Document MGyqNvRO2d48ek9OpkrEg68eL

FILE NAME: Z< DATE: DOC#: Z< DOCUMENT DESCRIPTION :ZDZZ ZD AMERICAN JOURNAL OF INDUSTRIAL MEDICINE Mesothelioma and Employment in Massachusetts: Analysis of Cancer Registry Data 1988-2003 Cora R. Roelofs, SeD, h Gabriela J. Kernan, MS, l Letitia K. Davis, SCD,2 Richard W. Clapp, DSc, 3 and Phillip R. Hunt, PhD4 Background Cancer registries can be used to monitor mesothelioma cases and to identifY occupations and industries previously and newly associated with mesothelioma-causing asbestos exposure by usmg standard regIstry data on the "usual" occupation and Industry afthe case. Methods We used the National Institute for Occupational Safety and Health:~ Standardized OccupatianalIndustry Coding Software to code 564 mesothelioma cases for occupation and 543 for industry of the 1,424 incident mesothelioma in the Massachusetts Cancer Registry from 1988 to 2003. AdditIOnally, we coded the occupation and industry of 80,184 companson cancer cases (35% of comparison cases in our database). These were used to compute Standardized Morbidity Odds Ratios (SMOR~). Results Seventeen occupations and 11 industries had statistically significant elevated SMOR~ for mesothelioma. Occupations and industries hzstorically associated with mesothelioma remained elevated in these results. However. we also found statistically significant elevated SMOfu for several occupations and industries for which there was preVIOusly weak or no association such as chemical engineers, machine operators, and automobile mechanics and machine manufacturing, railroads, and the US Postal Service. Conclusions Incident cases of mesothelioma do not appear to be declining in Massachusetts, as legacy exposures to asbestos contznue to produce cases in individual~ involved in shipbUilding and construction. Exposures in occupations and industries not previously associated with mesothelioma also contribute cases. Cancer registries, with improved data col/ection, should continue to be monitored for mesothelioma cases and asbestos exposures. Am. 1. Ind. Med. 2013 Wiley PeriodIcals. Inc. KEY WORDS: mesothelioma; asbestos exposure; surveillance system; occupations; industries; cancer 'Department 01 Work EnVironment. University of Massachusetts Loweli. Lowell. Massachusetts 2Dccupatlonal Health Surveillance Program, Massachusetts Department of PubliC Health, Boston, Massachusetts 30epartment of ~nvjronmental Health, Boston UniverSity, Boston, Massachusetts 4SoclalSectors Development Strategles.tnc ,Boston. Massachusetts Contract grant sponsor: BlIgham and Women's Hospital Intematlonal Mesothelioma Program. Research completed at. UnIVersity of Massachusetts Lowell and Massachusetts Department 01 Public Health. Disclosure Statement: The authors have no conlllcts of Interest to disclose Correspondenceto:CoraRoetofs.ScD,DepartmentofWorKEnvllOnment,Umversltyol Massachusetts Lowell,Kitson 200, 1UniversityAvenue, Lowell, MA01854 E-mail: CoraRoelofs@uml.edu Accepted 20 May 2013 DOI10.1002/ajim.22218. Published online inWlley Onhne Library (wlleyonllnell brary corn) 2013 Wiley Periodicals, Inc. 2 Roelofs et al. INTRODUCTION Mesothelioma is a rare and highly fatal cancer of the chest or abdominal lining caused by exposure to asbestos fibers [SelIkoff et aI., 1964]. InvestigatIOns of mesothelioma cases generally record experience of asbestos exposure in the workplace, although environmental exposure, exposure to products and exposure to "take-home" asbestos have also been documented [Albin et al., 1999; Miller, 2005; Rake et al., 2009; Carbone et al., 2011]. Public health surveillance of mesothelioma can reveal the burden of occupatIOnal and environmental disease in the population, evaluate the impact of prevention efforts over time, and identify prevlOusly unrecognized settings in which workers and community members may continue to be at risk of asbestos exposure [Hillerdal, 1999; Mirabelli et al., 20 I0). About 97 cases of mesothelioma have been reported to the Massachusetts Cancer Registry (MeR) annually since 2000. The ageadjusted incidence rate ofmesothelioma in Massachusetts for 2007 was 17.9 per million residents, 1.4 times the estimated national rate 12.6 [Occupational Health Surveillance Program, Massachusetts Department of Public Health, April 2011). The age-adjusted death rate for mesothelioma in Massachusetts between 1999 and 2005 was l4.8/milllon residents placing Massachusetts at the tenth highest mesothelioma death rate in the U.S. [U.S. National Institute for OccupatIOnal Safety and Health, March 2009] Massachusetts' long history of shipbuilding, an industry where many thousands ofworkers were exposed to asbestos, plays a SIgnificant part m explaming thIS hIgher than average rate. Recent analyses of national data predicted that mesothelioma incidence would peak in the United States in between 2005 and 2010 and decline sharply thereafter [Pnce and Ware, 2009]. However, it is not clear that a peak has occurred in Massachusetts (see Fig. 1). Despite the dramatic decline in the use of asbestos and Increases in worker and environmental regulatory protections, individuals continue to be exposed to asbestos at work and in other settings [U.S. National Institute for Occupational Safcty and Health, 2011]. In partIcular, an evolving category 120 , . - - - - - - - - - - - - - - - - - - - . . . , 110 ~--------------------~~------~----__1 100 +-----------~-----~~~--_=~~~~n 90 ~~~~~--~--~ 70 60 ~D +-~~--_r~~T_r_~~~~~r_~~~~ FIGURE1. Mesothelioma Incident cases diagnosed In Massachusetts (1968-2009) of exposure-exposure to m-place asbestos in buildingsmay result in mesothelioma cases in maintenance and abatement workers (as well as building occupants). In 2009, there were 165 licensed asbestos contractors in Massachusetts. These companies employ hundreds of workers, many ofwhom are new immigrants. While these workers may be protected by Occupational Safety and Health Admimstrallon's (OSHA) strict asbestos standard and additional Massachusetts' regulations, annual reports of enforcement actions against illegal asbestos removal suggest that exposure may occur despite the new regulatory environment. In this context, we initiated a surveillance mvestigallon to examme mesothehoma mcidence using data reported to the MCR 1988-2003, updating a prior report based on similar methods for the years 1983-1987 [Occupational Health Surveillance Program, Massachusetts Department of Public Health, 1991]. The goal of the study, funded by the International Mesothelioma Program of the Division of Thoracic Surgery at the Brigham and Women's Hospital, was to examine the association between mesothelioma incldence and usual mdustry and occupation and to identify changes in patterns over time by comparing results with those of the previous study MATERIALS AND METHODS The MCR was established in 1982 to collect informanon on the incidence of maiJgnant neoplasms in the state. All hospitals or organizations holding a clinic license m Massachusetts are required to report newly diagnosed cancer cases to MCR within 6 months of initial d18gnosis. (PhYSICians' offices and pathology laboratories began reporting in 2001; radiation therapy centers in 2002.) Case reports contain diagnostic and demographic information, including the case's description of their usual occupatIon and industry. International Classification of DIseases for Oncology (ICD-O) codes for primary cancer site and histology in the MCR are assigned by tumor registrars at the reporting hospitals (http://www.who.intlclassificatIonsl icdladaptationsloncology/enlindex.html). Following a research protocol and data request revIew by the University of Massachusetts Lowell Institutional Review Board and the Massachusetts Department of Public Health Human Research Review Committee, de-identified mesothelioma and comparison cancer cases among Massachusetts residents diagnosed in 1988 through 2003 and reported to the MeR were obtained for the analysis. Mesothelioma cases were defined by ICD-9 histology codes 9050--9053. Comparison cancer cases included cases with cancers that have not been associated with asbestos fibers: pems and scrotum, prostate gland, testis, bone and Joints, connective and soft tissue, vagina and labia, vulva, Mesothelloma in Massachusetts 1988-2003 3 cervix uteri, corpus uteri, other female genitalia, breast, melanoma, leukemia, and lymphoma. All other cancers, including lung cancer, were excluded. Usual industry and occupation information reported to the MCR is not routinely coded. Industry and occupation codes were assigned using Standardized Occupational Industry Coding Software (SOIC) developed by the U.S. National Institute for OccupatIOnal Safety and Health (http:// www.cdc.gov/niosh/soic/SOIC_About.html). SOlC uses codes from the 1990 U.S. Bureau of the Census Alphabetical Index of Industnes and Occupations. Data were cleaned prior to the application of SOlC to make text uniform in order to maXImize assignment of codes and minimize coding errors. MCR narrative fields could vary for the same occupatlOn. For example, a case with usual occupation "carpenter" who was retired at the tIme of diagnosis could be described as "ret. Carpenter," "carpenterretired," retired carpenter," "retired," "carpenter," "at home carpenter," etc. Thus, we "cleaned" the text to read only "carpenter" to be coded by SOIC. Initial frequency analysis of SOIC aSSIgned codes mdicatcd that multi-word occupation and industry strings were often assigned codes "900" and above indicating "unknown," or "unspecified." Many "current homemakers" or "disabled" had had previous jobs that were recorded as the second word in the narrative. As a result, these jobs were not mitially coded by SOlC. We modIfied the descriptions in order to assIgn codes based on these second words for all multi-word strings initially coded greater than 900. Applying this strategy to codes less than 900 was not feasible, as it would have required a manual review of all cases. ANALYSIS Because only numerator data were available for this study, we used Standardized Morbidity Odds Ratios (SMORs) to measure the association between mesothelioma and specific occupations and industry [Mlettinen and Wang, 1981; Smith and Kliewer, 1995J. Thc SMOR compares the ratio of mesothelioma to other cancers In the occupation or industry of interest (exposed group) cases with other known occupations or industries (unexposed group). The SMOR for a given occupation or industry can also be thought of as the ratio of the observed number ofcases in that group divided by the number expected, where the expected is based on the ratio of mesothelioma cases to comparison cancer cases in those employed in other industries and occupations. Cases employed in the slupbuilding or construction industnes, or in 32 construction occupatIOns that are known to have asbestos exposure, for example, plumbers, insulation workers, carpenters, were excluded from the unexposed industry and occupation groups. Cases with unknown occupation or industry were excluded from the analysis as it was not possible to detennine the exposure status. A SMOR greater than one Indicates Increased nsk of mesothelioma cancer in the industry/occupational group compared to the exposed reference group. Logistic regressIOn was used to compute SMORs and 95% Wald Confidence LImits for each industry and occupation group with five or more observed cases of mesothelioma, controllmg for gender and age. An SMOR was also computed for homemakers. Age was examined in three distribution-based groups III the final model: 20-54 year of age, 55-69 years of age, and 70 and above. We tested 10and 20-year intervals initially in order to control adequately for age differences between cases and the comparison cancers group. The stabihty of confidence interval was the same, and in light of mesothelioma's long latency, we used a parsimonious approach. Cases younger than 18 years old (n = 2) were excluded from the analyses. Analyses were performed using SAS v. 9.1. RESULTS There were 1,424 cases of mesothelioma tn the MCR 1988-2003 Table I shows the demographic distribution of the mesothelioma cases. This distnbution is similar to the dlstnbution seen in the previous study, except that the current results include more younger cases: 19 cases younger than 40 The majority of the cases were from counties and towns WIth a history ofshipbuilding industries. We were able to code 564 mesothelioma cases (40%) for occupation (excludtng retIred, unknown and disabled) and 543 (38%) for industry. The majority of the cases (and the comparison group) were reported as retired, unknown or disabled and were excluded. The comparison group consisted of 80,184 cancer cases coded for occupation and industry (35% of the total comparison cases). As shown in Table 11, l7 occupations had statistically significant elevated SMORs for mesothelioma. Most of these occupations historically have been assOCiated with asbestos exposure and mesothelioma, TABLE I. Characteristics of Mesothelioma Cases In the Massachusetts Cancer Registry1988-2003 n % Total cases 1,424 Male 1,166 82 While 1,371 96 Age 59 or younger 221 16 Age 60 or older 1,202 84 Occupation coded 1.258 88 Occupation coded excluding unknown, disabled, retired 564 40 Industry coded 1,324 93 Industry coded excluding unknown, disabled, retired 543 38 4 Roelofs et al. TABLE 11. Occupations With 5 or More Mesothelioma Cases, Massachusetts Cancer RegistrY,1988-2003 Occupation Code Number of Cases Insulation workers 593 9 BOiler makers 643 5 Plumbers. plpefitters, and steamfitters 585 49 Welders and cutters 783 22 Chemical engineers 48 5 Electricians 575 31 Bnckmasons and stonemasons 563 9 Stationary engineers 579 7 Machine operators, not specified 779 12 Drafting occupations 217 5 Sheet metal workers 653 7 Construction laborers 669 23 Production Inspectors, checkers. and examiners 796 7 Military occupations 905 12 firehghting occupations 417 19 Automobile mechanics 505 10 Carpenters 567 25 Technicians, n.e c. 235 9 Designers 185 5 Cooks 436 6 Machinists 637 20 Secretaries 313 14 Painters, construction, and maintenance 579 7 Mall earners 355 5 Janitors and cleaners 453 23 Miscellaneous machine operators 777 7 Social workers 174 5 Postal clerk 354 7 Bookkeepers, accounting, auditing clerks 337 5 ElectriC and electroniC engineers 55 7 Homemakers 914 35 Police and detectives 418 9 Constructton superVisors, n.e.c. 558 6 Sales supervisors, sales occupations 243 17 Truck dnvers 804 14 Managers and administrators n.e.c. 22 21 Teachers, elementary school 156 19 Laborers except constructIOn 889 8 Lawyers 178 8 Sales workers 274 12 Accountants and auditors 23 8 Registered nurses 95 6 Funeral directors 19 9 Engineers, n.e.c. 59 10 General office clerks 379 5 Confidence Intervals were rounded to the nearest digit Statistically significantSMORs are bolded. SMOR 38.4 22.6 9.5 10.1 5.3 5.1 4.6 1.6 3.5 3.0 3.5 2.9 2.9 2.3 2.2 2.1 2.2 1.8 1.8 1.7 1.8 1.7 1.6 1.5 1.4 1.5 1.7 1.3 1,4 1.0 1.1 0.9 1.1 1.0 0.9 0.7 0.9 09 07 0.7 0.7 07 0.7 0.7 06 95%CI 17.7-83.5 8.5-60.5 7.0-12.8 6.5-15.8 2.1-13.1 3.5-7.4 24-90 0.8-3.5 2.0-6.3 1.2-7.2 1.6-7.4 t 9-4.4 1.4-6.1 1.3-41 1.4-3.4 1.1-4.0 15-33 0.9-3.5 0.7-4.3 0.8-3.9 1.2-2.9 1.0-2.8 0.8-3.5 0.6-3.7 0.9-2.1 0.7-3.2 0.7-4.0 0.6-2.7 0.6-3.5 0.5-2.0 0.8-1.6 0.4-1.8 0.5-2.6 0.6-1.6 0.5-1.7 0.5-1.1 0.5-1.4 0.5-1.8 0.4-1.4 0.4-1.3 004-1.4 0.3-1.6 0.4-1.3 0.4-1.4 0.2-1.4 Mesothelioma in Massachusetts 1988-2003 5 however, some, including chemical engineers, brickmasons, machine operators, drafting occupations, production inspectors, military occupations, fuefighting occupations, and automobile mechanics, are less commonly Identified as having elevated rates of mesothelioma in comparisons to other occupatIOnal groups. Several other occupations had elevated SMORs that approached statistical significance, including technicians not otherwise classified, stationary engineers, painters, secretaries, and janitors and cleaners. The ship and boat building and repairing and construction industries contributed the largest numbers of cases (96 and 127, respectively) among the 11 industries with statistically significant elevated SMORs, but other industncs such as justice, public order and safety also contributed a large number of cases (Table HI). Ship and boat building and repair had the highest SMOR by far (38.2) with the next highest at 7.3 for miscellaneous repair services. (According to the Standard Industrial Classification system, "miscellaneous repair services" includes several diverse repair activities including of air conditioning machinery, farm machinery, clocks, furniture, lawn mowers and sewers.) Water transportat1On, construction, and the mlhtary also had highly elevated SMORs. Apparel, footwear manufacturing, and motor vehicle dealers showed SMORs that were notably elevated, although their SMORs were non-statistically significant. DISCUSSION Public health surveillance using data collected in disease registries can monitor patterns of disease in certain populatlOns known to be at risk, and can generate new hypotheses about populations potentially exposed to disease risk factors [Kang et aI., 2008]. This study confirms that occupations and industries historically associated with asbestos exposure continue to be sources of cases of mesothelioma at elevated levels. The long latency period of this disease means that histone exposures are still producing cases of this deadly disease. Additionally, despite increased regulation, compliance and awareness, asbestos exposures may have continued in the asbestos-using and removing industries. Little is known about the disease potential of occupational and environmental exposures to inplace asbestos in buildings and other settings. Our results pomt to specific industries and occupations where exposures should be characterized. Our study analyzed data from the MCR from the years 1988 to 2003. Because wc used a similar analysis strategy to that employed in a previous study for the years 1982-1987, we were able to compare the SMORs of occupations and industnes III these two time periods. Occupations with statistically significant elevated risk in both studies included: insulation workers, boilennakers, plumbers, pipe and steamfitters, construction workers, carpenters, and engmeers (may include chemical). The construction and ship and boat building industry sectors were also at elevated risk at a statlsttcally sigmficant level in both studIes. A few differences between these two studies warrant attention. We were able to find a greater number of occupations and industries with statistically significant elevated risk in the second study due to the greater number of cases in the dataset and greater specificity of occupational coding. Many of the occupations that newly appeared elevated at a statistically significant level: chemical engIneers, brick and stonemasons, draftmg occupations, machine operators, automobile mechanics and military occupatIOns, may have becn included in broader occupatIOnal categories, such as "engineers," "constructIOn laborers," and "mechanics and repairers" which were elevated in the earlier study lndustnes that showed statIstically Significant elevated nsk in the later study, but not the earlier one were railroads, V.S Postal Service, machine manufacturing, and the m1litary. Analysis of publically available cancer incidence and mortality data poses both advantages and limitations for understanding the patterns of mesothelioma [Levy et aI., 2001]. The large number of cases in the MeR allowed us to find a relatively great number of SMORs for occupations and industries that were statistically significant ba~ed on 95% confidence level. However, in some instances, SMORs were computed based on small number of cases resulting m wldc confidence intervals. Additionally, while demographic information is thought to be highly reliable for these cases, thc occupatIOn and mdustry categones are more problematic. Less than 40% of the mesothelioma cases and comparison cancers had sufficient information in the MCR occupation and industry narrative fields to allow coding. Additionally, we conducted a validation study on a subset of cases to compare manual and sorc coding and found that sorc correctly coded about 70% of the occupations and mdustries, leaving about 30% of information vulnerable to exposure misclassification. However, this misc1assification would likely be nondifferential, i.e., to the same degree in cases and the comparison group, and hence, bias the results towards the null. Due to the size of the database it was not feasible to manually code the occupations and industries, however, we used SAS to identify cases where we could improve the uniformity of the text narrative and thereby improve the completeness and specificity of sorc coding. This strategy mlmmlzed observer (coder) bIas sincc the samc, consistent approach was used to assign appropriate industrial/occupational codes to all cancer cases. Little bias is likely to have been mtroduced from these data hmltations, however, since there is no reason to believe they would be more or less likely to occur for mesothelioma versus comparison cancer cases. Additionally, we were not able to compare the comparison cancer cases to Massachusetts populatIOn data ovcr the time period of the study to detennine if this large group is representative of the Massachusetts population as a whole. 6 Roelofs et al. TABLE 111. Industry Groups and Subgroups With Five or More Reported Mesothelioma Cases, Massachusetts Cancer Registry, 1988-2003 Code Construction 060 Manufacturing Yarn, thread, and fabric mills 142 Apparel and accessories, except knit 151 Pulp, paper, and paperboard mills 160 Printing, publishing, and allied industries, except newspaper 172 Footwear, except rubber and plastiC 221 Machine, except electrical. n.e.c. 331 Ship and boat building and repairing 360 Not specIfied 392 Transportation Railroads 400 Trucking service 410 U.S. Postal Service 412 Water transportation 420 Communication Telephone communication 441 Utilities and sanitary services ElectriC light and power 450 Retail trade Motor vehicle dealers 612 Eating and drinking places 641 Finance, insurance, and real estate BankiOg 700 Real estate, includi09 real-estate Insurance offices 712 BUSiness and repair services Business serVices, n.B.C. 741 Automotive repair and related services 751 Miscellaneous repair services 760 Professional and related services Hospitals 831 Health services, n.e.c. 840 Legal services 841 Elementary and secondary schools 842 Colleges and Universities 850 Engineering architectural and surveying services 882 Accounting, auditing, and bookkeeping services 890 PubliC administration General government, n,e,c. 901 Justice, public order, and safety 910 National security and International affairs 932 MIlitary 942 Contldence Intervals were rounded to the nearest digit. Statistically signitlcant SMDRs are bolded Number of cases 121 149 5 6 5 5 5 9 96 18 39 7 7 19 6 10 10 8 8 14 7 7 14 6 8 27 6 11 10 95 15 7 9 31 11 17 5 70 16 33 8 17 SMOR 3.2 1.1 2.7 2.9 0.8 2.5 2.7 38.2 1.4 3.2 0.7 1.7 3.4 1.2 1.5 2.1 0,8 09 1.0 1.4 2.2 7.3 0.9 0,8 1,0 0.9 0.6 1.3 1.6 08 1.5 1.8 3.3 95%CI 2.6-3.9 0.4-3.3 1.0-7.3 1.2-7,1 0.2-2.4 08-28 1.3-55 29.4-49.7 09-2.4 1.4-7.3 0.3-1.6 11-27 1.5-7.7 0.6-2.5 0.6-4.1 1.0-4.5 0.4-1.6 0.4-2.1 0.5-2.0 0.6-31 1.2-3.9 3.8-13.9 0.5-1.7 0.4-1.7 0.5-2.0 06-1.3 0.3-1.1 0.8-2.1 0.7-3.9 04-14 1.1-2.2 0.7-4.3 1.8-6.1 The major limitation of a cancer registry-based surveillance strategy is that recorded usual industry and occupation is a limited ~urrogate for a detailed exposure history. Reported usual occupation and industry may miss or mask the true source of the asbestos exposures, or may suggest universal exposure for non-uniform occupations. For example, our study found an elevated SMOR for the U.S. Postal ServIce Postal workers may have had exposure to asbestos at work, Mesothelioma In Massachusetts 1988-2003 7 but it is also possible that V.S. Postal Service hiring may favor veterans, many of whom may have had asbestos exposure through their military SCrvICC. Addlhonally, we found elevated SMORs for automobile mechanics and janitors and cleaners (non-statistically significant). In both cases, and unlikc insulation work, these occupations mclude a wIde variety of tasks and job settings, only some of which may involve exposure to asbestos. Some automobIle mechanics may be exposed to asbestos when cleaning worn asbestoscontaming vehicle brakes. Janitors and cleaners may also face exposure to "in-place" asbestos put into buildings by the hIstorically at-nsk construcuon industry. While not all automobile mechanics or janitors and cleaners are exposed to asbestos on the job, our findings support the continue monitonng of these occupations and efforts to prevent exposure to asbestos from "in-place" asbestos and asbestos products. Despite the limitations ofthis "surrogate" exposure monitonng for a long-latency dIsease, the large number of cases reported to the Registry allows us to describe trends and to find suspect occupations and industries that may warrant further investigation of potential disease-causing exposures. CONCLUSIONS AND RECOMMENDATIONS Many results of the study are consistent with prevIous investigatIons ofthe association ofparticular occupations and industries with mesothelioma. Industries and occupations with historical asbestos exposure, such as msulation workers, and those who worked III ship and boat building and construction, have continued to be at risk of developing disease. There are number of occupations such as drafting occupations and occupations related to U.S. Postal Service, such as mail carriers or postal clerks that were not previously reported to be at risk for mesothelioma. It is not possible in this analysis to detennine If these cases resulted from exposure to asbestos experienced during employmc:nt in the reported "usual" occupation, i.e., work in a post office, or if these cases were exposed to asbestos in a prior occupation such as ship building, or in the military, or in another occupation or exposure context not reported as their "usual occupation." However, there should be further surveillance and investigation of potential asbestos exposure for all occupations and industries with elevated SMORs for which there has not been a previously demonstrated nsk or characterized exposure. The limited number of code-able occupation and industry fields points to a recommendatlOn for improvement in data collection. In many cases, the fields were blank and in many others hospital registrars recorded "retired," "dISabled," or "unemployed." Comparison of cancer registry data to dcath ccrtlficates may help Improve data capture and accuracy [Davis et aL, 1992]. Hence, electronic data linkage should be cOllSldered as a routine strategy m cancer registrybased surveillance. Despite the usual long latency between exposure and dIsease, a continuing program of mesothelioma surveIllance is recommended to monitor the progress of exposure control and preventlOn and to identifY suspect exposures [Teschke et aI., 1997]. Even with the increasing federal and state regulation of asbestos exposure through the last decades of the twentieth century, and even most recently with OSHA's National Emphasis Program on Shipbreakmg issued m 2010, some workers, such as those performing asbestos abatement activitIes or those With exposure to "m-place" asbestos m buildings and products may be at risk of the disease. Improved medical record keeping and reporting could help support an effective public health surveillance system for asbestos-related diseases and othcr dIseases related to occupational exposures. ACKNOWLEDGMENTS Dc. David Wegman and Dr. David Knebel provided essential aSSIStance to this study. We are also grateful to the staff of the Massachusetts Cancer Registry and to the anonymous reviewers who contributed significantly to the revised manuscnpt. REFERENCES Albin M, Magnani C, Krstev S, Raplli E, Shefer I 1999 Asbestos and cancer' An overview of current trends in Europe Envlron Health Perspeet 107(Suppl 2).289-298. Carbone M, Ly BH, Dodson RF, Pagano I, Moms PT, Dogan UA, Gazdar AF, Pass HI, Yang H lOll Malignant mesothelioma. Facts, myths and hypotheses. J Cell Physiol 227( I) 44-58. Davls LK, Martm TR, Kligler B. 1992. Use of death cerllficates for mesothehoma surveillance. Pubhc Health Rep 107(4):481483. Hlllerdal G 11)99 Mesothehoma- Ca,e, assocIated WIth non-occupa tlonal and low dose exposures. Occup Envlron Med 56(8)'505513. Kang 0, Davis LK, Hunt P, Knebel 0 2008 Cancer inCidence among male Massachusetts firefighters. 1987-2003. Am J Ind Med 51(5)'329335. Levy J, Brooks D, Davls L. 2001. Aval1ablllty and quality of mdustry and occupation infonnation in the Massachusetts cancer registry Am J Ind Med 40(1 )'98-\06 Mlettmen OS, Wang ID 1981. An alternative to the proportIOnate mortality ratio Am J Epldemiol 114(1):144-148 Miller A 2005 Mesothelioma in household members of asbestos exposed workers: 32 UnIted States cases since 1990. Am J lnd ~ed 47 (5):458-462. Mirabelli D, Cavone D, Merler E. Gennaro V, Romanc1lt A, Mensi C, Chellim E, Nlcila C, MannacclO A, Magnam C, Mustl M. 20 IO. Nonoccupational exposure 10 asbestus and malignant mesothelioma m the 8 Roelofs et al. ItalIan national registry of mesothehomas. Occup Environ Med 67 (11 )'792-794 Occupational Health Surveillance Program. Massachusetts Department of Public Health. 1991. Asbestos-related respiratory disease in Massachusetts workers 1982-1987. (unpubhshed report) Occupational Health Survelilance Pro!;ram, Massachusetts Department of Public Health. 2011. Puttmg data to work: OccupatlOnal health mdlcators for Massachusetts. Apnl (available at wwwmass.gov/eohhs/ docs/ .. .!occupational-health/putting-data-work rtf) Price B, Ware A. 2009. Time trend of mesothelioma Incldence In the Cmted States and projectIOn of tuture cases: An update based on SEER data for 1973 through 2005 Crit Rev Toxicol 39(7):576-588. Rake C, Gilham C, Hatch J, Damtan A, Hodgson J, Peto J 2009. OccupatIOnal, domestic and environmental mesothel1oma nsks In the British population' A case-control study. Br J Cancer 100(7):1175-1183. Sehkoff IJ, Churg J, Hammond EC. 1964. Asbestos exposure and neoplaSia. J Am Med Assoc 188(1).22-26. Smith KR, Kliewer EY. 1995. Estimating standardized mortalIty odds raltos with natIonal mortalIty follow back data EpldemlOlogy 6 (1)'55-60 Teschke K, Morgan MS, Checkoway H, Frankhn G, Sptnelh H, van Belle G, WCISS NS. 1997 Mesothelioma surveillance to locate sources of exposure to asbestos. Can J Public Health 88(:1) 163-168 V.S. National Instltute for Occupational Safety and Health. 2009 Work-related lung surveillance system Volumc 1 malIgnant Mesothehoma. March. v.s. NatIOnal Institute for OccupatIOnal Safety and Health. 2011 Current intellIgence Bulletin 62 Asbestos fibers and other elongate mmeral particles State of the sCience and roadmap for research DHHS (NIOSH) PublicatiOn Number 2011-159.