Document 6bNx7GQNbN3yVQpaN92x94pjm

DRAFT 10/17/80 MALIGNANT MESOTHELIOMA IN CONNECTICUT 1935-1977 by H. C. Lewinsohn J. W. Meigs M. J. Teta Presentation to the Connecticut Thoracic Society, November 4, 1980 UCC 010137 A0057 Malignant Mesothelioma in Connecticut 1935-1977 by H C Lewinsohn, J.W. Meigs, and M.J. Teta 1.Introduction and Alms The combined sex age-adjusted mesothelioma incidence rate for Connecticut was reported in 1977 to have Increased ten-fold since 1935 r'Although available statistics might be subject to diagnostic error, the apparent rise wa^ attri buted to the increase in the State's 'cumulative asbestos consumptiori'^Com plete occupational histories for the cases of mesothello^ were not presented. A de/tailed review of the available pathological material by an independent pathologist to investigate the degree of diagnostic certainty was not undertaken^The present study attempts to determine the role of various etiological factors, such as occupational and environmental asbestos exposures,and includes a review of available pathological material. -JUCC 010138 A00573 II. Methodology The CTR has identified 229 cases of malignant mesothelioma as well as 38 other pleural tumors, not mesothelioma, which were diagnosed in the state between 1935 and 1977 (Table 1). Medical, demographic, and occupational data have been collected for the cases and for the respective spouses of cases diagnosed 1955-1977. Similar Information has been gathered for a random sample of approximately 700 dece dents (1935-75) aged 20 to 98 years from the Division of Health Statistics of the Connecticut Department of Health Services. Descriptive epidemiology for this research pertains primarily to the . forty-three year time interval. Fut-gye. caserf-control comparislons will in ,, CC .T s, 6 e&wde cases (215) diagnosed after 1954 (Table 1), and controls (604) whose deaths occurred during this same time period. This procedure yields a case- control ratio of approximately 1:3, while reducing sources of error resulting from the limited occupational and medical data prior to 1955 and the lack of awareness of mesothelioma associated with this earlier time period (1935- 1954). The Price and Lee City Directories were searched for job title and name of specific employer or industry for cases, controls and spouses at 1, 10, 20,25, 30, 40 and 50 years prior to date of diagnosis, death or until the subject was less than twenty years old. An occupational history search was attempted for spouses to coincide with these intervals for their correspond ing cases. 1970 U.S. Census industrial and occupational codes (U.S. Dept, of Com merce, 197l/^ere assigned to the employment information ascertained from medical histories, death certificates, and City Directories. -- A computerized A005 7 4 UCC 010139 Table 1. Sex, age and diagnostic characteristics of 229 cases of malignant mesothelioma, and 38 other pleural tumours diagnosed In Connecticut, 1935-1977 Diagnosis8 Males Females Pleural mesothelioma Pleural tumour (other than mesothelioma) Peritoneal mesothelioma Mesothelioma at other sites & at unknown sites 102 (94)b 24 (12) 20 (18) 29 (21) 45 (37) 14 (8) 13 (11) 20 (14) Total 175 (145) 92 (70) ^0 (1976)^ ^Numbers in brackets refer to the period 1955-1977 Total 147 (131) 38 (20) 33 (29) 49 (35) 267 (215) Mean age 61 (62) 62 (63) 58 (59) 52 (54) 59 (60) UCC 010140 A0057b liBt of job and industry titles has been developed for all cases, spouses, and controls (1955-1977). This will form the basis for classification of study subjects into asbestos exposure categories for future case-control comparisons (sample from listing Fig. 1). -3- UCC 010141 A00576 III. Results Descriptive Epidemiology kilobit' The following ipneriptivc results are based upon tho farfsraation Vi-nvuiv y * 1 CTR and will require adjustment following 4b* completion he ^ of e*tr slide review. Using the 1950 US population as a standard, the age- adjusted incidence rate for mesothelioma in Connecticut is 2.1/million for the years 1935-1977. Rates per 100,000 population increased for both sexes, but there was a rapid rise from about 1960 for males (Fig. 2). The male- female ratio is approximately 2:1; the mean age at diagnosis is fifty-nine years. Average survival time from date of diagnosis to date of death is ten months. Lc^.w 1e n &c) ^ cases were reported in Qj^l (lM) where shipyards are lo- cated, and five of these were identified between 1975 and 1977 (Fig. 3). A The geographical distribution of mesothelioma shows evidence of urban clusters in the 5 largest cities (Bridgeport, Hartford, Waterbury, Stamford , New Haven) where 30 % of the cases resided at time of diagnosis (Fig. 3). Since these locations have comprised 20-30% of Connecticut's population (1940 1977), the suggested urban effect may reduce to a factor of population density. all LMft'b. These 5 large cities and New London are abac centers fo^aber Market Areas All 6 areas exhibit a similarly Increasing age-adjusted incidence rate for males. The Stamford LMA's mesothelioma rate Bhows an unexplained sharp increase since 1965 (Fig. 4). - yUCC 010142 A00577 AGE-ADJUSTED INCIDENCE RATES OF MESOTHELIOMA IN CONNECTICUT BY YEAR OF DIAGNOSIS AND SEX 8Z9Q0V UCC 010143 I_ <<0*>N l in O (A <o <T> lO in I co S S'0 * i in__ ro o> GEOGRAPHICAL MAPPING OF CASES OF MESOTHELIOMA (1 9 3 5 -1 9 7 7 ) BY TOWN OF RESIDENCE AND 1960 LABOR MARKET AREA UCC 010144 AGE-ADJUSTED INCIDENCE RATES OF MESOTHELIOMA FOR CONNECTICUT MALES BY YEAR OF DIAGNOSIS AND LABOR MARKET AREA o -o 3c 9o 0) *o s CO ooo O CM O cvi -- till________ i O O OO CD CD ^ CM * 000*001 /31VH UCC 010145 1935-44 45-54 55-64 65-74 75-77 1 SLIDE REVIEW Ui.fo & ^Malignant mesothelioma is a very rare disease, only 2 cases per million population expected annually. Resistance to the acceptance of mesothelioma as a disease entity persisted until the late 1960's?Wagner's widely pub licized association of mesothelioma with Cape Crocidollte asbestos exposure created the potential for the introduction of diagnostic blasJ-^ Positive diagnosis of mesothelioma is often complicated by its confusion with other forms of cancer..(Vidone discussion of simulators). The controversy over criteria for positive diagnosis is well documented in (0 the literature. Most experts agree, however, that a full autopsy is re quired to positively distinguish diffuse mesothelioma of the pleural or peritu oneum from other primary or secondary neoplasms. We examined, for all CTR reported cases of mesothelioma and for all pleural tumors other than mesothelioma (1935-77), the histological basis for diag nosis (Tables 2,3). For 12% (32) of the cases, no tissue was examined at time of diagnosis, while the origin of available material varied. Overaii^only^i^K I(utfl ranging from 33% to 40%p- ^ + tf i >'*e. , been autopsied, fewC.t-s f, lelloma, are low / These results suggested the advisability of a elUS review. Dr. Romeo Vidone, chief pathologist of St. Raphael's Hospital, is presently studying the medical records (except occupational data) and slides we have obtained for cases diagnosed after 1954. Cooperation was sought from 37 hospitals, of which 30 have thus far provided us with the materials requested. (Summary of Dr. Vidone's Findings) A - s- UCC 010146 A0058 1 Table 2: Basis for Diagnostic Evaluation for cases of Malignant Mesothelioma and Pleural Tumors other than Mesothelioma Diagnosed in Connecticut, 1935-1977 Diagnosis* Pleural Mesothelioma Tissue Available 136 X (93) Pleural Tumor 27 (71) (other than mesothelioma) Peritoneal Mesothelioma 31 (94) Mesothelioma at other sites and unknown sites 41 (84) No Tissue Available Z 11 (7) 11 (29) 2 (6) 8 (16) Total 235 (88) 32 (12) Total 147 38 X (100) (100) 33 (100) 49 (100) 267 (100) WHO (1976) ^specimen from biopsy, frozen section, surgery, autopsy, D and C UCC 010147 A0n58 2 CB 00 *H 0o0 du <0 H Q Table 3: Frequency o f Autopsy f o r Cases o f M a lig n a n t M esotheliom a and P le u ra l Tumors o th e r than M esotheliom a Diagnosed in C onnecticut, 1935-1977 /-w f5th, VO' 0B5 O4J >3 r- cn rH rH (1) (2) (3) (4) (5) Autopsy, M icroscopic Evidence o f Cancer Autopsy, Gross Evidence o f Cancer Autopsy Gross E v id e n c e , Unknown Whether Cancer Autopsy, but only In d ire c t Evidence o f Cancer Autopsy, no Report 43 62 1 8 13 21 2 11 21 (7) (8) Number Autopsy^ Unknown 1 Dead | % 18 134 40 11 37 35 1 28 89 5 39 33 tsi rH rH CO 1 > 83 12 98 35 238 ao H rH *-t 41 a 4= Mu 9O o) a sH 4J <rs 14 a SS SCO 3 -4 H 42 rH 44 4) rH 43 4^4 M 4) O 3X 41 44 41 rl O 1 PH XT' r4 O -H 4) rH C O 44 44 H O 14 0B 4) 4> Cu X UCC 010148 9 B X4> 4J V (4 d3 D 4) B oo 44 9o 41 hH H 44 a rH xH 0B M 4) 4) X 44 5O 0B X 3 4) X 44 O c od a3 rH a 44 o H Vor-0'\- IX c o la (l) + (2) + (3) + (4) + (5) Col (8) XJ tn CD CD IV. Discussion Although this study was Initially undertaken to discover whether it would be feasible to identify the environmental factors responsible for the in crease of malignant mesothelioma in the State of Connecticut, it has suffered from lack of detail in available records. Major deficiencies in the data are the low autopsy rate for the pleural mesotheliomata and the inadequacy of the A pathological material available and used for diagnostic purposes. (\h r Feltonhas pointed out several needs for post-motem review. A problem may arise in workers' compensation adjudication where a decision has to be made, years to decades after initial work exposure, in those instances where death has resulted from pulmonary cancer or a thoracic or peritoneal mesothelioma. It is therefore Important in such cases to be able to confirm by the presence of asbestos related effects that there has been exposure to respirable asbestos fibers. A further need for autopsy arises to confirm the diagnosis of malignant meso thelioma made on limited biopsy material obtained during life. This is Im portant for workers' compensation purposes and also to improve the epidemiolo gical data required to investigate the etiological factors involved with this disease. Valuable information can be gained from a comparison between radiographic apperances and histological changes in the lung. Such information will help to eliminate present diagnostic uncertainties. It has been our experience that occupational histories are not routinely ob tained and included in hospital records. In our search through records stored at the CTR (l.e. hospital records), we found job titles for only 17% of the mesothelioma cases. If we exclude from this group those designated as "retired", "housewife", or "student", the figure is reduced to 12%. We were only able to ascertain type of Industry in 7% of these cases. The sample size for these statistics was 220 cases, whose diagnoses were between 1955 and 1977. A recently passed Ct. statute, whose method of implementation is under study, will hopefully alleviate the paucity of employment data from medical records. - LUCC 010149 A U 0 b <_ 4* Two other areas of epidemiological interest which are not routinely recorded for patients admitted with suspected malignant disease are smoking habits and hobbles and or part-time activities. (Comment on the significance of the Slide Review) It is evident that until the physicians investigating cases of malignancy appreciate the importance of occupational faeeeee-eit and environmental factors eB-ehe-etielegy-ef-these-diseesesT-Be (lifestyle, habits, hobbles, part-time & ,a activltis, deatiled job histories) , any attempt to apportion blame to any particular factor for disease causation or promotion will be severely hampered. It is particular^ essential in the case of a rare tumor, which may present diagnostic difficulties, to obtain sufficient tissue for study before a diagno sis is made. Whenever a tumor is found and an association is suspected with a particular occupational or environmental factor, every attempt should be made to document all relevant facts and to subsequently verify the diagnosis by means of a full autopsy. - 1- UCC 010150 A0058b * References Bruckman, L., Rublno, R. 1., and Christine, B. (1977*) Asbestos epd Mesothelioma In Connecticut. APCA Journal. 27# 121-126 Bruckman, L. (1977b) A Study of Airborne Asbestos Fibers In Connecticut. Paper presented at the Workshop on Asbestos.: Definitions and Measurement Methods. National Bureau of Standards, Gaithersburg, Maryland ^Bhzcknan, L. and Rublno, R. A. (1978) Monitored Asbestos Concentrations in Connecticut. APCA Journal. 28, 1221-1226 Price and Lee Citr Directory (1890-1977) The Price and Lee Conpany, JTev Haven, Connecticut * ^ U. S, Department of Commerce, Bureau of the Census: 1970 Census of the Population. Alphabetical Index of Industries and Occupations (1971)* Washington, D. C., IT. S. Government Printing Office World Health Organization: ICD-0 International Clarification of Diseases for Oncology. (1976) Geneva, Switzerland UCC 010151 .I .......... .. M- Hilton C. Levinsohn,Corporate Medical Director, Raybestos-Manhattan, Inc. and Lecturer, Tale School of Epidemiology and Public Health (address: Raybestos-Manhattan, Inc., 100 Oakviev Drive, Trumbull, Connecticut 066ll, U. S. A.) J. Vieter Meigs, Director, Connecticut Cancer Epidemiology Unit and Clinical Professor of Epidemiology, Tale School of Epidemiology and Public Health (address: 30 College Street, Hev Haven, Connecticut 06520, U. S. A.) Mary Jane Teta, Associate in Research, Connecticut Cancer Epidemiology Unit, Tale School of Epidemiology and Public Health (address: 30 College Street, Hev Haven, Connecticut 06520, U. S. A.) ^ 7- UCC 010152 Auubc /