Below are the first 10 and last 10 pages of uncorrected machine-read text (when available) of this chapter, followed by the top 30 algorithmically extracted key phrases from the chapter as a whole.
Intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text on the opening pages of each chapter.
Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.
Do not use for reproduction, copying, pasting, or reading; exclusively for search engines.
OCR for page 271
A
Radiation as a Carcinogen
A.1 RADIATION AS A CAUSE OF CANCER
At low doses of radiation, cells may be damaged. The main initiating
event by which radiation damages the cells in the long term is damage to
DNA in the cell nucleus. With well-orchestrated and efficient mechanisms,
cells respond to the induced damage and attempt to repair it, but some-
times the damage cannot be repaired or is misrepaired, which may lead to
mutations. The modifications induced by low levels of radiation dose may
be transmitted to daughter cells and may lead to uncontrolled cell growth
and consequently cancer, the health effect of primary concern in the context
of radiation. Exposure to radiation is not the only way in which the DNA
within a cell can be damaged and become cancerous. In fact, DNA dam-
age can occur spontaneously or due to a number of other stressors such as
chemical exposure (for example, smoking and lung cancer) and infectious
agents (for example, hepatitis B virus and liver cancer). In other words, as
ionizing radiation exposure induces DNA damage to the tissue, that tissue
will already carry some damaged cells from other stressors.
Although small increases in the chance of developing cancer is the
main health effect of low levels of radiation, such effects in individuals are
probabilistic and known as stochastic effects. In other words, there appears
to be no threshold below which effects do not occur, but the greater the
exposure, the higher the probability that they will occur. Severity of the ef-
fects does not depend on dose. This is in contrast to the “deterministic” or
“nonstochastic” radiation effects of high doses of radiation, that is, doses
of several sieverts that can kill enough cells to cause injury such as skin red-
271
OCR for page 272
272 APPENDIX A
dening, burns, organ damage, radiation sickness, and even death. Patients
receiving radiation treatment for cancer often experience controlled acute
radiation sickness because they receive relatively high levels of radiation.
Infertility and cataract are two other examples of nonstochastic effects of
radiation; cataract may not occur until several years after exposure. Doses
to people near nuclear facilities are far below levels that would cause de-
terministic effects.
In the case of the effects of exposure to low levels of radiation (less than
0.1 Gy, or 100 mSv effective dose), the scientific uncertainty of radiation-
induced cancer is considerable as there is little or no empirical knowledge.
Despite the uncertainty, decisions are needed for use in setting standards
for protection of individuals against the side effects of low-level radiation.
Based on current scientific knowledge (or lack thereof), regulatory agencies
in the United States currently use a model that describes radiation injury as
a linear function of radiation dose that has no threshold; this is called the
linear no-threshold (LNT) model. According to LNT, if a dose equal to 1
Gy gives a cancer risk X, the risk from a dose of 0.01 Gy is X/100, the risk
from 0.00001 Gy is X/100,000, and so on. Thus, the risk of health effects
including cancer risk is not zero regardless of how small the dose is.
In the LNT model, data from high levels of exposure where radiogenic
cancers have been observed are used to extrapolate risks at lower doses
where cancers have not been observed, and if they exist they are beyond
the current science to observe and measure. One result of following the
LNT model is that a very small estimated risk, when multiplied by a large
number such as the population of the United States, results in an estimate
of a substantial number of cases or deaths, which in reality may not exist.
Scientific groups such as the International Commission on Radiologi-
cal Protection (ICRP), the National Council on Radiation Protection and
Measurements (NCRP), and the National Research Council Committee on
the Biological Effects of Ionizing Radiation (BEIR), repeatedly review and
endorse the use of this model for assessing risk, which is used to set radia-
tion protection standards and operating policies, such as the “as low as rea-
sonably achievable” (ALARA) policy. This approach is often considered to
be conservative and gives emphasis to public health. Data provided by the
updated report of the atomic bombing survivors in Japan continue to be in
support of the LNT model across the entire dose range. However, a concave
curve was the best fit for data restricted to doses of 0-2 Gy. This resulted
because risk estimates for exposure to 0.3-0.7 Gy were lower than those in
the linear model (Ozasa et al., 2012). The finding was not explained.
Not all countries support the LNT model at this time, but in general it
is perceived that with so much uncertainty about the effects at low doses,
it is appropriate to continue with the LNT model that has been in place for
several decades for purposes of radiation protection.
OCR for page 273
273
APPENDIX A
A.2 BIOLOGICAL RESPONSES AT LOW DOSES
A variety of different biological responses have been identified at low
doses of radiation, although it is difficult to identify effects at doses that are
close to those encountered from natural background radiation. It is highly
unlikely that epidemiologic studies of populations around nuclear facilities
will contribute toward knowledge of the effects of radiation at very low
doses. Because of the epidemiologic limitations, efforts are directed toward
improving understanding of the effects, response, and defense mechanisms
to low-dose radiation at the cellular and molecular levels. The Department
of Energy’s Low Dose Radiation Program is focused on understanding the
effects of doses of radiation under 100 mSv by supporting research of the
molecular and cellular responses to very-low-dose exposures. Some scien-
tists have argued that DNA repair capabilities are effective at low doses,
preventing the accumulation of DNA damage and mutations following
low-dose exposures, while others have argued that low doses may be even
more damaging per unit dose than high doses.
Major discussion on the biological consequences of low-dose radiation
despite being controversial has also led to the identification of pathways
of radiation damage that are evident at low doses but difficult to measure
at high doses in light of overwhelming DNA damage. Among these is the
adaptive response, which would tend to dampen the potential adverse
effects and perhaps even provide a beneficial (or hormetic) effect of radia-
tion exposure at low doses. In most studies of adaptive responses, cells in
vitro are given a “tickle” low dose of radiation (for example 20 cGy or 0.2
Gy) followed by a high dose of radiation (1 Gy). The administration of
the “tickle” dose prevents some of the damaging effects of the high dose,
including cell killing and chromosomal injury. In animal models a variety
of investigators have documented that low doses of radiation can enhance
immune responses (Cheng et al., 2010).
There are also several damaging responses observed at low doses, in-
cluding the bystander effect and delayed genomic instability. The bystander
effect is defined as genetic changes (chromosome damage, mutations) in-
duced in cells that are not directly hit by the radiation beam. The exact
mechanism by which the bystander effect occurs is unclear, although data
support both transmission of a factor either in conditioned medium (Sowa
Resat and Morgan, 2004) or through gap junctions (Gaillard et al., 2009).
Recent studies have documented that such bystander effects may occur in
vivo as well (Singh et al., 2011). Delayed genomic instability has also been
identified in irradiated cell populations where mutations do not occur in the
irradiated cells themselves but rather in the progeny of these irradiated cells
sometimes up to 13 generations later (Little et al., 1997; Morgan, 2003).
Another detrimental effect of low-dose exposures (mostly in the cGy
range) is low-dose hypersensitivity in which some cells in culture show an
OCR for page 274
274 APPENDIX A
enhanced response to the killing effects of x-rays at the very low doses (10-
60 cGy) than they do to slightly higher doses (1 Gy, for example). Whether
this is really a low-dose hypersensitivity or an induced radiation resistance
at the slightly higher doses (1 Gy) is not clear, and the mechanism for it
has not been defined, although some attribute it to the need for a threshold
number of double-strand breaks to induce cell-cycle arrest (Marples et al.,
2004).
Dose-rate factors are also important in considering the effects of low-
dose radiation. Most studies have documented that low-dose-rate exposure
is less damaging than similar doses administered at high rates, although
these studies are limited, difficult to conduct, and predominantly in animal
populations (Brooks, 2011; Vares et al., 2011). In long-term animal studies
carried out at Argonne National Laboratory in 1960-1990, dogs and mice
were exposed to doses of radiation daily with very low doses per day and
equal doses given in a single exposure; these studies revealed that life short-
ening and cancer incidence was significantly higher for animals given the
high-dose-rate compared to the low-dose-rate exposures (Carnes and Fritz,
1991; Carnes et al., 1998). In other mouse strains (AKR), a lower incidence
of cancer-induced thymic lymphoma was also found in mice exposed to
low-dose-rate compared to high-dose-rate radiation (Shin et al., 2011),
suggesting that there are significant differences in biological consequences
(Uehara et al., 2010).
Radiobiological data, some based on animal experiments, have been
the basis of the dose and dose-rate effectiveness factors (DDREFs), that is,
factors used to convert risk estimates from populations exposed in larger
acute doses such as the atomic bombing survivors to populations who are
exposed to lower low-rate doses. The ICRP derived estimates of the excess
cancer risk after low-dose exposures and after exposures with higher doses
but low-dose rates by reducing the corresponding risk value for the atomic
bombing survivors by a DDREF of 2.0 (ICRP, 2007). The BEIR VII Com-
mittee used a DDREF of 1.5 (National Research Council, 2005). It has been
speculated that these DDREFs underestimate the risks from low-dose-rate
exposures. For example, in a recent paper by Jacob et al. (2009), compari-
sons of risks of radiation workers who receive chronic exposures with those
of the atomic bombing survivors who received acute exposures indicated
that risks among workers tended to be higher, contrary to expectations.
A.3 BIOMARKERS
Most individuals exposed to radiation do not wear physical dosimeters
such as film badges or thermoluminescent dosimeters; therefore, recon-
structing their exposure requires collecting information through interviews
and available models and thus estimated exposures often contain a high
OCR for page 275
275
APPENDIX A
level of uncertainty. In an attempt to overcome this problem, biological
markers are being developed as a useful tool for estimating the exposure
and the effects of, or the response to, radiation. A biomarker is in general
an end point that is objectively measured and can be used as an indicator
of a biological state. Studies have highlighted the importance of biomarker
research in radiation epidemiology specifically in assessing occupational
exposure (Schneider et al., 1999), exposure following industrial accidents
(Menz et al., 1997), as well as response to radiation therapy (Wickremese-
kera et al., 2001). Two types of purpose-oriented categorizations of irradia-
tion biomarkers have been proposed. Brooks segregates them into markers
of exposure, sensitivity, and disease (Brooks, 1999), while others mention
predictive, prognostic, diagnostic, and dosimetric markers (Okunieff et al.,
2008). A single biomarker can often fit into several of these categories
which serve different purposes. For example, biomarkers of effect mea-
sure the biological responses in individuals who have been exposed to an
agent (and also include elements of individual sensitivity to that agent);
markers of exposure, on the other hand, do not necessarily indicate ef-
fects. A methodology-focused categorization of radiation biomarkers would
separate them into cytological and molecular markers, both with numerous
subcategories. In addition, while cytological markers in radiation research
are often very specific, molecular-based radiation biomarkers are often
compendia of molecules rather than isolated molecular species. Today, the
use of biomarkers in epidemiologic studies of low doses is unlikely to help
with dose reconstruction, as the variability of the assays within a person
and between persons is a major problem. However, the rapid advances in
the research on biomarkers may in the future provide more sensitive tools
that may also prove useful for epidemiologic purposes and significantly
reduce the uncertainties related with current dose reconstruction models.
A.4 EPIDEMIOLOGIC STUDIES OF IONIZING RADIATION
A.4.1 Studies of Residents near Nuclear Facilities
A British television program in 1983 reported a cluster of childhood
leukemia in Seascale, a village 3 km from the nuclear fuel reprocessing facil-
ity Sellafield on the Cumbrian coast, then known as Windscale. The televi-
sion team discovered seven childhood leukemia cases over the previous 30
years, while less than one case was expected (Urquhart et al., 1984). Given
the proximity of the village to the nuclear reprocessing plant, and in the ab-
sence of any other obvious causative agent, a direct effect of environmental
pollution with radioactive waste was hypothesized. The British government
appointed an independent advisory group to investigate the claims. The
group produced its report within seven months (Black, 1984), confirming
OCR for page 276
276 APPENDIX A
the TV broadcast, but could not explain the finding in terms of radioactive
discharges. In response, a governmental Committee on Medical Aspects of
Radiation in the Environment (COMARE) was set up in 1985 and over the
past 25 years has published several reports using data from the national
registry of children’s tumors. The reports include an extensive investigation
of the Sellafield area (COMARE, 1996) and the sites of Dounreay in Scot-
land (COMARE, 1988), Aldermaston in Berkshire, and Burghfield in North
Hampshire (COMARE, 1989). Reviews by COMARE of the discharges
from the nuclear installations showed that the doses that the general public
residing in the area were likely to have received were far too small to have
caused increases in childhood leukemia (COMARE, 1988, 1989, 1996). In
2011, COMARE published an update on the issue as its fourteenth report
(COMARE, 2011), undertaking a further review of the issues addressed
in the tenth report that covered the years 1969-1993 (COMARE, 2005).
The latest report covered the period 1969-2004 and found no significant
evidence of an association between risk of childhood leukemia and living
in proximity to a nuclear power plant (COMARE, 2011).
The sequence of cluster or ecologic studies finding excess cancers
around a nuclear site and more detailed examination following to confirm
the findings and research the associations has been a common approach for
many years. Studies from Great Britain, Germany, France, and the United
States contribute the most to the literature. Childhood leukemia is primar-
ily investigated as it is recognized to be a “sentinel indicator” for radiation
effects occurring with a shorter time latency following exposure and with
a stronger dose-risk relationship. Although initially mortality data were
used to evaluate the possible impact of living near nuclear facilities under
normal operating conditions, it was soon realized that, given the advances
in cancer treatment and consequent improvements in survival, incidence
data (the number of newly diagnosed cases in a given period of time) could
provide more relevant estimates.
Studies on the cancer risks associated with living near nuclear facilities
have come to different conclusions, with some suggesting a positive as-
sociation between living in proximity to a nuclear facility and cancer risk
and others suggesting that there is not a risk, or that the risk is too small
to be detected with the methodology used. The power of a study to detect
an effect, if there is one, depends highly on the hypothesized strength of the
association to be detected and the sample size. Neither of these variables is
likely to be high in an epidemiologic study of cancer risks in populations
near nuclear facilities:
a. The size of the estimated risks from reported radioactive effluent
releases from nuclear facilities is likely to be small. Consequently,
OCR for page 277
277
APPENDIX A
epidemiologic studies have a limited ability to discern associations
between radiation exposure and cancer risk in these populations.
b. The size of the populations most likely to be exposed (that is,
those living in very close proximity to a nuclear facility, for ex-
ample within a 5-10-km radius) is relatively small. This limits the
expected number of informative (exposed) incident cases or deaths
that will be available for study, especially for rare cancers such as
those of childhood.
Study conclusions are based on a very small local population size,
which makes the risk estimations statistically unstable because a single ad-
ditional case, or one less case, can change the rate estimate dramatically.
For example, in the study in Germany with 23 years of follow-up, out of
the 593 leukemia cases in children under 5 years old diagnosed in the study
area, only 37 cases (6 percent) were observed in the risk zone (≤ 5 km from
a facility) (Kaatsch et al., 2008). Similarly, in the recent COMARE report
(2011) with 35 years of follow-up, out of the 430 leukemia cases in children
under 5 diagnosed in an area up to 25 km from the nuclear power plants
in Britain, only 20 (5 percent) were in the risk zone (Table A.1). It is ex-
pected that a study in the United States would contain a larger number of
exposed individuals than those in the European studies because the number
of nuclear power plants in the United States is larger than that in any of
the European countries.
For this and other reasons related to differences in study design or
analysis stages (results may be influenced, for example, by unrecognized
bias in the data, the effect of other relevant factors, or by chance varia-
tion; these need to be discussed by the investigators even if they cannot be
quantified), interpretation of epidemiologic findings is not always easy and
there are often subjective elements to their interpretation that experts may
disagree upon. Evaluating well-designed studies that do not suggest the ex-
istence of an association between a factor and a disease is equally important
TABLE A.1 Number of Cases in the At-Risk Zone (≤ 5 km from a
facility) in European Studies of Pediatric Cancers (children < 5 years old)
Cases (≤ 5 km)
Country Reference Study Years End Point
Germany Spix et al., 2008 23 all cancers 77
Kaatsch et al., 2008 leukemia 37
France Sermage-Faure et al., 2012 17 leukemia 24
Britain COMARE, 2011 35 leukemia 20
Switzerland Spycher et al., 2011 24 all cancers 18
leukemia 8
OCR for page 278
278 APPENDIX A
to evaluating studies that show an association. However, it is often harder
to convince stakeholders of the validity of the so-called “negative” studies
especially if there are flaws or inefficiencies in their design, methods, or
analysis. A better term for flawed studies would be “uninformative.”
In absence of biological plausibility, a positive or somewhat positive
association may be underinterpreted. In studies that assess cancer risks as-
sociated with releases from nuclear facilities, there are examples where in-
vestigators are hesitant to conclude that evidence supported the hypothesis
when they find a positive association between risk and exposure associated
with nuclear facilities (Baker and Hoel, 2007; Hatch et al., 1990; Kaatsch
et al., 2008; Nuclear Safety Council and the Carlos III Institute of Health,
2009), even though direct radiation measurements were not made. This
phenomenon has led a researcher to emphasize the importance of having
explicit study hypotheses (Wing et al., 2011) and to the question, “Why
conduct a study if the results cannot be interpreted as providing evidence in
support of the hypothesis?” (Wing, 2010). Of course, there is the opposite
error, too—that of overinterpretation. A balanced “weight-of-evidence”
approach is the most appropriate.
It is important to be open to new information or novel interpretation
and alternative hypotheses that can impact assumptions about exposure
effects. A recent study from France demonstrated that children living in
very close proximity to nuclear power plants are twice as likely to develop
leukemia compared to those living farther away from the plants. However,
analysis of the same population of children using a dose-based geographic
zoning approach instead of distance, did not support the findings. The ab-
sence of any association with the dose-based geographic zoning approach
may indicate that the observed association with distance may be due to
factors other than the releases from the nuclear power plants (Sermage-
Faure et al., 2012). Among such potential factors are population mixing
(Kinlen, 2011a), a hypothesis that could not be evaluated in this study, and
exposures to agents including natural or manmade exposures to radiation
not modeled in the study.
From the reports published the past 4 years alone from Germany
(Kaatsch et al., 2008), Finland (Heinavaara et al., 2010), Great Brit -
ain (COMARE, 2011), Switzerland (Spycher et al., 2011), and France
(Sermage-Faure et al., 2012), it is obvious that additional scientific resolu-
tion to the question of whether living near a nuclear facility increases one’s
risk of developing cancer remains. Authors have called for collaborative
analysis of multisite studies conducted in various countries (Sermage-Faure
et al., 2012). Similarly, the need for a well-conducted meta-analysis that
would provide a more precise estimate of the risk remains.
Two meta-analyses were conducted recently in an effort to provide
more precise estimates of the possible risks associated with living near a
OCR for page 279
279
APPENDIX A
nuclear facility (Baker and Hoel, 2007; Greiser, 2009). Baker and Hoel
combined and statistically analyzed studies of childhood leukemia around
nuclear facilities published until 1999, but only included studies that calcu-
lated standardized incidence ratios (SIRs) or standardized mortality ratios
(SMRs) (see Sidebar A.1 for risk measures) for individual facilities. Studies
that calculated rates for multiple sites or those that did not distinguish leu-
kemia from lymphoma were excluded. Seventeen published studies (out of
37 individual studies published at the time) addressing 136 nuclear sites in
7 countries (Great Britain, Canada, France, United States, Germany, Japan,
and Spain) met the criteria. Due to variability between study designs, eight
separate analyses were performed stratified by age and zone. Meta-SMRs
and meta-SIRs were all greater than the reference group, implying an in-
crease in risk. More specifically, the overall estimated relative risk was 1.22
(95% CI=1.05-1.41) and the 0-9 age group accounted for the majority of the
excess cases and deaths. Excluding the Aldermaston nuclear weapons plant
and Amersham plant that produces radioisotopes (both in Britain) reduced
the overall estimate to a nonsignificant 14 percent increase in risk (RR=1.14,
95% CI=0.98-1.33). The authors discuss that although the meta-analysis
showed an increase in childhood leukemia near nuclear facilities, it “does
not support a hypothesis to explain the excess” (Baker and Hoel, 2007).
The meta-analysis by Baker and Hoel was criticized by authors of the
German Kinderkrebs in der Umgebung von Kernkraftwerken (KiKK) study
(Spix and Blettner 2009). The first issue they identified with the meta-
analysis was the general problem of combining heterogeneous data such as
different age groups (0-9 years or 0-25 years), the different types of nuclear
facilities (nuclear power plants and other facilities), and the different expo-
sure zone definitions (<10 km or county). Beyond that, there was criticism
over the completeness of the publication search and lack of justification for
excluding the 20 studies which were identified but did not fit the criteria for
inclusion; possible selection bias resulting from the exclusion of sites with
zero observed leukemia cases or deaths from leukemia; and a methodologi-
cal problem with the confidence intervals presented in the forest plots which
should be symmetric on a logarithmic scale but, contrary to expectation,
were skewed (Spix and Blettner, 2009).
The meta-analysis by Greiser included data from 80 nuclear power
plants in five countries (Germany, France, Great Britain, United States, and
Canada). Data were retrieved in the literature but also from cancer regis-
tries. (Rather than relying on the data used in the Jablon et al. 1991 analysis
of risks in nuclear facilities in the United States, the author retrieved cancer
incidence data from cancer registries of Illinois, Pennsylvania, and Florida.)
The incidence of leukemia was estimated to increase by 13 percent (95%
CI = 10%-17%) relative to the corresponding average national or regional
rate (Greiser, 2009). The latest COMARE report (2011) discusses the key
OCR for page 280
280 APPENDIX A
SIDEBAR A.1
Risk Measures, P Values, and Confidence Intervals
Several types of estimates of relative risk (RR) are used in epidemiologic studies.
RR is generically defined as the ratio of the risk of developing the disease or of dying
of the disease among an exposed population compared to an unexposed population.
A simple type of estimate of the RR is the standardized incidence ratio (SIR) or stan-
dardized mortality ratio (SMR) for the exposed group. An SIR is the ratio of the number
of cases observed in the exposed group in some time period to the number of cases
expected if the group had the same disease occurrence rates as a standard population.
The standard population is often the general population or a large reference population
with characteristics similar to the study group except for the exposure of interest, and
comparisons typically are based on cancer rates from population cancer registries. The
ratio of observed to expected cases is often multiplied by 100 to yield results without
decimals. Thus, an SIR of 100 indicates that the observed number of cases is the
same as that expected in the standard population. Thus, an SIR of 140 indicates that
incidence is 40 percent higher than expected, while an SIR of 80 indicates 20 percent
fewer cases than expected.
SIRs should be interpreted with caution as their significance partially depends on
the number of cancer cases in the exposed group. Imagine a situation where 5 cases
were expected and 6 were observed and a second situation where 500 cases were
expected and 600 were observed. In both instances the SIR is 120; however, because
in the second scenario the SIR is based on a greater number of cases, the estimate
is more precise, and hence more meaningful. In other words, although the one excess
case could have occurred due to chance alone, it is highly unlikely that an excess of
100 incident cases has occurred by chance. This is a common issue in interpreting
studies of risks in populations near nuclear facilities where the number of excess can-
cers in the exposed region is particularly small when rare diseases such as childhood
leukemia are examined (see Table A.1).
The SMR is similar to the SIR, except it is based on deaths due to some cause
rather than cancer occurrences to draw conclusions regarding whether there is excess
mortality. As age is one of the main determinants of mortality, and other factors such as
gender and racial composition may influence the mortality or tumor rates, SMRs and
SIRs are usually calculated by summing the observed and expected numbers of deaths
or cancers across categories of gender, age, and sometimes race with the expected
numbers calculated separately for each category.
Results from cohort and ecologic studies are sometimes described in terms of
SMRs or SIRs, but other techniques are often preferred which permit comparisons of
disease rates (often called rate ratios) between exposed and unexposed study groups,
usually with adjustment for gender, age, and perhaps other factors. More advanced
techniques use some type of “regression analysis” to estimate exposure-effect asso-
ciations, with study subgroups or individuals defined according to graded amounts of
exposure.
Case-control studies (which compare exposures observed in cases to those ob-
served in control subjects) are typically unable to calculate actual disease rates since
they lack appropriate population denominators, which means that SIRs, SMRs, and
rate ratios cannot be used. However, for case-control studies the odds ratio (OR) can
be calculated. The OR and relative risk are closely related (and are nearly identical for
“rare” diseases). The OR indicates the ratio of the probability of exposure to the prob-
OCR for page 281
281
APPENDIX A
ability of nonexposure among those with the disease of interest divided by the similar
ratio of probabilities among those without the disease. A value greater than 1 means
that the odds of disease are greater among the exposed than the unexposed. A value
less than 1 means that the odds are higher in the unexposed than in the exposed.
Similar to all the other statistics mentioned, the number of disease cases with exposure
has a major influence on the precision and statistical significance of the OR.
A useful measure of risk in epidemiologic studies is that of “excess” risk associated
with an exposure. Excess risk can be expressed as excess relative risk (ERR) or ex-
cess absolute risk (EAR). The ERR and EAR in principle are estimates of the amount of
risk due to the exposure of interest when the effects of other risk factors are removed.
Statistically, ERR = RR-1 and EAR = RE – RU , where RE is the rate of occurrence of
disease or death in the exposed group in a specified period, and RU is the correspond-
ing rate of occurrence in the unexposed group, which is the baseline rate. In contrast
to ERR, which represents the ratio of the excess rate associated with exposure to the
baseline rate, the EAR represents the additional rate of a disease due to the exposure
of interest over a given period of time. As baseline disease rates depend on a number
of factors, excess risks can vary not only with radiation dose but also with age at ex-
posure, time after exposure, age at risk (attained age), gender, and other factors such
as smoking. Therefore, risk estimates are usually reported for a specified combination
of these factors. ERR and EAR estimates can best be calculated in a cohort study,
although ecologic studies can sometimes permit such estimates to be made. A statistic
analogous to the ERR estimate can be calculated as OR-1 for case-control studies, but
usually EAR estimates cannot be obtained from a case-control study due to the lack
of population denominators.
By describing the excess number of people affected by the disease of interest, EAR
is a better descriptor than the ERR of the public health impact that an exposure may
have in a population. For example, in the Life Span Study (LSS) follow-up of the Japa-
nese atomic bombing survivors the ERR for leukemia is the highest among the various
cancer effects of radiation exposure (RR approximately 5 for a dose of 1 Gy, which
translates into an ERR of about 4), and the total number of radiation-related cases of
leukemia among the LSS survivors is estimated to be about 90-100. In contrast, the
ERR for solid cancers is much smaller (RR approximately 1.5 at 1 Gy, or an ERR of
about 0.5), yet the total number of LSS survivors who have developed solid cancers
due to the bombing is estimated to be about 850. This is because of the relative rarity
of leukemias compared to the group of cancers described as solid cancers. Common
cancers may appear to have a low ERR in an epidemiologic study, but the risk may
translate to a large number of cases, or a large EAR. One can say that the ERR is an
appropriate measure to assess disease etiology, whereas the EAR is useful for estimat-
ing the extent of a health problem.
Applying ERR or EAR estimates derived from individuals in one population to those
in another population sometimes has substantial uncertainties. Since most types of
cancer vary substantially in their baseline frequency according to age, both ERR and
EAR estimates can be affected by differences in the age distributions of populations
being compared. For instance, it would be inappropriate to compare radiation-related
leukemia risk of children in one population with adult leukemia risk in another popula-
tion. Sometimes there also are differences in the baseline rates of disease in different
populations even with the same age distributions. For example, the Japanese have
historically had much higher rates of stomach and liver cancers than in the United
States. It is therefore uncertain as to how to extrapolate stomach or liver cancer ERR
continued
OCR for page 320
320 APPENDIX A
COMARE (1989). Third Report. Report on the Incidence of Childhood Cancer in the West
Berkshire and North Hampshire area, in Which Are Situated the Atomic Weapons Re-
search Establishment, Aldermaston and the Royal Ordance Factory, Burghfield. London:
HMSO.
COMARE (1996). Fourth Report. The Incidence of Cancer and Leukaemia in Young People
in the Vicinity of the Sellafield Site, West Cumbria; Further Studies and an Update of
the Situation Since the Publication of the Report of the Black Advisory Group in 1984.
London: Department of Health.
COMARE (2005). Tenth Report: The Incidence of Childhood Cancer Around Nuclear Instal-
lations in Great Britain. London: Department of Health.
COMARE (2011). Fourtheenth report: Further Consideration of the Incidence of Child-
hood Leukemia Around Nuclear Power Plants in Great Britain. London: Department
of Health.
Cook-Mozaffari, P. J., S. C. Darby, et al. (1989a). Geographical variation in mortality from
leukaemia and other cancers in England and Wales in relation to proximity to nuclear
installations, 1969-78. Br J Cancer 59(3):476-485.
Cook-Mozaffari, P., S. Darby, et al. (1989b). Cancer near potential sites of nuclear installa-
tions. Lancet 2(8672):1145-1147.
Crump, K. S., T. H. Ng, et al. (1987). Cancer incidence patterns in the Denver metropolitan
area in relation to the Rocky Flats plant. Am J Epidemiol 126(1):127-135.
Cullings, H. M., S. Fujita, et al. (2006). Dose estimation for atomic bomb survivor studies: its
evolution and present status. Radiat Res 166(1 Pt 2):219-254.
Davis, S., K. J. Kopecky, T. E. Hamilton, and L. Onstad (Hanford Thyroid Disease Study
Team) (2004). Thyroid neoplasia, autoimmune thyroiditis, and hypothyroidism in per-
sons exposed to iodine 131 from the hanford nuclear site. JAMA 292:2600-2613.
de Gelder, R., G. Draisma, et al. (2011). Population-based mammography screening below
age 50: balancing radiation-induced vs prevented breast cancer deaths. Br J Cancer
104(7):1214-20
Degteva, M. O., M. I. Vorobiova, et al. (2000). Dose reconstruction system for the exposed
population living along the Techa River. Health Phys 78(5):542-554.
Delarue, N. C., G. Gale, et al. (1975). Multiple fluoroscopy of the chest: Carcinogenicity for
the female breast and implications for breast cancer screening programs. Can Med Assoc
J 112(12):1405-1413.
Doll, R., and R. Wakeford (1997). Risk of childhood cancer from fetal irradiation. Br J Radiol
70:130-139.
Doll, R., H. J. Evans, et al. (1994). Paternal exposure not to blame. Nature 367(6465):
678-680.
Doody, M. M., J. E. Lonstein, et al. (2000). Breast cancer mortality after diagnostic radiog-
raphy: Findings from the U.S. Scoliosis Cohort Study. Spine (Phila Pa 1976) 25(16):
2052-2063.
Dousset, M. (1989). Cancer mortality around La Hague nuclear facilities. Health Phys 56(6):
875-884.
Draper, G. J., and T. J. Vincent (1997). Death rates from childhood leukaemia near nuclear
sites. Findings were probably due to chance fluctuations in small numbers of deaths. BMJ
315(7117):1233; author reply 1234.
Draper, G. J., C. A. Stiller, et al. (1993). Cancer in Cumbria and in the vicinity of the Sellafield
nuclear installation, 1963-90. BMJ 306(6870):89-94.
Draper, G. J., M. P. Little, et al. (1997). Cancer in the offspring of radiation workers: A record
linkage study. BMJ 315(7117):1181-1188.
Dunn, K., H. Yoshimaru, et al. (1990). Prenatal exposure to ionizing radiation and subsequent
development of seizures. Am J Epidemiol 131(1):114-123.
OCR for page 321
321
APPENDIX A
Enstrom, J. E. (1983). Cancer mortality patterns around the San Onofre nuclear power plant,
1960-1978. Am J Public Health 73(1):83-92.
Evrard, A. S., D. Hemon, et al. (2006). Childhood leukaemia incidence around French nuclear
installations using geographic zoning based on gaseous discharge dose estimates. Br J
Cancer 94(9):1342-1347.
Ewings, P. D., C. Bowie, et al. (1989). Incidence of leukaemia in young people in the vicinity
of Hinkley Point nuclear power station, 1959-86. BMJ 299(6694):289-293.
Folley, J. H., W. Borges, et al. (1952). Incidence of leukemia in survivors of the atomic bomb
in Hiroshima and Nagasaki, Japan. Am J Med 13(3):311-321.
Forman, D., P. Cook-Mozaffari, et al. (1987). Cancer near nuclear installations. Nature
329(6139):499-505.
Fujiwara, S., R. Sposto, et al. (1992). Hyperparathyroidism among atomic bomb survivors in
Hiroshima. Radiat Res 130(3):372-378.
Gaillard, S., D. Pusset, et al. (2009). Propagation distance of the alpha-particle-induced by-
stander effect: The role of nuclear traversal and gap junction communication. Radiat
Res 171(5):513-520.
Gardner, M. J., M. P. Snee, et al. (1990). Results of case-control study of leukaemia and
lymphoma among young people near Sellafield nuclear plant in West Cumbria. BMJ
300(6722):423-429.
Garssen, B. (2004). Psychological factors and cancer development: Evidence after 30 years of
research. Clin Psychol Rev 24(3):315-338.
Gilbert, E. S. (2009). Ionising radiation and cancer risks: What have we learned from epide-
miology? Int J Radiat Biol 85(6):467-482.
Gilbert, E. S., S. A. Fry, et al. (1989). Analyses of combined mortality data on workers at the
Hanford Site, Oak Ridge National Laboratory, and Rocky Flats Nuclear Weapons Plant.
Radiat Res 120(1):19-35.
Gilbert, E. S., N. A. Koshurnikova, et al. (2000). Liver cancers in Mayak workers. Radiat
Res 154(3):246-252.
Goldsmith, J. R. (1989). Childhood leukaemia mortality before 1970 among populations near
two US nuclear installations. Lancet 1(8641):793.
Goldsmith, J. R. (1992). Nuclear installations and childhood cancer in the UK: Mortality
and incidence for 0-9-year-old children, 1971-1980. Sci Total Environ 127(1-2):13-35;
discussion 43-55.
Graham, S., M. L. Levin, et al. (1966). Preconception, intrauterine, and postnatal irradiation
as related to leukemia. Natl Cancer Inst Monogr 19:347-371.
Greiser, E. (2009). Leukämie-Erkrankungen bei Kindern und Jugendlichen in der Umge-
bung von Kernkraftwerken in fünf Ländern Meta-Analyse und Analyse [Leukaemia in
children and young people in the vicinity of nuclear power stations in five countries.
Meta-analyses and analyses.] Commissioned by the Bundesfraktion B’90/The Greens:
MUSAweiler. Available at http://www.ippnw.de/commonFiles/pdfs/Atomenergie/090904-
Metanalyse-Greiser.pdf.
Grosche, B., D. Lackland, et al. (1999). Leukaemia in the vicinity of two tritium-releasing
nuclear facilities: a comparison of the Kruemmel Site, Germany, and the Savannah River
Site, South Carolina, USA. J Radiol Prot 19(3):243-252.
Guizard, A. V., A. Spira, et al. (1997). [Incidence of leukemias in people aged 0 to 24 in north
Cotentin]. Rev Epidemiol Sante Publique 45(6):530-535.
Guizard, A. V., O. Boutou, et al. (2001). The incidence of childhood leukaemia around the
La Hague nuclear waste reprocessing plant (France): A survey for the years 1978-1998.
J Epidemiol Community Health 55(7):469-474.
Hatch, M., M. Susser, et al. (1997). Comments on A reevaluation of cancer incidence near the
Three Mile Island nuclear plant. Environ Health Perspect 105(1):12.
OCR for page 322
322 APPENDIX A
Hatch, M. C., J. Beyea, et al. (1990). Cancer near the Three Mile Island nuclear plant: Radia-
tion emissions. Am J Epidemiol 132(3):397-412; discussion 413-397.
Hatch, M. C., S. Wallenstein, et al. (1991). Cancer rates after the Three Mile Island nuclear
accident and proximity of residence to the plant. Am J Public Health 81(6):719-724.
Hattchouel, J. M., A. Laplanche, et al. (1995). Leukaemia mortality around French nuclear
sites. Br J Cancer 71(3): 651-653.
Heasman, M. A., I. W. Kemp, et al. (1986). Childhood leukaemia in northern Scotland. Lancet
1(8475):266.
Heinavaara, S., S. Toikkanen, et al. (2010). Cancer incidence in the vicinity of Finnish
nuclear power plants: an emphasis on childhood leukemia. Cancer Causes Control
21(4):587-595.
Hellquist, B. N., S. W. Duffy, et al. (2011). Effectiveness of population-based service screening
with mammography for women ages 40 to 49 years: evaluation of the Swedish Mam-
mography Screening in Young Women (SCRY) cohort. Cancer 117(4):714-722.
Hill, C., and A. Laplanche (1990). Overall mortality and cancer mortality around French
nuclear sites. Nature 347(6295):755-757.
Hoffman, F. O., A. J. Ruttenber, A. I. Apostoaei, R. J. Carroll, and S. Greenland (2007).
The Hanford Thyroid Disease Study: An alternative view of the findings. Health Phys
92(2):99-111.
Hoffmann, W., H. Dieckmann, et al. (1997). A cluster of childhood leukemia near a nuclear
reactor in northern Germany. Arch Environ Health 52(4):275-280.
Hoffmann, W., C. Terschueren, et al. (2007). Childhood leukemia in the vicinity of the
Geesthacht nuclear establishments near Hamburg, Germany. Environ Health Perspect
115(6):947-952.
Hoffmann, W., C. Terschueren, et al. (2008). Population-based research on occupational and
environmental factors for leukemia and non-Hodgkin’s lymphoma: The Northern Ger-
many Leukemia and Lymphoma Study (NLL). Am J Ind Med 51(4):246-257.
ICRP (International Commission on Radiological Protection) (2003). Biological Effects after
Prenatal Irradiation (Embryo and Fetus). ICRP Publication 90. Ann. ICRP 33(1-2).
ICRP (2007). The 2007 Recommendations of the International Commission on Radiological
Protection. ICRP Publication 103. Ann. ICRP 37(2-4).
Imaizumi, M., T. Usa, et al. (2006). Radiation dose-response relationships for thyroid nodules
and autoimmune thyroid diseases in Hiroshima and Nagasaki atomic bomb survivors
55-58 years after radiation exposure. JAMA 295(9):1011-1022.
Ivanov, E. P., G. Tolochko, et al. (1993). Child leukaemia after Chernobyl. Nature 365(6448):
702.
Ivanov, E. P., G. V. Tolochko, et al. (1996). Childhood leukemia in Belarus before and after
the Chernobyl accident. Radiat Environ Biophys 35(2):75-80.
Ivanov, V. K., A. F. Tsyb, et al. (1997a). Cancer risks in the Kaluga oblast of the Russian Fed-
eration 10 years after the Chernobyl accident. Radiat Environ Biophys 36(3):161-167.
Ivanov, V. K., A. F. Tsyb, et al. (1997b). Leukaemia and thyroid cancer in emergency workers
of the Chernobyl accident: estimation of radiation risks (1986-1995). Radiat Environ
Biophys 36(1):9-16.
Ivanov, V. K., A. I. Gorski, et al. (2004). Solid cancer incidence among the Chernobyl emer-
gency workers residing in Russia: Estimation of radiation risks. Radiat Environ Biophys
43(1):35-42.
Ivanov, V. K., A. I. Gorski, et al. (2006). Radiation-epidemiological studies of thyroid cancer
incidence among children and adolescents in the Bryansk oblast of Russia after the
Chernobyl accident (1991-2001 follow-up period). Radiat Environ Biophys 45(1):9-16.
Izumi, S., K. Koyama, et al. (2003). Cancer incidence in children and young adults did not
increase relative to parental exposure to atomic bombs. Br J Cancer 89(9):1709-1713.
OCR for page 323
323
APPENDIX A
Jablon, S., and H. Kato (1970). Childhood cancer in relation to prenatal exposure to atomic-
bomb radiation. Lancet 2(7681):1000-1003.
Jablon, S., Z. Hrubec, J. D. Boice Jr., and B. J. Stone (1990), Cancer in Populations Living
near Nuclear Facilities, Vols. 1-3. NIH Publication No. 90-874.
Jablon, S., Z. Hrubec, et al. (1991). Cancer in populations living near nuclear facilities. A
survey of mortality nationwide and incidence in two states. JAMA 265(11):1403-1408.
Jacob, P., W. Rühm, L. Walsh, M. Blettner, G. Hammer, and H. Zeeb (2009). Is cancer risk of
radiation workers larger than expected?, Occup Environ Med 66(12):789-796.
Janerich, D. T., A. D. Stark, et al. (1981). Increased leukemia, lymphoma, and sponta-
neous abortion in Western New York following a flood disaster. Public Health Rep
96(4):350-356.
Kaatsch, P., U. Kaletsch, et al. (1998). An extended study on childhood malignancies in the
vicinity of German nuclear power plants. Cancer Causes Control 9(5):529-533.
Kaatsch, P., C. Spix, et al. (2008). Leukaemia in young children living in the vicinity of German
nuclear power plants. Int J Cancer 122(4):721-726.
Kallen, B., P. Karlsson, et al. (1998). Outcome of reproduction in women irradiated for skin
hemangioma in infancy. Radiat Res 149(2):202-208.
Kato, H. (1971). Mortality in children exposed to the A-bombs while in utero, 1945-1969.
Am J Epidemiol 93(6):435-442.
Kazakov, V. S., E. P. Demidchik, et al. (1992). Thyroid cancer after Chernobyl. Nature
359(6390):21.
Kemenu, J. G., B. Babbitt, et al. (1979). Report of the President’s commission on the accident
at three mile island—the need for change: The legacy at TMI. Washington, DC: U.S.
Government Printing Office.
Kendall, G. M., C. R. Muirhead, et al. (1992). Mortality and occupational exposure to ra-
diation: First analysis of the National Registry for Radiation Workers. BMJ 304(6821):
220-225.
Kinlen, L. (2011a). Childhood leukaemia, nuclear sites, and population mixing. Br J Cancer
104(1):12-18.
Kinlen, L. (2011b). A German storm affecting Britain: Childhood leukaemia and nuclear
power plants. J Radiol Prot 31(3):279-284.
Kinlen, L. J., F. O’Brien, et al. (1993). Rural population mixing and childhood leukaemia: Ef-
fects of the North Sea oil industry in Scotland, including the area near Dounreay nuclear
site. BMJ 306(6880):743-748.
Kinlen, L. J., M. Dickson, et al. (1995). Childhood leukaemia and non-Hodgkin’s lymphoma
near large rural construction sites, with a comparison with Sellafield nuclear site. BMJ
310(6982):763-768.
Konogorov, A. P., V. K. Ivanov, et al. (2000). A case-control analysis of leukemia in accident
emergency workers of Chernobyl. J Environ Pathol Toxicol Oncol 19(1-2):143-151.
Koshurnikova, N. A., E. S. Gilbert, et al. (2000). Bone cancers in Mayak workers. Radiat
Res 154(3):237-245.
Krestinina, L. Y., D. L. Preston, et al. (2005). Protracted radiation exposure and cancer mortal-
ity in the Techa River Cohort. Radiat Res 164(5):602-611.
Krestinina, L. Y., F. Davis, et al. (2007). Solid cancer incidence and low-dose-rate radiation
exposures in the Techa River cohort: 1956-2002. Int J Epidemiol 36(5):1038-1046.
Laurier, D., D. Hemon, et al. (2008a). Childhood leukaemia incidence below the age of 5 years
near French nuclear power plants. J Radiol Prot 28(3):401-403.
Laurier, D., S. Jacob, et al. (2008b). Epidemiological studies of leukaemia in children and
young adults around nuclear facilities: A critical review. Radiat Prot Dosimetry 132(2):
182-190.
Law, G., and E. Roman (1997). Leukaemia near La Hague nuclear plant. Study design is
questionable. BMJ 314(7093):1553; author reply 1555.
OCR for page 324
324 APPENDIX A
Law, G. R. (2008). Host, family and community proxies for infections potentially associated
with leukaemia. Radiat Prot Dosimetry 132(2):267-272.
Li, C. Y., and F. C. Sung (1999). A review of the healthy worker effect in occupational epide-
miology. Occup Med (Lond) 49(4):225-229.
Linet, M. S., K. P. Kim, et al. (2009). Children’s exposure to diagnostic medical radiation
and cancer risk: Epidemiologic and dosimetric considerations. Pediatr Radiol 39(Suppl
1):S4-S26.
Little, J., J. McLaughlin, et al. (2008a). Leukaemia in young children living in the vicinity of
nuclear power plants. Int J Cancer 122(4):x-xi.
Little, J. B., H. Nagasawa, et al. (1997). Radiation-induced genomic instability: Delayed mu-
tagenic and cytogenetic effects of X rays and alpha particles. Radiat Res 148(4):299-307.
Little, M. P., E. J. Tawn, et al. (2008b). A systematic review of epidemiological associations
between low and moderate doses of ionizing radiation and late cardiovascular effects,
and their possible mechanisms. Radiat Res 169(1):99-109.
Little, M. P., E. J. Tawn, et al. (2010). Review and meta-analysis of epidemiological associa-
tions between low/moderate doses of ionizing radiation and circulatory disease risks, and
their possible mechanisms. Radiat Environ Biophys 49(2):139-153.
Lopez-Abente, G., N. Aragones, et al. (1999). Leukemia, lymphomas, and myeloma mortality
in the vicinity of nuclear power plants and nuclear fuel facilities in Spain. Cancer Epide-
miol Biomarkers Prev 8(10):925-934.
Ma, F., M. Lehnherr, J. Fornoff, and T. Shen (2011). Childhood cancer incidence in proximity
to nuclear power plants in Illinois. Arch Environ Occup Health, 66(2):87-94.
MacMahon, B. (1962). Prenatal x-ray exposure and childhood cancer. J Natl Cancer Inst
28:1173-1191.
Mangano, J. J. (1994). Cancer mortality near Oak Ridge, Tennessee. Int J Health Serv
24(3):521-533.
Marples, B., B. G. Wouters, et al. (2004). Low-dose hyper-radiosensitivity: A consequence
of ineffective cell cycle arrest of radiation-damaged G2-phase cells. Radiat Res 161(3):
247-255.
Mattsson, A., B. I. Ruden, et al. (1993). Radiation-induced breast cancer: long-term follow-up
of radiation therapy for benign breast disease. J Natl Cancer Inst 85(20):1679-1685.
McGale, P., and S. C. Darby (2005). Low doses of ionizing radiation and circulatory diseases:
A systematic review of the published epidemiological evidence. Radiat Res 163(3):
247-257.
McLaughlin, J. R., E. A. Clarke, et al. (1993a). Childhood leukemia in the vicinity of Canadian
nuclear facilities. Cancer Causes Control 4(1):51-58.
McLaughlin, J. R., W. D. King, et al. (1993b). Paternal radiation exposure and leukaemia in
offspring: The Ontario case-control study. BMJ 307(6910):959-966.
Menz, R., R. Andres, et al. (1997). Biological dosimetry: the potential use of radiation-induced
apoptosis in human T-lymphocytes. Radiat Environ Biophys 36(3):175-181.
Michaelis, J., B. Keller, et al. (1992). Incidence of childhood malignancies in the vicinity of
west German nuclear power plants. Cancer Causes Control 3(3):255-263.
Miller, A. B., G. R. Howe, et al. (1989). Mortality from breast cancer after irradiation dur-
ing fluoroscopic examinations in patients being treated for tuberculosis. N Engl J Med
321(19):1285-1289.
Mole, R. H. (1974). Antenatal irradiation and childhood cancer: causation or coincidence?
Br J Cancer 30(3):199-208.
Morgan, W. F. (2003). Non-targeted and delayed effects of exposure to ionizing radiation: II.
Radiation-induced genomic instability and bystander effects in vivo, clastogenic factors
and transgenerational effects. Radiat Res 159(5):581-596.
OCR for page 325
325
APPENDIX A
Muirhead, C. R., A. A. Goodill, et al. (1999). Occupational radiation exposure and mortality:
second analysis of the National Registry for Radiation Workers. J Radiol Prot 19(1):
3-26.
Muirhead, C. R., J. A. O’Hagan, et al. (2009). Mortality and cancer incidence following
occupational radiation exposure: Third analysis of the National Registry for Radiation
Workers. Br J Cancer 100(1):206-212.
Nakashima, E., K. Neriishi, et al. (2006). A reanalysis of atomic-bomb cataract data, 2000-
2002: A threshold analysis. Health Phys 90(2):154-160.
NCRP (National Council on Radiation Protection and Measurements) (2009). Ionizing Radia-
tion Exposure of the Populations of the United States. Report 160.
Neriishi, K., E. Nakashima, et al. (2007). Postoperative cataract cases among atomic bomb
survivors: Radiation dose response and threshold. Radiat Res 168(4):404-408.
Noshchenko, A. G., K. B. Moysich, et al. (2001). Patterns of acute leukaemia occurrence
among children in the Chernobyl region. Int J Epidemiol 30(1):125-129.
Noshchenko, A. G., P. V. Zamostyan, et al. (2002). Radiation-induced leukemia risk among
those aged 0-20 at the time of the Chernobyl accident: A case-control study in the
Ukraine. Int J Cancer 99(4):609-618.
NRC (National Research Council) (2005). Committee to Assess Health Risks from Exposure
to Low Levels of Ionizing Radiation, Health Risks From Exposure to Low Levels, of Ion-
izing Radiation: BEIR VII—Phase 2. Washington, DC: The National Academies Press.
Nuclear Safety Council and the Carlos III Institute of Health (2009). Epidemiological study of
the possible effect of ionizing radiations deriving from the operation of Spanish nuclear
fuel cycle facilities on the health of the population living in their vicinity, Spain.
Okunieff, P., Y. Chen, et al. (2008). Molecular markers of radiation-related normal tissue
toxicity. Cancer Metastasis Rev 27(3):363-374.
Ostroumova. E., B. Gagnière, D. Laurier, N. Gudkova, L. Krestinina, P. Verger, P. Hubert, D.
Bard, A. Akleyev, M. Tirmarche, and M. Kossenko (2006). Risk analysis of leukaemia
incidence among people living along the Techa River: A nested case-control study. J
Radiol Prot 26(1):17-32.
Otake, M., W. J. Schull, et al. (1996). Threshold for radiation-related severe mental retardation
in prenatally exposed A-bomb survivors: A re-analysis. Int J Radiat Biol 70(6):755-763.
Ozasa, K., Y. Shimizu, A. Suyama, F. Kasagi, M. Soda, E. J. Grant, R. Sakata, H. Sugi-
yama, and K. Kodama (2012). Studies of the Mortality of Atomic Bomb Survivors,
Report 14, 1950-2003: An Overview of Cancer and Noncancer Diseases. Radiat Res.
177(3):229-243.
Parkin, D. M., D. Clayton, et al. (1996). Childhood leukaemia in Europe after Chernobyl: 5
year follow-up. Br J Cancer 73(8):1006-1012.
Patton, T., A. F. Olshan, et al. (2004). Parental exposure to medical radiation and neuroblas-
toma in offspring. Paediatr Perinat Epidemiol 18(3):178-185.
Pearce, N., H. Checkoway, et al. (2007). Bias in occupational epidemiology studies. Occup
Environ Med 64(8):562-568.
Pobel, D., and J. F. Viel (1997). Case-control study of leukaemia among young people near
La Hague nuclear reprocessing plant: The environmental hypothesis revisited. BMJ
314(7074):101-106.
Poole, C., K. J. Rothman, et al. (1988). Leukaemia near Pilgrim nuclear power plant, Mas-
sachusetts. Lancet 2(8623):1308.
Preston, D. L., S. Kusumi, et al. (1994). Cancer incidence in atomic bomb survivors. Part
III. Leukemia, lymphoma and multiple myeloma, 1950-1987. Radiat Res 137(2 Suppl):
S68-S97.
Preston, D. L., Y. Shimizu, et al. (2003). Studies of mortality of atomic bomb survivors. Re-
port 13: Solid cancer and noncancer disease mortality: 1950-1997. Radiat Res 160(4):
381-407.
OCR for page 326
326 APPENDIX A
Preston, D. L., D. A. Pierce, et al. (2004). Effect of recent changes in atomic bomb survivor
dosimetry on cancer mortality risk estimates. Radiat Res 162(4):377-389.
Preston, D. L., E. Ron, et al. (2007). Solid cancer incidence in atomic bomb survivors: 1958-
1998. Radiat Res 168(1):1-64.
Preston, D. L., H. Cullings, et al. (2008). Solid cancer incidence in atomic bomb survivors
exposed in utero or as young children. J Natl Cancer Inst 100(6):428-436.
Prisyazhiuk, A., O. A. Pjatak, et al. (1991). Cancer in the Ukraine, post-Chernobyl. Lancet
338(8778):1334-1335.
Pukkala, E., A. Kesminiene, et al. (2006). Breast cancer in Belarus and Ukraine after the
Chernobyl accident. Int J Cancer 119(3):651-658.
Rajaraman, P., J. Simpson, et al. (2011). Early life exposure to diagnostic radiation and ultra-
sound scans and risk of childhood cancer: case-control study. BMJ 342:d472.
Richardson, D., H. Sugiyama, et al. (2009). Ionizing radiation and leukemia mortality among
Japanese atomic bomb survivors, 1950-2000. Radiat Res 172(3):368-382.
Roman, E., V. Beral, et al. (1987). Childhood leukaemia in the West Berkshire and Basingstoke
and North Hampshire District Health Authorities in relation to nuclear establishments
in the vicinity. Br Med J (Clin Res Ed) 294(6572):597-602.
Rommens, C., D. Laurier, et al. (2000). Methodology and results of the Nord-Cotentin radio-
ecological study. J Radiol Prot 20(4):361-380.
Ron, E. (2002). Ionizing radiation and cancer risk: Evidence from epidemiology. Pediatr Ra-
diol 32(4):232-237; discussion 242-234.
Ron, E. (2003). Cancer risks from medical radiation. Health Phys 85(1):47-59.
Sankila, R., J. H. Olsen, et al. (1998). Risk of cancer among offspring of childhood-cancer
survivors. Association of the Nordic Cancer Registries and the Nordic Society of Paedi-
atric Haematology and Oncology. N Engl J Med 338(19):1339-1344.
Schmitz-Feuerhake, I., H. Schroder, et al. (1993). Leukaemia near water nuclear reactor.
Lancet 342(8885):1484.
Schmitz-Feuerhake, I., B. Dannheim, et al. (1997). Leukemia in the proximity of a German
boiling-water nuclear reactor: Evidence of population exposure by chromosome studies
and environmental radioactivity. Environ Health Perspect 105(Suppl 6):1499-1504.
Schneider, A. B., T. C. Gierlowski, et al. (1995). Dose-response relationships for radiation-
induced hyperparathyroidism. J Clin Endocrinol Metab 80(1):254-257.
Schneider, J., P. Presek, et al. (1999). Serum levels of pantropic p53 protein and EGF-receptor,
and detection of anti-p53 antibodies in former uranium miners (SDAG Wismut). Am J
Ind Med 36(6):602-609.
Schubauer-Berigan, M. K., R. D. Daniels, et al. (2007). Risk of chronic myeloid and acute leu-
kemia mortality after exposure to ionizing radiation among workers at four U.S. nuclear
weapons facilities and a nuclear naval shipyard. Radiat Res 167(2):222-232.
Schull, W. J., and J. V. Neel (1959). Atomic bomb exposure and the pregnancies of biologically
related parents. A prospective study of the genetic effects of ionizing radiation in man.
Am J Public Health Nations Health 49:1621-1629.
Segerstrom, S. C., and G. E. Miller (2004). Psychological stress and the human immune sys-
tem: A meta-analytic study of 30 years of inquiry. Psychol Bull 130(4):601-630.
Senkus-Konefka, E., and J. Jassem (2007). Cardiovascular effects of breast cancer radio-
therapy. Cancer Treat Rev 33(6):578-593.
Sermage-Faure, C., D. Laurier, S. Goujon-Bellec, M. Chartier, A. Guyot-Goubin, J. Rudant,
D. Hémon, and J. Clavel (2012). Childhood leukemia around French nuclear power
plants—the Geocap study, 2002-2007. Int J Cancer, [Epub ahead of print].
Sharp, L., R. J. Black, et al. (1996). Incidence of childhood leukaemia and non-Hodgkin’s
lymphoma in the vicinity of nuclear sites in Scotland, 1968-93. Occup Environ Med
53(12):823-831.
OCR for page 327
327
APPENDIX A
Shilnikova, N. S., D. L. Preston, et al. (2003). Cancer mortality risk among workers at the
Mayak nuclear complex. Radiat Res 159(6):787-798.
Shimizu, Y., H. Kato, et al. (1992). Studies of the mortality of A-bomb survivors. 9. Mortal-
ity, 1950-1985: Part 3. Noncancer mortality based on the revised doses (DS86). Radiat
Res 130(2):249-266.
Shimizu, Y., K. Kodama, et al. (2010). Radiation exposure and circulatory disease risk: Hiro-
shima and Nagasaki atomic bomb survivor data, 1950-2003. BMJ 340:b5349.
Shin, S. C., K. M. Lee, et al. (2011). Differential expression of immune-associated can-
cer regulatory genes in low- versus high-dose-rate irradiated AKR/J mice. Genomics
97(6):358-363.
Shore, R. E. (1990). Occupational radiation studies: status, problems, and prospects. Health
Phys 59(1):63-68.
Shore, R. E. (2009). Low-dose radiation epidemiology studies: status and issues. Health Phys
97(5):481-486.
Shu, X. O., F. Jin, et al. (1994a). Diagnostic x-ray and ultrasound exposure and risk of child-
hood cancer. Br J Cancer 70(3):531-536.
Shu, X. O., G. H. Reaman, et al. (1994b). Association of paternal diagnostic x-ray exposure
with risk of infant leukemia. Investigators of the Childrens Cancer Group. Cancer Epi-
demiol Biomarkers Prev 3(8):645-653.
Signorello, L. B., J. J. Mulvihill, D. M. Green, H. M. Munro, M. Stovall, E. J. Tawn, R. E.
Weathers, A. C. Mertens, J. A. Whitton, L. L. Robison, and J. D. Boice Jr. (2012).
Congenital anomalies in the children of cancer survivors: A report from the Childhood
Cancer Survivor Study. J Clin Oncol 30:239-245.
Simes, R. J. (1986). Publication bias: The case for an international registry of clinical trials. J
Clin Oncol 4(10):1529-1541.
Singh, H., R. Saroya, et al. (2011). Radiation induced bystander effects in mice given low doses
of radiation in vivo. Dose Response 9(2):225-242.
Sofer, T., J. R. Goldsmith, et al. (1991). Geographical and temporal trends of childhood
leukemia in relation to the nuclear plant in the Negev, Israel, 1960-1985. Public Health
Rev 19(1-4):191-198.
Sokolnikov, M. E., E. S. Gilbert, et al. (2008). Lung, liver and bone cancer mortality in Mayak
workers. Int J Cancer 123(4):905-911.
Sowa Resat, M. B., and W. F. Morgan (2004). Radiation-induced genomic instability: a role
for secreted soluble factors in communicating the radiation response to non-irradiated
cells. J Cell Biochem 92(5):1013-1019.
Spix, C., and M. Blettner (2009). Re: BAKER P.J. & HOEL D.G. (2007) European Journal
of Cancer Care16, 355-363. Meta-analysis of standardized incidence and mortality
rates of childhood leukaemia in proximity to nuclear facilities. Eur J Cancer Care (Engl)
18(4):429-430.
Spix, C., S. Schmiedel, et al. (2008). Case-control study on childhood cancer in the vicinity of
nuclear power plants in Germany 1980-2003. Eur J Cancer 44(2):275-284.
Spycher, B. D., M. Feller, et al. (2011). Childhood cancer and nuclear power plants in Swit-
zerland: A census-based cohort study. Int J Epidemiol 40(5):1247-60.
Stewart, A. M., J. Webb, B. D. Giles, and D. Hewitt (1956). Malignant disease in childhood
and diagnostic irradiation in utero. Lancet 2:447.
Stsjazhko, V. A., A. F. Tsyb, et al. (1995). Childhood thyroid cancer since accident at Cher-
nobyl. BMJ 310(6982):801.
Susser, M. (1997). Consequences of the 1979 Three Mile Island accident continued: Further
comment. Environ Health Perspect 105(6):566-570.
Telle-Lamberton, M., E. Samson, et al. (2007). External radiation exposure and mortality in
a cohort of French nuclear workers. Occup Environ Med 64(10):694-700.
OCR for page 328
328 APPENDIX A
Tronko, M. D., G. R. Howe, T. I. Bogdanova, A. C. Bouville, O. V. Epstein, A. B. Brill, I. A.
Likhtarev, D. J. Fink, V. V. Markov, E. Greenebaum, V. A. Olijnyk, I. J. Masnyk, V. M.
Shpak, R. J. McConnell, V. P. Tereshchenko, J. Robbins, O. V. Zvinchuk, L. B. Zablotska,
M. Hatch, N. K. Luckyanov, E. Ron, T. L. Thomas, P. G. Voillequé, and G. W. Beebe
(2006). A cohort study of thyroid cancer and other thyroid diseases after the chornobyl
accident: Thyroid cancer in Ukraine detected during first screening. J Natl Cancer Inst
98(13):897-903.
Uehara, Y., Y. Ito, et al. (2010). Gene expression profiles in mouse liver after long-term low-
dose-rate irradiation with gamma rays. Radiat Res 174(5):611-617.
UNSCEAR (United Nations Scientific Committee on the Effects of Atomic Radiation). (2006a).
Sources and Effects of Ionizing Radiation, Volume I, Annex A: Epidemiological Studies
of Radiation and Cancer.
UNSCEAR (2006b). Sources and Effects of Ionizing Radiation, Volume I, Annex B: Epidemio-
logical Evaluation of Cardiovascular Disease and Other Non-cancer Disease Following
Radiation Exposure.
UNSCEAR (2008a). Effects of Ionizing Radiation, Volume I, Annex A: Medical Radiation
Exposures.
UNSCEAR (2008b). Effects of Ionizing Radiation, Volume II—Annex D: Health Effects Due
to Radiation from the Chernobyl Accident.
Upton, A. C. (1980). Radiation risks from nuclear power exaggerated. N Engl J Med 302(21):
1205.
Urquhart, J., M. Palmer, et al. (1984). Cancer in Cumbria: The Windscale connection. Lancet
1(8370):217-218.
Urquhart, J. D., R. J. Black, et al. (1991). Case-control study of leukaemia and non-Hodgkin’s
lymphoma in children in Caithness near the Dounreay nuclear installation. BMJ 302(6778):
687-692.
Vares, G., Y. Uehara, et al. (2011). Transcription factor-recognition sequences potentially
involved in modulation of gene expression after exposure to low-dose-rate gamma-rays
in the mouse liver. J Radiat Res (Tokyo) 52(2):249-256.
Viel, J. F., and S. T. Richardson (1990). Childhood leukaemia around the La Hague nuclear
waste reprocessing plant. BMJ 300(6724):580-581.
Viel, J. F., S. Richardson, et al. (1993). Childhood leukemia incidence in the vicinity of La
Hague nuclear-waste reprocessing facility (France). Cancer Causes Control 4(4):341-343.
Viel, J. F., D. Pobel, et al. (1995). Incidence of leukaemia in young people around the La Hague
nuclear waste reprocessing plant: a sensitivity analysis. Stat Med 14(21-22):2459-2472.
Wakeford, R. (1997). Leukaemia near La Hague nuclear plant. Scientific context is needed.
BMJ 314(7093):1553-1554; author reply 1555.
Wakeford, R. (2005). Cancer risk among nuclear workers. J Radiol Prot 25(3):225-228.
Wakeford, R. (2008). Childhood leukaemia following medical diagnostic exposure to ionizing
radiation in utero or after birth. Radiat Prot Dosimetry 132(2):166-174.
Waller, L. A., B. W. Turnbull, et al. (1995). Detection and assessment of clusters of disease:
an application to nuclear power plant facilities and childhood leukaemia in Sweden. Stat
Med 14(1):3-16.
White-Koning, M. L., D. Hemon, et al. (2004). Incidence of childhood leukaemia in the vicin-
ity of nuclear sites in France, 1990-1998. Br J Cancer 91(5):916-922.
WHO (World Health Organization) (1996). Health Consequences of the Chernobyl Accident.
Results of the IPHECA Pilot Projects and Related National Programs. Geneva: WHO.
Wickremesekera, J. K., W. Chen, et al. (2001). Serum proinflammatory cytokine response in
patients with advanced liver tumors following selective internal radiation therapy (SIRT)
with (90)Yttrium microspheres. Int J Radiat Oncol Biol Phys 49(4):1015-1021.
Wilcosky, T., and S. Wing (1987). The healthy worker effect. Selection of workers and work
forces. Scand J Work Environ Health 13(1):70-72.
OCR for page 329
329
APPENDIX A
Wilkinson, G. S., G. L. Tietjen, et al. (1987). Mortality among plutonium and other radiation
workers at a plutonium weapons facility. Am J Epidemiol 125(2):231-250.
Wilson, R. (1991). Leukemias in Plymouth county, Massachusetts. Health Phys 61(2):279.
Wing, S. (2010). Testable hypotheses for cancer risks near nuclear facilities. Statement to the
Nuclear and Radiation Studies Board of the National Academies.
Wing, S., C. M. Shy, et al. (1991). Mortality among workers at Oak Ridge National Labora-
tory. Evidence of radiation effects in follow-up through 1984. JAMA 265(11):1397-1402.
Wing, S., D. Richardson, et al. (1997a). A reevaluation of cancer incidence near the Three
Mile Island nuclear plant: the collision of evidence and assumptions. Environ Health
Perspect 105(1):52-57.
Wing, S., D. Richardson, et al. (1997b). Reply to comments on A reevaluation of cancer inci-
dence near the Three Mile Island. Environ Health Perspect 105(3):266-268.
Wing, S., D. B. Richardson, and W. Hoffmann (2011). Cancer risks near nuclear facilities: The
importance of research design and explicit study hypotheses. Environ Health Perspect
119(4):417-421.
Winther, J. F., J. H. Olsen, H. Wu, Y. Shyr, J. J. Mulvihill, M. Stovall, A. Nielse, M.
Schmiegelow, J. D. Boice Jr. (2012). Genetic disease in the children of Danish survivors
of childhood and adolescent cancer. J Clin Oncol 30:27-33.
Worgul, B. V., Y. I. Kundiyev, et al. (2007). Cataracts among Chernobyl clean-up workers:
Implications regarding permissible eye exposures. Radiat Res 167(2):233-243.
Yoshimoto, Y., S. Yoshinaga, et al. (2004). Research on potential radiation risks in areas with
nuclear power plants in Japan: Leukaemia and malignant lymphoma mortality between
1972 and 1997 in 100 selected municipalities. J Radiol Prot 24(4):343-368.
Zablotska, L. B., T. I. Bogdanova, E. Ron, O. V. Epstein, J. Robbins, I. A. Likhtarev, M.
Hatch, V. V. Markov, A. C. Bouville, V. A. Olijnyk, R. J. McConnell, V. M. Shpak, A.
Brenner, G. N. Terekhova, E. Greenebaum, V. P. Tereshchenko, D. J. Fink, A. B. Brill,
G. A. Zamotayeva, I. J. Masnyk, G. R. Howe, and M. D. Tronko (2008). A cohort study
of thyroid cancer and other thyroid diseases after the Chornobyl accident: Dose-response
analysis of thyroid follicular adenomas detected during first screening in Ukraine (1998-
2000). Am J Epidemiol 167(3):305-312.
OCR for page 330
