancer 1999; 79: 666–672.[CrossRef][Web of Science][Medline]
3. Segura O, Burdorf A, Looman C. Update of predictions of mortality from pleural mesothelioma in The Netherlands. Occup Environ Med 2003; 60: 50–55.
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