Document KJap245BML7oMbm30qrYk7gjQ

NEW. YOR School of Mecicim S50 FIRST AVENUE. NEW YORK. N.Y. 100T& area :i2 579*5230 CaSLE aOORE55 nyumEDiC Department of Pathology Occupational Safety & Eealch Administration Office of Consumer Affairs Room, N-3635 U.S. Department of Labor Third Street and Constitution Avenue, N.W. Washington, D.C. 20210 Re: Docket # H 090 Dear Sirs: Enclosed is ay Post-Hearing Comment. The statements, data and arguments in it .should not be interpreted as being those of the New York University Medical Center, as an institution. Enclosures Yours truly Harry 3. Denopculos, M.D. Associate Professor (for identification pureases only) HEC*"'*r~ Y FEB 1.4 1979 R. E. ucc 066354 ?cs t Hearing Coolants: A Dispassionate, Scientific Review of the ?: edoninar.t Causes of the Major Lethal Cancers in Pecpl United States by Harry B. Desopoulos, M.D. Regarding the proposed new regulation concerning the identificati on, classi- fication and regulation of conic sub stances posing a potent! or.a carcinogenic risk, by CSHA, docket # H C 30 The concents, data and arguments herein should not be interpreted as being those of the 27ew 'fork University Medical Center, as an Institution ucc 066355 Introduction -.'I hi7a4 participated In the- recent OSSA.' Hearings- that have focused on the proposed regulations to control carcinogens in the workplace because the studies that were conducted while I was the Director of the fledgling Cancer Canter Institute of New Jersey (CINJ) in 1975 are directly relevant to the fears and concerns expressed by OSSA., the labor unions, and selected academicians. This Host-Hearing Comment is made for the same reasons, and on the same basis, i.e., the responsibility to report to the public, the results of studies performed with public funds, that have a bearing on the public welfare. . A great deal of effort was expended at CINJ to probe the bedeviling question of what was causing so much cancer in the state of New Jersey, as.Jjadicated by .the-National Cancer-Institute1 s 17.S , Cancer Mortality by County? 1950-1969. In these probes we' sought help for che public at large, and for "the workers in the enormous chemical/petroleum plants in New Jersey by turning to the best available, objective data for clues as to the major causes cf the lethal cancers, The weapons that could bring about a significant reduction in the cancer statistics that had placed New Jersey at the top of the mortality rate were: 1) Prevention and 2) Early Detection. The latter weapon was clear cue in tnat several leading cancer killers, like breast, colon, and uterine cancer, were amenable to inexpensive screening tests, and numerous studies had demonstrated that early diagnosis, while the primary cancer was still small and asymptomatic, could result in immediate strik ing decreases in the projected, future death rates. Prevention, however, required the*knowledge of who the "real culprits" were in cancer causation; we recognized that if we chased the wrong ones, then the real culprits would continue to get away to add to the toll. When resources are limited, as ours were at CINJ then, and as the nation's are now, there is no margin for error. This search had become clouded in 1976 in New Jersey, with the media carrying almost daily retorts provided by various officials that "... it's in the water...7', -"./.it's in the air...", "___it's industry!" Now, in 1978, at the national level, the direction that Prevention efforts should proceed in are similarly enshrouded. The studies conducted at CINJ provide directions for Prevention efforts at a national level and* are reviewed herein. Cur data resources in cluded the bibliographic references in this document as well as two major works by the National Cancer Institute: UCC 066356 the ifrgf' s Third NationiTr~Cahcsr~Survey: Incidence Data (1969-1971;, wnicn yiei.Qs age-corrected cancer data on approximately 10# of the nation's population with sample areas that include: urban areas with heavy chemical industry (Detroit, Pittsburg, Birmingham); urban areas without heavy chemical industry (Atlanta, Dallas, Minnea polis); comparatively rural areas devoid of heavy chemical industry (States of Iowa and Colorado). The data is pro vided according to sex, race, age, standardized anatomic site cf the original primary malignancy, and geographic areas. The data is expressed per 100,000 population and wa certified as accurate by high-quality microscopic examina- tions of the malignancies. *. page -2- ucc 066357 3 the ITCl's U'.~5, Cane a r Mortality ay County: 195C-i;69, which, provic.es aga-ccrrsccaa cancer ceatn razes,, cysex,, race and' county, per 100,000 population for the 20 year period, 1953-1969] this data covered every county in the United States; by cross-checking with other federal studies and with encyclopedic references, we were able to compare geographic areas of similar urban density, with ana 'without heavy chemical and petroleum industry. II. Consideration of Major Variables in Cancer Causation. Our rationale for conducting these studies was as follows. If the Heavy Chemical and Petroleum Industries do pose a carcino genic threat to their employees, and vorse_ yet, to ..the public at large who live In juxtaposed communities,/then there.should be higher cancer incidence and higher cancer'mortality rates in these geographic, areas of the United States'"that have Heavy Chemical/ Petroleum Industries, compared to other areas of the U.S.A. that are similar in urban density and'in other major variables. Before emoaricing on studies that could guide Prevention efforts, we re viewed the major variables in cancer causation. Other studies, published by noted epidemiologists, including those from the NCI, have substantiated the need to control for the variable of urban density when malting comparisons of cancer inci dence and cancer mortality. (Hoover, R., Mason, T.J., McKay, F.W., and Frauaeni, J.F, Geographic patterns of cancer mortality in the United States. In: Persons At High Risk, (ed) J.F. Fraumeni, New York, Academic Press, 19^5, p. 3^5} Groan density is as important as age, sex and race in the deveTopmehc"oi!--cancer; the percentage differences between urban and rural areas are on the average larger than the differences seen between the sexes ana one races. For specific types of cancers the urban-rural differen ces can be very large, as shown in the accompanying Table I from Hoover's cited paper. The listed ratios can*be converted to per cent by subtracting 1 from the ratio and then multiplying by ICO, e.g., a ratio of 3.08 is 20ti$, a ratio of 2.96 is 196$, etc. The ' increases due to urbanization are substantial and as other studies to be cited in this presentation will show, the increases are not due to air pollution from cars and industry (see Section III Cancer and Air Pollution in this document). Table 2 from Hoover's cited paper, shows the relationship of Socio Hconomic Status (SSS) within a race, and increased cancer risk with higher SHS, certain major cancers are increased, e.g., rectum 113/5, thyroid 72$, colon 57$, bladder 67$, etc. The generally higher incomes and higher standards of living, particularly for whites, wish in urban areas compared to rural, may account for some of the urbanrural differences.' The question now at CINJ was, in view of the fact that New Jersey's population is the most urbanized of any state (nearly 9C$), were the rates really high? The surprising answer..was no. In fact, areas such as Nassau County, and Ve s tene s~cer "County {weal thy, urban ized suburbs of New York City devoid of industry), San Fransisco, and district of Columbia, had higher or equally high cancer mcr calif  page 350GSA?>-iC 3 :==\s 1 : i'JCSR '.1C3TAL w-0 table > Urban-rural maos of agt-adiustsd cancer mortality raied* among whites ir.the contiguous United States, according :o cones: sice aid sex. 19:0-1969 Male Fite Urban/rural Esophagus 3.OS Larynx 2.96 Mouth and throat 133 Resrura 171 Nasooh. lynx 117 Bladdc 110 Colon 1.97 Lung 1.S9 Breast 1.77 All malignant neoplasms 1.56 Thyroid hand 136 Other endocrine hands 1.53 Stomach 1.45 Kidney 1.44 Non-Hodgkin's lymphoma 139 Other and unspecified 133 Connective tissue 135 Pancreas 134 Biliary passages and liver (primary) 134. Salivary glands 131 Hodgkin's disease 135 Brain 131 Multipie myeloma 1.12 Nasal sinuses 1.10 Leukemia 1.07 Bone 1.05 Mcianoma of skin 1.01 Prostate .96 Testis .96 Eye .77 Other skin .67 Up 37 Female Site Urban/ rural Esophagus ** i T MA M Rectum 111 Larynx 1.92 Nasopharynx 1.66 Lung 1.64 Breast 1.61 Bladder 1.58 Other endocrine giands 1.52 Ovary 1.52 Coion 1.51 Non-Hodakin'i lymohcma 1.42 Hudgkm's disease 139 Thyroid 138 All malignant neoplasms 136 Stomach 135 Pancreas 134 Mouth and throat 139 Connective tissue 133 Brain 136 Multiple myeloma Other and unspecified 135 i .i* ^/ Leukemia 1.15 Kidney i.i: Salivary glands M2 Nasal sinuses 1.03 Biliary passages and liver 1.04 Corpus uteh 1.00 Cervix uten 1.00 Eye .92 Bone .39 Melanoma at skin .37 Other skin .65 Up .29 tfRnu were calculated for 100 percent urban and 100 percent rural cuunciut. ucc 066353 paga J-0 aC3Sf>.T HCOVSn *:*!. table : SaciaMass ratios of age-adjusted cancer mortality tates41 among wnites in ths contiguous United States, according to cancer site and sen. 1950-1969 Male Social-'ass ratio Site (histtlotVi Female Social-class ratio Site (high; low) Rectum Thyroid gland Colon Bladder Other endocrine glands Connective tissue Kidney Esophagus Non-Hodgkin`s lymphoma Multiple myeloma Mouth and throat Testis Breast Brain Ail malignant neoplasms Hodgkin's disease Leukemia Lung Nasopharynx Prostate Stomach Larynx Pancreas Melanoma of skin Nasal sinuses Biliary passages and liver Eye Other and unspecified Salivary glands Up Bone Other skin 2.13 1.72 1.67 1.67 1.59 1.54 1.49 1.49 1.37 US 1.19 1.13 1.18 1.18 1.16 1.14 U1 r.io 1.10 1.09 1.09 1.02 1.01 .98 .96 .38 .37 .33 .33 .81 .81 .53 Rectum Breast Ovary Other endocrine glands Non-Hodgkin's lymphoma Colon Connective tissue Multipie myeloma Hodgkin's disease Brain Nasopharynx Lung Bladder All malignant neoplasms Kidney Eye Pancreas Thyroid gland Leukemia Stomach Nasal sinuses Esophagus Corpus uteri Biliary passages and liver Salivary giands Other and unspecified Melanoma of skin Mouth and throat Cervix uteri Bone Larynx Other skin Up 1.6" 1.54 1.52 1.52 1.49 1.45 1.43 U9 1.37 1JS 1.23 1.27 1.19 L.1S 1.14 1.12 UO 1.09 1.06 1.03 1.01 .97 .94 .94 .36 .35 .85 .73 .74 .69 .67 .47 j; JSti cent foe metnoU of choosing hifn ami tow soctal<bss counuoi. ucc 066359 rates, Tor white males , per 100,COG. The white male cancer rat incidentally, are- most often used for comparisons because they . ac count for the -larges t numbers cf cancers. 3 Philadelphia St. Louis, Missouri New 'fork City Nassau County (an Eastern suouro of New York City) San Francisco Chicago New Jersey District of Columbia westernsstar County (a Northern suburb of New York City) U.S.A. Nationwide 221/100,000 220/100,000 215/100,CC0 212/100,000 206/100,000 206/100,000 '.05 100,000 203/100,000 200/100,000 174/100,000 This initial CXNJ study demonstrated that serious misimpressions could be made if comparisons were made against invalid controls, wherein a hey variable, such as urbanization, is noc considered. In -Dr.--Samuel S. Epstein's booh, the Politics ox" Cancer (Sierra Club 3oohs, San Fransisco, 1979) this type of error is made in his Table 1.10, p. 29, wherein he compares New Jersey, Wyoming and North Carolina. As a result of this comparison.he concludes that New Jersey's higher-races are due to the Chemical, Petroleum Industries. Unfortunately, uncontrolled comparisons such as these by Epstein fora the basis for omen of the book., ana for much of the document submitted,to QS2A by NI0S3, NCI, and NJ3HS, entitled Estimates of-the Fraction of Cancer in the United States Related to Occupational Factors. The latter cocumenc, guise erroneously, relies heavily on extrapolations from an article* published in Ca- A Journal for Clinicians (volume 2b, 1973, p.97) by I.J. Selihoff and E.C. Hammond, entitled Asbestos-associated disease in United States shipyards. In this article, comparisons are made between the cancer deaths in asbestos insulation workers, and those expected cancer deaths in the average white male, as obtained from age-specifio mortality daca from the U.S. National Center for Health Statistics. As seen in Table 1 and Table 3 of this article by Selihoff and Hammond, a comparison with the average U.S. white mala suggests that asbestos workers have approximately a 20C greater cancer rate; for example. Table 1, 319 total cancer deaths Expected, versus 994 Observed in the workers. Many,"-"if 'nof most^of^the_jLS^stqs^insulation_iior!s:ersuwere_.in. .urban. areas-,-which could.^ in-anci.nf^.ltseljfvaccou nfi for,_gmch^ofs_the^.2QO^rapo arent; in-- nreasa.:in.cancer, rates .aqgnp;- a.shgst:aa wopkars. further, Selihoff's data does not take into account other factors, besides urban-rural differences, that markedly increase the risk for sever al forms of cancer. For example, socio-economic status, cigarette sacking, alcohol consumption,*and fat ingestion (see References at end of this document). The asbestos insulation workers ware high wage earners, a factor that made Selikoff's follow-up re latively easy since there was a low race of job turn-over; however, this led to increases in socio-economic status. The lack of controlling for cigarette use in the asbestos cancer deaths is seriou since several forms of cancer are caused by sacking. Hammond (Tocac _____ ucc 066360 TABLE 1 Deaths among 17,300 asbestos insulation workers in the Unitad Sutas and Canada January 1, 1967-January 1. 1977 ; j Numoif. a# man . .. Man-yeariCf eaaarvation . , 17,300 165.253- j. j - Sxaactah* Cbsarvae j Total drathi, ail ssuaaa Total canear. all aitaa Lung cancer PIaural mesomaiioma Pamonaal meiotnailoma Canear of asoonaqua Canear of ttomtcn Canear of eston-recium All otdar eoncar Adsaatotis Ail other esuaoi 1,560.36 319.90 105.37 ** % * 7.01 14.53 37.3 154.23 1,351.06 3.270 994 4 66 109------13 72 59 325 162 1,114 'IxoMfM eaatni r Qaaae ueon v*nit mala age toeciflc mortality Oata at cna U.S. National Cantor for Hanoi Statlrtict lor l987-t973 ano aatraoeiacon to 1974. **Tha ara nra cause* of oaath in tha general pooulation. TTia mamoertnia of We tntamational Aiaociation of Haat ano Prott Intuiaton ano Aiaaatat Mora an, APU-CIO, CLC. a anroliao an January 1. 1967, and :ia saan ceaervad tines. ?3*s -c TABLE 3 Deadis among 17,300 asbestos insulation workers in tha Unitad States and Canada January 1,1967-January 1,1377: Analysis by duration from onsat of ampioyment Total man Man-yaaro of observation 1X333 69.466 1X061 77.389 Soforo 20 yoaro from onaat 20 or more years from onsat latpaetad* Observed Sxoectsd* Observed Total daatna, all eauaao 283.93 334 1J77.01 1.946 Canear, all titao 4X65 83 277.23 911 Lung eanear Pleural metocftelioffla Pantonaal meiotnetioma Canear of noonagua Cancer of ttomacn Cancer of eoicn**etum Aioastoaia 1X03 ** ** 0.66 1.58 4.07 " 36 2 3 1 1 4 3 93.94 * 5X5 1X57 33.79 o* 449 64 106 17 21 53 154 'IiarnM aratnt are Mud uodn --nt man *4* maciflo mormlry jni ad tna U.4, Nation* CtnUr far rurni tUMnlc* far 11I7-IJ71 hm vmkum <0 1974. "Thw an rtu cwui df Min In ou nHrl Msufttlrn. ._ ucc 066361 page -7 In: _ Parsons at Himh Pisk of Cancer, (ac.) J.7. Frauneni, Hew York, Academic Press }'yf5j ? 151; .nas^snown-statiscicaliy-significanc in..creases a\ cancer-death-rates-in-Smokers-in*-the-fallowing? forms. ct. buccal cavity 690# lung 681# larynx 5050 esophagus 3170 pancreas 1630 bladder 10C# It Is imperative when comparing cancer data for the purposes jf strategising a Prevention program to control for the variables discussed in this section. In using national data, it is often inpossi: to obtain information on socio-economic status, and.the consumption c cigarettes, alcohol and fats. However, urban densities can be'read:.! controlled and can prove valuable, as indicated in the next sec tier. IH. Urban Centers With and Without Cheaical/Petrolsum Indus try In studying the Third National Cancer Survey: Incidence Data (1369-1371) comparative data was ootainsc" wnicn is summarised an"the accompanying Table. The tabular data lists all cancers for all the standardised anatomic sites, as well as for tnree anatomic sites tha are allegedly more likely to develop malignancy if the person lives that the risk of developing cancers of the lung, nasopharynx ar.d This is ireeuy adaattaa in Blot's article. Hence, although Blot's study-was not meant to be representative, many individuals have made unwarranted extrapolations ana have concluded that 31ot's study shews that the chemieal/petroleun industries in the oCk petroleum counties pose a higher cancer risk to the public, and to the workers. There fore, these extrapolators of Sloths work continue, there is an urgent need to have far more stringent control over occupational exposures to - chemicals. Many of the extrapolations of 31ot'f s work show serious inconsistencies, e.g., there was no increase in lymphomas and leukemias in 31ot's, yet, Spstein, in his book, The Politics of Cancer, p. 122, states that benzene causes lymphomas and leukemias, ana cnat the petrolsum/chemical industries therefore cause these types of cancers through environmental pollution with ber.ece Jibe, data in. the. table -show,, quite,.surprisingly,-- that over-all cancer incidence-is lower in .those-urban areas-with-Indus try (average 239/100, CCO) comp area.. so_urban .areas., without inaustry (average ;!-/ 100,CCO), and that there is no significant "difference in the incident `of cancers that some individuals believe are mors likely to occur in areas with heavy chemical.-petroleum industry, i.e., .rates for lung, nasopharynx, and stomach are almost identical for the two types of. ,.Ilrh*.n_ 4 t*4 a UCC 086362 _a 1. page -3 Average Annual- Cancer- -Incidence'' In' Urb an Areas, ' with. and without Heavy Chsmicai/Petroleum Indus the 'Third "aticnal Cancer Curve*.*; rnc''dar,ca *3. lo^b-io?1, Tables 10c, 11c12c, 13c, i-c, ICC, 10c; age-adjusted, white males uer ICO.CCOl Urban Areas with Heavy Chemical/ Petrole.ua Industry" All Cancers Lung Naso pharynx S tcnach Detroit Pittsburg Birmingham &V'02T2.,3 303 57 q.3 13.5 299 57 0.8 11.5 S2t 2 o.l f -O 239 72 0.7 "-TU1L. ^" Urban Areas without Heavy Chemical/ Petroleum Industry1 Atlanta San Fransisco^ Dallas Minneapolis average . 301 72 1.1 7.1 330 63 0.8 11.2 321 73 1.0 9*2 311 57 0.3 13.3_ 311 69 0.8 11.0 Footnoces: 1. Heavy Chsmical/Petrolaum Industry includes those industries where chenical/petroleum products are produced, or used expansively in manufacture, e.g., automobile industry. 2. San Fransisco's data in the Third National Cancer Survey includes the city of San Fransisco, plus_the counties ox' Alamsca, Centra Costa, Marin and San Mateo. A study of the U.S. Cancer Mortality by Countv reveals that the cancer death rata/lCG,ooo, tor wni os maxes, from 2.^50 1969 was 212 for San Fransisco, ITS for Alameda, 171 for Contra Costa, l?i for Marin, and 175 for San Mateo, The average U.S. r.a t i0 nv:i d e was 171, indicating that the San Fransisco data in * ______f _ . - Cancer Survav is diluted by the inclusion of the ccuncues. iio attempt, however, wa3 made to cor ect for this in the above Ta'ol e; the San Fransisco data was used as it appeared in the Third National CancSr Survey. ucc 066363 page -9- Aa-a.--coosecjienca_o^pur.^CIiIJ^ajtudiea.JBwe-_cmacluda d tha t acco^rdiag .tcc.-.the. ,besu available-,. -caca_r- thar eis. ^no^corza lauion bezwae high-cancer-rates... and'. the.' pres ernes- of- hea7y.--chea1J.cal/petrcIaua- indue It therefore seams unlikely, with the exception of a few very specie, instancesthat occupational exposures of cheaical/petroleua workers or pollution of conaunities Juxtaposed' to industrial sites have con tributed vin` a significant way to the develop pen t^p :\, c anc s r. _ 'The___ e'stinate- thatlX-4^ioflhuaanr.:cahcerCSe-occunationaliyV indueea-.-is* a ggngraU2a.tion-fchat is - &qq high. Perhaps are Indus try-related - wherein am occupational exposure, .plua-aore^generally-usac carcinoge. .such-as^cigare-tte^saoka^orlalcohol, bring about additive or synergis effects under unusual circumstances, e.g., extra-ordinary asbestos exposure and cigarette smoke leading to bronchogenic cancer. Such instances are quite rare, when, put into perspective. --If additive or synergistic-* effects were-generally, significant for human carcinc- gene sis,---then we-should have been, higher., cancer rates in the se_ urban areas.that-have heavy chamica/petrolaun industries. Instead, we sav slightly lower rates in such urban, industrialized areas. It should be noted tnat the seven cities compared (Detroit, Pittsburg, and Birmingham versus Atlanta, San Fransisco, Dallas and Minnea polis) represent 16 million people out of the 21 million total in the Third National Cancer Survey. Hence, the data do net re present some type of exception. IV. Cancer and Air Pollution With respect to "../what is it about urbanisation that leads to cancer rates...?" seme people would Jump to the conclusion 0: it is the air pollution in crowded", urban areas. The cbje; ;ave ans; 1:.o_ thiis^ Jis_ , I"t .'..n^ ot s^o..."It , basedJ on NCI dJ a. !ta, as well...mm as data from c of the most heavily air-polluted countries in the world, Japan. Let us examine California first since it provides excellent dabs on the question of air pollution. Los Angeles*is notorious in the U. and averages over sCO days per year of air quality that is "unhealzhful, or hazardous" according to the National Wildlife Federation. Sar Fransisco has about 125 such days per year. Further, in Los Angeles, there is heavy petroleum industry concentrated near the coastline so" that the prevailing west to east winds carry the pollutants inland and add them to the stagnant automotive exhaust. "San Fransisco is bathed in pure Pacific Ocean breezes.- Yet, according to the NCI's IT.5. Cancer Mortality by Cour.cv: 19o0-1969? the figures are as follows for wniza male deacas in Los Angeles and San Fransisco.: ucc 066364 page -10- All. types of Car.cars . Los Angeles San-Fransisco (alone) U.S'. Nationwide i73/ioo,coo 212/100,000 174/100,000 Lung Los Angeles San Fransisco.(alone) U.S. Nationwide 41/100,000 47/100,000 38/100,000 Nasopharynx Los .'.ngeles San j'ransisco (alone) U.S. Nationwide 0.4/100,000 0.6/100,000 0.38/100,000 S tomach Los Angeles San Fransisco (alone) U.A. Natiowide 15/100,000 20/100,000 15/100,000 Again, there is an absence of the-'expected" correlation, that air-^*4icn must cause cancer, especially in a petroleum county. From japan, Kunio Aoki and Hiroyuki Shimizu published a oaoer entitled "Lung Cancer and Air Pollution" in an NCI Monograph, ~7', called Ipideniology and Cancer Registries in the Pacific*Basin. The; showed an absence of a "correlation between lung cancer anc hignly incus tria ized areas. Further, they shewed a gradati mci- that para ieled the-density of population; both rose :oisgaethr a r. V. The Predominant Causes of the Major Lethal Cancers .The question then is what urban factors do causa cancer; it is not industry,, and it is not air-pollution? The answer cay lie In life-styles and the consequent habits that develop in urban areas .with respect, to cigarette;use, alcoholism, and poor nutritional practises. Cigarettes alone account for virtually all of the lung cancers, and major percentages of cancer of the urinary bladder and pancreas; all told, cigarettes-alona-acounhifor_3C&.a. the_cancer mortality;, rata. When cigarette smoking is coupled with alcoholism, an additional of the cancer mortality is explained by the causae: of cancers of the mouth, larynx and esophagus following the conjoint use of cigarettes and alcohol. Poor nutritional practises> such as excess fat intake, and obesity lead to an estimated additional o: the car.cgr death rate by promoting the development of such cancers a. colon, rectum, breast and others. These life-style aspects of urban: zed humans may help explain the significantly higher cancer rates in urban areas. Additional evidence that life-style is involved comes from a study of the Seventh Day Adventists; many of these =00,000 Americans live in places like the Washington, D.C. area and Los ucc 066365 page -11 Angeles. They do not smoke, or drink and are vega tartars. Roland "S'-v* is an -4 ~T ar_ W. Euzna found that the over-all cancer rates In 7th Day Advent1st' males was one half that, of the U .5 _ Xatlor.wd.de rate for white males, (see Rations! and methods- for an epidemiolo gic .study of cancer among Seventh Day Adventists, in Epidemiology and Cancer Registries in the Pacific Basin, NCI mcnograpn ~-7) . ^ ^saa actacnec referencesj. 71. The Sole of Occupational Exposures Nich respect to the idea that occupational' exposures cause betwe 20-kc# of cancers, as expressed in the recently submitted'document, "Estimates of the Fraction of Camber in the United states Related to Occupational Factors', prepared by individuals from MIOSE, NCI, NIZEE and 'submitted to OSHA for the hearings on occupational carcinogens, c following should 'oe borne in mind: major reliance is placed on Selikoff's data which purports to show that asbestos insulation workers have higher cancer death rates from cancers of the lung and gastro-intestinal tract, compared to the average U.S. white male: this is a serious ""error in comparisons," since most of the workers were centrated within urban centers. The valid control groups are white males in urban areas, net average U.S. figures. extensive extrapolations are made upon data bases that are in themselves very limited, and uncontrolled, s.g.,' smoking, alcohol and nutritional factors are generally not considered in the original studies that were extra polated. The "Estimate" that 20-40JS of. cancers are occupationally relatac with directly causal agents in the workplace, or-additive/synergistic effaces is wrong. If the massive extrapolations in this "Estimate" document were valid then we should see more cancer in urban areas that have a great deal of industry. Instead, we do not see this wher we use National Cancer Institute data, e.g.. Third National Cancer Survey, (see Section III of this document). The pervasive question raised by the "Estimate" document is whether potentially'carcinogenic industrial substances have escaped into the communities and have caused cancer. The studies in Section III 3how that this is not the case. However, we went further in via*, of the continuing public remarks of some individuals that asbestos has not only escaped, but is ubiquitous, particularly in turban areas. An asbestos-risk study was initiated by.cINJ in la a 1976 in view of tthe fact that New Jersey has a major asbestos i ndustry in Man__v_i_ll_ _ _N_._J_. O__n_e__ofthe components of this study was to dec ami. the numbers of mesotheliomas seen in large urban medica1 cents rs i. the Greater New York/Mew Jersey Area over the ten years , in o*-.r'ic(- 4 --li-+ f } as one of several bases for future comparisons. Among the lar > most complete contributors to this data pool ware the : our aff hospitals of the New York University Medical Center: 3e Ilevue 'vr.m ver sity, Manhattan 7A, and Booth Memorial. The data from these ospi cal is particularly interesting in the light of the inplica tions n as by ucc 066366 page ccr.eal masotheiicmas} c v* c *-* -- i "r* v* iV**t2^*r*Cw * 3 c; aSOSStOS of a .74 .ssiva wavs of uicers in- tuced by- exposures to industrial. sources.. Supposedly, ere:;- a one-tin exposure to small cuar.octlss of asbestos' will cose an increased risk the future development of not onlv the "marker w `i^-TiO i ^ C*^i -- - C bronchogenic and gascrc-intestinal tract cancers,-in the general public as well as incus cry v:or:-cers. If Selikoff's dire predictions have objective, scientific validity, then there should be a cleariy evident brand in the appaaranca of plsural/peritoneal mesotheliomas . ever the tar* years, 1557-1976. The Third National Cancer Survey; Incidence Data catalogued a total or lj4 pleural/peritoneal neso'che- licnas in tne years 1969, 1970, 1971 in the" approximate 153,000 cancers included in the survey of ill the geographic areas. This is apprculmtely 1 mesothelioma per every 1,000 new' cancer cases seen. The Third National Cancer Survey did not provide a breaksown of the disoribuoion of these mesotheliomas according to geographic areas, but the figure of 1/1000 new cancer cases is useful. At the N.Y.T. hospitals an average of 3,000 new cancer cases are seen each year (Squamous and Basal Cell Carcinomas of Shun are not included). The excellence of the anatomic pathology services, coupled with good records and tumor registries provided the numbers of cases summarized in the accompanying Table. There was slightly less than one meso thelioma per 1000 new cancer cases (2& mesotheliomas in ten years, with 20,000 new cancer cases), or C.S6/1CC0 cancer cases/per year. The NYTJ figures are of interest for several reasons: there is no trend over the years, as would be expected if Selihoff's fears ware valid the four hospitals provide a significant cross-section of the public from the New Ycrk/New Jersey areas, and include balanced percentages of lower, middle and upper income patients heaw use of automobiles with reuease oi asbestos t._ __ the brakes, the clothing industry which sometimes has included asbestos fibers, etc. ucc 066367 TibIs 2. page Mesothelioma cases at the Mew YorV: University ---- i .w ^ * Procasle cr Cere at it le Definite Total for the four Hospitals 1967 ' 1963 1969 1970 1971 1572 1973 1371975 1576 W 1 0 2 0 0 0 1 2 2 7w 1 3 2 1 2 1 2 2 1 3 23 4 1 2 1 3 4 3 TOTAL: 3 IS 26 ^Footnote: 'iiew Tern university Medical Center includes four Hospitals: University, Bellevue, Manhattan Veterans Administration and the 3ooth'Memorial Hospital in Queans. UCC 066368 i pags -1^- `VTT.. Summary ' .la 5u.T.na_rv,^although we 'havs~sea-rehed..extensively,. we have -bean unaaie to find any. direct,-posisivs.-correlations between the -presence of..heavy.-.chemical/p e troieum-indus try, and. the developsent *of--cancer. This is true for the Hew Jersey and Hew York areas, as well as for the rest of the country as shown in the Third national Cancer Survey and in the CT, 5. Cane a r Mo r -a11tv' ay c ount-r: 1?'Je also found no increase In tne urcan areas v/icn neavy chemical/petroieum industry, in selected ana tonic sitas ths z are thought to be at greater risk, e.g. lung, nasopharynx, and stomach. These studies, plus the serious flaws in'the data base used for extrapolations in the HI0SE/HCI/HIZH3 "Estimates" document submitted to Q3HA, indicate that in no way can occupational facto: s account for 20-4055 of the cancar mortality in ths u'.S.A. Dr, Donald Louria, Chairman of the Department of Preventive Medicine and Community Health, in the Hew Jersey Medical School, studied Jersey and Methods of Cancer Control1', May 1-2, 1976. He con cludes his paper by stating, "...only about SCO or a percent of ths deaths can be felt to be related to industrial exposure". Wynder recently ascribed a similar low percentage to industrial exposure (Toward the Prevention of Cancar. Cancer 3ullatin 29: p. 186, 1977). There are many inconsistencies to CSHA's approach to the cancer problem. Some of these inconsistencies have been demens trace by the studies wa conducted at the Cancer Institute of Haw Jersey wi the aid of an NCI "Planning grant". Other serious inconsistencies that we did not specifically study are pointed cut in closing: it is widely acknowledged that cancer of the stomach is a rapidly disappearing disease, and the causes for this striking downturn over the past 15-20 years are net known: in any case, this most dramatic event (stomach cancer used to be the leading cancer killer in men) is not in keeping v/ith ths implications made from Blot's work (Science i.96: p.51, 1977) that petroleum/chemical industries pose an increased risk for ths development of certain cancers,.like stomach, in the public at large. if--lung-cancers-are--'excluded ^tha^c-var-all-.can.c5r..rs.t as have not-changed in-any--statistfdaUya.significant.-way. in the past! .15 years; ths lung cancers that we are seeing now were initiated 20-55 years ago, 'when filter tips were rare, and the great bulk of the smoking was dene by males; current trends in the use of greater filtration and more female smokers will not beneficially affect the male lung cancer rates for another 10-15 years. See attached tables, re printed from Ca - A Journal for Clinicians (volume 2a, 197a, pp. 20, 21). UCC 066369 Ila ia par 100.000 Itn w la population page -15 AG.AC..:JS723-.,:.-'!CSa DEATH RATcS* FOR SELECTSQ S1T3S 1930 1939 1940 1949 1990 1393 I960 IMS 1970 1379 1980 Yaar Sourets: U.3. Nation** Canw foa Ha* in Startitto ana U.3. 3ut*au of tha Canma. * Stanoaraiiaa on tna aa oiitriaution of tfia 1940 u.3. Cantu* aoauiation. a CA-a CA)>.CS* JC'-WOM.C.4 CuniC.-a.n5 ucc 066370 page -16- AOE-ADJUSTSD CANCER DEATH RATES' FOR SELECTED SITES MALES. UNITED STATES. 1530-1975 U(i|tP)tHf<nl !*! ooo'not *I*U u*3. National Cantar f9f Hntn Scjtntc4 U.S, Sgraau of Cantus. *Stan4*ra>tta on th* $ dittrtOution of :n 19-40 U.S. Cantus Poouution. vCL "! NO ! jamuabv wt j- ucc 066371 page -17- .;5C8T*t rsr*`* and "life-acyle '.in the . cancers, with reiev-.ct r* .-ties of diet, smoking, ethanol, -icr., of the majority of fatal. human 1. Armstrong, 2.., and Doll, ?:. Er.viro nnerrtal factors and cancer' incidence anc noreality in different countries, with special reference to dietary practises. Int. J. Cancer it: &17, 1975- 2. Lynch, E.T., Guirgis,~E., Lynch, J., Brodkey, ?.D. and Magee, H. Cancer of the colon: socioeconomic variables in a community. Am. J. Dpid-m. 102: 119, 1975., 3* Doll, R., and Mill, A.3. Mortality in relation to smoking-ten years' observations of British doctors. 3r Med. J. lj_ 1399 > h. Wvnder, E.L. Nutrition and cancer. Fed. Proc. "5 1309-, 1976. 5. Kuratsune, M. Test of alcoholic beverages and ethanol solution for carcinogenicity and tumor oromoting activity. Gann 62: 395> 1971. ------ 5. Wynder, E.L., Reddy, B.S., McCoy, G.D., Weisburzer, J.E., and Williams, G.M. Diet and Gastrointestinal cancer. In: Clinics in Gastroenterology, Vol. 5 1976, p.^63. 7- Wynder, E.L., and Reddy, 3.S, Diet and cancer of the colon. In: Nutrition and Cancer, (ed.) M. Winick. J. Wiley and Sons, Inc.,.1977, P-55. 3. Drasar, 3.5 , and Irving, D. Environmental factors and cancer of the colon and breast. 3r. J. Cancer 27: 167, 1973- 9. Wyr.der, I.L., MacCornack, ?., Hill, Cohen, L.A., Chan. P.C., and Weisburger, J.H. Nutrition and the etiology and prevention of breast cancer. Cancer Detection and Prevention lj_* 293, 1976. 1C. Gortner, W.A. Nutrition in the United States !9CC-197h. Cancer Res. 35: 32^6, 1975* 11. Alcantara, E.N., and Soeckman, 2.W. Diet, nutrition and cancer. Am. J. Clin. Nutr. 2^ 1035, 1976. 12. Oiso, T. Incidence of stomach cancer and its relation to dietary habits and nutrition in Jaoan between 1900 and 1975. Cancer Res. 35: 325^, 1975. 13. Phillips, R.L. Role of life-style and dietary habits in risk of cancer among Seventh-Day Adventists. Cancer Res. 35: 3513, 1975. lh, Rao. 3.A., and Abraham, S. Enhanced growth rate of transplanted mammary adenocarcinoma induced in C-sH mice by distarv linoleate J. Nat'l Cancer Inst. 56: ^31, 1976: ucc 066372 page -13- ucc 066373 epidemiologic s tud-1* '::' o? xn; srr*^ cn o^r*^ a "-3* 'fa*V^wWs4r*W-* t*^ *'^ **a *i* (NIH) 77-1273, P- 107*. icnale and mechoes far cer among, Seventh-Day Adventists r* Hscis tr Monograph i*s.*TJsT*!^ in a *wi"hns w?" auccliifcicat3ics ns1- . , 4 1 A Aoki, I., and Shiniso, H. Lung cancer and air pollution. In: ibid p. 17. (n.b., no relation found between lung cancer and industrial air pollution in Japan). T T Basa, G.F., Hirayaaa, T., and'Cruz-Basa, A.G. Cancer epidemiology in the Phiilipines. In: ibid p. 45. (n.b., elevated risks for several forms of cancer as a result of cigarette smoking noted in the P'nillipines, as well as other ''developing" nations). *16. Hill, Chan, ?., Cohn, L., Wyr.dsr. E.L., and Runo, I. Diet and endocrine-reintad cancer. Cancer 39: 1820, 1977. *19* Watte.nberg, L.W. Effects of dietary constituents on the metabolism of chemical carcinogens. Cancer Res. 35: 3326, 1975. 20. Walker, A.R.P, and 3urkitt, D.P. Colonic cancer-hypotheses of causation, dietary oroohylaxls, and future research'. Digestive Dis. 21: 910. 1976. 21. Reddy, 3.S., Martin, ,C.W., and Vynder, E.L. Fecal bile acids and cholesterol metabolites.of patients with ulcerative colitis,a high-risk group for development of colon cancer. Cancer Res. 37: 1697, 1977. 22 Wilkins, T.D., and Hackman, A. S Two patterns of neutral steroid conversion in the feces of normal North Americans Cancer Res. 34: 2250, 1974. 23. Williams, R.R. and Horn, J.W. Association of cancer sites with tobacco and alcohol consumption and socioeconomic status of patients: Interview study from the Third National Cancer Survey. J. Nat11 Cancer Inst. 53: 525, 1977. 24. Adelstein, A.M. Occuoational mortality: Cancer. Ann. Occup. Hyg. 15i 53, 1972. , 25- Pearce, M.L., and Dayton, S. Incidence of cancer in men on a diet high in polyunsaturated fat. Lancet 91^ -64, 1971. 26. Modan, 3., Bareli, V., Lubin, F., and Modan, M. Dietary factors and cancer in Israel. Cancer Res. 35: 3503, 1975- 27. Modan, 3. Cancer in Israel: Seme ethnic considerations In: Cancer Genetics (ed.) H.T. Lynch Soringfield, Illinois: C.C. Thcma TSTHTpTTcF-- <8. Carter, R.L., and Roe. F.J.C. Chemical carcinogens and industry. J. Soc. Occup. Med. ?5: S6, 1975. (n.'o. indicates types of cancers, by sites, that are caused by industrial substances, e.g., bladder, lung, liver). Bloc., W.J., Brintcr.. I.A. . Frauaeni,. J.F., and Stone, 3.J. Cancer mortality in 'J.2. counties with petroleum industries. C o 1 OM S "* " w w * _ !'-- -- ^ . ~7 (n.b. indicates vpss ox cancers, by sitesthat are industry- related, e.g. . Lung, nasal cavizy/3inuses. and stomach: also takes cognizance of controlling for percentage of population that is urban, population density, and socioeconomic factors). Eanmar.d, 3.C. Tobacco In: Persons at High P.lsk of Cancer Etiology and Control (ed.) J.'lF. Pr'aumeni7'Jr. New"Yo rk: Academic Press",' 19757 57 "1117 (n.b. cigarettes, alone and with ethanol, in causing cancers at numerous anatonic sites). Hothman, X.J. Alcohol. In: ibid, p. 1*9, U.S. Public Health Service. Cancer. In: Health Consequences of Smoking 1975. p. 41. Clarke, M. Carcinoma of the Cervix - An epidemiological perspec:!' In: Gynaecological Malignancy: Clinical and Experimental' Studies. (ed.), 'a.G. Srusn, and a.W. Taylor Baltimore: williams "ana Wilkins 1975. p.3. (n.b. association of life-style and cancer of the cervix). Vlgiiani, E.C. Leukemia associated with benzene exposure. Ann. N.Y. Acad. Sci. 271: 1*3. 1976. Lijinsky, W. Health problems with nitrites and nitrosamir.es. Ambio. 2L 7, 1975. Issenberg, P. Nitrite, nitrosamines and cancer. Ped. Pros. 3t: 1322, 1976. Mack, T.M.,?ike, M.C., Henderson, 3.3., Pfeffer, H.I., Gerkins Arthur, M., and 3rown, S.3. Estrogens and endometrial cancer retirement community. New Engl. J. Med 29^: 1262. 1975. Blitter, ?.H., Blitzer, E.C. , and Pimm, A.A.. Association between teen-age obesity and cancer in 56,111 women: all cancers and endo metrial carcinoma. ,?rev. Med. 20, 1976. Higgins, I.T. Smoking and cancer. Am. J. Public Health. 65: 159, 1976. Toxicants Occuring Naturally in Foods. National Academy of Scieces T7TT.--------------------------- ---------------------------------------------- Nutrition and Cancer (ed.) M Winick. New fork: John Wiley a nf* I377"i- - - - - - - - - - - - - - - - - - - - The Changing American Diet Canter for Science in the L. Brewster, and M.F. Jacobson. ublic Interest. Washington, D.C.197S. ucc 066374 C-r^-u.r.i 4-----v -C- K--- r- ft C c u c / 1/ #.dyc R t C u i v L i/ ivVAY I o 1373 R. A. PsCnunr-': i* YO/VTvr, KECY.n ,,~n -'-' 1 1270 >&* i. Q. hull deceived JUNO 6 1978. R. N. WHEELER, JR. A RATIONAL VIEW OF CANCER IN NEW JERSEY Harry B. Demopoulos, H.O. Associate Professor of Pathology New York University Medical Center New York, New York RECEIVED SEP 18 1978 r. N. WHEct-tR, JR. In the interest of an informed approach to the problem of cancer in New Jersey this paper has been reproduced, with permission of the author, by: New Jersey State Chamber of Commerce 5 Commerce Street Newark, New Jersey 07102 Addicional copies are available upon request. ucc 066375 / The following document contains simplifications for ease of under standing. As in most aspects of human disease, there are exceptions, and alternate opinions. The follow ing attempts to condense the contemp orary, responsible thoughts on the different aspects of cancer. This Analysis was prepared whila Dr. Demopoulos was Director of the Cancer Institute of Hew Jersey UCC 066376 SUMMARY A RATIONAL VIEW OF CANCER IN NEW JERSEY This summary outlines che essential points that are explained in the attached documents. I. Definitions o A major distinction is made between mortality and incidence races. Mortality rates simply represent statistics reported from death certi ficates and provide insufficient data for any solutions; incidence rates are the numbers of new cases/year and relate to living patients. The status of New Jersey as "the number one cancer state" is based on mortality rates. o The difference between industrial and environmental cancer is' stressed. Industrial exposures in Che "work place" cause a minor number of can cers, and there is an even smaller number attributable to industrial carcinogens that "have escaped into the community" (less th3n 0.00001* of cancer deaths). Environmental cancer refers to cancers Induced by an Individual's personal environment which includes cigarette smoking, excess alcohol consumption, 'ingestionjqf'high~fatt/low_fibre'diets .' use: of "nitrate/nitrite"^containing'meats, consumption of'foods'with artifircial^colors, and'other aspects of life-style; the occupational aspects of the environment are important, but relatively less Important. II. How Cancers Start o Normal cells have repair mechanisms to undo che damage caused by chemi cal and physical agents. However, these repair systems can be over loaded. o Cancer-causing agents generally take 20-25 years to produce a cancer. The example of the Hiroshima and Nagasaki survivors Is given. ` This 2025 year period is known as the "lag phase" in carcinogenesis, o Many substances can act together, either in an additive way or synergistically (the sum total of the effect is greater than just additive). III. The Causes of Human Cancers o Specific cancers have been linked with definite agents, but the major lethal cancers, lung and large bowel, are linked to personal habits. Only a small percent of cancers are industry-related, o Nitrites/nitTates and artificial colors are cancer causing chemicals (nltrltes/nitraces are converted into dangerous nitrosamlnes when preserved meats are heated), but specific human cancers have not yet been linked to these substances. o Life-styles that include obesity, and multiple pregnancies, are asso ciated with a greater risk for cancers of the breast and uterus, respectively. .. '0 The most dangerous human carcinogens^are _cigarettes, alcohol, dietary . i fats, nitrites/nitraces, and artificial food colors. These are the most widely distributed In che communities, and are proven to be respon sible for the largest percentage of cancers, estimated as high as S0% (by Dr. Frank Rauscher, the recent Director of the National Cancer Insti tute, and Dr. Theodore Cooper, che recent Assistant Secretary for Health in HEW). UCC 066377 IV. Specific Problems in New Jersev o There is a complex array of medical, social, geological aod geographic factors that must enter into any analyses and solutions for New Jersey's cancer problems, e.g., the dense urban population In N.J., Inadequate educational and medical leadership in the past, etc. The sensitive area of "the quality of medical care in New Jersey" may explain a por tion of the high cancer mortality.races during the period covered by the mortality study. o New Jersey's unfortunate prominence as the "number one cancer state" is based solely on mortality data from 1950-1969 and does not consider the mobility and shifts in populations from New York City and Philadel phia. These two cities, as well as other non-Industrlalized urban areas, have death rates as high as those of New Jersey. The density of the urban population of New Jersey confounds any analyses of Che data available. V. New Jersey Industry and Cancer o New Jersey had a 17Z greater death rate, for white males, and a 14" greater death rate, for white females, compared to Che rest of the country. This is the basis of New Jersey's infamy, o Other urban centers, even with light industry, share New Jersey's death rates, e.g.. New York City, its Northern Westchester suburb, its Eastern Nassau suburb, and San Francisco. The state of New Jersey, when com pared to other states, ranks number one. If, however, only populations are compared and state boundaries are ignored, then New Jersey's rates are equal to the rates of urban areas in ocher parts of the country. The-problem lies however in the fact that even the rural areas of New Jersey have "urban rates"; this is the heart of the problem and requires further study. The answer may be as simple as the fact that many New Jersey rural dwellers, who died in 1950-1969, may have been city inhab itants from New York and Philadelphia at some time in the past and carried their damaged cells with them when they moved, o The types of cancers that are typically "industry-related" do not account for New Jersey's excess 2,000 cancer deaths each year. All types of cancer deaths are increased, and in some cases there is a negative correlation (benzene causes lymphomas and leukemias, and benzene is a prominent industrial pollutant - yet, the mortality rates from lymphomas and leukemias are not above the national average), o Separate studies by Drs. Louria and Demopoulos have suggested that only 600 of the 14,000 deaths in New Jersey might be "industry-related". VT. The List of Carcinogens in S-3035, Section 6 o The list includes a mix of substances; some are no longer in use, some are not carcinogens, some are strong and others are weak carcino gens. Apparently, at the present time, all are being handled with ade quate precautions. o Asbestos and vinyl chloride are weak carcinogens. o Research is required to determine permissible exposure levels as has been done with the most powerful carcinogenic agent, x-rays. ii ucc 066378 A RATIONAL VIEW OF CANCER IN NEW JERSEY New Jersey has unfortunately achieved infamy because statistics from a National Cancer Institute study reveals that New Jersey had the highest mortality rate, per 100,000 general population, in America in the period 1950-1969. This means one of two things: a) if you developed cancer'and lived in New Jersey at that time, you were more likely to die of it because your cancer has been detected at a more advanced stage than in other states, and/or the complicated treatment that was needed was not as available as in other parts of the country; b) the risk of developing s lethal form of cancer was greater in New Jersey than in other states. It is not possible to deter mine which of these two reasons, or what combination- is the truth because reliable incidence data does not exist throughout New Jersey. The data that is available is mortality data, which only shows how many people die each year from cancer. The mortality data, although very inadequate, has triggered massive controversies regarding: o industry-related cancer o environmental cancer o the personal environment o life-styles and cancer o inadequate health resources 0 toxic substances o dietary factors o banning of so-called carcinogens o politics o early detection o financial aspects of cancer a possible solutions Cancer is the most complicated disease process, compared to the other major killers such as heart disease, strokes and accidents. There are over a hundred different forms of cancer, and they start in different organs of the body, in different types of individuals, and under poorly understood circumstances. No other disease process is so intricately interwoven with the very fabric of society; as though to emphasize their perplexing, intri cate nature, cancer cells remain very similar to the patient's normal cells, thereby frustrating most attempts to "weed" them out. In order to put cancer into perspective, so that possible solutions can be evaluated, the major complex aspects must be understood. -1- ucc 066379 1. DEFINITIONS Cancer - a malignant growth, composed of solid masses of disorganized cells that are ever-growing, and are capable of spreading to organs far from the original site, e.g., breast cancer starts as a lump, and some of its component cells will microscopically invade the blood stream which will carry them to the lungs, bones, liver, and brain. Metastasis -- the term used to refer to the spread of cancer cells from its site of origin, to other organs. Early Detection - the process of dstscting the cancerous mass while it Is still small and therefore less likely to have metastasized. Radical Surgery - the principal weapon in use today for treating cancer; the surgeon cuts widely around the cancerous mass hoping that none of the cancer cells have microscopically metastasized; the surgeon and other cancer experts generally have no way of .knowing whether an individual case has already spread microscopically; however, the smaller the original can cer mass, the less likely it is to have spread. Mortality Rate - the number of people dying as a result of cancer each year; it is generally given as the number of cancer deaths per 100,000 general pop ulation. In America, the average figure is about 170/100,000. Incidence Rate - the number of new cases that are diagnosed each year, again given per 100,000; in America the average figure is about 340/100,000; about one-half of this number will eventually die of their disease, but over'a period of 2-8 years; the other half of the newly diagnosed cancer cases will live out a normal life expectancy and die of some other cause. Industry-Related Cancer - a cancer whose cause can be, at least in part, traced back to a distinct exposure to a chemical or sometimes a physical agent that was present in the "work-place"; this generally encompasses employees and, more rarely, members of their families who are exposed to the employees "contaminated" work cloches. Environmental Cancer - refers to most cancers, possibly 80Z; however, the term "environment" is all-encompassing and relates mostly to the personal environment that results from life-styles, habits, and dietary factors; occupa tional exposures, and industry-related events comprise a minor component of "environmental cancer". Carcinogen - an agent, chemical or physical, that is capable of initiating irreparable damage to a cell, such that the cell may be unclmacely trans formed into a cancer cell. Co-Carcinogen - a chemical which by itself is incapable of causing cancer, but in combination with small doses of carcinogens (doses coo small to cause cancer) will cause the development of cancers. Epidemiology - the science of studying what disease occurs in which types of people, and under what circumstances - it constitutes medical detective work. -2- ucc 066360 II. HOW CANCERS START Cancer cells are no longer "self-controlled", Che way aortal cello are. Of the many trillions of cells in our bodies, many of them divide and multiply in order to replace "worn out" cells. Most remarkable is that the normal re placements are exactly like the worn-out ones. Cancers start as a result of some cells losing their normal control mechanisms. This happens as a result of damaging the genetic material and the delicate membranes of a cell beyond repair. It is important to realize that from conception, i.e., when a sperm and egg cell have united to fora a unique individual, that single cell and all of its subsequent dividing cells are constantly barraged by damaging agents such as viruses, chemicals, and Ionizing radiation. In the overwhelming majority of damaging Insults, our cells repair themselve_s. When repair Is inadequate, we see the development of birth defects, cancer, or death. The genetic material of the nucleus, the DMA, has incredible repair machinery, and the membranes of a cell, in spite of their extraordinary delicacy and complexity, are undergoing incessant replacement, 24 hours a day, 365 days a year. In short, evolution has given us resilient cells so chat our bodies can take a certain amount of damage. However, the repair systems can be overloaded and some damaging agents can specifically attack the repair systems. It is clear that there are certain tolerance limits, and if exceeded, the results may be birth defects, cancer or cell death. Most cancers are the result of a complex sequence of damaging events that have not been repaired. However, the damage need not be expressed; there is a need to have other factors.which will "bring out" the cancerous damage. In some instances, it may take 20-25 years to "bring out" the cancerous damage. This is referred to as the "lag phase" and is best exemplified by the survivors of the atomic blasts at Hiroshima and Nagasaki. These large amounts of radia tion caused irreparable damage to cells, but the cancerous nature of the damage was not expressed as a lump of uncontrolled cells until 20-25 years later. In these and a few other Instances, there are exposures to a single damaging agent and clear cut blame can be affixed to that agent. In che overwhelming majority of cancers, there are multiple agents which Interact and cause cumulative damage. While there are many hundreds of dam aging agents, there are only a few different types of parts in a cell; hence, the same type of cell part may be damaged by several different substances. We can therefore see additive effects, and sometimes synergism, wherein che result is more than just additive. -3- ucc 066381 III. THE CAUSES OF HUMAN CANCERS The causes of many cancers are known and are listed below. The numbers in parentheses represent the percent of total cancer deaths caused by chat particular type of cancer. Type of Cancer o lung cancer (Z of Deaths) (20Z) Causes cigarette smoking* o mouth cancer (2Z) cigarette smoking* plus excess alcoholism** plus Inadequate mouth care o larynx cancer ("voice box") (1Z) cigarette smoking* plus excess alcoholism** o esophagus cancer ("food tube") (5Z) cigarette smoking* plus excess alcoholism** o colon and rectal (16Z) high dietary fat plus low dietary fibre o liver cancer (ordinary type) (0.5Z) excess alcoholism** o urinary bladder cancer (5Z) unrestricted use of certain chemicals used in dye production o mesothelioma (0.001Z) unrestricted use of asbestos o hemangiosarcoma (a special type of liver cancer) (0.001Z) unrestricted use of vinyl chloride From the preceding list, it is clear that we know what causes over 502 of cancer deaths. There are several major cancer types whose causes are not known and account for a total of 30Z of the deaths; these are cancers of the breast, ovaries, pancreas, and prostate. In some of these cancers, we know a spectrum of associated findings that add up Co a greater risk, as in cancer of the breast, but this does not mean that a causal factor(s) that can be con trolled has been discovered. In addition to the above known causes of cancer, the following substances have been identified as potent carcinogens that are consumed in significant quantities (milligrams/day) by the majority of Americans; these substances have noc yet been linked as causative factors to a specific type of cancer, as in the case of cigarette smoking and lung cancer, but they are nonetheless * generally more than one pack/day ** generally nore than three ounces of distilled liquor/day, or more chan sixteen ounces of wine/day -4- ucc 066382 suspected of causing several different types of cancers. They may act as cocarcinogens, or act synergistically. o nitrites/nitrates - are converted to dangerous nitrosamines vhea preserved neats, such as frankfurters, ham, etc., are heated o artificial food colors - some colors that are widely used in a multitude of foods and beverages are powerful carcinogens Some aspects of particular lifestyles are associated with a greater risk for developing cancer and include: o obesity associated with breast, colon and rectal cancer o multiple pregnancies coupled with inadequate gynecologic care associated with cancer of the uterine cervix o repetitive sun exposure causes cancer of the skin Added to all of the above are many ocher agents that are carcinogenic, but they are either weak, sparsely distributee, or not well delineated. This includes: a hormones used to relieve associated with cancer of symptoms of the menopause the endometrium o pharmacologic drugs used to treat high blood pressure associated with cancers of the breast and colon o high benzene levels capable of causing leukemias o varied organic com pounds in the work place thought capable of causing cancers of the skin, stomach, liver, lungs and urinary bladder The conclusion that should be reached at this point is that everyone is exposed to some combination of carcinogenic substances every day and the most significant ones are uncontrolled. Many agents are carcinogenic and there is a desperate need to study and define which of these agents should be brought under more restrictive control. Logic would direct Immediate attention, at this time, to those carcinogens that cause the greatest number of cancer deaths, and are also widely used. This would result in a list, in order of importance, as follows: o cigarettes o alcohol o dietary fat and fibre . o nitrites/nitrates o artificial food colors -5- ucc 066383 IV. SPECIFIC PROBLEMS IN NEW JERSEY the State of New Jersey is characterized statistically in a number of areas that have a relevance to the high cancer mortality rates, and which may also be involved in the solutions: o Most densely urbanized population o Lowest average land elevation with respect to sea-level o Highest unemployment rates o Reliance on local water sources of household consumption, In contradistinction to other states where water sources are not derived from the water table or rivers found in the concentrated urban areas. o Ranks 46th among the states in money spent for higher education per capita. o Until recent years lacked any credible medical schools; the two existing ones are developmental and reportedly rank 85th and 87th out of the approximate 100 American Schools according to the average scores of the students on the National Medical Board Examinations. o 75% of the interns and residents in the hospitals are foreign medical school graduates; this is the highest in the country; in New York, the second highest, the figure is 50Z, while in Cali fornia, this number is 5Z; the reliance on foreigners is directly traceable to the absence of a large enough pool of graduating medical students who have a desire to undertake or continue their training in New Jersey hospitals. The intermingling of medical, social, geographic, and geological factors listed above, provide clues for analyzing New Jersey's complex cancer problems, and the thought that is required for the solutions. There is no simple approach. and to highlight this, a critical examination of the New Jersey cancer data is in order. The National Cancer Institute, under a program directed by Dr. Fraumeni, conducted a nationwide county-by-county study of cancer death rates per 100,000 general population. This was done by transcribing what was written on the death certificates. The medical records of the patients were not examined. The death rates from 1950-1969 were catalogued from death certificates, and were classified by anatomic site, and sex. Hence, the number of deaths from cancer of the mouth, or of the stomach, in males or females, in Atlantic County, or Essex County, and ocher such numbers became available. These num bers are interesting, and, in general, there is no county in New Jersey that could be considered "safe" according to these data. The 1950-1969 mortality study was noc designed by Dr. Fraumeni to provide information for definitive solutions. To employ this type of data for direct ing conclusive solutions is a frank misuse. The study was conducted to pro vide an overview of the scope of the cancer problem in the nation and nothing more. The reasons chat the Fraumeni data of 1950-1969 cannot be used to dir ect any solutions stem from the lack of medical records daca such as: o Size of cancer and extent of disease when the patient was first admitted and diagnosed in the hospital. These two UCC 066384 factors, size and extent of disease at time of diagnosis, are the principal determinants of the patient's prognosis as to life or death; if the cancer is large, chances are very high chat the cancer cells have already metastasized, o No treatment data is available to judge adequacy of therapy, and of long term, dedicated follow-up. o No patient histories with respect to dangerous habits, nature of the diet, previous places of residence, occupation, income and educational level. If the Fraumeni data were to be used for a direct attack on the cancer problem, without any further extensive studies, several false leads would be pursued based simply on mobility and shifting of the population, espec ially in the years from 1950-1969. Miami, Florida has cancer death rates equal to those of New Jersey. With a moment's careful thought, the reason becomes obvious - many Miami residents are retired Northeastemers who have come from crowded urban settings. It is critical to remember that a 20-25 year lag period is required to develop a cancer from the numerous environmental exposures (in cluding cigarettes and alcohol). Further examination of the N.C.I. mortality studies reveals the following death rates of ocher urbanized areas and their suburbs. o New York City o Westchester County (a Northern suburb of New York City) _ o Nassau County (an Eastern suburb of New York City) o Philadelphia o Chicago o St. Louis City, Missouri o San Francisco 215/100,000 200/100,000 212/100,000 221/100,000 206/100,000 220/100,000 206/100,000 Since New Jersey received formeT dwellers of New York City and Philadelphia during the post-war years of suburban expansion, circumstances in these two cities may ultimately be responsible. Westchester and Nassau Counties may be high in mortality rates for the same reason that New Jersey is, l.e., the city dwellers led life-styles chat predisposed to cancer and when the population shift out of the cities occurred, these individuals carried their irreparably damaged DNA and altered cell parts with them. If many of these individuals were in the lag phase (20-25 years), this could explain, at least in part, the findings. This is a similar explanation for the high races in Miami, Florida. There are many other confounding factors that preclude conclusions, and these are as follows: o While the population was shifting into the suburbs, including into New Jersey, industry also continued to grow in the state, o In the 1930's-1940's (the period of time when people were being exposed in order to develop their cancers and live 20-25 years later in 1950-1969), industry and government were largely ignorant of chemical carcinogens, hence fewer safeguards may have been used in this period. -7- UCC 066385 V. NEW JERSEY INDUSTRY AND CANCER The couaty-by-councy deach statistics of 1950-1969 are divided by anatomic site and by sex. The overall death rates for white males was the highest in the country, but this was not the case for females or non-whites. This can lead to a great deal of speculation, but the data is insufficient for reach ing a solution. The Fraumeni numbers indicate that the national average deach rate from cancer was 174/100,000 (for white males), while in New Jersey, it was 205/100,000, a 17X Increase. In females, Che national average was 130 and, in New Jersey, 148/100,000,about a 14Z increase. These are the increases that have precipi tated the current controversy. The Increases are significant and were consis tent through the 19 years (1950-1969) of the study. More detailed numbers are presented in appendix A. Adding to this data are the estimates of the American Cancer Sociecy, regarding New Jersey incidences and .mortalities. These are given in appendix B. The conclusions pertaining to New Jersey are as follows: 1. General Findings on New Jersey: Proportionally, New Jersey's figure on cancer mortality is greater chan that of any other state in America. Nearly all of New Jersey falls into the highest decile in the U.S. (cop 10Z) for white males and for white females (Appendix A). 2. Cancer categories In which the mortality, proportional to population, is higher in New Jersey chan in any ocher state: o Rectal cancer (males and females combined) The rating of New Jersey as having the worst concentration of mortality from rectal cancer is based largely on the extremely high death rates among both men and women in northern New Jersey, the Trenton-Princeton area Included. This would not be classified as an industry-related cancer by cancer specialists. o Bladder cancer (males only - women not significantly different from the rest of the United States) A proportion of these are industryrelated. o Cancer of the ovary - The mortality figures among the women of New Jersey's northwest comer -- Sussex and Warren Counties -- ranks with the worst in the country. Mortality figures are nearly as high among women In Bergen, Morris,.and Passaic Counties. This causes the mortality figures for women in northern New Jersey in this cancer classification to be worse than for any other single concentrated area in the nation. This would not be classified as an industryrelated cancer. 3. Cancer categories in which the mortality rates for the state of New Jersey rank approximately with the worst statewide records in the nation: o Cancer of the large intestine (males and females combined) New Jersey ranks with Rhode Island as the worst in the nation. This is not regarded as industry-related. -8- ucc 066386 o Cancer of the Trachea, Bronchus, and Lung - Mortality figures among New Jersey males rank as the highest in the U.S., along with the mortality among males in Louisiana and Florida. A small proportion of these are industry-related, o Breast Cancer among females - The record in this category is worst in New York, with New Jersey, Rhode Island and Massachusetts just behind. This is not classified as industry-related. 4. Cancer categories in which mortality for portions of New Jersey ranks with the worst areas in the nation. o Cancer of the Esophagus (males only) - Northern New Jersey, Connecti cut, New York City, Long Island, and the Greater Philadelphia Area of Pennsylvania, combined, comprise the worst single area in the U.S. for mortality figures in this category. The rate for females in northern New Jersey is above the national average. This is generallycaused by a combination of cigarette smoking and excessive alcoholism. In addition, women with rare benign esophageal problems are predis posed to cancer of this organ. It is not generally regarded as being Indus try-related. o Cancer of the Larynx (males only) - The highest concentrations of mortality from this type of cancer are in northern New Jersey, New York City, Long Island, the Greater Philadelphia Area and the Pittsburgh area. A small proportion of these are industry-related, but generally are caused by a combination of cigarette smoking and excessive alcoholism. If an attempt is made to correlate the types of cancers that are known to be "industry-related" (l.e., industrial substances contribute together with ocher factors to the development of cancer), with the types of cancers occur ring in New Jersey, it would be expected thae most of the excess cancer deaths in New Jersey would fall into the "industry-related" types - this is not the case. There are about 14,000 deaths each year in New Jersey, and about 26,000 new cases each year (from appendix 3, estimates for 1974). If New Jersey had average U.S. rates, these numbers would be 12,000 and 22,000, respectively. The excess 2,000 deaths each year and the excess 4,000 new cases each year should fall into the classical "industry-related" categories which Include a small portion of cancers of the: o Urinary bladder o Respiratory system o Liver o Skin o Lymph organs and bone marrow (lymphomas and leukemias) Instead, the "excess" 2,000 deaths are spread across all of the anatomic sites in the N.C.I. mortality study (lip, salivary glands, nasopharynx, mouth, esophagus, stomach, large intestine, rectum, liver, pancreas, upper and lower respiratory tracts, breast, uterine cervix, body of uterus, ovaries, prostate, testis, kidneys, urinary bladder, skin, eye, brain, endocrines, bones, and connective tissues). Further, there are some negative correlations, e.g. benzene is reportedly an industrial pollutant in New Jersey and supposedly is 9 UCC 066387 the highest in the nation, yet the cancer that should be caused by benzene, such as lymphomas and leukemias, occur at the lower national rates. o Lymphomas N.J, (White males) U.S. (White males) o Leukemias N.J. (White males) U.S. (White males) 4.93 4.89 8.74 8.81 Analyses performed by Dr. Donald Louria, Chairman of the Department of Preventive Medicine and Community Health, Hew Jersey Medical School, Newark, and presented under the tittle of "Cancer in New Jersey: An Overview" at the "Seminar for Physicians: Cancer Risk Identification within New Jersey, and Methods of Cancer Control", May 12, 1976, in Cherry Hill, found that only 600 of the 14,000 cancer deaths in New Jersey might by industry-related. A different analytic study conducted by Dr. Harry B. Demopoulos, former Director of the Cancer Institute of New Jersey, also revealed the same types of numbers, i.e., no more than 600 of the 14,000 cancer deaths could be industry-related, among Ch deaths reported in 1950-1969; this report was given by Dr. Demopoulos to the "Skevin Committee" in testimony on November 5, 1976. These two Independent analyses therefore indicate that 4.3Z of the total cancer deaths in New Jersey could be "industry-related". These percentages are important and yet it is essential Co realize that these analyses are based on insufficient data and represent the highest possible number of "industryrelated" exposures. This does not mean that industrial pollutants were solely responsible. If an analysis is attempted of how many cancer deaths were caused solely by industrial pollutants, the data is found to be totally inadequate and very soft estimates yield fractions of II. While the cited studies and analyses refer to past events, there is meager data since 1969. The American Cancer Society estimates do not provide sufficient information to answer the obvious question - are cancer mortality rates and inci dences in New Jersey the same, better, or worse than for the period 1950-1969? Current, but inadequate, "samples" from hospitals chat have excellent Tumor Registries indicate that their cancer case workload has Increased by 501 in the past 5 years, and that the average age of the cancer patient is younger by 5-6 years. This type of data is fragmentary and may reflect changes in referral patterns to some hospitals, or it may Indicate a worsening of the New Jersey cancer problems. Clear cut answers require far more data. -10- UCC 066388 VI. THE LIST OF CARCINOGENESIS IN BILL NO. $-3035. SECTION 6 The list includes a mix of substances o Some are no longer in use, e.g., 4 Aminodiphenyl o Some are not carcinogenic, e.g., alpha naphchylamine - its carcinogenicity was proven to be due to contamination of alpha naphthylamine o Some are very potent carcinogens, e.g., benzidine o Some are rather weak carcinogens, e.g., asbestos and vinyl chloride o All are currently handled with precautions that lead to low expo sures of workers such chat cancers will not develop. Asbestos and vinyl chloride are termed weak carcinogens on the basis of careful analyses of the cancers that they cause. Excessive concerns over asbestos as a carcinogen has been prompted by cases such as that of a 14 year old boy who developed mesothelioma; he apparently was exposed to this when he was helpj.no, his father to smooth down the joints of the newly replaced plaster board walls in their home. Asbestos was in the joint material, not in the plaster board. There was no other known asbestos exposure, and Che father did not other wise work with it. Cases such as this are exceedingly rare and form an inade quate data base. Mesothelioma does occur in nature, without asbestos exposure, and It cannot be ascertained whether this 14 year old boy would have been a "Natural" victim, or whether the asbestos was indeed causal. Far more numbers are needed for statistically valid studies in such unusual cases. The relative weaknesses of asbestos and vinyl chloride are borne out by the fact that workers who were exposed to very large, uncontrolled levels devel oped relatively few cancers as a result. This is in contrast to a powerful car cinogen such as 3,4-dimechyl 4-aminodiphenyl, wherein 15-20% of exposed workers developed urinary bladder cancer in a short lag phase (7-8 years). When the amounts of asbestos, vinyl chloride, and 4-aminodiphenyl are compared, versus the numbers of cancers developed, then asbestos and vinyl chloride are weak carcinogens. r The idea of a comprehensive ban on all carcinogens would lead to the restriction of many activities and substances. Radiation, by x-rays, is the most powerful carcinogenic agent. There are methods for converting physical carcinogens into chemical equivalents, and when this is done, x-rays are quite potent. When the Manhattan Projecc (building the A-Bomb during World War II) was in full swing, the Department of Pathology at Rochester University was given the job of determining the ill-effects of radiation. There were soma individuals who were so impressed by the pathologic changes chat they decreed a "Zero-expo sure". When subsequent, rational studies were done, it was found chat small doses of radiation could be tolerated, even though the effects were cumulative over a life time. This type of exacting research has made it possible to use x-rays for medical use, nuclear plants for energy, etc. The same type of informa tion must be obtained for chemicals. UCC 066389 APPENDIX A NATIONAL CANCER INSTITUTE MORTALITY STUDY 1950 - 1969 EXHIBIT 1 - New Jersey Cancer Mortality 1950-1963 EXHIBIT 2 - New Jersey Cancer Mortality 1950-1969, by County EXHI3IT 3 - States With Highest Cancer Mortality, 1950-1969 EXHIBIT 4 - All Malignant Neoplasms 1950-1969, by State UCC 066390 CANCER MORTALITY 1950-1969 APPENDIX A- EXHIBIT All Malignant Neoplasms (All cancer categories) causing mortality (Male, Female Combined) ' .1 Number Annual (per 100,000 pop Rate whites only) Total deaths. United States 2,572,035 - H 174.04 - M 2,253,282 - F' 130.10 - F Total deaths, New Jersey 106,900 - M 205.01 - M 93,379 - F 147.92 - F Highest Rates by New Jersey Counties * Hudson 14,049 - M 231.8 - M 11,004 - F 153.5 - F Middlesax 6.556 - M 5,251 - F 220.3 - M 149.2 - F Essex 16,975 - M 15,258 - F 215.1 - M 154.5 - F Highest Number> by New Jersey countie s: Essex 16,975 - M 215.1 - M 15,253 - F 154.5 - F Hudson 3 0 ^ g ,-y ^ 14,049 - M 11,004 - F 231.8 - M 153.5 - F 12,363 - M 11,894 - F 202.1 - M 148.1 - F Y. ^ ( e nt : qca,-i qq UCC 066391 APPENDIX A - EXHI3IT ALL MALIGNANT NEOPLA .5 fall cancer categories, causing mortality New Jersey, by counties White Non-white Male Total Rate Female Total Rate Male Total Rat e Female Total Rat_e Atlantic 3 ,213 195 .3 2 ,897 145 .2 598 220 .1 484 150 . 8 Bergen 12 ,863 202 .1 11 ,894 143 .1 373 281 .4 344 192 .2 Burlington 2 ,692 188 .5 2 ,395 139 . 9 196 216 .3 13 8 141 .0 Camden Cape May Cumberland Essex 6 ,329 204 .7 5 ,647 148 .4 586 1 ,264 1 ,683 194 .7 l 181 .4 1 ,037 142 .9 1 ,551 140 .0 72 150 16 ,975 215 .1 15 ,258 154 .5 2,385 228 .0 184 .2 520 177 .1 78 176 .8 155 .8 219 .2 141 2,155 144 .2 154 .6 Gloucester Hudson Hunterdon Mercer Middlesex Monmouth Morris Ocean 1 ,935 191 .1 14 ,049 231 .8 1 ,025 175 .7 4 ,639 205 .4 S ,S5S 220 .8 5 ,754 199 .0 3 ,851 179 .2 2 ,577 185 .5 1 ,674 11 ,004 325 141 .8 .5 153 143 .3 | ,V 182 64S 17 3 ,973 145 .2 422 5 ,251 149 .2 282 5 ,340 3 ,606 147 .6 | 515 135 .5 | ' 109 2 ,028 137 ,2 I 69 183 .1 289 .7 297 .1 203 .5 279 .0 225 .4 248 .6 265 .3 142 146 .0 571 197 .3 19 303 .2 351 150 .1 223 208 .2 35 0 135 .3 98 170 .1 64 231 .6 Passaic Salem Somerset Sussex Union Warren New Jersey 7 ,981 209 .5 6 ,631 147 .8 i 355 848 185 .9. 731 148 .6 1 147 2 ,151 182 . 8 923 180 .8 1 ,820 797 135 .7 ! 140 .5 i 7" i. 8 ,311 203 .4 7 ,757 151 .6 620 1 ,281 105 ,900 189 .3 205 .01 i i | 1 ,162 93 ,379 147 .7 15 147 .92 7,330 271 .5 t 302 132 .7 232 .0 97 161 .5 226 .9 66 228 .5 913 .3 12 465 .4 252 .2 534 166 .3 274 .2 10 187 .7 230 .33 6,709 163 .41 Ratea indicated are annual per 100,000 population Total deaths, for the period, 1950-1969, are given. UCC 066392 066393 ST IT I elisim juuoai bauxsis fcnifOBsn toLOJiOO CONNCCTICOT jDCLLVl M district or colohbir >LOR 101 CCCRCI1 10 RIIO ILLINOIS IN0I1N1 IOH1 KISS IS ItRTUCKl LOUISIINI MINI Mil LIND MSS XCHUSETTS HICHIC IN fll liSISOT 1 nississim MSSOUil SONTINI 1C CMS M NCV1C1 NCR 1IXHPSHI8E NEW JCPSEI siu nciico KEN (OIK NORTH CJ COLIN1 ROST It C1KOT1 OHIO oxiiHOei OREGON FENHSILV IN 11 RHODE IS LIUO SOUTH 0 801.2111 SOUTH D1KOT1 TENNESSEE tens UTlil VEIHOUT VlfCINIl NISHCIJTOS |WS5T f'.TGISll il I SCCSSI N H(cs::;o UNIT'D 3T1TE3 BHITI MLS Nunsca SITE 29066 152.44 14712 156.19 22197 144.14 216761 171.19 21016 144.19 44501 195.68 66 91 179.75 7915 203.75 76059 161.58 31499 153.77 0546 * 139.02 162672 182.81 67635 164.24 46097 156.60 30949 143.89 300 13 146.39 32662 190.39 17793 178.53 39157 192.43 95772 192.23 113318 182.42 54422 158.24 18050 156.40 70822 164.55 10201 153.07 23955 157.48 4050 167.39 1 1944 189. 19 106900 205.01 7689 136.30 107997 199.24 36533 140.11 9039 144.34 146265 178.41 34295 155.95 28314 155.12 189018 183.08 164 34 203.17 16754 154.96 10513 38356 ' 149.86 146.28 107557 158.51 8369 133.14 6981 173.02 38218 157.53 45015 164.20 26025 154.62 65376 166.23 39 53 138.93 2572035 171.04 NON VIIITS NILE NUU8E8 I1TE 10156 140.24 1062 128.83 4915 132.13 15086 170.77 620 169.99- 1419 211.75 1100 215.97 6190 264.55 10683 179.78 11546 152.23 103 121.(7 15012 216.77 4139 2io:e5 516 213.55 1644 189. 14 4220 199.50 14576 193.68 47 154. 11 8099 224.84 1971 215.92 9800 210.58 539 176.18 9flnt 136.74 7094 213.58 227 140.69 576 219.93 179 116.61 17 130.20 7U3*1 210,11 390 95.50 21572 227.69 1054 4 147.17 97 143.57 1252J > 226.35 2936 144.80 47 1 158.47 150c6 216.89 342 216.56 7135 145.59 252 137.79 7 174 163.79 15H21 167.53 198 152.86 18 207.22 11591 J89.62 !3.7 169.72 in 1 191.2a S76 191.54 C-4 123.16 26ilOj 184.20 1 If It XT 8 PENILE vunaca SITE 25643 113.88 11301 110.48 17726 108.OJ 195111 128.09 2 0219. 117.29 18333 138.64 5171 134.42 8123 141.73 56475 110.54 30381 111.27 6647 110.IS 142394 137.78 62111 130.60 42106 124. 14 28094 11S.08 36016 121.61 246 11 118.98 16135 140.46 35366 138.66 90506 139.47 92946 135.63 47219 127.05 15030 113.01 63213 12 S.58 7453 119.28 20736 2654 121.75 118.79 10655 140.20 9 3179 69 15 147.92 115.10 273316 148.01 33864 106.97 7084 1304 It 119.45 136.25 20870 116.03 23148 119.27 170851 140.26 14770 14 3.37 15295 111.59 8384 119.90 357 6 3 115.95 90072 111.34 7233 102.06 6551 136.41 35279 119. 12 36251 121.43 2224 1 56898 121.75 132.35 2962 109.09 2253292 130. 10 NONUMlfl'PENILE N0H8C8 mt 10915 127..17 811 111.76 4660 121.99 10705 124. 10 462 116.17 1047 139.39 774 162.57 5445 166.05 0959 131.14 12652 130.90 73 109.27 13040 160.98 3 408 157.97 380 151.28 1286 141 1 3500 154. i 12466 143.77 48 161.70 6080 154.73 1480 141.66 7830 151.26 380 128.98 10146 129.44 5882 159.07 207 157.24 482 175.99 180 148.97 16 110.02 6709 161.41 352 96.48 18920 152.80 10701 ' 124.39 110 165. 14 9762 159 To 2904 13" 1 307 122.US 11528 157.10 212 113.64 7647 123.97 302 184.07 7796 142.51 11452 128.45 101 108.96 It 119.06 9254 138.94 773 129.30 1173 149.77 7 07 140.97 52 1 30.09 226561 119.18 appendix b AMERICAS CANCER SOCIETY MORTALITY AND INCIDENCE ESTIMATES 1974 ucc 066394 F \, State Alabama Aiaika Arizona Arkanoa California Colorado Connecticut Delaware Din. of Columbia Florida Georgia Hawaii Idaho Illinois . Indiana Iowa Kanaai , Kentucky Louisiana Main* Maryland Manachuani Michigan Minnnota Mistangpi Miaouri Montana Nebratka Nevada New Hampihira New Jerrav New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Penniylvania Rhode Idand South Carolina South Dakota Ttnnetsae Ttaaa Utah Varment Virginia Wathmgton Watt Virginia Wisconsin Wyoming United Stain Estimated Cancer Deaths for All Sites, Plus Major Sites, by State -- 1974 APPENDIX B - EXHIBIT All Sitat Number Death Rata of per 100,000 Death] Population 5,400 200 2.500 3,500 33,200 2400 5,400 900 1,500 14,500 155 62 134 175 153 122 167 152 193 197 6.3C0 900 1.100 19.900 9,600 5,200 4,000 5,400 5400 2400 130 110 150 172 158 182 175 165 156 212 6,400 1U00 14.500 8,500 3,600 8400 1,300 2,800 750 1,500 150 189 155 >63 162 '134 185 185 133 189 14,000 1,200 37,700 6,900 1,100 19,000 4,500 3.700 23,500 2,000 184 115 200 132 181 172 170 1SS 197 204 3,500 1400 5,300 17,100 1,100 850 5,300 5,600 3,400 7,800 500 132 182 155 144 97 182 139 154 201 169 . 149 3ruit 425 15 225 225 3400 275 500 70 175 1400 550 60 90 1400 800 500 375 425 475 175 600 1400 1,400 600 275 800 100 250 SO 150 1,400 100 4,000 600 90 1,800 350 325 2,300 200 300 80 550 1,400 100 70 650 500 250 800 40 ColonRectum Lung 550 20 300 400 4400 400 800 125 200 1,900 1400 50 650 850 7400 500 1.000 225 325 3,500 *50 90 125 '/,S00 1,300 850 550 700 600 300 1,500 150 175 4,100 1,800 950 750 1,200 1,500 ' 425 850 1,700 1400 950 400 1400 150 425 30 250 1,600 2,200 3,100 1,100 750 2,100 200 475 200 325 2400 125 5,800 700' 150 2,700 550 500 3.600 350 3.000 200 7,400 1,400 175 4,100 950 850 4,600 400 375 175 750 1,800 150 150 800 700 400 1.200 60 750 200 1,400 4.000 175 175 1,500 1,200 350 1,300 75 Major Site] Leu Oral Uteru) Prostate Stomach Pancreai kemia 125 250 5 10 70 50 75 100 750 1,000 60 70 175 125 25 20 60 60 350 400 325 10 150 250 1,400 175 250 30 80 800 175 10 100 125 1,400 100 250 30 60 600 325 10 150 200 1,800 175 275 50 80 700 2QC 10 125 200 1,400 ISO 250 30 40 see 150 275 375 30 20 30 20 25 80 450 700 1,000 175 325 450 100 125 350 90 125 275 150 200 300 150 200 325 40 60 125 250 350 90 70 40 70 350 1,100 250 450 175 250 100 225 150 325 250 300 90 100 275 50 70 900 350 275 200 275 250 80 175 200 300 300 300 425 125 125 70 125 175 275 25 30 60 70 15 20 30 50 300 475 750 450 250 550 70 175 25 80 200 325 525 600 525 700 300 375 150 225 275 475 50 80 100 175 10 50 40 30 200 400 550 275 200 400 60 150 30 70 300 400 550 650 700 500 20 30 ------ 55" So ------ 73" 50 8C0 1,000 1,500 1,700 2,000 1,400 175 300 375 225 375 350 15 25 70 60 70 50 425 850 900 700 900 750 30 125 300 ISO 275 200 so 100 200 125 200 200 500 750 1,100 950 1,200 950 60 50 80 100 90 60 80 150 200 100 200 150 20 40 100 50 90 80 150 225 375 200 350 275 375 600 800 650 950 900 20 30 80 50 60 so 20 30 50 30 50 40 175 250 375 225 375 275 125 ISO 300 225 325 275 70 125 200 125 200 125 175 200 450 350 400 325 10 10 40 15 30 20 355,000 157 33,000 48,000 75,000 8.000 11,000 18,000 14,000 1 19,000 15,000 ucc 066395 9 State Alabama Alaska Arizona Arkanat California Colorado Connecticut Delevers Din. of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kanss Kentucky Louisina Maine Maryland Mischuam ^,gan PH Mississippi Missouri Montano Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Hhodt Island South Carolina South Oakota Tennessee Texas Utah Vermont Virginia Washington West Virginia ttteor.sin Estimated New Canoer Cases for AJI Sites, Plus Major Sites, by Stats -- 1974 | All Sites* Number of Casas 10,000 300 4,300 6,400 61,000 5,400 10,000 1,700 3,100 27,000 12,000 1,700 2,100 37,000 16,000 9,500 7,300 10,000 >1,000 3,600 12,000 21,000 27,000 12,000 6,600 16,000 2,000 5.300 1.300 2,800 26,000 2,200 70,000 13,000 2,000 35,000 8,200 6,300 43,000 3,700 6.300 2,200 12,000 31,000 2,100 1.600 13,000 10,000 6,200 14,000 800 Breast 1,100 50 600 600 8,700 750 1,400 200 500 3,300 1,500 150 250 5,200 2.200 1,400 1,000 1,200 1,300 500 1,600 3,300 3.800 1,600 750 2,200 250 700 150 400 3.800 250 10,800 1,600 250 4,900 950 900 6,300 550 800 250 1,500 3,800 300 200 1,800 1,400 7 CO 2,200 100 ColonRectum 1,100 50 600 800 8,700 800 1,700 300 400 3,900 1,400 200 250 5,800' 2.700 1,800 1,100 1,400 uoo 600 1,300 3,500 3,900 2,000 803 2.500 300 900 150 500 4,500 250 12,000 1,400 300 5,600 1.100 1,000 7,400 700 750 350 1,600 3,700 300 300 1,700 1,500 8QQ 2,500 100 Lung 1,300 60 700 1,000 8,100 550 1,100 250 350 3,300 1,700 200 200 4,500 2,000 1,000 800 1,300 1,700 450 UOO 2.400 3.400 1,200 800 2,300 250 550 250 350 3,300 250 8,200 1,600 200 4,500 1,100 950 5,100 450 850 250 1,500 4,400 200 200 1,700 1,400 300 1,400 90 Major Sites Oral 350 15 150 200 2,300 150 500 70 200 1,100 450 SO 50 1,400 500 300 300 450 450 125 500 900 900 400 200 500 70 150 50 30 900 60 2,500 500 SO 1,300 250 250 1,500 200 250 so 4SO 1,100 50 60 500 400 200 500 20 Uterus {Invasive) 1,000 20 350 500 3,900 3S0 550 100 250 1,600 1,100 80 100 2,700 uoo 650 650 900 850 250 900 U00 1,800 600 700 uoo 150 300 60 200 1.600 150 4,300 UOO 80 2,500 600 500 2.800 200 700 150 1,000 2.300 200 10Q 1,100 700 600 850 60 APPENDIX 8 - EXHIBIT UCC uuojyo Prostate 950 30 450 750 uoo 550 750 90 250 2,400 1,100 60 250 3,000 1,400 1,100 800 900 950 400 900 1,400 2400 UOO 750 1,700 200 500 80 250 1.700 150 4,500 1.100 200 2.700 900 600 3400 300 600 300 1,100 2,400 250 150 1,100 900 600 uoo 90 Stomach 300 IS 150 200 2400 150 400 50 90 1,000 400 150 70 1,400 400 300 150 250 400 150 350 850 850 500 250 450 80 150 15 70 1,100 80 2.300 350 100 uoo 250 2C0 t.soa ISO 150 80 300 1,100 80 50 350 350 200 600 20 Paneress 350 10 150 200 1400 200 300 50 80 750 350 70 70 uoo 450 250 250 350 300 100 350 600 750 400 250 500 80 200 0 . SO 750 >0 2,100 400 70 950 300 200 1,300 90 ZOO 90 350 1,000 SO 50 400 3S0 200 400 30 Leu kemia 300 20 150 300 2,000 200 350 40 60 700 400 70 100 1,200 500 400 300 400 350 100 300 550 750 400 300 550 80 200 40 100 700 70 2,000 500 70 1,000 300 300 uoo 30 200 100 400 uoo 30 60 400 400 ISO 450 30 United States 655.000 80,000 99,000 83,000 24,000 46,000 54,000 23,000 20,000 21,000 regef mHUr* fonom4'in`litu ol lh u*rin* cervix or lucerficial skin centers. These estimates ere offered u i rough guide end thauld not be is t initive. They ere celcultted according to the distributism of estimeted 1974 cencer dreths bv mte, Especially nor* that veer to year