Dr. Carolina Mensi: “Since 2017, the epidemiological surveillance activity of mesothelioma has become part of the Essential Levels of Assistance (LEA)”
Some movie fans have learned about mesothelioma through personal history Steve McQueenicon of American cinema, protagonist of films such as “The Great Escape” and “Bullit”: the actor passed away prematurely at the age of fifty from a form of mesothelioma, a rare malignant tumor whose onset is associated with exposure to asbestos. Since it is an occupational cancer, for years mesothelioma has been monitored through the activities of the Regional Operations Centers (COR), such as the one where the Doctor Carolina Mensi, Head of the Mesothelioma Registry of the Lombardy Region at the IRCCS Ca’ Granda Ospedale Maggiore Policlinico Foundation in Milan.
MESOTHELIOMA: RARE AND AGGRESSIVE
“Mesothelioma is a tumor that affects the mesothelium,” explains Mensi. “It is a sheet from which various structures derive: the pleura that envelops the lungs, the pericardium around the heart, the peritoneum that envelops the abdominal organs and, in humans, the tunica vaginalis of the testicle”. About 90% of mesotheliomas affect the pleura, therefore the manifestations of the tumor tend to be more often respiratory: Patients experience difficulty breathing and shortness of breath or chest pain. All these symptoms can lead to suspicion of other types of problems – especially cardiological – making the diagnosis less immediate. “The patient turns to the general practitioner for dyspnea or weight loss,” continues Mensi. “Subsequently, a pleural effusion may be found during the visit, thus making certain investigations necessary which, in the first instance, involve the execution of a chest x-ray and then, possibly, a CT scan which highlights a thickening of the pleura with nodular formations characteristics, called ‘mamelons’”. However, the reference test for mesothelioma remains the biopsy which is performed under thoracoscopy and allows tissue samples to be collected for histological confirmation.
“From a morphological point of view mesothelioma can be of three different subtypes: epithelioid, sarcomatoid or biphasic”, specifies Mensi. “The first corresponds to the most widespread form and most easily treatable with chemotherapy, while sarcomatoid mesothelioma is rarer and, unfortunately, has a survival of only six months, about half that of the epithelioid form”. It is, therefore, an aggressive tumor that is encountered occasionally and evolves rapidly. The main triggering cause is exposure to asbestos (or asbestos), for this reason there are CORs (Regional Operations Centers) in Italy for Mesothelioma, in charge of epidemiological surveillance through the collection of all cases of disease; a further task of these structures is to reach patients – possibly when they are still in good health – in order to collect valuable information on the work carried out by the patient, his life habits and usual visits. “In some cases, even just having lived in contaminated areas, such as Casale Monferrato, Bari or the town of Broni, where plants for the processing of products containing asbestos were active can constitute a risk.”, adds the expert citing the case of Broni, in Lombardy.
BRONI: A MUNICIPALITY WITH HIGH INCIDENCE OF MESOTHELIOMA
In this small municipality in the Oltrepò Pavia area, an asbestos-cement production plant was opened at the beginning of the last century – a material known as eternit – widely used in construction for the production of corrugated sheets for roofing or pipes for sewage systems . Being an excellent thermal and acoustic insulator, asbestos has been used in many other ways: from the creation of insulating panels for ovens and stoves to the overalls of firefighters. “In 1932, when in Broni the asbestos cement production factory started the activity, many citizens abandoned agricultural work for secure and profitable jobs in factories,” recalls Mensi. “The COR Mesothelioma has highlighted an incidence rate of mesotheliomas 20 times higher in men from Broni compared to the rest of Lombardy (100 vs. 5.6/100 thousand inhabitants) and over 30 times higher among women (68 vs. 2.2/100 thousand inhabitants)”. Values that greatly exceed those of another historical precedent, in Casale Monferrato, in Piedmont.
“The existence of the Mesothelioma Registry has allowed us to estimate the incidence rates of mesothelioma in Broni and Stradella – a neighboring municipality – highlighting thehigh risk of getting sick even just for those who had lived in those areas when the factory was active”, continues Mensi. “The data were provided to the Department for the Environment of the Lombardy Region, which forwarded the request to the Ministry of the Environment to re-delimit the Site of National Interest (SIN)”. The SIN is an area considered contaminated by a given substance and is, therefore, an object of interest for the Ministry which is responsible for carrying out the remediation and restoration work to the environment, just as happened in Casale Monferrato. “Unfortunately, to date the SIN of Broni is limited to the former site of the production plant and does not include the inhabited centers of the municipalities of Broni and Stradella”, continues Mensi. “The re-bordering is a fundamental step to ensure that the Municipalities have the funds with which to allow the remediation of the asbestos still present as a product in homes and eliminate the risks for the population: a real prevention intervention”. The request is currently being examined by the Ministry.
THE NATIONAL MESOTHELIOMA REGISTER
Broni and Casale Monferrato are just two examples of sites contaminated by asbestos but mesothelioma is also linked to other mineral substances, such as fluoroedenitis (in Italy the case of Biancavilla, in Sicily, is known) or erionite, a fiber with chemical characteristics similar to asbestos found in some villages of Cappadocia described in the work of Michele Carbone. In Italy the processing of asbestos has been prohibited since the beginning of the nineties of the last century (Law n. 257 of 25 March 1992), nevertheless the consequences of decades of manipulation of this material have made it necessary to establish collection bodies for data and surveillance of the most exposed populations. The need to collect information on mesothelioma led to Law 277 of 1991 – which came into force with the Decree of the President of the Council of Ministers (DPCM) n. 308 of 2002 – which explains how the epidemiological surveillance of mesotheliomas must be carried out.
“There is a National Mesothelioma Registry (ReNaM) which makes use of the work of the CORs, who all operate with the same methods, following national guidelines, and periodically sending the computerized data to the ReNaM located at INAIL”, explains Mensi. “The COR is not limited to epidemiological surveillance and, therefore, to estimate the incidence rates of the disease in one’s own Region, but also collects and evaluates any exposure to asbestoswith the collaboration of the occupational health services of the local health authorities. This allows the medico-legal procedure to be started to obtain compensation for the patient (or to the heir spouse) in cases of professional exposure or to provide access to the Asbestos Victims Fund for non-professional cases”. In fact, from 2015 INAIL is expected to provide a flat-rate allowance even if mesothelioma is not of professional origin: it is a unique case in the panorama of occupational cancers for a disease that can be contracted even just by coming into contact with with those who work with asbestos (for example, through the fibers deposited on the beard or hair or on work overalls taken home to wash), or by residing in contaminated areas or as a hobby (through the prolonged use of fireproof balaclavas which, in In the past, pilots or enthusiasts like Steve McQueen wore them to protect their faces from possible burns). Finally, since 2017, the epidemiological surveillance activity of mesothelioma carried out by the CORs has formally become part of the Essential Levels of Assistance (LEA). As with all other tumors of a professional nature, it is an activity that must be guaranteed by right to citizens.
The history of the use of asbestos in Italy has been long and the list of citizens involved is equally extensive: therefore contributing to the correct reclamation of the territories must remain a priority of the government in the interest of citizens’ health.
Tags: Mesothelioma asbestos cancer continues strike Italy
