MASSA program misrepresented by local doctor
To the Editor:
I recently read with interest the article regarding Brad Black's thoughts on the confusion of the asbestos screening program. It remains unclear to me why Brad continues to embark on his vitriolic diatribe regarding the state of Montana operated Montana Asbestos Screening and Surveillance Activity.
Although he along with Aubrey Miller, Jeff Lybarger and myself worked together, with extensive consultation from some of the most knowledgeable people in the United States regarding Asbestos Related Disease, in the development of the protocols that are used in the MASSA screening process, he continues to misrepresent the program. The MASSA program is not, as implied by Black, a program where a person meets screening criteria and has chest X-rays obtained and is told that they do or do not have asbestos related disease based on the interpretation of chest X-rays by an individual that has B-reader credentials and briefly scans the X-ray.
In reality the MASSA process includes skilled interviewers obtaining an extensive history that includes minimally all of the places the individual has lived, all of their occupations and potential asbestos exposures they have had, their tobacco use history and information on the signs and symptoms of disease that they may have. The participants then have pulmonary function measurements obtained by a trained individual to determine if there is evidence of abnormal lung function.
The results of the pulmonary function testing are interpreted by Dr. Brigitte Gottschall at the National Jewish Medical Center in Denver, Colorado. She is a Board Certified Pulmonologist and is the same individual that reviewed and interpreted the first 7,000-plus tests that were conducted in Libby during the summers of 2000 and 2001. Many of the technical aspects of the pulmonary function studies have been carried out by staff at both the St. John's Lutheran Hospital as well as the Clinic for Asbestos Related Disease.
The individual undergoing screening then has three view chest X-rays obtained. These chest X-rays are evaluated for both quality and evidence of disease that is in need of immediate attention before they are sent to National Jewish in Denver. The chest X-rays are then reviewed by fully trained radiologists that work on the thoracic radiology team at National Jewish. Basically the only thing that these radiologists do is review chest X-rays all day long, day in and day out. They are probably the most qualified individuals to determine if an abnormality related to asbestos exposure is present in the X-ray and by Brad's own statement to me he feels that they are doing a great job.
The results of the radiology evaluations along with the X-rays and the pulmonary function interpretations are then returned to MASSA. The staff at MASSA then contacts the individual and gives them the results of the screening. If the screening results indicate that there are abnormal findings consistent with be asbestos exposure this information is given to the individual and they are encouraged to seek medical care from a physician of their choice for further evaluation. MASSA does not provide the individual with a diagnosis.
In February of 2001 Dr. Jeff Lybarger went to extensive lengths to explain the difference between screening and diagnosis to a CAG meeting. Obviously some people still don't understand the difference. A Pap smear, a mammogram, a stool blood lab test and a prostate exam just like the MASSA evaluation are screening procedures. An abnormality in the screening test does not mean that a person has the disease that is being screened for. It just means that you need to be further evaluated to make a diagnosis. Likewise a negative screen does not mean that disease is not present. It only means that it was not detected using the techniques employed. If a person has a negative screen but has risk factors for a disease they need to be rescreened in the future at a frequency determined by the disease, the risk factors and the screening methods.
The case scenario of the woman with Asbestos Related Disease (ARD) is sad. It is sad because that scenario is so inane that it borders on the ludicrous. Look around at some of the people that you know that truly have ARD. Look at those that have had their disease for many years. They certainly, if they have advanced disease, could end up in respiratory difficulty and in an emergency room. However, there would most likely be a precipitating event or they would have another underlying problem such as emphysema, cardiac disease, bronchitis, pneumonia, obesity or a tobacco related problem.
It is hard for me to believe that a person that had chest X-rays obtained that were reviewed by a radiologist and thought not to demonstrate a problem in need of immediate attention, have these same X-rays evaluated by thoracic radiologists and thought not to have evidence of an abnormality that was asbestos related and also have pulmonary function testing, that may have been done in the CARD, and interpreted by a Board Certified Pulmonologist as not having evidence of an asbestos related problem can develop ARD in such a short period of time and have respiratory decompensation. The physician that made the diagnosis of ARD in this individual is either not adequately trained in pulmonary diseases or is so involved with ARD that they cannot see the forest for the trees and every patient that they see appears to have ARD.
ARD, when there have been recent normal X-ray findings and pulmonary testing, usually does not present as an acute, potentially life-threatening illness. The only other explanation that I can think of is that not all of the information in this case has been made available. Even in today's economy with the high rates that healthcare providers are charging, $7,000 seems very high for an emergency room visit. I would like to review that bill.
I do agree with Brad that if an individual feels that they have a medical problem that may or may not be related to asbestos exposure they are best served by seeking care from a healthcare professional. Libby has the luxury of having numerous family practice and internal medicine doctors that are very capable of evaluating patients for cardiac and respiratory illnesses. These doctors, upon evaluation, can then determine if they need to be referred for specialty care.
All in all I am hopeful that some of the information that I have tried to convey is helpful. I am also hopeful that Brad and the CARD and MASSA will strive to work cooperatively as they all have the common goal of identifying individuals with asbestos related diseases and getting them into healthcare.
I must also take this opportunity to point out that I continue to enjoy my retirement and have had the chance to log in some hiking and photographing in the Cabinets in the Bear Lake area this summer. One of my next stops will be hiking and photographing points of interest in the Yaak.
Michael R. Spence, MD, MPH
Note to defenders of W.R. Grace:
To the Editor:
This letter is in response to Dick Moore's letter in this last week's Western News.
The Nazis made really good roads.