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Health Surveillance of asbestos-exposed workers at Helsinki Asbestos 2014
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Health Surveillance of asbestos-exposed workers at Helsinki Asbestos 2014

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Presented by Professor Massimo Corradi from University of Parma, Italy.

Presented by Professor Massimo Corradi from University of Parma, Italy.

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    Health Surveillance of asbestos-exposed workers at Helsinki Asbestos 2014 Health Surveillance of asbestos-exposed workers at Helsinki Asbestos 2014 Presentation Transcript

    • Health surveillance of asbestos- exposed workers Prof. Massimo Corradi, MD University Hospital of Parma, Italy massimo.corradi@unipr.it
    • No conflict of interest
    • Clin Respir J 2014; 8: 1–10  Asbestsosis  Pleural plaques  Benign asbestos pleural effusion  Rounded atelectasis  Diffuse pleural thickening  Mesothelioma  Lung cancer
    • NIOSH 2007 Asbestosis deaths in USA
    • Time trend in age-adjusted mesothelioma worldwide Delgermaa. Bull World Health Organ 2011;89:716–724C
    • Peak incidence of mesothelioma Int. Agency Res. Cancer (IARC). 2007.
    • Asbestos-exposed workers have justifiable anxiety about their future and seek reassurance from the medical profession These people consult physicians for many reasons: •to be screened for asbestos-related disease •for evaluation of specific symptoms •for treatment and advice •for evaluation of impairment
    • Clin Respir J 2014; 8: 1–10  Asbestsosis Asbestosis is commonly associated with prolonged exposure, usually over 10 to 20 years. However, short, intense exposures to asbestos, lasting from several months to 1 year or more, can be sufficient to cause asbestosis.
    •  The chest radiograph (ILO-BIT, B-reader) remains an useful tool for the radiographic diagnosis of asbestosis  HRCT has an important role when experienced readers disagree about the presence or absence of abnormalities on a high quality chest film
    • Health surveillance for asbestosis There is no effective treatment for asbestosis but this is an independent risk factor for bronchial carcinoma and it is evidence of heavy asbestos exposure Stopping smoking in subjects suffering from asbestosis will reduce the incidence of bronchial carcinoma Markowitz. AJRCCM Vol. 188, No. 1 (2013), pp. 90-96.
    • Clin Respir J 2014; 8: 1–10 Asbestsosis  Pleural plaques  Benign asbestos pleural effusion  Rounded atelectasis  Diffuse pleural thickening
    • Health surveillance for asbestos- related benign pleural diseases There is no effective treatment for asbestos-related benign pleural diseases but these are markers of exposure The presence of pleural plaques has not been shown to be an aetiological factor for thoracic cancers Ameille. Rev Mal Respir. 2011
    • The threshold limit 80 % for FEV1 74 % for DLCO `Vehmas et al. Int Arch Occup Environ Health (2013)
    • Health surveillance of benign asbestos related diseases Imaging techniques (RX/CT) are mandatory for diagnostic purposes Lung function test (spirometry and DLCO) are necessary to grade the disease and to define the prognosis (thus useful in the follow up)
    • Clin Respir J 2014; 8: 1–10  Asbestsosis  Pleural plaques  Benign asbetos pleural effusion  Rounded atelectasis  Diffuse pleural thickening  Mesothelioma
    • Medical and public health benefits of screening for mesothelioma have not been demonstrated To date, there are no scientific data that quantitate the contribution of imaging to the early detection of mesothelioma Early detection will result in early treatment (however prognosis seems to be more closely linked to cell type than timing of treatment)
    • Blood/pleural biomarkers for mesothelioma  Mesothelin  Osteopontin  YKL-40  Fibulin  Megakaryocyte potentiating factor  CA125  High-mobility group box 1 (HMGB1)  Vascular endothelial growth factor  Circulating tumor cells  “omic”approach  Endothelial cell  miR625-3P  Thioredoxin 1  miR126  Procalcitonin Pubmed search 2014-2012
    • Clin Respir J 2014; 8: 1–10  Asbestsosis  Pleural plaques  Benign asbetos pleural effusion  Rounded atelectasis  Diffuse pleural thickening  Mesothelioma  Lung cancer
    • Lung Cancer (C33-C34): 2003-2006 One-Year Relative Survival (%) by Stage, Adults 15-99, Former Anglia Cancer Network
    • 1950-1990  Randomised and non randomised controlled trials:  John Hopkins Lung Project  Memorial Sloan Kettering Lung Project  Mayo Lung Project  Czechoslovakian Study  North London Cancer Study  Erfurt County Study  Kaiser Permanente Study  Chest radiograph ± sputum cytology every 4 to 12 months compared to less frequent or no screening over 3 to 16 years  52000 subjects in intervention groups and 48000 in control groups
    • 1950-1990  Intervention groups:  More lung cancers  More early stage lung cancers  More resectable lung cancers  No reduction in lung cancer mortality
    • Lung Cancer Screening Tools  Sputum Cytology  Chest X-ray Bach. ACCP guidelines, Chest 2007
    • Computed Tomography Screening and Lung Cancer Outcomes Increase of • cases • operated cases Back. JAMA 2007 No change in • late diagnosis • mortality
    • CT Screening for Lung Cancer Spiraling Into Confusion? Black, WC, and Baron, JA Editorial Formulation of screening policy should await the rigorous assessment provided by ongoing randomized controlled trials (National Lung Screening Trial and NELSON Trial). JAMA 2007
    • NLST: Design time 0 1 2 3 4 5 6 7 8 N 53,476 •Age 55-74 ys •Smoking hist. ≥30 PY CT Arm CXR Arm Randomize F/U T0 T1 T2 Aberle. N Engl J Med 2011 Non-calcified nodules ≥4 mm in CT or any size in X-ray were referred for diagnostic work-up Primary outcome: lung cancer related mortality
    • National lung screening trial (NLST) Aberle. N Engl J Med 2011 320 participants were needed to screen to prevent 1 lung cancer death
    • ….and CT Scan in asbestos exposed workers…..?
    • Ollier. Chest 2014 A meta-analysis of cohort studies involving CT scan in former asbestos-exposed workers
    • Ollier. Chest 2014
    • The prevalence compared favourably with the reported prevalence in the larger available trials in heavy smokers (1%; CI 95%: 0.09% - 1.1%) Ollier. Chest 2014
    • European Screening Trials Overview NELSON DLCST ITALUNG LUSI DANTE MILD Nr rounds 4 5 4 5 5 10 or 5 Enrollement 15,464 4,104 3,206 3,551 2,472 3,581 Completed Y Y Y N Y N Baseline detection 0.9% 0.8% 1.5% 1.0% 2.2% 0.8% Incidence 0.5% 0.6% 0.4% - 0.5% 0.5% de Koning, ECCO-ESMO meeting, Sept. 2011
    • Lung cancer in asbestos-exposed workers occurred at least 20-25 years following the initial exposure. Thus, such screening should not start prior to the prolonged latency period
    • From: Benefits and Harms of CT Screening for Lung Cancer: A Systematic Review JAMA. 2012;307(22):2418-2429.
    • Journal of Surgical Oncology 2014
    • Journal of Surgical Oncology 2014
    • Potential harms with CT scan Post-occupational follow-up may involve risks to health, particularly repeated irradiation and invasive diagnostic procedures It is also necessary to consider the psychological consequences inherent in all screening programmes
    • Nodule(s) (%) Cancer (%) ELCAP 23 2.7 Shinshu Univ 5.1 0.4 Hitachi HCC 26.3 0.44 ALCA 11.5 0.8 Mayo 51 2.0 Univ of Munster 43 1.5 Univ of Milano 19 1.1 Univ de Navarra 31.9 1.32 Beaumont, Ire 20.7 0.23 SMC, Korea 35 0.17 Helsinki Univ. 18.4 0.8 LSS, NCI 20.5 1.9 City Univ, NY 32 0.7 IELCAP 13 1.3 NY-ELCAP 41.8 1.6 Can-ELCAP 76 2.0 Depiscan, France 45.2 2.4 Cosmos, Italy 43 1.7 Pittsburgh 40.6 1.5 DANTE, Italy 15 2.2
    • Number of pulmonary nodules CT scans (UH Parma) • 5000/year • 100% Solitary Nodules • 500/year* • 10% of CT scans Stage I lung cancer • 25/year • 0.5% of CT scans • 5% of nodules PET FOR ALL? Biomarkers to be developed?
    •  Lung function tests  Biomarkers CT screening in higher individual risk
    • mRNA One miRNA mRNA mRNA mRNA mRNA … small noncoding RNAs that regulate gene expression by binding complementary sequences of target mRNAs and inducing their degradation or translational repression One miRNA has multiple targets microRNA: a new class of biomarkers
    • PNAS, 2011
    • Conclusions  Post-occupational follow-up might reduce the mortality of lung cancer due to asbestos  Lung fuction and biomarker driven screening procedures may reduce the very hight rate of false positives observed with CT scan  The theoretical benefits, have to be seen in perspective with the risks to physical and psychological health related to diagnostic procedures  SMOKING CESSATION is still a priority!
    • Thanks to  Antonio Mutti  Matteo Goldoni  Marcello Tiseo  Nicola Sverzellati Università degli Studi di Parma