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FILE NAME Brakes BRK DATE 2004 DOC BRK137 DOCUMENT DESCRIPTION Journal Article - Lung Cancer and Mesothelioma among Male Automobile Mechanics A Review 11904 11904 TL WU bP TUR a REVIEWS ON ENVIRONMENTAL HEALTH VOLUME 19 NO 1 2004 Lung Cancer and Mesothelioma among Male Automobile Mechanics A Review Francine Laden Meir J. Stampfer and Alexander M. Walker . Channing Laboratory Department ofMedicine Brigham and Women's Women's Hospital and Harvard Medical School Boston Massachusetts 2Department 2Department ofEnvironmental Health Departmentof Epidemiology and Department ofNutrition Harvard School of Public Heath Boston Massachusetts ABSTRACT BACKGROUND Extensive overt asbestos exposure clearly causes lung cancer mesothelioma Elevated cancer risk has and also been documented for short term or low levels of asbestos exposure Automobile mechanics are potentially exposed to asbestos through brake repair work Few studies have specifically examined the risk of lung cancer and mesothelioma associated with exposure to asbestos in brakes but automobile mechanics are included in many studies of occupation and cancer METHODS We critically reviewed all epidemiologic studies of lung cancer and mesothelioma risk among male automobile mechanics identified through a broadly based Medline search and scrutiny of references in primary and review articles We discuss the studies grouped by study design and control for smoking the major risk factor for lung cancer CONCLUSIONS We reviewed all individual analytical studies meeting our criteria plus all available case series and case When examined in aggregate the reports evidence did not support an increase in risk of either lung cancer or mesothelioma among male automobile mechanics occupationally exposed to asbestos from brake repair to Dr. Francine Laden Channing Reprint requests Boston Massachusetts Laboratory 181 Longwood Avenue USA mail francine.laden@chaning.harvard.edu francine.laden@channing.harvard.edu francine.laden@chaning.harvard.edu '2004 Freund Publishing House Ltd KEYWORDS epidemiologic studies occupational risk friction material brake repair asbestos INTRODUCTION Extensive overt exposure to asbestos fibers clearly causes lung cancer and mesothelioma Elevated cancer risk has also been documented for short term or low levels of asbestos exposure / Automobile mechanics are potentially exposed to low levels of asbestos through repair of friction materials Few studies however have specifically examined the risks of lung cancer and mesothelioma associated with work on automobile brakes In this paper we summarize and critically review the available epidemiologic studies on the risk of lung cancer and mesothelioma associated with work as an automobile mechanic About 50 of the composition of brake linings and brake shoes consists of chrysotile asbestos encapsulated in a phenolic resin The use of such products in automobiles buses and other heavy equipment causes them to wear releasing a fine dust of amorphous material together with very small fibers 2 Automobile mechanics are potentially exposed to asbestos fibers when they grind used linings bevel new linings or remove the loose dust from the brake drum and back plates using compressed air brushes or wet cloths 31 39 nl , 2 3963 40 F. LADEN M.J. STAMPFER A.M. WALKER OI WUTT NOW "002-8 1 Although total dust counts in the ambient air can reach high levels for short periods of time during these processes control methods such as enclosed vacuum systems or exhaust ventilation systems effectively lower the exposure 4-5 Furthermore the availability of asbestos fibers in used brakes is markedly reduced because high temperatures during braking degrade the vast majority of the asbestos into nonfibrous magnesium silicate 6 Less than one percent of the dust released in work on brakes contains chrysotile fibers that are longer than five microns the size known to be relevant to respiratory health 7 Grinding and drilling of friction pads also releases fibers which have been of concern Detailed study of this material has revealed however that the fibers consistently remained bound to the resin matrix 8 Thus grinding and drilling also appear to pose no important exposure to asbestos fibers The absolute exposure level is influenced by the distance to the source the type and duration of activity as well as by the type of brake For example drum brakes used for trucks buses and certain passenger cars require more cleaning than disc brakes used only in passenger cars 19 Industrial hygiene reports taking measurements of dust and fiber generated during clutch and brake repair work demonstrate that the exposure to asbestos from this work is low intermittent and brief 19. In the 1970s before the current permissible exposure limit of 0.1 mL fibers per milliliter of air was proposed by the United States U.S. Occupational Safety and Health Administration episodic peak concentrations of up to 16 mL were reported during blowing off of loose dust Practically all measured levels published after 1987 however were less than 0.2 mL and weighted average exposures during passenger vehicle repair in the 1980s were generally less than 0.05 mL 10-12 Nonetheless the question remains were these low levels of asbestos exposure associated with carcinogenic risk 31 Concerns about this possibility led to warnings from both government agencies and companies but with little or no epidemiologic evidence We therefore reviewed the epidemiologic studies that provided data on risk of lung cancer and mesothelioma among automobile mechanics METHODS We identified studies of lung cancer and mesothelioma risk among motor vehicle mechanics through computer searches and scrutiny of references in primary and review articles In an attempt to capture all published data on potential exposure to asbestos from work with brake linings we considered general surveys of occupation and cancer risk as well as studies focusing specifically on cancer among automobile mechanics Because of the potential for publication bias by both investi- gators andjournals to highlight positive findings we performed broadly based Medline searches 1966 through August 2003 using as key words cancer lung cancer occupation and mesothelioma We identified many useful studies that might have been overlooked because they did not specifically mention automobile mechanics in the title or abstract We also contacted authors for supplemental data and tables if it appeared that the relevant results were available but did not meet the criteria described for inclusion in the published paper We focused specifically on automobile mechanics as opposed to broad occupational or industrial categories For completeness however we also included papers that discuss the occupation mechanics unspecified Separately we considered papers that do not mention automobile mechanics but from their design and results we concluded that automobile mechanics would have been included if the results had been positive Therefore we included all studies in which specific occupations were considered The review is limited to studies of men 2.3900 2.3900 OI WUZT 80 NOW 002-8 LUNG CANCER AND MESOTHELIOMA IN AUTO MECHANICS 41 Not all studies in this discussion controlled for cigarette smoking Because smoking is such a strong risk factor for lung cancer however and there is evidence that smoking rates may vary by occupation we have placed more emphasis on the studies that included smoking information in their analyses Available occupational survey data on smoking is limited A survey in the U.S. however found that automobile mechanics ranked third in smoking prevalence out of 61 occupations surveyed with twice the average cigarette consumption of many other similarly skilled workers 13 In The National Center for Health Statistics 2000 National Health Interview Survey the prevalence of current smoking among repairers and mechanics was 31.5 among the highest of those occupations presented 14 Also some evidence indicates a higher prevalence of smoking causes of death such as chronic obstructive pulmonary disease COPD among mechanics For example in the 14 year state National Occupational Mortality Surveillance NOMS study covering 66,150 deaths among male automobile mechanics the proportional mortality from COPD was statistically significantly elevated at 1.15 15 Studies that do not control for smoking are therefore likely to be confounded and to overestimate any association between work as a vehicle mechanic and risk of lung cancer As an illustration Carstensen and colleagues 17 found that accounting for smoking eliminated an apparent excess lung cancer risk in mechanics and repairmen in Sweden We discuss separately studies of lung cancer and mesothelioma The details on study design including study population assessment of exposure and outcome comparison population and factors adjusted for and the main results are presented in the tables We present the risk estimates standardized mortality ratios SMR standardized incidence ratios SIR proportional mortality ratios PMR odds ratios OR relative risk RR among others and their statistical significance as the authors did including confidence intervals or p values whichever are available We made no attempt to calculate additional estimates from the information included in the papers The tables are organized by study design and for lung cancer by whether the authors controlled for smoking in their analysis LUNG CANCER Studies of Populations of Automobile and Bus Mechanics We identified five studies that focused specifically on populations of automobile and bus mechanics Table ) Jarvholm and Brisman 17 and Hansen 18 identified automobile mechanics through population census data and Schwartz 19 extracted this information from the usual occupation recorded on death certificates Rushton et al 20 and Gustavsson et al 21 constructed their cohorts and determined exposure from employee work history records at bus garages in London and Stockholm respectively In all but the Hansen study the cancer risk of the exposed population automobile mechanics was compared with the risk in the general population Hansen instead constructed a comparison group of skilled workers including carpenters electricians instrument makers dairymen upholsterers and glaziers This group was thought to be similar to automobile mechanics in terms of physical demands style including smoking geographic distribution and socioeconomic status With the exception of the Jarvholm and Brisman study SMR 1.70 0.01 17 no significant association of lung cancer risk with occupation as an automobile mechanic emerged from these studies Gustavsson and colleagues 21 calculated cumulative exposure to asbestos as well as diesel om pl tom tt re mge p ta hel m a ow teh wT mmm emtre a =-_. h 0 lCt 0 im Pb Si1904 Si1904 OI WHET NOW 002-8 LUNG CANCER AND MESOTHELIOMA IN AUTO MECHANICS 43 exhaust over a year period extrapolatfirnogm work histories and a current industrial hygiene assessment The authors observed a statistically nonsignificant elevation of lung cancer incidence overall SIR 1.61 95 CI 0.94-2.57 but no response association with asbestos exposure Schwartz reported a PMR of 1.12 95 CI 0.821.53 and the SMRs reported by Rushton et al 20 and Hansen 18 were not elevated None of these five studies adjusted for smoking Survey and Cohort Studies of Occupation and Cancer These studies were undertaken to understand the relation between a variety of occupations and the risk of lung cancer specifically or cancer in general in a defined population Table 2 Most relied on cancer registries or death certificates for outcome and exposure assessment usually defining exposure as last known or usual occupation Lung cancer rates among automobile mechanics are compared either to rates in the general population or to rates in the entire cohort under study Two large cohort studies controlled for smoking In the most comprehensive survey of cancer and occupation Blair and colleagues 22 evaluated the relation between occupation and specific cancer sites over a year period in 293,958 U.S. veterans 22 Information on usual occupation was obtained through two interviews administered near the beginning of follow in 1954 and outcome information was extracted from death certificates through 1970. The study was updated through 1980 by Hrubec 23 At the interview information on smoking habits was also obtained Risks for each occupation and each cancer site were calculated within categories defined by smoking habit No excess of lung cancer was found for automobile mechanics in the original Blair report SMR 0.05 or of cancer of the respiratory system in the update SMR CI 0.89-1.36 In contrast and as expected risks were elevated for lung cancer in occupations with known asbestos exposure such as shipyard workers and plumbers Carstensen and colleagues 16 took advantage of Sweden's extensive population records system to evaluate the incidence of lung cancer The authors focused on 1.6 million men aged 30 to 64 who were employed in 1960. The researchers reviewed national cancer registry files for any occurrence of lung cancer from 1961 through 1979. Occupation was determined from the 1960 _ census Carstensen's group did not attempt to evaluate the smoking habits of each worker but they did estimate the amount of smoking in each occupational group based on surveys and used those data to adjust for smoking indirectly After such adjustment the SIR for mechanics and repairmen taken together was 1.07 95 CI 0.921.22 No separate more specific estimate was made for automobile mechanics alone The remainodfetrhe cohort studies relied solely on registries or death certificatfeosr information on occupation and disease surveillance in a given geographic area Therefore information on potential confounders including smoking was not available The results from these studies were mixed Enterline and McKiever 24 observed a statistically significant association of work as an automobile mechanic with lung cancer mortality in the U.S. population in 1950 SMR= 1.28 Milham and colleagues 25 surveyed deaths in Washington State first in 1976 with updates every 10 years through 1999 26 In the 1999 publication the PMR for lung cancer deaths among automobile mechanics was statistically significantly elevated at 1.15 This result is similar to the findings reported in the NOMS study described above which included residents in 28 states In the latter study the PMR was 1.16 for white and 1.08 for black automobile mechanics 15 Although the excess mortality for each group was modest the sample size was large hi 7.3900 TABLE 2 44 7.390 General surveys of cancer and occupation organized by control for smoking lung cancer results 70-453174 Author | | Number | Comparison automobile Sample 770-453-1734 Outcomes Outcome Study population included size mechanics Exposure assessment | population no Cases 70-4531 Controlforsmoking Blair 1985 US Veterans age 31-84 in |cancer | 1953 deaths _T|otaldeaths |NA ~ 107,563 | | usual occupation cohort from questionnaires fe F. Hrubec et 1992 23 US Veterans who served | All deaths fr 1917-40 and held health | 1954-80 Insurance policies age updated from | 31-84 in 1953 Blair 1985 248,046 Total deaths |NA -164,785 -164,785 usual occupation from questionnaires Entire cohort . Nonsmokers 2 0.7 Current cigarettes 50 RR CI 0.93-1.49 Total smoking LADEN adjusted 63 RR CI 0.89-1.36 STAMPFER STAMPFER al 19882 | 30-age6304-64 1961-79 A.M. : n 1,622,547 Lemn for Didnotcontrol smoking Richard Enterline & United States males age |cancer NANA WALKER McKiever 1963 |20-64 deaths 1950 24 Richard Milharn WashingtonWashington State US | Alldeaths "| 681,485 DC DC General population with |119 SMR PMR work experience 0.05 | | ID Ossiander whites age 220 Males 1950- da 2001 26 99 Males fe BAI fr 811,526 fo a) Een ee NIOSH 2002 | National Occupational All deaths NA NA 00 NOMS population Whites 5,743 PMR 08:14 Ue 15 Mortality Surveillance p /0.01 + NOMS 28 states age 15-90 1984-1998 Blacks 769 PMR p /0.05 MON BO AN 8-204  TABLE 2 7 General surveys of cancer and occupation organized by control for smoking lung cancer results Number of Comparison Results for automobile PAGE F Author Studypopulation Outcomes Sample mechanics Exposure assessment Comparison mechanics Cases wt Andersen al Denmark 1971-1987 cancer Cancer "| 353,757 | Cancer Registry General population and fF ~~ 1999 |Sweden 1971-1989 cases | cases 7 : LUNG Oe ae + Norway 1971-1991 ege | mil CANER Nw aofPe: < wo fF Leigh 1996 California Occupational cancer | All deaths - NA DC General population Deaths Menck13 1979-81 173,438 AND Lung cancer - Henderson 2,161 1976 28 Petersen & California US white Cases Total deaths 1,833 DC MESOTHLIA Generalpopulation 69PMR0.05 IN AUTO | 1959-61 Milham 1980 males age 20 --200,000 --200,000 2 29 Hit Olse198n7 |Denmark etl 30 i = MECHANIS Whole cohort 34 SPIR0.88-1.63 Dat Morrison 1957 | Scotland males age 15 31 1,795,273 Pearce New Zealand males agecancer Howard 1986 15-64 RII 32 RII RII RIee General population Not mentioned General population 10 sample Census at mentioned ie ID 45 08:14 00 MON 00 00 ae 8-204 TABLE 2 continued General surveys of cancer and occupation organized by control for smoking lung cancer results 46 PAGE i | | | | | Exposure assessment | | ae Sample Comparison mechanics Author population Outcomes Number of mechanics Comparison Results for automobile 770-703 Minder and Working population Cancer deaths |Cancer NA -- General population Not mentioned" 70-703 Ponizek Switzerland males age | 1979-82 deaths- deaths- 230 1992 33 4,008 770-703 770-703 Howe & 10 Sample Canadian | cancer deaths | deaths NANA Death Registry Whole Not elevated Lindsay 1983 [ Labor Force males 1985-73 - 19,374 Unemployment 7 oe F. 89 415,201 Cancer Commission LADEN 4,203 LADEN Lung M.J. Lindsay et 10 sample Canadian |Cancer CancersCancers NA Death Registry | Whole cohort Not mentioned STAMPFER 1993 34 Labor Force males 1965-79 9,739 1961 Et 415,309 STAMPFER PER Firth et al New Zealand males age cancer |cases- NA C^ncerRegistry General employed Not mentioned A.M. Se he 199635 | 15-64 cases 1972-84 |26,207 population total me, WALKER AA Eat cancer registry WALKER Abbreviations death certificate from number not available proportional mortality ratio standardized incidence ratio standardized proportional incidence RW ratio standardized mortality ratio oN Confidence intervals are 95 unless otherwise indicated results are for automobile mechanics unless otherwise specified :: ID mechanics and repairmen nonspecific mechanicsiron and metalware workers grouped together not specifically automobile mechanics D70 0 0 D70 0 0 D7000 D70 08:15 D70 0 MON D70 0 0 Ww +i 8-204 1900 aon 101 WOST NUW ^ 002-8 LUNG CANCER AND MESOTHELIOMA IN AUTO MECHANICS 47 and the PMRs were statistically significant In another large study in the Nordic countries Andersen and colleagues 27 observed an elevated SIR 1.2 95 CI 1.2-1.4 for lung cancer among mechanics and iron and metal workers grouped together 27 The results for automobile mechanics were not presented separately The Leigh study mentioned earlier observed an SMR of 1.31 95 CI 1.08-1.54 in the California Occupational Mortality Study The authors did not control for smoking however although in the same publication they discuss the high smoking rates in this occupational group 13 Menck and Henderson 29 surveyed incidence and mortality of lung cancer in Los Angeles County and reported a statistically significantly elevated SMR for lung cancer in the automobile repair industry The authors examined a wide range of occupations including automobile mechanics but listed only _ the occupations with elevated rates Automobile mechanics were not included in that list Petersen and Milham 29 Olsen and Jensen 30 did not observe a statistically significant excess of lung cancer among automobile mechanics in California and Denmark respectively For comparison we examined the risks of lung cancer reported for other occupations included in these studies Consistently occupations with known asbestos exposure such as pipe fitters shipyard workers and steel workers had elevated risks of lung cancer Our search cohort studies identified five that defined additional exposure survey to the occupational level but did not mention automobile mechanics 31-35 For these studies we surmised from the level of detail of the occupation and exposure assessment that automobile mechanic would have been reported if an excess risk had been observed Typically such broad surveys examine dozens or even hundreds of categories but only present the positive or interesting associations That occupations with asbestos exposure are often identified as linked with lung cancer risk coupled with silence regarding automobile mechanics provides further although indirect confirmatory evidence against an association Control Studies We categorized the control studies by " whether the study controlled for smoking * the source of the control population and whether they specifically include information on automobile mechanics as opposed to a broader category of mechanics Control for smoking and other risk factors is closely related to the selection of the control population as most population and hospital studies can obtain information on potential confounders whereas certificate studies are not The details are presented in Table 3 The studies that rely on controls selected from the general population and include complete job and smoking histories collected by interview are the most informative In a U.S. study in areas of New Jersey with high lung cancer rates Schoenberg and colleagues 36 identified 763 lung cancer cases from the state cancer registry and 900 population controls The authors defined automobile mechanics as anyone working for at least 3 months after age 12 in that profession The adjusted OR was modestly elevated but not statistically significant OR = 1.4 95 CI 0.84-2.30 Vineis 37 and others incorporated these data with similar information from cancer registries and cooperating hospitals in Louisiana Florida Pennsylvania and Virginia but also found no statistically significant differences between the case and control groups in previous employment as an automobile mechanic Lerchen and coworkers 38 in New Mexico compared 333 men with lung cancer to 499 men selected from the state's eed F IF6 yawanyawan Djeu Djeu IN IN 271 n 80 , ,> , P.10 ' TABLE 3 control studies organized by population type Lung cancer results 48 ' 70-493-1734 Author Study population | Outcomes Exposure Controls Adjustment for Mechanic Lung cancer included assessment definition number Results Studies that control for smoking 70-4931 Schoenbergal |geo | cancer _| Interview 1987 36 Arewitah hisgh | 763 fatima cocu InclinuVdineeisdet | lung cancer rates al 1988 fr 1967-76 white pational history job moafter Race age =| Auto mechanics - |084-2,3 residence case Interview control smoking - ne males 1980-81 age Poe, rae Viners et al 1988* 37 Data fro5 mUS control Lung cancer 2,973 Interview lifetime Age birth cohort | Auto brake smoking worker OR 0.9-1.7 LADEN studies hospital and population based residents occupational history job 06 mo case M.J. control OR 0.9-1.7 STAMPFER STAMPFER ofLAFL PAVA NJ Lemn etal Lerchen 1987 | New Mexico |,Lung cancer A.M. 38 Hispawhinteiancd | males 333 WALKER Richard otherwhitemales | WALKER | Leveit nal 1988 Shanghai China | cancer | Interview General population Age smoking Auto mechanics NA 39 males age 35-65 | 733 Lifetime occ 760 1984-85 1 ID history job not mentioned after age yr 16 13a AM : : Abbreviations DC = death certificates number odds rafo standardized mortality ratio relative risk 08 08:16 Confidence bounds = 95 Cl unless otherwise indicated 04 MON ' 08 Includes data from Schoenberg et al 1987 other studies did not make our cut so not included individually Nov 8-204 5 I'd TABLE 3 control studies organized by population type Lung cancer results 11 : Author Study population Outcomes Exposure Controls Adjustment for Mechanic Lung cancer included assessment definition number Results PAGF as | =| | IntervieItwe Williams et al 1977 Third National cancer ime Not reported 70-4931734 40 | Cancer |males | recent elevated 70-493 1734 : 70-4931734 U.S. Bums & Swanson Detroit an Lung cancer ae Cancers of colon or LUNG 7 : Motor vehicle : ALL 1.72 1991 90 Occupational 70-4931734 CANER See Swansonetal |Cancer Incidence 1993 Surveillance AND System age 40- 5,935 rectum 3,956 race compared to occupation and industry with least potential for exp to mechanic occupation v case control blacks 1.15-2.59 BLACKS 4.16 1.27-13.64 85 1984-87 carcinogens only case control et al Swanson 1993 } seeBums & 41 Swanson 1991 MESOTHLIA | Automechanics a IN AUTO Lemn Benhamou etal Richard MECHANIS 198842 France 1976-80 Lung cancer n 1,260 Interview Hospital based non- Gender age lifetime occ tobacco related disease ~=| hospital history y1ear | cases admission , 2,084 i interviewer smoking Motor vehicle mechanics case control 1.06 0.73-1.54 RRrelative ID Abbreviations DC = death certificates number odds ratio standardized mortality ratio risk Confidence bounds = 95 Cl unless otherwise indicated 13a AM 08 49 08:16 04 MON 08 Nov 8-204 pe 12> TABLE3 continued control studies organized by population type Lung cancer results 50 Od 1727 Author Study population Outcomes Exposure Controls Adjustment for Mechanic Lung cancer 1727 included assessment definition number Results Spinelli et al 1990 | Diagnoses at 43 Cancer Control All cancer 6,389 Medical records | Hospital based other usual occupation | cancers Age yrnot | mechanics | NA control for not listed as 70-93 AgencyofBritish Columbia Canada males Morabia et al 1992 | 24 hospitals in 9 Lung cancer | Interview smoking : . elevated Hospital based other Age race Mechanics OR 44 metropolitan 1,793 usual occupation | cancer and cancer hospital date of {| repairmen auto areas US males admittances 3,228 admission controls F. 1980-89 smoking LADEN | Zahetmal1989 | Missouri US cancer | Registry Other cancers reported =| Age smoking Mechanics 45 white males 1980- | 4,431 occupation at | to Regis-terxcyl hip diagnosis repairers OR 1.0-1.7 wot M.J. unknown 11,326 Breslow et al * HAW7 STAA.MPMFE.R 1954 47 California US 11 hospitals 1949-52 | cancer 518 | Interview Employed in occupation at least 5 years n | Cs oe epeens Hospital based Non- cancer chest disease cases 518 : Age race | gender smoking available Mechanic and | repairmen not elsewhere classified cases 15 ee Not calculated Ae controls ET Wang et al 1995 Tianjin China Lung cancer | Registry most Other cancers 14,685 | Used survey data | Mechanicsrepair -| Notmentioned as WALKER 46 males > 20 1981- | 4,806 recent rank =} industrias elevated 87 occupations by AMET occupation smokingstatus | : yous: IN doo... Decoufle & Roswell Park All cancer Interview Hospital based Non- Age smoking Mechanics and Ever employed Stanis awczyk1977 | Memorial Institute { 6,434 ID 48 Buffalo NY US workers white males lifetime occ history cancer cases unexposed clerical repairmen lung ca case employed 5 yrs 1.12 0.05 Employed 5 0y.r0s5 TA 1956-65 EmployedEmployed lung cacase 1.10 0.05 AM U0.1 Abbreviations DC = death certificates number odds ratio standardized mortality rabo relative risk Confidence bounds = 95 Cl unless otherwise indicated 08:17 MON APL 8-204 C ,a ea 101 WB2 80 NUW 6002-8 NON LUNG CANCER AND MESOTHELIOMA IN AUTO MECHANICS 51 population The authors found proportionately fewer automobile mechanics identified as in the Schoenberg study among the cases than the controls OR = 0.9 95 CI 0.5-1.9 A similarly designed study in Shanghai China did not mention automobile mechanics in their results 39 Next we review control studies that compare lung cancer cases to men with other kinds of cancer This approach is not as reliable as selecting controls from the general population because the authors must assume that automobile mechanics are at the same risk as the general population for those other cancers used for comparison As in the general population studies work and smoking histories were obtained by interview Williams and colleagues 40 compared lung cancer cases with other cancers in the Third National Cancer Survey population No excess of lifetime or most recent work as an automobile - mechanic was found among cases compared with controls 40 Burns and Swanson 41 working in the Detroit Metropolitan Area found a statistically significant OR for automobile mechanics when comparing lung cancer cases with colorectal cancer cases OR = 1.72 95 CI 1.15-2.59 This result more likely represents a deficit of automobile mechanics among patients with colorectal cancer than a direct link with lung cancer In a follow of this study the authors evaluated the risk of lung cancer by number of years employed in specific occupations separately for black and white men The authors observed a significant excess of automobile mechanics who had been working for at least 20 years among black lung cancer cases OR = 6.9 95 CI 1.4-35.0 but not among white cases OR = 1.5 95 CI 0.70-3.00 The number of black cases and controls was small however and risk did not increase linearly with increasing years of employment in either white or black subjects Three control studies compared men hospitalized for lung cancer with men hospitalized for other causes controlled for smoking and specifically assessed automobile mechanics None of the three studies found an excess of automobile mechanics among the cases compared with the controls 42-44 We also identified six additional control studies using cancer controls that included results for a more general grouping of mechanics presumably including automobile mechanics Zahm et al 45 observed a modest excess of mechanics and repairers among lung cancer controls in Missouri OR = 1.3 95 CI 1.0-1.7 The other five studies found no material association between work as a mechanic and lung cancer risk 46-50 In three certificate based control studies the controls were drawn from among the lung cancer deaths in the general population These studies relied on the information provided on the death certificate to determine usual or last occupation and did not control for smoking Dubrow and Wegman observed 29 51 and Milne and colleagues 20 more automobile mechanics 52 among their cases than among their controls Neither result was statistically significant In a similarly designed study by Finkelstein and colleagues 53 % fewer automobile mechanics were found among lung cancer deaths than among other deaths MESOTHELIOMA Control and Cohort Studies Exposure to asbestos is strongly associated with risk of malignant mesothelioma of the pleural and peritoneal lining A baseline incidence of the disease is not attributable to asbestos exposure but in the majority of cases some contact with asbestos can be documented 54 Although only amphibole fibers as opposed to chrysotile the asbestos form used in friction products have been consistently ee EI'd ELI // // , p, ue >yot, a 80 to 80 now Pl 390d QI WUST NOW "002-8 52 F. LADEN M.J. STAMPFER A.M. WALKER linked with the disease 54 the association of mesothelioma with work as a brake mechanic has been explored We reviewed this literature here Table 4 Several of the studies discussed above included mesothelioma as well as lung cancer Four mesothelioma cases were reported in the cohort studies focusing on automobile and bus mechanics one each by Jarvholm and Brisman 17 and by Hansen 18 and two by Gustavsson et al 21 In all cases the authors mentioned possible other types of exposure to asbestos from previous employment and concluded that no suggestion of an increased risk of mesothelioma could be ascribed to work as an automobile or bus mechanic Mesothelioma was reported in three of the general cancer surveys Olsen and Jensen 30 stated that no mesothelioma cases were reported among men who repaired automobiles and motorcycles in Denmark Dubrow and Wegman 55 reported on mesothelioma but did not observe any cases among automobile mechanics The NOMS study reported 18 mesotheliomas among white automobile mechanics PMR = 0.77 and 2 among black mechanics PMR= 1.54 15 The Blair study of cancer mortality among U.S. veterans did not mention mesothelioma 22 and the follow study by Hrubec et al 23 grouped all respiratory cancers together We identified 11 studies that focused on mesothelioma and occupation 56-67 None of these studies reported a significant association between mesothelioma and work specifically as an automobile mechanic Malker and colleagues 68 observed a statistically significant elevated incidence of mesothelioma among the broad category of mechanics and repairmen not limited to automobile mechanics This finding however was based on only 16 cases dispersed across a variety of industries including railroad equipment manufacture sugar factories and shipbuilding so whether the cases were exposed to asbestos through work on brakes is unclear Jarvholm and Brisman's study 17 cited earlier extended Malker's work focusing more closely on automobile mechanics among whom only one case of mesothelioma was found All these studies reported an increased representation of insulation workers and other jobs with overt asbestos exposure among the cases lending further credibility to the null findings for automobile mechanics Woitowitz and Rodelsperger performed a casecontrol study of 324 cases of mesothelioma in Germany and presented the results relating to automobile mechanics in a separate publication 69 The authors identified 16 automobile mechanics among the case patients and 16 among 315 hospital controls most of whom had lung cancer and 12 among 182 population controls The comparison between the cases and the hospital controls is uninformative because lung cancer is also hypothesized to be associated with the exposure No evidence of an excess risk of mesothelioma was found for automobile mechanics using the population controls The authors include individual descriptions of duration of employment history of brake service and other asbestos exposure for each automobile mechanic All work histories were very similar regardless of their disease status Because no comparison statistics including ORs were calculated and the nature of this study was primarily descriptive it may be more appropriate to consider this investigation a case series as opposed to a formal control study In 2001 Wong 70 published a meta analysis combining the results from six studies that assessed mesothelioma among automobile McDonald and McDonald 1980 57 Teta et al 1983 58 Spirtas et al 1985 60 1994 61 Woitowitz and Rodelsperger 1994 1691 Teschke et al 1997 63 and Agudo et al 2000 65 Wong calculated the RRs for the individual studies from the available data when they were not ^ ELI-04/ ---- -- -- -- -- eGI to 80 AON } P.15 TABLE 4 Studies of mesothelioma among male automobile mechanics P Author | Study Population | Outcome Assessment | Exposure assessment | Comparison population Mesothelioma Results sal Studies ofall cancer including a mention ofmesothelioma 70-493174 construction | [ Jarvholm & Brisman 1988 17 Males age 20-69employed Death Registry asmechanicor carrepair 1961-73 In 1960inSweden Cancer Registry General population Car repairmechanic cases1 also worked as worker 21.905 21.905 1961-79 Occupationally LUNG Hansen 198918 active skilled Death Registry DC Carpenter electrician Auto mechanic or mechanic employed at 70-4931 | maleworkers age 15-74in |1970-80 instrument instrument maker dairyman repair workshop CANER 70-493-1734 1970 In Denmark 21,800 upholsterer glazier cases = 51,747 AND Gustavsson et al [|Malesemployed least |Death Registry& other 1990 21 monthsStockholm | local records 1952-86 generalpopulation MESOTHELIOMA garagesfrom 1945-1970 CancerRegistry Stockholm occupationally active populationand |cMeachsaneiscsservicemen hastlers and Repair vehicles cycles MESOTHELIOMA motor and | Olsen & Jensen DenmarkDenmark all cancer Cancer Registry ; Supplementary Whole cohort of cancer of motor 1987 30 1970-79 Supplementary pension | pension fund central cases cases IN 90,651 fund central population | population registry registry AUTO Dubrow & Massachusetts US all DC OC Lemn Wegman 1984a [1871-73while age 55 males 220 populatvioenr MECHANIS NIOSH200215 |NationalOccupational DC 18 Mortality Surveillance NOMS 28 states age 15- Richard 901984-1998 cinthosis DCbasedOtherauxiliary |Mechanicsand repairman vehiclegrouped diseases exceptcancerand no casesmentioned of the NOMS Automobile mechanic Pleura and peritoneal - Whites 18 0.77 Blacks 2 PMR 0.05 = TO Abbreviations DC death certificates number odds ratio proportional mortality ratio relative risk standardized incidence rate standardized mortality ratio Confidence bounds= 95 Cl unless otherwise indicated 15a 08 08:1 04 MON 08 Nov 8-204 P.16 TABLE 4 continued Studies of mesothelioma among male automobile mechanics ** * w 54 Author i Study Population Studies that focus on mesothelloma a Outcome Assessment | Exposureassessment | Comparison population | , | Mesothelioma Results - 70-4931 | McDonaldal = |Quebec Canada deaths from Identifiedthrough 197056 pleural and peritoneal registered pathologists mesothelioma 1959-67; 165 = : | McDonald and Quebec Canada 1959-72 Identified through McDonald 1980 =|and USA 1972 deaths from | registered pathologists Ever employment from |Primaryand secondarylung | Brakelining installation | next cancerdeathsfrom same |cases controls questionnaire pathologists ' . each pereach case . Next | questionnaire Secondary lung cancer deaths from same Garage workers cases controls 57 includes pleural and peritoneal pathologists 1 cases from mesothelioma in 344 men F. McDonald et al 1970 LADEN Teteet 1983 Industry Automobilerepair | and STMA.MJP.FER 58 |Connecticut USA deaths |Connecticut Tumor from mesothelioma and Registry confirmed by other pleural tumors males | pathology review > 30 yrs 1955-77 136 mesotheliomas 11 other employment directories for, employment 10 20 before RandomsampleofDCfiles Joblitle automobile mechanic - cases not listed related RR - >| services . 0.65 population services 0.8-5.3 0.8-5.3 STAMPFER Makeret 1985 |Sweden incident National Swedish Cancer|1960 Census 59 mesotheliomas 1961-79 _| Registry Lemn A.M. 318 ; General Swedish Mechanics and repairmen SIR 0.01 " 1975-1980 WALKER Spirtasetal 1985 60 LA County CA State |Cancer Registry Vatarans | Next Interviews |; Not specified ves ae : lining installation orrepair 0.6-1.6 0.6-1.6 Richard | | ( from | lining work Spirtaset LACountyCANYState CancerRegistriesand 1994 61 Veterans Admin hospitals | VA Central Office update of Spirtas mesothlmasmesothellomas 1975-1980 Next Interviews Deathcausses other Brake or repair than cancer respiratory cases 15.8 controls 13.5 at disease suicide or violence | least 55 had additional overt asbestos et al 1985 208 confirmed cases 533 exposure Motor 16a University AM Giessen Woitowitzand |Patients at theOutpedient | Hospital setting Rodelsperger dinle of and Interview ; 315 lung cancercases population controis -- . Motor vehicle caseslung mceacnchearnccontrols ID 1994 69Rodelsprg .| SocialMedicinethe populationcontrol1s2 GiessenGermany 08 * mesotheliomas324 08:19 Abbreviations DC = death certificates nenumber odds ratio proportional mortality ratio relative risk standardized incidence rate standardized mortality ratio 04 MON Confidence bounds = 95 Cl unless otherwise indicated 08 Nov 8-204 rd ~ TABLE 4 Studies of mesothelioma among male automobile mechanics Author Coggon et al 1995 62 Study Population Outcome Assessment England and Wales males DC age 20-74 cancer of pleura 2,848 cancer of peritoneum 362 asbestosis n281 1979-80 82-90 Exposureassessment Comparison population DC General population Mesothelioma Results Motor mechanics pleural cancer 12 PMR peritoneal cancer n PMR Teschke et al BritishColumbia pleural British Columbia Cancer Interview with patient Randomselection from 70-4931 1997 63 mesothelioma 1990-1992 Agency 51 provincialvotesrslist LUNG CANER Cocco & 24 US States peritoneal Dosemed 1999 mesotheliomas 1984-92 AND | DC Deaths frommalignant Not specifiedmechanicsand repairers diseases occ above 64 408 males 1.8 0.5-6.5 Agudo et al 2000 2 provinces Spain 65 Barcelona Cadiz pleural mesothelioms 1993-96 0-132 Hospital based Interview occupation m6onths ~ Occupation mechanics motor vehicles . casescontrols MESOTHLIA mechanics McDonald et UnitedKingdom SWORD records Occupationalhistory Census 1960 1970 1980AutombilAe utomobile notlisted IN 2001 66 Surveillance of related from Medical records 1990 and Occupational AUTO Respiratory Disease SWORD bom 1943 or Lemn later mesotheliomas 199096 = 115 males Wong 2001 70 analysis ofMcDonald see inidndiivvidiualdualstudies McDonald 1980 MECHANIS aalnd1983SpirieataslT1e9t8e5at | - |R^daalndsR^pdealrspger^g^rr Richard 1994Teschke al1997 Agudo et 2000 interview with see individualstudies see individual studies Automobilemechanics 0.90 0.66-1 Hemminki registry Standard European TO et 2003 67 Sweden all persons born Cancer after 1931 and their parents Census 1960 a population Mechanics -cases 0.86 0.31-1.87 peritoneal mesothelioma 1961-98 96 males 16a = 10 M Abbreviations DC death certificates number odds ratio proportional mortality ratio relative risk SIRstandardized incidence rate standardized mortality ratio Confidence bounds = 95 Cl unless otherwise indicated 08 QQ 55 04 MON 08 Nov 8-204 Cre ee COLL] 01 WO06 NUW P002-8 MUN 56 F. LADEN M.J. STAMPFER A.M. WALKER presented All of these studies separately were null and the combined relative risk was 0.90 95 CI 0.66-1.23 Case Series and Case Reports Because mesothelioma is rare Surveil- lance Epidemiology and Risk Program SEER reports an adjusted incidence rate of 2.1 cases per 100,000 males -diagnoses are often described in case series or case reports Such studies provide little useful information in assessing risk because the lack of a comparison group precludes any quantitative estimate Because of the rarity of the disease however exposure histories do provide important insights into the potential sources of exposure Therefore for completeness we include these studies in our summary Case series We identified six studies in which all mesothelioma cases in a population diagnosed during a specific time period were assessed for their potential exposure to asbestos including employment as an automobile mechanic In a series of 41 male patients diagnosed at the London Hospital from 1915 to 1965 one case reported _ exposure to crocidolite asbestos through the manufacture of brake linings 72 One case out of 413 identified by the Mesothelioma Register in Great Britain from 1967 to 1968 was employed as an automobile mechanic Ship workers n 75 asbestos factory workers n 39 and insulation workers = 13 were the most represented occupations 73 Seventy cases of mesothelioma were observed in the region of Nantes Nazairre France between 1956 and 1978 74 Four were employed as mechanics In the Australian Mesothelioma Surveillance Program 1980-1985 871 confirmed cases were identified Of these cases eight were mechanics 75 In employed as automobile a series of 148 cases of mesothelioma identified among peasants residing in rural parts of Turkey one patient reported employment as an automobile mechanic 76 In an additional study 13 cases of mesothelioma were reported over a year period among members of the International Association of Machinists and Aerospace Workers One case had been employed as an automobile mechanic 77 We also identified two studies where lungfiber analyses were performed on series of mesothelioma cases identified by occupation Roggli and colleagues 78 reported asbestos body counts and levels of commercial and noncommercial amphibole fibers a form of asbestos consistently associated with mesothelioma among 1445 cases including 51 with some work as an automobile mechanic repair worker or brake worker The results of the fiber burden analysis led the authors to conclude that the tumors were unlikely to be due to exposure to automotive brakes chrysotile fibers The same researchers also published a study focusing on 10 cases of mesothelioma for which brake dust was the only known source of asbestos exposure 79 Whether these cases were included in the 2002 study is not clear Again the lung fiber analysis suggested that work as an automobile mechanic is unlikely to contribute to the development of mesothelioma Case reports Three reports of individual mesothelioma cases potentially associated with exposure to asbestos through repair work were published in the 1980s Two were automobile mechanics who experienced no other recorded potential exposure to asbestos 80-81 The other case was an elevator mechanic who worked with elevator brake pads 82 In a letter in response to this report Kilpatrick 83 argued that elevator mechanics often work in buildings that are under- going renovations and construction Thus primary exposure might have been to amphibole from asbestos fire retardants sprayed into the building by other workmen as opposed to chrysotile asbestos in brake pads Without a quantitative comparison the case reports are merely anecdotal 8I -042 ---- -- --,-------- -- --,-- -- 241 to 80 noN Na ee Nr ead Sul Wold 80 NUW D002-8 D002-8 D0 2-8 UN LUNG CANCER AND MESOTHELIOMA IN AUTO MECHANICS 57 DISCUSSION AND CONCLUSIONS mesothelioma It is estimated that it takes at least In this paper we have reviewed the analytical studies of risks lung cancer or mesothelioma among automobile mechanics plus all available case series and case reports These studies 10 to 20 years after first exposure to a carcinogen these for diseases to develop When duration and ; timing of employment is not considered essentially | 5 unexposed people are included within the exposed group possibly leading to biased relative risks represent thousands of cases of disease and hundreds of thousands of individuals who were followed When examined in aggregate the consistent pattern that emerges from this research indicates no increase in risk of either lung cancer or mesothelioma in this occupational group The few studies that considered this however did not find increased risks latency Potential confounding factors are inadequately evaluated in the majority of these studies Cigarette smoking the key risk factor for lung cancer was seldom assessed Several studies indicate that conclusionconclusion , conclusion Many studies have important limitations smoking among brake mechanics was more principally in the exposure assessment in most common than in the comparison group which instances In many studies men were grouped into would yield observed relative risks that are occupation based on time reports of usual or last occupation on death certificates medical overestimates Although nearly all studies reported relative risks near the null value those that . records or the census Other studies included some a assessment of lifetime work history but often it adjusted for smoking tended to yield relative risks closer to 1.0 as one might expect from was not detailed One consequence of such inadequate exposure assessment is that the duration of exposure was largely ignored men who worked confounding by smoking In addition some automobile mechanics may have been employed in other occupations or involved in other activities an entire lifetime as an automobile mechanic might be grouped together with those who had worked in with overt exposures to asbestos potentially leading to an estimated relative risk this occupation for only a short time Furthermore some automobile mechanics who were employed a in the past might not have been identified because All these limitations also apply to evaluations in many of these same studies of other occupations ~ with known overt exposures to asbestos such as at the time of reporting they were working in pipefitters construction workers and insulation automobile (> another occupation Employment as an mechanic also does not necessarily capture ~~ workers The expected elevated relative risks however were indeed observed for these other exposure to brakes or clutch repair work Few of SS workers implying that if an excess risk of lung time vem the studies actually included an assessment of exposure to friction products The length of cancer or mesothelioma had been present among automobile mechanics these studies would have spent repairing brakes the actual activititehse been able to detect it Furthermore the exposure to condition of the brakes and the implementation of asbestos in a form likely to be carcinogenic was sa>fety measures all might influence a person's found to be quite small in industrial hygiene surveys exposure Grouping together workers with such of brake repair work 10 In addition studies of different experiences leads to a misclassification of * workers in factories that manufacture asbestos- exposure which may tend to attenuate relative risk estimates containing brakes do not appear to be at higher risk for such cancers 11 84-88 Thus these misclassification Another potential source of 4 of exposure is the long latency of lung cancer and 4 observations along with the weight of the evidence from the studies described here supports the 61 861-044 waway playsta 281 to 80 MON  er'ed 101 Wol2 NUW ^ 002-8 58 58 F. 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