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f PLAINTIFF'S EXHIBIT i ss\ Cancsr Prevention and Competitive Risks E. Ctrylcr Hammond, So D, Now York T HIS PAP'SR is divided Into three parts. The first part deals with methods of cancer control sow available to vs. The second part deals vith cancer prevention. The third deals wih competitive risks for cancer and other imf ortant diseases. There's an old saying, "Let not the best be toe enemy of the good.** For cancer, toe best would be prevention and toe next best would be a re nedy as quick and effective as toe miracle to ugs In relation to some infec tious diseases. Lacking these, toe ability to save many liv s by more laborious means is surely good. Discouragement over our slow progress toward the best has led some peo ple to disparage the good which has been achieved. Therefore, 1 will start by outlin ing what has been accomplished by means of early detection and modem methods of surgery end radiation therapy. The greatest accomplishment has been improvement in cure rates and reduction in death rates from uterine cancer. In 1900, Cullen1 reported on end results of 140 con secutive cases of uterine cancer seen at toe Johns Hopkins Hospital. Half of these cases were treated by hysterectomy while toe remainder were inoperable because of toe extent of the disease. Four (2.8%) of toe 140 patients were alive without evidence of toe disease live or more years after thera py while another eleven were alive and Submitted tot pubtlcatkw Feb 14, 1969; accepted April 23. From tifce Epidemiology and Statistics Section, American Cancer Society, Inc. New York. He^d before the annual meeting of the Association of Teaches c Preventive .Medicine, Detroit, Nov 10, 1968. . Keprint requests to Epidemiology and Statistics, American Cancer Society, Inc, 219 E 42nd St, New York 10017 (Dr. Hammond). symplora-frce for from ten months up to 3lA years after therapy. Thus the five-year cure rate for these 140 patients could net - have been greater than 10.7% butjnay have - been as low as 2.8%. Dr. Cullen commented that the number of cases coming tco late for effective therapy was "appalling" and il- tributes the "distressing" results largely to this fact. **- During the ensuing SO years, conditions improved both because of earlier diagnosis and the introduction of toe Wertheim oper ation together with the use of improved methods of radiation therapy. However, as late as 1931 Bloodgood3 wrote "... cancer ; of toe cervix is today predominantly a hopeless disease." like Cullen, he empha sized the need for earlier diagnosis and commented: "Apparently both surgery and radiation have readied their limits." He also suggested that It might be possible to prevent <cervical cancer by treating "the le sion which precedes cancer." In contrast to toe distressing.conditions of some decades ago, toe relative* five-year survival rate for patients treated in the period 1955 to 1959 is reported to be about 60%s (and for cervical cancer, five-year cure sates are not far below five-year surviv al rates). For toe United States as a whole, age standardized uterine cancer death rates declined from 27.5 per 100,000 females in 1930 to 1L6 in 1966.4 There is evidence that this progress has been made by toe combi nation of: (1) earlier detection, (2) more effective therapy, (3) prevention of invasive carcinoma of the cervix by detecting and treating carcinoma in situ of the cervix, and (4) treating women who have a high risk of developing uterine cancer (hysterectomy?-* being a frequent method of treatment of conditions other than cancer). Now let us turn to the picture for cancer as a whole (ie, all sites combined). We do not have records covering toe entire population of the United States, but the Cancer Registry of Connecticut pro vides information on nearly every case of cancer diagnosed in that state since 1935. Of all cases occurring from 1935 to 1940, excluding leukemia. and generalized lym phoma, 50.4% were localized, 23.6% had regional involvement, and only 1S.5% had evidence of remote metastasis at the time of Arch Environ Health--Vol 19, Sept 1969 ... ,, ' r 0348279 PLAINTIFF'S | EXHIBIT iMz&IMo 3S6 CANCER PREVENTION AND COMPETITIVE RISKS--HAMMOND diagnosis.* Early diagnosis bad been made woidd this prevent lung cancer, it -vroJld in half the cases. For cases diagnosed in also reduce death rates from coronary heart that period, the five-year survival rate was disease, stroke, aortic aneurysm, exzr-jt''; *?- . 25% overall; 19%.for men, and 29% for ma, and peptic ulcer, as well as from cancel women. . of the buccal cavity, pharynx,1 laryrov-and The picture improved in Connecticut dur urinary bladder. This is a challenge to pub ing die ensuing years, and the five-year lic health educators. \. surma! rate rose to 32% for cancer diag Other known, and preventable csnsfts'of nosed between 1947. and 1951. Analysis of cancer are exposure to ionizing xsdddfuon, data from the Cancer Registry shows tbafc- prolonged exposure to sunlight, and occupa the improvement during that period of time tional exposure to certain types of dusts was attributable only to a slight degree to and chemicals. The latter are well knownto earlier diagnosis. It was mainly due to more industrial hygienists. . effective therapy. Clearly, with present knowledge we are in Since we have to wait for si least five a position to achieve a significant reduction . years to evaluate success, the 1947-1951 hi cancer death rates by preventive mea figures reported above were not available sures. Equally dearly, the majority of can . until 1956. In that year I estimated bow cers occurring today are not preventable in much further progress could possibly be our present state of knowledge. However, I achieved hi improving survival rates by am optimistic for the-fafure. ' 'maximum tee of the methods then There are two reasons for my optimism. available.' I made three assumptions: (1) From experimental, `histologic and .epide great progress could be made in the early miologic evidence it is apparent that :fce detection of cancer of certain sites such as occurrence of carcinoma--that am inva the cervix uteri; (2) moderate progress sive neoplasm arising in epithelial tissue--is could be made in the early detection of preceded by what may be called a premalig- cancer of internal organs such as the stom nant state lasting for many years. During ach and lungs; and (3) most important, die that period, there & a gradual progression results achieved by the average surgeon and of changes which often (though not adways) radiologist could equal the best results eventuate in caned:. Presumably, cancer achieved by some surgeons and radiologists could be prevented by breaking the chain of according to reports released at the Third events at any time during those years. Some National Cancer Conference in 1936.* .recent evidence on this subject is of practi 'V Calculations based on these assumptions cal importance. - indicated that it was theoretically possible la a study* carried out In Toledo, Oh*?, a to raise the five-year survival rate to ap large number of women were examined rou proximately 50% with methods available in tinely for cancer. Each examination includ . 1947 to 195U This upper limit was based ed a history, recording of complaints, prlvlc Upon certain assumptions about the natural: examination by a physician, and examina history of cancer, assumptions which may tion of at least two cytologic smears.'^'am w may not be fully justified. Since that en whose smears were negative-enc! v.hc time further progress has been made, espe showed no signs of uterine cancer when first cially with respect to cancer of the uterus. examined were traced for many years there However, this progress has been partly after. *' - - offset by the great increase in the-incidence The women were divided - bate twe of lung cancer for which survivor rates re groups; those who on first examination com main low. plained of abnormalbleeding or dbekirgt Now let us turn to cancer prevention. from the vagina and those without this coni . Approximately 2S% of all male cancer plaint on first examihation.-Durm.srl deaths and 7% of all female cancer deaths five years, the mcid^ijfajr iate`of cciptw inc axe dee to lung cancer and the death toll is cervical uterine cancer in women withbu mounting every year. The great majority cancer on entry into .the study was well ove: of these deaths are preventable by persuad three times higher among women, with ..il ing people not to smoke cigarettes. Not only tial complaints as among women vrJlhou C Arch Environ Heclth--Vol 19, Sept 196$^ 0^^3280 CANCER PREVENTION AND COMPETITIVE RISKS--HAMMOND >07 * such complaints. This difference persisted findings lead me to turn my attend:'. to I up to 14 years. It is hard to escape the combinations of factors rather than tc- ;.:n- conclusion that the complaints reflected a disease state which in many instances even tuated in uterine cancer. IT we can deter mine the nature of this disease state and g!e factors. ' -':- Now I will turn to the problem oCcom petitive risks. It may be illustrated by a few examples. I correct it, then it should be possible to In addition to bronchogenic carcinoma, Interrupt the prostession of events leading two other diseases canresult from exposure ' up to uterine cancer. to asbestos dust: asbestosis and mesotheli Some of the women in'the Toledo study oma of the pleura and peritoneum.1! These with abnormal bleeding or discharge bad three diseases are in competition, as it vatre, . I the progression of events interrupted by a to claim the life of a 'person exposed, to hysterectomy for reasons other than cancer. asbestos dust There is. evidence'that '.nth Until such time as we can intervene by extremely heavy occupational exposure, as means less radical than hysterectomy, the bestosis develops quite rapidly and the indi finding that abnormal bleeding indentifies vidual is likely to die-of this caure or women with a high risk of uterine cancer secondary pulmonary infection long before should be of great value in early detection he readies the age at which cancer is likely as usually defined. We should make inten to occur. |n one experience--and this was sive efforts to examine these high-risk wom an extremely~bad 'occupational situation-- en periodically. over 60%~ofThe workera died of .asbestosis' A different type of evidence also leads me withlntwo years. Witlrfferlighter exposures, to optimism. For a long time we have know such as those to which -insulation-'withers of agents called co-carcinogens. These alone are subjected, asbestosis progresses very do not cause cancer when applied to experi dowly-and is not likely to prove Saba for mental animals; however, they greatly in many years if at all 'Some 20 years after crease the potency of true carcinogenic initial exposure, lung cancer, and mcsothcli- agents. This suggests the possibility that oma'begln to*appear ahia-Iarge percentage many human cancers may be caused by a of Ihsutktiorfworkers Hie1 of these two dis- combination of factors, a co-carcinogenic eases WhidTare ^'Competition with each factor plus ah otherwise ineffectual amount other. . of a carcinogenic agent Experimentally, it has been found- that Tentative and as yet inconclusive evi tigarette smoking produces7 at -least three dence on this has come from an epidemio- different serious effects on dogs.15-13 Ex - logic study of asbestos insulation workers tremely heavy smoking-produces acute toxic carried out by Selikoff et aL10 The lung effects which can result in death within a cancer death rate was eight times as high short time. The stnoldng of somewhat fewer among the asbestos workers as among men cigarettes--that Is, Just below the level fn die general population. The majority of where acute toxic effects cause death--fre asbestos workers were cigarette smokers, quently results in thrombus formats in , but some were not No lung cancer deaths have yet occurred among the asbestos work ers who did not smoke cigarettes. By now, there should have been at least several .such deaths among the nonsmokers if the effects of cigarette smoking and asbestos exposure were independent of each other. This sug gests that asbestos dust acts as a powerful co-carcinogenic agent for the production of lung cancer among cigarette smokers. A much larger study including all mem bers of the asbestos workers union in the United States is now being carried out to check these results. However, the tentative the right auricular appendix Wfth'vulmonary embolism resulting in death.'At the same level of smoking/some dogSiicape pulmonary embolism but emphysema7 de velops and progresses tod fatal or n't^r-fatal degree within. 400 rto 500 days, r.'arini this period of 400 to 500 days, prog ?sriv< changes, occur in the bronchial epitl 'iurr of the dog similar to-fh'e-chariges.'r- th$ remaining bronchial epithelium of n-^-nar cigarette smokers who/dier of lung tafxer Whether or not these changes represent car cinoma in situ is still' controversiaI -^-.jn.< pathologists. With longer exposure tV.- le X0348281Arch Environ Health--Vol 19, Sept 1969 398 ' CANCER PREVENTION AND COMPETITIVE RISKS--HAMMOND dons might progress to invasive carcinoma. However, this is effectively precluded by one of the other two causes of death men* tioned earlier; that is, the dogs with heavy exposure to cigarette smoke die before can cer could develop. Presumably, with some what lighter exposure, the dogs would live much longer. Under these conditions some might eventually die of lung cancer (but this has not yet been, determined), In human beings, cigarette smoking leads to greatly increased death rates from a mul tiplicity of diseases including lung cancer, cancer of several other sites, emphysema, .coronary heart disease and stroke.144* In autopsy studies, we have found that most cigarette smokers who die of lung cancer aim have emphysema and a considerable degree of coronary atherosclerosis. These diseases are in competition'to bring about death .of the smoker. Early death from one of these diseases precludes lata: death pr disability from any of the others. How, suppose that we develop a pill which would prevent one and only one of these effects of smoking, or suppose that cigarettes were altered in such a way that they were harmless in relation to one and only one of these diseases. The risk of smoking would be somewhat reduced but life expectancy would not be greatly extend-ed. On the other hand, avoidance of ciga rette smoking eliminates all risks involved and life expectancy is considerably extend ed. (There is a difference of about tight* years in the life expectancy of men who smoke 40 or more cigarettes and the life expectancy of men who never smoked regularly.)11 The same type of situation seems to ap ply to other factors which increase the risk of death from the principal atherosclerotic diseases--coronary heart disease, stroke, and aortic aneurysm.1*2 F* *o*r 6e7xample, death rates from all three of these diseases axe far higher among obese people than those not bbes% far higher among people who take no exercise than among people who take a little exercise, and far higher among heavy cigarette smokers than among people who never smoked regularly. This,together with other evidence strongly suggests that the same set of etiological factors is responsible for the occurrence of these three diseases (which may in fact be different manifesta tions of a single underlying disease rather than three separate diseases). It fc fortunate since it implies that steps taken to Teduce the rate of .occurrence of any. one of. the diseases would probably reducS'lhe rate .of occurrence of all three of fbem-r3hd togeth er they account for a large proportion of all deaths in the United States. !T, ._ . I .. * - References 1. Cullen, TSj Cancer of the Uterus, New York: D. Appleton, 1900. 2. Bloodrood, J.&: Responsibility of the Medical Profession for Cancer Education, With Special Ref erence to Cancer of the Cervix, Amer J Cancer 35:1577-1585 duly) 1931. 8.End Results in Cancer, Report 3, US Dept of Health, Education, and Welfare, Government Print ing Office, 1968. '4. Seidman, H, and SHvexfeerg, H: Cancer of the Uterus: Statistical Data, World Conference on Can cer of the Uterus, New Orleans, sponsored by American Cancer Society, March 1969. & MacMabon, B, and Worcester, J- Ace at Menopause, United States, 1960-1962, National Cen ter for Health Statistics, series 11, No. 19, Dept of Health. Education, and Welfare, 1966. 6. Hammond, E.G, et al: Detection of Uterine Canct_, Hich and Low Risk Groups, Cancel 22:1096-1107 (Dec) 1968. 7. Hammond, E.C.: The Possibility of Improving Cancer Cure Rates at the Present -Time, Cancer 10:531-586 (May-June) 1957. 8. Hammond, E.GL: Summation: End Results In Cancer, Proceedings ef the Third Nitional Cancer Conference, Philadelphia: J. B. IippincoQ Co 1957. 9. 1969 Cancer Facts and Figures, American Can cer Society, New York, 1968. r. ' 10. SeOknft U.J Hammond, E.C.; and Chuxg, Asbestos Exposure, Smoking and Neoplasia, JAMA 204:106-112 (April 8) 3968. ~\ lL SeUkoff, LT.; Chare, J4 and Hammond, E&: The Occurrence of Asbestos Is AmSbg Insulation Workers in the United States, Ann NY Aead d 332:139-155 (Dee) 1965. -, - - - 12. Auerbach, O^ et al: Histologic .Changes in Bronchial Tubes of Cigarette SmokinfDogs,' Cancer 20:2035-2066 (Dec) 1967. ~ - - --' ^ 13. Auerbach,' O., et al: Emphysemas Produced in Dogs by Cigarette Smoking, JAM&. J99^-l,.-246 (Jan 23) 1967. . 14. Hammond, E.Cj- 'Smoking in "Relajion . to' Death Rales of One 'Million Men arid Women,: National Cancer Institute Monograph: 19, jpp 127- 204,1966. . 1. 15. Kahn. HA.: The Dorn Study of-Smoking fad Arch Environ Health--Vol 19, Sept 1969 I 0348282 CANCER PREVENTION AND COMPETITIVE RISKS--HAMMOND 399 Mortality Among U- S. Veterans: Report oa Yean ot Observation, National Cancer Institute Monograph 19, pp 1-125,1906. 16. DoU, R, and Hill, AXu Mortality ol British Doctors la Rebtioa to Smoking: Observations on Coronary Thrombosis, Nalioaal Cancer Institute Monograph 19. pp 205-265, I960. 17. Hammond, XCL: The Scientific Background, A Summery ef the Proceedings, World Conlercuce oa Smoking and Health, 1967, chap 2, pp 14-44.' ~ IS. Hannnond, F..C-. and Carfinhel, Li Coronary Heart Disease, Stroke, and Aortic Aneurysm: Factors ~ in the Etiology, Arch Environ Health 19:167*182 (Aag) 190. Discussion . Geobce B. Hctchbox. MD, Chicago: Let me fiat speak about Dr. Hammond's initial comments relative to the effects of currently available therapy and what could be anticipated by optimal use of .this therapy and proper distribution of medical facilities. - The data that Dr. Hammond has presented are a little ditSeult to grasp for the fallowing reasons. He starts with some very bad results from some very early periods of time. The five-year survivors for this early period of time are Terr and far between'*--a difficult statistic to treat In 1935 to 1940,* he finds that the overall five-year survival figure for all malig nancies Is 25%.. This apparently Is to be taken as an Improvement as compared with "few and far between." By 2947 to 1951, this figure rose to 32%. The difference of 25 versus 82 seems encouraging. Following 2951, It is recognized that one has to wait five years from the appli cation of methods to see the five-year survival rate. The prediction Is that this rate may rise substantially above 32%. Again, "may rise sub stantially" Is a difficult statistic to grasp. Over all, we have a comparison between "few and far between" and "substantially above 82%." The statistic used in all discussion up to this point Is the five-year survival. This is the statis tic most commonly quoted in assessing the effect of cancer therapy. It Is a difficult statistic to handle for a number of reasons that have been discussed by many, including myself, in several papers. The first difficulty with the five-year survival statistic Is the problem of its use when early case finding is one of the activities expected to be effective. It is dear that early case finding gives an automatic Improvement In five-year survival statistics, even If nothing Is done as a result of early case finding. Another difficulty with this Statistic heeds to be mentioned, though I am not at all sure that it is a potent factor. This is the problem of possible nonspecificity of early case finding de tection activities. It Is best illustrated by the possible hazard in evaluating Papanicolaou screening for cervical cancer whereby a number of the cases picked up and enumerated as malignancy by Papanicolaou screening may, in fact, he individuals that, if left alone, would never advance to what is recognized as invasive cervical cancer. That b, these two diagnostic procedures do not have a one to one cone- . pondence. We have some evidence--I have never been entirdy satisfied with the evidence,. but there b a suggestion--that a substantial proportion, perhaps something on the order of - 15% to 20%, of eases detected in Papanicolaou- screening are not, in fact, -cases that would progress to invasive cancer. If, then, these axe thrown into five-year survival statistics, dearly - you'get an improved result simply because you are counting survival of.a.different disease or of a diluted category. . .. --. This b potentially effective In any eariy case finding activity. We have' discussed It in a recent paper on mammographic 'screening for breast cancer. My personal fading from our data at (his point b that it probably has a negligible effect fat mammographic screening. Lesions identified by mammography and-veri fied by biopsy in fact 'essentially correspond with cases ultimately recognized as. breast can cer. Our observations .on this are small aid., early, and whether some nonspecificity vrDl show up in mammographic screening I cannot say. I simply mention it as a factor that must always be held in mind in talking about and evaluating five-year survival as the statistical measure for cancer therapy effects. Another difficulty that Dr. Hammond men tioned in using the all-sites-five-year survival in evaluating time * trends b the fact that, the components of this aft-sites rate are .changing over the yean. Specifically, as Dr.'Hammond clearly noted, the lung cancer component has risen in recent yean while many, other jUes have remained stable and a few have fallen in incidence. This b obviously not a random rise as far as survival potential b concerned, be cause lung cancer b one'of the wont sites in terms of mortality aid survival. One has a number of other statistics'that on be looked at In evaluating -trends in effects of cancer therapy. The general- population-based mortality is a commonly..used 'statistic, and this almost invariably leads <$ne to -a somewhat more pessimistic outlook than the five-year- survival figures. I think this relates "to the factors. I have_ just mentioned in interpreting.five-year surviv- . als. T". * Another figure commonly used which seems Arch Environ Health--Vol 19, Sept 1969-j- fS 1- ?.* ? - / *< .. *.::r* * . - !. C % 400 . CANCER PREVENTION AND COMPETITIVE RISKS--HAMMOND to be increasingly popular is the so-called "cure any of the clinical trials. The formal clinical rate.** Cure rates in previous periods have often trials am almost invariably comparing. two been synonymous with five-year survival, but treatments known before the trial is initial *: to more recently a number of analytic statistical be not very different They are! tiling-Tbit devices have been used to attempt to say from highly competent groups of therapists are*will a given group of cancer survivors which shall be ing to try, with all the ethical considerations called cured. The most common interpretation involved, on a randomized basis for different of this cure concept is to say that one follows a groups of patients. So we know at the start of udiort of cancer patients over however long a these trials that vast differences are not going periqd of years it takes to snake appropriate to be seen between them. At best, there can only observations. If a point is reached. Jet ns say be small differences; this is what we must be perhaps ten years, after-which survival is simi looking for. We are not at all testing the lar to that of a proper general population question that Dr. Hammond has raised about control group, then you may call this group of the difference between poor and good medical survivors the cured fraction. This is a useful care. ' -. statistic when it is available. It doesn't develop Then Is another sort of test investigation to in all malignancy sites. There axe rites of be used, and this Is the clinical trial of early malignancy that, at least as far as entreat case finding. This contrasts with the clinical observations axe concerned, never do came to a trial of therapeutic methods. A possible such point where subsequent survival is the same for study would be a randomized clinical trial, for survivors as for a comparable general popula Instance, of Papanicotooujicreening. So tor as I tion. know, this has not been done in any of the Perhaps the best procedure to use in think studies that we have of -Papanicolaou screening. ing about effectiveness of therapy is to attempt We are at the moment doing a trial of fids to evaluate all these methods of looking at the sort In breast mammographic screening, as* el- question. If. for instance, one looks at breast ready mentioned. We can say dearly, as can be mortality, as has been done in the end results said in Papanicolaou screening for cervical can reports, you find the general population mortal- cer, that cases are found early by this pro - ity is approximately stable, and in most recent cedure, but finding cases* early is not in Itself a yean (he incidence seems to be rising. If fids is necessary equivalent of changing mortality. so, then one must conclude that, despite the The mortality effect in oiir study in mammo stride general population mortality, something graphy stiff remains obscunu'I agree with'Dr. effective is being done In this disease and b Hammond's overall optimism In. this issue. I am working In Just, the measure to counteract the optimistic for the mammographic study, butJt rise in incidence. is entirely wishful feeling at this moment-1 In cervical cancer, mortality is. foiling. Inci have no data to present to you as to whether or. dence Is essentially stable. This, again, is a not there Is any effect oh mortality In fins favorable combination of them statistics. If it study. Jibes with the changes one sees in five-year Let me shift to the second issue Jn Dr. survivals, it adds confidence to the conclusion Hammond's paper, prevention, and "here I that something effective is being done In man think we are in rather good agreement agement of fids disease. On the smoldng issue, 1 indeed am optimistic. We often think of the clinical trial as bring The data to support optimism remain rather* the thing really needed to get at a solid answer few. Dr. Hammond himself has been one of the to a number of those questions. Clinical trials most active people in making* available data on have become exceedingly popular perhaps a bit current trends In smoldng habits, and this re over popular, in the cancer field. Almost invari quires careful and sophisticated statistical, anal ably, clinical trials of therapy have shown little, ysis at this point if any, difference between the one, two or three However, over the long run, perhaps many of methods being compared. Do we need to be us will not live to see this because it"will be a totally pessimistic when we continue time after matter of a generation or -two away. I bdieve- time to see this result? I think not Dr. Ham smoking habits will be vastly different, a mond has specifically mentioned that one of the marked decrease from \\hat we'seC now." _ things he is most interested in seeing is the A number of industrial hazards ass**vairii best available methods of therapy made gene.- with carcinogenesis arqj.well. known and must ally available. He has made a 50% survival be controlled. Effective- results'can be aiiucjpat-.prediction in terms of this concept He has ed from this, but thi| accounts for si. vriy small compared this with survival in earlier time proportion of the overall malignancy picture periods. That isn't what is Being compared in Two other issues that Dr. Hammond "men* Arch Environ Health--Voi 10. Sept 1969j^ CANCER PREVENTION AND COMPETITIVE RISKS--HAMMOND tioned I think he didn't mean to emphasize: diseases--lung cancer, coronary heart disease, The breast feeding Issue relative to breast can emphysema, in addition to others.' - cer and the circumcision Issue relative to cervi He suggests that if we had a harmless' z'?.: . cal cancer. I think we agree that these Issues rettc, that is, if we remove the carcinogen frora' are not at all well supported by data that we cigarettes, this would in turn have little In have now. fluence on the total life expectancy simply The substantive description of how to look at because of tire competing causes of death. these data has been well covered by. Jerry Deaths from other causes produced by the Cornfield's discussion which gets exactly at the different components In cigarette smoke may issue in all discussions of this group. Cornfield's. well fill up the vacuum created by the decrease remarks in connection with his paper should be in lung cancer deaths.* the guide in considering this session ... In It seems to me the same situation applies to particular application to. cancer prevention, he coronary disease discussed earlier. In this case pointed up the problem that a very largo effect, we have a set of factors--cholesterol, blood the penicillin effect in pneumonia, for instance, pressure, cigarette smoke, and weight which can be studied and has been studied without produce coronary heart disease. ; randomized clinical trials. But I don't think the When we.look at these- various factors in - most optimistic of us expects that sort of mas .relation to coronary heart'disease, I do sot sive effect in cancer control. We are looking for think we necessarily conclude that the pathoge the email effect we expect in cancer therapy, netic mechanism is the same for all factors. - and these effects are so overburdened by possi Essentially we are probably dealing with dif ble selection that I am very dubious of being ferent pathogenetic mechanisms. If cur diag able to come to any firm conclusions by nostic tools were adequate we could subdivide methods other than strictly controlled studies. coronary heart disease into coronary heart dis Prof Cornfield also pointed out the problems ease one due to cholesterol; coronary heart of distinguishing in the double-blind concept disease two due to smoking; coronary heart between blind or random assignment and blind disease three due to hypertension and coronary assessment If one Is looking at total deaths heart disease four due to obesity- Using Dr. from all causes as the end result then one has Hammond's argument with respect to cigarette the equivalent of blind assessment This Is what smoke from carcinogen free cigarettes and its generally Is being done when we an talking subsequent influence on life expectancy, per about cancer data. This is true when , we are haps merely changing one -risk factor involved looking at the material presented by the Amer in coronary disease will not have much effect ican Cancer Society, by the End Results on the total coronary heart disease problem. Groups, and most large statistical studies in the Perhaps what one has to do is evaluate the cancer field. It is not what the clinician is whole set of risk factors in order to attempt to talking about* Clinicians are exceedingly opti change- the death rate from coronary heart mistic about the sort of things they are doing. disease. They are not looking at end results in terms of Fso? Jerome Cornfield, Bethesda, Md: I overall mortality. They are looking at early have a number of comments, but I think some, effects, so-called "responses" to one method or of them are not going to be resolved this mors- smother. They are counting, for Instance, the - ing, and I would like to make one upon which time of onset of recurrence, and this elusive perhaps we can all agree. We would all he concept of recurrence must he defined. They better off if we stopped looking at life, expect are talking about the disease-free interval, and ancy as an end point by .which to evaluate this, again, involves recognizing the point of intervention effects. onset of recurrence. The reason for this, skipping all subtleties, is These concepts are not worth discussing If that life expectancy is, roughly speaking, aver they have not been studied with -the most age age at. death. Now, if we are dealing with rigidly controlled sort of blind assessment, and Interventions that affect risks at earlier ages this is not what .is being done in the data that but have smaller or perhaps-nonexistent tffrjcis f>r dinicians are looking at in their optimism with at higher ages, and if half or more .of tire - the methods they are using. deaths occur at the higher ages, we may have-a 1 Abraham Lujexfeld, MD, Baltimore: One very important effect at the younger rges and I c* Dr. Hammond's comments relates to an no effect at the higher ages; and it . may show 1 earlier discussion on Mr. Cornfield's paper. Dr. up in a one or two-year decrease in overall life i Hammond states that if one selects cigarette expectancy. *- smoke as a variable there can be many factors, So let us dear^some of the underbrush awe * A, B, C, etc. which can cause a series cf in discussing these matters and talk ..bout Vf < Arch Environ Hcslil i--Vol 19. Sept 1969 / X-0348285 i*- 1 C 1 ' 402 CANCER PREVENTION AND COMPETITIVE RISKS--HAMMOND effects on the age specific probability of death. meeting for (he reason (hat as aresuVdf Thomas Fraxcts, Jr., MD, Ann Arbor, earlier overselling of early, diagnosis there is Midi: I would like to comment that In this such pessimism about it that X am afraii _--s discussion of the many factors with which one will lose the gains we now have. This would be might fay to Intervene, there Is a very old the height of folly. legend of the physician who was advising Ms There are also areas in (his country with ' patient of all things he shouldn't da He said to practically no medical services where people "he pLysidan, "Do you think It Is going to axe developing cancer (hat could have been make me live longer?* The physician said, "Na cured, but gets to the stage where it cannot be It will make it seem a lot longer." X think that cured. Is what some of this hokum Is all shout When It comes to' breast cancer. X am more E. Cmnxs Hammond, ScD, Hew York: A pessimistic about early diagnosis than Dr. rather well known person on television recently Hutchison. In this disease (here is every evi struggled for almost all of his comments and dence (bat a considerable proportion of the answered questions by saying, "X want to make cases metastasize not through the axillary node this very dear." Well, X would Eke to make it -but through the mediastinum; and they prob very dear that present methods I called Efesav- ably metastasize while stiE of a microscopic size. en--I called them that to indicate that it was As to (he five-year survival rate, I believe Dr. not the same thing as an unshakable ship. Hutchison must have been thinking primarily ' ' X will also say that I agree with a very large of breast cancer when he made his remarks, part of what Dr. Hutchison said. because 20 years after Apparent"---I put the Now, of course, we do not have figures avail word in quotation marks--"apparent" cure of able from way hade; wre couldn't; there Is no breast cancer, the death rate is stiE Way above way of getting them. You do not get decent that of the general population. statistics until you first have pretty good medi On breast cancer I think It is quite faEaduus cal services in general. We have no knowledge to use the argument that,-"early cases Eve of survival I think it was very low earlier. longer than cases late when first treated"; this hi the first place, there are Innumerable would be true if you' treated early cases with papers in the Etcrature, none supported by distilled water or anything die, any quack pood figures, hut all say that cancer was practi remedy. If you treat them early, they are going cally never cured. These are doctors speaking. to live longer after treatment than if you treat There is, however, better evidence now. In them lata the late 1940's X- made a study in Puerto Rica However, there are sites of cancer that are of At that time a very large proportion of the a totally different nature,-and this applies par doctors on that island had their medical degree ticularly to cancer of the uterus. This disease from a one-year course in medicine without the typically does not IdQ by metastasis, it ViEs benefit of. earlier college; and,- rather properly, primarily^by local extension. It is those, that the population did not think much of its medi kill Ey~local extension & which we have cur cal services and didn't go to its doctors when best results, and this is quite natural cancer was suspected. To my mind this is where we can main the Wen, at that date in Puerto Rico we found greatest progress, simply preventing rfi-caase' many cases of breast cancer with massive ful- ' from going to the incurable stage. X would hate urinating lesions, and the people were dying of to see this activity limited - this sort of disease. We found many cases of As tor as we have gone with canoer-of the death from other forms of cancer at a very uterus. Incidence rates have dropped somewhat advanced stage. Since that time, control activi and death rates have dropped Persons."?, I ties of one sort dr another, particularly im think this is more attributable to prevention, if provement in medical care, have teen initiated I may use the word, than It'is to- cure. J have and they are now curing some people. evidence that carcinoma in situ can develop It may surprise you to know that I originally very quickly into cancer. I also have evidence made my calculations not to show how wonder that people with positive -smears, about f ` % of ful early diagnosis was, but to point out limita them, live for a long, tune and don't develop tions to some people who seemed overly enthu invasive cancer. But by taking out carcinoma in siastic who were, practically speaking, telling situ, by taking out the uterus, I third.' (hey the public that if they just heeded the cancer have precluded the development of cancer in a warning signals they would prevent all cancer group of people who are- in a very high risk and need not worry about any further research. group. This is prevention' rather than cure. I have taken the other view here at this Nevertheless, it has worked. X 034828K Arch Environ Health- -Vol 19. Sept 1969 *3 i I' ll iI j*m%j ;< excess o' Vr.e limits set by jus Atomic. Energy Commis sion." The danger cf X-radixlica n color TV sets has been .dciy publicized. Tne federal government has proposed radiation standards for sets nyumfasturcd aher Jaauray 1, and advised viewers to sit [no closer than six to 10 feet. : Scientists say they do not 'knot? what effects low doses . of radiation may have on the * body over lac; periods, and they worry about exposure bringing a person closer to ; the unknown point were ^ genes are mutated. * - .. planes, tiie tclcpiione and the voices of children. The totensily of"sound is measured in decibels. The noise level of ccnversatica at three feet is 63 decibbs. Sixty is the point at which the use of the telephone becomes dif ficult, and above SO damage to hearing may result *be living room is ordinar ily satisfactory at S9 decibels. Punning a vacuum cleaner raises the level to 73 when the nozzle Is on the rug and 81 when the nozzle is raised. ?k Another less publicized haz' ard comes from microwave ovens -- new kitchen gadgets \ that cook food fast. A survey . Ja Pennsylvania found 31 per 1-eent of these ovens gave off -.radiation Is excess of .the v xafaljy standard. * ^. Americans a s su ra e when * (hey turn on a faucet in their homes, .they win get pure, fresh water. The Public . Health Service, however, .1 maintains that 3,000,000 peo* U*e servedby municipal - ater water systems consume .which exceeds toe if * bacteriological criteria set in .* the US/ Public Health Scrv- .- Ice** -drinking water stand ard!!. Water often bad " * C C. Johnson, Jr., adminis- L trator of the Consumer Pro tection and Environmental-i Health Service,: found that bacteriological analysis 'of more, than 700 samples of water coliform contamination, I- This means that householders . were drinldcg water contain?, lag other p e o p I e *s wastes." Furthermore, he said, out of 189 water supplies studied to one: area, 14 exceeded the ar senic standards, and 28 ex ceeded the nitrate Emits. Of. 79 samples tested, 76 con tained pesticide residues. ~ ! :If most home pollutants are. silent, there Is ere major one "that isn't-- noise! / ` to the average suburban home, there are as mary-as -A smaP. motors which whir a.fld burr, alcng with radio, hi-fi, TV, power ir.w-c- < jsj * ~~ -- The- lucdc.-n kiLhia is thi noisiest place i:i the house. The automatic dishwasher rumbles at 63 to 7C dodb-cls. the garbage disposal unit at 70 and the refrigerator at 30 to 40. The typical kildictf often reaches a decibel level of SO -- the equivalent to that of a big city su-eet earner. One expert observed "lie noise level in a modern kitchen is Just bclnw that of the cockpit of an dd DC-3." Food pollution is another problem, reed poisoning foes increased 1,5pci ecu', since 1531. Intentional ' additives now amount to COO rJllicr. pounds, and then th.ro are the unintentlanal additives such as nltnifes and- pesti cides. .:: X 0348289 SUMMARY AND EVALUATION \J ^ / '/ / r cJ^jLcL ; (jbuc, ' Subject; Speech on occupational health, including mention of asbestos hazards by a U.S. Public Health Service official. Of interest and importance. Evaluation: The speaker is Administrator of Consumer Protection and Environmental Health Service of the Public Health Service. While the subject is occupational health in general, asbestos comes in for special attention, both as a hazard and s an example of positive action underway. . Pages 5 & 6 mention the hazards of asbestosls, lung cancer and mesothelioma 4is reported among studies of insulation workers. Page 9 reveals that the Bureau* of Occupational Health is preparing position papers on several critical Issues; "The first of these reports, which I understand is nearing completion, will be on* the subject of asbestos. I think it will give us a much better understanding of what we can do now, and what we should do in the future, to control this growing threat to workers. Page 12 includes a laudatory reference to the cooperative program under way at Mount Sinai, mentioning Dr. Selikoff, J-M and the Asbestos * - Workers Union. The Insulation Industry Hygiene Research Program, as such, is not specifically named. Author: Johnson, C. C. Unpublished: Presented at the Occupational Safety and Health Conference, sponsored by the Industrial Union Department, AFL-CIO, June 4, 1969, Washington, D.C. Title; "Remarks" ' i * '* * *. *' ' ^ ~ Summary: As given above. T 0348291 -xxx- by Charles C. Johnson, Jr. Administrator Consumer Protection and Environmental Health Service -- - Public Health Service U. S. Department of Health, Education, and Welfare . . Washington, 1). C. 20204 I am pleased to have been given the opportunity to participate in this important meeting, and X certainly vant to commend the Industrial Union Department of the AFL-CIO for sponsoring these discussions. Certainly the problems associated vith occupational safety end health need to he clarified, for they are too little understood by all concerned -- * * . by'the public, by union members, "by industry, and by the government agencies vho have responsibility in these areas. But it seems to me that, in every important matter, there is a time for conversation end a time for action. In the occupational safety, and health field, ve have had 'quite* a lot of conversation in the past, hut . * very little action. I believe it's time ve translated some of this talk into action. * . . . . As.you knov, the occupational safety and health program of the Public Health Service is nova part of the Environmental Control Administration, one of three constituent units of the Consumer Protection and Environmental * HealthService. The other two Administ*rations are the National Air Pollution. Control Administration and the Food and Drug Administration. We in CPElIS'are committed to developing sound, coordinated, action programs that vill have a real impact on the various environmental and consumer ills that are so disturbing, and even frightening, an aspect of our co-.tenporary 11 fc. *For presentation at the Occupational Safety and Health Con'fercr.ce, sponsored by the Industrial Union Department, AFL-CIO, June 4, 1965, Washington, D. C. i 3^ 0348293 II Certainly occupational safety and health are a ciajor -- anc" urgent -- area i in which action has been too long neglected. .And, I'truly fee], that we arc entering a new era of public awareness of, and public concern for, these problems . ,- h- True, the general public -- even the working public, if you can make "such a distinction -- is so far more concerned about air end water pollution * than about the hazards of the-workplace. Someone said a few years ago, "The American public really isn't concerned about atomic fallout, because so far it has not affected television reception." Veil, I think people are beginning to feel, and recognize, the effects on themselves of the high-risk environment ve are so heedlessly creating, end there is a graving-demand for Vhatever changes are necessary, including adequate protection for workers. Iof course, 1 don't have to tell you that occupational health, and safety 4 --- and a good oany other environmental problems -- remain the subject of controversy. Ko one, not even the most cynical opponent, would dare, to say publicly that he is against worker health end safety. The trouble begins when we start to talk about how to go about achieving it. In one camp are those who maintain that all work involves, to a greater m or lesser degree, some element of risk and that we must, accept fatalistically - the resultant carnage. In this view, the worker should look out for himself, stay alert, be responsible -- because most'accidents (and occupational * * disease too, I presume, although this problem is usually glossed over) are the result of human failure. ' Theij there are those who would issue hard hats, safety shoes, respirator;. and vhat have you, to every employed American and would setand enforce standards for every conceivable hazard for every type of occupation. The aim would be to make the industrial world perfectly "idiot-proof X 0348294 I i divergent views could be brought close:! .ogether if all could come to share a coarion view of the fundament?.] nature of man and of the physical environment in which modern man works. Let1!; look for a moment, then, at what we know about the occupational setting today.. There are, in reality, two 'facets of the problem: . . <>n the one hand, ve still have with us old problems -- health hazards that in some cases go leek as far as the Bronze Age in man's industrial .life. Lead, zinc, mercury, silica sand, carbon tetrachloride, carbon monoxide, and cany other industrial exposures have been veil studied, and there is sufficient knowledge available to control.them. But still they offer threats to workers. Control procedures break.down, are Ignored, or are allowed to deteriorate. Our occupational health people recently ` re studied lead and zinc smelters In one State, and found that controls . instituted almost 20 years ago had deteriorated to the point where.they were little better than those they had replaced. .In other words, here we are in the Space Age, and find ourselves still suffering some of the old problems that were obvious to the medieval alchemists and first became widespread at the dawn of the.Industrial Revolution. In the meantime, new technology has created a.whole new kind of work environment, with a whole new set of hazards, and.potential hazards. In this new world, the threats themselves are little.understood and control technology, in cany cases, is not perfected. * For example, high energy sources, such as lasers, which just a few .years ago were tools of the scientist, are now commonplace in industry. Beryllium, a highly toxic metal which was used in the manufacture of ~ *..'* ' fluorescent light bulbs until chronic beryllium poisoning wis recognized as a health hazard to workers, is now finding new applications t< primarily in r.hc- atomic energy field and the:space effort. 1 X 034S295 in soap powders. They mny take the work out-of washday, but the unprotected worker in the manufacturing plant may develop dermatitis or respiratory irritation. ~ .... X don't need to tell you that new processes and massive, high-speed, . even automated, industrial machines have created possibilities for * accidental injury that go far beyond the worker's capability for self- protection. * The question we must ask then is: "To what extent may the individual be realistically expected to protect himself from .the hazards of the -modern work environment?" _ The answer, obviously, is that it is patently Impossible for the worker *! to take responsibility for his own health and safety in a complex world of I physical and chemical hazards which are .little understood even by the experts, and which are clearly beyond his control.. The fact is that man has created a new. environment but he has not created a new man. We are .the products of a*slow evolutionary process, and we still have the same physical characteristics that our caveman ancestors had. We still need clean air to breathe, clean water to drink, and are - * still helpless against unseen or uncontrollable hazards in the environment. We have developed no second sight that tells us when an Invisible beam or * a seemingly harmless vapor is doing insidious damage to our health. And -we still have the sar.e psychological makeup' that 'those far-off ancestors had too. X suppose, like most of us, the caveman was ready to. blame fate for every accident. And, if they'd had golf courses in. those days, he'd have felt personally responsible -- like us -- he ever made a holc-in-one. I i i .0348296 5 So, to come back to our original two divergent views -- certainly every worker needs to be made aware of the hazards he confronts in the % workplace and.educated to exercise caution ~ to "watch his step," to wear earplugs and a hard hat and safety shoes where required. It will be a never ending job for the union shop steward, for ve are not likely to change human nature. But the thing ve can do -- and must do -- is to create a working environment in which such a person, exercising reasonable care, can be assured that sudden death or the slow process of industrial disease will not be the wages of his work. ~ Certainly the occupational respiratory diseases, in terms of " # severity, represent one of our most important occupational health - ~ . * problems, and one in which adequate controls would pay big dividends, both in reduction of human suffering and in dollars and cents savings to the workers affected, to industry, and to the-taxpayer. Three and -a half million American workers are exposed to asbestos in their jobs. They face a dual threat: not only arc they subject to the .. lung scarring pneumoconiosis of their trade, asbestosis, but they are' Itf s .* ` . \r :> X 034S297 endangered by lung cancer associated with the inhalation of asbestos fibers. - Recent studies of asbestos insulators shoved that one of every.5 deaths in this group were caused by lung cancer -- 7 tines the expected rate. Half of the men who had worked in the ttade had X-ray evidence of asbestosis. . * . * " One in every 10 deaths.were caused by mesothelioma* a cancer of the lung pleura* so rare that it strikes only 1 in 10,000 in the general working population. ' Black lung, or coai miners' pneumoconiosis, is a term*which has become very familiar to us in the past few months. This disease which (the British call simply "chronic bronchitis" -- is caused by the .. I , . . .. inhalation of soft coal dust. It'is a progressive, crippling lung disease, i often complicated by emphysema in the later stages. The death rate from respiratory disease in soft coal miners is 5 times that of the general working population. The Sturgeon General, in Congressional testimony a few months ago, stated that "black lung", at a conservative estimate, affects* more than 100,000 soft coal miners in the U. S. Bast December after studying -all the data, I announced a recommended standard for respirable coal dust in soft coal mines of 3.0 milligrams per cubic meter of air, and there is -now legislation before the Congress in which this standard is proposed.as a goal.^ . * There are other industries whose workers run an extremely high risk of respiratory disease. In uranium mining, there is, as you know, a very * serious problem. Of the 6,000 men who have been uranium miners, an * . ' * * estimated 600 to 1,100 will die of lung cancer within the next 20 years because of radiation exposure on the job. J. 034S2S8 t 1 ^vcr- 3,000 eases of silicosis r?;c rcpov';e.d yearly from 'cxpocvrc to free silica -- the major ingredient of all rocks, soils, sands and clay. !?o:c years, ve had the comfortable illusion that byssinosis, the. lung disease caused by inhaling cotton dust, was not a problem for American ;;; textile workers , liven though British workers using American cotton came down with this crippling lung disease, ve relied on a limited X-ray survey done years* ago which did not reveal a byssinosis problem. *KoW, . %* m our scientists arc discovering that America*s 230,000 cotton textile workers * arc also threatened by this respiratory disease. In one mill, employing 500 people, 12 percent were found to have byssinosis. Thirty percent of the workers in the carding room had the disease. In another mill^ 26 percent of the.workers in the carding and spinning, room were victims ,of byssinosis* The disease begins with "Monday morning chest tightness" . and progresses to chronic bronchitis and emphysema. Ilalc, diatoaite, carborundum, sugar cane fiber, even dust from moldy . silage all produce their own fora of iung damage, wherever dust control and worker protection arc inadequate. ._ * Our National record^in-preventing occupational respiratory disease is . . * . .not a good one. We have allowed too many productive people to become disabled, and finally to die prematurely, because we have not paid attention to controlling the dust, fumes, and'vapors to which they are exposed. Must X we wait until we can count the corpses before, we are sufficiently arou*sed " to take preventive action? In West Virginia, it took a walk-out of AO,000 miners to bring about the passage of a comprehensive State workmen's compensation law. It took a mine disaster killing 78 men. iir Farmington, West Virginia, to make the passage of a national mine health:and safety act a possibility. * 034S2S9 i i ..v iuu^l miui: uy uov? Liinl luc cnronic inaair.L3.on or any lorcxgn material -- cigarette smoke, polluted air, coal dust, of asbestos fibers and many others -- can harm the lungs and cause disease. Moreover, since for the most part, occupational respiratory diseases arc entirely proventab diseases, I think we can all agree that we have a responsibility to take * * action to prevent them. * . We in the Consumer Protection and Environmental Health Service are .. restructuring our occupational health programs with a view to creating as strong and effective effort as our resources will permit an effort that will begin to have, as soon as possible, an impact on workers health and safety. We feel that it is our primary responsibility -- in occupational health, and in ell areas of environmental control and consumer protection to define as well as possible, and to enunciate as clearly as possible the effect on man of the various environmental impacts, to which he. is sub-. jected- We are, therefore, giving first priority in all areas of our ^ *. responsibility to the development of criteria which can. he used as a base line throughout the Nation^ to avert damage to human health. .With this end in view, our Bureau of Occupational Health is _ . presently reviewing the current status of a number of urgent problems affecting the health and safety of workers. Our purpose, first, then, " * ie to develop, wherever the current knowledge is sufficient, sound, reasonable recommendations to limit worker exposure, or alternatively, to 0348300 9 - - __-y determine what steps are necessary to lead to an early enunciation of such criteria and to the control or elimination of the hazard. 'The Bureau is preparing position papers on several such."critical * - m issues". The first of these reports, which I understand is nearing .completion, .will be on the subject of asbestos. X think it will give us a much better understanding of what ve can do now, and what we should do m in the future, to control this growing threat to workers. _ * * Secondly, ve have taken steps to assure that all of our occupational health research is mission-oriented, that is, that its purpose is early identification and control of known or potential hazards, and that it is -directed at problems which appear to be most widespread and severe. With a limited budget, long-term, basic research is a luxury.ve cannot afford. We are developing our research priorities in accordance with strict guide lines which take into account the number of workers currently or potentially exposed, the severity of the hazard, and the magnitude of individual -i l . exposures. We believe that, with careful direction of our research toward the purpose of establishing health criteria, and control methodology, we can greatly improve our results. Certainly, ve propose to continue studying these problems. Ve are *. continuing our research in coal worker's pneumoconiosis, because there is 0348301 I and new knowledge could lead to better and easier methods of control, but 11 'viqcj are convinced that, in occupational safety and health, as in air pollution control and water hygiene and many other difficult environmental problems ve~~ face today, the time ha$ come vhen ve must begin to put to vork the scientific \I knowledge we now have to reduce the very real and growing threat to human * 1 .. life and health. . If ve wait until vc have dotted all the scientific "i's" I` ' and.crossed all the sdientific "t's" before we take positive action, it may veil he too late. He have to recognize that science is never immutable, .and the time will never come when ve have all the answers. Ve have taken another small, but important step in the direction of a more effective, action program, and one in which you will be especially A interested since it will enable us to work more closely with State and local * governments, with industry, and vith union groups. This year, ve vill* have occupational health representation in two of the Department's regional -offices -- in Chicago and San Francisco. These two regions include approxi mately 37 percent of the Nation's manufacturing vork force. And, 1 might * add, .the occupational health activities in the States covered range from non-existent to highly sophisticated programs. As soon as ye can see our vay clear to do so, ve vant to assign occupational health staff to each of the nine regional offices. . ____ I hope that you vill bring your, occupational safety and health problems, to the attention of these regional representatives, because I am sure that effective liaison at the State and local level can help us get an understanding of good occupational safety and health practices out of the laboratory and into the plant where it will really make some difference to the workers. % 0348302 Ve arc making progress in another area that I-think may be of some interest to you. As you know, there has never been any sort of national reporting system for occupational illness and injuries, so that our Public Health Service program has been weakened by a lack of adequate data. Kore- over, our inability to^ precisely assess the scope and magnitude of the . occupational safety and health problem has stood in the way of public understanding and support of a National effort to protect workers. ' * To try to get more adequate information, ve are beginning to develop an effective national monitoring and surveillance system. The Bureau of Occupational Safety and Health, some years ago, began, conducting surveys in seven major metropolitan areas, covering 'some 2,500 plants and over . 400,000 employees. -The surveys were so designed that they can give us a statistical picture of environeatal threats to 2,150,000 workers in 34,500 plants. We are currently examining the data that we have gathered thus far, and taking steps to insure that continued work in this direction will provide information that will be of value to all who are concerned with occupational health. A preliminary appraisal of the information we have ^ gathered suggests, to no one*s surprise I am sure, that many varities of working environments are beset with health and safety problems that require correction. J- 0348303 Wc believe that we can, by following this pattern of surveillance, and drawing on the information available from workmen's compensation and Social '* * Security records, develop a far more complete picture of worker health end : safety throughout the Nation than we have ever had before. We are also planning a reporting system through which a number of industrial `physicians will provide us with case histories and other information obtained in their * practice. All of us who are concerned about the health and safety of workers have a great many problems confronting us today -- and they are going to grow * ... 4 rather than diminish in the years ahead unless we.stake a very great effort to reduce them. * . *The problems associated with asbestos exposure -- about which Dr. Selikoff .will speak later -- is one of them. It is also a good example of how essential *. . it is in the occupational health field for Government, industry, and unions tp give their support to a dedicated university-based investigator like * Dr. Selikoff, who has added so much to our knowledge of the asbestos problcr Dr. Selikoff*s current study of insulation and other workers in the construc tion industry, conducted under the auspices of Kt. Sinai School of Medicine, is bdng jointly financed by the International Association of Heat'and Frost Insulators and Asbcsto> Workers and the Johns feanvillc Corporation.* Our Bureau of Occupational Health is providing technical assistance, consul tr- tion, training, and loan of equipment. This is the kind of'cooperative effort that will be required if vie are to make significant progress in the many ar."-.:- of concern to the worker 0348304 o.rgi.nia -tiro cooperating vitli tts now on a study ol ucaj.cn luyyiKwa m ui-ju |. try, as arc the International Chemical Workers in Florida, We have l had | long-standing agreement with the United Mine Workers of America in connection vith our research on hazards to coal workers, We look forward to I ,, developing other projects vith labor and industry that can be mutually beneficial \\ ' 'V I I hope you will agree vith me that ve in the Consumer Protection and 'Environmental Health Service are*, in fact, marshalling the resources ve have : i. *' ' :%v- to build a stronger, more effective occupational safety and health program, < : and one that vill begin to have a teal impact on the problem. But, I vill be the first to say that the future vill judge, the vhole pattern of bur efforts today inadequate. I mean not only the efforts of government, at all levels, but the efforts of. industry, and of labor. All of us, the public included--and ve are, after all, a working public-- have neglected to place on occupational safety and health the emphasis and the resources that this important problem merits. We have made progression recent years.in our unsteady and halting march toward an improved'environment. Certainly all of us have shown a desire for clean air and pure water. There is growing public demand for more sensible use of our environment, which, in our rush to gain the bene fits of technology, we have heedlessly exploited, defaced, and polluted. But I have not noted a similar impulse toward improvement with regard to the work environment--which is, after_all, the place .where virtually all of us spend approximately one-third of our lives. And it is, unfor tunately, this part of the environment in which contamination and other hazards to our health and well-being are most severe. 0348305 Society, judging by the response to the Air Quality Act of 1967, seems unwilling to continue to accept present levels of particulate pollution in the city air. Yet, at this moment, there are those vho contend that it is"p2riaissiblc for coal miners to'breathc, every working day, disease- \I *' producing dusts at levels that exceed by many times anything we have ever eLdulcd in the ambient air. - 1 Last year, the Congress passed tlie Radiation Safety and Health Act to protect citizens from X-ray and other hazards resulting from color television sets, microwave ovens, and other marvels of our new technology. |* . *. Vejinay he sure that this Act was passed in response to the public will. But such exposures are most acute in the work environment. I'm not suggesting that we do not need the protection in our homes that this important legislation i . will afford. But I offer it as another piece of evidence which suggests to ms that public concern for the total environment--though late in arriving-- - is still far ahead of our concern for-the occupational setting. All of us '* . \ . . . . must redouble our efforts to Insure that, the rising interest in the environment encompasses a full appreciation of occupational hazards. - -- . Interest in environmental health and consumer, protection is quicken - ing at.a very gratifying rate. We are hopefully moving toward the day . . when Americans everywhere will be able to breathe clean air, bathe and boat in clean water, and find true recreation in a countryside unblemished by the blight of automobile graveyards and Smoking dunips. We will reach that day when we have learned to employ our wondrous technology to solve the byproduct problems that technology has created. But what a hollow victory we will have achieved If a clean and healthful environment is to be enjoyed on weekends only. ... I assure you that we in the Consumer Protection and Environmental Health. Service will do everything within our power to make environmental health a geven-day-a-week, 52-v/cck-per year reality. 034S306 ft 11  - *. ;\ I e- * *-4. 7 riic- t.v;s*- !<07'I ,!i t ; i7rcr> Tcchmlogy^ Cy roseht RsncroLn u TVf Xnt V.-ri Tc ( DALLAS. Dec. 2S--A paast of experts ia environmental sci-i !nce warned, today that the' "unanticipated* hazards of| [spreading technology threat ened man's existence. For five hours, one sslsntlstj after another stood up and dls (cussed what they termed the [grave consequences Implicit fni the continued use of nucleart (power, herbicides in South Vietnam, asbestos In building materials sad deep wells for s storage of chemical wastes, ? "We are altering mi's cn- e ivironmect ia ways we do not s ruederstand and la ways that {may be disastrous." said Dr. tf {Margaret Mead, the anthrepol-ju jogist, who opened the session!a {at the annual meeting of thejir {American Association for thsjs- Advancement of Science at theivi iStatler-Kfiton. . Many Scientists Present A standing-room-only audi- fence of scientists attended theld [session, a reflection of the ris-'hl 'leg concent of scientists fort the consequences of the tech-'U jnology they have spawned, jsl "I believe that unless we be-'K '-gin to match our technological a* power with a deeper under*! a {standing of the environment we c run the risk of destroying this C 'planet as a suitable piece for; f human habitation." said Dr. r. [Barry Commoner, director of! n the Center of the Biology of* ir Natural Systems at Washington b University in Sc. Louis. c He said, for example, that the ^Continued cn Page SS, Column S t 0348321 r e. A 9r-./"/I\- /C'Zso ./? 8 *> >y 4 f, O' 7 ~ I '-'--i.,,- . > *- ---1>tftv:Tiv*' ai- i,,;` .1 --. " -' T-. r-.4; " y'->4r v-* ;{ m* Qy Technology to Continued 7rcm JYga I, CoL 4*--------- " - l Z? -------------- s arc changing the balance cf the - use of nuclear reactors hsd to srcund we stand on." A (be evaluated In tfcs fight of; The number of disposal wen* "hidden costs" to human health'in rite United States, up to; from the release cf Iodise 131.|wre chan 110 from one or two! a radioactive substance that si ,,. . permanent oarage; price for "tedmotogical intru*' to farmland and urban areas'o sions," such as iodine 131, he'in the Southwest. > -said, adding Giac "the powerful* He cited the events la Den*` Illusion that we can avoid pay-jver In ISS2, when the Artnyif ment of this price Is fostered* drilled a 12.0-tO-foot-deep weuih by the enormous accomplish*: to dispose of unwanted cheat!*) - ' meats of technology." (cal warfare agents. "The fol-'6 con"Etiencuaeuds,e o"wf oeuhraIlvluesiotnesco."mhce! Venoeweindgthmeofnirths.t eDaernthvqeuraekxepfeertl-t ^ unwitting victims of environ-;!* 0 years. Tbere fs a per*- mental pollution." He cited the ^y beautiful correletuw be- . damaging effects of automobile! tween the number-of earth-p smog, insecticides, detergents.! <5u^k and the nwTibar of radioactive fallout,, chemical; _ poured Into a omurtooawf -greuerdn, baurct mouatceof oIgw*i!i--wa-s--te^wells in Teas^ with s*. t aorance." lastrous effects. He noted that A f... . lone barrel of oilfield brit!c Use of Herblclecs Scored Jcdd conUminate 20.000 gal-.c Prof. Arthur W. Galston of Ions of drinkable water and; Yale University charged that) pointed'to buildings damaged the use of herbicides Ir. South! by sinking land in Houston. Vietnam had violated the nor*] View Is Disputed was disputed by 2S? S SDr. Boysle E. Day. a hcrblddei defoliition CXp.rt from ifo university efj* of enetnj'-held areas. ,--T-- * -->-- -j--1- required ...... ____ .tent and nature of the undeni-;herbicides* in the scientific and-; areas should be strictly circum-'of nature. Hefbicidcs'are afaetji scribed until wx ha\x accurate of the world." it knowledge of the consequences; The "widening spectrum" of: 1 of our action." {diseases traced to the use of!' The biologist also said that;asbestos in building materials;; some of the herbicides in use .was discussed by Dr. Irving J.|s in South Vietnam, such as Pie-'Sclikoff. chairman of the Di-:< loram, were not broken down'vision of Environmental Med;-! by the soil and persisted in thc.cinc at the Mount Sinai School'* earth for some time afteriof Medicine in New York. He!j spraying. He suggested that'said that recent studies had de*!; these poisonous agents wcre.tected an unusually high inci*! finding their way into human denca of lung cancer and other food supplies ir. South Victr.am.:discases among construction' Well Use Assailed iand msuhtion vvorkers. : ., , _ _ . There are 2.500.000 mer.. or Another speaker. Dr. David 5 pc- ccnt of ^ tou) cm.- M. Evans, a geologist at '- " ployed population of the United: {Colorado School of Mines, pro- st ues. working in ccnstruction! 'tested against the u-uiemn; atuj huildir.; industries. Dr.* practice cf pumping industrial s.Mikoff said that "sicm/icant! vvasMs down deep well.*. ^ exposure may even exrer.d to "The surface of the eurtii is families cf thmen irr n-.r- not just rock but alee Uq-.-*;! ** to residents in the- r.e;*:;- ha said. "Any time v.x chnr.gc hor-'tonu surrounding titel;. the pressure of tl'.ose fieldt v/e place's of en:ploy:r.crt.'' Reprinted from the Archives at Environmental Health \ . - September 1969. Volume 17 Copyright 1969. American Uedical Association > \ L t.':;7 . "' ' - -V.- j\_ t * ; t itV r *.`;V' r% .tV Ferruginous Bodies in r .- .y rf&yp.Z&fg'fy:-. . v.V;o.. : - ^ Prevalence at Random Autopsies ^Michael D. Utidjivu MB; Pod Gross. MD; mi Robert T. P. deTrevUle;MD, Pittsburgh^: J'Fwroglnouv .bod-ies w.it.h. a- t.r--ans-p--a--r-e-n-t c--e-n--t-r-a-l jjj jQg^ in Pittsburg, Cauna/etal* re^ core or no visible central filament wen present in 97 of 100 autopries; they were found In 65 of 56 men (98%) and In 42 of 44 women (95%). The youngest subject with ferruginous bodies was a 24-year-old woman. The bodies were generally more abundant In the lungs of the men. Thirty-two patients In this series had some forim of malignant disease, but there was no apparent association between the mafignsndes and the relative abun parted finding 47% and 84%, respectively, in men and women autopsied. * i v : The same year, AnJSvel and Thuribeck* studied autopsies in Montreal, and found 67% in men and 34% in women. . Meanwhile, Meurman* was finding an overall prevalence of 70% in the urban cle ment of a regional survey for asbestos bodies dance of ferruginous bodies. There were two eases In Finland. - .vr, - of primary lung cancer In men, but no case of In I960, Ghezzi, et al reported finding mesoOieHcma, nor of asbestosls. ' The significance of these findings from an epi demiologic point of view must await Identification of the central core of the ferruginous bodies, but In any event, pulmonary fibrosis or neoplasm Is rarely associated with their presence In the lungs of these aulopsled city dwellers not occupationally exposed to asbestos dust 64% and 44%. respectively, in men ssd women autopsied in Milan, Italy. As it appears that all the series studied so far have been of comparable age range and occupational backgrounds, the most likely explanation for this trend is that pro gressively more Intensive searches are being conducted. The techniques employed in the foregoing studies, with the exception of the In RECENT years studies have been con Finnish, have been basically the same; ex ducted in a number of cities of the prevalence amination of unstained air-dried smears of of ferruginous bodies in the lungs of city. -Juice expressed from cut portions of fresh dwellers at autopsy. postmortem lung or scraped from a cut lung ' In 1960 in Cape Town, South Africa, surface. Some took their samples from the Thomson et al1 reported finding that 30% of lung bases (Thomson et al1-3) and some, the men and 20% of the women at autopsy from both upper and lower lobes (Cauna were found to have asbestos bodies present et aP). Anjilvel and Thurtbeck* sampled only in their lungs. left lungs. Meurman8 examined 20 micron The following year, Thomson and Graves3 sections, stained for iron by Ferle's stain in reported finding a similar prevalence in Mi his search for bodies. ami, Fla. Men and women showed positive In all the above studies, their authors results in 31.6% and 20.4% respectively. have defined the bodies morphologically jin similar terms, and have described them as Submitted for publication April 25. 2965; accepted May 9. "asbestos bodies" on the grounds that they From the Industrial Hygiene Foundation of Amer ica, Inc, 4400 Fifth Ave, Pittsburgh. Reprint requests to the Industrial Hvgiene Foun dation of America. Inc^ 4400 Fifth Ave. Pittsburgh 15213 (Dr. Gross). considered only asbestos fibera to be respon sible Tor the formation of such bodies ai-)-* to be iat their core. However, as MeunTian5 points out, bodies with a striking or even Ardt Environ Health--Vol 77..Sept 1968 i)348323 323 > i^iFERRUGIXOUS BODIES--VTIDJIAX ET AL ' ; HP*?r/v-1-i5.T. r j . ' - . __ C"": complete resemblance to asbestos bodies Thirteen of the men and six of fhe women rt; reform layer was no:';' c.- f been found to have at their core, not were Negroes. Death had resulted from a wide . colored and contained th: a*--altos, but elongated or fibrous particles variety of causes; 32 died from mWHgnant con of a variety of other minerals including bio* ditions, including two cases of primary lung : hotnbl*n^Hvtflf| diatomaceous ,-cancer (both men). There was so evidence of earth,, , graphite, and carborundum. More ^mesothelioma in airy of the patients at autopsy* -The hinp were examined superficially for cal- , _ ,a game, insoluble, .! ` gested portion of tht&? J .. .t bodies thatmight tic pres- ''-'i^ri-'llayer was turbidand gre ' 'J chloride, eny'tmdeco over, it has recently been shown by Gross et aF that bodies morphologically fndSstza* . dfied pleural plaques, and none were found; however, as some of the lungs were incomplete :;^^-\dilorito and otherioiubi< ':;^5^if.tion of tang tissue^? * guishable from true asbestos bodies can be 1" when revived, there is a possibility fiat their produced ; in hamsters by three . different '..presence may have been missed fa same in* mazHinade, nonasbestos fibrous materials stances.' ' ;; ' `variable amount. et.-jg&g: sion. At; the IntcrfeJ^.1 was'Invariably (namely, silican carbide ^whiskeis", ceram-* - .~The lungs were sliced longitudinally on m B aluminum silicate, and fibrous glass). The commercial electric "bacon sEcer;" Into slices term ^^ferruginous "body** - h ^tberefore.^ approximately 3 mm In thickness and a total of ' layer, from 1 mm to ? c: j';';.-th amount of carbohec- 1 `*.the^original lung, consi been adopted by G>e authors, to describe aQ such bodies W*** *d until the central fiber has been positively identified as asbestos. about 300 gm (wet weight) was sliced far rids ' way in each case. The slices were floated on the surface of about 2V4 indies of domestic laundry Ueach, undiluted (active constituent &25% This generic tom encompasses both asbes* sodium hypochlorite), contained la individual *-- tos and pseudo-asbestos bodies as previously plastic pails of 9V4 inches internal diameter at - - - - ----- -- employed. - - the base. Immediately as the lung tissue came In this paper, the ferruginous body is into contact with the bleach, there was vigorous defined as an elongated golden to reddish ' effervescence with the evolution of chlorine, brown structure usually with dubbed ends; which ceased after a few hours. Only the sur (he shaft which often shows a segmented or beaded appearance is usually straight, but sometimes curvilinear with a tendency to wards symmetry; usually it is from S to 5/i diameter and 20. to IGO/t in length. The .og contains iron demonstrable by face in contact appeared to be attacked. The paSs were left undisturbed in a fume hood for 16 to 24 hours. At the end of this period (he floating lung slices were seen to have shrunk considerably in area. The attacked undersur face was seen to be bleached yellowish white. At the bottom of the bucket, a dirty-lookuig Perle's stain (prussian blue reaction), and grey to blade sediment had formed. In some which is probably composed of ferritin or a cases fins was firmly adherent to the bottom ferritin-like protein material (Davis* and end aides of the bucket as a greyish film. In Cdlct, written communication, June 1966); others, the sediment appeared to be quite loose it may cover the structure completely, mask ing the central fiber from direct view, or may he Incomplete in the central portion of jhe shaft or in the interstices of the body, revealing an expanse of naked fiber. In this study, only ferruginous bodies with trans parent or no visible central fibers were counted. - - and readily resuspended in the spent bleach. In the former cases with an adherent film it was possible, after picking off and discarding the shriveled lung tissue, to decant all the spent bleach which was also discarded. The film was then dissolved off the inner surface of. the pail by gentle agitation with about 200 ml of a 60% mixture of chloroform and 96% ethanoL The turbid, grey suspension so obtained was then Materials and Methods decanted Into a liter-separating funnel and shaken with an equal volume of dean water * The 100-lungs comprising the material for this study were supplied to us, formalin-fixed, through the central autopsy room of the Pres byterian University Hospital, Pittsburgh, and .came from autopsies performed on patients who died in five metropolitan Pittsburgh hospi tals during the period from late 1966 through June 1967. The lungs were not, therefore, from consecutive autopsies and were unselected by us. There were 56 men, age range 37 to 87 and allowed to stand. In the cases in which the sediment was nonadherent, about three fourths of the spent bleach only was carefully decant ed, leaving most of the sediment in the re maining one fourth bleach. This was then mixed in the bucket with a similar volume of the chloroform-alcohol mixture and the whole swirled around the pail a few times and then decanted into a separating funneL On standing for ten minutes or so, the con yean (mean age 65), and 44 women, age range tents of the separating funnel were seen to sepa 145 to 90 (mean age 59). rate into three layers. The lower, denser chlo- 1 Arch Environ Health--Vol 17, Sept 1S6S % 034324 FERRUGINOUS BODIES--UTIDJIAN ET AL m&teA t %on?cn v .c ' reform layer was more or less dear and amber together with a certain amount of lipidic^ea- *u Aunt m*vm * wide "' v, colored and contained the denser, mainly inor- : terial (there was also evidence -that some lipid cases'of j*11*8* con- sank, insoluble, mineral residue from the di- . material was .held in solution -in. the chloro; ett C;; *ded portion of the lung, plus any ferruginous form).The lower layer only was runoff into an the f_rfrnr, */"*"** v;. bodies that might be present The upper watery donated (lass tube with ground-glass stopper, d superfldall ^J"op*y` layer was turbid and grey, and containcd sodi- 'mixed with a similar volume of fresh dear, wa- mf nm^werl r d- i tun chloride, any undecomposed sodium hypo* ' ^ ter and vigorously shaken. This time the ezhul- lnnca wmJT** and other soluble products of the diges* ' slbn formed was usually, much' more stable; and * ' lung tissue and blood, formalin, and a..; was poured into 60-ml centrifuge tubes end - mfiniJiL ***** i? jo'^varfable amount of organic debris in suspen* -spun for ten minutes at 2,000 rpml Once snore A* *h* interface between the two- main .there was a three*layer separationwith rela- | was invariably a dark grey to jet black tivriy llttle carbonaceous material at the chlo- qq * *-J- -fi*-:*^.''r,ttlayer, hon 1 mm to 2 cm in depth, according to. -reform-water interface, plus * dense deposit at i,i^-Tn *? f**0** ,>^^jN^;:the amount of carbonaceous material present in / the very apex of the tubej from l<to 8 mm In Li. .. *otai of hi) wits s&ced fa fids *s werefloated on the s of domestic laundry * comfituent &2% ... r- the original lung, consisting mainly of carbon .Vt - r-r." ^X'Hg 1.--End of asked fiber seen In concentrate smear from human Iuoq in this series. Appearance fcnpO^fusioR (unstained. depth and ranging incolor toomtdirty white through greyish pink'to a^distinctreddish brown. Occasionally this deposit'was almost tfnf the persistence'of carbona^teri^h^e^fiSdenser m*t*r. stained in indhddi internal diameter at fii* imj titwi* came h, there was rigorous rotation of chlorine, hours. Only the eur- to be attacked. The t in a tome hood for d of fids period fire een to have shrunk - ""bribed nndersur- eQowish white, a dirty-looking d framed. In earns rent to the bottom 'a greyish film. In ed to be quite loose the spttnt bleach. In ihereat film it was tad discarding the cant all the spent rded. The film was ?.<>~ - jjj cases, a further-separation was per formed by resuspending the deposit in more chloroform-water emulsion and recentrifuging. Both chloroform and watery layers were finally decanted and discarded, and any carbonaceous- lipid ring* adhraent to the walls of the tube rismoved with cotton wooTiwabs before the tube was righted The apical deposit was suspended to two or three drops of distilled water, plus two drops of dimethyl sotpSoxidn as a preserv ative and was then ready for microscopy as a smear.- .u.* . Smears were prepared from a drop of the; suspension of as near constant size as possible, using uniform- pipettes held vertically, andjd-l lowing a free-tolling drop'to form and fall onto : the slide. The smear was allowed to form by / the natural spread of the drop only. It was found leasible to examine the smears Initially In thq wet state under low power (16 mm), un der which conditions the majority of the ferru surface of the p&Q ginous bodies were very readily seen 'and zt 200 ml of a 60% counted under transmitted light Subsequently,' % etbanoL The as they became air dried, they were-'cc*r- Abrined was then atiag tonne! le of dean water rases in which the tout three fourths carefully decantintent in the re- This was then imEtar volume of x and tlie whole ? times and then tnneL t or to, the conere seen to sepa- ~ \nser chlo- slipped with a mounting medium (Fermoxmt)- and- reexamined under high power for confirma tion of very small bodies or otherwise doubtful structures:' T r* ' * Quantitative Estimation of Relative Abun dance*--^ is appreciated that employing -a technique of this kind, with possibilities of sam pling variation at almost every stage, only a very crude estimate as to the relative abun dance of ferruginous bodies in the original lung tissue can be formed. However, thd specimens did seem to. form'naturally into .three catego ries. There were those .in which examinaiic r. of several smears (fij/eSyas the maximum Jiv.. . ?;: -r practicable with the amount of material avuil- Arch Environ Health--V'o.' 17, Sept 19S . 034S325 830 i ' FERRUGINOUS BODIES--UTIDJIAN ET AL - ; -r ''-VSv - / - - w)was necessary to find a tingle ferruginous Therewas definite histologic evidence of '- were a,, ___ > . . -.ri i_________________ _______________________________ t,, j _* '-. . id ^ne . . ,. ; .^andbacc Category: dude those where no: found In any one smear. *?.'JNest, those specimens five bodies were found in -- TM y Naked Ftben^-Tte digest placed in "Abundance Category 2" and lastly, those yielding over five bodies in any one smear : contain not ooiy ferruginous bodies, nuag^cf were classified as "Abundance Category S." . varying amounts of insoluble and wiatfawly ^>.i^P^^^foir-.fte--fanvjri The three negatives in this series yielded no dense debris, denser, thatis, than 15 gm/cc, jXp:fractufrc bodies far five smears (approximately 2,000 low. . the density of chloroform. Whoa carbon power fields). The specimen in category 8 with .< have'iu the most bodies showed 82 hi one smear. For Zr-One end of naked ffeer show* fC4'^2^,;'?^p.crookH configu. fcqmpaiison. a smear was prepared by the same 'technique, from the lung of a known clinical ^d;>-:ho multiple tongltucBnal fission ss seen - bto. fto, 0-t.uwd. x uoo). ; case of asbestods. The resulting density of as>v bestos bodies was so high that they could not be counted with any accuracy, but would be of the 1 .order of many hundred In one smear. " Routine histological sections stained with he* mato:ryiin and eosin were prepared from 20 of the lungs showing the most ferruginous bodies by flie digestion technique. . f 4'iVV>: : , TsiiHV jVafcr, ;i ` ...Vli *' "1 ` \ `1 , -y ft , ... .. 2**.. - ;'*i-.v".rv'* "?+ V- - j . ' >' .Alt - -ir '. 1 jti- which, steam or ai: '^^0^`^^^^A/fSaeeai--. t H'%^y^tf^9fe!5srfoai assodat 2).JWhether sc .'?~3 ` fcome ferruglno v' ^^vy3e- n-ivnenigng death op;f alts ,?***.;.* v : V->-^ j .1 t* - ** y 6i Ferruginous Bodies^-Ferruginous bodies were found in all but one of the lungs taken ' n men (98%), an SS-year-oId white man. arruginous bodies were found in all but " ; * j t ! h. i* :.. it'-j if ' Fibrous dust part of the m< least of indust: ^wo of tire lungs taken from women (955%). The two negative results were ment upon thei They give a lo: found in the lungs of white females; one 16 vegetable, and years of age, and the other 42. and synthetic, .... The Abundance Categories, mean ages in each category, and percentage in each cate* forming fibers far as thc- nak gory with malignant disease for both sexes are concerned, are given in the Table. ruled out as. 1 '' The relative abundance of ferruginous bodies is significantly higher in men than in women (X* " 8.973, indicating that sex and abundance category are associated, at a 97.5% significance level). The age range for prolonged ac\` and also bei?:^ form. However. coated -to for.r well survive ii: men 'was 37 to 87, and for women, 24 to 90. Ferruginoue There seems to be a slight tendency for the ferruginous bc-r relative abundance to increase with age, but ible central tl: the range of mean ages between the different these are. abundance categories is small compared to ly, asbestos the overall age ranges, and it was not possi-. ble to demonstrate statistical significance for'* smears gdd.-ric seen with'crc. this tendency. There does not appear to be any definite association between malignancy in general and relative abundance of ferruginous bod . '{ ; ,i \ :i. ' (Fig 3). A small :*.i. were seen whk of the ce:v. ul r ies in the lungs in this series. ties. Figure Arch Environ Health--Vol 17, Sept 1968 X 034832(J FERRUGINOUS BODIES-VTIDJIAN ET AL persists in the concentrate from heavily pig mented lungs/It presumably does so by adhesion to denser mineral matter. Of par ticular interest, however, is the presence of what appear. In the light microscope at least, to be naked fibers of various typ*s. '.Sftg Nearly all are translucent and rectilinear. Their range of dimensions is similar to that for the ferruginous bodies. Most appear to have fractured ends, and the fracture Is usu- ' \ * ally conchoidal in appearance. Some,bow- || ever, have fused ends or a "shepherd** C*M. crook* configuration (Fig 1). The latter we v -. ** A* -iXS' consider to be undoubtedly man-made, el- \ ther "mineral wool" or fibrous glass, both of v*. -t* which materials are made from fused ma terial which is spun and drawn out in a jet of steam or air. One naked fiber was found which shows the characteristic longitudinal fission associated with asbestos fibers (Fig 2). Whether such fibers were destined to be come ferruginous bodies, but ter the super- * < vening death of the host, we cannot say. / ' *' '>V' V } *' - ' - - - - '331 ';X'2Z-J"* 3cr ' 1 * "* l'-f. . Comment v Fibrous dust particles would appear, to be. part of the modem urban environment, at. least of industrial cities. Cralley et el* com-' ment upon thfeir ubiquity in a recent paper. They give a long list of materials of animal,, vegetable, and mineral origin, both natural and synthetic, which have-the capability of forming fibers of respirable dimensions. As far as the naked libers in our concentrates are concerned, organic materials may be ruled out as being unlikely to survive-the., prolonged action of sodium hypochlorite,' and also being of lower density than chloro form. However, onoe such a fiber has become coated to form a ferruginous body, it may' well survive into the concentrate. Ferruginous Bodies.--In this series, only ferruginous bodies with transparent or invis ible central filaments have been counted, as these are potentially, though not necessari ly, asbestos bodies. However, in many smears additional ferruginous bodies were seen with opaque black central filaments ; (Fig 3). C>:- .J 4 \f t* '*V*,Vl, - ai ..Jr7- ?A . # (Ct - fr W cc '1* :C c C\ -' f ; .# A small number of ferruginous bodies were seen which exhibit longitudinal fission of the central filament and multiple extremi ties. Figure 4 shows such a body with one Fig 3.--Ferruginous body, showing marked beading or segmentation in coating, and opaque centra! filament (unstained. X 1100). ~ Arch JEnviron Health--Vol 17, Sept 1963 % 0348327 3. 3. 2Vf*>-><. . FERRUGINOUS BODIES--VTIDJIAN ET.AL ilSbife . ^........ . Distribution of Coses9 ' - ` . v Oistri- Abundance No.of bution Category Cases ' .(%) . - ' With . /, - Malic* Mean nancy Age v.' (SO . i-Men V "V 21 - aa''. 62 r-.t ---r?c.Hv/is . >. .64 v S3 40 Tout Women X -' 19 . i-'-as 66 . ,100 --V A-.- ; 70 65 ?> i ?r* 21 S3 ,1 ^ .<:* :- 29 ' - a # '..67 l* . -.68 sSaI : a *'-.v 5 " -12 ..-64 . '-X 20 Total 42 100 60 SI : !*; . . "Mean age, prevalence of malignancy by so*. and. .^abundance of ferruginous bodies. . 'i-l V:However, full and positive identification of both central filaments and naked fibers will have to await the further development of physical or physicochemical techniques. Positive identification of asbestos fibers by their distinctive electron-diffraction pattern is already underway in this laboratory.*. Significance of Findings.--There is an ur gent need for more data in order to form any estimate of the significance of ferru ginous bodies and naked fibers in the human lung in terms of pathogenesis, actual or po- tentiaL The definite facts are few. It is now widely accepted that asbestos dust, if in haled in sufficient quantity such as only oc curs in those occupationally exposed in the absence of adequate dust control, may be carcinogenic to the human lung. In rats, the Inhalation of duysotile asbestos dust in high concentrations has been associated with a 35% prevalence of lung cancer.10 There Is- also strong evidence that croddolite, a par ticular variety of asbestos largely mined In South Africa and little used in -the United States, may cause pleural mesothelioma--a rare tumor in man, after a time lag of many years. Lastly, there is the established fact that primary carcinoma of the lung has increased in incidence In most industrialized countries over the past 50 years. However, little or Fig 4.--Femiginou* body showing bifurcation of shaft and one double end. Appearance strong ly suggestive of asbestos body (unstained. X HOC). nothing is known at present about the quan titative relationships involved. In the case of asbestos, what is the minimum pathogenic or carcinogenic dose? The only data on this ouble end. Such bodies are almost certainly question are afforded by the observation ibestos bodies, for we know of no other ma- that the excess experience of lung cancer n-this microscopic scale. fission shown by certain asbestos industry workers in the 1930's and 1940's has been greatly re- Arch Environ Health--Vol 17. Sept ]968 I FERRUGINOUSBODIES--UTIDJIAN ET AL . '333 duccd or altogether eliminated by the imple shown that fibrous glass, ceramic alurri'huro mentation of dust-control measures in the silicate fibers, and silicon carbide whiskers iv plant11 However, it is unlikely that such relatively inert in animal lungs, beyondth.s ' v dust-control measures have reduced the lev- fact of ferruginous body formation. - "V . ' el of exposure of the workers to respirable In conclusion it can be said that at* this i-W, isbcstos dust as low as that of the general time there is no evidence that the presence ^ .population. Is the asbestos fiber rendered of asbestos dust particles or dust particles of ..^'completely and permanently innocuous to other fibrous materials, coated or uncoated .V the human body once it has become coated with ferruginous material, in the lungs of Y #to form an asbestos body so that only the individuals not occupationally exposed to naked asbestos fibers are pathogenic? Which these dusts in industrial urban communities. f . Jf any of the nonasbestos fibers, coated or Is making any contribution to pulmonary ^uncoated, are pathogenic to the human lung disease. Inflammatory or neoplastic. X-^'ind In what quantity? Can ability of non- ' This study was supported fa the Department of asbestos fibers to provoke ferruginous body Health, Education and WeUare Public Health Serv ice cootract PH 86-66-156 from the Bureau of formation be related in any degree to patho- Disease Prevention and Environmental Control. genidty? There Is evidence from animal ex* Chairman Emmanuel Father, MD. Department of Pathology, University of Pittsburgh School of idcr-l- Y: ^ periments that it cannot Gross et aF*13 have cine, provided the lungs tm^ttigated fa this -strdy. > 1. Thomson, J.G.; Kaachula, R.O.C.; and Mac- ies, Development fa Response to FQameniaui Dusts . . Donald, RR: Asbestos as a Modem Urban Hazard, and a Method of Isolation and Concentration, Arch. . S Afr Med J 87:77-61 (Jan 19) 1963. Path 85:539-346 (May) 1968. 2. Thomson. J.G., and Graves, VfJSAd Asbestos as 8. Davis, J.M.G4 Electron-Microscopic Studies of : an Urban Air Contaminant Arch Path 81:458-464 Asbestos** fa Man and Animals, Ann NY Acad Sci (May) 1966. 13228-111 (Dee 81) 1965. " -8. Chuns. D.; Totten, RS.; end Gross, Pj Ashes- 9. GraHey, I*J,, et eh Source and Identification of toa Bodies fa Human Lungs at Autopsy, JAMA - Respirable Fibers, AIHA 29:129-135 (March-Aptil) 192:371-373 (May 8) 1965. 1961 ' : A AnJQvet. L^and Thuribeck, WJvL: The loci- 10. Gross, P., et ah Experimental Ashestosis: The deace of Asbestos Bodies fa the Lungs at Random Development of Lung Cancer fa Rats with .Pulmo- Necropdes fa Montreal. Canad Med Attoc J nary Deposits of ChrysotEe Asbestos Dust Arch 50179-1162 (Dee 8) 19G6. Environ Health 15043-355 (Sept) 1967. N . 5. Meutmaa, L: Asbestos Bodies and Pleural 1L Knox, J-FYDoll, RS.; and H3L LDj Cohort Pla<tues fa a Finnish Series of Autopsy Cases, Acta Analysis of Changes fa Incidence of Bronchial Car- Path Microbiol Scand. supp 181, 1966. cfaams fa a Textile Asbestos Factory, Ann NY 6- Gbezxi, L; Molted. G.; and Puccett, U.: Ashes- Acad Sci 132:526-535 (Dec 31) 1965. toe Bodies fa the Lungs of Inhabitants of Milan, 12. Gross, P-, et ah The Effect of a Synthetic Ce- Med Laooro 58223-227 (March) 1967. ramie Tiber Dust Upon the Lungs of Rats. Arch In- 7. Gross, P, et ah Pulmonary Ferruginous Bod-*/ dtutr Health 13:161-166 (Feb) 1956. X 0348329 Arch Environ Health--Vol 17, Sept 1968 Printed and Published in the United States of America S2 9.. p r VtT'' .">** THE MONTREAL STAR,_TUESDAY. OCTOBER^l^JlMS * . &midu* rtu a recent Cancer Orientation. In addition, the Interna- Finland and.Czechoslovakia. ' .TORONTO -- An article to institute for Science Writers tional Union Against Cancer7 'Dr.HamraonsaidUls ase- * ; ,- ^pwlntheAntumi^aieof at Annville, Pa. has organized a committee rious problem because the use national news tettersays that <nie trUcIe **5* 0181 fa under Dr. J. C GBsonof Car-, of asbestos in building has In- a cancer which occurain the Canada a national committee diff, Wales, to collect evi- creasoi in the last few years, r fining of Ore lung may result to study the asbestos problem dence on the disease from ' "On the face of it, the use from exposure to asbestos. has beeen organized under the' across the world. -of asbestos would seem to be * - -The cancer, called mesothe- sponsorship of the occupa- The article quotes Dr. Ham- more serious than smokL^ as -\ a7 r^exami- tional health division of the aoa as saying that until re- a threat to heatth because cig- nation of modern building federal department of nh- cently only 15 to 20 cases of arettes are not essential, but techniques which call for the tional health and welfare.mesothelioma were uncovered it would be extremely difficult # use of asbestos. . It says special studies are . annually In the United States, to build skyscrapers; tft power The article says this was being conducted in the asbes- But he said the rate is plants, or any one of a num- the opinion of Dr. E. Cuyier tos-producing areas of Thet- climbing in the U.S. and Can- ber of constructions without Hammond, vice-president of ford Mines and Asbestos in ada and has been found fre- using asbestos for insulation," the.American Cancer Society, Quebec and Casslar in British - quentiy among asbestos min- the article quotes Dr. Ksm- . who discussed this cancer at Columbia. . ers in South Africa; Poland, mond as saying. % 034S429