Document M4bvEVo8mx5wNxkJ6aGK4mkxj

.. Occupational risk factors! for multiple myeloma:arnbng n *I l A large population-baredrase-contml study maluated vccu&tional expo ures in 1,&8 Danish males diag- nosed with multiple myeloina from 197'0 to 1984 and in 4,369 kc-and gen er-match4 csnrrols olive at the time of casediagnosis. Industrialhigiorieswere obtained btaryPcnsim Fund which, since 3 964, has recorded employmentsofadult Danes; (bjccts'most recent tax records. Four industrial hygienistscreated a job-exposure @redon 15,000 unique indwtry/ occupation combinationsinsubjects' histories. ekvatcd amongmad t 6 d railroad workers. precisionmctalworlrersga, nd indnstrim, Risk increased slignificantlywith duration of fivcidd witb crposurcs and dis- exposureto vinylchlor- longer cxpsure. Assodadons w i t hdurationand probability of exposure. rmcd by these data, Key words: Denmark, induncry, mctalworking, multiple mydo I a, occupatio1i phthalam, risk factors, vinyl chloride, f factors in rnyclornr haw been holnpcrcd by ~-elrri~cly I sman sizc(given h e rarity of thc disease)aid by laak of detailed information on potential exyosum. In ,this collaborative study. w e artcmptcd to overcnmc some of the limitations of prior studim by amassing a forge numbcr of incident c a m and einploying indus rid hygienists to asess exposures in subjects' jobs. +his paper, which evaluates occupational txposures and M M rmmg mcn, is a companion rcpol-I to i l l 8 ertiisr publication on womcn.5 uec.ornbinationsof occsparionand/or for the study subjcns wctr divided industrial hygienists, who assess& Me, probable, or unknown) to 20 substances and 27 rpecjfic ~tanccsI. n their asscsornent, the hygienists gave pri- t r y whght ]to industry. Occupation was us& to d&trminc whether or not a subject w a ~ be a 'blue-collar' workc: (exposed to pro- prud/Jcdon} within an industry, with two Mcthada and materials &+ons. Poi jobhdur- combinations in which Sdjects 1 Men diagnosed with MM in Denmark bctwan 1970 and 1981and reported to the Danish Cancer Registry wcrc eligible for die study. Of all malignoncies dlag- nosed in Denmark since 1943, an erdmatcd 95 ta 98 jxrccnt arc inciuded io the Hegisuy.6Subjectsborn he. foro April 1897 or under q c I 8 at date of diagnasis wctc cxdudcd, bccausc they wcrc not included in tlic Daiiisli Supplementary Pmsion Fund (SPF), ~ h cpri- *&!Ia perno3 was likely to be rmploycd whilc alp0 fbrming. If SO, t h industry/ut.cupacion combination +as assigned exposurcs tyyicd for bvth the industry ahd the farniiiid occupatiuo, ! +dyseEs mary souirc of employment information for chis study. Ninety-two percciit ol c a w had been verified histolagicaily. Four live controls were chosen randomly from the Danish Ceiitral Population Registry for rhc ycar 111 which the c ~ 5 Wc AS d i r g m d , riraulhcd tu che case on sex and year of birth. Subjcdo were excluded if [Hey were diagnosedwith amdignancyother than rnycbnia Of :he I&? cdcs azid 4,885 contrcds, no intormation available on tithrqb occupation windustry for 124 c#ocs ( t 0perccrip dnd 719controls( I 5 pcrctnr). 'I*hcst sybiects were o nittcd from further consideration. Maximum lijdihnod esharcs of the odds ratio (6R)and 95 pkrcem confidence intervats $3) were insto Gart,#-adjustingfor agc in four for a casc or any malignancy for A eontrd, 91 01 nwrr dayirpnorto ~ n i n d c x d a ~ c t h e d a t ~ o f d ~ uo~it~hoes i s casc. Datr muecrion Inforinntionon emphymcnt histodes was D L l d i I l d b y linking Csiurr Registry rccards to those d the SPY, us in^; subjccts' unique Danish identicy nunibel, aad name. *Estaldished in 1964. the SPF contains infqrmation on dl wage-earners aged 16 w 66 whn are crnploycd a1hi10b p u wcck by any one enip&oyFr. X.nformation is kept for pcnsionetb and drccarcd pcrs w s , Type of industry was identified for jobs lield L y subjects from I ~ Mto the index daw, except for a smlf number of jobs (8.8 percent) fur which the employw was iiot in tusinc~saftcr 1977. No data wcrc available for jobs hdd while self-emplo>rcd. Occupation was dctcroiincd by dae job iidc m- odd on subjrctdmost rccciit wx rcrotds. Norm-od oc carhcr ozcuupirtions was avahhlc. occupation and industry WCIYZclassified u & ~ gDad& d e s , which arc based on &e 1919 Iotcmational Standard fndustrjal Classificationof all Economic htivitics {ISIC).~ 556 ~ i l w z c G u * c sa d ConimI. VoI 3.1912 I student,worker Icaving 833 caws and ~ , W J analysea, as werc subjects a given substance. J ! .. . 1 1 Risk fictoA[or mA@ my&= the Mantel wtchsion test for trend,' as wore 4 n d s with duration of exposure (LE,employment in iobs judged to entail kosriblc or probable cxyarure tb an agent). Risks aUowing fort latency pctirnl were c&lard hy IagIjlsIng exposure data, that is, by disregarding employmcniorcxposum within &e or 10yeanu( the index date (thc daze of diagnusis of the case). ' Lngisuc rcpr~~sionwas u s 4 to adjust simul- raiieously for exposure to multiph agcntn (catcgori- cally, byprobabihryand duration),eontrollingfor age as a continuous variable. Among the 3,%2 'sabjem with in the Penrim Fund (75 perccnt), percent) had one to thrce jobs ken whose dost recent tax record listed either no nrioner'had a Eigpificantlylowerrisk Danish men (81 cases, OR = 0.4, cases, OR = 0.8, CIS 0.6-0.9, in the referent would h a w inflated , Results The 1,098 cases m d 4,169~0neobwith jnformatioi on occupation and/or indusrry wcrc mostly in their Hs and 70s at diaposis. Of thc 843cxcbdcd rubjeCt8d d l information un neither, 87percent bad beenmore tban : 55 years ofaBe in 1964, whm Ac Pension Fund b%an recording jnformatioix, compared with 47 percent of I 147 ' I 20f \ I 444 1.1 (0.9- 1.1) 2.B (0.9 -B.3) 1.5 (0.8-2.6) 2.2 1.1 1.0 1.1 1.8 . J.3 1.6 . 0.4 i.4 2.8 0.9. 0.7 i.n (0.6- 75) (0.9-1.3) (0.0- 13) (0.9.1.5) (Q.5-6.6) (C.3 - 5.51 (1.1 -20.5) -(0.1 13) (0.6- 1.5) (0.6-12.1) (U7-w (0,3-1!3). (0.8 - 4.3 . .CE UNI PED CTR LIBRARY El12 Occuprtion clra ---( n k W IO 11 0 c 96 31 19 7 2 1 4 I 2 0 26 1Y 8 2 I+ 4 6 6 1. 2 3 0 1 3 7 6 3 6 I B s 2 -I I w L)U -57 0.6 (0.3 IJ) - -38 t .O (0.5.2.1) 2 46 is0 SE 75 40 22 2 12 I6 20 6 74 55 . 27 6 46 22 11 8 2+ 2 4 n5 b IC it 4 18 13 I! 05 1.4 0.1 0.9 Ok 03 1-9 12 0.9 0-.4- 1.3 I .2 1.1 , 12 1.1 0.6 20 2.7 1.8 I ,a 5-.4 1*+ 1.9 I .6 1.1 2.6 12 0.3 2.0 (az- l.1) (0.8- 13) (Os- 1.2) (0.5- 1.6) (0.3 -IS) (0.t-1.f) (0.1 -243) (0.3 - 4 4 (a3 -.?dl -(0.1 -1.6) (0.8-2.0) (0.7- 2.1 ) (0.9"t.S) (0.2-64) (0.6-2.0) (0.2- 2.0) (0.6- 5.7) p.n-8 . 7 (0.1 -25.1) (0.2-11.5) --(0.7 - 466) (1.0 -2.J) (0.9- 3-8) (0.6 -4.1) (0.6 -2.0) (0.5- 13.8) (0.4 -32) (0.0.2.0) (0.6-5.7) 19 I.2 (0.9- 16) I 9 2.3 (l.Q-4.9] !.r I .I (0.8 - 1.7) 2 7.4 (14%- 58.0) wal wnrha ufdl vlhm utcuprrimr.Subjccrs Indkrtv Mea who w o r k 4 in transportationor communiation. had a siaiisricallysignificant 30 percent excess of MM (Table 21, an exccsb seen mong those employed parcicululy in &e railtoad,bus/uxi/frHight, andcommunication indusma. None of the other eight bdad 558 CUIMJ Cnurrbaid Cunid. Y d 3.1992 . .I! lusiry-cnqc ies showed a significantly e l c v a d r K,'Amungm mwcx industries, a significant dcficir C mydoniawa observed among workers in che food/ a ohol/robncct industry. Also significant wcrc 4 n uly thrceforc .~kfo+workeraincementplant~uhda r DfoM risk as rciatcd with vnpkoymcnt in fabriatii ; structural II d and stnriona7 taiikr {with similar r LS found in ooth subdivisions of the industry). P though nor s itistically significant, ORs were twoD threefold in: roe1 spinniagand wuvin%;manufac- P e of synthet yarns; `other' chemical compounds 12.40147 13:57 DUKE UNIU. E D CTR LIBRRRY 011 Tabk 2. Risk of rnuIIipicmyclomnainorlgDaniPh menuploycd ii odds ratios (OR)and 95% mnfidcnn intern) [CJ) 69 43 10 ' 1D 11 , 319 71 31 15 5 11 6 2 3 J 34 12 B 15 50 5 3 6 9 s 49 11 3 9 19 4 13 122 15 I) ia 16 12 b 140 82 21 ZQ 12 5s 2 21 tit 100 ' 34 1.0 1.1 13 1d o IS Q9 0.7 0.9 1.3 0.6 12 2.9 1.3 2.9 0.8 I.o 0.7 I.6 0.7 009 2.2 2.3 1.0 0.9 2.5 1.a i,l 1.5 2.7 1.o . 2.0 0.11 1.9 ZAl l.8 146 1.6 1.5 1,B LO Q.9 0.J 1.D 1!0 1.2 1.2 QB 10 1.5 0.9 1.1 1.3 L4 (OS- 1.4) (0.8-13) (O,S.Z,S) (0.5-2.1) (17-32) (W-1.1) 14.6- 1.3) -(a51. I ) (0.7 2.4) (0.2- 1.5) (6.7-11) (0.?.9,3) p.2- 72) (0.5 -15,4) (0.3-2.3) ( O h - 1.4) A [0.3-i.3] (0,7-4.a) t00,s.t , I ) (0.7- I .J) (0.6- 7.2) (0.4-11.1) -(0.4 1,f] -(0.4 2.0) p.7-8.3) (0.7- lA] (0.6-2.4) (a5-4.4 (1.1. -63) (0.6- 1,7) -(as-7.3) (QA 1.6) (PS- t g -(1.0- 4.0) p.7 4.5) (U9-1.9) (a9-3.0) (a7.3.1) (W.6- 5.1) (0.6- 12) (0.7- 1.2') (0.1 -1.9) -(0.9 13) (0.8- t.3) (0.7.2.0) (OJ-2.0) -(0.4 - t .6) p.3 I J) (0.2-9.0) (0.5-1.5) . (1.0-1.6) . (1.0-1.6) (0.9-2.1! . ... C~atinwcd. .* 12110/4$ 13:56 DUKE UNIV. PED CTR LIBRHR`I 01B T a b k 2. t h d n ~ e d jI I Industry -.".* Bankindlinancchul at+tdsdmlnttrarlon ( 8 ) I 1$9 I 28 154 cdlm1r (n= 3,070) ::I $20 O R (CI) 1.3 (as-2.0) I 2 (0.8 -2.Q -IJ (f .O 15) Scrviee(9) Chimney sweeping (92023) H d J i un (933) Rcpairlhmdrylpcrewd ~crvicrs(951 Rep& (951) Auto painring(95133) IS3 j 1+1 0.9 (0.8-1.1) 1 ,4 1 ff 12 1 2 2.0 ( O J - t l . 6 ) I, 3.8 (02 2.6) -:71 1.1 (0.7 1 . 3 131 1.s (0.7-3.11 2 1 2 5.9 (OA -38.0) (including emulsifiers, cnzyms, tmiung tract^, dyes, sulfonamides, and pesticidcj 13 single coinpounds); plrstic~ack;lging;`orhcr'o~ntc,lay and glass (including asbestos) products; aitd body f a a m i t s I I I i 1 I pdint atid wzlfp~pcl-S.tatistically sigiiificant iiicruscs wid1 duration >ienipluymcni were ayprrcnt ftw: m;anufacrureof stynthetic yams (OR= 1.Yfor lcss than fiyc years {basad 011 Q(IP CASC]; OR L- for nmrc t h u excluding auroinabilcs (cg., uailcrs, camping, and farm vchiclcs). Risk ofmyeloma was elevated in paint manufacture, retail salc ofpaint, and auto painting, but !lye year$[inw c.&xs,:IOctmiruh]); frbrkdted Sir UC~UInl'mctaland stationary tanks (OR = 2.3 [10cas~sJa,nd 3.9 [rhree cases]): body factory (2.9 [five caies] and 2.6 not among painting and wolfpapering Cvnvacwrs- [ri..cases]); and 1r~ais1atc of paint and wallpaper (1.3 Smaller risk incrcascs were evident in Loth clcccrical two cater] and 15.5 [four urcs]'l)-lGsk cicvatrioi>swith plants and orhci utilities. Risk of rnyelomr wds not inkremed duachn were enhanced atid rrends were elevated ;ir agricuiturc { u x e p t fur a nunsignificant 30 statisticdy signjficant for rnanufacturc of rniscch- pcrccnt incr-camhi truck gudcning, c~rchdrd~v,r r n ~ r - nquus svvud pnnlu~zs(OH= !,I [~lmcei a x s ] and 6.0 series) or forestry, the leather or shoe, paper or print- [thrcc cases]), abd wholesalc tndc in grain (1.4 (12 ing, or rubbw industries. &], 2.1 [sevta) cases]), The increase with duration Ainong meti lor whorn five 01 nborc total ycarv of employmeni were recorded, risk of myeloma did not incrcasc with duratim in the b r o d industrial c a t e p ries, except for small.stiltistically signiticanr imrqsc ncarty sigqificrnt for crnployincnt in rlecxri~ (1.2 [five cases] and 2.1 [five ~aserj).Longer 9e ploymcnt in &mufacture of plastic packrgitig was sal1 arfociatcd s i t h increased risk of mydoma (1.Y for anploymenr In banking, finance, and real cstqtc (Table 3). Risk of myeloma increased significantlywith [one case]) but thc trend wav no duration ol crripluyrncnt in rnanufacrurc of synthetic n contrast, afyr lagging cxposurcb,risnof myeloma yarns, `othcr'chmical compounds, plastic yackagidg, whs higher arnool; mea who worked fewer thar, five fabricated srrucmral meal and stariamy tailks, body factories, and r c t j l sale of paint and wallpaper. Employment in the food, alcohol, and tobacco indystry ol ciihcr morc or lcvr than livc ycars was associated with thc same rcduccd risk ( O R = 0.61,though rhc test ygrs, but low dinoiis incn `cny~,loycdIoligcr iir dnufacturt OS $her chemical compounds (OR=4.0 for trend was significant. Compared with H n employedfor lcss than five ytars, risk of myeloma was higher, though not significantly so, among nitn cmplaycdlongcr in dairies, in manufactureof m;scelfa- for a 10-yearIatmcy period(not shbwn)were srmrhr to those presentedabove. I neous wood products, ditmicd raw Awcrbls, paiqc, porcelain and g l i l ~ ~in. elrcuical platits, in wholesale uadc in grain, and in real estate. I nmostindustries,disrcgardingcmployiiicnt within five y c m ofthc indcx drtc (not shown)had lirrlc effer on the ORs. The only significant individual risk was . chatforfive ormoreyears' cmpIoymcntin m a i l saic of prpbahly e x p o d chrn .1010ng chosepossibly cxposcd 56D <:nvwcrird c h m r d . vnl J. JWZ 12/10/47 . .. R+r (951 13:55 DUKE UNIU. I*ED CTR ! Ii trial code), amongDanishmenwith Idjus~cdodds rauos (OR)and 95% 37 128 24 78 7 15 9 16 91 339 25 14s 6 23 6 18 55 03 l6 54 3 13 12 40 35 I4 2 16 6 23 34 39 33 33 iu17 08 (0.4- .3) t 20 1.4 tb.5- .4} 6 8 224 [ 0 3 - .2) -s 19 Id (4.7- .q 4 12 1.3 (0.3 4.3) 4 7 2.J (0.6-$6) 70 23I t9 I (Q.9-1tL) 18 ?Q 255 12 36 13 (0.6-216) 11 34 1 .j (0.6 216) ~ I 1 5 as (a,o-bsl 41 142 1.1 (03-I6) 9 24 1.4 (a.6-33) ?3 241 I$ @.9-16) I 59 61 9 -Empbyed 5--+-.y.*'.c.-m P lor 17 9 1 1 177 IS 5 a 1 3 II J 9 z 1 2 3 2 7 5 1 15 7 2 7 6 1 48 1 84 7 6 5 53 13 60 39 143 '2 78 43 8 8 734 163 13 22 3 i 47 3 23 2 I IO Y 2 19 7 4 36 s 2 nt is 5 225 9 29% 14 19 3 197 67 182 199 597 8 0.4 (05-15) 0.a (0.4-1.7) 0.5 (0.0.3.Iq Odz 0.95 0.80 os ( 0 ~ ~ 1 4O M 0.9 (0.7-1.t) 0.6 (0.4-1.0) 1.5 fo.5-4.5) -1.4 (ab-3.3) 1.3 (0.1 13.9) 11.9 Cl.1 *t9721 as (0.4- 1.0) 3.9 p.6-24.4) 037 oms 052 0.49 0.38 0.03 0.84 0.19 1.5 {OJ-3.5) -3.9 (0.4*3Rf) 3.8 (0.1 139.7) 0.8 (Q.1-3,8) 1.3 (6.3-5.2) 3.9 (0.4-3B.2) -1.4 13S-h) 1.7 (9-3 7.1) 1.0 (0.0-9.2) 0.40 3.M 6.44 6.64 0.74 0.W 0.311 0.18 0.39 1.6 (0.6-3.1) 5.5 (1.6-13.9) J.9 (0.4.36.7) I.* (85-3.4) 1,5 (05-4.3) 6.8 (0.0-6.6) 08 (ar-14 0.4 (a0-3.2). -1.1 (aa-1.5) 2.0 (0.7 5.2) I?. (U.4 - 3.3) 6.4 (1.3-33.8) 13 (a9-U) 1.0 (US-1.7) IJ p o - q 0.50 0m3 0.01 015 0.32 0458 OS 0.29 3.39 0.1 0 0.48 0.01 I RII 0.95 &Oil 1,4 (0.Y-2.1) a9 (0.7-1.11 1,O (0-1-4.9) 0.07 0.43 , 0.29 .I w ga~ollinco, il producw, vxrile dyes, phtluhies, rad vinyl chloridc.AlchrmghORsw a r I2or greater with possible exposure to benzene,hi& dycs (based on unc .case), manufactum of rubber. leadiet ducrt, furred ai+ inalp aid products, b k g farm animal,mw milk, and iunizi~igr a d i d m , risksw a r nor elevated among m m prvbabiy urposqxl to these agents. . ik ofmyeloma with durationof ability catcgorirs among men recorded in the Pension P d not lagged (Table 5, column? I I f t x p w r e to gnsalinc and to td a similar 20 to 50 percent lorna. Alhough tests for trend G uClurcsirndConud VoI3.1992. 562 I 12/'10/47 E, F.H & m m et a1 13:55 DUKE UNIV. PED CTR LIBRFlRY E708 Products of md and OH Cases 199 S8 19 178 146 zoo 125 214 127 151 150 110 4 69 $8 8 I1 I 5 Crlnrrnlr I 73 679 bm P71 695 @9-1A) (1.0-1.6) (a9- I.+) -(009-L4) [I .o Lb) (02-7.4) (0.8- 1.4) (0,7-144) {DS-Za (05-2.1) (0.1 -132.1) (CM-I 1.0) 126 79 .34 99 1.1 (03-2.0) 22 83 102 356 1!0 387 144 527 1 I7 155 t 70 s92 4 6 204 31 too 72 24 B 110 360 3 b: 123 406 -l0.9 I.5) 835 449 97 320 206 693 40 133 11 2b 26 :76 31 116 17 '31 -(0.6 1.4) I.13 >Y1 106 333 24 78 (0,s- 1,>) _ _(0.7-1.9) IS 37 17 70 r* Forclch agm&the rdcrent p u p consdr of menconsidwcd by the indintid by&nist ti h Principally ' f U f - f A I h M ' (e+, ofmink. ermine) and work- hmdliqfu or hid- ofther 134 I2 17 48 41 s7 $9 119 52 70 39 41 0 31 17 7 5 0 .3 325 I .a (01.1 J) -45 l . I (as2.q 111) 0.6 (03 1.O) 191 1.0 (0.7.1.4) 123 1.4 (0.9-2.1) 171 I .4 (1.O.l.Y) 267 1 3 (03-1.6) 4 9 a9 (ar-1.2) 263 3.8 (Ob-1.1) 264 1.o (01-1.4) 1% 1.0 (0.6- 1.4) - -192 0.8 (U.6- 13) I2 174 0.8 (0.4-1.2) 101 0.6 (0.4 -1.1) - --21 1J (0.5-3.1) 32 0.6 (0.2 1.6) 7 13 0.9 (0.2-3.3) 60 221 1.1 (OS- 1.5) -6 *$ 0.5 (0.1 L>) I 1 21 2.0 (089-4.+) 4 20 l . ? (0.7 -4.0) -I5 a t 0.9 (0.5-1.S) 9 46 0.8 (0.3 1.5) 41 142 1.1 (Q,7-1&} 1s i3R 0.9 (4-6-13) -78 330 0.9 (0.7- i.2) 11 53 0.7 (0.4 15) 3 1s 0.7 (0.2.24 -10 45 0 8 (0.4 1.7) - -49 212 0.8 (0.6.1.2) d7 137 615 3.a (0.7-1.0) 19 79 I .5 (0.6- 1.7) is 81 1 1 (0.7-2.0) 116 qb? 1.0 (U.8. I.3) a7 2.w 3.9 (0.7-1.1) IO e6 0.6 @.3-1.2] $9 117 1.o Q.7- 1.4) 29 162 0.T (0.4. t .O) 60 222 1.0 (Q.8-1.4) -105 394 t .o (0.d 1J) 20 $3 0.9 (0.5 -1.5) -111 JW 1,0 (0.8 i.4) --0 10 -3 26 0.4 @.I 1.5) _I i I. 48 1% 1.3 (O.P.1.9) 1) 85 M? 1.2 (X?-l 5) U 0.09 Y 131 .. 52 76 $8 147 1.5 (1.1-2.1) 69 246 1.1 # , 8 - U ) Ill6 22 25 5 7 2.7 (Q.T-YA) 4 4 21 0.7 (0.272.2) I 0.50 13 41 1.1 (0.6-1.3) 3 17 IJ 1 2 (C.7-22) 7 .021 9 M 0.3 (0.4.20) 2 7 37 0.7 (0.1-1.7) 7 022 . 53 b5 0.42 I P f a nrnd 9.M 0.22 L?4 'Diarcprdingmploymcm within IO years of tile index date ( h i e ofdir(;nwiaof caw). T"Trmd o w duration withinc4chprobabilityp u p . I with duration wcn significant, risk estimates were slightly lower among thost probably arplssd for five or'morc years to gas;OIine, oil products, and engine exhausts than men exposed for shorterperiods. When ernpioymcntwithiii 10yean of the indexdate was dis- regarded (Table 5, cofumns 3 and 4), myeloma risks among men exposed to gasoline wwc sign;ficmdy elevated, and were higherin the intermcdiarccategories (possibly exposed for fire or morc year$ probably exposcd forless thanfive years), rhn in malysuwithout lagging. However, risk felI among thore probably exposedfarfive ormoreyeamtogasoline.Among men possibly mrposcd t~ mgiw exhatsrrs, ibks hacrcucd ta 6 20 ? 29 94 1.3 (0.8-2.1) 19 75 !.I (P6-1.9) 0.24 2: 6 T 7 3.5 (ab.4.4) 0 5- - 0.a0 4 1 4 3 7 6 32 I2 and probable/ 12/18/97 13:53 DUKE UNIV. iYED CTR LIBRARY i E306 E n p t exhaust Pbthalincr Possible Finable PfObllrlC rrwba~le Pomiblr Possible P:obrhlr Probable =5 ;years 5 -I-ICs" i S years 5 +-".CJ e 3 years 5 + years <5 p r s 5+J W S 'js (1.0-233) 1 3 (1.1- 1.9) Iiz (0.7-2.1) 112 (0.B - 1.9) l i r (0.0-2-4) 2 -(0.8-25) (0.5 10.5) (0.5-5.5) t .$ (I.a- L3) t .5 (0.9-2.7) 1.o (0.6- 13) 1.O (0.5-2.0) 0.7 (03- 1.8) 2.2 (0.8-6.0) 3.5 (0.7-1') 3) 0.3 (0.042) ~ to nearly fivcfold (CI= 1.4-15A) among those prob. i eliced an clcv&xl risk of myelonlacompared with mcn 1ably exposed fox more than iivve years. The inwrmcdi- 1 neverexposed rocihcr. Mcnprnl,ablyexyosad ro Loth ate catcgoncs showed slig'nr risk deficits. Disqarding phthiatesang vinyJ chiaridc for five wr x x ~ ~yreeais l i d cmploymeiit within 10 years of the index darc, thc incrcase of risk with duration of ernployniair among menprobably cxposed to vhyl chloride rcmaincdstatistically significant, but fish in most categories werc yet higher risks(OR=S& Cl = 1.0-29.5 Ifour cases]}. 1 A sirnilirr iri$ytis considering gasoline and en& /I exhausts (no4shown) yielded results similar to t h s c from the Iogisric rcgrtssiun pr:scnr;.d &&w. Too fm 1lower Than without lagging. ; cascs wcrc a&aiIaNefor thcsc analyscs LO cons;der Without legging, for oil productsand rubber manu. lawmy by lagging cxpasurcs. ifactum and vulcanization{notshown), risk was higher We a l w usidlogistic regression to evduarc risks for among the probably than among the posaibly cxposed, exposurc to gawlint, ai+e eXhdUStP, yhtlialatcs, and but without consisteiit patterns with duration. For vinyl ciiloridCtirnultancously(Table 6). When latcncy benzene, tcxtile dyes, silica (notghown), and raw milk was not considered, men myoscd to gasoline had no (not shown),risk was Iowmt among men exposcd lon- i w x e s a d rid( of mydoma,but wick hgging, risk rosc ger with higher probability. Similarly, for ~skstos, slightly in the inlermcdiatc catcgorka of exposure. piunls and lacquers (not shown), and wood dust (nor shovh), nsk was lightst among those possibly exposed for five or fewer yearn. For oil products, ben+ ztnc,textile dyes, asbestos, and agriculcuid pntkidrs, Risks werc &hmircd iwr men in afl catcgorks d cxpusurc iuc&~icexhuo~swhen all cinploymenr was considered; &e risks rase slighdy fur those: poss;bly eqxscd, a d fell fortboseprobablyarpvscdwhcnjobs whcn exposureswithin 10y c m of the index date were witlin 0years ofthc indcx date were disregardcd. For disregarded, risk of myc!oma changed only slkhdy, phthalatcs, {ithour tagging, iricn probably nposcd and decreased among men probably exposed for morc had higher risk of my-duma than thosc possibly than five years. e x p c d . Whin C X ~ Q S U ~ CwS cre !sgcd, 110 clear pt- Because exp&surcs ovcrlapprd. we excluded men terns wid, du&dort and probability ol exposure wcrc-, with a potcndally confounding exposure in stradied observed, diiugh risks msc inthe intermediatecawgo- -lyses. In the highcsr cxpsure catego~y(men can- rks. Rink of$Ycloma was highest aoiong mcn judgd aidwed probably expoxed forfive or more years}, those at high prohbihy of cxpclsur~.tovinyl cliloridc far aposcd to phdidates but nwer to vinyt chloride five or more jeprs, with a stitipriuIlysignificant O R of . ( O R= 2.4 CI = 0.1 -27.5 [one castlj and those 3,6 without jlaggrng and a fiveiold risk 'when d~ -exposed to vinyl chloride bur never pbthalam ( O R= 2.6, CI = 0.3 19.2 [ m o cases]) both e~peri- within IO year8 of the ;dm daw was .. $64 O n e r r Cw.n m d Cnntrnl VwI>. 1-2 I -,-- I Discussion -We conducred this populntion-based cdsc cuntro1 scudy a m n g Danish men to evduare Imvioudy r e p n e d associations ofoccupational factors and M M and to gcncrate n m hypotheses. Because of the large number ofco~paflwm5ome obtervcd associations nuy bc duc to chancc. Howcvcr, exposure-rcspotise iinyl flcotcovcrings, *ircrafcjct engineiubricancs, and esticides.l`Js The m a cinnmon, di-2-erhylh+ hthalate (DEBP}, caLI.~S peroxkome pro6fera&n,14 nd is an animal hepatocarcinogen and tcrat0gen.l. utyf benzyl phthalate and diaJlyI pl~thalacei x r e a d 8t e incidence of leukemia in female rats,* AItltough thcnumbcrsof cases and controlsm p o d t phihalaus is small and the cxcesscs ~nrybc &me reinionshipsand thcconnstencyofchcscfindingswith kardings,some chamcterisiicsof phrhbtcs suggest &e previous reportssuggast that a h a s s o c i a t ~ o nms ay hc worthy of funher maluauon. `I'hc most mtcreshg associations wcrc bcrrween M M and ptential ;r1tw>clationsmay deservta second look.Phthficrnhydtides inducean immunologicaily mediatedh y p m c n &i;y r e s p o n w : . "W~o~rk~e~rs who manifwest allergic exposures to vinyl chloride, phthalates and ccrtdn metat industries. Men probably exposed to vinyl chloride for five or s$mptorns to 2 phthalate compuund have devrid b d r d 1 g E m&or &X spccific rgthat phthhw w*D hiply cxposod workers have higher levels of specific more ycars had a statistically significant foud`oid 1gGthui workav with lowerexposure, irrespectiveof acess rislr.With considcrationnfd IO-yearlatencyrvld a1Icrgic ~ ~ ~ ~ ~ p t Ioncrrenases. ~in~ M M have k c n exposures to other agcnts, risk rose to fivduld, otbrved in workers with potrmtisl exposure to o m - although it was no h g e r sigmficmt. `fiose possibly pationaj dervns, such as farmer&,:`and grrin" and exposcd had 110 excess risk d myeloma. Mcli con- inirile workers.z'Imimne stimulatiml, d&nd vari- i sidercd prnbably exposed 7 9 wnyl chloridc werc prc- ously as chmhic infections.2* autoimmune disdorniiiately eleL.xricianror electricd installers. line and ~ r d c r s , ! * .a~s~~bn~:'hay fevcf2'~z'atid aIIr*rgieSa2`h= cable workers, or emplrqed in plastics mannufactwig. bein cvduated previous studies but results lire not In thc nnIy cdiort snidy':oivinyl ddoridc workers in colbsistcnt."~~'Howeveri,sk of myelonla has not which data arc reported sc;el~ratelyfor mye~oma,no been evaluated in populations with quantified elevatcd rirk for mydoma incidcnce or for mariafity exposure :o specific occupational allcrgeas, indcpcn- horn myeloma and other lyrnphrtic neoplasms dcnr of dlicrgic (ICD-8 codes 202 -203) w15 ohxi-vcd. Elecuic cable Uittle evidence is a d a b i e to cvaluatc an association manufacture was associared with a nonmignificani risk of mydoma and phthalate exposure. A population- . . . (approximardy threefold (calculated by authors]) in haskd caw-coned studyJ'of incident niyeloma found m e case-control study nf mye1ona-l' Vinyl chlorideis twafold nsks (borderlinesut&ricalaignificanlr) with carcinogcnicin humans and experimcntalmimais;tar- getsites in huminr iaiciude the h e r , andperhaps bran, lung, and lymphatic arid Iiema~opoctic systcm in humrms.12 Risk ol` myeloma imreascd significantly with dur- cxphoure io "organicallyhighpolymers."hcohonina tpol, amide-polyester facioly;\2 whose mporum inrl dcd tcrephthrlic acid and dimethylrcrephthalac, gufffrcd no cxecjb of lymphatic and hematnpoietic c m q m othcr t h n leukemia (rwo obscmd. 4.4 aiion m n n g Danish men probably expos4 to phtha- e x p t ~ r d[calculated by authors]). N o risk extimates laws, ri.singto 2.5 among men exposed for fivc or more wry providedforhcmatopoictic tumors in a cohortai years. Afwr considerationof latcncy and lidjusiment Swedish mcn3*=posed to both vinyl chloride and f o r nrposurc to vinyl chloride, rrsk ofinyclorna from pJddjcpcid est~1'sA. lthoughDEHDir rcldily leached exposure tt3 phthalates no longer displayed a duration f r o d flexible p(asric medical deviccs;`J) patients on of exposure dtccr. However, if duration of employ- dial$& ]lave no exkcss risk of myeIoma."-' Howcvcr, rnent is a poor surrogatcfor cumulativu exposure, the idlop-up time in dialysis cohom is typically short nsuiting exposure misclassification would tend to (usuallyless than five ycarsJ'C" ornq~cloorrti?s cxcludrd difutc exposure-rcsponre gradients.1'Scarly a11 men dpriQrl brcause chrbnicrmial failure may inJic;rtecu!y considered probably exposed to phihafates worked in plastics nranufatturing, or were plintcro (inchding building, auto, and rnachinc painters); over me-third stageb of myelo Previous spa&$ have reported signi$cant cxces myeloma in 3 Swe&& cohortin p&nt1 rnmufact~dng, particularly with higher were considered also to h3ve becn cxposcd to viiiyi mid among painters.",* Two studies"+" chloride. Phthdatr e s m plasticizers are uscd widely, p i rnarjfyin plastics, rubber, and as a substitutefor PCBs in clwtric capscitors.1` They art also used in paints repa cd nonsignificant excess~sw t h paints or painting. Yighcr risks L v ebeenobsrrvcd amongcar/spray/ signsrp-ita painters (OR=2.8) than conmucuod gencrff p&ccrq {C& = f .t?).J` In this srudy, Danish (including alkyd resins uscd on cars), hydraulic fluids, mcn e+nployedin paint manufacturing (OR= 2.3) or 12./1B/47 1-5:51 DUKE UPIIV. E L I CTE LIBRARY C84 auto painting (OR= 3.9) had highcr risk of myclomr yfighrly am& prccision wood-workers (OK= 1.3) than those employed by (constructicm)painii trg con- and row to {early fourfold m u n g men cmplaycd in tractors (OR = 03). miscellanenus wood-pmducr fabricarion, rcsulu did Risk of mycloma was clcvatcd also among nsnisb i i a i confirm ioseible associations witti wood dust17 or Inen with p d h k a i d yriibable BX~OJUIVto gasoliilc it a h w00d.f Sevcrai occupations and in&a& and engine erhausu. Consideration of latency and associated with higlicr risk of rnydnmn in previous overlapping exposures dampcncd thcsc risks. O h studks, sucg as cooks," lcathcr tanncn," and rhc rcmaintd slightly clcvatcd among men possibly expascd for m o a than five y c m , or probahIy exposed for shortcv periods to gasoline a d arntrns thosc posa- food," shoe 4r lcathcr? paper," or rubber".*.- in&- uics, h3d & dcreccnble excess of M M in this population. i ibly, but not probably, cxposctf to cnginc c-xhauutyA Without jrddiuunrl irrfvrmativn &out thc PrcvioutB stu4cs have reported significant micew risks cmpioycts an? jobs, wc could not attributcancarly 12- of Inyrloma with cnginc exhaust5 (considwing a Gvc- fnld Ask [hasbd <inthree cares) among rnw employed year latency period)? with self-rcportcd ~xposurcIO for five or more ycirs inathe manufaciurc oC synthetic pctruleurn yrodiUcu,'n r i d carbon moiioxidc (includ- y m t to. any syccik exyosurc. 'IIXrororjation may ing diesel, JCL. and auto exhaust, as well as coal fumes; wurant htu@investigation. A p a d e l study of Dan- and srnnkc)." In a care-control study ncstcd in the ish womcn' 4bscrvcd e slight cicvarion of risk among Anicrican Cancer Society Prospec;ive study,27rinks spinnersarid+eavcrs ( O R= 1 .A, CI = 0.3 - 6.8).Others wcrc nonsigoificlnrly increased for self-reponed have reported t risk of'2.7 (P.;.O.O1j for myeloma exposure to diesel exhaun (VR= 1.4) but not gasdine among fernalc tcxtile workcrs in the Swcdish wool exhaust ( O K= 9.9). A rcccnt caw-conud study in indusiry,'.. an$ a nearly rwofold incrchsc (CI= 0.8 - 4 . 1 Northern Swededl found a siiflit clevidonof risk with [eight cases3)Q with nrif-reported exposum to tcxdic exposum to cnginc cxhausis (OR= I .J, 90 percent filxrs and dusts in che US.Counties in the US with a CI = 0.Y- 2.1 161cases]); this risk fell in thr multivtriav highcr propoftion ofthe puptllationcrnployd in syn- analysis when numeraw agriculture-related variablct thetic fiber naknufacture had signifkantly higher rates wcrc included. Although the widencc for an aswd- of rnyeloma.~A neiiriy threefold risk ofdeath from ation of inyeloma with gasoline or eiigine exhausts mycbrna (standardimd mortality ratio = 2.7, Cl =: h c > r &la 1 3 weak, Iw-hlJCr expusurc should bc dis- D.7-6.9 14 c&sJ) WJS obstwcd in A ,tfibon of cmoi) missed utitilstudies with morc prccirc c x p ~ s auss~ess- textile work& in the US>^ metits arc availabic. Precision &ctrl workns and machinist%tmiths, Ah associationwith agricuiturc"24m7w.a9s3not con- machine fitteb. and welders dl bad slightly dewted finned by thcsc data. We saw 30 increase in myeloma risks. Risks &ong inen employed in m a n u h u r c of d ~ i ~ t SiUgkJjCCk3 whosc most rccciit t u form lisrcd structural mcdd or stationarywdu and inbody factor- occuyatioij as iarrn owner,tenanx farmer, o r agricul- ies (excludink.autnmobilcs) rosc dpifiandy with iura1 or garden workcr. Sclf-crnpkciycdfarmcrs 3rc not Juration of+ployrnonr to 5.5 and 3.9, r e u p d v d y . included in the Pension Fund, hut farm ou'ncr is gcncr- Scvrralsrudics havc rcportcd sliglx ar nunsignificantlY ally a Melongoccupationin Denmark, so r e d t s Lased &mated riaki in nictal-working ocrupatioiu and .Ioil tlic icccnt :ax furm I I rcA~ cct A tiqc lack of a c e s $ tndufrries (s&lrcr. and metallwgy worker$,:* com- risk of myeloma among farnicrs in Dcamark. In ?cSsicors;'' Eodndry workers,'" in dicsd engine m n u - rcccrlt popubrion-based case-control study;' farmers kctures') or kith exposure TQ No specific who reported rracwr-driving hod a highcr risk of MM xposurc clc$?- cxplains thcsc risks; risks wcrc nut than uucs who did not (OR-2.3, 90 pawnr h a t e d for cxposurc to nictalsOY mcrat duma,lead, or CI = 0.3 -7.11. Farmers m y be exposed to ciiginc mercury. ; w..haustsqz and ga~ulincI,IICW& it sceais uirliticly that A ncarty f&rfold rick in Ua&h steketo ( b a d 011 rhese rxposurcs would cnrircly cxplainfarmcrs' cxt-css Ionr E~SJCS)is +nlikdy t.cr m u ~ c l yc x p h h h e ~nyclomr r i s k obscrvcd EJSCW~ICCC. N u associaiion w a s nlservcd xccss obscricd among clcclricrl wvrkcrs, but thc with pcstiCidcs, in contrast to an association with self- rt&ers could not bc ;drniit;ed se$ararcly in ihjs repot ted exposure in oiic study.z7Specific cissscs of itudy.5' Elcci&ians were at significmdy lower risk of pesticides or indmdual compounds wcrc not myeloma in a$tcent casc-coiitrol study id SwCda." cvduatcd. The strengths of thisstudy wen: its Iargcsia, allow- Our data did not confirm previously suggstcd :ng31c cxam+ation of a grcarcr numbcr of specific asssocialionswith AibcsiosL'S Aitd molvenu,"'"'wparu- ,. xiuparions and indunties; the availability of accuratc cularly benzene,'' which have been contradic;ed by ndusdal tmftluymcnt histories after 1964; and ILGMSS- other Studies*?A*.*' Although risks wmc clcvazcd nmt of cxposbrc hy industrial hygienists, basedon job .. 566 Cmwz Caua.barld L s 1 r r - d Vol3 1992 tidcs and crnployrncrir hiswry ofsubjects. However, the occupationai histories havc iimitations. Because myeloma i s prcdominatdy a disersc of older people, most subjects l i ~ dspnt at least tvo decades of rhclr working lives before 1961,when the SPF k g a n rec- ording employment histories. Risks considering latency,in particular, were difficult lo iiitcr;rret due to small nnmbers. For nuny substanccs,for cxample, CIS often cncompasscd hoth the risks and Cis cakuiated wirhoui consideration of Inicncy. We therehe did not dismiss otherwise suggestive findings r h i were weakened io the latency andlysrr.jobs in which subjects were self-cmploycd w e n exctuded, which mrdc it difficult to cvduate risk for farmers a n d with agricultural exposuresin detail. Occupationai title, limited io &ai recorded oh the tax form, reflected only the most recent occupation.However, job mobility, at !cast for farmers and skilled workers, is very low in Denmark comprcd wirb that of,c.R.,the US, reducing somc of the likely niisclassificatinn. We 3 1 ~ 0diimiptcd to reduce mischsrificau'onby using occupat:on primarily to distinguisl: Ixiwcen productmn ('biue collar') and managerial('whire d l o r ' ) jobs,eliminating pensioners (morc!ikely to be survivingcontrols)from all analyws, omittingd j e c t s rid only oca~padof~riom analysts of specific subtatma, a d rcrtricllng analysts of duration tn subjects wirh ~t lcasr fivr years recorded in the Pciision Fuiid. Thesc 1ini;t.ations would i m d to reducc sratistical power, and to mi~cfasxifymen employed (in an industry) or exposed (to a substance) bdorc 1964 as unexposed. This misclacisifjcarion,nondilfrrcotialwirh respect to cdsc status, ]nost likely wmld rcsuh in diminution of true risks. Associarims corrobaratcd by prcvious studies tlierefore may be stronger rhw indicated by these d.m alone. The lack of strong and cc;nsistcntissocjaijnns in these and uthcr data, and rhc low atuibuublc risk for most occupationif exposures probably rcfleci P relutivcly minor roleforotcupation2'i;nthe etiology of this tumor. Nonerhdess, iinyrovemcnta in expoiurc arsessmmtarc likely to bettcr ourunderstandingofthe importance of widespied exyosum such IS solverits and engine exhausts in the devclgmcnr of myeloma. References 2. MurrC,Wateskuuse J. hia&T,PowellJ,WhelmS. Cancrr.lncrdmcsI# fiw Ctmu'nrm Vol 3. Lyon,Frascc Initrmationd Agciicy for Rcscarch 011 Cancer, 1987; 20. Gratmmer LC,tiurir KE,ChvldierMJ,Flabcrtv D,Pat- tn3nn R. Establishiq ciinicrl and imrnunvlogiccriteria for& nosifi of occupationalrnrmunologic lungdisme wirhpfrhalic anhydtidc and reuachbmphthdic an&- !'.dridd exposures as a model f O m p Msd 19R7; 2% 866- 21. Blair4,7.&m SI-:, Paarce Hcinmrn EF.Frrumeni 1 JPJr. Clues to canccr ctiolo frbm studies of farmers. Sccrnd J Work Envimn H&aix(inprcss). 22. Alavanja MCR, Rusb GA. Stewart P, Blair A. I'mprtionaw mvmlity smdy ofworkers in thcgrainindusUY. J N C ~19~77;8: 247.32. r'23, M~hJghhlinK. tinct MS,StoncJ5J. Blot Wl,kraurneni JFJr Multip c myeloma and c;rcfuparioninSntcdcn.Arcb Etrmron .?ca&h 1988; 43: ?- 10. 24. Galhghcr RP, Spinclli JJ, Elwood JM, Ski pen DH. PAllcrgics and rgriculturrl cxpwurc a rish rciorj lor -multiple inye!nmr. B Y ] C a n m 1983;M 853 7. 25. Pcuct NE,Smith A H , HowardjK, S y a r d RA,Gika H,J.TeagireCA. Caset o m d study ofmu tiplc rnycloma and fuming.571Udnect 198b; 54: 493-509. 26. Unec MS,I4arlow SD,McLaughlin jK.A cue-control study of mlriplc mydoma in whites: chronic mtigenic - .st)muIarion,occupation, and dnrgusc. Cancer Res 19BiS. 4 2 2978 H! 27.hffcm P, Stellnivl SD,Garfinkel L. A case-conrml study olmultiptc myeloma nertcd in rhc American G n - ccr Sockry Prospecrive Swdy. int I Cancer 198% 43: 554 - 9. J28. KoepscU rD,Daliog JH,Weirs NS, cf A. A d cnic otimulruon and drc occurrcncc of muhiplc my om& Am J &pw!emra~I9R11;26: J 1 - 62. 27. Linct MS.Is chronic antigenic silmulaiion etiologically xtared to mulnplc myclomn? In: Obramr GI.Porrcr M, cds. Eyrdcmidogy and Skdogy of Mi&k Myeloma. Berlin: !3priaget-Vcrlq. 1991; 93-192. 30. Heinman EP,Okcn J, Pottcrn LM,Gornez MR,Raffn E,B k r AE.Lcads forfurureswdlcs from a casc-conad study of occupationd exposures and multiple myeloma in Denmark. in: Obnms GI,Potter M,eds. Lpidtmidogy mtd ~mlogyrf Mdlpfc hfyolonra. Berlin: Sprin. p - V e r h g , 1991; 17-29. 31. Morris PD,Kocpadl TD,Daling JR,et d.Toxic sub- s w t c aposlrrc old mulriplc m)ieIomo: R csscsonrIo1 srudy.INC1 i886;76+. 9117.94. 32. Iiours iw, Cardis E, Mvcillhk A, Qoelin P, Fabry J Mortality oiicohonina polyrmidc-polyesterfactoryin -Lyon: a furdm follow up. 8 r 3 ind Mcd 1w19;46: 66s m. 33. Hagmar I,, Akessod 3,Niclscn 1, CL d Morulky and C I I ( C C ~mnrhidity irr wwkcrs exposed to low Jech of vinyl chlnridc monmicr IL a polyvinyl chlnridc process- 5:1% lam. A n J h d . M d 1990;lft 5113-65. 9.h c G,Labow HS,Yocchi iM. Dircributitmof di(l-cthyUrcxyt) phthalate and producu in tJoud and blood compmcnu. Envirou HerW Pe 1986;65: 399- 16. 35. Caner SA. The pountial hcahh n a r d ai substanccs leached from plasuc packaging,J Etrvima H c d h t 971; 20; 73- 6. 3e. Pon FK. Regheb NE,Scbwvartt. AG, Hawthorne VM. Am Kidicy Dis 1?8!$14: 119- 23. 37. Kinin LJ, Eastwoaf jB,Kcrr DNS. et JI. Cancer in patients reaiving dimlyis. 5r Medl 1380; 1: I401-3. i38. fCIncw AF, Iioovcr RN, Kinlcn Lf, McMuilan MK, FrdUmClli JF Jr. Gamer ib prtrcnts t-cceini~glong ccrm dtlysir rrcarmcnr. Ani) Lpdemf1987; 12L: 370.6. 9. Twndbcrg 1. %fortdkyand cancer incidence Swedish paint itidustry workcrr mth l o ~ ~ 1 cxpwurc tQ organic solvents. Smnd Work &Wwn 1 Hrdr$ !986: 12% !28- 13. /40. Bethwaitc DB,P w c c N. Froset 1. Cancer risks in pain- ,I tcrs: study b r d 011 tho NLWZealand Cancer RcFginry. Rr3 Ind M&f !9%; 4R 742 -6. -?I. Adelstein AM. Octvpatimd mortality: canccr. Ann CkrhljJIiyg 1972;Is: 53 7. 12. FloJm U,fidriksron M, Persson 3.Multiple myeloma 1 and engine exhausw, fnsh wood, and crwsotc:a case- , rderent study. A m j I n d Med 1987; I2519-ZY. 43. Enksson M. Karlsson M. Occupational and mhcr j ctwiranmcritaI factors and mulliplc iuycloma: a pop- 1 1 l3a5ti-o1n03b. w d case-contra1study. 8 r l f n d M c d 199%41: CCC. Spirw R,Sqcwan PA, LeeJS, e t d . Ketrospcrivecohort 7.1 monniit Mdy OC workers at an aircraft m*intcruncc 1 facility. Epidmriob$k results. 5 t j I d Mrd 1991: i 515-530. 'k5. lkc~uflcPi Bhrtncr Wh. Blair A. Murtality rnong clwnicrl wqrkcrs eAp(>$ed CY bmtrnc and othcr agcnts. , Enirirm Rei 19W.3Q 16-29. ' s66. WValrarh J, hccouflc P, Thomas TL.Mondity amoii ' wvrkers in 4 Ehrw rnanuhtunn6 company. A m ] in Med 1987: 12: hl5-23. m