Document 5n0XMX4KMqwo7nDnRo5JVqrV

Medical Department Charles H.Hine.M.D. Medical Director I RW*. M. O.Vkmt ! Cco jbc Jftimam 26 June 1930 Messrs. KWNelson and MOVarner t / MOV RDP .. oar .. q LOW .. D SD.-5 ^ .. .as Re: Mortality Experience in Asbestos-Exposed Persons I recently saw a case of pharyngeal cancer in a person who had relatively low exposures to asbestos fibers. He wa? a warehouseman and his exposures occurred while unloading boxcars in which the shipped asbestos .had broken loose-from their containers. As I was not aware of any data indicating a relationship between pharyngeal cancer and asbestos exposure," I requested a review by the Institute of Occupational & Environmental Health (which ASARCO helps support). They sent me the enclosed paper by Selikoff. I think that you will find the statistics interesting. CHHine/ CHH:cab Enclosure CC r- DHSoutar:M-JMessel ASARCO Incorporated 7604 Rincon Annex, Sail Francisco.California HAlzu 357 Tehama Street (415) 777-2210 1 i l ASARCO ALV 0002076 o30: 91-116. 1979. MORTALITY EXPERIENCE OF INSULATION WORKERS IN THE UNITED STATES ' AND CANADA; 1943-1976* 1 V.. ; .. Irving J. Sdikoff " * 'Environmental Science! Laboratory ;V: r .*"'* Mount Sinai School of Medicine t--.= v:Lu.J'e The City University ofNew York * ' ^'\'J;:r.:.:.NewYork.New York 10029 * * Code ww 10 36 37 38 63 70 80 81 ..... yr-.--T-'V.. , i* t. jl*. * .r. asbestos-insulation workers in the New York-New Jersey metropolitan area 1943-- .i'jarsre'.: 1962.1 Significant Increases in deaths of lung cancer, mesothelioma, gastrointestinal 3=eSi:.`cancer.and asbcstcsis.were found. Ftndings..were limited to observation of only-632 men.' howcveriuOa January.-1;-1967,'a larger cohort was enrolled for prospective .v.;S3^trobservation and included aIM7,800 men on the rolls of thrinsulation workers' union (Internatiunal Association , of .Heat and Frost Insulators and Asbestos Workers, 'i=Sesf/c-AFLiCIO, CLC) in the United States and-Canada on that day. This second cohort '-IiS5L":s:.included the survivors of the-original 632 New York-New jersey men. Observation has been maintained and an interval report of deaths in this group since January 1, ; 1967 has been made.1 The present analysis details findings among these men through "`i-isTyt:- December31,1976.--^*'r*-""rserd-c:rar ` * lb1';'!'"? - - * J::tV'itiS-'i-. Asbestos Insulation in the United States Asbestos, as a mixture of fiber and sodium silicate, was first used as an insulation .... ' material in 1866 and as asbestos cement about 1870. Magnesia with asbestos as a "/. . binder soon followed and air-cell covering, using corregated asbestos paper, was introduced in 1898. --- .s r-.---.i-- The first union of insulation workers in the United States was formed in New York ' City in 1883 under a charter issued by the Knights of Labor (predecessor of the American Federation of Labor), as "The Salamander Association of Boiler and Pipe Fellers."-The present union of insulation workers in this country as chartered by the - AFL in 1910, as the International Association of Heat and Frost Insulators and - Asbestos Workers, by the amalgamation of the Salamanders Association of New York with other independent locals throughout the country. Members of this union are insulation workers, primarily employed in the building trades doing construction insulation work but also employed as insulation workers in refineries, industrial plants. ' 'This study was supported by grams from the American Cancer Society (R-53), the National Institute for Occupational Safety and Health (0H00320) and the National institute of Environ mental Health Sciences (ES0092S) of the US. Department of Health. Education and Welfare, and the Health Research Council of the City of New York (U1272). 91 0077-4923/79/03:0-0091 St.75/0 o 1979. NYAS ASARCO ALV 0002077 92 Annals New York Academy of Sciences shipyards and powerhouse construction and repair. Much of their work is in the open but sometimes, as in shipyards, in rather tight quarters. The men generally work in all parts of the trade, with few specialists at one or another pan of it. Conditions at work vary from job to job and from company to company, with fewer than 1 Oro of the mea ' remaining with one company during their working lifetimes.' Data published concern ing work practices in other countries suggest that asbestos exposure in insulation work has been approximately the same the world over.4 *' o . Asbestos exposure to which insulation workers are subject has been limited, varied ' and intermittent. Some of the materials used have contained no asbestos. In the early part of the century, magnesia pipe coverings used shredded rope as a binder, with no asbestos. Somewhat later, wool-felt. cork and rock wool,were used. Starting during World War II, fibrous glass products came into increasing use and, during the 1970s, their utilization was greatly expanded, as asbestos content of insulation materials sharply ..decreased. Magnesia block insulation, including molded pipe coverings, usually .contained approximately 15% asbestos, while asbestos cement generally had Jl5-20% or. less*of-asbestos. Asbestos paper products contained a higher asbestos content, buLwere used in much smaller quantities. . . r at Until approximately the early 1940s, chrysotilealone was utilized in the manufac ture of the asbestos insulation products used by these men.'Amosite began to be used in the.mid-1930s in small quantities but became more widely utilized during World .War II and subsequently.2.^, - .m.tt . . -. : -rr n. Few dusfeounts were made in insulation work until the mid-1960s. However, analysis of available data, including reconstruction of work situations and extrapola tion to the past of observations made more recently, suggest that insulation workers would have been exposed to dust levels of 4--12 .fibcrs/ml (as time weighted Table 1A - ' -* Membership or New York and New Jerset Insulation Workers' Union* January 1, 1943, Classified by Ace and Years from First Exposure to asbestos Dust ' Total . .. ., .Number Age. or Number of Years Since First Exposure to Asbestos Years Members 0-9 10-14 15-19 20-24 25-29 -30-34 35-39 40--44 45-49 50+ 15-19 2 ;. 2 . ' * ; .1 . * '* 20-24 25-29 30-34 35-39 . - 14 .14 38 . 19 19 n* v.*:m ` 76 '.2 l '.V "*! 9241'....'..'26 .'--6 . i J--t* < */>*. a . r''* "*'** * * v.* . . .. . ' M 1 * *** 40-44 ,4 -l - . 45-49- J=;r;77.:lr^ . 4 .is . 30 . 2;:eiAl9-. :.~29 - to - ::i 24 : r i * * * ** .... ,*.f 50-54 82' 2 9 - 24 - - 18 : .24*..*' 4 . 55-59 - .5 . i .. 4 9 11 -'20 19 1 60-64 41 2 5 8 3 13 6 4 ; 65-69 70-74 75-79 80-84 Total 23 13 3 2 632 l 2 21 3 8 * 222 * *I 40 14J 140 108 70 67 40 4 2' 3 1 15 2 2 4 3 3 'Locals 12 and 32 of the International Association of Heat and Frost Insulators and Asbestos Workers, AFL-CIO. * I ASARCO ALV 0002078 SeHkofTer c/.: Mortality of Insulation Workers 93 Table IB Man-years of Observation. January I. 1943-December 31. 1962. or January 1. 1943 Membership of New York and New Jersey Insulation Workers* Union* Classified by attained Aoe and Years from First Exposure to asbestos Dust - - Attained - v Age. Yeais Man-years - ''.<20 Year* from Onset 20-34 ` 354* i 15-19 . 20-24-.- 25-29 -f 30-34 ' --* ' *. 4 *=--.*"4 . * 144 - *; ' 44 * . .. ,--- ' S165 -xl '.' * 165 542 tt.-.. -542 iiT*. * .* ; r r-* * " t_ __ ----- 35-39 40-ti 1.068 1.339 773 .... *. 295 ... llwuu _ J-- 253 .. 1086 . 4-^^45-49~V:- L I_5SS ' 74 -- V 50-54 ------ - 55-59 js ... . 1.562.-- --.39-.-.-=.-=.-^1368 [ J44 --- 28 . jTfilie- 782 155 -- 534 -A-C 50--64--^" -Web'v " 22 = i:r 361 i. * 759 .: 65-69 - V 849 17 . j75 --657 70-74 v" v ------------------j;.-513.-9 75-79 *' ; .. 242 ,.v- . . -- ' 80-84 84 -- .72 33 1- -' 432' 209 \ I; .. .. ,85-t- ;:*29~ -- *' * - -- --29 Toul : * 10.515 ' 1970 *' 5683 2862 Jnternau'onit Association of Heat and Frost Insulators and Asbestos Workers, AFL-CIO." averages).1 While there might have been periods of little or no exposure, jhere could also have been times of peak exposures much higher than the calculated averages. Mortality Experience of New York-New Jersey . .-. Insulation Workers 1943-1976 On January 1, 1943, there were 632 men registered as members of the two locals of the International Association of Heat and Frost Insulators and Asbestos Workers in the New York-New Jersey metropolitan area (Locals 12 and 32). Their age distribu tion according to years 'from onset is contained in Table IA and man-years of observation 1943-1962 are shown in Table IB. . ". . .- Each of these men was traced to December 31. -1962; expected and observed deaths are found in Table. 2. Nine men died before reaching 20 yean from first employment, and they are excluded from -Table 2, which is limited to the 623 men who achieved, that point. While deaths related to asbestos exposure of the kind experienced by insulation workers may sometimes occur in less than 20 years from onset of employment (lung cancer, asbestosis and, occasionally, mesothelioma) these are not common and we consider that analyses of experiences beyond the 20-year point more clearly define the influence of such exposure. It was of interest, parenthetically, that there was no excess in total deaths of all causes during the first 10 years of observation. 1943-1952. in the post 20 yean from onset experience-fahhough an excess was seen for lung cancer specifically), as example of the "healthy worker effect.*" .... . .. Observation of the survivon of the original cohort has continued prospectively and by December 31.1976,478 of the original 632 men had died. The same overall pattern of causes of death has continued, although distribution ofdeaths by cause has changed i ? * ' i *.* ( / ASARCO ALV 0002079 94 Annals New York Academy of Sciences ' Table 2 Expected and Observed Deaths Among 623 asbestos Insulation Wo*,iceas New York-New Jersey. 20 oa Moae Yeaas After Onset of Work Januaay I. 1943-DECSmbex 31. 1962 (8J45 Man-years of Observation) Underlying Cause or Death Expected* Observed Total'dealhs-all causes Totalcancer-allsites--ru-.-r -. .- Lit.: 195.4 : jit 253 ` -95 -- ; Cancer of lung xer--:.nTi'. eee.'.: - ltt. * .6.0 - 42 ... -.l:--- - Pleural mesothelioma ' l---: . Peritoneal mesothelioma-- "" t .:.v; 3 ; l_r,' 4----- . Cancer ofesophagus, stomach, colon-rectum ; . 9.7 29 ;. Cancer of Larynx, pharynx, buccal cavity. J 1-7 ,, . .. Cancer of kidney 0.7 - o ' --. All other cancer ' 14.0 15 -Noninfectious pulmonary diseases, total ~-J , .. . AtbesttKii' -I---/,.* rr-. 4.0 " - . t__- - -.7 E..12._f . All other causes '* ` * 159.3 144 *.* Expected deaths are based upon white male age-specific U.S. death rates of the US__ National Center for Health Statistics. 1949-1 >o2. Rates for specific causes of death for 1943-1948 were extrapolated from rales for 1949-1955. _ : tRates are not available, but these have been rare causes of death in the general population. * somewhat, reflecting a number of epidemiological influences. Thus, pleural and peritoneal mesothelioma, which tend to occur somewhat later than bronchogenic carcinoma, became proportionately more common (Table 3). This change in prepon derance also reflects the smaller proportions of older men who ever smoked cigarettes, and also a "survivor effect." Since the cigarette smokers in the original group had i .. Table 3 -: Expected and Observed Deaths Among 632 New York-New Jersey . Asbestos Insulation Workers January 1. 1943-Decemier 31. 197S (13.925 Man-years of Observation) Underlying Cause of Death Tout deaths, all causes Tout cancer, all sites Canceroftung . - -y'J - Pleural mesothelioma Peritoneal mesothelioma Cancer of esophagus ....... .. . Cancer of stomach ' _"* .* > Cancer of colon-rectum "*' ** Cancer oflarynx, pharynx, buccal cavity Cancer of kidney -.; *- All other cancer Noninfectious pulmonary diseases, total Asbestosis All other causes Expeaed* Observed 328.9 478 57.0 210 := ' . 13.3 . : 93 . .. j> :* t r..\` ..11 ' t. 27 . 7 .I:.- ... - 1-4 _______ - 1 . .7*.". 5.4 19 . : - '. 8.3 ; 23 2.8-'.-; ' u -. - ---*.-j -- --.tz 24S - - 2S* 9J 45 t 41 262.6 223 `Expected deaths are based upon white male age-specific U.S. death rates of the US; National Center for Health Statistics. 1949-1976. Rates for specific cause of death for . 1943-1948 were extrapolated from rates for 1949-1955. t Rates are not available, but these have been rare causes of death in the general population. | ' c- ' c ASARCO ALV 0002080 Selikoff <*/ a!.: Mortality of Insulation Workers 95 increased mortality risk (especially from lung cancer and cardiovascular disease) there would likely have been comparatively fewer men with a history of cigarette smoking and still fewer who continued smoking at least the same amounU-among the cohort survivors, as the years went by. Except as influenced by other factors associated with advancing lapsed time since onset of asbestos work, this would make for fewer deaths of lung cancer.* with more men at risk of dying of other asbestos-associated disease. / Lung cancer remained the most important cause of excess deaths, with 93 such deaths observed vj.,13.3 expected. Thirty-eight deaths occurred of mesothelioma. 11 pleural and 27 peritoneaL The increase in gastrointestinal cancer originally reported in 1964 was again seen, with 43 deaths cbserved_l5.l expected. There were41 deaths of asbestosis. In addition. 4 deaths were observed of other noninfectious pulmonary diseases. Apart from cancer, asbestosis. and other noninfectious pulmonary diseases, observed deathsj.were fewer than expected of all other, causes; .only-223 seen, approximately 40 fewer than anticipated. This experience, with 19% of deaths due to lung cancer, 8% the result of mesothelioma. 9% of gastrointestinal cancer and 9% of asbestosis and other noninfec- tious pulmonary diseases, begins to provide a broad outline of the total mortality experience of insulation workers employed under conditions of the past (much less asbestos insulation was used in new construction after 1972. although variable and intermittent asbestos exposai e would be expected to h-ve continued to occur during repair work).`765& of the original cohort enrolled in 1943 had died by the end of 1976. Variations in distribution of deaths by cause over time may be seen in TablE`4. Among the 9 deaths listed before 20 years from onset of exposure, there was none of lung cancer, mesothelioma, gastrointestinal cancer, or asbestosis and other noninfec tious pulmonary diseases. Variations are also evident in the two periods, 20-34 years and 35 or more years from onset. Although the proportion of deaths due to cancer of all sites was virtually identical in the two periods (44.5% and 44.3%), the specific neoplasms were quite different in proportional distribution. Lung cancer accounted for 49% of the cancer deaths in the shorter period but only 43% later. There were 7 deaths of mesothelioma in the 6263 man-years of observation during the 20-34 year span but 31 such deaths in the 5692 man-years later on. It is of interest, too, that the proportion of mesotheliomas that were pleural in location also changed over time; 4 of the 7 were . pleural in the earlier period, against only 7 of 31 in the second period. It is clear that * unless opportunity for prolonged observation is available, it will be difficult to fully evaluate the distribution of deaths by cause among asbestos-exposed groups. Concomi tantly. such analysis will be enhanced by considering deaths in each period of duration from onset, separately. ; . Not unexpectedly, deaths of asbestosis were again largely concentrated in the 35 or more years from onset period; 38 of the 41 such deaths were found at this time. It has been of interest to inquire concerning the experience of those insulation workers whose exjxssure began after 1943, since this would reflect postwar conditions. Eight hundred and ninety men joined the New York-New Jersey metropolitan area:, locals of the union during the period January 1, 1943-December 31.1962. Most (833) had had no prior asbestos employment before entering the union.These men have been observed prospectively from the time of admission to the union to December 31,1976 (Tables 5A and 5B). Our experience with their pre-1943 predecessors had demon strated that we were to expect relitively few deaths before 20 years from onset of their work. Still, because of the importance of evaluating postwar experience among men not exposed in earlier years, we undertook this study. Table 6 details their mortality experience from first employment to December 31, 1976. In the 15.520 man-years of observation`during the less than 20-year period, there was no unusual mortality experience. Altogether, there were fewer deaths than expected (again, the "healthy .t asarco alv 0002081 96 Annals New York Academy of Sciences > r* <r n o r* r* .O . < =v%> r Ko 3- i"s# .i; o MN < -o ^ . n c -- < r ^o< * .> * * i .. ..V . t 2 *% ,A w --,s*. . . ^srsi'iaTrrx1: ^ T **v %o r- no< c. . . ....... rti S ^ 2i >5 A z5 M 23 << Q au > o2 ; r-!< ^.o *r *> ^ Ok 39 ' * -- s> P ft O O O O O < 0~r><*_4~~r4 o c d-o ooo < => rl. t-T.-t- ?.* ' H o -. "d , -&TSe * ** -CK 5 0.0 Arr --. ---- s C .... C -5 . . 3cs 3"g=o2 ? . * W **sU: . f|8 is- . o ! - : .- aSS. . E u - - ' u "" ----------------- -1 -- _*aS* o M s (U1 w oe 1: E z9 o _=MuS*J3s25* mcDffosmt ,roo2. --iwcocc&*.j5oW25z -2Cs^ 2 c. 5=>C**;KSsrJj*S-3 BS vJut*=2E ~ .1 c..2 s s - 8.2 g 3 = 3 S e E u? R= O^ 5 ae 0 u V uw- u wo wo-u5s w uSS'? -- s U i2u^elSus" Z_ g S-5 .............g-3 _ ar 2 SOEfc uuuu o< < hi- 5^ * c2 j 3 -*-.* ;v- 5" l S -- .** - uMr? as *2 * * I r ttc^> .............. ft S M C fl S u> *05**0i c <9 O -25 SbCUSw3*' ty JSsS^L * ** ; I k* * ct ASARCO ALV 0002082 I Table 5A . _ New York and New Jersey Insulation Workers Observed January l. 194JDecemrer 31. 1962. AND Subsequently to December 31. 1976 (Number of'Men Attaining Category) Period 1943-1952 1953-1962 1963-1969 1970-1976 Union Member! Jan. 1.194) . Yean from Oniet Men Joining Union 1943--1962 * ' Years from Onict Total <20 20-34 35-- Total . <20 20-34 35* 632 - 325 . 523 190 412 -- 412 _ 542 40 393 321 833 833 -- -- . .t*~**^ 370 : : \ 154 ;-32S. --- 828 v.- 828 ;'258 .* .* - 234 !---_r-. 2 32 zr.--.224 - -811 561 515 *: -- ... . .. ' * 'V;.r s', ST'.S^ '"5 V'r?f'`Taue'5B -/- Man-years or Observation of Nr*1 York and New Jersey ... Insulation Workers, 1943-1976 'm '. --" *' (Number of Maa-yeirs) " '* -i - ... Union Members Jan. 1.1943 4 Yean from Onset . * Men Joining Union 1943-1962 ; ,, Years from Onset. ~.*,t .. .. . '- * Period ' Total <20 20-34 - 35* Total <20 20-34 -- -35* *::;; 1943-1952 5928 . 1682 3253 ..993 1658 . 1658 . _ . 1953-1962 .' 4587 288 `*2430 ' 1869 5906 *'"5906 ` j. 1963-1969' J 2088 -- 418 1670 5752 -'5156 596 *.*.; 1970-1976 1322 * 162 " * 1160 5485 . 2800 2685 ' -- -T- V-* **" Table 6 Expected and Observeo Deaths Among 833 New ;York-New Jersey Asbestos Insulation Workers First Employed January 1. 1943-December 31, 1962. and Observed from First Employ.ment-Dece.mber 31. 1976 (Duration from Onset of Employment) Number of Men Attaining Category Man-years of Observation .. Underlying Cause of Death To;:! deaths, all causes ................ TotT. cancer.all sites ' ''' I' ""' Cancer of lung Pleural mesothelioma Peritoneal mesothelioma .." . Cancer of esophagus, stomach.;: ; colon-rectum - . \. .... Cancer of larynx, pharynx, buccal cavity - Cancer of kidney . ... All other cancer " - Noninfectiou* pulmonary diseases, total Asbestos!* All other causes Less than 20 Years 20-34 Years 833 15520 523 - -. 3281 Expected* Observed Expected* Observed 39.8 - ' 5.1 23 *. - 24.8 39 5.- ::c' 5.0 * ' 15 ` `- ' 1.1 -* . t t 2 0 ` . 0 .- t 1.8 8- -- ^ i *, .! * * 2 . - . t- . :* 1 . -` .4... ------ .0.1- .... 02. 0.1 3.0 1- --- l` 0. 1* 0.8 .... 2 05 '.r- . 0.1 V r *; 2.0 0 ; -. 05 * 0 0.6 7 t 0 t 6 .T 34.2 IS 19.2 17 ^4pned deaths are based upon white male age-specific US. death rate* -of the US. > ationat Center for Health Statistics, 1949-1976. Rates for specific causes of death for 1943-1948 were extrapolated from rates for 1949-1955. tRates are not available, hut these have been rare causes of death in the general population. j 98 Annals New York Academy of Sciences worker effect") and there was no increase in cancer deaths. No mesotheliomas were seen, nor deaths of asbestosis. There was no significant increase of cither lung cancer or gastrointestinal cancer. Since the 20^year point, we have begun to see the changes predicted by our earlier studies. In the 3281 men-years of observation 20-34 years from onset.'therc were approximately three times as many cancer deaths as expected, primarily due to lung cancer. Mesotheliomas were now first seen and some deaths of , asbestosis occurred. These had occurred primarily during the period 1970-1976 * (Table7)__ ; - 1 .*- . ` . When the post-1943 workers were compared with those first exposed before that \ . time; and evaluation was limited to observations less than 20 years from first exposure, it was found that neither group had unusual lung cancer, mesothelioma or asbestosis : experience. Table 8 demonstrates that among 325 pre-World War II men who had not reached 20 years from onset of exposure during their period of observation, covering 1970 man-years, no excess of these diseases was seen. Similarly, among the 833 post-war men, with 15,520 man-years of observation during the shorter than 20-year from onset point, and with exposures starting 1943-1962, neither mesothe lioma nor asbestosis dealhs.occurred and there were not significant excess deaths ofl. lung cancer. This is of interest in that, by and large, only chrysotiie exposure had occurred before 1943 for the first group, while amosite was added to chrysotiie in terms of potential rxposure.-from 1943 en. The after-1943 group was potentially.-, exposed to-both`types of asbestos throughout their work experience. These data- jpdicatc that amosite did notsWten fh nerio-t y-K-'T-.t for <[%. . associatc^JiKsse in these insulation workers. Further, taken together with the data in': ` Tables 6 and 7. these observations suggest that the mortality experience of insulators exposed to both chrysotiie ano amosite wiii pe in the same direction as those originally.. yrniTwl nnivtneHrysotile and later to insulation dusts also containing amosite. TaSTe 9, reviewing deaths of selected causes 20-34.years from onset in the posi-1943 group, and comparing the findings with observations in the prc-1943 group for the same time span, suggests that this will be the case. ' Mortality Experience of Insulators in the "United States and Canada 1967-1976 * There were 17,800 men on the rolls of the asbestos workers union in the United Stales and Canada on January l. I967t. A good deat of information concerning these men was available, including date of birth, date of first insulation work, employment status on January 1, 1967. Additional information was obtained by questionnaire from ' a majority of the men concerning current symptoms, respirator use, smoking habits, work practices. . . ...... Wc have maintained observation of this cohort since 1967, with the. valuable * ' assistance of the local and international officers of the union. The men are registered in approximately 120 local unions in the various parts of the United Slates and Canada, including Alaska and Hawaii. Whenever an insulation we*' associated with the union dies, we are notified. In most instances, a dcatn certificate is forwarded; - - if not, it is obtained. As with the New York-New Jersey group, information is then sought concerning the details of the circumstances of death.1-1 including 'inical data, roentgenograms, histological material obtained at surgery or autopsy.The clinical and tlntemationa! Association of Heat and Frost Insulators and Asbestos Workers. AFL-CIO, CLC .I ASARCO ALV 0002084 ! Selikoff ei a!Mortality of Insulation Workers 99 ( / ASARCO ALV 0002085 Annals New York Academy of Sciences o iS sU >* Qa Z<a M* 25< tZBJ O2 it S s Zg 5j. Uai 3" s LK t-l 5 UH. M E" 2 S -9uo Cnev*ro*, >u " ^(cI %^o i23 e e * o= e3. un *5 ^ us M U. 2" s1 it *o o~ ras o 6ws0 %0 sSo *vO5** = if *ss Pi -it W M I ll - ' a> u to 5u 1u ,5* O< -5< 2^ Oei UJ C Co. 3 <" w 5 foc. p*r 52 *1 < ir P?. o2 ' * * sS o2 o2 aa <o eS &g Is * 5 .". Jo5 --e o Pis5,-..' ..2. .*5 2 2i aO?.v*O*>7\' < SM9 g5 b- SKo a9 *5? 5o* cU il e- u --.o M 2 ;3" e TuT ta g.f5 " Is ol. ct3 n-- -- n *3 g 9 * 25 o g g >* e >* c .O ,* n r2n,,5 "&cwt n*s v *lcos n !SJ O9 o* CO --S zuV <-r*sWw^'Zo *7 ** c Untf< ASARCO ALV 0002086 SelikofT et al.: Mortality of Insulation Workers !,, 3S I 5. I I I . : - II ill sJZ i r\=-Z ^ S 22 2 : 0 --r* I --00 -- -------- " V ! .. irr.Tr1 * ? Xis%\~ r -- *r -- -- r" | j - r<n r~ m- 1 :6 co 2IS5S 22" ::v 2; O 1-1 r* *-l , . -- ll~3S *5 >. - -2 S Z;- . "" ' 522 nr^o^o9 *ffk_wvct''Ocssoapo* I siSSS'-ASSSS:1* 101 .I ASARCO ALV 0002087 102 ` Annals New York Academy of Sciences *. Ta*le to MEMSERSHir OF ASBESTOS INSULATION WORKERS' UNION'*. JaNUaRT J. 1967, Classified by Ace and iy Years from First F-sfosure to Asbestos Dust Total n; ' -* ~ ^1 Number of Years SinerFirst Exposure to Asbestos ; Years Memben .0-9 10-14 15-19 20-24 25-29 30-34 35-39 40--19 504- - - 15-19 ;-.+.244 -.244 -_L- .. .. 20-24 1.695 -1695 ? .i t - 25-29 '2.412.- 2066" -345 " 1 30-34 2.762 ' 1065 1356 341 v ;V A.-" IT * * -- J-** V ** * * * if r* U * * 35-39 2.988 . 313 INI . 1342 . 192 A . . *. A A- ~T--------- - - 40--S4 : "424-V'1026 .;.."i7QZI39 -4>-49'; ^589^.^49'--jji ~ 433 442- -- 487 * 47" *' * 50-54 ' U97 27 88 214 332 --- 377 182 . 77 .55-59.:;T/-S.984. ' 13 --7703 1 - 65-69-7 "1419 ------ 70-74 . ."255 -- 75-79 ' tel 11 -- 80-84 .7'52 -- 85+ - 29 Total 17.800 5552 49 ' 21 6. -- 1 129 " 59 . 18 6 -- -- 3562 3569 206 131 41 14 :4 * 1953 176 126 58 . 22 8 ;2 1395 146 193 "87 * 99 45 29 . '. 16 : -4. 2- 7 . 1- * 534 'J2 2 425 72 179 201 .105 37 16 7 617 '' *-- * ' "* * 2i 71 50 31 ' 20 1*3 ....................... Membership in the United States and Canada of the International Association of Heat and Frost Insulators and Asbestos Workers. AFL-CIO. CLC roentgenological data are reviewed and the pathological material examined. Most of the presentation for this cohort is in terms of underlying cause of death categorized according to best evidence available (BE). Further details are also given in the tables .for underlying cause assigned on the basis of death certificate information only (DC). .At the outset of the study, a majority of the men were below the age of 40 (10,101 of 17,800). The majority, too, had yet to achieve 20 years from first exposure (12.683 or 17,800) (Table 10). During the period January 1,1967-December 31, 1976. the cohort changed its age and duration from onset distribution with the passage of time. Many of the men who started in the less than 20 year from onset group achieved 20+ years from onset during the decade of observation (Table II). Altogether, 12,683 men. with 89,462 man-years of experience, suffered 325 deaths in the period before 20 years. There Observation of 17.800 Asbestos Insulation Workers in the United States and Canada January I. 1967-December 31. 1976 Number of men Man-years of ; ** - observation Deaths Average age during observation Total ..... 1.7 ,800. 166.853 X271 44.4 - <20 Years from Onset 12.683 89.462 325 36J 20- Yean from Onset ; **...1*2 ,051..... . 77.391 1.946 53.8 --" ASARCO ALV 0002088 Sdikoff el al.: Mortality of Insulation Workers 103 occurred 19-16 deltas among 12.051 men whohad achieved 20-t- years from onset, with 77.391 man-years of observation. The average age during observation was 36.3 years for the shorter group and 53.8 years for those with longer duration from onset.. During the decade of observation 2271 deaths occurred (Table 12), whereas only 1658.9 deaths were expected (based upon white male age specific mortality data of the ' U.S. National Ccater for Health Statistics). The excess deaths were primarily the 'result of an increased number.of instances of cancer of several sites. Investigation of* the deaths, found 486 .due. to bronchogenic carcinoma, between 4 and.5 times the . number antidpatetL--Tbere were 175 deaths of mesothelioma, 63 pleural in. location j*> . numsek or Wen 17.800 .r.aiLLrna /.jV := Man-years of- Observation. 166.853 .r^r.r v.-j- eje: -:T -a. ncrC-.v.-r.-.r-. - - '- Underlying Cause of Death........Expected* ... Observed r>~ Katioo/e - .** ? "`sc* ar;* - V1 *. -.r (BE) ' (DC) (BE) (DC) tf: ~\<z 'J 'ccX Toul deaths. xll auses -A--< i 1655.9 v. -227 t--J,,*2271..r.cr-U7 Toul cancer, all sites.'-LCT *:; .` 1 ' : 319.7 *- 995 vyr: 922 3.11 -157 2.88 *' *** .7 a ' - '.A.V*- Cancerof lung - 105.6- i -- 486-- 429 4.60 :... 4.06 - *i* i * f*. ;. Pleural mesothelioma ' -j .- t. . . .. 63 . '25 * -w.r-- *. ..--- , Peritoneal mesothelioma .... .. t . Mesothelioma aaxs. . * \:;t' .112 . * ' 24 0 . 55 --J 1 -- --` v>C. * Cancer of esophagus ' 7.1 . 18 ' IS 253 253 Cancer of stomach 14.2 22 IS 154 156 Cancer of colon-factum Cancer of larynx * '5-- 36.1 J 4.7 59 -. -n . 5S US 152 9 . "254 -. :l.9l - Cancer of pharynx, buccal Cancer ofkidoey . "10.1 * . 21:. - S.l - 19- . 16 2.08 ... 159 IS 256 2.23 All other cancer 131.8 184 252 1.40 1.91 Noninfectious pulmonary diseases, total Asbestosis .. ..... . 59.0 t * * \ 212 1SS .359 3.19 168 78 -- _ All other causes 1250.2 i064 U61 ' 0.S3 0.91 'Expected deads are based upon white male age-specific U.S. death rates of the U2S. : National Center for Health Sutistics. 1967-1976. .. V.IRates are not available, but these have been rare causes of death in the general population. .- (BE): Best evidence Number of deaths categorized after review of best available information ' .(autopsy, surgical. eSnieal).*- e :..r t`n. t-.i ; 'ir'i-Kt-.'.' 'x* (DC): Number of deaths as recorded from death certificate information only." ; r*.: * "** and 112 peritoneal. There was a modest increase in deaths of gastrointestinal cancer (esophagus.stomach.colon-rectum). ": Cancers of several other sites were also significantly increased over the number expected. There were 11 deaths of cancer of the larynx, 21'of the buccal cavity and oro-pharynx. as well as 19 deaths of cancer of the kidney. In each instance, this was twice-the-number-anticipated. Comment had'previously been made* concerning, interest in these sites but. at the time, there were inadequate data for evaluation. Additional experience has indicated that the early hints were predictive... Review or information concerning the deaths allowed a distinction to be made between deaths caused by ashestosis and those of other noninfectious pulmonary ASARCO ALV 0002089 104 Annals New York Academy ofSciences diseases, including emphysema and ccr pulmonale. Thereby. 163 deaths were assigned to asbestosis and 44 were attributed to other noninfectious pulmonary diseases. . comoared with a total expectation of 59.0 in the general population. The question of whether noninfectious pulmonary diseases, other than asbestosis, are or are' not increased in asbestos workers is a complex problem. Continuing questions of nomen clature of "chronic obstructive lung disease" in general; and uncertainties of designa- tion and pathological categorization were recently well reviewed by C. M. Fletcher.' Chronic nonspecific lung disease, particularly that due to cigarette smoking, may ;;have-an influence on the course of the asbestosis, providing an added burden to ' damaged lungs. We have evidence that there is such influence.* On the other hand, diffuse interstitial parenchymal fibrosis or diffuse pleural fibrosis would be disadvan- * .' tageous for individuals with extensive chronic obstructive lung disease, particularly with superimposed pulmonary infections or other physiological stress. Such disadvan- ;____ ^ tageous additional contributions, in individual cases, may play important roles in 4 jrC'^j^detehrunmg. the-adequacyof-a'patienlls^espiratory.reservc. Categorizing deaths .irt^ ---- ; Terms ofa single underlying cause; however, does not allow for inclusion of nuances.of. 'iTi-' `s interaction among the several factors, nor-to depict, the full spectrum of such "interacting disease, from cases in which little other lhan asbestotic pulmonary fibrosis may be-involved to those in which all evidence indicates that cigarette smoking and ' _chronic obstructive lung disease were the principal factors. _ ;....... . For causes other than cancer and asbestosis and other noninfectious'diseascs, there were fewer deaths than expected, 1064 against 1280.2. In particular, there were fewer deaths of arteriosclerotic cardiovascular disease and its consequences. This is further considered elsewhere,* and it may well be that the active physical work associated with employment as'insulation workers is advantageous in preventing or delaying death of * cardiovascular disease, although the influence of initial selection upon admission to the trade cannot be disregarded. > It is evident that most excess dea'ths in this cohort were due to cancer (675) rather 1 than to asbestosis and other noninfectious pulmonary diseases (153). This is notewor- / thy. since the present United States Standard for occupational exposure to asbestos is /. in large part derived from reported recommendations designed to prevent asbestosis.* Deaths of Less Common Malignant Neoplasms Apart from lung cancer, mesothelioma, gastrointestinal cancer, cancer of the larynx, pharynx and oral cavity and cancer of the kidney, there was still as excess of cancer of other-sites, with 184 observed, compared with 131.8 expected. Table 13 "'* provides information concerning expected and observed deaths for a number of other .. sites. For some, there was no evidence or increased incidence, as w'ith leukemia, " --...lymphoma, primary'cancer of the liver, testes,'bladder. Relatively small'increases" were suggested for brain, skin, pancreas, prostate. The overall increase is of some . `-'interest, especially in view of the known possibility of asbestos fibrils being dissemi nated to virtually all organs following inhalation or ingestion.''" We have long been properly accustomed to seeking verification of increases beyond chance expectation - ("statistically significant") in incidence of cancers of defined sites. This perspective docs not contradict the potential importance of more general increases in cancer Vrinddencs of a large .variety of sites, perhaps not reaching levels of statistical ' significance in any one' location but still yielding definite increases`of the overall' ' cancer burden of the groups investigated. . . ..................... ASARCO ALV 0002090 Sdikoffeta!.: Mortality of Insulation Workers . .* **?*.*'. r * .'ps-' ". .. --.w *: Mc'ctiple Cancers ..*c. ... 105 From a purely statistical point of view, in view of the increased incidence of cancer of several sites among asbestos insulation workers, we would expect that a proportion of these men would suffer multiple cancers simultaneously, even beyond the tendency of such findings to be made among individuals with cancer, in general.11 Again, this . would not be reflected in tabulations of causes of death by single underlying cause, as \ is the usual practice. Analysis of our experience demonstrated one hundred malignant `neoplasms prcsenf.bufnoL causing.death (Table 14). Sometimes these additional ; "neoplasms werc/mentioned. on the death certificate but as an ."other significant ;'enndition,T;not.in the section.on the underlying cause of death. Forty, were present.':, `"among ihe.1064 cases-where death - `*r;i*5*- was due (6 t**2*'/* causes *. other than cancer or asbestosts ..........A.* \ ,.v*rrvir,l iT.r.r j v: "= IUL 13^*-- --"r rur; v t% t ?y^^Da*isgC^o.s^tr^W^amcSiysIXTtbfciWdirg;as'avT><c:U.vtTEP.STATEsr^-V-^LvS-:'-:'-'--' xmo^Canada.jANUAart.t ~ l967-Dece.vier. itTl97'f:: Observed ^xmnc-atotfsT.xxsiCa s rc^-.rcjtiv Underlying Cause of Death 'Expected*' . T" (BE) ; (DC) ".`.Total deaths, all causes 1652.9 - 2271 :: Cancer, all sits ;.Vj.zitf.v.."* . : :.319.7 * :. 995 'Deaths of less common- * .* .f. - * '.1*"* ' - malignant neoplasms.- ... ... Pancreas 17.5 ~ 23" Liver, biliary passages 7.2 5 Bladder '. Testes ^ - -- . \ 9.1 9 1.9 .'* 2 ' Prostate" " :20.4'-*-- `30 ` * Leukemia- f: u.i - 15 .. ' Lymphoma .- `: : 20.1 . 19 Skin . J 6.6 12 Brain ` 10.4 M 2271 .922 49 19 7 l 2S 15 16 8 17 Ratio o/e "(BE) (DC) . -.1.37 ; J.l! 07 - ` 2.88 . *' 1.32 2.81 0.70 2.65 0.99 0.77 ---- 1.47 .07 us ... 05 0.95 0.80 1.82 * 1.22 U5 1.63 . 'Expected deaths are based upon white male age-specific US. death races of the VS. National Center for Health Statistics. 1967-1976. ' (BE); Best evidence. Number of deaths categorized after review of best available information (autopsy.surgical.clinical)...... ... . -;..\(DC): Number of deaths as recorded from death.certificate information only. -.. . '. (TABLETS)-Among: the-T68 deaths of asbestosts, cancer was also present in 7,6 of. '.these being bronchogenic carcinoma. Analysis of the circumstances leading to death,. . however, indicated that the underlying cause was asbestotic pulmonary insufficiency, and that the lung cancers were present but with no decisive influence at the time of death. Nineteen other cancers were present among the 486 deaths of lung cancer and 10 other cancers accompanied the 175 deaths or mesothelioma. There were 9 "incidental" neoplasms among the 99 deaths of gastrointestinal cancer. Although experiences are so far limited, it may not be wholly unexpected that there were proportionately more incidental* neoplasms, accompanying dcaths .of co!on-rectunv_ cancer, compared to those of lung cancer (8.5% vs. 3.9%). One may speculate-that this * -- . 41#- ^ ** * * i(i .I t ASARCO ALV 0002091 106 Annals New York Academy of Sciences *.* '" Table m- . .. MORTALITY EXPERIENCE AMONG I7.S00 ASBESTOS INSOLATION* WORKERS IN THE UNITES States and Canada 1967-1976: Observations in 7771 Consecltive Deaths Miiijnint Neopiasmi present, but not Causing Death* Site Number ,, . .-...Lung t.-.-j- '-'id."'. 3PleuralmeMlheliom* i, ' ?i.viiPeritonealmesothelioma. . EPp*- Wj-- re-~5."- Stomach. -t.-GoJob* ^ *. ' i ! Other * * T --.. -- . * - wenty-Ofte-.nT;theser neoplasms. werg..mentioned. on_the deaxlv certificate:,(but were. naL.-'.~~:;- oategorizsd is underlying cause oC deatht-=r-^ 7.. -nj^a^.nrVy-.. -..^Including ieuVemia 5.lymphoma 3. bladder 5. prostate 13. thvroid. etc. . '*{In 92 individuals: total includes multiple canaers in eight cases. . . could be due to the longer clinical course of many patients with colon-rcctum cancer, compared to lung cancer,.with greater opportunity, simply in terms of time, to develop -'additionaldisease. :' .*. - :. Multiple cancers were present, overall, in 2.1% of deaths among these asbestos insulation workers (48 of 2271). It is perhaps to be expected that this.was more likely to be the case among those for whom cancer was the primary cause of death (4.5%) while only 3 of the 1276 other deaths had this finding. From a clinical point of view, in-the management of patients with asbestos* associated disease, the potential for incidental or multiple cancers is of some importance, and awareness of the possibility may assist in both the diagnostic investigation and long-term surveillance of individuals with history of significant asbestos exposure. J Lapsed Period J- It is now well appreciated that most asbestos associated disease is first seen after considerable periods from onset of exposure in both occupational and environmental ' circumstances. This is true both for the presence and extent of parenchymal fibrosis . and pleural fibrosis and/or ea!cification,,,, and for asbestos-associated neoplasms.14 . Data obtained in this investigation now provide a more complete overview of this . question. Broadly, we saw some limited excess disease in 's than I- ,, .ars from onset of exposure (Table 16). Among 12,683 men. with such experience: covering 89,462 - man-yeare of observation, the number of cancer deaths was about doubled, with 42.6 deaths expected and 83 observed. There were no excess deaths c. gastrointestinal cancer and only S deaths of mesothelioma, with these in the 15-19 years from onset category. Age, year and sex specific mortality data of the US. National Cancer for Health Statistics indicated that 11.9 deaths of lung cancer were to be expected. Thirty-six occurred.There were 8 deaths of asbestosis. .. ; i f. ASARCO ALV 0002092 Selikoff el alt Mortality of Insulation Workers 107 On the other hand,'extensive disease was seen among the 12.051 men who had reached 20 or more years from onset during the decade of study. Hers, 1376.0 deaths were anticipated; 1945 occurred. There were 160 deaths of asbestosis and 912 of cancer. It was at this time that bronchogenic carcinoma mads its heaviest contribu tion, with 93.7 such deaths expected and 450 observed. One hundred and seventy deaths of mesothelioma were then seen and.the increase in gastrointestinal cancer found. TaSLE 17 depicts these data in some detail, in five-year periods from onset of* employment. Lung cancer data are given as both expected and observed numbers of death. This practice cannot be followed for mesothelioma, where expected deaths' cannot be computed for the general population. Instead, we have provided data in both . f ,_ number of deaths of pleural and peritoneal mesothelioma, as well as in terms of number of deaths of these causes per thousand persons years at risk; The latter does ^ ly. not take into account variations in achieved age,-but this may have less influence than - achieved duration from onset of employment. It will be seen that very major increases in numbers of deaths of lung cancer are first seen at 15-24 years from Onset of work,' _^.:with continued further increases.-'nie extraordinary increase-in deaths of mesothe-- as-Coma-, .botinofthcplcura ^an&thfcpcriioneum^ifnofobserved1 until so'meVKar IaTerf-^" _V.rachihg"2.'7S'deaths per thousand person-years at risk for pleural mesothelioma at.. 35-39 years from onset of work, and 5.47 deaths of peritoneal meso'helioma per-7*--r Cn.usas person-years at 45years from onset-'' V-rr^*': `'-'7! jv-'-T la another reflection of the clinical concerns among these workers. Table 18 V indicates that approximately one-third of all deaths were due to lung cancer at 30-34*. * *:7j & yean from onset, while mesothelioma accounted for 13% of all deaths at 35-39 years.'.. Taile 13 MORTALITY ExFERIENCE AMONG 17.800 AsJESTOS INSULATION WORKERS IN THE UNITEO States and Canada 1967-1976; Observations in 2271 Consecutive Deaths Nuhier. of Incidental Malignant Neoplasms. (not Causing Death) in Relation to Underlying Cause of Death as Established ar Best Evidence (BE) *. / :'.t Underlying Cause of Death Number of Deaths of Underlying Cause Incidenut Malignant Neoplasms No. of.. Total .. Deaths - ' Cancers Cancer all sites 995 45 - 50 Cancer of tung . 486 17 19 . Pleural mesothelioma ' 63 .4 Peritonea! mesolhdiomr *'' 112 s. 5 ?. 6 ` Cancer of esophagus 18 .1 ? - 1 ' V- ` -Cancer of stomach - 22 %--v 3. 3 . . * .Cancer of colon-rectum- . j.-. Canceroflarynx ..' as - "sneer ofpharynx, buccal cavity a ' 59 4 .-If 11 . 21 . w r r. . . Cancer of kidney E;..-* Z-' ~ 1 _ ' u. ,; - 19 -r '**- 5 -.i-' 5 / i-v 0 >.* 0 2 rr ... 3 : 0 -0 '. All other cancers ;. j-. 4; . /- i . v. r-'j I 184 Noninfeetjous pulmonary ~ * . ~ f'T-' ' 9 diseases, tout -Asbestosis . _ All other causes * Toul .. ' "' , i ' 212 168 1064 2271 . 10 T 7 37 ' 92 10* 7* 40 1Q0 al;__I?*? thesewere lung cancer.-- I ASARCO ALV 0002093 6 108 Annals New York Academy of Sciences sSsssls:; il A. ^ . rvll ~ *. S33SSS~.S |S n -- - piMM-n *0 Crro^r*(Nr..T. *Mor-T^ hr--^-Nr^o^ re - .e ". ..` - . ....... \ .* * <oro -- 50h-^e>oocoo ;sv?2.:irrr .--sgss Js^r=wsg?p=. p-.*; <=^r--AA ^ ~ - => - ~- o> r* > , . . ~ 'r^-r^raop'***^ v> 5 R * TJT...... ^ = "..T s ` U .3 . I^IA-II ih*c*X-:.-. ir?l 2*->5--,1* .I Wlj^.~ l M I J. 522" I. S- hr `w r ~^?n s ,,... ?,V-_5, . *.: -'-- ,: -rA^'. ife's zy v^ c? 22s .i-W r l i I I I 55 l g o If o ..fra'-c.i 1 .. -`-r ^ f" esl - 3 t s|| 1| 3 jG .3 H2 p 5 -15 "'"il = S5 "Nv Sc 0 vr< >nnono--TNnnM9nT \ 1 * :i SS5*.*.32v53I-S3^: S-- "s u ------- -r~ --.! . . .. * .;: * ____ __ :^:-C----~ ' - '.* 2 Ip , pin 1I sJ S is...'3 ?l I ca ,,l II!i r ..... ]*. i 5|S; -I Ill| 2 ? PlPJM Mil T .. -- - -- - . .***.* . ':**'-.."** **...*- ----* . ;.*-*'* *.. . ." ^ ^ .**. *. * . .* : * * . ASARCO ALV 0002094 Selikoff et al.: Mortality oflnsulation Workers 109 ---v* v'r ASARCO ALV 0002095  110 Annals New York Academy of Sciences Tails. IS Deaths Among 17.800 AsassTos Insulation Workers in-the United States and Canada, January 1. ) 967-DeCEMRER 31. 1976. Analysis by Duration from Onset of Employment j J j Percent of AU Deaths * Mesothelioma Year* from Onset of Employment Tout Deaths Lung ; Cancer ' (BE) (DC) Pleural (BE) - (DC) Peritoneal (BE) (DC) Total (BE) (DC) <10' ^ ... 51 10-M 85 15-19 - -it-:-. 189 20-24 - 320 0. .. ..0 .. ` 8.2 55 - 155 14.3 i 18.4 17.8 0 ... 0 . ; o. 0. -- 0 1.1 -. l.l 1.6 1.9 -::.u 0.9 0 o 0 . 0 .0 o. 0 2.7 - 15 . _ 0.6 - 2.8 . 25 - ' 25-29 388 1 27.1 . 24.7- 3.4 -> u . 4.9 -.0.1 .. 85 . 55 30-34 340 ' 3Z9 305-'- 2.7 0.9- 6.8 1.8 9.4 65 35-39 253 25.7 225 5.9 1.6 7.5 2.0 13.4 7.9 40--44 203 19.7 15J 2.0 15. 7.9 15- 9.9 6.4 . 45+ ; 442 - 15.6 12.0 - 3.2 ` 0.9' 6.6 1.1 9.7 4.1 - - .--Total. 2271-~^2\A '18.9 ~ *.5.'--.-rlrT?-o~r.i~."-7.7: 4.6-^^=-:- *TouI includes mesothelioma nol specified as either pleural or peritoneal. (BE): Best evidence. Number of death catc.-riied after review best cvailabtn information (autopsy, surgical. clinical). .-_ .; (DC): Number of deaths as recorded from death certificate information only. . ' Altogether, lung cancer was responsible for 21% of all deaths observed by us in this cohort and mesothelioma for 8%. - * .* Investigation and Categorization of Causes of Death ' It is widely known that causes of death as recorded on death certificates may be in error and that, even when accurate, these may be coded with considerable variation among different agencies, despite the existence of agreed upon international rules and recommentations.1' Yet death rates based upon large series of causes of death as recorded on death certificates are nevertheless useful, and are widely utilized. This distinction, however, leads to the understanding that comparisons between observed causes of death and those expected from national or local "death rates" should not be considered in rigid exact terms, especially when considering the mortality experience of very specific groups. For these, there are no perfect "controls" that would take into account their age distribution, ethnic derivation, smoking habits, economic circum stances, prior personal and social history, and so on. The matter is further-complicated by the fact that deaths in the general population, which provide the basis for established comparison death rales, are not verified by investigation or. examination of available data concerning the circum stances associated with the deaths. Of course, one may elect to treat the deaths in the study population in exactly the same way, with no attempt to review data other than that recorded on the death certificate, explicitly accepting whatever errors might exist. in causes of death recorded and implicitly hoping that whatever errors exist are very much the same in the two sets of data, deaths in the general population and those in the group under investigation. Certainly this latter method Is simpler, cheaper, much less time consuming.1* ASARCO ALV 0002096 ScUkofT et a!.: Mortality of Insulation Workers 111 But this approach has a number of drawbacks. First, where the distribution of causes of death in the group being studied is different than that found in the general population, one may expect that, the- distribution of inherent error might also be. different. Second, data may be available which can shed much light on the causes of death under investigation and not including such information permits the risk of reporting results which are simply inaccurate. It is perhaps inadequate comfort to skirt this difficulty by clearly stating that only death certificate diagnoses are reported: this only gives, the reason for potential, inaccuracy..There are also technical issues, and these are of particular concern among asbestos-exposed groups.in the sixth, seventh ; 'and eighth revisions of the International Classification of causes of death. There have ..' beea no dearcatcgories for the diffuse.*malignant mesotheliomas of the pleura and "peritoneum which-occur; and while some.improvements have been made in theninth. revision now being introduccdjwe feat that these will still not resolve the problem. .. ^ t. IvviJust as-tbere'are no perfect controlsi there is also no singleperfect solution, and ito. Is unlikely that there-wilt be such in.the foreseeable future'.'especially since data-- available for ascertainmentofcause of death, even when.invesiigitions during life and at autopsy have been undertaken, are not always completeand are surely not uniform. "T re;'!&> v, r, ~-^.Mo*TALnY'Exrxi>cziAaoNG7l7.SOO Assesrof Insulation--Workers iv the L;Jia'UmTErs States-A-so Canada 1967-1977: Observations in 2271 .Consecutive . rJaxfc Deaths wrm Underlying Cause.of Death Cooed-according-to Death'.- - .s;,.. Certificate- Information Only-and According to Best Evidence-- 'i-';-". ` ' *-* ,v Underlying Cause of Death f*1 -..-rr-i.,'. * Certificate ** Evidence . ^ v-as-oss*. (DCr-2*i* ,(BBEB) .... of Best Expected* ` No. e/e - No. o/c Evidence * Cancer all sites " : . * . 319.7 922 2.88 995 3.11 93 Canceroflung * -. . . 105.fi 429 4.06 486 4.60 Pleural mesothelioma* - -.-t .* 25 -- ..... .63 --- . --. Peritoneal mesothelioma ...... t '...... .24 --; .112 -- . 88 . <0 '21 : Moathelioma.-n.ox. .... ,. .. t. 55 -- ` o *-- "* --- ' Cancer of esophagus " * " ' 7.1 ' 18 2.J3 IS 2.53 100 Cancer of stomach 14.2 ' 18 1.26 22 1.54 82 ' Cancer ofcolon-rectum *; * " 38.1 ' 58 1.52 - Cancer of larynx, pharynx. ** , .* ** .4 59 us ' 98 **. . ' buccal cavity ' i-; 14.* 25 1.69 . '-i- 32 2.16 78 r Cancer of kidney V I.l Ig 123 . 19 2.36 .95 Cancer of prostate . . x - - 20.4 r. .28- 1.37 . .. 30 - 1.47 . 93 .s.f . Cancer of bladder .,.-rV:.._ v -V 9.1 ,7. 0.77 ... -.. 9 0.99 . _. -78 . . Cancer or paneTcas ..., . . ns -.'-N--oCC.naa-indnnficcseeeecrratiooosffuelbssivr.ptaeouirnulmt_*'*o--:na--r:y''-'`-v'-S^?*".'-v'--r.r* iV'S1079.-042 -I,4' fs'r.<. J.,97..:. '"-'-'-IBS 2.81 ' - .23. 2.65 1.63 3.19 -*? 212. 1J2''.".' 0.70 * ' 1.35---* * ** * ;*=-s '3.59 - ** 213 380 121 * 89 . i* ! -* Asbestoslx :: -V ?+ -t *'* 78 . *46 *.:ri All other causes 1280.2 T" 1161 0.91- ' 1064- - 0.83- ' ^ '109 'Expected deaths based on white male age-specific U.S. death rates of the U.S. National Center for Heatth Statistics. 1967-1976. tRales not available, but these have been rare causes of death in the general population. -(BE): Best evidence. Numbtf ofdeaths categorized after review of best available information. (DC). Number ofdaths as recorded from death certificate information only. . : ,. / ASARCO ALV 0002097 I 112 Annals New York Academy of Sciences We have elected to approach this problem by providing data in mors than one way, including causes of death as recorded, on the death certificate in our cases, for comparison with'"expected" deaths based upon the data of the U.S. National Center for Health Statistics, as well as causes' of death established after detailed review of all ' available information. Such data were retrieved in 1961 of the 2271 deaths. However, detailed information was not equally available for .all categories of causes of death. .- This was to be expected, in the nature of things. As a rule, the best .available information for establishing the cause of death was considered to be autopsy findings, with pathological information derived from surgical intervention next, and, in their*. ' absence, clinical and roentgenological observations made during life, particularly in . the period before death.'Where no such details were available, the cause of death as - recorded from death certificate information was then utilized. Among the 995 cases of.* cancer, we were required to depend upon the death certificate alone in only 2S, with other information available in 967 cases (977a). In ail 175 cases of mesothelioma,. surgical and/or autopsy findings were utilized. We dependcd.upon death certificate. ___ information alone in-10 of the 486 cases of lunscaacerrTtTM*^ ^J^TSimilarly.m 166 of 168 deaths of asbestosis, information was available in?addition" to the death certificate, leaving dependence of the latter in only 1%. In contrast, for causes other than cancer and asbestosis, additional information was available in only- three-q-sarters of ths cases. Analysis of the distribution of de-ihs within this category ' showed that this was by no means unexpected. Sudden death attributed to myocardial infarction or cerebrovascular accident is often not further investigated nor need clinical abnormalities have preexisted. It was therefore no surprise that in 156 cases the medical attendant or the medical examiner warranted such death certificate `' diagnosis without other information being available. It would seem difficult to avoid differerces in quality of ascertainment, under such varied circumstances. Analysis of our data suggests that, by and large, death certificate diagnoses were not far off the mark. This speaks highly for ihe'diagnosiie acumen and quality of care provided to these men by their medical attendants. Cancer as the underlying cause of death was indicated by the death certificate in 922 instances compared with 955 so categorized after considering alt available information (Table 19). The specific diagnosis of cancer of the lung and cancer of the several sites of gastrointestinal cancer, as well as cancer of the larynx, oropharynx and kidney was also generally welt predicted by the death certificate diagnosis. . .. ` ....' In a number of instances, however, there was important disparity between causes of death as recorded on the death certificate and those judged to be the case after review of available clinical and pathologicat material. This was true for pleural and peritoneal mesothelioma, asbestosis. cancer of the pancreas, primary cancer of the liver, cancer of the brain and chronic obstructive lung disease. *. -.s~ -O In 49 cases, cancer of the pancreas was listed on the death certificate as cause of death. Only 17-5 such deaths were expected (Table 14). If we were to accept cause of death as listed on the death certificate to establish the "observed'* number of deaths . for this disease, we would have to conclude that cancer of the pancreas is significantly" increased as a cause of death among asbestos insulation workers. But this is not the' case; when all .available material was reviewed, it was found that only 22 deaths compared with the 49 so categorized on the death certificate were due to cancer of the pancreas. Four were the result of metastatic lung cancer, 15 were found on review of histological material to be eases of peritoneal mesothelioma and 5 were best categor ized as abdominal carcinoma, primary site not established. Two were due to cancer of the. colon. This is not to say that we have established that there is no increased - -..-.incidence, of cancer.of.lhe pancreas among asbestos workerr: lt is possible there is"* some limited increase and we are cognizant of the uncertainties inherent in the i\ t r \ \ -v-1* - ------ ASARCO ALV 0002098 SciikofT^tf/.: Mortality of Insulation Workers 113 computation of "expected" rates forcancer of the pancreas since it may well be that some of the cases.so categorized in the general population from which the expected rates were derived, might really be instances of lung cancer, colon cancer and even, perhaps, peritoneal mesothelioma. Since these deaths in the general population have not been investigated to verify death certificate cause of death, it is not possible to ! know whether such inaccuracy exists..nor its degree. :i ...r . 1 Asbestosis. was another example where categorization by death certificate would be misleading since only 78 deaths, of this disease were so categorized compared with j$8 afterreview. A.'variety of other diagnoses were offered in the discrepant cases. A -. .`..V.T primarily=those of "chronic, obstructive lung disease," or other noninfectious respira--.. - ."*'**V;*. iiS>sT'tory disease.-acuteinfcctions; and-in two cases, cancer of the lung. It was of interest i-ri'a'.-that in 16of the.97 cases called asbestesis after review.butin which asbestosis was not hr Sri: listed as the underlying-cause of death, it was mentioned on the death certificate under the rubric of "other significant conditions." In 129 other cases, asbestosis was again *.`1*7, * -".^mentioned on the death-certificate, but-not as underlying cause of death. Altogether,'.-: asbestosis wiTfnentTo'ned in:230 of the 2271 death certificates;' "T.. ; lar 7 cases,, asbestosis so-categorized by death certificate designation was '--.-'rmilgned to other categories after review, with death found due to lung cancer in 5.. peritoneal mesotftelioma in one and myocardial infarction in another..*--- - 'txkriy- -Accuracy of diagnosis of mesothelioma, and its being recorded on death certifi- ;p-*cates. is a special problem^First; there are the difficulties and subtleties of patholog* .Sx^riical- diagnosis, of-particular-importance-when'cases, of this neoplasm are seen ' efijss. throughout the United.States and. Canada by-pathologists with varied, experience. : Um Sometimes, there is the added difficulty of extending the pathological diagnosis to the death certificate, not infrequently completed by a physician who may or may not have . been the regular medical attendant and fully cognizant of pathological findings; to this ' - could be added the problem occasioned by the fact that the death certificate must - often be completed before there has been full consideration of postmortem findings. - When these differ with the death certificate, diagnosis, an amended certificate is expected to be filed. In our experience, this is rarely done. When to these are added the administrative uncertainties and insecurities of classification, it is not surprising that only about one-quarter of the'deaths of mesothelioma in this scries were correctly - : recorded on death certificates as pteurat or peritoneal, although 104 of the 175 cases -were recorded as "mesothelioma." even if not with full details. We are presently analyzing the 175 deaths of pleural and peritoneal mesothelio- ' ma. and the results will be reported. In 108 of the 112 cases of peritoneal mesothelio- * ma, surgical and pathological material was submitted to us for review and this was the r case as well as 61 of the 63 pleural mesotheliomas (96S% and 96.8%). *.... .The association of pleural and peritoneal mesothelioma with prior asbestos - . exposure is so striking1' that it is not surprising that overdiagnosis might now sometimes occur;.We found such to be the case in this study. In 8 cases in which .`--..-mesothelioma was.-recorded as underlying cause or death on the death certificate, review of the histological material showed the diagnosis to be other than mesothelioma _.`:`_-.. (ncerof the lung in 5 cases, metastatic carcinoma in 1 and Wegener's granulomato- -. -: -.sis involving the pleura in another). In the eighth case, pleural mesothelioma was ' present but was not the cause of death, which was better attributed to concurrent ; cancer of the stomach. .... ' ... .. Where mesothelioma appeared as the diagnosis on the death certificate, depending upon the exact phrasing used, this might be coded in the eighth revision of the International List'm'categaries 158.9 (malignant neoplasm of peritoneum). 163.0 (malignant neoplasm of pleura). 197.0 (secondary malignant neoplasm of lung). 195.0 (malignant neoplasm of abdomen), 198.9 (secondary malignant neoplasm, specified as ,*r.L --. i m ASARCO ALV 0002099 114 Annals New York Academy of Sciences secondary} 199-0 (mutlipte malignant neoplasm -{carcinomatosis, disseminated canc-rll 199 1 (malignant neoplasm without specification of site) and. not infreouently *228 (baum neoplasm of other and unspecified organs and tissues). There ts ' at the moment no reliable way to extract the'numbers or pleural and peritoneal mesotheliomas from death certificate data categorized and recorded by health, statistics agencies in the past, using the several revisions of the International < Classification of causes of death. * ., We might add that, overall. pathologistsVdiagncsc* were muen more accurate than ' 'death c-rtificate characterization of causes of death would lead one to believe. This `"'aeain bespeaks a high degree or competence on the part of pathologists in the United at State* and-Canada, (we are awire. or.course.-that diagnostic suspicion may be ^--increased in those instances in which it is-known that asbestos exposure had occurred, --^'as with individuals among whom occupational history indicated such exposure; this ar&could perhaps have accounted for some of the over-diagnosis). However this might be. is clear that a problem exists in translating the information obtained in pathological -'-''study to the death certificate diagnosis, as well as a problem of subsequent coding of ,.zthe stated cause of death..*- ''3 }' -- .---Ir i';X<-ONCI-'USIONS' c.'.ruiacwi. v-~w v*-- 'zcJz-.j; .risrieKestij- 2^@r??~Asbestos insulation workers in'the Uniteu Sutes and Canada suffer an exircordi- j/^naiy increased risk of death of cancer and asbestosis. associated with their employ- -j^'ment. Thisindudes-increases in death of lung cancer; pleural mesothelioma, perito* neal mesothelioma, cancer of the esophagus, colon and rectum, cancer of the larynx, -^"'oropharynx, kidney and perhaps stomach. Some increases were seen in cancer of -.'several other sites, as well, but data are inadequate at this time to permit characteriza* tion of their significance, although attention is called to such wider increase. : , Utiljjjisjgsejnjcancerdeaihijjij^jj^ijtSSlISSiiJiiaS^fcSSSSSLilUSSS^^ yeara Irom PDiLoLgxgosu^ln general, the period of latency between onset of exposure and death was 2. 3, 4. or more decades. Large increases in lung cancer occurred at 15-35 years from onset while pleural and peritoneal mesothelioma showed their greatest incidence somewhat later. Under the conditions of exposure which ' ** obtained, the period of clinical latency for asbestosis was also prolonged and in many -- * cases was 30-40 years or more from onset of employment. It would appear that in -- studies of the effects of such asbestos exposure it would be advantageous to analyze . . the experience of exposed individuals in duration-from-onset exposure categories, with - particular reference to durations of more than 30 years. If this is not done, the risk is *--* run of obscuring the neoplastic effects of asbestos exposure by the co-mingling of later deaths with those which may have occurred much earlier and which would be much less likely to have been influenced by asbestos exposure. In the same way, studies should include, whenever possible, the opportunity for observation of the mortality experience of the individuals at risk at least 30-35 and. preferably 40 or more years from onset of their exposure. Again, unless this is possible, on'- 've very limited early effects will be identified and the full import of the exposures may not be appreciated. Our experiences demonstrate the advantages of review of all available information ~ ^"concerning the-circumstances associated with the deaths tv't occur. Depending entirely upon death certificate diagnosis can lead to erroneous reports of causes of death, a problem that can be mitigated by characterizing causes of death according to the best available, information. Using this approach, we found that the apparent . increased incidence of cancer of the pancreas among asbestos insulation workers. . indicated "by death certificate diagnosis, did not really exist, and that many so ASARCO ALV 0002100