Fighting for every breath

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Fighting for every breath

Wednesday, April 12, 2000

By CAROL SMITH
SEATTLE POST-INTELLIGENCER REPORTER

DETROIT -- For decades, patients who contracted asbestosis were told there was nothing medical science could do for them.

You lingered for years while your lungs scarred over. Eventually, you suffocated.

Dr. Michael Harbut, 48, is one of a small group of physicians trying to change the course of asbestos-induced disease. To do that, he essentially is having to experiment on his own patients.

Although millions of dollars have been poured into asbestos litigation on all sides, and although companies and unions have invested countless hours in asbestos screenings, almost no money has gone into investigating treatments or better ways to manage asbestos disease.

"Basically, there's an enormous paucity of reliable clinical data on how to treat asbestosis," said Harbut, who is chairman of the Occupational and Environmental Medicine Section of the American College of Chest Physicians, and a clinical assistant professor of medicine at Wayne State University in Detroit.

In 1987, when Harbut was finishing his residency in occupational medicine at the University of Michigan, physicians were writing off most asbestos patients. "They still teach you that there's nothing you can do," he said.

But Harbut, who took his medical training in Poland, where he helped set up cancer clinics for workers, and who still has an original Solidarity poster on his office wall, is not convinced of that.

Harbut's soft voice and teddy-bear demeanor with patients belie his indignation at the way many of his patients were exposed to asbestos in their jobs, and at the lack of resources for new research into treatments.

As an occupational physician, he used to spend the bulk of his time doing diagnosis and screening for asbestosis.

"But it seemed to me a doctor should do more than that," he said. "So I started aggressively treating (the diseases)."

Currently, for example, he's using a new class of drugs called "leukotriene blockers" to treat asbestosis. The drugs originally were approved for use in treating asthma, and there is no research on how they work for treatment of asbestos-related disease.

But based on the biology of the two diseases, both of which involve inflammation in the lungs, Harbut figured they might help.

"We know they (the new drugs) block inflammatory mediators in the lung," he said. Inflammatory mediators are biological molecules that help trigger inflammation. When the microscopic, sliverlike fibers of asbestos lodge in lung cells, they inflame the tissue, eventually leading to scarring or malignancy.

The new drugs appear to be helping some patients, Harbut said. The treatment has improved their diffusing capacity, a sensitive measure of the ability of air to cross over the lungs, and an indicator of lung health. Using a combination of leukotriene blockers and standard bronchodilator medication, Harbut has been able to get a 20 percent improvement in lung capacity, compared with about 7 percent improvement from bronchodilators alone.

"Patients feel better," he said. "We didn't make the scarring go away, but we made the good tissue work harder."

This piecemeal approach to new therapies is currently the best option doctors and their patients have.

"In terms of therapies, the options for individuals are pretty limited," said Dr. Drew Brodkin, associate professor of internal medicine and environmental health at the University of Washington. "This is truly a disease where prevention is key. Once you've developed it, there's very little in terms of therapeutics."

There is anecdotal evidence that some treatments work to help asbestosis, Brodkin said. "But nothing's been tried in a systematic way."

That's partly because some of the therapies that might be helpful in combating inflammation also have significant side effects, he said.

Steroids and immune-system suppressants, for example, may help. But they also leave patients vulnerable to infections, which can be devastating for people with underlying lung problems.

But there is a more fundamental disincentive to doing research on asbestos.

"If you go after a product that company X makes that makes people sick, then company X goes after you," said Harbut, who believes his phone has been tapped at least twice, and says he has been hounded by asbestos companies for his testimony in court. "And nobody sticks up for you."

Early detection is key

Asbestosis is not the only way asbestos kills patients. Asbestos-caused lung cancer is just as deadly.

Asbestos exposure alone results in a fivefold increase in cancer risk. Cigarette smoking, by comparison, increases cancer risk approximately tenfold.

When combined, however, asbestos and cigarettes interact synergistically to increase cancer risk between 50 and 90 times.

The best hope of survival in those cases is early detection, said Dr. Christine Oliver, assistant clinical professor of medicine at Harvard Medical School, and a pulmonary and critical medicine specialist at Massachusetts General Hospital.

For decades, the primary means of screening for both asbestosis and lung cancer was the chest X-ray.

That's the equivalent of diagnosing someone with cardiac disease and making treatment decisions using a stethoscope, Harbut said. "You wouldn't do that in the year 2000. It's irresponsible medicine."

Instead, Harbut and other physicians who see large numbers of asbestos-exposed patients are turning to high-resolution CT scans, which are sophisticated radiological scans that look at the lungs in thin cross sections at 2-centimeter intervals. Although high-resolution CT scans are about 10 times as expensive as standard chest X-rays (about $500 compared with $50 for a chest film), they also can find tumors at earlier stages.

Murray Walker, 63, found that out just in time.

A former heavy equipment operator for Ford Motor Co., Walker used to dump debris for the company in Detroit. Some of it contained asbestos, although he did not know it at the time.

One day, an outside health inspector came to monitor the dust kicked up by his machinery.

"He asked me, 'Did anybody ever tell you there's a lot of stuff in it you shouldn't be breathing?'" Murray said. At the time, Murray was already having trouble with his breathing. Shortly after that, the company enrolled him in its corporate asbestos-screening program.

He retired in 1992 with a clean bill of health from the company's screening program.

Eighteen days later, a high-resolution CT scan revealed a tumor on his lung. He and his doctors believed the tumor was asbestos-related, but Ford rejected his claim.

"They said, 'You were OK when you left here,'" Walker recalled bitterly.

Within the next three years, his lungs showed clear signs of asbestosis. Today, he uses medication to ease his breathing, and tries not to think about his close call.

"I was just lucky the cancer hadn't gone anyplace," he said. "I dodged a bullet."

CT scan disadvantages

But Brodkin says the ultimate value of CT-scan detection remains unclear.

The standard five-year survival rate for lung cancer is about 5 percent. High-resolution CT scans for detecting tumors caused by asbestos have been in use for only about the past six years, so it's too early to know whether their use will improve the survival rate, Brodkin said.

And there's a downside to their use. Scarred lungs are difficult to read, even with CT scans, he said. Scanning for tumors, doctors may get more false positives, which could lead them to do unwarranted invasive procedures.

CT scans have other limitations as well. They don't necessarily help pick up malignant mesothelioma, an asbestos-induced cancer of the lining of the lungs or stomach. Mesothelioma is difficult to detect, and by the time people have symptoms (such as pain in the chest), the disease is already advanced.

High-resolution CT scans could have another significant benefit, however. They could lead to earlier diagnosis of asbestosis, or scarring of the lungs.

Only about 20 percent of asbestosis is picked up by the general medical community, said Dr. Lonnie Joe, president of the Detroit Medical Society and a pulmonologist at Providence Hospital in Southfield, Mich. "As a result, much asbestos disease is undertreated or not treated at all."

Early asbestosis diagnosis allows patients to avoid further asbestos exposure, or other lung irritants, and lets them get started on regular cancer screening.

The emotional toll

Devastating physical illness isn't the only fallout from asbestos disease.

"The psychological and emotional aspects can be as debilitating as the physical ones," said Dr. Bernard Kole, a psychiatrist at Providence Hospital in Michigan, who sees a large number of patients with asbestosis and related diseases.

"People lose their place in life," he said. "They lose their stature. They have loss of function, loss of occupational status. Depression is common.

"It changes their relationship with family and friends. It can cause social isolation. And the economic burden of it is tremendous."

Mike Wolfe is a prime example.

He is only 46, but sometimes he feels like an old man. Wolfe started working for Hitachi near Detroit in 1976. By 1985, he'd worked his way up to a job in the foundry's "demag and blast" area. He loaded parts into steel trays lined with asbestos as part of a demagnetization process.

"A lot of people I worked with had emphysema and asthma," he said. "Most of the people who were old enough to retire died within two to three years (after retirement.)"

He didn't imagine his own "retirement" would come at age 35.

He was diagnosed with asbestosis in 1986. In 1988, he was barely able to breathe and was hospitalized for six months. He weighed 186 pounds when he went in. By the time he came out, he weighed 128.

Doctors told him he'd need a lung transplant to survive. He's needed two.

Even so, his breathing is labored.

"Every time I take a breath, it's like sandpaper on a wooden block," he said. "It feels like a vise."

His illness has robbed him of his youth and family life. "It's been tough on the kids," he said, wiping away tears. "I couldn't go anywhere because I was tied to the oxygen tanks."

Harbut wishes there were something else he could do for Wolfe and others like him.

He's asked the American Trial Lawyers Association, whose members represent many patients in claims against asbestos companies, to set up a fund for the study of improved treatment and diagnosis of asbestos-related diseases.

"They're getting rich off my patients," he said. So far he's had no response.

In the meantime, litigation continues to be an occupational hazard for doctors, such as Harbut, who treat a lot of patients with asbestos-related diseases.

Harbut tries not to take on patients involved in lawsuits. Nevertheless, he gets about 15 subpoenas a week for workers compensation or legal cases involving his patients.

But Harbut takes it in stride.

"I'm obligated to stick up for my patients," he said. "That's my job."

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