Model History-taking Form for Clinicians Dealing with Mesothelioma Patients Validated by Delphi Expert Consensus

Model History-taking Form for Clinicians Dealing with Mesothelioma Patients Validated by Delphi Expert Consensus; Raja Singh, Rohit Kumar, Mukesh Nagar, Satish Kaipilyawar, Henry A Anderson, Abhijeet V Jadhav, Tarang Patel, Tim R Drischoll, Prriya E, Siddharth R Yadav, Sukhram Bishnoi, Navneet Singh, Kanwalpreet Kaur, Ashish Jakhetiya, Nico van Zandwijk, Sarita Kumari, Divya Khosla, Shiv Rajan, Ajay K Verma, Aditi Bhatt, Aparna Sharma, Dinesh K Sinha, Akhil Kapoor, Ritu Gill, Rima Dada, Jugal Kishore & Arthur L Frank; 2025. Doi: 10.5281/zenodo.15627876 1 Title: 1 Model History-taking Form for Clinicians 2 Dealing with Mesothelioma Patients Validated by 3 Delphi Expert Consensus 4 5 Running Title: 6 History-taking form for mesothelioma patients 7 8 Authors: 9 10 Raja Singh* a, Rohit Kumar b, Mukesh Nagar c, Satish B Kaipilyawar d, Henry 11 A Anderson e, Abhijeet V Jadhav f, Tarang Patel g, Tim R Drischoll h, Prriya E i, 12 Siddharth R Yadav j, Sukhram Bishnoi k, Navneet Singh l, Kanwalpreet Kaur m, 13 Ashish Jakhetiya n, Nico van Zandwijk o, Sarita Kumari p, Divya Khosla q, Shiv 14 Rajan r, Ajay K Verma s, Aditi Bhatt t, Aparna Sharma u, Dinesh K Sinha v, 15 Akhil Kapoor w, Ritu Gill x, Rima Dada y, Jugal Kishore z, Arthur L Frank a. 16 17 18 a. Department of Environmental and Occupational Health, Dornsife School of Public Health, Drexel University, 19 Philadelphia, USA. 20 b. Department of Pulmonary Medicine, Critical Care Medicine and Sleep Disorders, Vardhman Mahavir Medical College & 21 Safdarjung Hospital, New Delhi, India. 22 c. Department of Medical Oncology, Vardhman Mahavir Medical College & Safdarjung Hospital, New Delhi, India. 23 d. Public Health, Society for Health Allied Research & Education, Hyderabad, India. 24 e. Department of Population Health Sciences, School of Medicine and Public Health, University of Wisconsin, Madison, 25 USA. 26 f. Department of Epidemiology, ICMR-National Institute of Virology, Pune, India. 27 g. Department of Pathology, All India Institute of Medical Sciences, Rajkot, India. 28 h. Sydney School of Public Health, The University of Sydney, Sydney, Australia 29 i. Thoracic Surgery, Navi Mumbai, India. 30 j. Department of Pulmonary Medicine, Vallabhbhai Patel Chest Institute, University of Delhi, New Delhi, India. 31 k. Thoracic Surgery, Medanta Hospital, Gurugram, India. 32 l. Department of Pulmonary Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India. 33 m. Department of Pathology, Jawaharlal Institute of Postgraduate Medical Education & Research, Puducherry, India. 34 n. Department of Surgical Oncology, Geetanjali Medical College, Udaipur, India. 35 o. Department of Cell and Molecular Therapies, Royal Prince Alfred Hospital, Sydney Local District & University of 36 Sydney, Sydney, Australia. 37 p. Gynae-Surgical Oncology, Max Hospital, New Delhi, India 38 q. Department of Radiotherapy and Oncology, Post Graduate Institute of Medical Education and Research, Chandigarh, 39 India. 40 r. Department of Surgical Oncology, King George’s Medical University, Lucknow, India. 41 s. Department of Respiratory Medicine, King George’s Medical University, Lucknow, India. 42 t. Department of Surgical Oncology, Shalby Cancer and Research Institute, Ahmedabad, India. 43 u. Department of Medical Oncology, National Cancer Institute, Jhajjar, (All India Institute of Medical Sciences, New 44 Delhi), India. 45 v. Department of Radiation Oncology, Indira Gandhi Institute of Medical Sciences, Patna, India. 46 w. Department of Medical Oncology, Mahamana Pandit Madan Mohan Malaviya Cancer Centre & Homi Bhabha Cancer 47 Hospital, Tata Memorial Centre, Varanasi, India. 48 x. Department of Radiology, Columbia University, New York, USA. 49 y. Laboratory for Molecular Reproduction and Genetics, Department of Anatomy, All India Institute of Medical Sciences, 50 New Delhi, India. 51 z. Department of Community Medicine, Vardhman Mahavir Medical College & Safdarjung Hospital, New Delhi, India. 52 53 *Corresponding author: Raja Singh, Post-Doctoral Fellow, Department of Environmental and 54 Occupational Health, Dornsife School of Public Health, Drexel University, Philadelphia, 55 USA. Email: [email protected] [email protected] 56 57 58 Model History-taking Form for Clinicians Dealing with Mesothelioma Patients Validated by Delphi Expert Consensus; Raja Singh, Rohit Kumar, Mukesh Nagar, Satish Kaipilyawar, Henry A Anderson, Abhijeet V Jadhav, Tarang Patel, Tim R Drischoll, Prriya E, Siddharth R Yadav, Sukhram Bishnoi, Navneet Singh, Kanwalpreet Kaur, Ashish Jakhetiya, Nico van Zandwijk, Sarita Kumari, Divya Khosla, Shiv Rajan, Ajay K Verma, Aditi Bhatt, Aparna Sharma, Dinesh K Sinha, Akhil Kapoor, Ritu Gill, Rima Dada, Jugal Kishore & Arthur L Frank; 2025. Doi: 10.5281/zenodo.15627876 2 Abstract: 1 2 Mesothelioma is causally established to be exclusively related to asbestos exposure as a risk 3 factor. Before considering other possible causative factors linked to mesothelioma, a detailed 4 exposure history may be warranted which looks at possible exposures to asbestos. Some of 5 these exposures may be unknown to patients, may be forgotten or may not be readily 6 available as a comprehensive tool for the clinicians dealing with mesothelioma patients. This 7 study uses the Delphi anonymous consensus technique to develop and validate a detailed, 8 seven-sectioned, and comprehensive questionnaire which can be readily used by clinicians. 9 After two rounds, the experts followed a thorough and rigorous process to validate the 10 questionnaire. This includes medical history along with occupational, non-occupational as 11 well as para-occupational exposure to asbestos. It also consists of many parameters which can 12 be used to rule out rather than rule in the possibility of mesothelioma. Questions have also 13 been included to factor in other types of dust exposure for an informed differential diagnosis. 14 Overall, this attempt creates a readily available history-taking questionnaire validated by 15 experts which can be replicated for other conditions and become an essential tool for 16 diagnosis. Apart from accurate and informed diagnosis, this documentation can be valuable 17 for epidemiological, research, policy-informing, legal and compensation related issues. 18 19 Keywords: pleural mesothelioma, peritoneal mesothelioma, asbestos exposure, marble, 20 stone-cutting, occupational medicine, differential diagnosis. 21 22 23 24 Model History-taking Form for Clinicians Dealing with Mesothelioma Patients Validated by Delphi Expert Consensus; Raja Singh, Rohit Kumar, Mukesh Nagar, Satish Kaipilyawar, Henry A Anderson, Abhijeet V Jadhav, Tarang Patel, Tim R Drischoll, Prriya E, Siddharth R Yadav, Sukhram Bishnoi, Navneet Singh, Kanwalpreet Kaur, Ashish Jakhetiya, Nico van Zandwijk, Sarita Kumari, Divya Khosla, Shiv Rajan, Ajay K Verma, Aditi Bhatt, Aparna Sharma, Dinesh K Sinha, Akhil Kapoor, Ritu Gill, Rima Dada, Jugal Kishore & Arthur L Frank; 2025. Doi: 10.5281/zenodo.15627876 3 Background: 1 Mesothelioma is a rare malignancy that is ‘uniquely elicited by asbestos’ and may even be a 2 surrogate marker for asbestos exposure 1. There may be other very rare sources of exposure 3 such as carbon nanotubes and erionite which are causative factors for development of 4 mesothelioma 2,3. In this study, while there is no attempt to list all possible exposures or 5 conditions that can lead development of mesothelioma, the fact that asbestos is the key 6 causative factor needs to expand beyond the most obviously linked exposures 4. This means 7 that there may be other sources of asbestos, but some of them may not be appreciated or may 8 be distant exposures that may be forgotten or may not be known 5. There is also the long latency 9 of mesothelioma where the delayed recognition may lead to lack of pinpointing of the exact 10 exposure, and workers may not identify the sources of exposures 6. It is also a problem these 11 sources of exposures may not be available as a ready reference for most clinicians who are 12 clinically evaluating the patients (including history-taking). This study attempts to create a 13 model history taking form for clinicians who are dealing with mesothelioma (suspected or 14 diagnosed) cases. This may be useful either for the differential diagnosis in case of suspected 15 patients or for conclusive diagnosis in pathologically and otherwise clinically diagnosed 16 patients. This may also be useful for screening, research, epidemiological, legal or 17 compensation related issues 6. 18 An illustrative example would be a person who may have never had any exposure in an asbestos 19 factory, may have never worked or live near a mine or disposal site of asbestos, but may have 20 used talcum powder (with asbestos contamination naturally present) unknowingly for a large 21 part of his or her life. Another example may be a person who again may never had used talcum 22 powder or had any occupational or non-occupational exposure to asbestos, but be a jeweller, a 23 naval officer, or a teacher with unknowing exposure to asbestos in the work environment. 24 Clinicians may not be aware of many such non-occupational exposures, or due to the large 25 possibility of exposure sources, may not be able to recall or remember possible sources in the 26 Model History-taking Form for Clinicians Dealing with Mesothelioma Patients Validated by Delphi Expert Consensus; Raja Singh, Rohit Kumar, Mukesh Nagar, Satish Kaipilyawar, Henry A Anderson, Abhijeet V Jadhav, Tarang Patel, Tim R Drischoll, Prriya E, Siddharth R Yadav, Sukhram Bishnoi, Navneet Singh, Kanwalpreet Kaur, Ashish Jakhetiya, Nico van Zandwijk, Sarita Kumari, Divya Khosla, Shiv Rajan, Ajay K Verma, Aditi Bhatt, Aparna Sharma, Dinesh K Sinha, Akhil Kapoor, Ritu Gill, Rima Dada, Jugal Kishore & Arthur L Frank; 2025. Doi: 10.5281/zenodo.15627876 4 limited time they may have with patients, in likely very busy clinical scenarios. Worth noting 1 is that there may be a scope of delay in mesothelioma diagnosis, when the most well-known 2 exposure to asbestos may be investigated, but other indirect exposures or not well known 3 asbestos exposure may not be considered 7. This may also lead to some other studies not 4 attributing mesothelioma to asbestos exposure, as some less well-known asbestos exposures 5 may not have been asked and/or noted. 6 The issue of asbestos contaminating other minerals, like talcum powder (soapstone), marble, 7 or even allied minerals in a coal mine may be important but may not be part of the mainstream 8 knowledge resources accessible for patients, caregivers, and medical professionals 8–10. An 9 example is a study from a single hospital in Udaipur (Rajasthan, India) that reported 76 cases 10 of mesothelioma in four years 10. It was surprisingly stated that no patient had any past exposure 11 to asbestos. However, 91% of the patients had a history of direct or indirect exposure to mining 12 and quarrying of marble and granite. The study speculated the close association of marble and 13 asbestos but did not investigate further. A later study performed geological investigations of 14 the marble waste slurry deposited at a marble quarrying and milling site in Rajasthan 9. This 15 study found the presence of tremolite (which is one of the six forms of asbestos, others being 16 chrysotile, actinolite, crocidolite, anthophyllite and amosite). 17 18 Mesothelioma are prone to misdiagnosis as there may be medical facilities where the needed 19 histo-pathological investigations and ultra-structural studies may not be present and differential 20 diagnosis may be a challenge in the absence of these 11. But for such patients reaching a facility 21 where differential diagnosis may be based on basic investigations, the history taking may be 22 an important tool 12. Such exercise if done at a primary or secondary care centre may provide 23 for an informed input for the specialists at tertiary care centres. This may also be important as 24 in many countries, tertiary care centres may have a large patient load and lack of knowledge of 25 patient’s local language (as the patients may travel from their regions to tertiary centres in 26 Model History-taking Form for Clinicians Dealing with Mesothelioma Patients Validated by Delphi Expert Consensus; Raja Singh, Rohit Kumar, Mukesh Nagar, Satish Kaipilyawar, Henry A Anderson, Abhijeet V Jadhav, Tarang Patel, Tim R Drischoll, Prriya E, Siddharth R Yadav, Sukhram Bishnoi, Navneet Singh, Kanwalpreet Kaur, Ashish Jakhetiya, Nico van Zandwijk, Sarita Kumari, Divya Khosla, Shiv Rajan, Ajay K Verma, Aditi Bhatt, Aparna Sharma, Dinesh K Sinha, Akhil Kapoor, Ritu Gill, Rima Dada, Jugal Kishore & Arthur L Frank; 2025. Doi: 10.5281/zenodo.15627876 5 metropolitan cities) 13. The physician at the primary or secondary level itself may be able to 1 better initiate the process of getting a correct history will be very useful as a patient record the 2 tertiary level. 3 4 Aims and Objectives: 5 6 The aim of this study is to validate a questionnaire for clinicians to undertake detailed 7 history-taking for mesothelioma patients. 8 9 The objectives include, first, a collation of possible exposures to asbestos through literature 10 which can be attributable to potential mesothelioma in exposed patients. Second, is to create a 11 questionnaire which can be used by clinicians to undertake history taking of mesothelioma 12 patients. Third, is to create a consensus of experts using the Delphi technique for validation 13 of the questionnaire. 14 15 Methodology: 16 A questionnaire was developed for clinicians by taking the most likely causes of asbestos 17 exposure along with other basic clinical parameters. This questionnaire was based on literature 18 from which the most common sources of occupational, para-occupational, or non-occupational 19 exposure to asbestos was collated. This was then shared with experts using the Delphi 20 Technique for its validation 14. The process took place through two rounds of anonymous 21 feedback between a moderator and 30 experts. The experts were selected from a wide range of 22 specialities related to mesothelioma, which includes physicians dealing clinically with patients 23 and others diagnosing the patients. 24 Expert Selection: 25 30 experts were included in the validation of the questionnaire. Out of the 30, 20 dealt with 26 mesothelioma patients clinically while the remaining 10 dealt with mesothelioma patients for 27 Model History-taking Form for Clinicians Dealing with Mesothelioma Patients Validated by Delphi Expert Consensus; Raja Singh, Rohit Kumar, Mukesh Nagar, Satish Kaipilyawar, Henry A Anderson, Abhijeet V Jadhav, Tarang Patel, Tim R Drischoll, Prriya E, Siddharth R Yadav, Sukhram Bishnoi, Navneet Singh, Kanwalpreet Kaur, Ashish Jakhetiya, Nico van Zandwijk, Sarita Kumari, Divya Khosla, Shiv Rajan, Ajay K Verma, Aditi Bhatt, Aparna Sharma, Dinesh K Sinha, Akhil Kapoor, Ritu Gill, Rima Dada, Jugal Kishore & Arthur L Frank; 2025. Doi: 10.5281/zenodo.15627876 6 diagnosis and exposure history, or were researchers involved in an allied area related to 1 mesothelioma, or asbestos. Some, who did not deal with patients clinically were from the field 2 of community medicine, nursing, genetics, toxicology, epidemiology, and public health. Others 3 were pathologists who play an important role in confirmatory diagnosis of mesothelioma. The 4 experts dealing with mesothelioma patients clinically included medical oncologists, surgical 5 oncologists, pulmonologists, radiation oncologists, internal medicine physicians and 6 occupational physicians. 7 Questionnaire for Physicians for validation: 8 The final questionnaire for validation is presented below as Appendix A. The questionnaire 9 composes of seven sections with one section dealing with patient background, occupation, 10 geographical region of work and residence. The other six sections were arranged from ‘A’ to 11 ‘F’. Section A deals with patient medical history. This is especially related to tuberculosis as 12 some if not many patients who have mesothelioma, may have had asbestosis first, and were in 13 the past incorrectly diagnosed tuberculosis and administered anti-tubercular medicines. There 14 are other questions related to ruling out type of pulmonary diseases (whether restrictive or 15 constructive). There are additional questions related to diagnosis and treatments which may be 16 useful for patients who may not know the details of their condition but may know the process 17 of past medical care received. This is particularly useful as many workers may not be aware of 18 medical terminology, and questions, for example about whether past CT scan has been taken 19 may serve as a useful clue for the kind of past medical examination the patents would have 20 undergone. Section B deals with a detailed history of the occupation of the patient which not 21 only includes questions to rule in asbestos exposure, but also questions which may possibly 22 rule out asbestos exposure. It provides a detailed list of possible occupations shown in the 23 literature to lead to asbestos exposure and in some cases attributable to occurrence of 24 mesothelioma. Some sources with citations are listed in discussion section below. 25 Model History-taking Form for Clinicians Dealing with Mesothelioma Patients Validated by Delphi Expert Consensus; Raja Singh, Rohit Kumar, Mukesh Nagar, Satish Kaipilyawar, Henry A Anderson, Abhijeet V Jadhav, Tarang Patel, Tim R Drischoll, Prriya E, Siddharth R Yadav, Sukhram Bishnoi, Navneet Singh, Kanwalpreet Kaur, Ashish Jakhetiya, Nico van Zandwijk, Sarita Kumari, Divya Khosla, Shiv Rajan, Ajay K Verma, Aditi Bhatt, Aparna Sharma, Dinesh K Sinha, Akhil Kapoor, Ritu Gill, Rima Dada, Jugal Kishore & Arthur L Frank; 2025. Doi: 10.5281/zenodo.15627876 7 Section C mainly deals with environmental exposures where a person may be exposed to 1 asbestos in settings including living and working near asbestos sources like mines, factories, 2 construction sites, etc. Section D mainly deals with non-occupational sources of asbestos 3 exposure where the issues of using asbestos containing products is covered. Section E deals 4 with the para-occupational sources of asbestos exposure. This relates to Section B, but now for 5 relatives and people within the same household of the patient who may be exposed to asbestos 6 and may become a source of exposure through proximity to the person or the processes of 7 cleaning the clothes etc of the person. Section F dealt with other exposures which may be useful 8 in ruling out asbestos exposure and to find out the possibility of other exposure which may be 9 useful in differential diagnosis of other conditions. The questionnaire was based on narrative 10 review of literature with some sources describe in Table 2 and others were contributed by the 11 experts. 12 Validation of the questionnaire: 13 Round 1: In the first round, the seven sections were separately presented to all the experts in 14 the form of an online form where they could select one out of the three options for each section. 15 The first option was ‘Ok’ if the expert considered the section to be included as it is int the 16 questionnaire for clinicians. The second option was ‘Revise’ where the expert provided 17 feedback to revise the section. And the third option was ‘Reject’ where the expert rejected a 18 section as it is. Another section was provided to the experts where they could provide feedback 19 to the questionnaire as a whole. The individual responses of experts were collected by the 20 moderator (first author) and integrated into a revised questionnaire. 21 Round 2: The revised questionnaire with all the comments integrated were now sent as a 22 compiled document to the experts through email, where the experts again provided their 23 feedback, and this was further integrated into the questionnaire. Anonymity was maintained. 24 25 26 Model History-taking Form for Clinicians Dealing with Mesothelioma Patients Validated by Delphi Expert Consensus; Raja Singh, Rohit Kumar, Mukesh Nagar, Satish Kaipilyawar, Henry A Anderson, Abhijeet V Jadhav, Tarang Patel, Tim R Drischoll, Prriya E, Siddharth R Yadav, Sukhram Bishnoi, Navneet Singh, Kanwalpreet Kaur, Ashish Jakhetiya, Nico van Zandwijk, Sarita Kumari, Divya Khosla, Shiv Rajan, Ajay K Verma, Aditi Bhatt, Aparna Sharma, Dinesh K Sinha, Akhil Kapoor, Ritu Gill, Rima Dada, Jugal Kishore & Arthur L Frank; 2025. Doi: 10.5281/zenodo.15627876 8 Results 1 2 The result of the consensus after two rounds led to the creation of the detailed questionnaire 3 for history-taking of mesothelioma patients by clinicians which is present in Appendix A below. 4 The details of the two rounds of the Delphi consensus building are present in Table 1 below. 5 6 Table 1: Details of the two Rounds of the Delphi consensus for the validation of the history-taking questionnaire for 7 mesothelioma patients by clinicians. 8 Description of Section Round 1: Sharing Online, Section wise questionnaire for validation. Round 2: Sharing the revised complete questionnaire for validation. Section dealing with occupation status. 22 experts accepted section as it is (~73%). 8 experts suggested revisions (~27%). None rejected. These mostly pertained to a more detailed and nested description to be added. 8 experts suggested further changes to the revised version which had revisions integrated from Round 1. Comments included: Detailing out smoking and cough history, adding some more exposure scenarios; detailing out weight loss and making the occupation history more detailed. Section A: Deals with patient medical history 16 experts accepted section as it is (~53%). 14 experts suggested revisions (~47%). None rejected. This included many revisions including taking detailed historysmoking, cough, cancer in family, etc. Section B: Deals with a detailed history of the profession of the patient. 20 experts accepted section as it is (~67%). 10 suggested revisions (~33%). None rejected. This included many more possible occupations from around the world to make it more comprehensive. Section C: Deals with environmental exposures where a person may be exposed to asbestos to scenarios including living and working near asbestos sources 25 experts accepted section as it is (~83%). 5 suggested revisions (~17%). None rejected. Some additional environmental exposures were added including asbestos textile unit. Model History-taking Form for Clinicians Dealing with Mesothelioma Patients Validated by Delphi Expert Consensus; Raja Singh, Rohit Kumar, Mukesh Nagar, Satish Kaipilyawar, Henry A Anderson, Abhijeet V Jadhav, Tarang Patel, Tim R Drischoll, Prriya E, Siddharth R Yadav, Sukhram Bishnoi, Navneet Singh, Kanwalpreet Kaur, Ashish Jakhetiya, Nico van Zandwijk, Sarita Kumari, Divya Khosla, Shiv Rajan, Ajay K Verma, Aditi Bhatt, Aparna Sharma, Dinesh K Sinha, Akhil Kapoor, Ritu Gill, Rima Dada, Jugal Kishore & Arthur L Frank; 2025. Doi: 10.5281/zenodo.15627876 9 Section D: Deals with nonoccupational sources of asbestos exposure 23 experts accepted section as it is (~77%). 7 suggested revisions (~23%). None rejected. Questions pertaining to duration of exposure and use of respirators was added. Section E: Deals with the paraoccupational sources of asbestos exposure 24 experts accepted section as it is (80%). 6 suggested revisions (20%). None rejected. Professions as in Section B increased. A specific question pertaining to cleaning/washing clothes of family member added. Section F: Deals with other exposures (including dust exposures) which may be useful to ruling out asbestos exposure 22 experts accepted section as it is (~73%). 8 suggested revisions (~27%). None rejected. The duration of exposure parameter was added. Comments by experts on overall questionnaire (as a whole); In case there is a need for addition of a new question, or any revision. Comments ranged from including exposure time, adding more exposure scenarios, adding antitubercular treatment, past CT scan, fluid drawn from chest in history. History of smoking to be included; Family cancer history to be added; Farming exposure to be added. 1 2 3 Discussion and Conclusion: 4 5 Some sources of asbestos exposure and possibility of mesothelioma occurrence are cited in 6 Table 2. Such a list is not truly exhaustive as that exercise has been done in detail by other 7 studies, and the list may increasingly expand15,16. What is essential is that based on the clinical 8 experience of the physicians dealing with mesothelioma patients, a basic literature-generated 9 list has been expanded. This has justified the first objective by not only creating a list of 10 exposures from literature, but also including some exposures and scenarios from clinical 11 Model History-taking Form for Clinicians Dealing with Mesothelioma Patients Validated by Delphi Expert Consensus; Raja Singh, Rohit Kumar, Mukesh Nagar, Satish Kaipilyawar, Henry A Anderson, Abhijeet V Jadhav, Tarang Patel, Tim R Drischoll, Prriya E, Siddharth R Yadav, Sukhram Bishnoi, Navneet Singh, Kanwalpreet Kaur, Ashish Jakhetiya, Nico van Zandwijk, Sarita Kumari, Divya Khosla, Shiv Rajan, Ajay K Verma, Aditi Bhatt, Aparna Sharma, Dinesh K Sinha, Akhil Kapoor, Ritu Gill, Rima Dada, Jugal Kishore & Arthur L Frank; 2025. Doi: 10.5281/zenodo.15627876 16 27. Mensi C, Zellino C, Polonioli M, et al. Pleural mesothelioma in a circus worker. 1 Journal of Occupational Health. 2021;63(1):e12250. doi:10.1002/1348-9585.12250 2 28. Frank AL. Four mesothelioma cases from a single automotive dealership: A case 3 series. American J Industrial Med. 2023;66(10):904-906. doi:10.1002/ajim.23521 4 29. Gothi D, Gahlot T, Sah R, et al. Asbestos-induced lung disease in small-scale clutch 5 manufacturing workers. Indian J Occup Environ Med. 2016;20(2):95. 6 doi:10.4103/0019-5278.197533 7 30. Mancuso TF. Relative risk of mesothelioma among railroad machinists exposed to 8 chrysotile. American J Industrial Med. 1988;13(6):639-657. 9 doi:10.1002/ajim.4700130604 10 31. Moline J, Bevilacqua K, Alexandri M, Gordon RE. Mesothelioma Associated With the 11 Use of Cosmetic Talc. Journal of Occupational & Environmental Medicine. 12 2020;62(1):11-17. doi:10.1097/JOM.0000000000001723 13 32. Moline J, Patel K, Frank AL. Exposure to cosmetic talc and mesothelioma. J Occup 14 Med Toxicol. 2023;18(1):1. doi:10.1186/s12995-023-00367-5 15 33. Fitzgerald S, Harty E, Joshi TK, Frank AL. Asbestos in commercial Indian talc. 16 American J Industrial Med. 2019;62(5):385-392. doi:10.1002/ajim.22969 17 34. Gordon RE, Fitzgerald S, Millette J. Asbestos in commercial cosmetic talcum 18 powder as a cause of mesothelioma in women. International Journal of 19 Occupational and Environmental Health. 2014;20(4):318-332. 20 doi:10.1179/2049396714Y.0000000081 21 35. Kitamura Y, Zha L, Liu R, et al. Association of mesothelioma deaths with 22 neighborhood asbestos exposure due to a large-scale asbestos-cement plant. 23 Cancer Science. 2023;114(7):2973-2985. doi:10.1111/cas.15802 24 36. Ferrante D, Bertolotti M, Todesco A, Mirabelli D, Terracini B, Magnani C. Cancer 25 Mortality and Incidence of Mesothelioma in a Cohort of Wives of Asbestos Workers 26 in Casale Monferrato, Italy. Environ Health Perspect. 2007;115(10):1401-1405. 27 doi:10.1289/ehp.10195 28 37. Jadhav AV, Gawde N, Veerappan R, Choi Y, Frank AL. Understanding exposure risk 29 using soil testing and GIS around an abandoned asbestos mine. Annals of Global 30 Health. 2025;91(1):2. doi:10.5334/aogh.4624 31 38. Berge LAM, Shala NK, Barone-Adesi F, et al. Exposure to fibres and risk of pleural 32 mesothelioma in the Norwegian O_shore Petroleum Workers cohort. Occup Environ 33 Med. 2024;81(7):331-338. doi:10.1136/oemed-2024-109424 34 39. Crosignani P, Forastiere F, Petrelli G, et al. Malignant mesothelioma in 35 thermoelectric power plant workers in Italy. American J Industrial Med. 36 1995;27(4):573-576. doi:10.1002/ajim.4700270410 37 Model History-taking Form for Clinicians Dealing with Mesothelioma Patients Validated by Delphi Expert Consensus; Raja Singh, Rohit Kumar, Mukesh Nagar, Satish Kaipilyawar, Henry A Anderson, Abhijeet V Jadhav, Tarang Patel, Tim R Drischoll, Prriya E, Siddharth R Yadav, Sukhram Bishnoi, Navneet Singh, Kanwalpreet Kaur, Ashish Jakhetiya, Nico van Zandwijk, Sarita Kumari, Divya Khosla, Shiv Rajan, Ajay K Verma, Aditi Bhatt, Aparna Sharma, Dinesh K Sinha, Akhil Kapoor, Ritu Gill, Rima Dada, Jugal Kishore & Arthur L Frank; 2025. Doi: 10.5281/zenodo.15627876 17 40. Singh R, Cherrie JW, Rao B, Asolekar SR. Assessment of the future mesothelioma 1 disease burden from past exposure to asbestos in ship recycling yards in India. 2 International Journal of Hygiene and Environmental Health. 2020;225:113478. 3 doi:10.1016/j.ijheh.2020.113478 4 41. Hemminki K, Försti A, Chen T, Hemminki A. Incidence, mortality and survival in 5 malignant pleural mesothelioma before and after asbestos in Denmark, Finland, 6 Norway and Sweden. BMC Cancer. 2021;21(1):1189. doi:10.1186/s12885-021-7 08913-2 8 42. Oberta AF, Poye L, Compton SP. Releasability of asbestos fibers from weathered roof 9 cement. Journal of Occupational and Environmental Hygiene. 2018;15(6):466-473. 10 doi:10.1080/15459624.2018.1448401 11 43. Obmiński A. Asbestos cement products and their impact on soil contamination in 12 relation to various sources of anthropogenic and natural asbestos pollution. 13 Science of The Total Environment. 2022;848:157275. 14 doi:10.1016/j.scitotenv.2022.157275 15 44. Kang D, Kim YY, Shin M, et al. Relationships of Lower Lung Fibrosis, Pleural Disease, 16 and Lung Mass with Occupational, Household, Neighborhood, and Slate Roof-17 Dense Area Residential Asbestos Exposure. IJERPH. 2018;15(8):1638. 18 doi:10.3390/ijerph15081638 19 45. Kottek M, Yuen ML. Public health risks from asbestos cement roofing. American J 20 Industrial Med. 2022;65(3):157-161. doi:10.1002/ajim.23321 21 46. Jadhav A, Gawde N. Current asbestos exposure and future need for palliative care in 22 India. Indian J Palliat Care. 2019;25(4):587. doi:10.4103/IJPC.IJPC_51_19 23 47. Magnani C, Mensi C, Binazzi A, et al. The Italian Experience in the Development of 24 Mesothelioma Registries: A Pathway for Other Countries to Address the Negative 25 Legacy of Asbestos. IJERPH. 2023;20(2):936. doi:10.3390/ijerph20020936 26 48. Singh R, Frank AL. Analysis of mesothelioma cases and National Cancer Registry 27 data to assess asbestos exposure in India. public health action. 2024;14(1):30-33. 28 doi:10.5588/pha.24.0003 29 49. Singh R, Frank AL. Indian Health Ministry Refuses to Make Cancer a Notifiable 30 Disease Despite ICMR’s Recommendation. Published online December 5, 2024. 31 doi:10.32388/IL4JV0 32 50. Singh R, Frank AL. Notification and recordkeeping of occupational mesothelioma in 33 India. Published online February 15, 2025. doi:10.1101/2025.02.11.25322115 34 51. Government of India. The Occupational Safety, Health and Working Conditions 35 Code, 2020.; 2020. Accessed February 10, 2025. 36 https://labour.gov.in/sites/default/files/osh_gazette.pdf 37 52. Government of India. The Mines Act, 1952.; 1952. Accessed February 10, 2025. 38 https://labour.gov.in/sites/default/files/theminesact1952.pdf 39 Model History-taking Form for Clinicians Dealing with Mesothelioma Patients Validated by Delphi Expert Consensus; Raja Singh, Rohit Kumar, Mukesh Nagar, Satish Kaipilyawar, Henry A Anderson, Abhijeet V Jadhav, Tarang Patel, Tim R Drischoll, Prriya E, Siddharth R Yadav, Sukhram Bishnoi, Navneet Singh, Kanwalpreet Kaur, Ashish Jakhetiya, Nico van Zandwijk, Sarita Kumari, Divya Khosla, Shiv Rajan, Ajay K Verma, Aditi Bhatt, Aparna Sharma, Dinesh K Sinha, Akhil Kapoor, Ritu Gill, Rima Dada, Jugal Kishore & Arthur L Frank; 2025. Doi: 10.5281/zenodo.15627876 18 Appendix A: 1 The Model History-taking Form for Clinicians Dealing with Mesothelioma Patients Validated 2 by Delphi Expert Consensus 3 4 Note: The clinician attending the patient may fill the following history-taking form. First, the patients’ 5 details should be taken. This should be followed by the sets of questions from A to F. All questions 6 may be asked while a detailed history is being taken. A vernacular version (provided separately) may 7 be used if needed. The form is of 5 pages (Pages 3 to 7). 8 9 Personal Details: Name Expunged/ Address Expunged/ Phone Number Expunged 10 Age: _________ 11 Gender: _________ 12 Pin Code/Zip Code/Postal Code of residential address (permanent): _______ 13 Whether Working or Retired:___________ 14 If Retired, age of retirement: __________ 15 If Retired, reason for retirement: _________ 16 Started work at what age: ___________ 17 Occupation (Current): ________ 18 Occupation (Major period of career): _________________ 19 Pin Code/Zip Code/Postal Code of Current workplace: _______ 20 Other Occupations during lifetime with duration of work; pin/zip/postal code; beginning and 21 end year: 22 _______________________ 23 _______________________ 24 _______________________ 25 26 A. Additional Details: 27 28 1.Past History of COPD? Yes/No? _______ 29 2. Past History of Any other lung disease: ILD/Restrictive Disease: 30 Asbestosis/Silicosis/Any other chest/lung disease: Yes/No? ________ 31 3. Past History of Asthma: Yes/No?_________ 32 4. Past History of Tuberculosis: Yes/No? _________ 33 5. Past History of Cancer (Self): Yes/No? _________ 34 6. Family History of Cancer: Yes/No____ Details________ 35 36 If yes, please provide details: ________ 37 38 7. Cough History: 39 i. If one time: Yes/No? _________Details: _________ 40 ii. If >3 weeks: Yes/No? ________Details: ________ 41 8. Breathlessness: Yes/No? _______ 42 9. Weight Loss (in last one year): Yes/No? ______ 43 10. Chest Pain: Yes/No? _______ 44 11. Cough with blood-stained sputum: Yes/No? Details_________ 45 12. History of Smoking/Tobacco Use: Yes/No? ___________ 46 i. If smoker, age of initiation:_____ 47 ii. If smoker, Whether currently smoking: Yes/No:____ Detail:_____ 48 iii. If quit smoking, age at which done: 49 50 13. Was any fluid drawn (fluid aspiration) ever from your chest?________ 51 Model History-taking Form for Clinicians Dealing with Mesothelioma Patients Validated by Delphi Expert Consensus; Raja Singh, Rohit Kumar, Mukesh Nagar, Satish Kaipilyawar, Henry A Anderson, Abhijeet V Jadhav, Tarang Patel, Tim R Drischoll, Prriya E, Siddharth R Yadav, Sukhram Bishnoi, Navneet Singh, Kanwalpreet Kaur, Ashish Jakhetiya, Nico van Zandwijk, Sarita Kumari, Divya Khosla, Shiv Rajan, Ajay K Verma, Aditi Bhatt, Aparna Sharma, Dinesh K Sinha, Akhil Kapoor, Ritu Gill, Rima Dada, Jugal Kishore & Arthur L Frank; 2025. Doi: 10.5281/zenodo.15627876 19 14. Any prior Anti-Tubercular Treatment (DOTS) taken: Yes/No? 1 If Yes, How many months?:_____ 2 15. Have you ever had Chest X-Ray before?: Yes/No?:_______Details:_______ 3 a. Have you ever had Chest CT Scan before? Yes/No?:_______Details:_______ 4 16. Any past history of pleural effusion?_________ 5 i. If yes, please provide details: _________ 6 7 Any other remarks: __________ 8 9 B. Have YOU ever worked in: 10 1. An Asbestos Factory: Yes/No 11 2. Asbestos Mine: Yes/No 12 3. Soapstone (Talc/Sheatite) Mine: Yes/No 13 4. Soapstone (Talc/Sheatite) Mill/Crushing Unit: Yes/No 14 5. Dolomite Mine: Yes/No 15 6. Dolomite Mill/Crushing Unit: Yes/No 16 7. Granite Mine: Yes/No 17 8. Granite Mill: Yes/No 18 9. Car/Scooter Mechanic Work: Yes/No 19 10. Marble Mine: Yes/No 20 11. Marble Cutting Unit: Yes/No 21 12. Talcum Powder Factory: Yes/No 22 13. Construction work dumping site: Yes/No 23 14. Construction work installing asbestos cement sheets: Yes/No 24 15. Construction work working with cement pipes: Yes/No 25 16. Construction work involved with demolition: Yes/No 26 17. Asbestos/Soapstone/Dolomite/Marble/Granite store/shop/trading: Yes/No 27 18. Shipyard: Yes/No 28 19. Ship Recycling Work: Yes/No 29 20. A Power Station: Yes/No 30 21. As an Electrician: Yes/No 31 22. As a Plumber: Yes/No 32 23. As a Road construction worker dealing with asphalt/tar and related 33 machinery: Yes/No 34 24. A Coal mine: Yes/No 35 25. A diamond mine: Yes/No 36 26. A Circus: Yes/No 37 27. Fireproofing Equipment manufacturing unit: Yes/No 38 28. Fire Services: Yes/No 39 29. As a Professional Tabla Player/percussionist using talc: Yes/No 40 30. As a Professional or hobby carrom board player: Yes/No 41 31. As a Sculptor using marble/soapstone: Yes/No 42 32. As a person involved in gold, silver, diamond, and gemstone jewellery 43 making industry: Yes/No 44 33. Laboratory work, instructor/handler where asbestos handling was performed: 45 Yes/No 46 34. Asbestos Textile Factory/Workshop/Tailoring unit: Yes/No 47 35. Service in the Navy/Merchant Navy: Yes/No 48 36. Worked in an automobile brake/clutch factory: Yes/No 49 37. Subway/Tunnel Work: Yes/No 50 38. Agriculture work involving paddy/sugarcane: Yes/No 51 39. Any work that involves use of talcum powder: Yes/No 52 Model History-taking Form for Clinicians Dealing with Mesothelioma Patients Validated by Delphi Expert Consensus; Raja Singh, Rohit Kumar, Mukesh Nagar, Satish Kaipilyawar, Henry A Anderson, Abhijeet V Jadhav, Tarang Patel, Tim R Drischoll, Prriya E, Siddharth R Yadav, Sukhram Bishnoi, Navneet Singh, Kanwalpreet Kaur, Ashish Jakhetiya, Nico van Zandwijk, Sarita Kumari, Divya Khosla, Shiv Rajan, Ajay K Verma, Aditi Bhatt, Aparna Sharma, Dinesh K Sinha, Akhil Kapoor, Ritu Gill, Rima Dada, Jugal Kishore & Arthur L Frank; 2025. Doi: 10.5281/zenodo.15627876 20 40. Furnace/Boiler Manufacture, Install and Repair: Yes/No 1 41. Construction-Marble and Tile cutting and installation: Yes/No 2 42. Train Cabin and Engine Manufacture/Maintenance: Yes/No 3 43. Stone Crusher Unit: Yes/No 4 44. As a waste picker/waste handler/waste processing plant or unit: Yes/No 5 45. As a person exposed to carbon nanotubes? Yes/No 6 46. Any other Mine: Yes/No (If yes, which one? - Answer below) 7 47. Other Work involving asbestos: Yes/No; Describe below. 8 9 If answer was Yes, please describe the work______________________________ 10 What was the duration of work/exposure: ___________ 11 Remarks: ________________________ 12 13 14 C. Have you ever lived or worked near: 15 a. An Asbestos Factory: Yes/No 16 b. Asbestos Mine: Yes/No 17 c. Soapstone (Talc/Sheatite) Mine: Yes/No 18 d. Soapstone (Talc/Sheatite) Mill/Crushing Unit: Yes/No 19 e. Dolomite Mine: Yes/No 20 f. Dolomite Mill: Yes/No 21 g. Granite Mine: Yes/No 22 h. Granite Mill: Yes/No 23 i. Car/Scooter Mechanic Work: Yes/No 24 j. Marble Mine: Yes/No 25 k. Marble Cutting Unit: Yes/No 26 l. Talcum Powder Factory: Yes/No 27 m. An asbestos waste dump yard: yes/no 28 n. A construction waste dumping site: yes/no 29 o. Asbestos Cement Sheet Factory: Yes/No 30 p. Cement Pipe Factory: Yes/No 31 q. Asbestos/Soapstone/Dolomite/Marble/Granite store/shop/trading: Yes/No 32 r. Ship Recycling Unit: Yes/No 33 s. Any construction site where marble/granite/tile cutting was taking place: 34 Yes/No 35 t. Brake/clutch manufacturing unit: Yes/No 36 u. Asbestos textile unit: Yes/No 37 v. Any other place where asbestos/talcum/marble related work was performed: 38 Yes/No 39 If answer was Yes, please describe ______________________________ 40 41 42 D. Have you ever used: 43 a. An asbestos sheet roofing: Yes/No 44 b. Asbestos insulation: Yes/No 45 c. Loose or sprayed asbestos for insulation: Yes/No 46 d. Talcum Powder for personal use: Yes/No. if Yes, Details: ______________ 47 e. Talcum powder as part of your professional work: Yes/No 48 f. Asbestos Cement Pipe: Yes/No 49 g. Asbestos textile like asbestos gloves etc: Yes/No 50 51 Model History-taking Form for Clinicians Dealing with Mesothelioma Patients Validated by Delphi Expert Consensus; Raja Singh, Rohit Kumar, Mukesh Nagar, Satish Kaipilyawar, Henry A Anderson, Abhijeet V Jadhav, Tarang Patel, Tim R Drischoll, Prriya E, Siddharth R Yadav, Sukhram Bishnoi, Navneet Singh, Kanwalpreet Kaur, Ashish Jakhetiya, Nico van Zandwijk, Sarita Kumari, Divya Khosla, Shiv Rajan, Ajay K Verma, Aditi Bhatt, Aparna Sharma, Dinesh K Sinha, Akhil Kapoor, Ritu Gill, Rima Dada, Jugal Kishore & Arthur L Frank; 2025. Doi: 10.5281/zenodo.15627876 21 Remarks: If Any answer is Yes, what was the duration of exposure; Any other 1 details: __________ 2 3 h. Have you ever used a respirator or personal protective equipment during your 4 occupation? Yes/No: _____ 5 Details: _______ 6 7 E. Has your MOTHER/FATHER/FAMILY MEMBER/OTHER PERSON 8 LIVING WITH YOU ever worked in: 9 1. An Asbestos Factory: Yes/No 10 2. Asbestos Mine: Yes/No 11 3. Soapstone (Talc/Sheatite) Mine: Yes/No 12 4. Soapstone (Talc/Sheatite) Mill/Crushing Unit: Yes/No 13 5. Dolomite Mine: Yes/No 14 6. Dolomite Mill/Crushing Unit: Yes/No 15 7. Granite Mine: Yes/No 16 8. Granite Mill: Yes/No 17 9. Car/Scooter Mechanic Work: Yes/No 18 10. Marble Mine: Yes/No 19 11. Marble Cutting Unit: Yes/No 20 12. Talcum Powder Factory: Yes/No 21 13. Construction work dumping site: Yes/No 22 14. Construction work installing asbestos cement sheets: Yes/No 23 15. Construction work working with cement pipes: Yes/No 24 16. Construction work involved with demolition: Yes/No 25 17. Asbestos/Soapstone/Dolomite/Marble/Granite store/shop/trading: Yes/No 26 18. Shipyard: Yes/No 27 19. Ship Recycling Work: Yes/No 28 20. A Power Station: Yes/No 29 21. As an Electrician: Yes/No 30 22. As a Plumber: Yes/No 31 23. As a Road construction worker dealing with asphalt/tar and related 32 machinery: Yes/No 33 24. A Coal mine: Yes/No 34 25. A diamond mine: Yes/No 35 26. A Circus: Yes/No 36 27. Fireproofing Equipment manufacturing unit: Yes/No 37 28. Fire Services: Yes/No 38 29. As a Professional Tabla Player: Yes/No 39 30. As a Professional or hobby carrom board player: Yes/No 40 31. As a Sculptor using marble/soapstone: Yes/No 41 32. As a person involved in gold, silver, diamond, and gemstone jewellery 42 making industry: Yes/No 43 33. Laboratory work, instructor/handler where asbestos handling was performed: 44 Yes/No 45 34. Asbestos Textile Factory/Workshop/Tailoring unit: Yes/No 46 35. Service in the Navy: Yes/No 47 36. Worked in an automobile brake/clutch factory: Yes/No 48 37. Subway/Tunnel Work: Yes/No 49 38. Agriculture work involving paddy/sugarcane: Yes/No 50 39. Any work that involves use of talcum powder: Yes/No 51 40. Furnace/Boiler Manufacture, Install and Repair: Yes/No 52 Model History-taking Form for Clinicians Dealing with Mesothelioma Patients Validated by Delphi Expert Consensus; Raja Singh, Rohit Kumar, Mukesh Nagar, Satish Kaipilyawar, Henry A Anderson, Abhijeet V Jadhav, Tarang Patel, Tim R Drischoll, Prriya E, Siddharth R Yadav, Sukhram Bishnoi, Navneet Singh, Kanwalpreet Kaur, Ashish Jakhetiya, Nico van Zandwijk, Sarita Kumari, Divya Khosla, Shiv Rajan, Ajay K Verma, Aditi Bhatt, Aparna Sharma, Dinesh K Sinha, Akhil Kapoor, Ritu Gill, Rima Dada, Jugal Kishore & Arthur L Frank; 2025. Doi: 10.5281/zenodo.15627876 22 41. Construction-Marble and Tile cutting and installation: Yes/No 1 42. Train Cabin and Engine Manufacture/Maintenance: Yes/No 2 43. Stone Crusher Unit: Yes/No 3 44. As a waste picker/waste handler/waste processing plant or unit: Yes/No 4 45. As a person exposed to carbon nanotubes? Yes/No 5 46. Any other Mine: Yes/No (If yes, which one? - Answer below) 6 47. Other Work involving asbestos: Yes/No; Describe below. 7 8 If answer was Yes, please describe the work______________________________ 9 Relationship with family member exposed: ______________________________ 10 Remarks: ________________________ 11 Also, please provide the duration of exposure to above: _______ 12 48. Has any of your MOTHER/FATHER/FAMILY MEMBER LIVING WITH 13 YOU used talcum powder? Yes/No_____ Describe:_________ 14 49. Have you been involved with the cleaning, washing, ironing of clothes of 15 your MOTHER/FATHER/FAMILY MEMBER LIVING WITH YOU? 16 Yes/No_______ Describe:__________ 17 18 F. Any other exposure to any other dust? Yes/No?________ 19 If Yes, which type of dust?:_________ 20 If yes, was it metallic/chemical or mineral dust, Describe: ________ 21 What was the duration of exposure? _________ 22 23 Any other Remarks: 24 25 ____________________________________________________ 26 ____________________________________________________ 27 28