1. Medical aspects of asbestos exposure Sjaak Burgers respiratory physician Netherlands Cancer Institute, Amsterdam s.burgers@nki.nl

2. Medical consequences mesothelioma asbestosis lung cancer benign pleural plaques

3. Today Medical introduction Asbestos – mesothelioma – lung cancer (Problems in) risk assessment

4. Mesothelioma captures the lung

5. Mesothelioma captures your breath

6. Mesothelioma: local growth

7. Mesothelioma: high mortality Cisplatin vs cisplatin-pemetrexed. Vogelzang, JCO 2003 survival with the BEST available treatment

8. Lung cancer 15% cure rate 50% 1-year mortality 90% smoking-related asbestos – increases the risk for lung cancer – more than adds to the smoking-induced risk 40-y old women. Lung cancer recently diagnosed.

9. Risk assessment Whatever the risk is, the consequences are life threatening.

10. Difference between exposure to asbestos and sigarette smoke

11. Mesothelioma mortality in North American insulation workers is independent of age Age at first exposure (years) ---- 15-24 ---- 25-34 ---- 35+ Peto et al 1982: Br J Cancer 45: 124-135

12. Lung cancer mortality is almost constant in ex-smokers Age stopped 60-64 55-59 50-54 40-49 Halpern et al 1993: JNCI 85, 457

13. Evidence individual data – “All my colleagues died of this disease”. local data national data global data

14. Environmental exposure: Cape blue asbestos 33 cases median age 49y (31- 68y) exposed to asbestos no other cases in South Africa Wagner et al Br J Industr Med 1960

15. Environmental exposure: Dutch example mesothelioma incidence in the Netherlands, females

16. Environmental exposure roads paved by Eternit remnants mean exposure 0,11 fiber years expected 4 cases, observed 26 cases

17. 2 national examples

18. 194019601980200020202040 0 500 1000 1500 2000 Mesothelioma deaths 0 50 100 150 200 Exposure index Fitted/projected deaths Observed deaths Exposure index (fitted/projected) Projected British male mesothelioma deaths Hodgson et al (2005) Br J Cancer 92: 587

19. Banning asbestos helps 1993 1982 1977

20. Global data: asbestos consumption /meso deaths Nawrot, Lancet 2007 Lin, Lancet 2007

21. Translation to risk assessment still no answer to the question “What is the risk that a particular person gets cancer due to a particular asbestos exposure?”

22. Complicated exposure-response relation for mesothelioma I=incidence; t= time since exposure; f=fiber count; d=duration of exposure; K M = fiber dependent EPA, 1986

23. Is there a safe exposure level? fibres/m 3 (fibres/ml) Occupational exposure level corresponding to the risk level chrysotileupto 20% amphibamphibole 4.10 -3 200,000 (0.2) 130,000 (0.13) 42,000 (0.042) 4.10 -5 2,000 (0.002) 1,300 (0.0013) 420 (0.00042) current Dutch safety level 0.02 fibres/ml = 1/10 of EU standard Risk level: likelyhood of dying of cancer as a result of exposure Theoretically there is; Netherlands Health Counsil:

24. Thus, abundant evidence relating asbestos to mesothelioma and lung cancer exact risk levels hard to calculate