Document kDZ98nBMLq9KjQJpYGm8qxydO

FILE NAME: Oil Industry and American Petroleum Institute (API) DATE: 1958 Mar DOC#: API135 DOCUMENT DESCRIPTION: Report - An Epidemiological Study of Cancer Among Employees in the American Petroleum Industry - Kettering Lab A a E p id em io lo g ica l Study A ftring E m p lo y e e s M a r c h 195 THE KETTERIN6 LABORATORY M dw Si Mcdida ad ladusbMf HmMi ' j-C cfc* oftu& fat .. f - . - : ' - rT - > UNIVERSITY O F CINCINNATI, CINCINNATI, OHIO API 06632 F o r Information Only - Not for Publication An Epidemiological Study ^ of C a n c e r Among Employees in the V American Petroleum Industry M a r c h 1958 The Kettering Laboratory in the D e p a rtm e n t of P re v en tiv e M edicine and Industrial Health College of M edicine University of Cincinnati INDEX Summary and C onclusions ' In tro d u c tio n Planning and Developm ent of the Investigation R esults Study Period Reporting Sex Race Clinical History Prim ary Sites Type of Jumor.^. Occupational History Geographic Location Other Irritants Relative Frequencies P r i m a r y Site as R elated to Date of O nset Occupational Assignment Age Geographic Location Histological Type Discussion Page 1 2 4 13 13 14 16 16 17 17 18 19 19 30 31 31 31 33 34 36 (Included in only a l im ite d n u m b e r of copies) API 06634 Summary and Conclusions B etw een 1949 and 1957, an i n d u s tr y -w id e e ffo rt w as m ad e to escribe the o c c u rr e n c e of v a rio u s kinds and sites of c a n c e r in p e r s o n s employed in re f in e r ie s and c e rtain other installations of the p e troleum industry, in association with occupations concerned This epidemiological study was u n d e rta k en as one phase of a l a r g e r p r o je c t that included the biological testing of m any products of the industry, and the exploration and further development of physical and chem ical methods for detecting the presence of c a r c i n o g e n i c s u b s t a n c e s in p e t r o l e u m p r o d u c t s a n d f o r the i d e n t i f i c a t i o n of individual s u b s ta n c e s and c l a s s e s of s u b s ta n c e s of this type in p e tro le u m . As the information received from the cooperating companies did ' not p e r m i t the calculation of atta ck r a t e s , relian c e had to be placed upon simple c o m p a ris o n s of the relative frequency of different kinds and p r im a r y sites of tu m o rs as reported. In this investigation, the variables included, among o th ers, w e re the m a j o r occupational a s s ig n m e n ts of em ployees, the principal type or source of their contact with petroleum products, and their geographic location. The e x p erience of the populations of ten large U.S. cities, as reported by the U.S. Public Health Service, was employed as the ''expected" or "normal" occurrence. No significant d ifferen ces w ere found in the lim ited and v ery small sample of c a se s available for study in this fashion. This finding m u st be interpreted with unusual caution. The rep o rts received were not only few but there was very definite bias in their selection. However, the fact that there was reasonable correspondence in the relative frequencies both as to -p rim a ry site and kind of c a n c e r s e e m s noteworthy. API 06635 .r.' r 3q u c`.;; Some twenty y e a rs ago, various procedures for the catalytic cracking and ref o r m in g of p e tro le u m cam e into c o m m e r c i a l use in c e rta in large units of the A m e r i c a n oil i n d u s t r y . Out of these p r o c e s s e s com e side s tr e a m s and p ro d u c ts of crude p e tr o l e u m in which the r e f o r m e d and original hydrocarbons are so distributed as to create m ixtures with new physical and chemical c h a r a c te r is tic s C ertain of these, parti :ularly in the high boiling ranges, p r o v e d capable of producing c a n c e r s of the skin of m i c e . F u r t h e r , these m a t e r i a l s contain a p p re c ia b le am o u n ts of polycyclic h y d r o c a r b o n s identical or sim ila r in their chemical stru ctu re to those incrim inated earlier as having a possible^ causal relationship to human skin cancers and generally accepted today as potential carcinogens. The recognition of th e s e fac ts , suggesting that the h a z a r d of skin cancer in petroleum w o rk e rs might a ssu m e significant proportions, led the M edical A d v i s o r y C o m m it te e of the A m e r i c a n P e t r o l e u m Institute to recom m end a com prehensive study of this pro b le m . After the n e c e s s a ry and appro p riate negotiations, the K ettering L a b o rato ry was authorized to undertake this in v e s tig a tio n . C h e m ic a l and biologica l testin g of v a r i o u s fractions began in 1948. While these experimental studies were developing, it was reported from England that "cuts" obtained from thermally cracked petroleum had proved to be carcinogenic for both m ice and rabbits. This early observation was acted upon by the B ritish Medical R e se a rc h Council, under whose sp o nsorship a "Special C om m ittee on the C arcinogenic Action API 06636 0; M in eral Oils ' was f o r m e d in 1948. U n d e r the d ire c tio n and s tim u la tio n I 0 this C o m m i t t e e , s e v e r a l g r o u p s of i n v e s t i g a t o r s u n d e r t o o k c o o r d i n a t e d and in tegrated explorations of this pro b le m . T he se well controlled studies I a r e still in p ro g ress, but, in general, the attack has been centered on the chemical and biological testing of crude pe tro leu m sa m ples and e x tra c ts obtained without severe therm al cracking. The B ritish efforts are to be considered essentially as com plem ent ing r a t h e r than duplicating the i n v e s t ig a t io n s a u th o r i z e d by the A m e r i c a n Petroleum Institute, since the latter w ere directed p rim a rily at the hazard of c o n ta c t with c a t a l y t i c a l l y ^ c r a c k e d o i ls . F u r t h e r m o r e , the B r i t i s h p r o g r a m did not provide for ep id e m io lo g ic a l studies n or the re c o r d in g of the incidence or p r e v a le n c e of c a n c e r among p e tr o l e u m w o r k e r s . In neither country was any g reat apprehension felt until the m odern catalytic p r o c e s s e s began to r e p la c e t h e r m a l cracking. R e p o r ts of the o c c u rr e n c e of c a n c e r am ong r e f in e r y w o r k e r s had not been notew orthy save for those cases associated with exposure to crude waxes and oils in p ressing out paraffin. In lim ited review s of th e ir experience, two U.S. com p an ies had found r a t e s of o c c u r r e n c e se em in g ly lo w e r than those of the g eneral population. It is evident, th e re fo re , that these investigations were directed toward the appraisal of a potential or future hazard than they w ere to the elucidation of an actual or dem o n stra b le incidence of neoplastic disease. At the inception and throughout the planning of the experim ental program sponsored by API, it was recognized that, beyond exhaustive API 06637 -4 biological and chem ical investigations, it would be desirable to d eterm ine, if possible, the prevalence and incidence of neoplastic disease among the em ployees of the p e tr o le u m in d u s tr y a c c o rd in g to occupational c la s s and period of em ploym ent Industry-w ide epidem iological investigations with such goals are not entered into lightly, especially when directed at a disease such as occupational can ce r, for the induction of which a long period of significant exposure to the etiological agent is required. New techniques m u s t be developed and s p e cia l channels of rep o rtin g i m p r o v is e d . F u rth e rm o re , there being no legal or other compulsion in these a r r a n g e m ents, the s u c c e s s o r failu re of the m e c h a n i s m s of r ep o rtin g depends upon the extent of the i n t e r e s t and c o o p e ra tio n of the v a r i o u s p a rt i c i p a ti n g groups. Planning and D evelopm ent of the Investigation . The technical a sp ec ts of this attem pt to estim ate the h a z a rd of neoplastic dise a se of p etroleum w o r k e r s w ere disc u sse d repeatedly and at length with the M edical A dvisory C om m ittee of the A m e ric a n P e tro le u m Institute, its Subcom m ittee on Carcinogenicity, and individually with a m ajo rity of the m e d ic a l d i r e c t o r s of the com p a n ies that had signified their intention to support and participate in the investigation It was thoroughly explained and em p h a size d on m any occasions that the securing of any results whatsoever, either positive or negative, would demand prolonged investigation and the complete cooperation of the participating companies. The apparent lack of a readily dem onstrable in c re a s e d incidence or prevalence of cancer in the industry seem ed to indicate that any hazard API 06638 vs/o-ild be of a Low o r d e r of m a g n i t u d e On the o t h e r hand, it w a s r e c o g n i z e d that the concentration of carcinogenic m a t e r i a ls , both in amount and kind, w a s u s u a l l y low in the p r o d u c t s of t h e r m a l c r a c k i n g , and the c o n t a c t s of workmen with these products, even under the primitive condition said to exist ea rlie r in the petroleum industry, apparently were not sufficiently severe to be actually hazardous. Human skin cancers related to polycyclic hydrocarbons o ccu rred in the past only a fte r long and close contact with soot, coal ta r, shale waxes and lubricating oils, and crude paraffin waxes and oils. The ex p erience of the w o r k e r s with the c a talytically c r a c k e d e x tr a c t s w as, of n e c e s s ity , r e c e n t and of relatively short duration. F u r th e r , the fast moving developm ents in modern petroleum technology could be relied upon to produce a constantly changing situation. It was recognized at the same time that the resu lts obtained by chemical methods in correlation with the responses of experim ental anim als could be used only guardedly to predict or explain human reactions. By m eans of m odern technological m ethods, complex m ixtures, such as crude petroleum , can be se p a ra te d with varying d e g re e s of com pleteness into their m a jo r components and fractio n s. These can then be d e scrib ed as to their composition, and their biological activity can be compared with that of a known carcinogen under p red e term in e d and uniform experim ental con ditions. By combinations of such m eans, the potential hazards of petroleum p r o d u c t s , f r o m the a s p e c t of c uta ne ous c a n c e r , m a y be e x p l o r e d and located and, at lea st in te rm s of relative severity, can be given a tentative or API 06639 O in fe rre d rating. In this a s in o th e r fields of a nim a l e x p e rim e n tatio n , g r e a t caution is justified in any attem p t to apply the re su lts to human experience either before or after the fact. Such interpretations become even more difficult with the recognition that w o rk e rs a re subjected only ra re ly to the s trin g en t conditions w hich in the l a b o r a to r y a r e p u rp o se ly designed to produce rea c tio n s within a lim ited period of tim e. A f t e r c a r e f u l c o n s i d e r a t i o n ,the s p o n s o r s in 1949 e s t a b l i s h e d I certain desirable objectives. These were: 1 1. To a s c e r t a i n the i n c i d e n c e and p r e v a l e n c e r a t e s of n e o p l a s . i c | disease in the employee population of the various p a r t i c i p a . i , i i petroleum companies; ;|l v ; i ***** 2. To c o m p a r e th e i r e x p e r i e n c e with that o b s e r v e d in the g e n e r a l population and other in d u strie s, particu la rly those in the sam e geographical areas; 3. To e v a l u a t e , i n s o f a r a s p o s s i b l e , with a v a i l a b l e m e t h o d s and j re c o rd s , the p r e s e n t p r o g r a m s of hygiene control; and : 4. To suggest i m p r o v e m e n t s and changes in m e t h o d s of e n v i r o n m e n ta l co n tro l in a c c o r d a n c e with the r e s u l t s of the field . j investigations. j With the setting of these goals and with g e n e ra l a g r e e m e n t that the e x p e rie n c e of the p a rtic ip a tin g c o m p a n ies in r e g a r d to c a n c e r should be a s s e m b le d in a s p re c is e and c o m prehensive a m a n n e r as could be devised and supported by the M edical A dvisory Com m ittee, the f ir s t steps ; i w e r e taken d u r in g 1950 to e x p lo r e p o s s i b l e m e t h o d s fo r the conduct of epidemiological investigations. F ro m the many ideas, varying concepts, and special needs of the m ed ic al d i r e c to r s and the individual com panies aoparent :na: ^ woa^ be n e c e s s a ry to scrutinize minutely and weigh thoroughly all approaches. On the other hand, it was acknowledged that only those objectives and p ro c e d u re s could be im plem ented that seem ed to offer at l e a s t a re a s o n a b le chance of s u c c e s s within a finite p e rio d of time. In this planning, The K ettering L ab o rato ry sought advice and guidance fro m many so u rc e s . Among these w ere the m e m b e r s of the API Medical Advisory Com m ittee, G overnm ental agencies such as the National Cancer Institute and several State health departments, and finally other epidem iologists who had undertaken a s im ila r solution of one or another of the complex p ro b le m s of chronic d ise a s e . These apparently prolonged consultations and discussions were justified by the realization that this venture would req u ire e x tr a o rd in a rily careful planning, if it w ere to be brought to a satisfactory conclusion. Seven possible approaches were submitted to the Medical A uvisory Committee for their review, with the full realization that not all would be acceptable or feasible within the lim its of the financial support and the time available for this asp ec t ot the API project. It was also recognized that other limiting factors would also play a part in the decisions both from s h o rt and long r an g e points of view. The a v e n u e s o ffe red f o r t h e i r c o n s i deration are given below. The justification for these recommendations is d i s c u s s e d in detail in Appendix I. It is obvious that the fea sib ility , value, and p rio rity of the sev eral p ro p o sals v ary widely. In this ordering, they are listed, without reference to their desirability or practicability, in the pattern established in e a rlie r rep o rts. API 06641 3 1- H i s t o r i c a l S u r v e y - To a s se m b le and review the r e c o r d s of known c a s e s in the files of the p a r t i c i pating companies. 2. C u r r e n t R e g i s tr y - To create by mutual agreem ent a central file for receiving and tabulating cases as they occur among the em ployees of the oil companies. 3- I n s u r a n c e R e c o r d s - To i n v e s t i g a t e a n d u t i l i z e i n s u r a n c e a n d health benefit records for intra- and extramural comparisons. 4. C ontrolled F ie ld Studie s To repeat and expand investigations that have indicated the existence of hazard due to certain cutaneous contacts. 5. C o n t a c t C o n t r o l P rogram s >' - 6. Con sultation Service To survey and evaluate for the industry as a whole the p r o g ra m s of personal hygiene that have been instituted. To offer for the use of the participating com panies such s e rv ic es as m ay be required to establish adequate medical reco rd s, and to aid in planning individual inve stigations. 7. L i t e r a t u r e S u r v e y To collect and review c ritically the m ed ic al lite r a tu r e in the field of occupa tional and environmental carcinogens. At the A p r i l 1950 m e e t in g of the M e d ic a l A d v i s o r y C o m m it te e and their technical ad v iso rs, general approval in principle was given to the several approaches as outlined. For many cogent reasons, acceptance was asked and granted at that time for only two of the suggested studies, namely the "H istorical Review" and " C u rre n t R egistry. " It was acknowledged that both would be of little im m ed ia te value and that em barking on the latter approach p articularly implied a long range effort. The others w ere held for future consideration, pending better definition of the m ethods and techniques to be employed and a s s u r a n c e that they would be acceptable to the cooperating companies. (See Appendix I.) API 06642 With this limited authorization, clinical and occupational history record fo rm s were devised, based essentially upon the fo rm a t and the inclusion of item s custom arily required for notification of occupational cancers to State health d ep artm ents. Instruction books outlining the r e p o r t ing m ec h a n ism s and the objectives w e re p re p a r e d and d istributed in the late fall of 1950. (See Appendix III.) The r e p o r t s t r i c k le d in slowly during the w inter of 1950-1951, m ain ly b e c au se m an y of the com panies found that th e ir records did not lend them selves readily to this reporting procedure. O thers had to a rra n g e entirely new channels and sy stem s in o r d e r to secure and extract the n e c e s s a r y data. S ev eral special field trips w ere m ade to further explain the objectives and methods to be employed. Taking advantage of this n e c e s s a r i l y slow p r o g r e s s , and p o s t poning e x p l o r a t i o n of the r e m a i n i n g a p p r o a c h e s , 1951 w a s u s e d l a r g e l y to o b s e rv e a t f i r s t hand the w o rk of the E n g l i s h i n v e s t i g a t o r s and to e s t a b l is h working relationships that would insure ready access to their results. This activity was c a rr ie d on without reducing the funds available for the in v e s ti gation, a s p a r t of a f e l l o w s h i p p r o g r a m of the W o r l d H e a l t h O r g a n i z a t i o n project, thereby furnishing an unusual opportunity to bring to the Medical Advisory Com m ittee the findings and underlying philosophies of the B ritish w orkers in this re s tric te d a re a of occupational cancer. L a te r events proved the value of the re la tio n s h ip s so cultivated, in keeping open channels for additional information as to developments, particularly in England. The details of the tr i p a r e d e s c r i b e d in the i n t e r i m r e p o r t su b m itte d in the fall of 1951. API 06643 - :o - The historical and current case reco rd s came in slowly. By M a r c h of 1952, 900 r e c o r d s had been f o r w a r d e d f r o m t h ir te e n c o m p a n i e s . A y e a r l a t e r , a total of 1239 c a s e s ha d b e e n r e p o r t e d by f o u r t e e n p a r t i c i p an ts . D u r i n g 1952 and 1953, the i n f o r m a t i o n a s r e c e i v e d w a s coded and t r a n s f e r r e d to M cBee Key Sort c a rd s. All of the r e c o rd s w ere lacking in certain details, but m o st proved usable in the p re p a ra tio n of simple tabu lations. Much time and energy was expended in attempting to complete the re c o rd s , but in m o st in stan ces this effort proved unproductive. L a t e r in 1954, when it se e m e d likely that a rea so n a b ly large s e g m e n t of the i n d u s t r y would p a r t i c i p a t e in at l e a s t the r e g i s t r a t i o n of current cancer cases, a m ajor alteration was made in the handling and p r o c e s s in g of the r e p o r t s . The n e c e s s a r y m anipulations of the key s o r t c ards had become c u m b e rs o m e , and the n u m b er of a nalyses possible was n e c e s s a rily limited. It seem ed wise th erefo re to shift to IBM equipment and utilize electronic sorting for the preparation of m ore complex tabu lations . Throughout 1955, the w o rk was c e n te re d on the developm ent and testing of the new code. The g r e a t e r flexibility of the IBM p e rm itte d the inclusion of many m o re v a ria b le s in m uch g r e a t e r detail. On the other hand, this change fo rc e d discarding of the e a r l i e r key so rt code and r e e d i t ing of all the r e c o r d s . With this m a n e u v e r , it b e c a m e a p p a r e n t that m any m o re re p o rts w ere deficient, with p a rticu la r reference to certain features of the occupational histo ry . Additional c le r ic a l a s s is ta n c e was assig n ed to the project, but m any of the coding p ro b le m s finally proved insoluble. API 06644 rn* v By S e p t e m b e r 1955.. 1877 r e p o r t s h a d bee n r e c e i v e d f r o m s ix t e e n com panies. G e o g ra p h ic a l c overage of the in d u s tr y was a lm o s t complete, and an additional company had begun to send in records. Steps had been take n (1) to i m p r o v e the a c c u r a c y a n d c o m p l e t e n e s s of the r e c o r d s , to insure reporting of all known cases, and to stimulate g r e a te r effort in in div id ual c o m p a n i e s to ob ta in i n f o r m a t i o n a bou t c a s e s ; (2) to i n c l u d e a l a r g e r n u m b e r of e m p l o y e e s (ten of the p a r tic ip a tin g c o m p a n ie s i n d ic a te d that their reports represented the cases found among approxim ately 120,000 w orkers, but others w ere sending in reports from only a single refinery); and f in a lly , (5) to s e c u r e r e p o r t i n g f r o m a l l of the m a j o r c o m p a n i e s r e p r e sented on the Medical Advisory Com m ittee. T h e s e e f f o r t s a c h i e v e d s o m e r e s u l t s a n d by A p r i l 19 5o, 210b records w ere in the files of the central reg istry . Participation in the r e p o r t ing seem ed to be gradually widening, but it was evident likewise tha" many of the c o m p a n i e s still had little o r no knowledge of the o c c u r r e n c e or n o n o c c u r r e n c e of c a s e s of c a n c e r within the bulk of t h e i r e m p l o y e e s . This deficiency was re p o rte d to the m e m b e r s of the Subcom m ittee on C a r c in o genicity of the M edical A dvisory C om m ittee. It was indicated that although the notification of c a n c e r c a s e s was not e n tir e ly s a tis fa c to r y , the sam ple of cases might still be studied in a lim ited m anner if this e r r o r proved entirely random . F u rth e r, it was pointed out that in o rd er to get a suffi ciently l a r g e group of c a s e s a m u ch lo n g e r collection p e rio d would be re q u ire d . During the w in ter of 1955-1956, all of the r e p o r ts on file w ere recoded. The t r a n s f e r of the clinical a b s tr a c t s , while tim e-c o n su m in g and laborious, pro v ed to be f a r s im p l e r than the classification of the p rincipal occupation and the petroleum product with which contact occurred. Only half of the r e c o r d s could be r e a d i ly s e p a r a t e d by the c l e r k s alone, a c c o r d ing to occupatio n. F o r t h is r e a s o n , a " w o r k a s s i g n m e n t " g l o s s a r y w a s formulated for the possible use of the personnel departm ents of the companies, utilizing the v a r i o u s job d e s c r i p t i o n s a s l is t e d on the r e p o r t s . This was planned jointly with r e p r e s e n t a t i v e s of one of the p a r t i c i p a ti n g c o m p a n i e s who had b e c o m e i n t e r e s t e d in the d e v e l o p m e n t of a m o r b i d i t y r e p o r t i n g mechanism and had discovered a similar need for better classification of occupational a s s i g n m e n t s It w a s b e lie v e d th at a c a re f u ll y c o n s i d e r e d ordering of the occupations would prove useful to the industry as a whole and would be a significant additional benefit of this a sp ec t of the project. Late in April 1956, the M edical A dvisory C om m ittee, upon the recom m endation of the Subcom m ittee of Carcinogenicity, decided to te rm in a te the e p i d e m i o l o g i c a l i n v e s t i g a t i o n s a s of J u l y 1, 1956. The j u s t i f i c a t i o n f o r this action stem m ed essentially from the failure of the Medical Advisory Committee to secure complete cooperation and g re a te r participation in the reporting of c a s e s . Since the sam ple would be lim ited, both in n u m b er and kind and the r e s u lts forthcom ing would be of doubtful validity, the C om m ittee was unwilling to support the longer study period required to overcom e the reporting deficit. In asm uch as the occupational coding and tra n s fe re n c e to cards could not be com pleted in the two rem aining months, it seem ed wise to stop all w ork im m ed iately and rea ssig n the statistical staff to other ongoing projects of The K ettering L aboratory. - io Meanwhile, it seem ed wise to determ ine whether the Medical Advisory Com m ittee could find m eans for supporting the tabulation of reports r e c e iv e d through 1956 and the p r e p a r a ti o n of final s u m m a r y tables. t was r e c o g n iz e d that th ese c o m p a r is o n s would not be s a tis fa c to r y , and that little reliance could be placed on the findings. However, so m uch time and effort had gone into this a tte m p t to re la te the site and kind of c a n c e r to specific occupations that it seemed desirable to reexamine the tumor cases, employing the rev ised occupational classifications, if only to te st the capacity of the procedure to reveal suggestive trends. Late in 1956, this J u r t h e r support was granted, but the final recoding, punching, and preparation of sum m ary tables had to be post poned until the spring of 1957, since the c le ric a l staff of the statistical team was not available immediately. F urtherm ore, all doubtful or questionable records had to be reviewed individually by the professional staff of the Laboratory before they could be included or excluded. These m aneuvers were finally com pleted late in 1957, with the a ssem bling of the work tables required for the p r e p a ra tio n of this final re p o rt. Results Study P e r i o d . When the decision to discontinue the support of the in d u s tr y -w id e r e g i s t r a t i o n of c a n c e r c a s e s and deaths w a s finally m ade by the M e d i c a l A d v i s o r y C o m m i t t e e , A p r i l 1, 1956, w a s s e l e c t e d a s the c lo s i n g date for this phase of the API C ancer P ro je c t. The study period, therefore, c o v ered a p p ro x im a te ly six y e a r s , running f r o m 1950 through 1955. R e p o r ts have and still continue to filter in from some companies and physicians. API 06647 -u These are filed but not processed and are not included in the tabulations and analyses herewith presented. The relative short period of collection and the adm ittedly s m a ll sam ple of the c a s e s and deaths which o c c u r r e d during this period also lim ited se rio u sly the n u m b er of co m p a riso n s that could be readily m ad e. Reporting. As indicated earlier, special clinical and occupational record f o r m s w e re devised for the use of the cooperating m edical d e p a r t ments. The first forms were modified slightly after a short preliminary trial, but the information requested was not altered essentially during the study period. The form s were so arranged that the patients were identified solely by num ber, thus preserving the employer-employee and the p r o fessional re la tio n s h ip s and p rotecting the legal re s p o n s ib ilitie s of the participating companies. ' The rep o rt blanks w ere modeled after the one designed originally by the New York State Health Department, since this form had been copied widely by other state cancer reg istries. It was hoped that this sim ilarity would reduce the clerical effort required to assem ble the needed data. At the sta rt of the project, the reports came in slowly, and the response was not uniform for what appeared at that time to be good and sufficient reaso n s. The firs t was that certain of the companies had no c e n tralize d m e d ic a l d e p a rtm e n t, no files of e a r l i e r c a s e s , and usually no m echanism for notification of deaths or illn esse s among their employees. Even in full time medical departm ents, the central recording arrangem ents API 06648 T[ were - 15 recent and there w ere no past histories, or the recording system employed, was not a rr a n g e d to provide this type of information, or the i n f o r mation was not readily accessible. Furtherm ore, this was a tradition-breaking venture. The companies and physicians w ere required to report regularly and accurately to an un official central agency. It has alw ays been difficult to secu re official rep o rts from busy physicians, but in this instance additional clerical help and super vision w ere frequently required of the cooperating company. This made it almost im possible at tim es to secure the requested information. A few com panies r e m a in e d w a r y to he end and n e v e r r e l e a s e d th e ir c ase h i s t o r i e s * * to the in d u stry pool. O th e rs sent in the c a s e s a lr e a d y in th eir files and reported subsequently only a scattering or none of their c u rre n t cases. Some furnished only current records for a year or two. The inadequacies of r e p o r t i n g a r e q u ite a p p a r e n t e v e n w i t h only a s u p e r f i c i a l stu dy of T a b l e 1* of the Appendix II. i F o r example, one large oil company with an excellent m edical departm ent and an adequate followup among some 26, 000 w o r k e rs has re p o r te d 516 new c a s e s within the f i v e - y e a r perio d of 1951-1955 - an a v e ra g e of 103.2 c a s e s p e r y e a r . In c o n tr a s t, only 1367 c a se s w e re r e p o r t e d during a six-year period (1950-1955) from seventeen companies from an employee I population of at l e a s t 100, 000. At b e s t, t h e r e f o r e , one will b elie v e that l e s s *In this tabulation, the 1964 individuals with single n e o p la sm s a r e distributed I according to year of onset and reporting company. Those with multiple :l tum ors are excluded because in some of these individuals the onsets were $ both before and a f t e r the sta rtin g date of the c u r r e n t r e g i s t r y . API 06649 A than half of the c a se s w ere rep o rted . It is also noteworthy, although not important to these an aly ses, that it proved im possible to determ ine the exact y e a r of on set - a s c o n tr a s te d to the y e a r of r e p o r t - of m o r e than a third of the c a se s . S e x . In Appendix II, Table 2, the 2055 c a se s with both single and multiple n eo p lasm s rec o rd e d in the historical and current re g is trie s are classified according to sex and race. Cancer among female employees a ccounted f o r only 99 or a p p r o x i m a t e l y 5 p e r c e n t of the to ta l r e p o r t e d . T h is disproportion obviously reflects the fact that m ale s predom inate among the employees of this industry. However, without exact knowledge of the p r o portion of fem ales, one cannot draw any conclusion from these data. The female cases both in the historical group and cu rren t registry ( o n se t b e f o r e a n d a f t e r J a n u a r y 1, 19 50) a r e - r e d i s t r i b u t e d in A p p e n d i x II, T a b l e 3, a c c o r d i n g to p r i m a r y s i t e . T h e r e w e r e only 19 in the f o r m e r a n d 71 in the l a t t e r c a t e g o r y . S i n c e the s a m p l e s a r e so v e r y s m a l l , f u r t h e r comparisons a re not feasible. However, as one might expect, the d istrib u tion of p r i m a r y s ite s of the t u m o r s a s r e p o r t e d in both c l a s s e s do not differ g r e a t l y f r o m that obtained by the P u b l ic H e a lth S e r v ic e in t h e i r 1947 su rv e y . R a c e . This is another im portant variable in carcinogenesis, but unfo rtu n ately the r e c o r d s f r o m the p e t r o l e u m i n d u s t r y as a s s e m b l e d do not p e r m i t r e a d y e v a l u a t i o n of i t s f o r c e . O n ly 31 of the c a s e s w e r e l i s t e d a s having o c c u r r e d a m o n g n e g r o e s , but no i n f o r m a t i o n w a s a v a il a b l e f o r 146. This inability to se p ara te out r a c ia l groups s te m s fro m the t e r m s of the API 06650 - 11 F a ir E m ploym ent P r a c tic e Acts which p rev en t recording of this kind of i n form ation on official or company f o r m s . It is p a rtic u la rly unfortunate that while the selection for disease has always a genetic component, the force of social and econom ic changes now h a m p e r and probably in the future will prevent g e n e ra l investigations of this v a ria b le in ind u stria l populations. Clinical H i s t o r y . This portion of the r e c o r d w as usually filled in very well. Seldom was there need to seek additional information, but some editing and professional interpretation were required for approximately 25 p e r c e n t of the r e p o r t s . The q u e s t i o n s u s u a l l y r a i s e d c o n c e r n e d the p r im a ry site, histogenic type, stage of the d ise a s e , and the extent and n u m b e r of m t a s t a s s . It b e c a m e a p p a re n t e a r l y that the date of diag n o sis and the date and kind of tre a tm e n t could not be readily confirm ed or ta b u lated. When available, this kind of inform ation was coded and t r a n s f e r r e d to the IBM c a r d s , b u t a c c e p t a b l e a n s w e r s w e r e l a c k i n g in m o r e than 50 p e r cent of the fo rm s . P r i m a r y S i t e s . The p r im a r y sites w ere s e p a ra te d according to the classificatio n s originally d ev ised by D r. H arold Dorn of the National In stitutes of Health for the M a ry la n d State C a n c e r P r o g r a m . This code also indicates the stage of the disease, as well as the num ber and location of m e t a s t a t i c s ite s . It w a s difficult a t t i m e s to c la s s if y c le a r l y som e of the c a n c e r s , p a r t i c u l a r l y those of the skin an d m u c o s a l s u r f a c e s of the lip. Otherwise, the categories proved reasonably sound and adequate, and the cases were easily grouped. - 13 - A p p e n d i x II, T a b l e 3, r e a r r a n g e s the c a s e s , both h i s t o r i c a l and current, m ale and fem ale, according to the p r i m a r y site of the tum or as reported. A s im ila r distribution (at all ages) of the ca n ce r c a se s re p o rted i from the ten cities included in the study of the National C an cer Institute, is also provided for comparison. The m ajor differences will be noted in the n u m b e r of t u m o r s of the d ig estiv e s y s t e m and p e r i t o n e u m am ong m a l e s with on se t p r i o r to 1950, and n e o p la s m s of the skin and soft tissue with onset after that date. These variations have been noted in earlier reports. The relative p ro p o rtio n s of c a s e s with oth er p r i m a r y s ite s, on the other hand, correspond reasonably well with the U.S. experience. Type of T u m o r . The h i s t o g e n ic ty p e s of the t u m o r s r e p o r t e d w e r e classified following the code devised and recommended by the American Cancer Society. This num erical system also p e rm its separation as to the degree of m aligna nc y. It p r o v e d v e r y s a ti s f a c to r y for the p u r p o s e s of the study, and all of the acceptable r e c o r d s w e re finally coded without undue difficulty. The tum ors reported w ere largely malignant. Among the cases r e p o r t e d a s h a vin g t h e i r o n s e t p r i o r to 1950, 53 of 668 ( 7 . 9 p e r c e n t ) w e r e benign, and of those oc c u rrin g subsequently, 103 of 1367 (7. 5 percent). All subsequent tabulations a r e lim ite d solely to the distribution of the m alignant neoplasm s both as to site and kind. The n u m b er of benign lesions is far too small to justify a sim ilar study. Eight individuals were re p o rted with multiple n e o p la sm s. T w en ty -se v e n had m ultiple sites of the same type of tumor. . 'Q Occupational H is to ry . With the questions in this p a rt of the report form, an attempt was made to secure an orderly chronological lis t ing of the p a t i e n t 's v a r i o u s o c c u p atio n s a s well a s his specific w o rk a s s i g n ments in the petroleum industry. This inform ation was sought with the goal of a s s e m b l i n g s u f f i c i e n t d a t a to p e r m i t the c l a s s i f i c a t i o n , of the a f f e c t e d persons, at the onset of the tumor, according to employment status and work assignm ents in the petroleum industry, and also as to other contacts with possible irr ita n ts , and s im ila r v a ria b le s. It was recognized that only very gross separations would be possible, and that the severity and duration of e x p o s u r e could only be a p p r o x i m a t e d . H o w e v e r , it s e e m e d d e s i r a b l e to divide into a few b r o a d c a te g o r i e s the h a z a r d p a t t e r n s of the r e p o r t e d cases for correlation with the type and p rim a ry site of their tum ors. The answ ers received proved m ost troublesom e, both in coding and in the preparation of w ork tables. As can be seen in the accompanying s u m m a r y (T a b le 1), a f a i r l y s i z e a b l e p r o p o r t i o n (35 p e r c e n t ) of the c a s e s could not be c ategorized even with the use of v e ry broad occupational g ro u p ings. This w as true of those having th e ir onset e it h e r b e fo re o r a fte r 1950. Geographic Location. As the reports were received and processed, they w ere classified according to the geographic location of the refinery or plant where the employee was working at the time of onset of the tum or. This was done in o rd er to ascertain if climatic factors influenced in any way the relative fre q u e n c ie s eith e r a s to p r i m a r y site or type of c a n c e r among petroleum w o r k e rs . These data would also p e r m i t a d ju stm e n t of the o b served differences that might be related in some way to residence. It has been API 06653  TABLE 1 MALES WITH MALIGNANT NEOPLASMS PETROLEUM BEFORE 1 9 5 0 ! AFTER 1950 OCCUPATION NO. % NO. % o KNOWN 367 62.7 744 64.2 P UNKNOWN 218 37.3 415 35.8 TOTAL 585 100.0 1159 100.0 API 06654 - 20 shown in m a n y o th e r stu d ie s th a t sk in c a n c e r s a r e ta r m o r e fre q u e n t in the South- In the table on the following page (T able 2), the g e o g ra p h ic a l distribution of the re p o rte d c a se s has been s u m m a riz ed . They have been grouped into four large a r e a s , North, South, C entral, and West. Of the 1867 c a s e s r e p o r te d , 1448 could be so located. It will be noted that m o r e cases having th eir onset p r io r to 1950 came fro m the South, w h e re as the West in c re a s e d its proportion subsequent to that date. C ases among marine w orkers, pipe line crews, and production w orkers, and those arising outside of the U-S. , accounted for 326 of the re p o rts. F ifty - s ix had too little information to perm it classification. As a whole, however, the r e c o r d s w e r e sufficiently com plete to p e r m i t distrib u tio n of the r e p o r t e d cases into these broad geographic categories for comparison with the U.S. experience. Other Irritants. The record form included questions dealing with exposure to i r r i t a n t s o th er than p e tr o l e u m , e it h e r in or out of the oil industry. These w ere p h r a s e d and a r r a n g e d so a s to give some i n f o r m a tion both a s to d e g r e e , kind, and d u ra tio n of contact. U nfortunately, most of these ite m s proved too difficult to a n sw e r, and while the resp o n se s as given w ere coded and tr a n s f e r r e d to the IBM c a rd s, no tabulations w ere prep a re d for this rep o rt. Without a c c u r a te knowledge of the work history and, in m any cases, without ac ce ss to the patient, the participating m edical directors could not collect these data. It becam e evident early that only general s ta te m e n ts could be m ade, p a rtic u la rly since m o st of these hazardous contacts do not o c c u r in the plant e n v iro n m e n t. API 06655 API 06656 TABI 2 YEAR OF ONSET BEFORE 1950 AFTER 1950 PERCENTILE DISTRIBUTION OF CANCER REPORTED ACCORDING TO GEOGRAPHIC LOCATION NORTH NO. % SOUTH NO. % CENTRAL -------- !-------- NO. % WEST NO. % TOT/1lL NO. % 172 33.1 241 46.4 18 3.5 89 17.1 520 100.0 338 36.4 223 24.0 38 4.1 329 35.4 928 100.0 - 21 P r i m a r y S i t e . In A p p e n d ix II, T a b le 3, the r e p o r t e d c a s e s with malignant n e o p la s m s a r e d istr ib u te d a c co rd in g to sex, date of onset, and prim ary site of the tum or. The U.S. experience, as collected by the Public Health S erv ice, is included for comparison. It will be noted that the pro p o rtio n of tu m o r s of the digestive system and p e rito n e u m , having th e ir onset among m a le s p r i o r to 1950, was much la rg e r than that found in the U-S. as a whole and among the current c a se s re p o rte d after 1950. In the latter group, in turn, the relative number of c a n c e r s of the skin and soft tis s u e s was g r e a te r . The d is tr ib u tion of o th e r t u m o r s dfffe r e d .only slightly f r o m the U .S . v a lu e s . No valid comparisons a re possible because of the small num ber of c ases reported, but it m ay be said that in g e n e ra l the U .S . p a tte rn for sites of tu m o r s was paralleled. In Appendix II, Table 4, the m alignant n eo plasm s having their onset p r i o r to 1950 a r e r e d i s t r i b u t e d both a s to p r i m a r y site an d o c c u p atio n a l assignm ent The e x c ess of n e o p la s m s of the digestive sy ste m and peritoneum c a rrie s on through m o st of the job classifications, even including the unknown group. Thus it seem s unlikely that this difference is related to any special occupational factor in the petroleum industry. This point of view is further supported by the finding that there is no concentration of such sites in a s s o c i ation with any p a r t i c u l a r occupation am ong the c a s e s r e p o r t e d a f t e r 1950. N e a rly all of the a s se m b le d c a se s, both h isto ric a l an d c u rre n t, are d eriv e d fro m a m a le w orking population betw een 20-69 y e a rs of age. API 06657 With the th oug ht that th is b i a s e d age g r o u p in g m i g h t ex plain , in p a r t , s o m e oi the d i f f e r e n c e s in re l a ti v e n u m b e r s of t u m o r s of the digestive t r a c t , the data c o n c e r n e d with U . S . e x p e r i e n c e w e r e r e d i s t r i b u t e d into the t h r e e p e r t i n e n t b r o a d g r o u p s . The r e s u l t s a r e given in t e x t T a b l e 3. It w il l be noted that there is much g rea ter correspondence in the relative frequencies. To rein fo rce f u rth e r this assu m p tio n , the figures of one company that has followed its tumor cases very carefully within recent years were also obtained- (These cases a re not included in the API sam ple.) The pattern of p r i m a r y s i t e s a g a i n w a s found to be quite s i m i l a r to the v a l u e s f o r the older age groups in the U S. /See text Table 3.) The excessive proportion of tu m o rs of the skin and soft tissues in the c a s e s having th e i r o n s e t a f t e r 1950 a ls o r e q u i r e d som e explanation. It will be n o ted again in A ppendix II, T a b le 4, th at t h e r e w a s no obvious association with any given occupational classification. An accounting of the age g r o u p i n g s ( te x t T a b l e 3) f a i l e d to e x p l a i n the d i f f e r e n c e . F u r t h e r m o r e , the e x p e rie n c e of Com pany X p a r a l l e l e d c lo se ly the distrib u tio n of the current cases reported by the petroleum industry as a whole. Accordingly, consideration was given to the possible effect of clim ate and solar exposure. Alm ost 25 p e r c e n t of the A P I c a s e s , a s i n d ic a te d in te x t Table 2, was rep o rted f ro m oil in sta lla tio n s in so u th e rn s ta te s . In the tabulation of the U.S. experience, only four large southern cities were included. Of these, the c l i m a t i c c onditions in New O r l e a n s a n d D a l l a s a r e s i m i l a r to those to which the p e tro leu m w o r k e rs w ere exposed. T hese sub-tabulations a re given in A p p e n d i x II, T a b l e s 9 t h r o u g h 12 i n c l u s i v e . API 06658 ) T A H U i :i PH t MAIf ' S 1TE 1 *1 . l u I , N < I I J'l 11 I S I l ( I I I * ' I l M N 4*1*' ( I N N I V i Ul*: I < >U ' K U A U ' O H I M N li *11) 1*111 MA I f ' S i ','K ALT AGES IJ .S . MAGES + PREVALENT IN 1947 20-69 20-39 40-69 Wn ITE MAIE EMP . X C .ti \ P i MATE EMPLOYEES ] 9FT ORE 1950 AFTER 1950 UfJCCAl. CAVITY DIGESTIVE SYSTEM RESPIRATOR'' SVSTEM 6.9 28.7 12.6 7 .3 31 .2 14 1 6.3 15.0 6 0 7 3 32 7 ' 3.3 30.1 14.8 , 15 2 3.3 35 0 11 .5 4.1 26 2 15 7 UREAS! .2 .3 .2 .2 3 .0 .2 i j i GENITAL. ORGANS 10.4 8.2 8 .6 8.1 7.0 8.6 7 .9 r-> URINAIli S /STEM SKIN AND SOFT TISSUES BONES 6 9 19.3 .8 7 2 16.6 .7 41 .2 21 .7 2. I 7.5 16 0 .5 5.1 29.2 .6 6 5 15 7 2 1 5 .6 28.5 .8 BRAIN 2.7 2 . 1 8.1 1 .8 2.1 1 .7 1.8 LVMPH. AND REMA. S VSTEMS 6.7 7.6 20.7 6.0 4.0 6.5 5 .0 OTHER SITES 4.8 4 .6 7.8 4.3 3. I 6.2 4 .2 fr'rorn M o r b i d i t y f r o m C a n c e r i n Ui e U n i t e d S t a t e s , ' P u b l i c M e n i t i . Mo u o g r a p i i , No . 2 i i t PUS o f DIIEW ( 1 0 4 7 ) . ^ Pe r s o n a l Commun i c a t i mi ( C a s e s r e p o r t e d b e t w e e n 11)50 - 1 0 5 6 ) . m* API 06659 In Appendix II, Table 9, the U .S. exp erien ce for m a le s aged 5-64 for the "Ten City" study has been c o m p a red with the API group of cases. It is obvious that there is a larg e difference betw een the southern and northern cities. In A p p e n d i x II, T a b l e 10, the A P I t u m o r c a s e s a r e d i v i d e d g e o graphically, a n d the e x c e s s of t u m o r s of the skin in the South, in both the "Historical" and " C u rre n t" categories, b ecom es even m o re apparent. In this tabulation it will be noted that the U .S. experience with skin tum ors, when examined according to b ro ad age grouping as well as geographical location, is essen tially the sam e in all re s p e c ts as that re c o rd e d in the petroleum industry. A m o re detailed breakdown of these observations is given in Appendi x II, T a b l e 11. In t h is t a b u l a t i o n , the b r o a d g r o u p s of t u m o r s of the skin and the digestive and r e s p i r a t o r y s y s t e m s a r e s e p a r a t e d a c c o r d ing to the p r in c i p a l s it e s in clu d e d within th e s e c a t e g o r i e s an d a r e a r r a n g e d according to the geographical location of the case. The n u m b er of tu m o rs that fell into each classification was not large and the differences found were not tested statistically. It is noteworthy, however, that once again the p a tte rn of p r in c ip a l s it e s follows e s s e n t i a l l y the U .S . e x p e r i e n c e as adjusted for geographical distribution. In A p p e n d i x II, T a b l e 12, t h e s e s a m e b r o a d g r o u p s of t u m o r s have been re a rra n g e d according to the m ajo r occupational c la s s e s and the date of onset of the tu m o r. It is in te re s tin g to o b se rv e that the failu re API 06660 - 24 to provide sufficient inform ation to p e rm it occupational grouping was not limited to any particular prim ary site but was seemingly entirely random. There a re some differences in the distribution of the h isto ric a l and c u rr e n t cases. The tum ors of the digestive system , especially those having their onset p r i o r to 1950, stand out again. This phenomenon is smoothed out in the c u rre n t group of c a se s. W it hout v a li d d a ta a s to the s iz e of th e p o p u l a t i o n s c o n c e r n e d , incidence ra te s cannot be calculated from the num bers of cases. C om parisons, therefore, can only be considered as speculative. N evertheless, it is in te r e s t ing to o b s e rv e that a p p ro x im a te ly the sam e n u m b e r of tu m o r s of the r e s p i r a t o r y system were reported among refinery workmen and executives. The very slightly h igher p ro portion of skin tu m o rs in the production and refin ery w orkers might, p e rh a p s, be con sid e red indicative of g r e a t e r occupational risk. All that can be said of th e s e findings i s that they a r e not r e m a r k a b l e or co n trary to what m ight be expected. i H i s to lo g ic a l T y p e . A ppendix II, T a b l e s 6 and 8, a r e tabulations of the h i s t o l o g i c a l t y p e s of the m a l i g n a n t t u m o r s r e p o r t e d a c c o r d i n g to se x , date of onset, and occupation. The p r o p o rtio n of n o n - g la n d u la r epithelial tumors is somewhat la rg e r in the API group as com pared to the U.Svalues. This holds generally in all of the broad occupational classes and with r e s p e c t to the c a s e s r e p o r te d before and a fte r 1950. In text Table 4 these data have been s u m m a riz e d and com pared to U.S. experience adjusted for age. The ob serv ed differen ces a re in c r e a s e d API 06661 ) TABLE 4 TYPE OF NEOPLASM GLANDULAR EPITHELIUM NON-GLANDULAR EPITHELIUM PERCENTILE DISTRIBUTION OF CANCER REPORTED ACCORDING TO HISTOLOGICAL TYPE ALL CASES AND AGES 22.4 U . S . MALES* NEW CASES 1947 20-64 20-34 35-64 34.2 22.1 ' 35.3 API MALE EMPLOYEES BEFORE 1950 AFTER 1950 11.3 14.2 60.1 51.7 43.0 ' ) 52.5 66.5 69.9 LEUKEMIA 2 .9 2 .5 4.8 2 .2 2.2 1.2 i j LYMPHOMA 3.8 3 .6 8.6 3.1 4 .8 4.1 P' NERVOUS TISSUES 2.0 1.3 3.7 1.1 .7 1.5 VASCULAR TISSUES .2 .2 .6 .1 .0 .1 MUSCLE .2 .4 .9 .4 .2 .2 NON-EPITHELIAL 2.0 TISSUES EMBRY.-MIXED 1.5 TISSUES 2.1 5.1 1.8 3.2 2 .0 .8 2.3 .6 1 .0 1.8 NOT CLASSIFIED 4.8 2 .6 8.4 2.0 10.1 5.2 F r o m " M o r b i d i t y f r o m C a n c e r i n t h e U n i t e d S t a t e s , ' P u b l i c l l e a l l . i M o n o g r a p h , N o . 2 9 , PUS o f DREW ( 1 9 4 7 ) . . ..u*t.+.T/trm-t-mr API 06662 by this c o m p a r is o n . If they a r e v a lid , the e x p la n a tio n a g a in l i e s in the ' biased geographic grouping of the API c a se s. As indicated in the discussion of the p r im a ry site s, the a p p a re n tly e x c essiv e p ro p o rtio n of tu m o rs of the skin could be accounted for by considering the geographic location. Although a sim ilar tabulation was not made for histological types, it m ay be assum ed reasonably that these differences would again disappear. API 06663 - 2o D iscussion F r o m s e v e ra l points of view, this attem p t to e s tim a te by e p id e m io logical techniques the h a z a rd of occupational c a n ce r fro m ex p o su re to petroleum and its fractions cannot be considered an entirely successful venture. Only two relatively sim ple approaches w ere im plem ented, and neither w as expected to do m ore than to indicate the p resen ce of a possible h azard. E v e n though the lim ite d o b je c tiv e s w e re se le c te d , the n u m b e r of old and c u rre n t c a se s a s s e m b le d p ro v ed fa r too sm all to p e rm it d e ta ile d or elaborate analyses. Accordingly, only a few pertinent variables w ere examined, although as many m ore w ere of equal in te re st and concern. On the other hand, the s im ila ritie s d e m o n s tra te d in the p a tte rn s of d istrib u tio n betw een the U S. an d the A P I c a s e s w e re n o tew o rth y . The a p p a re n t d iffe re n c e s could generally be explained eith er because of the age group involved or because of the geographic location of the cases. It is unfortunate that the size of the sam p le so la b o rio u sly c o llected did not w a rra n t em ploym ent of standard significance tests. The e p id e m io lo g ic a l w o rk , h o w e v e r, w as p ro d u ctiv e of c e rta in indirect b e n e fits. The in te r e s t stim u la te d by this in v estig atio n of c an cer among em ployees of the oil com panies c a rrie d over into other a re a s , It pointed up the need for m ore and b etter m edical supervision, coupled with adequate re c o rd s of the m edical and occupational h isto ry of each em ployee. As a m a t t e r of fa c t, in o r d e r to im p r o v e th e i r r e p o r t s , s e v e r a l c o m p a n ie s took steps during the study p erio d to in su re that such se rv ic e s and inform ation API 06664 would be provided. Im petus was given also to the m ovem ent fo r the creation and support of c e n tra liz e d m ed ic al d e p a rtm e n ts. It w as reco g n ized a lm o st at once that the rep o rtin g m ec h a n ism s devised for the tum or studies dealt only with one occupational problem , while th ere w ere m any other im p o rtan t hygienic m a tte rs facing the m edical departm ents. As a consequence; im petus w as given to the growing dem and for a p ractical and system atic m eans of gathering and recording in a centralized agency the a c c e s s ib le data on m o rb id ity and m o rta lity . The benefits to be d erived, within a single in d u strial organization, among the organized u n its of an in d u stry a s a w hole, and within a still l a r g e r seg m e n t of our in d u s tr ia l population , a r e in c a lc u la b le . No such data a r e av a ilab le now. n o r, with few ex cep tio n s, will they be in the fu tu re, d espite the urgent need, u n le ss n u m e ro u s p ro b le m s of this type, com ing to a social or economic head m ake a stern necessity of what is now an opportunity. The inability to categ o rize occupational a ssig n m en ts also dem o n strated the d e sira b ility of clarifying in one way or another "job titles. " As indicated in the body of the re p o rt, m a rk e d d iffe re n c es w e re found in the te rm in o lo g y e m ployed, a s betw een in s ta lla tio n s of the s a m e o r g a n iz a tions as w ell a s am ong the v a rio u s co m panies. Since the definition of occupational hazard will depend in larg e p art upon an orderly, painstaking recording of w ork a s sig n m e n ts , the need for u n ifo rm ity and specificity is obvious. A djustm ent for other hazards or stre s se s in the home, community, or prior (as well as coincidental) occupations rem ains a vexing and possibly API 06665 1 ' - 23 insoluble problem . It does not seem likely that any adequate m echanism for recording and appraising such influences will be devised readily or soon. It m ust be reco g n ized that in d u stry cannot dem and o r o th erw ise in su re reporting of such h a z a rd s by all em ployees despite their potentially i i m p o r t a n t r o le in the c a u s a t i o n o r a g g r a v a t i o n of d i s e a s e . T h e s a m e i s equally tru e of other physical and clim atic fa c to rs, such a s so lar radiation, which in relatio n to the pro b lem under investigation in this instance is of unquestioned im portance. :* The m o st im p o rtan t product of this study, esp ecially for the investigators and for the m edical and technical personnel of the petroleum com panies that have been intim ately concerned with it, has been the sh arp en ing of th eir a p p re c ia tio n of the m any and v a rie d p ro b le m s of occupational 5 i health which a re am enable to attack by a p p ro p riate epidem iological m ethods 1 when coupled with adequate techniques for m edical and environm ental i k a p p ra is a ls . It b ecam e a p p a re n t at once that the su c ce ssfu l conduct of these studies depends directly upon the industrial physician and his place .1 in the a c tiv itie s of his com pany. Such a physician m u st reco g n ize that the p r o v i s i o n of the p r i m a r y d a t a of s u c h i n v e s t i g a t i o n s i s am e s s e n t i a l p a r t of his task. Routine p ro ce d u re s and re c o rd s m u st be designed to p erm it e a s y a c c e s s to p e r t i n e n t i n f o r m a t i o n f o r m e t h o d i c a l c o m p i l a t i o n . In so doing, :L. an active, resourceful industrial physician, with the w holehearted cooperation It .1 of his m an a g e m e n t, can p a rtic ip a te in fru itfu l stu d ies f a r beyond the c a p a !f i bilities of any outside agency. Finally, investigative and advisory organiza tio n s cam h elp , b u t in no w ay s u p p la n t, the i n d u s t r i a l m e d i c a l d e p a r t m e n t in th e 'a p p ra is a l of th e ir sp ecial health h a z a rd s . - 29 - F r o m The K e tte rin g L a b o ra to ry in the D e p a rtm en t of P re v e n tiv e M edicine and In d u s tria l H ealth, C ollege of M edicine, U niversity of Cincinnati, Cincinnati, Ohio. E xperim ental W ork and R eport by: J ohn J . Phai r , M . D . D a te : M a r c h 15, 1958 Approved: R obert A. KehoeJ M.D API 06667 APPENDIX I Selection of Study M ethods I -1 In opening a d is c u s s io n of the r e a s o n s fo r the s e le c tio n of m ethods utilized in this study of can cer among em ployees of the petro leu m industry, it seem s ap p ro p riate to point out that the investigation dealt essentially with a pure pro b lem in "chronic d ise a se " epidem iology. This usage of i the te rm "chronic d is e a s e " excludes such p ro b le m s as: a. R esidual conditions that m ay follow acute infectious diseases or accidental injuries; b. Infectious diseases that m ay have a prolonged period of clinical reaction or frequent rela p ses; and c. C ongenital le sio n s that m ay re s u lt fro m p re n a ta l factors or intrauterine infections. I The p rin c ip a l objective is to d e te rm in e the rela tio n sh ip between the occurrence of chronic o r degenerative diseases and repeated but, apparently, as they occur individually, insignificant noxious in su lts. Among the m ajo r o b stacles to be overcom e a re the trem endous and possibly insoluble problem s - first, of adjusting or talcing into acco u n t o th er "com peting c a u se s , " and second, the im p o rta n c e of the single, v e rs u s the cum ulative, effect of both " re a c tiv e " and " su b rea c tiv e " stim uli. As for the f o rm e r, con sid eratio n m u s t be given to the ro le s of o th er e x trin sic a s w ell a s in trin s ic v a ria b le s . T h ese m ay be few or m any, m ild o r s e v e re , r a r e o r freq u en t, depending upon the individual, his occupation, his h abits, and his environm ent. In the la tte r _ instance, the re p e titio n of m in o r in fectio n s, ex p o su re to a v a rie ty of toxic ; m aterials, and other insults over a lifetim e may either prom ote suscepti- ! f ' \ bility or even finally produce the host reaction. i To i llu s tr a te th ese points better., a crude th e o r e tic a l d ia g ra m of the p otential chain of c a u se s of one type o r a n o th e r that m u s t be su m m a te d in such a n a ly se s, is given on the next page. This d e m o n s tra te s in a s o m e what e x a g g era te d way the p ro b le m of relatin g in some fashion all the possible contributing factors Since they will vary in degree, kind, and rela.tive im portance at e a ch point, adds only to the com plexity of the p ro b le m s of chronic disease epidem iology facing the investigator. A c c o rd in g ly , the choice of p r o p e r in d ic e s and the devising of m eans to secure the data req u ired to d escrib e and evaluate a p articu la r occupational hazard is neither sim ple nor quickly accom plished. However, because epidem iological techniques have proved so su ccessfu l in the elucidation of fa c to rs involved in the dynam ics of infectious d ise a se s and in the m e a s u re m e n t of the effe c tiv en e ss of control p ro c e d u re s, this approach is suggested m o re and m o re for use in the description and identification of causal factors of noninfectious p ro ce sse s. T hese attem p ts can be su ccessfu l only to the extent to which the degree and kind of exposure re q u ire d to produce the rea c tio n of the host can be defined accu rately and distinguished from all the other possible factors. This becom es then the m ajo r problem in the design of an in v esti gation. Some of the deficiencies and gaps commonly found in the m edical facilities and in the knowledge of the h a z ard s a sso c ia te d with the w ork of groups of em ployees include the following: 1. A la c k of, a n d f r e q u e n tl y a n i n a b i li t y to p r o v id e , p e r i o d i c , uniform comprehensive m edical examinations and/or API 06670 POSSIBLE RELATIONSHIPS OF COMPETING CAUSAL AGENTS -- tv fu API 06671 I -3 su p e rv isio n for all of the w idely s c a tte re d em ployees of any given company, despite its m aintenance of a full-tim e centralized m edical departm ent. Many companies rely e n tire ly on local phy sician s a n sw erab le solely to the local supervisors. 2. A g re a t d e a rth of a c c u ra te and s a tisfa c to ry m ed ical re c o rd s , p a rtic u la rly of the type and detail that m ight be expected, to fu rn ish in fo rm atio n as to the incidence and p rev a len c e of cancer or any chronic disease, either past or present. This is especially true where a modern medical service has been fo rm e d only recen tly . In m any in sta n c e s, even com panies w ith good a ll-in c lu s iv e m e d ic a l p r o g r a m s do not m ain tain reco rd system s by which the diseases that occur among their em ployees can be enum erated readily. 3. The com plete im p ra c tic a b ility of d e scrib in g and categorizing the p rec ise occupational h a z ard s of the em ployees. This will alw ays be a b a r r i e r to the estim a tio n of p ro p e r incidence rates according,to occupational exposure not only for cancer but any other chronic disease. This obstacle is due generally to the lack of a p ra c tic a l m e c h a n ism for rec o rd in g the occupational a ssig n m en ts of all em ployees. Such data a re usually obtainable from the rep o rted cases, but there is no way to d e te rm in e the n u m b er of individuals with a s im ila r history in any given plant, large industrial company, or the industry as a whole. This situation becom es even m ore confused by the em ploym ent and seniority policies. F u rth e r m o re , the technological advances constantly m ad e prove to be equally im portant variab les since they change m arkedly the nature and the degree of h azard within very short time periods. S im ilar questions of equal or g re a te r difficulty can be anticipated in the effort to a sse m b le c a s e s fo r the n u m e ra to rs of the d e s ire d incidence and prevalence ra te s. This proved p a rticu la rly true in this special study of in d u stria l c a rc in o g e n e sis. Among those u n c o v e re d during the in v e s ti gation were: 1. The i n a b ility to s e c u r e the r e c o r d s of a ll c a n c e r c a s e s , p articularly those with skin neoplasm s and/or precancerous lesions. This stem s from the custom ary m ethods employed by physicians in the treatm en t of such lesions. A large API 06672 ; 4 m a jo r i'y of these m m o rs wiU be diagnosed and rem oved as a sim ple office p ro ced u re. There will be no request for a pathological study and the individual employee will not think of reporting the incidents. 2. The av ailability of only a v a ria b le proportion of the ca se s of cancer among em ployees that have left employment or re tire d Some inform ation can be had if the company m ain tains or supports a retire m e n t p ro g ram . However, all too frequently, these reco rd s a re held by the in su ran ce c a rr ie r and are not readily accessible or available. Also, the in fo r mation generally recorded, such as a death certificate, is not verified. M oreover, usually no feasible m echanism can be utilized or developed for tracing any large num ber of p erso n s who leave the em ploy of a given industry. 3. The i m p o s s ib ility of a d ju s tin g o r a cco u n tin g in any r e a s o n able fashion for "competing causes" and "cum ulative effects. " In addition to the occupational contacts, the em ployees have prior and.even coincidental work, community, and home risks. Local clim atic conditions, such as sunlight, may play a larg e p a rt Many of the em ployees have other occupations or hobbies. They have significant contacts with other known carcinogens. All these possible variables m ust be taken into account, especially in relation to en v iro n m ental or occupational cancer with its long incubation period and a g re a t n u m b er of p o ssib le etiological agents acting individually, conjointly, and possibly synergistically. 4. The lack of reliab le and a c cep tab le evidence a s to the relative im p o r tance of' a. the period and kind of exposure required to induce a cancer The la tte r variable will probably be given m uch i m o re con sid eratio n in the future than in the p a st as t i knowledge and understanding of the biological activity of carcinogens and p a rtic u la rly the role of a c c e le ra to rs A grows; 4 b. the difference in reactiv ity and resp o n ses of the individual w orker at various ages and situations; c the possible differences m the genetic susceptibility of c e rta in w o rk e r g ro u p s, e s p e c ia lly a s re la te d to skin pigmentation; and d. the possib le v aria tio n in su sce p tib ility that m ay a ris e from the nutritional status. I- 5 These difficulties in the selection and collection of data for the calculation of proper incidence and prevalence rates generally force the in v estig a to rs of chronic d is e a s e , p a rtic u la rly in in d u stria l situ atio n s, to rely instead upon "R elative F req u en cies, " that is the com parison of the proportions of certain types, kinds, o r sites of lesions in the various groups. The decision is usually reached reluctantly, since this latter statistic can only indicate and not evaluate the im portance of any given hazard. F u rth erm o re, p ro p er controls are not easily found. O rdinarily, the experience of the g en eral o r som e other in d u strial population in the same a re a m ust be u sed . F u rth e rm o re , the validity of any conclusions that are draw n depend definitely upon the size of the sam ple and this m ust be a c co rd in g ly quite la rg e . E pidem iologists concerned with the description of factors govern ing the spread of acute infectious d ise a se s can easily calculate incidence rates since the tim e and period of exposure in m ost instances m ay be d is regarded and there is usually no need to take into account other variables. Likewise, while differences in susceptibility are also recognized as a factor, it can be a ssu m e d to have an "all o r none" role. T hese Limitations also govern, to a larg e extent, the population groups and the p erio d to be studied. F o r chronic disease pro b lem s, three approaches usually a re con !i" sidered, nam ely, "re tro sp e c tiv e," "prospective, " and "closed population or cohort" studies. All three can be c a rrie d out by following only a sam ple i of the total group involved. $ I- 6 In a "re tro sp e c tiv e" survey, the investigator custom arily initiates the observations with individuals or groups who a re ill o r have died and w orks backw ard in tim e to determ ine if their habits, living places, or other environm ental conditions could have had any causal relationship This m ethod has g reat advantage in that, providing the patients or groups involved can be easily defined, a search is not required for individuals reacting clinically to the exposure or responding in a way that an objective laboratory test can identify them . F u rth e r, since the study extends back in tim e, the re su lts a re m o re quickly obtained, p a rticu la rly if a long incubation or latent period is involved. The great disadvantage is that any conclusions that m ay be draw n depend essentially upon the com parison of the cases under study with the experience of a selected control. Thus, much time m ust be spent in determ ining and providing a satisfactory un biased control group to be studied in a sim ilar fashion. The p ro p er choice of this group all too frequently p roves to be a m ajo r stum bling block. In a "p ro sp ectiv e" o r fo rw ard epidem iological survey, selected individuals o r a group with comm on exposures with full p rio r definition and knowledge of th eir ch a ra c te ristic s and composition a re followed for p redeterm ined periods of tim e accom panied by controlled observations of the p a rtic u la r v a ria b le s u n der study. The advantage of this m ethod is that the frequency or incidence as w ell as the prevalence of reactions, clinical or su b clin ical, can be re a d ily d e s c rib e d in the e x p e rim e n ta l group. If a sufficient num ber of w o rk ers or subjects can be followed, fu rth er and m ore minute subdivisions and studies according to age, sex, race, and sim ilar API 06675 I- 7 variables a re possible. The m ajo r obstacle generally is the length of tim e that m ay be req u ired to obtain the d e sire d a n sw ers. If a long latent or incubation period is involved, observations m ust be planned for ten or twenty y e a rs. Such experim ents are not only costly, but the initial size of the sam ple chosen is determ ined not only by the expected differences, but m u st be la rg e enough to allow fo r the unavoidable lo s s e s due to m i g r a tion or deaths from other causes. Socio-econom ic variables m ay also change greatly during the observation period, and in dealing with industrial problem s th ere is alw ays the e v e r-p re s e n t danger of g reat changes in the exposure due to technological advances. The "cohort" type of study dem ands an entirely different approach. In it, a group is a rb itra rily selected by definition and the total ex p erien ce is recorded, not only for those individuals who react, becom e ill, or die, but also all others as well. Knowing when the period of observation begins, the num ber and tim e of o ccu rren ce of the reaction, valid m orbidity and m ortality rate s can be calculated and com pared with those observed in the com m unity. This approach req u ires a c c e ss to rec o rd s that fu rn ish sufficient inform ation to enter and rem ove individuals fro m the tim e p erio d of the study in a reasonably accu rate m anner in o rd er to calculate "person y ears. " This is not u n reaso n ab le fo r m o st in d u stria l situations. Recognition of cases is m o re of a problem unless the reaction is readily recognizable. However, "exposure" can be described far b etter since it can be sharply defined in the planning and im plem entation of the investigation. API 06676 I- 8 In considering definitions for use in in d u stria l epidem iological studies, it has been found that "work contacts" as described by an occupa tional histo ry are influenced greatly by the custom ary company-union relationships, in that the job assignm ents and length of such em ploym ent depend p rim a rily upon the seniority attained and the frequency with which vacancies occur. In other w ords, the individual p ro g re sse s gradually up the lad d er, beginning u su ally a s a la b o r e r and m ounting step by step to the better positions. There usually is no o rd er in this advancem ent and, fu rth e rm o re , no m ark e d specialization as one m ight expect in highly tech nical operations. It was quickly discovered as various in d u strial situations w ere studied also that job titles differed g reatly from company to company and indicated little if any relationship to the degree and kind of h azard . Men charged with the actual operation of the equipm ent, fo r exam ple in the petroleum industry, m ay have very little or no contact with either petroleum or the various refined products, but the sa m p le rs and m aintenance personnel may have frequent and heavy exposures. At the sam e tim e, m aintenance and labor classifications m ay w ork in all p a rts of the refinery or, equally com m on, be a s sig n e d fo r a significant p e rio d of tim e to a single a r e a . In reviewing the effect of technical changes in the refining p ro c e sse s on the exposure factor, one is im m ediately im p re sse d by the fact that this is an extraordinarily fluid and dynamic industry. New p ro cesses evolve constantly, and this has been particularly true in recent years as companies moved rapidly fro m "batch" type of o p e ra tio n s to e s s e n tia lly " a s s e m b ly lin e " API 06677 I - 9 p rocedures. With this evolution, the degree and kind of contact change m arkedly. M aintenance problem s are reduced, and even the presently w idely-spaced "turn arounds" are being subcontracted by many com panies.* Consequently, even if accurate and reliable occupational records w ere obtainable, the local situations are constantly changing and im proving so that the exposures of today a re m uch le ss than those ten y e a rs past, and it can be predicted confidently that they are probably much g reater than those of ten years hence. T hese p roblem s and other likely difficulties to be encountered should long-range epidem iological studies be attem pted in the petroleum in d u s try , w e r e d is c u s s e d b ro a d ly and th o ro u g h ly . At the N o v e m b e r 1949 m eeting the objectives w ere finally d escrib ed by the M edical A dvisory C om m ittee of the A .P .I . and their technical ad v iso rs. T here w as general agreem ent then that the only way to achieve a uniform understanding of the problem s and to in su re satisfacto ry w orking relationships would be through individual interview s and discussions with the in terested m edical d irecto rs, their scientific ad v iso rs, rep re sen ta tiv e s of m anagem ent, and the responsible investigator. Only by complete cooperation in an o v er-all joint effort could one be sure of successfully m obilizing their experience in and knowledge of the industry and its m edical problem s in the organization and implementing logical and feasible studies. *It m ust be adm itted that, although this developm ent m ay dim inish the exposure hazard for the refin ery w o rk er, it m ay be concentrating and augmenting the danger to the em ployees of com panies specializing in this se rv ic e-ty p e operation. API 06678 I - 10 T D uring the r e m a in d e r of 1949 and the n ex t two y e a r s , field trip s were arran g ed so that all of the participating m edical d irecto rs had an opportunity to contribute not only to the basic planning but also to a s s is t in the developm ent of satisfacto ry reporting m ech an ism s. It w as found d e s ira b le to spend m uch tim e on the c la rific a tio n of the le g a l a s p e c ts of the p ro p o sed studies to be conducted by The K ettering L a b o rato ry as the ! com panies would be re le a sin g th eir a b s tr a c te d but p riv a te re c o r d s to an outside agency. At the sam e tim e, sim ilar projects of private and govern m ental ag en cies w ere review ed such as the N ational C ancer Institute of the Public H ealth S ervice; State and lo cal C ancer Control U nits; M edical C enters; and other R e se a rc h Institutions concerned with various asp ects of the can cer pro b lem . Such contacts w ere d ire c te d p rim a rily at determ ining their in te r e s t and p a rticip a tio n , p ast, p re se n t, or future, in r e s e a rc h on occupational carcinogenesis; to establish working relationships with in v estig ato rs concerned w ith this possible health hazard; and to in su re that th e ir o b s e rv a tio n s w e re u tiliz e d to the f u lle s t extent in the planning of the A .P .I . p ro ject. F ro m this w elter of discussions, m eetings, and interview s, some seven approaches w ere cry stallized out for study and evaluation by the p a r ticipating com panies. All had certain advantages and disadvantages, but none could be expected to fu rn ish final and definitive a n sw e rs to the questions posed by the petroleum industry. These a re described briefly in the p a ra graphs that follow: API 06679 I - 11 1. H is to ric a l R eview T his req u ired all of the cooperating com panies to forw ard to a c e n tr a l a g e n cy (in th is in s ta n c e , the U n iv e rs ity of Cincinnati) the clinical and em ploym ent h isto rie s of all the known proved or suspected cases of neoplastic disease that had occu rred among th eir em ployees in the past. It was con ceded that, due to the g re a t differen ces in the availability and accessibility of such rec o rd s in the various M edical D ep art m en ts, the num ber of cases reported and the period covered could not be the sam e for all com panies. It was acknowledged also that these reports would not be sufficiently uniform , since they would be sent in from so m any sources and a rise from an unknown population base, both as to tim e and exposure, to p e rm it even crude estim atio n s of past h azard s. The principal retu rn s expected from the com pletion and assem bling of detailed clinical and occupational fo rm s fo r c a s e s in the file s of the com panies would be p rim a rily : a. the indication of the kind and am ount of inform ation that was readily available for inclusion in study, and an indi cation of additional ite m s that m ight be req u ired in the fu tu re re c o rd in g of such c a se s; b. the training of the staffs of the resp ectiv e M edical D e p a rt m en ts in the m e c h a n ic s of handling and filing uniform reports and participating in this unique industry-w ide recording system . It was hoped that this prelim inary "seasoning" exercise would insure better records for the proposed "C urrent R egistry;" c. the testin g of a sta n d a rd iz e d fo rm a s to content and fo rm a t, with p articu lar attention directed at the developm ent of m ethods that would p erm it a reasonably accurate d e scrip tion of the occupational h isto ry , and a rough estim ation of the d eg ree and kind of w ork contact not only to petro leu m and its products, but other possible "competing" irritants; and d. that although it could be p red ic te d confidently that the deficit in skin cancer rep o rts would not p erm it any evalu ation of the risk in w ork exposures under refinery conditions, the relative frequencies of cancer of other types and sites m ight point to other problem s or, in turn, dem onstrate that future e ffo rts should be focused alone on skin contact. API 06680 I - 12 2. C urrent R e g istry I This second approach envisioned the expansion of the central I reg istra tio n of the h isto ric a l cases (at the U niversity of I Cincinnati) to include re p o rts and occupational h isto rie s of cancer patients as they are discovered by and/or reported by p h ysicians to the M edical D ep artm en ts or any sim ila r responsible and designated office of the participating companies. The pretested standardized and corrected rec o rd form would be used, and it was believed that the inform ation obtained in this m anner would be much m ore reliable since the questions would be answ ered im m ediately upon notification of the o c c u rre n ce of a case. i The absolute risk of an individual or a p articular population Ij group for a given disease is best m easured always by a m o rb id ity or attack rate . The assem bling of cu rren t cases still would not p e rm it the calculation of such incidence or even crude prevalence rate s. Even if all of the com panies I rep o rted all of their cases and if satisfactory m ean popula tions by broad occupational grouping could be sketchily estim ated, the values thus obtained could not be considered a c c u ra te d e s c rip tio n s of the a c tu a l ex p o su re ris k . As in d i cated e a rlie r, this situation a ris e s from the inability to describe the "w orker exposure" in any w orkable term s for : these refinery populations. However, particularly for chronic and degenerative diseases such as cancer, the "relative frequency" of different types and sites for the lesions in individuals with some common characteristic such as age, sex, race, nutritional status, o r occupational h isto ry can be expected to give some in d ic a tion of the p rese n c e or absence of some unusual cuasal facto r, * even though such statistics are known not to be n ear as sensitive as incidence rates. ? It was believed, therefore, that if satisfactory channels for 3 sending and receiving the rep o rts could be arran g ed with the | individual com panies through tjieir m edical departm ents, then i the com parisons of the relative frequencies of types and sites I of cancer occurring in the w o rk e rs' refin erie s with sim ilar values for the general population an d /o r other industrial groups in the same geographical a re a m ight indicate unusual hazards. The inherent dangers and difficulties in this approach w ere fully appreciated, but the proposal m erited very serious ' con side ration. API 06681 I - 13 The crux of the problem would be the num ber of cases that could be a s s e m b le d an d the c o m p le te n e s s of the c o v e ra g e of the industry. To secure a reasonable and worthwhile sam ple m eant that a m ajo rity of the participating com panies had to re p o rt all of th eir known c a se s for a significant p eriod of t im e . A t l e a s t 10, 000 r e c o r d s h a d to be a s s e m b l e d if th e analyses w ere to be valid, and it w as estim ated that this would require at lea st ten y e a rs at the rate cases w ere being seen in a reasonably larg e segm ent of the industry. The only p ra c tic a l solution to the problem of securing adequate re p o rtin g would seem to be a slow, p e rs is te n t, patient app ro ach , g ath erin g w hat can be a s s e m b le d fro m tim e to tim e and g a in ing the tr u s t and co o p eratio n of the groups involved. T h is is acceptable when long range support is a ssu re d and the im m ed i ate attainm ent of a definite and final objective is not e sse n tia l. It m ust be reem phasized that the validity of epidem iological observations depends entirely upon the accuracy and com plete n e s s of the av ailab le m e d ic a l su p e rv isio n and re c o rd s . It follows, then that there can be no sound ap p raisals of occupa tional hazards until facilities and methods are made available in in d u stry not only for the detection of clin ical rea c tio n s but for the recording of them in an orderly m anner. Occupational assignm ents and hazardous contacts m ust be sim ilarly noted for possible future correlations. Even in enlightened interested m edical departm ents, entirely satisfactory m echanism s and procedures have not yet been devised or perfected. Unfortunately fo r m e d ic a l s c ie n c e , the a c c e p ta n c e of th is n e e d is lik e ly to be slow for som e tim e to com e. How ever, some acceleratio n m ay be expected from the im pact of health insurance p ro g ram s and the widening recognition of the im portance of in d u stria l e x posures for certain chronic diseases. A s a sup p lem entary activity of the cen tral re g is try , it seem ed w ise for s e v e ra l re a s o n s to plan the p ro vision of a pathological se rv ic e . F ir s t, because the availability of and easy a c c e s s to this a ssista n c e would in su re uniform ity in the tissue d iagnosis. Second, b ecau se of the definite need to stim ulate the i n te r e s t and co operation not only of the v a rio u s M edical D epartm ents, but also the local p art-tim e plant and private rt physicians. Finally, because this action would em phasize the d esirability of m icroscopic exam ination of all suspicious lesions no m atter when or w here they occur, as well as serve to standardize the n om enclature u sed to re p o rt their o ccu rren ce. 3. H e a lth B e n e fit a n d I n s u r a n c e R e c o r d s $ I M ost of the participating petroleum com panies had health benefit and retire m e n t in su ran ce p ro g ra m s of one kind or API 06682 I - 14 another. One m aintained a com plete m edical care program not only for the employee but also his fam ily as well, supported by joint contributions. All of the m edical claim s of em ployees of this company, re g a rd le s s of kind or degree, w ere recorded. Like arrangem ents can be found in other industries operating in the sam e geographical a re a and drawing from the common lab o r pool. F u r th e r m o r e , a wide v a rie ty of in d u s trie s and different work exposures will carry their insurance coverage with a single company. U tilization of these re c o rd s seem ed to offer a re a l opportunity for com parisons of the effect and force of "com peting causes. " These would include such factors as usual or unusual geo graphical and community risks, outside plant exposures, and personal habits. However, before an experim ental design for this a p p ro a c h could be draw n, read y a c c e s s had to be a s su re d not only to the health benefit and in su ran ce reco rd s of the participating com panies but also those of at least one o r two other m ajo r in d u stries or plants operating in the sam e geographical area. It was thought that this might be arranged either d ire c tly b y using the rec o rd s in the company files or indirectly with th eir perm issio n , obtaining the required in fo r m ation from the insurance files. The success of this approach would depend e s s e n tia lly upon com pany p o lic ie s, the types of m edical program s, m anagem ent interest, and em ployee-em ployer relationships. If it proved w orkable in the petroleum industry, it would re su lt in an exceptional "co h o rt" type of study with unusual c o n tro ls. An investigation of such re c o rd s could be far m ore extensive and cover m ore occupational assignm ents than the "p ro sp e c tiv e " type of field studies under consideration. Several m ajor obstacles im m ediately arose. The first was the need to a ssem b le far m o re inform ation than custom arily required for an ordinary insurance claim. M ost insurance c a r r ie r s do not verify the cause of death since this introduces a serious e rro r and further search for death certificates would be n ecessary . A second bias, and one always inherent in this problem , a r is e s b ecau se skin carcin o m as, due to early detection and m inor local treatm ent, will not result in lost time or a m edical claim , and so would be undercounted. The th ird point w orthy of em p h asis is that in all likelihood only crude m ortality rates can be calculated if this approach is applied in d u stry -w id e since som e of the com panies have death but not health p ro g ram s. Finally, it would still be very diffi cult to take into account those em ployees who have left or leave the company rolls for any reaso n other than retirem en t. API 06683 I - 15 4. C ontrolled F ield Studies Two types of field studies had to be considered se rio u sly as p o ssib le avenues to be. explored in an attem p t to a s c e rta in d ire c tly the h a z ard of v ario u s d e g re e s of skin ex p o su res. Both require periodic field observations of selected groups of em ployees with proper controls over a significant period of tim e. These would be essentially "prospective" investiga tions and would req u ire support fo r a significant p eriod of tim e. a. Slack Wax W orkers The f ir s t of these w as the p roposal for a repetition of the studies that had dem onstrated the in creased risk of scrotal cancer among em ployees involved in processing slack wax. T hese could be redesigned to take into account process variations as well as clim atic differences and answ er certain criticism s that had been brought fo rw ard in re g a rd to the e a rlie r ob serv atio n s. R acial susceptibility as well as skin pigm entation would also be taken into account. The approach contem plated was a joint effort of The K ettering L a b o rato ry staff, including com petent d e rm a to lo g ists, and the clinicians of the M edical D epartm ents of the in te rested com panies. 3 Insofar as the em ployees a re concerned, these studies i could be justified as p a rt of the routine periodic physical exam ination, and the L aboratory participation would be I c o n f in e d e s s e n t i a l l y a t i n s u r i n g a s t a n d a r d p r o c e d u r e f o r the identification and reco rd in g of the skin and sc ro ta l lesions. It has been found that the various m edical d e p a rt m ents w ere not at all consistent or uniform in their diagnosis and handling of such cases. It was also known that one or two com panies had undertaken independent investigations of the probability and risk of skin contact not only in slack wax p ro cesses but also other refinery procedures, and it seem ed not only desirable but wise to bring together this inform ation fro m m any different sources for the benefit of the industry as a whole. f I The principal obstacles, granting that m anagement interest and cooperation was forthcoming, w ere the technological advances that have been m ade in this p ro c e ss by the installation of solvent extraction. It is apparent that any p ro sp ectiv e study would be too lim ited to give valid rate s for the older m ethods. F u rth e rm o re , the evidence already gathered am ply dem onstrates the h azard that w as presen t in the p ast and had alread y indicated the need for changes in plant and personal hygiene practices. I - 16 b. E x p o su res to C atalytic C racked R esid u als The second "prospective" field investigation w arranting consideration was observation of those individuals exposed to skin contact with petroleum fractions known through the chem ical and biological tests to have a high concentration of possible carcinogens a n d /o r a c c e le ra to rs or to be com paratively potent in the production of skin tum ors in m ice. This method would require careful periodic exam inations and notation of the appearance of retrograde, hyperkeratotic or m alignant lesio n s. Again, it would be n ec essa ry to take into account variations in p ro cesses, as well as clim atic conditions, racial susceptibility, and personal hygiene. As in the instance of the slack wax investigations, the dynam ic, alm ost fluid, state of m odern petroleum refining technology would seriously interfere with any attem p t to define a c c u ra te ly , for any significant p eriod of t i m e , tl^e d e g r e e a n d k in d of w o r k e x p o s u r e sav e in the bro ad est of te rm s. When this variable is weighed in the light of the relatively long and severe exposure to carcinogenic m a te ria ls that w as re q u ired to produce neoplastic disease in m an in the past, then p ro cess changes b ecom e quite im p o rta n t and a r e difficult to evaluate. F urtherm ore, this situation is even m ore com plicated by the long interval that m ay elapse between the term in atio n of exposure and the a p p earan ce of a tu m o r. It is obvious, th ere fo re , a s in the investigation of the slack-w ax problem , that the observation of the test and control groups in the refin eries would have to be continued and m aintained for a long period if one w ished to m ea su re the risk of the new er p ro ce sse s. It was to be hoped that the evaluation of the older refinery m ethod could be term inated much e a rlie r, provided adequate occupational h isto ries could be obtained from the w o rk ers as they w ere exam ined and accepted into the study groups. 5. S u rv e y of P e r s o n a l H ygiene a n d C o n ta c t C o n tro l P r o g r a m s Each company differed widely in refinery p ractices, and it was proposed that arrangem ents be made for The Kettering L ab o rato ry to assem b le, collect, and su m m arize this in fo r m ation for the industry as a whole. Several reaso n s w ere offered in justification of this activity. F ir s t and probably m ost im portant was the need for a com pilation of the contact control p ro g ram s. A second is the value of classifying in an ord erly fashion the probable w ork exposures that would be API 06685 I I - 17 recorded in the occupational h isto rie s. The resu lts of such a survey would a lso be valuable in the planning of sp e cia l studies such as have been proposed. These data would guide and a s s is t in the selection of plants a n d /o r p ro c e sse s to be studied. F u r th e r , the bringing to g eth er of this in fo rm a tio n in a usable form would be helpful in raising the refinery and personal hygiene standards of the industry as a whole. The item s suggested for inclusion in this study w ere: a. M anufacturing A ctivities - i . e. , a list of the various processes at that particular plant or refinery; b. Employee Population - i. e . , race, sex, occupational classification, etc. ; c. Em ployee F acilities - i . e . , num ber of show ers, locker room s, toilet facilities, eating are a s, etc. ; d. Hygiene P r o g ra m - i . e . , degree and type of su p erv isio n regarding personal hygiene, changing of clothing, etc. ; e. Contact Control - i . e . , provision of protective clothing, special equipment or procedures, etc. ; f. H ealth E ducation - i . e . , objectives, m ethods em ployed, degree and type of supervision, etc. ; g. M edical C are - i . e . , p erso n n el, equipm ent and re s o u rc e s , therapeutic and preventive program s; and h. Insurance P ro g ra m s - i . e. , accessib ility of reco rd s; extent and type of M edical C are, H ospital C are, Sick Benefit, R etirem ent Benefit, and Death Benefit P ro g ra m s. 6. M edical R eco rd C onsultation Service As soon as epidem iological techniques are considered for an attack on m edical problem s in industry, the clinical and occupational rec o rd s of the em ployees as m ade and m aintained by the m edical and personnel departm ents becom e all im portant. Yet even a very superficial survey of the situation in this instance uncovered the fact that there w ere g reat gaps and serious deficiencies not only in the reco rd s them selves but also the m echanism s for tabulating, sum m arizing, and analyzing the o bservations. Even though the petroleum industry as a whole is m uch further advanced in the provision of m edical serv ices than industry in the USA in general, it is obvious that a g rea t deal m o re rem ains to be accom plished, p a rtic u la rly in relating the m ed ical p ro b le m s of the em ployees to occupational fa c to rs. I - 18 The importance of this point was repeatedly emphasized in the discussion of the various approaches. Accordingly, it appeared wise to provide in some fashion advice or assistance in the devising of medical records and the planning of facilities for their proper analysis. The interest and concern of the industry as a whole with the possible cancer hazard had pointed up the desirability of maintaining adequate medical departments with proper clinical records and occupational histories. This, in turn, had generated a demand for com petent assistance in the planning of such facilities, particularly in the preparation and tabulation of medical records. Moreover, there are other needs of the medical departments to be satisfied with such records beyond the simple question of occupational carcinogenesis. These include the causes of absenteeism and injuries, the incidence of acute and chronic disease as related to the employee, the plant environment, and job requirements. There is no question that the value and many applications of standardized recording methods, uniform tabulations, and. evaluation of various indices were generally recognized by the medical directors and their compani.es. Consequently, it was proposed in this approach that the University of Cincinnati furnish guidance and advice upon request to any of the participating companies. This could include suggestions as to contents and format of the medical records, first as they concern the cancer problem and later to take in other medical problems. It was believed that the channels developed for the current reporting of cancer cases to a central agency could be utilized in the future for expansion into other areas. 7. Literature Survey As the importance of occupational carcinogenesis grew and the varied sources of information on this subject were tapped, it seemed desirable to collect and critically abstract scientific articles as they appeared in the medical literature. Abstracts were to be prepared, duplicated, and circulated periodically to the members of the Advisory Committee. Consideration of this activity could be justified although there are at least two major compilations of this material available. Most of the published information had never been interpreted critically and put in the proper perspective. It would be worth while, therefore, as one aspect of the API project, to provide the Medical Directors of the participating companies with current summations and critical reviews of the various investi gations in the field of occupational carcinogenesis. API 06687 I - 19 As indicated in the report, these proposed attacks, while con sidered generally acceptable, w ere never completely im plem ented. Only two, n am ely the H isto rica l R eview and C u rren t R eg istry , w ere selected finally f o r e x p lo ra tio n . B etw een 1952 and 1955 the rem a in in g su g g e ste d approaches w ere reviewed many tim es. Methods and applications w ere d iscu ssed fre e ly and m inutely not only a t the m eetings of the M edical A dvisory C om m ittee but with individual m edical d ire c to rs. Active steps could not be taken for two principal rea so n s. F ir s t, all outside or unusual investigations were postponed because of the high p rio rity of technological changes in refining operations brought about by the K orean em ergency. Consequently, it proved im p o ssib le to se c re serio u s consideration of sim ple req u ests for a c c e s s e it h e r to r e c o r d s o r w o r k e r s . S econdly, b e tw e en 1950 and 1953 t h e r e w e r e m a n y in n o v a tio n s in the m e d ic a l p r o g r a m s of th e p a r t i c i pating com panies, including m ajo r shifts in personnel and policies. All in all, it seem ed d esirab le not to in s is t on expansion of the epidem iological investigations until the entire situation stabilized. As the p ro ject p ro g re ssed during the late r y ears, the exploration of the p o s s ib le u se of h e a lth b e n e fit an d in s u r a n c e r e c o r d s w as p o stp o n ed also tim e and again because of the cost of this type of review and the g rea t differences in the type and kind of in su ran ce coverage offered by the com panies. D uring 1954 the m ed ic al and occupational re c o r d s of two m a jo r oil com panies w ere carefully review ed with th eir m edical d ire c to rs. It API 06688 1-20 was hoped that at this tim e an opportunity had been p re se n te d to develop Tfea sib le m e th o d s f o r the u tiliz a tio n of ro u tin e m e d ic a l an d in s u r a n c e records. U nfortunately, it was found that they did not contain sufficient inform ation nor w ere they in a form that would perm it valid or useful studies. All thought of "prospective" field studies among refin ery popu lations was dropped alm ost at once because it becam e apparent early that investigations of this kind can only be c a rrie d out by the individual com panies with th eir own staffs and could not be undertaken readily as a group effort. Until the discontinuance of the epidem iological phases of the p ro je c t, advice and help w as so lic ite d and provided fo r the planning of records and reco rd keeping system s in various situations. The literatu re review proposal was rejected early by the M edical A dvisory C om m ittee. The failure to em ploy all of the proposed avenues in this essentially exploratory investigation should not preclude trials with such m ethods in other fields in the future. It was recognized that the selection that w as m ade would not p e rm it the calculation of r a te s and at best only p e rm it the c o m p a riso n of "R elative F re q u e n c ie s . " It se em e d w iser and fa r m o re p rac tic a l, how ever, to begin with the reco rd s im m e d i ately at hand and proceed to the m o re com plex approaches as they appeared feasible. APPENDIX II Summary Tabulation a NUMBER OF INDIVIDUALS WITH SINGLE TUMORS AND SIT E S ACCORDING TO THE YEAR OF ONSET AS REPORTED BEFORE 1950 1950 1951 1952 AFTER 1950 1953 1954 1955 1956 ALL CASES UNKNOW TOTAL REPOR1B 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 V dtal 3 107 34 80 24 15 3 2 49 31 14 232 27 24 645 2 74 48 4 9 4 6 1 - 2 2 2 1 6 10 2 2 8 13 3 2 11 18 15 14 5 5 9 12 150 140 NO IEPORTS NO USPORTS 4 5 NO IEPORTS 1 9 9 13 7 4r 4 2 3 5 3 2 10 10 15 23 no : [SPORTS 8 16 18 18 5 4 12 1 NO 1!EPORTS 11 29 30 31 3 8 8 3 16 13 10 4 NO 1[SPORTS NO I SPORTS NO ] SPORTS 5 9 16 10 7 19 8 12 26 9 16 18 99 134 165 134 2 5 3 12 ' 12 20 143 250 27 78 112 4 14 94 29 38 62 3 18 18 6 10 25 13 74 77 3 79 79 26 28 1 48 171 220 190 217 248 10 82 96 1 48 112 344 15 86 113 76 1.57 181 2 495 1319 1976 API 06691 NUMBER OF NEOPLASMS ACCORDING TO SEX , RACE, MALIGNANCY, AND REGISTRY STATUS AS REPORTED FROM 17 COMPANIES APPENDIX I I - 2 SEX RACE MALE WHITE COLORED NOT GIVEN OTHER ONSET PRIOR TO 1 9 5 0 MALIGN BENIGN TOTAL 558 48 606 20 0 20 37 4 41 0 0 0 FEMALE TOTAL 615 WHITE 20 COLORED ! i NOT GIVEN 0 TOTAL 20 52 667 1 21 0 0 1 21 TOTAL BOTH SEXES 635 53 688 ONSET SUBSEQUENT TO 1 9 5 0 MALIGN BENIGN TOTAL 1100 -, 68 1168 11 0 11 75 30 105 5 0 5 1191 67 98 1289 1 68 6 73 1264 4 10 5 78 103 1367 TOTAL NEOPLASMS REPORTED MALIGN BENIGN TOTAL 1658 31 116 1774 0 31 112 34 146 5 0 5 1806 87 150 1956 2 89 6 93 1899 4 10 6 99 156 2055 API 06692 ArrM HBX i t - 3 SITE BUCCAL CAVITY DIOBST. SYS. AND P E R IT . RESPIRATORY SYSTEM 0 0 -OX 10-1X -20->2X USA * 1947 6 .9 2 8 .7 MALE SUBSEQU1ENT TO PRIOR TO 1 9 5 0 ___ ________ I S p o NO. % ** NO. % ** 19 3 .3 48 4 .1 USA * 1947 2 .2 205 3 5.0 304 2 6 .2 19 .8 1 2 .6 85 1 4 .5 182 1 5.7 ' 2 .3 FEMALE V \ SUBSEQUENT TO ] PRIOR TO 1 9 5 0 1950 NO. % + NO. % 0 0 .0 0 0 .0 5 2 6 .3 2 1 0.5 8 1 1.3 0 0 .0 R P tlR T GENITAL ORGANS 30 0 .2 0 1 0 .4 50 4 0 --4X URINARY SYSTEM 50-55 6 .9 38 SKIN AND 1 9 .3 92 SOFT TISSUES 6 0-6X BONES 70-75 0 .8 12 BRAIN LYMPH. AND HEM. SYSTEM OTHER SITES 76-78 8 0 -RY 9 0 - 9X 2 .7 10 6 .7 38 4 .8 36 0 .0 2 8 .6 91 0 .2 ! 2 2 .0 5 7 .9 25 .5 3 6 .5 65 1 5 .7 330 2 .1 9 1 .7 21 6 .5 58 6 .2 49 5 .6 28 .5 0 .8 1 .8 5 .0 4 .2 3 .1 0 1 3 .1 1 0 .5 1 1 .9 0 4 .2 1 5 .4 1 26 .3 26 1 5.8 21 0 .0 2 5 .3 8 5 .3 0 0 .0 1 5 .3 2 5 .3 3 TOTAL 1 00.0 585 1 0 0 .0 1159 1 0 0 .0 1 0 0 .0 19 1 0 0 .0 71 * From "Morbidity from Cancer in the United States", Public Health Monograph No. 29, U.S .P.H.S.. ** Columnar percentage totals may vary slightly from 100% due to .5 adjustment In each computation. 3 6.6 2 9 .6 2 .8 1 1 .3 0 .0 1 .4 2 .8 4 .2 1 0 0 .0 PERCENTILE DISTRIBUTION OF MALIGNANT NEOPLASMS IN MALES WITH ONSETS BEFORE TO JANUARY 1 , 1 9 5 0 , ACCORDING TO S IT E OF TUMOR AND PETROLEUM OCCUPATION (INDIVIDUALS WITH SINGLE NEOPLASMS, SINGLE S IT E ONLY) APPENDIX I I PRINCIPAL PET. OCCUPATION SITE BlICCAL CAVITY 0 0 -OX UN KNOWN 00 (9) 4 .1 PRODUCT ION 01-09 (0) 0 .0 CRACK ING 20-29 (0) 0 .0 REFINING LUB. AND GREASE PARAFFIN 30-35 36-39 STR. RUN 40-49 (0) (0) (0) 0 .0 0 .0 0 .0 SPEC. PROD . 50-59 (0) 0 .0 MAINTENANCE 60-69 (3) 2 .7 OTHERS 70-79 (2) 3 .2 TRANS PORT 80-89 (1) 2 .2 EXEC. AflD MARKET 90-98 (3) 3 .1 OTHERS 99 (1) 5 .9 DIGEST. SYS. (81) (3) (0) PERIT. 10-1X 3 7 .2 15 .8 0 .0 (0) (2) 0 .0 4 0 .0 (0) ] (0) (37) (26) (20) (31) (5) 0 .0 0 .0 3 3.0 4 1 .9 43 .5 3 1 .6 2 9 .4 RESPIRATORY (32) (9) (0) (3) (0) (0) SYSTEM 2 0 -2X 1 4 . 7 47 .4 0 .0 5 0 .0 0 .0 0 .0 BREAST 30 (0) (0) (0) 0 .0 0 .0 0 .0 (0) (0) (0) 0 .0 0 .0 0 .0 GENITAL (22) (1) (0) ORGANS 4 0 -4X 1 0 . 1 5 .3 0 .0 (0) (2) (0) 0 .0 4 0.0 0 .0 URINARY SYSTEM 5 0 - 5 5 SKIN AND SOFT TISSUE 60 -6X BONES 7 0 - 7 5 BRAIN 7 6 - 7 8 LYMPH. AND HEN SYSTEM 8 0 -8 Y (12) 5 .5 (37) 1 7.0 (4) 1 .8 (5) 2 .3 (7) 3 .2 (1) 5 .3 (4) 2 1.1 (0) 0 .0 (0) 0 .0 (0) 0 .0 (0) 0 .0 (1) 1 0 0 .0 (0) 0 .0 (0) 0 .0 (0) 0 .0 (1) (0) (0) 1 6 .7 0 .0 0 .0 (1) (0) (0) 1 6.7 0 .0 0 .0 (0) (0) (0) 0 .0 0 .0 0 .0 (0) (1) (0) 0 .0 2 0 .0 0 .0 (0) (0) (0) 0 0 0 .0 0 .0 OTHER S 1TES 90-9X (9) 4 .1 (218) * TOTAL 1 0 0 .0 C olum nar p e rc e n ta g e (1) 5 .3 (19) 100 0 to ta ls (0) 0 .0 (1) 1 0 0 .0 may v a ry (1) J 6 .7 (6) 1 0 0 .0 slig h tly N o te: Item s in p a re n th e se s a re a c tu a l co u n t (0) 0 .0 (5) 100 ,0 fro m 100% to ta ls . (0) 0 .0 (0) 1 0 0 .0 due to (1) 1 0 0 .0 (10) (4) fi.9 6 .5 (6) is n (15) 1 5.3 (5) 29 .4 (0) (0) (0) 0 .0 0 .0 0 .0 (0) (0) (0) 0 .0 0 .0 0 .0 (0) (8) (4) (5) (8) (0) 0 .0 7 .1 6 .5 10-9 8 .2 0 .0 (0) (5) (4) 0 .0 4 .5 6 .5 (2) (12) (1) 4 .3 1 2 .2 5 .9 (0) (27) (7) 0 .0 2 4 .1 11 .3 (3) (8) (4) 6 .5 8 .2 23 .5 (0) (5) (2) (0) (1) (0) 0 .0 4 . 5 - . 3 ^ 2 ____ 0 . 0 _ L f l ___ (0) (0) (0) (2) (2) (0) 0 ,0 0 .0 0 .0 (0) Hl) (8) 0 .0 9 .8 1 2.9 4 .3 2 .0 0 .0 (4) (7) (1) 8 .7 7 .1 5 .9 (0) 0 ,0 (1) 100 0 (6) (5) (3) (ID (0) J b J ____ __6_J____ __________ -ULJi__ .... (L.Q . (112) (62) (46) (98) (17) 100.0 100.0 100.0 100.0 100.0 .5 a d ju stm e n t in each c o m p u tatio n . SM. .y. a; API 06694 ) PERCENTILE DISTRIBUTION OF MALIGNANT NEOPLASMS IN MALES WITH ONSETS AFTER JANUARY 1 , 1 9 5 0 , ACCORDING TO S IT E OF TUMOR AND PETROLEUM OCCUPATION (INDIVIDUALS WITH SINGLE NEOPLASMS, SINGLE S IT E ONLY) appendix i l - a PRINCIPAL PETROLEUM OCCUPATION SITE BUCCAL CAVITY DIGEST. SYS. P E R IT . RESPIRATORY SYSTEM oo-ox 10-IX 20-2X UN KNOWN 00 (15) 3 .6 (109) 2 6 .3 (62) 14 .9 'RODUCT- CRACK [ON ING 01-09 20-29 (4) (0) 5 .5 0 .0 (14) 1 9 .2 (3) 50 .0 (ID 1 5 .1 (2) 33 .3 JJB . AND IREASE ARAFFIN 30-35 36-39 (0) (0) 0 .0 0 .0 (1) 2 0 .0 (3) 4 2 .9 (2) (0) 4 0.0 0 .0 STR. RUN 40-49, SPEC. PROD. 50-59 (1) (0) 1 4 .3 0 .0 (1) . (1) 14 .3 1 5 0 .0 (1) (0) 1 4.3 0 .0 MAINTEN ANCE OTHERS 60-69 70-79 (9) (1) 5 .0 1 .5 (55) 3 0.4 (13) 1 9 .4 (28) 1 5 .5 (9) 1 3.4 TRANS PORT 80-89 (6) 4 .8 (32) 2 5 .8 (20) 16 .1 EXEC. AND MARKET 90-98 (11) 4 .7 (68) 2 8 .8 (40) 16 .9 OTHERS 99 (1) 2 .8 (4) 1 1 .1 (7) 1 9 .4 BREAST (2) (0) (0) (0) (0) (0) (0) (0) (0) (0) (0) (0) 30 0 .5 O .u 0 .0 0 .0 0 .0 0 .0 0 .0 0 .0 0 .0 0 .0 0 .0 0 .0 GENITAL ORGANS 40-4X (27) 6 .5 (4) (0) 5 .5 0 .0 (0) (1) 0 .0 1 4.3 (0) (0) 0 .0 0 .0 (13) 7 .2 (7) 1 0 .4 (18) 14 .5 (17) 7 .2 (4) 1 1 .1 URINARY SYSTEM (25) (5) (0) (0) (1) (0) (0) (9) (3) (7) (ID (4) 50-55 6 .0 6 .8 0 .0 0 .0 1 4.3 0 .0 0 .0 5 .0 4 .4 5 .6 4 .7 1 1 .1 SKIN AND SOFT (124) (25) (0) (2) (l) TISSUE 60-6X 2 9 . 34 .2 0 .0 40 ,0 14 .3 (4) (0) (51) (27) (30) (56) (10) 5 7 .1 0 .0 2 8 .2 4 0.3 2 4 .2 2 3 .7 27 .8 BONES BRAIN (3) 70-75 0 .7 (9) 76-78 2 .2 (1) (0) (0) (0) (0) (0) (2) (0) (2) (1) (0) 1 .4 0 .0 0 ,0 0 .0 0 .0 0 .0 1 .1 0 .0 1 .6 0 .4 0 .0 (1) (0) (0) (0) (0) (0) (4) (0) (0) (6) (1) 1 .4 0 .0 0 .0 0 .0 0 .0 0 .0 2 .2 0 .0 0 .0 2 .5 2 .8 LYMPH . AND HEM. (24) (5) (0) (0) (1) (0) (1) (5) (5) (3) (10) (4) S VSTEM 80-8Y 5 .8 6 .8 0 .0 0 .0 1 4 .3 0 .0 50 0 2 .8 7 .5 2 .4 4 .2 1 1 .1 OTHER SITES (15) (3) (1) (0) (0) (01 (0) (5> (2. (6) (16) (1) 90-9X 3 .6 4 .1 1 6 .7 0 .0 0 .0 0 .0 0 .0 2 .8 3 .0 4 .8 6 .8 2 .8 * (415) (73) (6) (5) (7) (7) (2) ( 1 8 1 ) <6 7 ) (124) (236) (36) ___________TOTAL___ 1 100.0 1 0 0 .0 1 0 0 .0 1 0 0 . Q 1QQ.Q 1Q Q .L J 1 0 0 .0 1 0 0 .0 1 0 0 .0 lQ p .O i o o . n _ 1QQ.Q * Columnar percentage totals ay vary slightly from 100% due to .5 adjustment in each iomputatIon. Note: Items In parentheses are actual count totals. API 06695 A P P E fiD lX J I - 6 TYPE OF NEOPLASM GLAND E PIT H NON-GLAND EPITH- 00-09 11-19 UA I.KlMAN-r ACCOKUIHQ TO MK ( l>ATK oar (>MniL'\ , KMU V i \*E Olr TOMUlH UNDIVIUUAL WITH SINQIJS NB01>lA8Mt, BLHOl ITte OHiri ) USA * 1947 MALE PRIOR TO 1 9 5 0 NO. % ** SUBSEQUENT TO 1950 NO. % ** USA * 1947 FEMALE PRIOR TO 1 9 5 0 NO. % ** w SBSEQI Nt t o 1 9 : >0 NO. A> ** 2 2 .4 66 1 1 .3 164 1 4 .2 3 1.1 3 1 5 .8 27 3 8 .0 6 0.1 389 6 6.5 810 6 9.9 5 4.7 12 6 3,2 38_____ ____ S 3 ^5_...... LEUKEMIA 20-29 2 .9 13 2 .2 14 1 .2 1 .7 1 5 .3 0 _____ Q . LYMPHOMA NERVOUS TTGGIIPQ VASCULAR TISSUES 30-39 40-49 50-59 3 .8 28 2 n 4 4 .8 47 4 .1 0 .7 17 1 .5 2 .4 0 0 .0 2 _____ J 3 ____ 1 . 4 ___0_______ _____Lr-- ____ I ______ _____ L -4 ____ 0 .2 0 0 .0 1 0 .1 0 . 2 __ _______ _____U.O . -- 0--------- -------- CM3------ MUSCLE 66-69 NOW E P IT H . TISSUES 70-79 EMBRY. AND MIXED TISSUES 80-89 NOT CLASS. 97-99 TOTAL 0 .2 2 .0 1 .5 4 .8 1 0 0 .0 1 0 .2 2 0 .2 19 3 .2 23 2 .0 6 1 .0 21 1 .8 59 1 0 .1 60 5 .2 585 1 0 0.0 1159 1 0 0 .0 0 .4 0 1 .6 0 1 .3 0 5 .0 2 1 0 0 .0 19 _____Q ^ L . ____0 0 .0 1 0 .0 0 1 0 .5 2 1 0 0 .0 71 _____ Q-U____ 1 .4 0 .0 2 .8 1 0 0 .0 * F ro m 'M o rb id ity from C a n ce r In th e U n ite d S ta te s " P u b lic H e a lth M onograph No. 2 9 , U .S .P .U .S . *+ C o lu m n a r p e r c e n t a g e t o t a l s may v a r y s l i g h t l y fro m 100% d u e t o .5 a d j u s tm e n t in e a c h c o m p u ta t io n . API 06696 PERCENTILE DISTRIBUTION OF MALIGNANT NEOPLASMS IN MALES WITH ONSETS PRIOR TO JANUARY 1 , 1 9 5 0 , ACCORDING TO TYPE OF NEOPIASM AND PETROLEUM OCCUPATION (INDIVIDUALS WITH SINGLE NEOPLASMS, SINGUC S IT E ONLY) APPENDIX I I PRINCIPAL PET. OCCUPATION TYPE OF NEOPIASM GLAND EPITH. 00-0 7 UN KNOWN 00 (24) 1 1.0 PRODUCT ION 01-09 (2) 1 0 .5 CRACK ING 20-29 (0) 0 .0 REFINING LUB. ANI GREASE 30-35 (1) PARAFFIN 36-39 (0) 2 5 .0 0 .0 STR. RUN 40-49 (0) 0 .0 SPEC. PROD. 50-59 (0) 0 .0 MAINTEN ANCE 60-69 (18) 1 6.0 OTHERS 70-79 (5) 8 .1 TRANS PORT 80-89 (4) 8 .7 EXEC. AND MARKET 90-98 (10) 10 .3 OTHERS ___ 9 9 (2) 1 1.1 NON-GLAND EPITH. H - l (150) 6 8 .8 (17) 89 .5 (1) 1 0 0 .0 (3) 7 5 .0 (4) 5 7 .1 (0) (D 0 .0 LOO.O (62) 55 .4 (35) 56 .5 (33) 7 1 .7 (71) 73 .2 (12) 6 6 .7 LEUKEMIA 2 0 - 3 1 LYMPHOMA 3 0 - 3 6 NERVOUS TISSUES 40-49 VASCULAR TISSUES 5 0 -5 9 (2) 0 .9 (7) 3 .2 (0) 0 .0 (0) 0 .0 (0) (0) 0 .0 0 .0 (0) (0) 0 .0 0 .0 (0) (0) 0 .0 0 .0 (0) (0) 0 .0 0 .0 (0) (0) (0) (0) (4) (2) (1) (4) (0) 0 .0 0 .0 0 .0 0 .0 3 .6 3 .2 2 .2 4 .1 0 .0 (0) (0) (0) (0) (7) (7) (3) (3) (1) 0 .0 0 .0 (0) (1) 0 .0 14 .3 0 .0 0 .0 6 .3 (0) (0) (1) 0 .0 0 .0 0 .9 11 .3 (0) 0 .0 6 .5 (1) 2 .2 3 .1 (0) 0 .0 5 .6 (1) 5 .6 (0) (0) 0 .0 0 .0 (0) (0) (0) (0) (0) (0) (0) 0 .0 0 .0 0 .0 0 .0 0 .0 0 .0 0 .0 MUSCLE 6 6 - 6 9 NON-EPITH. TISSUES 7 0 - 7 9 EMBRY. AND MIXED T ISSU ES 80-89 NOT CIASS. 9 7 -9 9 * TOTAL (0) 0 .0 (7) 3 .2 (3) 1 .4 (25) 1 1.5 (218) 0 0 .0 (ft) 0 .0 (0) 0 .0 (0) 0 .0 (0) 0 .0 (19) 1 0 0 .0 (0) 0 .0 (0) 0 .0 (0) 0 .0 (0) 0 .0 (1) 1 0 0 .0 (0) 0 .0 (0) 0 .0 (0) 0 .0 (0) 0 .0 (4) LOO. 0 (0) 0 .0 (0) 0 .0 (0) 0 .0 (2) 2 8 .6 (7) LOO.O (0) 0 .0 (0) 0 .0 (0) 0 .0 (0) 0 .0 (0) 1 0 0 .0 (0) 0 .0 (0) 0 .0 (0) 0 .0 (0) 0 .0 (1) 0 0.0 (0) 0 .0 (2) 1 .8 (1) 0 .9 (17) 1 5 .2 (112) LOO.O (0) 0 .0 (3) 4 .8 (0) 0 .0 (10) 1 6 .1 (62) 1000 (0) 0 .0 (4) 8 .7 (0) 0 .0 (0) 0 .0 (46) 1 00.0 (1) 1 .0 (3) 3 .1 (2) 2 .1 (3) 3 .1 (97) 1 0 0 .0 (0) 0 .0 (0) 0 .0 (0) 0 .0 (2) 1 1 .1 (18) 1 0 0 .0 * Columnar percentage totals may vary slightly from 100ft due to .5 adjustment In each computation,. Note: Itees In parentheses are actual count totals. API 06697 PERCENTILE DISTRIBUTION OF MALIGNANT NEOPLASMS IN MALES WITH ONSETS SUBSEQUENT TO JANUARY 1 , 1 9 5 0 , ACCORDING TO TYPE OF NEOPLASM AND PETROLEUM OCCUPATION (INDIVIDUALS WITH SINGLE NEOPLASMS, SINGLE S IT E ONLY) APPENDIX I I PRINCIPAL PET. OCCUPATION TYPE OF NEOPLASM 8 UN KNOWN 00 GIAND E PIT H . 00-09 (56) 1 3 .5 PRODUCT CRACK ION ING 01-09 20-29 (8) (0) 1 1 .1 0 .0 REFINING LUB. ANI GREASE PARAFFIN 30-35 36-39 5TH. RUN 40-49 (1) 1 6 .7 (1) (0) 1 6 .7 0 .0 SPEC. PROD. 50-59 U) 5 .0 MA1NTEN ANCE 60-69 (25) 1 3.8 OTHERS 70-79 (5) 7 .5 TRANS PORT 80-89 (26) 2 1 .0 EXEC. AND MARKET 90-98 (35) 1 4 .8 OTHERS 99 (6) 1 6 .7 NON-GLAND EPITH. 11-19 LEUKEMIA 2 0 - 2 9 (288) 69 .4 (7) 1 .7 (54) 74 .0 (0) 0 .0 (4) 6 6.7 (0) 0 .0 (4) 6 6 .7 (0) 0 .0 (3) 50 .0 (0) 0 .0 (6) 8 5.7 (0) 0 .0 (0) 0 .0 (1) 5 0 .0 (125) 6 9 .1 (1) 0 .6 (50) 7 4.6 (1) .1 .5 (87) 7 0 .2 (0) 0 .0 (167) 7 0 .8 (2) O.B (22) 6 1 .1 (2) 5 .6 LYMPHOMA 3 0 - 3 9 NERVOUS TISSUES 40-49 VASCULAR TISSUES 5 0 -5 9 MUSCLE 6 6 - 6 9 NON-EPITH. TISSUES 7 0 -7 9 EMBRY. AND MIXED T IS g ty E g q (18) 4 .3 (6) 1 .4 (0) 0 .0 (1) 0 .2 (5) 1 .2 (4) 1 .0 (5) (0) 6 .8 0 .0 (1) (0) 1 .4 0 .0 (0) (0) 0 .0 0 .0 (0) (0) 0 .0 0 .0 (1) (0) 1 .4 0 .0 (2) (0) 2 .7 0 .0 (0) 0 .0 (0) 0 .0 (0) 0 .0 (0) 0 .0 (0) 0 .0 (0) 0 .0 (1) (0) 1 6 .7 0 .0 (0) (0) 0 .0 0 .0 (0) (0) 0 .0 0 .0 (0) (0) 0 .0 0 .0 (0) . (0) 0 .0 0 .0 (0) (0) 0 .0 0 .0 (0) 0 .0 (0) 0 .0 (0) 0 .0 (0) 0 .0 (0) 0 .0 (0) 0 .0 (4) (4) 2 .2 6 .0 (3) (0) 1 .7 0 .0 (1) (0) 0 .6 0 .0 (1) (0) 0 .6 0 .0 (7) (2) 3 .9 3 .0 (3) (2) 1 .7 3 .0 (5) 4 .0 (0) 0 .0 (0) 0 .0 (0) 0 .0 (1) 0 .9 (2) 1 .6 (8) 3 .4 (6) 2 .5 (0) 0 .0 (0) 0 .0 (5) 2 .1 (7) 3 .0 (2) 5 .6 (1) 2 .8 (0) ____ o . o (0) 0 .0 (2) 5 .6 (1) 2 .8 NOT. C IA S S . 97-99 * TOTAL (30) 7 .2 (415) 1 0 0 .0 (2) 2 .4 (73) 1 0 0 .0 (2) 33 .3 (6) .0 0 .0 (1) 1 6 .7 (6) 1 0 0 .0 (1) 1 6 .7 (6) 1 0 0 .0 (1) 1 4 .3 (7) 00 .0 (0) 0 .0 (2) 1 0 0 .0 (ID 6 .1 081) 1 0 0 .0 (3) 4 .5 (67) io o .o (3) 2 .4 (124) 1 0 0 .0 (6) 2 ,5 (236) 1 0 0 .0 (0) 0 .0 (36) 1 0 0 .0 * Columnar percentage totals may vary slightly from 100% due to .5 adjustment In each computation. Note: Items in parentheses are actual count totals. API 06698 APPENDIX I I PRIMARY SITE 9 I API 1 MALE EMPLOYEES COM PARISON o r PERCENT I LE D IS T R IB U T IO N S OF CANCER REPORTED WITH TEN REPRESENTATIVE CITIES* U .S . MALES 2 5 - 6 4 BEFORE 1950 AFTER 1950 SAN NEW ATLANTA FRANCISCO ORLEANS DENVER P IT T S BURGH CHICAGO DALLAS BIRMING DETROIT PHILA HAM DELPHIA BUCCAL CAVITY 3 .3 4 .1 7 .1 1 0 .4 5 .0 6 .5 6 .4 8 .4 5 .4 6 .6 6 .7 6 .7 DIGESTIVE SYSTEM 3 5 .0 26 .2 18 .9 2 5.7 2 3 .4 2 4 .8 3 1.6 3 6 .8 1 5 .8 2 1 .3 32 .5 3 4.3 ) RESPIRATORY SYSTEM 1 4.5 1 5 .7 1 0 .1 1 2 .4 2 0 .0 1 0.2 1 4.6 1 5 .2 1 1 .2 11 .9 1 7 .7 1 6 .2 \ BREAST .0 .2 .3 .4 .1 .8 .1 .2 .3 .0 .3 .2 GENITAL ORGANS 8 .6 7 .9 7 .8 5 .9 5 .5 2 .8 7 .5 6 .1 7 .3 5 .4 6 .6 6 .2 URINARY SYSTEM SKIN AND SOFT TISSUES 6 .5 1 5.7 BONE 2 .1 BRAIN 1 .7 LYMPH. AND HEMA. SYSTEMS 6 .5 O'lHER S IT E S 5 .6 28 .5 .8 1 .8 5 ,0 4 .2 4 .8 35 .6 .5 3 .3 7 .0 3 .9 6 .2 2 2.9 7 .2 2 5 .8 6 .5 2 6 .5 .8 .9 .8 2 .1 2 .0 4 .9 8 .0 5 .5 8 .1 4 .6 4 .0 3 .3 7 .6 7 .8 1 4 .7 9 .2 .9 .7 2 .9 3 .2 7 .3 7 .5 5 .8 4 .1 4 .5 4 0 .0 .7 3 .3 3 .5 3 3 .1 .8 4 .4 7 .9 1 1.0 .7 2 .4 6 .7 8 .6 1 0 .5 6 5 3 .6 4 .6 7 .8 1 1 .5 .7 2 .0 8 .6 5 .2 API 06699 a p p e n d i x II - 10 SKIN, DIGESTIVE, AND RESPIRATORY CANCERS AS REPORTED COMPARED WITH U.S. EXPERIENCE AS TO AGE AND GEOGRAPHIC LOCATION 0 U .S . MALES* A PI MALE EMPLOYEES PRIMARY SITE AGE NEW CASES ALL REGIONS BEFORE 1 9 5 0 AFTER 1 9 5 0 ALL NORTH REGIONS SOUTH WEST ALL CASES DEATHS NORTH SOUTH CENTR, WEST NORTH SOUTH CENTRAL WEST 20-69 16.4 1 3 .0 3 2 .0 2 4 .9 15.9 1 .5 SKIN 20-39 15.3 1 1 .7 3 7 .4 2 8 .2 1 8.4 ' \ 2 .2 6 .9 20 .7 5 .5 16.8 14.2 37 .2 18 .4 2 6 .4 40-69 15.6 13.2 3 1 .3 2 4 .6 15.7 1 .5 DIGESTIVE 2 0 -6 9 SYSTEM 20-39 33 .0 1 1.6 40-69 20 .5 4 7 .8 1 8.1 2 7 .0 3 1 .7 4 4 .6 17 .6 9 .9 1 1 .6 1 5 .0 2 5 .7 >3 6 .6 3 3 .6 2 7 .7 2 2 .4 3 3 .7 5 1 .2 1 9.2 2 8 .3 33.4 4 5 .9 2 1 .9 2 8 .9 23 .1 API 06700 20-69 RESPIRATORY SYSTEM 20-39 1 4 .4 4 .7 40-69 15.1 1 9 .8 1 2 .7 11.2 11.2 1 9 .8 7 .4 4 .8 2 .0 6 .0 1 0.0 87 1 2 .4 1 6 .6 10.1 17.7 2 1 .2 1 3 .7 12.0 11.7 2 0 .5 1 0.3 2 3 .6 1 4 .2 F ro n " M o r b i d i t y f r o * C a n c e r i n t h e U n i t e d S t a t e s , " P u b l i c H e a l t h M o n o g r a p h , N o , 2 9 , PHS o f DHEW ( 1 9 4 7 ) , APPENDIX I I PRIMARY SITE SKIN PERCENTILE D IS T R IB U T IO N OF S K I N , D IG E S T IV E , AND RESPIRATORY CANCERS II REPORTED BY GEOGRAPHIC LOCATION ALL REGDNS U S. MALES 20-69 WHITE NEW C:ases NORTH SOUTH WEST ALL REGIONS MAUE SUP. CAASLELS DEATHS x-co.< NORTH API MALE EMPLOYEES BEFORE 1950 AFTER 1950 SOUTH 3NTRAL WEST NORTH SOUTH 'ENTRAI 1 16.4 13.0 32.0 24.9 L5.9 1.5 29.2 6.9 20.7 5.5 16.8 14.2 37.2 18.4 WEST 26.4 LIP PACE, HEAD, AND NECK 8.9 70.8 7.2 72.7 11.6 70.8 11.3 73.6 9.4 72.8 2.5 54.6 17.0 64.6 16.6 66.6 22.0 .0 58.0 100.0 26.6 46.6 12.5 62.5 15.8 65.0 42.8 57.1 10.3 75.8 OTHER 17.8 20.0 17.5 15.6 18.0 42.8 18.4 16.6 20.0 .0 28.5 24.8 19.2 .0 13.5 SYSTEM ESOPHAGUS STOMACH 33.0 8.0 31.4 47.8 8.8 31.0 18.1 6.6 37.8 27.0 5.8 31.5 31.7 7.6 30.4 44.6 10.0 28.1 30.1 ,?8.6 7.9 19.0 33.8 3.7 32.0 27.7 .0 60.0 22.4 10.0 35.0 33.7 4.3 26.3 21.9 2.0 28.5 28.9 .0 27.2 23.1 7.8 14.4 SMALL INT. 1.0 1.0 .4 1.8 1.0 1.0 .0 .0 .0 .0 .0 2.0 .0 1.3 LARGE INT. RECTUM 21.8 20.0 44.8 20 .'fl 23.1 18.2 21.2 22.1 22.4 22.3 23.3 18.0 34.9 22.2 23.4 18.5 .0 35.0 .0 5.0 27.1 19.2 18.3 18.3 27.2 9.0 30.2 13.1 BILE PASS. LIVER 4.8 4.6 2.0 2.6 8.3 4.5 4.2 6.0 2.4 1.6 1.9 2.5 1.5 1.2 4.7 4.9 .0 5.0 .0 5.0 1.7 2.0 .0 3.9 5.2 14.2 9.0 5.2 PANCREAS 8.7 8.1 14.0 9.8 8.0 10.5 1.5 7.4 20.0 5.0 11.4 12.2 18.1 21.0 OTHER RESPIRATORY SYSTEM 1.9 14.4 2.5 19.8 2.8 12.7 1.6 11 .2 1.7 11.2 1.9 19.8 15.2 7.9 8.8 20.0 .0 8.7 12.4 16.6 10.1 4.3 17.7 8.1 10.3 9.0 23.8 2.8 14.2 LARYNX LUNG AND BRONCHI 18.8 77.8 18.3 20.1 76.1 18.8 76.9 27.0 67.3 12.4 84.3 4.7 76.1 30.0 63.3 33.3 .0 33.3 100.0 13.3 75.0 17.3 .0 78.2 100.0 8.5 78.7 OTHER 3.3 3.5 3 .7 4.1 5.6 3.2 19.0 6.6 33.3 .0 11.8 4.3 .0 12.7 Froa "Morbidity froa Cancer In the United States," Public Health Monograph, No. 29, PHS of DHEW (1947). Personal Coaaunlcatlon (Cases reported between 1950 - 1956). ^4 CD N API 06701 B APPENDIX 1 1 - 1 2 MALIGNANT NEOPLASMS OF S K IN , D IG E STIV E , AND RESPIRATORY SYSTEMS AS REPORTED ACCORDING TO OCCUPATION IN THE PETROLEUM INDUSTRY CANCER TOTAL UNKNOWN PRODUCTION PETROLEUM OCCUPATION REFINING TRANS PORTATEN EXECUTIVE AND MARKETING OTHERS % % % % % % NO. TOTAL NO. KNOWN NO. KNOWN NO. KNOWN NO. KNOWN NO. KNOWN B SKIN AND E SOFT TISSUES 37 F 0 R E DIGESTIVE 81 SYSTEM 1 9 5 RESPIRATORY 32 0 SYSTEM 40 .2 3 9.5 3 7 .6 4 7 .3 36 6 5 .5 3 M 8 1 4 .5 3 2 .4 65 5 2.4 20 1 6 .1 31 2 5 .0 9 1 7.0 18 3 4.0 6 1 1.3 15 2 8 .3 4 7 .3 5 4 .0 5 9 .4 TOTAL KNOWN TOTAL % NO. TOTAL 55 5 9 .8 92 124 6 0.5 205 53 6 2 .4 85 A SKIN AND 124 F SOFT TISSUES T E R DIGESTIVE 109 SYSTEM 1 9 5 RESPIRATORY 62 0 SYSTEM 3 7 .6 25 12 .1 85 4 1 .3 30 3 5 .9 14 7 .8 77 3 9 .5 32 3 4.1 11 9 .2 42 3 5 .0 20 14 .6 56 27 .2 1 6.4 68 3 4 .9 1 6.7 40 33 .3 10 4 .9 206 6 2 .4 330 4 2 .1 195 6 4 .1 304 7 5 .8 120 6 5 .9 182 API 06702 A PPEN D IX HI Record Forms and Codes API 06703 CONFIDENTIAL CLINICAL ABSTRACT AND OCCUPATIONAL HISTORY OBJECTIVES AND INSTRUCTIONS Epidemiological Survey Kettering Laboratory U niversity of Cincinnati Eden and B ethesda A ves. Cincinnati 19. Ohio V * The Epidem iological Studies as auggeated by the Kettering Laboratory recommended two approaches, nam ely (I) the R etrospective or H istorical Study and (II) the Current R egistry, insofar as p ossible and/or fea sib le, with due consideration and understanding of the wide variation in company p o licies, medical care program s, management in terest and labor relation s. T hese two approaches envision cen tra lisin g , by an independent agency (Kettering Laboratory under contract), the assem blage of the clinical records and employ ment h isto r ie s of all proved c a se s of neoplastic d isea se known to have occurred or as they occur among em ployees of the cooperating com panies, reg a rd less of: a. sex b. site c . type of tumor d. status and kind of em ploym ent at the tim e of the report e. degree of exposure to various carginocenic agents or substances in or out of the interested industry. Periodic tabulations and analyses are provided with the understanding that all tables, statem ents and summations w ill be arranged to protect the identity of the participating com panies and/or individual patients. Standard Reports The completed final reports should be filed without resorting to the prelim inary notification of the Survey Group. Two records, a brief clinical . abstract.and a detailed occupational history, have been devised and are d istri buted to perm it standardised reporting and description of the known ca ses by the various M edical D epartm ents. They are used for both old and new ca ses even though in many instances the information available for the old c a ses may be m eager. . However, even if an inadequate or partial abstract or history can sent, it w ill prove useful. The abstracts and h isto r ie s when com pleted should be sent promptly and directly to the Epidem iological Survey Group of the University of Cincinnati where the n ecessa ry clerica l m echanism s have beeh arranged to receive, p rocess, tatfiftlateand file the records. Even if a significant delay is envisioned due to the need of contacting a private physician; hospital, clin ic or laboratory.. send in the partially completed report at once. The m issing item s can be supplied later, either through correspondence or by the subsequent subm ission of a duplicate report. Both of the records, clinical abstracts and occupational h isto ries, are to be com pleted.in the offices of the participating M edical D irectors, All correspondence, supplementary reports and/or requests w ill be directed only to the M edical D irector of the' interested company u n less, by prior mutual agreem ent betw een him and the Survey Group other channels are authorised or arranged. It should be noted, however, that the details of the clin ical API 06705 I * - 2- record w ill probably have to be augmented, supplemented and/or verified, insofar as p ossib le, by the various Medical Departments through their own channels with their subordinate offices, private physicians, hospitals, clinics nd lab oratories. It is hoped a lso that the M edical Departm ents can persuade their personnel Departments to furnish, insofar as their records cover and/or permit, a relatively com plete and adequate occupational history, including not only inform ation (job description and period so occupied) regarding the employment of the patient in the reporting company, but also any other work ip other oil com panies and/or other industries. It should be noted here that the printed and padded form s provide for a Medical Department copy of the clin ica l record and occupational history and a Personnel Department copy of the occupational history. If more copies are required for the inform ation of other departments or offices, use additional sets of the fo rm s. When m ore pads are required, send the request to the Kettering Survey Group in Cincinnati. Special Instructions and Definitions The occupational history differs from the clinical record in that a chronological listin g of the patient's various occupations and jobs has been substituted for the record of his clinical experience. The duplication of the questions in the fir st and la st section s, such as those dealing with occupation or trade at the tim e of (he report, employment status, exposure to possible irritants, w ill permit the gathering of information recorded by the Personnel Department. The latter answ ers may not agree entirely with the clinical abstract but, on the other hand, additional important item s may be added which would benefit the total record. Since (1) the total number of c a se s reported by any single Medical Depart ment w ill not be large, (2) this is the first effort to produce a report which w ill serve to satisfy the objectives of the investigation, and (3) many additional items may be proved useful, it is hoped that the various Medical Directors w ill feel fr e e , by adding a page or by a separate letter, to supplement or modify this basic report. It is very essen tial that the experim ental exploratory nature of this investigation be em phasised and recognised by the participating directors. O therw ise, it w ill be im possible to maintain the required flexibility in the approach to the problem and to make, from tim e to tim e, the n ecessary changes in technique and m ethods. Most of the answ ers required for the objectives of the investigation *re obvious and custom ary. T here are sev era l points in the form s which may need explanation. On the sam ple co p ies, the doubtful item s or those questions where there may be some confusion are distinguished by a number corresponding to the numbered sp ecial instructions given on the following page. API 06706 V #1. The section above the perforated line of both the clin ical and occupational records should be detached and discarded before forwarding to the Survey Group in Cincinnati. This w ill p erm it the entry of certain useful data* such as the name and address of the patient, Social Security and job number, on the company copies but w ill prevent disclosure of his identity to the survey personnel. This method satisfies any legal obliga tion of the reporting company. #2. Since the patient's name w ill not be available, the case number w ill be an extrem ely important item because all correspondence, enquiries, etc. between the survey personnel, the various M edical D irectors and other company departments w ill depend upon this number for identification of the individual c a se s. Each Medical D irector can devise a code best suited for his own particular requirements; however, a sim ple number w ill suffice if the reports or records are filed or listed according to year, division and/or plant. .'For exam ple, employing the sample illustration of the completed form , if this were listed as l i , 1950, Pineville Refinery, there would be little probability of losing or m isfiling the record since ample identification would rem ain. #3. The patient's age when he began his working lift should be given in completed y ea rs. This item is needed to verify the accuracy and extent of the employment history. It w ill serve also to check on the reliability of the birth year. #4. The entry under occupation or trade relates solely to the occupa tion of the patient at the tim e of the report or as of the last record in or out of the company. Only the broad job descriptions as listed on the back of the form should be employed to describe the various occupations commonly found. As indicated, the type of work requiring 2 /3 to 3 /4 of the individual's assignm ents determines the cstqgqry to be reported. A ! It is pagfA le that the job classification s that have been listed for u se w ater this question are far too broad and future m o d ifies- . .< tions may becom e n ecessa ry . For instance, one or two questions have been raised regarding the need to differentiate further the Marketing and Executive gpoup. However, this is one foactfon of the detailed occupational history. If the patient has had a significant field record or exposure, this w ill come to light as individual assignm ents are listed . Furtherm ore, any additional qualifying comments can be easily added if fits Medical or Personnel Director feels that the occupational classttleatlen as recorded is deficient or inadequate. API 06707 y - 4- #5. The dates in this section of the clinical record can be approximate. Month and year should suffice for all possible useful tabulations. #6. It should be noted that the Survey Group recognize and accept the fact that in many instances, particularly with patients who have only small skin lesion s, slides or tissu es will not be available for study. They also know that the provision of pathological services varies widely in various geographical areas. However, it is hoped that as the investigation proceeds and as m edical program s develop, m ore and more attention w ill be paid to the need for confirming, whenever possible, the clinical diagnosis by an adequate pathological examination. It was thought also that through the cen tralized agency, a co llectio n can be built up and maintained which would perm it uniform classification of the various neoplasms that are discovered by the interested partici pating companies. #7. D escription of treatm ent may be expanded at length on the reverse sid e under "Additional Comments" or in a separate letter if the available information warrants further detailing. Again the dates may be approximate. These data w ill not be important for the objectives of this survey but w ill be found on m ost of the reports required by the various State Health Department Cancer R eg istries, Therefore, in order to have all the information assem bled th at may be required by official agencies now or in the future, these questions were included on the Survey Record. #8. The more important agents and irritating substances have been listed . This group are those generally accepted by m ost workers but exposure to other m aterials or agents may be considered significant by the M edical D irectors. If so , list them and give the reason s if n e c essa ry under "Additional Comments" on the back of the report. The description of the degree and type of the unusual exposure is not easy and yet is important if an adequate record is to be filed , A heavy exposure would mean that the worker has an experience' that is totally unusual for the average person. For exam ple, if his occupation is outdoors without protection for the entire working period, it could be considered as heavy in regard to solar radiation if the plant or work w ere located in the southern United States. If the patient worked in the North or only occasionally in the sun, it must be classified as light. Under type, an additional description is possible. If the worker was continuously engaged in an outdoor occupation, his exposure #ould be greater than if the duties w ere only occasional. ' ' API 06708 - 5- #8. The individuel Medical D irectors in completing the form w ill be (Cost, ) required to make these decisions. If additional information or descriptions of the exposure are n ecessary and/or available, the space under "Additional Comments" may be used to call attention to the unusual degree and type of exposure. #9. Space for the nam es and ad d resses of the private physician and hospital has been provided on the back of the report. The various Medical D irectors may find that this will be useful to their offices in the collection of the necessary information for this report and in the future follow-up of the patient. Since these entries are above the perforated line, they w ill be detached when the report is forwarded to the Survey Group in Cincinnati, thus maintaining the required secrecy regarding the identity of the patient. #10. This space under "Additional Comments" is available, as indicated e a rlier, for the modification and supplementation of various questions in the body of the report. It can be used a lso to add extraordinary item s that w ere not included. Since this is the first edition of the two records, additional desirable m aterial w ill be certain to turn up. This is particularly true with the occupational history record. Only a crude classification of job descriptions has been suggested. In a ll probability, a much m ore elaborate description w ill prove d esirab le. In the in terim , how ever, the additional entries w ill serve to delineate future m odifications. #11. In the listin g of various occupations and job s, begin with the la st or present employment. The dates for the period can be approxim ate by y e a r s . When the type of industry is known, . g . , w all paper factory, but the exact occupation or job cannot be given, sim ply report 'V a il paper factory - job unknown". Additional inform ation w ill be furnished if the products handled can be described in some detail. Here again it may be necessary to expand the des ription of the product or m aterials in question under "Additional Comments" on the reverse side of the form. API 06709 V =- *- SAMPLE COPY CONFIDENTIAL OCCUPATIONAL HISTORY To be prepared in triplicate * JOHN J. DOE V *1 ^ ^ 6 3 9 -1 4 -6 1 3 9 .................. t) O C C D P lT IO M A i ^C C O B D ADDRESS- 639 46TH Pay Roll 365 .Number_________ PINE VILLE City -ffl OtKWNAL. COPY ta be Mat ta. . ' 0mgt% a# Identifying data) --lOW COPY ta be retained a* lfe myony Medical Department henrd COPY ta b . retained ai 6m ^ tpon y Personnel Department Record DR. JOHN J. PHAIR KETTERING LABORATORY EDEN AND BETHESDA AVES. CINCINNATI 19, OHIO STREET OKLA. CASE ^UMBERSEX- JORN #6 14 1896 Vw DATE of REPORT. RACEAGE 1* JOBPOLAND Cowntry 4/8/50 W 20 COMPANY.FPIIRNSETVICLLLAESS OIL~ C 4OA. N T E - PLANT. REFINERY defV a n c e . P1PEF1TTER ( t y ) WORK STATUS Activa Retirad Leave ^] Other OCCUPATIONAL HISTORY (List Occupation Chronologically, Beginning with the LAST or PRESENT JOB) YEAR TO 1936 1950 1934 1936 1933 1934 1922 1933 1921 1922 1918 1921 EMPLOYS! AND ADDRESS ( 0 y t L * 7 JO* DESCRIPTION OR TYPE OP WORK* FIRST CLASS OIL CO. PIPE FITTER B B B F"* HOT BREAD BAKERY NEW YORK CITY pm ^aj .. c o r N .J. CARBON COMPANY-----CLARKSBURG, W. VA. LABORER BAKER PORTER LABORER PRODUCTS HANDLED* PRODUCTS `'R Y LODUCTS UCTS CARBON INSULAlT ING MATERIALS' 1916 1918 FARM LABORER FARM-------PRODUCTS ih UNUSUAL EXPOSURES TO POSSIBLE IRRITANTS* (From Personnel Record) ( ^ I r C u * r ) OND FROM TO DEGREE CARBON INSULATING MATERIALS 1921 1922 Lgt. SUNLIGHT 1916 1918 HEAT W 22 1 9 3 3 77 PETROLEUM PRODUCTS 'M it. 1933 1 9 5 0 - ro t lists op jo* D csctim o m , rn to u u M n o o u e n and imitants to h mpo*t o Hvy. Hvy. ' lgt. TYPE Cont. Cent. XUL API 06716 JO B DESCRIPTIONS To be based upon 2/3 to 3/4 OF WORK ASSIGNMENTS. DISTINGUISH BE TWEEN AND ALWAYS INDICATE if the worker was an operator, laborer, still cleaner, or "other" duty. PRODUCTION Rigger and driller Well puller Others with frequent exposure to crudes Others with infrequent exposure to crudes REPINING Catalytic cracking (includes thermal cracking of catalytic feeds) Thermal cracking Coking operations Blending of heavy fuel oils (No. 3-6) Blending of heating oil No. 2 Others on cracking operations Refining and blending of lubricants Packaging of lubricants . Manufacture and packaging of greases Others--Lubricants and greases Refining and filtration (pressing centrifugation) of paraffin Packaging of paraffin Others--Paraffin Distillation of crude oil Production of asphalt Straight run distillations--Others White oil manufacturing Petro-chemical operations Special products---Others Maintenance--Pipe fitters Maintenance--Boilermakers Maintenance--Mechanics Maintenance--Tank Cleaners Maintenance--Others Loading department Control laboratory Others not otherwise specified--General Refining Operations TRANSPORTATION Pipe line workers Marine division --Transportation of light and medium distillates (end boiling point less than 650*F.) Marine division--Fuel oil carriers Fuel oil carriers--Others (Tank cars, etc.) Transportation--Others MARKETING AND EXECUTIVE Service stations Others--Office workers, etc. * ( 4 OTHERS (Not included in four main divisions) Job to be described in detail PETROLEUM PRODUCTS TO BE REPORTED This is a broad grouping of petroleum products. INDICATE FOR EACH JOB tire principal material the worker encounters. If there is an exposure to another product (equal or less frequent), note this fact under "Additional Comments". Crude petroleum, reduced crude, as phalts Gasoline, light ends and solvent naph thas (less than or equal to 400*F.) Medium distillates (400-650'F.) Lube distillates and related uncracked intermediates (600-1000`F.) Refined products Products derived from thermal crack ing units in refineries before or without catalytic cracking (600- 1000'F.) Products derived from coking opera tions (greater than or equal to 600*F) Products derived from catalytic crack ing and reforming processes.' from thermal cracking units in refineries with catalytic crackers (600-1000F.) Chemical additives Petro -chemicals SKIN IRRITANTS TO BE REPORTED This is a broad grouping of skin irritants. If a history is given of unusual exposure to any of them, either during the workers employment in the petroleum industry or in some other occupation, indicate in the appropriate columns the period, degree and kind of exposure. PHYSICAL AGENTS Trauma Radiant heat Solar rays Ultraviolet rays Radioactive substances or roentgen rays INORGANIC SUBSTANCES Arsenic Chromates Others (Specify in detail) ORGANIC SUBSTANCES Aromatic amines Tar or pitch Soot Creosote and anthracene oils Others (Specify in detail) ADDITIONAL COMMENTS, f y g L * / _ ) API 06717 HAS WORKED ON THE. CATALYTIC EQUIPMENT PERIODICALLY - LAST SEVEN YEARS - AJLSO HAS SMALL FARM NEAR TOWN WHICH HE WORKS, ~ - >-*" ijAME--IO I Social SNwuumribtyerCBloS WHITE ORIGIN (Remove oM YRIOW COfT Company Me HUE CO fT to Company for CASE NUMBER---- i s e x ------------; BORN occ YEAR FROM --1936 1 -- LS3A-1 -1933 1 --1322-- 1 --m u J --1SJL8--1 --1 3 1 6 -1 I ---------- -i --______ - unusual e Kin d --. CARB -SI1ML1 - He a t - Petr ' OvEt not i T (ia, * y ^ E - JOHN J, DQE OCCUPATIONAL ECOBO ADDRESS__ 2 fL AIE___ STREET t^ial Pay ucur ity Roll ^ (lib>r6 39 1 4 6 l 39------------Number. J& i. PINE VILLE City QKLA. Slat wHITE ORIGINAI COPY to bo lout to: (l.movt all identifying dota) ,&l0W COPY to bo rotainod a t tbe Company Modleal Department locord ^UE COPY to bo rotoinod a i the Company Porionnol Dopartmont Record DR. JOHN J. PHAIR KETTERING LABORATORY EDEN AND BETHESDA AYES. CINCINNATI 19, OHIO CASE HUMBER 0 ------ ( L --. j r ~ \ date of 46 report. L i ------------------- RACE__ AGE -1A9S------------ l*t JOB Y#of ________ POLAND Country ^ 8/5Q ,, 20. COMPANY FIRST CLASS Oil, CO,______ PINE VILLE MAINTE- PLANT------ REFINERY----------- DEPJJANCE- OCC. or TRADE- PIPE FITTER___ Q ; WORK STATUS Active Retired Leave 47) Other [ J OCCUPATIONAL HISTORY (List Occupations Chronologically, Beginning with the LAST or PRESENT JOB) YEAR from to 1<J36 1950 1934 1Q3A 1933 1934 19?.?. 1933 10?1 i a ? ? 1918 19? 1 EMPLOYER AND ADDRESS ( . 'V FIRST CLASS OIL CO. H ft HOT BREAD BAKERY NEW YORK CTTY PISTON RING CO, NEWARK N T CCIA.ARRBKOSNRTCTORMr,,PAWN,YVA, \ JOS DESCRIPTION ~fFJ! J or type op w o rk * y PIPE FITTER PIPE FITTERS HF1 PER LABORER RAKER PORTER__________ laborer PRODUCTS HANDLB)* PETROLEUM pnnnnrTS Vf tt BAKERY PRODUCTS______ METAL PP QDUCTS____ CARBON INSUJ..ATING__ MATERIALS 191 A 1Q 1A r s n u FaAn RM f ....... ____ t t n r i P f f B _____ n n i i f T C ---------- UNUSUAL EXPOSURES TO POSSIBLE IRRITANTS* (From Personnel Records):____ ( O i o X . KIND FROM t o ' ' DEGREE ' . CARBON INSULATING MATERIALS 1921 1922 -SITNT.TOHT -Je a t lai A 107? 1918 1033__ --PETROLEUM PRODUCTS______________ ____1933---- 1950 ' oyh for lists o r jos descriptions, petroleum products and irritants to be reported Hvy. Hvy. 3C Lgt. X Lgt. TYPE Cont. Occ. Cont. Oec. PETROLEUM PRODUCTS TO BE REPORTED This is a broad grouping of petroleum products. INDICATE FOR EACH JOB the principal material the worker encounters. CA If there is an exposure to another product Nil PRODUCTION (equal or less frequent), note this fact Rigger and driller under "Additional Comments". SB Well puller Crude petroleum, reduced crude, as Others with frequent exposure to phalts crudes Gasoline, light ends and solvent naph Others with infrequent exposure to thas (less than or equal to 400'F.) crudes Medium distillates (400-650*F.) Lube distillates and related uncracked BO REFINING intermediates (600-1000'F.) Catalytic cracking (includes thermal Refined products cracking of catalytic feeds) Products derived from thermal crack- Thermal cracking mg units in refineries before or Coking operations without catalytic cracking (600- Blending of heavy fuel oils (No. 3-6) 1000'F.) Blending of heating oil No. 2 Products derived from coking opera Others on cracking operations tions (greater than or equal to 600*F) Refining and blending of lubricants Products derived from catalytic crack Packaging of lubricants ing and reforming processes or from Manufacture and packaging of greases thermal cracking units in refineries Others--Lubricants and greases with catalytic crackers (600-1000F.) Chemical additives Refining and filtration (pressing or Petro-chemicals centrifugation) of paraffin Packaging of paraffin Others--Paraffin Distillation of crude oil Production of asphalt Straight run distillations--Others White oil manufacturing Petro-chemical operations Special products--Others Maintenance--Pipe fitters Maintenance--Boilermakers Maintenance--Mechanics Maintenance--Tank Cleaners Maintenance--Others Loading department Control laboratory Others not otherwise specified--General Refining Operations TRANSPORTATION Pipe line workers Marine division --Transportation light and medium distillates (end boiling point less than 650'F.) Marine division--Fuel oil carriers Fuel oil carriers--Others (Tank cars, etc.) Transportation--Others MARKETING AND EXECUTIVE Service stations /ri. Others--Office workers, etc. VU \ . ** HJ ' OTHERS (Not included in four main divisions) Job to be described in detail SKIN IRRITANTS TO BE REPORTED This is a broad grouping of skin irritants. If a history is given of unusual exposure to any of them, either during the workers employment in the petroleum industry or in some other occupation, indicate in the appropriate columns the period, degree and kind of exposure. PHYSICAL AGENTS Trauma Radiant heat Solar rays Ultraviolet rays Radioactive substances or roentgen rays INORGANIC SUBSTANCES Arsenic Chromates Others (Specify in detail) ORGANIC SUBSTANCES Aromatic amines Tar or pitch Soot Creosote and anthracene oils Others (Specify in detail) ADDITIONAL COMMENTS API 06719 HAS WORKED ON THE.CATALYTIC EQUIPMENT PERIODICALLY - LAST SEVEN YEARS - ALSO HAS SMALL .FARM NEAR TOWN WHICH. HE WORKS. * : 3-S5>--** ('W -v o cc* JOHN J . DOE 639-14-6139 Pay Roll .N um bor. Otto INAI COPY t# ba n o t tT' I Mantffrinfl data) COPY la ba ratalnod a dia VZ-00C1 Madien! Daportmora baaed "TcOPY to ba ratalnad a* Paraonnal Department Record #6 fi___ V X M 1896 Y*or DATE.of ___ s REPORT R A fT AGE U t JOB POLAND DR. JOHN J. PHAIR KETTERING LABORATORY EDEN AND BETHESDA AYES. CINCINNATI T9, OHIO 4/8/50 W FIRST CLASS OIL CO, COM PANY. P IN E Y IL L E HXNTE- PIA NT REFINERY DEpfiANCE_ rtftzz-* PIPE FITTER 20 WORK STATUS OCCUPATIONAL HISTORY (LI* Occupation Chronologically; S p in n in g with tho LAST or PRESENT JOB) mm * API 06720 JOB DESCRIPTIONS PETROLEUM PRODUCTS I TO BE R&ORTED 1- To be beaed upon 2/3 to 3/4 OF WORK .ASSIGNMENTS. DISTINGUISH B E TWEEN AND ALWAYS .INDICATE tf This is a broad grouping of petroleum the worker wee an operator, laborer, till cleaner, or "other" doty- ' " products. INDICATE FOR EACH JOB the principal material the worker encounters. PRODUCTION .1 If there la an exposure to another product (equal or leas frequent), note this fact Rigger and driller under "Additional Comments". Well puller Crude petroleum, reduced crude, as 4 Others with Inequaet exposure to phalts crudes Gasoline, light ends and solvent naph Others with infrequent exposure to thas (last titan or equal to 400'F.) crudes Medium distillates (400-650'F.) REFINING Lube distillates and related uncracked intermediates (800-1000'F.) ... Catalytic cracking (includes thermal . Refined products cracking of catalytic feeds) - Products derived from thermal crack- - Thermal cracking . inf units' in refineries before or Coking operations without catalytic cracking (600- Blending of heavy fuel oils (No. 3-6) 1000'F.) Blending of heating oil No. 2 Products derived from coking opera Others on cracking operations tions (greater than or equal to 600*F) Refining and blending of lubricants Products derived from catalytic crack Packaging of lubricants . ing and reforming processes or from Manufacture and packaging of greases thermal cracking units in refineries Others--Lubricants and graaaas with catalytic crackers (600-1000*F.) Refining and filtration 'fpreasing or Chemical additive* Petro-chemical* centrifugation) of paraffin Packaging of paraffin Others--Paraffin Distillation of crude oil Production at asphalt Straight run distillations--Others White oil manufacturing ~ Petro-cbemical operations Special products--Others ^ SKIN IRRITANTS TO BE REPORTED Maintenance--Pipe fitters "' Maintenance--Boilermakers This is a broad grouping of skin irritants. Maintenance--Mechanics If a history is given of unusual exposure Maintenance--Tank Cleaners to any of tiiem, either during the workers Maintenance--Others employment in the petroleum industry or Loading department in some other occupation, indicate in the Control laboratory appropriate columns the period, degree Others not otherwise specified--General and kind of exposure. Refining Operations PHYSICAL AGENTS i TRANSPORTATION Trauma i Pipe line workers Marine division --Transportation of Radiant heat Solar rays light and medium distillates Ultraviolet rays (end boiling point less than S50*F.) Radioactive substances or roentgen rays Marine division--Fuel oil carriers Fuel oil carriers--Others (Tank cars, INORGANIC SUBSTANCES etc.) Arsenic Transportation--Others Others (Specify in detail) MARKIfllNG AND feAtdJ'nVk, Servioe stations /Q , a W *f ) ORGANIC SUBSTANCES Others--Office workers, etc. U ' Aromatic amines Tar or pitch OTHERS (Not included in four main Soot divisions) Creosote and anthracene oils Job to be described in detail Others (Specify in detail) API 06721 ADDITIONAL COMMENTS___ HAS WORKED ON THE CATALYTIC EQUIPMENT PERIODICALLY - LAST SEVEN YEARS - ALSO HAS SHALL FARM NEAR TOWN WHICH k HE WORKS, " Column 1-2-3 IBM Card Code API Project February 1, 1955 Case Number - Punch directly Column 1 - Hundreds 001 Column 2 - Tens Column 3 - Digets Year of Report X - Prior to 1950 Y - As a double punch - 1960 and over 0 - 1950 1 - 1951 2 - 1952 3 - 1953 4,- 1954 5 - 1955 6 - 1956 7 - 1957 8 - 1958 9 - 1959 API 06722 Column 7 (Kote double * punching) Page 2 Geographic Location (Residence or place of employment at time of report) 0 - Not Specified - Unknown 1 - North Eastern States: Connecticut Delaware Illinois Indiana Kentucky Maine Maryland Massachusetts Michigan New Hampshire New Jersey New York Ohio PennsylYania Rhode Island Vermont Virginia West Virginia Wisconsin 2 - South Eastern States: Alabama Florida Georgia Mississippi North Carolina South Carolina Tennessee 3 - North Central States: Colorado Idaho Kansas Montana Nebraska North Dakota South Dakota Utah Wyoming *3 North Eastern - Central States: Iowa Missouri fc-r Minnesota 4 - South Central States: Arizona New Mexico Oklahoma Texas South Eastern - Central States: Arkansas Louisiana 5 - South Pacific States: California Nerada - North Pacific States: Oregon Washington 6 - Marine Workers (Crews and Terminal Employees) 7 - Pipe Line Crew and Production Workers . 8 - Outside USA ' API 06723 T - 9 10 11 12 3ex and Race Page 3 0 - Unknown or not given 1 - Male, white 2 - Male, colored 3 - Male, other races 4 - Male, race unknown 5 - Female, white 6 - Female, colored . 7 - Female, other races 8 - Female, race unknown Work Status at Time of Report 0 - Unknown or not given 1 - Active 2 - Leave 3 - Retired 4 - Other Age on Date of Report X - Under 30 years Y - Dead 0 - Unknown or not 1 - 30-34 2 - 35-39 3 - 40-44 4 - 45-49 5 - 50-54 6 - 55-59 7 - 60-64 8 - 65-69 9 - 7 0 and over given Age at Onset (First definitive diagnosis of a neoplasm) Follow the code of Column 10, except for Y which can be disregarded. Survival Period (From onset to date of report or death) 0 - Unknown or not given 1 - 0-5 months 2 - 6-11 months 3 - 12-17 months 4 - 18-23 months 5 - 2 4-29 months 6 - 30-35 months 7 - 36-47 months 8 - 48-59 months 9 - 6 0 and over months API 06724 Page 4 Type of Tumor - Histoqenic Classification (American Cancer SocietyCode) Column 13 - Tens Column 14 - Digits Tumors of Glandular Epithelium (00-09) 00 01 02 03 04,05 06,08 09 - Ductal tumor - Tumor of mucinous secreting epithelium - Papillary tumor, not elsewhere classified - Neoplastic cyst, not elsewhere classified - Functionally active tumors - Other specific glandular tumors - Unspecified tumors of glandular epithelial origin Tumors of Nonqlandular Epithelium (11-14) 11 - Tumor of transitional epithelium 12 - Tumor of basal epithelium 13. - Tumor of baso-squamous epithelium 14 - Tumor of squamous epithelium 1 5 , 1 6 ........................... Tumors of Melanin Forming Tissue (17) 17 - Tumor of melanoblast Tumors of Epithelium, not elsewhere classified ---------------------- e ------------- ------------------------------------ ( 1 8 - 1 9 ) " 18 - Specific tumors of epithelium, not elsewhere classified 19 - Unspecified tumors of epithelial origin Leukemias (20-29) 20 21 22 23,25 26 27 28 29 - Lymphocytic leukemia - Monocytic leukemia - Granulocytic leukemia ........................... - Compound leukemias - Leukemia and lymphoma - Other specific leukemias - Leukemia, type not specified Lymphomas (30-39) 30 - Lymphosarcoma 31 - Reticulum cell sarcoma 32 - Hodgkin's disease 33 - Plasma cell myeloma 34 - Giant follicular lymphoma 35 ....................... . 05725 Column 13-14 (Cont.) Page 5 Type of Tuaor - Histogenic Claaaification Lymphomas (Cont.) 36 - Compound lymphomas 37 38 - Other specific lymphomas 39 - Lymphoma, type not specified --Tumo-r-s---o-f---N-e-r--v-o-u--s---T-i-s-s--u-e-s---a--n-d---A-s-s--o-c-i--a-t-e--d- Sntcrr-uTcSt")u--res 40 - Tumor of ganglion 41 - Tumor of sympathicoblast 42 - Tumor of neuroepithelium 43 - Tumor of paraganglion 44 - Argentaffinoma 45 - Tumor of peripheral nerve sheath 46 - Tumor of meninges 47 - Tumor of glia 48 -- Other specific tumors of nervous tissue and structures 49 - Unspecified tumors of nervous tissue origin Tumors of Vascular Tissue (50-59) 50 51 52 53 54 55, 57 58 59 - Tumor of blood vessel - Hemangiomatosis - Multiple hemorrhagic hemangioma of kaposi - Tumors of specialized vascular structures - Tumor of lymph vessel ^ ......................... - Other specific tumors of vascular tissue - Unspecified tumors of vascular tissue origin Tumors of Muscle (66-69) 66 - Tumor of smooth muscle 67 - Tumor of striated muscle 68 - Other specific tumors of muscle 69 - Unspecified tumors of muscle origin Tumors of Connective Tissue (70-77) 70 - Tumor of fibrous tissue 71 - Tumor of mucinous connective tissue 72 - Tumor of lipoid tissue 73 - Tumor of cartilage 74 - Giant cell tumor 75 - Ewings sarcoma 76 - Tumors of osseous tissue, not elsewhere classified 77 - Tumors o f ser o u s and s y n o v ia l su r fa c e s API 06726 Column 13-14 (Cont.) 15 Page 6 Type of Tumor - Hiatogenic Classification Tumors of Nonepithelial Tissues. not elsewhere " * classified (78-771 78 - Specific tumors of nonepithelial tissue, not elsewhere classified 79 - Unspecified tumors of nonepithelial tissue origin Tumors of Embryonal and Mixed Tissues (80-89) 80 - Tumor of trophoblast 81 - Tumor of embryonal gonadal tissue 82 - Tumor of teratoid tissue 83 - Tumor of epithelial and mesodermal tissues 84 - Tumor of epithelial and lymphoid tissues 85 - Tumor of mixed tissues, salivary gland type 86 - Tumor of dental tissues 87 - Tumor of mesenchyme 88 - O t h e r specific tumors of embryonal and ` '"mixed tissues 89 - Unspecified tumors of embryonal and mixed tissue origin Tumors, not elsewhere classified (97-99) 97 - Tumors of uncertain histologic type-no agreement as to classification 98 - Tumors of specific tissues, not elsewhere classified 99 - Tumor, cancer, neoplasm, and other general and nonspecific terms Other Conditions (XX, X8 and X9) XX - No information X8 - Not a neoplasm X9 - Diagnosis not completed, possibly a neoplasm Type of Tumor - Degree of Malignancy General Malignancy Code (Used with all Histogenic Code Numbers except Code Numbers 20-39) X - Not a neoplasm, no premalignant significance 0 - Not a neoplasm, but haying premalignant significance 1 - Benign neoplasm, nopremalignant significance 2 - Benign neoplasm, but having premalignant significance API 06727 Colum n }5 (Cont.) 16-17 (Note double punching for melanomas 60-65) Page 7 Type of Tumor - Degree of Malignancy General Malignancy Code (Cont.) 3 - Diagnosis not completed, suspected malignancy 4 - Neoplasm, malignancy not determined 5 - Malignant neoplasm, non-infiltrating ' (including carcinoma in situ) 6 - Malignant neoplasm, differentiated 7 - Malignant neoplasm, undifferentiated (anaplastic) 8 - Malignant neoplasm, differentiation not determined 9 - Malignant neoplasm, metastatic site Leukemia Malignancy Code (Used with Histogenic Code Numbers 20-29) 5 - Aleukemic, not otherwise specified 6 - Chronic 7 .- Acute 8 - Not determined Lymphoma Malignancy Code (Used with Histogenic Code Numbers 30-39) 1 - Specified as benign (except the term 'benign lymphoma') 6 - Single 7 - Multiple 8 - Multiplicity not stated Primary Site (Based on Maryland State Cancer Program Code) Column 16 - Tens Column 17 - Digits Buccal Cavity and Pharynx International Classification Number 00 - Lip, upper 01 - Lip, lower 02 - Lip, unspecified 03 - Tongue 04 - Floor of mouth 05 - Salivary Gland 06 - Other and unspecified parts of mouth 07 - Oral nasopharynx 08 - Nasopharynx 09 - Hypopharynx OX - Pharynx, other and unspecified parts 140A 140B 140C 141 143 142 144 145 146 147 148 ^niunm j6-l7 (Cont. ) Primary Site Digestive System and Peritoneum 10 - Esophagus 11 - Stomach 12 - Duodenum 13 - Small intestine 14 - Large intestine, except rectum 15 - Rectum 16 - Biliary passages 17 - Liver 18 - Pancreas 19 - Peritoneum IX - Unspecified digestive organs Respiratory System , MU'* 20 21 22 23 24 25 2X 0 30 - Nose, nasal cavities, .and middle ear - Accessory sinuses - Larynx - Trachea - Bronchus and lung - Media stinum - Other and unspecified thoracic organs - Breast Genital Organs 40 - Cervix uteri 41 - Corpus uteri 42 - Other specified parts of uterus 43 - Uterus, unspecified parts 44 - Ovary and oviduct 45 - External and unspecified female genital organs 47 - Prostate 48 - Testis 49 - Penis 4X - Other and unspecified male genital organs (scrotum) Urinary System 50 - Kidney 51 - Bladder 55 - Other and unspecified parts of urinary system Page 8 Internati Classifica' Number 150 151 152A 152B 153 154 155A 155B 157 158 159 160A 160B 161 16 2A 162B 164 165 170 171 172 173 174 175A, 176 177 178 179A 179B 180 181A 181B API 06729 (Vilumn j6-17 (Cont. ) Primary Site rfftlanoma {Juble K m c h niait column Y Skin Melanoma Other Types ' -- o', .<?/. " ^ 60 - Skin of lip 4^3 61 - Skin of face, head, 190A 190B neck 62 - Skin of upper 190C extremities 63 - Skin of trunk 190D 64 - Skin of lower 190E extremities 65 - Skin, unqualified 190F Soft Tissue Page 9 Other 191A 191B 191C 191D 191E 191F 66 - Soft tissues of face, head, neck 67 - Soft tissues of upper extremities 68 - Soft tissues of trunk 69 - Soft tissues of lower extremities 6X - Other and unspecified soft tissues 197A 197B 197C 197D 197E (Note : This group will include neoplasm of peripheral nerves which are coded to 193 of the International List.) Bones 70 - Jaw bone 71 - Bones of head and face 72 - Bones of upper extremities 73 - Bones of trunk 74 - Bones of lower extremities 75 - Bones, unspecified sites 196A 196B I960 196D 196E 196F Brain and Other Parts of Central Nervous System 76 - Eye 77 - Brain 78 - Other central nervous system and intracranial nerves 192 193A 193B Lymphatic and Hematopoietic System 80 - Reticulum cell sarcoma 81 - Lymphosarcoma 82 - Other malignant neoplasm of lymphoid tissue 200.0 200.1 200.2 API 06730 rolunm 16-17 (Cont.) 18 19 Page 10 Primary Site International Classification Number_ Lymphatic and Hematopoietic System 83 - Hodgkin's disease 84 - Giant follicular lymphoma 85 - Other forms of lymphoma 86 - Multiple myeloma 87 - Lymphatic leukemia 88 - Myeloid leukemia 89 - Monocytic leukemia 8X - Other and unspecified leukemia 8Y - Mycosis fungoides 201 202.0 202.1 203 204.0 204.1 204.2 204.3,204.4 205 Malignant Neoplasm of Other Sites 90 - Thyroid 91 - Adrenal 92 - Pituitary 93 - Thymus 94 - Pineal 95 - Other and unspecified endocrine glands 96 - Other specified sites 9X - Unspecified sites or unknown 194 195A 195B 195C 195D 195E 199A 199B Stage of Disease 0 - Unknown, not given, or pre-cancerous 1 - Early local, confined to primary site with no evidence of metastases and no extension 2 - Advanced local, no evidence of distant metastases but extension to adjacent anatomical sites 3 - Regional nodes and/or extension to adjacent anatomical sites 4 - Distant metastases, including extensive spread to adjacent anatomical sites 5 - Recurrence, original site 6 - Recurrence, metastatic site Metastatic Sites X - Regional nodes Y - Local extension 0 - Unknown, not given, or none 1 - Remote metastases, bones upper extremities 2 - Remote metastases, bones lower extremities 3 - Remote metastases, bones spine 4 - Remote metastases, bones skull Metastatic Sites 5 - Remote mtastass, mediastinum 6 - Remote mtastass, lungs 7 - Remote mtastass, liver 8 - Remote mtastass, brain 9 - Remote mtastass. generalized Original Diagnosis 0 - Unknown or not given 1 - Medical department of the company 2 - Private physician 3 - Public clinic 4 - Self or other Method of Diagnosis 0 - Unknown or not given 1 - Periodic examination 2 - Special study 3 - Symptoms 4 - Other Treatment X - Hormone Y - Chemotherapy 0 - No treatment or unknown 1 - Surgery 2 - Surgery with X-Ray 3 - Surgery with radium 4 - Surgery with radioactive isotope 5 - X-Ray only (Radiation) 6 - Radium only 7 - Radioactive isotope only 8 - X-Ray and radium or isotope Present or Last Occupation in Petroleum Industry Column 23 - tens Column 24 - digits 00 - Unknown, not given, or none Production 01 - Rigger and driller 02 - Well puller 03 04 05 - Others with frequent exposure to crude petroleum 06 07 08 09 - Others with infrequent exposure to crude petroleum  rnluinn 23-24 (C ont.) Page 12 Present or Last Occupation in Petroleum Industry Refining 20 - Catalytic cracking (includes thermal cracking of catalytic feeds) - Operators 21 - Catalytic cracking (includes thermal cracking of catalytic feeds) - Laborers, still cleaners, etc. 22 - Thermal cracking - Operators 23 - Thermal cracking - Laborers, still cleaners, etc. 24 - Coking operations - Operators 25 - Coking operations - Laborers, still dciriTs 26 - Blending of heavy fuel oils (#3-6) 27 - Blending of heating oil (#2) 28 - 29 - Others on cracking operations 30 - Refining and blending of lubricants - Operators 31 - Refining and blending of lubricants - Laborers, still cleaners, etc. 32 - Packaging of lubricants 33 - Manufacture and packaging of greases 34 - 35 - Others - lubricants and greases 36 - Refining and filtration (pressing or centrifugation) of paraffin - Operators 37 - Refining and filtration (pressing or centrifugation) of paraffin - Laborers, still cleaners, etc. 38 - Packaging of paraffin 39 - Others - paraffin 40 - Distillation of crude oil - Operators 41 - Distillation of crude oil - Laborers, still cleaners, etc. 42 - Production of asphalt - Operators 43 - Production of asphalt - Laborers, still cleaners, etc. 44 - 45 - 46 - 47 - 48 - 49 - Straight run distillations - Others 50 - White oil manufacturing - Operators 51 - White oil manufacturing - Laborers, still cleaners, etc. 52 - 53 - 54 - 55 - 56 - Petro-chemical operations - Operators 57 - Petro-chemical operations - Laborers, still cleaners, etc. 23-24 (C ont.) Page 13 Present or Last Occupation in Petroleum Industry Refining (Cont.) 58 59 Special products - Others 60 Maintenance - Pipe Fitters 61 62 Maintenance - Boilermakers 63 Maintenance - Mechanics 64 Maintenance - Tank Cleaners 65 66 67 68 69 Maintenance - Others 70 71 Loading department 72 73 74 75 76 - Control laboratory 77 78 79 Others not otherwise specified General Refining Operations 80 81 82 83 84 85 Pipe line workers 86 Marine division - Transportation of light and medium distillates (end boiling point <C650) Marine division - Fuel oil carriers Fuel oil carriers - Others Transportation - Others Marketing and Executive Column 23-24 (Cont. ) Page 14 Present or Last Occupation in Petroleum Industry Others (Not included in the four main divisions) 99 - Job to be described in detail on card 26-27 28 29-30 31 32 0 - Unknown, not given, or none 1 - 0-1 year 2 - 2-4 years 3 - 5 - 9 years 4 - 10-14 years 5 15-19 years 6 - 2 0 and over years Principal Occupational Assignments in the Petroleum industry (2/3-3/4) Follow the code of Column 23-24 Approximate Number of Years so Engaged in Principal Assignments Follow the code of Column 25 Secondary Occupational Assignments in the Petroleum Industry Follow the code of Column 23-24 Approximate Number of Years so Engaged in Secondary Assignments Follow the code of Column 25 Principal Petroleum Product Contact The information will be punched as a secondary petroleum contact if only one product is listed and if the exposure is described as rare, infrequent, or light. 0 - No contact 1 - Not given or unspecified petroleum products 2 - Crude petroleum, reduced crude, asphalts 3 - Gasoline, light ends, and solvent naphthas (C 400 F. ) 4 - Medium distillates (400-650 F.) 5 - Lube distillates and related uncracked intermediates (600-1000 F.) 6 - Refined products 7 - Products derived from thermal cracking units in refineries before or without catalytic cracking (600-1000 F.) C olu m n 32 (Cont.) 33 35 36-37 Page 15 Principal Petroleum Product Contact 8 - Products derived from coking operations ( => 600 P. ) 9 - Products derived from catalytic cracking and reforming processes or from thermal cracking units in refineries with catalytic crackers (600-1000 F.) X - Chemical additives Y - Petro-chemicals Approximate Number of Years so Exposed X - No exposure 0 - Unknown or not 1 - 0-1 2 - 2-4 3 - 5-9 4 - 10-14 5 - 15-19 6 - 2 0 and over given Secondary Petroleum Contact Follow the code of Column 32 0 - No exposure in any degree Approximate Number of Years so Exposed Follow the code of Column 33 X - No exposure Principal Other Occupation - Punch as Coded Column 36 - Tens Column 37 - Digits 00 - Unknown, not given, or none Professional and Semi-Professional 01 - Doctors, lawyers, clergymen, dentists, pharmacists, chemists, chiropractors, veterinarians, optometrists 02 - Midwives 03 - Nurses 04 - Students 05 - Teachers 06 - Auditors, clerical workers, bookkeepers, secretaries, draftsmen, tellers, steno graphers, telephone and telegraph operators, cashiers, librarians, accountants, pay m asters API 06736 w V Column 36-37 (Cont. ) Pag 16 Principal Other Occupation Professional and Semi-Professional (Cont.) 07 - Technicians, photographers, musicians, artists, assayers 08 - Other professional and semi-professional theatrical people, reporters, publishers, undertakers, opticians, managers of theaters, civil and mechanical engineers, dieticians 09 - Housewives Proprietors (10-19 inclusive apply only to people who own their own business) 10 Store owners (sellers of merchandise, not food), jewelers, furriers, clothing stores, hardwood, art stores, florists, etc. 11 Store owners (of food), grocers, stalls in market, produce dealers, bakers, oyster business, ice business, huckster 12 Cafe and restaurant owners, saloon keepers 13 Barbers, cleaners, laundry hairdressers 14 Turners, plumbers, paper hangers, con tractors, cabinet makers, shoemakers, tailors, stone cutters, blacksmiths, sheet metal, printers, upholsterers, carpenters 15 Painters 16 Garages 17 Manufacturers (small) (not food) (food under 11) . Junk dealers Other business (owner), funeral directors, owner of business (business unknown), organ builder, taxi proprietor, farmer, hauling, pool room, coal and wood, real estate Skilled Labor 20 - Craftsmen (men with specific trades demand ing a certain amount of specialized skill). Wheelwright, millwright, glaziers, copper smiths, glass blowers, tool makers, car penters, plumbers, electricians, machinists, cabinet makers, pattern makers, surveyors, silver engravers, paper hangers, tinners, printers, wood-workers, mechanics, lineman, slaters 21 - Blacksmiths, pipe fitters, boiler makers, brass molders, riveters, welders, sheet metal workers 22 - Stone masons, cement workers, bricklayers, plasterers, pottery makers, brickmakers [iet* API 06737 Principal Other Occupation Page 17 Skilled Labor (Cont.) 23 - Marine and stationary engineers and firemen, railroad engineers and firemen 24 - Railway men (steam and street), dispatchers, motormen, conductors, signalmen, brakemen 25 - Painters 26 - Taxi drivers, truck drivers, chauffeurs 27 - Mechanics (garage) 28 - Tailors, dressmakers, shoemakers, milliners 29 - Others. Jockeys, ship fitters, crane operators, lumber inspectors, simplex operators, watchmakers, tiremakers, riggers, jewelers, car repairmen, tractor drivers, tar men (Trade apprentices are in their specific trades.) Sales and Service 30 Interior decorators, window dressers, sales men and clerks in stores (not food handlers) 31 - Workers in food trades, salesmen, hucksters, milkmen, brewers, millers in food stores, ice handlers, bakers, sugar testers, meat dealers, canning, pickling, oyster shuckers 32 - Workers in slaughter houses, meat packers 33 - Waiters, waitresses, stewards, bartenders, butlers, chefs 34 - Barbers, hair dressers, manicurists, matrons, masseurs 35 - Cleaners, laundry workers 36 - Commercial travelers, insurance agents, insurance collectors, tax collectors, real estate agents, insurance adjusters, credit investigators 37 - Policemen, firemen, mail carriers, city inspectors and guards 38 39 - Other miscellaneous sales and services, U. 3. Army and Navy, Marine pilot, gas station attendants, manager of paper routes, weather bureau observer, manager hotel store room, foreman coal company, meter readers, carpet and linoleum layers, sea captains, salesmen (business unknown), paker (business unknown), bill-poster Factory Workers and General Laborers 40 - Factory workers, clothing, shoes 41 - Factory workers (others), machine operators, upholsterers, still men, furniture finishers, awning makers, bookbinders, cigar makers, nickel platers, brass polishers, brush makers, coopers, grain handlers API 06738 rolumn 36-37 (Cont.) Principal Other Occupation Page 18 Factory Workers and General Laborers (Cont.) 42 - Janitors, watchmen, orderlies, porters, sextons, parlor car porters, elevator tenders, window washers, dish washers 43 - Domestics, cooks, housemaids, maids, laundresses, charwomen, housework by day, nursemaids 44 - Day laborers, street cleaners, stevedores, garbage collectors, farm hands, hostlers, (wood workers, if colored) 45 46 47 48 49 - Factory worker (factory unknown) Miscellaneous 50 - Newsboy, messenger boys, errand boys, ushers, bootblacks, movie operators, bundle wrappers 51 52 53 54 55 56 57 Ragmen, light housekeepers, miscellaneous odd jobs, car parkers, lamp lighters, pin setters, pugilists, gardeners, attendants at public baths, grave diggers 58 Invalids 59 Mentally deficient 5X Reform school 38 Approximate Number of Years Em]iployed at Principal m , er Occupation - Punch as co 0 - Unknown or not given 1 - 0-1 year 2 - 2 - 4 years 3 - 5-9 years 4 - 10-14 years 5 - 15-19 years 6 - 2 0 and over years 39 Exposure to Irritants Other Than Petroleum - i^r ineipai Physical Agents **> 1 - Trauma 2 - Radiant Heat 3 - Solar or Ultrariolet Rays 4 - Radioactive Substances or Roentgen Rays API 06739 1 Colman 39 (Cont.) ! 40 i 41 i Page 19 Expoaure to Irritant Other Than Petroleum (Cont.) Inorganic Substances 5 - Araenic 6 - Chromates Organic Substances 7 - Aromatic Aminea 8 - Tar, Pitch, Creosote and Anthracene Oils 9 - Soot .,,sa - Others (Specified in detail) (0 - Unknown, not given, or none Approximate Number of Years Exposed to Principal Irritants Other Than Petroleum ^ 0 - Unknown, not given, 1 - 0-1 year 2 - 2 - 4 years 3 - 5-9 years 4 - 10-14 years 5 - 15-19 years 6 - 2 0 and over years or none Degree of Exposure to Principal Irritant Other Than Petroleum 0 - Unknown, not given, or none 1 - Heavy and continuous 2 - Heavy and occassional 3 - Heavy, amount not indicated 4 - Light but continuous 5 - Light but occassional 6 - Light, amount not indicated Secondary Irritant Other Than Petroleum Products Follow the code of Column 39 Approximate Number of Years Exposed to Secondary Irritant Other flian Petroleum Products Follow the code of Column 40 Degree of Exposure to Secondary Irritant Other Than Petroleum Products Follow the code of Column 41 * <^SO Kfe J) O JQHXM PQE 639-14.6139 Cr UxMi ICJU i ______________ Poy Roil -Numbor. 365 B I U 1-D ADDRESS___ 639 46TH___ STREET Street PINE VILLE City Qk l a , ggjOINAL COTY lo bo tont tot oll idoolifyia data) c o f t ta bo retained a* dta ModicoI Department loeord DR. JOHN J. PHAIR KETTERING LABORATORY EDEN AND BETHESDA AVES. CINCINNATI 19, OHIO JJbL-- 16 ( ^ g S ^og^PORT-. 4 /6 /5 0 M 1896 r RACE. W AGE Tat JO B. 20 ' POLAND COMPANY. PLANT____ FIRST c l a s s o n , r n PINE VILLE REFINERY MAINTE- DEPT__ ------- P IPE -FIT T E R ---- * \WjjOr>RmKr Aactiva i--i i_La_av_ai--i STATUS Ratlrod Othar jjoSIS*___ A P E N O -CARCINOMA PRIMARY SITE TRANSVERSE (TiMua of Orifhei COLON_______ STAGE of DISEASE Early Local Rag. Nodac METASTATIC SITES________LIVER Adv. Local Dtoanf Mat.: s COMPLICATIONS INTESTINAL PERFORATION WITH LOCALIZED ABSCESSES COVERED BY Co. Mad. Dapt. Privata Doctor QJ PubJk O ink Othar ROES ___ FIRST s y m p t o m s INDEFINITE PRIMARY D IA G N O S IS 2 / 2 0 / 5 0 ______ BATMENT PROCEDURES (Surgary, Radiation, ate.) (a)___SURGERY 0uzL*7) tto POST O P, X-RAY METHOD Rout. Exam Q Spoc. Exam Symptoms Othar FIRST VISIT ' PHY5IOAN__ 1 1 * 1 * 9 ._________ ** s ) . DATE. DATE. 2/20/50 2/25/50 (0_ DATE. ITHOLOGIC DIAGNOSIS*. Biopsy S Autopsy TiosuorQ SfitMo ^ APSPCARCBK>M A - COLON TO CINCINNATI (Data Sant)____ DATE of 4 / 6 / 3 0 _______________ DEATH__ fcSUAL EXPOSURES TO POSSIBLE IRRITANTS* (From Modicol History) FROM (O f TO 1 .*?) DEGRET TYPE t. CARBON INSULATING MATERIALS to* lists o r jo s D tsciim oM S, tumocs ano imitants to h r o m o 1921 1 9 2 2 - l ' 1* - ~ C * 1-" t e ' " Hvy. ig t / C Con. O cc . 'V. - ..A - " TV t i T r i 5 1 1-*~X----- Hvy. Igt. Cont. O n. Hvy. Lgt. Cont. Occ. PERSONAL physic.anDR. PAUL SMITH ( 4 i CLINIC OR MncPiTAi PINEVILLE HOSPITAL . Ann* DOCTORS B L D G ., PINEVILLE AnnpFfLs 15TH S T ., PINEVILLE, OKLA. NAME Social Securrl Num b JOB DESCRIPTIONS To be based upon 2/3 to 3/4 OF WORK ASSIGNMENTS. DISTINGUISH BE TWEEN AND ALWAYS INDICATE if the worker was an operator, laborer, still cleaner, or "other" duty. PRODUCTION Rigger and driller Well puller Others with frequent exposure to crudes Others with infrequent exposure to crudes REFINING Catalytic cracking (includes thermal cracking of catalytic feeds) Thermal cracking Coking operations Blending of heavy fuel oils (No. 3-6) Blending of heating oil No. 2 Others on cracking operations Refining and blending of lubricants Packaging of lubricants Manufacture and packaging of greases Others--Lubricants and greases Refining and filtration (pressing or centrifugation) of paraffin Packaging of paraffin Others--Paraffin Distillation of crude oil Production of asphalt Straight run distillations--Others White oil manufacturing Petro-chemical operations Special products--Others Maintenance--Pipe fitters Maintenance--Boilermakers Maintenance--Mechanics Maintenance--Tank Cleaners Maintenance--Others Loading department Control laboratory Others not otherwise specified--General Refining Operations TRANSPORTATION Pipe line workers Marine division --Transportation of light and medium distillates (end boiling point less than 650) Marine division--Fuel oil carriers Fuel oil carriers--Others (Tank cars, etc.) Transportation--Others MARKETING AND EXECUTIVE Service stations /> Others--Office workers, et*.' V OTHERS (Not included in four main divisions) Job to be described in detail PETROLEUM PRODUCTS TO BE REPORTED This is a broad grouping of petroleum products. INDICATE FOR EACH JOB the principal material the worker encounters. If there is an exposure to another product (equal or less frequent), note this fact under "Additional Comments". Crude petroleum, reduced crude, as phalts Gasoline, light ends and solvent naph thas (less than or equal to 400*F.) Medium distillates (400-650'F.) Lube distillates and related uncracked intermediates (600-1000'F.) Refined products Products derived from thermal crack ing units in refineries before or without catalytic cracking (6001000Fj Products derived from coking opera tions (greater than or equal to 600'F.) Products derived from catalytic crack ing and reforming nrocesses or from thermal cracking units in refineries with catalytic crackers (600-1000`F.) Chemical additives Petro-chemicals SKIN IRRITANTS TO BE REPORTED This is a broad grouping of skin irritants. If a history is given of unusual exposure to any of them, either during the workers employment in the petroleum industry or in some other occupation, indicate in the appropriate columns the period, degree and kind of exposure. PHYSICAL AGENTS Trauma Radiant heat Solar rays Ultraviolet rays Radioactive substances or roentgen rays INORGANIC SUBSTANCES Arsenic Chromates Others (Specify in detail) ORGANIC SUBSTANCES Aromatic amines Tar or pitch Soot Creosote and anthracene oils Others (Specify in detail) TUMORS TO BE REPORTED LIST IS NOT EXHAUSTIVE BUT COM PRISES THE GREAT MAJORITY OF TERMS USUALLY USED. WHEN THEM IS DOUBT CONCERNING THE MA LIGNANT NATURE OF A TUMOR. IT SHOULD BE REPORTED. Carcinoma j , Sarcoma ,erm oi Epithelioma ( onf, of 111655 wordi " * Endothelioma ) part Acanthoma Astrocytoma Brain Tumors Chorioma Chloroma Cholesteatoma Embryoma Ependymoma Ganglioneuroma Glioma Granulosa Cell Hypernephroma Hodgkin's Disease Leukemia Lymphoma Lymphosarcoma Linitis Plastica Melanoma Meningioma Myeloma Medulloblastoma Mesothelioma Mixed Tumor Neurocytoma Oligodendroglioma Pinealoma Syncytioma Seminoma Sympathoblastoma Spongioblastoma Teratoma Thymoma Paget's Disease Wilms' Tumor Ewing's Tumor Grawitz' Tumor WHITE (ftmc YELIOW Comp CASE NUMB SEX-- BORN CLINIC DIAGT DISCO dates treat pATHC API 06712 ADDITIONAL COMMENTS P A T IE N T IS NOW CO N V A LESCEN T AM BULATORY - PROGNOSIS GRAVE J*-i Si-* L LE L*. Hrrv^the M? ruM oO ; mwoorfds'`S h CLINICAL B E w iR D JOHN J. POE jjrity 639-14-6139 A" ____ _____ _______ ADDRESS Poy Roll .Number. 365 639 46TH ,, STREET_____ Srrvf PINE VILLE City OKLA. 0,|0INAL COPY to b. wnt to: i H|1 0u identifying doto) w COPY to bo rotainod at tho P10 Medical Department Record Co-P"' DR. JOHN J. PHAIR KETTERING LABORATORY EDEN AND BETHESDA AVES. CINCINNATI 19, OHIO s w . M 1896 jORH |ATE of EPORT. RACE___ AGE 1st JO B. POLAND Country y W 20 COMPANY. PLANT____ FIRST CLASS OIL CO. PINEVILLE REFINERY MAINTEDEPT____NANCE . AvORK STATUS PIPE FITTER ( Z G J * # ) Active Retired Leave l~jc Other iJlMlCAL J,AGN0SIS*- ADENO-CARCINOMA STAGE of DISEASE Early Local Reg. Nodes Adv. Local Distant Met. PRIMARY SITE TRANSVERSE (Tissue of Origin)- COLON METASTATIC SITES_______ LIVER rnMPiirATinMs INTESTINAL PERFORATION WITH LOCALIZED ABSCESSES discovered BY Co. Med. Dept. Private Doctor a Public Clinic Other dates FIRST SYMPTOMS. INDEFINITE PRIMARY DIAGNOSIS_____ 2 /2 0 /5 0 'EATMENT PROCEDURES (Surgery, Radiation, etc.) SURGERY (b)_ POST OP. X-RAY METHOD Rout. Exam Spec. Exam Symptoms Other FIRST VISIT PHYSICIAN. 2 /1 5 /5 0 ** S ') DATE. DATE. 2/20/50 2/25/50 (c)--- DATE. 'ATHOLOGIC DIAGNOSIS Biopsy 3 Tissue TO CINCINNATI 4/6/50 DATE of DEATH USUAL EXPOSURES TO POSSIBLE IRRITANTS* (From Medical History) KIND FROM TO ' CARBON INSULATING MATERIALS 1921 1922 ^ R FOR LISTS OF JOB DESCRIPTIONS, TUMORS AND IRRITANTS TO BE REPORTED 2) DEGREE"' Lg*- Hvy, Lgt. Hvy. Lgt. Hvy. Lgt. TYPE Cont. Cont. Occ. Cont. Oec. Cont. Occ. API 06713 JOB DESCRIPTIONS To be based upon 2/3 to 3/4 OF WORK ASSIGNMENTS. DISTINGUISH BE TWEEN AND ALWAYS INDICATE if the worker was an operator, laborer, still cleaner, or "other" duty. PRODUCTION Rigger and driller Well puller Others with frequent exposure to crudes Others with infrequent exposure to crudes REFINING Catalytic cracking (includes thermal cracking of catalytic feeds) Thermal cracking Coking operations Blending of heavy fuel oils (No. 3-6) Blending of heating oil No. 2 Others on cracking operations Refining and blending of lubricants Packaging of lubricants Manufacture and packaging of greases Others--Lubricants and greases Refining and filtration (pressing or centrifugation) of paraffin Packaging of paraffin Others--Paraffin Distillation of crude oil Production of asphalt Straight run distillations--Others White oil manufacturing Petro-chemical operations Special products--Others Maintenance--Pipe fitters Maintenance--Boilermakers Maintenance--Mechanics Maintenance--Tank Cleaners Maintenance--Others Loading department Control laboratory Others not otherwise specified--General Refining Operations TRANSPORTATION Pipe line workers Marine division --Transportation of light and medium distillates (end boiling point less than 650") Marine division--Fuel oil carriers Fuel oil carriers--Others (Tank cars, etc.) Transportation--Others MARKETING AND EXECUTIVE Service stations /'h.ZGe, `*4-) Others--Office workers, ete. * OTHERS (Not included in four main divisions) Job to be described in detail PETROLEUM PRODUCTS TO BE REPORTED This is a broad grouping of petroleum products. INDICATE FOR EACH JOB the principal material the worker encounters. If there is an exposure to another product (equal or less frequent), note this fact under "Additional Comments". Crude petroleum, reduced crude, as phalts Gasoline, light ends and eolvent naph thas (less than or equal to 400"F.) Medium distillates (400-650`F.) Lube distillates and related uncracked intermediates (600-1000*F.) . Refined products Products derived from thermal crack ing units in refineries before or without catalytic cracking (6001000-F.) Products derived from coking opera tions (greater than or equal to 600*F.) Products derived from catalytic crack ing and reforming nrocesses or from thermal cracking units in refineries with catalytic crackers (600-1000'F.) Chemical additives Petro-chemicals SKIN IRRITANTS TO BE REPORTED This is a broad grouping of skin irritants. If a history is given of unusual exposure to any of them, either during the workers employment in the petroleum industry or in some other occupation, indicate in the appropriate columns the period, degree and kind of exposure. PHYSICAL AGENTS Trauma Radiant heat Solar rays Ultraviolet rays Radioactive substances or roentgen rays INORGANIC SUBSTANCES Arsenic Chromates Others (Specify in detail) ORGANIC SUBSTANCES Aromatic amines Tar or pitch Soot Creosote and anthracene oils Others (Specify in detail) TUMORS TO BE REPORTED LIST IS NOT EXHAUSTIVE BUT COBPRISES THE GREAT MAJORITY Of TERMS USUALLY USED. WHEN THEM IS DOUBT CONCERNING THE Ha. LIGNANT NATURE OF A TUMOR, r: SHOULD BE REPORTED. I and any term of which Epithelioma ( "I of ,hese words * Endothelioma ' part Acanthoma I Astrocytoma I Brain Tumors ! Chorioma Chloroma Cholesteatoma Embryoma Ependymoma Ganglioneuroma Glioma Granulosa Cell Hypernephroma Hodgkin's Disease Leukemia Lymphoma Lymphosarcoma Linitis Plastics Melanoma Meningioma Myeloma Medulloblastoma Mesothelioma Mixed Tumor Neurocytoma Oligodendroglioma Pinealoma I Syncytioma Seminoma Sympathoblastoma | Spongioblastoma I Teratoma Thymoma Paget's Disease Wilms' Tumor Ewing's Tumor Grawitz' Tumor I ADDITIONAL COMMENTS ( O u z Z ' * / c ) PATIENT IS NOW CONVALESCENT AMBULATORY