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Yuan H, Kehm RD, Daaboul JM, Lloyd SE, McDonald JA, Mu L, Tehranifar P, Zhang K, Terry MB, Yang W. Cancer incidence trends in New York State and associations with common population-level exposures 2010-2018: an ecological study. Sci Rep 2024; 14:7141. [PMID: 38531903 DOI: 10.1038/s41598-024-56634-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 03/08/2024] [Indexed: 03/28/2024] Open
Abstract
The impact of common environmental exposures in combinations with socioeconomic and lifestyle factors on cancer development, particularly for young adults, remains understudied. Here, we leveraged environmental and cancer incidence data collected in New York State at the county level to examine the association between 31 exposures and 10 common cancers (i.e., lung and bronchus, thyroid, colorectal, kidney and renal pelvis, melanoma, non-Hodgkin lymphoma, and leukemia for both sexes; corpus uteri and female breast cancer; prostate cancer), for three age groups (25-49, 50-69, and 70-84 year-olds). For each cancer, we stratified by age group and sex, and applied regression models to examine the associations with multiple exposures simultaneously. The models included 642,013 incident cancer cases during 2010-2018 and found risk factors consistent with previous reports (e.g., smoking and physical inactivity). Models also found positive associations between ambient air pollutants (ozone and PM2.5) and prostate cancer, female breast cancer, and melanoma of the skin across multiple population strata. Additionally, the models were able to better explain the variation in cancer incidence data among 25-49 year-olds than the two older age groups. These findings support the impact of common environmental exposures on cancer development, particularly for younger age groups.
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Affiliation(s)
- Haokun Yuan
- Department of Epidemiology, Mailman School of Public Health, Columbia University, 722 West 168th Street, Room 514, New York, NY, 10032, USA
| | - Rebecca D Kehm
- Department of Epidemiology, Mailman School of Public Health, Columbia University, 722 West 168th Street, Room 514, New York, NY, 10032, USA
| | - Josephine M Daaboul
- Department of Epidemiology, Mailman School of Public Health, Columbia University, 722 West 168th Street, Room 514, New York, NY, 10032, USA
| | - Susan E Lloyd
- Department of Epidemiology, Mailman School of Public Health, Columbia University, 722 West 168th Street, Room 514, New York, NY, 10032, USA
| | - Jasmine A McDonald
- Department of Epidemiology, Mailman School of Public Health, Columbia University, 722 West 168th Street, Room 514, New York, NY, 10032, USA
- Herbert Irving Comprehensive Cancer Center, Columbia University Medical Center, New York, NY, USA
| | - Lina Mu
- Department of Epidemiology and Environmental Health, School of Public Health and Health Professions, The State University of New York at Buffalo, Buffalo, NY, USA
| | - Parisa Tehranifar
- Department of Epidemiology, Mailman School of Public Health, Columbia University, 722 West 168th Street, Room 514, New York, NY, 10032, USA
- Herbert Irving Comprehensive Cancer Center, Columbia University Medical Center, New York, NY, USA
| | - Kai Zhang
- Department of Environmental Health Sciences, School of Public Health, State University of New York at Albany, Rensselaer, NY, USA
| | - Mary Beth Terry
- Department of Epidemiology, Mailman School of Public Health, Columbia University, 722 West 168th Street, Room 514, New York, NY, 10032, USA
- Herbert Irving Comprehensive Cancer Center, Columbia University Medical Center, New York, NY, USA
| | - Wan Yang
- Department of Epidemiology, Mailman School of Public Health, Columbia University, 722 West 168th Street, Room 514, New York, NY, 10032, USA.
- Herbert Irving Comprehensive Cancer Center, Columbia University Medical Center, New York, NY, USA.
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Xie C, Lu W, Wang H, Wang X, Yu T. Temperature-humidity evolution and radon exhalation mechanism of red clay-bentonite covering layer in uranium mill tailings pond. Sci Rep 2024; 14:2476. [PMID: 38291042 PMCID: PMC10827743 DOI: 10.1038/s41598-023-50733-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 12/24/2023] [Indexed: 02/01/2024] Open
Abstract
To ensure the safety and stability of the beach surface of the decommissioned uranium mill tailings pond, this paper uses red clay-bentonite and red clay (1:1) to carry out covering layer radon reduction simulation experiments to study the temperature, humidity, and radon reduction effect of the covering layer under natural conditions. The results show that the radon exhalation rate of red clay-bentonite cover layer is only 0.32 times that of red clay, which has a better radon reduction effect. The red clay-bentonite cover layer has better water retention and comparable heat preservation effect than red clay cover layer. The red clay-bentonite and red clay temperature curves follow the same evolution trend and were close together in the same outdoor conditions, and the humidity curves showed a difference of 1% to 3%. Soil temperature is the dominant factor affecting the variation of radon exhalation of red clay-bentonite and red clay covering layer with unsaturated water content.
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Affiliation(s)
- Chao Xie
- School of Nuclear Science and Technology, University of South China, Hengyang, 421001, China
- School of Resources, Environmental and Safety Engineering, University of South China, Hengyang, 421001, China
- Key Laboratory of Advanced Nuclear Energy Technology Design and Safety Ministry of Education, University of South China, Hengyang, 421001, China
| | - Wenjun Lu
- School of Resources, Environmental and Safety Engineering, University of South China, Hengyang, 421001, China
| | - Hong Wang
- School of Nuclear Science and Technology, University of South China, Hengyang, 421001, China.
- School of Resources, Environmental and Safety Engineering, University of South China, Hengyang, 421001, China.
| | - Xiangshuai Wang
- School of Resources, Environmental and Safety Engineering, University of South China, Hengyang, 421001, China
| | - Tao Yu
- School of Nuclear Science and Technology, University of South China, Hengyang, 421001, China
- Key Laboratory of Advanced Nuclear Energy Technology Design and Safety Ministry of Education, University of South China, Hengyang, 421001, China
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Shahrokhi A, kovács T. Characterization of environmental radiological parameters on dose coefficient - Realistic dosimetry compared with epidemiological dosimetry models. Heliyon 2023; 9:e19813. [PMID: 37809865 PMCID: PMC10559164 DOI: 10.1016/j.heliyon.2023.e19813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 09/01/2023] [Accepted: 09/01/2023] [Indexed: 10/10/2023] Open
Abstract
Radiation exposure due to all-natural sources amounts to about 2.4 mSv per year. However, this amount might be changed to over 3 mSv y-1 according to the recently introduced ICRP radon dose coefficient factor. Previously, the radon contribution to the total dose from natural sources was about 1.2 mSv y-1. However, after the latest introduced dose conversion factor by ICRP, this value could technically be increased to around 2 mSv y-1. This paper attempts to address the following questions: (i) whether reducing radon concentration to the recommended level could address concerns about radiation exposure in underground workplaces, and (ii) the effects of the difference between the epidemiological dosimetry models and realistic dose estimation. The actual dose conversion factor (DCF) was calculated using measured annual average unattached and equilibrium factors, ranging from 16 ± 9 to 25 ± 10 mSv·WLM-1. Then, the estimated inhalation dose, both from self-calculated DCF and the value reported by ICRP-137, was compared: 5.6 ± 0.7-7.6 ± 0.9 mSv y-1 and 3.3 ± 0.4-3.6 ± 0.5 mSv y-1, respectively. It can be observed that exposure to a radon concentration lower than the recommended level does not guarantee a lower dose than the recommended value. The estimated dose was at least two times greater than the dose using pre-estimated values from epidemiological dosimetry models, specifically in this case study. Further experiments in different underground working environments, excluding caves, are needed for more precise observations. It might also be time to update the data regarding the dose contribution from natural radiation sources, as the radon contribution increased according to ICRP.
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Affiliation(s)
- Amin Shahrokhi
- Department of Radiochemistry and Radioecology, Research Centre for Biochemical, Environmental and Chemical Engineering, University of Pannonia, 8200, Veszprém, Hungary
| | - Tibor kovács
- Department of Radiochemistry and Radioecology, Research Centre for Biochemical, Environmental and Chemical Engineering, University of Pannonia, 8200, Veszprém, Hungary
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Maier A, Bailey T, Hinrichs A, Lerchl S, Newman RT, Fournier C, Vandevoorde C. Experimental Setups for In Vitro Studies on Radon Exposure in Mammalian Cells-A Critical Overview. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:ijerph20095670. [PMID: 37174189 PMCID: PMC10178159 DOI: 10.3390/ijerph20095670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 04/20/2023] [Accepted: 04/24/2023] [Indexed: 05/15/2023]
Abstract
Naturally occurring radon and its short lived progeny are the second leading cause of lung cancer after smoking, and the main risk factor for non-smokers. The radon progeny, mainly Polonium-218 (218Po) and Polonium-214 (214Po), are responsible for the highest dose deposition in the bronchial epithelium via alpha-decay. These alpha-particles release a large amount of energy over a short penetration range, which results in severe and complex DNA damage. In order to unravel the underlying biological mechanisms which are triggered by this complex DNA damage and eventually give rise to carcinogenesis, in vitro radiobiology experiments on mammalian cells have been performed using radon exposure setups, or radon analogues, which mimic alpha-particle exposure. This review provides an overview of the different experimental setups, which have been developed and used over the past decades for in vitro radon experiments. In order to guarantee reliable results, the design and dosimetry of these setups require careful consideration, which will be emphasized in this work. Results of these in vitro experiments, particularly on bronchial epithelial cells, can provide valuable information on biomarkers, which can assist to identify exposures, as well as to study the effects of localized high dose depositions and the heterogeneous dose distribution of radon.
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Affiliation(s)
- Andreas Maier
- Biophysics Department, GSI Helmholtzzentrum für Schwerionenforschung GmbH, 64291 Darmstadt, Germany
| | - Tarryn Bailey
- Department of Physics, Stellenbosch University, Stellenbosch, Cape Town 7600, South Africa
- Radiation Biophysics Division, Separated Sector Cyclotron Laboratory, NRF-iThemba LABS, Cape Town 7129, South Africa
| | - Annika Hinrichs
- Biophysics Department, GSI Helmholtzzentrum für Schwerionenforschung GmbH, 64291 Darmstadt, Germany
- Physics Department, Goethe University Frankfurt am Main, 60438 Frankfurt am Main, Germany
| | - Sylvie Lerchl
- Biophysics Department, GSI Helmholtzzentrum für Schwerionenforschung GmbH, 64291 Darmstadt, Germany
| | - Richard T Newman
- Department of Physics, Stellenbosch University, Stellenbosch, Cape Town 7600, South Africa
| | - Claudia Fournier
- Biophysics Department, GSI Helmholtzzentrum für Schwerionenforschung GmbH, 64291 Darmstadt, Germany
| | - Charlot Vandevoorde
- Biophysics Department, GSI Helmholtzzentrum für Schwerionenforschung GmbH, 64291 Darmstadt, Germany
- Radiation Biophysics Division, Separated Sector Cyclotron Laboratory, NRF-iThemba LABS, Cape Town 7129, South Africa
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Moon J, Yoo H. Residential radon exposure and leukemia: A meta-analysis and dose-response meta-analyses for ecological, case-control, and cohort studies. ENVIRONMENTAL RESEARCH 2021; 202:111714. [PMID: 34274332 DOI: 10.1016/j.envres.2021.111714] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 07/12/2021] [Accepted: 07/14/2021] [Indexed: 06/13/2023]
Abstract
INTRODUCTION In this study, the authors conducted a comprehensive systematic review and meta-analysis (including a dose-response meta-analysis) for a possible causal association between residential radon exposure and leukemia. All 3 types of study design, including ecological, case-control, and cohort studies, were included in this study. In particular, different measurement units of radon exposure among studies were dealt with and analyzed thoroughly. METHODS A medical librarian searched MEDLINE (PubMed), EMBASE, and the Cochrane Library (from January 01, 1970 to November 05, 2020). For ecological studies, a conventional meta-analysis and subgroup analyses with meta-ANOVA analyses were conducted. For case-control and cohort studies, a two-stage dose-response meta-analysis was conducted. RESULTS A total of 8 ecological, 9 case-control, and 15 ecological-cohort studies were analyzed. For ecological studies, the pooled correlation coefficient was 0.48 (95% CI 0.41-0.54). In the meta-analysis of variance (ANOVA) analyses, the age group (childhood vs. adult) showed a statistically significant result (Q = 7.93 and p = 0.019) with the pooled correlation coefficient for childhood, adult, and all age group of 0.67 (95% CI 0.53-0.77), 0.46 (95% CI 0.05-0.74), and 0.44 (95% CI 0.36-0.51), respectively. For case-control studies, the dose-response meta-analysis showed the pooled OR increase of 1.0308 (95% CI 1.0050-1.0573) for each 100 Bq/m3 increase of radon dose. The pooled OR increase was 1.0361 (95% CI 1.0014-1.0720) for each 100 Bq/m3 increase of radon dose for lymphoid leukemia subgroup and 1.0309 (95% CI 1.0050-1.0575) for each 100 Bq/m3 increase of radon dose for childhood leukemia subgroup. Because of the inclusion of ecological studies with larger exposure assessment units, the pooled RR from ecological-cohort studies should be interpreted conservatively (a tendency towards a higher risk estimate). The overall pooled RR increase for each 100 Bq/m3 increase of radon dose was 1.1221 (95% CI 1.0184-1.2363). The pooled RR increase was 1.2257 (95% CI 1.0034-1.4972) for each 100 Bq/m3 increase of radon dose for the myeloid leukemia subgroup and 1.2503 (95% CI 1.0233-1.5276) for each 100 Bq/m3 increase of radon dose for adult leukemia subgroup. DISCUSSION A number of epidemiologic concepts, including the issue of sample size justification, the possibility of differential participation selection bias for case-control studies, the possibility of random and systematic errors in radon measurement, ecological fallacy for ecological studies, were discussed. The effect of age group, socioeconomic status, and gamma radiation exposure was also discussed. Future more accurate and conclusive large-scale case-control and cohort studies are needed.
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Affiliation(s)
- Jinyoung Moon
- Department of Environmental Health Science, Graduate School of Public Health, Seoul National University, Gwanak-ro 1, Gwanak-gu, Seoul, 08826, Republic of Korea; Department of Occupational and Environmental Medicine, Seoul Saint Mary's Hospital, Banpo-daero 222, Seocho-gu, Seoul, 06591, Republic of Korea.
| | - HyeKyoung Yoo
- Department of Environmental Health Science, Graduate School of Public Health, Seoul National University, Gwanak-ro 1, Gwanak-gu, Seoul, 08826, Republic of Korea
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Mozzoni P, Pinelli S, Corradi M, Ranzieri S, Cavallo D, Poli D. Environmental/Occupational Exposure to Radon and Non-Pulmonary Neoplasm Risk: A Review of Epidemiologic Evidence. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:10466. [PMID: 34639764 PMCID: PMC8508162 DOI: 10.3390/ijerph181910466] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Revised: 09/29/2021] [Accepted: 09/29/2021] [Indexed: 12/01/2022]
Abstract
Although Radon (Rn) is a known agent for lung cancer, the link between Rn exposure and other non-pulmonary neoplasms remains unclear. The aim of this review is to investigate the role of Rn in the development of tumors other than lung cancer in both occupational and environmental exposure. Particularly, our attention has been focused on leukemia and tumors related to brain and central nervous system (CNS), skin, stomach, kidney, and breast. The epidemiologic literature has been systematically reviewed focusing on workers, general population, and pediatric population. A weak increase in leukemia risk due to Rn exposure was found, but bias and confounding factors cannot be ruled out. The results of studies conducted on stomach cancer are mixed, although with some prevalence for a positive association with Rn exposure. In the case of brain and CNS cancer and skin cancer, results are inconclusive, while no association was found for breast and kidney cancers. Overall, the available evidence does not support a conclusion that a causal association has been established between Rn exposure and the risk of other non-pulmonary neoplasms mainly due to the limited number and heterogeneity of existing studies. To confirm this result, a statistical analysis should be necessary, even if it is now not applicable for the few studies available.
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Affiliation(s)
- Paola Mozzoni
- Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (P.M.); (S.P.); (M.C.); (S.R.)
- Centre for Research in Toxicology (CERT), University of Parma, Via A. Gramsci 14, 43126 Parma, Italy
| | - Silvana Pinelli
- Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (P.M.); (S.P.); (M.C.); (S.R.)
| | - Massimo Corradi
- Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (P.M.); (S.P.); (M.C.); (S.R.)
- Centre for Research in Toxicology (CERT), University of Parma, Via A. Gramsci 14, 43126 Parma, Italy
| | - Silvia Ranzieri
- Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (P.M.); (S.P.); (M.C.); (S.R.)
| | - Delia Cavallo
- INAIL Research, Department of Occupational and Environmental Medicine, Epidemiology and Hygiene, Via Fontana Candida 1, 00078 Monte Porzio Catone, Italy;
| | - Diana Poli
- INAIL Research, Department of Occupational and Environmental Medicine, Epidemiology and Hygiene, Via Fontana Candida 1, 00078 Monte Porzio Catone, Italy;
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Berlivet J, Hémon D, Cléro É, Ielsch G, Laurier D, Faure L, Clavel J, Goujon S. Residential exposure to natural background radiation at birth and risk of childhood acute leukemia in France, 1990-2009. JOURNAL OF ENVIRONMENTAL RADIOACTIVITY 2021; 233:106613. [PMID: 33895630 DOI: 10.1016/j.jenvrad.2021.106613] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 03/26/2021] [Accepted: 04/02/2021] [Indexed: 06/12/2023]
Abstract
BACKGROUND The role of natural background radiation (NBR) in childhood acute leukemia (AL) remains unclear. Several large record based studies have recently reported heterogeneous results. Differences in exposure assessment timing may explain this heterogeneity. OBJECTIVES In a previous ecological study we did not observe any association between childhood AL incidence in France and NBR exposure at the time of diagnosis. With the same methodology, the present study focused on NBR exposure at the time of birth. Based on data from the French national registry of childhood cancer, we analyzed all AL together, and lymphoblastic and myeloid AL, separately. METHODS We included 6,059 childhood AL cases born and diagnosed in mainland France between 1990 and 2009. NBR levels in municipalities of residence at birth were estimated by cokriging models, using NBR measurements and precise geological data. The incidence rate ratio (IRR) per unit variation of exposure was estimated with Poisson regression models, with adjustment for socio-demographic indicators and ultraviolet radiation levels. NBR exposures were considered at the time of birth, and cumulatively from birth to diagnosis. We also estimated a total NBR dose to red-bone marrow (RBM). RESULTS There was no evidence for an association between NBR exposure at birth and childhood AL incidence, neither overall (gamma radiation: IRR = 0.99 (0.94,1.05) per 50 nSv/h; radon: IRR = 0.97 (0.91,1.03) per 100 Bq/m3) nor for the main AL types. The conclusions were similar with the cumulative exposures, and the total RBM dose. CONCLUSIONS The study was based on high quality incidence data, large numbers of AL cases, and validated models of NBR exposure assessment. In all, the results further support the hypothesis that NBR are not associated to childhood AL in France.
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Affiliation(s)
- Justine Berlivet
- Inserm, UMR 1153 Epidemiology and Biostatistics Sorbonne Paris Cité Research Center (CRESS), Epidemiology of Childhood and Adolescent Cancers Team (EPICEA), Paris University, Villejuif, F-94807, France
| | - Denis Hémon
- Inserm, UMR 1153 Epidemiology and Biostatistics Sorbonne Paris Cité Research Center (CRESS), Epidemiology of Childhood and Adolescent Cancers Team (EPICEA), Paris University, Villejuif, F-94807, France
| | - Énora Cléro
- Institute for Radiological Protection and Nuclear Safety (IRSN), Health and Environment Division, Fontenay-aux-Roses, F-92262, France
| | - Geraldine Ielsch
- Institute for Radiological Protection and Nuclear Safety (IRSN), Health and Environment Division, Fontenay-aux-Roses, F-92262, France
| | - Dominique Laurier
- Institute for Radiological Protection and Nuclear Safety (IRSN), Health and Environment Division, Fontenay-aux-Roses, F-92262, France
| | - Laure Faure
- Inserm, UMR 1153 Epidemiology and Biostatistics Sorbonne Paris Cité Research Center (CRESS), Epidemiology of Childhood and Adolescent Cancers Team (EPICEA), Paris University, Villejuif, F-94807, France; French National Registry of Childhood Hematological Malignancies (RNHE), Villejuif, F-94807, France
| | - Jacqueline Clavel
- Inserm, UMR 1153 Epidemiology and Biostatistics Sorbonne Paris Cité Research Center (CRESS), Epidemiology of Childhood and Adolescent Cancers Team (EPICEA), Paris University, Villejuif, F-94807, France; French National Registry of Childhood Hematological Malignancies (RNHE), Villejuif, F-94807, France
| | - Stéphanie Goujon
- Inserm, UMR 1153 Epidemiology and Biostatistics Sorbonne Paris Cité Research Center (CRESS), Epidemiology of Childhood and Adolescent Cancers Team (EPICEA), Paris University, Villejuif, F-94807, France; French National Registry of Childhood Hematological Malignancies (RNHE), Villejuif, F-94807, France.
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Harbron RW, Pasqual E. Ionising radiation as a risk factor for lymphoma: a review. JOURNAL OF RADIOLOGICAL PROTECTION : OFFICIAL JOURNAL OF THE SOCIETY FOR RADIOLOGICAL PROTECTION 2020; 40:R151-R185. [PMID: 33017815 DOI: 10.1088/1361-6498/abbe37] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 10/05/2020] [Indexed: 06/11/2023]
Abstract
The ability of ionising radiation to induce lymphoma is unclear. Here, we present a narrative review of epidemiological evidence of the risk of lymphoma, including chronic lymphocytic leukaemia (CLL) and multiple myeloma (MM), among various exposed populations including atomic bombing survivors, industrial and medical radiation workers, and individuals exposed for medical purposes. Overall, there is a suggestion of a positive dose-dependent association between radiation exposure and lymphoma. The magnitude of this association is highly imprecise, however, with wide confidence intervals frequently including zero risk. External comparisons tend to show similar incidence and mortality rates to the general population. Currently, there is insufficient information on the impact of age at exposure, high versus low linear energy transfer radiation, external versus internal or acute versus chronic exposures. Associations are stronger for males than females, and stronger for non-Hodgkin lymphoma and MM than for Hodgkin lymphoma, while the risk of radiation-induced CLL may be non-existent. This broad grouping of diverse diseases could potentially obscure stronger associations for certain subtypes, each with a different cell of origin. Additionally, the classification of malignancies as leukaemia or lymphoma may result in similar diseases being analysed separately, while distinct diseases are analysed in the same category. Uncertainty in cell of origin means the appropriate organ for dose response analysis is unclear. Further uncertainties arise from potential confounding or bias due to infectious causes and immunosuppression. The potential interaction between radiation and other risk factors is unknown. Combined, these uncertainties make lymphoma perhaps the most challenging malignancy to study in radiation epidemiology.
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Affiliation(s)
- Richard W Harbron
- Population Health Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom
- NIHR Health Protection Research Unit in Chemical and Radiation Threats and Hazards, Newcastle University, United Kingdom
- Barcelona Institute for Global Health, (ISGlobal), Barcelona, Spain
- Universitat Pompeu Fabra (UPF), Barcelona, Spain
- CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| | - Elisa Pasqual
- Barcelona Institute for Global Health, (ISGlobal), Barcelona, Spain
- Universitat Pompeu Fabra (UPF), Barcelona, Spain
- CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
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9
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Shallis RM, Weiss JJ, Deziel NC, Gore SD. Challenging the concept of de novo acute myeloid leukemia: Environmental and occupational leukemogens hiding in our midst. Blood Rev 2020; 47:100760. [PMID: 32988660 DOI: 10.1016/j.blre.2020.100760] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 07/28/2020] [Accepted: 08/27/2020] [Indexed: 12/20/2022]
Abstract
Myeloid neoplasms like acute myeloid leukemia (AML) originate from genomic disruption, usually in a multi-step fashion. Hematopoietic stem/progenitor cell acquisition of abnormalities in vital cellular processes, when coupled with intrinsic factors such as germline predisposition or extrinsic factors such as the marrow microenvironment or environmental agents, can lead to requisite pre-leukemic clonal selection, expansion and evolution. Several of these entities have been invoked as "leukemogens." The known leukemogens are numerous and are found in the therapeutic, occupational and ambient environments, however they are often difficult to implicate for individual patients. Patients treated with particular chemotherapeutic agents or radiotherapy accept a calculated risk of therapy-related AML. Occupational exposures to benzene, dioxins, formaldehyde, electromagnetic and particle radiation have been associated with an increased risk of AML. Although regulatory agencies have established acceptable exposure limits in the workplace, accidental exposures and even ambient exposures to leukemogens are possible. It is plausible that inescapable exposure to non-anthropogenic ambient leukemogens may be responsible for many cases of non-inherited de novo AML. In this review, we discuss the current understanding of leukemogens as they relate to AML, assess to what extent the term "de novo" leukemia is meaningful, and describe the potential to identify and characterize new leukemogens.
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Affiliation(s)
- Rory M Shallis
- Section of Hematology, Department of Medicine, Yale University School of Medicine, New Haven, USA.
| | - Julian J Weiss
- Section of Hematology, Department of Medicine, Yale University School of Medicine, New Haven, USA
| | - Nicole C Deziel
- Department of Environmental Health Sciences, Yale School of Public Health, New Haven, CT, USA
| | - Steven D Gore
- Section of Hematology, Department of Medicine, Yale University School of Medicine, New Haven, USA
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10
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Mazzei-Abba A, Folly CL, Coste A, Wakeford R, Little MP, Raaschou-Nielsen O, Kendall G, Hémon D, Nikkilä A, Spix C, Auvinen A, Spycher BD. Epidemiological studies of natural sources of radiation and childhood cancer: current challenges and future perspectives. JOURNAL OF RADIOLOGICAL PROTECTION : OFFICIAL JOURNAL OF THE SOCIETY FOR RADIOLOGICAL PROTECTION 2020; 40:R1-R23. [PMID: 31751953 PMCID: PMC10654695 DOI: 10.1088/1361-6498/ab5a38] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
The empirical estimation of cancer risks in children associated with low-dose ionising radiation (<100 mSv) remains a challenge. The main reason is that the required combination of large sample sizes with accurate and comprehensive exposure assessment is difficult to achieve. An international scientific workshop, 'Childhood cancer and background radiation', organised by the Institute of Social and Preventive Medicine of the University of Bern, brought together researchers in this field to evaluate how epidemiological studies of background radiation and childhood cancer can best improve our understanding of the effects of low-dose ionising radiation. This review summarises and evaluates the findings of these studies with regard to their methodological differences, identifies key limitations and challenges, and proposes ways to move forward. Large childhood cancer registries, such as those in Great Britain, France and Germany, now permit the conducting of studies that should have sufficient statistical power to detect the effects predicted by standard risk models. Nevertheless, larger studies or pooled studies will be needed to investigate disease subgroups. The main challenge is to accurately assess children's individual exposure to radiation from natural sources and from other sources, as well as potentially confounding non-radiation exposures, in such large study populations. For this, the study groups should learn from each other to improve exposure estimation and develop new ways to validate exposure models with personal dosimetry.
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Affiliation(s)
- Antonella Mazzei-Abba
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland
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11
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Boulton F. Ionising radiation and childhood leukaemia revisited. Med Confl Surviv 2019; 35:144-170. [PMID: 30821174 DOI: 10.1080/13623699.2019.1571684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Increased incidences of childhood acute leukaemia were noted among survivors of the atomic bombings of Hiroshima and Nagasaki. In Western societies, Childhood Acute Lymphoblastic Leukaemia has a distinct epidemiology peaking at 3 years old. Exposure to ionising radiation is an established hazard but it is difficult to gauge the precise risk of less than 100 mSv. Since 1983 significant leukaemia incidences have been reported among families residing near nuclear installations. The target cells (naïve neonatal lymphocytes) get exposed to multiple xenobiotic challenges and undergo extraordinary proliferation and physiological somatic genetic change. Population movements and ionising radiation are considered taking account of updated understanding of radiation biology, cancer cytogenetics and immunological diversity. Double Strand Breaks in DNA arise through metabolic generation of Reactive Oxygen Species, and nearly always are repaired; but mis-repairs can be oncogenic. Recombinant Activating Gene enzymes in rapidly dividing perinatal pre-B lymphocytes being primed for antibody diversity are targeted to Signal Sequences in the Immunoglobulin genes. off target pseudo-sequences may allow RAG enzymes to create autosomal DSBs which, when mis-repaired, become translocated oncogenes. Immunogens acting by chance at crucial stages may facilitate this. In such circumstances, oncogenic DSBs from ionising radiation are less likely to be significant.
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Affiliation(s)
- Frank Boulton
- Medact , London , UK.,Faculty of Medicine, University of Southampton , Southampton , UK
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12
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Oancea SC, Rundquist BC, Simon I, Swartz S, Zheng Y, Zhou X, Sens MA, Schwartz GG. County level incidence rates of chronic lymphocytic leukemia are associated with residential radon levels. Future Oncol 2017; 13:1873-1881. [PMID: 28835109 PMCID: PMC5618932 DOI: 10.2217/fon-2017-0165] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Aim: We previously reported that incidence rates for chronic lymphocytic leukemia (CLL) among US states are significantly correlated with levels of residential radon (RR). Because these correlations could be influenced by confounding and/or misclassification among large geographic units, we reinvestigated them using smaller geographic units that better reflect exposure and disease at the individual level. Methods: We examined the relationships between CLL and RR per county in 478 counties with publicly-available data. Results: After adjustment for ultraviolet radiation, a possible risk factor for CLL, county rates for CLL and RR were significantly correlated among males and females both together and separately (p < 0.0001). Conclusion: CLL is significantly associated with RR at the county level.
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Affiliation(s)
- S Cristina Oancea
- Department of Population Health, School of Medicine & Health Sciences, University of North Dakota, Grand Forks, ND 58202, USA
| | - Bradley C Rundquist
- Department of Geography & Geographic Information Science, University of North Dakota, College of Arts & Sciences, Grand Forks, ND 58202, USA
| | - Isaac Simon
- Department of Earth System Science & Policy, University of North Dakota, John D. Odegard School of Aerospace Sciences, Grand Forks, ND, 58202, USA
| | - Sami Swartz
- Department of Geography & Geographic Information Science, University of North Dakota, College of Arts & Sciences, Grand Forks, ND 58202, USA
| | - Yun Zheng
- Department of Pathology, University of North Dakota, School of Medicine & Health Sciences, Grand Forks, ND 58202, USA
| | - Xudong Zhou
- Department of Pathology, University of North Dakota, School of Medicine & Health Sciences, Grand Forks, ND 58202, USA
| | - Mary Ann Sens
- Department of Pathology, University of North Dakota, School of Medicine & Health Sciences, Grand Forks, ND 58202, USA
| | - Gary G Schwartz
- Department of Population Health, School of Medicine & Health Sciences, University of North Dakota, Grand Forks, ND 58202, USA
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13
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Kaczmarska M, Żydek D, Wilkłacz-Potoczny J, Fornal M, Grodzicki T, Kochowska E, Kozak K, Gocal Ł, Pohorecki W, Matlak K, Korecki J, Burda K. The influence of very small doses of alpha radiation on the stability of erythrocytes. Microsc Res Tech 2016; 80:131-143. [DOI: 10.1002/jemt.22803] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Accepted: 10/28/2016] [Indexed: 02/02/2023]
Affiliation(s)
- Magdalena Kaczmarska
- Department of Medical Physics and Biophysics, Faculty of Physics and Applied Computer Science; AGH University of Science and Technology; Kraków Poland
| | - Dominika Żydek
- Department of Medical Physics and Biophysics, Faculty of Physics and Applied Computer Science; AGH University of Science and Technology; Kraków Poland
| | - Justyna Wilkłacz-Potoczny
- Department of Medical Physics and Biophysics, Faculty of Physics and Applied Computer Science; AGH University of Science and Technology; Kraków Poland
- SOLARIS, Jagiellonian University; Kraków Poland
| | - Maria Fornal
- Department of Internal Medicine and Gerontology, Collegium Medicum; Jagiellonian University; Kraków Poland
| | - Tomasz Grodzicki
- Department of Internal Medicine and Gerontology, Collegium Medicum; Jagiellonian University; Kraków Poland
| | | | | | - Łukasz Gocal
- Department of Medical Physics and Biophysics, Faculty of Physics and Applied Computer Science; AGH University of Science and Technology; Kraków Poland
| | - Władysław Pohorecki
- Faculty of Energy and Fuels; AGH University of Science and Technology; Kraków Poland
| | - Krzysztof Matlak
- Department of Medical Physics and Biophysics, Faculty of Physics and Applied Computer Science; AGH University of Science and Technology; Kraków Poland
| | - Józef Korecki
- Department of Medical Physics and Biophysics, Faculty of Physics and Applied Computer Science; AGH University of Science and Technology; Kraków Poland
- Institute of Catalysis and Surface Chemistry PAN; Kraków Poland
| | - Květoslava Burda
- Department of Medical Physics and Biophysics, Faculty of Physics and Applied Computer Science; AGH University of Science and Technology; Kraków Poland
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14
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Schwartz GG, Klug MG. Incidence rates of chronic lymphocytic leukemia in US states are associated with residential radon levels. Future Oncol 2016; 12:165-74. [DOI: 10.2217/fon.15.275] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: Environmental risk factors for chronic lymphocytic leukemia (CLL) have not been consistently identified. An etiologic role for ionizing radiation in CLL is controversial. Because most of the ionizing radiation to which individuals are exposed comes from radon at home, we examined CLL incidence rates in relation to residential radon levels. Methods: We used population-based rates for CLL for US states from 2007 to 2011 and measurements of residential radon made by the US Environmental Protection Agency. Results: Incidence rates for CLL were significantly correlated with residential radon levels among whites (both genders together and each gender separately; p < 0.005) and among blacks (p < 0.05). Conclusion: We speculate that radon increases CLL risk and that the mechanisms may be similar to those by which radon causes lung cancer.
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Affiliation(s)
- Gary G Schwartz
- Department of Population Health, University of North Dakota School of Medicine & Health Sciences, Grand Forks, ND 58202, USA
| | - Marilyn G Klug
- Department of Family Medicine & Center for Rural Health, University of North Dakota School of Medicine & Health Sciences, Grand Forks, ND 58202, USA
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15
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Zablotska LB, Lane RSD, Frost SE, Thompson PA. Leukemia, lymphoma and multiple myeloma mortality (1950-1999) and incidence (1969-1999) in the Eldorado uranium workers cohort. ENVIRONMENTAL RESEARCH 2014; 130:43-50. [PMID: 24583244 PMCID: PMC4002578 DOI: 10.1016/j.envres.2014.01.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/18/2013] [Revised: 12/03/2013] [Accepted: 01/09/2014] [Indexed: 06/01/2023]
Abstract
Uranium workers are chronically exposed to low levels of radon decay products (RDP) and gamma (γ) radiation. Risks of leukemia from acute and high doses of γ-radiation are well-characterized, but risks from lower doses and dose-rates and from RDP exposures are controversial. Few studies have evaluated risks of other hematologic cancers in uranium workers. The purpose of this study was to analyze radiation-related risks of hematologic cancers in the cohort of Eldorado uranium miners and processors first employed in 1932-1980 in relation to cumulative RDP exposures and γ-ray doses. The average cumulative RDP exposure was 100.2 working level months and the average cumulative whole-body γ-radiation dose was 52.2 millisievert. We identified 101 deaths and 160 cases of hematologic cancers in the cohort. Overall, male workers had lower mortality and cancer incidence rates for all outcomes compared with the general Canadian male population, a likely healthy worker effect. No statistically significant association between RDP exposure or γ-ray doses, or a combination of both, and mortality or incidence of any hematologic cancer was found. We observed consistent but non-statistically significant increases in risks of chronic lymphocytic leukemia (CLL) and Hodgkin lymphoma (HL) incidence and non-Hodgkin lymphoma (NHL) mortality with increasing γ-ray doses. These findings are consistent with recent studies of increased risks of CLL and NHL incidence after γ-radiation exposure. Further research is necessary to understand risks of other hematologic cancers from low-dose exposures to γ-radiation.
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Affiliation(s)
- Lydia B Zablotska
- Department of Epidemiology and Biostatistics, School of Medicine, University of California, San Francisco, CA 94118, USA.
| | - Rachel S D Lane
- Radiation and Health Sciences Division, Directorate of Environmental and Radiation Protection and Assessment, Canadian Nuclear Safety Commission, Ottawa, ON, Canada K1P 5S9
| | | | - Patsy A Thompson
- Radiation and Health Sciences Division, Directorate of Environmental and Radiation Protection and Assessment, Canadian Nuclear Safety Commission, Ottawa, ON, Canada K1P 5S9
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16
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Wakeford R. The risk of childhood leukaemia following exposure to ionising radiation--a review. JOURNAL OF RADIOLOGICAL PROTECTION : OFFICIAL JOURNAL OF THE SOCIETY FOR RADIOLOGICAL PROTECTION 2013; 33:1-25. [PMID: 23296257 DOI: 10.1088/0952-4746/33/1/1] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Since the early years of follow-up of the Japanese atomic-bomb survivors, it has been apparent that childhood leukaemia has a particular sensitivity to induction by ionising radiation, the excess relative risk (ERR) being expressed as a temporal wave with time since exposure. This pattern has been generally confirmed by studies of children treated with radiotherapy. Case-control studies of childhood leukaemia and antenatal exposure to diagnostic x-rays, a recent large cohort study of leukaemia following CT examinations of young people, and a recent large case-control study of natural background γ-radiation and childhood leukaemia have found evidence of raised risks following low-level exposure. These findings indicate that an ERR/Sv for childhood leukaemia of ~50, which may be derived from risk models based upon the Japanese atomic-bomb survivors, is broadly applicable to low dose or low dose-rate exposure circumstances.
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Affiliation(s)
- Richard Wakeford
- Dalton Nuclear Institute, The University of Manchester, Pariser Building-G Floor, Sackville Street, Manchester M13 9PL, UK.
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17
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Tong J, Qin L, Cao Y, Li J, Zhang J, Nie J, An Y. Environmental radon exposure and childhood leukemia. JOURNAL OF TOXICOLOGY AND ENVIRONMENTAL HEALTH. PART B, CRITICAL REVIEWS 2012; 15:332-347. [PMID: 22852813 DOI: 10.1080/10937404.2012.689555] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Despite the fact that animal and human epidemiological studies confirmed a link between radon exposure in homes and increased risk of lung cancer in general population, other types of cancers induced by radon, such as leukemia, have not been consistently demonstrated. The aim of this review was to summarize data published thus far from ecological and case-control studies in exposed populations, taking into account radon dose estimation and evidence of radon-induced genotoxicity, in an effort to clarify the correlation between home radon exposure and incidence of childhood leukemia. Among 12 ecological studies, 11 reported a positive association between radon levels and elevated frequency of childhood leukemia, with 8 being significant. In conjunction with ecological studies, several case-control studies on indoor radon exposure and childhood leukemia were examined, and most investigations indicated a weak association with only a few showing significance. A major source of uncertainty in radon risk assessment is radon dose estimate. Methods for radon exposure measurement in homes of children are one of the factors that affect the risk estimates in a case-control study. The effects of radon-induced genetic damage were studied both in vitro and in vivo using genetic endpoints including chromosomal aberration (CA), micronuclei (MN) formation, gene mutation, and deletions and insertions. By applying a meta-analysis, an increased risk of childhood leukemia induced by indoor radon exposure was noted for overall leukemia and for acute lymphoblastic leukemia (ALL). Data thus indicated an association between environmental radon exposure and elevated leukemia incidence, but more evidence is required in both human investigations and animal mechanistic research before this assumption may be confirmed with certainty.
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Affiliation(s)
- Jian Tong
- School of Public Health, Soochow University, Suzhou, China.
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18
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Madas BG, Balásházy I. Mutation induction by inhaled radon progeny modeled at the tissue level. RADIATION AND ENVIRONMENTAL BIOPHYSICS 2011; 50:553-570. [PMID: 21894440 DOI: 10.1007/s00411-011-0382-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/24/2011] [Accepted: 08/12/2011] [Indexed: 05/27/2023]
Abstract
The observable responses of living systems to ionizing radiation depend on the level of biological organization studied. Understanding the relationships between the responses characteristic of the different levels of organization is of crucial importance. The main objective of the present study is to investigate how some cellular effects of radiation manifest at the tissue level by modeling mutation induction due to chronic exposure to inhaled radon progeny. For this purpose, a mathematical model of the bronchial epithelium was elaborated to quantify cell nucleus hits and cell doses. Mutagenesis was modeled considering endogenous as well as radiation-induced DNA damages and cell cycle shortening due to cell inactivation. The model parameters describing the cellular effects of radiation are obtained from experimental data. Cell nucleus hits, cell doses, and mutation induction were computed for the activity hot spots of the large bronchi at different exposures. Results demonstrate that the mutagenic effect of densely ionizing radiation is dominated by cell cycle shortening due to cell inactivation and not by DNA damages. This suggests that radiation burdens of non-progenitor cells play a significant role in mutagenesis in case of protracted exposures to densely ionizing radiation. Mutation rate as a function of dose rate exhibits a convex shape below a threshold. This threshold indicates the exhaustion of the tissue regeneration capacity of local progenitor cells. It is suggested that progenitor cell hyperplasia occurs beyond the threshold dose rate, giving a possible explanation of the inverse dose-rate effect observed in the epidemiology of lung cancer among uranium miners.
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Affiliation(s)
- Balázs G Madas
- Hungarian Academy of Sciences KFKI Atomic Energy Research Institute, Budapest, Hungary.
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19
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Enhanced frequency of micronuclei in lymphocytes from current as opposed to former uranium miners. J Appl Biomed 2011. [DOI: 10.2478/v10136-011-0002-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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20
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Is there any interaction between domestic radon exposure and air pollution from traffic in relation to childhood leukemia risk? Cancer Causes Control 2010; 21:1961-4. [DOI: 10.1007/s10552-010-9608-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2010] [Accepted: 06/23/2010] [Indexed: 10/19/2022]
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21
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Little MP, Wakeford R, Kendall GM. Updated estimates of the proportion of childhood leukaemia incidence in Great Britain that may be caused by natural background ionising radiation. JOURNAL OF RADIOLOGICAL PROTECTION : OFFICIAL JOURNAL OF THE SOCIETY FOR RADIOLOGICAL PROTECTION 2009; 29:467-82. [PMID: 19923647 DOI: 10.1088/0952-4746/29/4/001] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
The aetiology of childhood leukaemia remains generally unknown, although exposure to moderate and high levels of ionising radiation, such as was experienced during the atomic bombings of Japan or from radiotherapy, is an established cause. Risk models based primarily upon studies of the Japanese A-bomb survivors imply that low-level exposure to ionising radiation, including to ubiquitous natural background radiation, also raises the risk of childhood leukaemia. In a recent paper (Wakeford et al 2009 Leukaemia 23 770-6) we estimated the proportion of childhood leukaemia incidence in Great Britain attributable to natural background radiation to be about 20%. In this paper we employ the two sets of published leukaemia risk models used previously, but use recently published revised estimates of natural background radiation doses received by the red bone marrow of British children to update the previous results. Using the newer dosimetry we calculate that the best estimate of the proportion of cases of childhood leukaemia in Great Britain predicted to be attributable to this source of exposure is 15-20%, although the uncertainty associated with certain stages in the calculation (e.g. the nature of the transfer of risk between populations and the pertinent dose received from naturally occurring alpha-particle-emitting radionuclides) is significant. The slightly lower attributable proportions compared with those previously derived by Wakeford et al (Leukaemia 2009 23 770-6) are largely due to the lower doses (and in particular lower high LET doses) for the first year of life.
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Affiliation(s)
- Mark P Little
- Department of Epidemiology and Public Health, Imperial College, London W2 1PG, UK.
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