AbstractThere are currently in the United States over 600,000 asbestos-disease claimants, with another 600,000 estimated in the future. Most of these claimants are not ill and have questionable radiologic changes of asbestos disease. The huge volume of these claims has bankrupted dozens of businesses, clogged the nation's courts, and delayed compensation for people ill with documented asbestos-related disease, such as mesothelioma. While these claims are an acknowledged legal dilemma, they are also a medical problem, for two reasons. First, the claimants' chest x-rays were interpreted by physicians paid to find disease, so bias is inherent in the process. Plaintiff-hired-physicians' diagnoses of asbestos-related disease seldom meet either reasonable medical standards (such as review for confounding factors) or published criteria for asbestosis. Second, organized medicine has been largely silent about this abuse of diagnostic standards. Specific recommendations are offered to improve the diagnosis of mass asbestos-disease claims. |
Hardly a month goes by without a news story about runaway asbestos litigation (Berenson, 2002; Crenshaw, 2002; Girion, 2002; Glater, 2002; Hudak, 2002; Kook Sim, 2001; Parloff, 2002; Schmitt, 2001; Sherrid, 2001; Thomas, 2002). According to the RAND Institute for Civil Justice, "More than 600,000 individuals have brought claims against more than 6,000 companies nationwide through 2000, and optimistic projections suggest at least as many people will file claims in the future. The cost to U.S. businesses is estimated at $54 billion thus far and could grow by another $210 billion" (Carroll, 2002). Even though American industry substantially reduced asbestos use decades ago, and asbestos-related deaths are dropping, new claims are actually increasing. Currently more than 200,000 claims for asbestos injuries jam dockets in U.S. courts, including more than 34,000 in Cuyahoga County, which includes Cleveland (Hudak, 2002).
The vast majority of current claimants are current or retired factory, railroad and
shipyard workers, solicited through union rolls or newspaper ads (Schmitt, 2001;
Berenson, 2002; Girion, 2002; Hudak, 2002; Brickman, 2004). Told asbestos was in their
plant or workplace years ago, they are offered a free screening chest x-ray.
This chest x-ray is then interpreted by physicians certified by National
Institute of Occupational Safety and Health (NIOSH) as "B-readers"
(so called because they pass Part B of a test on x-ray interpretation).
B-readers are hired by plaintiff attorneys specifically
to find asbestos-related disease; as a result, the chest x-rays are not read blindly,
but always with knowledge of some asbestos exposure and that the lawyer wants
to file litigation on the worker’s behalf.
With a "certified" diagnosis in hand, and a willing claimant, lawsuits are filed,
often dozens per claimant (Parloff, 2002; Berenson, 2002; Hudak, 2002; Carroll, 2002, Setter, 2003;
Brickman, 2004). The sued companies can either fight the claims or settle them. Most sued
companies settle without going to trial or medically challenging the alleged diagnoses (Parloff,
2002; Carroll, 2002).
An unintended consequence of quickly settling mass claims is that more and more workers and ex-workers are recruited for class action lawsuits, eventually overwhelming the ability of companies to pay the claims. To date 60 companies have claimed bankruptcy because of asbestos litigation, 22 of them in the last two years. At the same time it is widely acknowledged that most of these attorney-solicited claimants are not ill and have no demonstrable impairment from asbestos. Because so many companies that actually mined or manufactured asbestos products have gone bankrupt or out of business, plaintiff attorneys have casted a wider net for companies to sue. (Carroll, 2002)
The result is tens of thousands of claimants who are not ill suing thousands of companies that, more and more, are only peripherally (often through mere acquisition) related to the old asbestos industry (WSJ, 2001). As one defense lawyer noted, "You've got people who are not sick suing people who never made the stuff" (Hudak, 2002). One consequence is that workers truly harmed by asbestos (e.g., patients with mesothelioma) are often under compensated, or suffer delayed compensation, because of the huge volume of non-ill claimants (and with questionable diagnoses) clogging the courts (Berenson, 2002; Crenshaw, 2002; Carroll, 2002[p. 85]; Hensler, 2002; Hudak, 2002; Parloff, 2002; Taylor, 2002; Thomas, 2002; Setter, 2003; Brickman 2004). 'Scam', 'swindle' and 'fraud' are just some of the terms used to characterize this unfortunate state of affairs.
The legal morass presented by mass asbestos claims will likely not be fixed without legislative action (Asbestos Alliance, 2002; Carroll, 2002; Hudak, 2002; Martin, 2002; Parloff, 2002). Yet it is also a "medical" problem, for two reasons: physician complicity, and the silence of organized medicine.
First, mass attorney-instigated claims of disease could not go forward without the complicity of physicians who have hired themselves out to plaintiff attorneys. Despite NIOSH-defined standards, B-reading for pneumoconiosis is highly subjective (Ducatman, 1988); when you are paid to read chest x-rays as abnormal, subjectivity will naturally favor excessive diagnosis.
The potential for abuse is obvious. According to one physician who has worked as a plaintiff's B-reader, more money is paid for an abnormal than normal chest x-ray reading, and in some cases chest x-rays are shopped around to other B-readers until the attorney gets the reading desired (Egilman, 2002).
Not surprisingly, blinded review of screening chest x-rays reveals that a
substantial percentage are over interpreted for asbestos lung disease (Reger, 1990;
Houser, 2002; Brickman, 2004). In one study of 439 tire workers designated as having an
abnormal chest x-ray due to inhaled asbestos, an independent panel of three
radiologists could only confirm that diagnosis in less than 4% (Reger, 1990).
Over-diagnosis has also been my experience in examining individual claimants ( Martin, 2002).
Most lawsuits are generated from diagnosis based on a single chest x-ray, taken and then intepreted by a plaintiff-hired expert. As a proper method for diagnosis of any disease, including asbestos disease, this method is simply indadequate (Lawson 2001, Ross 2003). As one physician has written: "The clinical diagnosis of asbestosis in this century requires more than a chest radiograph" (Ross 2003).
Interestingly, claimants' own treating physicians are usually unaware of the
"diagnosis" of asbestos-related disease. In fact, asbestosis, a disease now rarely
seen by practicing pulmonologists, is being claimed by tens of thousands of
people! For all practical purposes, for most asbestos claims today the diagnosis
was borne out of a legal impetus and remains confined solely to the legal arena.
For the relatively few cases that are litigated in court, the medical issues come
down to a battle of physician "experts," each of whom has been hired by one side
or the other. Bias can be claimed on both sides, of course, and before a lay jury
one expert's B-reading may be viewed as valid - or invalid - as another's.
In a legal argument, my experience and comments would no doubt be discounted as testimony of a biased witness. But it is hard to see how any objective analyst could not agree that there has to be a better way to screen for asbestos disease, one that minimizes inherent bias (on either side), and facilitates settling of legitimate claims. Otherwise you end up with 'junk science' in the courtroom (Bernstein 2004).
If the diagnosis really mattered medically, or if legal standards demanded an objective method of diagnosis, the best approach would be to have all chest x-rays read blindly. This could be accomplished by an impartial panel of B-readers paid out of a common fund, and not directly by plaintiff or defense attorneys (Martin, 2002). A percentage of x-rays sent for blind reading (perhaps 25%) should come from middle-aged men without any history of occupational dust exposure.
Agreement on equivocally abnormal chest x-rays in asbestos-exposed claimants
could be followed up with a high resolution chest CT scan (Lynch, 1995),
also read blindly. Radiologically-abnormal claimants
(with or without a chest CT scan) could then be examined by
physicians experienced with pneumoconioses (perhaps also with
NIOSH certification, like chest x-ray B-readers). These clinicians would also be
paid from the same common fund, and not be beholden to attorneys for either
side. Only in this way can essential criteria for diagnosing asbestos disease --
abnormal chest x-ray or CT scan, requisite exposure history, exclusion of
confounding factors (Lynch, 1995; Rosenberg, 1997) -- be fulfilled without undue
bias. Unfortunately, mass asbestos litigation is not about making a medically-correct
diagnosis, or objective assessment, but about compensating the greatest number
for any past asbestos exposures, no matter how trivial or incidental (Brickman, 2004).
For these reasons -- over interpretation of chest x-ray and false assumption that any
abnormal reading = asbestos disease -- the asbestos-related diagnoses rendered by
plaintiff-hired physicians, in the aggregate, carry no epidemiologic validity. (A 2004
article in the medical journal Chest would seem to validate these attorney-paid-for diagnoses,
since it takes them all at face value, without any objective assessment; I have written elsewhere
on the internet that
this Chest article is 'junk science', and should be retracted.)
Only a situation where chest x-rays are read blindly, and followed up as necessary with
a chest CT scan and thorough examination for confounding factors, can erase the
stigma of diagnoses for hire.
* * *
The current situation is also a medical problem because our medical organizations have been silent about the increasing abuse of diagnostic standards. I am not suggesting that any medical organization should take a legal position. However, it is most disturbing that two publications in 2004, by the American College of Chest Physicians (in journal Chest) and the American Thoracic Society (in Journal of Respiratory and Critical Care Medicine) seemed to support the asbestos scam, since they accepted its diagnoses as prima facie legitimate. Issues raised by these two articles are discussed in the following web sites:
ATS and ACCP are not alone. Neither the American Medical Association (AMA), the American
College of Radiology (ACR), nor any other American medical group has tackled
the problem, authored an editorial, or addressed the abuse of diagnosis that is now
so rampant. In 2004 a landmark article appeared that further demolishes the phony asbestos
readings, and it was accompanied by an editorial hinting at widespread abuse (Gitlin, et al., and
Janower & Berlin).
Lack of medical involvement in these issues has allowed the legal profession to
co-opt diagnostic standards for asbestos lung disease. One result is the directly-stated
or inferred assumption by journalists and non-medical analysts that the
principal medical argument in mass claims is about impairment, and not about
diagnosis. The assumption is that all or most asbestos claimants do have
'something asbestos-related' on chest x-ray, leaving the main argument over
whether "healthy" or "unimpaired" asbestos-injured people should be
compensated (Berenson, 2002; Carroll, 2002; Girion, 2002; Glater, 2002;
Hudak, 2002; Kook Sim, 2001; Parloff, 2002; Schmitt, 2001; Sherrid, 2001).
In the lay media, legitimacy of diagnosis or extent of chest x-ray over-interpretation
may be peripherally discussed, but are never presented as central issues.
Even the RAND Institute for Civil Justice, a prestigious group that has long
written dispassionately about asbestos litigation, has failed to clearly focus the
medical issues. In one section of their lengthy Interim Report, the RAND authors
comment on a study by the Manville Trust to the effect that “approximately 50%
[of chest x-rays] failed independent B-reader review.” Continuing in the very
next paragraph, the authors write: "Several more recent studies have found
fractions of unimpaired claimants ranging from two-thirds to up to 90% of all
current claimants. Because most of these studies were commissioned by
defendants and because the issue is central to the asbestos litigation controversy,
their findings are hotly contested" (Carroll, 2002).
That is the extent of mention about possible erroneous diagnosis of these mass
claims, and even that discussion seems to confuse 'over-diagnosis' with
'unimpaired claimants'. (No peer-reviewed medical literature is cited in this
section. Also, though the authors conducted 60 lengthy interviews to prepare their
report, none was apparently with physicians.) If RAND's experts seem unaware
of the full extent of over- and mis-diagnosis in these claims, one can expect no
better from the journalism profession - or the lay public in general.
My point is that the absence of peer-reviewed comment and analysis by the
medical establishment (ATS, ACCP, AMA, ACR, et. al.), as opposed to a few
isolated medical articles (Dick, 1992; Ducatman, 1988; Egilman, 2002; Meyer, 1997;
Reger, 1990; Rosenberg, 1997; Weiss, 1984; Weiss, 1991), has made
methodology of diagnosis in these mass claims almost a non-issue, when it should
be a major one. To underscore that point, the RAND Institute estimates that “at
best, only about half the final number of claims has come forward” (Carroll 2002).
The medical profession needs to enter the fray and at least make clear some
standards for diagnosis.
While researching this article I learned that an ATS panel is meeting to produce
an updated Statement on non-malignant asbestos diseases, due out in mid-2003
(Malanga, 2002). This is long overdue, but the effort should not preclude other
organizations from also addressing the issues. In my opinion, any official
statement should accomplish the following: 1) discuss the origin and original
purpose of the B-reading program, and the current use and abuse of the screening
chest x-ray in diagnosing pneumoconiosis; 2) advocate blinded chest x-ray
interpretation in mass screenings for asbestos disease; 3) address the role of high
resolution chest CT scanning in the diagnosis; 4) provide a state of the art review
of extant literature on diagnosis, including the 1986 ATS and 1997 Helsinki
papers; 5) make specific recommendations for medically-sound diagnosis of
asbestosis and asbestos pleural disease; and, not least, 6) reveal each author’s
conflict of interest, if any, regarding personal involvement with asbestos litigation.
Let’s hope that the highly charged, litigious nature of asbestos diagnoses does not
thwart fulfilling these recommendations.
American Thoracic Society. The diagnosis of nonmalignant diseases related to
asbestos. Am Rev Resp Dis 1986; 134:363-368.
Asbestos Alliance. Experts Speak Out: The Asbestos Problem Asbestos, asbestosis, and cancer: The Helsinki criteria for diagnosis and
attribution. Scand J Work and Envir Health 1997;23:311-16.
Beckett WS. Diagnosis of asbestosis: Primum non nocere (editorial). Chest
1997;111:1427-1428.
Berenson A. A surge in asbestos suits, many by healthy plaintiffs. New York
Times, April 10, 2002; page A1.
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.
Carroll S, Hensler D, Abrahamse A, Gross J, White M, Ashwood S, Sloss E.
Asbestos Litigation Costs and Compensation: An Interim Report.
RAND Corp, Santa Monica, CA, 2002.
Crenshaw AB. For asbestos victims, compensation remains elusive.
Washington Post, September 25, 2002; page E01.
Dick JA, Morgan WK, Muir DF, Reger RB, Sargent N. The significance of
irregular opacities on the chest roentgenogram. Chest 1992;102:251-260.
Ducatman AM, Yang WN, Forman SA. 'B-Readers' and asbestos medical
surveillance. Journal of Occupational Medicine 1988; 30:644-647.
Egilman D.
Asbestos screenings. Amer J Indust Med 2002;42:163.
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. (See also Editorial by Janower & Berlin, below)
Girion L. Asbestos suits become more widespread. Los Angeles Times,
September 26, 2002.;
Glater JD. Defending a United Detroit on Asbestos. New York Times,
November 3, 2002.
Hensler DR. As time goes by: Asbestos litigation after Amchem and Ortiz.
Texas Law Review 2002;80:1899-1924.
Houser PG: Affadavit in Manville Personal Injury Settlement Trust Medical Audit
Procedures Litigation, 98 Civ. 5693, March 13, 1999, p. 9; quoted in Carroll S,
Hensler D, Abrahamse A, Gross J, White M, Ashwood S, Sloss E.
Asbestos Litigation Costs and Compensation: An Interim Report.
RAND Corp, Santa Monica, CA, 2002.
Hudak S, Hagan JF. Asbestos litigation overwhelms courts. Cleveland Plain
Dealer, November 5, 2002.
Idiopathic Pulmonary Fibrosis: Diagnosis and Treatment. International
Consensus Statement. Am. J. Respir. Crit. Care Med 2000;161;646-664.
Janower ML, Berlin L. "B" Readers' Radiographic interpretations in asbestos
litigation: Is something rotten in the courtroom? Academic Radiology 2004;11:841-842. Kook Sim Q. Asbestos claims continue to mount: Did broker of settlements
unwittingly encourage more plaintiff’s suits? Wall Street Journal, February 7,
2001; page B1.
Lee YC, Runnion CK, Pang SC, de Klerk NH, Musk AW. Increased body mass
index is related to apparent circumscribed pleural thickening on plain chest
radiographs. Am J Ind Med 2001 39:112-6.
Light RW. Pleural Diseases, fourth edition, 2001. Lippincott, Williams &
Wilkins, Baltimore.
Lynch DA. CT for asbestosis: value and limitations. Amer J Roentgen
1995;164:69-71.
Malanga, Elisha, American Thoracic Society. Personal communication,
November 11, 2002.
Martin L, 2002:
Asbestos
Lung Disease: A Primer for Patients, Physicians and Lawyers
www.lakesidepress.com/Asbestos/asbestos/questions.htm
Meyer JD, Islam SS, Ducatman AM, McCunney RJ. Prevalence of small lung
opacities in populations unexposed to dusts. A literature analysis. Chest
1997;111: 404-10.
Parloff R. The $200 billion miscarriage of justice. Fortune, March 4, 2002;
145:154-8.
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.
Rosenberg D. Asbestosis: A Realistic Perspective (editorial). Chest
1997;111:1424-26.
Schmitt RB. Burning issue: How plaintiffs' lawyers have turned asbestos
into a court perennial. Wall Street Journal, March 5, 2001; page A1.
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.
Sherrid P. Looking for some million dollar lungs. U.S. News &
World Report, December 17, 2001.
Taylor S, Jr.
Greedy lawyers cheat real asbestos victims. The Atlantic Online. Thomas L. Floor of asbestos lawsuits from people who aren't sick threatens
to dry up funds. Pittsburgh Post-Gazette, November 3, 2002.
Wall Street Journal: The Job Eating Asbestos Blob (editorial). Wall Street
Journal, January 23, 2002.
Weiss W. Cigarette smoking, asbestos and small irregular opacities. Am Rev
Resp Dis 1984;130:293-301.
Weiss W. Cigarette smoking and small irregular opacities. Br J Indust Med
1991; 48:841-844.
- - - - -
Revised November 20, 2004.
References
www.asbestossolution.org/experts.html
www.RAND.org/publications/DB/DB397
www.RAND.org/publications/DB/DB397; page 20.
www.theatlantic.com/politics/nj/taylor2002/-10-01.htm
Copyright © 2002, 2003, 2004,
Lawrence Martin, M.D., FACP, FCCP
9000 Mentor Avenue
Mentor, OH 44060
440-974-4442