Epidemiology of mesothelioma in the 21 century in Europe and the United States, 40 years after restricted/banned asbestos use

Abstract

Research has established a strong association between asbestos exposure and malignant mesothelioma, a deadly form of cancer. Since the early 1980's many countries have restricted or banned the production of asbestos, leading to a decline of occupational asbestos exposure in many industrialized countries. However, some countries continue to use asbestos, and worldwide rates of mesothelioma are still increasing. Because of the long latency between exposure and mesothelioma occurrence and the persistence of environmental exposure, incidence rates (IR) may decrease very slowly for several years ahead. In this review, we examine estimates of asbestos consumption before widespread asbestos regulations and the trends in incidence and mortality rates, as well as changes over time for the United States and Europe. In some countries with earlier asbestos restrictions, mesothelioma incidence has been in a modest decline over time. However, asbestos exposure is still a burden worldwide and legislative action is needed to obtain a full ban. The pattern of mesothelioma is shifting from a mostly male disease to a disease that affects females as well in substantial numbers. Studies on unknown sources of asbestos exposure, of other sources of natural exposure to asbestos and asbestos-like fibers, as well as of individual genetic susceptibility to asbestos fibers are needed.

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© Translational lung cancer research. All rights reserved. Transl Lung Cancer Res 2020;9(Suppl 1):S28-S38 | http://dx.doi.org/10.21037/tlcr.2019.11.11
Introduction
Mesothelioma is a rare, but deadly form of cancer, arising
in the mesothelial surfaces (1) in the pleura, peritoneal,
and pericardial cavities; the most common form of
mesothelioma, accounting for 65–70% of all cases, is
malignant pleural mesothelioma followed by peritoneal
(30%) and pericardial mesothelioma (1–2%) (2). There are
three subtypes, according to the histological morphology:
epithelial, sarcomatoid, and biphasic (1).
Mesothelioma has a very poor prognosis with a median
survival from the time of presentation of approximately
9–12 months (3). Despite the introduction of modern
therapeutic interventions, only modest changes in survival
are observed over time (1). There is a well-established
causal relationship between asbestos exposure and
malignant mesothelioma, although the latency period can
be long. Research suggests that the average latency period
is approximately 40 years, although in some cases, it may be
as long as 60–70 years (4-9). The association with asbestos
exposure is especially strong for the pleural site, where
80% of patients report a history of asbestos exposure (2).
Among asbestos highly exposed individuals, the lifetime
risk of mesothelioma can vary from 5–10% to 25% (3,4,10).
Increased knowledge and better regulations since the early
1980’s, with restrictions or bans on production and use of
Review Article
Epidemiology of mesothelioma in the 21st century in Europe and
the United States, 40 years after restricted/banned asbestos use
Naomi Alpert1, Maaike van Gerwen1,2, Emanuela Taioli1,3,4
1Institute for Translational Epidemiology, 2Department of Otolaryngology-Head and Neck Surgery, 3Department of Thoracic Surgery, 4Tisch
Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
Contributions: (I) Conception and design: All authors; (II) Administrative support: All authors; (III) Provision of study materials or patients: None;
(IV) Collection and assembly of data: N Alpert; (V) Data analysis and interpretation: All authors; (VI) Manuscript writing: All authors; (VII) Final
approval of manuscript: All authors.
Correspondence to: Emanuela Taioli, MD, PhD. Icahn School of Medicine at Mount Sinai, One Gustave L Levy Place, Box 1133, New York, NY
10029, USA. Email: Emanuela.Taioli@mountsinai.org.
Abstract: Research has established a strong association between asbestos exposure and malignant
mesothelioma, a deadly form of cancer. Since the early 1980’s many countries have restricted or banned
the production of asbestos, leading to a decline of occupational asbestos exposure in many industrialized
countries. However, some countries continue to use asbestos, and worldwide rates of mesothelioma are still
increasing. Because of the long latency between exposure and mesothelioma occurrence and the persistence
of environmental exposure, incidence rates (IR) may decrease very slowly for several years ahead. In this
review, we examine estimates of asbestos consumption before widespread asbestos regulations and the trends
in incidence and mortality rates, as well as changes over time for the United States and Europe. In some
countries with earlier asbestos restrictions, mesothelioma incidence has been in a modest decline over time.
However, asbestos exposure is still a burden worldwide and legislative action is needed to obtain a full ban.
The pattern of mesothelioma is shifting from a mostly male disease to a disease that affects females as well in
substantial numbers. Studies on unknown sources of asbestos exposure, of other sources of natural exposure
to asbestos and asbestos-like bers, as well as of individual genetic susceptibility to asbestos bers are needed.
Keywords: Carcinogen regulation; environmental exposure; incidence trends; mortality
Submitted Jul 24, 2019. Accepted for publication Nov 07, 2019.
doi: 10.21037/tlcr.2019.11.11
View this article at: http://dx.doi.org/10.21037/tlcr.2019.11.11
38

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asbestos in many developed countries has led to abatement
of exposure, particularly in the occupational setting. Four
subsequent bans on asbestos between 1973 and 1989 in the
United States (US) resulted in decreased asbestos consumption
and production, followed by a decline of mesothelioma
incidence and mortality rates 20 years later (11). However,
despite bans, people may still be exposed to asbestos, due
to its presence in several structures such as schools or
public buildings, and the construction of residential areas
in close proximity to former asbestos mines, factories,
or soil containing natural asbestos. Thus the disease
burden associated with environmental asbestos exposure
remains difficult to quantify and is understudied (6,7,12).
Furthermore, a ban on the use and production of asbestos
has not been implemented globally; countries that have a
ban instituted it at different points in time (5), making the
estimate of the future mesothelioma risk in the general
population uncertain.
The goal of this report is to provide an overview of
asbestos use, and mesothelioma incidence and mortality
in the US and Europe [defined as the 53 countries in
the European region of the World Health Organization
(WHO)] (13), within the context of changes in asbestos
policies around the world.
Data sources and methods
This report used several publicly available data sources.
Asbestos consumption (calculated as production plus imports
minus exports) was assessed per capita, in 1980 and 2007,
using reports from the United States Geological Survey
(USGS) (14,15), with population estimates compiled by the
World Bank (16). Negative values of asbestos consumption
(reflecting export of storage from previous years) were
treated as zero. Overall and age specific mesothelioma
incidence rates (IR) [2008–2012] were extracted from the
Cancer Incidence in Five Continents Volume XI (CI5 Vol.
XI) data made available by the WHO and the International
Agency for Research on Cancer (IARC) (17). IR over time
were calculated using Surveillance, Epidemiology, and
End Results (SEER) data (18) (US) and WHO C15plus
data (Europe) (17,19), which includes annual incidence of
selected cancers for the longest possible period. For this
analysis, only registries with continuous information from
1980–2012 were included (SEER-9 Registries for the US;
Denmark, France Calvados, France-Doubs, France-Isere,
Germany-Saarland, Iceland, Israel, Italy-Parma, Norway,
Switzerland-Geneva and UK-Scotland for Europe).
Mortality rates were queried from the IARC WHO Cancer
Mortality Database (20). All incident and mortality rates are
age-adjusted to the world standard population (21).
Results
Worldwide bans on asbestos and asbestos consumption
Since the 1970’s, countries have banned asbestos to varying
degrees, with 67 countries worldwide having a total ban, as
of July 15, 2019 (22). Although the US banned some forms
of asbestos in 1973, and attempted to ban most asbestos-
containing products in 1989 through the Toxic Substances
Control Act, the ban was overturned in 1991 (23). To
this day, the US does not have a full nationwide ban on
asbestos. However there are many laws regulating the use of
asbestos at the federal, state, and local level (24). In Europe,
individual regulations banning asbestos were passed from
the 1980’s through the early 2000’s in many countries
(13,22,25,26). Member states of the European Union (EU)
banned five of the six types of asbestos in 1991 (amosite,
crocidolite, anthophyllite, tremolite, and actinolite) and a
ban prohibiting the new use of chrysotile went into effect
on January 1, 2005 (27). Details of asbestos bans, by country
are shown in Table 1 (13,22,25,26).
Previous research (5,13) has defined asbestos
consumption >1 kg/capita/year as “high”, as it corresponded
to a 2.4- and 1.6-fold increase in mesothelioma deaths
among men and women, respectively. Consumption
>2 kg/capita/year was considered “very high”. Data from
1980 (14), before asbestos bans were widely implemented,
show that asbestos consumption was very high in some
parts of Europe, exceeding 5 kg/capita in the former
Soviet Union (estimates for Russian Federation and
Kazakhstan: 9.6 kg/capita), Cyprus (7.4 kg/capita), Germany
(5.6 kg/capita), and former Yugoslavian states (combined
estimates for all former Yugoslav nations: 5.2 kg/capita).
Asbestos consumption for Belgium and Luxembourg
(4.7 kg/capita), Hungary (4.0 kg/capita), Switzerland
(3.3 kg/capita), Italy (3.2 kg/capita), Czech Republic
and Slovakia combined (3.1 kg/capita), Austria
(2.7 kg/capita), Denmark (2.7 kg/capita), Ireland
(2.5 kg/capita), Poland (2.3 kg/capita), France
(2.3 kg/capita), and Portugal (2.04 kg/capita) all exceeded
2 kg/capita, while it exceeded 1 kg/capita in Spain, Greece,
United Kingdom, Netherlands, and Finland. Consumption
in the US was also high at 1.6 kg/capita (Figure 1A), although
it was already in decline from its peak in the early 1970’s (28).

S30 Alpert et al. Epidemiology of mesothelioma in Europe and the US
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Table 1 Asbestos bans and regulations in the United States and Europe
Country Year Description
United States 1973 Ban on spray-applied surfacing asbestos-containing material for fireproofing and insulation
1989 Toxic Substances Control Act bans most asbestos-containing products
1991 Ban overturned, no current nationwide ban
European Union
Austria†1990 Ban on chrysotile asbestos
Belgium†1998 Ban on chrysotile asbestos is introduced
Bulgaria 2005 Ban on import, production, and use of all asbestos
Croatia 1993 Ban on crocidolite and amosite
2006 Asbestos added to list of prohibited substances, in line with EU regulations, but ban is not thought
to be well enforced
Cyprus†2005 Prohibits new use of chrysotile, other forms of asbestos previously banned under EU regulations
Czech Republic†1998 Ban on the import of asbestos
2005 Prohibits new use of chrysotile, other forms of asbestos previously banned under EU regulations
Denmark†1980 Ban on uses of asbestos, with exceptions
1985 Extends ban to include asbestos cement products, further restrictions in 1986–1988
Estonia†2005 Prohibits new use of chrysotile, other forms of asbestos previously banned under EU regulations
Finland†1992 Phase-out ban on chrysotile
France†1996 Ban on chrysotile
Germany†1993 Ban on chrysotile asbestos (minor exemptions), amosite and crocidolite were banned previously
Greece†2005 Prohibits new use of chrysotile, other forms of asbestos previously banned under EU regulations
Hungary†1988 Ban on amphibole asbestos, with further bans on non-chrysotile asbestos in 1992, 2001, and 2003
2005 Prohibits new use of chrysotile, other forms of asbestos previously banned under EU regulations
Ireland†2000 Ban on chrysotile asbestos
Italy†1992 Ban on all types of asbestos (with some exceptions until 1994)
Latvia†2001 Ban on asbestos (some exemptions)
Lithuania†1998 First law restricting asbestos use
2005 Prohibits new use of chrysotile, other forms of asbestos previously banned under EU regulations
Luxembourg†2002 Phase out ban on asbestos
Malta†2005 Prohibits new use of chrysotile, other forms of asbestos previously banned under EU regulations
Netherlands†1991 First in a series of bans on chrysotile
Poland†1997 Ban on all asbestos
Portugal†2005 Prohibits new use of chrysotile, other forms of asbestos previously banned under EU regulations
Romania 2005 Prohibits new use of chrysotile, other forms of asbestos previously banned under EU regulations
Slovakia†2005 Prohibits new use of chrysotile, other forms of asbestos previously banned under EU regulations
Slovenia†1996 Ban on production of asbestos cement products
Table 1 (continued)

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Table 1 (continued)
Country Year Description
Spain†2002 Phase out ban on asbestos
Sweden†1982 First in a series of bans on various uses of asbestos
1986 Ban on use of all asbestos products
United Kingdom†1999 Ban on chrysotile asbestos, with minor exceptions
Other European nations
Albania – No ban
Andorra – No ban
Armenia – No ban
Azerbaijan – No ban
Belarus – No ban
Bosnia and
Herzegovina
– No ban
Georgia – No ban
Iceland 1983 Ban on all types of asbestos (with exceptions); bans updated in 1996
Israel 1980 Series of restrictions on asbestos, which eventually became a de facto ban
Kazakhstan – No ban
Kyrgyzstan – No ban
Monaco 2016 Total ban on all forms of asbestos
Montenegro – No ban
North Macedonia 2014 Total ban on all forms of asbestos
Norway 1984 Ban on all asbestos
Republic of Moldova – No ban
Russian Federation – No ban
San Marino – No ban
Serbia 2011 Ban on all asbestos
Switzerland 1989 Ban on crocidolite, amosite, and chrysotile
Tajikistan – No ban
Turkey 2010 National regulation banning use of all types of asbestos
Turkmenistan – No ban
Ukraine 2017 Complete ban on asbestos announced, implementation may be delayed
Uzbekistan – No ban
†, members of the European Union as of 2005, subject to the directive mandating all member states ban new uses of chrysotile. Other
forms of asbestos were banned in 1991 for EU member states. All member states of the EU, Iceland, Israel, Macedonia, Monaco, Norway,
Serbia, Switzerland, and Turkey have banned the use of all types of asbestos, as of July 15, 2019. EU, European Union.

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The most recent available data refer to 2007 (15),
and indicates that asbestos consumption has declined
considerably in most countries in the years since bans were
enacted (or attempted) (Figure 1B). US consumption was
0.003 kg/capita in 2007, while most of the countries in the
EU had decreased to 0 (or nearly 0) kg/capita. Asbestos
consumption remained high or very high in Kazakhstan
(7.0 kg/capita), Kyrgyzstan (4.0 kg/capita), Belarus
(3.5 kg/capita), Uzbekistan (3.2 kg/capita), Russian
Federation (2.0 kg/capita), and Ukraine (1.8 kg/capita).
An advance report from the USGS for 2016 (29)
indicates that consumption has started to decline in Ukraine
(0.4 kg/capita) and Belarus (0.6 kg/capita), although it
remains high or very high in the Russian Federation
(1.6 kg/capita), Kazakhstan (1.4 kg/capita), Kyrgyzstan
(1.1 kg/capita), and Uzbekistan (2.2 kg/capita).
Mesothelioma IR
Research has shown that IR of mesothelioma are lower in
women than in men, and this difference has been attributed
to historical differences in occupational asbestos exposure
(30,31). From 2008 to 2012, the world standardized IR
(WSIR), per 100,000 persons in the US was 0.9 for males
and 0.3 for females. Overall in Europe, the WSIR per
100,000 was 1.7 for males and 0.4 for females. Data is
limited for nations of the former Soviet Union, Russian
Federation and former Yugoslavia, but for those with data,
reported WSIR for males and females were 0.5 and 0.3
(Russian Federation), 1.5 and 0.3 (Croatia), and 1.5 and
0.5 (Slovenia) per 100,000 persons. In some of the other
countries with very high asbestos consumption, WSIR
remain high, particularly for males versus females: 2.0
and 0.4 (Belgium), 2.0 and 0.3 (Switzerland), 1.9 and 0.3
Apparent Consumption
of Asbestos (kg/capita)
Apparent Consumption
of Asbestos (kg/capita)
1 3 5 7 9
1 3 5 7
A
B
Figure 1 Apparent consumption (kg/capita) of asbestos in (A) 1980 and (B) 2007 in the United States and Europe.

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(Denmark), 1.8 and 0.6 (Italy), and 1.6 and 0.3 (Germany)
per 100,000 persons. WSIR are also very high in the
Netherlands (2.8 in males and 0.4 in females), and United
Kingdom (3.4 and 0.6) (Figure 2). As women generally are
less likely to be occupationally exposed, the high WSIR
in females observed in certain countries, such as Italy,
United Kingdom, and Turkey may indicate other sources
of exposure that are difficult to detect, such as higher
levels of environmental exposure. The classification of
environmental, non-occupational exposure to asbestos is
very heterogeneous in the literature and often includes (I)
areas with naturally occurring asbestos, (II) neighborhood
exposure based on residence in close proximity to industrial/
mining sources of asbestos, and (III) household exposure
for family members of occupationally exposed people, of
which the latter two are more specic exposure risk factors
for females (6). Furthermore, a caveat when comparing
data collected in different countries is that there may be
differences in patterns of reporting for mesothelioma,
misclassification in diagnosis, or lack of the medical
resources required to accurately diagnose the disease.
Age related patterns
Mesothelioma is extremely rare in younger subjects,
with a sharp uptick in IR starting between 50–60 years of
age (4). Prior to age 50, the annual WSIR in the US for
males is ≤0.3 per 100,000 persons, while for females it is
≤0.2. In Europe, the rates are ≤0.6 per 100,000 for males
and ≤0.4 per 100,000 for females for the same age group.
In the US, the IR for males aged 50–54 years is 0.6 per
100,000, while for females it is 0.4 per 100,000. The rate
Figure 2 World standardized incidence rates of mesothelioma in the United States and Europe for (A) men and (B) women, 2008–2012.
Incidence Rate
(per 100,000)
Incidence Rate
(per 100,000)
1 2 3
0.2 0.4 0.6
A
B

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starts climbing faster in Europe, with an IR of 1.4 per
100,000 for males, and 0.6 per 100,000 for females at age
50–54 years. As people age, this gap across the US and
Europe continues to widen, particularly for males. For
those ≥80 years, the IRs for males in the US and Europe are
18.9 and 22.8 per 100,000, respectively; for females, it is 3.0
and 3.4 per 100,000 (Figure 3).
Time trends
Given the long latency period of mesothelioma
(approximately 40 years, on average) (4), we may now
just be beginning to see the effects of asbestos bans. In
the US there is no ofcial ban in place, however attempts
were made to ban asbestos as far back as 1973, and as a
result general consumption was lower in 1980 in the US
as compared to Europe. Over time, the IR has started to
decline in the US from 1980–2016, mostly driven by a
decline in the IR for males, while females have mostly held
steady (Figure 4A). In Europe, rates of mesothelioma were
rising sharply in the early 2000’s, and may just now be
beginning to level off (Figure 4B). This may be partly due to
the later introduction of asbestos bans in parts of Europe,
and the higher consumption observed at least 40 years
ago in many geographic areas. As overall rates have slowly
fallen in the US, and risen in Europe, with steady rates for
females, females now make up a larger portion of those with
mesothelioma in the US than in Europe (Figure 4C).
Mesothelioma mortality
Survival rates for mesothelioma are low, with estimated
median survival of 9–12 months (3). Research has shown
that females have significantly better overall survival
(32-34), and speculated reasons include less amount
and duration of exposure (35), more favorable clinical
characteristics (36,37), and protective effects of estrogen
(38,39). For countries in which IR and mortality rates
were available, the ratio of the mortality rate to the IR was
calculated. In almost all cases, this ratio exceeds 0.5, and
in many cases exceeds 0.75, indicating high mortality rates
among those with mesothelioma. Generally, the ratio was
lower for females (Table 2), reflecting the better survival
reported by individual studies for females with all forms of
mesothelioma.
Comment
Although the US recognized the dangers of asbestos
exposure early and in 1973 produced the first asbestos
regulation followed by a complete ban in 1989, the country
currently has no nationwide ban. Many countries in Europe
independently implemented partial or total asbestos bans
in the 1980’s and 1990’s, while member states of the EU
banned most types of asbestos in 1991, with a complete
ban on all remaining types of asbestos in effect starting in
2005. However, many non-EU states implemented bans
Figure 3 Age specic annual incidence rates [2008–2012], for (A) United States and (B) Europe, by gender.
Incidence Rate
(Per 100,000)
Incidence Rate
(Per 100,000)
Age (years) Age (years)
Female Male
0-4
0-4
10-14
10-14
20-24
20-24
30-34
30-34
40-44
40-44
50-54
50-54
60-64
60-64
70-74
70-74
≥80
≥80
20
15
10
5
0
20
15
10
5
0
A B

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later, while some still have no ban in place. The difference
in the timeframe for asbestos ban legislation in the US and
Europe, combined with a latency period of decades between
exposure and mesothelioma partly explains why a slight
decrease in mesothelioma standardized IR is seen in the US,
consistent with previous research (11), while the incidence
has just started to level off in Europe. There is speculation
that the observed decrease in mesothelioma incidence is
slower than projected (40), and that other factors, including
individual genetic susceptibility, could play a role (41).
However, observational data from cancer registries
prove that legislation on asbestos use and production is an
effective way to decrease occupational exposure to asbestos,
and therefore, mesothelioma rates in the general population,
especially in males. Current legislation is insufficient to
address neighborhood asbestos exposure based on residence
in close proximity to industrial/mining sources of asbestos
and household asbestos exposure for family members of
occupationally exposed people, as well as other sources
of environmental exposure. To further decrease risk from
environmental asbestos exposure, legislation for building
in regions with naturally occurring asbestos should be
explored. These results stress the need for a global forum to
urge countries that currently don’t have an asbestos ban to
start implementing appropriate legislation.
One interesting observation is that any change in IR is
mainly caused by a decrease in mesothelioma occurrence
among males, while the IR of mesothelioma for females
remains more stable. This may reflect the fact that
asbestos exposure has shifted from occupational, mostly
present in males, to environmental exposure, and indicates
that current asbestos regulations do not sufficiently
consider all sources of environmental exposure. The male/
female (M/F) ratio has been used as a relatively reliable
surrogate to distinguish environmental from occupational
exposure (6,7), with a M/F ratio approaching one as a sign
Figure 4 World standardized incidence rates (per 100,000) over time, overall and by gender in the (A) United States, and (B) Europe. (C)
Ratio of world standardized incidence rates for females vs. males, over time in the United States and Europe.
WSIR (Per 100,000)
WSIR (Per 100,000)
WSIR Ratio (female vs. male)
Year Year
Year
Female Male Overall
Europe US
1980
1980 1980
1984
1984
1984
1988
1988
1988
1992
1992
1992
1996
1996
1996
2000
2000
2000
2004
2004
2004
2008
2008
2008
2012
2012
2012
2016
2.0
1.5
1.0
0.5
0
2.0
1.5
1.0
0.5
0
0.3
0.2
0.1
A B
C

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that environmental exposure plays a more important role.
The identification of current sources of environmental
exposure to asbestos and the associated health effects in
the general population remains an important area of future
research, including the identication of geographic areas
where asbestos is naturally present in the environment (42).
The difference in incidence with gender is of special
importance because females with malignant mesothelioma
have a significantly better survival than males, although
the precise reasons for this observation are still uncertain
(32,33). Given the positive effects of legislation on
occupational exposure to asbestos, the next step will be to
shift the focus of research and legislation to environmental
sources of asbestos exposure, in order to target all potential
avenues of asbestos exposure. Because mesothelioma is a
rare but deadly disease, and combined with the changing
landscape of asbestos exposure, mesothelioma registries
capturing mesothelioma cases in real-time are of utmost
importance to investigate the many unanswered scientic
questions. Countries with mesothelioma registries are
able to research and respond to the current scientic and
legislative needs associated with mesothelioma incidence
and mortality.
In conclusion, we report here the status of mesothelioma
epidemiology in the recent years, and observe that asbestos
exposure is still a burden worldwide, and legislative
action is needed to obtain a complete ban. The pattern of
mesothelioma is shifting from a mostly male disease to a
disease that affects females as well in substantial numbers.
Studies on unknown sources of asbestos exposure, of other
sources of natural exposure to asbestos and asbestos-like
fibers, as well as of individual genetic susceptibility to
asbestos bers are needed.
Acknowledgments
Funding: None.
Footnote
Conicts of Interest: The authors have no conicts of interest
to declare.
Ethical Statement: The authors are accountable for all
aspects of the work in ensuring that questions related
to the accuracy or integrity of any part of the work are
Table 2 Ratio of annual world standardized mortality rates to
incidence rates [2008–2012], by country, for males and females
Country Mortality rate to incidence rate ratio [2008–2012]†
Male Female
United States 0.89 0.67
Austria 0.82 1.00
Belgium 0.80 0.75
Bulgaria 0.20 0.00
Croatia 0.87 1.00
Cyprus 0.62 0.33
Czech Republic 0.75 0.50
Denmark 0.68 1.00
Estonia 1.00 0.50
France 0.85 0.75
Germany 0.69 0.67
Iceland†0.42 1.00
Ireland 0.90 0.50
Israel 0.86 0.50
Italy 0.83 0.67
Latvia 1.00 1.00
Lithuania 1.00 1.00
Malta 0.74 1.00‡
Netherlands 0.89 0.75
Norway 0.80 0.67
Poland 0.80 0.67
Portugal 0.60 –
Slovakia 0.29 0.50
Slovenia†0.60 0.80
Spain 0.67 1.00
Switzerland 0.90 0.67
United Kingdom 0.88 0.83
†, combined incidence rates are available from 2008–2012.
Combined mortality rates are queried from all years available
from 2008–2012 for each country. For some countries, not
all years from 2008–2012 were available. ‡, due to data from
difference sources, some mortality rates exceed incidence
rates for the same time frame. Those ratios are recorded as 1.
Russian Federation, Turkey, Ukraine, and Belarus reported
incidence rates, but no mortality information. Armenia, Finland,
Georgia, Hungary, Kazakhstan, Kyrgyzstan, Luxembourg,
Republic of Moldova, Romania, Serbia, and Sweden, reported
mortality rates, but not incidence information. Albania, Andorra,
Azerbaijan, Bosnia and Herzegovina, Greece, Macedonia,
Monaco, Montenegro, San Marino, Tajikistan, Turkmenistan, and
Uzbekistan reported no mesothelioma information.

S37
Translational Lung Cancer Research, Vol 9, Suppl 1 February 2020
© Translational lung cancer research. All rights reserved. Transl Lung Cancer Res 2020;9(Suppl 1):S28-S38 | http://dx.doi.org/10.21037/tlcr.2019.11.11
appropriately investigated and resolved.
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Cite this article as: Alpert N, van Gerwen M, Taioli E.
Epidemiology of mesothelioma in the 21st century in Europe
and the United States, 40 years after restricted/banned asbestos
use. Transl Lung Cancer Res 2020;9(Suppl 1):S28-S38. doi:
10.21037/tlcr.2019.11.11