January 21, 2003
Group Health Medical Center-Tacoma
209 Martin Luther King Jr. Way
Tacoma, WA 98405
(253) 596-3300
RE: ROBERT FARMER
Dear Sir:
Mr. Farmer has asked me to write a letter regarding his prior exposure to benzene as it relates to his chronic myelocytic leukemia which was diagnosed in 1993 and was pH
1 positive. He underwent hydroxyurea therapy initially at diagnosis in February through September 1993, and then underwent bone marrow transplant from his HLA related sibling on September 9, 1993. This was complicated by vaso-occlusive disease of the liver during the transplant and other associated problems such as hypomagnesemia, hyponatremia, hypotension, nutritional deficiency, nausea, vomiting, which was ultimately shown to be due to GVH disease involving the GI tract. This was ultimately controlled with cyclosporine and prednisone and he had tapered off his prednisone on December 23 on day 127 post transplant but then had recurrence of the symptoms of nausea and vomiting. He restarted steroids at that time and, again, his symptoms improved. Endoscopy at that time also showed candidal esophagitis and biopsies of proximal small bowel were consistent with GVH disease again as well as skin biopsy proof on day 80 of GVH disease. He continued on high dose prednisone, cyclosporine and a number of other medications with consistent weakness, fatigue, malaise, anxiety, some feelings of depression. He also required transfusion therapy during the period up through 1994.
Patient states that he had exposure to ionizing radiation doing his work as a nuclear worker, which has been clearly associated with leukemia, including chronic myelocytic leukemia. This is as reported by what the Japanese experienced in the atomic bomb exposures at Hiroshima and Nagasaki as well as studies including patient's exposure to radiation therapy for ankylosing spondylitis with spine radiation and women with cervix cancer who had undergone radiation who later developed CML. In addition, the patient had exposure to benzene, which has been documented in his ongoing claims against the US Navy where these exposures were experienced. The benzene exposure has been noted in several reports to be associated with CML specifically in a study by Yin et al, which was a retrospectively cohort study of leukemia and other cancers in benzene workers in Environmental Health Perspective, Volume 22: 207-21 1989 and in a subsequent article in Environmental Health Perspective,
Volume 104, supplement 6, December
1996. In a study by Lynette et al, which was a study sponsored by the National Cancer Institute and the Chinese Academy of Preventative Medicine, which was a large cohort study of benzene-exposed worker's in China, which depended not only on death certificates, but also extensive reviews of clinical data to confirm the specific clinical diagnosis including laboratory data in over 90% of cases described. This study population included 74,828 benzene-exposed workers, less than 30 years of age at study entry, and a comparison group of 35,805 non-exposed workers. Among the benzene-exposed workers there were 81 cases of hematopoietic in lymphoproliferative related disorders diagnosed in the benzene-exposed workers and 13 in the non-exposed workers in a study extending from 1972 through 1987. Of the 81 cases among benzene-exposed workers 9 were CML cases; an incidence in 1 in 8,304 and in the non-exposed workers there were 2 CML cases, an instance of 1 in 17,900; thus the incidence was twice as high in the benzene-exposed workers as in the non-exposed workers. In this large study this indicates a clearer increased risk of chronic myelocytic as one of the hematopoietic disorders associated with benzene and I believe that with support Mr. Farmer's claim that his exposure contributed to the development of his chronic myelocytic leukemia.
The patient's initial claim filing was delayed because of serious illness during his initial treatment in 1993 and 1994 and I think, therefore, allowance should be made for his acute illness during this period of time to allow him longer time to file his complaint. His illness clearly extended into 1994. No exposure the patient had to agents after February 1993 would be pertinent in this situation because the patient's leukemia had already developed by that point.
Sincerely,
IRWIN B DABE, MD
ONCOLOGY/HEMATOLOGY
IBD:jIm