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FILE NAME: Asbestos Cement Pipe and Sheet (ACPS) DATE: ^
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MORTALITY STUDY OF ITALIAN WORKERS
. COMPENSATED FOR ASBESTOSIS (1980--1990)
Daniela Germani (l),Mario_Grignoli (2),Stefano Belli (2),Pietro Maiozzi (2), Luigi Anibaldi (l),Ottavio Raparelli (1) ..Pietro Comba (2)
(1) National Institute for lnsu.rance of ~ccupational Accidents (INAIL),RomeJtaly
(2) National Institute of liealth {ISS)1RomeJtaiy
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OBJECTIVES
;he purpose of the present investigation-~-:-\
to study cause..specific mortality in a cohort
of subjects compensated for asbestosis .
I The rationale for this study can be
I
summarized as fallows.
Even if the carcinogenic action of asbestos
I
has been ascertained with regard to lung
!
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cancer and mesothelioma- of pleura,
I
I
perito11eum, pericardium and tunica
i
vagirialis of testisr conflicting opinions exist
about other cancer sites (Edelman 1992,
Garabrant et al 1992, Iioma et al 1994).
The present cohort , which deals with
subjects certa.inely exposed to elevated
concentrations of asbestos, can provide
information in this respect. Further1nore, it
may- be of interest to co111pare the mortality
pattern of asbestosic subjects from
different industrial sectors, corresponding_
to different 1nodes of exposure to asbestos.
Finally, this study may contribute to the very
issue of the n1ortality experience of
asbestosic patients, which has been the
object of some previous studies in various
countries and is currently being debated
(Berryl981, Cookson et al 1985, Browne
1986, liughes & Weill 1991 ).
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METHODS
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The cohort included all subjects compensated \
l for asbestosis- who were alive at 31. 12. 1979.,
aitogether 3417 subjects ( 2776 men and 641
women.).
The source of data was constituted by the files
of the Statistical Actuarial Service of INAIL.
Information available for every cohort
member included among else anagraphic data
and branch of activity, which were abstracted.
Vital status was ascertained at 30.6.1990 ; for
deceased subjects, causes of death were
obtained from the Registry office of the
municipality where death had occurred. The
subjects whose vital status was unknown at
the end of the study period were assumed to
be alive.
Cause-specific 1nortality ratios, standardized
fo~ age ( five--year bands ), sex and five-years
calendar periods., were calculated using the
PC--OCMAP pacl{age ( Ma~sh et al_ 1986 ). The
mortality rates of the Italian population were
used as standard; two-sided 95% confidence .
intervals ( 95% CI ) of standardized mortality
ratios ( SMR's ) were computed assuming a
Poisson distribution; the exact method was
used when observed death were fewer than 200; the chi-square approssimation was
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considered in the remaining cases.
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Table 1
Distribution of cohort members b
sex and branch of activity
Asbestos-cement industry
Textile ..industry
Naval industry
.
/ :
.r.
Insulators
: Others
Total
Men No. (~)
1298 159 369
57 893
.(46. 8)
( 5 ! 7)
(13. 3)
( 2 .o>
(32.2)
2776
Women No. ( %)
261 209
1
(40' J
(32
(
0
170 (26
641
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'i (
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., : ~.- ~- ~:- =fi?j,~.1l~.-:~(-.:j~f~-~it~--if~. 1. ---:
~- :, . -~':~ ~/t. --~ ~~-.~,:~~- =-":.~i'~. ,. :::.~ '-::-r . . ---~ -:~---'{'~ -
Pg: 6
Table 2
Mortality among asbestosic subjec:
(men)
CAUSE OF DEATH
OBS
All causes
980,
Infectious diseases
7
cardiovascular diseases
223
All ma1ignancies
380
Benign and unspecified tumours
0
Blood disorders
0
I. Respiratory diseases
184
1 Digestive diseases
46
Cirrhosis of the liver
33
Diseases of the genito-urinary tract
4
Psychological disorders
0
Diseases of the nervous system
3
Diabetes
5
Violence
32
Ill defined and unknown
7
SMR
153(* 201
84(* 188(*
361(* 99
107 44
34(* 31(* 125 111
, ~ : ,.; .. . . . . . , .
~c'ER SITES
------~-----------------~-------------
Buccal cavity Digestive tract
Esophagus .Stomach Small intestine Big intestine Rectum Liver Pancreas l?eritoneum Respiratory tract Nasal si.nuses Larinx
Bronchus and lungs Fleura
Connective tissue Melanoma Skin Prostate Bladder Kidney Nervous system Thyroid Lymphohaematopoietic
tissue
8
88
2
24
2
14 10
14
8
11 217
0 4
180 27 1
2 l
11 13
4 6
0
10
Pg: 7
126
125 ( *)
41 108 697 140 162 114 107 1344 (*) 297 (*)
59 281 (*)
2408 (*)
362 185 150
88 128
98 150
88
= lower limit of 95% CI> 100 or upper limit of 95% CI< 100
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Table 3
!Mortality among asbestosic subjects
(women}
j! CAUSE OF DEATH
II - - - - ..... - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - I
All causes Infectious diseases
Cardiovascular diseases
Al.l malignancies Benign and unspecified tumoure Blood disorders Respiratorydiseases Digestive diseases
Cirrhosis of the liver Diseases of the genito-urinary tract Psycho~ogical disordars
Diseases of the nervous system
D~abetes
Violence
Ill defined and unknown
OBS
154 0
43
58 0 O
34 3 2
3 0 o
3
2
1
SMR
151 (*)
86
228 (*)
653(*) 55
69
224
55
59 49
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CANCER SITES
-----------------------------.--------
Buccal cavity Digestive tract
Esophagus stomach smal1 intestine Big intestine Rectum Liver Pancreas l?eritoneum Respiratory tract Nasai sinuses Larynx
Bronchus and lungs l?leura
Connective tissue
Mel.anoma
Skin Breast 'ovary Bladder Kidney Nervous system
Thyroid Lymphohaematopoietic
tissue
0
17
163
0
l
36
2
4652 (*)
7
371 (*)
1
104
0
2
166
3
1481 (*)
34
653 ( *)
1
5486 (*)
0
10.
538 (*)
7
5967 (*)
1
1910
0
0
4
89
6
545(*)
0
0
0
0
l
55
. (*) - lower l.imit of 95% CI > 100 or upper limit ot
95% CI< 100
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Table 4
Mortality among asbestosic subjects
in asbestos-cement industry
(Casale Monferrato plant)
CAUSE OF DEATH
All causes Respiratory diseases All malignancies
MN of lung pJ.eura peritoneum in.testine and ovary
rectum
OBS
248
49
124
50 19
5 8 3
SMR
---'
154(*) 409(*) 258(*) 381(*) 7348(*) 2192 (*)
189
844 (*)
Table 5
;Mortality among asbestosic subject in asbestos-cement industry
(other plants)
CAUSE OF DEATH
OBS
'--------~~~---------------------------
All causes
199
Respiratory diseases
28
All malignancies
61
MN of lung
26
pleura
2
peritoneum
2
S'.MR
122(* 245(* 113
153(*
665(* 849(*
_.x. regu de :
.
.
Pg: 11
... :,..,._:.
. Table 6' .
Mortality among asbestosic subjects
in textile industry
CAUSE OF DEATH
All causes Respi~atory diseases
All malignancie_s
MN' of lung pleura peritoneum intestine and
ovary
rectum
OBS
141 33
46 19
2 2 3 3
SMR
178(*) 583(*) 221 (*) 428 (*) 1878(*)
1765(*) 148 910 (*)
Table 7 Vlortality among asbestosic subjects
in naval industry
CAUSE OF DEATH
OBS
----------------~---------------------
All causes
115
Respiratory diseases
19
Al1 malignancies
53
MN of lung
26
pleura
5
peritoneum
1
,-,.
SMR
126 (*) 259 (*)
185 ( *) 290 (*) 3153 (*)
871
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Tables
-.. .
, L..:~~/ -
Mortality among asbestosic
insulators
CAUSE OF DEATH
Al1 causes Respiratory .diseases
All malign~cies MN of lung
pleura
peritoneum intestine and
rectum
OBS
21 l
12 8
0
0
1
SMR
227 (*:
161 367 (*) 722 (*)
407
RESULts
.,,....,.,.--
.
. -- - - - - -..._ .....,,
At the end of the study period, 22.35 subjects were
alive and 1134 deaths occurred; 48 subjects were
lost, corresponding to 1.4 % of the initial cohort. The cause of death was not ascertained for 78 subjects,
corresponding to 6.9 % of the deceased.
Observed and expected 1nortality for men and
women are shown in tables 2 and 3, respectively.
Mortality from all causes, all malignant neoplasms
and diseases of the respiratory tract were
significantly increased in both sexes. The increase in neoplasms was essentially due to tumors of the
respiratory tract (lung and pleura) and peritoneum
and, an1ong won1en, ova1y and intestine. Analysis by branch of activity provided some further
information of interest.
Asbestos cement workers constituted the largest
subcohort; about half of them came from a single
facility located in Casale Monferrato ( Piedmont ),
and they were the object of a separate analysis
( table 4 ). As it can be seen asbestos cement
workers fro1n Casale showed significant increases for
most SMR's in both sexes. Asbestos cement workers
from other facilities ( table 5 ) showed significant
increases for most of the causes of death at study,
even if SMR's were lower than in the Casale
subcohort among 1nen; a1nong women, because of
Ihnited size, no final conclusion could be reached.
Significantly increased SMR's for most of the causes
of death at study were seen among textile workers in
I ,i both sexes ( table 6 ). Naval industry workers, all men , showed significantly increased mortality for lung and pleural neoplasms, all neoplasms, respiratory diseases and all causes of
death ( table 7 ).
Among insulators, 57 male subjects, a, striking
increase of lung cancer was detected ( 8 observed
versus 1.1 expected).
CONCLUSIONS
;;:-:-~en; study revealed slgnlflcant increases in mortality fro~-:espi~:~
disease and from cancer among asbestosic subjects; the excesses in neoplastic causes of death concerned pleural and perttoneal mesotheliomas lung, intestinal and ovmian cancer. This study Is consistent with other coho1t studies of asbestosJc subjects pertonned In Finland { ttuuskonen 1978 ), Geat Britain ( Beny l 98 l ), Australia ( Cookson et al 1985 ) and US (Hughes and Weill 1991 ), and With previous findings from Italy ( Rubfno et al 1981 ). Besides confirming the causal association between exposure to asbestos and occurrence of lung cancer and pleural and peritoneal mesothelioma, this
study detected a significant Increase of ovruian and intestinal cancer.
ovarian cancer has previously been associated with occupational exposure to asbestos with special reference to the manufacture of gas masks (WlgnalJ & Fox 1982 , Acheson et al 1982 ), of asbestos textiles ( Newhouse et al 1985 ) and the extraction of rock salt ( Tarchl et al 1994).The Issue or intestinal cancer in asbestos workers has been studted with confl!cting
results, Ehrlich et al (l 991) detected asbestos fibres in the colon of cancer
patients previously exposed to asbestos but not In colon carcinoma patients without previous occupational exposure and Vineis et al (1993) de8cribed an excess risk of colon cancer among plpefitters and boilermakers; on the other hand, no association between colon cancer and asbestos exposure was found by Oarabrant et al (1992) in a large case-control study. Recently, t1oma
et al (1994) suggested that exposure to relatively high concentrations of
amphiboles in required in order to induce colon cancer. The present study detected significant Increases in rtsk associated with different occupations, in agreement with previous resUlts from various counuies ( IA~C 1987 ). The extremely severe disease pattern of asb~to~ cement workers from the Eternit facility 111 Casale Monferrato is coherent with
the findings of the Casale occupational cohort (Magnani et al 1987), the workers wive-s cohort ( Magnani et al 1993 ), and the figures on
mesotheliomas in Casale's general population (Magnani et al 1991 ). The major limitation of the present study is due to potential misclassification
of causes or deat11. In Italy, death certification of lung cancer has a good
agreement \Vith clinical diagnosis { over 80% ), but lt underestimates the occurrence of the disease if a compmison is made with necropsy data
( Delendi et al 1991 ). A national survey showed that about 75% or pleural
mesothe!Ioma cases are correctly classtned on deatl1 ce1tiflcates, while a necropsy based study in Trieste provided a much higher estimate of false .negatives {80%), and a 20/o estimate of false positives ( Delendl et al 1991 ).
Misclassification of abdominal neopJasms,includfng peritoneal mesotheliomc:t and ovmian cancer, Is commonly thought to be relatively high (Bruno et al 1990), "Best pathologic evidence procedures, such a5 lho~1;:; applied by
Selilwff to US and Canadian insulators, may be Implemented with respect to
the coh01t at study in order to achieve a deeper Insight in the emerging pattern of disease. With respect to misclassification, It should nnally be noted that three more subjects had a mention of mesothelioma In the death ceJtificate ( In one case it was not the underlying cause of death; in two cases the JocalizaUon was not specifled), while for 8 subjects the cause of death was peritoneal carcinosis or peritoneal neoplasm of unspecitled nature; 14
deaths were ascribed to unspecified neoplasms.
Permanent epidemiologic surveillance of the cohort of ltalian asbeslo~ic subjects is required in order to follow In tlme the evolution of their cause-speclflc mortality; in the meanwhile, a llmlted number of actions aimed
at decreasing Individual Tisi{ of these subjects, sue has ad hoc antismok.e
campaigns, should be seriously considered.
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REFERENCES
-~------ --------------------'-,,\
Marsh et al. 1986 Amer. Statist. 40:308--309 Edelman 1992 Int. Ard. Occup. Environ. Health
63:469-475 Garabrant et al. 1992 Amer. J. Epidemiol.
135:843-853
ttoma et al 1994 Amer. J. Ind. Med. 139: 121 o~ 1222
tluuskonen 1978 Scand. J. Work Environ. Health
4:265,.,274
Beny 1981 Br. J. Ind. Med. 38:130--137
Cool\son et al. 1985 Br. J. Ind. Med. 42:461~468
Bro\vne 1986 Br. J. Ind. Med. 43:145-149.
Hughes & Weill 1991 Br. J. Ind. Med. 48:229-233
Rubino et _al. 1981 Atti 44 Congr. Naz.Soc.It.Med. Lav.
Ig.lnd.1Pactova 73-79 Wignall & Fox 1982 Br. J. Ind.. Med. 39:34.,38 Acheson et al. 1982 Br. J. Ind.. Med. 39:344--348 Newhouse et al. 1985 Br. J. Ind. Med. 42:4-11 Tarchi et al. 1994 Amer. J. Ind. J\1ed. 25:251 w256 Ehrlich et aL 1991 Amer. J. Ind. Med. 19:629-636 Vineis et al. 1993 Tumori 79:301-303
IARC l 987 Suppl. 7: 106-1 16
Magnani et al. 1987 Med. Lav. 78:441-453 Magnani et al. 1993 Br. J. Ind. Med. 50:779,.784
Magnani et al. 1991 Lancet 338:50 Delendi et al. 1991 IARC Sci. Publ. 112:55-62
Bruno et al. 1990 Epid. Prev. 45:39~47
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