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and He alth 8 / 5 [1997] 1 7 7 –1 7 8 © MCB Unive rs ity Pre s s [ISSN 0956-6163]
The Australian mesothelioma programme and
register
James Leigh
He ad o f the Epide mio lo gy and Surve illanc e Unit o f the Natio nal Ins titute o f Oc c upatio nal He alth and Safe ty and Se nio r Le c ture r o f the Unive rs ity o f Sydne y, Aus tralia
Confi rms that malignant mesothelioma has a very high and increasing incidence rate in Australia. Describes the establishment of a national mesothelioma register
Background
Ma lign a n t m es ot h eliom a is in cr ea sin g in in cid en ce t h r ou gh ou t t h e in d u s t r ia l wor ld a n d is ver y fr eq u en t ly a ss ocia t ed w it h p a s t exp os u r e t o a s b es t os. It is u su a lly fa t a l a n d h a s n o d ir ect r ela t ion t o s m ok in g. Au s t r a lia h a s a ver y h igh a n d in cr ea sin g in cid en ce r a t e.
The Australian mesothelioma
programme and register
T h e Au s t r a lia n Mesot h eliom a Su r veilla n ce P r ogr a m m e (Fer gu son et a l., 1987) b e ga n on 1 J a n u a r y 1980. For m a l volu n t a r y n ot ifi ca t ion of ca s es w a s a ct ively sou gh t fr om a n et wor k of r es p ir a t or y p h y sicia n s, p a t h ologist s, gen er a l a n d t h or a cic su r geon s, m ed ica l su p er in -t en d a n -t s, m ed ica l r ecor d s a d m in is -t r a -t or s, s t a t e a n d t er r it or y d e p a r t m en t s of occu p a t ion a l h ea lt h , ca n cer r e gist r ies, com p en s a -t ion a u -t h or i-t ies or a n y o-t h er s ou r ce. A fu ll occu p a t ion a l a n d en v ir on m en t a l h is t or y w a s ob t a in ed for ea ch ca s e, eit h er fr om t h e p a t ien t or n ext -of-k in . T h e h is t or y t a k in g w a s n on -d ir ect ive bu t in clu d ed s p ecifi c q u es t ion s on a s b es t os exp osu r e a t t h e en d .
Occu p a t ion a l a n d en v ir on m en t a l exp os u r e w a s b a s ed on t h e op in ion s of t wo exp er ien ced h ygien is t s, w h o w er e, h ow ever, n ot in d e p en -d en t n or blin -d e-d a s t o -d is ea s e s t a t u s. T h e d ia gn os in g p a t h ologist w a s r eq u est ed t o p r o-v id e s lid es a n d / or t iss u e sp ecim en s. T h ese w er e cir cu la t ed a m on g a p a t h ology exp er t p a n el for con fi r m a t ion of d ia gn os is. P os t -m or t e-m exa -m in a t ion w a s a ct ively sou gh t for in ever y ca s e in or d er t o con fi r m d ia gn os is a n d t o ob t a in lu n g t iss u e fr ee of t u m ou r for lu n g fi b r e con t en t a n a ly sis.
F r om 1 J a n u a r y 1986, a less d et a iled n ot ifi -ca t ion sy st em h a s op er a t ed , w it h a sh or t q u es t ion n a ir e h ist or y, w h ich is follow ed u p by m a il. On ly h ist ologica lly con fi r m ed ca s es a r e a cce p t ed bu t t h er e is n o p a t h ology p a n el t o con fi r m t h e d ia gn os is. T h e n ot ifi ca t ion s y s t em is n ow k n ow n a s t h e Au s t r a lia n M esot h eliom a Re gist er bu t is m er ely a con -t in u a -t ion of -t h e p r ogr a m m e. Cr os s-ch eck s w it h s t a t e ca n cer r e gist r ies a r e r e gu la r ly ca r r ied ou t . An n u a l r e p or t s a r e p u blis h ed
a n d a com p r eh en s ive r ev iew is ava ila ble (Leigh , 1994).
Mesothelioma incidence in
Australia and future estimates
Up t o t h e en d of 1995, a t ot a l of 4,129 n ot ifi ca -t ion s h a d b een r eceived . N o-t ifi ca -t ion s sh ow a con t in u in g u pw a r d t r en d .
An a ly sis is n ot com p let e for 1996 bu t t h e n u m b er of n ot ifi ca t ion s t o t h e en d of 1996 w a s 461, a la r ge in cr ea se over 1995 (358). Bot h m a le a n d fem a le r a t es h ave in cr ea sed bu t t h e m a le r a t e is over seven t im es t h e fem a le r a t e. In 1995, t h e m a le cr u d e r a t e w a s 6.7 p er 100,000 p er yea r a n d t h e fem a le cr u d e r a t e 1.1 p er 100,000 p er yea r. T h ese a r e t h e h igh est r e p or t ed r a t es in t h e wor ld . T h e in cid en ce is n ow s im ila r t o H od gk in ’s ly m p h om a or liver ca n cer a n d t h e m or t a lit y gr ea t er t h a n t h a t of cer v ica l ca n cer. Wes t er n Au s t r a lia h a s t h e h igh est in cid en ce bu t con t r ibu t es on ly 15 p er cen t of t h e t ot a l ca ses. Wit t en oom con t r ibu t es a b ou t 5 p er cen t of t h e Au st r a lia n ca ses. Most of t h e ca s es com e fr om t h e t wo m ost p op u lou s a n d in d u st r ia lized st a t es, N ew Sou t h Wa les a n d Vict or ia (Leigh et a l., 1991).
In 93.2 p er cen t of a ll ca ses, t h e m es ot h e-liom a w a s p leu r a l in s it e, 6.5 p er cen t p er i-t on ea l a n d on ly fou r ca ses w er e in oi-t h er sii-t es. Of t h e ca ses t h a t u n d er w en t p a t h ology p a n el r ev iew 96 p er cen t w er e con fi r m ed a s m esot h eliom a . In t h e ca ses r e p or t ed w it h d et a iled h ist or ies (u p t o t h e en d of 1985), t h e m ost com m on occu p a t ion a l exp osu r es w er e r e p a ir a n d m a in t en a n ce of a sb es t os m a t er ia ls (18 p er cen t ), sh ip bu ild in g (11 p er cen t ), a sb est os cem en t p r od u ct ion (7 p er cen t ), a sb est os cem en t u s e (7 p er cen t ), r a ilw ay s (6 p er cen t ), Wit t en oom cr ocid olit e m in in g/ m in -in g (6 p er cen t ), -in su la t ion
m a n u fa ct u r e/ in st a lla t ion (4 p er cen t ), w h a r f la b ou r in g (3 p er cen t ), p ow er st a t ion s (3 p er cen t ), b oiler m a k in g (2 p er cen t ) p a r a occu p a -t ion a l, h obby, en v ir on m en -t a l (15 p er cen -t ). T h e d efi n it ion of exp osu r e w a s ext en d ed t o sligh t exp os u r es su ch a s wor k in g w it h a sb est os cem en t in h om e con st r u ct ion a n d m a in t en a n ce, v isit in g Wit t en oom , or liv in g close t o a n a sb es t os fa ct or y or m in e. (T h ese ca t e gor ies h a d b een ca t e gor ized a s “n o
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k n ow n h ist or y ” in som e ea r lier r e p or t s.) On ly 18 p er cen t h a d n o k n ow n h ist or y of exp os u r e a ccor d in g t o t h e ext en d ed d efi n i-t ion . Of i-t h is “n o k n ow n h isi-t or y ” gr ou p, 81 p er cen t h a d fi b r e cou n t s d et ect ed in t h e lu n gs, 30 p er cen t w it h m or e t h a n 106fi b r es / g > 2µ in clu d in g “lon g” (> 10µ) fi b r es su gges t in g t h a t n ea r ly a ll ca s es h ave b een exp osed t o s om e level of a sb est os. In d eed a b sen ce of fi b r es in t h e lu n gs d oes n ot n e ga t e exp osu r e a s fi b r es m ay h ave in it ia t ed m es ot h eliom a a n d t h en b een clea r ed b efor e d ea t h . Mea n la t en cy fr om fi r st exp os u r e t o p r es u m p t ive d ia gn os is w a s 37.4 yea r s (r a n ge 4-75 yea r s) (Fer gu son et a l., 1987).
In t h e ca s es r e p or t ed sin ce 1 J a n u a r y 1986, w h en les s d et a il of h ist or y of exp os u r e w a s s ou gh t , 86 p er cen t of m a les r es p on d in g t o t h e q u est ion n a ir e a n d 46 p er cen t of fem a les gave a h is t or y of a sb es t os exp osu r e (over a ll 83 p er cen t ) (n on -r es p on s e 11 p er cen t ).
Som e com m on exp os u r e h ist or ies w er e: r e p a ir a n d m a in t en a n ce of a sb es t os m a t er ia ls (13 p er cen t ), sh ip bu ild in g (3 p er cen t ), a s b est os cem en t p r od u ct ion (4 p er cen t ), r a il-w ay s (3 p er cen t ), p oil-w er s t a t ion s (3 p er cen t ), b oiler m a k in g (3 p er cen t ), Wit t en oom (5 p er cen t ), w h a r f la b ou r (2 p er cen t ), p a r a occu p a -t ion a l, h obby, en v ir on m en -t a l (4 p er cen -t ), ca r p en t er (4 p er cen t ), bu ild er (6 p er cen t ), n av y (3 p er cen t ), p lu m b er (2 p er cen t ), b r a k e lin in gs (2 p er cen t ), m u lt ip le (12 p er cen t ). T h e p a t t er n of exp os u r e is sh ift in g aw ay fr om t h e old er t r a d it ion a l in d u st r ies t ow a r d s p r od -u ct , d om est ic a n d en v ir on m en t a l exp os -u r e. T h e in cid en ce is s t ill in cr ea sin g a n d , a ss u m -in g p ea k a m p h ib ole exp os u r e occu r r ed a b ou t 1965 a n d p ea k ch r y s ot ile a b ou t 1975, p ea k in cid en ce is n ot exp ect ed u n t il a b ou t 2010. T h e exp ect ed t ot a l n u m b er of ca s es fr om 1945 t o 2020 is es t im a t ed t o b e a b ou t 18,000, b a s ed on m od els by Ber r y (1991) a n d d e Kler k et a l. (1989) for Wit t en oom , ext r a p ola t ed for Au s t r a lia a s w h ole (a ss u m in g Wit t en oom con t r ibu t es 5 p er cen t of ca s es ), a n d d ir ect ext r a p -ola t ion fr om t h e b est fi t t o t h e em p ir ica l in ci-d en ce cu r ve, con st r a in eci-d t o h ave a m a xim u m va lu e a t 2010, follow in g a 40-yea r la t en cy fr om t h e t im e of m a xim u m exp os u r e (1970). Given t h a t t h er e a r e a t lea st t wo p a r t ia lly a sb es t os -r ela t ed b -r on ch ia l ca -r cin om a ca s es fo-r ea ch
m esot h eliom a ca se (Ba r r oet aven a et a l., 1996), t h e t ot a l bu r d en of a s b est os -r ela t ed ca n cer in Au s t r a lia is lik ely t o b e in excess of 50,000 ca ses.
Comment
Ot h er cou n t r ies, esp ecia lly d evelop in g on es, cou ld d o w ell t o t a k e h eed of t h e d r ea d fu l Au st r a lia n exp er ien ce in m a lign a n t m esot h e-liom a . On ce wor k er s h ave b een exp osed t o a sb est os (es p ecia lly cr ocid olit e a n d a m osit e), t h er e is n ot h in g effect ive in m ed ica l scien ce t od ay t o p r even t t h e d evelop m en t of t h a t ca n -cer in a t lea st som e in d iv id u a ls, a lt h ou gh t h e la t en cy p er iod is n ot or iou sly lon g. Un d ou b t -ed ly, t h e p r ot ect ion of wor k er s a ga in st u n d u e exp os u r e is t h e on ly effect ive m ea su r e a t t h e p r esen t t im e.
References
Ba r r oet aven a , M.C., Tesch k e, K. a n d Ba t es, D.V. (1996), “Un r ecogn ized a s b es t os -in d u ced d is-ea s e”, A m er ica n J ou r n a l of In d u str ia l M ed
i-cin e, Vol. 29, p p. 183-5.
Ber r y, G. (1991), “P r ed ict ion of m esot h eliom a , lu n g ca n cer, a n d a sb est osis in for m er Wit t en oom a s b es t os wor k er s ”, B r itish J ou r
-n a l of I-n d u str ia l M ed ici-n e, Vol. 48, p p. 793-802.
d e Kler k , N.H ., Ar m st r on g, B.K., M u s k , A.W. a n d H obb s, M .S.T. (1989), “P r ed ict ion s of fu t u r e ca ses of a sb est os r ela t ed d isea se a m on g for m er m in er s a n d m iller s of cr ocid olit e in West -er n Au s t r a lia ”, M ed ica l J ou r n a l of A u stra lia , Vol. 151, p p. 616-20.
Fer gu s on , D.A., Ber r y, G., J elih ov sk y, T., An d r ea s, S.B., Roger s, A.J ., F u n g, S.C., Gr im wood , A. a n d T h om p s on , R. (1987), “T h e Au st r a lia n M es ot h eliom a Su r veilla n ce P r ogr a m 1979-1985”, M ed ica l J ou r n a l of A u stra lia , Vol. 147, p p. 166-72.
Leigh , J . (1994), “T h e Au st r a lia n Mesot h eliom a P r ogr a m 1979-1994”, in P et er s, G.A. a n d P et er s, B.J . (E d s), T h e Cu r ren t S ta tu s of th e
A sb estos Pu blic H ea lth Pr oblem (Vol. 9 S ou rce-b ook on A srce-b estos Disea ses), Bu t t er wor t h , N H ,
p p. 1-74.
Leigh , J ., Cor va la n , C.F., Gr im wood , A., Ber r y, G., Fer gu s on , D.A. a n d T h om p s on , R. (1991), “T h e in cid en ce of m a lign a n t m esot h eliom a in Au s t r a lia 1982-1988”, A m er ica n J ou r n a l of
