Educational Needs of Physicians and Public  Regarding Asbestos Exposure National Institutes of Health Consensus Development Conference Statement May 22, 1978 This statement is more than five years old and is provided solely for historical purposes. Due to the cumulative nature of medical research, new knowledge has inevitably accumulated in this subject area in the time since the statement was initially prepared. Thus some of the material is likely to be out of date, and at worst simply wrong. For reliable, current information on this and other health topics, we recommend consulting the National Institutes of Health's MedlinePlus http://www.nlm.nih.gov/medlineplus/. This statement was originally published as: Educational Needs of Physicians and Public Regarding Asbestos Exposure. NIH Consens Statement 1978 May 22;1(2):9-12. For making bibliographic reference to the statement in the electronic form displayed here, it is recommended that the following format be used: Educational Needs of Physicians and Public Regarding Asbestos Exposure. NIH Consens Statement Online 1978 May 22 [cited year month day];1(2):9-12. Introduction A meeting on the Educational Needs of Physicians and the Public Regarding Asbestos was sponsored by the Division of Cancer Control and Rehabilitation, NCI, on March 15,1978. Participants included representatives of key government agencies, national professional and voluntary health organizations and unions with special interest in the asbestos problem. The purpose of the meeting was to discuss the public health implications of exposure to asbestos and particularly the related educational needs for physicians and the public. There urgency in examining this issue because of the growing national concern about long term health hazards of asbestos as new information becomes available. Following an excellent summary of the present status of our knowledge about asbestos-related disease and the magnitude of the problem by Dr. Irving J. Selikoff, there was a discussion of what physicians need to know, including radiologists, chest physicians, practicing physicians and public health personnel. It was agreed that the physicians should be provided with concise, accurate information as rapidly as possible, so that they would be prepared to answer the questions of their patients, to provide medical care and counselling to patients with a history of asbestos exposure or with asbestos-related disease. What the public needs to know was discussed in relation both to shipyard workers and their families and to the general public. The group was in complete agreement that one-to-one notification of workers employed in both Naval and private shipyards, some as far back as the 1920's, would be very costly and, most important, would take too long to be effective. Millions of people are involved, many of whom have not been in contact with the shipyards for over 30 years. Tracing them on an individual basis would be totally impracticable and many patients would lose whatever chance of benefit medical support could provide if given now. Therefore, the mass media will have to be used to reach the exposed shipyard workers. However, it is hoped that a media campaign can be delayed until information can be provided to physicians to prepare them for the consequences. A review of past, present and proposed educational programs on the subject of asbestos-related disease for physicians, workers and the public resulted in the identification of the following needs and opportunities: 1. Physicians throughout the country, both specialists (radiologists and chest physicians) and general practitioners (family physicians and osteopaths) need to develop greater awareness of asbestos-related disease as soon as possible. This need will be met in part through the publication of an article on asbestos-related disease by Dr. Selikoff in the American Cancer Society's CA -- A Journal for Clinicians. This will appear in the issue to be released in mid-April. CA has a mailing list of over 400,000 and is sent to all practicing physicians. A short Physician-Alert designed for wide circulation will be developed by the NCI within the next six weeks and can be distributed as a Special Communication from the Director of the National Cancer Institute and the Director of the Division of Cancer Control and Rehabilitation. Efforts will be made to have the CA article reprinted in whole or in part or editorialized in such journals as the JAMA, the NEJM, Chest, American College of Radiology Bulletin, etc. Reference can be made to it also in government-issued or supported newsletters which are widely circulated. It is of great importance for physicians to know that it is not only asbestos or insulation workers who are at increased risk of developing asbestos-related disease, but workers in any trade who were employed in shipyards, even executives and secretaries, and also the families of shipyard workers who were in the past exposed to the dust the worker brought home on his clothing. Although the incidence of asbestos-related disease is somewhat proportional to the degree and length of exposure, cases of mesothelioma have now appeared in people exposed for as little as one month many years ago. Since the civilian population began to be exposed to asbestos somewhat later than shipyard workers (through dust from brake linings, home construction materials, air conditioning installation, building demolitions, serpentine gravel, etc.), the long latent period of 20-40 years for the development of lung cancer and mesothelioma will not have elapsed for perhaps another 5-10 years, but a major increase in asbestos-related disease in the general population must be anticipated. The institution of methods for the primary prevention of asbestos exposure are mandatory, including use of substitutes for asbestos where possible, improved ventilation and air filtration and the use of respirators. Physicians, union leaders and plant managers need accurate, up-to-date information about respirators and what type should be recommended in various situations. Some individuals who have impairment of pulmonary function cannot use respirators at all and should accordingly be placed in or encouraged to seek a job where respirators are unnecessary. Also, the use of respirators should not be limited to insulation workers in shipyards, but urged for all construction workers who enter an area where asbestos is in the air. 2. Physicians need help in eliciting a more accurate occupational exposure history from their patients. Since this requires more time than a busy practitioner can devote to an individual patient, it was suggested that occupational history forms be designed to be filled out by the patient, possibly with help from an appropriately trained nurse, and that such forms be printed or distributed through appropriate journals. Some public or private agency might consider furnishing these forms to physicians' offices free of charge. Forms already prepared by NIOSH and by the Metal Trades Union will be reviewed and adapted for self-administration. 3. Most radiologists need additional training in the interpretation of x-ray changes related to asbestos. There has been little instruction about the early or late x-ray changes related to asbestos in medical school or resident training and most radiologists who have not seen much asbestos-related disease are likely to consider the early changes within the range of normal. Some of the later x-ray changes represent serious problems in differential diagnosis, but few radiologists have seen enough asbestos-related disease to be competent in that field. The American College of Radiology is prepared to act quickly under a supplement to their present contract with NIOSH to prepare 200 sets of 24 films each, of the highest quality and most instructive films they can select, showing the various x-ray changes due to asbestos. These can be used, with or without an accompanying syllabus, for the teaching of radiologists, chest physicians and general practitioners in a great variety of group situations or on an individual basis in the physician's office. 4. There is a great need for more well-trained consultants who are experts in the field of asbestos-related disease. Intensive courses of 3-5 days are needed for respiratory disease specialists and others to gain increased competence in this area. At present one such course, supported by the American Cancer Society, is scheduled at Mount Sinai, Medical School, New York, April 17-19. Another is needed on the West Coast, probably at the University of Southern California where there is another concentration of experts in the field of asbestos-related disease who can serve as faculty. Others can be mounted as additions to national meetings of the American College of Chest Physicians, the American Thoracic Society, The American College of Radiology and other appropriate national professional organizations. Eventually, it should be possible for practicing physicians to find an expert consultant on asbestos-related disease in every major medical teaching center and in every comprehensive cancer center in the U.S. 5. There is need for sources of quick, accurate information about asbestos-related diseases for both physicians and the public. It is proposed to provide the Office of Cancer Communications, NCI, the Cancer Information Services of the Comprehensive Cancer Centers and the Divisions and Chapters of the American Cancer Society and the American Lung Association with appropriate information for response to questions from the medical profession and the public about asbestos. These resources should also be provided with lists of consultants on asbestos-related disease to whom the callers may be referred. A Question and Answer document on asbestos has already been prepared by the Office of Cancer Communications and is now being circulated to a number of experts for comment and criticism. 6. There is a major need for good educational materials for physicians, workers and the public. For physicians these should include x-ray films, pathology slides or pictures thereof, audiovisual cassettes, and informational material about the course of the disease, prevention, detection, diagnosis, treatment, follow-up and what options to suggest in counselling. This also requires appreciation of the economic factors involved. Opportunities for transmitting the needed information should be explored, including such natural gatherings as national professional meetings; conferences; seminars; meetings sponsored by the state medical societies; and grand rounds, cancer committee and tumor board meetings in hospitals. For public or worker education, the message should be personalized when possible, relating to the individual's own x-rays when possible, relating to the individual's own x-rays when abnormalities are found, and spelling out how asbestos-related disease may affect his life style. He should be warned to avoid further exposure by careful compliance in wearing respirators. He should be told that continued smoking will greatly increase the chance of developing lung cancer, and that, if he stops, the risks will be reduced by 50% within 5 years. He should be warned that upper respiratory infections pose a much greater risk to anyone who has begun to develop asbestosis than to the unexposed individual and that he should try to avoid upper respiratory infections, as much as possible. When acquired, he should treat them early, carefully and take the antibiotics prescribed. Instruction via cartoon presentations has proved particularly effective. 7. There is a need for a Clearing House of information, and educational materials about asbestos which will provide information about resources available to all interested parties and to which inquiries for information can be directed. The Cancer Information Clearinghouse of the Office of Cancer Communications has offered to serve in that capacity. It was emphasized that information about non-malignant forms of asbestos-related disease should be included. All groups present volunteered to contribute whatever information and educational materials they had, including forms for occupational histories. It was requested that these be sent to the DCCR for review. The DCCR will then forward appropriate material to the CICH. 8. Education of workers potentially exposed to asbestos should be the joint responsibility of the Occupational Safety and Health Administration and the unions. Major assistance can be provided through the educational materials and resources to be developed by the other organizations and agencies represented in the workshop. The most effective communicators to workers have been their peer group leaders--the shop union stewards. 9. Programs must also be developed for the education of managers and executives regarding the asbestos problem. 10. Additional research is urgently needed on improved methods for prevention, diagnosis and treatment for asbestos-related disease. 11. Agreement was reached that the DCCR would serve as the coordinating focus for the development of educational programs and materials. These programs and materials need to be prepared for radiologists, respiratory disease specialists, general practitioners and the public and would provide as much help as possible to the ongoing efforts of NIOSH, OSHA and the unions in worker education. 12. The group agreed to meet again in about four weeks under the auspices of the Division of Cancer Control and Rehabilitation to discuss special educational needs, to review the Physicians Alert and the informational and educational materials received from the participants. Conference Sponsors National Cancer Institute, Division of Cancer Control and Rehabilitation National Institute of Environmental Health Sciences Office of Medical Applications of Research, NIH

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