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Turner MC, Cogliano V, Guyton K, Madia F, Straif K, Ward EM, Schubauer-Berigan MK. Research Recommendations for Selected IARC-Classified Agents: Impact and Lessons Learned. ENVIRONMENTAL HEALTH PERSPECTIVES 2023; 131:105001. [PMID: 37902675 PMCID: PMC10615125 DOI: 10.1289/ehp12547] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 09/27/2023] [Accepted: 10/03/2023] [Indexed: 10/31/2023]
Abstract
BACKGROUND The International Agency for Research on Cancer (IARC) Monographs program assembles expert working groups who publish a critical review and evaluation of data on agents of interest. These comprehensive reviews provide a unique opportunity to identify research needs to address classification uncertainties. A multidisciplinary expert review and workshop held in 2009 identified research gaps and needs for 20 priority occupational chemicals, metals, dusts, and physical agents, with the goal of stimulating advances in epidemiological studies of cancer and carcinogen mechanisms. Overarching issues were also described. OBJECTIVES In this commentary we review the current status of the evidence for the 20 priority agents identified in 2009. We examine whether identified Research Recommendations for each agent were addressed and their potential impact on resolving classification uncertainties. METHODS We reviewed the IARC classifications of each of the 20 priority agents and identified major new epidemiological and human mechanistic studies published since the last evaluation. Information sources were either the published Monograph for agents that have been reevaluated or, for agents not yet reevaluated, Advisory Group reports and literature searches. Findings are described in view of recent methodological developments in Monographs evidence evaluation processes. DISCUSSION The majority of the 20 priority agents were reevaluated by IARC since 2009. The overall carcinogen classifications of 9 agents advanced, and new cancer sites with either "sufficient" or "limited" evidence of carcinogenicity were also identified for 9 agents. Examination of published findings revealed whether evidence gaps and Research Recommendations have been addressed and highlighted remaining uncertainties. During the past decade, new research addressed a range of the 2009 recommendations and supported updated classifications for priority agents. This supports future efforts to systematically apply findings of Monograph reviews to identify research gaps and priorities relevant to evaluation criteria established in the updated IARC Monograph Preamble. https://doi.org/10.1289/EHP12547.
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Affiliation(s)
- Michelle C. Turner
- Barcelona Institute for Global Health, Barcelona, Spain
- Universitat Pompeu Fabra, Barcelona, Spain
- CIBER Epidemiología y Salud Pública, Madrid, Spain
| | - Vincent Cogliano
- California Environmental Protection Agency Office of Environmental Health Hazard Assessment, Oakland, California, USA
| | - Kathryn Guyton
- National Academies of Sciences, Engineering, and Medicine, Washington, District of Columbia, USA
| | - Federica Madia
- International Agency for Research on Cancer, Lyon, France
| | - Kurt Straif
- Barcelona Institute for Global Health, Barcelona, Spain
- Boston College, Massachusetts, USA
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Deen L, Hougaard KS, Clark A, Meyer HW, Frederiksen M, Gunnarsen L, Andersen HV, Hougaard T, Petersen KKU, Ebbehøj NE, Bonde JP, Tøttenborg SS. Cancer Risk following Residential Exposure to Airborne Polychlorinated Biphenyls: A Danish Register-Based Cohort Study. ENVIRONMENTAL HEALTH PERSPECTIVES 2022; 130:107003. [PMID: 36306207 PMCID: PMC9616107 DOI: 10.1289/ehp10605] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 08/14/2022] [Accepted: 09/19/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND Polychlorinated biphenyls (PCBs) are biopersistent chemicals classified as human carcinogens. This classification is primarily based on evidence on higher-chlorinated PCBs found in food. The carcinogenic potential of airborne lower-chlorinated PCBs remains largely unexplored. OBJECTIVES We aimed to investigate cancer risk following residential exposure to airborne PCBs. METHODS Cancer risk was examined in the Health Effects of PCBs in Indoor Air (HESPAIR) cohort of 38,613 residents of two partly PCB-contaminated residential areas in Greater Copenhagen, identified by nationwide registries. PCB exposure was based on relocation dates and indoor air PCB measurements in subsets of apartments. Cancer diagnoses were extracted from the Danish Cancer Registry for the follow-up period of 1970-2018. We estimated adjusted hazard ratios with time-varying cumulative exposure and a 10-y lag using Cox regression. RESULTS Overall risk of cancer was not associated with PCByear, [hazard ratio (HR) for high-exposed vs. low-exposed =0.98; 95% confidence interval (CI): 0.88, 1.09], but residents exposed to ≥3,000 ng/m3 PCB×year had higher risk of liver cancer (HR =2.81; 95% CI: 1.28, 6.15) and meningiomas (HR =3.49; 95% CI: 1.84, 6.64), with indications of exposure-response relationships. Results were suggestive of a higher risk of pancreatic cancer (HR =1.59; 95% CI: 0.95, 2.64) at the highest aggregated PCB level. For testis cancer, a higher risk was observed among residents exposed to 300-949 ng/m3 PCB×year relative to residents exposed to <300 ng/m3 PCB×year (HR =2.97; 95% CI: 1.41, 6.28), but the risk was not higher for residents exposed to ≥950 ng/m3 PCB×year. Apart from this, the risk of specific cancers was similar across exposure groups. DISCUSSION In this, to our knowledge, first population-based cohort study of residential exposure to airborne PCBs, we found no association between exposure to PCBs in indoor air in private homes and the risk for most of the specific cancers. Higher risk of liver cancer and meningiomas were observed. https://doi.org/10.1289/EHP10605.
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Affiliation(s)
- Laura Deen
- Department of Occupational and Environmental Medicine, Copenhagen University Hospital – Bispebjerg and Frederiksberg, Copenhagen, Denmark
- Department of Public Health, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Karin Sørig Hougaard
- Department of Public Health, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
- National Research Centre for the Working Environment, Copenhagen, Denmark
| | - Alice Clark
- Department of Epidemiology, Novo Nordisk, Copenhagen, Denmark
| | - Harald William Meyer
- Department of Occupational and Environmental Medicine, Copenhagen University Hospital – Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - Marie Frederiksen
- National Research Centre for the Working Environment, Copenhagen, Denmark
| | - Lars Gunnarsen
- Department of the Built Environment, Aalborg University Copenhagen, Copenhagen, Denmark
| | - Helle Vibeke Andersen
- Department of the Built Environment, Aalborg University Copenhagen, Copenhagen, Denmark
| | | | - Kajsa Kirstine Ugelvig Petersen
- Department of Occupational and Environmental Medicine, Copenhagen University Hospital – Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - Niels Erik Ebbehøj
- Department of Occupational and Environmental Medicine, Copenhagen University Hospital – Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - Jens Peter Bonde
- Department of Occupational and Environmental Medicine, Copenhagen University Hospital – Bispebjerg and Frederiksberg, Copenhagen, Denmark
- Department of Public Health, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Sandra Søgaard Tøttenborg
- Department of Occupational and Environmental Medicine, Copenhagen University Hospital – Bispebjerg and Frederiksberg, Copenhagen, Denmark
- Department of Public Health, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
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Polychlorinated Biphenyls (PCBs) in the Environment: Occupational and Exposure Events, Effects on Human Health and Fertility. TOXICS 2022; 10:toxics10070365. [PMID: 35878270 PMCID: PMC9323099 DOI: 10.3390/toxics10070365] [Citation(s) in RCA: 36] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 06/24/2022] [Accepted: 06/28/2022] [Indexed: 02/04/2023]
Abstract
In the last decade or so, polychlorinated biphenyls (PCBs) garnered renewed attention in the scientific community due to new evidence pointing at their continued presence in the environment and workplaces and the potential human risks related to their presence. PCBs move from the environment to humans through different routes; the dominant pathway is the ingestion of contaminated foods (fish, seafood and dairy products), followed by inhalation (both indoor and outdoor air), and, to a lesser extent, dust ingestion and dermal contact. Numerous studies reported the environmental and occupational exposure to these pollutants, deriving from building materials (flame-retardants, plasticizers, paints, caulking compounds, sealants, fluorescent light ballasts, etc.) and electrical equipment. The highest PCBs contaminations were detected in e-waste recycling sites, suggesting the need for the implementation of remediation strategies of such polluted areas to safeguard the health of workers and local populations. Furthermore, a significant correlation between PCB exposure and increased blood PCB concentrations was observed in people working in PCB-contaminated workplaces. Several epidemiological studies suggest that environmental and occupational exposure to high concentrations of PCBs is associated with different health outcomes, such as neuropsychological and neurobehavioral deficits, dementia, immune system dysfunctions, cardiovascular diseases and cancer. In addition, recent studies indicate that PCBs bioaccumulation can reduce fertility, with harmful effects on the reproductive system that can be passed to offspring. In the near future, further studies are needed to assess the real effects of PCBs exposure at low concentrations for prolonged exposure in workplaces and specific indoor environments.
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Fiolet T, Casagrande C, Nicolas G, Horvath Z, Frenoy P, Weiderpass E, Katzke V, Kaaks R, Rodriguez-Barranco M, Panico S, Sacerdote C, Manjer J, Sonestedt E, Grioni S, Agudo A, Rylander C, Haugdahl Nøst T, Skeie G, Tjønneland A, Raaschou-Nielsen O, Ardanaz E, Amiano P, Dolores Chirlaque López M, Schulze MB, Wennberg M, Harlid S, Cairat M, Kvaskoff M, Huybrechts I, Romana Mancini F. Dietary intakes of dioxins and polychlorobiphenyls (PCBs) and breast cancer risk in 9 European countries. ENVIRONMENT INTERNATIONAL 2022; 163:107213. [PMID: 35364416 DOI: 10.1016/j.envint.2022.107213] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 02/10/2022] [Accepted: 03/24/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND Dioxins and polychlorobiphenyls (PCBs) are persistent organic pollutants that have demonstrated endocrine disrupting properties. Several of these chemicals are carcinogenic and positive associations have been suggested with breast cancer risk. In general population, diet represents the main source of exposure. METHODS Associations between dietary intake of 17 dioxins and 35 PCBs and breast cancer were evaluated in the European Prospective Investigation into Cancer and Nutrition (EPIC) cohort from nine European countries using multivariable Cox regressions. The present study included 318,607 women (mean ± SD age: 50.7 ± 9.7) with 13,241 incident invasive breast cancers and a median follow-up of 14.9 years (IQR = 13.5-16.4). Dietary intake of dioxins and PCBs was assessed combining EPIC food consumption data with food contamination data provided by the European Food Safety Authority. RESULTS Exposure to dioxins, dioxins + Dioxin-Like-PCBs, Dioxin-Like-PCBs (DL-PCBs), and Non-Dioxin-Like-PCBs (NDL-PCBs) estimated from reported dietary intakes were not associated with breast cancer incidence, with the following hazard ratios (HRs) and 95% confidence intervals for an increment of 1 SD: HRdioxins = 1.00 (0.98 to 1.02), HRdioxins+DL-PCB = 1.01 (0.98 to 1.03), HRDL-PCB = 1.01 (0.98 to 1.03), and HRNDL-PCB = 1.01 (0.99 to 1.03). Results remained unchanged when analyzing intakes as quintile groups, as well as when analyses were run separately per country, or separating breast cancer cases based on estrogen receptor status or after further adjustments on main contributing food groups to PCBs and dioxins intake and nutritional factors. CONCLUSIONS This large European prospective study does not support the hypothesis of an association between dietary intake of dioxins and PCBs and breast cancer risk.
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Affiliation(s)
- Thibault Fiolet
- Paris-Saclay University, UVSQ, Univ. Paris-Sud, Inserm, Gustave Roussy, "Exposome and Heredity" Team, CESP, F-94805 Villejuif, France
| | - Corinne Casagrande
- Nutrition and Metabolism Branch, International Agency for Research on Cancer, 150 cours Albert Thomas, CEDEX 08, 69372 Lyon, France
| | - Geneviève Nicolas
- Nutrition and Metabolism Branch, International Agency for Research on Cancer, 150 cours Albert Thomas, CEDEX 08, 69372 Lyon, France
| | - Zsuzsanna Horvath
- European Food Safety Authority, Via Carlo Magno 1A, 43126 Parma, Italy
| | - Pauline Frenoy
- Paris-Saclay University, UVSQ, Univ. Paris-Sud, Inserm, Gustave Roussy, "Exposome and Heredity" Team, CESP, F-94805 Villejuif, France
| | - Elisabete Weiderpass
- International Agency for Research on Cancer, 150 cours Albert Thomas, CEDEX 08, 69372 Lyon, France
| | - Verena Katzke
- Division of Cancer Epidemiology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Rudolf Kaaks
- Division of Cancer Epidemiology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Miguel Rodriguez-Barranco
- Escuela Andaluza de Salud Pública (EASP), Granada, Spain; Instituto de Investigación Biosanitaria ibs.GRANADA, Granada, Spain; Spanish Consortium for Research on Epidemiology and Public Health (CIBERESP), Madrid, Spain
| | - Salvatore Panico
- Dipartimento di medicina clinica e chirurgia Federico II University, Naples, Italy
| | - Carlotta Sacerdote
- Unit of Cancer Epidemiology, Città della Salute e della Scienza University-Hospital, Via Santena 7, 10126 Turin, Italy
| | - Jonas Manjer
- Dept Surgery, Skåne University Hospital Malmö, Lund University, Malmö, Sweden
| | - Emily Sonestedt
- Nutritional Epidemiology, Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden
| | - Sara Grioni
- Epidemiology and Prevention Unit, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Via Venezian, 1, 20133 Milano, Italy
| | - Antonio Agudo
- Unit of Nutrition and Cancer, Catalan Institute of Oncology - ICO, L'Hospitalet de Llobregat, Spain. Nutrition and Cancer Group, Epidemiology, Public Health, Cancer Prevention and Palliative Care Program, Bellvitge Biomedical Research Institute - IDIBELL, L'Hospitalet de Llobregat, Spain
| | - Charlotta Rylander
- Department of Community Medicine, Faculty of Health Sciences, University of Tromsø (UiT), The Arctic University of Norway, Tromsø, Norway
| | - Therese Haugdahl Nøst
- Department of Community Medicine, Faculty of Health Sciences, University of Tromsø (UiT), The Arctic University of Norway, Tromsø, Norway
| | - Guri Skeie
- Department of Community Medicine, Faculty of Health Sciences, University of Tromsø (UiT), The Arctic University of Norway, Tromsø, Norway
| | - Anne Tjønneland
- Danish Cancer Society Research Center, Copenhagen, Denmark; Department of Public Health, University of Copenhagen, Denmark
| | - Ole Raaschou-Nielsen
- Danish Cancer Society Research Center, Copenhagen, Denmark; Department of Environmental Science, Aarhus University, Roskilde, Denmark
| | - Eva Ardanaz
- Spanish Consortium for Research on Epidemiology and Public Health (CIBERESP), Madrid, Spain; Navarra Public Health Institute, Pamplona, Spain; IdiSNA, Navarra Institute for Health Research, Pamplona, Spain
| | - Pilar Amiano
- Spanish Consortium for Research on Epidemiology and Public Health (CIBERESP), Madrid, Spain; Ministry of Health of the Basque Government, Sub-Directorate for Public Health and Addictions of Gipuzkoa, Biodonostia Health Research Institute, Group of Epidemiology of Chronic and Communicable Diseases, San Sebastián, Spain
| | - María Dolores Chirlaque López
- Spanish Consortium for Research on Epidemiology and Public Health (CIBERESP), Madrid, Spain; Department of Epidemiology, Regional Health Council, IMIB-Arrixaca, Murcia University, Murcia, Spain
| | - Matthias B Schulze
- Department of Molecular Epidemiology, Germen Institute of Human Nutrition, Potsdam-Rehruecke, Nuthetal, Germany; Institute of Nutritional Science, University of Potsdam, Potsdam, Germany
| | - Maria Wennberg
- Department of Public Health and Clinical Medicine, Section of Sustainable Health, Umeå University, Umeå, Sweden
| | - Sophia Harlid
- Department of Radiation Sciences, Oncology Unit, Umeå University, Umeå, Sweden
| | - Manon Cairat
- Paris-Saclay University, UVSQ, Univ. Paris-Sud, Inserm, Gustave Roussy, "Exposome and Heredity" Team, CESP, F-94805 Villejuif, France; Nutrition and Metabolism Branch, International Agency for Research on Cancer, 150 cours Albert Thomas, CEDEX 08, 69372 Lyon, France
| | - Marina Kvaskoff
- Paris-Saclay University, UVSQ, Univ. Paris-Sud, Inserm, Gustave Roussy, "Exposome and Heredity" Team, CESP, F-94805 Villejuif, France
| | - Inge Huybrechts
- Nutrition and Metabolism Branch, International Agency for Research on Cancer, 150 cours Albert Thomas, CEDEX 08, 69372 Lyon, France
| | - Francesca Romana Mancini
- Paris-Saclay University, UVSQ, Univ. Paris-Sud, Inserm, Gustave Roussy, "Exposome and Heredity" Team, CESP, F-94805 Villejuif, France.
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Wan MLY, Co VA, El-Nezami H. Endocrine disrupting chemicals and breast cancer: a systematic review of epidemiological studies. Crit Rev Food Sci Nutr 2021; 62:6549-6576. [PMID: 33819127 DOI: 10.1080/10408398.2021.1903382] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Endocrine-disrupting compounds (EDCs) are ubiquitous substances that are found in our everyday lives, including pesticides, plasticizers, pharmaceutical agents, personal care products, and also in food products and food packaging. Increasing epidemiological evidence suggest that EDCs may affect the development or progression of breast cancer and consequently lead to lifelong harmful health consequences, especially when exposure occurs during early life in humans. Yet so far no appraisal of the available evidence has been conducted on this topic. OBJECTIVE To systematically review all the available epidemiological studies about the association of the levels of environmental exposures of EDCs with breast cancer risk. METHODS The search was performed in accordance with the PRISMA guidelines. We retrieved articles from PubMed (MEDLINE) until 10 March 2021. The key words used in this research were: "Endocrine disruptor(s)" OR "Endocrine disrupting chemical(s)" OR any of the EDCs mentioned below AND "Breast cancer" to locate all relevant articles published. We included only cohort studies and case-control studies. All relevant articles were accessed in full text and were evaluated and summarized in tables. RESULTS We identified 131 studies that met the search criteria and were included in this systematic review. EDCs reviewed herein included pesticides (e.g. p,p'-dichlorodiphenyltrichloroethane (DDT), p,p'-dichlorodiphenyldichloroethylene (DDE), atrazine, 2,3,7,8-tetrachloridibenzo-p-dioxin (TCDD or dioxin)), synthetic chemicals (e.g. bisphenol A (BPA), phthalates, per- and polyfluoroalkyl substances (PFAS), parabens, polychlorinated biphenyls (PCBs), polybrominated diphenyl ethers (PBDEs), contraceptive pills), phytoestrogens (e.g. genistein, resveratrol), and certain mycotoxins (e.g. zearalenone). Most studies assessed environmental EDCs exposure via biomarker measurements. CONCLUSION We identified certain EDC exposures could potentially elevate the risk of breast cancer. As majority of EDCs are highly persistent in the environment and bio-accumulative, it is essential to assess the long-term impacts of EDC exposures, especially multi-generational and transgenerational. Also, since food is often a major route of exposure to EDCs, well-designed exposure assessments of potential EDCs in food and food packing are necessary and their potential link to breast cancer development need to be carefully evaluated for subsequent EDC policy making and regulations.
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Affiliation(s)
- Murphy Lam Yim Wan
- Faculty of Science, School of Biological Sciences, The University of Hong Kong, Pokfulam, Hong Kong S.A.R.,Department of Microbiology, Immunology and Glycobiology, Institute of Laboratory Medicine, Lund University, Lund, Sweden
| | - Vanessa Anna Co
- Faculty of Science, School of Biological Sciences, The University of Hong Kong, Pokfulam, Hong Kong S.A.R
| | - Hani El-Nezami
- Faculty of Science, School of Biological Sciences, The University of Hong Kong, Pokfulam, Hong Kong S.A.R.,Institute of Public Health and Clinical Nutrition, University of Eastern Finland, Kuopio, Finland
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Fernández-Martínez NF, Ching-López A, Olry de Labry Lima A, Salamanca-Fernández E, Pérez-Gómez B, Jiménez-Moleón JJ, Sánchez MJ, Rodríguez-Barranco M. Relationship between exposure to mixtures of persistent, bioaccumulative, and toxic chemicals and cancer risk: A systematic review. ENVIRONMENTAL RESEARCH 2020; 188:109787. [PMID: 32798941 DOI: 10.1016/j.envres.2020.109787] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 06/03/2020] [Accepted: 06/03/2020] [Indexed: 05/15/2023]
Abstract
Environmental risks are responsible for one in five of all deaths worldwide. Persistent, bioaccumulative, and toxic substances are chemicals that can subsist for decades in human tissues and the environment. They include heavy metals, organochlorines, polychlorinated biphenyls, organobromines, organofluorines, and polycyclic aromatic hydrocarbons among others. Although humans are often exposed to multiple pollutants simultaneously, their negative effects on health have generally been studied for each one separately. Among the most severe of these harmful effects is cancer. Here, to compile and analyze the available evidence on the relationship between exposure to mixtures of persistent, bioaccumulative, and toxic chemicals and the risk of developing cancer in the general population, we provide a systematic review based on the main databases (Cochrane, PubMed and Embase), together with complementary sources, using the general methodology of the PRISMA Statement. The articles analyzed were selected by two researchers working independently and their quality was evaluated by reference to the Newcastle-Ottawa scale. The initial search yielded 2379 results from the main sources of information and 22 from the complementary ones. After the article selection process, 22 were included in the final review (21 case-control studies and one cohort study). Analysis of the selected studies revealed that most of the mixtures analyzed were positively associated with risk of cancer, especially that of the breast, colon-rectum or testis, and more strongly so than each contaminant alone. In view of the possible stronger association observed with the development of cancer for some mixtures of pollutants than when each one is present separately, exposure to mixtures should also be monitored and measured, preferably in cohort designs, to complement the traditional approach to persistent, bioaccumulative, and toxic chemicals. The results presented should be taken into account in public health policies in order to strengthen the regulatory framework for cancer prevention and control.
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Affiliation(s)
- Nicolás Francisco Fernández-Martínez
- Unidad de Gestión Clínica Interniveles de Prevención, Promoción y Vigilancia de La Salud, Hospital Universitario Reina Sofía, Córdoba, Spain; Maimonides Institute for Research in Biomedicine of Cordoba (IMIBIC), Córdoba, Spain
| | - Ana Ching-López
- CIBER de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain; Andalusian School of Public Health (EASP), Granada, Spain
| | - Antonio Olry de Labry Lima
- CIBER de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain; Andalusian School of Public Health (EASP), Granada, Spain; Instituto de Investigación Biosanitaria Ibs.GRANADA, Granada, Spain
| | - Elena Salamanca-Fernández
- Andalusian School of Public Health (EASP), Granada, Spain; Instituto de Investigación Biosanitaria Ibs.GRANADA, Granada, Spain
| | - Beatriz Pérez-Gómez
- CIBER de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain; Department of Epidemiology of Chronic Diseases, National Centre for Epidemiology, Carlos III Institute of Health, Madrid, Spain
| | - José Juan Jiménez-Moleón
- CIBER de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain; Instituto de Investigación Biosanitaria Ibs.GRANADA, Granada, Spain; Department of Preventive Medicine and Public Health, University of Granada, Granada, Spain
| | - Maria José Sánchez
- CIBER de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain; Andalusian School of Public Health (EASP), Granada, Spain; Instituto de Investigación Biosanitaria Ibs.GRANADA, Granada, Spain; Department of Preventive Medicine and Public Health, University of Granada, Granada, Spain.
| | - Miguel Rodríguez-Barranco
- CIBER de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain; Andalusian School of Public Health (EASP), Granada, Spain; Instituto de Investigación Biosanitaria Ibs.GRANADA, Granada, Spain
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Fuoco R, Giannarelli S. Integrity of aquatic ecosystems: An overview of a message from the South Pole on the level of persistent organic pollutants (POPs). Microchem J 2019. [DOI: 10.1016/j.microc.2019.04.076] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Engel CL, Sharima Rasanayagam M, Gray JM, Rizzo J. Work and Female Breast Cancer: The State of the Evidence, 2002-2017. New Solut 2019; 28:55-78. [PMID: 29658425 DOI: 10.1177/1048291118758460] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The authors undertook a scoping review to assess the literature from 2002 to 2017 on the relationship between occupation and female breast cancer. Case-control, cohort, and meta-analytic studies suggest that women working as flight attendants, in medical professions, some production positions, sales and retail, and scientific technical staff are likely to have elevated risk of breast cancer. In addition, occupational exposures to night-shift work, ionizing radiation, some chemicals, job stress, and sedentary work may increase risk of breast cancer. Occupational physical activity appears to decrease risk. Workplace exposures to passive smoke and occupational exposure to nonionizing radiation do not appear to affect breast cancer risk. Some studies of occupational categories and workplace exposures indicate that risk may be modified by duration of exposure, timing of exposure, dose, hormone-receptor subtypes, and menopausal status at diagnosis. The compelling data from this review reveal a substantial need for further research on occupation and breast cancer.
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Affiliation(s)
- Connie L Engel
- 1 Breast Cancer Prevention Partners, San Francisco, CA, USA
| | | | - Janet M Gray
- 1 Breast Cancer Prevention Partners, San Francisco, CA, USA
| | - Jeanne Rizzo
- 1 Breast Cancer Prevention Partners, San Francisco, CA, USA
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Sritharan J, MacLeod JS, Dakouo M, Qadri M, McLeod CB, Peter A, Demers PA. Breast cancer risk by occupation and industry in women and men: Results from the Occupational Disease Surveillance System (ODSS). Am J Ind Med 2019; 62:205-211. [PMID: 30648268 DOI: 10.1002/ajim.22942] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/20/2018] [Indexed: 12/18/2022]
Abstract
BACKGROUND The recently established Occupational Disease Surveillance System (ODSS) was used to examine breast cancer risk in women and men by occupation and industry. METHODS Ontario workers in the ODSS cohort (1983-2016) were followed up for breast cancer diagnosis through the Ontario Cancer Registry. Cox-proportional hazard models were used to calculate age-adjusted hazard ratios (HRs) and 95% confidence intervals (CIs). RESULTS A total of 17 865 and 492 cases were identified in working women (W) and men (M), respectively. Elevated risks were observed in management (W: HR = 1.54, 95% CI = 1.40-1.70; M: HR = 2.79, 95% CI = 1.44-5.39), administrative/clerical (W: HR = 1.16, 95% CI = 1.11-1.21; M: HR = 1.45, 95% CI = 1.06-1.99), and teaching (W: HR = 1.54, 95% CI = 1.44-1.63; M: HR = 3.00, 95% CI = 1.49-6.03). Other elevated risks were observed in nursing/health, social sciences, and janitor/cleaning services for both genders. CONCLUSIONS Common occupational associations in both genders warrant investigation into job-related risk factors, such as sedentary behavior, shift work, ionizing radiation, and chemical exposures.
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Affiliation(s)
- Jeavana Sritharan
- Occupational Cancer Research Centre; Cancer Care Ontario; Ontario Canada
| | - Jill S. MacLeod
- Occupational Cancer Research Centre; Cancer Care Ontario; Ontario Canada
| | - Mamadou Dakouo
- Occupational Cancer Research Centre; Cancer Care Ontario; Ontario Canada
| | - Maria Qadri
- Occupational Cancer Research Centre; Cancer Care Ontario; Ontario Canada
| | - Chris B. McLeod
- School of Population and Public Health; University of British Columbia; British Columbia Canada
- Institute for Work & Health; Ontario Canada
| | - Alice Peter
- Population Health and Prevention; Cancer Care Ontario; Ontario Canada
| | - Paul A. Demers
- Occupational Cancer Research Centre; Cancer Care Ontario; Ontario Canada
- Dalla Lana School of Public Health; University of Toronto; Ontario Canada
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10
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Acheampong T, Yuan JM, Koh WP, Jin A, Odegaard A. Occupational exposure to endocrine disrupting substances and the risk of breast Cancer: the Singapore Chinese health study. BMC Public Health 2018; 18:929. [PMID: 30055614 PMCID: PMC6064056 DOI: 10.1186/s12889-018-5862-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Accepted: 07/18/2018] [Indexed: 11/28/2022] Open
Abstract
Background Evidence from basic research links exposure to endocrine disrupting chemicals (EDCs) with a higher risk for breast cancer. However, there is less evidence from observational epidemiological research and the results are equivocal. Therefore, we examined the association between occupational exposure to substances where exposure to EDCs is likely and the risk of breast cancer. Methods A prospective study consisting of a population-based cohort of 33,458 Singaporean Chinese women aged 45–74 years enrolled in the Singapore Chinese Health Study (SCHS) from 1993 to 98 and followed through 2014. Subjects’ self-reported occupational exposure and duration to industries, job titles, and substance types were garnered at baseline, and cases of incident breast cancer (N = 988) were determined by linkage with the Singapore Cancer Registry. Hazard ratios (HR) and 95% confidence intervals (CI) were estimated for exposure to substances, job titles, and industries. Results There was no association between cumulative exposure to substances via occupation where EDC exposure is likely and risk of breast cancer. These results were consistent for hypothesized high (HR 0.94, 95% CI: 0.66–1.35), medium (HR 1.03 95% CI: 0.77–1.38) and low (HR 0.74, 95% CI 0.48–1.13) combined substance exposure groups when compared with those who were not exposed via occupation. Similar null associations were observed when examining job titles and industry categories. Conclusions There was no association between EDC related occupational exposures and breast cancer risk in working women of the Singaporean Chinese Health Study. Future studies that employ rigorous methods with regard to exposure assessment of EDCs are needed. Electronic supplementary material The online version of this article (10.1186/s12889-018-5862-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Teofilia Acheampong
- Department of Epidemiology, University of California Irvine, School of Medicine, 224 Irvine Hall, Irvine, CA, 92697, United States.
| | - Jian-Min Yuan
- University of Pittsburgh, University of Pittsburgh Medical Center (Shadyside) Cancer Pavilion, 5150 Centre Avenue, Pittsburgh, PA, 15232, United States
| | - Woon Puay Koh
- Health Services and Systems Research, Duke-NUS Medical School, 8 College Road, Singapore, 169857, Singapore.,Saw Swee Hock School of Public Health, National University of Singapore, 12 Science Drive 2, Singapore, 117549, Singapore
| | - Aizhen Jin
- Health Services and Systems Research, Duke-NUS Medical School, 8 College Road, Singapore, 169857, Singapore
| | - Andrew Odegaard
- Department of Epidemiology, University of California Irvine, School of Medicine, 224 Irvine Hall, Irvine, CA, 92697, United States
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11
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Rodgers KM, Udesky JO, Rudel RA, Brody JG. Environmental chemicals and breast cancer: An updated review of epidemiological literature informed by biological mechanisms. ENVIRONMENTAL RESEARCH 2018; 160:152-182. [PMID: 28987728 DOI: 10.1016/j.envres.2017.08.045] [Citation(s) in RCA: 213] [Impact Index Per Article: 35.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Revised: 08/28/2017] [Accepted: 08/29/2017] [Indexed: 05/20/2023]
Abstract
BACKGROUND Many common environmental chemicals are mammary gland carcinogens in animal studies, activate relevant hormonal pathways, or enhance mammary gland susceptibility to carcinogenesis. Breast cancer's long latency and multifactorial etiology make evaluation of these chemicals in humans challenging. OBJECTIVE For chemicals previously identified as mammary gland toxicants, we evaluated epidemiologic studies published since our 2007 review. We assessed whether study designs captured relevant exposures and disease features suggested by toxicological and biological evidence of genotoxicity, endocrine disruption, tumor promotion, or disruption of mammary gland development. METHODS We systematically searched the PubMed database for articles with breast cancer outcomes published in 2006-2016 using terms for 134 environmental chemicals, sources, or biomarkers of exposure. We critically reviewed the articles. RESULTS We identified 158 articles. Consistent with experimental evidence, a few key studies suggested higher risk for exposures during breast development to dichlorodiphenyltrichloroethane (DDT), dioxins, perfluorooctane-sulfonamide (PFOSA), and air pollution (risk estimates ranged from 2.14 to 5.0), and for occupational exposure to solvents and other mammary carcinogens, such as gasoline components (risk estimates ranged from 1.42 to 3.31). Notably, one 50-year cohort study captured exposure to DDT during several critical windows for breast development (in utero, adolescence, pregnancy) and when this chemical was still in use. Most other studies did not assess exposure during a biologically relevant window or specify the timing of exposure. Few studies considered genetic variation, but the Long Island Breast Cancer Study Project reported higher breast cancer risk for polycyclic aromatic hydrocarbons (PAHs) in women with certain genetic variations, especially in DNA repair genes. CONCLUSIONS New studies that targeted toxicologically relevant chemicals and captured biological hypotheses about genetic variants or windows of breast susceptibility added to evidence of links between environmental chemicals and breast cancer. However, many biologically relevant chemicals, including current-use consumer product chemicals, have not been adequately studied in humans. Studies are challenged to reconstruct exposures that occurred decades before diagnosis or access biological samples stored that long. Other problems include measuring rapidly metabolized chemicals and evaluating exposure to mixtures.
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Affiliation(s)
- Kathryn M Rodgers
- Silent Spring Institute, 320 Nevada Street, Newton, MA 02460, United States.
| | - Julia O Udesky
- Silent Spring Institute, 320 Nevada Street, Newton, MA 02460, United States.
| | - Ruthann A Rudel
- Silent Spring Institute, 320 Nevada Street, Newton, MA 02460, United States.
| | - Julia Green Brody
- Silent Spring Institute, 320 Nevada Street, Newton, MA 02460, United States.
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12
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Gray JM, Rasanayagam S, Engel C, Rizzo J. State of the evidence 2017: an update on the connection between breast cancer and the environment. Environ Health 2017; 16:94. [PMID: 28865460 PMCID: PMC5581466 DOI: 10.1186/s12940-017-0287-4] [Citation(s) in RCA: 109] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Accepted: 07/17/2017] [Indexed: 05/23/2023]
Abstract
BACKGROUND In this review, we examine the continually expanding and increasingly compelling data linking radiation and various chemicals in our environment to the current high incidence of breast cancer. Singly and in combination, these toxicants may have contributed significantly to the increasing rates of breast cancer observed over the past several decades. Exposures early in development from gestation through adolescence and early adulthood are particularly of concern as they re-shape the program of genetic, epigenetic and physiological processes in the developing mammary system, leading to an increased risk for developing breast cancer. In the 8 years since we last published a comprehensive review of the relevant literature, hundreds of new papers have appeared supporting this link, and in this update, the evidence on this topic is more extensive and of better quality than that previously available. CONCLUSION Increasing evidence from epidemiological studies, as well as a better understanding of mechanisms linking toxicants with development of breast cancer, all reinforce the conclusion that exposures to these substances - many of which are found in common, everyday products and byproducts - may lead to increased risk of developing breast cancer. Moving forward, attention to methodological limitations, especially in relevant epidemiological and animal models, will need to be addressed to allow clearer and more direct connections to be evaluated.
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Affiliation(s)
- Janet M. Gray
- Department of Psychology and Program in Science, Technology, and Society, Vassar College, 124 Raymond Avenue, Poughkeepsie, NY 12604-0246 USA
| | - Sharima Rasanayagam
- Breast Cancer Prevention Partners, 1388 Sutter St., Suite 400, San Francisco, CA 94109-5400 USA
| | - Connie Engel
- Breast Cancer Prevention Partners, 1388 Sutter St., Suite 400, San Francisco, CA 94109-5400 USA
| | - Jeanne Rizzo
- Breast Cancer Prevention Partners, 1388 Sutter St., Suite 400, San Francisco, CA 94109-5400 USA
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13
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Saeedi R, Khakzad S, Koolivand A, Dobaradaran S, Khaloo SS, Jorfi S, Abtahi M. Transformer oils as a potential source of environmental exposure to polychlorinated biphenyls (PCBs): an assessment in three central provinces of Iran. ENVIRONMENTAL SCIENCE AND POLLUTION RESEARCH INTERNATIONAL 2017; 24:19098-19103. [PMID: 28660512 DOI: 10.1007/s11356-017-9576-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/15/2017] [Accepted: 06/19/2017] [Indexed: 06/07/2023]
Abstract
Polychlorinated biphenyl (PCB) contamination of oils from all transformers of the national electrical grid in Tehran, Qom, and Alborz, three central provinces of Iran, was assessed. The concentration of PCBs in transformer oils was determined by gas chromatography. At the national level, the proportions of transformers with oil PCB contents of <5, 5-49, 50-499, 500-4999, and >5000 ppm were determined to be 85.7, 12.4, 1.6, 0.1, and 0.1%, respectively. About 0.5% of transformer oils (66,000 kg out of 13,342,000 kg) exhibited PCB levels higher than 50 ppm that based on the Stockholm Convention should be phased out before 2025. The contaminated oils contained 91.4% of detected PCBs (132 kg PCBs out of 144 kg PCBs) and were located in 1.9% of transformers (27 transformers out of 1449 transformers). Statistical analysis indicated that the year of manufacture and manufacturing company provided significant effects on PCB contamination (p value <0.001). PCB contamination of transformer oils in Tehran was higher than that of the other provinces that could be mainly caused by the older average year of manufacture. PCB levels higher than 499 ppm were also observed only in Tehran. This study provided valuable information for future studies on identification of PCB-contaminated transformers as well as planning and design of waste management facilities for PCB-contaminated oils at the national level.
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Affiliation(s)
- Reza Saeedi
- Department of Health Sciences, School of Health, Safety and Environment, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Saeed Khakzad
- Department of Virtual Education, School of Medical Education Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Ali Koolivand
- Department of Environmental Health Engineering, Faculty of Health, Arak University of Medical Sciences, Arak, Iran
| | - Sina Dobaradaran
- The Persian Gulf Marine Biotechnology Research Center, Bushehr University of Medical Sciences, Bushehr, Iran
- Department of Environmental Health Engineering, Faculty of Health, Bushehr University of Medical Sciences, Bushehr, Iran
- Systems Environmental Health, Oil, Gas and Energy Research Center, Bushehr University of Medical Sciences, Bushehr, Iran
| | - Shokooh Sadat Khaloo
- School of Health, Safety and Environment, Shahid Beheshti University of Medical Sciences, P.O. Box 16858-116, Tehran, Iran
| | - Sahand Jorfi
- Environmental Technology Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
- Department of Environmental Health Engineering, School of Public Health, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Mehrnoosh Abtahi
- Department of Environmental Health Engineering, School of Public Health, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
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Wielsøe M, Kern P, Bonefeld-Jørgensen EC. Serum levels of environmental pollutants is a risk factor for breast cancer in Inuit: a case control study. Environ Health 2017; 16:56. [PMID: 28610584 PMCID: PMC5470290 DOI: 10.1186/s12940-017-0269-6] [Citation(s) in RCA: 75] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Accepted: 06/06/2017] [Indexed: 05/20/2023]
Abstract
BACKGROUND Environmental Persistent Organic Pollutants (POPs) can alter the hormone homeostasis by mimicking, interfering or blocking the function of hormones; moreover POPs are hypothesized to modify the risk of breast cancer. The association between POPs and breast cancer has been widely studied but the conclusions are inconsistent. The present study examined the associations between serum levels of POPs and breast cancer with focus on the highly exposed Greenlandic Inuit population. METHODS The study design was a case-control study of Inuit women from Greenland. The participants were asked to complete a questionnaire with information on reproductive history and lifestyle and to provide a blood sample. The sampling was carried out in two time periods (2000-2003 and 2011-2014). The serum levels were determined of 14 polychlorinated biphenyls (PCBs), 11 organochlorine pesticides (OCPs), 16 perfluoroalkyl acids (PFAAs), 1 polybrominated biphenyl (PBB), and 9 polybrominated diphenyl ethers (PBDEs). Independent samples t-test was used to compare differences between cases and controls and odds ratios (OR) adjusted for identified confounders were obtained using logistic regression. RESULTS The study population included 77 breast cancer cases and 84 controls. The majority of the measured compounds declined significantly from 2000 - 2003 to 2011-2014. However, for the perfluorinated carboxylic acids (PFCAs) an increase was observed. The serum levels were significantly higher in cases compared to controls for the majority of the compounds, and after adjusting for age the difference was maintained for ∑OCP, dichlorodiphenyldichloroethylene (p,p'-DDE), ∑PFAA, ∑perfluorinated sulfonic acids (PFSA), perfluorohexane sulfonate (PFHxS), and perfluorooctane sulfonate (PFOS). For the lipophilic POPs, high serum levels (middel/highest vs. lowest tertile) of ∑PCB, ∑estrgoenicPCB, PCB99, PCB138, PCB153, PCB170, PCB170, and PCB183 was associated with breast cancer risk; for the amphiphilic PFAAs, high serum levels of ∑PFAA, ∑PFCA, ∑PFSA, perfluorooctanoic acid (PFOA), perfluorononanoic acid (PFNA), perfluorodecanoic acid (PFDA), PFHxS, and PFOS were associated with breast cancer risk. CONCLUSION Significant, positive associations between breast cancer risk and PCBs and PFAAs were observed. The associations indicate that environmental exposure to POPs can be a factor increasing the risk for breast cancer in Inuit women.
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Affiliation(s)
- Maria Wielsøe
- Centre for Arctic Health & Molecular Epidemiology, Department of Public Health, Aarhus University, Aarhus, Denmark
| | - Peder Kern
- Department of Gynecology and Obstetrics, Dronning Ingrid’s Hospital, Nuuk, Greenland
| | - Eva Cecilie Bonefeld-Jørgensen
- Centre for Arctic Health & Molecular Epidemiology, Department of Public Health, Aarhus University, Aarhus, Denmark
- Institute for Nursing and Health Science, University of Greenland, Nuuk, Greenland
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15
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Ekenga CC, Parks CG, Sandler DP. Chemical exposures in the workplace and breast cancer risk: A prospective cohort study. Int J Cancer 2015; 137:1765-74. [PMID: 25846061 PMCID: PMC4503499 DOI: 10.1002/ijc.29545] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2014] [Revised: 03/20/2015] [Accepted: 03/24/2015] [Indexed: 11/08/2022]
Abstract
We investigated the relationship between workplace chemical exposures and breast cancer risk among women enrolled in the Sister Study, a prospective cohort study of US and Puerto Rican women. A total of 47,640 participants reported work outside of the home. Workplace exposure to eleven agents (acids, dyes or inks, gasoline or other petroleum products, glues or adhesives, lubricating oils, metals, paints, pesticides, soldering materials, solvents and stains or varnishes) was characterized based on self-reports of frequency and duration of use. Approximately 14% of the study population reported exposure to only one agent and 11% reported working with two or more of the 11 agents in their lifetime. Hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated for each agent, adjusting for established breast cancer risk factors. During follow-up, 1,966 cases of breast cancer were reported. Although there were no significant associations between ever use of the eleven agents evaluated and breast cancer risk, women with cumulative exposure to gasoline or petroleum products at or above the highest quartile cutoff had an elevated risk of total (HR: 2.3, 95%CI: 1.1-4.9) and invasive (HR: 2.5, 95%CI: 1.1-5.9) breast cancer compared with women in the lowest quartile group (ptrend = 0.03). Workplace exposure to soldering materials was associated with an increased risk of premenopausal breast cancer (HR = 1.8, 95% CI = 1.1-3.0). Findings support the need for further studies to elucidate the role of occupational chemicals in breast cancer etiology.
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Affiliation(s)
- Christine C Ekenga
- Epidemiology Branch, National Institute of Environmental Health Sciences, National Institutes of Health, Department of Health and Human Services, Research Triangle Park, NC
| | - Christine G Parks
- Epidemiology Branch, National Institute of Environmental Health Sciences, National Institutes of Health, Department of Health and Human Services, Research Triangle Park, NC
| | - Dale P Sandler
- Epidemiology Branch, National Institute of Environmental Health Sciences, National Institutes of Health, Department of Health and Human Services, Research Triangle Park, NC
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16
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Zoller HM, Fujishiro K, Mobley A, Lehman E. Perspectives on Communication and Participation in Research Notification Focus Groups. HEALTH COMMUNICATION 2014; 30:986-1000. [PMID: 25296941 DOI: 10.1080/10410236.2014.913221] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Researchers are slowly acknowledging an ethical obligation to inform research participants about study findings. Research notification may help participants become aware of and manage potential health risks. Scholars and practitioners have acknowledged the need for better understanding of this process. This study investigates transcripts of focus groups conducted to gauge audience reactions to notification materials that communicate scientific research findings about occupational exposures. Focus groups are a useful way to tailor notification materials to audiences, but we caution that transmission models of communication used in risk research may obscure the full value of focus groups. The emphasis on translating scientific communication into "lay" language may overlook how scientists and lay audiences can work together to bridge differences in language, experiences, goals, and orientations toward health. This study demonstrates limitations in scientific risk communication that minimize participation in communicating science. The conclusion provides instructive insights for strengthening the process of communicating science.
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17
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Hopf NB, Ruder AM, Succop P, Waters MA. Evaluation of cumulative PCB exposure estimated by a job exposure matrix versus PCB serum concentrations. ENVIRONMENTAL SCIENCE AND POLLUTION RESEARCH INTERNATIONAL 2014; 21:6314-23. [PMID: 23475397 PMCID: PMC4557726 DOI: 10.1007/s11356-013-1574-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/21/2012] [Accepted: 02/11/2013] [Indexed: 04/12/2023]
Abstract
Although polychlorinated biphenyls (PCBs) have been banned in many countries for more than three decades, exposures to PCBs continue to be of concern due to their long half-lives and carcinogenic effects. In National Institute for Occupational Safety and Health studies, we are using semiquantitative plant-specific job exposure matrices (JEMs) to estimate historical PCB exposures for workers (n = 24,865) exposed to PCBs from 1938 to 1978 at three capacitor manufacturing plants. A subcohort of these workers (n = 410) employed in two of these plants had serum PCB concentrations measured at up to four times between 1976 and 1989. Our objectives were to evaluate the strength of association between an individual worker's measured serum PCB levels and the same worker's cumulative exposure estimated through 1977 with the (1) JEM and (2) duration of employment, and to calculate the explained variance the JEM provides for serum PCB levels using (3) simple linear regression. Consistent strong and statistically significant associations were observed between the cumulative exposures estimated with the JEM and serum PCB concentrations for all years. The strength of association between duration of employment and serum PCBs was good for highly chlorinated (Aroclor 1254/HPCB) but not less chlorinated (Aroclor 1242/LPCB) PCBs. In the simple regression models, cumulative occupational exposure estimated using the JEMs explained 14-24% of the variance of the Aroclor 1242/LPCB and 22-39% for Aroclor 1254/HPCB serum concentrations. We regard the cumulative exposure estimated with the JEM as a better estimate of PCB body burdens than serum concentrations quantified as Aroclor 1242/LPCB and Aroclor 1254/HPCB.
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Affiliation(s)
- Nancy B. Hopf
- Institute for Work and Health (IST), Route de la Corniche 2, CH-1066 Epalinges-Lausanne, Switzerland
| | - Avima M. Ruder
- National Institute for Occupational Safety and Health (NIOSH), Centers for Disease Control and Prevention (CDC), 4676 Columbia Parkway, Cincinnati, OH 45226, USA
| | - Paul Succop
- Department of Environmental Health, University of Cincinnati, Kettering G29, PO Box 670056, Cincinnati, OH 45267, USA
| | - Martha A. Waters
- National Institute for Occupational Safety and Health (NIOSH), Centers for Disease Control and Prevention (CDC), 4676 Columbia Parkway, Cincinnati, OH 45226, USA
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18
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Ruder AM, Hein MJ, Hopf NB, Waters MA. Mortality among 24,865 workers exposed to polychlorinated biphenyls (PCBs) in three electrical capacitor manufacturing plants: a ten-year update. Int J Hyg Environ Health 2013; 217:176-87. [PMID: 23707056 DOI: 10.1016/j.ijheh.2013.04.006] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2012] [Revised: 03/21/2013] [Accepted: 04/16/2013] [Indexed: 11/16/2022]
Abstract
The objective of this analysis was to evaluate mortality among a cohort of 24,865 capacitor-manufacturing workers exposed to polychlorinated biphenyls (PCBs) at plants in Indiana, Massachusetts, and New York and followed for mortality through 2008. Cumulative PCB exposure was estimated using plant-specific job-exposure matrices. External comparisons to US and state-specific populations used standardized mortality ratios, adjusted for gender, race, age and calendar year. Among long-term workers employed 3 months or longer, within-cohort comparisons used standardized rate ratios and multivariable Poisson regression modeling. Through 2008, more than one million person-years at risk and 8749 deaths were accrued. Among long-term employees, all-cause and all-cancer mortality were not elevated; of the a priori outcomes assessed only melanoma mortality was elevated. Mortality was elevated for some outcomes of a priori interest among subgroups of long-term workers: all cancer, intestinal cancer and amyotrophic lateral sclerosis (women); melanoma (men); melanoma and brain and nervous system cancer (Indiana plant); and melanoma and multiple myeloma (New York plant). Standardized rates of stomach and uterine cancer and multiple myeloma mortality increased with estimated cumulative PCB exposure. Poisson regression modeling showed significant associations with estimated cumulative PCB exposure for prostate and stomach cancer mortality. For other outcomes of a priori interest--rectal, liver, ovarian, breast, and thyroid cancer, non-Hodgkin lymphoma, Alzheimer disease, and Parkinson disease--neither elevated mortality nor positive associations with PCB exposure were observed. Associations between estimated cumulative PCB exposure and stomach, uterine, and prostate cancer and myeloma mortality confirmed our previous positive findings.
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Affiliation(s)
- Avima M Ruder
- Division of Surveillance, Hazard Evaluations and Field Studies, National Institute for Occupational Safety and Health, Cincinnati, OH, USA.
| | - Misty J Hein
- Division of Surveillance, Hazard Evaluations and Field Studies, National Institute for Occupational Safety and Health, Cincinnati, OH, USA
| | - Nancy B Hopf
- Institute for Work and Health (IST), Rue du Bugnon 21, CH-1011 Lausanne, Switzerland
| | - Martha A Waters
- Division of Applied Research Technology, National Institute for Occupational Safety and Health, Cincinnati, OH, USA
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19
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Hopf NB, Ruder AM, Waters MA, Succop P. Concentration-dependent half-lives of polychlorinated biphenyl in sera from an occupational cohort. CHEMOSPHERE 2013; 91:172-8. [PMID: 23336921 DOI: 10.1016/j.chemosphere.2012.12.039] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/27/2012] [Revised: 12/04/2012] [Accepted: 12/15/2012] [Indexed: 05/20/2023]
Abstract
Polychlorinated biphenyls (PCBs) are carcinogenic. Estimating PCB half-life in the body based on levels in sera from exposed workers is complicated by the fact that occupational exposure to PCBs was to commercial PCB products (such as Aroclors 1242 and 1254) comprised of varying mixtures of PCB congeners. Half-lives were estimated using sera donated by 191 capacitor manufacturing plant workers in 1976 during PCB use (1946-1977), and post-exposure (1979, 1983, and 1988). Our aims were to: (1) determine the role of covariates such as gender on the half-life estimates, and (2) compare our results with other published half-life estimates based on exposed workers. All serum PCB levels were adjusted for PCB background levels. A linear spline model with a single knot was used to estimate two separate linear equations for the first two serum draws (Equation A) and the latter two (Equation B). Equation A gave half-life estimates of 1.74 years and 6.01 years for Aroclor 1242 and Aroclor 1254, respectively. Estimates were 21.83 years for Aroclor 1242 and 133.33 years for Aroclor 1254 using Equation B. High initial body burden was associated with rapid PCB elimination in workers at or shortly after the time they were occupationally exposed and slowed down considerably when the dose reached background PCB levels. These concentration-dependent half-life estimates had a transition point of 138.57 and 34.78 ppb for Aroclor 1242 and 1254, respectively. This result will help in understanding the toxicological and epidemiological impact of exposure to PCBs in humans.
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Affiliation(s)
- Nancy B Hopf
- Institute for Work and Health (IST), Rue du Bugnon 21, CH-1011 Lausanne, Switzerland.
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20
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Fujishiro K, Mobley A, Lehman E. Communicating risks after exposure has ended: former workers' perspectives on PCBs. New Solut 2013; 23:347-67. [PMID: 23896076 PMCID: PMC4552038 DOI: 10.2190/ns.23.2.i] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
While the importance of worker notification has been widely recognized, little attention has been paid to social and psychological contexts in which worker notification occurs, especially after the exposure has ended. This study explores workers' perspectives on exposure to polychlorinated biphenyls (PCBs), a toxic material whose manufacture in the United States ended in 1977. Four focus groups were conducted with former workers (n = 29) who were exposed to PCBs. Verbatim transcriptions were analyzed. Participants considered living in the PCB-contaminated community more dangerous than handling PCBs on the job. While they firmly believed that PCBs in the environment caused serious health problems, participants expressed doubts about the toxicity of PCBs in the workplace. Both beliefs undermined the value of worker notification about occupational exposure to PCBs. A long-term relationship between workers and researchers would provide opportunities to cultivate better understanding of the hazard and facilitate the process of worker notification.
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Affiliation(s)
- Kaori Fujishiro
- National Institute for Occupational Safety and Health (NIOSH), 4676 Columbia Pkwy (R-15) Cincinnati, OH 45226, USA.
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21
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Zani C, Toninelli G, Filisetti B, Donato F. Polychlorinated biphenyls and cancer: an epidemiological assessment. JOURNAL OF ENVIRONMENTAL SCIENCE AND HEALTH. PART C, ENVIRONMENTAL CARCINOGENESIS & ECOTOXICOLOGY REVIEWS 2013; 31:99-144. [PMID: 23672403 DOI: 10.1080/10590501.2013.782174] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
Polychlorinated biphenyls (PCBs) are toxic and persistent chemicals produced between 1930s and 1980s primarily for insulating fluids in heavy-duty electrical equipment in power plants, industries, and large buildings. They persist in the environment and accumulate in plants and animals, and have been classified as probable carcinogens to humans. We performed a systematic review and meta-analysis of scientific literature on the relationship between PCB exposure and human cancer. Two cohorts of people highly exposed to PCBs through ingestion of contaminated rice oil and some cohorts of occupationally exposed workers failed to show a definite increase in total cancer mortality and provided inconsistent results regarding single cancers. Several cohort and case-control studies investigated the association between PCBs and specific cancers, showing an association between PCB serum levels and non-Hodgkin lymphomas (NHL), with a summary odds ratio of 1.5 (95% confidence interval: 1.1-1.7), but no consistent results for the other cancer sites and types. In conclusion, this review provides some evidence for the role of PCBs in the development of NHL, although the inconsistent results of studies performed on highly polluted people and occupationally exposed workers do not allow a firm conclusion to be drawn.
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Affiliation(s)
- Claudia Zani
- Institute of Hygiene, Epidemiology and Public Health, University of Brescia, Italy.
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22
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Stewart BW. Priorities for cancer prevention: lifestyle choices versus unavoidable exposures. Lancet Oncol 2012; 13:e126-33. [DOI: 10.1016/s1470-2045(11)70221-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Recio-Vega R, Velazco-Rodriguez V, Ocampo-Gómez G, Hernandez-Gonzalez S, Ruiz-Flores P, Lopez-Marquez F. Serum levels of polychlorinated biphenyls in Mexican women and breast cancer risk. J Appl Toxicol 2011; 31:270-8. [DOI: 10.1002/jat.1672] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2010] [Revised: 12/15/2010] [Accepted: 01/19/2011] [Indexed: 11/09/2022]
Affiliation(s)
- Rogelio Recio-Vega
- Centro de Investigación Biomédica, Facultad de Medicina, Unidad Torreón; Universidad Autónoma de Coahuila; México
| | | | - Guadalupe Ocampo-Gómez
- Centro de Investigación Biomédica, Facultad de Medicina, Unidad Torreón; Universidad Autónoma de Coahuila; México
| | - Sandra Hernandez-Gonzalez
- Centro de Investigación Biomédica, Facultad de Medicina, Unidad Torreón; Universidad Autónoma de Coahuila; México
| | - Pablo Ruiz-Flores
- Centro de Investigación Biomédica, Facultad de Medicina, Unidad Torreón; Universidad Autónoma de Coahuila; México
| | - Francisco Lopez-Marquez
- Centro de Investigación Biomédica, Facultad de Medicina, Unidad Torreón; Universidad Autónoma de Coahuila; México
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Rocheleau CM, Bertke SJ, Deddens JA, Ruder AM, Lawson CC, Waters MA, Hopf NB, Riggs MA, Whelan EA. Maternal exposure to polychlorinated biphenyls and the secondary sex ratio: an occupational cohort study. Environ Health 2011; 10:20. [PMID: 21418576 PMCID: PMC3070618 DOI: 10.1186/1476-069x-10-20] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2010] [Accepted: 03/18/2011] [Indexed: 05/29/2023]
Abstract
BACKGROUND Though commercial production of polychlorinated biphenyls was banned in the United States in 1977, exposure continues due to their environmental persistence. Several studies have examined the association between environmental polychlorinated biphenyl exposure and modulations of the secondary sex ratio, with conflicting results. OBJECTIVE Our objective was to evaluate the association between maternal preconceptional occupational polychlorinated biphenyl exposure and the secondary sex ratio. METHODS We examined primipara singleton births of 2595 women, who worked in three capacitor plants at least one year during the period polychlorinated biphenyls were used. Cumulative estimated maternal occupational polychlorinated biphenyl exposure at the time of the infant's conception was calculated from plant-specific job-exposure matrices. A logistic regression analysis was used to evaluate the association between maternal polychlorinated biphenyl exposure and male sex at birth (yes/no). RESULTS Maternal body mass index at age 20, smoking status, and race did not vary between those occupationally exposed and those unexposed before the child's conception. Polychlorinated biphenyl-exposed mothers were, however, more likely to have used oral contraceptives and to have been older at the birth of their first child than non-occupationally exposed women. Among 1506 infants liveborn to polychlorinated biphenyl-exposed primiparous women, 49.8% were male; compared to 49.9% among those not exposed (n = 1089). Multivariate analyses controlling for mother's age and year of birth found no significant association between the odds of a male birth and mother's cumulative estimated polychlorinated biphenyl exposure to time of conception. CONCLUSIONS Based on these data, we find no evidence of altered sex ratio among children born to primiparous polychlorinated biphenyl-exposed female workers.
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Affiliation(s)
- Carissa M Rocheleau
- Division of Surveillance, Hazard Evaluations and Field Studies; Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health; Cincinnati, Ohio, USA
| | - Stephen J Bertke
- Division of Surveillance, Hazard Evaluations and Field Studies; Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health; Cincinnati, Ohio, USA
- Department of Mathematical Science, University of Cincinnati, Cincinnati, Ohio, USA
| | - James A Deddens
- Division of Surveillance, Hazard Evaluations and Field Studies; Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health; Cincinnati, Ohio, USA
- Department of Mathematical Science, University of Cincinnati, Cincinnati, Ohio, USA
| | - Avima M Ruder
- Division of Surveillance, Hazard Evaluations and Field Studies; Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health; Cincinnati, Ohio, USA
| | - Christina C Lawson
- Division of Surveillance, Hazard Evaluations and Field Studies; Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health; Cincinnati, Ohio, USA
| | - Martha A Waters
- Division of Surveillance, Hazard Evaluations and Field Studies; Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health; Cincinnati, Ohio, USA
- Division of Applied Research and Technology; Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health; Cincinnati, Ohio, USA
| | - Nancy B Hopf
- Division of Surveillance, Hazard Evaluations and Field Studies; Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health; Cincinnati, Ohio, USA
- Institut universitaire romand de Santé au Travail/Institute for Work and Health (IST), Lausanne, Switzerland
| | - Margaret A Riggs
- Division of Surveillance, Hazard Evaluations and Field Studies; Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health; Cincinnati, Ohio, USA
- Coordinating Office for Terrorism, Preparedness and Emergency Response (Kentucky Department for Public Health); Centers for Disease Control and Prevention; Frankfort, Kentucky, USA
| | - Elizabeth A Whelan
- Division of Surveillance, Hazard Evaluations and Field Studies; Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health; Cincinnati, Ohio, USA
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Villeneuve S, Cyr D, Lynge E, Orsi L, Sabroe S, Merletti F, Gorini G, Morales-Suarez-Varela M, Ahrens W, Baumgardt-Elms C, Kaerlev L, Eriksson M, Hardell L, Févotte J, Guénel P. Occupation and occupational exposure to endocrine disrupting chemicals in male breast cancer: a case-control study in Europe. Occup Environ Med 2010; 67:837-44. [PMID: 20798010 DOI: 10.1136/oem.2009.052175] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVES Male breast cancer is a rare disease of largely unknown aetiology. In addition to genetic and hormone-related risk factors, a large number of environmental chemicals are suspected of playing a role in breast cancer. The identification of occupations or occupational exposures associated with an increased incidence of breast cancer in men may help to identify mammary carcinogens in the environment. METHODS Occupational risk factors for male breast cancer were investigated in a multi-centre case-control study conducted in eight European countries which included 104 cases and 1901 controls. Lifetime work history was obtained during in-person interviews. Occupational exposures to endocrine disrupting chemicals (alkylphenolic compounds, phthalates, polychlorinated biphenyls and dioxins) were assessed on a case-by-case basis using expert judgement. RESULTS Male breast cancer incidence was particularly increased in motor vehicle mechanics (OR 2.1, 95% CI 1.0 to 4.4) with a dose-effect relationship with duration of employment. It was also increased in paper makers and painters, forestry and logging workers, health and social workers, and furniture manufacture workers. The OR for exposure to alkylphenolic compounds above the median was 3.8 (95% CI 1.5 to 9.5). This association persisted after adjustment for occupational exposures to other environmental oestrogens. CONCLUSION These findings suggest that some environmental chemicals are possible mammary carcinogens. Petrol, organic petroleum solvents or polycyclic aromatic hydrocarbons are suspect because of the consistent elevated risk of male breast cancer observed in motor vehicle mechanics. Endocrine disruptors such as alkylphenolic compounds may play a role in breast cancer.
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Affiliation(s)
- Sara Villeneuve
- CESP-INSERM (National Institute of Health and Medical Research), Villejuif, France
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Hormonal exposures and the risk of uveal melanoma. Cancer Causes Control 2010; 21:1625-34. [PMID: 20524054 DOI: 10.1007/s10552-010-9591-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2009] [Accepted: 05/19/2010] [Indexed: 10/19/2022]
Abstract
OBJECTIVES Several studies suggest that hormonal mechanisms may be associated with the development of uveal melanoma. Therefore, the association between the risk of uveal melanoma and exposure to hormonal exposures was investigated in a case-control study from nine European countries. METHODS Incident cases of uveal melanoma were frequency-matched to population and hospital controls by country, age, and sex. Female subjects were asked about their reproductive history, use of menopausal hormone replacement therapy and oral contraceptives. Among men, occupational handling of oils while working with transformers or capacitors which contain polychlorinated biphenyls (PCB) was solicited. Unconditional logistic regression analyses were calculated, adjusting for several potential confounders. Analyses were stratified by sex. RESULTS Two hundred and ninety-three cases (165 men, 128 women) and 3,198 control subjects (2,121 men, 1,077 women) were interviewed. Among women, no associations were observed with hormonal status variables, intake of hormonal therapy or intake of oral contraceptives. Men showed an increased risk with occupational exposure to transformer/capacitor oils (OR = 2.74; Bonferroni-corrected 99.3% CI 1.07-7.02). However, these results were based on few exposed subjects only. CONCLUSION The results of this study do not support the hypothesis of a hormonal influence in the carcinogenesis of uveal melanoma. Our finding of a potentially increased risk with PCB-containing oils requires further research.
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Hopf NB, Waters MA, Ruder AM. Cumulative exposure estimates for polychlorinated biphenyls using a job-exposure matrix. CHEMOSPHERE 2009; 76:185-93. [PMID: 19394668 DOI: 10.1016/j.chemosphere.2009.03.058] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/30/2008] [Revised: 02/20/2009] [Accepted: 03/24/2009] [Indexed: 05/04/2023]
Abstract
UNLABELLED PCB exposure has been associated with increased risk for cancer, neurological disease, and for birth defects in children exposed in utero. Because of the long half-lives of PCB congeners, they remain a public health problem in the United States 30 years after being banned. Workers (n=3569) at an Indiana capacitor manufacturing plant were exposed to polychlorinated biphenyls (PCBs) from 1957 to 1977. The purpose of this work was to develop a period-specific job-exposure matrix (JEM) for a follow-up epidemiologic study investigating the increased risks for cancer previously observed in the cohort. METHODS We used eight exposure determinants to estimate PCB exposures systematically. Work history, job description, capacitor production factors, PCB usage trends, and air sample data were used to develop the JEM in four steps: (1) all job titles (n=884) were assessed for exposure determinants, (2) jobs with similar exposure determinants were grouped, (3) for each job exposure category, exposure intensity (high-medium-low-background) and frequency (continuous-intermittent) were qualitatively rated separately for inhalation and dermal exposure, and (4) for each job exposure category, the product of intensity (based on air sampling data) and frequency (fraction of day exposed) was calculated. The JEM was then modified for two eras of different PCB exposure conditions. RESULTS The resulting JEM consists of inhalation and dermal exposure values for 19 job exposure categories. CONCLUSION The JEM showed an exposure-response trend associated with increased brain cancer mortality in the epidemiologic study.
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Affiliation(s)
- Nancy Brenna Hopf
- National Institute for Occupational Safety and Health (NIOSH), Centers for Disease Control and Prevention, Cincinnati, OH, USA.
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