© 2005 American Thoracic Society
2004 Asbestos Disease Guidelines Ignore Mass Screening AbuseTo the Editor:I had hoped that the long-awaited ATS update on diagnosis of nonmalignant 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. 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 nonspecific and nondiagnostic, as it is commonly found in middle-aged smokers and in ex–factory workers never exposed to asbestos (2–4). 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 International Labour Organization readings by PAHP are overinterpreted (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. 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"). 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 naïve 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. 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 that the CIS is an ironclad requirement. Is the ATS itself exempt? Considering the partisanship of asbestos litigation, each author's experience consulting for plaintiff versus the 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 nonmalignant asbestos disease.
CWRU School of Medicine Cleveland, Ohio FOOTNOTES Conflict of Interest Statement: L.M. has examined mass asbestos claims on behalf of the Ohio Bureau of Workers' Compensation and defending companies. REFERENCES
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