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Original Letter to the editor of AJRCCM, e-mailed 10/25/04 and rejected within 24 hours of receipt

2004 Asbestos Disease Guidelines Ignore Mass Screening Abuse

I had hoped that the long-awaited ATS update on diagnosis of non-malignant asbestos diseases (1) would be thorough and point out the diagnostic abuse of mass asbestos claims. Instead, key references are omitted and some of the statements seem slanted toward supporting these claims. This is unfortunate when one considers the growing evidence that most of these claims are medically specious.

1) The authors provide no reference for their assertion that the difference between 1/0 and 0/1 profusion readings "is generally taken to separate films that are considered to be positive for asbestosis from those that are considered to be negative." 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 (2-4).

2) The authors do not reference their assertion that "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%." Is this information from plaintiff-attorney-hired B-readers (PAHP)? The authors do not acknowledge the fact that most ILO readings by PAHP are over-interpreted (5-7), or that PAHP are paid more for a positive diagnosis than a negative one (8). This is crucial information, as it should invalidate all medical conclusions based on "diagnoses" generated by PAHP.

3) The authors provide no explanation of why ATS lowered the profusion score for diagnosing asbestosis from 1/1 (in 1986) to 1/0 ("presumptively diagnostic").

4) The disclaimer that the 2004 criteria "are intended for the diagnosis of nonmalignant asbestos-related disease in an individual in a clinical setting for the purpose of managing that person's current condition and future health" is naive at best, disingenuous at worst. Just like the 1986 article, the new ATS review will be quoted in the legal arena. Unwittingly or not, the authors have published unsupported statements that can (and will) be taken out of context and quoted in court.

5)There is (incredibly) no Conflict of Interest Statement (CIS) for the authors, yet such a statement is provided in every other article in the same issue, including letters to the editor and studies where it would be hard to imagine any conflict. Furthermore, the web site regarding manuscript submissions indicates the CIS is an ironclad requirement. Is ATS itself exempt? Considering the partisanship of asbestos litigation, each author's experience consulting for plaintiff vs. defense sides should have been spelled out in detail.

I have had the opportunity to examine hundreds of these mass asbestos claims on behalf of defendants, and am dismayed at the lack of scientific or medical merit for most of them. Solid legal and medical discourse is beginning to acknowledge this abuse of diagnosis (6-11). Now, sadly, ATS has squandered a golden opportunity to publish an above-suspicion review and champion science and objectivity in the diagnosis of non-malignant asbestos disease.

Lawrence Martin, M.D.

CWRU School of Medicine
Cleveland, Ohio


1. Official Statement of the American Thoracic Society. Diagnosis and Initial Management of Nonmalignant diseases related to asbestos. Amer Rev Res Crit Care Med 2004;170:691-715.

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

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

4 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.

5. 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.

6 Gitlin JN, Cook LL, Linton OW, Garrett-Mayer E. Comparison of "B" readers' interpretations of chest radiographs for asbestos related changes. Academic Radiology 2004;11:843-856.

7. Janower ML, Berlin L. "B" Readers' Radiographic interpretations in asbestos litigation: Is something rotten in the courtroom? [Editorial] Academic Radiology 2004;11:841-842.

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

9. Setter DM, Young KE, Kalish AL. Asbestos: Why we have to defend against screened cases. Mealey's Litigation Report, November 12, 2003;18:1-16.

10. Bernstein DB. Keeping junk science out of asbestos litigation. Pepperdine Law Review, Volume 31, No. 1, 2004; 11-28.

11. Brickman L: On the Theory Class's Theories of asbestos litigation: Disconnect between scholarship and reality. Pepperdine Law Review, Volume 31, No. 1, 2004; 33-170.

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