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Letters to the Editor S-r\Tir<gi_ 'bte-KGS PLAINTIFF'SignrTPiT DOW-1833 STO130160 Identification of Occupational Setting* With Very High Risks of Lung Cancer 0) :L jot: We would like to comment on your editorial in 30 die April 1979 issue of JNC1 entitled, "The Case for Cancer Prevention." in which you state: "There seem 0 be no immediate opportunities for large-scale cancer prevention strategies that are not already well known... We suggest that probably some worth id while ideas for strategies have been thought of by ai people who would be happy to air them if a suitable a place to do so were available. )- For example, at this institute we have been interested ae in the temporal aspects of tumor induction by carcino ts gens for many years.1* In the course of an epidemio logic study on lung cancer in workers exposed to the ie sety potent carcinogen bisfchloromethyl) ether (BCME), of we were struck by the youth of some of the workers m with lung cancer at one plant where 4 of the 23 patients were less than 40 years of age.2 *The chance of finding lung cancer in such young men is very low; .g.. in New York State only 0.6% of lung cancers occur in men between the ages of 35 and 40 years.2 The induction of lung cancer at an early age is consistent with considerable evidence in humans and other ani mals that the higher the level of exposure to a carcino gen. the sooner the cancer cases are observed to ap pear.1 The type of cancers that these workers exposed to BCME developed was also striking. All of the patients, including those under 40 years of age, developed either squamous carcinoma of the bronchus or small-cell undifferentiated carcinoma of the bronchus. According to Kreyberg,2 only a minority (*-20%) of lung cancers , that occur in persons under 40 years of age are of the aforementioned types. Chemical and physical agents that cause lung cancer in humans, e.g,, cigarette smoke,2 radon daughters in uranium mines,* and BCME,* commonly produce squamous or small-cell undifferentiated carcinoma. Hence the occurrence of squamous carcinoma or small-cell undifferentiated bronchial carcinoma in persons under 40 years of age strongly suggests that they had intense exposure to a powerful carcinogen. Even with cigarette smoking, the occurrence of lung cancer in young people is not common. In British physicians taken as a group, who probably did not have high-level exposure to carcino genic inhalants other than cigarette smoke, no patients under the age of 40 were found in a toul of 201 lung cancer cases? We recently learned of a second example of lung cancers in young chemical workers in a German plant where intense inhalation exposure to the carcinogen vinylidene chloride was associated with 5 lung cancer cases, 2 of which occurred in workers under 40 years of age (Frentzel-Beyme R: Personal communication). The only situation in which sus tained high-level inhalation exposure to respiratory carcinogens other than cigarette smoke is likely to occur is in occupational environments that are poorly controlled from the standpoint of industrial hygiene. All of the previously mentioned instances suggest that we may have the ingredients for an efficient "alert" system for identification of situations with high-level carcinogen exposure to men (because of the relevance to the chemical industry) who are under 40 years old and who develop squamous or small-cell undifferentiated lung cancer. This alert system would be particularly effective if it focused primarily, but not exclusively, on cases that occur in nonsmokers; of the 4 lung cancer cases in young workers exposed to BCME, 2 involved nonsmokers.4 Such an alert system for the detecrion of high-level occupational respiratory carcinogen exposures would require a method for screening of very large popula tions because of the rarity of the cases of interest. This | 1 Albert RE. Altshuler B: Considerations relating to the (ormuj boon of limits for unavoidable population exposures ro environ> aenul carcinogens. In Radionuclide Carcinogenesis (Sanders CL. screening could be done through the use of cancer registries. For example, the New York, New Jersey, and Connecticut cancer registries contain about 10,000 cases . Susch RH. Ballou JE. et al. edt). AEC Symposium Series, GONF^9505. Springfield. Va.: Nail Tech Information Sen-, 1975. pp . 1 Pasternacs BS. Shore RE. Albert RE: Occupational exposure a chlororaethyl ethers: A retrospective cohort mortality study (1948!972l J Occup Med 19:741-746. 1977 i 1 Bureau of Cancer Control: Cancer incidence and mortality in . Sew- York Sute (exclusive of New York City). Albany. N.Y.: New ` Vork Sute Dept Health. 1976 i ` Figueroa WC. Raszxowski R. Weiss W: Lung cancer in ehloroi ethyl methyl ether workers. N Engl J Med 288:1096-1097, 1973 I ' Kreyrerc L: Histological lung cancer types. A morphological of lung cancer in men each year. If we assume that 0.6% are under 40 years of age, this percentage would amount to 60 cases. This is a small number, but the small number would be an advantage because relatively little effort would be required to investigate them, and most likely the detection of occupational settings with exceedingly dangerous levels of carcinogen exposure could be accomplished. If only a few of these settings could be identified each year, the return in public health benefits would be great for a modest amount of effort. *"d biological correlation. Acu Pathol Microbiol Scand (suppl) { fc*:l-92. 1962 \ * Saccomakno C. Archer VE. Auerrach O, et al: Histologic Tprs of lung cancer among uranium miners. Cancer 27:515-323. l'*' 2 Doll R. Petd R_- Cigarette smoking and bronchia] carcinoma: Dose and time relationships among regular smokers and lifelong non-smokers. J Epidemiol Community Health 32:303-313. 1976 t 1289 JNCl. VOL 6S. NO. 6. DECEMBER 1979 1290 Lotion to tho Editor By this example, we suggest that people might devise ail sons of cancer prevention strategies if they were encouraged to think about cancer prevention and if a suitable publication were available for discussion ofprevenuon strategies. Roy E. Alrert, M.D. Bernard S. Pasternack, Ph.D. Roy E. Shore, Ph.D. Norton Nelson, Ph.D. New York University Institute of Environmental Medicine 550 First Avenue New York, New York 10016 tstiu::1. i.fc-'i. ' Sir: In just a few paragraphs, Albert et al. raise four important issues. First, and most limited, is the signify cance of the specific example they cite. Their evidence is striking and should lead promptly to further study and, one may presume, to control of another occupa fion-retatdd 'tisF.'`Sedond, they express the need for an "alert" system for detection of large proportionate in. creases in rare tumors. One can only agree, though problems would be formidable. Such mechanisms have been discussed for several'decades at least, without the development of a comprehensive workable system. The third issue' may be the interpretation of my statement about "large-scale cancer prevention strat. egies." That statement still seems accurate, although I did not mean to imply that we should ignore ntienerically limited risks. Every carcinogenic hazard should be fully investigated and attacked, regardless of how few persons may be exposed. However, we must not let such work distract us from the greater problems that may cause far more illness and mortality. Last is' the question of publication of worthwhile ideas on strategies for the prevention of cancer. Outlets do exist. The Journal of the National Cancer Institute is one of them, and we encourage the submission of soundly based, carefully reasoned, adequately docu mented discussions on all aspects of the control of cancer. John C Bailar III, M.D., Ph.D. Journal of the National Cancer Institute National Cancer Institute Bethesda, Maryland 20205 OO -H O CO o <T\ JNQ. VOL. SI. NO. . DECEMBER 1979