After nearly four decades of decline, the prevalence of coal workers’ pneumoconiosis (CWP, or black lung) in the United States has been on the rise since the mid-1990s (Laney et al., 2014; Laney et al., 2010; Suarthana et al., 2011; Pollock et al., 2010; Antao et al., 2005; Blackley et al., 2016). Particularly alarming is the number of cases of rapidly progressive disease such as progressive massive fibrosis (PMF) (Pollock et al., 2010; Antao et al., 2005; Blackley et al., 2016; Laney et al., 2017). A recent study by Laney et al. (2017) observed 192 U.S. coal miners participating in the Coal Workers’ Health Surveillance Program (CWHSP) who had been diagnosed with PMF since 2000. Of the 163 (85 percent) that had a normal radiograph on file to use as a baseline, 27 (17 percent) of these individuals had progressed from a normal radiograph to PMF diagnosis in less than 10 years. Moreover, 162 (84 percent) of the individuals in that study worked in Kentucky, West Virginia or Virginia, and 169 (88 percent) had only ever mined underground. Blackley et al. (2016) also reported on a group of 60 PMF cases that were discovered by a single black lung clinic in eastern Kentucky. Since seeking care at such clinics and participation in the CWHSP are voluntary, and could be influenced by a number of factors, there has been some concern that these reports may overestimate the degree of resurgence in severe disease (i.e., versus disease that was previously under-reported). Even so, they highlight a critical need to better understand the cause(s) of disease development and progression — such that effective interventions can be devised.