Document 15JKJQRJ1YdaB8QODJbq41nMm
BIOMEDICAL AND ENVIRONMENTAL SCIENCES 17, 459-468 (2004)
Cohort Studies on Cancer Mortality Among Workers Exposed Only to Chrysotile Asbestos: a Meta-analysis1
Lu LI*,#, Tong-Da SUN#, Xing ZHANG1, Rui-Nan LAI#, Xiu-Yang LIa, Xue-Jin FAN#, and Kenji MORINAGA+
#Institute ofSocial Medicine and Family Medicine, Zhejiang University, Hangzhou 310031, Zhejiang, China; *Institute ofHygiene, Zhejiang Academy ofMedical Sciences, Hangzhou 310013, Zhejiang, China;ADepartmentofEpidemiology and Health Statistics, School ofMedicine, Zhejiang University, Hangzhou 310031, Zhejiang, China; +Department ofEpidemiology and Field Research, Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka 537-8511, Japan
Objective To determine whether there was excessive risk of cancer among workers exposed to chrysotile fiber alone by applying a meta-analysis technique. Methods All data meeting the criteria of cohort studies on cancer mortality among workers exposed only to chrysotile were incorporated into meta-analysis. Pooled standardized mortality ratios (SMRs) and their corresponding 95% confidence intervals (CIs) for main cancer sites were calculated using two approaches of unweighted ratio and random effect model. The heterogeneity and its sources of the results were examined with a Q-statistic and Z-score test. The dose-response effect as reflected in the percentage of all deaths due to mesothelioma served as a proxy measure of chrysotile exposure. Results A cohort of twenty six workers exposed to chrysotile alone was summarized. The significantly elevated meta-SMRs for all deaths (1.27), all cancers (1.28), cancers of respiratory organs (2.51), cancers of lung (2.35) and cancers of stomach (1.24) were observed. The significantly elevated meta-SMRs for lung cancer within occupational strata were observed among textile workers (3.55), asbestos product manufacturers (3.30), miners and millers (2.24), cement product workers (1.22), and for stomach cancer among asbestos product manufacturers (1.49). Meta-SMRs for cancers at other sites were not significant. Meta-SMR for lung cancer showed an increasing trend with an elevated percentage of all deaths from mesothelioma, but no such trend for stomach cancer. Conclusion There are excessive risks of lung cancer and mesothelioma among workers exposed to chrysotile fiber alone, and likely no convincing indication of an etiological association between chrysotile exposure and cancers at other sites.
Key words: Chrysotile asbestos; Cancer; Mortality; Cohort study; Meta-analysis
INTRODUCTION
Asbestos is one of the most versatile and useful industrial materials, known for its multiple important applications. Inhalation of asbestos dust may not only result in fibrosis of the lung, but also induce lung cancer and malignant mesothelioma. However, there are
1This study was partially supported by a grant from the Research Foundation in the year of 1997 of the Japan-China Medical Association (No. 001).
^Correspondence should be addressed to Professor Lu LI, Tel: 86-571-87217200. Fax: 86-571-87217006. E-mail: lilu@zju.edu.cn
Biographical note of the first author: Lu LI, male, born in 1959, MPH, professor, Ph. D., advisor, majoring in public health, occupational and environmental medicine.
00895-3988/2004 CN 11-2816 Copyright 2004 by China CDC 459
460 LI ET AL.
conflicting opinions on the carcinogenic effects of exposure to chrysotile fibesr alone[1"4]. The mineral oil hypothesis, the amphiobole hypothesis, or the disproportionate distribution of dimension and biopersistence of asbestos fibers have been put forward[5]. Since there were some limitations such as consistency and representation in individual cohort studies, the relationship between asbestos exposure and cancer was explored by applying a meta-analysis[6,7]. But those workers who exposed exclusively and predominantly to chrysotile usually constituted 5% or less of amphibole asbestos and were classified into the same category, i.e. the predominantly chrysotile-exposed workers. So it was difficult to explain the carcinogenic effects of exposure only to chrysotile. To provide a summary measure of risk for malignant tumors associated with exclusively chrysotile exposure, we conducted a meta-analysis of cohort studies on cancer mortality among workers exposed only to chrysotile.
MATERIALS AND METHODS
Inclusion Criteria
Only cohort studies on cancer mortality among workers exposed to chrysotile alone were incorporated into the meta-analysis.
Exclusion Criteria
Workers who were exposed to other types of asbestos fibers except for chrysotile fiber, or predominately to chrysotile but to mixed other asbestos fibers simultaneously, with unknown and non-occupational exposure were excluded. Descriptive epidemiological study, case-control study, experimental epidemiological study, and cohort study of incidence were also excluded.
Search Strategy
We conducted searches of MEDLINE database from 1966 to January 2003, and Chinese BioMedical disc (CBMdisc) from 1978 to February 2003, using Mesh headings including "asbestos or chrysotile" and "cancer or tumor or neoplasm", and "mortality" without restriction on language, supplemented by manual searching the relevant articles listed in medical key journals in China during recent 10 years and references of all identified studies. The authors of all identified articles were contacted in order to obtain or check the relevant information.
Data Extraction
The data were independently extracted by two investigators with blinding method using a standardized data-abstraction form. The following information was sought from each identified study: author's name, title, year of publication, occupation, location; follow-up size, person-year and period, observed and expected number of deaths for all causes, all cancers and cancers at major sites, latency of lung cancer, number of mesothelioma deaths. Standardized mortality ratios (SMRs) for cancers and their corresponding 95% confidence intervals (CIs) of the identified study were calculated. As some papers on the same cohort study were published several times, only independent studies and the most recent publications were included. When a study consisted of several groups exposed to different types of asbestos, only the subgroup in which workers were exposed to chrysotile alone was included
CANCER MORTALITY AMONG CHRYSOTILE WORKERS
461
in the meta-analysis. As direct measurements of airborne asbestos dust were not obtained in most cohort
studies, we analyzed the dose-response effect as reflected in the percentage of all deaths due to mesothelioma that served as a proxy measure of chrysotile exposure. Since the dose-response relationship between asbestos exposure and mesothelioma has been proven[7], studies were stratified by the percentage of deaths due to mesothelioma into three groups: 0%-0.49%, 0.50%-0.99%, and over 1.00%.
Statistical Analysis
The pooled estimates of SMRs and their corresponding 95% CIs were calculated according to the following two approaches:
(1). Unweighted ratio of the sum of observed and exposed deaths[7]: meta-SMR=EOi/Ei, meta-SMRU>L=exp[ln(meta-SMR) 1.96/VZ Oi ].
(2). Random effect model ( REM)[6]: meta-SMR=exp[E Wi* 8 i/ Wi*], meta-SMRU>L=exp [ln(meta-SMR) 1.96/V Wi* ],
Wi*=(si2+ T2)-1, si2=Oi-1, t2 =max{0, [Q-(K-1)]/(Wi2/EWi)}, 8 i=ln(SMRi), Wi=si-2, si2=Oi-1, The heterogeneity and its sources of the results for each study were examined with a Q-statistics[6] and Z-score[7] test:
Q=EWi(8i-^w)2, dw =EWi8i/EWi,
Z=[log(SMRi)-log(meta-SMR)]/SE, SE=1/VO. Where Oi, Ei, SMRi denote the number of observed and expected deaths and SMR in the cohort, respectively, K is the number of cohort. Meta-SMRU>L denotes the upper limit and lower limit of 95% CI of meta-SMR. Sensitivity analysis was performed by calculating again the meta-SMRs for cancers at main sites after exclusion of those cohorts of principal sources of heterogeneities in all cohorts[8]. All data were assumed as a Poisson distribution and calculations were performed by using SAS system for Window, release 6.03 Edition[9]. Statistical significance of SMR and Q-statistics were evaluated by using the score-test and Chi-square test, respectively.
RESULTS
Initially, a total of 453 articles were searched. Two hundred and fifty three articles were excluded due to non-cohort study after reviewing the abstracts. One hundred fifty seven articles were excluded because types of exposed asbestos and study outcomes could not meet the inclusion criteria after reviewing the full texts and contacting the authors of the identified studies. Eighteen repeated publications were rejected. Our final literature search identified 25 articles reporting 26 cohorts that met the inclusion criteria. Table 1 summarizes the study characteristics[10-34]. Ten (38.46%) of the 26 identified cohorts were in China, 6 (23.08%) in USA, 4 (15.38%) in UK, 2 (7.69%) in Canada and Italy, 1 (3.85%) in Sweden and Denmark, respectively. The earliest cohort study was published in USA in 1977[34] and the most recent one in China in 2003[13]. By occupation, the major was among asbestos product manufacturers (38.46%), followed by textile workers and asbestos cement workers (19.23%, respectively), miners and millers and friction material workers (11.54%, respectively).
462 LI ET AL.
TABLE 1
Study Characteristics of All Identified Cohorts
First Author
Occupation Location Size
Total Cancers
Cases of Lung Cancer
Cases of Stomach Cancer
% of All Deaths Due to Mesothelioma
Peto, J.l9]
Textileb
UK 145 34
20
4
5.69
McDonald, A. D.l10] Dement,
J. M.l11]
Textile Textile
USA USA
2543 3022
120 283
NAa 126
NA 9
0.12 0.16
Sun, T. D.l12]
Textile
China
5681
213
87
42
0
Germani, D.l13]
Textile
Italy
276
43
9
2
5.00
Liddell, F. D. K.l14]
Minerc
Canada 10 918
1900
646
183
0.47
Piolatto, G[15]
Miner
Italy
1058
82
22
12
0.47
Wang, Z. m.[16]
Miner
China
7668
116
36
NA
0.88
Hughes, J. m.[17]
Cementd
USA
3594
226
107
15
0.34
Raffn, E.l18]
Cement
Denmark
163
NA
12
NA
NA
Gardner, M. J.l19]
Cement
UK 2167 121
41
15
0.21
Thomas, H. F.l20]
Cement
UK 1540 74
30
NA
0.57
Ohlson, C. g[21]
Cement
Sweden
1176
44
11
1
0
McDonald, A. D.l22]
Frictione
USA
3515
202
73
NA
0
Newhouse, M. L.l23]
Friction
UK
12 571
735
254
NA
0.07
Finkelstein, M. M.l24]
Friction
Canada
701
35
12
NA 1.55 (double)
Acheson, E. D.l25]
Productf
USA
570
44
7
4
0.56
Cheng, w. n.[26]
Product
China
1172
44
21
7
NA
Zhang, z. q.[27]
Product
China
370
10
6
2
0
Wang, z. m.[28]
Product
China
515
50
22
NA
1.43
Wang, Z. H.l29]
Product
China
551
75
32
16
1.33
Pang, Z. C.l30]
Product
China
530
22
9
NA
NA
Zhou, K. H.l31]
Product
China
669
50
24
5
0
Zhu, H.l32]
Product
China
5893
183
67
28
0.40
Wang, z. m.[16]
Product
China
9950
106
42
NA
0.31
Weiss, W.l33]
Product
USA
264
13
4
NA
NA
Note. aNA, data not available; bTextile, asbestos textile workers; cMiner, asbestos miners and millers; dCement, asbestos cement workers; eFriction, friction material workers; fProduct, asbestos product manufacturers.
CANCER MORTALITY AMONG CHRYSOTILE WORKERS
463
Follow-up study ranged in size between 145[10] and 12 571[24] subjects, in length of the follow-up period ranging from 5 years[33] to 51 years[12], and in person-years from 3761[14] to 14 122 000[15], however person-years could not be obtained in 8 cohorts. The earliest follow up period started in 1933[10] and the latest follow-up ended in 2000[13]. The percentage of all deaths due to mesothelioma was 0.41% on average ranging from 0%[13,22,23,28,32] to 5.69%[10]. The proportion of deaths due to mesothelioma could not be calculated in 4 cohorts[19,27,31,34].
Table 2 shows the pooled analysis results of SMRs for cause-specific cancers.
Meta-SMRs (REM, similarly hereinafter) for all causes (1.27) and all cancers (1.28) were significantly elevated (P<0.01), significant heterogeneities were both present, and their principal sources were from the cohort of Newhouse et a/.[24] (Z=-5.93) and Zhang et a/.[28] (Z=4.58), the cohort of Wang et a/.[30] (Z=4.90) and Newhouse et a/.[24] (Z=-3.42), respectively.
Meta-SMRs for cancers of respiratory organs (2.51) and cancer of lung (2.35) were both significantly elevated (P<0.01), but not for cancer of laryngeal (1.42, P>0.05). The highest SMR for lung cancer of the single cohort study was reported among miners and millers of the cohort of Wang et a/.[17] (SMR 7.63), the lowest among asbestos product manufacturers of the cohort of Thomas et a/.[21] and Weiss[34] (SMR 0.93, respectively). The percentage of excessive lung cancer cases was 52.97% on average from -9.09%[21] to
TABLE 2
Meta-SMRs for Site-specific Cancers Among Workers Exposed Only to Chrysotile
Cancer Sites
No. of Cohorts
Unweighted Ratio
Meta-SMRa
95% CIb
Random Effects Model Meta-SMRa 95% CIb
All Causes
20
1.10**
1.08-1.12
1.27**
1.09-1.48
All Cancers
25
1.22**
1.18-1.26
1.28**
1.24-1.33
Cancers of
17
1.03 0.97-1.09
1.12
0.96-1.31
Digestive
Organs Oesophagus
Stomach
5
0.79
0.54-1.17
15
1 19**
1.07-1.32
0.85 1.24**
0.59-1.22 0.95-1.62
Intestine
9
0.90
0.76-1.07
1.09 0.74-1.61
Liver Cancers of
5
1.06
0.84-1.33
1.11 0.82-1.51
7
1.57**
1.48-1.67
2.51**
1.67-3.76
Respiratory
Organs
Larynx Lung
8
1.13 0.87-1.45
1.42
0.72-2.80
25
1.53**
1.46-1.60
2.35**
1.43-3.86
Breast Cancer
4
0.97
0.76-1.25
0.97
0.75-1.26
Cancers of Genitourinary
6
1.13 0.96-1.32
1.25 0.90-1.75
Organs
Ovary Cancers of
3
1.33 0.84-2.11
1.81 0.61-5.36
4
1.02 0.83-1.25
0.99
0.73-1.33
Lymphatic and Hematopoietic
Tissues
Note. aSMR, standardized mortality ratio; bCI, confidence interval; *P<0.05; **P<0.01.
Q 447.59** 425.06** 37.64**
1.94 31.79** 18.09* 4.85 135.50**
21.28** 505.00** 0.46 11.74*
7.74* 4.28
464 LI ET AL.
662.71%[17]. Meta-SMR for lung cancer demonstrated extreme heterogeneity (Q=505.00, P<0.01), its principal sources were the cohort of Liddell et al.[15] (Z=-5.96) and Wang et al.[17] (Z=3.07). The calculated results of Z-scores for all cancer of lung studies are presented in Fig. 1. Eight (30.77%) cohorts with latency of lung cancer were available, ranging from 12 years[3u] to 48 years[3u].
| Wang*1''1 -------
_ n n n n fl
UUUUUU-
-6
| Liddell11411
Fig. 1. Z-scores of meta-SMR for all cancer of lung studies.
Table 3 shows the re-calculated results of summary SMRs for all deaths, all cancers and cancer of lung after exclusion of those cohorts of principal sources of heterogeneities in all cohorts. The results were similar to those of all their corresponding cohorts (Table 2).
When studies were stratified according to occupation categories (Table 4), the pooled analysis results showed a significant elevation except for friction material workers
(meta-SMR 1.25, P>0.05). The highest meta-SMR for lung cancer was among textile workers (3.55), followed by asbestos product manufacturers (3.30), miners and millers (2.24) and asbestos cement workers (1.22). When studies were stratified according to the percentage of all deaths due to mesothelioma (Table 4), the data showed an increasing trend in the meta-SMR for lung cancer with percentages of all deaths due to mesothelioma, but no such trend was seen for cancer of stomach.
TABLE 3
Sensitivity Analysis Results of Meta-SMRs for Main Cancers Among Workers Exposed Only to Chrysotile
Cancer Sites
No. of Cohortsa
Unweighted Ratio Meta-SMRb 95% CIc
Random Effects Model Meta-SMRb 95% CIc
Q
All Causes
18
1.12**
1.10-1.14
1.18**
1.05-1.33
267.74**
All Cancers
23
1.28**
1.23-1.33
1.34**
1.29-1.39
232.93**
Cancer of Lung 23
1.60**
1.51-1.70
2.28**
1.09-4.78
383.83**
Note. aNo. of cohorts, after exclusion of those cohorts of principal sources of heterogeneities in all cohorts; bSMR, standardized mortality ratio; cCI, confidence interval; **P<0.01.
The pooled analysis results for other cancers of digestive organs, cancer of larynx, cancer of breast, cancers of genitourinary organs, cancers of lymphatic and hematopoietic tissues were all not significantly elevated except for cancer of stomach (meta-SMR 1.24, P<0.01). The significantly elevated meta-SMR for stomach cancer was among asbestos product manufacturers (1.49, P<0.05), not for other occupations.
CANCER MORTALITY AMONG CHRYSOTILE WORKERS
465
TABLE 4
Stratification Analyses of Major Site-specific Cancers Rates Among Workers Exposed Only to Chrysotile
All Cancers
Cancer of Lung
Cancer of Stomach
No. of Meta-SMRa Q
No. of Meta-SMR Q
No. of Meta-SMR Q
Cohorts (95% CIb)
Cohorts (95% CI)
Cohorts (95% CI)
By Occupation: Textile
5 1.66** 29.65**
4 3.55** 33.20**
4 1.06 1.40
Workers Miners and
(1.20-2.30) 3 1.26** 15.06**
(2.00-6.32) 3 2.24** 102.61**
(0.80-1.40)
2 1.21
1.16
Millers
(1.05-1.52)
(1.37-3.69)
( 1.04-1.41)
Cement
4 0.98 5.83
5 1.22* 9.51
3 1.01
3.73
Workers Friction
(0.83-1.15) 3 1.12 13.70**
(0.90-1.65) 3 1.25 7.48
(0.57-1.79) NAc NA NA
Materials Workers Asbestos
(0.93-1.35) 10 1.70** 153.66**
(0.98-1.58) 10 3.30** 58.88**
6 1.49* 17.03**
Products Workers
(0.84-3.45)
(1.59-6.85)
(0.77-2.89)
By % ofAll Deaths Due to Mesothelioma:
0- 14 1.21** 234.28**
15 2.11** 330.75**
10 1.28* 28.93*
0.50-
(1.17-1.26) 4 1.75** 114.61**
(1.23-3.43) 4 2.08** 79.55**
(0.93-1.76) 2 0.92 0.53
1.00-
(1.56-1.96) 3 1.92** 6.80
(0.44-9.86) 3 5.33** 4.49
(0.59-1.43) 2 1.50 0.31
(1.61-2.28)
(3.23-8.80)
(0.67-3.34)
Note. aSMR, standardized mortality ratio; bCI, confidence interval; cNA, data not available; *P<0.05; ** P<0.01.
DISCUSSION
The primary focus of the study was to determine whether there was excessive risk of malignant tumors among workers exposed only to chrysotile asbestos by applying a meta-analysis technique.
There has been a heated debate on carcinogenic effects of exposure only to chrysotile during the recent 20 years. It was not only for scientific interest, but also had legal, public policy, and public health importance[1-3,5]. The amphibole hypothesis[1] postulated that amphiboles are the major cause of mesotheliomas in asbestos workers, the lung burden of chrysotile and non-asbestos fibers bear no relation to the occurrence of mesotheliomas and
lung cancer, and amphiboles are more potent than chrysotile in the induction of fibrotic lung disease and associated lung cancers. Chrysotile asbestos mining companies in Canada stated that chrysotile was harmless and indispensable[35]. However, some investigators demonstrated
that the fiber counts found in the lung might not accurately reflect the concentrations found at the sites for mesothelioma induction, and raised serious questions about the validity of
using lung burden studies to assess mesothelioma risk[2,3]. All types of asbestos had the potential to induce cancer of lung and mesothelioma in experimental animal models[2,3].
Meanwhile, the significantly elevated mortality of lung cancer and mesothelioma among
workers exposed to chrysotile alone was found in some cohort studies. Thus, a controversy apparently existed between those who supported the amphibole hypothesis (the
`chrysophiles') and those who opposed it (the `chrysophobes'), and remains unsolved until
466 LI ET AL.
According to our study, meta-SMRs for all cancers (1.28) and lung cancer (2.35) were significantly elevated (P<0.01). The sensitivity analysis showed that the results from this meta-analysis were robust. The proportionate mesothelioma mortality was 0.41% on average. As the incidence of mesothelioma was extremely low in general population, its expected number was nearly close to null[7]. Goodman et al.[1] demonstrated that meta-SMR for lung cancer among workers exposed to mixed asbestos was 163 and 148 with and without years of latency, respectively. This was similar to our results. It was suggested that chrysotile asbestos was similar potent in carcinogenic risks as other types of asbestos. There were excessive risks of lung cancer and mesothelioma among workers exposed to chrysotile fibers alone. In fact, chrysotile constitutes 95% of all asbestos used worldwide, and it has been the main cause of pleural mesothelioma in humans[3]. No threshold has been identified
for carcinogenic risk. Some asbestos-containing products have posed particular concern and chrysotile use in these circumstances should not be recommended[36].
We found that meta-SMRs for other cancers of digestive organs, cancer of larynx, cancer of breast, cancers of genitourinary organs, cancers of lymphatic and hematopoietic tissues were all not significantly elevated except for cancer of stomach (meta-SMR 1.24, P<0.01). But we did not find an increasing trend in meta-SMR for stomach cancer with the percentage of mesothelioma deaths. This was consistent with that in other literatures[6,7]. It
was suggested that there was likely no convincing indication of an etiological association between chrysotile exposure and cancers at other sites[36].
The quality of the data and some limitations of the study, however, should be discussed. Firstly, measurements of airborne asbestos dust concentration were not reported in most cohort studies. So it was difficult to establish the direct quantitative exposure-response relationship between chrysotile exposure and cancers. When using the percentage of all deaths due to mesothelioma as a proxy estimate of asbestos exposure, we found an increasing trend in meta-SMR for cancer of lung with the percentage of all deaths due to mesothelioma, but we did not find any support evidence of a dose-response relationship by a statistically significant positive correlation coefficient (r=0.319, P>0.05). This finding was difficult to interpret. Misclassification rate of mesothelioma was possibly significant because it was often quite difficult to diagnose. The diagnosis of a rare cancer needed pathological examinations, especially postmortem, which was not so well practiced in some areas. Pleural mesothelioma that was misdiagnosed as lung cancer and peritoneal mesothelioma as gastrointestinal cancer might affect the risk of estimates of individual studies[7]. Secondly, specific pooled-analysis cohorts were less. There were some inherent limitations including publication bias, overrepresentation and oversimplification in the meta-analytical approach[7]. They may affect the pooled-analysis results.
In conclusion, the findings in the present meta-analysis study suggest that there are excessive risks of lung cancer and mesothelioma among workers exposed to chrysotile fibers alone, and that no convincing indication of an etiological association between chrysotile exposure and cancers at other sites is likely present.
ACKNOWLEDGEMENTS
We are grateful to Professor Yi-Lan WANG from School of Public Health, Fudan University, Shanghai, China, and Professor Chang-Qi ZOU from Chinese Center for Diseases Control and Prevention, Beijing, China, who served as scientific advisors. We also thank anonymous reviewers for their helpful comments. Dr. Kenji MORINAGA was supported by the Grant (Contract No.1997-2001) from the Japan-China Medical Association.
CANCER MORTALITY AMONG CHRYSOTILE WORKERS
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(Received September 21, 2003
Accepted April 12, 2004)