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References on Asbestos Lung Disease

Lawrence Martin, M.D., FACP, FCCP

What is the harm from inhaling asbestos?

Becklake MR. Asbestos-related diseases of the lung and other organs: Their epidemiology and implications for clinical practice. State of the art review. Amer Rev Resp Dis 1976;114:187-227. (An extensive review with 231 references.)

Becklake MR. Asbestos-related diseases of the lungs and pleura. Amer Rev Resp Dis 1982;126:187-94.

An editorial that updates Dr. Becklake's 1976 State-of-the-art article in the Amer Rev Resp Dis. Among the points emphasized: the risk of lung cancer from asbestos is linear and "almost certainly without a threshold below which there is no risk."

Craighead JE, Mossman BT. The pathogenesis of asbestos-associated diseases. New Engl J Med 1982;306:1446-55.

Mossman BT, Gee BL. Asbestos-related diseases. New Engl J Med 1989; 320:1721-30.

Dunn MM. Asbestos and the lung. Chest 1989; 95:1304-1308.

Who is at risk for asbestos-related disease?

Anderson HA, Lilis RL, Daum SM, et al. Household-contact asbestos neoplastic risk. Ann NY Acad Sci 1976; 272:311-323.

In a study of 326 household contacts to amosite asbestos workers, 35% had chest x-ray abnormalities. Authors conclude that "significant household contamination with asbestos from industrial sources can and does commonly occur." Authors point out that four household contacts, not part of the study, had already developed mesothelioma.

What are the asbestos-related lung and respiratory diseases?


Selikoff IJ, Churg J, Hammond EC. The occurrence of asbestosis among insulation workers in the United States. Ann NY Acad Sci 1965; 132:139-155.

Report of investigation of 1522 workers examined more than 20 years after first exposure; radiologic evidence for asbestosis was found in 339. In half it was "moderate or extensive." In 307 consecutive deaths in this group, lung cancer was found to be 7x, and GI cancer 3x, as common as expected.

Murphy RLH Jr., Becklake MR, Brooks SM, et al. The diagnosis of nonmalignant diseases related to asbestos. Official statement of the American Thoracic Society. Am Rev Resp Dis 1986; 134:363-368.

(See also follow up letters to the editor: Franzblau A, Lilis R. Amer Rev Resp Dis 1987;136:790-1, arguing for a more liberalized definition of asbestosis; and Murphy RLH Jr., et al, Am Rev Resp Dis 1987,136:1516-17 who argue for the definition given in the original ATS statement.)

Burns DM. TLC in combined restrictive and obstructive lung disease. Editorial. Chest 1988;93:225-26.

Churg A. Nonneoplastic asbestos-induced disease. Mt Sinai J Med 1986; 53:409-415.

Review article by a pathologist who has published widely on asbestos diseases. Dr. Churg notes that if diffuse fibrosis is present on pathologic examination of lung tissue, then "the finding of even one asbestos body serves to establish the diagnosis [of asbestosis]."

Harber P, Smitherman J. Asbestosis: diagnostic dilution. J Occup Med 1991;33:786-93.

Mossman BT, Churg A. Mechanisms in the pathogenesis of asbestosis and silicosis. State of the Art. Amer J Respir Crit Care Med 1998;157:1666-1680.

...pathologic examination may reveal mild cases [of asbestosis] that do not have obvious function changes... The clinical, physiologic, and radiologic findings of asbestosis are not in any way specific, and they can be seen in diffuse interstitial fibrosis of other causes, particularly usual interstitial pneumonia (idiopathic interstitial fibrosis), except that patients with asbestosis always have a history of heavy occupational asbestos exposure...
...Epidemiologic studies indicate very clearly that the development of asbestosis requires heavy exposure to asbestos and provide strong evidence that there is a threshold fiber dose below which asbestosis is not seen; this dose appears to be, at a minimum, in the range of approximately 25 to 100 fiber/ml/yr. Thus, asbestosis is usually seen in workers who have had many years of high level exposure, for example, asbestos miners and millers, asbestos textile workers, and asbestos insulators. Asbestosis can also be produced by very high exposure of relatively short duration such as in shipyard workers employed for a few years inside ship compartments during and after the Second World War, where exposure levels sometimes reached hundreds of fibers per ml or air. (Pages 1666-1667)


Friedman AC, Fiel SB, Fisher MS, et al. Asbestos-related pleural disease and asbestosis: A comparison of CT and chest radiography. Amer J Roentg 1988; 150:269-275.


Gaensler EA, Kaplan AI. Asbestos pleural effusion. Ann Intern Med 1971; 74:178-91.

First report of benign pleural effusion from asbestos exposure; effusion occurred in 21% of all their asbestos patients. Asbestos exposure ranged from 3 to 38 years. Biopsy specimens showed nonspecific pleuritis with rare asbestos bodies and fibers.


Selikoff IJ, Churg J, Hammond EC. Asbestos exposure and neoplasia JAMA 1964; 188:22-26.

The first report from Selikoff, et al on mortality experience of a cohort of 632 asbestos insulation workers in the New York area, during their working years of 1943-1962. Found significant increases in deaths from lung cancer, mesothelioma, gastrointestinal cancer, and asbestosis.

Selikoff IJ, Hammond EC, Seidman H. Mortality experience of insulation workers in the United States and Canada, 1943-1976. Ann NY Acad Sci 1979; 330:91-116.

A follow up to Selikoff's 1964 study in JAMA. Beginning in 1967, 17,800 North American insulation workers were followed for incidence of disease, through 12/31/76. "Asbestos insulation workers in the U.S. and Canada suffer an extraordinary increased risk of death of cancer and asbestosis... Little increase in cancer deaths, nor of asbestosis, was observed in less than 15-19 years from onset of exposure... period of latency between onset of exposure and death was 2,3,4 or more decades."

Hammond EC, Selikoff IJ, Seidman H. Asbestos exposure, cigarette smoking and death rates. Ann NY Acad Sci 1979; 330:473-491

This 1979 paper reported the following lung cancer death rates
Group Smoking Mortality Ratio
Control No 1.0
Asbestos Workers No 5.2
Control Yes 10.9
Asbestos Workers Yes 53.9

Churg A. Lung cancer cell type and asbestos exposure. JAMA 1985;253;2984-85.

Cullen MR. Controversies in asbestos-related lung cancer. Occupational Medicine: State of the Art Reviews 1987;2:259-272.

Cullen MR. Controversies in asbestos-related lung cancer. State of the Art Reviews: Occupational Medicine. Hanley & Belfus, Inc., Philadelphia, 1987, pages 259-272.

An excellent discussion of the principle controversies: dose response; presence of asbestosis; chrysotile carcinogenicity. On question "Is lung cancer a complication of pulmonary fibrosis (asbestosis) or a risk factor for exposed individuals, with or without asbestosis?" the authors present arguments on both sides. "The conclusion...that asbestosis is an obligatory precursor lesion to cancer remains presumptious...present data do indeed suggest a close biological relationship between the two major respiratory tract toxicities [fibrosis and carcinoma]."

Edelman DA. Does asbestosis increase the risk of lung cancer? Int Arch Occup Environ Health 1990;62:345-9.

Hughes JM, Weill H. Asbestosis as a precursor of asbestos related lung cancer: results of a prospective mortality study. Brit J Indust Med 1991;48:229-33.

Mollo F, Piolatto G, Bellis D, et al. Asbestos exposure and histologic cell types of lung cancer in surgical and autopsy series. Int J Cancer 1990;46:576-80.


Selikoff IJ, Churg J and Hammond EC. Relation between exposure to asbestos and mesothelioma. New Engl J Med 1965; 272:560-65.

Driscoll R, Mulligan WJ, Schultz, et al. Malignant mesothelioma. A cluster in a native American pueblo. New Engl J Med 1988; 318;1437-38.

Shepherd KE, Oliver LC, Kazemi H. Diffuse malignant pleural mesothelioma in an urban hospital; clinical spectrum and trend in incidence over time. Am J Ind Med 1989;16:373-83.

Kazemi H, Mark EJ. Clinico-Pathologic Conference. New Engl J Med 1990; 323:659-667.

Churg A. Chrysotile, tremoline, and malignant mesothelioma in man. Chest 1988:93:621-628.

Pisani RJ, Colby TV, Williams DE. Malignant mesothelioma of the pleura. Mayo Clin Proc 1988; 63:1234-44.

Hillerdal G. Pleural malignancies including mesothelioma. Curr Opin Pulm Med 1995;1:339-43.

Metintas M, Hillerdal G, Metintas S. Malignant mesothelioma due to environmental exposure to erionite: follow-up of a Turkish emigrant cohort. Eur Respir J 1999;13:523-6.

Grondin SC, Sugarbaker DJ. Malignant mesothelioma of the pleural space. Oncology (Huntingt) 1999;13:919-26; discussion 926,931-2.

How does smoking affect asbestos diseases?

Neuberger M, Kundi M. Individual asbestos exposure: smoking and mortality -- a cohort study in the asbestos cement industry. Brit J Indust Med 1990;47:615-20.

Why is there so much argument over asbestos?

Kook Sim Q. As asbestos claims continued to grow, broker of settlements closes its doors. Wall Street Journal, February 7, 2001.

Schmitt RB. Asbestos litigation continues to grow as suits widen net for deeper pockets. Wall Street Journal, March 5, 2001; Page 1.

Berenson A. A surge in asbestos suits, many by healthy plaintiffs. New York Times, April 10, 2002.

Glater JD. Defending a United Detroit on Asbestos. New York Times, November 3, 2002.

Hudak S, Hagan JF. Asbestos litigation overwhelms courts. Cleveland Plain Dealer, November 5, 2002.

Why is There Controversy Over Diagnosis of Pleural Plaques?

Muller. Imaging of the Pleura. Radiology 1993;186:297-309.

Do Pleural Plaques Lead to Cancer?

Hillerdal G. Pleural Plaques and Risk for Bronchial Carcinoma and Mesothelioma. A Prospective Study. Chest 1994:105:144-50.

Smith D. Plaques, Cancer, and Confusion (Editorial). Chest 1994:105:8-9.

Van Cleemput J, et. al. Surface of localized pleural plaques quantitated by computed tomography scanning: no relation with cumulative asbestos exposure and no effect on lung function. Am J Resp Crit Care Med 2001;163:705-710.

What is the Browne Hypothesis?

Browne K. Is asbestos or asbestosis the cause of the increased risk of lung cancer in asbestos workers? Brit J Indust Med 1986;43:145-149.

Jones RN, Hughes JM, Weill H. Asbestos exposure, asbestosis, and asbestos-attributable lung cancer. Thorax 1996;51:S9-S14.

The mortality statistics for asbestos workers found by Hammond and Selikoff are often quoted to support the notion that asbestos exposure alone, without asbestosis, is a cause of lung cancer. However, as pointed out by Jones in this 1996 article, the workers with lung cancer who died and were autopsied in fact had asbestosis. (Quote from page S10).

"Selikoff's cohort study of US insulation workers provided the most widely quoted estimates of lung cancer mortality from asbestos "exposures" and cigarette smoking (Hammond EC, Selikoff IJ, Seidman H. Asbestos exposure, cigarette smoking, and death rates. Ann NY Acad Sci 1979;330:473-91.)

"For many years, whether in estimates of the proportion of occupational lung cancers, in projections of their future numbers, or in disputed causation in individual cases, experience of the insulation workers was routinely offered as quantifying the carcinogenic effect's of "exposure". The interaction between "exposure" and smoking was multiplicative or synergistic, which was regarded as evidence that asbestos was implicated in the majority of lung cancer deaths among the "exposed population". When this was controverted it was usually on the grounds that the insulation workers were the most heavily exposed group, and their cancer experience would not apply in individuals or groups with lesser exposures. Then, in a 1987 publication, Kipen and others (including Selikoff) reported surgical or necropsy results in a series of consecutive cases of insulation workers with lung cancer (Kipen, et al. Brit J Ind Med 1987;44:96-100) Of 138 cases with acceptable tissue and radiographs, all had histological evidence of lung fibrosis and 113 (82%) also had radiographic evidence of fibrosis. The mortality experience from lung cancer in the insulation workers therefore derived not merely from exposure to asbestos but from asbestosis."

Weiss W. Asbestosis: A Marker for the Increased Risk of Lung Cancer Among Workers Exposed to Asbestos. Chest, February 1999;115(2):536-549

Banks DE, et al.; Asbestos Exposure, Asbestosis, and Lung Cancer (Editorial). Chest, February 1999; 115(2):320

What are the standard criteria for diagnosing asbestosis?

Murphy RLH Jr., Becklake MR, Brooks SM, et al. The diagnosis of nonmalignant diseases related to asbestos. Official statement of the American Thoracic Society. Am Rev Resp Dis 1986; 134:363-368.

(See also follow up letters to the editor: Franzblau A, Lilis R. Am Rev Resp Dis 1987;136:790-1, arguing for a more liberalized definition of asbestosis; and Murphy RLH Jr., et al, Am Rev Resp Dis 1987, 136:1516-17 who argue for the definition given in the original ATS statement.)

Gaensler EA, Jederlinic PJ, Churg A. Idiopathic pulmonary fibrosis in asbestos-exposed workers. Am Rev Respir Dis 1991;144:689-696. (See also Jones RN. Editorial: The diagnosis of asbestosis. Am Rev Resp Dis 1991;144:477-478.)

Gaensler, et al found an approximately 5% false-positive rate for the clinical criteria formulated in the 1986 ATS standards (see first reference), i.e., that 95% of the clinically diagnosed cases did have asbestosis, and 5% had other disease.

Harber P, Smitherman J. Asbestosis: diagnostic dilution. J Occup Med 1991;33:786-93.

Rosenberg D. Asbestosis: A Realistic Perspective. Chest 1997;111:1424-26.

Beckett WS. Diagnosis of Asbestosis: Primum Non Nocere. Chest 1997;111:1427-28.

The two editorials by Rosenberg and Beckett in the 1997 issue of Chest are presented as opposing viewpoints on the question: "Are claims of asbestosis being made in excess of the true number of claims?" In fact, a careful reading of both editorials shows the authors are more in agreement than apart. Rosenberg: "...due to inaccurate diagnoses, far fewer individuals probably have asbestos-related disease than are implied by the number of personal injury claims that have been made." Beckett: "...our practice should be, as in all other situations, guided by informed clinical judgment. The [1986 ATS criteria for diagnosing asbestosis; see first reference in this section] wisely settled on a thorough but noninvasive evaluation which would be expected to have a high degree of sensitivity and specificity, recognizing that all tests have some fasle-positives and false-negatives."

What are the Helsinki Criteria?

Asbestos, asbestosis, and cancer: The Helsinki criteria for diagnosis and attribution. Scand J Work and Envir Health 1997;23:311-16.

How are claims based only on the chest x-ray?

Egilman D. Asbestos screenings. Amer J Indust Med 2002;42:163

Weiss W. Cigarette smoking, asbestos and small irregular opacities. Am Rev Resp Dis 1984;130:293-301.

"The long term inhalation of cigarette smoke is associated with the appearance of diffuse small irregular opacities of mild profusion on chest roentgenograms of some subjects in a limited number of reports.. Human histologic and experimental animal studies have shown the presence of pulmonary interstitial fibrosis. The radiographic abnormalities may be explained by interstitial fibrosis, although bronchiolar wall thickening may also be involved." (Page 293)
"Given that both cigarette smoke and asbestos can each cause pulmonary fibrosis histologically, the assessment of each agent's contribution during combined exposure cannot be made in the current state of knowledge. This is especially true because the human response to each agent is quite variable, and some exposed persons show no discernible fibrotic reaction to either material." (Page 300)

Ducatman AM, Yang WN, Forman SA. 'B-Readers' and asbestos medical surveillance. Journal of Occupational Medicine 1988; 30:644-647.

"Analysis of 23 participating observers, interpreting more than 105,000 radiographs, demonstrated a 300-fold prevalence range of perceived "definite" pulmonary parenchymal abnormalities...Individual diagnoses, legal decisions, and population assessments ought to rely on multiple readings...The data presented here show the probable scope of the problem and underline a need for new quality assurance in the B-reading program."

Reger RB, Cole WS, Sargent EN, Wheeler PS. Cases of alleged asbestos-related disease: a radiologic re-evaluation. J Occup Med 1990;32:1088-90.

Chest radiographs were re-evaluated from 439 active and retired tire workers previously designated as having a condition consistent with an asbestiform mineral exposure...The percentage of cases with abnormalities consistent with an asbestiform mineral exposure found separately by the three radiologists was 3.7, 3.0, and 2.7%...A more detailed review, however, revealed that only 11 workers, or 2.5% of the total, would have a reasonable likelihood of having such a condition. Most cases were normal and the majority of abnormalities present on the radiographs evaluated were nonoccupational in origin.

Weiss W. Cigarette smoking and small irregular opacities. Br J Indust Med 1991; 48:841-844.

"The prevalence [of small opacities] increased with increasing age to 31.6% among smokers aged 50-64. Prevalence was 10% among ex-smokers of cigarettes. Among current cigarette smokers, prevalence was 5.3% in those who smoked less than one pack per day, 31.3% in heavier cigarette smokers, and 52.9% in 17 heavy cigarette smokers aged 50-64. Profusions of 0/1 and 1/0 are classified as "suspect" pneumoconiosis according to the ILO guidelines. The data in this study indicate that such abnormalities are directly related to age and smoking habits among workers not exposed to hazardous dust."

Dick JA, Morgan WKC, Muir DFC, et al. The significance of irregular opacities on the chest roentgenogram. Chest 1992;102:251-260.

"Scanty irregular opacities are not uncommonly observed on the chest roentgenogram in the absence of interstitial fibrosis of the lungs. In such circumstances the irregular opacities, when present, tend to be relatively scanty and seldom, if ever, exceed ILO category of 1/1. They are found in association with cigarette smoking, especially when emphysema is also present. (Page 251)
...Among the factors known to influence the prevalence of small irregular opacities on the chest roentgenogram are radiographic technique, age, obesity, cigarette smoking, and exposure to dusts encountered in the workplace. Small irregular opacities may be seen in asbestos workers in the absence of asbestosis, besides being present in various interstitial fibroses, the etiology of which are non-occupationally related. (Page 251)
...It therefore seems that the weight of the evidence indicates that cigarette-smoking asbestos workers can develop small irregular opacities in their lungs which closely mimic the changes of asbestosis. Such opacities may be present in the lungs of those exposed to asbestos but who have no evidence of asbestosis. These observations argue compellingly against the hypothesis that cigarette smoking delays clearance of asbestos fibers from the lung and that the hypothetic delay is solely responsible for the increased prevalence of irregular opacities in smokers. (Page 258)
...Clearly, several factors are involved in the pathogenesis of irregular opacities, but there is no justification for assuming that their presence in an asbestos-exposed population is always related to asbestos in the absence of the other criterial listed by the American Thoracic Society [ATS: The diagnosis of non-malignant respiratory diseases related to asbestos. Am Rev Respir Dis 1986;134:363-68.] as necessary for diagnosing this condition." (Page 259)

Meyer JD, Islam S, Ducatman AM, et al. Prevalence of small lung opacities in populations unexposed to dusts. A literature analysis. Chest 1997;111: 404-10.

"...a background level of opacities consistent with the radiographic appearance of pneumoconiosis exists in populations considered to be free of occupational dust exposure. Environmental and unaccounted exposures, as well as reader variability, all may play a role in the determination of small opacity prevalence in these subjects..."
End of References

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