Document yjvBvOX6OVO9JD878QVo9o93
FILE NAME: Kent (KNT)
DATE: 1955
DOC#: KNT138
DOCUMENT DESCRIPTION: Book Excerpt - Diseases of the Chest Industrial Aspects of Bronchiogenic Neoplasms -Asbestos Workers Pg. 424
In d u s tria l A sp e c ts o f Ilronchio.uenic N e o p la sm s
hK ST K U ISKKSl.tiW . M.H.
llerkclcy, California
Medical students usually learn as tin- classical example of occupational cancer that scrotal cancer occurred intmi).' chimney sweeps`in 18th century England.1 Their attention would perhaps more readily he attracted to the story of lung cancer among miners in the Schiiccborg- and Joachimsthal mines.'1 The fact that approximately half of all deaths among miners in the latter area resulted 1'rum lung cancer establishes the occupational origin of this disease, in at least some cases. Furthermore, the striking increase in frequency of lung cancer and the millions of persons employed in the several 2Uth century occupations now suspected of having a relation ship to the disease confirm the importance of this subject today.
Lung cancer now causes more than 18,000 deaths annually in the United States.1 Even adjusting for the aging of our population, this represents a four-fold increase during the past two decades.'1 Diagnostic techniques have improved tremendously. Dut the fact that lung cancer mortality among males has been rising much more rapidly than among females in dicates that we are dealing with a real increase in the disease. Jt now accounts for more deaths than tuberculosis in many states.
llecently attention has focused oil cigarette smoking as a cause of lung cancer. Several studies1, based upon interviews with a series of lung cancer patients and a matched group of ``controls" have demonstrated a greater frequency of cigarette smoking, especially heavy cigarette smok ing, among the lung cancer jiatiepts;
As a further investigation of this question7 we obtained cigarette smok ing histories from 518 lung cancer patients and a like number of matched "controls" in 11 California hospitals. The control group consisted of pa tients admitted to the same hospitals for conditions other than cancer and other than chest disease--matched for age, sex and race with the lung cancer patients, 'fables 1 and 11 indicatc the similarity of our two groups in respect to biological characteristics. The greater frequency of cigarette smoking, especially in excessive amounts, among lung cancer patients as compared with controls is shown in Table 111.. In Table IV one may observe that several other measures of the degree of cigarette smoking--age at which began, inhaling, and smoking before breakfast--all confirm that lung cancer patients smoked cigarettes to a greater extent than did the control group. Of particular interest to physicians is that so-called "ciga rette cough" occurred among approximately two-fifth of the lung cancer patients; this usually antedated the onset of illness by many years. One
Chief, B ureau of Chronic D iseases, C a lifo rn ia S ta le D epartm ent of Public H ea lth , Berkeley, C alifornia. T his paper is based on a study supported l>v a re.-eau-h g r a n t, (CS-1UU7) from the X alhm nl C ancer In stitu te , Public H ealth Service, lb S. D e partment of H ealth, Kducation and W elfare. Presented at the JUtli A nnual M eeting. A m erican College of ( 'lx--1 P hysicians, San Francisco, C alifornia, Ju n e Hi, 105-1.
121
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t
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i ra I fifti -
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LKSTKK HKF-RI-OW
i?:.i
hundred twcnlv of the patients staled that they had noted cough for '
five years or more whereas only 3d of the control group gave a similar
history.
j
These data, consistent with the other recent well-controlled investiga
tions" of the subject, demonstrate a substantial correlation of cigarette
smoking and lung cancer. This correlation increases steadily with the
amount of cigarett e snioki ng. Levi lCHas most recent ly'assembled the find-
ings of these several studies and. using a method developed by Cornfield.*
compared the relative prevalence of lung cancer among cigarette smokers
and non-smokers. Table V indicates that, for men aged 50-50 years lung
cancer is four to 1] times as prevalent among smokers as among non- j
smokers, and seven to 27 times as common among heavy smokers as among
non-smokers.
One must accept the conclusion of the New England Journal of Medi
cine10 that the evidence-for cigarette smoking as a factor in lung cancer is
"so strong as to be considered proof within the every day meaning of the
word."
TABLE I A(JE DISTRIBUTION OF LUNO CANTER
PATIENTS AN il CONTROLS
Ajfr Total U nder 40 40-40
pnrrin*nti> 4* -n <1
CASKS O i l i e r Tyjn-s
of
472 >>
51
Total SIS
25 62
50-5!)
in
1!)4
2in
GO-6!)
14
154
16S
70 and over
4
46
50
!
.TA B LE 11 S E X AND RA CE m S T R II'.CTIO X OF LUNO CANOE! : PATIENTS AND CONTROLS
CASKS
S o x nn<t K nee
A tlen o * rn rritio m n
l )th-r Tytn nf Crircmimia
Tntiil
Total
4G
172
51S
T otal Male
- 42
451
4 IK!
W hite
41
420
461
Negro
20
20
O ther
1
11
32
Total l-'vniale
4
21
25
W hite
a
Negro
i
~ Other
15
1S
n
4
t *
.7
CONTROLS T..lnl SIR 26 5! ;217 16ft 51 '
CUNTHOI.S T..UI 51R 407 461 20 12 25 18 4 7
*'.'i f . - T
- I
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VU. XXY1I1
BRONCHIOGENJC NEOPLASMS
T A B L E 111
A M O UN T OK C IG A R E T T E SMOKING D URING T W E N T Y V E A L S 1'LIOK TO STUDY R E P O R T E D BY LUNG C A N C E L P A T IE N T S AND CONTROLS
TASKS
ruNTuoi.s
l*arktfn **f Cigurvili-b Smokiti lVr Liny KuiiiUt
Total
51
IVr Cent loo
Number 518
IVr *Vil inn
None
34
7
124
24
nr
4
50
HI
71
14
105
20
1--
:it)4
...
2 or more
80
Not recorded
10
551
15151
as
15
*}
4
2
18
3
T A B L E IV <
l AGE OF BEG INN IN G CIG A RETTE SMOKING,
rL-
SMOKING HABITS AND "C IG A RETTE COUGH"
R E P O R T E D BY LUNG C A N C E R P A T IE N T S AND CONTROLS
>
CASKS
CONTmil-X
Cigarette SimikiiiK Chamctertaiies
Number
lVr ('nil HukM uii Cigarette Smokers
Only
lVr Cent Has'! PI! Total
Number
IV Tent on
ricairtu* Smoker
Only
1Vr Cent Hasol nit Total
Total
518
100
518
100
Total cigarette smokers
484
100
Began 15 y ears of age
100
34
03
304
100
70
32
11
251
>
Began 15-24
28G
55
55
243
G2
47
Began 25 years of age
32
7
G
35
0
7
"Inhale"
440
03
87
327
83
G3
"Smoke before b re a k fa st"
373
77
72
220
58
44
V
"Cigarette cough"
204
42
30
112 ' 28
>>
f\ However it is not the sole cause. Some persons with lungcancer deny [; ever having smoked cigarettes. Levin11 estimates on the. basis of our data
I that 70 per cent of all lung cancer may be "attributable to smoking."
i Application of the same method of estimation to other data gives a range
\ of 56 to 92 per cent "attributable to smoking."
i.
In the present and justified concern about cigarette smoking as a cause
of lung cancer too little note has been taken of evidence that several occu
pations may likewise be involved in the etiology of the disease. Unlike
the infectious diseases where specific micro-organisms have been identified
as the cause, sine <jua non, cancer appears to result from a variety of
exogenous agents. The classical studies of the Schneeberg and Joaehimsthal miners do not
stand alone. Machle and Gregorious1- found that those employed in cer-
b s:.
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rmpm
1 * .' "'t
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r . i; I
f-
V
. - 1i
I
i iI
;k i i
b?
i
I
,1
t
\ F- {
424
LKSTKK BKKSLOW
()ft.vr. 1 t
lrr *.
tain chromate ore operation.- in the United Stales experienced a ]G tinvj
greater mortality for lung cancer Ilian (lift the general population of t 'j
same age-sex distribution. Kennaway and K ennaw ay'' using death n j '
tificate data for England and Wales noted that metal grinders, work-'
exposed to road dust, coal gas and tar, asbestos -workers, cabinet make
and painters were reported as occupations more frequently among hn
cancel* paljents than would be expected from the general mortality c
.... ..........
'
:
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TABLE V
j 11
E S T IM A T E D P R E V A L E N C E K A T E S ' O F I.PN(> C A N C E R PEP. loo.oud MALI: ' OK SELEC TED AGES AND VARIOUS C IG A R ETTE SMOKING H ISTO RIES. -
M'MUF.H
KSTIMATKD I'lSKVAI.KNCK KATKS. QUANTITY
i ' tIF.I.ATIVV : ;
SMOKK1) DAll.Y-
PHKVALKM , : ;
titine
All
qu-.i
(*crr rttnlrnl llvjivy*
Ntuip Hiavy Mii;
P a tie n ts aged 50 to 50 years
Doll and 1H11IV yiulerand Graham*
270
275
-i
42
7
in
h
25
21
117
47
4
27
n;
Sadowsky, Gilliam: ^nd Cornfield7
ioa
20
87
44
12
i
4
Breslow, lloaglin,
R asm ussen, an d Ain m ils' 21"
2 in
102
40
0
17
7
Roswell Park Memorial Institute
17::
057
Ml
1 (11
35
!
I
P a tie n ts aged 00 and 00 years
t
Doll and H ill'
107
1
M7
on
tt
AVymler and G raham
1X7
i f.o
ms
70
5
20
ir
Sadowsky. Gilliam, anil Cornfield'
7;
71
44
71
5
:
4
. Breslow. Hoaglin.
i
R asm ussen, and Abrams Iox
10
4n:s
78
17
25
s
Roswell P ark Memorial Institute
107
075
470
280
50
i !l
c '1
E stim ated aecording to Ihe method of Cornfield.*
j
'All d a ta ap p e arin g in this tattle, except for Roswell P a rk M em orial In stitu te figures
a rc taken from the paper hv P.reslow et nl.r
!
(Juantity smoked daily, except fo r (lie present stu d y , is all fo rm s of sm oking ex
pressed as eig aretles with pipes and eig ars converted to th e ir equivalents in ciga
rettes as follows:
!
Doll and Hill-- 1 ounce tobacco j cigarettes a day.
j
AVyndcr and G raham -- 1 cig ar ^ 5 e ig a re tle s; 1 pipeful -- 2 '.. cig arettes.
Sadow sky. Gilliam, and Cornfield-- 1 cig ar = 10 c ig a re tte s; 1 ounce pipe tnbaccf -- 20 cigarettes.
F or the Breslow et al. study quantity smoked daily includes only cig arette smoking
'Relative prevalence arc the following ratios; heavy rate am ong heavy smokers, rate am ong non-sm okers; all q u an tities =: ra le am ong sm o k e rs /ra te am ong non smokers.
`H eavy sm oking is defined as the following n um ber of c ig a re tte s or equivalents ol c ig arettes p er d ay ; Doll and Hill, ho or m ore; M 'ynder an d G raham , 05 or more Sadow sky, G illiam , ami Cornfield. -II or m ore; Breslow et al., -10 or m o re; presen study; 20 or more.
S ource: Ix'vin. M. L. Etiology i,f Lung C ancer; P resen t S tatu . New York S tate .1 Med., 54:G, p. 770, M ar. 15, 1051.
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va xxviii
HRONCHKiOEXIC NF.OPI.ASMS
425
pcrieme. Information obluined by interview with hospitalized patients in St. Louis and elsewhere in the United States, studied by Wynder and Graham." diselosed that painters and " hot metal workers" stood out as excessive amnu^r Inntr cancer patients as compared with a control jjTonp. Mortality experience amone industrial policy holders in the Metropolitan Life Insurance ( Yunpauy indicated.' accordiiijr tii 'Lew,17, several occupa tions with a higher than average rale from cancer of the lunjr; Table VI
TA B LE VI
" MORTALITY EX PER IEN C E AMONO W H ITE MALE WACE. EA RN ERS INSURED fX liE R IN D U STR IA I. PO LIC IES IN THE M ETROPOLITAN L IF E
INSURANCE COMPANY 1 1 : OCCUPATIONS WITH PROBABLY HKIHER-TH AN-A VKRAUE DEATH RA TES FROM CANCER OF T H E I.UNOS"'
Ocru|i<diemil tiroui
that.* Kroin All
Da-lath* Knimi All Formi of l*an'*T
Donili* From Caiui r a*f I.uiur.
Numticr
IVrcrntaire lU'lativ* ( Driithv From All CnitMr*
IVrrrHWitit* Ikt ltiliM' I*
Froti* AIJ Korin* of Camvr
All W aee E arn ers
i I2,:r.u
Blacksmiths
503
. Brick and Slr.ne Masons''
722
Cooks-- Hotel
and R e sta u ra n t''
345
Coppersmiths, Tinsmiths,
E tc.v-- Nut Roofer-
4U2
Engravers (Metal)
anil Photoenaravei s
81
l.aundry W orkers (Except I.almrers)
Mail C arriers
242
Miners ( Umlei ^l oiind, excludin'; Coal Miners) 222
Rain let's and V arnishersHuuse, Shop, etc.
2,821
Plasterers
P.IO
Plumbers, Steam litters, and O asfillcrs '
1,178
Hoofers ami Slaters'
225
Slaughter and Packing-
House Operatives
27U
Street Cleaners
Tannery Operatives
227
Tailors anil Other Clothing Workers
1,504
Traveling Salesman
274
W elders-
21 r,
1:1,858
1,082
1.5
75 <
11
2.2
124
18
2.5
48
8
2.3
01
1)
2.2
15
5
0.0
27
5
2.3
41
7
2.1)
20
C
2.7
:;i;o
G2
2.2
21
5
2.G
150
2!)
2.5
21
5
* >
41
7
2.5
(4
!)
2.7
22
5
2.2
228
27
2.4
40
10
2.7
24
*4
3.2
12.1 14.7 14.5
10.7
14.8
33.3
18.5 17.1
30.0
1G.U 10.1
18.G 10.1
17.1 14.1 15.2
10.2 21.7 2D.2
Mn these occupations the m o rtality from all forms of cancer was som ew hat higher than a v e ra g e as follows: HricU anil Slone Masons, 1 5 5 'I of a v e ra g e ; Cooks-- Hotel' anil R e s t a u r a n t , l l ! 1'! o f a v e ra - ie ; Cu|i|icrsinitlis, T in sm ith s, etc.-- .Not Hoofers, 12371 of a v e r a g e ; l'lum liers, S te a m F i l t e r s , am i (bis F i t t e r s , 1'10','L of a v e r a g e ; Roofers an d S laters, 11275 of a v e r a g e ; W elders, 12lP.i of a v erag e.
`Lew, E. A., U se of Life I n s u r a n c e C o m p a n y Records, fo r C a n c e r S tu d ie s. A rc h , of lnd. Ily y . an d Occup. Med., 5:1'J'J-2U3, M ar., l `J52.
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TAU LE VII
('A S K ? A N I > CO N TRO LS EM PLO Y E D I-'OU A T L E A S T -- 15-YEAUS-IN -S E L E C T E D O C C U PA TIO N C KOU I'S ` --
Orrtipiiiion
1 Weldors and sheet nielal workers lining welilinjr 2 Steamfiltcrs, hoilerninkers, asbestos workers
PKKSONS KMri.OVF.H In o c c u p a t io n at i.kast
. S VKAHS
C*** Contr**!* --
I
14
2
t ; t,
t ;
10
1
i f
.1 E lectric bridge cran e o p era to rs-- m etal in d u stry
5
1
4 Occupations in the extraction of lead, zinc, anil copper ore
!
i :
5 M arine engineers, firemen, oilers and wipers
12
r.
6 Construction and m aintenance painters 7 Cooks, commercial (excluding cannery cooks)
22
12
115
21
Occupation groups based on regrouping according to common occupational exposures a fte r dctiiled examination of records.
shows these occupations. Hueperln mentions several exposures suspected
of being involved in lung cancer.
!
Interviews with lung cancer patients and a control series in our study7
included life-long occupational histories taken by persons skilled in occupa
tional analysis. Information about every occupation in which the person
had engaged was so detailed that the session often lasted two hours or
more. It covered an exact description of the work, the industry, the dura
tion of employment, known exposures to toxic materials, and other factors.
Interviewer bias as to the occupational data can be practically ruled out ; .
inasmuch as both lung cancer patients and the controls mentioned hundreds j
J of occupations, none of which was suspected by the interviewers.
` j
Although the information included type of industry and exposure to
known toxic agents, efforts to analyze these were not productive. There- ;
fore major emphasis in the analysis went to occupation itself, coded ac- :
cording to the United Slates Dictionary of Occupational Titles (Second
Edition) Washington. 1). U. S. Employment Service. 1040. This lists j :
"G7 categories.
! |
Table VII presents a list of apparently significant occupations based `
upon our study. This tabulation was developed by first observing the rela
tive frequency of occupations in which individuals of the case and control
series had spent at least five years. This gave leads for further study.
Thereafter, since the code used was not designed to reflect common occu
pational exposures, analysis was carried to the examination of records of
individual cases and controls. Regrouping of occupations based upon
common exposures resulted in Table VII. It. appears th at exposure to 1
metallic particles or fumes, asbestos, paint and other materials appear '
to play some role. Similarity of this list to other studies, particularly that
of Lew'*1 is immediately apparent.
h
Comparability of the findings in four studies is shown in Table VIII.
These separate investigations, extending over a 20-vear period and two : -
t.
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r' "..'T-. i t --v-i-rw'VS'>V*_'ir' ^';.. *tV."V>i;ei#'/ * -,' *->^v: He.'.
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HKONCllitlGKNlC NEOPLASMS
-127
countries, utilized general niurtality statistics, lift* insurance statistics and
interviews with hospitalized patients. The fact that such varied data,
analyzed in different ways, consistently identify certain occupations attests
their probable significance in the development of Iuiik cancer. Uesides the
occupations listed repeatedly in Table V III--painting, welding and other
metal work, steam fitting,and. other-asbestos-work--additibhariypos of
"work are mentioned l'retpiently in the findings of studies of occupational
aspects of lung cancer. These include furnace men, engineers, workers
exposed to petroleum and petroleum combustion, carpenters, cabinet
makers and wood workers generally.
Thus, several types of employment may constitute etiologic factors in
lung cancer. The most clear-cut evidence pertains to the Schneeberg and
Joachimsthal mines and to chromate ore operations in the United States:
in fact, one can hardly doubt the causative role of work exposure in these
groups. Other studies, including our own, strongly implicate the occu
pations shown in Table V III: painting, welding and other work involving
hot metals, commercial cooking, metal mining, steam fitting and other
asbestos work.
<
We are now engaged in another type of investigation designed to con
firm or refute the hypothesis that these latter occupations carry an exces
sive risk for lung cancer. This involves obtaining information about em
ployment from persons engaged in suspect occupations. It will include
cigarette smoking history as well as details about type of work and dura
tion of employment in it. Such information is being assembled for approxi
mately 10,000 pci-sons in the age range 35-64, now employed in each of
the suspect occupations listed in Table VII. During the next few years we
will observe the mortality experience of these groups through checking
TABLE VIII
C O R R E S P O N D E N C E OK FOU R S T U D IE S 1MPL1CAT1NO SELECTED O tT U P ATKINS IN LUNG CANCER
Katun u ny 1' \Yijmi* ohttm*'
Ih'rsItiUt t ttY
Painters
Metal grinders
Painters
Welders, foundry and .steel-mill wurker.s and other "hot m etal" w orkers
Painters and varnishers-- house, shop, etc.
Welders, copper smiths, tin smiths, etc. b lacksm iths
t Cooks--hotel and restaurant
- Construction and maintenance painters
Welders and slieetm etal Workers doing welding. Klcrtrie bridge crane(ivralors, mtal iudustry
Cooks, commercial (excluding cannory cooks)
Miners (under ground, excluding enal-ininers)
Occupations iu tbe extraction of Icad, zinc ami copper ore
Asbestos workers
Plumbers, steam-
fitters and gasfitters
Steam fittci s, Ixiifcnnakers, astiestos workers
- w nt!. ./: ...
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428
LKSTEIt JiKKSLOW
o r t.^ r . uns
with the vital statistics mlex of the California State Department of Public
!
Health. Thus, the actual lung cancer mortality rates will be determined
for persons in occupations identified by previous studies as possibly having
tiologie significance. Comparison of the rates with that of the general
population of the state (corrected Tor_age-se.\distribution) will"indicate
---- the degree of excessive risk, if any. in the occupational groups. If their
1
lung cancer mortality rate substantially exceeds the rate for the general
j
population, one may conclude that some occupational exposure is involved.
j
Thereafter it will be necessary to determine the precise environmental
|
agent and undertake preventive measures.
As occupations are identified as causative factors in lung cancer we will
be in a better position to establish control of this disease not only by
prevention, but also by intensive ease-finding efforts in high risk groups.
SUMMARY
Lung cancer has increased strikingly in recent years: it now causes more than 18.000 deaths annually in the United States. Although much evidence incriminates cigarette smoking as a major factor in the disease, it is not the sole cause. Previous studies are cited to indicate the role played by occupational exposure.
Interviews with 518 lung cancer patients in California hospitals, and a like number of non-cancer "control" patients, confirmed the greater frequency of cigarette smoking among lung earner patients. The inter views also covered life-long occupational history. Analysis of this data disclosed that the following occupational groups appeared with substan tially greater frequency among the lung cancer ease histories, as com pared with the controls: welding and sheet metal workers doing weld(ing; electric bridge crane operators, metal industry: construction and maintenance painters; commercial cooks: occupations in the extraction of lead, zinc and copper ore: steamfitlers. boilermakers, asbestos workers; marine engineers; firemen, oilers and wipers. The correspondence of this list of occupations with those arising from other studies of occupational factors in lung cancer is demonstrated.
Further work is underway to confirm or refute tin- hypothesis that these occujiatious carry an excessive risk for lung cancer.
JiEStr.M FA*
El cncer del pulmn ha .aumentado notablemente en los aos recientes: ahora causa ms de 18.000 defunciones al ao en los lisiados Unidos.
Aunque existen evidencias de (pie el fumar cigarrillos tiene gran respon sabilidad en la enfermedad, no es la nica causa.
Existen trabajos anteriores que se citan indicando el papel que de sempea la exposicin orupacinnal.
Las entrevistas llevadas a cabo con 51S enfermos de cncer del pulmn en los hospitales de California y con un nmeri igual de enfermos de "control" no cancerosos, confirm la gran frecuencia del cncer entre los
SU?*1,
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'`,''Ai* or'.r . < Cf
V"L XXVIII
JJ!O.N H 1 ( h ; m c N D O P L A S M S
-12'J
fumadores de cigarrillos. Las entrevistas incluyeron tambin las historias ocupaeionalcs de toda la vida. El anlisis de estos datos descubri que los siguientes gruais de ocu paciones mostraron demudo substancial mayor frecuencia entre las historias de cncer del pulmn en comparacin con los controles: trabajadores en soldadura y enlmina-do-acero,- operadoresde gras elctricas t-n los puentes, industria de metales, pintores de con strucciones y de mantenimiento, cocineros comerciales, trabajados en la extraccin de plomo, zinc y cobre de los minerales, traba jadores n m quinas de vapor, constructores de calderas, trabajadores ,de asbestos, maquinistas marinos, bomberos, engrasadores y limpiadores. La corre spondencia de esta lista de ocupaciones con las pie resultan de otros estudios de factores de ocupacin se demuestra. Est en preparacin ms investgacin para conlirmar o refutar la hiptesis de que estas ocupa ciones tienen consigo un riesgo mayor conrespeclo al cncer.
RESUME
La.frquence du cncer pulmonaire s'est accrue de faon frappante ces dernires annes. 11 cause maintenant plus de 18.000 dcs par an aux Etats-Unis. Iien que, de toute vidence, on puisse incriminer la fume des cigarettes comme facteur principal de cette affection, ce n'est pas l la cause unique. L'auteur cite les tudes antrieures qui ont montr le rle jou par certains risques professionnels.
L'interrogatoire le 518 malades des hpitaux de Californie, atteints de cancer pulmonaire, et d'un nombre semblable de malades tmoins non cancreux, confirme la plus grande frquence des fumeurs chez les pre miers. L'interrogatoire porta aussi sur les antcdents professionnels de toute leur existence. L'analyse de ces donnes a dmontr que comparative ment au groupe tmoin, les professions suivantes figurent avec une fr quence, notablement plus grande dans les cas de cancers: soudeurs et ouvriers lamineurs travaillant dans la soudure, conducteurs de grue, ouvriers de l'industrie mtallurgique, peintres en btiments, cuisiniers, travailleurs s'occupant de l'extraction du plomb ou'du zinc, ou des minerais cuivreux, chaudronniers, conducteurs de machines vapeur, ouvriers exposs y'amiante, mcaniciens de la marine, pompiers, graisseurs et nettoyeurs. Cette liste de professions est en accord avec celles qui ont t tablies au cours d'autres tudes des facteurs professionnels dans la frquence du cancer.
Des travaux ultrieurs sont en cours pour confirmer ou infirmer 'hypo thse selon laquelle ces professions comportent un risque de cancer extr mement important.
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