American Thoracic Society Publishes Biased, Flawed Review of Non-Malignant Asbestos Disease
Medical Journal Violates Its Own Ethical Standard in Publication
SummaryIn September 2004 the American Thoracic Society published a long awaited update on diagnosis of nonmalignant asbestos diseases. Authored by 11 physicians, it appeared in the ATS publication, Journal of Respiratory and Critical Care Medicine (AJRCCM). The update covers developments over the past 2 decades and offers guidelines for diagnosis. By making statements regarding x-ray diagnosis that are unsupported (indeed contradicted) by the peer-review literature, and omitting numerous key references, the authors evidence bias in favor of mass screenings by plaintiff-attorney-hired physicians (PAHP). The vast majority of diagnoses by PAHP have been discredited as non-objective, but this is not mentioned by the ATS statement. Instead, the authors assume PAHP diagnoses are valid in making their recommendations. Apart from inherent bias in the article's content and presentation, AJRCCM also violated its own ironclad policy by not publishing the authors' conflict of interest statements. |
A) There has been an ongoing 'epidemic' of asbestos disease over-diagnosis in the United States, fueled by plaintiff-attorney-manufactured mass asbestos claims. The vast majority of these diagnoses, when objectively analyzed, have been proven inaccurate. The process by which plaintiff attorneys have manufactured these asbestos claims has been labeled a 'scam' and 'swindle.' (See Runaway Asbestos Litigation - Why it's a Medical Problem)
B) After a delay of 18 years, in 2004 the American Thoracic Society -- one of two major medical lung organizations in the U.S. -- published an update on the diagnosis of non-malignant asbestos claims. Non-malignant asbestos disease covers the two principal diagnoses in mass asbestos claims: asbestosis and asbestos pleural disease. This ATS update, authored by 11 physicians, appeared September 15, 2004 in the American Journal of Respiratory and Critical Care Medicine (AJRCCM). AJRCCM is the American Thoracic Society's major scientific publication, aimed at both practicing physicians and researchers in the field of lung diseases. The article's full title (with web link) is
C) The ATS "Official Statement" shows evidence of author bias, as it contains several unreferenced and unfounded assertions that seem to support plaintiff-attorney-manufactured asbestos claims. The most telling evidence for author bias is that AJRCCM violated its own ethical standard by failing to publish any Conflict of Interest statements for the authors. Lack of any Conflict of Interest statements is an ethical lapse that cannot go unanswered indefinitely, at least not by an organization dedicated to science.
D) Attempt to publish a brief letter-to-the-editor, pointing out this lapse and biases in the article, was rebuffed by the AJRCCM editor, Dr. Edward Abraham (University of Colorado Health Science Center). An e-mail promise from Dr. Abraham to forward my letter to the authors, so that they could individually respond, elicited zero responses. A follow up e-mail to Dr. Abraham asking if there would be any financial disclosure by the authors elicited a response that “The issue of financial disclosures is an important one and the appropriate approach is being actively discussed within the ATS."
E) I put together this and related web sites so that anyone with an interest can clearly see the concerns, and take appropriate action. They have already elicted an e-mail promise to eventually publish some disclosures, although the full extent of the biases I have uncovered will likely never see print in AJRCCM.
WHY DOES AJRCCM REQUIRE CONFLICT OF INTEREST STATEMENTS FOR ITS AUTHORS?
The answer is simple: So readers can judge for themselves if the authors'
financial interests affect the article's findings. Asbestos litigation is a multi-billion dollar business.
Physicians who take part in plaintiff-attorney-manufactured asbestos claims stand to make a lot of money if
they can opine about asbestos disease when none exists. And if authors of the "Official
Statement" can change the criteria for mass asbestos diagnosis to fit in with plaintiff-attorney
theories (as opposed to results from objective scientific studies), they also stand to benefit
handsomely. And 'benefit' doesn't have to be purely monetary. There may be political or personal
biases served by this work, such as a desire to punish big business for past sins, or as a way to
thank attorneys the authors may have worked for in the past. Bias can be subtle and non-monetary,
but it is bias nonetheless. I am sure the 11 authors of this paper don't see themselves as
influenced by plaintiff attorneys, but that's not for them to decide; that's why medical journals have
mandatory financial disclosure, to discover hidden biases so readers can judge for themselves. Hence,
if ever there was an article that cried out for full financial disclosure of the authors,
the ATS "Official Statement" is it. Lack of such disclosure for this article represents a
major lapse in medical journal ethics.
AJRCCM recognizes the importance of financial disclosure, at least in theory. Below is the
journal's position on conflict of interest for its authors. It is quoted verbatim from the
AJRCCM
web site on author requirements ("Disclosure of Financial Interest").
|
AJRCCM Disclosure of Financial Interest Every author on the manuscript is required to complete this formA conflict-of-interest is defined as a set of conditions in which professional judgment concerning a primary interest, such as the validity of research, may be influenced by a secondary interest, such as financial gain. As such, a conflict-of-interest is a condition, not a behavior -- being determined by circumstances, not outcome. A conflict exists not only when judgment has been clearly influenced. It also exists when judgment might be influenced or might be perceived to be influenced. That is, a conflict exists before any actual breach of trust, and irrespective of whether a breach of trust actually occurs. When submitting a manuscript to the Journal, authors are required to disclose any financial relationship with a biotechnology manufacturer, a pharmaceutical manufacturer, or other commercial entity that has an interest in the subject matter or materials discussed in the manuscript. The Journal's policy on personal financial interests also embraces money received in the names of the children, spouse, and partner (i.e., life companion) of an author. |
For inexplicable reasons, "Every author" did not include the 11 authors of the ATS "Official Statement" on asbestos diagnosis. They published NOT A SINGLE "Disclosure of Financial Interest" statement. Why are they exempt? To show how strict AJRCCM is on its conflict of interest disclosure requirement, here are some articles in the same issue of the AJRCCM for which financial disclosure WAS published:
None of the above articles (nor others published in that issue of AJRCCM), comes close to the ATS "Official Statement" in terms of potential financial importance to the authors or the authors' associates. Regarding the AJRCCM requirement, "other commercial entity" would include the dozens of law firms that rake in billions of dollars a year from filing mass asbestos claims. Virtually every asbestos claim is predicated on a physician-authored diagnosis, but these diagnoses (arising from plaintiff-attorney-sponsored mass claims) are seldom based on objective evaluation of the claimant, and never on blinded interpretation of chest x-rays. The physicians involved in these attorney-sponsored mass claims know what diagnoses they are expected to deliver, and they deliver them.
Intentionally or not, the authors of the Official ATS Statement on asbestos disease diagnosis seem to be playing into the hands of those plaintiff attorneys who set up, pay for, and profit handsomely from, mass asbestos claims. Because of all the biases in this article, it stands as a classic example of (to use AJRCCM's own language): "A conflict exists not only when judgment has been clearly influenced. It also exists when judgment might be influenced or might be perceived to be influenced."
For the authors not to state their own financial involvement in asbestos litigation (or to be required to do so by AJRCCM) is unethical in the extreme, and a genuine 'black eye' for both ATS and AJRCCM. By violating its own standard, AJRCCM makes much of the Official Statement suspect. Certainly unreferenced statements and conclusions in the article cannot be considered authoritative, and should not be used in any legal situation. The only solution is for AJRCCM to disclose the detailed financial interests of all the authors, and also to publish a reasoned rebuttle.
WHAT ARE THE SPECIFIC BIASES AND FLAWS IN THE AJRCCM ARTICLE?
Listed below are the 2004 Asbestos Statement's major flaws and biases. In each example a passage is quoted from the article, followed by my Comment.
Page 696
COMMENT: There is no reference for this statement, because none exists; it appears
to be simply made up, and thus to reflect inherent bias of the authors. In fact, this
dividing point (0/1 to 1/0) exists only in the play book of plaintiffs' attorneys and their hired
experts. It is well known that a B-reading of 1/0 is non-specific and
non-diagnostic, as it is commonly found in middle-aged smokers and in
ex-factory workers never exposed to asbestos (see
References omitted from
ATS Official Statement).
Furthermore, the prevalence of asbestosis among asbestos-exposed workers is far
less than what is promulgated by mass asbestos screenings (Ross RM. The clinical
diagnosis of asbestosis in this century requires more than a chest radiograph.
Chest 2003;124:1120-28), making it clear that a "1/0" reading alone does not make a
diagnosis of anything.
Page 692, Table 1
This table supposedly compares the 1986 guidelines with 2004 guidelines.
However, in this table there is no explanation for why a profusion of 1/0 is the threshold for
asbestosis in 2004 (as stated on page 696, quoted above), whereas the stricter 1/1
was the profusion threshold for this diagnosis in 1986. Here is what the table includes for
the category dealing with x-ray diagnosis (quoted verbatim).
|
1986 Guidelines:
2004 Guidelines:
Comparison and notes:
|
COMMENT:
Unlike other categories in Table 1, the statements here do not convey any information about why
there was a change between 1986 and 2004 for this category (i.e., why the profusion criterion was changed).
It is as if the authors purposely do not want to answer this all important question, and is remindful
of the way plaintiff-attorney-hired physicians diagnose most cases of asbestosis:
'It is because we say it is'.
Page 697 COMMENT: The authors are misleading here. First, mixed
impairment is "frequently seen" only in cigarette smokers." This mixed
pattern is NOT frequently seen in non-smokers. Leaving out smoking as the cause of air flow
obstruction in asbestos claimants allows the sentence to be quoted as an isolated "ATS statement"
in a legal proceeding. The authors can deny this was their intent, but anyone with litigation
experience knows that a medically-incomplete statement like this one is ripe for legal abuse.
Second, "isolated obstructive impairment" is not unusual, it is non-existent.
Like other made-up statements in this article, it is unreferenced. Most likely the architect
of this statement is
Dr. Tee Guidotti, ATS Statement committee chairman, who wrote an article on the subject
published in 2002:
Apportionment in Asbestos-Related Disease for Purposes of Compensation. In that
article he attempts to show how reduction in FEV-1 can be apportioned to asbestos,
but his argument is full of unwarranted assumptions and does not prove that
airway obstruction, as most physicians understand it (reduced FEV-1/FVC), occurs from asbestos
inhalation. Nonetheless, the clear intent of the phrase on page 697 is that you can
sometimes find reduced FEV-1/FVC from just asbestos inhalation, even though that has not
been documented, and was not shown in Dr. Guidotti's 2002 review. (If such article existed,
it would have been referenced.) Like the first example from page 697,
this phrase opens the door for plaintiff attorneys
to argue for causation when there is air flow obstruction but no smoking history.
There are of course other causes for air flow obstruction in non-smokers
(e.g., chronic asthma, industrial bronchitis), but they are not mentioned.
Page 700 COMMENT: The authors make no attempt to reconcile the above statement and the
following unreferenced statement that appears on page 710. "The sensitivity of the
plain chest film for identifying asbestosis at a profusion level of 1/0 has been
estimated at or slightly below 90%. The corresponding specificity has been
estimated at 93%."
(Note: The 3rd paragraph under pulmonary function testing discusses diffusing capacity,
and states: "Although a low diffusing capacity for carbon monoxide is often reported
as the most sensitive indicator of early asbestosis, it is also a relatively nonspecific finding."
This is true, and the statement helps counter the oft-assumed idea that EVERY low diffusing
capacity means asbestosis. The PFT section should have also clarified/qualified
statements in the 2nd paragraph.)
Page 700
COMMENT:
This statement is a major distortion of the extant literature on the subject. It quotes only one article,
a study from Finland, and omits several disproving articles, including:
This omitted literature shows that 1/0 profusion in smokers and ex-smokers is not rare,
and may be confused with asbestosis.
As Weiss wrote in his 1991 paper: “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...The data in this study indicate that such abnormalities
are directly related to age and smoking habits among workers not exposed to hazardous dust.”
Page 710
COMMENT: This paragraph leads to a single reference, an article published by
Ohar, et al in Chest. That Ohar, et al article has been discredited, by three letters: 2 published in
print format in Chest, and a third letter,
published in e-format, by myself. Though ostensibly 'peer reviewed', Ohar, et al is an example of
"junk science" because the diagnoses of asbestos disease in their cohort were made exclusively by
plaintiff-attorney-hired physicians (PAHP). Thus the article was based on diagnoses
not made objectively, but by physicians paid to make asbestos diagnoses and
ONLY asbestos diagnoses. Unfortunately, the article is now being quoted as if its
conclusions were valid, when they have no medical validity whatsoever. The total lack of response by
Ohar, et al to any of the published criticisms supports this contention.
Page 710
COMMENT: Note that only the last sentence of this paragraph is referenced, and
the title of that reference speaks clearly to much of what is wrong with the ATS
Official Statement. Being committee-authored, the Official Statement twists and
turns in its deliberations, never sure if it wants diagnostic criteria to be simple and
subjective (favored by plaintiff attorneys) or comprehensive and objective (the real
world, apart from litigation). Thus there are unreferenced statements about the plain
chest x-ray that can be used by plaintiff attorneys to make or support a claim, and
then there are more reasoned statements that the authors can use to say 'this is
what we really mean'. I doubt that all the authors are naive in the ways of litigation,
and surely they must at some level appreciate the quagmire they have written.
Page 711
COMMENT: This is the only mention of problems with attorney-manufactured
asbestos claims, and it is an oblique one at that. Yet in this paragraph the authors
assume that the main problem arising from the screening programs is inadequate
"counseling and education" for people diagnosed with asbestos disease. Nowhere
do the authors acknowledge the fact that most ILO readings by plaintiff-attorney-hired
B-readers (PAHP) are inaccurate (the films are generally over-interpreted), or
that PAHP are paid more for a positive diagnosis than a negative one. This is
crucial information, as it should invalidate all medical conclusions based on
"diagnoses" generated by PAHP (such as those published by Ohar, et al). Nowhere
do the authors acknowledge that the real abuse is a process by which attorneys solicit
hundreds of thousands of factory workers and ex-workers, then pay a handful of physicians to
make diagnoses the vast majority of which are not supported by objective medical evidence.
"Counseling and education" are lacking because the real world of treating
doctors does not find the diagnoses made by PAHP.
Page 711
COMMENT: The Helsinki criteria was a completely unreferenced editorial, and thus
offered not a single reference for any statements in the article. That article also did not
acknowledge any of the mass-asbestos claim abuse evident at the time, nor did it
list any financial disclosure of the authors. Page 711
COMMENT: This conclusion, while seemingly rational, is at singular variance with many
of the unreferenced statements in the article. This is another example of how
the Official Statement twists and turns, at one point allowing for simplistic and subjective
diagnosis, then reversing course and requiring comprehensive and objective assessment. This
would all be academic were it not for the fact (again, never acknowledged) that the vast majority
of asbestos diagnoses in this country are attorney-driven (e.g., all the cases in the Ohar, et al cohort),
and do not "exclude other possible conditons," do not satisfy the "additional requirement for
impairment assessment." (Never once, in evaluating hundreds of claims on behalf of defendants, have
I come across PAHP-authored reports that considered a non-asbestos diagnosis
for an abnormal profusion reading. In the real world or pulmonary medicine, such an obviously
biased evaluative process would be instantly discredited.)
The next three quotes are related, and will be commented on as a group
COMMENT:
The authors have ignored a mountain of data that either
contradicts these statements or at least puts them in
perspective. Of the three statements, only one (p. 705)
is referenced, citing just one article and one abstract,
both by Dr. Hillerdal, a Statement Committee author.
Conspicuously omitted are several countervailing studies, including:
The phrase "history of exposure" is so vague and broad
that it could encompass every patient with lung cancer
(170,000 new diagnoses each year in U.S.) who ever
worked in a factory, warehouse, gas station or garage.
Considering the fact that very few of the hundreds of
thousands of attorney-solicited asbestos claimants have
a documented history of working with friable asbestos,
this wording is, in the context of asbestos litigation,
irresponsible. (See also
ATS Bias: Origins of Anti-Science in the 2004 Official Statement [Dr. Wagner].)
FINAL COMMENT
In summary, there are 3 basic problems with the ATS Official Statement
as published in AJRCCM:
1) There is no Conflict of Interest Statement for any of the 11 authors.
This omission casts doubt on the article's honesty and integrity.
2) Numerous references - legal and medical - that should have been included in
a comprehensive review (26-pages, 160 references) are omitted, references that disprove some of the
authors unfounded conclusions.
3) There is no acknowledgment that 'non-malignant asbestos-disease' diagnosis has been almost
entirely co-opted by plaintiff-attorney-hired-physicians, who have provably over-diagnosed it in
the extreme. There is no acknowledgment that this PAHP-driven 'epidemic' of asbestos disease (over 500,000
claims to date) is a legal fabrication, not at all evident to either the body of pulmonary physicians
in the U.S., or the specific physicians who actually care for these claimants.
Sadly, inexplicably, ATS/AJRCCM has published a tarnished "Official Statement" on diagnosis
of nonmalignant asbestos disease. The root cause of this is easy to see -
bias among key ATS Officials and Statement Committee members.
I have also authored an
'open letter' to ATS/AJRCCM about theses issues, and recommended
an independent panel of non-asbestos experts to examine the ATS
article and write a report.
Originally posted November 15, 2004; updated through February 14, 2005.
Lawrence Martin, M.D., FACP, FCCP
Return to Dr. Martin's asbestos index
Return to Dr. Martin's global index