Wireless phone use in childhood and adolescence and neuroepithelial brain tumours: Results from the international MOBI-Kids study

In recent decades, the possibility that use of mobile communicating devices, particularly wireless (mobile and cordless) phones, may increase brain tumour risk, has been a concern, particularly given the considerable increase in their use by young people. MOBI-Kids, a 14-country (Australia, Austria, Canada, France, Germany, Greece, India, Israel, Italy, Japan, Korea, the Netherlands, New Zealand, Spain) case-control study, was conducted to evaluate whether wireless phone use (and particularly resulting exposure to radiofrequency (RF) and extremely low frequency (ELF) electromagnetic fields (EMF)) increases risk of brain tumours in young people. Between 2010 and 2015, the study recruited 899 people with brain tumours aged 10 to 24 years old and 1,910 controls (operated for appendicitis) matched to the cases on date of diagnosis, study region and age. Participation rates were 72% for cases and 54% for controls. The mean ages of cases and controls were 16.5 and 16.6 years, respectively; 57% were males. The vast majority of study participants were wireless phones users, even in the youngest age group, and the study included substantial numbers of long-term (over 10 years) users: 22% overall, 51% in the 20-24-year-olds. Most tumours were of the neuroepithelial type (NBT; n = 671), mainly glioma. The odds ratios (OR) of NBT appeared to decrease with increasing time since start of use of wireless phones, cumulative number of calls and cumulative call time, particularly in the 15-19 years old age group. A decreasing trend in ORs was also observed with increasing estimated cumulative RF specific energy and ELF induced current density at the location of the tumour. Further analyses suggest that the large number of ORs below 1 in this study is unlikely to represent an unknown causal preventive effect of mobile phone exposure: they can be at least partially explained by differential recall by proxies and prodromal symptoms affecting phone use before diagnosis of the cases. We cannot rule out, however, residual confounding from sources we did not measure. Overall, our study provides no evidence of a causal association between wireless phone use and brain tumours in young people. However, the sources of bias summarised above prevent us from ruling out a small increased risk.

Cancer cluster and citizen alarms: epidemiological and statistical approaches

Background

Respond to alarms for possible cancer cluster is a public health problem, but the management of these alarms is difficult and sometime conflictual.

Methods

We reviewed the guidelines on the management of disease clusters developed in various countries and the approaches used in previous disease cluster episodes in Tuscany. Statistical approaches for cluster detection were also reviewed. We performed a clustering analysis (spatio or spatio-temporal when appropriate) on childhood leukemia using data from Tuscany Cancer Registry (RTT). We used spatial hierarchical Bayesian model on aggregate data at municipality level. We performed test for general clustering and cluster detection on individual data.

Results

More than 100 tests for clustering analysis has been identified in the literature. Bayesian analysis on aggregate data did not show areas at higher risk with the exception of the city of Florence for childhood cancer among males. We did not found clusters for leukemia. In previous studies on disease clusters in Tuscany, most investigations have been started from community concerns and in the majority of situations a multidisciplinary approach was used. In some case an increase of incidence rate was observed, but rarely specific cluster cancer tests were used.

Conclusions

Hierarchical Bayesian models to aggregate data provided useful to identify long range geographical patterns while clustering analysis on individual data is a useful tool for small scale patterns. Both represent important tools for epidemiological surveillance studies particularly on childhood cancer. The best test for all situations doesn't exist, but the choice is determined by the type of question being asked from the data, by different situations and by different approaches. The Tuscany cancer clusters survey and the review of the guidelines on the management of clusters developed in different countries, give us the opportunity to formulate some suggestions for the health agencies.

Key messages

Respond to alarms for cluster of cancer and suggest recommendations for epidemiological and statistical standardized approaches is a public health issue. Tuscany cancer clusters survey and the review of the guidelines on the management of clusters developed in different countries, give the opportunity to formulate some suggestions for health agencies.

Risk of nasopharyngeal cancer in productive sectors and formaldehyde exposure in bakeries industry

Background

The International Agency for Research on Cancer evaluated formaldehyde (F) as carcinogenic for human in association with Nasopharyngeal Cancer (NPC). Occupational exposure to F occurs in many industrial sectors also in those non-traditional. For example in Tuscany F was detected in a bakery where a NPC case had ever worked.

Methods

In this study a) A case control approach (OCCAM) was used for monitoring occupational risks based on current information sources. Three Italian Regional Operating Centres, collected NPC cases from cancer registries and/or hospital discharge records. Controls were randomly sampled from the regional health service population data. Occupational histories were available through record linkage with the social security pension database (INPS). Study results were reported by industrial sectors, area and gender. b) A specific study on F exposure was conducted in bakeries and pastry industry carrying out measurements to determine the concentration of F in specific tasks and positions.

Results

717 cases linked with INPS database. Increased ORs for several industrial sectors such as iron and steel, wood and plastic were observed. In two regions also health and veterinary services and hairdressers were at increased risk, but based on few cases of exposed workers. In the non traditional sector of bakeries and pastry industries, where workplaces were monitored, high levels of F in personal air samplings were found, in particular in processes that involve a strong leavening.

Conclusions

Many productive sectors, in which F exposure could occurred, were observed to be at higher risk. The measurements performed in the non traditional sector monitored, confirmed the F exposure in some phases of the work process. With this study we contributed to increased knowledge on the risk of NPC within the monitoring system of occupational risks, and to deepen exposure to F in a non traditional productive sector such as bakeries and pastry industries.

Key messages

The epidemiological method used (OCCAM) in this study provides further information on the role of occupational exposure in the development of nasopharyngeal cancer. The measurements performed in the bakeries and pastry industries provide new additional information on the exposure to formaldehyde in some work process phases of a non-traditional productive sector.

Occupational exposure to trichloroethylene and risk of non-Hodgkin lymphoma and its major subtypes: a pooled InterLymph [correction of IinterLlymph] analysis

OBJECTIVES

We evaluated the association between occupational exposure to trichloroethylene (TCE) and risk of non-Hodgkin lymphoma (NHL) in a pooled analysis of four international case-control studies.

METHODS

Overall, the pooled study population included 3788 NHL cases and 4279 controls. Risk of NHL and its major subtypes associated with TCE exposure was calculated with unconditional logistic regression and polytomous regression analysis, adjusting by age, gender and study.

RESULTS

Risk of follicular lymphoma (FL), but not NHL overall or other subtypes, increased by probability (p=0.02) and intensity level (p=0.04), and with the combined analysis of four exposure metrics assumed as independent (p=0.004). After restricting the analysis to the most likely exposed study subjects, risk of NHL overall, FL and chronic lymphocytic leukaemia (CLL) were elevated and increased by duration of exposure (p=0.009, p=0.04 and p=0.01, respectively) and with the combined analysis of duration, frequency and intensity of exposure (p=0.004, p=0.015 and p=0.005, respectively). Although based on small numbers of exposed, risk of all the major NHL subtypes, namely diffuse large B-cell lymphoma, FL and CLL, showed increases in risk ranging 2-3.2-fold in the highest category of exposure intensity. No significant heterogeneity in risk was detected by major NHL subtypes or by study.

CONCLUSIONS

Our pooled analysis apparently supports the hypothesis of an increase in risk of specific NHL subtypes associated with occupational exposure to TCE.

Cigarette smoking and risk of Hodgkin lymphoma and its subtypes: a pooled analysis from the International Lymphoma Epidemiology Consortium (InterLymph)

BACKGROUND

The etiology of Hodgkin lymphoma (HL) remains incompletely characterized. Studies of the association between smoking and HL have yielded ambiguous results, possibly due to differences between HL subtypes.

PATIENTS AND METHODS

Through the InterLymph Consortium, 12 case-control studies regarding cigarette smoking and HL were identified. Pooled analyses on the association between smoking and HL stratified by tumor histology and Epstein-Barr virus (EBV) status were conducted using random effects models adjusted for confounders. Analyses included 3335 HL cases and 14 278 controls.

RESULTS

Overall, 54.5% of cases and 57.4% of controls were ever cigarette smokers. Compared with never smokers, ever smokers had an odds ratio (OR) of HL of 1.10 [95% confidence interval (CI) 1.01-1.21]. This increased risk reflected associations with mixed cellularity cHL (OR = 1.60, 95% CI 1.29-1.99) and EBV-positive cHL (OR = 1.81, 95% CI 1.27-2.56) among current smokers, whereas risk of nodular sclerosis (OR = 1.09, 95% CI 0.90-1.32) and EBV-negative HL (OR = 1.02, 95% CI 0.72-1.44) was not increased.

CONCLUSION

These results support the notion of etiologic heterogeneity between HL subtypes, highlighting the need for HL stratification in future studies. Even if not relevant to all subtypes, our study emphasizes that cigarette smoking should be added to the few modifiable HL risk factors identified.

Alcohol consumption and risk of Hodgkin's lymphoma and multiple myeloma: a multicentre case-control study

BACKGROUND

Few studies have analysed the association between alcohol intake and Hodgkin's lymphoma (HL) or multiple myeloma (MM) risks.

MATERIALS AND METHODS

A multicentre population-based case-control study of 363 HL, 270 MM cases, and 1771 controls offered the opportunity to evaluate the relationship between alcohol and HL/MM risks. Unconditional logistic regression was carried out to estimate odds ratios (ORs) and 95% confidence intervals (CIs), associated with alcohol intake (servings per week, grams per day of ethanol intake) or duration of exposure (year).

RESULTS

For HL, considering nonsmokers only, ever drinkers had a significantly decreased risk than never drinkers (OR=0.46). Significantly lower risks in all levels of total alcohol intake were also detected, considering servings per week (OR for one to four servings per week=0.51, 95% CI 0.32-0.82; OR for five to nine servings per week=0.39, 95% CI 0.21-0.73; OR for 10-19 servings per week=0.26, 95% CI 0.12-0.54; OR for >or=20 servings per week=0.34, 95% CI 0.15-0.79) and grams per day of ethanol intake (OR for 0.1-9.0 g/day=0.45, 95% CI 0.27-0.74; OR for 9.1-17.9 g/day=0.52, 95% CI 0.30-0.90; OR for 18.0-31.7 g/day=0.27, 95% CI 0.13-0.57; OR for >31.7 g/day=0.35, 95% CI 0.15-0.79). In the analysis for ever-smoking HL cases and controls, ever drinkers had the same risk as never drinkers. For MM, ever drinkers had a non-significantly decreased risk than non-drinkers (OR=0.74), and ORs in almost all consumption levels were not significant (OR for 0.1-9.0 g/day=0.93; OR for 9.1-17.9 g/day=0.82; OR for 18.0-31.7 g/day=0.47; 95% CI 0.28-0.81; OR for >31.7 g/day=0.68). For HL and MM, the beverage type did not affect the risk significantly, and no consistent dose-response relationships were found, considering intensity or duration of alcohol consumption.

CONCLUSIONS

Our study indicates a protective effect of alcohol consumption for nonsmoking HL cases.

Cigarette smoking and alcohol consumption as determinants of survival in non-Hodgkin's lymphoma: a population-based study

BACKGROUND

The risk of non-Hodgkin's lymphoma (NHL) seems to be enhanced by cigarette smoking and lowered by alcohol drinking.

PATIENTS AND METHODS

To assess whether cigarette smoking and alcohol drinking affect NHL survival, a population-based prospective study on 1138 Italian patients, diagnosed in 1991-1993, followed-up until 2002, was carried out. At diagnosis, clinical and socio-demographic data were recorded and lifestyle habits were assessed through a validated questionnaire. Survival analysis was performed with Kaplan-Meier methods. Hazard ratios (HR) were estimated by Cox regression.

RESULTS

The mean follow-up was 6.6 years (standard deviation (SD) 4.3). The mean survival time was 7.56 years (SD 0.155). At both univariate and multivariate analysis heavy cigarette smoking and alcohol drinking were associated with poor survival. Compared with those with a lower cumulative exposure to tobacco smoking, those who had smoked>31 pack-years had a worse survival (HR=1.60, 95%CI=1.18-2.18). Drinkers had a higher risk of death compared with non-drinkers (HR=1.41, 95%CI=1.10-1.81). Considering only those who had NHL as cause of death, the HR for the higher category of pack-years smoked, compared with the lowest, was 1.63 (95% CI=1.15-2.33) and for drinkers, compared with non-drinkers, it was 1.33 (95% CI=1.01-1.80).

CONCLUSIONS

cigarette smoking and alcohol drinking may influence NHL survival.

[Epithelial naso-sinusal cancer incidence and the role of work in 100 cases diagnosed in the Province of Brescia (northern Italy), in the period 1978-2002]

BACKGROUND

Naso-sinusal cancers (NSC) cover a group of rare tumours in Italy for which the role of occupational risk has been established. The systematic survey of NSC in the province of Brescia made it possible to analyse the jobs of the cases occurring in the area.

OBJECTIVES

The aims of the research were: estimation of epithelial NSC incidence both in the general population and among wood and leather workers, description of the frequency and type of occupational exposure to substances or manufacturing processes.

METHODS

The epithelial type cases were obtained from the Naso-sinusal Cancer Register (population-based) operating in the Province of Brescia since 1994. Work histories were obtained via a standardized questionnaire.

RESULTS

The annual incidence ofepithelial NSC (for 100,000) in the entire population (1,090,000 inhabitants, ISTAT census 1991) from 1993 to 1997 and from 1998 to 2002 was nearly the same, 0.82 and 0.90 for men, 0.37 and 0.37 for women, respectively. The nasal cavity was the most affected anatomic site (45%) and squamous cell carcinoma was the most frequent histotype (44%) among the first 100 cases whose case histories were appropriate; in the ethmoidal sinus adenocarcinoma represented 62% of the cases; 25% of all cases were exposed to occupational carcinogens (list A) and particularly to wood dust (17%), even if only of softwood species (30%), and leather dusts (7%) especially in the shoe repair. The average latency period was 47 years (SD 7.4) and 44 years (SD 5.6) respectively; 71% of these epithelial NSC cases involved the ethmoid and 85% were adenocarcinomas. Only 1% of the cases was exposed to chromium and nickel and occurred in galvanization processes. Among the exposures to occupational risks with limited epidemiological evidence (list B) there was one case exposed to formaldehyde and 42 cases occurring in the building, agricultural, metallurgic and textile sectors. Thus all the exposures to occupational risks, both certain and probable (lists A and B) reached 84% among men and 17% among women. Epithelial NSC annual incidence rates (for 100,000) estimated among the wood and leather workers for the period 1985-2002 were 13 and 6.5 respectively.

CONCLUSION

The results confirm the meaning of sentinel event for these tumours in occupational health and justify maintaining an active surveillance programme for the cases occurring in the area.

Delayed infection, late tonsillectomy or adenoidectomy and adult leukaemia: a case-control study

In a population-based case-control study among adults in Italy, of 261 lymphoid and 313 myeloid leukaemias and 1718 controls, a later age at adenoidectomy and tonsillectomy (after age 10 years) increased considerably the risk of lymphocytic (but not myeloid) leukaemia (odds ratio 4.2, 95% confidence interval 1.1-16.2). We propose that late infection is a proliferative stimulus for B-cells.

Smoking and hematolymphopoietic malignancies

OBJECTIVE

Tobacco use is the most prominent cause of respiratory cancers. Little is known, however, about the influence of smoking on hematolymphopoietic malignancies. To evaluate this relation, a population-based case-control study was carried out in 12 areas of Italy.

METHODS

Detailed interviews on tobacco smoking habits were administered to 1450 non-Hodgkin's lymphoma (NHL), 365 Hodgkin's disease (HD), 270 multiple myeloma (MM), and 649 leukemia (LEU) patients occurring from 1990 to 1993, and 1779 population controls.

RESULTS

We found a slightly increased risk for NHL in smokers (odds ratio 1.2, 95% confidence interval 1.0-1.4 for ever smokers), but a consistent positive association was shown only for follicular NHL. In this subtype, a significant excess risk was observed for ever versus never smokers, after adjustment for gender, age, geographic residence, education, and respondent (OR = 1.8, 95%, CI 1.3-2.7), with a positive exposure-response gradient for smoking duration (p < 0.01). The risk for follicular NHL was significantly elevated only among women, with ever smokers showing OR = 2.3 (CI 1.4-3.8), while for men we found OR = 1.3 (CI 0.69-2.3). No major differences were shown according to age. Female subjects also showed significant positive exposure-response trends for duration.

CONCLUSION

Cigarette smoking could be a risk factor for follicular NHL among women. For HD, MM, or LEU, no clear association was observed.

A multicenter case-control study in Italy on hematolymphopoietic neoplasms and occupation

We conducted a population-based, case-control study on hematolymphopoietic malignancies in 12 areas in Italy to investigate associations between different hematolymphopoietic malignancies and exposure to solvents and pesticides. We collected all incident cases 20-74 years of age from 12 areas, with a combined population of approximately 7 million residents. The control group was formed by a random sample of the study population. Data presented in this paper refer to 2,737 interviewed cases of 3,357 eligible cases and to 1,779 of 2,391 eligible controls. We analyzed risks associated with occupation using job-title information to evaluate disease pattern according to job category. An earlier publication presented results for women; here, we report the findings for men and discuss the overall patterns in both genders. The most consistent overall finding was an approximate doubling in relative risk for all four types of malignancies among male managers and related occupations. Several additional occupations were associated with elevated risk of one or more malignancies among men. These included cooks, waiters, and bartenders, and building caretakers and cleaners, for non-Hodgkin's lymphoma; textile workers and machinery fitters for Hodgkin's lymphoma; metal processors, material handlers, rubber workers, and painters for leukemia; and hairdressers, metal processors, tailors, electrical workers, and plumbers for multiple myeloma. The finding of increased risk of non-Hodgkin's lymphoma among both male and female cooks, waiters, and bartenders has not been previously reported; nor has the elevated risk of leukemia among material handlers. Among people engaged in agriculture, those employed as tractor drivers and as "orchard, vineyard, and related tree and shrub workers" appeared to be at increased risk for hematolymphopoietic malignancies.

Delayed infection, family size and malignant lymphomas

BACKGROUND

The annual incidence of non-Hodgkin's lymphomas (NHL) is increasing by 3%-4% in different parts of the developed world. Excesses of NHL have been observed in populations exposed to immunosuppressants and to HIV, but these causes do not explain the increasing trends. It is suggested that delayed infection could explain NHL trends, through an impairment of the Th1/Th2 lymphocyte patterns.

METHODS

In a population-based study on 1388 patients with NHL, 354 with Hodgkin's disease (HD) and 1718 healthy controls, the age of first occurrence of bacterial and viral diseases was investigated. Clinical records were perused in one centre to check the anamnestic data.

FINDINGS

The age of occurrence of bacterial and viral diseases was significantly higher among NHL patients than in the controls. The association between later age at first bacterial or viral disease was limited to small families (OR= 1.95; 95% confidence intervals 1.26, 3.00, for age 4-8 at first infection; OR=1.91; 1.19, 3.06, for age 9+, compared with less than 4). The association was more obvious for bacterial diseases (possibly for the lower degree of misclassification). High grade lymphomas showed the strongest association. The later age of occurrence of bacterial or viral diseases in NHL patients is consistent with a higher incidence of lymphomas observed in higher social groups. No clear association was found between HD and age at first bacterial or viral diseases.

INTERPRETATION

It is proposed that delayed infection could explain the increasing NHL trends, through an impairment of the Th1/Th2 lymphocyte patterns. The model of delayed infection has been proposed also to explain increasing prevalence rates of asthma.

Haematopoietic cancer and medical history: a multicentre case control study

BACKGROUND

Viruses (such as Epstein-Barr virus) and pathological conditions (mainly involving immunosuppression) have been shown to increase the risk of haematolymphopoietic malignancies. Other associations (diabetes, tonsillectomy, autoimmune diseases) have been inconsistently reported.

METHODS

The association between different haematolymphopoietic malignancies (lymphomas, myelomas and leukaemias) and the previous medical history has been studied in a population-based case-control investigation conducted in Italy, based on face to face interviews to 2669 cases and 1718 population controls (refusal rates 10% and 19%, respectively). Controls were a random sample of the general population.

RESULTS

Previous findings were confirmed concerning the association between non-Hodgkin's lymphoma (NHL) and lupus erythematosus (odds ratio, OR=8.4; 95% CI 1. 6, 45), tuberculosis (OR=1.6; 1.05, 2.5) and hepatitis (1.8; 1.4, 2. 3). An association was found also between NHL and maternal (OR=2.8; 1.1, 6.9) or paternal tuberculosis (OR=1.7; 0.7, 3.9). Odds ratios of 4.0 (1.4, 11.8) and 4.4 (1.1, 6.6) were detected for the association between NHL and Hodgkin's disease, respectively, and previous infectious mononucleosis, but recall bias cannot be ruled out. No association was found with diabetes, tonsillectomy and adenoidectomy. An association with malaria at young age and "low grade" lymphatic malignancies is suggested. One interesting finding was the observation of four cases of poliomyelitis among NHL patients, one among Hodgkin's disease and one among myeloid leukaemia patients, compared with none among the controls (Fisher's exact test for NHL and Hodgkin's disease, p= 0.03, one tail).

CONCLUSIONS

Some of these findings are confirmatory of previous evidence. Other observations, such as the putative role of the polio virus and of malaria are new. A unifying theory on the mechanisms by which previous medical history may increase the risk of haematolymphopoietic malignancies is still lacking.

Hematopoietic cancer and peptic ulcer: a multicenter case-control study

Helicobacter pylori has been suggested as a cause of gastric carcinoma and gastric non-Hodgkin's lymphoma (NHL). In a previous cohort study, a relative risk of six for gastric NHL was reported among subjects who tested positive for anti-H.pylori antibodies. The association between peptic ulcer and NHL has been studied in a population-based case-control investigation on hemato-lymphopoietic malignancies in Italy, based on face-to-face interviews to 2671 cases and 1718 controls (refusal rates 10 and 19%, respectively). Subjects who reported a diagnosis of peptic ulcer had a relative risk of 5.6 [95% confidence interval (CI) 3.8-8.0] for gastric NHL, whereas the estimate for non-gastric NHL was 1.3 (1.0-1.6). The association with recent diagnosis of ulcer was stronger, but the odds ratio (OR) was as high as 2.1 (95% CI 1.1-4.2) after >/=20 years since such diagnosis. After exclusion of the last 2 years before the diagnosis of NHL, and of ulcers diagnosed before 1978 (when gastroscopy became common in Italy), the OR was still 5.3 (95% CI 3.0-9.2). We found a strong effect modification by educational level, with ORs for ulcer more elevated in higher social groups. Gender was an effect modifier (OR = 4.1 in males, 9.2 in females; P = 0.03 for heterogeneity). The association with other gastrointestinal pathologies was much lower and statistically not significant. Almost all gastric lymphomas were B-cell NHLs of intermediate grade according to the working formulation; the majority belonged to the mucosa-associated lymphoid tissue (MALT) type. The association with ulcer was much stronger among MALT lymphomas, but only for recent ulcer diagnoses (2-10 years). Our study shows an increased risk for gastric NHL, very similar to the estimate reported in a previous cohort study. The risk was higher among more educated subjects.

Occupational, environmental, and life-style factors associated with the risk of hematolymphopoietic malignancies in women

BACKGROUND

The etiology of lymphomas, leukemias, and multiple myeloma is still largely unknown. The known risk factors (ionizing radiation, solvent exposure, pesticide exposure, immunosuppression) explain only a small proportion of the cases that occur.

METHODS

We conducted a multicenter population-based case-control study on hematolymphopoietic malignancies in Italy and interviewed 2,011 women (1,183 cases and 828 controls).

RESULTS

There was a suggestion of a positive association between smoking and the risk of non-Hodgkin's lymphoma + chronic lymphocytic leukemia. A slight increased risk of leukemias was observed among women using permanent hair dye. Housewives were at increased risk for leukemia and multiple myeloma. The risk of non-Hodgkin's lymphomas + chronic lymphocytic leukemia, leukemias, multiple myeloma, and Hodgkin's disease increased among women employed as hairdressers and textile workers. Teachers were at increased risk for non-Hodgkin's lymphomas + chronic lymphocytic leukemia, leukemias, and Hodgkin's disease.

CONCLUSIONS

These results confirm previous associations and may provide additional clues to some determinants of hematolymphopoietic malignancies in women.

Occupational cancer in Italy

This article is a discussion of occupational cancer in Italy. The introduction provides the necessary context of Italian industrialization and occupational health regulation. This is followed by a review of Italian epidemiologic studies of occupational cancer risks considered in terms of relative measures of risk and attributable risk of carcinogenic agents or exposure circumstances. We attempt to establish the number of workers exposed to carcinogens in Italy and the intensity of their exposures. Finally, the Italian system of compensation for occupational cancer is discussed. Several cohort and case-control studies have addressed the issue of occupational risks, mostly among male workers. The results of these studies suggest that the growing incidence of and mortality by mesothelioma is explained by the widespread and intense exposure to asbestos in some Italian industrial settings. A high attributable risk of lung tumors among male populations in industrial areas of northern Italy is explained by occupational exposures. However, insufficient data are available for clear definition of the extent and intensity of occupational exposure to carcinogenic substances. In Italy, we must prioritize and maximize resources in occupational cancer epidemiology and revitalize the role of national institutions. Recent legislation has established new regulations on the handling of carcinogenic substances in industrial settings, a new list of occupational diseases, and a national registry of mesothelioma linked to asbestos exposure. These legislative changes are expected to have positive effects.

Health and work among women in Italy: an overview of the epidemiological literature

The objective of this paper is to give an overview of the epidemiological studies completed in Italy during the past 25 years, about the role of occupational exposures on the development of adverse health effects on women. The implications for research developments are also discussed. The epidemiological investigations of selected categories of work-related health effects published in Italy in the years 1970-1995 were identified from the medical literature databases. The total number of studies is 142, including cohort mortality studies (n = 12), case-control studies of different neoplasms (n = 14), investigations of adverse reproductive effects (n = 8) and studies of occupational diseases different from the above (n = 94). In most investigations, women workers were not the main study objective and hence the number of females under study was small. The conclusions is that in Italy, given the dearth of studies of female workers and the preponderance of women in many economic sectors, i.e. the textile and shoe industry, health care, personal services and schools, there is a need to identify women workers in the above industries and occupations as priorities for epidemiological research and surveillance.

[An Italian multicenter case-control study on malignant neoplasms of the hematolymphopoietic system. Hypothesis and preliminary results on work-related risks. WILL (Working Group on Hematolymphopoietic Malignancies in Italy)]

A multicenter case-control study was conducted in Italy in twelve areas covering a population of 7 million persons with the aim of verifying the hypothesis of an association between exposure to herbicides and to organic solvents and occurrence of lymphoma, leukaemia and multiple myeloma. 3420 cases were recruited in a three-year period (1991-1993), through periodical surveys in the main hospitals in each area. A random sample of the general population (2317 subjects) constitutes the control group. Cases and controls were face to face interviewed by trained personnel. A questionnaire was used asking about personal habits, residential and occupational history, past health status. Preliminary analyses, concerning a total of 1388 cases and 1718 controls, focused risks by occupation. Elevated risks of non Hodgkin's lymphoma (OR: 1.7; IC 95%: 0.92-3.02; based on 28 exposed cases), and of multiple myeloma (OR: 3.6; IC 95%: 1.51-8.63; based on 9 exposed cases) were shown for welders. Among female hairdressers there were elevated risks of non Hodgkin's lymphoma (OR: 1.8; IC 95%: 0.76-4.30; based on 8 exposed cases), multiple myeloma (OR: 3.3; IC 95%: 0.77-14.15; based on 3 exposed cases) and Hodgkin's disease (OR: 2.0; IC 95%: 0.93-4.47; based on 16 exposed cases).

[Occupational cancer in Italy]

The paper is a discussion of occupational cancer in Italy. The introductory section provides the necessary context of Italian industrialization and occupational health regulation. This is followed by a review of Italian epidemiological studies of occupational cancer risks, considered in terms of relative measures of risk and Attributable Risk to carcinogenic agents or exposure circumstances. A section attempts to establish the number of workers who have been exposed to carcinogens in Italy and the intensity of their exposures. Several cohort and case-control studies have addressed the issue of occupational risks, mostly among male workers. The results of these studies suggest that the growing incidence of and mortality by mesothelioma is explained by the widespread and intense exposure to asbestos in some Italian industrial settings. A high Attributable Risk of lung tumors among male populations in industrial areas of northern Italy is explained by occupational exposures. However, insufficient data are available for the clear definition of the extent and intensity of occupational exposure to carcinogenic substances. In Italy, we need to prioritize and maximize resources in occupational cancer epidemiology and to revitalize the role of national institutions. Recent legislation has established new regulations on the handling of carcinogenic substances in industrial settings, a new list of occupational diseases, and a national registry of mesothelioma linked to asbestos exposure. These legislative changes are expected to have positive effects.

Incidence rates of leukemias, lymphomas and myelomas in Italy: geographic distribution and NHL histotypes

The annual incidence of non-Hodgkin's lymphomas is increasing by 3 to 4% in different parts of the developed world, while rates for Hodgkin's disease, myelomas and leukemias are more stable. In the case of this group of malignancies, hypothesis generation on risk factors has been limited by the use of the ICD classification in mortality and incidence statistics. We have computed incidence rates in different Italian areas after careful re-classification of diagnoses, and considering specific histotypes (Working Formulation for NHL, Rye's classification for HD). While no particularly interesting pattern is suggested for Hodgkin's disease (even after considering specific Rye subgroups), multiple myeloma and leukemias, for non-Hodgkin's lymphomas the high rate in one agricultural area (Forli) was mainly due to the A sub-group in the Working Formulation (low-grade). In a heavily industrialized area (Varese), the high incidence rate was at least partly explained by a higher proportion of cases classified in the G sub-group (intermediate grade). Excesses of non-Hodgkin's lymphomas have been observed in populations exposed to phenoxy-acetic-acid herbicides, to insecticides and to organic solvents. One can hypothesize that different risk factors act on different stem cells and induce lymphoid malignancies belonging to different histologic sub-types.

Cytogenetic monitoring of a group of Italian floriculturists: no evidence of DNA damage related to pesticide exposure

The induction of sister chromatid exchanges (SCE), structural chromosome aberrations (CA) or micronuclei (MN) was investigated in peripheral lymphocytes of a group of Italian floriculturists exposed to a mixture of pesticides. No statistically significant difference in the frequencies of cytogenetic damage was detected between exposed and control subjects. Assessment of the effect of confounding factors indicated that smoking affected both SCE and CA frequencies. Multiple regression analysis showed that in heavy smokers (> or = 20 cigarettes/day), SCE and CA levels increased significantly by 17% and 54%, respectively, as compared to non-smokers.

Cytogenetic biomonitoring of styrene-exposed plastic boat builders

Earlier studies have produced evidence for an association between work-related styrene exposure and cytogenetic damage, while more recent studies have failed to show such an association. In the present study, chromosome aberrations (CA) and sister chromatid exchanges (SCE) were measured in peripheral blood lymphocytes of 46 male workers employed in a fiber-reinforced plastic boat building factory and exposed to styrene. Two groups of 23 workers each, characterized by different exposure levels (ranges: 2-120 mg/m3 and 86-1389 mg/m3 ambient air) were studied, fifty-one controls matched by sex, age and smoking habits were included. Randomized blood samples were analyzed for cytogenetic damage separately in two laboratories. Interlaboratory differences in the scoring of CA and SCE were noted. However, increases of the considered cytogenetic endpoints in exposed vs control groups were consistently observed in both laboratories. Multivariate statistical analysis of pooled data revealed increases of CA ranging between 19% (RR = 1.19; 95% C.I., 0.80-1.78; chromatid-type aberrations, low exposure group) and 144% (RR = 2.44; 95% C.I., 1.26-4.70; chromosome-type aberrations, high exposure group). Parallel excess of SCE in styrene exposed workers was also observed, although at a lesser extent (RR = 1.22; 95% C.I., 1.05-1.43, low exposure group; RR = 1.26; 95% C.I., 1.07-1.47, high exposure group). These findings suggest the presence of a causal association between occupational exposure to styrene and cytogenetic damage in the plastic boat building factory that was the object of the study.

Studying cancer among female workers: methods and preliminary results from a record-linkage system in Italy

In the context of a national program for occupational health surveillance, we examined cancer mortality among women from two study populations. The Torino Longitudinal Study includes 159,039 women, resident in Torino, northern Italy, 18 to 64 years old and economically active at the 1981 census. The Italian Cross-sectional Study includes 2,038 deaths among 6,073,071 Italian women, 18 to 64 years old and economically active at the 1981 census. Preliminary results indicate that women in higher socioeconomic classes showed excess overall cancer mortality. This excess was almost entirely explained by increased breast cancer among teachers, managers, and public officials. Metal, wood, and clothing manual workers showed a significantly increased risk of ovarian cancer. Some excesses of lung and digestive cancers were noticeable among women in the textile and clothing industry and in the restaurant, bar, and hotel trade. Further study is under way.

Solvents in pesticides

Solvents are extensively used in pesticide formulations. This study concerns the solvents notified to the Italian Registry of Pesticides, which has information on approximately 8000 pesticide formulations. Solvents with evidence of carcinogenicity in humans or animals, including benzene, chloroform, carbon tetrachloride, 1,2-dichloroethane, 1,4-dioxane, and 2-nitropropane, have been notified for use in pesticides. Exposure to such solvents could partly explain some of the reported excesses of leukemia and non-Hodgkin's lymphoma among farmers.

Pesticide exposure assessment: a crop exposure matrix. The Working Group on Pesticide Exposure Assessment

A crop exposure matrix (CEM) was developed in the context of two Italian case-control studies. The CEM relates agricultural practices to pesticide exposures taking into account change over time and the use of chemicals by geographical area for farming. The matrix is specific to 14 areas and to 10 major crops. The exposure axis is made up of 440 chemicals used in the last 40 years in the areas of interest. In the matrix the association between crop growing and pesticides is expressed in terms of presence or absence of exposure. Accuracy of the matrix was initially evaluated using 26 occupational histories collected within the two case-control studies. Sensitivity and specificity of CEM for some compounds were estimated versus assessment of exposure by experts. Sensitivity ranges from 83.3% to 100%, specificity from 66.2% to 95.8% depending on the chemicals.

Exposure to solvents in the shoe and leather goods industries

The shoe and leather goods industries are two of the main economic sectors in Tuscany. Organic solvents are the most important risk factors responsible for leukaemias and polyneuropathies. Job exposure matrices for solvents have been developed with two different aims: to contribute to the general matrix in different industries involving exposure to solvents and to provide a data source for use by health professionals. The matrices have been constructed on the basis of: scientific literature, notices of chemical compositions of trade products, technical reports collected by local services, the survey of a sample of industries in the province of Florence.

Aplastic anemia, leukemia and other cancer mortality in a cohort of shoe workers exposed to benzene

Benzene is a well documented carcinogen for the hematic and lymphopoietic system, and experimental research confirms its carcinogenicity for tumors of other sites. This report presents the results of a historical cohort study in a shoe manufacturing plant in Florence where cases of aplastic anemia and leukemia were reported in the 1960s. A total of 1008 men and 1005 women were considered eligible members of the cohort. For total mortality, comparing the rates of the cohort with the national rates, the standardized mortality ratio (SMR) was 79 for the women and 95 for the men. For the men excesses of risk for aplastic anemia [SMR 1566; 95% confidence interval (95% CI) 547-3264] and leukemia (SMR 400, 95% CI 146-870) were observed. The increased risk occurred among workers first employed during the period in which benzene was used, but the expected number of cases in the subsequent period was too small to evaluate whether any reduction in risk had occurred. No increasing pattern with duration of employment was discernible.

Cancer mortality among workers in the Tuscan tanning industry

The mortality of 2926 male workers at the tanneries in the "leather area" of Tuscany was examined from 1950 to 1983 comparing it with the national mortality. Cancer mortality was of particular concern because of the many chemicals known to be definite or suspected carcinogens used in the tanning cycle, in particular chromate pigments, benzidine based dyes, formaldehyde, and organic solvents. There was no excess of deaths for cancers of all sites but slight increases in deaths from cancer of the lung (SMR = 131, CI 95% = 88-182), bladder (SMR = 150, CI 95% = 48-349), kidney (SMR = 323, CI 95% = 86-827), pancreas (SMR = 146, CI 95% = 39-373), and leukaemias (SMR = 164, CI 95% = 53-382) occurred. Two cases of soft tissue sarcomas were observed versus 0.09 expected (SMR = 2178, CI 95% = 250-8023).