exposure to asbestos fibers increases the risk of disease and death for different causes , but its impact on health is not properly reflected in statistics on occupational disease and must be quantified in specific studies . there have been some local studies of this type1 and in relation to specific diseases in spain2 , 3 , but none in which all asbestos - related diseases ( ards ) were considered . exposure to asbestos has specific pathological effects , including asbestosis , the formation of pleural plaques on the parietal pleura with or without calcification , visceral pleura thickening ; benign pleural effusion , and malignant mesothelioma ( involving pleura , peritoneum , pericardium , and tunica vaginalis of the testes)4 . exposure can also increase the risk of other cancers , notably lung cancer5 . in 2012 , the international agency for research on cancer added the larynx and ovaries as two further cancer sites related to asbestos exposure6 . in addition , positive associations have been observed between exposure to all forms of asbestos and cancer of the pharynx , stomach , and colorectum6 . the who has estimated that more than 107,000 people die annually from asbestos - related mesothelioma , lung cancer and asbestosis7 . in spain , 2,514,346 tons of asbestos were imported between 1906 and 2001 , the year in which the utilization , production , and sale of asbestos fibers and associated products were prohibited8 . a large proportion of the imported asbestos was used in buildings , pipes , and roofs constructed between the 1960s and 1990s ; hence , the mortality and morbidity burden due to asbestos exposure will continue to rise over the next few years , given the usually long latency period before the appearance of these diseases ( e.g. , up to 4050 years for mesothelioma)9 . an account was recently published of the asbestos - related occupational diseases recognized by the spanish national insurance system between 1961 ( when asbestosis was first acknowledged as an occupational disease ) and 2010 , recording 815 cases of asbestosis10 . in addition , 164 asbestos - related occupational cancers were recorded between 1978 , when asbestos - related bronchopulmonary cancers and mesothelioma were first recognized as occupational diseases , and 201111 . these data contrast with the more conservative estimates published in other studies , suggesting that an accurate picture of the true impact of asbestos on health requires the integration of information on patients with asbestosis , pleural plaques , or mesotheliomas treated in the spanish national health service ( nhs ) and on the population - attributable fraction of tumors known to be associated with asbestos exposure , i.e. , in lung , larynx , ovary , colon , and rectum6 . the objective of this study was to estimate the burden of malignant ards to the spanish nhs between 2004 and 2011 , calculating the direct medical costs of its treatment . estimation of the burden of a disease and its costs is essential for taking optimal public health decisions in relation to risk reduction / control measures and the planning of human and material healthcare resources . the burden ( number ) of ards in spain between 2004 and 2011 was estimated by identifying all cases due to asbestosis , almost all cases due to mesothelioma , and the proportion ( and therefore number ) of cases of lung , laryngeal , ovarian , colon and rectum cancers attributable to asbestos exposure . table 1 provides a matrix of disease categories [ with international classification of diseases-9 revision ( icd-9 ) codes ] and the population - attributable fraction by sex12 , 13 , 14 , 15 . these data were combined with healthcare and associated costs obtained from the different nhs care levels . the study period begins in 2004 , the first year with available data on specialist outpatient care , and ends in 2011 , the latest year for which data are available on each disease type.table 1 . matrix of diseases , icd codes , and attributable fractions due to occupational asbestos exposure by sexdiseasecie-9cie-10attributable fraction ( % ) ( 95% confidence interval)sourcemalesfemalestotalasbestosis501j61100100100who12mesothelioma158 , 163c4597(96.098.0)82.5(75.090.0)94.9(93.096.9)rushton et al.13lung162c33-c34140.6nurminen , karjalainen14laryngeal161c328.30.3nurminen , karjalainen14ovarian183.0c560.20.50.3driscoll15colon153c182.30nurminen , karjalainen14rectum154c202.90nurminen , karjalainen14 the spanish nhs uses the icd-9 classification system , which has no specific code for mesothelioma . therefore , we applied a multiplier obtained in a previous study on the proportion of pleural and peritoneal cancers estimated to be mesotheliomas in spain between 2004 and 20069 , in which 362 out of 496 deaths coded as cancer of the pleura were pleural mesotheliomas , and 51 out of 673 coded as cancer of the peritoneum were peritoneal mesotheliomas . hence , the number of cases due to pleural mesothelioma was estimated by multiplying the number of pleural cancer cases by 0.68 ( 0.73 in men and 0.55 in women ) , and the number due to peritoneal mesothelioma was estimated by multiplying the number of peritoneal cancer cases by 0.08 ( 0.1 in men and 0.05 in women ) . two types of analysis were performed : a ) using nhs data on the cost of specialist ( hospital and outpatient ) care to compute the cost of cases treated at nhs hospitals ; and b ) mining secondary data sources to estimate the costs of primary healthcare and prescription drugs . data in the information system of the nhs was accessed using the nhs interactive consultation program , selecting the registry of hospital discharges ( cmbd - h ) and registry of specialist outpatient care ( cmbd - aae)16 . the study variables and inclusion criteria were as follows : years : from 2004 through 2011 ; age and sex : males or females aged 25 years or older for asbestosis , 40 years or older for mesotheliomas , and 25 years or older for other asbestos - related cancers ; diagnosis : main diagnosis coded using the icd-9 system ( 5 digits ) ; subjects in the cmbd - h database : patients discharged from a spanish public hospital , excluding those with discharge date unavailable or outside the study period , those with admission and discharge on the same day ( non - hospitalized ) , and discarding duplicate records ; subjects in the cmbd - aae database : patients receiving specialist outpatient care ( sessions , visits , contacts ) in day hospital , outpatient department , or at home , excluding those with discharge date unavailable or outside the study period and discarding duplicate records ; mean length of hospital stay ; cost : mean estimated cost of treating these patients in a representative sample of nhs hospitals for each year studied ; weighted activity unit ( wau ) : the unit cost of specialist outpatient care in the years under study , based on the official measure wau ( known in spain as the unidad ponderada asistencial upa)17 , 18 . estimations of primary healthcare and pharmaceutical costs were based on data from a catalonian health district ( baix empord ) for 2004 , 2005 , 2006 , 2007 and 2011 , the years for which cost data were available by clinical risk group . we calculated the costs for primary care and pharmaceutical care as a proportion of costs for specialist care . primary care included the total use of primary healthcare resources ( family doctor , nursing staff or emergencies ) , pharmaceutical care included all expenditure on prescription drugs , and specialist care included inpatient care , specialist outpatient care and also the hospital pharmaceutical costs , which are included in the cmbd and wau databases . information on costs related to long - stay hospitals was not considered because these data are not included in the cmbd database . because the baix empord district covers a relatively small population ( around 134,000 in 2013 ) , only a small number of patients were recorded in each diagnostic group under study . it would therefore have been inappropriate to calculate the mean cost of each disease per year , which may be heavily influenced by the severity of a given patient . for this reason , we computed the mean cost of each disease over the entire study period and for the whole population ( males and females ) . the ratios obtained were applied to the time - series data on specialist care costs in order to obtain the primary care and pharmaceutical care expenditure . table 2 exhibits these calculations , in which the  cost factor for primary care is the primary care expenditure divided by the specialist care expenditure , and the  cost factor for pharmaceutical care is the pharmaceutical care expenditure divided by the specialist care expenditure.table 2 . distribution of number of patients and public healthcare budget across disease categories and types of service in baix empord ( euros ) and cost factors ( relative weights ) for primary healthcare and pharmaceutical carelunglarynxovarycolon / rectumnmean costnmean costnmean costnmean costprimary care349345.8461345.887322.3495259.9pharmaceutical care3491,302.64611,302.687710.54951,418.5specialized care3491,652.24611,652.2871,777.64951,826.7cost factor for pc ( pc / sc)0.210.220.180.14cost factor for phc ( phc / sc)0.790.600.400.78pc = primary care , sc = specialist care , phc = pharmaceutical caresource : prepared by the authors from primary data provided by serveis de salut integrats baix empord . pc = primary care , sc = specialist care , phc = pharmaceutical care source : prepared by the authors from primary data provided by serveis de salut integrats baix empord . the cost factors for primary care and pharmaceutical care were not available for asbestosis or mesothelioma , because there were no records of patients with these diseases in baix empord during the analyzed period . therefore , the cost factor obtained for lung cancer was used for these diseases , on the grounds that their medical costs would be relatively similar . the spanish nhs uses the icd-9 classification system , which has no specific code for mesothelioma . therefore , we applied a multiplier obtained in a previous study on the proportion of pleural and peritoneal cancers estimated to be mesotheliomas in spain between 2004 and 20069 , in which 362 out of 496 deaths coded as cancer of the pleura were pleural mesotheliomas , and 51 out of 673 coded as cancer of the peritoneum were peritoneal mesotheliomas . hence , the number of cases due to pleural mesothelioma was estimated by multiplying the number of pleural cancer cases by 0.68 ( 0.73 in men and 0.55 in women ) , and the number due to peritoneal mesothelioma was estimated by multiplying the number of peritoneal cancer cases by 0.08 ( 0.1 in men and 0.05 in women ) . two types of analysis were performed : a ) using nhs data on the cost of specialist ( hospital and outpatient ) care to compute the cost of cases treated at nhs hospitals ; and b ) mining secondary data sources to estimate the costs of primary healthcare and prescription drugs . data in the information system of the nhs was accessed using the nhs interactive consultation program , selecting the registry of hospital discharges ( cmbd - h ) and registry of specialist outpatient care ( cmbd - aae)16 . the study variables and inclusion criteria were as follows : years : from 2004 through 2011 ; age and sex : males or females aged 25 years or older for asbestosis , 40 years or older for mesotheliomas , and 25 years or older for other asbestos - related cancers ; diagnosis : main diagnosis coded using the icd-9 system ( 5 digits ) ; subjects in the cmbd - h database : patients discharged from a spanish public hospital , excluding those with discharge date unavailable or outside the study period , those with admission and discharge on the same day ( non - hospitalized ) , and discarding duplicate records ; subjects in the cmbd - aae database : patients receiving specialist outpatient care ( sessions , visits , contacts ) in day hospital , outpatient department , or at home , excluding those with discharge date unavailable or outside the study period and discarding duplicate records ; mean length of hospital stay ; cost : mean estimated cost of treating these patients in a representative sample of nhs hospitals for each year studied ; weighted activity unit ( wau ) : the unit cost of specialist outpatient care in the years under study , based on the official measure wau ( known in spain as the unidad ponderada asistencial upa)17 , 18 . estimations of primary healthcare and pharmaceutical costs were based on data from a catalonian health district ( baix empord ) for 2004 , 2005 , 2006 , 2007 and 2011 , the years for which cost data were available by clinical risk group . we calculated the costs for primary care and pharmaceutical care as a proportion of costs for specialist care . primary care included the total use of primary healthcare resources ( family doctor , nursing staff or emergencies ) , pharmaceutical care included all expenditure on prescription drugs , and specialist care included inpatient care , specialist outpatient care and also the hospital pharmaceutical costs , which are included in the cmbd and wau databases . information on costs related to long - stay hospitals was not considered because these data are not included in the cmbd database . because the baix empord district covers a relatively small population ( around 134,000 in 2013 ) , only a small number of patients were recorded in each diagnostic group under study . it would therefore have been inappropriate to calculate the mean cost of each disease per year , which may be heavily influenced by the severity of a given patient . for this reason , we computed the mean cost of each disease over the entire study period and for the whole population ( males and females ) . the ratios obtained were applied to the time - series data on specialist care costs in order to obtain the primary care and pharmaceutical care expenditure . table 2 exhibits these calculations , in which the  cost factor for primary care is the primary care expenditure divided by the specialist care expenditure , and the  cost factor for pharmaceutical care is the pharmaceutical care expenditure divided by the specialist care expenditure.table 2 . distribution of number of patients and public healthcare budget across disease categories and types of service in baix empord ( euros ) and cost factors ( relative weights ) for primary healthcare and pharmaceutical carelunglarynxovarycolon / rectumnmean costnmean costnmean costnmean costprimary care349345.8461345.887322.3495259.9pharmaceutical care3491,302.64611,302.687710.54951,418.5specialized care3491,652.24611,652.2871,777.64951,826.7cost factor for pc ( pc / sc)0.210.220.180.14cost factor for phc ( phc / sc)0.790.600.400.78pc = primary care , sc = specialist care , phc = pharmaceutical caresource : prepared by the authors from primary data provided by serveis de salut integrats baix empord . pc = primary care , sc = specialist care , phc = pharmaceutical care source : prepared by the authors from primary data provided by serveis de salut integrats baix empord . the cost factors for primary care and pharmaceutical care were not available for asbestosis or mesothelioma , because there were no records of patients with these diseases in baix empord during the analyzed period . therefore , the cost factor obtained for lung cancer was used for these diseases , on the grounds that their medical costs would be relatively similar . between 2004 and 2011 , there were 37,557 admissions for ards to spanish public hospitals of individuals over the age of 25 years ( > 40 years in the case of mesothelioma ) , 97.1% of whom were male and 2.9% female . the rate of hospital discharges for ards per 100,000 social security - affiliated employees was 43.9 in males and 1.9 in females . over this period , men showed a slight increase in this rate ( 43.9 in 2004 vs. 49.2 in 2011 ) , while women evidenced stability ( 1.8 in 2004 vs. 1.9 in 2011 ) . hospital admissions for mesothelioma increased , especially among males ( 350 occupational - related cases in 2004 vs. 449 in 2011 ) , while admissions for asbestosis decreased ( 39 in 2004 vs. 31 in 2011 ) ( table 3).table 3 . spain 20042011asbestos - related disease(ard)number of hospital dischargesmean length of stay(days)cost per process(in euros)cases attributable to occupational exposurehospital cost per ard(in euros)mfmfmfmfmfasbestosis200436311.925.334,093.893,434.31363147,379.9410,302.9220112838.61124,128.486,344.86283115,597.4519,034.5720042011268219.877.484,110.274,290.10268211,101,552.1590,091.99mesothelioma200436110714.2413.975,832.205,907.79350882,041,270.00519,885.52201146312311.2512.138,093.188,481.004491023,633,837.82865,062.00200420113,16596012.9613.946,815.737,228.293,0779120,924,690.935,719,074.03malignant neoplasm of trachea , bronchus and lung200423,0413,06011.7812.405,092.205,072.773,2261816,427,451.1491,309.94201122,8684,7769.9210.135,621.335,405.073,2022917,999,483.46156,747.1720042011182,47630,52711.1311.395,411.895,436.9225,547183138,257,940.44995,173.44malignant neoplasm of larynx20045,15226315.0714.207,056.816,753.1442813,020,313.56,753.1420114,74232312.8412.768,704.338,864.7639413,429,504.728,864.762004201139,9362,23414.4613.568,329.038,318.363,314827,601,055.3866,140.42malignant neoplasm of ovary20043,70413.225,506.381160,570.1420114,04610.748,077.141296,925.732004201131,19112.126,313.9993586,988.37malignant neoplasm of colon200410,7657,84316.7916.687,614.877,209.0424801,888,488.060201114,51910,02913.7513.0610,932.3110,125.4333403,651,392.64020042011100,49172,38115.3714.929,490.838,840.002,311021,933,092.350malignant neoplasm of rectum20047,7154,50416.5116.556,831.676,594.4222401,530,293.27020118,8684,94913.7313.1710,030.189,441.1725702,577,757.2402004201167,27038,20515.5414.938,651.768,158.301,951016,877,571.210total ard200447,07015,78014.0818.856,174.197,894.714,51212125,055,195.91688,821.66201151,48820,20311.9414.538,183.6810,428.774,66414731,407,573.331,146,634.2320042011393,606144,32813.3216.777,313.389,284.8336,4611,096226,695,902.467,457,468.25source : prepared by the authors from data provided by the national health system  consulta interactiva instituto de informacin sanitaria ( 2013)16 source : prepared by the authors from data provided by the national health system  consulta interactiva instituto de informacin sanitaria ( 2013)16 between 2004 and 2011 there were 5,253 specialist outpatient visits for the diseases under study , 97.4% by men and 2.6% by women ( table 4 ) . although the male - female ratio differed among the diseases , there was always a predominance of males . cases attended in day hospitals were 6-fold higher in 2011 than in 2004 , with a 14-fold increase for females , and an increase was observed in both sexes for all diseases under study with the exception of asbestosis.table 4 . spain 20042011asbestos - related disease(ard)number of consultations in specialist outpatient careweighted activity unit cost(in euros)specialist outpatient care consultations attributable to occupational exposurespecialist outpatient care cost per ard(in euros)mfmfmfmfasbestosis200400000000201120359.74020719.49020042011154308.61481.361544,629.201,925.43mesothelioma200452295.85299.52511,479.23299.5220116235472.20416.07602828,331.9611,649.872004201119693396.28369.591917575,595.2627,703.06malignant neoplasm of trachea , bronchus and lung2004852190324.25306.87119138,585.41306.8720114,5071,399424.91400.206318268,117.363,201.622004201122,7655,438379.94373.613,188331,211,236.4812,325.12malignant neoplasm of larynx200436323351.23356.7430010,536.81020111,17568508.62520.8698049,844.410200420115,990370454.05494.744980226,139.290malignant neoplasm of ovary2004393312.451312.4520111,516564.2052,821.01200420117,290426.55229,548.98malignant neoplasm of colon2004545389340.18324.101304,422.40020116,0463,697596.40552.38139047,285.6802004201130,59919,699499.10464.887050239,830.240malignant neoplasm of rectum2004289202310.37298.78802,482.95020113,4331,865548.04515.86100054,804.4802004201117,94710,121453.21449.675220236,610.880total ard20042,0541,199331.22313.87175357,506.80918.84201115,2258,580527.42375.361,03041449,103.3817,672.52004201177,51243,015449.70344.785,1191341,994,041.3551,502.59source : prepared by the authors from data provided by the national health system  consulta interactiva  , ministerio de sanidad , servicios sociales e igualdad . instituto de informacin sanitaria ( 2013)16 source : prepared by the authors from data provided by the national health system  consulta interactiva instituto de informacin sanitaria ( 2013)16 hospital cost per disease was highest for colon and rectum cancers , which also required a longer hospital stay . the mean length of hospital stay tended to decrease over the study period for all diseases in both sexes except for asbestosis in women . the total public hospital cost for the eight - year study period was 234,153,370.71  , of which 96.8% corresponded to male patients . between 2004 and 2011 , these costs rose by 25.3% for men and by 66.5% for women . the total cost of specialist outpatient care for these diseases was 2,045,543.95  over the same period ( table 4 ) and evidenced the greatest rise in costs between 2004 and 2011 , with a 19.2-fold increase in females and 7.8-fold increase in males . table 5 displays the annual costs of healthcare services and prescriptions for the seven ards studied between 2004 and 2011 . the total cost over the 8-year period was 463,983,511  , being 30.4-fold higher for male vs. female cases . this total cost began to rise after 2006 , increasing by 27.8% between 2004 and 2011 ( 26.7% for males vs. 68.9% for females ) . this increase was not uniform over the period and even decreased slightly in 2005 and 2010 . among the years showing an inter - annual increase , this ranged from 2.5% between 2008 and 2009 to 8.9% between 2006 and 2007 . the only ard evidencing a reduction in total costs over the study period was asbestosis in men . these inter - annual changes were relatively similar among the three types of healthcare considered . the highest costs incurred over the period were for tracheal and bronchopulmonary cancers , both globally ( 60.5% ) and among the men ( 62.1% ) , whereas mesothelioma incurred the highest costs among the women ( 77.9% of total for females ) . the next highest cost was that for pharmaceutical care , which represented 38.95% of the total , while primary healthcare was responsible for 10.15% of the total costs.table 5 . total healthcare cost per asbestos - related disease by type of service and sex ( euros ) . spain 20042011asbestos - related disease(ard)specialist care costprimary care costpharmaceutical care costhealthcare cost per ardmfmfmfmfasbestosis2004147,379.9410,302.9230,949.792,163.61116,430.158,139.31294,759.8820,605.842011116,316.9319,034.5724,426.563,997.2691,890.3715,037.31232,633.8638,069.14200420111,106,181.3592,017.41232,298.0819,323.66873,883.2772,693.752,212,362.70184,034.82mesothelioma20042,042,748.22520,184.67428,977.13109,238.781,613,771.09410,945.894,085,496.441,040,369.3420113,662,168.71876,712.17769,055.43184,109.562,893,113.28692,602.617,324,337.421,753,424.342004201121,000,285.215,746,776.184,410,059.891,206,822.0016,590,225.324,539,953.1842,000,570.4211,493,552.36malignant neoplasm of trachea bronchus , and lung200416,466,036.5591,616.813,457,867.6819,239.5313,008,168.8772,377.2832,932,073.10183,233.62201118,267,600.82159,948.793,836,196.1733,589.2514,431,404.65126,359.5436,535,201.64319,897.5820042011139,469,176.911,007,498.5729,288,527.15211,574.70110,180,649.76795,923.87278,938,353.822,014,997.14malignant neoplasm of larynx20043,030,850.316,753.14666,787.071,485.691,818,510.194,051.885,516,147.5612,290.7120113,479,349.138,864.76765,456.811,950.252,087,609.485,318.866,332,415.4216,133.862004201127,827,194.6666,140.426,121,982.8314,550.8916,696,316.8039,684.2550,645,494.28120,375.56malignant neoplasm of ovary200460,882.5910,958.8724,353.0496,194.49201199,746.7417,954.4139,898.70157,599.8520042011596,537.34107,376.72238,614.94942,528.00malignant neoplasm of colon20041,892,910.460265,007.4601,476,470.1603,634,388.08020113,698,678.310517,814.9602,884,969.0807,101,462.3602004201122,172,922.5803,104,209.16017,294,879.61042,572,011.350malignant neoplasm of rectum20041,532,776.220214,588.6701,195,565.4502,942,930.34020112,632,561.720368,558.6402,053,398.1405,054,518.5002004201117,114,182.1102,395,985.50013,349,062.05032,859,229.650total ard200425,112,701.70689,740.135,064,177.79143,086.4819,228,915.92519,867.4049,405,795.411,352,694.01201131,856,675.621,164,307.036,281,508.57241,600.7224,442,385.00879,217.0262,580,569.192,285,124.7720042011228,689,942.827,508,969.9245,553,062.611,559,648.97174,985,016.805,686,869.99449,228,022.2314,755,488.88source : prepared by the authors from tables 1 , 2 , 3 , 4 . source : prepared by the authors from tables 1 , 2 , 3 , 4 . finally , table 6 lists the mean costs per case for each ard in 2004 and 2011 and in the whole period under study ( 20042011 ) as well as the mean age ( sd ) of hospital inpatients , the only patients for whom these data are available.table 6 . mean age ( sd ) and mean healthcare cost per asbestos - related disease by sex ( euros ) . spain 20042011asbestos - related disease ( ard)mean age ( sd)mean healthcare cost per ard ( in euros)mfmfasbestosis200472.8 ( 7.4)80.3 ( 2.9)8,187.776,868.61201173 ( 10.2)73.6 ( 10.4)8,308.3512,689.712004201172.6 ( 8.9)74.3 ( 13.1)8,307.789,057.85mesothelioma200467.5 ( 10.7)67.2 ( 13.2)11,672.8511,822.38201169.4 ( 10.6)69.1 ( 11.6)16,312.5617,190.432004201168.6 ( 10.3)68.9 ( 12.1)13,571.9214,444.55malignant neoplasm of trachea , bronchus , and lung200466.2 ( 11)62.5 ( 13.8)10,208.3310,179.65201167.5 ( 10.7)64 ( 12.9)11,410.1211,030.952004201166.8 ( 10.9)63.2 ( 13.3)10,914.8910,935.89malignant neoplasm of larynx200462.7 ( 10.8)57.4 ( 13.5)12,888.2012,290.71201164.1 ( 10.6)61.5 ( 12.6)16,072.1216,133.862004201163.4 ( 10.8)60 ( 12.8)15,294.4515,046.94malignant neoplasm of ovary200461.5 ( 14.1)8,744.95201161.3 ( 14.3)13,133.322004201161.1 ( 14.3)10,086.77malignant neoplasm of colon200469.5 ( 11.1)14,654.790.00201170.4 ( 11.2)21,261.860.002004201170.1 ( 11.2)18,199.750.00malignant neoplasm of rectum200468.5 ( 11.2)13,138.080.00201168.6 ( 11.6)19,667.390.002004201168.6 ( 11.4)16,720.290.00source : prepared by the authors from data provided by ministerio de sanidad , servicios sociales e igualdad ( 2013)16 and table 5 source : prepared by the authors from data provided by ministerio de sanidad , servicios sociales e igualdad ( 2013)16 and table 5 the historic use and handling of asbestos in spain continue to evidence a major impact on health . ards produce around 4,700 hospital admissions and over 650 specialist outpatient consultancies per year , and their direct annual cost to the spanish nhs is estimated to be around 58 million euros . in fact , this is an underestimation of the global expenditure by the nhs on ards , given that the fraction of pharynx and stomach cancers attributable to asbestos has not been considered . in industrialized countries , occupational exposure is responsible for 100% of asbestosis cases , at least 85% of mesothelioma cases , and a variable proportion of the other diseases studied . between 2004 and 2011 , 37,557 public hospital admissions were for ards in individuals aged 25 years or more ( > 40 yrs for cases of mesothelioma ) , mainly for lung cancer , mesothelioma , or laryngeal cancer . furthermore , 2,611 individuals aged 40 years or older ( 1,952 men and 659 women ) died from pleural mesothelioma over the eight - year study period16 . in contrast , only 490 cases of ards were recognized as occupational diseases under the spanish national insurance system over the same period : 81 cases of mesotheliomas , 66 of bronchopulmonary cancer , 280 of asbestosis , and 63 of pleural plaques10 , 11 . evaluating the costs of ards based on workers compensation can lead to gross underestimations and hinder comparison between countries , because of differences in national legislative frameworks , insurance systems , and recognition rates . thus , compensation schemes cover 35% of mesothelioma cases in italy and between 16% and 25% of those in france , depending on the region19 , whereas only 6.4% of mesothelioma cases in men and 0.3% of those in women are considered as occupational diseases in spain11 . the gross under - recognition of ards in spain not only reveals the deficiencies of the spanish national insurance system but also has a negative economic impact on the nhs , which is estimated to incur healthcare costs of 58 million euros every year that should be paid under the compensation scheme for occupational ards victims . it is estimated that over a thousand individuals will die from pleural mesothelioma in spain between 2016 and 2020 , and asbestos - related deaths are expected to continue until at least 20409 . for this reason , the gathering , analysis , and diffusion of data on these diseases and on their relationship with occupational exposure is crucial for planning prevention and healthcare programs and for the appropriate compensation of victims . the calculations and analysis of the healthcare burden of ards in our study represent useful tools for informing decisions and redefining health policies and the human and material resources required . more than half ( 68.5% ) of hospital admissions for ards were for bronchopulmonary cancers , followed by mesothelioma ( 10.3% ) and laryngeal cancer ( 8.8% ) , while the smallest number was for asbestosis ( 0.8% ) , similar to previous findings in europe20 . we highlight the marked increase in specialist outpatient consultancies for ards from 178 in 2004 to 1,071 in 2011 , which may be attributable to a trend for the outpatient rather than in - hospital treatment of these diseases . it should be borne in mind that the coverage of the information system is complete for hospitalizations and for specialist outpatient surgery but is only 46.7% for the medical activity of the outpatient day hospital21 . a further potential limitation is that our utilization of ratios for the whole period as a proxy of primary , specialist , and pharmaceutical care costs assumes that there was no substantial variation in the treatment of these diseases between 2004 and 2011 . this appears to be a reasonable assumption , but a certain degree of bias can not be ruled out . there was an increase in consultancies for all ards with the exception of asbestosis , responsible for the smallest number of consultancies , which rose until 2006 and then declined , consistent with published evidence on the decline in the morbidity and mortality of this disease in spain and europe10 , 20 . previous studies on the attribution of ards to occupational exposure concluded that this approach is highly unlikely to overestimate the true impact of this exposure on morbidity and mortality22 , 23 , 24 . in fact , as noted above , our data likely represent an underestimation , because no account was taken of pharyngeal or stomach cancers , as the proportion due to asbestos exposure has not yet been elucidated . the who concluded that occupational exposure to asbestos remains a major cause of death and disability in europe , despite the conservative assumptions that underlie published estimates12 . all studies have found that more than half of occupational cancers involve the lung , and that asbestos is the main occupational carcinogen25 . we calculated the direct costs to the nhs of the diagnosis and treatment of the disease but took no account of indirect costs , such as the loss of productivity caused by the temporary / permanent disability and premature death of workers or the cost of carers , etc . even though our estimate of the total costs generated by these conditions is therefore at the lower end , it indicates an expenditure of more than 463 million euros between 2004 and 2011 ( 51 in 2004 and 65 in 2011 ) , with a mean annual increase of 3.5% . it has been reported that 66%85% of the total health costs of cancer are indirect costs , including sick leave and early retirement , and especially the cost of mortality in people of working age12 , 26 , 27 , 28 . evaluation of the full economic impact of ards in spain requires an assessment of the indirect costs and their addition to the direct costs calculated in the present study . the greatest proportion of direct healthcare costs were for specialist care services ( around 51% ) , followed by pharmaceutical prescriptions ( 39% ) . it was previously reported that 50% of the cost of cancer in spain was for the hospitalization of patients , and that 15% was for pharmacologic treatments . over the period from 2004 through 2011 , there was no difference in the time course of costs among the components of specialist care with the exception of day hospital costs , which showed a mean annual increase of more than 100% ( 10-fold higher in 2011 than in 2004 ) , whereas the average annual increase in hospitalization was only 2.9% . comparison of our findings is hampered by the different methods used in research on medical costs as a function of the specific objectives and resources available , as affirmed at the who meeting in bonn in 201212 . the annual global cost of medical treatment for ards has been estimated at 4.34 billion usd29 . at the aforementioned who meeting in bonn , it was stated that the mean acute treatment cost per case of mesothelioma was 15,899.34  in the united kingdom12 , compared with previous estimates of 15,000  in scotland in 200630 , 24,000  in italy in 201119 , and 20,218  for males in 2011 ( present study ) . lifetime healthcare costs of pleural mesothelioma in taiwan were estimated to be 14,900 usd in 1997200531 . an investigation of the direct healthcare sources of occupational lung and bladder cancers in spain in 200824 estimated a cost per lung cancer patient of 9,277  , lower than the cost of 11,566  estimated in the present study . in canada , the median cost per case in the 2000s of non - small cell lung cancer and small cell lung cancer were 10,928 ( range 9,23411,047 ) and 15,350 ( range 13,03321,436 ) respectively12 . the aforementioned study on cancer costs in spain found a cost of 19,535  per case of colon cancer27 , similar to the present finding although different computational methods were used . our calculation of the direct healthcare costs of occupational ards in spain should be considered the lower limit for the reasons noted above , but it is not possible to calculate the degree of underestimation from the information available . the assumptions used to calculate the components of healthcare also represent a bias , especially with respect to the costs of prescriptions and primary care , whose estimation was derived from a geographic area that can not be considered representative of the nation as a whole , given the variability in disease prevalence and in the offer of medical services among regions . nevertheless , there can be no doubt about the high healthcare costs of ards in spain , especially given the potentially preventable nature of these diseases . the elevated economic burden of ards underlines the need to increase their prevention and their early diagnosis and treatment . as declared by the who european region at its latest meeting12 , asbestos continues to present a public health threat , despite bans on its import and use , due to wide exposure in the past . however , estimation of their costs is of particular importance at a time of economic pressures on the health service . the proper demarcation of financial responsibilities between the national insurance system ( including work accidents and occupational diseases insurance institutes ) and the national health system is a highly relevant issue . costs of occupational diseases should be funded by social contributions from employers and employees under the national insurance system rather than by the tax - funded national health system .