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I have chosen three papers (see box 1) from the archives of Occupational and Environmental Medicine which, from its founding in 1943 until 1993, was called the British Journal of Industrial Medicine.1–3 Published during a 10-year period, together they are arguably the three most influential papers in occupational lung disease of the 20th century. Asbestos had been recognised as a cause of fibrosis of the lungs (pneumoconiosis – asbestosis) since the early 20th century, leading in 1931 to the Asbestos Industry Regulations to control exposure to asbestos dust. These three papers showed conclusively that inhaled asbestos was also carcinogenic, causing lung cancer and mesothelioma. The implications were stark. Whereas the incidence and severity of asbestosis could in principle be reduced by improved control of asbestos in the workplace, no threshold of safety could be confidently identified probably for lung cancer and certainly for mesothelioma. While the excess of lung cancer cases reported in Doll’s study were in those employed in an asbestos textile factory, the reported cases of mesothelioma, a rare tumour, occurred not only in those exposed to asbestos at work but, most troublingly, also in those exposed to crocidolite asbestos only in their home and in those living in the vicinity of an asbestos mine in South Africa and a factory in the East End of London, UK.
Doll’s paper is remarkable for the clear answer it provides to the question: does asbestos cause lung cancer?4 Previous observations had suggested an excess of lung cancer in those with asbestosis, but no previous reports had provided a clear answer. Merewether, as Chief Inspector of Factories, in 1949 had reported that lung cancer was found more frequently in post mortems of cases of asbestosis (13% of 235 cases) than silicosis (1.3% of 6884 cases).5 …
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