Recent data confirm the continuation of a European mesothelioma "epidemic," as first revealed in a 1999 paper by J Peto, A Decarli et al in The British Journal of Cancer. UK statistics show an overall increase in mesothelioma deaths of nearly 300% in twenty years: from 393 in 1978 to 1527 in 1998. In Denmark "a further increase in the number of mesothelioma cases can be expected, and the effect of regulating the environmental exposure to asbestos cannot be expected within the next 10-15 years," according to the authors of Incidence Rates of Malignant Mesothelioma in Denmark and Predicted Future Numbers of Cases Among Men [Scand. J. Work Environ. Health 2000 April]. In the paper: Future Trends in Mortality of French Men from Mesothelioma, researchers predict that between 1997 and 2050, the national mesothelioma death-toll will exceed 44,000 [Occup. Environ. Med. 2000 July]. This Autumn, a team of fifteen scientists from Italy, Spain and Switzerland published epidemiological evidence that: "living within 2000 m(etres) of an asbestos mine or works such as asbestos cement plants, asbestos textiles, shipyards, or brake factories, entailed an almost 12-fold increase in risk (of pleural mesothelioma)" in the paper: Multicentric Study on Malignant Pleural Mesothelioma and Non-occupational Exposure to Asbestos [Brit. J. Cancer 2000 83 (1)]. Another important conclusion they reached was that: "low-dose exposure to asbestos at home or in the general environment carries a measurable risk of malignant pleural mesothelioma…our results suggest that non-occupational exposure to relatively low-doses of asbestos is a hazard that may contribute to the burden of mesothelioma over the next few decades."
Government reports documenting the scale of the UK's mesothelioma problem make disturbing reading. Health and Safety Statistics 1999/2000 (HSE Stats), Mesothelioma Area Statistics: County Districts in Great Britain part 1 (1976-1992) and part 2 (1986-1995) and Mesothelioma Occupation Statistics confirm that those at highest risk (bearing in mind that workers in asbestos manufacturing did not constitute an identifiable occupational group in these analyses) include: "metal plate workers (including shipyard workers), and vehicle body builders (including rail vehicles); both of these occupations had rates over six times the average. Plumbers and gas fitters had a rate over four times the average and carpenters had a rate over three times the average." Other trades showing elevated proportional mortality rates were: electricians, construction workers, managers in construction, plasterers, builders and handymen, steel erectors, painters and decorators and scaffolders. Male mesothelioma deaths are concentrated in the regions around the ports and dockyards. With 626 deaths in twenty-five years, Strathclyde is second only to Greater London in the league table. Within Strathclyde, which accounts for nearly 70% of Scottish mesothelioma mortality, the biggest cluster of deaths (280) was from Glasgow. Included in the HSE Stats are projections that "male mesothelioma deaths would be in the range of 1400 (reached around 2005) to 2100 (reached around 2020)." Table A2.38 records 1328 male mesothelioma deaths in 1998; using 1328 as a base figure and factoring into the equation the overall upward trend, the long latency period and improvements in diagnosis, the figure of 1400 appears to woefully underestimate the situation. Hedging their bets, the HSE urges caution in placing too much reliance on official predictions: "these projections rest on a number of uncertain (and largely unverifiable) assumptions and should be regarded as informed guesses rather than firm forecasts." Perhaps, a more useful measure of the extent of the problem is feed-back from asbestos victim support groups such as Glasgow's Clydeside Action on Asbestos, where Phyllis Craig reports "there has been a substantial increase in the number of mesothelioma clients we are seeing. Previously, these clients tended to be in their 60s or 70s, these days they are in their mid 40s to early 50s." John Flanagan, at the Merseyside Asbestos Victims Support Group, says: "I'm not surprised that HSE figures show the North West to be one of the worst affected regions. Our records show a continuing rise in the number of mesotheliomas being diagnosed locally particularly on the Wirral Peninsula."
There is an epidemiological consensus: the incidence of mesothelioma is increasing and will continue to do for the foreseeable future. Programs to quantify, control, treat and possibly reduce the suffering caused by asbestos have been initiated. In the UK, the aim of the National Case-Control Study of Mesothelioma and Asbestos Exposure is to: "identify the occupations and work practices conferring the highest risk of mesothelioma and in particular to determine whether construction workers involved in renovation and maintenance are still at risk of substantial asbestos exposure." The three year study combines personal interviews with lung burden measurements. During the initial twelve months, much of the groundwork has been laid: ethical approval has been obtained from English and Scottish authorities, a questionnaire has been developed, permission to access Scottish Morbidity Records has been granted, a database of English chest physicians has been compiled and the design and distribution of a computer program to all health authorities has been completed. In an announcement in September, 2000, the Cancer Research Campaign was optimistic about clinical trials at Newcastle General Hospital where doctors, using a new drug combination of carboplatin and alimta, found measurable improvements in the conditions of twenty-five mesothelioma patients. Attempts are being made to ensure that Scottish patients are included during the next phase of these drug trials. Current research at St. Bartholomew's Hospital in London is focusing on irinotecan, a new drug, in combination with cisplatin and mitomycin. A pilot study (MESO-1) being run by the British Thoracic Society and the Medical Research Council is recruiting patients for a program which will compare the efficacy of three regimes: vinorelbine alone, mitomycin, vinblastine plus cisplatin and active supportive care.
Interesting research is being done in Australia. Professor Bruce Robinson's team at the Sir Charles Gairdner Hospital in Perth continues to explore the promise of gene therapy: "we've already got existing therapies like surgery and chemotherapy. Why can't we combine these treatments with gene therapy…we've argued if gene therapy had a certain effect by itself what about if you took out as much of the cancer as possible. Would gene therapy be able to work even more effectively…this is indeed what happens." At the University of Sydney, Dr Judith Black is working on a therapeutic approach to control the progression of pleural mesothelioma; techniques to measure levels of enzymes and cyberkines could allow doctors to diagnosis the disease before symptoms develop thereby improving survival rates. Also in Sydney, Dr Helen Wheeler a clinician at the Royal North Shore Hospital, has been monitoring the effectiveness of thalidomide, which can inhibit the growth of blood vessels in new tumors, in the treatment of mesothelioma. Although it is early days, anecdotal evidence suggests that the drug is beneficial for pain management and symptom relief: "In a couple of patients it caused stablisation of their cancers and in one patient it may have even caused tumour regression…With the patients we were treating, they didn't seem to be requiring near as many analgesics. They stopped losing weight and they felt much better within a couple of days of taking the drug."
The Proceedings of an International Expert Meeting on New Advances in Radiology and Screening of Asbestos-Related Disease, published by the Finnish Institute of Occupational Health, contains papers updating the Helsinki criteria for individual attribution, analysing epidemiological trends, proposing screening and surveillance schemes for exposed workers and discussing new techniques for early diagnosis of lung cancer. Conclusions reached in Espoo, Finland this year include: "At present, there are no clear health benefits from screening for mesothelioma because of the lack of adequate treatments and interventions. However, lung cancer screening directed at asbestos-exposed cohorts may provide important information leading to earlier identification of mesotheliomas (e.g. through the evaluation of small pleural effusions detected by CT) and potentially improved outcomes depending on the introduction of new treatment modalities. By analogy with other cancers, one might suspect that innovative therapies for mesothelioma are more likely to be effective for early-stage minimal-bulk tumours than for advanced mesothelioma."
For many years, information available to one set of professionals has remained virtually unknown to others; e.g. social workers did not know how or if mesothelioma clients could claim compensation from former employers or the government. Patients remained unaware of the existence of drug trials; the wife of one mesothelioma patient used the internet to find out about a clinical trial which has helped prolong her husband's survival by two years and ten months. In the bad old days, geography and subject constraints constituted unbreachable barriers to the flow of information. For this reason, efforts to create a public dialogue on mesothelioma issues are good news. Clydeside Action on Asbestos, which held an extremely successful conference four years ago, has set a provisional date of 13 February, 2001 for a mesothelioma conference at which current treatment options and clinical trials will be discussed by leading UK experts. Information can be obtained from Phyllis Craig at: 0141 552 8852. The inaugural meeting of the British Mesothelioma Interest Group (BMIG) will be held in Leicester on 22 February, 2001. The program will include clinical and scientific research presentations and open discussions "on the roles of current and future treatment modalities, with particular emphasis on possible trial protocols." While the BMIG website is being designed, more information can be obtained from Linda Hollis at: LHollis@uhl.trent.nhs.uk
Protracted latency periods, inaccurate diagnoses, multiple employers and the destruction of crucial documentation often frustrate attempts by asbestos victims to obtain compensation. A recent judicial ruling which significantly increases litigation required and concomitant costs is already adversely effecting pleural disease plaintiffs. With the abolition of legal aid for personal injury cases, the higher costs make it more difficult to obtain after-the-event insurance without which lawsuits in England and Wales will not proceed. These developments stem from the Court of Appeal verdict in Holtby v Brigham & Cowan (Hull) Ltd. on April 6, 2000. Mr Holtby, a marine fitter, alleged that occupational exposure to asbestos over a forty year period caused him to contract asbestosis. Finding that the exposure was periodic and not continual, the Court estimated the number of exposure years as twenty-four, of which twelve occurred during employment by the defendant. The issue of causation was paramount; if asbestosis was caused by cumulative exposure, was the negligent employer liable for all the damages or only an appropriate proportion? Upholding the High Court ruling, the Court of Appeal agreed that Brigham & Cowan had been negligent and in breach of statutory duty; liability was assessed at 75% of the damages awarded. In the majority judgment, Lord Justice Stuart-Smith wrote: "the onus of proving causation is on the claimant; it does not shift to the defendant… the defendant is liable only to the extent of that contribution…. the court must do the best it can to achieve justice, not only to the claimant but the defendant, and among defendants." The ramifications of the innocent/guilty dust concept for indivisible injuries such as mesothelioma while not considered by Stuart-Smith were addressed by Lord Justice Clark, in the minority opinion: "where the claimant proves that two employers have made a material contribution to his condition, he is entitled to judgment in full against each, leaving them to contest issues of contribution between them. That would certainly be the case where the injury was truly indivisible, so that each material contribution to the same damage, as in a case of damage caused by, say, a collision." According to Jim Wyatt, Mr. Holtby's solicitor: "Many clients with pleural disease have experienced exposure at several companies. Holtby means that in cases where former employers are now untraceable or defunct, the surviving defendants are only liable for a proportion of the damages. Claimants are already receiving substantially less damages than previously." Leave to appeal the Holtby judgment to the House of Lords is being sought. Defendants have not been slow to appreciate the lee-way this ruling has given them. Plaintiffs are once again faced with a causation nightmare; can they ever prove conclusively whose fiber caused their mesothelioma? Fortunately in Wix vs Wilton Cobley Ltd. and others, Judge Rudd sitting at the Southampton County Court on May 12, 2000 agreed with Lord Justice Clark: "the effect of mesothelioma is different to that of asbestosis, the one involving physical damage, the other involving risk of mutation… For these reasons I hold the third defendant to be one hundred per cent liable to the claimant." Predictably, the Wix decision is being appealed.
The paper which first identified the continuing increase in mesothelioma mortality in Britain included caveats about the as yet unquantifiable risks experienced by asbestos removal workers: "Any contribution of asbestos removal to the mesothelioma epidemic cannot yet be assessed. Asbestos removal did not develop as a specialised industry until the 1980s, and the latency is too short for these workers to have developed mesothelioma… the creation of the new, and initially inadequately regulated, industry of asbestos removal may well have increased the burden of future occupational asbestos disease." It is ironic that while some struggle to come to turns with the enormous toll asbestos has taken, others still persist in underestimating the severity of the situation. So, while the HSE's Epidemiology and Medical Statistics Unit beavers away collecting and analysing asbestos-related data, the HSE's Field Operations Directorate (FOD), responsible for inspecting and enforcing regulations, exhibits a degree of complacency which is breath-taking: "In only three of 939 visits to asbestos removal activities was dry stripping an issue. In one of these cases the contractor was prosecuted. If this level of response is sustained, our target of eliminating dry stripping methods has all but been achieved." Someone who works in the asbestos removal industry and who has asked to remain anonymous was surprised by this finding saying: "In our experience, dry stripping remains the norm, without a doubt." In an article published in The Academy, an asbestos removal trade journal, Graham Gwilliam, a director of Asbestostrip Innovations, writes: "It is accepted by many of these (HSE) inspectors that 50% of all removal work is carried out dry. A senior member of the H.S.E has given the figure of 60%. A very reliable source, close to the workforce… states that a more realistic figure is 80%." The HSE is sending out mixed messages; on the one hand they have adopted a high profile campaign to "name and shame" those who fail to comply with occupational health and safety regulations (Health and Safety Offences and Penalties; HSE website at www.hse.gov.uk), on the other they are claiming victory for a battle only just begun. The government's failure to acknowledge the prevalence of inadequate controls and the continued use of dangerous practices, such as dry-stripping, will ensure that the mesothelioma tragedy will endure well into the twenty-first century.
December 1, 2000