New exposure, ancient disease: patient experiences with artificial stone silicosis

From denim sandblasting to microwave popcorn manufacturing, novel occupational exposures contributing to lung disease are a regular feature on news cycles and case reports.¹ Perhaps the most widespread and morbid of these associations in the past decade is that of artificial stone manufacturing. The popularity of relatively inexpensive artificial stone kitchen countertops has led to an increase in patients with silicosis stemming from work with these materials.² Outbreaks have been described worldwide, from Israel to California, and Australia particularly has experienced a rapid increase in the number of workers compensation claims related to this material.³

Most concerning, however, is the severity of illness some workers are experiencing, despite relatively few years of working with artificial stone. One case series of workers in California requiring lung transplantation, for instance, found that these patients were younger (in their fourth and fifth decades of life) and had lower lung function than their counterparts without silicosis.⁴ While this phenomenon has resulted in increased advocacy toward prevention of this disorder, little has been published to date regarding the experiences of patients with silicosis themselves and what priorities they may have in the identification and treatment of their disease.

In this issue of AnnalsATS, Tikellis and colleagues aim to amplify these patient experiences.⁵ The authors conducted a qualitative study using semi-structured interviews and thematic analysis to develop a model of health and supportive care for patients with occupationally related silicosis. They interviewed 40 patients from 2 tertiary clinics in Australia by telephone to explore the impact of silicosis on health, well-being, and supportive care needs. Analysis of the interviews revealed 5 themes that led to the development of a model of care, which they validated in focus group discussions and individual interviews with patients and using feedback from respiratory physicians completing an online questionnaire.

Some themes resulting from these assessments are particular to occupational lung disease, with one theme of patients’ frustration at the limited provision of information including from employers and regulators and another theme of patients’ inability to continue their livelihoods as a direct result of their condition. In a patient’s own words from the semi-structured interview, “When I first started, someone saying that this stuff can kill you if you don’t wear a mask would have been awesome. Bit late now though.” These issues underscore that the well-established medical knowledge of the harms of silica are still not being translated to individual workers most at risk.

Other themes are applicable toward patients affected by most chronic lung diseases. These include unclear pathway to diagnosis, the mental health burden of being diagnosed with a preventable disease without cure, and patients’ self-made strategies for managing their lives with the disease. “All I had in my head was, ‘I’ve got this frigging rare lung disease. I don’t know if I’m going to survive. I don’t know what my lifespan is going to be now.’” These themes suggest avenues for further research for the pulmonary community to prioritize. On this latter point, the authors then developed a model of care validated in patient focus groups and reviewed by respiratory physicians. This model included some disease-related aspects (lung health, reliable information, care coordination) and many environment- and systems-based elements of care, including occupational and peer support, fitness programs, and lifestyle management strategies. While ambitious, these proposed pillars of care are a call to action for all respiratory physicians managing patients with occupational lung disease.

The work succeeds in clearly presenting the findings and potential impact of the study. Additional strengths are the relatively large number of subjects who underwent semi-structured interviews and adherence to qualitative methodology. Weaknesses, while present, are inherent to the difficulties of qualitative research and include unknown generalizability to other countries and health care settings. In addition, the vast majority of the patients included in the study were exposed to artificial stone from work in the benchtop industry. The proposed care model, while thoughtfully constructed, will need rigorous validation in the clinical setting. While silicosis is a relatively rare disease, some of the insights from these interviews can undoubtedly be applied toward other more common occupational or exposure-related lung diseases.⁶

Despite the novel association in the form of countertops, silicosis is one of the earliest described lung diseases, occurring in miners throughout history.⁷ Silica exposure can occur from a variety of occupations and industries, from foundries to telecommunication. Despite overall declining dust levels, the persistence of coal workers’ pneumoconiosis has been attributed to silica present in the mined coal dust.⁸ Additionally, silica exposure can contribute to parenchymal lung disease outside the bounds of typical pneumoconiosis and its prevalence has been noted across a wide variety of interstitial lung disease subtypes.⁹ In particular, its association with systemic autoimmune rheumatic diseases, such as systemic sclerosis and rheumatoid arthritis, is well established.¹⁰

This novel framework is proposed in the context of systemic policy change that has yet to occur elsewhere. Australia recently became the first country to ban the production of artificial stone.¹¹ Although the state government of California recently enacted a proposal increasing worker protections, current investigations have noted a large proportion of countertop shops that do not submit to already set standards.^12,13 Additionally, the disproportionate effect that silicosis has on the migrant worker community is deserving of further study and patient-centered assessment.¹⁴

Overall, the authors should be commended for prioritizing the voice of the patient, both literally in the form of qualitative interviews as well as in the development of a novel patient-proposed model of care. Through rigorous qualitative research methods such as outlined in this study, the needs of patients themselves can and must be prioritized, particularly when their illness stems from their surrounding work environment.

Supplementary Material

Supplementary material is available at Annals of the American Thoracic Society online.