Document 2NJoJ1Rw5OeGgp75qYJX3mKMR
RETROSPECTIVE COHORT STUDY OF REFINERY WORKERS
by
C,P. Men S.P. Tsai W.A, McClellan R.L. Gibson
Gulf Oil Corporation (Gulf Science and Technology Co,} P.0. Box 2100
Houston, Texas 77252.
To be presented at the Occupational Health of Epidemiology Section
American Public Health Association 109th Annual Meeting
Los Angeles,. California
November 3, 1981
'
RETROSPECTIVE COHORT STUDY OF REFIMERY WORKERS .
Several epidemiological studies have examined the association of cancer risk and employment in oil refineries, Results from these studies* especially the positive findings* have been inconsistent with each other and different conclusions have been made based on relatively small samples of workers* on limited lengths of observation and on different methodologies. This study is undertaken to examine the mortality expert ience of workers from a single refinery for a period of over 40 years with a total of 402*554 person-years of observation. The sample size of this study should be capable of providing sufficient statistical power to detect a moderate increase (or decrease) of mortality risk associated with work exposure.
Methodology The study cohort includes employees at this Texas refinery who were
ever employed: between January 1* 1937 and January 1* 1978. The incep tion and operation of the social security system, which began in 1937* was taken into consideration for determining the starting date of this study. Demographic and work history information of each cohort member were reconstructed from review of personnel records and verified by other company records, such as annuitant records, insurance benefit records, seniority lists, medical records and mortality records. The'
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pay status of each study subject was determined from the work history
and then classified according to the: duration of employment (expressed
as percentage of total employment) that was spent on an hourly or salaried
basis* Two subgroups, 100% hourly (blue collar workers) and 75% or more
salaried (white collar workers) are subjects for further analysis in
this study,- The vital status, of the cohort as of January T, 1978 was
determined from company records, the Social Security Administration,
motor vehicle bureaus and local follow-up sources.
'
Death certificates Were collected and the underlying cause of death
was classified by a trained nosologist according to the rules of the ICO
revision in effect at the time of death and then recoded to the 1CDA 8th
revision,
-
Person years were calculated for each cohort member during the
observation period. For those lost.to follow-up, person-years were
*?, * . calculated up to the last known date, usually the date of separation
from1 employment. Utilizing- the computer program developed by Monson,
standardized mortality ratios (SHRs) were calculated by comparing age-
sex-race-year-cause specific mortality rates with comparable IKS,
general population rates. Mortality rates that were not available from
Hanson's program were generated from MCHS and NIOSH data.. Confidence
intervals for each SHR were calculated arid significance testing was
based on the assumption of a Poisson distribution for the. observed
deaths, using a two-sided test of significance.
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Results
The characteristics of the cohort are described in Table 1. A
total of 16*710 workers were included in the study, with 74% white male*
15% nonwhite male and 1.1% female. A grand total of 402,554 person-years
were observed and 77% of these were contributed by white males* The
average age a .study subject entered Into the cohort (not necessarily the
age at hire) was 28.9 years* and subjects were followed for an average
of 24 years. The vital status was ascertained for 93.8%, of the male .
cohort and 6.2% (923) of then were lost to follow-up. .Death certificates
were unavailable for 7,2% of the male deaths (304). These deaths were
included in the analysis of overall statistics and in the SMR for all
causes but not In the cause-specific analysis,:
The follow-up of the females in the cohort was less successful *
with vital status identified for S8%, More women were lost to follow-up,
probably because they usually changed their last name after marriage.
Furthermore, 54% of the females left work between 1942 and 1947 and
nearly half (45%) of all females worked less than one year. In view of
these characteristics of the females in the cohort and the relatively
small sample size (females only contributed 91 deaths and 8% of the
total person-years), the following results and discussion will be
limited only to the males in the cohort,
Tables 2-6 show additional characteristics of the cohort. Approxi
mately one-third (33%) of the cohort was hired before 1940 and another
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one-third (37?') hired between 1940-1949. On the other hand, 80% of
those with vital status unknown were hired before 1950. Over one-half
(55%) were hired before age 25. One-quarter each of the cohort had
either worked less than 1 year or mors than 30 years. According to pay
status, 84%-of the cohort were hourly workers and 11.5% were salaried
workers with 75% or more of their time being salaried. It is inter- .
esting to note that the percent lost to follow-up is highest among those
born between 1910-1929 and whose employment status might have been
interrupted and affected by World War II (i.e. the highest concentration
of short timers and turnovers)..
Tables 7-9 show the SMRs and their confidence intervals for hourly,
75%+ salaried, and total males from the cohort. The SMRs for .white males
and nonwhite males are calculated separately and then combined as total
male in each table. Among the hourly* 706 cancer deaths were observed
and 743.30 expected with a resultant SMR of 0,95. Of some 50 causes of
death examined, only bone cancer showed statistically significant in
crease, with 12 cases observed and 4,51 expected (SMR - 2,66). A sig
nificant deficit was observed in all causes, cancer of digestive organs
and peritoneum, cancer of esophagus, cancer of rectum, cancer of bladder,
lymphosarcoma and reticulosarcoma, nonmalignant respiratory diseases,
cirrhosis of liver, arteriosclerotic heart diseases, cerebrovascular
diseases, accidents and suicide.
Several cancer sites showed a nonsignificant increase of SMR,
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Notable among than were Hodgkin's disease (SMR * 1.42}, kidney cancer {SMR 1.21),.leukemia (SMR. 1.1S) and skin cancer (SMR ** 1.11}. (Note that observed cancer cases less than 5 or SMR less than 1.10 and p > 0.20 were not mentioned in the increased SMR.) No increase was seen in lung cancer (SMR = 0.99) and brain cancer (SMR * 0.97).
Among the. salaried* 62 cases of cancer were observed and 76.88 expected with an SMR of 0*81. Of those causes of death examined, none showed significant increase while several causes showed significant decrease.. These included-all. causes, circulatory system diseases* normalignant respiratory diseases, tuberculosis and other infectious diseases, cirrhosis of liver, accidents and suicide.
Several cancer sites, including pancreas and lymphatic and hemato poietic tissue, showed nonsignificant excesses (SMR 2.14 and 1.48 , ' respectively).
Among the total male population, 4,239 deaths were observed with a significantly decreased SMR of 0.84. The SMR for all cancer was 0.94 with 813 cases observed. Examination of the cause-specific SMRs showed that the pattern was very similar to that of the hourly male. The only significant increase was bone cancer. Those showing the significant de creases were the same as those seen in the hourly male. This is not un expected because the latter contributed 84$ of the study subjects to the total.
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Discussion There have been several published papers studying the mortality
experiences of refinery workers. Blot et. al. surveyed the cancer mor tality from '1950 to 1969 in U.S. counties with petroleum industries. Significant increases were found for cancers of the lung, stomach, rectum, testis, nasal cavity and sinuses and skin, while:brain, cancer showed a significant decrease. From the same data. Hoover and Fraument described an increased pattern of bladder, lung and liver cancer among U.S. counties with a concentration of chemical industries.
Tabershaw/Cooper' found in a study of workers at 17 oil refineries in the United States that these workers experienced significantly less overall and cancer mortality than a comparable U.S. male-population.. Although mortality from lymphomas was greater than expected (24 Observed vs 19.26 expected), the SMR (l.25) was not statistically significant. Hants et al. found that employees exposed on a daily basis to crude petroleum or its by-products had a three fold risk of esophageal and stomach cancer (28 cases observed) and about a two fold risk of lung cancer (69 cases observed). A study by Theriault and Goulet of employees at a Canadian oil refinery showed a significant increase in brain tumor mortality for those workers employed less than 20 years (3 cases observed), yet lung cancer mortality was less than expected (3 cases observed). Thomas et al, found increased PMR of cancer of the brain* stomach, pancreas, liver, lung, leukemia and multiple myeloma, in the Texas Gulf
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coast regions, and yet a study by Rushtoir and ATderson of eight oil refineries in the United Kingdom reported a deficit-of lymphoma, lung, brain, and genital cancer mortality, Manet al. reported no increased brain cancer risk among workers in a Texas refinery. In regard to the possibilitiesTof increased cancer risk, no definite conclusion can be made because these mortality results have been inconsistent and some times contradictory among refinery workers. Methodological differences such as SMR vs PMR, differing sample sizes and lengths of'observation as well as lack of control of confounding variables, may account for most of the discrepancies. The data presented in this study represent the largest and longest study of refinery workers ever reported in North America.
Of some SO causes of death examined, bone cancer is the only site showing a statistically significant increase. None of the literature has reported such an increase. These bone cancer cases are currently under review to verify their diagnostic validity. There are, however, some indications that not. all of these bone cancers are bonafide primary bone cancer. Two out of the three cases in this study were reviewed previously and this review reflected that the cause of these deaths was . misclassified due to either Inaccurate entry on the death certificate or coding artifacts of the 8th revision of I-CDA classification. This has occurred in previous cancer surveys as well as in the present study, Percy et al. reviewed a large set of cancer deaths collected from the
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Third National Cancer Survey. Of 252 bone cancers stated on death cer
tificates as the underlying cause of death* more than half (127) were
not confirmed.in the hospital records. Bone was .actually a secondary
site of these cases and the authors concluded that bone cancer was prone
to be .arise! ass ifled and overreported:. Nevertheless, further efforts in
cluding clinico-pathological verification of these cases are in progress.
Of great Interest is the .lack of a significant increase of lung
cancer which is the number one cause Of cancer and which has been im
plicated in many study reports as increased among petrochemical workers. '
The negative finding in this study is also augmented by a statistically
significant decrease in normalignant respiratory diseases (200 cases
observed and 295.29 expected with SMR - 0.68},
'
It is also of interest to note from this study significant decreases
of SMR in several cancer sites. Significant decreases are seen in cancer
of esophagus, rectum,, bladder, lymphosarcoma and reticulosarcoma, and
"
digestive organs and peritoneum in contrast to some previous reports. -
These findings could be interpreted to mean that being a refinery worker
is associated with decreased risk of dying from these cancers. Further
study is needed, however, to elucidate the validity of such ah association.
This study also failed to show a significantly increased cancer
risk of brain, lung, leukemia, stomach and pancreas as reported in other
studies.. Varying amounts of nonsignificant cancer excesses, have been
observed in this study in Hodgkin's disease, leukemia, skin, pancreas.
8-
and kidney. However, given the TYpe I error (a) - 0.05 and Type II error (B) 0.2 the sample size of this study Is sufficiently Urge to detect at least a two fold risk of each of these cancers, if such a risk did Indeed exist. It is worth noting that salaried workers accounted for more of such excesses than hourly workers in the cases of pancreas, skin cancer and Hodgkints disease. This may not be consistent with the proposition that these excesses are work exposure related. Further re finement of the data and their implications are underway, and are being prepared for publication.
In summary> a 41 year follow-up study of employees from a. large Texas refinery revealed no significant increase of cancer risk, except for bone cancer. Significant decreases were found in. bladder, rectal and esophageal cancer. Implications of these findings have been discussed.
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REFERENCES
l; Slot WJ, Brinton LA, Fraumenl OF and Stone BJ: Cancer mortality in U.S. counties with petroleum industries'. Science 198:51-53, 1977.
2. Ham's MM, Stavraky KM, and Fowler JL: Cancer mortality In oil refinery
workers. -JOM-21: 167-174, 1979.
;
3. Hoover R and Fraumenl OF: Cancer mortality in U.S. counties with chemical industries. Environ Res 9:196-207 1975.
4. Monson RR: Analysis of relative survival and proportional mortality.
Cornput Biomed Res:. 7:325-332, 1974.
.
5. Percy C, Stanek" and Gloeckler L: Accuracy of cancer death certifi cates and its effect on. cancer mortality statistics. Am J Pub HIth. 71 (3); 242-250, 1981.
6. Rusbton L and Alderson MR: "An epidemiological survey of eight oil
refineries in the U.K." Final report prepared for the Institute of
Petroleum, 1980.
,
7. Tabershaw/Cooper Associates. A mortality study of petroleum refinery workers. Project OH-1 prepared for the American Petroleum Institute, 'Washington, p.C., 1974.'
8. Theriault G and Goulet: t: A mortality study of oil refinery workers. JOM 21: 367-370, 1979.
9. Thomas TL, Decoufle P and Moure-Erase R: Mortality among workers employed in petroleum refining and petrochemical plants. ". JOM 22:97 103, 1979.
10. Wen CP, Tsai SP, Weiss NS, McClellan WA, and' Gibson RR; A populationbased cohort study of brain tumor mortality among oil refinery workers with a discussion of methodological issues of SMR and PMR. Banbury Report 9: Quantification of Occupational Cancer, 1981.
TABLE 1 COHORT STATISTICS
1937-1573
Male White * Nonwhite
Total
Female
Number studied {%)
Person-years observed (56)
1.2,397 (74.25)
310,037 (77.0%)
Average years of follow-up
25.0
Average age of entry
29,2
Number alive
8*288
Number dead
3,417
Cause known
3*176
Cause unknown (*) '
241 (7.0%)
Number Tost to follow-up (*)
692 (5.6%)
2,547 (15.2%)
14,944 (89.4%)
1,766 (10.6%)
59,260 (14.7%)
369,297 (91.7%)
33,257 (8.3%)
23.3
24.7
18.8
30.4
29.4
24.2
1,494
9,782
1,112
822 4,239
91
759 : 3.535
S3 304 {7,7%) ' (7,2%)
81
10 (11.0%)
231 92.3 563
(9.m (6.2%) . (31.95)
TOTAL
16,710
402,554
24,0 28.9 9,894 4,330 4,016 314 (7.2-5 1,4.85 (8.9',)
is Hale employees whose race is unknown (1.8%) are included in the'"white*1
category
'
TABLE 2 VITAL STATUS OF THE KALE COHORT BY YEARS OF SERVICE
1937-1978
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923 (1 0 0 .0 ) 14*944 (100.0)
9782 (100.0) 4229 (9 9 .8 )
TOTAL
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TABLE 4 DISTRIBUTION OF THE MALE COHORT BY VITAL STATUS AND AGE AT HIRE
1937-1978
Age at Hire (Years)
Alive No- { % >
Dead No. ( % )
Unknown No. ( % )
TOTAL No. ( % )
24 25-29 30-34 35-3.9 40-44 45+
TOTAL
5147 (62.8) 2166(22.1) ' 927 ( 9.5) 328 ( 3.4} 131 ( 1.3)
83 { 0.8.)
9782 (100.0)
1584 (37.4) 938 (22.1) 711 (16.8) 431 (10.2) 280 ( 6.6} 295 ( 7,0)
561 (60.8) 204(22.1)
70 ( 7.6} 50 { 5.4) 20'( 2.2) . 18 ( 1.9)
.
8292 (55,5) 3308 (22.1) 1708 (11..4) 809 ( 5.4) 431 { 2.9) 534 ( 3.6)
4239 (100.0). 923 (100.0) - 14>944 (100.0)
TABLE 5 DISTRIBUTION OF THE HALE COHORT BY PAY STATUS AND RACE
1937-1978
Percentage of Employment* 'Salaried Hourly
White No. (%)
OX 100%
.10,089 (81.4)
25% 75%
* Z94 ( 2.4}
Nonwhite . No. <S) 2482 (97,4}
7 { 0.3)
TOTAL Mo. {%) 12,571 (84,1)
301 ( 2.0)
50% 50%
1 279 ( 2.2}
7 ( 0.3}
286 ( 1.9)
75% 25%
196 { 1.6}
3 ( 0.1)
199 ( 1.3) .
90% 10%
254 { 2.0} .
3 ( 0.1)
257 ( 1.7)
oo
0%
1,235 00.0}
33 { 1.3)
1 ,268 ( 8.5)
Unknown TOTAL
50 ( 0,4)
12,397
*.
(100.0)
12 ( 0,5)
62 ( 0.4)
2547 (100.0) 14,944 (99,9)
* Based on the percentage of employment rounded to the nearest percentage category.
TABLE 6 VITAL STATUS BY YEAR OF BIRTH FOR HALE COHORT
Year of Birth
Alive Mo. (1)
. ..Deceased No. {%)
Unknown No. (S)
< 1890 1890-1899' 1900-1909 1910-1919 1920-1929 1930-1939 1940-1959
39 ( 5} 370 (22} 1227 (50} 2290 (69) 2627 (80} 1291 (91) 1938 (97)
-
727 (92) 1231 (75) 1094 (42) 772 (23) 354 (11)
54 ( 4) 7 ( 0)
24 (3) 44 (3) 143 (6) 269 (8) 307 (9) 75 (5) 61 (3)
'
TOTAL
97B2 (65)
' 4239 (28)
923 (6)
TABLE 7 STANDARDIZED KORTAim RATIOS FOR SELECTED CAUSES OF DEATH
HOURLY HALES'*'
_______________________1937-1978
cause of Death (ICDA 8th Revision):
Observed Expected SftR
AT) Causes (000-999}
374S
4305.15 0.87**
AD Malignant Neoplasms (140-209)
706
Cancer of Buccal Cavity*. Pharynx. {T40-1491)
17
Cancer of Digestive Organs and Peritoneum (140-159)
Cancer of Esophagus (T50)
199 n
Cancer of Stomach (151) Cancer of large Intestine (153) Cancer of Rectum (154)
.
63 56 12
Cancer of LIver (135-156)
Cancer of Pancreas (157)
-
Cancer of Respiratory System (150-153)
Cancer of Lung (162-163)
10 42: 2)2 203
Cancer of Bone (170)
12
Cancer of Shin (172-173)
12
Cancer of Prostate (185.)
63
Cancer of Testis (186)
S'
Cancer of Bladder (13S)
.
n
Cancer of Kidney (189) .
20
Cancer of Eye (190)
1
Cancer of Brain * ether CHS (191-192,225,238) 25
Cancer of Thyroid (193)
1
Lymphatic and Hematopoietic Cancer {2C0-20?) 63
Lymphosarcoma S Retied osarcons (200) , 2
Hodgkin's Disease (EOT):
13
Leukemia 3 Aleukemia (204-207)
32
Cancer of other Lymphatic Tissue (208)
14
Diabetes Mellitus (250)
54
Infective & Parasitic Diseases
51
Tuberculosis Arteriosclerotic Heart Disease (410-413)
29 1145
Cerebrovascular Disease (420-438)
267
Nonrnalignant.Respiratory Diseases (460*519)
185
Emphysema (492)
46
Sastrlc l Duosenal Dicer (531-534)
13
Cirrhosis of Liver (571)
37
Diseases of Genito-Orinary System (80-629)
67
Accidents (BOO-949)
234
Suicide (956-959)
60
743.30 0.95 25.03 0,68-
240.44 0.83**
23.67 0.46**
59.81 1,05
64.59 0.87
26.48 0.45**
19.33 .0-52* 41.14 1,02
219.27 0.97
204.BE 0.99
4.51 2,66**
10.78 1.11
61M 1.02
4.84 1,03 23,44 0.47**
16.51 1.21
0.58 1.72
25.68 0.97 1 0.70
65.96 0.96
13.66 0.15**
9.17 1.42 27.76 1.15
14.86 62.18 152.20
0-94 0.87 0.34**
95.02 0.30** 1326.91 0.86**
360.05 0,74** 252.39 0.73**
49.79 0,92
35.43 0-37**
86.16 0.43**
100.02 0.61**
287.31 0,81**
74.05 0.81
tipii
d
be*; C.I. tower Upper Limit Limit
0.84
6.89
0,88 0.40
1.02 1,08
0.72 D.23 0.81
0.23 0.25 0.74 0.84 0.86 1.37 0.57 0.78 0.33 0.23 0,74. 0.02 0.63 0.01 0.73 0.02 0.75 0.79 C.S1 0.65 0.25 0-20 0.81 0.65 0,63 0.67 0.20 0.30 0.47 0.71 0.62
0,95 0.83 1.34 1.12 0.79 0.95 1.38 1.11 1.13
4.65 1.94 1.30 2,41 0.S4 1,87 S.SS 1,44 3.89 1.22 0.S3 2.42 1.63 1 ,.58 1.13 0,44 0,44 0.91 0.84 o.as 1.23 0.63 0.59 0.77 0.92 1,04
p < 0.05 ** p < 0.01
+ white and nonwhite combined
TABLE 8 STANDARDIZED MORTALITY RATIOS FOR SELECTED CAUSES 0? DEATH
SALARIED KALES4 1937-1978
Cause of Death (1C0A 8th Revision}
Observed Expected SMR
.995 C I, Loner Upper limit Limit
All Causes (000-999)
300 444.79 0,67** 0.68 0.76
All Malignant ^Neoplasms (140-209)
Cancer of Buccal Cavity and Pharynx (140-149)
Cancer of Digestive Organs A Peritoneum (150-159)
Cancer of Stomach (151)
,
Cancer of Large Intestine (153)
Cancer of Rectum (154)
Cancer of Pancreas (157)
Cancer of Respiratory System (160-163)
Cancer of Lung (162-163)
Cancer of Bone (170)
.
Cancer of Skin (172-173)
Cancer of Prostate (185)
Lymphatic S Hematopoietic Cancer (Z0D-2QS)
lymphosarcoma & Reticulosarcoma (200)
Hodgkin's Disease (201)
Leukemia A Aleukemia (204-257)
Cancer of other Lymphatic Tissue (203)
Diabetes Mellftus (230)
Infective & Parasitic Diseases
All Diseases of Circulatory System (390-4585
Arteriosclerotic Heart Disease (410-413)
Cerebrovascular Disease (430-438)
Nonaalignant Respiratory Diseases (460-51S)
Emphysema (492)
'
Gastric A Duodenal Ulcer (531-534)
Cirrhosis of Liver (571)
Diseases of 6enito-Urih.ary System (530-629)
Accidents (30D-S49)
Suiciae (950-959)
62 1
16 1 3 3 9
is
17 0 2 4
It 2 * 3 3 3 8
165 125
23 6 i i i 5
14 3
76,88 2,88
0,81 0,35
0,62 0.00
1.03 1.93
24.46 5,79 7.2D 2.97 4.19
22.08 20.64
0.60 1,42 6.01 7.43 1,57 l.U 3.23 T.45 6.41 10.72 231.80 147,62 35.22 25.20 5.49 3,76 9.33 9.79 32.86 9,96
O.SB 1 0.37
0.17* 0.00
0.42
0.08
1.01
0.20
2.14
0.98
0.86
0.52
0,82
0.48
0.00
0.00
1,41
0.16
0,67
0.18
1.48 0.74-
1,27
0,14
2-63
0.53
0.93
0.19
2.07
0,42
0.47
0,09
0,47
0.15
0.71**
0,85
0,70
0.65 * 0.41
0.24** C.09
0.18
Q,00
0.27
0.00
o.n* 0.00
0.51
0.16
0.43** 0.23
0.30* 0.06
1.06 0,96 1,22 2.96 4.08 1.34 1.32 0.00 5.09 1.70 2,65 4,60 7,76 2,71 6.04 1.37 1,09 0.83 1,00 0,98 0.52 r.oi 1.48 0*60 1.19 0.71 0,88
: p < 0.05 " p * 0.01 4 white arid nonwhite combined.
TABLE 9
STANDARDIZED MORTALITY RATIOS FOR SELECTED CAUSES OF DEATH TOTAL KALES*
1937-1978
Cause of Death (ICDA Sth Revision) All Causes (ODD-999)
Observed Expected SMS
4239
5046.15 0.84**
95L c.r.
Loner Upper Limit LiiSi t
0.81
0.87
All Malignant Neoplasms (140-209)
Cancer of Buccal Cavity & Pharynx {140*149) Cancer of Digestive organs and
Peritoneum (140-159) Cancer if.Esophagus (150)
813 18
229 12
Cancer cf Stomach (1ST) Cancer of Large Intestine (153) Cancer of Rectum (1S4) Cancer of Liver (155-156) Cancer of Pancreas (1ST) Cancer of Respiratory System (160-163) Cancer of Lung (162-163) Cancer of Bone (170) Cancer of Skin (172-173) Cancer of Prostate (IBS) Cancer of Testis (136) Cancer of Bladder (188) Cancer of Kidney (169)
.66 6S>18 - TO 52 244 233 12 TS 76 .5 12 22
Cancer of Eye (190)
2
Cancer of Brain & other CHS (191-192*225,238) 28
Cancer of Thyroid (193)
1
Lymphatic and Hematopoietic Cancer (200-209) 7$
Lymphosarcoma & Reticulosarcona (200)
4
Hodgkin's Disease (201}
16
Leukemia A Aleukemia (204-207)
36
Cancer of other Lymphatic Tissue (208)
18
Diabetes Bellitus (250! Infective & Parasitic Diseases
59 57
Tuberculosis Arteriosclerotic Heart Disease (410-413)
29 1328
Cerebrovascular Disease (430-438)
306
iionmalignant Respiratory Diseases (460-5T9)
eaohysesia (492) Sastric & Duodenal Ulcer (531-534)
'
200 49 17
Cirrhosis of Liver (571)
40
Diseases of Denito-Urinary System (5S0-629)
75
Accidents (SOD-949)
256
Suicide (950-959)
64
872.75 0,94
0,87
29.36 0.61* - 0.36
.1.00 0,97
281.80 0.81**
26.84 0.45**
69.52 0.95
76.77 0.85 31.45 0,57* 22,54 0.44**
46.28 1.08 257.24 0.95 240.40 0.97
5.32 2.26* 13.01 1,15 72.11 1.05 5,75 0.87 27.84 0.43**
19.59 1.12
.69 2.90 30.43 0,92
1.68 0.60 78.26 ,0.97
16,27 0,25**
10,94 33,09 17.34
1,46 1.09 1.04
72.93 0.81 170.89 0.33**
106.75 0.27** 1576.33 0.84**
418.67 295.29
59.42 41.80
0.73** 0.68** Q.S2 0.41**
101.45 0.39**
126.11 0.60**
338.30 0.76**
89,59 0,71:**
0.71 0.23 0,73 ` 0.55 0.34 0.21 0,80
0.92 0.78 1,20 1.08 0.90 0.81 1.41
0.83 0.84 1,16 0.84 0.33 0.23 0.22 0,70
1.07 1,10 3.94 1*90 1,31 2.03 0.75 1.70
0.33 0,61 0.01
10.47 1.33 3,31
0.77 0.07
1,21 0.63
0.83 2.3S
0.76 1,51
0.61
1.64
0.61 * 1.04
0.25 0.43
0.18 0.39
0.80 0,89
0.65 0.82
0.59 Q,7S
0.61 ' 1.09
0.23 0.65
0.28 0.54
0.47 0.75
0,67 0.86
0.55 0.91
- p 0.05 ** p < 0,01
T whi te and nonwhi te combi tied