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^ IEVEWS ON ENVIRONMENTAL HEALTH iO J-S3 S VOLUME NO. 1,2004 Lung Cancer and Mesothelioma among Male Automobile Mechanics: A Review Fraocine Laden,1,2 Melr I. Stampfer,A* and Alexander M. Walker1 1Channing LaboratoryDepartment ofMedicine, Brigham and Women's Hospital and HarvardMedical School, Boston, Massachusetts;2Departmeat ofEnvironmentalHealth.1Department ofEpidemiology and *Dtparpnenlofhharifioh. Harvard School ofPublic Heath, Boston. Massttchusetts , ABSTRACT' 70 ' MACKGRQIUND: Extensive, overt asbestos exposure' eleaity. .causes Jn'ng: ameer . and : jni&Sitt(dibni*.~. Eteyatpd: .[cancer psk . bis '^also KEYWORDS . epidemiologic studies,' occupational risk, friction niatcriai, brake'repair, asbestos' repilr .worK'':Fewy Siiidfcs 'fcve"'.s^feelfi|pilfy ' .'ettSteedT i&e .'ftaR'wig ' caiseer: and 'feteo&ilfomi r': }ks%4.li'ted;:; .witli ;;s|msart * to asbestos li brakes,'but adfomobHe mechanics rtlndodedia many itndfes of- oeeapatiozfindi cancer. METHODS: We critically reviewed alt epMewfolsgk'' sMiflte of . lapg- cancer' id rnesfttfsdfomW risk among .-.male automobile mtehsala Weatifiect through dJbtbtidly -Based Medline search and scrutiny..of references .In primary -and `review 'articles. We dbenss the studies gronprii bjrstndjr design and control for smoking, the major risk hetor fot lung cancer. RMSULTS/CONCLUSIONS: We reviewed all todivldnai 'analytical studies 'meeting our criteria,, plw ill available Case series and case reports. -When examined hi aggregate, the evidence.did' hoisupport. in increase In risk of either Sang icahcw or mesothelioma among imile automobile mechanics occupationally exposed to asbestos from brake repair; Reprint - requests io: Dr. Fraorine Laden, Ctetming Labwstaiy, 181 Loogwood Avqiue,.Boston, MassaduseOs, USA; Mnafl: frandtto.iadewadimntng.hafvaid.edB '.^enav^-.bveTtVexposiiTe'^to'.asbtetttS'.fibfcrs.- Clearly causes lung'. ieaheef 'anif- 'iri&otbeiioma. Elfcvsted short tent or low levels of asbestos exposure /]/. Automobile mechanics are potentially exposed .to low levels of asbestos through repair of friction .materials.- Few studies; however, have Specifically examined [the - risks of. -lung cancer and mesothelioma associated with work bh atAoinobile brakes. In.this paper,' toe summarize and critically review the' available' epidemiologic studies On the risk' of lung cancer, and mesothelioma associated withwork as rut automobile mechanic. ' '' ; About 50% oftoe composition of brake linings and briike shoes Consists iof "chrysofile asbestos encapsulated in a phenolic resin: The use of suth products-in automobiles, buses, and other heavy equipment causes them to wear, releasing a fine dust of amorphous material together with very small' fibers til. Automobile mechanics are potentially exposed to asbestos fibers when they grind used'Iihings; bevel hew linings, of remove the loose dust from the brake drum and back plates using compressed air, brushes, or wet cloths BL 2004 Bound PeMishisg House Ltd 39 HWBUI0011502 40 F. LADEN. MJ. STAMPFER, A.M. WALKER Although total dust counts in the ambient air can Concerns about this possibility led to warnings, reach high levets for short periods of time during from bolh government agencies and companies, these processes, control methods, such as enclosed but with little or no epidemiologic evidence. We vacuum systems or exhaust ventilation systems, therefore reviewed the epidemiotogic studies that effectively lower the exposure /4~5/. Furthermore, provided data on risk of Sung cancer and the availability of asbestos fibers m used brakes is mesothelioma among automobile mechanics. markedly.. reduced because^ .high temperatures during braking degritde the vast majority- of |he 'asbestos into 'nonfibrous magnesium' silicate ft*/.' . -s " ' " ' ' ' METHODS : Less than one-percent ofthe dust released- in work on brakes-contains chiysotile fibers that are.Ionger We identified studies of: lung cancer and than rive microns,'the size known to. berelevant to mesothelioma risk among motor vehicle mechanics respiratory health flL Grinding, and drilling of through computer searches and scrutiny, ofreferences friction pads also releases' fibers; 'vriiich hayp been in primary and review articles:..Id .an `attempt to of:concern. Detailed study of.ihu materia! has capture .all. published data oil ppfentiaLagxxttire to revealed, -'hbwpverj . tfiial. die fibers;- consistently, remained .bound .to', the resin, matrix. IV. Thus, asbfsfes\ 6ojn. we considered, general- - surveys' .of-occupation .and grindings and'drilling also appear..to-pose no cancer risifc*.BS .welf-as studies. focusing specifically impoirtaRt expjsyre to asbestos fibers., . ....... Tfie 'ijeojirtfe cxpos^'leyei is Ihfiueaped by ' thfe ipotefffia! for jmb&cleioh' Sias by-Both of the'distaiice.to the`source, the (ype.a^dwa^on of activity; as well:as`6y- tfie type.of brake,.- For jgatorsaajfjopmfdsfpblgW|gJjt'pasit)5re.fiadj5gsJ.w performed broadly -based' Medline searches' (1966 example, drum brakes used .for trucks, .buses, and certain passenger cars, require more cleaning than disc--.brakes .used only , in passenger Cars 19/. industrial hygjme. reports taking measurerjients of dust and -fiber.gemmated during c|utch. artd. brake tfirpt^h August 2003),...u^ng.BS,key. wptds ameer, lung cancer, opctjwtibm and mesothelioma.' We identifi^i'.many, userid studies that migltt.ba.ve been ovcripokedbecriuse theydid noj specifically mention . ayjQfnobile-.niKhanics -in' the title or. abstract...We repair ;wotk demonstrate .that, the .exposure to also', contacted authors, for supplemental data, and asbestos :Irom: thiswork. is low, intoinitlent and tables' If it; appeared that. the relevant, results jwere brief 19!. In tits 1970s, before the current available but did pot meet the criteria described for permissible pxpqsure limit qtf Oil ffrnL (fibers per milliliter ofair) was proposed by the United States .inclusion;In .foe publishedpaper. .We: focused specifically on automobile mechanics, as opposed to (UJ5.) Occupational'. Safety utd . Health broad .ocogwrional -TSC industrial - categories..; For .Administradpn, episodic peak ppncpntratiafts.pf up amqpleteness, boweyer,-we also-included, papers to iri fftnL were reported during blowing off of that discuss the occupation mechanics, unspecified. loose dust. Practically all measured levels Separately,, we . considered papas, .that do not I- published after 19$7 however, were less than 02 mention automobile.. mechanics but' from their ffcnL, end time-weighted average exposures during design, and.results we concluded that automobile passenger vehicle rtpair. in the 1980s were generally mechanics would have been included if the results less than 6.05 ffmL /I0-12/.. Nonetheless, the had beat positive. Therefore, we included all studies question remains, were these low levels of asbestos exposure associated with carcinogenic risk HI. in which specific occupations were considered. The review is limited to studies ofmen. HWBUI0011503 LUNG CANCER AND MESOTHELIOMA IN AUTO MECHANICS 41 Not all studies in this discussion controlled for among others) and their, statistical significance as cigarette smoking. Because smoking is. such a the authors did, including confidence intervals or p strong risk factor for lung ameer, however, and values, whichever are available. We made no there is evidence that smoking rates may vary by attempt to calculate additional estimates from the occupation, we have -placed.more emphasis on the information included lit the papers. The tables are studies that included smoking information in their . organized by.study design, and, for lung cancer, by analyses. Available occupational Survey data on whether the authors controlled for smoking in their smoking is limited, A survey in the U.S., however, analysis. ; . .. found that automobile mechanics ranked third in smokingprevalence out of61 oeaipatioite surveyed, with twice the- average cigarette consumption of -' i' LUNG GANGER many,ether similarly skilled. workers -Mi,: In.'The National Center for.Health .Statistics iOflO Nationsd . .Studies of Populations of Automobile and Bus Health Interview-Survey^ the.prewjdeifoe of current- Mechanics ; smoking among repairers . and mechanics whs 31.5%^. Biosobligations . -'.i.'.Veidentified -^fiVe i studiesthat.-..focused ; presented /1.4/f ;Alspi. somi evidrace;'iddiaii.es;-1 ' . fspec^call]f-.<MK^^^pl!lmi; -jf tiMtiu^jtjp,ai|d bus ; ,;of. ;1'' -Btebhanics' (Tabibri); JajVhoiso'ahd Brisnjan /17/ death;, such--as/' chronic- otetnictivcr; pdWicmfiy,. . ;and:Haaisen/IB/identified ;'antomp^i|e-mechanics '. -tiir6tigh.poptilart6n-certsik:dat8,-iiKS'5chwmtz7.19/ in' the .14. yeaii. 28^tate -Natioirial..'Occupatjotsal. .. ve?tiw#4<this^; .tnfonretti.on. .'front; flfoj. `usual. Mortality Surveillance" (NOMS) ^udy;-'sijythg ' Occupation* recorded!on death'certificates. Rusht6n 66,150 deaths among male automobile.raechunicsj- et aL /2()/ and Gustavsson 'et a), ill! .constructed the propottiohal mortality from COPD was thr cohorts' and determined exposure . from statistically significantly elevated; af iJ-5 /IS/. employee .work history records at bus garages In Studies' that do hot 'control' for smirking are . therefore - likely. - tp .-be -.-confounded ''-and ` to. London'arid Stockholm, respectively. In all but the Hansen study: the> cancer' risk, of'the `exposed- overestimateany association between, work as a vehicle mechanic find risk of lung-cancer. As an illustration, Caisfeosen and colleagues Mi found that aecountirigibr smoking eliminated an apparent excess lung' Cancer risk in. mechanics and' population (automobile mechanics) was compared with the risk .in. the.'general , population. Hansen .. instead constructed a comparison group of skilled ' Workers. tnciudihg 'c&ipenters, electricians, instm. 'merit iriakenv dairymen, 'ppholsteren, and glaziers. 'repairmen in Sweden..' ' -.. ' 1 .. This group was thought tobersimilar to-automobile. We discuss, separately studies of. lung,cancer . mechanics in terms of physical demands, life-style and mesothelioma. The details orr study design, Habits--including smoking, geographic distribution including study population, assessment of exposure and socioeeonornie status.. 1 / .. .. and .outcome, comparison population, and factors adjusted.for;.and the main results arc presented in With foe exception bfthe Jarvhohn and Busman study (SMR: 1.70, p <0.01) Mi, no significant the tables. We present the risk' estimates (standardized mortality ratios [SMR], standardized incidence ratios [SIR]', 'proportional mortality ratios [PMR], .-odds ratios [OR], relative -risk [RR], association of lung.cancer risk with occupation as an automobile' mechanic emerged, from .these studies. Gustavsson and colleagues HU calculated cumulative exposure to asbestos, as well as diesel HWBUI0011505 LUNG CANCER AND MESOTHELIOMA IN AUTO MECHANICS 43 exhaust, over a 25-year period, extrapolating from (SMR-1.10. 90%CI: 0.89-136). In contrast, and as work histories and a current industrial hygiene expected, risks were elevated for lung cancer in assessment. Hie authors observed a statistically occupations with known asbestos exposure, such nonsignificant elevation of lung cancer incidence as shipyard workers and plumbers. overall (SIR: 1.61; 95% Cl: 0.94-2.57), but no Caratemsen and colleagues /! 6f took advantage dose-response, association with asbestos exposure. of Sweden's extensive population records system Schwartz repotted .jjlPMR pf 1.12 (95% Cl: 0.82- to evaluate the incidence of lung cancer. The 133} and the SMRs.it?ported by Rushton etzLflQ/ . authors focused.on i.6 million men aged30 to-64 and Hansen !W were riot elevated. None of these Who Were employed-in 1960. The researchers five studies adjusted for smoking. : ' - .. -reviewed national;, canker registry`fife, for any occurrence* of lung cancer from 1961 through Survey and Cohort.Studies ofOccupation and 1979. - Occupation was .determined 'fiorit .'the i960' Cancer ' ' ; I..- . ' : census. CarstenseoV group;'did not attempt to .. evaluate, the smoking habits, 6f each worker, but These studies were undertaken to understand, they .did estimate the amount of smoking in each the jefation i^twimTAp^j^-oL^upaihnslmd '' occupational, group\ba;ed/ of),- surveys; apd-'nised the risk of lung canoer'i^,. .those,data to;adjust|fer smokarig. ipdirectly.; After ' gerieral in' a. defiHed.lpdpiiliiliori -(Kfiie Sj/'MpsC' --siicW.''3&0^trt^rat,\;i^te'V-Slit -for wiechasics: 'arid relied, on cancer registries .or death bejtificjfce^fpr- .. repaiitp^ri tafei^togejjigr.Ssas..l.07;(9^;-CI: 0.92- outcome:and wcposurc assessment, usually* defining", festfitute was ejtpnsiire as.;last Jotowri:-or usual;.'. oecupatioo... ; madefbr autofrtobrleroecharifes;alone.;..;. ;; Lung cancer rates amprig automobile' mechanics The remainder ofthe cohort studies relied' solely are comparedkdtfier to rates in the genera! popu on registries or death certificates for information on lation or to rates'in the entire cohort under study! occupation and disease surveillance in* a given Two. large, cohort - studies controlled for . geographic .area. Therefore; information on potential smoking. In the most comprehensive survey of confbuoders, including smoking, was* not available. cancer and occupation, Blair.and colleagues 122/ .The results, from therestudies'were mixed.'Enterline evaluated the' relation between occupation' and and McKiever HA!- observed ' a statistically specific .cancer sites, over a- i6-year period in significant association of work as an automobile 293,958 U.S. veterans 1221. Information on. usual ' mechanic with lung cancer mortality In the U.S. occupation. ;was. obtained, through two interviews ' administered near the beginning'of follow-up- in population in -1950' (SMR f 138).. MUbanv and colleagues F25f surveyed deafos .6a.'Washington 1954; and outcome information was'adjected from State, first in 1976,-With updates every 10 years death certificates' through 1970. The study was updated, through.-1980 by Hrubec f23f. At the interview, information on smoking habits was also ' thrbugh 199912l. In the 1999.publicatkm, the PMR for lung cancer deathsamong automobile mechanics was statistically significantly elevated at. 1,15. This obtainedL Risks for each occupation arid each ' cancer-site were calculated, within categories-, result is similar to the findings' 'reported in the NOMS -study,' described! above; which included defined by' smoking habiti No excess of lung cancer was found for automobile mechanics in the * residents'm 28 states.' Til the latter Study, the PMR was 1.16 for white and 1.08 for blade automobile original Blair report -(SMR,o1.03, p>0.05) or of mechanics /15/. Although the excess mortality for cancer of the respiratory system in the update each group was modest, the sample size was large HWBUI0011507 LUNG CANCER AND MESOTHELIOMA IN AUTO MECHANICS 45 HWBUI0011508 HWBUI0011509 LUNG CANCER AND MESOTHELIOMA IN AUTO MECHANICS <7 anti the PMRs were statistically significant In exposure are often identified as linked with lung another large study, in the Nordic countries, cancer risk, coupled with silence regarding Andersen and colleagues fill observed an elevated automobile mechanics, provides further, although SIR (1.2; 95% Cl: 1.2-1,4) for lung cancer among indirect, confirmatory- evidence against an mechanics and- iron and metal workers grouped association. together Hit. The resulte - for automobile mechanics were...not presented separately. The Case-Control Studies Leigh study, mentioned earlier, observed an SMR of 1J1 (95% Cl: ` LOlt-i254) in ie" California . We Categorized the case-control studies by Occupational Mortality Study. .The aptfidts,did not. V'.whetherthe study controlled for smoking; control 'for smoking, however, although lo die. the' source ofthe-control population, and same' publication they, discuss. the High - stodking whether .'theyspecifically include,information rates in this occupational group /13/J Menck and on automobile mechanics as opposed to a Hehdersoh 729/ stayeyed incidence-and mortality ' broadhr teihry dfmeichaiiics. .of hing cancer iHLpfc.Angeles Cosing and reported , a.stetistic^ly.sigoifi^ily:eleVated; SMR'Jor-liing' . Cpnti;bl-;:.foR'smoWng' ap<L;other: xisk-.factors;, is cancer in the- autohrobile repair .Inddstey.': The /authors. exmnSiedl ;a:^dte^RM^gB-j^:bOT|^Uon$;, closely, related to. the : selection, of the "control '? .'1 - f ? v. S. *-. %s * * population^ bao& .puliation arid hospital-abased .including .autonwbjle. 'meeijanJcsi irt.Ilstfeci* only ' ,, Studies ' ran ^obtain' 'jnfprmatlon ; oa' potential the occiipatiohs-'-with elevated' rates:' Xufcihobite ebnfcrirtderri^whereas desfthxcrtificat&'stodjcs are. mechanics urgra not included Hn that, 'KsL'yctcrsen; ; ;. '' not The.det^t'Ato;pr^OTted.m TabIe 3. -. ... :ind Mi[ham f29f ahiobcri.arid Jertseri tiphid, not ;2 ''Uie studies thatjrety ph controls selectel from observe a statistically significant - excess of Tung the .general -population and include complete job cancer among automobile mechanics in California and smoking histories collected by.interview are and Denmark, respectively. .. ' . . . . the most informative, lit -a U.S. study, in areas of For comparison,'We examined the.risks of lung cancer reported ToF: Other -occupations included in . New. 'Jersey-' with' high lung cancer rates, Schoetiberg arid <x>ileagues/36/-identified 763 lung these studies. Consistently, occupations with known cancer- cases from the state cancer.registry and 900 asbestos exposure, such as- pipe fitters;.-shipyard . population-based- controls;' The authors defined Workers, and steel, workers; had elevated risks of `automobile mechanics' as anyone working for at lung-cancer. '; . .. ' . least 3 months after age 12 In that profession. The -' Our search identified five additional survey/ cohort: studies that - defined exposure to the" smoking-adjusted OR was modestly elevated but not statistically-significant -(OR0 1,4; 95% Cf: occupational level but did not mention automobile mechanics /3 i+'SSL. FortKsse studies, we surmised from the level of . detail of the occupation and exposure assessment that `automobile mechanic' 0J4-2JO). Vineis 737/ and others incorporated these WithSimilar information from cancer registries arid- cooperating hospitals in Louisiana, Florida, Pennsylvania, and Virginia, but also found would have-been reported if an excess risk had . no statistically significant differences between the beat observed. Typically, such broad surveys case and control groups inpreyictus employment as examine dozens or even hundreds of categories, but only present tire positive or interesting" an automobile mechanic. Lerehen and eoworkers B& in New Mexico compared.333 men with.lung associations. That occupations with asbestos cancer to 499 men selected from the state's 41 F. LADEN, Mi. STAMPFER, AM. WALKER HWBUI0011511 M i i l(refute <Mi Sehoenbeigel 1987;other'itudlesdWnot nitfwourcut, sbpot induM MMdiiallif.' LONG CANCER AND MESOTHELIOMA IN AUTO MECHANICS 49 HWBUI0011512 JO F. LADEN, MX STAMPFER, AM. WALKER HWBUI0011513 * 0 C * M t i N t U s , ti'mnftv, O tM ik rtjto,*MQFf*9Ssnd&ajwvMy mfe^RfcnMw rf* booidi9$%Ciunlm'jMienKiNMesM . ; ' ........... LUNG CANCER AND MESOTHELIOMA IN AUTO MECHANICS 51 population. The authors found proportionately specsficaJly assessed automobile mechanics. None fewer automobile mechanics (identified as in the of the three studies found an excess of automobile Schoenberg study) 'among die cases than foe mechanics among the cases compared with the controls (OR = 0.9; 95% Cl: 3-1.9). A similarly controls /42-44I. designed study in Shanghai China did not mention, * We also identified six additional case-control automobile mechanics in their results /39/. studies using cancer controls that included results Next we - review case-control studies that for a more- genera! grouping of mechanics, compare, lung cancer cases to men with other kinds presumably, including . automobile mechanics. of cancer. This- approach' is.not 'aS reliable as Zahm ef al. ,-/45/ observed a modest excess of selecting -controls > ftoni the generalpopulation mechanics and., 'repairers ;.-among ` -lung'- cancer because foe-authors must assume thatautomobile controls'in MSsoiirifOR = I3;95% Cl: I.0-1.7). mechanics are at the same, risk-as. the"g6fieraJ. The.- other' five - studies 'found -fno -material population, for those other: .cancers used'.'for association .between work as'a mechanic.and lung comparison. As in'foe 'general population-''Studies, - cancer-risk/46r-50/. ' > ~ Work'.and. smoking-histories'were'cfotaftsed'by ^fldagtibs /^.cdfopared,' In three' death-certificate based case^centrol -studies;tire'.eolttfols rvrere fifoin 'ampfigilhe Itog CMcer'cases-wrifo odiet.cancers-its .foe Third- = niro-lung-<^cj rfoafosin.the-geowal population. `Nattc^sGBM&r$im^ po^td^pribKcf.tototos!tif 1 - T^^efstudses^tejiSj- onjks'C' Ihfonriaffos/ptovlded lifesiriie; .of %n>st.;recint Workgs.\*n - -automobile. . . <m :fo%;deafo- e^li^e.,to' deteuTOne I or. list meehaHC' was'tfoiitid. among 'cases-coiispami^ With-: . oedjfitttioif and -dld vhot "control'' for-'-stnoMiiigr controls' I4QL Buros'aod Swapson; /414'wpriqtijg.rn .; .Diibrowr-/ and .Wegmaa observed ` 2^%-' fSl'f find tffc Beiroii'Metrbpblhah. Area,- found ^statistically' Milne" and colltoiu'es- -20% -tnfnt aiitomobite' significant OR for 'automobile mechanics when mechanics752/ among their cases than among their comparing lung eaheer-'cases with colorectal etiheer controls. Neither resultwaS Statistically Significant: cases (OR =..1.72; 95% Cl: USt-239). This result more likely represents a-deficit- of automobile In a similarly, designed study by Finkelstein and colleagues /53/,^12% fewef-automobile mechanics mccbmics.8mong.:patients .with' colorectal cancer were found among' lung cancer deaths, than among than a direct link' with lung canCer. In a follow-up other deaths.' ' '. of this study, the; authors, evaluated foe risk of lung cancer* by number of years employed in specific bccupatidps separately for black fold white men. /-MESOTHELIOMA The authors -observed 'a significant excess - of automobile mechanics, who had been working for at least 20 years among black lung cancer oases Oue-CoRtrol/and.CobdrtSniiiies "' (OR --5.9; 95%l: 1.4-35.0) hut not among while cases (OR 13; 95%'Cl: 0.70-3.00)'. The number Exposure'to asbestos strongly.;a$s6ciateil with risk of malignant mesothelioma offoe pleural of black Cases' and controls was sinalf however., and risk did not. increase.linearly with increasing and peritoneal- lining.' A' baselihe incidtmce of the disease is not attributable .16 asbestos exposure, but years of employment in either white or black in the'majority ofcases some contact with asbestos subjects. Three case-control studies compared men hospitalized for lung cancer with men hospitalised can be documented /54/. Although only arophibote fibers;'as opposed to chrysotile (foe asbestos form for other causes, controlled for smoking, and used In fnctioh- products), have been consistently 52 E LADEN, MJ. STAMPFER. A.M. WALKER linked with .the disease /54/, the association of through work on brakes is unclear, larvhobn and mfesothelioma with work as a brake mechanic has Brlsman's study /I?/, cited earlier, extended been explored. We reviewed this literature, here Walker's work, focusing .more closely on auto (Table 4). mobile mechanics; among whom only one case of Severn] ofthe studies discussed above Included mesothelioma- was found. All. these studies mesothelioma as well as lung cancer. Four reported an increased representation of insulation mesothelioma-cases were reported in the cohort. . workers and otherjobs with overt asbestos exposure studies focusing on automobile and bus mechanics among the cases,. letMliog-furtiier. credibility Ip the (one each' by Jarvholra and Brisman till and by null findings for automobile mechanics. Hansen /US/and twOjry Gustnysson it al. #i/),,.ln Woitowits.and Rodetsperger performed a case-. all -cases'the authors ' mentioned possible other* control' study -of 324 cases, of mesothelioma in types.;of exposure to -.asbestos from previous Germany - and ..presented: the results ..relating to employment and concluded that no suggestion'of , . automobile mechanics in a..separate -publication ah increased risk of.-, mesothelioma, could be . 169L ...The ..-.authors identifiedKl 6-. -automobile . ascribed:, to work" as ' ah. - automobile * or 'bus mechanics among the. case-patients, and 16 among mechanic.; hfesothplloma :vm:feportdd'.ipj'date'pf 3l^'k^iMv0pttsls-` inrtwhom. bad.- lung thja.general canm.surveys. 0%nahd`Jensen./30/ - capper, and] j2;among- 1.83-ppputaiibh dontmLs..-The * staft^.-itet/sa were-'repottef : - cc^parisjpn -[ among' men.:.whp repmred.' -aikomobilsfc had bb'nttoh- -is twjMormatiye because hmg .cancer is 'niotorcyjdes:-jhr Nehmarieiv-piittf.ow.. gnd'^qgman' }' i-t^.^pdljaaad :;,tp >ttoriisstipiBtd-'.with --ibe' /55/ repofted.onrmesb^Itomabiut did/not*oteerye , ejt^aina. --Ntf-^pwdeiCft,.-<(f.;ttn. .-excess risk 'of - ahy. xaws-. ahtofig :-^utrinobHe'-rhechanics'. -.:The\' :. mesothe!ioma'[Was found wraiftoii^iSe'rriedianics' NOMS. study reported .11 ijnesothehomas,among. using- tile, population controlsi-The authors,-prelude white automobile mechanics (PMR A 0.77) and 2 individual desorptions of duration ofemployment, among black mechanics (PMR " 1-54) f\SL The history, .of brake .. service,, -and other -asbestos- Blair study : of- cancer mortality among lj.S. exposure'for each automobile mechanic, Alt work veterans :did not mention mesothelioma 122/, - stud histories were very, .similar.:., regardless, of -their the follow-up study by Htubec et al. /23/.gifouped all respiratory cancers together. disease status.- Bocause- no comparison statistics, including ORs, were calculated, and the nature of We identified 11 studies' that focused on tills study, was. primarily descriptive, it may be mesothelioma and. occupation- 756-67/. None of more appropriate to consider this investigation a these studies reported a significant association case series as opposed .to a formal case-control between mesothelioma and work specifically as an automobile mechanic.-.Malker and colleagues /6S/ study. - :i- .... In 2001, Wong 1701 published a met* analysis observed a statistirartly .significant. elevated combining - .the results - from vSt* studies that incidence of roesothelioma. among the .bread category of mechanics, and repairmen (not limited to automobile mechanics). This finding, however,, assessed . mesothelioma . among . automobile mechanic*--McDonald'arid .McDonald; 1980 /57/, Tetaetai., 1983 /58/,Spitta$ et al, 1985 /60/, 1994 was based on only 16 cases dispersed across a variety of industries, Including railroad equipment manufacture, sugar factories, and shipbuilding, so whether the cases were exposed to asbestos /61/, ; Woitowitz and Rodelsperger,- 1994 /69/, Teschkeet al, 1997 (63) and Agudo et al, .2000 /65/. Wong calculated the RRs for the individual studies from the available data when they were not HWBUI0011515 HWBUI0011516 HWBUI0011517 "i v 7^V^.T7*. HWBUI0011518 36 F. LADEN, MJ. STAMPFER, AM. WALKER presented. All of these studies separately were null employment as an automobile mechanic H6f. In an and the combined relative risk was 0.90 (95% Cl: - additional study, 13 cases of mesothelioma were 0.66-1.23). reported over a S^year period among members of Case Series and Case Reports the Interna:tiona.l-yA,,s sociation of Machinists and Aerospace Workers: One case had'been employed . as an automobile mechanic /77/. Because. mesothelioma' is tare--The SinVeil- We'also .identified: two studies where lunglance. Epidemiology, and Risk Program (SEER) ' fiber. analyses;were .performw) on se.ri.es of mes~ reports ah age-^adju&ed'incidence rate of2.1 cases - ' thetiortta cases.' identified, by occupation.' Roggli per 100,000; 'njafaj,,/7T/4-Adtagn6ses- are'-jriftcn. described in case senes' or-cisc.reports. Such.sttidies ' and colleagues. tfS/repctrted asbestos body counts `anil levels 'offrainraerclal-aod' noncommercial provide little ureful.information',in assessing'n$k : .jmyBhiboits.fibm..(C ferm ojf .asbestos consistently because the lack' of a comparison group precludes associated'with; mesothelioma);among 1445 cases, any 'qiimtitSiy.e' estimate.' Because of the' rarit^'pf -'Jndudmg. 51 .witSsSrpi!. work'as ancaptompbile the disease, .however, exposure' histories do provide 'mechanic, 'brakerri^ii' worker, ?-ibrake-line impoflknt' iflslgjjfs soutt&; ;.--' \V'-: u%k:the^ulte.Othe fibef..burdenj:anaiysis.ied . expoafre.' ^aefo^fpr f^pleterressi we'-ktltide th"^-s|udiM Jy- 'ify-'X'; ' i. '.-liehitibriyytolbe-^^ tfm'MiWeldehTifit^ sixstiidies in whidi '' .'' ':'Bf^e5'^c^iys&tiie-!ti}^).:Tl.lsaTO'jr^bch'ere silt mesbthefitima cases'jft ^population diagnosed; y also ptibllsKet}-^focusing'Oh l&ic&es-bf .dynfj&.'ft specific tTm<? peritii.were sss|etiJ0r'.f.^^fne^otheKmiM. fpf:whibh,brajie dusi.'VrasMteonly thieir potential' exposure- ti:;iSbesto$ mclh'ding, : f . ^o.wn'sdorwbf'^liestps' exposure I79f: (Whetlidr employment as. -art' automobile - mechanic. In ;a - ' -wereinducediifthe-20Q2:SNidy.isnot series of 41 male patients diagnosed at the London Hospital. from 1915. to 1965, one case, reported ; clear.) Again the lung fiber.analysis suggested that workaptomoblje.mechanic Is;unlikely to exposure to crocidolrte .'asbestos' through -the contribute to the development ofmesothelioma. manufacture of Brake lipings'jra/. One'case oirTof 413 identified by the 'Mesothelioma Register, in .-.-Case:reports'. Three reports :of'individual : mesothelioma cases -potentially associated with Great Britain jibm 1967. to 1968 was employed'as '-'exposure to asbestp's-tiirough -brake-repair work an automobile mechanic. Ship workers (n'=75), .. were published in the 1980s. Two were automobile -asbestos; &Ctory'workers ( 39), and insulation' "mec'!anI'-'*bo:'.ekperiencl."no other recorded workers' (n13) Wei*'*; the most represented . . potential exposure .torirsbestes /80-8JI, The other occupations. fJV._ Sevmty Coses, pf^mesothelioma. /. case'was tin elevator-fnechaiiic'who 'worked with were observed.ia die region ,oNahtes^St.Naaaiiie,. , elevator brake-pads /ZV.lh'i letter ip response to France .between,! I95(K4nd' I%78 ''Four/were ' ' tilii report, Kilpatrick 7837 argutidk that elevator employed . .ps mechanics. .Id .-the: Australian. - mechanics often work iabujidings thatare under- Mrapthdioma: Surveillance Program,.. 1 980^1985,; ' ' going renovations and construction.. Thus, primary 871' confirmed cases' were Identified. Of these- .exposure " might Have been to amphibble- from cases, eight. were employed as automobile - asbestos fire retardants sprayed into the building mechanics f75A . In -a series of 148' cases' of by Other workmen;: as' opposed to chrysqtile mesothelioma: identified among peasants residing asbestos in brake pads. Without a quantitative in rural parts of Turkey, one patient reported comparison, (he case.reports are merely anecdotal. LUNG CANCER AND MESOTHELIOMA IN AUTO MECHANICS S7 DISCUSSION AND CONCLUSIONS In this paper, we have reviewed the analytical studies of risks of lung cancer or mesothelioma among automobile.mechanics, plus all available case series, and case reports. These studies represent .thousands of cases of disease and hundreds .of thousands of individuals who were followed. 'When 'examined in' aggregate, the consistent patterjn that emerges from this research indicates noiricreasein risk of cither .lung, cancer or mesotheliomg ip this occupational group... .: Many .studies - have-.important limitations, principally..in' etqrosum.ass^Sttient- In most . instances.In many studies, men were grouped into '.occupation'd$$4'rqjok^' of usuaf.or test .prouparipn^ on' .death' '^certtficaies, .. medical repoidsi.orjKe nsus, jOtha-#udies secluded scrrrt assessment. of .lifetime work; fustoryv/but .often- it :was 'h6t::-detailed;-v (^.cors^iiehce-.'Df/sach inadequ&eexposure assessment is. tfaftbdufatioii ofe^pOsihO Vriih largely fgnbreri; en Who Worked an eopre lifetime as an autpmohile mechanic might be grouped together with those who had worked in this occupation for only a short time* Furthermore, some Witomobi le mechanics Who were employed in-the pis* might hot have been identified because at - tfe time of reporting they were' working in anpther .occupation. :Enrrployment tis'an `automobile mechanic'' also does not-, necessarily, capture otposurc lo.brakes or clutch repair.work..Few of the-studies actually included an assessment of exposure to friction products. The- length of time spent repairing brakes, the actual activities, the condition of the brakes, and the implementation of safety measures all might influence a person's exposure. Grouping together Workers with such different experiences leads to a misclassiftcation of exposure, which may tend to attenuate relative risk estimates. -' - ' Another potential''source ofmisclassificaiion of exposure is the long latency of (ling cancer and mesothelioma. It is estimated that it takes at least 10 to 20 years after Cist exposure to s carcinogen for these diseases to develop. When duration and timing ofemployment is not considered, essentially unexposed people are included within the exposed group, possibly leading to biased relative risks. The few studies that considered this latency, however, did not find Increased risks. . . ' Potential eoijfoundihg fectofs are inadequately evaluated .inlhe-majority of the;$tiidics.Cigareite smoking, the key .risk factor for lung carreer, was seldom .. assessed. ' Several studies indicate thigt smoking among- brake mechanics was - more Conuntih "tihan jin\- thf comparisongroup, which ttonld"yield' dtrierved" relative frisks" thsto-are repbfieil reiktivc ` risks , ri.rar. the.riufl' value, thrise^.fhat adjtKtti'fbr^^mgfisrKiiid.fe'.yfcid -relatiVe-risks closer'-...to. :1.0,. . as-.one., might;,expect-'.from confounding- try - smoMh^ '"addition, ' -some automobile mechanics may haVe be^employed, in other occupations of'mvolved' in ether' activities with . overt exposures to . asbestos, potentially leading to an over-estiririated relative risk. .. All dhese limitations also apply to. evaluations, in many ofthese same studies, of other occupations with 'known'overt exposures'to asbestos such as pipefitters; construction' workers, and insulation workers.' The ' expected elevated reiqfive '"risks, however, were indeed observed tor- these other workers, .impiyihg.fliat-if.an .excess,mk of lung cancer or mesothelioma- had been present among automobile' mechanics, these' studies-would have been able to defect it Furthermore, the exposure to asbestos, in a form likely to.be .'carcinogenic, was foundto be quite small m iridustrialjiygierre surveys of brake repair, work* /10/. in addition, studies of workers in factories .that;manufacture asbestos* containing'brakes do' not appear to be at higher risk for such cancers /II; 84-88/. Thus, these observations, along with the weight of the evidence from the studies described here, supports the HWBUI0011520 ss F. 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