Medical knowledge | Diseases » Chamming-Clin-Brochard - Compensation of Pleural Mesothelioma in France, Data from French National Mesothelima Surveillance Programme

Source: http://www.doksinet TITLE: COMPENSATION OF PLEURAL MESOTHELIOMA IN FRANCE: DATA FROM THE FRENCH NATIONAL MESOTHELIOMA SURVEILLANCE PROGRAMME Running head: Compensation of pleural mesothelioma in France. * * Soizick CHAMMING’S1 , Bénédicte CLIN2, 3 , MD, PhD, Patrick BROCHARD4, MD, PhD, Philippe ASTOUL5, MD, PhD, Stéphane DUCAMP6,7, Fançoise GALATEAU-SALLE8, MD, PhD, Annabelle GILG SOIT ILG7, MD, 7 Marcel GOLDBERG , MD, PhD, Céline GRAMOND4, Ellen IMBERNON7, MD, Patrick ROLLAND6,7, Jean-Claude PAIRON1,2,9, MD, PhD 1 - Institut Interuniversitaire de Médecine du Travail de Paris-Ile de France, Paris, France 2 - INSERM, Unité 955, Créteil, 94000, France 3 - Centre Hospitalier Universitaire de Caen, Service de santé au travail et pathologie professionnelle, Caen, 14000, France 4 - Centre Hospitalier Universitaire de Bordeaux, Institut de Santé Publique d’Epidémiologie et de Développement (ISPED), Laboratoire Santé Travail Environnement, Centre INSERM U897,

Université Bordeaux Segalen, Bordeaux, 33000, France 5 - Centre Hospitalier Universitaire de Marseille, Department of Thoracic Oncology, Pleural Diseases, and Interventional Pulmonology, North Hospital, Marseille, 13000, France 6 - Institut de veille sanitaire (InVS) - Département Santé Travail - Equipe associée en santé travail, Univ. Bordeaux, ISPED, Centre INSERM U897, Bordeaux, 33000 - France 7 - Institut de veille sanitaire (InVS), Département Santé Travail, Saint-Maurice, 94415, France 8 - Centre Hospitalier Universitaire de Caen, Service d’anatomie pathologique, Caen, 14000, France 9 - Centre Hospitalier Intercommunal de Créteil, Service de Pneumologie et de Pathologie Professionnelle, Créteil, 94000, France * Both authors contributed equally to this work Corresponding author: Dr Bénédicte CLIN Service de Santé au Travail et Pathologie Professionnelle (Occupational Health Department) CHU (University Hospital) Côte de Nacre 14033 CAEN Cedex – France Tel: (33) 2

31 06 54 65 clin-b@chu-caen.fr Conflict of interest: The authors declare that they have no competing interests, or other interests that might be perceived to influence the results and discussion reported in this paper. Word count: 3078 1 Source: http://www.doksinet ABSTRACT: Background The aim of this study was to determine the rates of compensation awarded to patients presenting with pleural mesothelioma and factors linked to such compensation in France. Methods The study population consisted of 2,407 patients presenting with pleural mesothelioma, recorded by the National Mesothelioma Surveillance Programme between 1st January 1999 and 31st December 2009. Analysis of claims for recognition as “occupational disease” (OD) and claims for compensation by the Compensation Fund for Asbestos Victims (FIVA) were analysed. Results Approximately 30% of subjects presenting with pleural mesothelioma, affiliated to the General National Health Insurance fund, neither sought recognition as

an occupational disease nor claimed for FIVA compensation. Gender, age at diagnosis, type of health insurance and socio-professional category influence the likelihood of patients presenting with mesothelioma seeking compensation for this disease. Conclusions Results show an under-compensation of pleural mesothelioma as OD and by the FIVA in France. Keywords: pleural mesothelioma, medical compensation, occupational disease 2 Source: http://www.doksinet INTRODUCTION Pleural mesothelioma is a rare and almost always fatal cancer of the pleura, almost entirely attributable to asbestos exposure in men [Tossavainen et al., 2004] Indeed, for known asbestos exposure, the attributable risk of mesothelioma ranges from 74% to 88% in men, whereas in women, less than 40% of pleural mesothelioma is attributable to asbestos exposure [Goldberg et al., 2006; Spirtas et al, 1994; Teschke et al, 1997] Other forms of mesothelioma can occur (peritoneal mesothelioma, pericardial mesothelioma and

mesothelioma of the tunica vaginalis). Since asbestos exposure is typically due to occupational sources, mesothelioma of the pleura and sometimes of the peritoneum is recognised as a compensable occupational disease (OD) in many countries [EUROGIP, 2002, 2010; Kirkham et al., 2011; Hyland et al, 2007; Payne et al., 2008] In France, the National Mesothelioma Surveillance Programme (PNSM) was established early 1998, in order to ensure the epidemiological surveillance of the effects of asbestos exposure on the population, by recording pleural mesothelioma cases. Mesothelioma of other sites is not covered by the PNSM. Overall coordination of the PNSM has been assigned to the Occupational Health Department of the National Institute for Public Health Surveillance (DST-InVS). In 2011, the PNSM records incident pleural tumours in 23 French départements, covering approximately a quarter of the French population. The objectives of this programme are not only to estimate trends in mesothelioma

incidence in France and the proportion attributable to occupational asbestos exposure, but also to contribute towards research into other possible aetiological factors and to improve the pathological diagnosis of mesothelioma. Details of the PNSMs organisation and operation have been previously published [Goldberg et al., 2006] 3 Source: http://www.doksinet The social component of this programme assesses the extent of compensation awarded to pleural mesothelioma sufferers, as an occupational disease and/or by the Compensation Fund for Asbestos Victims (FIVA). Indeed, patients occupationally exposed to asbestos and presenting with pleural mesothelioma can benefit from compensation for the damage they have sustained on the grounds of occupational disease, whether they are affiliated to the General National Health Insurance (organisation covering worker compensation for over 80% of the French population) or to a different health insurance fund, with the exception of selfemployed

workers. Furthermore, the FIVA, which has been operational since 2002, enables any patient suffering from pleural mesothelioma (or from other diseases associated with asbestos exposure) to claim complementary compensation for damage sustained, over and above compensation for acknowledged occupational disease, without seeking litigation. The FIVA also enables any patient suffering from pleural mesothelioma to claim integral compensation for the damage sustained, even in the case of non-occupational asbestos exposure, provided such exposure occurred within the French territory. In France, claims for the recognition of pleural mesothelioma as OD have been shown to be lower than expected, and important geographical disparities in compensation have been observed, despite confirmed occupational exposure to asbestos [Goldberg et al., 1999, 2006; Chamming’s et al., 2003] The aim of our study was to describe the rates of claims for compensation by patients presenting with pleural mesothelioma

in France and recorded by the National Mesothelioma Surveillance Programme on the grounds of OD, and by the FIVA, together with the factors linked to these claims for compensation. 4 Source: http://www.doksinet MATERIAL AND METHODS Study population The study population consisted of 2,407 patients presenting with pleural mesothelioma, recorded by the PNSM between 1st January 1999 and 31st December 2009 in any of the 21 départements having recorded more than 15 cases during this period (Figure 1). The number indicated for each département on this map corresponds to the associated French administrative code. Département names: 06=Alpes Maritimes, 13=Bouches du Rhône, 14=Calvados, 24=Dordogne, 25=Doubs, 33=Gironde, 34=Hérault, 38=Isère, 40= Landes, 44=Loire Atlantique, 47=Lot et Garonne, 50=Manche, 61=Orne, 64=Pyrénées Atlantiques, 67=Bas Rhin, 68=Haut Rhin, 76=Seine Maritime, 80=Somme, 83=Var, 93=Seine Saint Denis, 94=Val de Marne. Corse du Sud (2A) and Haute Corse (2B),

currently included in the PNSM, together with Côte d’Or (21) and Tarn (81), not included in the PNSM since 2003, have been excluded from this study since they recorded less than 15 cases. Analysis of claims for recognition as OD was restricted to patients affiliated to the General National Health Insurance. In contrast, claims for compensation by the FIVA were analysed for all patients, independently of their health insurance, for cases recorded by the PNSM from 1st January 2005 to 31st December 2009. No approval from an ethics Committee or an Institutional Review Board was necessary; since no biological sample was needed in this study (only medical and administrative data were collected). Authorisation for data computerisation was obtained (agreement n°998100 granted by the CNIL, Commission nationale de l’informatique et des libertés). Data collection 5 Source: http://www.doksinet Demographical data For each included subject, information on age, gender, socio-professional

category of the last job, and département of residence was collected. Exposure data As previously described, trained investigators used a standardised questionnaire to collect information from recorded subjects, during a face-to-face interview [Goldberg et al., 2006] In the case of a patient’s death, or in the case of the patients impossibility to respond via a face to face interview, a family member, friend or a doctor was interviewed using a shorter questionnaire, in order to collect minimal data concerning occupational and extraoccupational exposure to asbestos. For all patients responding to this standardised questionnaire, we were able to determine place of residence, schools attended, detailed job history including tasks performed for each job, as well as home repairs and do-it-yourself handiwork. Furthermore, the questionnaire enquired on other situations during the subject’s lifetime likely to have involved exposure to asbestos. Each questionnaire was analysed by

industrial and environmental hygiene experts to assess probability, intensity and frequency of exposure [Rolland et al., 2010, Gramond et al, 2012] Social data Concerning claims for recognition as OD, the following data were collected: affiliation to the General National Health Insurance, declaration of pleural mesothelioma as an occupational disease and associated date, response from the General National Health Insurance and date, and reasons for possible refusal. The proportion of patients eligible for compensable OD from the General National Health Insurance and the proportion of subjects who did not apply for compensation were compared, according to gender and type of questionnaire. 6 Source: http://www.doksinet Trends in rates of claims for compensation as OD were analysed for the 15 départements included in the PNSM between 1999 and 2009 (Calvados (14), Dordogne (24), Doubs (25), Gironde (33), Isère (38), Landes (40), Loire-Atlantique (44), Lot et Garonne (47), Manche (50),

Orne (61), Pyrénées Atlantiques (64), Bas Rhin (67), Haut Rhin (68), Somme (80), Seine Saint Denis (93)). Concerning claims for compensation by the FIVA, the following data were collected: claims for compensation for pleural mesothelioma, response by the FIVA and patient’s health insurance (General National Health Insurance or other health insurance fund). The proportion of patients having sought FIVA compensation was analysed according to health insurance, département of residence, year of diagnosis, gender, age and socio-professional category. Statistical analysis Qualitative variables were compared using the Chi-square test (rates for compensation as occupational disease depending on gender and type of questionnaire, rates of claims for compensation by the FIVA depending on social security scheme, age at diagnosis or gender). The trend in rates for compensation were analysed using the Pearson’s correlation test. Significant probability for these tests was defined as: p ≤

0.05 Odds ratios were calculated using the method of Miettinen [Miettinen, 1970]. RESULTS Between 1999 and 2009, 2,407 cases of pleural mesothelioma were recorded in the départements covered by the PNSM with more than 15 cases and, hence, not excluded by the diagnostic confirmation procedure. Among these cases, 75% (n=1,814) were covered by the General National Health Insurance fund. 7 Source: http://www.doksinet Only 62% (n=1123) of these subjects sought recognition as an occupational disease, which was granted to 91% of claimants (n=1022). Refusals were all explained by failure to meet the administrative criteria for recognition (essentially the failure to confirm asbestos exposure, due to a lack of administrative archives within since-closed plants). Among the 38% of subjects who did not seek recognition, 39% were considered as having been occupationally exposed to asbestos after expertise via the occupational questionnaire. The proportion of claims varied according to

département (table 1) and was significantly higher in men (70%) than in women (32%, p<0.001), and among the 77% of subjects attending a face to face interview compared to subjects responding to a shorter questionnaire (69% versus 53%, p<0.001) Trends in rates of claims for compensation on the grounds of OD were analysed between 1st January 1999 and 31st December 2009 for the 15 départements included in the PNSM since 1999. A non-significant decrease in claims for OD was observed (from 70% in 1999 to 66% in 2009) independently of whether they were evaluated by year or by period. The number of granted OD claims was globally stable (from 98% in 1999 to 95% in 2009; minimum 87% in 2006 maximum in 1999) (table 2). Among the 1,418 cases of pleural mesothelioma recorded in the PNSM since 1st January 2005, 51% of patients (n=723) sought FIVA compensation. Once mesothelioma diagnosis was confirmed, the FIVA proposed compensation in 100% of cases. The proportion of subjects having

claimed for FIVA compensation was significantly higher (p<0.001) among the 1,114 subjects affiliated to the General National Health Insurance (55% of claims), than for the 304 subjects affiliated to a different health insurance fund (only 37% of claims). Variability was observed in the percentages of claims for FIVA compensation, according to département: from 26% in Alpes Maritimes (06) to 77% in Manche (50). Furthermore, the proportion of claims for FIVA compensation varied according to age at diagnosis, being 8 Source: http://www.doksinet significantly higher for younger subjects (66% in subjects aged under 65 years versus 36% in subjects aged over 75 years, p<0.001) A total of 30% of subjects presenting with pleural mesothelioma and affiliated to the General National Health Insurance neither sought recognition as an occupational disease nor claimed for FIVA compensation. The proportion of women having sought neither recognition as occupational disease nor FIVA

compensation was significantly higher than men (47% of women versus 24% of men, p<0.001) Furthermore, the proportion of subjects seeking neither recognition as OD nor FIVA compensation was significantly higher in older subjects (44% of subjects aged over 75 years versus 19% of subjects under 65 years, p<0.001) (figure 2) Analysis of the relationships between socio-professional categories and rates of claims for compensation of pleural mesothelioma as OD or for FIVA compensation is reported in table 3. Among subjects with identified exposure to asbestos, labourers/workmen more frequently claimed compensation for occupational disease than managers (OR=3.0 [IC 95% 18-49]) Concerning FIVA compensation, labourers/workmen also tended to claim more frequently than managers (OR=1.4 [95%CI 09-22]) DISCUSSION In this study, the main finding was the observation of an under-compensation of pleural mesothelioma as OD and by the FIVA for patients recorded by the PNSM in France. Indeed, around

30% of subjects presenting with pleural mesothelioma, affiliated to the General National Health Insurance, neither sought recognition as an occupational disease nor claimed for FIVA compensation. On the grounds of OD, for patients affiliated to the General National Health Insurance fund and recorded between 1999 and 2009 in the 21 départements with more than 15 cases included in the PNSM, the overall compensation rate for pleural mesothelioma was 62%, which is comparable to data obtained in a study conducted in New South Wales, Australia. 9 Source: http://www.doksinet Indeed, the authors observed that 64.6% of mesothelioma cases reported to the cancer registry from 1972 to 2004 were compensated by the worker’s compensation system [Hyland et al., 2007]. In a study conducted in British Columbia, Canada, compensation rates were also lower than anticipated for cases believed to be work-related, the overall compensation rate for mesothelioma from 1970 to 2005 being 33%, but slowly

increasing over the study period [Kirkham et al., 2011] In another study, conducted in the Canadian province of Ontario, 38% of pleural and peritoneal mesothelioma cases between 1980 and 2002 claimed for compensation and 87% of claimants received it for an overall compensation rate of approximately 33% [Payne et al., 2008] In our study, even if high rates of pleural mesothelioma were granted as occupational diseases (91%), claims for recognition of pleural mesothelioma as OD were lower than expected, since among the 38% of subjects who did not seek recognition, at least 39% were considered as asbestos exposed, with an additional 36% of subjects for whom information on occupation was unavailable. The complexity of procedures and patients’ ignorance of their eligibility for compensation could explain this lack in claims for compensation of their disease [ThebaudMony, 2004]. Furthermore, the severity of disease at the time of diagnosis could result in the patients first concern being

the battle against disease, any claim for recognition being considered as secondary. The physicians in charge of these patients play a very important role, particularly in identifying a possible link between pleural mesothelioma and the patient’s job history, but also in informing patients of the modalities involved in having their condition acknowledged as an occupational disease [Saliba et al., 2007; Verger et al, 2008] This could explain the higher rate of compensation as occupational disease for subjects attending a detailed face to face interview, for whom the link between disease and exposure was easier to establish for the physician, than for subjects for whom only response to a shorter questionnaire was available. It should be emphasised that the rate of claims for recognition as OD was relatively 10 Source: http://www.doksinet high in subjects with a clear identification of occupational exposure to asbestos, 75.5% of them actually claiming for compensation. Another

possible explanation for this difference in proportion concerns the investigator. During a face-to-face interview, it is easier for the investigator to increase the patients awareness of potential possibilities for acknowledgement as OD or for obtaining FIVA compensation, than during exclusive contact with a family member, less inclined to embark on such a claim after the patients death, even he/she still has the possibility to do so. It should be emphasized that, for a given subject, occupational exposure to asbestos may have occurred in a job other than the latest occupied position and may partly explain why identifying previous exposure to asbestos can prove difficult for the physician. The global low rate of claims for recognition could also be explained essentially by the physician’s own awareness of the issue and/or the patient’s decision (to claim for compensation or not). Analysis of trends in rates of claims for compensation on the grounds of OD from 1st January 1999 to

31st December 2009, for the 15 départements included in the PNSM since 1999, showed a non-significant decrease in claims for OD, with geographical disparities. There is no clear explanation for these discrepancies. Gender, age at diagnosis, département of residence and type of health insurance influence the likelihood of patients presenting with mesothelioma seeking compensation for this disease. Indeed, between 1999 and 2009, the rates of claims for compensation as occupational disease were significantly higher in men (70%) than in women (32%, p<0.001) This difference could be explained by historical working patterns and gender differences in occupational exposure to asbestos for men and women. Indeed, the sectors of occupational activity exposing to asbestos, with the exception of asbestos-based textiles, were almost exclusively occupied by men. Consequently, certain women, who may have developed mesothelioma due to residential exposure in the home via occupationally exposed

family members, were not 11 Source: http://www.doksinet eligible for compensation as occupational disease. This low rate of claims for compensation as occupational disease in women presenting with pleural mesothelioma is similar to patterns reported in Canada and New South Wales [Kirkham et al., 2011; Hyland et al, 2007; Payne et al., 2008] Nevertheless, even if women who may have developed mesothelioma due to residential exposure can seek for integral compensation from the FIVA, the rate of women having sought neither recognition nor FIVA compensation was surprisingly significantly higher than for men (47% in women versus 24% in men, p<0.001) Furthermore, the proportion of subjects seeking neither recognition as OD nor FIVA compensation was higher in older subjects (44% in subjects aged over 75 years versus 19% in subjects under 65 years). This lower number of claims for compensation in older subjects was previously observed in another study [Kirkham et al., 2011] One

hypothesis to explain this trend could be that for older subjects, a majority of retired workers and physicians may not be aware that retired workers are still eligible for compensation. Claims for compensation among patients presenting with pleural mesothelioma also depends on the type of health insurance, since the proportion of subjects having claimed for FIVA compensation was significantly higher (p<0.001) among subjects affiliated to the General National Health Insurance (55% of claims) than those affiliated to a different health insurance fund (only 37% of claims). This was unexpected since the FIVA was created in order to allow compensation for all subjects having been exposed within the French territory, independently of the source of exposure (i.e occupational, domestic or environmental) For the FIVA, mesothelioma is considered as proof of previous exposure to asbestos. The standardised procedure of pathological and clinical diagnosis certification developed by the 23

départements included in the PNSM for identifying and reporting pleural mesothelioma, enabled us to avoid incorrect diagnosis of these neoplasms and potential 12 Source: http://www.doksinet confusion with non-specific pleural carcinosis (mainly secondary tumours, pleural metastasis of another cancer). In order to determine if the under-compensation of patients presenting with pleural mesothelioma was only observed in the départements included in the PNSM, we compared the ratio of OD for pleural mesothelioma/number of deaths by pleural mesothelioma in the 74 French départements which are not included in the PNSM with those included in the PNSM, over an 11-year period (1999-2009). In these 74 départements, the ratio was 32% between 1999 and 2004, and 36% between 2005 and 2009. In the départements covered by the PNSM, the ratio was slightly (but not significantly) higher, respectively 40% and 45%. Therefore, and even if this ratio is a crude surrogate to estimate a rate of

compensation for patients presenting with mesothelioma in France, these data suggest that the phenomenon of under-compensation of pleural mesothelioma is probably higher in other départements than in those included in the PNSM (reflecting a probable “PNSM effect” on the management of the medico-social consequences of the disease by healthcare professionals). Moreover, over the last study period (2005-2009), rates of compensation (number of cases compensated/number of deaths by pleural mesothelioma) by the FIVA were lower in the départements which are not covered by the PNSM, than in those included in the PNSM (respective rates: 72% and 91%, p=0,76). During the period corresponding to the FIVA’s creation, some cases registered before 2005 could have received compensation between 2005 and 2009, responsible for an overestimation of the numerator of the ratio “cases compensated by FIVA/number of deaths by pleural mesothelioma”, but not differentially in the départements

included in the PNSM than in those not included in the PNSM. Analysis of the relationships between socio-professional category and rates of claims for compensation for pleural mesothelioma as OD or by the FIVA suggests that claims are more frequent in patients with a lower educational level (mainly “labourers/workmen”) than for 13 Source: http://www.doksinet “managers”. Similar results for claims on the grounds of OD have already been observed [Kirkham et al., 2011], but were less expected for FIVA claims The higher rate of OD and/or FIVA compensation claims in “labourers/workmen” might be linked to more persuasive action by physicians for these subjects, less familiar with administrative procedures, and perhaps to better established occupational exposure to asbestos. CONCLUSION In France, although all healthcare professionals are aware that most cases of pleural mesothelioma are of occupational origin and despite the existence of a complementary system of compensation,

operational since 2002 (FIVA) and for all cases, claims for compensation of pleural mesothelioma on the grounds of OD and by the FIVA are largely lower than expected. This suggests the need to inform the healthcare professionals involved in the medical management of these patients, in order to sensitise them to the social stakes associated with this disease. ACKNOWLEDGEMENTS The authors would like to thank the correspondents of local PNSM centres who recorded information concerning patient occupational data, together with C. Fresnay, N Lestang, D Luce, A. De Quillacq for their contribution to this study The authors are also indebted to the statistical mission conducted by the DRP (Direction des Risques Professionnels) of the CNAMTS (Caisse Nationale d’Assurance Maladie des Travailleurs Salariés) for data concerning occupational diseases in France; the CépiDC (INSERM) for mortality data, Huguette MAUSS and Daniel JUBENOT for data concerning the FIVA, and the correspondents from the

départements districts included in the PNSM, who transmitted data concerning occupational diseases twice yearly. GRANT SUPPORT: 14 Source: http://www.doksinet PNSM has received financial support from the National Institute for Health Surveillance (InVS), the Ministry of Labour, and the Ministry of Health CONFLICT OF INTEREST They authors declare that they have no competing interests, or other interests that might be perceived to influence the results and discussion reported in this paper. 15 Source: http://www.doksinet References Chamming’s S, Bertin N, Rolland P, et al. Impact du PNSM sur la prise en charge médicosociale des mésothéliomes pleuraux, 1999-2001 BEH 2003;oct:40-47 EUROGIP. State of the art on occupational cancer in Europe Rapport Eurogip-02/F Paris, December, 2002. EUROGIP. Cancers d’origine professionnelle, quelle reconnaissance en Europe? Rapport Eurogip-49/F. Paris, April, 2010 Gisquet E, Chamming’s S, Pairon JC, et al. The determinants of

under-reporting occupational diseases. The case of mesothelioma Rev Epidemiol Sante Publique 2011 Oct 27 [Epub ahead of print]. Goldberg M, Goldberg S, Luce D. Regional differences in the compensation of pleural mesothelioma as occupational disease in France (1986-1993). Rev Epidemiol Sante Publique 1999;47:421–31. Goldberg M, Imbernon E, Rolland P, et al. The French National Mesothelioma Surveillance program. Occup Environ Med 2006;63:390-5 Gramond C, Rolland P, Lacourt A, Ducamp S, Chammings S, Creau Y, Hery M, Laureillard J, Mohammed-Brahim B, Orlowski E, Paris C, Pairon JC, Goldberg M, Brochard P; PNSM Study Group. Choice of rating method for assessing occupational asbestos exposure: study for compensation purposes in France. Am J Ind Med 2012;55(5):440-9 Hyland RA, Ware S, Johnson AR, et al. Incidence trends and gender differences in malignant mesothelioma in New South Wales. Scand J Work Environ Health 2007;33:286-92 Kirkham TL, Koehoorn MW, McLeod CB, et al. Surveillance of

mesothelioma and workers’ compensation in British Columbia, Canada. Occup Environ Med 2011;68:30-5 16 Source: http://www.doksinet Miettinen O.S Estimation of relative risk from individually matched series Biometrics 1970;26:75-86. Payne JI, Pichora EC. Clarification on mesothelioma rates in Ontario Int J Occup Environ Health 2008;14:157-8. Rolland P, Gramond C, Lacourt A, Astoul P, Chammings S, Ducamp S, Frenay C, GalateauSalle F, Ilg AG, Imbernon E, Le Stang N, Pairon JC, Goldberg M, Brochard P; PNSM Study Group. Occupations and industries in France at high risk for pleural mesothelioma: A population-based case-control study (1998-2002). Am J Ind Med 2010;53(12):1207-19 Saliba ML, Larmarcovai G, Souville M, et al. Physicians and occupational health: a qualitative study in South-Eastern France. Rev Epidemiol Sante Publique 2007;55:376-81 Spirtas R, Heineman EF, Bernstein L, et al. Malignant mesothelioma: attributable risk of asbestos exposure. Occup Environ Med 1994;51:804-11

Teschke K, Morgan MS, Checkoway H, et al. Mesothelioma surveillance to locate sources of exposure to asbestos. Can J Public Health 1997;88:163-8 Thebaud-Mony A. Work and social inequalities in health: the case of professional cancers Rev Prat 2004;54:2247-54. Tossavainen A. Global use of asbestos and the incidence of mesothelioma Int J Occup Environ Health 2004;10:22-5. Verger P, Arnaud S, Ferrer S, et al. Inequities in reporting asbestos-related lung cancer: influence of smoking stigma and physicians specialty, workload and role perception. Occup Environ Med 2008;65:392-7. 17 Source: http://www.doksinet FIGURES AND TABLES LEGENDS Figure 1 – The 21 PNSM départements included in the study. Table 1 – Compensation of pleural mesothelioma as occupational disease for patients affiliated to the General National Health Insurance: data for 21 départements (n >15 cases recorded). Table 2 – Trend in compensation as occupational disease for pleural mesothelioma diagnosed in the

15 départements included in the PNSM from 1999 to 2009. Figure 2 – Claims for FIVA compensation and / or claims for recognition as OD (2005-2009). Cases affiliated to the General National Health Insurance (n=1114). Table 3 – Relationships between socio-professional category and rates of claims for compensation of pleural mesothelioma as OD or for compensation by the FIVA. 18 Source: http://www.doksinet 19 Source: http://www.doksinet Table 1: Compensation of pleural mesothelioma as occupational disease for patients affiliated to the General National Health Insurance: data for 21 départements (n >15 cases recorded). Département (a) number 06 13 14 24 25 33 34 38 40 44 47 50 61 64 67 68 76 80 83 93 94 Total Recorded cases 64 159 118 45 29 260 16 231 45 324 45 82 57 78 93 39 148 89 88 222 175 2407 GNHI cases (b) % 54 84% 138 87% 85 72% 32 71% 25 86% 166 64% 10 63% 182 79% 26 58% 247 76% 24 53% 47 57% 41 72% 55

71% 72 77% 30 77% 134 91% 52 58% 63 72% 186 84% 145 83% 1814 75% Claims for compensation as OD(c) (%) 26% 56% 68% 50% 52% 60% 50% 72% 73% 75% 46% 77% 51% 49% 57% 63% 71% 54% 41% 67% 53% 62% 10 58 43 13 11 78 3 81 15 128 7 25 13 17 40 13 84 13 16 112 72 852 1 0 5 1 0 4 0 12 0 5 0 1 0 3 1 2 7 0 1 9 2 54 3 19 10 2 2 17 2 38 4 52 4 10 8 7 0 4 4 15 9 4 3 217 Granted OD % 14 100% 69 90% 55 95% 15 94% 10 77% 81 82% 5 100% 121 92% 18 95% 173 94% 9 82% 36 100% 19 90% 25 93% 36 90% 16 84% 85 89% 24 89% 24 92% 118 97% 69 90% 1022 91% No claims for compensation as OD 74% 44% 32% 50% 48% 40% 50% 28% 27% 25% 54% 23% 49% 51% 43% 37% 29% 46% 59% 33% 47% 38% 10 29 11 8 4 27 4 12 4 22 3 4 4 10 19 4 15 3 19 30 34 276 13 15 9 5 4 19 1 13 1 18 2 3 5 5 9 3 19 2 4 22 28 200 17 17 7 3 4 21 0 26 2 22 8 4 11 13 3

4 5 19 14 9 6 215 Exposed to asbestos Not exposed to asbestos Not available (d) Exposed to asbestos Not exposed to asbestos Not available (d) 20 Source: http://www.doksinet (a): 06 (Alpes Maritimes), 13 (Bouches du Rhône), 14 (Calvados), 24 (Dordogne), 25 (Doubs), 33 (Gironde), 34 (Hérault), 38 (Isère), 40 (Landes), 44 (Loire-Atlantique) , 47 (Lot et Garonne), 50 (Manche), 61 (Orne), 64 Pyrénées Atlantiques, 67 (Bas-Rhin), 68 (Haut Rhin), 76 (Haute Normandie), 80 (Somme), 83 (Var), 93 (Seine Saint Denis) and 94 (Val de Marne). (b): General National Health Insurance (c): Occupational Disease (d) : Patients without face to face interview 15 départements participated from 1999 to 2009: 14 (Calvados ), 24 (Dordogne), 25 (Doubs), 33 (Gironde), 38 (Isère), 40 (Landes) , 44 (Loire-Atlantique), 47 (Lot et Garonne), 50 (Manche) , 61 (Orne), 64 (Pyrénées Atlantiques), 67 (Bas-Rhin), 68 (Haut Rhin), 80 (Somme) and 93 (Seine Saint Denis). The 6 other départements

participated for a shorter period from 1999 to 2009: 06 (Alpes maritimes), 13 (Bouches du Rhône), 34 (Hérault), 76 (Seine Maritime),83 ( Var), 94 (Val de Marne) 21 Source: http://www.doksinet Table 2: Trend in compensation as occupational disease for pleural mesothelioma diagnosed in the 15 départements included in the PNSM from 1999 to 2009. 1999 Recorded cases GNHI cases (a) % 140 2000 % 141 2001 % 151 2002 % 144 2003 % 171 2004 % 155 2005 % 160 2006 % 151 2007 % 178 2008 % 184 2009 % 182 Total % 1757 86 61% 98 70% 101 67% 103 72% 122 71% 117 75% 117 73% 109 72% 136 76% 144 78% 137 75% 1270 72% 60 70% 63 64% 68 67% 71 69% 77 63% 87 74% 76 65% 77 71% 78 57% 82 57% 90 66% 829 65% Exposed to asbestos Not exposed to asbestos Information on asbestos (d) exposure not available 41 2 17 68% 4% 28% 51 2 10 81% 3% 16% 52 3 13 76% 5% 19% 51 2 18 72% 3% 25% 47 2 28 61% 3% 36% 66 4 17 76% 5%

19% 57 3 16 75% 4% 21% 56 8 13 73% 10% 17% 63 1 14 81% 1% 18% 63 9 10 77% 11% 12% 62 7 21 69% 8% 23% 609 43 177 74% 5% 21% OD Granted 59 98% 57 90% 62 91% 65 92% 74 96% 78 90% 70 92% 67 87% 71 91% 73 89% 80 95% 756 92% Exposed to asbestos Not exposed to asbestos Information on asbestos (d) exposure not available 41 1 17 69% 2% 29% 47 0 10 82% 18% 48 2 12 78% 3% 19% 47 1 17 72% 2% 26% 45 2 27 61% 3 36% 63 1 14 81% 1% 18% 52 3 15 74% 4% 22% 51 5 11 76% 7% 17% 57 1 13 80% 2% 18% 58 6 9 80% 8% 12% 55 4 21 69% 5% 26% 564 26 166 75% 3% 22% OD Refused 1 2% 6 10% 6 9% 6 8% 3 4% 9 10% 6 8% 10 13% 7 9% 9 11% 4 44% 67 8% Exposed to asbestos Not exposed to asbestos Information on asbestos (d) exposure not available No claim for compensation as OD 0 1 0 100% - 4 2 0 7% 3% - 4 1 1 66% 17% 17% 4 1 1 66% 17% 17% 2 0 1 67% 34% 3 3 3 33% 33% 33% 5 0 1 83% 17% 5 3 2 50% 30% 20% 6 0 1 86% 14% 5 3 1

56% 33% 11% 3 1 0 75% 25% - 41 15 11 61% 22% 17% 26 30% 35 36% 33 33% 32 31% 45 37% 30 26% 41 35% 32 29% 58 43% 62 43% 47 34% 441 35% 5 9 12 19% 35% 46% 15 7 13 43% 20% 37% 16 6 11 49% 18% 33% 11 3 18 35% 9% 56% 13 15 17 29% 33% 38% 13 8 9 43% 27% 30% 21 10 10 52% 24% 24% 6 9 17 19% 28% 53% 32 10 16 55% 17% 28% 17 22 23 27% 36% 37% 14 19 14 30% 40% 30% 163 118 160 37% 27% 36% Claims for (b) compensation as OD Exposed to asbestos Not exposed to asbestos Information on asbestos (d) exposure not available The 15 départements were: Calvados (14), Dordogne (24), Doubs (25), Gironde (33), Isère (38), Landes (40), Loire-Atlantique (44), Lot et Garonne (47), Manche (50), Orne (61), Pyrénées Atlantiques (64), Bas-Rhin (67), Haut Rhin (68), Somme (80) and Seine Saint Denis (93). (a): General National Health Insurance (b): Occupational Disease (c): non-significant (d): Patients without face to face interview 22 P trend NS (c) NS (c)

Source: http://www.doksinet Table 3: Relationships between socio-professional category and rates of claims for compensation of pleural mesothelioma as OD or for compensation by the FIVA. OD 1999-2009(b) Socio-professional categories (a) Farmers, craftsmen, tradesmen, company managers Managerial / intellectual professions Middle level occupations Employees Labourers/workmen Total Claim for OD n (%) FIVA 2005-2009(c) OR [95% CI] Total Claim for FIVA n (%) OR [95% CI] 73 58 (79%) 2.3 [1.1-46] 88 54 (61%) 1,3 [0.7–24] 84 53 (63%) 1.0 88 48 (55%) 1,0 154 118 (77%) 1.9 [1.1-34] 166 108 (65%) 1,6 [1.0-26] 104 69 (66%) 153 75 (49%) 529 442 (84%) 420 264 (63%) 1.2 [0.6-21] 3.0 [1.8-49] 0.8 [0.5-14] 1.4 [0.9-22] OD: occupational disease (a): Socio-professional category concerns the last job (b): Presented data concerns subjects for whom information on socio-professional category was available, affiliated to the GNHI and with definite or probable exposure

to asbestos identified by the occupational questionnaire. (c): Presented data concerns subjects for whom information on socio-professional category was available, independently of their health insurance system, with definite or probable exposure to asbestos identified by the occupational questionnaire. 23