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Asbestos: Selected Cancers (2006)

Chapter: 6 Description of Epidemiologic Studies Included in Evidentiary Dataset

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Suggested Citation:"6 Description of Epidemiologic Studies Included in Evidentiary Dataset." Institute of Medicine. 2006. Asbestos: Selected Cancers. Washington, DC: The National Academies Press. doi: 10.17226/11665.
×

6
Description of Epidemiologic Studies Included in Evidentiary Dataset

COHORT STUDIES

Reports Included in the Evaluation of Cancer Risks

Table 6.1 delineates the 40 main cohort populations that passed the committee’s primary eligibility criteria and were found to contain usable information on the risk of cancer at one or more of the sites of interest for this review. Some of the cohorts contained subpopulations (such as men and women) whose results were reported separately. Furthermore, tracking of multiple aspects of the health over decades in many of the cohort populations has resulted in numerous published analyses. Among these, this committee was interested in the most complete, and thus usually the most recent, citation addressing cancer incidence or mortality. Specific citations contributing information to this review are given in the rightmost column. In some instances, different publications provided the most complete information on a given subpopulation or cancer site, so more than one citation may have served as a source of evidence on a single main cohort population. Table B.1 in Appendix B provides more detail about the overall history (such as updates and the nature of asbestos to which the subjects were exposed) of each studied population on a citation-specific basis; boldface indicates particular citations that were the source of evidence abstracted for any of the cancer sites under consideration.

Table 6.2 presents results observed in the informative cohort populations with regard to the recognized asbestos-related health effects: asbestosis, mesothelioma, and lung cancer. Those findings provide a rough indication

Suggested Citation:"6 Description of Epidemiologic Studies Included in Evidentiary Dataset." Institute of Medicine. 2006. Asbestos: Selected Cancers. Washington, DC: The National Academies Press. doi: 10.17226/11665.
×

TABLE 6.1 Description of Cohorts Informative for Selected Cancers

Cohort Population (location—number, description)

Results for Selected Cancers (ICD range specified; mortality unless otherwise noted)

Source Citation

Pharynx

Larynx

Esophagus

Stomach

Colon

Rectum

Patients with Asbestos-Related Disease

 

  1. Italy—631 women compensated for asbestosis

 

161

 

151

153

154

Germani et al. (1999)

  1. Finland—

 

161?

150?

151?

153?

154?

Karjalainen et al. (1999)

  1. 1,376 asbestosis patients

 

  1. 4,887 patients with pleural disease

 

  1. Poland—

 

161

150

151

153

154

Szeszenia-Dabrowska et al. (2002)

  1. 907 men with asbestosis

 

  1. 490 women with asbestosis

 

  1. US clinical trialmonitoring asbestos-exposed men

 

153-154 ?

Aliyu et al. (2005)

Suggested Citation:"6 Description of Epidemiologic Studies Included in Evidentiary Dataset." Institute of Medicine. 2006. Asbestos: Selected Cancers. Washington, DC: The National Academies Press. doi: 10.17226/11665.
×

Cohort Population (location—number, description)

Results for Selected Cancers (ICD range specified; mortality unless otherwise noted)

Source Citation

Pharynx

Larynx

Esophagus

Stomach

Colon

Rectum

Mining

  1. Wittenoom Gorge, Western Australia

140-149,

160 ?

161 ?

150 ?

151 ?

 

152-154 ?

Armstrong et al. (1988) [mortality to 1980]

 

C09.0-C14.8

C32.0-C32.9

C15.0-C15.9

C16.0-C16.9

 

C18.0-C20.9

Reid et al. (2004) [incidence 1979–2000]

  1. Quebec, Canada—Asbestos and Thetford

 

161

150

151

 

152-154

McDonald et al. (1993) [through 1976–1988]

Mines

 

161

#150

151

 

#152-154

Liddell et al. (1997) [through 1950−1992]

  1. Finland—Paakkila and Maljasalmi mines

 

161 ?

150 ?

151 ?

 

153-154 ?

Meurman et al. (1994)

  1. Balangero, Italy

140-149 ?

161

 

150-151 ?

 

152-154 ?

Piolatto et al. (1990)

  1. Northern Transvaal, South Africa—North West Cape Blue and Penge Mines

140-149

161

#150

#151

#153

#154

Sluis-Cremer et al. (1992)

  1. Libby, MT, US—NIOSH sample

 

 

 

151

 

 

Amandus and Wheeler (1987)

Suggested Citation:"6 Description of Epidemiologic Studies Included in Evidentiary Dataset." Institute of Medicine. 2006. Asbestos: Selected Cancers. Washington, DC: The National Academies Press. doi: 10.17226/11665.
×

Insulation Manufacture/Insulators (Laggers)

 

  1. Canada/USA

 

  1. 632 male insulation workers before 1943 in NY and NJ, US

 

140-149, 161 ?

150 ?

151 ?

 

153-154 ?

Selikoff et al. (1979) [through 1976]

  1. Paterson, NJ, US—820 men producing amosite asbestos insulation for ship building

 

140-149,

161 ?

150 ?

151 ?

 

153-154 ?

Seidman et al. (1986)

  1. 17,800 male members of asbestos insulation unions in 1967

146 ?

161

150

151

 

153-154

Selikoff and Seidman (1991) [through 1986]

  1. Uxbridge, UK—Cape [insulation] Boards Plant

 

 

150

151

153

154

Acheson et al. (1984)

  1. East London, UK—1,400 male laggers (a) (subgroups b and c makeup population 32)

140-148

161

150

151

153

154

Berry et al. (2000)

  1. Tyler, TX, US—753 white male asbestos pipe-insulation plant workers

140-149

161

150

151

153

154

Levin et al. (1998)

Suggested Citation:"6 Description of Epidemiologic Studies Included in Evidentiary Dataset." Institute of Medicine. 2006. Asbestos: Selected Cancers. Washington, DC: The National Academies Press. doi: 10.17226/11665.
×

Cohort Population (location—number, description)

Results for Selected Cancers (ICD range specified; mortality unless otherwise noted)

Source Citation

Pharynx

Larynx

Esophagus

Stomach

Colon

Rectum

Asbestos Textile Workers

 

  1. Italy—889 male and 1,077 female textile workers

140-149

161

 

151

 

152-154,

159.0

Pira et al. (2005)

  1. Rochdale, Northern England

 

161 ?

150 ?

151 ?

 

153-154 ?

Peto et al. (1985)

  1. Charleston, SC, US—asbestos-textile workers

 

161

 

151

 

 

Dement et al. (1994) [through 1990]

Asbestos Cement

 

  1. Denmark—Danish Eternit Ltd. cement factory

140-148

161

 

151

153

154

Raffn et al. (1989) [incidence through 1984]

 

 

 

 

 

153

154

Raffn et al. (1996) [incidence through 1990]

  1. Emilia Romagna, Italy—10 cement factories

140-149 ?

161

 

 

 

 

Giaroli et al. (1994)

  1. Casale Monferrato, Italy—asbestos-cementproduction

 

161 ?

 

151 ?

 

153-154 ?

Botta et al. (1991)

  1. Lithuainia—Daugeliai and Akmene Factories

 

161

 

151

 

153-154

Smailyte et al. (2004a) [incidence]

Suggested Citation:"6 Description of Epidemiologic Studies Included in Evidentiary Dataset." Institute of Medicine. 2006. Asbestos: Selected Cancers. Washington, DC: The National Academies Press. doi: 10.17226/11665.
×
  1. Southern Sweden—asbestos cement plant

 

 

 

150-152

 

153-154

Albin et al. (1990) [mortality through1986]

 

 

 

 

 

153

154

Jakobsson et al.(1994) [incidencethrough 1989]

  1. Tamworth, England, UK—TAC Construction Materials Ltd.

 

161

150

151

153

154

Gardner et al. (1986)

  1. New Orleans, LA, US—workers at two asbestos cement plants

140-149

161

150

151

 

153-154

Hughes et al. (1987)

Friction Materials

 

  1. Ontario, Canada—two automotive-parts factories

 

161

 

 

 

 

Finkelstein (1989a)

  1. Ferodo, UK—friction materials factory

 

161

 

 

 

 

Berry (1994)

  1. USSR

 

 

 

151 ?

 

 

Kogan et al. (1993)

  1. New York, US—friction-products manufacture

140-149 ?

161

 

 

 

 

Parnes (1990)

Suggested Citation:"6 Description of Epidemiologic Studies Included in Evidentiary Dataset." Institute of Medicine. 2006. Asbestos: Selected Cancers. Washington, DC: The National Academies Press. doi: 10.17226/11665.
×

Cohort Population (location—number, description)

Results for Selected Cancers (ICD range specified; mortality unless otherwise noted)

Source Citation

Pharynx

Larynx

Esophagus

Stomach

Colon

Rectum

Generic “Asbestos Workers”

 

  1. China—eight asbestos factories

 

#161 ?

#150 ?

151 ?

 

#153-154 ?

Zhu and Wang (1993)

  1. Qingdao, China—asbestos plant

 

 

 

151 ?

 

 

Pang et al. (1997)

  1. Federal Republic of Germany—asbestos-related workers innational register

 

 

 

150-151

 

153-154

Woitowitz et al. (1986)

  1. East London, UK—3,000 male (b) and 700 female(c) asbestos factoryworkers [subgroup amakes up population 13]

140-148

161

150

151

153

154

Berry et al. (2000)

  1. Lancashire, UK—gas mask manufacture

 

 

 

151

 

 

Acheson et al. (1982)

  1. England and Wales, UK—national survey of asbestos workers

 

 

150 ?

151 ?

153 ?

154 ?

Hodgson and Jones (1986)

  1. US—asbestos industry retirees

140-148

161

150

151

153

154

Enterline et al. (1987)

Suggested Citation:"6 Description of Epidemiologic Studies Included in Evidentiary Dataset." Institute of Medicine. 2006. Asbestos: Selected Cancers. Washington, DC: The National Academies Press. doi: 10.17226/11665.
×

Other Occupations with Substantial Asbestos Exposure

 

  1. Ontario, Canada—members of plumbers’ and pipefitters’ union

 

161 ?

150 ?

151 ?

 

153-154 ?

Finkelstein and Verma (2004)

  1. Finland—7,775 male shipyard workers

 

161

 

151

 

153-154

Tola et al. (1988) [incidence]

  1. Tuscany, Italy—railway-carriage construction and repair

140-149 ?

161 ?

 

151 ?

 

152-154 ?

Battista et al. (1999)

  1. Genoa, Italy—ship repair, refitting, and construction

140-149

161

150

151

 

153-154

Puntoni et al. (2001)

  1. Gothenburg, Sweden—shipyard workers

 

 

 

151

 

152-154

Sanden and Jarvholm (1987) [incidence]

NOTES: # = number observed given but no estimated risk; ICD or range = explicit or evident; ICD? or range? = exact sites included in grouping not completely clear.

Suggested Citation:"6 Description of Epidemiologic Studies Included in Evidentiary Dataset." Institute of Medicine. 2006. Asbestos: Selected Cancers. Washington, DC: The National Academies Press. doi: 10.17226/11665.
×

TABLE 6.2 Rates of Accepted Asbestos-Related Health Outcomes in Cohorts Informative for Selected Cancers

Cohort Population (location—number, description)

Accepted Asbestos-Related Health Outcomes (number observed, RR, 95% CI)

Source Citation

Asbestosis

Lung Cancer

Mesothelioma

Patients with Asbestos-Related Disease

 

  1. Italy—631 women compensated for asbestosis

all

16, 4.8 (2.7-7.8)

14, 64.0 (35.0-107)

Germani et al. (1999)

  1. Finland—patients

 

  1. 1,376 asbestosis

all

  1. 127 M, 6.7 (5.6-7.9);

6 F, 19.80 (7.3-43.1)

  1. 9 M, 31.6 (14.4-60.0);

1 F, 95.7 (2.4-533)

Karjalainen et al. (1999)

  1. 4,887 patients with pleural disease

 

  1. 44 M, 1.3 (1.0-1.8);

0 F

  1. 4 M, 5.5 (1.5-14.1);

0 F

  1. Poland—

 

  1. 907 men with asbestosis

all

  1. 39, 1.68 (1.22-2.26);

  1. 3, 26.8 (5.5-78.3);

Szeszenia-Dabrowska et al. (2002)

  1. 490 women with asbestosis

all

  1. 13, 6.21 (3.31-10.62)

  1. 3, 72.1 (10.3-146)

  1. US clinical trial

 

 

 

Aliyu et al. (2005)

Mining

 

  1. Wittenoom Gorge,

Western Australia

—6,505 men

 

91 M, 1.60 (1.31-1.97)

32

Armstrong et al. (1988) [mortality through 1980]

Berry et al. (2004) [incidence through2000]

  1. 6,493 men

 

 

  1. 235

  1. 235 women

 

 

  1. 7

Suggested Citation:"6 Description of Epidemiologic Studies Included in Evidentiary Dataset." Institute of Medicine. 2006. Asbestos: Selected Cancers. Washington, DC: The National Academies Press. doi: 10.17226/11665.
×
  1. Quebec, Canada—Asbestos and Thetford Mines

 

646, 1.37

38

Liddell et al. (1997) [1950-1992]

  1. Finland—Paakkila and Maljasalmi Mines

 

76 M, 2.88 (2.27-3.60);

1 F, 2.22 (0.06-12.4)

4 M, 45.6 (12.2-115)

Meurman et al. (1994)

  1. Balangero, Italy

16

22, 1.1

2, 6.7

Piolatto et al. (1990)

  1. Northern Transvaal, South Africa—North West Cape Blue and Penge Mines

1

63, 1.72 (1.32-2.21)

16

Sluis-Cremer et al. (1992)

  1. Libby, MT, US

 

 

 

 

  1. NIOSH sample

 

20, 2.23 (1.36-3.45)

Included with lung

Amandus andWheeler (1987)

  1. McGill sample

 

21

2

McDonald et al. (1986)

Insulation Manufacture/Insulators (Laggers)

 

  1. Canada/US—17,800 male asbestos insulation unions members in 1967

427

1,168, 4.35, p<0.001

458

Selikoff and Seidman (1991)

  1. Uxbridge, UK—Cape [insulation] Boards Plant

 

57, 2.0

5

Acheson et al. (1984)

  1. East London, UK—1,400 male laggers (a)

 

38, 3.67

13

Berry et al. (2000)

  1. Tyler, TX, US—753 white male asbestos pipe-insulation plant workers

3

35, 2.77 (1.93-3.85)

4, 28.8 (7.9-73.8)

Levin et al. (1998)

Suggested Citation:"6 Description of Epidemiologic Studies Included in Evidentiary Dataset." Institute of Medicine. 2006. Asbestos: Selected Cancers. Washington, DC: The National Academies Press. doi: 10.17226/11665.
×

Cohort Population (location—number, description)

Accepted Asbestos-Related Health Outcomes (number observed, RR, 95% CI)

Source Citation

Asbestosis

Lung Cancer

Mesothelioma

Asbestos Textile Workers

 

  1. Italy—889 male and 1,077 female textile workers

38

76, 2.82 (2.22-3.54)

37, 27.8 (19.6-38.6)

Pira et al. (2005)

  1. Rochdale, Northern England

7

132, 1.31, p<0.01

11

Peto et al. (1985)

  1. Charleston, SC, US—546 black and 1,247 white maleand 1,229 white female asbestos textile workers

 

4, 1.55 (0.53-3.55)

2

Dement et al. (1994)

Asbestos Cement

 

  1. Denmark—Danish Eternit Ltd. cement factory

 

162, 1.80 (1.54-2.10)

10, 5.46 (2.62-10.1)

Raffn et al. (1989) [incidence through 1984]

 

 

1.63 (1.26-2.08)

 

Raffn et al. (1996) [incidence through 1990]

  1. Emilia Romagna, Italy—10 cement factories

 

33, 1.24 (0.91-1.66)

6, 4.11

Giaroli et al. (1994)

  1. Casale Monferrato, Italy—asbestos cement production

85 M;

4 F

110 M, 2.71 (2.23-3.27);

7 F, 3.96 (1.59-8.16)

 

Botta et al. (1991)

Suggested Citation:"6 Description of Epidemiologic Studies Included in Evidentiary Dataset." Institute of Medicine. 2006. Asbestos: Selected Cancers. Washington, DC: The National Academies Press. doi: 10.17226/11665.
×
  1. Lithuainia—Daugeliai and Akmene Factories

 

29 M, 0.9 (0.7-1.3);

1 F, 0.7 (0.1-4.6)

0 M;

1 F, 20.1 (2.9-142)

Smailyte et al. (2004a)

  1. Southern Sweden—asbestos cement plant

 

35, 1.8 (0.90-3.7)

13, 7.2 (0.97-54)

Albin et al. (1990)

  1. Tamworth, England, UK—TAC Construction Materials LTD

 

34 M, 0.9 (0.6-1.3);

6 F, 1.4 (0.5-3.1)

1 M;

0 F

Gardner et al. (1986)

  1. New Orleans, LA, US—workers at two asbestos cement plants

 

154, 1.34

1

Hughes et al. (1987)

Friction Materials

 

  1. Ontario, Canada—two automotive parts factories

 

11, 1.40

Included with lung

Finkelstein (1989a)

  1. Ferodo, UK—friction materials factory

 

 

 

Berry (1994)

  1. USSR

 

2, 0.11

 

Kogan et al. (1993)

  1. New York, US—friction products manufacture

 

15, 0.95

 

Parnes (1990)

Suggested Citation:"6 Description of Epidemiologic Studies Included in Evidentiary Dataset." Institute of Medicine. 2006. Asbestos: Selected Cancers. Washington, DC: The National Academies Press. doi: 10.17226/11665.
×

Cohort Population (location—number, description)

Accepted Asbestos-Related Health Outcomes (number observed, RR, 95% CI)

Source Citation

Asbestosis

Lung Cancer

Mesothelioma

Generic “Asbestos Workers”

 

  1. China—eight asbestos factories

 

67, 4.2

 

Zhu and Wang (1993)

  1. Qingdao, China—asbestos plant

 

3 M, 5.1;

6 F, 6.8

 

Pang et al. (1997)

  1. Federal Republic of Germany—asbestos-related workers from national register

 

a. 26, 1.70

b. 12, 4.62

a. 6

b. 6

Woitowitz et al. (1986)

  1. East London, UK—3,000 male (b) and 700 female (c) asbestos factory workers

 

b. 157, 2.55

c. 37, 7.46

b. 60

c. 25

Berry et al. (2000)

  1. Lancashire, UK—gas mask manufacture

 

22, 2.00

3

Acheson et al. (1982)

  1. England and Wales, UK—national survey of asbestos workers

11

157, 1.30

34

Hodgson and Jones (1986)

  1. US—asbestos industry retirees

22

77, 2.71

Included with lung

Enterline et al. (1987)

Suggested Citation:"6 Description of Epidemiologic Studies Included in Evidentiary Dataset." Institute of Medicine. 2006. Asbestos: Selected Cancers. Washington, DC: The National Academies Press. doi: 10.17226/11665.
×

Other Occupations with Substantial Asbestos Exposure

 

  1. Ontario, Canada—members of plumbers’ and pipefitters’ union

 

393, 1.27 (1.13-1.42)

8

Finkelstein and Verma (2004)

  1. Finland—7,775 male shipyard workers

 

227, 1.18 (1.03-1.35) for all 7,775 shipyard workers

1, 1.13—in a machinist, not pipe fitter

Tola et al. (1988) [incidence]

  1. Tuscany, Italy—railway carriage construction and repair

 

26, 1.24 (0.87-1.72)

[90%CI]

5, 13.27, (5.23-27.9)

[90%CI]

Battista et al. (1999)

  1. Genoa, Italy—ship repair, refitting, and construction

18, 46.6 (27.6-73.6)

298, 1.77 (1.57-1.98)

60, 5.24, (4.00-6.74)

Puntoni et al. (2001)

  1. Gothenburg, Sweden—shipyard workers

 

11, 1.12 (0.56-2.0)

4

Sanden and Jarvholm (1987)

Suggested Citation:"6 Description of Epidemiologic Studies Included in Evidentiary Dataset." Institute of Medicine. 2006. Asbestos: Selected Cancers. Washington, DC: The National Academies Press. doi: 10.17226/11665.
×

of asbestos exposure and of how informative each of the cohorts might be expected to be in contributing evidence to the committee’s evaluation of asbestos’s role in others cancers.

For the cohorts that provided information on at least one of the selected cancer sites, Figure 6.1 gives a graphic indication of the period when exposure was occurring and of the length of the most recent (most complete) follow-up of the vital status of the cohort members. The figure also includes the percentage of the original cohort members found to have died as an index of a cohort’s “maturity,” which suggests how much additional information might be garnered if follow-up were extended for the cohort.

Figure 6.2 presents an analogous picture for the roughly six dozen asbestos-exposed cohorts that the committee screened for the selected cancers but found no usable information. The most recent citation related to cancer outcomes is specified. The considerably greater number of cohorts in the uninformative category gives an indication of the extent to which research has focused on reporting respiratory outcomes of asbestos exposure.

The cohort studies retained for the evidentiary dataset addressed defined occupational cohorts in specific asbestos industries (such as mining and milling, cement, textile, and friction products), in less clearly specified industries (such as “asbestos factory”), or employed in certain occupations with documented asbestos exposures (such as insulators). Some of the cohort studies derived qualitative categories of asbestos exposure based on individual work history or clinical factors (such as presence of pleural plaques). Quantitative exposure assessments to enable dose estimation were available only for a small percentage of the studies.

We summarized findings from reports of cohort studies of asbestos-exposed workers in which cancer-risk data were available on at least one of the specific cancers of interest as delineated in Table 6.1. The main cohort populations were made up of workers employed in asbestos mining (6); manufacturing and use of insulation (3), textiles (4), cement (7), friction materials (4), and various other asbestos products, such as gas masks (7); and in other occupations with substantial asbestos exposure (5). The most recent report of a cohort study was selected if there had been repeated follow-ups; this was the case for studies of the London East End factory (Berry et al. 2000), US textile workers (Dement et al. 1994), Quebec miners (Liddell et al. 1997, McDonald et al. 1993), and North American insulation workers (Selikoff and Seidman 1991); see Table B.1 for a listing of the citations that were superseded.

We also included in our review three studies of cohorts of patients with asbestosis or nonmalignant pleural disease who had worked in any of numerous unspecified industries and occupations (Germani et al. 1999, Karjalainen et al. 1999, Szeszenia-Dabrowska et al. 2002) under the assumption that there was a high likelihood of exposure of cohort members

Suggested Citation:"6 Description of Epidemiologic Studies Included in Evidentiary Dataset." Institute of Medicine. 2006. Asbestos: Selected Cancers. Washington, DC: The National Academies Press. doi: 10.17226/11665.
×

FIGURE 6.1 Follow-up on informative cohorts.

Suggested Citation:"6 Description of Epidemiologic Studies Included in Evidentiary Dataset." Institute of Medicine. 2006. Asbestos: Selected Cancers. Washington, DC: The National Academies Press. doi: 10.17226/11665.
×
Suggested Citation:"6 Description of Epidemiologic Studies Included in Evidentiary Dataset." Institute of Medicine. 2006. Asbestos: Selected Cancers. Washington, DC: The National Academies Press. doi: 10.17226/11665.
×

to asbestos. Additionally, we included a cohort of asbestos-exposed people who had been monitored in a clinical trial (Aliyu et al. 2005).

We reviewed but did not include cancer-risk data from studies of cohorts of workers in several industries in which modest asbestos exposure occurred in conjunction with major exposure to other toxic agents, such as a refinery and petrochemical plant (Tsai et al. 1996), rubber industry (Straif et al. 1999), and a nitric acid factory (Hilt et al. 1991).

Health Outcome Data

In most of the cohort studies reviewed, cancer mortality was the health outcome analyzed. There were very few cancer incidence studies; the excep-

Suggested Citation:"6 Description of Epidemiologic Studies Included in Evidentiary Dataset." Institute of Medicine. 2006. Asbestos: Selected Cancers. Washington, DC: The National Academies Press. doi: 10.17226/11665.
×

FIGURE 6.2 Follow-up on asbestos-exposed cohorts without information on selected cancers.

Suggested Citation:"6 Description of Epidemiologic Studies Included in Evidentiary Dataset." Institute of Medicine. 2006. Asbestos: Selected Cancers. Washington, DC: The National Academies Press. doi: 10.17226/11665.
×
Suggested Citation:"6 Description of Epidemiologic Studies Included in Evidentiary Dataset." Institute of Medicine. 2006. Asbestos: Selected Cancers. Washington, DC: The National Academies Press. doi: 10.17226/11665.
×
Suggested Citation:"6 Description of Epidemiologic Studies Included in Evidentiary Dataset." Institute of Medicine. 2006. Asbestos: Selected Cancers. Washington, DC: The National Academies Press. doi: 10.17226/11665.
×
Suggested Citation:"6 Description of Epidemiologic Studies Included in Evidentiary Dataset." Institute of Medicine. 2006. Asbestos: Selected Cancers. Washington, DC: The National Academies Press. doi: 10.17226/11665.
×
Suggested Citation:"6 Description of Epidemiologic Studies Included in Evidentiary Dataset." Institute of Medicine. 2006. Asbestos: Selected Cancers. Washington, DC: The National Academies Press. doi: 10.17226/11665.
×
Suggested Citation:"6 Description of Epidemiologic Studies Included in Evidentiary Dataset." Institute of Medicine. 2006. Asbestos: Selected Cancers. Washington, DC: The National Academies Press. doi: 10.17226/11665.
×

tions were studies of Swedish insulation workers (Sanden and Jarvholm 1987) and of cement workers in Sweden (Jakobsson et al. 1994) and Denmark (Raffn et al. 1989, 1996). Consequently, disease occurrence may have been under-ascertained in some cohort studies, especially for pharyngeal, laryngeal, and colorectal cancers, which generally have higher survival rates than esophageal and stomach cancers. Although under-ascertainment would tend to diminish the power of these studies, it is unlikely to have created an important systematic bias because it is reasonable to assume that the extent of disease ascertainment was unrelated to asbestos exposure.

Cancer mortality information in the cohort studies was derived predominantly from death certificates. Death-certificate data were augmented with clinical information (such as an autopsy reports or medical-chart reviews) in studies of North American insulation workers (Selikoff and Sediman 1991) and German workers in various industries (Woitowitz and Seidman 1986) to derive “best-evidence” risk estimates. We reported those “best-evidence” relative risks (RRs) in our summary of findings, acknowledging that they may over-estimate risks somewhat because comparison rates, typically from national populations, were limited to death-certificate data.

Suggested Citation:"6 Description of Epidemiologic Studies Included in Evidentiary Dataset." Institute of Medicine. 2006. Asbestos: Selected Cancers. Washington, DC: The National Academies Press. doi: 10.17226/11665.
×

To evaluate the individual risks of cancer of the pharynx, larynx, esophagus, stomach, colon, or rectum, one would want to consider together reported statistics for International Classification of Diseases (ICD) codes 146-148, 161, 150, 151, 153, and 154, respectively, but in practice many publications grouped their findings into broader ranges. As explained in Chapter 2, the committee determined that the only coarser groupings of sites that could be considered meaningful were pharynx with oral cavity, larynx with epilarynx (portions of the oropharynx specified as ICD codes 146.4, 146.5, and 148.2), and rectum with colon.

In addition to studies reporting on the selected cancers in acceptable categories, the assembled literature on asbestos-exposed cohorts included some papers presenting data only for “gastrointestinal” or “abdominal” cancers. Such groupings make the findings for esophagus, stomach, colon, and rectum indistinguishable, and also potentially included cancers of the pancreas, liver, gall bladder, and small intestine, which are not relevant to this review. Although the desired site-specific findings are not recoverable, for completeness, Table 6.3 presents results for aggregated gastrointestinal cancers from those cohort studies that provided their findings only in such form. The information gathered in this table could not be used by the committee in reaching its conclusions.

Data on the specific cancers of interest to the committee (cancers of the pharynx, larynx, esophagus, stomach, colon, or rectum) came from 40 major cohort populations. None of the cohort studies included data on histologic type of cancer; although many of the 36 case-control studies (discussed in the following section) involved histologic confirmation of cancer diagnosis, their results were not generally presented by histologic type. Furthermore, few of the studies provided data specific for cancer subsites. As a result, the committee did not attempt to draw conclusions at a more refined level than the groupings specified in its charge.

Exposure Assessment

Considerable attention has been given to possible differences among fiber types in their potential to cause cancer, especially in the context of examining mesothelioma risk. Recent reviews suggests that, rather than having no carcinogenic activity, chrysotile has a generally lesser degree of potency than amphibole fibers and that the various types of amphibole fiber have differing potency in the extent of their biological activity (Britton 2002, IPCS 1998, Roggli 2006, Roggli et al. 1997, Suzuki et al. 2005).

In this review, we noted predominant fiber types where information was provided. Table 6.4 provides an alphabetical listing of the informative citations and the corresponding cohort populations, which will facilitate cross-referencing from the citations listed in the summary figures of site-

Suggested Citation:"6 Description of Epidemiologic Studies Included in Evidentiary Dataset." Institute of Medicine. 2006. Asbestos: Selected Cancers. Washington, DC: The National Academies Press. doi: 10.17226/11665.
×

TABLE 6.3 Cohort—Study Results on Various Groupings of Gastrointestinal Cancers (Grouped)

Source Citation

Location

Industry Type or Occupation

Fiber Type (primary)

Population

Overall Cohort Results No. cases RR (95% CI)

Highest Exposed Results No. cases RR (95% CI)

Comments

McDonald et al. (1986)

Libby, Montana, US (1986) Overlap with NIOSH cohort in Amandus and Wheeler (1987)?

Mining

Vermiculite

406 men

7

SMR = 0.88 (no CI or p-value)

5

SMR = 1.11 (no CI or p-value)

ICD8 150-159; highest exposed: ≥20 yrs since first exposure

Sluis-Cremer et al. (1992)

South Africa

Mining

Amosite, crocidolite

7,317 men

36

SMR = 0.88 (0.62-1.22)

ICD9 150-159 digestive + peritoneum

Thomas et al. (1982)

Wales

Cement

Chrysotile, some crocidolite

1,592 men

18

SMR = 0.92 (no CI or p-value)

6

SMR = 1.20 (no CI or p-value)

ICD8 151-154; highest exposed: employed 1935-36

Finkelstein (1984)

Ontario, Canada

Cement

Chrysotile?

535 men

8

SMR = 2.85 (no CI or p-value)

2 (or 1 best evidence)

SMR = 5.00 (no CI or p-value)

ICD? 150-154; highest exposed: 30-34 yrs since first exposure

Giaroli et al. (1994)

Italy

Cement

Chrysotile, crocidolite

3,341

28

SMR = 0.91 (0.65-1.25)

Digestive tract + peritoneum (1)

Suggested Citation:"6 Description of Epidemiologic Studies Included in Evidentiary Dataset." Institute of Medicine. 2006. Asbestos: Selected Cancers. Washington, DC: The National Academies Press. doi: 10.17226/11665.
×

Hughes and Weill (1991)

New Orleans, Louisiana, US

Cement

??

839 men

6

SMR = 0.65 (no CI or p-value)

ICD8 150-159

McDonald et al. (1983)

South Carolina, US Overlap with cohort population in Dement et al. (1994)

Textile

Chrysotile

2,543 men

26

SMR = 1.52 (no CI or p-value)

0

SMR = 0 (irregular d-r trend, increaseuntil last stratum, then 0 cases)

ICD? 150-159; highest exposed: ≥80 mppcfy

McDonald et al. (1982a)

Pennsylvania US

Textile, friction products

Chrysotile

1,200 men + women

54

SMR = 1.13 (no CI or p-value)

7

SMR = 2.37 (no CI or p-value) RR = 2.85 from nested c-c analysis (no CI or p-value)

ICD? 150-159; highest exposed: ≥80 mppcfy

McDonald et al. (1984)

Connecticut, US

Friction materials

Chrysotile

3,641 men

59

SMR = 1.14 (no CI or p-value)

3

SMR = 1.27 (no CI or p-value)

ICD? 150-159; highest exposed: ≥80 mppcfy

Newhouse et al. (1985b) vs Berry et al. (1985)

England

Friction materials

Chrysotile

8,404 men

4,167 women

men: 156

SMR = 0.93 (0.81-1.06)

women: 46

SMR = 0.98 (0.74-1.22)

men: 56

SMR = 0.89 (0.70-1.09)

women: 13

SMR = 1.23 (0.73-1.96)

highest exposed: ≥10 yrs employed, ≥20 yrs since first exposure

Suggested Citation:"6 Description of Epidemiologic Studies Included in Evidentiary Dataset." Institute of Medicine. 2006. Asbestos: Selected Cancers. Washington, DC: The National Academies Press. doi: 10.17226/11665.
×

Source Citation

Location

Industry Type or Occupation

Fiber Type (primary)

Population

Overall Cohort Results No. cases RR (95% CI)

Highest Exposed Results No. cases RR (95% CI)

Comments

Finkelstein (1989b)

Ontario, Canada

Friction materials

Chrysotile

1,194 men

6

SMR = 0.81 (no CI or p-value)

5

SMR = 0.92 (no CI or p-value)

ICD9 150-159; data presented for ≥20 yr since first exposure; highest exposure: ≥20 yr employed

Enterline and Kendrick (1967)

US

Various Building, friction, textile products

???

21,755 men

building products: 36

SMR = 0.89 (no CI or p-value)

friction materials: 36

SMR = 1.19 (no CI or p-value)

textile: 11

SMR = 1.46 (no CI or p-value)

ICD7 150-159; cohort age 15-64 years, multiple companies; cotton-mill worker comparison group

Suggested Citation:"6 Description of Epidemiologic Studies Included in Evidentiary Dataset." Institute of Medicine. 2006. Asbestos: Selected Cancers. Washington, DC: The National Academies Press. doi: 10.17226/11665.
×

Kolonel et al. (1985)

Hawaii, US

Shipyard

??

7,971 men

63

SMR = 0.87 estimated from Table 6 (no CI or p-value)

10

SMR = 1.0 (0.5-1.9)

Esophagus + stomach + colon + rectum; highest exposed: ≥15 yr exposed, ≥30 yr since first exposure

Jarvholm and Sanden (1998)

Gothenburg, Sweden

Shipyard workers

Amosite, crocidolite

248 men; subset of 3,900 in Sanden and Jarvholm (1987)

1970-1979:

SIR = 2.9 (0.95-6.9)

1980-1992: 8

SIR = 2.2(0.96-1.4)

ICD8 150-159 results SIRs for pancreatic cancer (10.0, 6.0)

NOTE: c-c = case-control; CI = Confidence interval; d-r = dose-response; ICD = International Classification of Diseases; mppcfy = millions particles per cubic foot per year; RR = relative risk; SIR = standardized incidence ratio; SMR = standardized mortality ratio.

Suggested Citation:"6 Description of Epidemiologic Studies Included in Evidentiary Dataset." Institute of Medicine. 2006. Asbestos: Selected Cancers. Washington, DC: The National Academies Press. doi: 10.17226/11665.
×

TABLE 6.4 Asbestos Types Associated with Exposures of Cohorts Informative for Selected Cancers (alphabetical order by author to correspond with plots in Chapters 7-11)

Source Citation

 

Cohort Population (location—number, description)

Type(s) of Asbestos Comprising Exposure

Serpentine Chrysotile

Amphibole

Mixed (M) or Not Stated (?)

Crocidolite

Amosite

Anthophyllite

Tremolite-Actinolite

Acheson et al. (1982)

33.

Lancashire, UK—gas mask manufacture

X

X

 

 

 

 

Acheson et al. (1984)

12.

Uxbridge, UK—Cape [insulation] Boards Plant

 

 

X

 

 

 

Aliyu et al. (2005)

4.

US clinical trial monitoring asbestos-exposed men

 

 

 

 

 

?

Amandus and Wheeler (1987)

10.

Libby, MT, US—NIOSH sample—miners

 

 

 

 

X

 

Armstrong et al. (1988)

5a.

Wittenoom Gorge, Western Australia—miners [deaths before 1980]

 

X

 

 

 

 

Battista et al. (1999)

38.

Tuscany, Italy—railway-carriage construction and repair

X

X

 

 

 

 

Berry (1994)

26.

Ferodo, UK—friction materials factory

X mainly

X

 

 

 

 

Berry et al.

13.

East London, UK—1400 male laggers (2000)

X

X

X

 

 

 

Suggested Citation:"6 Description of Epidemiologic Studies Included in Evidentiary Dataset." Institute of Medicine. 2006. Asbestos: Selected Cancers. Washington, DC: The National Academies Press. doi: 10.17226/11665.
×

Berry et al. (2000)

32.

East London, UK—3,000 male and 700 female asbestos factory workers

X mainly

X

X

 

Botta et al. (1991)

20.

Casale Monferrato, Italy—asbestos cement production

X

X

 

 

Dement et al. (1994)

17.

Charleston, SC, US—asbestos textile workers

X

 

 

 

Enterline et al. (1987)

35.

USA—asbestos industry retirees

X

X

X

 

Finkelstein (1989a)

25.

Ontario, Canada—two automotive parts factories

 

 

 

?

Finkelstein and Verma (2004)

36.

Ontario, Canada—members of plumbers’ and pipefitters’ union

 

 

 

?

Gardner et al. (1986)

23.

Tamworth, England, UK—TAC Construction Materials Ltd.

X

 

 

 

Germani et al. (1999)

1.

Italy—631 women compensated for asbestosis

X

X

 

 

Giaroli et al. (1994)

19.

Emilia Romagna, Italy—10 cement factories

X

X

 

 

Hodgson and Jones (1986)

34.

England and Wales, UK—national survey of asbestos workers

 

 

 

M

Hughes et al. (1987)

24.

New Orleans, LA, US—workers at two asbestos cement plants

X mainly

X

X

 

Jakobsson et al. (1994)

22.

Southern Sweden—asbestos cement plant

X mainly

X

X

 

Suggested Citation:"6 Description of Epidemiologic Studies Included in Evidentiary Dataset." Institute of Medicine. 2006. Asbestos: Selected Cancers. Washington, DC: The National Academies Press. doi: 10.17226/11665.
×

Source Citation

 

Cohort Population (location—number, description)

Type(s) of Asbestos Comprising Exposure

Serpentine Chrysotile

Amphibole

Mixed (M) or Not Stated (?)

Crocidolite

Amosite

Anthophyllite

Tremolite-Actinolite

Karjalainen et al. (1999)

2.

Finland—

a. 1,376 asbestosis patients

b. 4,887 patients with pleural disease

 

 

 

 

 

?

Kogan et al. (1993)

27.

USSR

X

 

 

 

 

 

Levin et al. (1998)

14.

Tyler, TX, US—753 white male asbestos pipe-insulation plant workers

 

 

X

 

 

 

Liddell et al.(1997) and McDonald et al. (1993)

6.

Quebec, Canada—Asbestos and Thetford Mines—miners

X

 

 

 

 

 

Meurman et al. (1994)

7.

Finland—Paakkila and Maljasalmi Mines—miners

 

 

 

X

 

 

Pang et al. (1997)

30.

Qingdao, China—asbestos plant

X

 

 

 

 

 

Parnes (1990)

28.

New York, USA—friction products manufacture

X

 

 

 

 

 

Peto et al. (1985)

16.

Rochdale, Northern England

X

X

 

 

 

 

Suggested Citation:"6 Description of Epidemiologic Studies Included in Evidentiary Dataset." Institute of Medicine. 2006. Asbestos: Selected Cancers. Washington, DC: The National Academies Press. doi: 10.17226/11665.
×

Piolatto et al. (1990)

8.

Balangero, Italy—miners

X

 

 

 

Pira et al. (2005)

15.

Italy—889 male and 1,077 female textile workers

 

 

 

?

Puntoni et al. (2001)

39.

Genoa, Italy—ship repair, refitting, and construction

 

 

 

?

Raffn et al. (1989)

18.

Denmark—Danish Eternit Ltd. cement factory

X mainly

X

X

 

Reid et al. (2004)

5b.

Wittenoom Gorge, Western Australia—miners [incidence 1979-2000]

 

X

 

 

Sanden and Jarvholm (1987)

40.

Gothenburg, Sweden—shipyard workers

X mainly

X

X

 

Seidman et al. (1986)

11.

b. Paterson, NJ, US—820 men producing insulation for shipbuilding

 

 

X

 

Selikoff et al. (1979)

11.

a. 632 male insulation workers before 1943 in NY/NJ

 

 

 

?

Selikoff and Seidman (1991)

11.

Canada/USA

c. 17,800 male members of asbestos insulation

unions in 1967

 

 

 

?

Sluis-Cremer et al. (1992)

9.

Northern Transvaal, South Africa—North West Cape Blue and Penge Mines—miners

 

X

X

 

Smailyte et al. (2004a)

21.

Lithuainia—Daugeliai and Akmene Factories

X

 

 

 

Suggested Citation:"6 Description of Epidemiologic Studies Included in Evidentiary Dataset." Institute of Medicine. 2006. Asbestos: Selected Cancers. Washington, DC: The National Academies Press. doi: 10.17226/11665.
×

Source Citation

 

Cohort Population (location—number, description)

Type(s) of Asbestos Comprising Exposure

Serpentine Chrysotile

Amphibole

Mixed (M) or Not Stated (?)

Crocidolite

Amosite

Anthophyllite

Tremolite-Actinolite

Szeszenia-Dabrowska et al. (2002)

3.

Poland—

a. 907 men with asbestosis

b.490 women with asbestosis

 

 

 

 

 

?

Tola et al. (1988)

37.

Finland—7,775 male shipyard workers

 

 

 

 

 

?

Woitowitz et al. (1986)

31.

Federal Republic of Germany—asbestos-related workers from national register

 

 

 

 

 

?

Zhu and Wang (1993)

29.

China—eight asbestos factories

X

 

 

 

 

 

NOTE: Column 1 of Tables 6.1-6.2 reordered by source citation.

Suggested Citation:"6 Description of Epidemiologic Studies Included in Evidentiary Dataset." Institute of Medicine. 2006. Asbestos: Selected Cancers. Washington, DC: The National Academies Press. doi: 10.17226/11665.
×

specific Chapters 7-11. Table 6.4 also specifies the types of asbestos to which the cohorts were exposed. The contents of Table 6.4, however, demonstrate for workers in these cohorts that exposures have often been mixed, with one type of asbestos commonly being contaminated by others and with some industrial processes intentionally involving mixtures. If inferences could only be drawn from studies of exposure to a single type of asbestos, the database would be inadequate to draw any conclusions. There was only one informative cohort population for exposure to anthophyllite and one for exposure to tremolite or actinolite; two separate populations were said to have been exposed to amosite exclusively; two populations divided only by time from Wittenoom Gorge were the only ones considered as exposed only to crocidolite; while 10 of the 45 citations reported only exposure to serpentine chrysotile. For the remainder, the researchers stated the exposure was mixed or did not attempt to characterize it beyond “asbestos.” Predictably, chrysotile was the most frequently mentioned type. There were too few studies of single forms of asbestos to support separate evaluations according to fiber type and inclusion of studies with exposure to mixed or unknown fiber types would have generated fiber-type-specific associations subject to considerable uncertainty; consequently the committee did not characterize associations by fiber type.

The type and quantity of data available for assessing asbestos exposures varied considerably among studies. The committee partitioned these methods of exposure assessment into categories of relative quality. Although the underlying data may have been gathered with a variety of methods having different sensitivities, the highest category of relative quality was quantitative estimates of the concentration of asbestos fibers based on workplace measurements. The optimal, but rarely available, exposure metric was deemed to be cumulative exposure, in which concentrations measured with reliable industrial-hygiene techniques would be combined with each individual’s job history to obtain years of exposure to concentrations expressed as mppcf (million particles per cubic foot) or f/cm3 (fibers per cubic centimeter) of air. Such estimates of cumulative exposure were derived only in studies of South Carolina textile workers (Dement et al. 1994; McDonald et al. 1982, 1983), Quebec chrysotile miners (McDonald and McDonald 1997), Italian chrysotile miners (Rubino et al. 1979), Wittenoom Gorge, Australia crocidolite miners (Reid et al. 2004), and Louisiana cement-factory workers (Hughes et al. 1987).

A second tier of exposure assessment quality consisted of more qualitative approaches to deriving scales for dose-response analyses. In numerous studies, less specific data, such as duration of employment in the industry or occupation or ordinal rankings of jobs (for example, “heavy” and “light”), served as surrogates in dose estimation.

In the remaining studies, absence of any sort of detailed exposure data

Suggested Citation:"6 Description of Epidemiologic Studies Included in Evidentiary Dataset." Institute of Medicine. 2006. Asbestos: Selected Cancers. Washington, DC: The National Academies Press. doi: 10.17226/11665.
×

from which gradients could be defined limited risk estimation to contrasts between exposed and non-exposed (“any vs none” in the meta-analyses), typically formulated as risk comparisons between an entire cohort and the general population. In practice, even studies in which quantitative exposure data had been gathered seldom reported dose-response gradients for the selected cancers of interest in this review. Lung cancer, which is far more common, was the principal focus in those studies; perhaps concerns about limitations of statistical power prevented partitioning the small observed number of these other cancers into exposure categories. Consequently, many of the cohorts in which exposure had been extensively assessed contributed no more to this evaluation for the selected cancers than an “any vs none” comparison with the general population. The dearth of quantitative dose-response data is clearly a limitation of the literature on the selected cancers.

As reflected in the results tables in Appendix D, for each cohort study, we transcribed estimates of RR for the entire cohort compared with the general population (a contrast of any exposure vs no exposure) and, when exposure gradients were defined, for the subgroup in the most extreme exposure category (a contrast of high exposure vs no exposure).

CASE-CONTROL STUDIES

Reports Included in the Evaluation of Cancer Risks

The committee’s search for relevant case-control studies first screened the literature for investigations of the selected cancers that included occupation among the risk factors considered and then retained those that actually assessed and reported asbestos exposure. Table 6.5 summarizes the 36 case-control studies that were found to be informative for any of the cancer sites of interest, ordered by the quality of the method of exposure assessment used (as described below). Details about the design characteristics of the studies can be found in Table C.1 in Appendix C.

Although multiple publications may result from a single case-control investigation, in general they do not have as complex histories as do cohort studies carried out over several decades. This chapter’s presentation of the case-control studies evaluated in a single one-page table, in contrast to the several multipage tables and figures shown concerning the cohort studies, is not a reflection of the relative importance of these two study designs in the committee’s evaluation. Both designs have their merits, and the results from both are complementary.

The case-control method has several specific strengths in comparison to the cohort study design, some of which may be particularly advantageous for studies of asbestos. First, case ascertainment can be accompanied by pathological review of cancers, thus validating the cancer type and allowing

Suggested Citation:"6 Description of Epidemiologic Studies Included in Evidentiary Dataset." Institute of Medicine. 2006. Asbestos: Selected Cancers. Washington, DC: The National Academies Press. doi: 10.17226/11665.
×

TABLE 6.5 Summary of Case-Control Studies Addressing Selected Cancers

Quality of Exposure Characterization

Type of Cancer Investigated

Pharyngeal

Laryngeal

Esophageal

Stomach

Colorectal

High

 

 

 

 

 

11 unique citations

Berrino et al. (2003)

Berrino et al. (2003)

 

 

 

 

 

Dietz et al. (2004)

 

 

Dumas et al. (2000)

 

Gustavsson et al. (1998)

Gustavsson et al. (1998)

Gustavsson et al. (1998)

 

Goldberg et al. (2001)

 

Marchand et al. (2000)

Marchand et al. (2000)

Parent et al. (2000)

Parent et al. (1998)

 

 

Merletti et al. (1991)

Muscat and Wynder (1992)

 

 

 

 

 

Wortley et al. (1992)

 

 

 

Medium

 

 

 

 

 

15 unique citations

 

Brown et al. (1988)

 

Cocco et al. (1994)

Demers et al. (1994)

 

 

Burch et al. (1981)

 

Krstev et al. (2005)

Fredriksson et al. (1989)

 

 

De Stefani et al. (1998)

 

 

Garabrant et al. (1992)

 

 

Elci et al. (2002)

 

 

Hardell (1981)

 

 

Hinds et al. (1979)

 

 

Neugut et al. (1991)

 

Luce et al. (2000)

Luce et al. (2000)

 

 

Spiegelman and Wegman (1985)

 

 

Zagraniski et al. (1986)

 

 

 

Suggested Citation:"6 Description of Epidemiologic Studies Included in Evidentiary Dataset." Institute of Medicine. 2006. Asbestos: Selected Cancers. Washington, DC: The National Academies Press. doi: 10.17226/11665.
×

Quality of Exposure Characterization

Type of Cancer Investigated

Pharyngeal

Laryngeal

Esophageal

Stomach

Colorectal

Low

 

 

 

 

 

10 unique citations

 

Ahrens et al. (1991)

 

Ekstrom et al. (1999)

Gerhardsson de Verdier et al. (1992)

 

 

Olsen and Sabroe (1984)

Hillerdal (1980)

Hillerdal (1980)

Hillerdal (1980)

 

 

Shettigara and Morgan (1975)

 

 

Vineis et al. (1993)

 

 

Stell and McGill (1973)

 

 

 

 

Zheng et al. (1992b)

Zheng et al. (1992a)

 

 

 

36 unique citations

6

18

3

5

11

differentiation among histologic types. For example (although not specifically considered in the studies gathered for this review), esophageal cancer can be squamous or it can be adenocarcinomatous; the types are biologically and epidemiologically distinct. Second, cases can be (and generally are) studied shortly after diagnosis, and so survival rates do not so strongly influence case inclusion, as they do in occupational cohorts that rely on mortality records to define outcomes. Incidence-based case-control studies would be expected to be useful for investigating all the cancers in this review aside from esophageal cancer. Third, case-control studies are well suited to less common diseases, which would not occur in enough subjects in a typically sized cohort to permit any detailed analysis. This characteristic applies to laryngeal, pharyngeal, esophageal, and stomach cancers. Finally, case-control studies are well suited to exposures that cause disease only after a long latent period, as is presumed to occur between asbestos exposure and cancer.

Case-control studies also have disadvantages. First, there is a potential of unanticipated selection factors in choosing controls, leading to selection bias. Second, because the design is retrospective, it can be unclear whether exposure preceded or concurred with the outcome of cancer, although this

Suggested Citation:"6 Description of Epidemiologic Studies Included in Evidentiary Dataset." Institute of Medicine. 2006. Asbestos: Selected Cancers. Washington, DC: The National Academies Press. doi: 10.17226/11665.
×

is unlikely to be an issue for health effects arising from asbestos exposure, which typically have long latency periods. Third, recall bias poses some concern, but the greatest disadvantage and challenge of case-control studies is the overall difficulty of validly and reliably assessing exposure.

Health Outcome Data

Case-control studies examine the association between asbestos and cancer by identifying people with cancer (cases) and comparing their asbestos exposure with that of people without cancer (controls). Because exposures occurred in the past, the case-control design is termed retrospective. Cases can be ascertained over a specified period from a hospital or medical practice where cancer is treated. When cases are selected that way, the case-control study is called a hospital-based case-control study and typically involves as controls people who were treated at the same institutions for noncancer conditions. Cases can also be ascertained from a source that allows identification of all cancer occurring within a defined geographic area over some period, often through a hospital network or cancer registry. This type of case-control study is called a population-based case-control study and typically involves as controls people sampled in the underlying community from which cases arose. For example, controls may be selected from driver’s-license or voter-registration lists, by random dialing of telephone numbers, or by random contacting of neighbors.

In either the hospital-based or the population-based design, the strategy is to find controls that differ from cases only with regard to asbestos exposure. Cases and controls should not systematically differ in other important respects. For that reason, the population-based case-control method is sometimes considered methodologically superior to the hospital-based method. In the latter, controls with diseases other than cancer may have nonrandom patterns of asbestos exposure. Every attempt is made to avoid selection of controls who would have been systematically exposed to asbestos, such as hospital-based people with pleural plaques or mesotheliomas. Similarly, every attempt is made to avoid controls who systematically would not have been exposed to asbestos. For example, one would avoid a comparison of men with cancer to women without cancer, because women are less likely to have worked in an asbestos-exposed occupation.

Exposure Assessment

Unlike cohort studies, which have access to workplace data, assessment of exposure in occupational case-control studies almost always relies on subject recall. Information on the type of asbestos fiber to which subjects were exposed was uniformly unavailable in the case-control studies. The

Suggested Citation:"6 Description of Epidemiologic Studies Included in Evidentiary Dataset." Institute of Medicine. 2006. Asbestos: Selected Cancers. Washington, DC: The National Academies Press. doi: 10.17226/11665.
×

quality of an exposure assessment is determined by the type and amount of data collected, how the information was collected, and how it is used to assign exposure.

The best case-control studies collected detail lifetime work histories by using a structured interview or extensive questionnaires and assigned exposure on the basis of a review of the data by an “expert” in exposure or the use of a job-exposure matrix (JEM) created specifically to look at asbestos exposure. Those methods avoid some of the limitations of recall bias because exposure is not directly self-assessed, and they greatly improve the quality of the assessment.

Moderate-quality studies collected less detailed or more limited work-history information (for example, relied on proxy respondents or collected information on only the longest held jobs) or assigned exposure by using a multipurpose JEM that did not consider level of exposure. The best- and moderate-quality studies were combined in the exposure-assessment method (EAM) category “EAM = 1” for the meta-analyses.

The lowest-quality studies (“EAM = 2” for the meta-analyses) considered in this review used self-ascribed exposure based on direct questions or had very limited work-history information, as was the case for the lowest tier of studies in Table 6.5.

The method used to measure exposure to asbestos was an important criterion in reviewing the case-control studies. Case-control studies that used job information abstracted from death certificates were excluded from this evaluation, and none of those retained happened to have gathered exposure information from workplace records. They all used some sort of structured or semi-structured interview administered in person, over the telephone, or by mail (with or without the option of follow-up by telephone); these are listed in decreasing order of desirability. The committee decided to set aside case-control studies in which exposure to asbestos could only be inferred from an occupational category (such as insulator or ship repair) rather than from the original researchers’ explicit attribution of asbestos exposure.

The ability to assess dose-response relationships depends heavily on the quality of the underlying data. For example, dose-response relationships cannot be analyzed if the data collected were too crude to assign a level of exposure or some surrogate of dose. Therefore, the quality of exposure assessment correlates with the thoroughness and overall quality of analyses ultimately possible.

INTEGRATION OF EPIDEMIOLOGIC EVIDENCE WITH NON-EPIDEMIOLOGIC EVIDENCE

Results from epidemiologic studies of both cohort and case-control designs constitute an important component, but not the only type of evidence

Suggested Citation:"6 Description of Epidemiologic Studies Included in Evidentiary Dataset." Institute of Medicine. 2006. Asbestos: Selected Cancers. Washington, DC: The National Academies Press. doi: 10.17226/11665.
×

considered in the approach applied in Chapters 7-11 to assess the likelihood and strength of causal associations between asbestos and cancer at the selected sites. The committee’s strategy for integrating all the evidence closely follows that used by the surgeon general’s report on health risks related to tobacco-smoking (HHS 2004). To illustrate, we would characterize as strongly supportive epidemiologic evidence those datasets that contain consistently increased risks with increasing dose-response gradients from both case-control studies performed in different places and cohort studies conducted in various industries. The magnitude of observed risks and their statistical precision also entered into the committee’s evaluations. Many of the case-control studies addressed potential confounding by non-occupational risk factors (such as smoking, alcohol use, and diet), but this was not possible in most cohort studies; these factors are seldom correlated with exposure strongly enough to greatly bias estimated risks through confounding (Axelson 1989, Kriebel et al. 2004). Consequently, the impossibility of controlling for potential confounding by risk factors not related to occupation was not considered a major concern for evaluation of the cohort studies. The epidemiologic evidence thus distilled is then considered in the context of the available non-epidemiologic information in reaching a determination about a causal role for asbestos exposure on a site-specific basis.

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In conjunction with drafting comprehensive legislation concerning compensation for health effects related to asbestos exposure (the Fairness in Asbestos Injury Act), the Senate Committee on the Judiciary directed the Institute of Medicine to assemble the Committee on Asbestos: Selected Health Effects. This committee was charged with addressing whether asbestos exposure is causally related to adverse health consequences in addition to asbestosis, mesothelioma, and lung cancer. Asbestos: Selected Cancers presents the committee's comprehensive distillation of the peer-reviewed scientific and medical literature regarding association between asbestos and colorectal, laryngeal, esophageal, pharyngeal, and stomach cancers.

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