Did the Ban on Asbestos Reduce the Incidence of Mesothelioma?
2023; Elsevier BV; Volume: 18; Issue: 6 Linguagem: Inglês
10.1016/j.jtho.2023.03.013
ISSN1556-1380
AutoresMichele Carbone, Haining Yang, Harvey I. Pass, Emanuela Taioli,
Tópico(s)Occupational and environmental lung diseases
ResumoHuang et al.1Huang J. Chan S.C. Pang W.S. et al.Global Incidence, Risk Factors, and Temporal Trends of mesothelioma: a population-based study.J Thorac Oncol. 2023; 18: 792-802Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar report in the Journal of Thoracic Oncology a significant declining trend in the incidence of diffuse malignant mesothelioma for the past decade in most industrialized countries that implemented a ban or restrictive measures on asbestos. Similar results were recently reported for Australia by Walker-Bone et al.2Walker-Bone K. Benke G. MacFarlane E. et al.Incidence and mortality from malignant mesothelioma 1982–2020 and relationship with asbestos exposure: the Australian mesothelioma Registry.Occup Environ Med. 2023; 80: 186-191Crossref PubMed Scopus (6) Google Scholar The decrease in the incidence of mesothelioma was seen only in men, as expected, because men are much more frequently occupationally exposed to asbestos than women. To quantify the positive effect that the asbestos ban has had in reducing the incidence of mesothelioma, Huang et al.1Huang J. Chan S.C. Pang W.S. et al.Global Incidence, Risk Factors, and Temporal Trends of mesothelioma: a population-based study.J Thorac Oncol. 2023; 18: 792-802Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar measured the present annual incidence of mesothelioma in industrialized countries and compared it with past rates, revealing a significant decrease. What they could not measure is the inevitable increase of mesothelioma we would have seen at this time if the commercial use of asbestos had not been reduced and then halted in the 1980s and 90s in industrialized countries. In other words, the asbestos ban may have saved many more lives than what is exhibited by comparing the incidence of mesothelioma 40-some years ago with today's incidence. These findings are important because they illustrate that the measures taken in the 1980s and 90s to severely restrict (United States) or entirely ban asbestos use (Western European countries, Australia, etc.) did, as anticipated, save lives from mesothelioma. In Figure 1, for example, we present the annual incidence of mesothelioma in the United States from 1975 to 2019. We hope that this evidence will convince those countries that still allow the use of asbestos to implement similar restrictive measures to save lives from mesothelioma, a cancer that, for the most part, is still resistant to therapy.3Carbone M. Adusumilli P.S. Alexander Jr., H.R. et al.Mesothelioma: scientific clues for prevention, diagnosis, and therapy.CA Cancer J Clin. 2019; 69: 402-429Crossref PubMed Scopus (273) Google Scholar Huang et al.,1Huang J. Chan S.C. Pang W.S. et al.Global Incidence, Risk Factors, and Temporal Trends of mesothelioma: a population-based study.J Thorac Oncol. 2023; 18: 792-802Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar found that most mesotheliomas continue to be recorded in the Western world even though asbestos use is increasing exponentially in the developing world.3Carbone M. Adusumilli P.S. Alexander Jr., H.R. et al.Mesothelioma: scientific clues for prevention, diagnosis, and therapy.CA Cancer J Clin. 2019; 69: 402-429Crossref PubMed Scopus (273) Google Scholar As noted by Huang et al.,1Huang J. Chan S.C. Pang W.S. et al.Global Incidence, Risk Factors, and Temporal Trends of mesothelioma: a population-based study.J Thorac Oncol. 2023; 18: 792-802Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar there is reduced life expectancy in these countries and there is limited reliability of the diagnosis of mesothelioma in developing countries, likely accounting for this apparent paradox. The long latency period of 30 to 60 years between exposure and mesothelioma occurrence may also play a role. Asbestos is inhaled and deposited in tissues where it causes a chronic inflammatory process driven by HMGB1, which, over the course of several decades, may cause mesothelioma.4Baumann F. Ambrosi J.P. Carbone M. Asbestos is not just asbestos: an unrecognised health hazard.Lancet Oncol. 2013; 14: 576-578Abstract Full Text Full Text PDF PubMed Scopus (130) Google Scholar, 5Yang H. Rivera Z. Jube S. et al.Programmed necrosis induced by asbestos in human mesothelial cells causes high-mobility group box 1 protein release and resultant inflammation.Proc Natl Acad Sci U S A. 2010; 107: 12611-12616Crossref PubMed Scopus (213) Google Scholar, 6Xue J. Patergnani S. Giorgi C. et al.Asbestos induces mesothelial cell transformation via HMGB1-driven autophagy.Proc Natl Acad Sci U S A. 2020; 117: 25543-25552Crossref PubMed Scopus (45) Google Scholar, 7Novelli F. Bononi A. Wang Q. et al.BAP1 forms a trimer with HMGB1 and HDAC1 that modulates gene x environment interaction with asbestos.Proc Natl Acad Sci U S A. 2021; : 118Google Scholar, 8Xue J. Suarez J.S. Minaai M. et al.HMGB1 as a therapeutic target in disease.J Cell Physiol. 2021; 236: 3406-3419Crossref PubMed Scopus (112) Google Scholar Because of the field effect of asbestos, most mesotheliomas are polyclonal.9Comertpay S. Pastorino S. Tanji M. et al.Evaluation of clonal origin of malignant mesothelioma.J Transl Med. 2014; 12: 301Crossref PubMed Scopus (74) Google Scholar In the context of professional exposure and considering that most mesotheliomas occur in workers continuously exposed to asbestos for 10 or more years, this cancer develops during the seventh decade of life or later.3Carbone M. Adusumilli P.S. Alexander Jr., H.R. et al.Mesothelioma: scientific clues for prevention, diagnosis, and therapy.CA Cancer J Clin. 2019; 69: 402-429Crossref PubMed Scopus (273) Google Scholar Therefore, the older the population is, the more mesothelioma cases we may expect. This largely accounts for the finding that, although the incidence of mesothelioma per 100,000 is decreasing in industrialized countries because of the ban on asbestos1Huang J. Chan S.C. Pang W.S. et al.Global Incidence, Risk Factors, and Temporal Trends of mesothelioma: a population-based study.J Thorac Oncol. 2023; 18: 792-802Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar,2Walker-Bone K. Benke G. MacFarlane E. et al.Incidence and mortality from malignant mesothelioma 1982–2020 and relationship with asbestos exposure: the Australian mesothelioma Registry.Occup Environ Med. 2023; 80: 186-191Crossref PubMed Scopus (6) Google Scholar (Fig. 1), the overall number of mesotheliomas in these same countries has remained stable for the past decade. This is partly because of the larger fraction of older people in these populations and the time lag between exposure and cancer occurrence.3Carbone M. Adusumilli P.S. Alexander Jr., H.R. et al.Mesothelioma: scientific clues for prevention, diagnosis, and therapy.CA Cancer J Clin. 2019; 69: 402-429Crossref PubMed Scopus (273) Google Scholar,4Baumann F. Ambrosi J.P. Carbone M. Asbestos is not just asbestos: an unrecognised health hazard.Lancet Oncol. 2013; 14: 576-578Abstract Full Text Full Text PDF PubMed Scopus (130) Google Scholar,10Alpert N. van Gerwen M. Taioli E. Epidemiology of mesothelioma in the 21(st) century in Europe and the United States, 40 years after restricted/banned asbestos use.Transl Lung Cancer Res. 2020; 9: S28-S38Crossref PubMed Scopus (71) Google Scholar,11Baumann F. Carbone M. Environmental risk of mesothelioma in the United States: an emerging concern-epidemiological issues.J Toxicol Environ Health B Crit Rev. 2016; 19: 231-249Crossref PubMed Scopus (44) Google Scholar In addition, the risk of developing most cancers, including mesothelioma, increases with old age because of the inevitable accumulation of genetic damage in our cells. Therefore, the older the population, the higher will be the incidence of cancer, including mesothelioma. Conversely, the fraction of the population that reaches old age is much smaller in developing countries where the use of asbestos is still massive. This has been a major issue until the end of the past century, when novel immunohistochemical markers, calretinin, and WT1 in particular, allowed pathologists to distinguish mesothelioma more reliably from other malignancies.3Carbone M. Adusumilli P.S. Alexander Jr., H.R. et al.Mesothelioma: scientific clues for prevention, diagnosis, and therapy.CA Cancer J Clin. 2019; 69: 402-429Crossref PubMed Scopus (273) Google Scholar,12Nasu M. Emi M. Pastorino S. et al.High Incidence of Somatic BAP1 alterations in sporadic malignant mesothelioma.J Thorac Oncol. 2015; 10: 565-576Abstract Full Text Full Text PDF PubMed Scopus (245) Google Scholar, 13Chapel D.B. Schulte J.J. Husain A.N. Krausz T. Application of immunohistochemistry in diagnosis and management of malignant mesothelioma.Transl Lung Cancer Res. 2020; 9: S3-S27Crossref PubMed Scopus (68) Google Scholar, 14Tsao M.S. Carbone M. Galateau-Salle F. et al.Pathologic considerations and standardization in mesothelioma clinical trials.J Thorac Oncol. 2019; 14: 1704-1717Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar More recently, it was discovered that the lack of BAP1 nuclear staining combined with fluorescence in situ hybridization analyses for biallelic loss of CDKN2A allows distinguishing mesothelioma from benign reactive mesothelial proliferations.3Carbone M. Adusumilli P.S. Alexander Jr., H.R. et al.Mesothelioma: scientific clues for prevention, diagnosis, and therapy.CA Cancer J Clin. 2019; 69: 402-429Crossref PubMed Scopus (273) Google Scholar,12Nasu M. Emi M. Pastorino S. et al.High Incidence of Somatic BAP1 alterations in sporadic malignant mesothelioma.J Thorac Oncol. 2015; 10: 565-576Abstract Full Text Full Text PDF PubMed Scopus (245) Google Scholar, 13Chapel D.B. Schulte J.J. Husain A.N. Krausz T. Application of immunohistochemistry in diagnosis and management of malignant mesothelioma.Transl Lung Cancer Res. 2020; 9: S3-S27Crossref PubMed Scopus (68) Google Scholar, 14Tsao M.S. Carbone M. Galateau-Salle F. et al.Pathologic considerations and standardization in mesothelioma clinical trials.J Thorac Oncol. 2019; 14: 1704-1717Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar However, despite these advances, in 2018, a team of expert pathologists in mesothelioma changed the diagnosis of 14% of 5258 mesotheliomas diagnosed in France in recent years to either benign lesions, primary pleural or lung sarcomas invading the pleura, metastases from various carcinomas, or direct pleural invasion by lung cancer.3Carbone M. Adusumilli P.S. Alexander Jr., H.R. et al.Mesothelioma: scientific clues for prevention, diagnosis, and therapy.CA Cancer J Clin. 2019; 69: 402-429Crossref PubMed Scopus (273) Google Scholar The rate of erroneous diagnosis is much higher in developing countries, which can approach 50%.3Carbone M. Adusumilli P.S. Alexander Jr., H.R. et al.Mesothelioma: scientific clues for prevention, diagnosis, and therapy.CA Cancer J Clin. 2019; 69: 402-429Crossref PubMed Scopus (273) Google Scholar,15Guo Z. Carbone M. Zhang X. et al.Improving the accuracy of mesothelioma diagnosis in China.J Thorac Oncol. 2017; 12: 714-723Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar Therefore, published estimates about the incidence of mesothelioma in developing countries are, for the most part, unreliable.1Huang J. Chan S.C. Pang W.S. et al.Global Incidence, Risk Factors, and Temporal Trends of mesothelioma: a population-based study.J Thorac Oncol. 2023; 18: 792-802Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar,3Carbone M. Adusumilli P.S. Alexander Jr., H.R. et al.Mesothelioma: scientific clues for prevention, diagnosis, and therapy.CA Cancer J Clin. 2019; 69: 402-429Crossref PubMed Scopus (273) Google Scholar As for the Western world, the population that has been professionally exposed to asbestos is decreasing, as former asbestos workers die because of old age. However, asbestos present in old buildings and in other types of constructions, and also in the natural environment will continue to cause exposure and may cause mesothelioma.11Baumann F. Carbone M. Environmental risk of mesothelioma in the United States: an emerging concern-epidemiological issues.J Toxicol Environ Health B Crit Rev. 2016; 19: 231-249Crossref PubMed Scopus (44) Google Scholar In the past, mesotheliomas occurred mostly in asbestos miners, pipefitters, insulators, shipyard workers, and their family members who were indirectly exposed to asbestos through their relatives' contaminated clothes. For example, about 4.6% of workers who mined asbestos for 10 or more years developed mesothelioma.16Sluis-Cremer G.K. Liddell F.D. Logan W.P. Bezuidenhout B.N. The mortality of amphibole miners in South Africa, 1946–80.Br J Ind Med. 1992; 49: 566-575PubMed Google Scholar These workers and their immediate relatives were exposed to high levels of asbestos and were easily identified using questionnaires. At present, most mesotheliomas occur outside of these professions, and the questionnaires developed to identify work-related exposure are not equipped to identify reliably other possible forms of exposure.17Vimercati L. Cavone D. Delfino M.C. et al.Asbestos air pollution: description of a mesothelioma cluster due to residential exposure from an asbestos cement factory.Int J Environ Res Public Health. 2020; 17: 2636Crossref PubMed Scopus (12) Google Scholar For example, asbestos and other carcinogenic mineral fibers such as erionite and antigorite are present in the natural environment in many geographic areas, including the United States, sometimes in high amounts.18Carbone M. Baris Y.I. Bertino P. et al.Erionite exposure in North Dakota and Turkish villages with mesothelioma.Proc Natl Acad Sci U S A. 2011; 108: 13618-13623Crossref PubMed Scopus (184) Google Scholar,19Baumann F. Buck B.J. Metcalf R.V. McLaurin B.T. Merkler D.J. Carbone M. The presence of asbestos in the natural environment is likely related to mesothelioma in young individuals and women from Southern Nevada.J Thorac Oncol. 2015; 10: 731-737Abstract Full Text Full Text PDF PubMed Scopus (96) Google Scholar The development and gentrification of rural areas produce a cohort of workers first and residents later who are exposed to these carcinogenic fibers from the natural environment and may later develop mesothelioma.3Carbone M. Adusumilli P.S. Alexander Jr., H.R. et al.Mesothelioma: scientific clues for prevention, diagnosis, and therapy.CA Cancer J Clin. 2019; 69: 402-429Crossref PubMed Scopus (273) Google Scholar,11Baumann F. Carbone M. Environmental risk of mesothelioma in the United States: an emerging concern-epidemiological issues.J Toxicol Environ Health B Crit Rev. 2016; 19: 231-249Crossref PubMed Scopus (44) Google Scholar,18Carbone M. Baris Y.I. Bertino P. et al.Erionite exposure in North Dakota and Turkish villages with mesothelioma.Proc Natl Acad Sci U S A. 2011; 108: 13618-13623Crossref PubMed Scopus (184) Google Scholar, 19Baumann F. Buck B.J. Metcalf R.V. McLaurin B.T. Merkler D.J. Carbone M. The presence of asbestos in the natural environment is likely related to mesothelioma in young individuals and women from Southern Nevada.J Thorac Oncol. 2015; 10: 731-737Abstract Full Text Full Text PDF PubMed Scopus (96) Google Scholar, 20Carbone M. Ly B.H. Dodson R.F. et al.Malignant mesothelioma: facts, myths, and hypotheses.J Cell Physiol. 2012; 227: 44-58Crossref PubMed Scopus (291) Google Scholar These exposures are often unknown to workers and residents and, thus, will not be caught by a questionnaire.17Vimercati L. Cavone D. Delfino M.C. et al.Asbestos air pollution: description of a mesothelioma cluster due to residential exposure from an asbestos cement factory.Int J Environ Res Public Health. 2020; 17: 2636Crossref PubMed Scopus (12) Google Scholar Personal histories are also of limited value. Some patients may recall having been exposed to "dust" but they cannot tell with any reliability whether that "dust" did or did not contain asbestos; only microscopy can identify the type and nature of the fibers present in the dust. For example, when some of us conducted an electron microscopy study of 38 lung biopsies from patients with mesothelioma operated at the U.S. National Cancer Institute (by Dr. Pass), there was no significant association between reported exposure collected through the American Thoracic Division of Lung Disease adult questionnaire and the amount of asbestos in the lungs of these patients.20Carbone M. Ly B.H. Dodson R.F. et al.Malignant mesothelioma: facts, myths, and hypotheses.J Cell Physiol. 2012; 227: 44-58Crossref PubMed Scopus (291) Google Scholar An additional problem discussed2Walker-Bone K. Benke G. MacFarlane E. et al.Incidence and mortality from malignant mesothelioma 1982–2020 and relationship with asbestos exposure: the Australian mesothelioma Registry.Occup Environ Med. 2023; 80: 186-191Crossref PubMed Scopus (6) Google Scholar is the potential bias derived from the significant economical incentive associated with reporting asbestos exposure, which, in the United States, is several millions of dollars awarded to patients with mesothelioma or their family members. On their lawyer's advice, many patients decline to provide information and compile questionnaires.2Walker-Bone K. Benke G. MacFarlane E. et al.Incidence and mortality from malignant mesothelioma 1982–2020 and relationship with asbestos exposure: the Australian mesothelioma Registry.Occup Environ Med. 2023; 80: 186-191Crossref PubMed Scopus (6) Google Scholar A similar problem was observed when conducting genetic testing in patients with mesothelioma.21Carbone M. Pass H.I. Ak G. et al.Medical and surgical care of patients with mesothelioma and their relatives carrying germline BAP1 mutations.J Thorac Oncol. 2022; 17: 873-889Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar However, over 90% of patients with mesothelioma whose lungs contained higher than background levels of asbestos had medical evidence of exposure, including bilateral pleural plaques, lung fibrosis, and ferruginous bodies in their lung tissue.22Kato K. Gemba K. Ashizawa K. et al.Low-dose chest computed tomography screening of subjects exposed to asbestos.Eur J Radiol. 2018; 101: 124-128Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar,23Dodson R.F. O'Sullivan M. Corn C.J. McLarty J.W. Hammar S.P. Analysis of asbestos fiber burden in lung tissue from mesothelioma patients.Ultrastruct Pathol. 1997; 21: 321-336Crossref PubMed Scopus (57) Google Scholar Therefore, in the absence of obvious work history of exposure—that is, asbestos miners, and so on—objective medical evidence is more reliable than interviews and questionnaires to identify patients whose mesotheliomas were caused by asbestos. At the epidemiologic level, mesotheliomas associated with asbestos exposure are more likely to occur in older individuals with a male-to-female ratio of 5:1 and a pleural-to-peritoneal ratio of 5:1. Mesotheliomas occurring in individuals younger than 55 years, with a male-to-female ratio close to 1:1, and equally distributed between pleura and peritoneum, are often caused by environmental exposure to carcinogenic fibers present in the natural environment, by germline mutations of BAP1 or other tumor suppressor genes. Moreover, in older individuals, mesothelioma, like any cancer, may develop spontaneously after the inevitable accumulation of DNA damage that occurs during the aging process.3Carbone M. Adusumilli P.S. Alexander Jr., H.R. et al.Mesothelioma: scientific clues for prevention, diagnosis, and therapy.CA Cancer J Clin. 2019; 69: 402-429Crossref PubMed Scopus (273) Google Scholar,11Baumann F. Carbone M. Environmental risk of mesothelioma in the United States: an emerging concern-epidemiological issues.J Toxicol Environ Health B Crit Rev. 2016; 19: 231-249Crossref PubMed Scopus (44) Google Scholar,21Carbone M. Pass H.I. Ak G. et al.Medical and surgical care of patients with mesothelioma and their relatives carrying germline BAP1 mutations.J Thorac Oncol. 2022; 17: 873-889Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar In summary, the article by Huang et al.1Huang J. Chan S.C. Pang W.S. et al.Global Incidence, Risk Factors, and Temporal Trends of mesothelioma: a population-based study.J Thorac Oncol. 2023; 18: 792-802Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar in this issue of the Journal of Thoracic Oncology and the recent article by Walker-Bone et al.2Walker-Bone K. Benke G. MacFarlane E. et al.Incidence and mortality from malignant mesothelioma 1982–2020 and relationship with asbestos exposure: the Australian mesothelioma Registry.Occup Environ Med. 2023; 80: 186-191Crossref PubMed Scopus (6) Google Scholar revealed that the measures implemented in the 1980s and 90s in the Western world to reduce asbestos exposure have been effective—the incidence of mesothelioma per 100,000 persons is decreasing. However, the overall number of mesotheliomas has not declined, at least in the United States, because of a combination of several factors, namely: (1) the realization that about 12% of mesotheliomas are linked to germline mutations of BAP1 or other genes—presumably, in the past, these mesotheliomas were attributed to asbestos21Carbone M. Pass H.I. Ak G. et al.Medical and surgical care of patients with mesothelioma and their relatives carrying germline BAP1 mutations.J Thorac Oncol. 2022; 17: 873-889Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar,24Hassan R. Morrow B. Walsh T. et al.Inherited predisposition to malignant mesothelioma (MM) due to mutations in DNA repair genes.J Clin Oncol. 2018; 36 (8504–8504)Google Scholar,25Panou V. Gadiraju M. Wolin A. et al.Frequency of germline mutations in cancer susceptibility genes in malignant mesothelioma.J Clin Oncol. 2018; 36: 2863-2871Crossref PubMed Scopus (142) Google Scholar; (2) the development of rural areas containing asbestos and other carcinogenic fibers, which has caused exposure in workers first and residents later18Carbone M. Baris Y.I. Bertino P. et al.Erionite exposure in North Dakota and Turkish villages with mesothelioma.Proc Natl Acad Sci U S A. 2011; 108: 13618-13623Crossref PubMed Scopus (184) Google Scholar,19Baumann F. Buck B.J. Metcalf R.V. McLaurin B.T. Merkler D.J. Carbone M. The presence of asbestos in the natural environment is likely related to mesothelioma in young individuals and women from Southern Nevada.J Thorac Oncol. 2015; 10: 731-737Abstract Full Text Full Text PDF PubMed Scopus (96) Google Scholar; (3) the development and use of radiation therapy in the past decades to treat several malignancies, which may cause mesothelioma years later26Chirieac L.R. Barletta J.A. Yeap B.Y. et al.Clinicopathologic characteristics of malignant mesotheliomas arising in patients with a history of radiation for Hodgkin and non-Hodgkin lymphoma.J Clin Oncol. 2013; 31: 4544-4549Crossref PubMed Scopus (43) Google Scholar, 27Farioli A. Ottone M. Morganti A.G. et al.Radiation-induced mesothelioma among long-term solid cancer survivors: a longitudinal analysis of SEER database.Cancer Med. 2016; 5: 950-959Crossref PubMed Scopus (39) Google Scholar, 28Yano M. Ikeda Y. Kato T. et al.A case of peritoneal malignant mesothelioma following radiation therapy for cervical cancer.Mol Clin Oncol. 2018; 8: 302-305PubMed Google Scholar, 29Naeini Y.B. Arcega R. Hirschowitz S. Rao N. Xu H. Post-irradiation pericardial malignant mesothelioma with deletion of p16: a case report.Cancer Biol Med. 2018; 15: 97-102Crossref PubMed Scopus (5) Google Scholar; and (4) mesothelioma is a cancer that prevalently strikes old people—as the fraction of the population that reaches the eighth and ninth decade of life increases, the number of people most susceptible to develop mesothelioma increases.11Baumann F. Carbone M. Environmental risk of mesothelioma in the United States: an emerging concern-epidemiological issues.J Toxicol Environ Health B Crit Rev. 2016; 19: 231-249Crossref PubMed Scopus (44) Google Scholar At times, some of these factors may also interact with each other and promote the development of mesothelioma.30Carbone M. Arron S.T. Beutler B. et al.Tumour predisposition and cancer syndromes as models to study gene-environment interactions.Nat Rev Cancer. 2020; 20: 533-549Crossref PubMed Scopus (76) Google Scholar As for the incidence of mesothelioma in the developing world, as noted by Huang et al.,1Huang J. Chan S.C. Pang W.S. et al.Global Incidence, Risk Factors, and Temporal Trends of mesothelioma: a population-based study.J Thorac Oncol. 2023; 18: 792-802Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar the data are unreliable because of the reasons previously discussed.3Carbone M. Adusumilli P.S. Alexander Jr., H.R. et al.Mesothelioma: scientific clues for prevention, diagnosis, and therapy.CA Cancer J Clin. 2019; 69: 402-429Crossref PubMed Scopus (273) Google Scholar Given that, in the developing world, the use of asbestos is increasing, it is reasonable to expect that the incidence of mesothelioma will increase. Therefore, we suggest that restrictive measures similar to those introduced in the Western World should be introduced in the developing world before we are faced with a mesothelioma epidemic in those countries. Michele Carbone: Investigation, Writing - original draft. Michele Carbone, Haining Yang, Harvey I. Pass, Emanuela Taioli: Reviewing and editing subsequent drafts. Emanuela Taioli: Visualization. Global Incidence, Risk Factors, and Temporal Trends of Mesothelioma: A Population-Based StudyJournal of Thoracic OncologyVol. 18Issue 6PreviewMesothelioma is an uncommon type of cancer which has received little attention. This study aims to evaluate the global disease burden; trends of mesothelioma by age, sex, and geographic locations; and its risk factors on the population level. Full-Text PDF Open Access
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