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FILE NAME State of the Art Literature SAL DATE 1976 DOC SAL077 DOCUMENT DESCRIPTION Journal Article - Occupational Carcinogenesis we tt Te eS -* ANNALS OF - . NEW YORK ACADEMY -- OF SCIENCES De - Editors Umberto Saffiotti Joseph K. Wagoner PUBLISHED BY THE NEW YORK ACADEMOY F SCIENCES ANYAAS 271-1 1976 ANNALS OF THE NEW YORK ACADEMY OF SCIENCES Volume 271 OCCUPATIONAL CARCINOGENESIS Edited by Umberto Saffiotti and Joseph K. Wagoner The New York Academy of Sciences New York New York 1976 ee oo sone LUNG CANCER AND MESOTHELIOMA DURING PROSPECTIVE SURVEILLANCE OF 1249 ASBESTOS INSULATION WORKERS 1963 197*4 a ; . 1 a 1 Irving J. Selikoff nd or . Environmental Sciences Laboratory Mount Sinai School of Medicine The City University of New York New York New York 10029 4: >t, man had INTRODUCTION In 1963 it was found that a large group of asbestos insulation workers in the New York metropolitan area had experienced unusual mortality during 1943-1962 Six hundred and thirty men had been on the union's rolls on January , 1943. reaching 20 years employment lung By December 31 1962 262 men had died nine before on the job Of those who died after 20 years from first cancer was found in marked excess 6.02 such deaths had been expected and 42 occurred In addition there were several deaths due to pleural or peritoneal mesothelioma and a modest increase in deaths due to gastrointestinal cancer where 9.71 were expected and 29 were observed There were 12 deaths due to pulmonary asbestosis Table ) TABLE 1 EXPECTED AND OBSERVED DEATHS AMONG 632 ASBESTOS INSULATION WORKERS NEW YORK JERSEY 20 OR MORE YEARS AFTER ONSET OF WORK January 1 1943 to DECEMBER 31 1962 Total deaths all causes ; Total cancer all sites Lung cancer Pleural mesothelioma Peritoneal mesothelioma Cancer of stomach colon rectum All other cancers Asbestosis All other causes Expected 196.16 31.44 6.02 + t 9.71 15.71 164.72 Observed - 253 95 42 3 1 29 20 12 146 * Nine men died before reaching 20 years from first employment Expected deaths are based upon white male specific death rate data of the U.S. National Office of Vital Statistics from 1949 to 1962. Rates were extrapolated for 1943 1948from rates for 1949 1955 Rates are not available but these diseases are rare causes of death in the general population * Supported by the Health Research Council of the City of New York 1272 448 Selikoff Lung Cancer & Asbestos 449 It had previously been established that lung cancer was a formidable hazard of asbestos factory workers and that termination of employment did not abort the risk apparently once sufficient exposure had occurred with continued retention of asbestos within the lung risk remained This factor was of considerable a concern because significant number of men were known to have worked as asbestos insulation workers in the New York metropolitan area and were still in the trade In addition to the 370 survivors of the original 19m4a3ncyohort 890 men had joined the insulation union during the period 1943-1962 and 879 of them were alive on January 1 1963. Together the two groups consti- tuted a total of 1249 men who were either working regularly as asbestos insula- tion workers in 1963 or who had been recorded as having worked regularly at this trade for shorter or longer periods in previous years TABLE 2 MEMBERS OF ASBESTOS WORKERS UNION ON JULY , Union Before December 31 1942. Classification by on or About January 1 1963 1963 ADMITTED TO THE AGE AND SMOKING HABITS Age yr 35-39 40-44 45-49 50-54 53-30 60-64 65-69 70-74 75-79 80-84 Total Total No. 2 13 32 109 60 42 49 38 21 4 370 Never Smoked Regularly 1 2 2 12 6 7 6 7 3 2 48 Pipe Cigar Only Ex- cigarette Smokers 11- 1 11- 2 11- S 6 26 5 16 4 15 8 17 7 12 7 6 I 1 39 101 Cigaret e Current Cigarette SmokerSsmokers 1-9 Day 10-19 20-39 Day Day 40 Day =_ _ _ 523827ml5 WWAZ201 WWAZ201 _ ~ 5238227ml5 WWAZ201 3 5 5238227ml5 WWAZ201 _ 3 5238227ml5 WWAZ201 - 52382 7ml5 WWAZ201 1-11 4 52382 7ml5 W AZ201 1-1 4 52382 7ml5 W AZ201 1-11 1-11 I 523827ml5 Ll 5238227ml5 | 5 17 97 63 * Includes cigarette smokers who also smoked pipes or cigars Before 1963 there had been no regular surveillance of these asbestos workers because they were not aware of their special risk It was considered that potential benefit might be obtained if a program of regular medical surveillance could be initiated with special focus on the principal risks that had been identified namely bronchogenic carcinoma pleural and peritoneal mesothelioma gastrointestinal cancer and asbestosis Of these risks lung cancer took first place In addition to the nsk associated with asbestos exposure a majority of the men had been regular cigarette smokers TABLES 2 & 3 Such history even in the absence of asbestos exposure carried a lung cancer risk of its own It was later to be learned that the combination of the two factors asbestos exposure and cigarette smoking resulted in many more lung cancers than would be assumed from mere summation of the two effects with asbestos exposure sharply increasing the lung cancer risk of cigarette smoking ) * International Association of Heat AFL CLC Locals 12 and 32 and Frost Insulators and Asbestos Workers 450 ; t TABLE 3 4 An als MEMBERS OF ASBESTOS WORKERS UNION ON JULY CLASSIFICATION 1 1963 ADMITTED TO THE UNION January , 1943 BY AGE AND SMOKING HABITS ON TO DECEMBER 31 1962 a . OR ABOUT JANUARY 1 1963 ~ e O Lte LIES Pn. rir 250 . CEE se oe TF Pipe Never Age Total Ex- cigaret e =. nunoninieneieaeehaat arnt An als yr 15-19 20-24 25-29 30 34 35-39 40-44 45-49 50-54 55-59 60-64 60-69 70-74 75-79 80-84 Total Smoked Cigar cigarette Current Cigarette Smokers Annals Smoking No. Regularly we Only Smokers > ee ee 10-19 Habits 25 Day 20-39 Day 40 Day Not Known New 9 New 0 118 19 0 04 8 1 7 4 3 1 York 173 38 4 IS 54 17 S 235 36 9 1 11 72 22 York 151 16 23 6 19 74 10 S 24 2 46 22 Academy 101 3 7 15 6 45 41 12 3 2 40 Academy 40 SN I 4 26 S 0 Academy 20 2 1 3 19 7 t -N 0 Academy 9 - 0 -N 1 i 6 5 4 Academy 7 NO O I 3 - 0 0 0 0 01 30 0 of of 000 0 U0 0 0 NOO 0 000 0 NO O 0 000 0 a 0 0 } o Sciences C 0 Sciences { 0 NO O 0 ) 0 U 0 ) 0 Sciences 879 131 28 92 0 Qo Sciences 17 59 322 170 60 Selikoff Lung Cancer & Asbestos 451 TABLE 4 RAY CHANges in AsbestOS INSULATION WORKERS Onset of Exposure yr 40+ 30-39 20-29 0-9 No. 121 194 77 346 1117 * From Reference 7 Normal % 5.8 12.9 27.2 55.9 51.5 Abnormal % 94.2 87.1 72.8 44.1 48.5 Asbestosis grade 1 2 3 35 51 28 102 49 18 35 17 4 158 0 Q 366 126 50 PROSPECTIVE Clinical Surveillance The program of clinical surveillance that was instituted was based on the realization that the chest x ray offered the best method for early detection of lung cancer then available An initial pilot survey had demonstrated that the cooperation of the workers involved could be expected Examination facilities including ray equipment were set up in the union halls to facilitate attendance of the men it is not known whether equal cooperation would have as readily been achieved had it been necessary to site the survey in hospital facilities The nature of the disease under surveillance required several modifications in usual chest ray survey design First it was considered that the standard yearly chest film would be inappropriate for many of the group as it was later to be shown to be inadequate for many other individuals as well In the preliminary survey chest ray examination had shown that many of the men especially those with more than 20 years from onset of exposure already had considerable asbestosis TABLE 4 If cancer were found it would be best to discover it at a stage at which limited resection as lobectomy or even segmental resection was possible Diminished respiratory reserve might make pneumonectomy unavailable even if the neoplasm was otherwise resectable Therefore serial chest x rays were advised at month intervals for workers with more than 20 years from onset of exposure yearly for those 15-19 years from onset and every 1-2 years for those with shorter histories of duration from onset Further rather than the usual posteroanterior film alone being taken four films were made at each examination two in the posteroanterior projection one with increased penetration and one in each of the two oblique projections With ray changes of asbestosis predominantly to be seen in the lower lung fields and with a known predilection for asbestos lung cancer to be found in these areas it was considered advisable to visualize the lower lung helds as well as possible Other studies were simultaneously undertaken Physical examination with particular reference to the chest abdomen and oropharynx was supplemented by careful occupational clinical and smoking histories fingers were examined for clubbing although it was recognized that this finding would have f^r less diagnostic utility in the presence of asbestosis than it would for sung cancer in general urine hematocrit and serum for rheumatoid factor were examined and pulmonary function studies including FVC and FEV were performed 452 Annals New York Academy of Sciences After evaluation of the findings each man was informed of the results of the examination and when requested a detailed review of the data was sent to the individual's personal physician Confidentiality of examination results was care fully guarded with none of the individual findings made known either to the employer or to the union although statistical summaries of resuits were made available to both In some instances in which it was difficult for the worker to attend for the examination some retired and were living in California Florida or other distant states and others were residing up to 150 miles from the unions headquarters the worker was encouraged to regularly visit his personal physician for similar examination and to send the films obtained for review Also a union health plan included opportunity for regular examination of the worker and his family in a program of general medical surveillance and the advantages of participation in such surveillance were stressed When an abnormality was suspected or found immediate review with the ~ worker's personal physician was sought and details were provided Close co- operation during the ensuing special studies was offered and in many instances the diagnostic and treatment facilities of the Mount Sinai Hospital were requested and utilized LUNG CANCER AND MESOTHELIOMA 1963 1974 From January 1 1963 to December 31 1974 198 of the 370 survivors of the original 1942 cohort died The distribution of causes of death was very much the same as that in the previous 20 years but the percentages within each category and the ratios between observed and expected deaths were appreciably altered TABLE 5 Three factors influenced this change First as the indi- TABLE 5 EXPECTED And ObserveD DEATHS Among 370 New York JERSEY ASBESTOS Insulation Workers January 1 1963 to December 31 1974 Total deaths Total cancer all sites Lung cancer Pleural mesothelioma Peritoneal mesothelioma Cancer of stomach Cancer of colon rectum All other cancers Asbestosis All other causes Number of men Person of observation * Expected 109.04 20.58 6.18 + + 1.17 2.75 10.48 + 88.46 370 3075 Observed 198 105 +7 T 21 ? 7 638 638 68 * Expected deaths are based upon specific white male death rate data of the U.S. National Office of Vital Statistics from 1963 to 1973. Rates were extrapolated for 1973-1974 from rates for 1968 1972 . U.S. death rates not available but these diseases are rare causes of death in the general population 454 ' Annals New York Academy of Sciences TABLE 7 Lung Cancer in New York JERSEY Asbestos Insulation WorkerS January 1 1963 to DecemBER 31 1974 Number as of January 1 1963 Lung cancers to January 31 1974 Deaths due to lung cancer Admitted to Union Before 1943 1943-1962 370 49 48 879 10 9 the Insulation Workers Union in 1942 and 10 cases occurred among the 879 younger men who first became members of the union at some time from January 1 1943 to December 31 1962 Table 7 Review of the clinical status of these 59 men on January 1. 1975 showed that 57 were dead two were alive One a member of the 1942 cohort had been found to have a bronchogenic carcinoma during the clinical survey undertaken in 1963. Lobectomy was performed and observation since has yielded no evidence of recurrence He still works actively at his trade The second man joined the union in 1946. In 1972 he suffered hemoptysis underwent lobectomy and has remained well Both men had been regular cigarette smokers no instance of lung cancer was seen among workers without history of regular smoking Analysis is now underway to study the causes of this dismal record It is already evident that the usual causes for failure in the management of bronchogenic carcinoma were also present here in addition there were other factors such as peripheral location of the neoplasm and early pleurai involvement important respiratory insufficiency and occasional difficulty in radiologic diagnosis due to concomitant pleural and parenchymal asbestosis Twenty instances of pleural and peritoneal mesothelioma occurred in the 1942 cohort and three cases of these diseases occurred in the men who joined the trade more recently All are dead Table 8 There was no effective therapy available TABLE 8 Mesothelioma among NEW YORK JERSEY ASBESTOS INSULATION January 1 1963 to December 31 1974 Workers Number of men Pleural mesothelioma Deaths Peritoneal mesothelioma Deaths Admitted to Union Before 1943 1943-1962 370 7 7 21 21 879 NN 2 --- asbe Dec thes dise clini grat SUC ach draz is to evic the joir 192 we the ---- 28 28 456 Annals New York Academy of Sciences 8. WEISS W. H. SEIDMAN & K. R. Boucor 1975. The neoplasm research project Thwarting factors Philadelphia pulmonary cancer Amer Rev. Resp Dis 111 289 in periodic screening for 297 tung 9. SELIKOFF J. C. Hammond & J. CHURG asbestos insulation workers In 1970. Mortality experiences of tional Pneumoconiosis Proceedings of the Internas Conference Johannesburg 1969. H. A. Shapiro Ed : 57 69 University Press Capetown South Africa Oxford 10. PERNIS E. C. Vigliani & [ J. Selikoff 1965. Rheumatoid factor of individuals exposed to asbestos Ann N.Y. in serum 11. Bader M. R. A. Bader A. S. Acad Sci 132 12120 112 120 Teirstein A. Miller & 1. Selikoff 19TO Pulmonary function and radiographic changes in 598 workers with duration of exposure to asbestos J. Mount Sinai Hosp XXXVII 492 va5ry0i9ng