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Commentary |
1
Department of Radiology, University of Cincinnati Hospital, Cincinnati, OH
45267-0742.
2
1128 Hurdle Hill Dr., Potomac, MD 20854.
Received November 29, 1999;
accepted after revision January 21, 2000.
This article is a commentary on the content of the preceding Centennial
Photo Page.
Introduction
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Although silicosis was recognized as an important pneumoconiosis early in the century, pneumoconiosis of coal workers was not appreciated as a distinct pneumoconiosis until the 1940s. The use of asbestos goes back to the Vestal Virgins [1, 2], but as late as 1955, there was little concern about the hazards of exposure. Interest in and knowledge about these diseases were further limited because most exposures were regionally confined, primarily to Kentucky, West Virginia, and Pennsylvania for coal and to the Midwest, the location of most foundries, for silica. Also, most examinations were under the control of plant physicians who did their own interpretations, and survey work was limited.
In 1958, Eugene Pendergrass (Fig. 1), who must be considered the father of the radiographic manifestations of occupational lung disease, made a plea in his Caldwell Lecture as follows (Felson B, personal communication):
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There is a job to be done. If we as radiologists do not do the job, others will. You and I know certain areas of radiology that have been taken over by others because of the default of the radiologists.
Few radiologists paid heed to his concerns, and the work remained with other professionals.
In 1969, the federal Coal Mine Health and Safety Act was passed by the United States Congress and signed into law [3]. Fewer than two pages of the law addressed the health of the miner. Part of the law provided that every active coal miner (about 100,000) was entitled to a chest radiograph within 18 months of the enactment of the law, a second in 3 years, and a third in 5 years. Additionally, about 100,000 retired miners were also entitled to a chest radiograph. Part of the law addressed disability benefits and compensation, depending on the length of exposure and radiographic findings. The law stated that the radiographs were to be interpreted using the International Union Against Cancer/Cincinnati system. What is the system? This was the question asked by most radiologists and other physicians who saw the potential of guaranteed remuneration for performing and interpreting the examinations.
In 1964, the International Congress on the Biological Affects of Asbestos renewed interest in the health hazards of asbestos dust and the need for epidemiologic studies. Additionally, the International Union Against Cancer working group on asbestos and cancer recognized the need for a classification system for epidemiologic purposes. They proposed that this new system be based on the International Labor Office 1958 system. About the same time, a committee consisting of Leonard Bristol, chief radiologist, the Trudeau Institute (Fig. 2); Benjamin Felson, professor and chairman of radiology, University of Cincinnati (Fig. 3); George Jacobson, professor and chairman of radiology, University of Southern California (Fig. 4); and Eugene Pendergrass, chairman emeritus of radiology, University of Pennsylvania (Fig. 1) was working under the auspices of the U. S. Public Health Service in Cincinnati, OH, developing a classification system for chest radiographs of individuals working in the asbestos industry in the United States. A third group was also working in Canada because of a need to classify several thousand radiographs for the asbestos and Thedford mines in Quebec. These three groups met in Cincinnati in 1967 and developed the International Union Against Cancer/Cincinnati system, an extension of the International Labor Office 1958 system. The International Union Against Cancer/Cincinnati system was introduced in 1968.
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Because so few physicians, including radiologists, knew of this classification system, the National Institute for Occupational Safety and Health of the U. S. Public Health Service asked the American College of Radiology (ACR) to develop a method to teach physicians the classification system and the findings of occupational lung disease early in 1970, particularly those of pneumoconiosis of coal workers. The ACR Task Force on Pneumoconiosis was born. The program was the first to use radiographs and viewboxes as a teaching method, a method now used to teach other disciplines of radiology (Fig. 5). This type of teaching was made possible because Eastman Kodak (Rochester, NY) had just developed copy film, and the original study sets were made for the task force by Eastman Kodak. The teaching method was a test-teach-test method with active participation by the attendees. The courses were held on weekends to encourage participation; limited to 220 attendees; and because the National Institute for Occupational Safety and Health supported the program, free and open to all physicians. In the first year, six courses were offered with primarily radiologists in attendance, but also other physicians, and at the first course, a lawyer and a veterinarian pathologist. Since then, about 30 courses have been offered that were restricted to physician attendees. Also, courses for technologists, stressing technique, and for administrative law judges and lawyers, explaining the disease processes and the evaluation method, have been offered. To facilitate the courses, an at-home study syllabus and printed educational materials were developed.
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Attendees who completed the course were certified A readers, entitled to interpret coal miners' radiographs and guaranteed pay for their work. Radiologists finally got involved, but so did other physicians and trial lawyers. Why the trial lawyers? Because many miners' claims were in dispute because of interobserver variability, and there was an opportunity for litigation [4].
Each radiograph was interpreted twice, with an A and a B interpretation. The A readers were those who completed the course. Twenty-seven B readers, primarily radiologists with additional training and expertise, and seven C readers also participated. If the A and B readers agreed on the major degree of perfusion and the presence and extent of large opacities, the interpretations were accepted as final. If the readers disagreed in either of the parameters, the radiographs were sent to a C reader for arbitration. Radiograph quality was a significant factor in the difference of opinions. Because of poor radiograph quality in many mining areas, the task force developed an evaluation method so that facilities could apply to be approved to participate in the program.
Another big stimulus for interest in occupational lung disease by all physicians and lawyers came in the 1960s when Irving Selikoff published work on the occurrence of asbestosis and related malignancies in insulation workers. Because workers other than insulation workers had some exposure to asbestos, industry, the federal government, and plaintiffs' attorneys immediately became involved with routine surveys of thousands of workers. The ACR Task Force on Pneumoconiosis, under contract with the National Cancer Institute, broadened its educational program to include work on the manifestations of asbestos-related disease.
Evaluation of the A and B readers and the arbitration interpretation by C readers in the federal coal study indicated a significant problem in the correct interpretation by the A reader. This problem was caused by a lack of experience of A readers and a poor understanding of the findings of pneumoconiosis and the use of the classification system.
In 1976, Russell Morgan of The Johns Hopkins University (Fig. 6) developed a certifying examination, validated by the ACR Task Force on Pneumoconiosis, at the request of the National Institute for Occupational Safety and Health. The examination consisted of 125 radiographs to be classified using the International Labor Office 71 system. However, it became evident that if an individual passed the examination but did not interpret occupational radiographs using the classification system, skills were lost. Therefore, 8 years later, in 1984, a recertification examination was introduced consisting of 50 radiographs. To remain certified as a B reader, an individual was required to be recertified every 4 years or to begin the process over after a waiting period. As revealed in Figures 7 and 8, the pass-fail rate indicates that overreading is the major factor in failing the examination (Eschenbacher W, personal communication). However, radiologists have a better pass rate than all other professionals (Eschenbacher W, personal communication) (Table 1).
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The interpretation of the minimal changes of occupational lung disease, particularly the basal changes of early asbestosis, is difficult. Therefore, radiologists must take an active role to ensure high radiograph quality and accurate interpretations. Too often we deal with poor radiograph quality and incorrect interpretations. Overreading remains a major problem, even with certified B readers. Additionally, a lack of experience in evaluating the subtleties and variabilities of chest radiographs related to technique, age, body build, and residual changes from previous non-occupational-related diseases remains a major problem.
Since 1969, the ACR, through its Task Force on Pneumoconiosis, has made major contributions to the understanding of occupational lung disease and the importance of pulmonary radiology in the correct evaluation of exposed individuals. In addition to its educational responsibilities, the ACR Task Force on Pneumoconiosis has been a major contributor on committees of the International Labor Office responsible for the development of the 1971, 1980, and 1998 systems. The 1998 system will be introduced in 2000. We urge the ACR and all radiologists to continue to be active in this program. As Pendergrass said in his Caldwell Lecture, "If we as radiologists do not do the job, others will" (Felson B, personal communication). We add, "And less well."
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  K.-I. Kim, C. W. Kim, M. K. Lee, K. S. Lee, C.-K. Park, S. J. Choi, and J. G. Kim Imaging of Occupational Lung Disease RadioGraphics, November 1, 2001; 21(6): 1371 - 1391. [Abstract] [Full Text] [PDF]
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