PROPOUMON: Systematic screening for occupational exposures in lung cancer patients. A prospective French cohort

Abstract

Introduction Although the population attributable fraction of lung cancer deaths due to occupational carcinogens has been estimated at between 8% and 24% worldwide, occupational lung cancers are largely under-reported and under-compensated. Several reasons can explain under-reporting, including the long latency between occupational exposures and cancer; the limited knowledge about occupational cancers and patients’ difficulties with administrative processes. We assessed systematic screening for occupational exposures to carcinogens combining a self-administered questionnaire and an occupational consultation to improve the detection of occupational lung cancers and their compensation. Social deprivation and the costs of this investigation were estimated. Methods Patients with a histologically confirmed lung cancer were identified through the weekly multidisciplinary lung cancer board; they received a self-administered questionnaire to collect their job history (job-title, start and end dates, employer and sector of activity and tasks performed), potential exposure to carcinogens and deprivation (EPICES score). When the patients had not returned the questionnaire after three weeks, a research technician called and offered help to complete it. At reception, a physician assessed the questionnaire and recommended an occupational consultation if necessary. During the consultation, a physician assessed if the lung cancer was work-related and, if it was, delivered a medical certificate to claim for compensation. Patients were offered help from a social worker for the claim process. The cost assessment was based on a bottom-up micro-costing approach from the healthcare providers perspective. Data on resource consumption during the process between the questionnaire administration and the consultation and social worker costs, if applicable were collected. Results Between March 2014 and September 2015, 440 patients received the self-administered questionnaire: 234 (53%) returned a completed questionnaire, including 105 (24%) after phone contact (average delay overall 47 days). Among the 206 patients who did not complete the questionnaire, 84 patients declared they did not feel concerned and 32 patients could not be contacted by phone after three attempts. Newly diagnosed patients returned the questionnaire more frequently within the first three weeks than those with disease progression. Of the 120 patients invited to the occupational consultation, 97 attended. Among them, 59 (61%) were considered to have occupational-related lung cancer. The main occupational exposures were asbestos (53%) and welding fumes (13%). A claim for compensation was judged possible under the French system for 41 patients and the medical certificate was delivered to 35 patients (five patients did not want to claim and one had already filed a claim). A compensation claim was judged unlikely to be successful for 18 patients. For the remaining 38 patients, lung-cancer was not considered to be work-related. Compensation was awarded to 19 patients (4.3% of the overall population and 8% of responders), five claims were rejected, three are still under assessment and eight patients did not submit a claim. The mean EPICES score was 28.7. Patients classified as deprived (46% with EPICES score > 30) took significantly longer to return the SAQ. The mean cost of the systematic screening of occupational exposures was € 62.65 per patient. Conclusions Our study confirms the frequency of occupational exposures among lung cancer patients, social deprivation in this population and the necessity to accompany patients during the compensation process. Our results showed a systematic self-administered questionnaire can be used to identify patients potentially exposed to carcinogens. In France, only 2.3% of lung cancers have been compensated in 2014; this percentage was doubled with our systematic screening which shows its capacity to improve the compensation of occupational lung cancers.