Quality of Evidence Must Guide Risk Assessment of Asbestos

In 2011, we reported on the sensitivity of lung cancer potency estimates for asbestos to the quality of the exposure assessment component of underlying evidence. Both this meta-analysis and a separate reassessment of standards published by the Health Council of the Netherlands (Gezondheidsraad) have been commented on by Berman and Case. A criticism is that we used a truncated data set. We incrementally excluded poorer-quality studies to evaluate trends in meta-analyzed lung cancer potency estimates (meta-K (L) values). This was one of three analysis approaches we presented. The other two used the full set of studies: a meta-analysis stratified by covariates and dichotomized by poorer and better exposure assessment aspects; and a meta-regression modeling both asbestos fiber type and these covariates. They also state that our results are not robust to removal of one study. We disagree with this claim and present additional sensitivity analyses underpinning our earlier conclusion that inclusion of studies with higher-quality asbestos-exposure assessment yield higher meta-estimates of the lung cancer risk per unit of exposure. We reiterate that potency differences for predominantly chrysotile- versus amphibole-asbestos-exposed cohorts are difficult to ascertain when meta-analyses are restricted to studies with fewer exposure assessment limitations. We strongly argue that the existence of any uncertainty related to potency issues should not hamper the development of appropriate evidence-based guidelines and stringent policies in order to protect the public from hazardous environmental and occupational exposures.