Document ZJ13Zem93Rm55OXwbaO9j5Ezd

fc* - ' xy V': "'TV PLAINTIFF'S EXHIBIT * Reprinted from the A. it. A. Archives of Industrial Health June 1958, Vat. 17, pp. 634-653 Copyright 1958, by American Medical Association An Epidemiological Study of Lung Cancer in Asbestos Miners DANIEL C. BRAUN, M-D,, and T. DAVID TRUAN, M-A_ Pittsburgh Ever since the pronounced increase in the incidence of lung cancer among males became apparent, there have been attempts to associate it with one or another of the various elements in the environment of man. The approach used by some workers has been to suspect one or several sub stances and then set about in an intensive search for lung cancer among persons who have had any exposure to those materials. In this connection. Smith82 writes: ``The tendency of authors reporting the coinci dental occurrence of primary lung cancer with silicosis or with any other theoretical' etiologic conditions, has been to emphasize the percentage relationship in extremely small series of cases, with control cases which are not in any way comparable." It would seem inevitable that asbestos should come under scrutiny in this manner, because prolonged exposure to this material is known to cause a specific type of pneu moconiosis, and because persons who show this form of pneumoconiosis often come to autopsy and provide a ready source of material for study. It was in this way that reports of the simultaneous occurrence of lung cancer and asbestosis began to accu mulate after the report of a case by Lynch and Smith 48 in 1935. Within the next 10 years, about 15 additional cases were re ported, and in 1954 Merewether 74 reviewed all deaths from asbestosis recorded in Eng land since March, 1924. Lung cancer oc curred in 16% of these cases. Gloyne.*1 Accepted for publication Tan. 20, 1958. This study was made possible through-a-grant from the Quebec Asbestos Mining Association. Medical Director (Dr. Braun) and Statistical Consultant (Mr. Truan), Industrial Hygiene Foundation. whose work is also frequently referred to as establishing a connection between asbes tosis and cancer of the lung, reported in 1951 that cancer of the lung was present in 14.1% of asbestosis cases examined by him. In 1941, Nordmann and Sorge78 claimed to have produced lung cancer in mice which they exposed to asbestos dust. Since 1951, additional cases of cancer of the lung coexisting with asbestosis have been reported, and, according to Hueper58 about 100 such cases had been reported up to 1955. As a result, an association between the two diseases appears to have been ac cepted by many authors, and several writers were using the term "asbestosis cancer" of the lung. VVerber,8* in 1952, stated cate gorically that in 7% to 17% of cases of asbestosis, after a latent period of about \z/t to 20 years, carcinoma becomes estab lished in the lung. On the other hand, not all authors ac cepted this alleged association without reservation. Saupe80 in 1939 reported that he had discovered no cases of lung cancer among 620 cases of asbestosis which he had examined; and in 1942, Holleb and Angristis expressed the opinion that the number of cases of asbestosis with lung cancer was too small for statistical evalua tion. In, 1947, Wegelius88 reported 126 radiologically diagnosed cases of asbestosis among 476. workers in Finland, and found no cases oi lung cancer in this group. Goldblatt and Goldblatt in their section of Merewether's latest book,*4 state: "But at no stage in all'these impressive researches was any clue obtained which might have offered any support to the possibility that asbestos could act as a carcinogen. There 634 '-n LUNG CANCER IN ASBESTOS MINERS is no reliable criterion by which one can anticipate carcinogenicity and, as is well known, relatively minute changes in the structure of a chemical carcinogen are suffi cient to diminish or eliminate carcinogenic action. . 'ijf If asbestos is indeed to be regarded as a carcinogen, the need is felt to demonstrate some property which can be regarded as something more than inertness." These authors advance the theory that, until some.more experimental evidence of direct carcinogenesis by asbestos or a de composition product of it can be obtained, asbestos might be considered as a "co-car cinogen" which only induces a further de velopment of a preneoplastic condition brought about by something independent of the asbestos, such as an endogenous factor. Thus the literature, while tending to sup port the thesis that asbestosis is in some way related to the development of lung cancer, is by no means unanimous. Alto gether, it is perhaps more confusing than enlightening. A careful review shows that the majority of the reports are clinical and not epidemiological. The)- lack many ele ments necessary for the application of epidemiological techniques to their content, and most of the authors do not make claim to having done so. What has happened is that succeeding authors have drawn conclu sions and generalized beyond the scope of the works which they quote. Nowhere, for example, have we found references to a population of asbestos workers, although several authors who have quoted the ob served incidence of lung cancer in autopsies of persons who also had asbestosis imply that this incidence applies 10 asbestos workr ers. generally. We have likewise been unable to find any study which actually calculated the incidence of lung cancer among a population of persons who had asbestosis, and not just those who came to autopsy. With the exception of a paper by Doll,28 none of those reviewed gave any data on exposure and dust concentrations, and even Doll's paper merely mentions "scheduled" areas, by which is meant, "those areas where processes are carried on which were scheduled under the Asbestos Industry Regulations of 1931 as being dusty." There is, furthermore, a complete lack of definition of terms as used in the pub lished literature. For example, the term "asbestosis/' as used, may refer to changes observable only by microscopic examination of the lung tissue, or it may mean a radiologically detectable condition. Most of the published reports obviously included women among their cases, but some of them do not give the number or proportion of women involved in the study. There is also a lack of uniformity as to what type of exposure most studies have dealt with. Of 99 cases enumerated by Huepcr 58 in 1955, only 10 appear to have originated in the United States, and 7 in Canada. Some of the earlier reports ap parently included asbestos miners, but it can be assumed, since 82 of the 99 cases had originated in England, and since no asbestos mining operations are carried on in that country, that most of the reported cases have involved workers in the textile or fabricating industries. Such factors as smoking habits, family history cf cancer, length of time in the industry, and age of the individual case are also, notably absent in the majority of these reports. With this understanding of the limita tions of the existing literature with respect to epidemiological generalization, it may be of value to consider in somewhat more de tail some representative earlier publications, a few of which were referred to briefly above. " One of the most detailed studies and one which deserves the most serious considera tion is that reported by Doll28 in 1955. This study reviews causes of death among asbestos workers based on coroners' rec ords. It also attempts to estimate the risk by studying records of men who worked for at least 20 years in exposed situations. Braun--Tntan 635 A. M. A. ARCHIVES OF INDUSTRIAL HEALTH Doll concluded that lung cancer was a spe cific industrial hazard of certain asbestos workers and that, after 20 years of expo sure, the risk is 10 times as great as tor the general population. This article is important for several rea sons, in addition to the definite conclusions at which it arrives. For example, it begins by stating that "in view of the infrequency of asbestosis, this large number of cases (61 cases of lung cancer) suggests--but does not prove--that lung cancer is an occupational hazard of asbestos workers." ""Neither this article nor any previous one which we have examined presents any fig ures to prove that asbestosis is an infre quent occurrence. Estimates of the number of persons potentially exposed to asbestos dust in the United States alone vary from 10,000 to 35,000, and the incidence of as bestosis of any degree might be higher than Doll imagines. This study, like so many others, involves autopsy records. The number of persons involved in the statistical analysis is only 113, representing only 1,042.25 man-years of life. It is also true that in selecting men who had been employed for at least 20 years, the study automatically excluded those who died from other causes after shorter employment Another reason why this publication is of importance is a statement which it con tains to the effect that "the strongest evi dence that it (lung cancer) may be a hazard (in asbestos workers) has been produced by Merewether and by Gloyne." In 1951 Gloyne41 presented a review of 1205 autopsies on persons who had worked in various dusty occupations. This number included 132 asbestos workers, of whom 121 showed "pneumoconiosis"--pre sumably asbestosis. Primary cancer of the lung occurred 17 times in this group, an incidence rate of 14.1% for lung cancer among asbestosis cases coming to autopsy. There were in his series 796 cases with sili cosis, and 6.9% of these also showed pri mary cancer of the lung. The incidence of lung cancer in other forms of pneumoconio sis was 67%, and in 169 cases which proved not to have any type of pneumo coniosis it was S.3%. Gloyne considered "the mortality of the asbestos workers" to be "disturbing." First of all, it is obvious that the paper does not deal with the "mor tality of asbestos workers," and secondly, it must be borne in mind that all of Dr. Gloyne's cases were submitted to him for study because the findings were unusual for uncomplicated pneumoconiosis. It can reasonably be assumed that cases, including those of asbestosis. in which the findings were not considered unusual were not sent to Dr. Gloyne for examination. .As a mat ter of fact, in the same paragraph in which he expresses concern over the incidence rate in asbestosis. Dr. Gloyne himself points out that the rate for lung cancer based on necropsies at the London Chest Hospital was 21.3% while the figures of the Registrar-General showed only 2.4%. He thus recognized that autopsies on a cer tain selected group of cases were not rep resentative of the general population. It would seem, then, that notwithstanding the value of Dr. Gloyne's work, its importance as an index of the prevalence of lung can cer in asbestotics has been misinterpreted by some who have quoted him. All that it really shows is the fact that in a group of 121 cases, selected for special study pri marily because they seemed abnormal bypreliminary examination, 17, or 14.1%, had lung cancer. MerewetherTs in 1947. in the report of the Chief Inspector of Factories, reviewed all cases reported between 1924 and 1946 in which asbestosis was the cause of death or a coexisting condition. This work was later extended to include all such cases re- r* 4 ported up to December, 19a4, by which time there were 344 deaths, including 205 males and 139 females. Among them were 55 cases (16%) of cancer of the lung, 41 in males and 14 in females. It is quite possible that a large number of asbestotics who did not die of their asbestosis, or in whose 636 Vol. 17, June, 1958 LVXG CAXCER IX ASBESTOS MIXERS death certificate it was not mentioned, may have been missed. The import of this 16% is enhanced by the simultaneous statement that the incidence of lung- cancer in autop sies of the general population is only 1%. The danger of attempting to compare a rate found in 344 cases with the rate for the general population without respect to age, occupation, and many other variables, such as smoking habits, is obvious. Lynch,70 who with Smith ** had reported the first case in 1935. reported 4 cases of carcinoma of the lung in a series of 49 autopsies on workers in an asbestos manu facturing plant who were shown to have "`demonstrable deposits of asbestos in the lungs." This, of course, is not necessarily identical with the disease asbestosis. Lynch, himself, points out that, although this is an incidence of S.2%, "both figures are too small for very serious statistical types of calculation." Nevertheless, later writers have used this paper to strengthen the case for an association of carcinoma of the lung with asbestosis. It is also of interest that Klotz ** found only the same number of cases of lung cancer in a series nearly 10 times as large, i. e.. 4 in 47S cases of asbestosis. Behrens, as cited by Merewether,7* esti mated that, of 309 cases of asbestosis in the literature, 44 showed associated cancer of the lung--giving an incidence of 14.2%. This is an illustration of generalizing an incidence obtained in a group of cases which were undoubtedly reported only be cause some of them showed lung cancer, to possibly hundreds of asbes:o:ics whose cases were never reported. The same ap plies to the conclusion of Teleky,83 who appears to have reviewed reports of 39 autopsies on persons with asbestosis among which 6 cases of lung cancer occurred. In formation from sources such as these does not justify generalizations with regard to mortality rates. Perhaps no one has written so exten sively on the subject as has Hueper.s2'ss In 1955 he reviewed the casesss reported prior to that date and enumerated a total of 99. Eleven of these were those dis cussed by Doll5* and may have been cases covered by other authors. Eight were dis covered by Kennaway and Kennaway42 in an analysis of death certificates, and, unless Merewether's study was incomplete, these cases should have been included in his re port. Of the remaining SO. it is quite pos sible that the 31 contributed by Merewether and the 17 by Gloyne contain some duplica tion with each other or with those of other English authors. Principles of the Epidemiological Method - Dom 30 has pointed out that much of what is now thought to be pertinent concerning the comparative frequency of lung cancer in different population groups has been de veloped from the analysis of clinical ma terial, particularly surgical and autopsy records, supplemented to some extent by the reported impressions of various clini cians based upon their personal observa tions. More recently, however, attention has turned to the systematic investiga tion of this problem by the same methods that have proved so successful previously in the study of communicable diseases, that is to say, by epidemiological methods. In order to apply this method of investi gation to the problem under discussion, we were of the opinion that a study should be planned so as to provide 'I) a well-defined population group: (2) available data for all members of this population, including the healthy as well as the ill: (3) a sample which is truly representative of the popula tion; (4) reliable and valid observation; relating to the problem of the study. 'A serious defect, common to most of the studies which have been reported, is that little or no information concerning the healthy people in the group seems to have been available to the author. In order to draw a generalization regarding all asbestos workers, it is necessary for a study to in clude living persons as well as the dead. B raun--Truan A. M. A. ARCHIVES OF INDUSTRIAL HEALTH the investigation to cases coming as has been frequently done in idies, still further restricts its- use ization. The problem with which concerned is whether asbestos i'perience more lung cancer than general population. The answer s the collection of reliable infor- asbestos miners as a group, as t the general population, s advisable to discuss the differreen the epidemiological approach used in the studies which have rted to date. A very important ion is the fact that lung cancer, its increasing numbers, is still a low incidence; that is, in a given not many persons will contract ular disease. This fact requires samples or groups must be studride meaningful results, zing the difficulty of obtaining i samples, most earlier writers rom the epidemiological method t to circumvent the requirement ng well persons by (1) compar ative frequency of cancer in vari- (2) comparing the relative of cancer in a group of hospitalits: (3) comparing the relative of cancer in a group of cases autopsy. ing to compare two population oking only at the relative fre cancer in various body sites, t in finding a higher percentage requency) in one of the groups, `act, the mortality rate of cancer cular organ is exactly the same oups. This is very clearly demn the excellent article by Dorn.30 .litv rate from a particular cause : measure of comparison, parent that selected groups such lized patients or autopsy cases e in any way representative of roup. and that in dealing with les, the observer may easily find > of a given disease than would be found in another group of the same size, but representative of the general population. It is true that investigation of cases from such a sample can furnish information valuable for research, but the use of this information in drawing generalizations is necessarily restricted. It is the obligation of both the investigator and of those who read his report to make proper comparisons and to draw only those conclusions which are valid and justified. A good statistical study of cases of cancer of the lung occur ring in a group of autopsies can lead to a proper inference concerning the frequency of lung cancer among cases coming to autopsy, but only to such cases. For in formation from such a study to be pro jected to some larger group, it is necessary that the autopsies represent a good sample of that larger group. To assume that such is the case in any particular series is dan gerous and likely to be false. There is some danger that the figures reported by some authors may be miscon strued as applying to asbestos workers or even asbestos miners, when, in fact, the authors in question do not make this gen eralization, nor can the generalization be made for the reasons stated. Gose study of the reports reveals that the percentages cited relate only to the group of autopsies covered by the particular investigation. The present study, in contrast to the earlier works, has been planned to utilize the epidemiological method. A well-defined group of asbestos miners has been estab lished in such a way that it constitutes a good sample of the whole population of asbestos miners in Quebec. Data for all members of this group have been collected and analyzed. Those concerning lung can cer have received most careful considera tion. Details of the methods emploved will be set forth later, but the type of approach is considered to permit of fair comparisons and valid generalizations. Collection and Analysis of Data A preliminary survey of potential sources of information in February, 1956, involved Vol. 17.'-Tune. 1958 LCXG CANCER IN ASBESTOS MINERS discussions with the physicians in charge cohort was then followed by means of the of the asbestos companies' programs and with clinicians, pathologists, representatives of City and Provincial health departments annual physical examination records through a six-year interval, 1950 through 1955. All data .regarding this group were and of the Canadian Cancer Society, and then tabulated in order to determine the other interested persons. It was found that characteristics of the cohort. For those who morbidity data, although somewhat limited, survived the entire period, reference was were available from such sources as the made to the physical examination results hospitals in Montreal and- Quetec City, and and x-ray findings at the end of the period. the 13 cancer detection centers in the- Prov Those who had died were tabulated sepa ince. However, because of the high- mor rately, and the cause of death was tality in lung cancer, it seemed advisable corroborated by examination of the death to depend upon data relating to deaths. certificates. A further search was made These we found to be obtainable at the concerning those in the original cohort who vital statistics department of the Ministry remained unaccounted for when the living of Health in Quebec City. From the pre and the known dead. had been tabulated. liminary survey, it was apparent that exten They represent men who had left' employ sive and detailed information could be ment through retirement or resignation. gathered with respect to both the persons Eventually, all but a small number of these employed in the asbestos mining industry were accounted for as either living or dead, and the mortality figures for the general and in the latter event, the cause of death population. was substantiated in a similar manner, and Following this exploratory survey, the the results added to the original list of initial effort was directed to the collection deaths. of data relating to all workers who had Death certificates for the Province of been processed through the clinic ax Thet- Quebec for the years 1952 to 1955, inclu ford Mines since its inception in 1947. and sive, were reviewed in the department of similar information regarding all workers vital statistics of the Provincial Health at Asbestos, Que. Data from the clinical Ministry, together with statistical sum records included the age, family and per maries of the causes of deaths in the Prov sonal medical histories, smoking habits, ince by counties. All cases in which death number of years of exposure, an estimate was certified as having been due to pri of weighted exposure, and the course of mary cancer of the lung were examined for the individual's health status or the cause such information as place of residence, of his death. occupation, date of death, hospital in which From this information it was possible death occurred, and whether or not an to formulate a "cohort" which could be well autopsy was performed: Cases in which defined, should be representative of the lung cancer was given as a cause of death, whole group, and could be followed for a but in which it was not specified as to definite period of time. All of the available " .whether the cancer originated in the lung, experience indicates that the development were also reviewed in an effort to include of asbestosis in less than five years of ex all instances of primary carcinoma of the posure must be somewhat rare. Accord lung in the study. ingly, the cohort was defined as including The statistics for the" Province of Quebec every miner wrho had a total exposure of relate to population, total deaths from all five or more years, and who was on the causes, total deaths from cancer of all types, employment rolls in 1950. Office and other and deaths from lung cancer. These were nonexposed personnel, regardless of length collected and tabulated by countips and by of employment, were not included. This sex for the years 1950 to 1955. inclusive. Braun--Truan _ _' 639 A. M. A. ARCHIVES OF ISDUSTR1AL HEALTH From them, death rates for the general population of Quebec and of individual counties were calculated for specific years and analyzed by cause. Practically all employees of one company are covereif by a group policy of life insur ance which, fortunately, nearly all of them continue to carry when they retire. A very few are not covered by this policy, and those who leave the industry for one reason or another except retirement usually are no longer covered, but this is likewise a small number. As an additional check upon the information obtained from the clinical records on this group, the records of the life insurance company "were examined for all death claims paid under the policy, and particular notice was taken of the claims in which the proof of death was based on cancer of the lung. Deaths from lung cancer among asbestos miners were thus determined from the clinical records in the medical sendee of the industry and checked by means of the death certificates and insurance company records. The deaths were then verified individually bv renewing them with the physicians in charge of the medical sendees. In this man ner, there was established a list of cases in which primary cancer of the lung is con sidered to have been proved as the cause of ' death. A few cases in which lung cancer is strongly suspected but not proved as the cause of death were considered separately. Mortality rates have been calculated using both the "proved" and the total of "proved" and "suspected" cases during the years un der obsenation. Comparisons were then made between the death rates from the same cause among specific segments of unexposed persons. All lung cancer deaths, both suspected and proved, were carefully ana lyzed to determine possible relationship or correlations between the development of lung cancer and any factor known from the clinical records, such as family history of cancer, personal history of heavy smoking, coexistence of asbestosis, or exposure to asbestos. In addition to this analysis of deaths oc curring in the cohort and during the years under observation, every known death from cancer of the lung, as well as every case diagnosed but still firing, has been tabulated and analyzed. They will be discussed separ ately from those included in the population and time-interval under study. A comparison of lung cancer mortality in the asbestos-producing counties has been made with that-in counties which are far r removed from the asbestos mines and in which, presumably, no asbestos miners five. Finally, in order to broaden the compari son of death rates in different population groups, the rates have been collected for Canada generally, and tor the United States, according to the most recent published and unpublished material. Results and Interpretation The cohort which was constructed accord ing to the criteria described in the preceding section has been considered individually and compared with the general population. Description of the cohort will be presented here as a preface to the results of the study: Original Cohort Lost Persons Deducted Final Cohort Living in 1955 (working an*; retired) Dead by 1955 Cancer ot lung Questionable cancer of lung Ocher causes Unknown causes Smokers Nonsmokers Unknown 6.091 133 5.9S3 5.771 187 9 3 169 6 4.673 1,263 20 Tables 1, 2, 3, and 4 present age, number of years of employment, weighted average exposure, and smoking habits of the cohort. A comparison of the exposure to asbestos dust is presented in Table 3. All members of the cohort were placed'in one of three categories, representing increasing degrees of exposure based on a weighted average of the years spent at various levels of dustiness. The degree of dustiness for each job category was determined after consulta tion with persons familiar with the environ ment and conditions in the various work 640 17;~fune. 1958 LUNG CANCER IS ASBESTOS MINERS Table 1.--Number and Percentage Distribution Table 2.--Number and Percentage Distribution by by Age Length of Employment Age 20-44....................... . 45-54.......... .............. 55-64......................... S+............................ Unfcnowxu-....,., Totals____ Averate A*o______........................... Number 41 * Less than 0.4%. Per Cent 66 19 10 5 100 Lenphol Employment 5-0........ . 10-19........................ .......... .. _ ... 20-29______________________ ____ 30-39............ .................................. 40-49...................................... ............... so+------------------------------------------ ... Touts____________________ Averast yean of employment.... Number 55 Per Cent 30 40 16 10 3 1 100 areas. For the purposes of calculation, the assumption has been made that the relation ship between these categories is linear, and that Category II is twice as dusty, and Category III three times as dusty as Cate gory I. ually smoking more than five cigarettes per day. Persons who smoke pipes or cigars exclusively were not considered to be smok ers for the purpose of this study. Table 5 presents the year-by-year ex perience of the cohort and indicates the Table 3.--Number and Percentage Distribution by Exposure Category Table A.--Number and Percentage Distribution by SmoJking Habits Exposure Catetorr I.................................................. II.................................................. Ill................................................. Unknown__________ __________ Totals......................... ........... -Overate Exposure............. ........... Number 5.950 2X * Less thin 0-3%. Per Cent 34 36 30 100 Smofcirj Habit! Scooters.............................. ................. Xousratrers..................... .. ................. Unkno*Tu............... Totals.......... .......... Number 4.073 L26S * Less than 0.5%. Per Cent T9 21 100 The fourth variable, smoking habits, was similarly tabulated and is shown in Table 4. This was included because the informa tion was available and because smoking was regarded as one of the variables which, besides the environment, could conceivably influence the development of lung cancer. As used in this presentation, the term smoker refers to a cigarette smoker, habit- number of deaths each year from specified causes. In general, a case was considered to be "proved" as one of primary cancer of the lung when the records showed that the diagnosis had been supported by an autopsy or surgical resection of the lung with microscopic examination of the re moved tissue. In one case so considered, however, diagnosis was .confirmed by bron- Table 5.--Year-by-Year Experience of Cohort and Death Rates per lOOfiOO Man-Years of Risk Cause of Death Yeor No. Alive At Beginning of Year Proved Suspected Primary r Primary Ca. of Lung Ca. of Long Other Causes 1950 ... 1951........................... . 1952........................... . 1953........................... 1954........................... . loss . .... 5,95$ 5.SS5 534$ 5410 1 0 2 l 3 2 12 0 1; 0 3T l 34 0 33 0 36 Totals....... 9 ,$ Proved** rate par 100.000 man-years of risfc-=7--rrr---- 25.5 35 271.3 3 169 'Total4* rate per 100.000 man-yeara of -- 34.0 Unknown 1 1 0 0 4 0 6 Man-Yeara of Risk 5,950 5,932 5,903.5 5.866.5 5329 5,790.5 35.271.5 Braun--Truan ^ _ _^>4I Case No. I 3 3 6 7 $ AX* *6 ii 43 50 * 4$ 41 M 37 ` s A. M. A. ARCHIVES OF INDUSTRIAL HEALTH Table 6.--"Proved" Cases of Primary Cancer of the Lung Smoker Ye* Ye* Ye* Ye* Ye* Yes Ye* Ye* Yes Exposure 24 JT- In Cat. It M IT. In Cat. 1 37 it. In Cat. I 32 IT. In Cat. I 22 TT. In Cat. U 33 it. In Cat. Ill 90 yr. In Cat. U 16 yr- In Cat. I 2$ it. In Cat. IQ Died 10-13-51 3- 3-55 7-30-55 6-30-50 -51 4-3t>-53 11-32-53 6- 5-54 5- -55 Autopsy Yes Yes No Ye* Yes Ye* Yes Ye* Brooch. Asbesiosls Ye* No No No Ye* Yea Yes No No choscopy with visualization and biopsy. In another, although there was no autopsy, the diagnosis of primary cancer of the lung seems to have been beyond question. - The term "suspected" primary cancer of the lung was applied to those cases in which the diagnosis remains in doubt but some of the evidence points to cancer of the lung. There were three such cases. The term "man-years of risk" has been used to mean the number of men at risk for the year under observation. A person who lived throughout the year was counted as a full man-year of risk, but one who died during the year was counted as one-half a man-year. Deaths occurring in the cohort, and in which lung cancer is considered to have been proved as a cause, are shown in Table 6. In Table ~ are shown three deaths which have been considered as "suspected" lung cancer cases. An indication of the importance of these `"'suspected" cases in interpreting the results of the calculations is desirable before fur ther discussion of the mortality rates which are derived in later tables. For example, it happens that the rate found for the proved cases is dose to the "expected" rate based on the general population figures for the Province, as will be shown later, and on this basis we should find eight deaths from lung cancer among the cohort. Actually, nine cases were observed. If. however, the 3 additional "`suspected" cases were in cluded. increasing this figure to 12. the total would be very close to the 95% level of significance. However, having found just 12 cases, we are not above this level, and therefore the hypothesis that asbestos miners do not have a higher mortality from lung cancer than does the general population can not be rejected. Nevertheless, the occur rence of 12 cases in this sample would increase the rate to a point which approaches the significant level. Because of the tre mendous imp"Ortance of the questionable cases in this respect, some detail regarding them wiil be given here. In one of these cases, the suspicion of cancer of the lung is based upon the x-ray interpretation, and. although no autopsy was performed, the death certificate indicates that death was due to lung cancer. It is well known that the x-ray appearance of fibrosis, especially if a localized density or a superimposed tuberculous lesion is pres ent, can simulate that of a tumor, and by itself, does not justify the inclusion of this case as one of "proved" cancer of the lung. A second case was certified as having died by reason of hydrothorax, possibly due to lung cancer, but again there was no surgery and no postmortem examination. In the third case, although it was subjected to autopsy, two pathologists disagreed as to whether lung cancer was present. The death was certified as having been due to chronic myocarditis with nephritis, and pulmonary congestion, and possibly cancer of the lung. On the basis of these facts, it seems unwar ranted to include these three cases among Table 7.--"Suspected" Primary Cancer of the Lung Cast So. 1 2 3 Stc 49 4*5 45 Smoker Yes Yes Yes Exposure 32 yr. In Cat. Ill 33 yr. In Cat. HI 42 yr. In Cat. II Ot<l 10-25-30 -53 9-30-55 Autopsy No Yes No Asbestoels No Yes No 642 Vol. 17, June. 1958 LL'XG CASCER IS ASBESTOS MISERS "proved" instances of lung cancer. On the other hand, they cannot, in fairness, be dis regarded completely. It is for this reason that mortality rates have been calculated both ways. Table 8 gives the rates by age groups. The rates by length of employment are shown m Table 9. During the first 40 years of employment, the rate rises, an observa tion which seems plausible since the men were growing older. However, after 40 years of exposure there are no "proved" cases reported for a total of 240 men dur ing the six years, or about 1440 man-years of exposure. When the "suspected" cases are added, one case does show up in this Table 8.--Lung Cancer Deaths by Age Groups Table 9.--Lung Cancer Deaths by Length of Employment Number of Persons and Number of Long Cancer Death:- Length of Etnpioymont No. of Deaths No. of ------------------------------------- Persons Prucod Total 3-9............................. 10-19............................ 20-29.......... 30-39............................ --........................... 59+.............................. l.^S 2J9S 922 03 ISS Si 0 t J S >) 0 0 1 J T 1 0 Totals............ A45S 4 12 Annual Luncr Cancer Death Rates per 100.000 Man-Years of Exposure Length of Employment Pl*v*d Total 5-9............................................. 10-19. .. . 20-29........................................... 30-39.... . 40-49........................................... 30+............................................. A - 54 193 90 0 Over-all............. 34 Nutsber of Persons and dumber of Lung: Cancer Deaths Age Group No. of Deaths No. of ------------------------------------- Persons Proved Tout 20-44..................... 45-54............................. 35-^4............................. 6H-............................... Unknown...... ............. 3,901 1,124 615 313 3 l \ 3 4 0 I Z 3 * > Totals............ 5,95S 9 12 Annual Lung Cancer Death Rates per 100,GOO Man-Years of Exposure Ate uoup Proved Total 2NL...................................... ............. ........................................ 3H4......................................... ^.......................................... Unknown............................. 4 4 44 $1 2$5. < Over-oil......... .. ............. 25 34 period. This would produce a rate oi 69 per 100,00X3, again demonstrating the im portance of these questionable, but un proved, cases to the final conclusion, because, if there were no cases in this number of men with long exposure, and if asbestos is a carcinogenic agent, it must be concluded that these 240 men have demdristrated considerable resistance. This is a bio logical phenomenon which has been observed previously and is consistent with the theory of an intrinsic or endogenous factor in can cer. The only other explanation would be that the susceptible members of this age group had died earlier of lung cancer. Table 18. which appears later in this section, in- dicates that the members of the cohort did not die from lung cancer at a younger age than the general population. The rates by weighted exposure are shown in Table 10. and it will be noted that they present strong evidence against asbestos being a carcinogenic agent, for, if exposure to asbestos is in any way con nected to lung cancer, we would expect that the longer and heavier the exposure, the higher the rate that would be found. The only possible error in this interpretation could occur if the weighted exposures were inversely related to years of employment. Table 10.--Lung Cancer Deaths by Exposure Category Number of Persons and Number'of Lcng Cancer Deaths Exposure Category No.of Persons No. of Deaths ... ... --------- Proved Total . 'X.............................. II.............................. til.............................. Unknown............... 2.031 2.130 1.172 5 4 3 2 4 4 4 0 Totals............ 5.95$ 9 12 Annual Lung Cancer Death Rates per 100,000 Man-\ eat s of Exposure Exposure Category Proved Tota I............................................ It............................................ ......... Ill............................................ Unknown................................ 23 33 31 37 0 Over-all...................... 34 Brcun--Tman. _ _ - - . M3-' }* # `!fj W [ ----- A. M. A. ARCHIVES OF INDUSTRIAL HEALTH Table 11.--Number of Persons in Various Weighted Exposure Categories by Length of Employment Length of Employment Wl(hied EipMurr Catori 1 ll in 5-9 10-19 20-29 30-39 40-49 504- 707 . 59S 663 $S3 314 363 247 31$ 76 67 24 21* 490 851 243 137 41 10 Totals 2.031 Average years of exposure I7i 2.150 17.S 1.772 16.6 - Gnknown 0 1 2 t L 0 5 29j0 Total UU Z396 922 603 185 55 5,958 17-5 _in which case the heaviest weighted ex posure (Category lilt would show the shortest length of employment. Table 11, which lists the number of persons in various exposure categories by length of employ ment indicates that this error has not oc curred. In tact, the average number of years of employment for each exposure category is almost identical. Table 12, which develops the rates for smokers and nonsmokers, is most striking. It shows that not a single case of lung cancer developed among the 1265 nonsmokers and that all cases of lung cancer, both "proved" and "suspected," occurred in smokers. Table 12 was so striking that it was felt that further verification was necessary. It was possible that some abnormal distribu tion may have occurred, e. g.. the non- Table 13.--Number and Percentage Distribution of Smokers and Nonsmokers by Age Groups Ate Group 20-U.............................. 45-54............................. 55-64.............................. 65+.............................. unknown.................... Totals............. Average .............. Xumber Smoker Nonsmoker 3.200 596 411 164 2 659 224 202 150 0 4.673 39.3 1.265 Unknown 12 4 2 t 1 20 40.7 Table 12.--Lung Cancer Death for Smokers and Nonsmokers ==:, ----- r - r- , r. Number of Persons and Number of Lung Cancer Deaths by Stnolaag Habits No. of Deaths Persons Proved Tout Smokers. Nooraokers_________ Unknown 4.673 1.265 20 9 0 0 12 0 0 Totals_______ 5,958 $ 12 Annual Lang Cancer Death Rates per 100.000 Man-Years of Exposure by Smoking Habits No. of Deaths Pro red Total Smokers. ....................... ............... Nonsmokers ........... ........ .............. Unknown.0 32 c 43 0 0 Over-oil.:............................... u 34 smokers may have included a larger percentage of young men. Consequently, ad ditional Tables, 13, 14, and 15 were con structed to show the distribution of smokers and nonsmokers by age, length of employ ment, and degree of exposure. Although there are slight differences, they do not account for the fact that all observed cases of lung cancer were in smokers. In respect to age (Table 13) the combined average age of the smokers was 4.9 years less than that of the nonsmokers. Table 14 shows that as far as length of employment is con- Table 14--Number and Percentage Distribution of Smokers and Nonsmokers by Length of Employment Length of Employment Number Smokers Nonsmokers Unknown 5-9 ............................. 10-19............................. 20-29__-... ..................... 30-39............................. 40-49............................. 50+............................... 1.406 1.967 722 433 110 33 _ 377 42** 19$ 166 75 10 4 2 4 0 0 Totals............ Average length of employment_______ 4.673 17.0 1.265 19.3 20 16.0 Percentage Distribution Age Group Smoker Nonsmok~r 20-44.................................. 45-54................................... 55-04.......... 95+............................... Unknown.................... 6S-5 19.2 Si 3.5 - 54.5 17.7 16.0 lti o.o TocaU........... 100% 100% Unknown 00.0 20.0 JO.O 5.0 5.0 100% Less than 0.05%. 644 Percentage Distribution Length of Employment 5-9........................... 10-19.......................... 20-29.......................... an- . ._ 40-49.......... .............. 304-........................... Totals......... Smoker 30.1 42.1 15.4 9.3 2.4 0.7 100% Nonsmoker 29jS 33.7 15.7 13.1 5.9 li 100% Unknown 50.0 20.0 10.0 20.0 Q.Q 0.0 100% ` - Vz>l. ]7,_JjmC, 1958- LUNG CANCER IN ASBESTOS MINERS Table 15.--Number and Percentage Distribution of Smokers and Nonsmokers by Exposure Category Exposure Cte*oty I............................... II........................... Ill............................... Unknown--.... ........ . Totals_______ Average exposure category___ _______ Number Smokos Nonsmoken US3 1.591 1.425 4 474 452 33$ 1 4.673 1*265 2.0 1.9 Unknown 4 9 0 20 2-3 Percentage Distribution Exposure Category Smokers Nonsmokecs I............................... II............................... hi............................... Unknown............ 33.2 36.2 30.5 i).i 37.5 35.7 26.7 0.1 Totals..--... 1005* 1007c * Unknown 20.0 354 45-0 0.0 100% cenied. the smokers had worked about 2.3 years less on the average than the nonsmokers. With longer exposure and greater age, one would expect the nonsmoking group to show a higher rate if lung, cancer were due to asbestos. Table 15 shows that the average exposure category was almost the same for the two groups. Therefore, this variable seems to be of no importance in accounting for this difference. The result of this additional analysis is that none of these factors appears to lessen the effect of Table 12. Con:parison of the Cohort Experience saith that of the Province of Quebec, Do minion of Canada, and the United States.-- In order to make a comparison of the experience among asbestos miners with that of the general population of the Province of Quebec, statistics were gathered, as stated earlier, in the office of the Division of Demography in the Provincial Ministry of Health. The data on total deaths, deaths front an forms of cancer, and deaths from cancer of the lung were obtained by sex and by county for the years 1950 through 1955. fn addition, all death certificates which specified primary cancer of the lung, and all those which indicated lung cancer but did not specify the origin, were exam ined for the years 1952 through 1955. Table 16 gives a tabulation of the number of deaths from lung cancer in the Province and in me cohort for the years 1950 through 1955, and shows the annual rate per 100,000 in these segments. It will be noted from the table that the mortality Tate for the "proved" cases in the cohort is only slighilv higher than the rate for the Province. When the "suspected'1 cases are' included in the calculation, the rate for the cohort rises to 33.8 per 10*0,000, which is about 50^2 higher than the rate for the Province. This, it will be recalled from the previous dis cussion of the effect of the "'suspected'' cases on the results, approaches but does not exceed the significant level. One further interesting observation from Table 16 is the rather marked increase in the total numfc-er of cases for the Province between 1950 and 1955. It is assumed that at least part of this increase is due to im proved recognition and reporting of lung cancer during the interval. For this reason, the years 1954 and 1955 were thought to be more nearly representative of actual condi tions. Even so, it is quite likely that the general population is not studied for lung cancer with the same diligence with which Table 16.--Comparison of Cohort 'with Province of Quebec Lung Cancer Deaths Annual Persons 1950 1951 1952 1953 LftM 1955 Total wojgST Province 1.19S.OOO 196 220 245 303 3**3 357 1.624 Cohort Total Prove! 5.923 * 3*0 3 3 12 1 0 21 39 Province 1.192.000 193 21S 245 300 3*.3 354 1,612 (excluding asbestos workers) 22.6 33.> 253 223 In tbe Province fipores, it has beea assumed all male Inns cancer deaths nre fee men of 20+* rears. * Approximate midpoint of the enumerated population for 1951. and the estimated population for 1951 (Rapport. Div. <5e Is De* raoerapbie). tNumfcer alive in cohort at berlnnln? of 1952. Braun--Truatt 045 Ac Qroup 3M4 45-54 65-64 65+ Totals A. M. A. ARCHIVES OP INDUSTRIAL HEALTH Table 17.--Lung Cancer Deaths for the Province of Quebec* Estimated t Population "BOO 302400 137,000 121400 1,237,000 Number of Deaths lost Total Certified Specified Primary Total Proved Total Proved 17 13 11 9 67 36 43 29 100 38 69 32 111 33 68 29 293 120 191 99 1935 Total Certified Specified Primary Total Proved Total Proved 17 9 17 9 60 35 56 32 117 57 116 57 148 54 148 54 342 135 337 152 Ace Group 20-44._______ 45-54............. 55-64________ 65+-------------- Over-alL..... Death Rates per 100,000 1951 Total Certified Specified Primary Total Proved Total Proved 1-7 1.4 1.2 17-S 27- 214 50.4 14.4 23.4 27-3 562 24.0 9.7 15.4 &4 t 1955 Total Certified Specified Primary Total Proved Total Proved * 29.7 55.4 1223 1.2 174 41.6 444 2.2 27.7 $4.7 122-3 1.2 154 41.6 44.6 27.6 124 27.2 124 * Data bom death certificates. t Estimate (or population obtained by applyini 1051 peroantaies for ace nouns (or males to tii total population (or ISM. as liven In Rapport. Dlv. de la Demonaphle. this disease is looked for in the miners, and it seems probable that the mortality rates for the Province may be low. This would appear to be substantiated by the fact that the reporting of cases in the cohort showed no such increase over the same period. Table 17 was compiled to show the an nual age-specific lung cancer rate of cases in which the death certificate merely read "cancer of the lung," as distinguished from those in which the diagnosis was confirmed by autopsy, surgery, or biopsy. The term "specified primary" refers to those cases in these two categories in which the tumor was specified as having originated in the lung. It will be noted that, of the total cases reported in 1955, a much higher percentage than in 1954 were specified as primary. The table also shows that a higher percentage of the total cases certified in 1955 were proved, again indicating increasing interest in this disease. A comparison has been made between the age-specific rates shown in Table 17, and those for the cohort, shown in Table 8. An average of the 1954 and 1955 rates for the Province has been used, since the 1955 figure was higher and may have been ex ceptional. This comparison, summarized in Table 18, shows that the observed number of deaths in our sample is not significantly greater than the expected number of deaths, based on the average of the 1954 and 1955 figures for the Province. It is true that, in the case of the age group of 65 and over, the five deaths provide a figure which is almost significant at the 95% level. How ever, it should be noted that this number includes one of the suspected but unproved cases previously reierred to. Furthermore, it is rather likely that the rate for the general population is understated in this age group, for the obvious reason that the exact cause of death in the very old is not Table 18.--Comparison of the Actual and Expected Number of Lung Cancer Deaths by Age~Among Asbestos Miners Ape Group Ptorlnce Total Specified Primary Rate per 100.000 20-44 45-54 55-64 65+ Unknown 1.S 24-5 67.6 m ** r~ Observed No. Expected of Deaths No. of No. of MLoera Deaths Proved Total 3.901 1.124 615 315 3 dOf % l 1 3 1 3 3 2 45 - 00 * Tbe espccted number is -need on tho averaieol the IBM end 1955 ace-spcclflc rmes (or the Province o( Quebec, t Actually O.L 646 Vol. IT, June, 1958 LONG CAXCER IX ASBESTOS MIXERS Table 19.--Age Distribution of Adult Males for Table 20.--Annual Death Rates per lOOflOO for the Province of Quebec, 1951 * Cancer of the Lung in Canada* As* Group Number Perccnuftt Percentage In Cohort Ape Group Group* of Yean 1931-1933 1941-1943 1930-1932 aw*..................... 727.135 63 66 45-54.................... 1&.962 16 19 iHC................... 125.944 11 10 +...................... 113.467 10, 6 Total_____ 1.U6.49S 100 100 Rappon. ism. a matter o the same intensity of interest as it is in younger persons. Voder 30 30-34 36-39 40-44 43-49 30-34 33-39 60*64 63-69 70-74 73-79 $0-44 All Apes 0.2 0.3 L0 0.9 0.9 OA 2.0 3.2 ZM Xfl 3.4 6.5 S2 16.7 $.2 37.2 13.7 39.7 12.5 33.7 *77.8 13.1 34.5 102.9 10.7 S>.* $62J 13.$ }.> S3.9 $.2 27St 11.4 1425 39.7 71J) 2.$ :.i 15A Table 18 also answers a question pre viously raised. It shows that the members - "Mortality from Lunr Cancer In Canada." 1931 to 1932. of the cohort have not died from lung can cer at an age earlier than the general popu lation. and that such an explanation cannot be offered for the absence of lung cancer in 240 men with more than 40 years of increase is particularly marked after age 50, confirming an observation previously made, to the effect that until recently lung cancer has probably been underdiagnosed in the older age groups in the general popu employment referred to on page 643. lation. Before leaving this comparison of the Province with the miners, it should be shown that their age distributions are rea sonably the same. That this is the case can To use these figures for purposes of comparison, it is necessary to combine the rates for certain age groups in order to conform to the age distributions used in this be observed from Table 19. It should be remembered that the miners retire and consequently, it can be expected study. Since the exact populations in each age group for the years indicated is not known, this must be an approximation. that the oldest age group will be larger in However, the rates would be somewhat as the general population. The data presented in Table 20 indicate that the lung cancer rate generally decreases after age 70. There fore, we could expect the rate for all people over 65 to be smaller than the rate for the follows: Ape Group 20-44 45-54 55*64 65-!- Rate 5 27 69 90-95 group between 63 and 75. which would apply These rates are, in general, lower than to the oldest group of miners. It is felt those developed for the total (proved and that by using the whole adult male popula tion. we have developed rates for the gen eral population which are somewhat lower suspected) cases ot lung cancer among the asbestos miners. The only large difference, however, is in the age group of 65 years and than if we had been able to exclude the over, and it is quite possible that the rate people in the general population over 75. for this group may have increased for A comparison between the asbestos miners 'Canada between 1952 and 1954 as it did and the population of the Dominion as a for the Province of Quebec (Table 17). whole was made, using statistical material A further comparison has been made with from several sources. In one source, Phil an over-all rate obtained front the American lips T* gave age- and sex-specific rates for Cancer Society for respirator}- cancer deaths Canada for three periods between 1931 and in Canada in 1953. This rate, for males, 1952. The rates for males are given in is 20.8 per 100,000, or 5 more per 100,000 Table 20. than Phillips' 1950-1952 rate, and compares These figures show strikingly the increase with 25.3 per 100,000 for proved cases and in rates between 1931 and 1952, and this 33.8 per 100,000 for total .cases among the Braun--Truan _^ 647 Assist'*-'- A. M. A. ARCHIVES OF INDUSTRIAL HEALTH Table 21.--Number of Deaths and Death Rates per 100,000 by Age Groups for the Adult Male Population of the United States* At Qroc? 20-44 45-64 55-64 + Total Population 24,544.000 8465,000 6^40,000 5,670,000 ' 44.619,000 Cue, S83 2,979 UH 6,483 16^09 K*l, per 100.000 3.0 3&9 984 UU J7-2 Dtu bam **Viul Statistics ot tbs United States,'* Vol. 1 and 2, MM. asbestos miners in this study. It is there fore obvious that there are no important differences between the rates for asbestos miner; and those for the general population _of Quebec and the Dominion of Canada. Since it is probable that figures for the United States are more complete and, there fore, possibly more comparable to the data for the miners, age^specific rates were com puted from "Vital Statistics of the United States," Volumes I and II, for 1952. These rates have been tabulated in Table 21. It is apparent that these rates compare favorably with those for the asbestos miners as shown in Table S. Still other rates for the United States were obtained from the American Cancer Society, and for males, these were 25.3 per 100,000 in 1953, and 28.0 per 100,000 in 1955. They are not identical with the rate calculated from the figures of the office of Vital Statistics, but this is possibly because the American Can cer Society rates are for males of all ages. Nevertheless, they, too, compare favorably with the rates of 25 (or 34 for total cases) obtaining among the asbestos miners. Turning for a moment to a comparison between the asbestos miners and persons who are exposed to asbestos in one form or another (as distinguished from the gen eral population groups just discused, who have no exposure) an interesting observa tion can be developed by deduction. Hueper15 has stated that there are about 35,000 persons exposed in the United States, and we have found that the Canadian mines employ about 8000. Elsewhere, it has been estimated that the workers in England who have exposure total between 3000 and 5000. With workers in Africa, Denmark, Nor- way, and other countries, at least 50,000 persons must be exposed throughout the world, and it can be assumed that this number has been fairly constant in the 20 years since 1935 when the first case of asbestosis with lung cancer was reported. At least 1,000,000 man-years of exposure has thus been accumulated, and this figure can be divided by the approximately 150 cases of lung cancer with asbestosis re ported during the 20-year period. This gives a rate of 15 per 100,000, which is at least indicative that any lung cancer rate which can be calculated for workers ex posed to asbestos dust is not much greater than that for the unexposed population. Comtarisou Betxoeen Eight Counties Ad jacent to the Asbestos-Producing Areas and Eight Selected Counties.--To compare lung cancer mortality rates in the counties sur rounding the asbestos-producing areas with another group of counties in which no as bestos miners are likely to reside, the rates were compute! on the basis of figures for the years 1950 through 1955. The eight counties selected for comparison were Argenteuil. Chateaugav. Montmagny, Portneuf. Richlieu. Riviere-du-Loup, St. Hvacinche, and Terrebonne, mainly because they represent a wide geographic distribu tion throughout the Province. The counties selected because of their proximity to the asbestos mines include Arthabaska, Beauce, Drummond, Frontenac, Megantic, Rich mond. Sherbrooke, and Wolfe. Table 22 shows the .number of lung cancer deaths for the years 1950 through 1955 for each of these counties, and a mortality rate, based on the adult male population in 1952. To emphasize the comparison, Megantic Counn* has been shown separately, as has the Province of Quebec and also the Prov ince with the eight "asbestos-producing" counties subtracted. Because of its unique lung cancer death rate, Montreal et Isle de Jesus has also been listed in order to provide further comparison. It is apparent from the table that the lung cancer death rate tor the eight counties 648 Vol. 17, June, 1955 i ii ii iii ii LUNG CANCER IN ASBESTOS MINERS Table 22.--Number of Lung Cancer Deaths and Rate per lOOflOO Man-Years Coontfes Metsntle Count? Eight "Adjeceet Counties Eight Selected Counties Provtnoe of Quebec Province ot Quebec less eight "sdiecenc" counties Montreal tt Isle 6* Jesus Adult Mala Population 1952 1950 13.100 97.000 63A l.lK.i*.' 3 $ 3 190 1.100AX) 394,000 190 3 1951 X 3 10 220 217 4 Male Lon* Cancer Deaths 1952 3 9 5 245 236 158 1953 3 16 18 303 2S7 XS2 1954 1 4 5 303 299 185 1955 4 16 9 357 341 225 Total 15 54 49 1624 1570 770 Base per 160.000 15.9 9.4 9.8 22.6 23.$ 324 * It b **ww*t that aU male tunc cancer deaths occurred after ate 30. immediately surrounding the asbestos-pro ducing areas is practically identical \tith that of eight counties selected tor comparison. While Megantic County has a rate nearly twice that of the combined eight selected counties, it is lower than the rate for the Province, and considerably lower than the rate for Montreal. The figure for Montreal would certainly be higher except for the very low numbers of deaths reported for 1950 and 1951, and it would appear that in those years some error in reporting has undoubtedly been made. On the basis of the other years, 1950 and 1951 deaths would be expected to be about 200 greater. This would result in a rate of 40 per 100,000. The only possible conclusion from this comparison is that there is no evidence that the persons who live and work in the coun ties surrounding and adjacent to the as bestos-producing areas have any greater incidence of lung cancer than those who live elsewhere in the Province. Comment on All Recorded Lung Cancer Cases, Living and Dead, among the Asbes tos Miners.--Although a simple enumera tion of all the known or suspected cases of cancer of the lung in these areas has no particular value from a statistical point of view, it is of interest to summarize, such cases for the record. There were nine deaths" prior to the beginning of the time period covered by the study, including one in which the diagnosis was mediastinal lymphosar coma. During the period covered by this investigation, there were nine proved cases and three suspected cases in the cohort. Through 1956 and to date in 1957, there were eight deaths, six of which were merely suggestive of cancer of the lung and in cluded such diagnoses as mediastinal lymphosarcoma, mesothelioma, cancer of the leg with metastases to lung, abscess of lung, and cancer of the pancreas. One other was diagnosed on the basis of x-ray only. In addition, there are now living four cases in which the diagnostic evidence is strongly suggestive of lung cancer. This is a total of 33 cases of all types, including 10 "sus pected" but unproved cases, and 4 that are stilt living. The remaining 19 constitute the total of proved cases of cancer of the lung among the asbestos miners since 1940. The proved cases averaged 59 year; of age at death, and varied between 57 years and 68 years. Their working span covered periods varying from a minimum of 14 years to a maximum of 37 years. Only three men had less than 25 years of em ployment in the industry. Seven among those on whom such information is avail able had a weighted exposure placing them in Category III, and six worked in an exposure represented by Category I. There were only 17 among these proved lung cancer cases in which we have in formation regarding the presence of asbestosis. Asbestosis was present in nine, although it was minimal in two. Two path ologists disagreed regarding its presence in .another. At least seven of the 19 proved lung cancers, therefore, were no: accom panied by asbestosis. Summary and Conclusions Interest in the question of whether there may be an association between lying cancer Braun--Truan 649 ^JSSSi- LUNG CANCER IN ASBESTOS MINERS of 372., 25.3, and 28.0 obtained from various sources for adult males in die United States. Finally, in this matter of comparison, it would appear that the world-wide experience of persons exposed to asbestos dust is not worse with respect to lung cancer than that of the unexposed population. The counties surrounding the asbestosproducing areas, in which it is presumed most of the asbestos miners live, have al most identical mortality rates with those of eight counties widely scattered through the Province, and are lower than those for the remainder of the Province, and much lower than the rate for Montreal. Since 1940 there have been 19 cases in which the diagnosis of primary cancer of the lung may be considered to have been proved. Approximately half of these cases were associated with asbestosis.. All but one died in the recognized "cancer-age" and at least one-third had only the lightest ex posure (Category I) to asbestos dust. On the basis of what are believed to be complete and reliable data, it seems fair to conclude that the asbestos miners in the Province of Quebec do not have a signif icantly higher death rate from lung cancer than do comparable segments of the general population. Furthermore, the death rate from lung cancer in the areas contiguous to the asbes tos operations is comparable to that in areas widely scattered throughout the Province of Quebec and is lower than in some urban ized areas within the Province. REFERENCES 1. Alascio Escobar, R.: Bronchial Carcinoma: Review of 200 Cases, J. IntemaL Coll. Surgeons 26:375-379 (Sept.) 1956. 2 Allen, M. L.: Bronchiogenic Carcinoma As sociated with Pneumonoconiosis: Report of 2 Cases, J. Indust. Hyg. 16:346-347 (Nov.) 193C' 3. Cartier, P.: A Contribution to the Study of Asbestosis, Arch. mai. proiess. 10:589-595, 1949. 4. Anderson, C. S., and Dible, J. H.: Silicosis and Carcinoma of the Lung, J. Hyg. 38:185-204 (March) 1938. 5. Baader, E. W.: Asbestosis, Deutsche med. Wchnschr. 65:407-408 (March 17) 1939. 6. Behrens, W.: Experimental Asbestosis, Schweiz. Ztschr. allg. Path. 14:275-297, 1951. 7. Behrens, \V, Jr.: The Clinical Picture and Pathology of Asbestosis, Ztschr. Unfallmed. u. Berufskrankh. 45:129-140 (June 15) 195Z 8. Berblinger, W.: Increase of Lung Cancer and Diseases Due to Dust Inhatation, Med. Klin. 27:1337-1342 (Sept. 11) 1931. 9. Berenblum, I.: Irritation and Carcinogenesis, Arch. Path. 38:233-244 (Oct) 1944. 10. Bohne: Asbestosis, Deutsche med. Wchnschr. 62:928-930 (June 5) 1936. 11. Bohme, A.: Results of Periodical Examina tions of Workers in an Asbestos Factory, Beitr. Silikose Forscli. 11:34, 1951. 12. Bowles, O.: Asbestos-Milling, Marketing and Fabrication, Information Circular No. 6869, L". S. Department of the. Interior, Bureau of Mines. 1935. pp. 1-26. 13. Breslow, L.; Hoaglin, L.; Rasmussen, G., and Abrams. H. K.: Occupations and Cigarette Smoking as Factors in Lung Cancer. Am. I. Pub. Health. 44:171-181 (Feb.) 1954. 14. Bristol. L. J.: Roentgenologic Aspects of Silicosis and Asbestosis, A. M. A. Arch. Indust. Health 11:189-195 (March) 1955. 15. Cancer of the Lung: An Evaluation of the Problem, Proceedings of the Scientific Section, Annual Meeting, American Cancer Society, Inc.. Nov. 3-4, 1953, New York, American Cancer Society, Inc., 1956. 16. Cartier, P.: Asbestosis Cancer of the Lung, in discussion on Smith, W. E.: Survey of Some Current British and European Studies of Occupa tional Tumor, Problems, A.M. A. Arch. Indust. Hyg. 5:262-263, 1952. 17. Cartier, P.: Some Clinical Observations of Asbestosis in Mine and Mill Workers, A. M. A. Arch. Indust. Health 11:204-207 (March) 1955. 18. Clerens, J.: Research into Pulmonary Asbes tosis in Belgium, Arch, beiges med. Sodale 8:557565 (Nov.) 1951. 19. Clynes: Asbestosis and Silicosis. Brit. M. T. 1:379. 1931. 20. Coffin, G. J.; Duryee, H. C; Maier, H. C; Pardee, H. E. B., and Wynter, E. L.: The Effects of Tobacco Smoking, Panel Meeting, Bull. New York Acad. Med. 32:133-156 (Feb.) 1956. " 21. Cohart, E. M.: Lung Cancer and Economic Status, Cancer 8:1126-1129 (Nov.-Dee.) 1955. 22. Cooke, W. E.: Pulmonary Asbestosis; Brit. M. J. 2:1024-1025 (Dec 3) 1927. 23. Cureton, R. J. R.: Squamous Cell Carcinoma Occurring in Asbestosis of the Lung, Brit. I. Cancer 2:249-253 (Sept.) 1948. 24. Cutler, S. J.; Schneiderman, ^M. A., and Greenhouse, S. W.: Some Statistical Considera- Brattn--Truan 651 A. M. A. ARCHIVES OF INDUSTRIAL HEALTH dons in the Study of Cancer in Industry, Am. J. Pub. Health 44:1159-1166 (Sept) 1954. 25. Davies, D. F.: Current Status of Lung Cancer Research: Some Pathogenetic Aspects, CA 6:169-174 (Sept) 1956. 26. Desneules, R-; Rousseau, I_; Giroux, M., and Sirois, A.: Asbestosis and Pulmonary Cancer, Semaine de.. hop. Paris 23:1820-1823 (Aug. 7) 1947. 27. Doll, R.: Bronchial Carcinoma: Incidence and Aetiology (Milroy Lectures, abridged), Brit M. J. 2:521-527 (Sept 5); 585-590 (Sept 12) 1953. 28. Doll. R.: Mortality from Lung Cancer Among Asbestos Workers, Brit I. Indust Med. 12:81-86. 1955. 29. Donnelly, J.: Pulmonary Asbestosis, Am. J. -Pub. Health 23:1275-12S1 (Dec.) 1933. . 30. Dom, H. F., and Cutler, S. J.: Morbidity from Cancer in the United- States, Pub. Health Monograph No. 29, P. H- S. Publication No. 418, U. S. Public Health Service, 1955, 121 pp. 31. Dorn, H. F.: Cancer Morbidity Surveys: A Tool tor Testing Theories of Cancer Etiology, Am. I. Pub. Health 45:615-621 (May) 1955. 32. Egbert, D. S., and Geiger, A. J.: Pulmonary Asbestosis and Carcinoma: Report of a Case with Necropsy Findings, Am. Rev. Tuberc. 34:143-150 (July) 1936. 33. Eibnan, P.: Pulmonary Asbestosis: Its Clinical. Radiological, and Pathological Features and Associated Risk of Tuberculosis Infection, J. Indust Hyg. 15:165-183 (July) 1933. 34. Eilman. P.: Pulmonary Asbestosis, Proc. Roy. Soc. Med. 34:557 (July) 1941. 35. FeSl, A.: Pneumoconiosis in Asbestos Workers. Presse medL 39:1872-1S74 (Dec. 19) 1931. 36. Fulton, W. B.; Dooley, A; Matthews, J. L., and Houtz, R. L.: Asbestosis: Part III. The Effects of Exposure to Dust Encountered in Asbestos Fabricating Plants on the Health of a Group of Workers, Special Bulletin No. 42, Pennsylvania Department of Labor and Industry, Bureau of Indust Standards, Sept 20, 1935. 37. Gardner, L. U., and Cummings, D. E.: Studies on Experimental Pneumocooiosis: Inhala tion of Asbestos Dust; Its Effect upon Primary Tuberculous Infection, J. Indust Hyg. 13:65-81 (Feb.); 97 (March) 1931. 38. Gilliam, A. G.: Mortality Trends in Lung Cancer, Cancer 8:1130-1136 (Nov.-Dee.) 1955. 39. Gilliam, A. G.: Mortality Attributed to Lung Cancer in the Large Cities of the United States in 1948 and 1949, J. Nat. Cancer Inst 15:1307-1312, 1955. 40. Gloyne, S. R.: Two Cases of Squamous Carcinoma of the Lung Occurring in Asbestosis, Tubercle 17:5-10 (Oct.) 1935. 41. Gloyne, S. R.: Pneumoconiosis: A Histo logical Survey of Necropsy Material in 1205 Cases, Lancet 1:810-814 (April 14) 1951. 42. Gloyne, S. R-: A Case of Oat-Cell Car cinoma of the Lung Occurring in Asbestosis; Tubercle 18:100-101 (Dec.) 1936. 43. Gloyne, S. R-, and Mcrewethcr, E. R. A: Asbestos, Occupation and Health, Supplement to Encyclopedia on Occupation and Health, Geneva, International Labor Office, 1938. 44. Goldblatt M. W., and Goldblatt, J.: In dustrial Carcinogenesis and Toxicology, in In dustrial Medicine and Hygiene, edited by E. R. A Merewether, London, London, Butterworth & Co., Ltd, 1956, Vot 3, pp. 185-188. 45. Haenszel, W. M.: Epidemiological Tests of Theories on Lung Cancer Etiologv, Pub. Health Rep. 71:163-172 (Feb.) 1956. 46. Hammond, E. C.: Lung Cancer and Com mon Inhalants, Cancer 7:1100-1108 (Nov.) 1954. 47. Hammond, E. C: Etiology of Bronchiogenic Carcinoma, CA 6:156-168 .(Sept) 1956. 48. Holleb, H. B., and Angrist A: Bronchiogenic Carcinoma in Association with Pulmonary Asbestosis: Report of 2 Cases, Am. J. Path. IS: 123-135 (Jan.) 1942 49. Homburger, F.: The Co-Inddence of Primary Carcinoma of Lungs and Pulmonary Asbestosis: Analysis of Literature and Report of 2 Cases, Am J. Path. 19:797-807 (Sept.) 1943. 50. Horn, D.: Is Lung Cancer on the Increase? Evaluation of Present Day Evidence: Cancer of the Lung, Proceedings of the Scientific Section, Annual Meeting, American Cancer Societv, Inc, Nov. 3-4, 1953. 51. Homig, F.: Clinical Considerations on the Question of Industrial Cancer of Asbestos Work ers, Ztschr. Krebsforsch. 47:281-287, 1938. 52 Hueper, W. C.: Cancer in Its Relation to Occupation and Environment, Bull. Am. Soc. Control Cancer 25:63-69 (June) 1943. 53. Hueper, W. C.: Significance of Industrial Cancer in the-Problem of Cancer, Occup. Med 2:190-200 (Sepi.) 1946. 54. Hueper, W. C: Environmental and Occupa tional Cancer, Public Health Service, Supp. 209, U. S. Public Health Service; 1949. 55. Hueper, W. C.: A Methodology for Environ mental and Occupational Cancer Surveys, Public Health Monograph No. _1, P. H. S. Publication No. 12, U. S. Public Health Service, 1950. 56. Hueper, W. C.': Environmental Lung Cancer, Indust. Med. 20:49-62 (Feb.) 1951. 57. Hueper, W. C: Occupational and Environ mental Pulmonary' Cancers with Special Reference to Pneumoconiosis, Proceedings, 7th Saranac Symposium on Pneumoconiosis, 1952. 58. Hueper, W. C: A Quest into the Environ mental Causes of Cancer of the Lung, Pub. 652 Vo!. IT, June, 1953 LUNG CANCER IN ASBESTOS MINERS Health Monograph No. 36, P. H. S. Publication No. 452; U. S. Public Health Service, 1955. 59. Hueper, W. C: Environmental Causes of Cancer of the Long other than Tobacco Smoke, Dis. Chest. 30:141-158 (Aug.) 1956. 60. Isselbacher, K. J.; Klaus, H., and Hardy, H- L.: Asbestosis and Bronchogenic Carcinoma: Report of One Autopsied Case and Review of Available literature. Am. J. Med. 15:721-732 (Nov.) 1953. 61. Kennaway, E 1L, and Kennaway, N. M.: A Study of the Incidence of Cancer of the Lung and Larynx, J. Hyg. 36:236-267 (June) 1936. 62. Kennaway, E. L., and Kennaway, N. M.: Studies of Incidence of Cancer of the Lung and Larynx, Brit. J. Cancer 5:153-158 (June) 1951. 63. Klotz, M. O.: Association of Silicosis and Carcinoma of the Lung, Am. J. Cancer 35:3S-49 (Jan.) 1939. 64. Lanza, A. J.; McConnell, W. J., and Fehnel, J. W.: The Effects of die Inhalation of Asbestos Dust on the Lungs of Asbestos Workers: Pre liminary Study, Pub. Health Rep. 50:1-12 (Jan. 4) 1935. 65. Lanza, A. J., editor: Silicosis and Asbestosis, New York and London, Oxford University Press, 1938. 66. Lew, E A.: Use of Life Insurance Com pany Records for Cancer Studies, A. M.A. Arch. Indust. Hyg. 5:198-203 (March) 1952. 67. Linzbach, A. J., and Wedler, H. W.: Occu pational Cancer among Asbestos Workers, Arch, path. Anat. 307:387-409, 1941. 68. Lynch, K. M~, and Smith, W. A.: Pul monary Asbestosis: Carcinoma of Lung in Asbesto-Silicosis, Am J. Cancer 24:56-64 (May) 1935. 69. Lynch, K. M., and Smith, W. A.: Pul monary Asbestosis: A Report of Bronchial Car cinoma and Epithelial Metaplasia, Am. J. Cancer 36:567-573 (Aug.) 1939. 70. Lynch, K. M, and Cannon, W. M.: Asbes tosis: Analysis of 40 Necropsied Cases, Dis. Chest 14:874-889 (Nov.-Dee.) 1948. 71. McPheeters, S. B.: A Survey of a Group of Employees Exposed to Asbestos Dust, J. Indust Hyg. 18:229-239 (April) 1936. 72. Merewether, E R. A.: The Occurrence of Pulmonary Fibrosis and Other Pulmonary' Affec tions in Asbestos Workers, J. Indust Hyg. 12: 198 (May) ; 239 (June) 1930. 75. Merewether, E R- A.: Annual Reports of the Chief Inspector of Factories, 'London, His Majesty's Stationery Office, 1947. 76. Merewether, E R. A_, editor: Industrial Medicine and Hygiene, London, Bu'tterworth & Co., Ltd, 1956, Vol 3. 77. Nordmarm, iL: The Industrial Cancer of Workers in Asbestos, Ztschr. Krebsforch. 47:288302, 1938. 78. Nordmann, M, and Sorge, A.: Pulmonary Cancer Produced by Asbestos Dust in' Experi mental Animals, Ztschr. Krebsforch. 51:168-182, 1941. 79. Phillips, A- J.: Mortality from Cancer, of the Lung in Canada (1931-1952), Canad. M. A. J. 71:242-244 (Sept.) 1954. 80. Saupe. E: Further Contributions to the Roentgenological Diagnosis of Asbestosis, Arch. Gewerbepath. u. Gewerbehyg. 9:391-406, 1939. - 81. Smith. K. \V\: Pulmonary Disability in Asbestos Workers, A. M. A. Arch. Indust. Health 12:198-203 (Aug.) 1955. 82. Smith. L. W.: Pneumoconiosis and Lung Cancer with Special Reference to Silicosis and Asbestosis, Compens. Med. 2:3-10 (Nov.) 1949. 83. Smith, W. E: Survey of Some Current British and European Studies of Occupational Tumor Problems: Part III. Asbestos, A.M.A. Arch. Indust. Hyg. 5--42-263 (March) 1952. 84. Stoll, R.; Bass, R, and Angrist, A.: Asbestosis Associated with Bronchogenic Car cinoma, A.M. A. Arch. Int. Med. 88:831-834 (Dec) 1951. 85. Teleky, L.: Occupational Lung Cancer, Acta Union internat. centre Cancer 3:253-273, 1938; also, Zentrzlbl. Gewerbehyg. 27:33, 1940. 86. Vorwald, A. J.; Durkan, T. M, and Pratt, P. C.: Experimental Studies of Asbestosis, A. if. A Arch. Indust. Hyg. 3 :l-43 (Jan.) 1951. 87. Wedler. H. W.t Asbestosis and Lung Cancer, Deutsche' med. Wchnschr. 69:575-576 (Aug. 6) 1943. 88. Wegelius, C-: Changes in the Lungs in 126 Cases of Asbestosis Observed in Finland, Acta radiol. 28:139-152, 1947. 89. Werber, M.: Pulmonary Asbestosis Asso ciated with Carcinoma- Zentralbl. Arbeitsmed. u. Arbeitsschuiz 2:179-180 (Nov.) 1952. 90. Wood. W. B, and Glovne, S. R-: Pulmonary Asbestosis C6mplicated by Pulmonary Tubercu losis, Lancet 2:954-936 (Oct. 31) 1931. 73. Merewether, E R. A., and Price, C W.: Report on Effects of Asbestos Dust on the Lungs and Dust Suppression in the Asbestos Industry, London, His Majesty's Stationery Office, 1930. 74. Merewether, E R. A.: A Memorandum on Asbestosis, Tubercle 15:109; (Dec.) 1933; 15: 152 (Jan.) 1934. 91. Wyers, H.: Asbestosisr~Postgrad. Med. 25: 631-638 (Dec.) 1949. 92. Wynder, E L, and Graham, E A.: Etiologic Factors in Bronchiogenic Carcinoma with Special Reference to Industrial Exposures; Report of 857 Proved Cases, A. M. A. Arch. Indust. Hyg. 4:221-235 (Sept.) 1951. Braun--Tmatt Printed and Published in the United. Slates of America -- 653