Impact of measurement error in radon exposure on the estimated excess relative risk of lung cancer death in a simulated study based on the French Uranium Miners' Cohort

Uranium's hazardous effects on humans and recent developments in treatment

Uranium, a naturally occurring element, is predominantly recognized for its role as fuel in both civilian and military energy sectors. Concerns have been raised regarding the adverse environmental impacts and health risks associated with uranium mining due to the exposure it causes. Such exposure leads to systemic toxicity, affecting pulmonary, hepatic, renal, reproductive, neurological, and bone health. This review identifies significant research gaps regarding detoxification methods for uranium contamination and recommends further advancements, including genetic modification and exploration of plant compounds. A comprehensive review of published research materials from diverse sources of uranium, including various treatments and hazardous impacts on the human body, was conducted. Additionally, a PRISMA analysis was performed in this study. This review emphasizes the importance of collaboration and the formulation of research-informed regulations to effectively safeguard vulnerable communities from the consequences of contamination. Public discourse often emphasizes the significance of radiotoxicity; however, the non-radioactive chemotoxicity of uranium has been identified as a significant risk factor for environmental exposures, contingent upon species, enrichment, and exposure route. Given these serious health consequences, several methods are being investigated to ameliorate uranium toxicity. In response to these concerns, several techniques, such as phytomedicinal treatments, biochemical approaches, and chelation therapy, have been investigated to minimize the adverse effects of uranium exposure in the human body.

Radon exposure and potential health effects other than lung cancer: a systematic review and meta-analysis

Context and objective

To date, lung cancer is the only well-established health effect associated with radon exposure in humans. To summarize available evidence on other potential health effects of radon exposure, we performed a comprehensive qualitative and quantitative synthesis of the available literature on radon exposure and health effects other than lung cancer, in both occupational and general populations.

Method

Eligible studies published from January 1990 to March 2023, in English and French languages, were identified in PubMed, ScienceDirect, Scopus, ScieLo and HAL. In the meta-analysis, we estimated average weighted standardized incidence ratios (metaSIR), standardized mortality ratios (metaSMR), and risk ratio (metaRR) per 100 unit (Bq/m3 or Working level Month) increase in radon exposure concentration by combining estimates from the eligible studies using the random-effect inverse variance method. DerSimonian & Laird estimator was used to estimate the between-study variance. For each health outcome, analyses were performed separately for mine workers, children, and adults in the general population.

Results

A total of 129 studies were included in the systematic review and 40 distinct studies in the meta-analysis. For most of these health outcomes, the results of the meta-analyses showed no statistically significant association, and heterogeneity was only present among occupational studies, especially between those included in the metaSIR or metaSMR analyses. However, the estimated exposure-risk associations were positive and close to the statistical significance threshold for: lymphohematological cancer incidence in children (metaRR = 1.01; 95%CI: 1.00-1.03; p = 0.08); malignant melanoma mortality among adults in the general population (metaRR = 1.10; 95%CI: 0.99-1.21; p = 0.07); liver cancer mortality among mine workers (metaRR = 1.04; 95%CI: 1.00-1.10; p = 0.06); intestine and rectal cancer mortality combined among mine workers (metaRR = 1.02; 95%CI: 1.00-1.04; p = 0.06).

Conclusion

Although none of the exposure-risk associations estimated in the meta-analyses reached statistical significance, the hypothesis that radon may have other health effects apart from lung cancer could not be ruled-out and call for additional research. Larger and well-designed studies are needed to further investigate this question.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023474542, ID: CRD42023474542.

Miner studies and radiological protection against radon

Fundamental estimates of radon-associated health risk have been provided by epidemiological studies of miners. In total, approximately 15 studies have been conducted worldwide since the 1960s. These results have contributed directly to radiological protection against radon. The present article summarises the main results, with a focus on analyses of miners exposed more recently, estimates of radon lifetime attributable risk, and interaction between radon and smoking. The potential for the upcoming Pooled Uranium Miner Analysis project to further improve our knowledge is discussed.

Uncertainties associated with assessing Ontario uranium miners' exposure to radon daughters

The Ontario uranium miners study is a large (n = 28 546) cohort with low levels of radon exposure relative to other uranium miner cohorts. Multiple methods were used over time to estimate annual occupational exposure to radon daughters including: mine-specific extrapolations by mining engineers, area sampling in limited areas of the mines combined with approximate working time and lastly, consistent exposure sampling in different locations of the mine combined with workers' time cards. Nonetheless, estimating exposures involves assumptions that lead to some uncertainty in occupational exposure characterisation arising from the assessment approach and variability within workplace, over time and by individual. An evaluation of the total uncertainty associated with radon daughter exposure estimation in Ontario miners over time has not been conducted. The objective of this study was to identify the contributing sources and assess the total uncertainty associated with estimating occupational radon daughter exposure among underground Ontario uranium miners over the course of uranium mining. The five sources of radon daughter exposure uncertainty evaluated were: natural variations in radon concentration, estimation of working time, precision of the radon measurement method, unintended errors during sampling, and record keeping and transcription of exposure data. These sources were examined separately for the period 1958 to 1967 and then 1968 onward due to changes in radon daughter concentration measurement practices between these periods. The magnitude of uncertainty associated with each of these sources over time were determined by reviewing historical literature on uranium mining in Ontario as well as through expert advice. Using the root sum square method, the total radon daughter exposure uncertainty was found to be 53 to 67% in the earlier period of uranium mining from 1958 to 1967. This decreased to 31 to 39% for the period 1968 to 1996 with natural variations of radon daughter concentrations in mines accounting for the largest percentage of uncertainty. This assessment provides an initial step in understanding the effect of exposure uncertainty on risk estimates. The impact of this uncertainty on the dose-response relationship between radon exposure and cancer risk will be assessed in future work.

A cautionary comment on the generation of Berkson error in epidemiological studies

Exposure measurement error can be seen as one of the most important sources of uncertainty in studies in epidemiology. When the aim is to assess the effects of measurement error on statistical inference or to compare the performance of several methods for measurement error correction, it is indispensable to be able to generate different types of measurement error. This paper compares two approaches for the generation of Berkson error, which have recently been applied in radiation epidemiology, in their ability to generate exposure data that satisfy the properties of the Berkson model. In particular, it is shown that the use of one of the methods produces results that are not in accordance with two important properties of Berkson error.

Shared and unshared exposure measurement error in occupational cohort studies and their effects on statistical inference in proportional hazards models

Exposure measurement error represents one of the most important sources of uncertainty in epidemiology. When exposure uncertainty is not or only poorly accounted for, it can lead to biased risk estimates and a distortion of the shape of the exposure-response relationship. In occupational cohort studies, the time-dependent nature of exposure and changes in the method of exposure assessment may create complex error structures. When a method of group-level exposure assessment is used, individual worker practices and the imprecision of the instrument used to measure the average exposure for a group of workers may give rise to errors that are shared between workers, within workers or both. In contrast to unshared measurement error, the effects of shared errors remain largely unknown. Moreover, exposure uncertainty and magnitude of exposure are typically highest for the earliest years of exposure. We conduct a simulation study based on exposure data of the French cohort of uranium miners to compare the effects of shared and unshared exposure uncertainty on risk estimation and on the shape of the exposure-response curve in proportional hazards models. Our results indicate that uncertainty components shared within workers cause more bias in risk estimation and a more severe attenuation of the exposure-response relationship than unshared exposure uncertainty or exposure uncertainty shared between individuals. These findings underline the importance of careful characterisation and modeling of exposure uncertainty in observational studies.

Factors Modifying the Radon-Related Lung Cancer Risk at Low Exposures and Exposure Rates among German Uranium Miners

It is still not fully understood whether and how factors such as time, age and smoking modify the relationship between lung cancer and radon at low exposures and exposure rates. Improved knowledge is necessary for the dose conversion of radon in working level month (WLM) into effective dose, as currently discussed by the International Commission on Radiological Protection (ICRP). An update of the German uranium miner cohort study (n = 58,974 men) with a 10-year extension of mortality follow-up (1946-2013) was used to further examine this issue. Internal Poisson regression was applied to estimate the excess relative risk (ERR) for lung cancer mortality per unit of cumulative radon exposure in WLM with exponential time-related effect modifiers. In the full cohort restricted to <100 WLM the estimated overall ERR/WLM was 0.006 [95% confidence interval (CI): 0.003; 0.010] based on 1,254 lung cancer deaths and 1,620,190 person-years at risk. Both age at and time since exposure turned out to be important modifiers of the ERR/WLM and were included in the final model. Here, the ERR/WLM centered on age at exposure of 30 years, and 20 years since exposure was 0.016 (95% CI: 0.008; 0.028). This value decreased statistically significantly by approximately 40% and 60% for each 10-year increase in age at exposure and time since exposure, respectively. The joint effect of smoking and radon exposure was investigated in the sub-cohort of miners hired in 1960 or later, which includes data on smoking status. The centered ERR/WLM was slightly higher for non/light smokers compared to moderate/heavy smokers (0.022 versus 0.013). The current findings provide evidence for an increased lung cancer risk at low radon exposures or exposure rates that is modified by age and time. The observed risk is lower, but statistically compatible to those of other miner studies at low exposures or exposure rates. These findings reject an additive- and support a sub- to (supra-) multiplicative interaction between smoking and radon.

Recent aspects of uranium toxicology in medical geology

Uranium (U) is a chemo-toxic, radiotoxic and even a carcinogenic element. Due to its radioactivity, the effects of U on humans health have been extensively investigated. Prolonged U exposure may cause kidney disease and cancer. The geological distribution of U radionuclides is still a great concern for human health. Uranium in groundwater, frequently used as drinking water, and general environmental pollution with U raise concerns about the potential public health problem in several areas of Asia. The particular paleo-geological hallmark of India and other Southern Asiatic regions enhances the risk of U pollution in rural and urban communities. This paper highlights different health and environmental aspects of U as well as uptake and intake. It discusses levels of U in soil and water and the related health issues. Also described are different issues of U pollution, such as U and fertilizers, occupational exposure in miners, use and hazards of U in weapons (depleted U), U and plutonium as catalysts in the reaction between DNA and H₂O_2, and recycling of U from groundwater to surface soils in irrigation. For use in medical geology and U research, large databases and data warehouses are currently available in Europe and the United States.

Measurement Error and Environmental Epidemiology: a Policy Perspective

PURPOSE OF REVIEW

Measurement error threatens public health by producing bias in estimates of the population impact of environmental exposures. Quantitative methods to account for measurement bias can improve public health decision making.

RECENT FINDINGS

We summarize traditional and emerging methods to improve inference under a standard perspective, in which the investigator estimates an exposure-response function, and a policy perspective, in which the investigator directly estimates population impact of a proposed intervention. Under a policy perspective, the analyst must be sensitive to errors in measurement of factors that modify the effect of exposure on outcome, must consider whether policies operate on the true or measured exposures, and may increasingly need to account for potentially dependent measurement error of two or more exposures affected by the same policy or intervention. Incorporating approaches to account for measurement error into such a policy perspective will increase the impact of environmental epidemiology.

Healthy worker survivor bias in the Colorado Plateau uranium miners cohort

Cohort mortality studies of underground miners have been used to estimate the number of lung cancer deaths attributable to radon exposure. However, previous studies of the radon-lung cancer association among underground miners may have been subject to healthy worker survivor bias, a type of time-varying confounding by employment status. We examined radon-mortality associations in a study of 4,124 male uranium miners from the Colorado Plateau who were followed from 1950 through 2005. We estimated the time ratio (relative change in median survival time) per 100 working level months (radon exposure averaging 130,000 mega-electron volts of potential α energy per liter of air, per working month) using G-estimation of structural nested models. After controlling for healthy worker survivor bias, the time ratio for lung cancer per 100 working level months was 1.168 (95% confidence interval: 1.152, 1.174). In an unadjusted model, the estimate was 1.102 (95% confidence interval: 1.099, 1.112)-39% lower. Controlling for this bias, we estimated that among 617 lung cancer deaths, 6,071 person-years of life were lost due to occupational radon exposure during follow-up. Our analysis suggests that healthy worker survivor bias in miner cohort studies can be substantial, warranting reexamination of current estimates of radon's estimated impact on lung cancer mortality.

Comparing the metal concentration in the hair of cancer patients and healthy people living in the malwa region of punjab, India

The cancer prevalence in the Malwa region of Punjab (1089/million/year) is much higher than the national average cancer prevalence in India (800/million/year). The participants in the present study were 50 healthy individuals and 49 cancer patients all living in the Malwa region of Punjab, with the healthy people being selected from the same household as the cancer patients. High concentrations of several potentially toxic elements were found in hair samples from people living in Punjab. Compared to standard reference ranges, the metals in excess in both the control and patient groups were aluminium (Al), barium (Ba), manganese (Mn), strontium (Sr) and uranium (U). The most significant findings were high lead (Pb), U and Ba concentrations. The maximum values for Ba, Mn, Pb and U were found in hair from breast cancer patients. The mean concentration of U in hair from the breast cancer patients was 0.63 μg U/g, which is more than double the value found in the control group and over six times higher than the reference range of 0.1 μg U/g. Water, soil, and phosphate fertilizers all seem to play a potential role, causing an increased metal burden in Punjabi people living in the Malwa region. The present study indicates that metals, and especially U, may be a factor in the development of breast cancer among Punjabi women.

The performance of functional methods for correcting non-Gaussian measurement error within Poisson regression: corrected excess risk of lung cancer mortality in relation to radon exposure among French uranium miners

A broad variety of methods for measurement error (ME) correction have been developed, but these methods have rarely been applied possibly because their ability to correct ME is poorly understood. We carried out a simulation study to assess the performance of three error-correction methods: two variants of regression calibration (the substitution method and the estimation calibration method) and the simulation extrapolation (SIMEX) method. Features of the simulated cohorts were borrowed from the French Uranium Miners' Cohort in which exposure to radon had been documented from 1946 to 1999. In the absence of ME correction, we observed a severe attenuation of the true effect of radon exposure, with a negative relative bias of the order of 60% on the excess relative risk of lung cancer death. In the main scenario considered, that is, when ME characteristics previously determined as most plausible from the French Uranium Miners' Cohort were used both to generate exposure data and to correct for ME at the analysis stage, all three error-correction methods showed a noticeable but partial reduction of the attenuation bias, with a slight advantage for the SIMEX method. However, the performance of the three correction methods highly depended on the accurate determination of the characteristics of ME. In particular, we encountered severe overestimation in some scenarios with the SIMEX method, and we observed lack of correction with the three methods in some other scenarios. For illustration, we also applied and compared the proposed methods on the real data set from the French Uranium Miners' Cohort study.

Lung cancer mortality in the European uranium miners cohorts analyzed with a biologically based model taking into account radon measurement error

The biologically based two-stage clonal expansion (TSCE) model is used to analyze lung cancer mortality of European miners from the Czech Republic, France, and Germany. All three cohorts indicate a highly significant action of exposure to radon and its progeny on promotion. The action on initiation is not significant in the French cohort. An action on transformation was tested but not found significant. In a pooled analysis, the results based on the French and German datasets do not differ significantly in any of the used parameters. For the Czech dataset, only lag time and two parameters that determine the clonal expansion without exposure and with low exposure rates (promotion) are consistent with the other studies. For low exposure rates, the resulting relative risks are quite similar. Exposure estimates for each calendar year are used. A model for random errors in each of these yearly exposures is presented. Depending on the used technique of exposure estimate, Berkson and classical errors are used. The consequences for the model parameters are calculated and found to be mostly of minor importance, except that the large difference in the exposure-induced initiation between the studies is decreased substantially.