Download RR595 The burden of occupational cancer in Great Britain Technical Annex 3: Non­melanoma skin cancer 

Health and Safety Executive
The burden of occupational cancer
in Great Britain
Technical Annex 3: Non­melanoma skin cancer Prepared by Imperial College London and
the Health and Safety Laboratory
for the Health and Safety Executive 2007
RR595
Technical Annex 3
Health and Safety Executive
The burden of occupational cancer
in Great Britain
Technical Annex 3: Non­melanoma skin cancer Lesley Rushton & Sally Hutchings
Imperial College London
Department of Epidemiology and Public Health
Faculty of Medicine
St Mary’s Campus
Norfolk Place
London W2 1PG Terry Brown
Health and Safety Laboratory
Harpur Hill
Buxton SK17 9JN
The aim of this project was to produce an updated estimate of the current burden of occupational cancer specifically for
Great Britain. The primary measure of the burden of cancer used was the attributable fraction (AF), ie the proportion of
cases that would not have occurred in the absence of exposure. Data on the risk of the disease due to the exposures of
interest, taking into account confounding factors and overlapping exposures, were combined with data on the proportion
of the target population exposed over the period in which relevant exposure occurred. Estimation was carried out for
carcinogenic agents or exposure circumstances that were classified by the International Agency for Research on Cancer
(IARC) as Group 1 or 2A carcinogens with strong or suggestive human evidence. Estimation was carried out for 2004 for
mortality and 2003 for cancer incidence for cancer of the bladder, leukaemia, cancer of the lung, mesothelioma, non­
melanoma skin cancer (NMSC), and sinonasal cancer.
The proportion of cancer deaths in 2004 attributable to occupation was estimated to be 8.0% in men and 1.5% in
women with an overall estimate of 4.9% for men plus women. Estimated numbers of deaths attributable to occupation
were 6,259 for men and 1,058 for women giving a total of 7,317. The total number of cancer registrations in 2003
attributable to occupational causes was 13,338 for men plus women. Asbestos contributed the largest numbers of
deaths and registrations (mesothelioma and lung cancer), followed by mineral oils (mainly NMSC), solar radiation
(NMSC), silica (lung cancer) and diesel engine exhaust (lung and bladder cancer). Large numbers of workers were
potentially exposed to several carcinogenic agents over the risk exposure periods, particularly in the construction
industry, as farmers or as other agricultural workers, and as workers in manufacture of machinery and other equipment,
manufacture of wood products, land transport, metal working, painting, welding and textiles. There are several sources
of uncertainty in the estimates, including exclusion of other potential carcinogenic agents, potentially inaccurate or
approximate data and methodological issues. On balance, the estimates are likely to be a conservative estimate of the
true risk. Future work will address estimation for the remaining cancers that have yet to be examined, together with
development of methodology for predicting future estimates of the occupational cancers due to more recent exposures.
This report and the work it describes were funded by the Health and Safety Executive (HSE). Its contents, including any
opinions and/or conclusions expressed, are those of the authors alone and do not necessarily reflect HSE policy.
HSE Books
© Crown copyright 2007
First published 2007
All rights reserved. No part of this publication may be
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Applications for reproduction should be made in writing to:
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ii
ACKNOWLEDGEMENTS
Funding was obtained from the Health and Safety Executive (HSE) and managed through the
Health and Safety Laboratory. We would like to thank Damien McElvenny for initiating the
project and Gareth Evans for his management role. Andy Darnton from the HSE was responsible
for the work on mesothelioma. The contributions to the project and advice received from many
other HSE and HSL staff is gratefully acknowledged. Two workshops were held during the
project bringing together experts from the UK and around the world. We would like to thank all
those who participated and have continued to give advice and comment on the project.
iii
iv
CONTENTS
Acknowledgments
iii
1. Incidence and Trends
1
2. Overview of Aetiology
2.1. Introduction
2.2. Exposures
3
3
6
3. Attributable Fraction Estimation
3.1 General Considerations
3.2 Arsenic and arsenic compounds
3.3 Mineral oils, shale oils or shale-derived lubricants
3.4 Polycyclic Aromatic Hydrocarbons – Coal tars and pitches
3.5 Solar Radiation
9
9
11
12
14
16
4. Overall attributable fraction
4.1 Comparison of exposure AFs
4.2 Exposure Map
4.3 Overall AF
4.4 Summary of results
4.5 Exposures in construction
4.6 Exposures by industry / job
4.7 Reading high versus low exposures
21
21
22
23
25
30
31
31
5. References
33
v
vi
1. INCIDENCE AND TRENDS
Non-melanoma skin cancer (NMSC) (ICD-10 C44; ICD-9 173) is the most common malignant
neoplasm in Caucasian populations around the world. There are two forms of the cancer, basal
cell carcinoma (BCC) and squamous cell carcinoma (SCC), of which the former is by far the
most common malignancy in white people (Miller, 1995). Based on 2003 Scottish registration
data, 71% of male and 78% of female NMSC are basal cell carcinomas.
The incidence of NMSC shows a marked geographical variation as highlighted in the article by
Diepgen and Mahler (2002), who cited figures as high as 2,058 per 100,000 population in parts of
Australia, and 175 per 100,000 in the USA, and 129.9 per 100,000 in South Wales. The incidence
is increasing rapidly in white populations in Europe, the US, Canada and Australia; the average
increase of NMSC was 3-8% per year since the 1960s. The rise in England and Wales is reflected
in Table 1. The rise in rates has been attributed to a combination of increased sun exposure or
exposure to UV light, increased outdoor activities, changes in clothing style, increased longevity
and ozone depletion. The incidence in white populations increases proportionally with proximity
to the equator, with the incidence of SCC doubling for each 8-10 degree decline in latitude (Giles
et al., 1988). The estimated number of skin cancer cases reported by dermatologists and
occupational physicians to EPIDERM/OPRA for 1996-2005 has also steadily increased 1. Among
both men and women, the incidence increases with age. According to Holme et al., (2000) the
incidence in 75-79 year olds is about five times that of 50-54 year olds. Holme et al., (2000) also
demonstrated that the incidence had significantly increased between 1988 and 1998 (Men 102.5
to 127.9; Women 49.6 to 104.8).
NMSC is rarely fatal; the cure rates are close to 99% (if caught early), with only a small
percentage being metastatic or resulting in death (Preston & Stern, 1992). This is reflected in
Table 2, and in the mortality: incidence ratio, which for both men and women is about 0.01. This
compares with 0.26 (men) and 0.18 (women) for malignant melanoma and 0.92 (men) and 0.89
(women) for lung cancer. NMSC has a 20-30-year latency.
The Office of National Statistics (ONS) note that NMSC is greatly under-registered 2, so that data
in Tables 1 +2 should be interpreted in terms of trend in registrations only. Data are not available
for Welsh registrations from 1995.
1
2
http://www.hse.gov.uk/statistics/tables/thors01.htm
ONS, 2005. Cancer statistics: registrations. Series MB1 No 34, section 4.2
1
Table 1: Non-melanoma skin cancer registration trends in England and Wales.
Males
Year
Females
Total
Cancer
%
Registrations Registrations Total
*
Rate
Total
Cancer
%
/100000 Registrations Registrations Total
*
Rate
/100000
1994$
131549
19404
14.8
76.7
129558
17383
13.4
66.1
1995#
122869
18883
15.4
78.7
122143
16992
13.9
68.3
#
122907
18804
15.3
77.9
122451
16990
13.9
68.1
#
1997
125569
21234
16.9
87.6
126206
18917
15.0
75.6
1998#
131583
24838
18.9
101.9
131624
21667
16.5
86.3
#
133539
24712
18.5
100.7
134266
22029
16.4
87.4
#
2000
137788
26245
19.0
110.1
135204
23138
17.1
92.0
2001#
139387
26871
19.3
111.3
135657
23523
17.3
93.2
#
2002
140971
28392
20.1
116.9
136831
24621
18.0
97.1
2003#
142602
29870
20.9
122.3
139901
25161
18.0
98.9
Average
132876
23925
17.9
98.4
131384
21042
15.9
83.3
1996
1999
* including non-melanoma skin cancer; $ England and Wales; # England only
Table 2: Non-melanoma skin cancer mortality trends (England and Wales).
Males
Year
Females
Total
Deaths
NMSC
1999
300368
212
0.07
8
331694
156
0.05
5
2000
290186
201
0.07
7
318180
138
0.04
5
2001
286757
219
0.08
7
315511
187
0.06
6
2002
287835
259
0.09
9
318381
187
0.06
6
2003
288604
259
0.09
8
322584
187
0.06
3
2004
242885
299
0.12
9
267447
177
0.07
3
Average
282773
242
0.09
8
312300
172
0.06
4.7
Deaths
%
Total
Death Rate Total
(/1,000,000) Deaths
2
NMSC
Deaths
% Death Rate
Total (/1,000,000)
2. OVERVIEW OF AETIOLOGY
2.1. Introduction
It is well established that ultraviolet radiation (UVR) from the sun is the dominant risk factor for
NMSC (IARC, 1992; Kricker et al., 1994). The evidence is based on a number of factors,
including the high rates among occupational groups with outdoor exposures (Scotto et al., 1996).
Sir Percival Pott first established the link between occupational exposure and NMSC in 1775
when he observed the occurrence in chimney sweeps of SCC of the scrotum, since when a
number of other exposures have been described (Gawkrodger, 2004). The relation between
NMSC to occupation is often confounded by concurrent exposure to UV light (from the sun)
from leisure pursuits. In fact, in 1,608 cases of skin cancer reported via the Health and Safety
Executive’s occupational skin disease surveillance scheme, EPIDERM and OPRA, all but 4% of
cases could be attributed to UV radiation (Cherry et al., 2000). Three-quarters of these worked in
agriculture, construction or the armed forces; other causes of NMSC, each accounting for less
than 1% of reported cases, included tar and tar pitches, mineral oils, infrared radiation, burns and
trauma, cutting oils, ionising radiation and bipyridyl/paraquat.
The Occupational Health Decennial Supplement (Drever, 1995) examined mortality (1979-1980,
1982-1990) and cancer incidence (1981-1987) in men and women aged 20-74 years in England
and Wales. It concluded for many diseases that differences in mortality between job groups
appeared to be determined mainly by non-occupational influences. Occupations that had a high
proportional mortality rate (PMR) and/or high proportional registration rate (PRR) for NMSC
were predominantly work outdoors and included farmers, seafarers, construction workers
(managers, builders, carpenters, bricklayers) and mains and service layers (Table 3). The
increased risk among aircraft flight deck officers could also be related to UV or, possibly, others
types of radiation. Several occupations within the healthcare sector also exhibit a high risk. In the
1971 decennial supplement, which examined mortality around 1961, NMSC was high in
labourers. Other population-based studies of occupation and cancer incidence in the Nordic
countries (Andersen et al., 1999) and Switzerland (Bouchardy et al., 2002) had mixed findings. In
the Nordic study the risk for farmers, forestry workers, bricklayers and other construction
workers was less than expected, whereas in Switzerland the opposite was observed. Excess risks
were seen among high-income occupations (and teachers) that were attributed to sun exposure
during spare time activities.
The risk of NMSC is increased among workers in a number of industries and occupations. The
responsible agent(s) have been identified for several, but not all, of these high-risk workplaces.
Evidence for the carcinogenicity of many occupational agents has been classified by the
International Agency for Research on Cancer (IARC)(Table 4). Siemiatycki et al,. (2004)
summarise the evidence used in the classification of these agents and substances as strong or
suggestive and this is also given in Table 4. However, incidence data of high epidemiological
quality on NMSC are sparse because traditional cancer registries often exclude NMSC or at least
are incomplete (Diepgen & Mahler, 2002), as most cases are easily treated and cured in GP
surgeries. Although the malignancy causes considerable morbidity and places a huge burden on
healthcare services, mortality is low as the tumour rarely metastasises (Wong et al., 2003). As
most epidemiological studies only report mortality, figures for NMSC are rarely given, and they
would not reflect the true burden of the disease.
3
Table 3: Job codes with significantly high PRRs and PMRs for non-melanoma skin cancer. Men
and women aged 20-74 years, England, 1979-80 and 1982-90.
Job group
SIC code
PRR
95%CI
PMR
95%CI
182
110-285
660
180-1690
321
104-749
419
169-864
Description
Men
006
Sales managers, etc.
118
104-134
011
Teachers nec
163
150-178
013
Welfare workers
129
104-160
014
Clergy
133
109-163
015
Doctors
148
126-173
024
Literary and artistic occupations
028
Physical scientists and mathematicians
153
117-198
034
Aircraft flight deck officers
207
134-306
036
Seafarers
150
127-178
039
Managers in construction
127
101-158
047
Farmers
118
110-127
062
Ambulance workers
147
107-199
063
Railway station workers
126
104-152
066
Fishing and related workers
151
101-219
097
Printers
121
103-143
104
Carpenters
112
101-125
115
Metal drawers
124
Machine tool operators
111
105-119
139
Telephone fitters
128
106-156
165
Bricklayers and tilesetters
126
112-144
169
Builders nec
119
108-133
173
Mains and service layers
Women
011
Teachers nec
117
107-130
015
Doctors
144
104-194
017
Nurses
110
101-122
047
Farmers
069
Preparatory fibre processors
172
101-277
180
Railway engine drivers
354
115-828
4
Table 4: Occupational agents, groups of agents, mixtures, and exposure circumstances classified
by the IARC Monographs, Vols 1-77 (IARC, 1972-2001), into Groups 1 and 2A, which have the
skin as the target organ.
Agents, Mixture,
Circumstance
Main industry, Use
Evidence of
carcinogenicity
in humans*
Strength
of
evidence$
Other
target
organs
Group 1: Carcinogenic
to Humans
Agents, groups of agents
Arsenic & arsenic
compounds
Nonferrous metal smelting; production, packaging,
and use of arsenic-containing pesticides; sheep dip
manufacture; wool fibre production; mining or ores
containing arsenic
Sufficient
Strong
Lung
Liver
Mineral oils, untreated and
mildly treated
Production; used as lubricant by metal workers,
machinists, engineers; printing industry (ink
formulation); used in cosmetics, medicinal and
pharmaceutical preparations
Sufficient
Strong
Skin
Bladder
Shale oils or shale-derived
lubricants
Mining and processing; used as fuels or chemicalplant feedstocks; lubricant in cotton textile industry
Sufficient
Strong
Solar radiation
Outdoor workers
Sufficient
Strong
Melanoma
Coal-tar and pitches
Production of refined chemicals and coal tar
products (patent fuel); coke production; coal
gasification; aluminium production; foundries; road
paving and construction (roofers and slaters)
Sufficient
Strong
Lung
Bladder
Soots
Chimney sweeps, work involving burning organic
materials
Sufficient
Strong
Lung
Oesophagus
Benzo[a]pyrene
Work involving combustion of organic matter;
foundries; steel mills; firefighters; vehicle
mechanics
Suggestive
Suggestive
Lung
Bladder
Coal gasification
Coal tar; coal tar fumes; Polyaromatic hydrocarbon
(PAH)s
Sufficient
Strong
Lung
Bladder
Coke production
Coal-tar fumes
Sufficient
Strong
Lung
Bladder
Kidney
Benz[a]anthracene
Work involving combustion of organic matter;
foundries; steel mills; firefighters; vehicle
mechanics
Suggestive
Suggestive
Lung
Bladder
Dibenz[a,h]anthracene
Work involving combustion of organic matter;
foundries; steel mills; firefighters; vehicle
mechanics
Creosotes
Brickmaking; wood preserving
Limited
Suggestive
Exposure circumstances
Group 2A: Probably
Carcinogenic
to Humans
Agents & groups of
agents
Exposure circumstances
None identified
* Evidence according to the IARC monograph evaluation; $ taken from Siemiatycki et al. (2004)
5
2.2. Exposures
Arsenic and arsenic compounds
Arsenic is a group 1 carcinogen according to IARC (1987). In non-occupational situations
arsenic has been observed to increase the risk of NMSC in individuals treated for syphilis,
trypanosomiasis and psoriasis, and in the treatment of cancer (acute promyelocytic leukaemia),
and in areas where the drinking water is contaminated with high levels of arsenic (Cantor, 1997).
Studies in Taiwan found that exposure to drinking water containing arsenic at concentrations
from 0.3 to 1.14 mg/L increased the risk of BCC (IARC, 2004). It has also been estimated that the
lifetime risk of developing NMSC for a 76-year lifespan of an individual exposed to 1 g/kg/day
would be 3.0 x 10-3 (Brown et al., 1989).
Arsenic is used in a variety of industrial processes, including the manufacture of glass and
nonferrous alloys, and of insecticides and herbicides, although not in vast quantities nowadays.
Gallium arsenide is an important semiconductor material used in integrated circuits. Arsenic is
also used in substantial quantities as a wood preservative (chromated copper arsenate). Exposure
to arsenic may also occur during the smelting of copper, lead and zinc, and during its mining.
The regulatory history for arsenic began after the IARC review was published (IARC, 2004)
when a UK occupational exposure limit (OEL) of 0.2mg/m3 (8-hr time weighted average (TWA))
was set. This was reduced to 0.1mg/m3 (8-hr TWA) in 1989, and was established as the
workplace exposure limit in 2005. This is currently under review.
Most studies of other smelter workers have not reported any statistics for NMSC (Cocco et al.,
1997; Englyst et al., 2001; Lundstrom et al., 2006; Steenland & Boffetta, 2000; Wong & Harris,
2000; Wong et al., 1992). In a study of copper smelter workers no excess risk of NMSC was
observed (Lubin et al., 2000). Primary smelting of copper, however, is not currently carried out in
the UK (Coggon, 1999). Tissue levels of arsenic are higher in smelter workers than others but
not high enough as yet to give rise to excess NMSC risk. However, because of the long latency
between exposure and the development of NMSC, it has been reported the risk is elevated for up
to 60 years after exposure (Susitaival et al., 2004; Tapio & Grosche, 2006).
The principal route of exposure to arsenic in the majority of occupational settings is through
inhalation and this situation does not ordinarily lead to NMSC. For arsenic to be a risk factor for
NMSC it must be ingested.
As highlighted in the decennial supplement, farmers have an increased risk of NMSC that, to
some extent, could be related to their use of arsenical pesticides in the past, especially in sheep
dips. Studies of farmers have shown them to be at an increased risk (Acquavella et al., 1998;
Becher et al., 1996; Blair & Zahm, 1991; Kogevinas et al., 1997), although several have not
included NMSC in their reports (Alavanja et al., 2005; MacLennan et al., 2002). The use of
arsenic in sheep dip has long since disappeared in farming and the use of these chemicals was
also intermittent. In addition, farmers are also regularly exposed to UV radiation.
Mineral oils, shale oils or shale-derived lubricants
Oils derived from the distillation of petroleum or shale have been used in a number of
occupational settings and applications, many of which involve enclosed systems with little
opportunity for human exposure (Tolbert, 1997). However, there are some occasions where oil
mist is generated with the potential for dermal or inhalation exposure, and possible ingestion.
These occupations include metalworking, print press operating, and cotton and jute spinning.
Exposure has been associated strongly and consistently with the occurrence of SCC, especially of
6
the scrotum, and thus IARC have classified them as Group 1 carcinogens (IARC, 1984b). A
recent review of cancer risk and exposure to metal working fluids (MWF) stated there is an
increased risk of NMSC in individuals exposed to straight oil MWF (Calvert et al., 1998),
especially workers exposed before the mid-1970s. More recently an increased risk was noted for
straight and soluble MWF (Eisen et al., 2001). However, as a result of changes in MWF
composition and reduction of impurities over the last several decades, current straight oil MWF
exposures may be associated with a substantially reduced risk of NMSC.
Polycyclic Aromatic Hydrocarbons
PAHs are formed by the incomplete combustion of carbon-containing fuels such as wood, coal,
diesel, fat or tobacco. Workers are exposed by inhalation, ingestion and skin contact, the main
route of exposure being inhalation. PAHs are produced in a number of occupational settings
including coal gasification, coke production, coal-tar distillation, chimney sweeping (soots), coal
tar and pitches, creosotes, and others (IARC, 1984a; IARC, 1984b; IARC, 1984c; IARC, 1985),
most of which have been classified by IARC as Group 1 carcinogenic situations (creosote is
Group 2A) (IARC, In preparation). However, the risk of skin cancer has been difficult to assess
because most studies have only analysed for mortality, and also the risk only increases after
heavy occupational exposures. In most situations, the lung is the primary target organ for any
PAH exposure, and the risk of NMSC only increases when substantial dermal exposure occurs
(Boffetta et al., 1997).
Exposure to creosote, a mixture of over 150 compounds derived from the distillation of coal tar
and used primarily as a wood preservative, has been shown to increase the risk of NMSC
(Karlehagen et al., 1992). However, other studies reporting mortality have not given any results
for NMSC (Wong & Harris, 2005). Studies of aluminium workers show inconclusive results for
incidence (Romundstad et al., 2000; Ronneberg & Andersen, 1995). The evidence for an
association between NMSC and coal gasification is weak, mainly because studies have examined
mortality patterns rather than incidence (Boffetta et al., 1997). Roofers and asphalt workers are
exposed to PAHs from fumes formed during heating of bitumen and are exposed to levels ranging
from 1-100mg/m3 (IARC, 1985). A recent review of these occupational groups obtained a
combined relative risk (RR) of 1.74 (95%CI 1.07-2.65), with roofers (4.00, 95%CI 0.83-1.17)
having a greater risk than more general workers (Standardised mortality ratio (SMR) = 0.82,
95%CI 0.22-2.09) and pavers/highway maintenance workers (SMR= 2.18, 95% CI 1.19-3.66)
(Partanen & Boffetta, 1994).
Solar radiation
Solar radiation and sunlamps or sun beds give rise to exposures to ultraviolet radiation (UVR),
and are known to be carcinogenic to humans (IARC, 1992). The incidence rate is of NMSC
higher in fairer skinned, sun-sensitive rather than darker skinned, less-sun-sensitive people. Risk
increases with increasing ambient solar radiation. The highest densities are on the most sunexposed parts of the body and the lowest on the least exposed. NMSC is associated with total
(mainly squamous cell carcinoma (SCC)), occupational (mainly SCC) and non-occupational or
recreational sun exposure (mainly basal cell carcinoma (BCC) and a history of sunburn and
presence of benign sun damage in the skin (Armstrong & Kricker, 2001). An increased
occupational UVR exposure through natural sunlight is assumed to be associated with NMSC
(Armstrong & Kricker, 2001; Elwood & Jopson, 1997; IARC, 1992). Thus any individual
working outside regularly would be at an increased risk; these include farmers, construction
workers, roadwork labourers, policemen, fishermen/sailors, etc. Pilots and flight deck crews also
come into contact with cosmic radiation and an increased risk has been observed (Pukkala et al.,
2002).
7
Occupational exposure to artificial broad-spectrum UVR occurs in industrial photo processes,
principally UV curing of polymer inks, coatings and circuit board photoresistors, sterilisation and
disinfection, quality assurance in the food industry, medical and dental practices and welding.
These have also been implicated as risk factors for NMSC but have received little attention.
8
3. ATTRIBUTABLE FRACTION ESTIMATION
3.1 General Considerations
Substances and Occupations:The substances considered in the estimation of the attributable
fraction (AF) for the NMSC are those outlined in Table 5. PAHs have been considered the
primary exposure in exposure to coal-tar and pitches, soots, coal gasification, coke production
and creosotes. AFs for these exposures and industries have been estimated under PAHs (coal tar
and pitches).
Table 5: Substances considered in the estimation of the attributable fraction for non-melanoma
skin cancer.
Agents, Mixture,
Circumstance
AF
calculation
Strength
of
evidence
Comments
Established (E)
or Uncertain (U)
carcinogen
Group 1: Carcinogenic
to Humans
Agents, groups of
agents
Arsenic & arsenic
compounds
N
Strong
Mineral oils, untreated and
mildly treated
Y
Strong
Shale oils or shale-derived
lubricants
N
Strong
Solar radiation
Y
Strong
Coal-tar and pitches
Y
Strong
Soots
N
Strong
Considered under coal-tar
& pitches as a group
Benzo[a]pyrene
N
Suggestive
Not considered
Coal gasification
N
Strong
Considered under coal-tar
& pitches as a group
Coke production
N
Strong
Considered under coal-tar
& pitches as a group
Dominant exposure is
solar radiation
E
Considered under mineral
oils
E
E
Exposure
circumstances
Group 2A: Probably
Carcinogenic
to Humans
Agents & groups of
agents
Benz[a]anthracene
N
Suggestive
Dibenz[a,h]anthracene
N
Suggestive
Not considered
Creosotes
N
Suggestive
Considered under coal-tar
& pitches as a group
9
E
Not considered
Established and Uncertain Carcinogens
‘Established’ carcinogens for NMSC are those recognised by IARC as Group 1 carcinogens and
with ‘strong’ evidence of an association with the particular site of interest, as judged by
Siemiatycki et al (2004). ‘Uncertain’ carcinogens for NMSC are those recognised by IARC as in
Groups 1 or 2A, and judged by Siemiatycki et al., (2004) to have ‘suggestive’ evidence of an
association with the particular site of interest. Other exposures from sources other than
Siemiatycki will normally be included in the ‘uncertain’ group, unless there is ‘strong’ evidence
to the contrary, probably founded in UK experience.
For NMSC all the exposures for which AF is calculated are considered to be in the ‘established’
group.
Latency
A latency of up to 50 years and at least 10 years has been assumed for all types of NMSC.
Relevant Exposure Period
Based on the above observations on latency, the relevant exposure period (REP) assumed for
solid tumours was used i.e. 1955 to 1994, for a target year of 2004 (and 2003 for registrations)
The highest number of NMSC leading to current deaths or registrations are likely to relate to
exposures in the early 1970s.
Calculation of AF
The two data elements required are an estimate of relative risk (RR), and either (1) an estimate of
the proportion of the population exposed (Pr(E)) from independent data for Great Britain, or (2)
an estimate of the proportion of cases exposed (Pr(E|D)) from population based study data. In the
case of the skin cancer, independent data (1) have been used throughout to estimate the
attributable fraction (AF). For one exposure (Polyaromatic hydrocarbons (PAHs) – coal tar and
pitches) an alternative estimate using study data (2) has been calculated as a supporting check on
the independent data result.
The RR chosen from a ‘best study’ source is described for each exposure, with justification of its
suitability. Information on the ‘best study’ and independent data sources for the proportion of the
population exposed are summarised in Table 15.
In the absence of more precise knowledge of cancer latency, it is assumed that exposure at any
time between 1955 and 1994 can result in a cancer being recorded in 2004 as a registration or
underlying cause of death. For an independent estimate of the proportion of the population
exposed, numbers of workers ever exposed during this period are counted using a point estimate
of exposed workers taken from the period. If this is from CARcinogen EXposure (CAREX)
database relating to 1990-93, an adjustment is made to take account of gross changes in
employment levels which have occurred particularly in manufacturing industry and the service
sector across the REP. Otherwise a point estimate that represents numbers employed as close as
possible to about 35 years before the target year of 2004 is used, as this is thought to represent a
‘peak’ latency for the solid tumours, and is also close to the mid-point of the REP for estimating
numbers ever exposed across the period (for which a linear change in employment levels is
implicitly assumed). Where the Census of Employment (CoE) is used, the data are for 1971.
Where the Labour Force Survey (LFS) is used, the first year available and therefore used is 1979.
A turnover factor is applied to estimate numbers ever exposed during the REP, determined
mainly by the estimate of staff turnover per year during the period. For each exposure therefore, if
10
an AF has been based on independent estimates of numbers exposed, the table of results includes
the point estimate of numbers employed, the adjustment factor for CAREX if applicable, the staff
turnover estimate, and the resulting estimate of numbers ever exposed during the REP. Other
estimates used in the calculations that remain constant across exposures (unless otherwise stated)
are given below:
(1)
Number of years in REP = 40.
(2)
Proportion in the workplace ever exposed is set to one, i.e. all are assumed to be exposed,
in the absence of more detailed information. Where sources other than CAREX are used
for the point estimate of numbers exposed, such as the LFS or Census of Employment, a
precise as possible definition of workers exposed is sought.
(3)
Numbers ever of working age during the target REP = 19.2 million men, 20.9 million
women. This is the denominator for the proportion of the population exposed, and is
based on population estimates by age cohort in the target year.
(4)
Total deaths from NMSC, Great Britain (GB, 2004 = 323 for men, 203 for women
(5)
Total registrations for NMSC, GB, 2003 = 33,766 for men, 28,661 for women. 2003 is
the most recent year for which data are available.
For each agent where data on worker numbers are only available for men and women combined
(CAREX data), the assumed percentage of men is given in addition to the numbers exposed. The
allocation to high and low, and occasionally negligible, exposure level categories, or division into
separate exposure scenarios, is also included (see for example Table 7).
Full details of the derivation of the above factors and the methods of calculating AF are published
separately. Unless otherwise stated, Levin’s formula was used for estimates using independent
estimates of numbers exposed, and Miettinen’s formula was used for ‘study based’ estimates.
3.2 Arsenic and arsenic compounds
(a) Risk estimate: As mentioned in section 2, for arsenic to give rise to NMSC it must be
ingested or come into direct contact with the skin, for example in the treatment of certain skin
conditions and in contaminated drinking water. Amongst the industries given in table 4 the ones
where this mainly occurs are in individuals involved in wood preservation and in the historical
use of arsenical pesticides and sheep dips. Although some ingestion/dermal exposure may have
occurred in the other industries the main route would have been through inhalation. In addition
most studies of smelter workers have not reported any statistics for NMSC, and in a study of
copper smelter workers no excess risk of NMSC was observed (Lubin et al., 2000). Primary
smelting of copper is not currently carried out in the UK (Coggon, 1999). For pesticide/sheep dip
users, e.g. farmers, we would expect the dominant exposure leading to an increased risk for
NMSC to be solar radiation. For those exposed to wood preservatives containing arsenic
(chromated-copper-arsenate) reports of epidemiological studies of their carcinogenicity have not
been found in the literature (Huff, 2001).
(b) Numbers exposed: The numbers of workers exposed to arsenic, according to CAREX for
1990-1993 are given in Table 6.
11
Table 6: Numbers of workers exposed to arsenic according to CAREX in 1990-1993
Industry
CAREX Data 1990-1993
Number
Exposed
Number in
Industry
Manufacture of wood and wood and cork products, except furniture
6,435
132,975
Manufacture of furniture and fixture, except primary of metal
1,523
144,325
805
130,000
Manufacture of other chemical products
50
175,175
Petroleum refineries
44
18,075
1,284
43,275
Manufacture of other non-metallic mineral products
222
70,875
Iron and steel basic industries
325
48,425
Manufacture of industrial chemicals
Manufacture of glass and glass products
Non-ferrous metal basic industries
9,277
79,325
Manufacture of electrical machinery, apparatus, appliances and supplies
1,450
473,750
Manufacture of transport equipment
21
456,900
Other manufacturing industries
53
59,375
Electricity, gas and steam
304
Construction
2,820
Sanitary and similar services
Recreational and cultural services
Total
140,975
1,753,450
370
274,225
37
534,600
25,020
4535,725
(c) AF calculation: The AF will not be calculated.
3.3 Mineral oils, shale oils or shale-derived lubricants
(a) Risk estimate: Shale oil is of little concern in the calculation of an AF for NMSC because it
has been used very little in GB since the 1950s. The only study identified found no significant
excess of mortality in relation to any jobs in the industry, although an examination of men who
joined the industry prior to 1953 showed an excess of deaths from skin cancer (Miller et al.,
1986). Metalworking fluids (MWF) appear to be the dominant main use of minerals oils and
therefore workers using them are of most concern. A cohort study of mortality for workers in the
US car industry found significant deficit of NMSC overall (Eisen et al., 2001), but an association
between soluble MWF exposure and NMSC was seen (an increase in RR of 1.48, 95%CI – 1.171.53) for each one standard deviation (30 mg/m3 years) change in cumulative exposure. A nonsignificant excess was found in workers exposed to straight MWFs (change in RR – 1.22, 95%CI
– 0.97-1.53 per one SD (13 mg/m3 years)), but none was found for those using synthetic MWFs.
The risk was reduced in those hired after 1970, but a separate estimate of RR is not given. An
overall MWF weighted average RR of 0.90 (fixed effects model, Q = 7.74, p = 0.36; 95% CI 0.62
– 1.30) is from Eisen’s study, and a weighted average of 1.20 (0.67 – 2.15) for exposure to
soluble MWF has been used for the AF calculation, for jobs with known exposure. An RR of 1
has been used for workers at background exposure levels. However, using a mortality risk
estimate may greatly underestimate the true skin cancer incidence risk.
(b) Numbers exposed: The numbers of workers potentially exposed to metalworking fluids are
given in Table 7. ‘Lower’ (L) and ‘Background’ (B) exposure levels are indicated as such.
Exposure level (H) indicates jobs with known dermal exposure to soluble MWF.
12
Table 7: Number of workers with potential exposure to metalworking fluids in 2002-2004
compared to 1979 (Source: Labour Force Survey).
SIC code Description
Male
Female
Total
Exposure
Level
LFS 2002-2004
Metal machine setter & setter-operator
89,685
Metal working machine operatives
91,591
Assemblers (vehicle & metal goods)
60,855
Metal plate workers Ship rig riverters
13,562
Metal working prod & maint fitter
249,360
Metal marketing & treating process operative
22,935
LFS 1979
111.1
Foremen of Press and Machine Tool Setters
111.2
Foremen of other Centre Lathe Turners
111.3
Foremen of Machine Tool Setter Operators
581
111.4
Foremen of Machine Tool Operators
8,947
111.5
Foremen of Press Stamping and Automatic Machine
Operators
1,498
111.6
Foremen of Metal Polishers
111.7
Foremen of Fettlers Dressers
111.8
Foremen of Shot Blasters
-
-
-
B
112.1
Press and Machine Tool Setters
64,157
740
64,897
H
112.2
Other Centre Lathe Turners
49,774
-
49,774
H
112.3
Machine Tool Setter Operators
10,818
232
11,050
H
112.4
Machine Tool Operators
335,097
50,424
385,521
H
113.1
Press Stamping and Automatic Machine Operators
34,002
18,281
52,283
H
113.2
Metal Polishers
11,112
1,425
12,537
B
113.3
Fettlers Dressers
12,391
1,619
14,010
B
114.1
Foremen of Toolmakers Tool Fitters Markers-Out
4,319
-
4,319
H
114.2
Foremen of Precision Instrument Makers and
Repairers
969
-
969
L
114.3
Foremen of Watch and Chronometer Makers and
Repairers
-
-
-
L
114.4
Foremen of Metal Working Production Fitters and
Fitter/Machinists
27,544
-
27,544
H
114.5
Foremen of Motor Mechanics Auto Engineers
13,825
-
13,825
H
114.6
Foremen of Maintenance Fitters (Aircraft Engines)
522
-
522
H
114.7
Foremen of Office Machinery Mechanics
-
-
-
H
115.0
Toolmakers Tool Fitters Markers-Out
92,886
510
93,396
H
116.1
Precision Instrument Makers and Repairers
28,071
1,667
29,738
L
116.2
Watch and Chronometer Makers and Repairers
6,527
225
6,752
L
117.0
Metal Working Production Fitters and
Fitter/Machinists
546,544
6,933
553,477
H
118.1
Motor Mechanics Auto Engineers
269,925
1,271
271,196
H
118.2
Maintenance Fitters (Aircraft Engines)
3,957
-
3,957
H
119.0
Office Machinery Mechanics
11,506
-
11,506
H
13
2,164
-
2,164
H
736
-
736
H
-
581
H
252
9,199
H
-
1,498
H
265
-
265
B
-
-
-
B
131.8
Shot Blasters
6,049
-
6,049
B
160.5
Labourers and Other Unskilled Workers in Foundries
in Engineering
15,469
567
16,036
H
160.6
Labourers and Other Unskilled Workers in
Engineering and Allied Trades
TOTAL
21,276
259
21,535
1,580,931
84,405
1,665,336
H
(c) AF calculation: The estimated attributable fraction for men is 5% (95% CI 0-24%)
resulting in 1,745 attributable registrations, and for women is 0.4% (0-2.4%) resulting in 122
registrations for skin cancer (see Table 8).
Table 8: Summary of estimates of numbers exposed, proportion exposed, relative risks and
attributable fractions for mineral oils.
Occupational exposure
Mineral oils
'Best study' for RR estimate
Eisen et al (2001)
Independent data:
Type of study
Cohort mortality study in US automobile industry
Sex
Male
Exposure period
1955-1994
Exposure level
Higher
Lower +
Background
Industry Sectors
C-E
C-E
LFS 1979 numbers
exposed
Annual employment
turnover
Numbers exposed in
the REP
Female
1,515,547
65,384
0.09
0.09
5,236,273
225,904
Proportion of the population exposed
0.27
0.01
Relative risks
1.20
1.00
0.05
0.00
17
1,745
Attributable fraction
Levin's
Random error 95%
confidence interval
Attributable deaths
Attributable registrations
Total
Lower +
Background
C-E
C-E
4,936
0.14
0.14
5,462,177
445,697
27,683
473,380
0.28
0.02
0.00
0.02
1.20
1.00
0.05
[-0.10 0.24]
0.004
[-0.007 0.024]
0.00
0.004
[-0.007
- 0.024]
0
17
1
0
1
0
1,745
122
0
122
Industry sectors:
A-B = Agriculture, hunting and forestry; fishing
C-E = Mining and quarrying, electricity, gas and water; manufacturing industry
F = Construction
G-Q = Service industries
3.4 Polycyclic Aromatic Hydrocarbons – Coal tars and pitches
(a) Risk estimate: As noted in section 2, exposure to PAHs is mainly through inhalation and this
route does not increase the risk of NMSC, neither does ingestion (ATSDR, 1995). There is little
evidence of a direct association between human dermal exposure to individual PAHs and NMSC.
However, there are reports of NMSC among individuals exposed to mixtures of PAHs in certain
industrial processes/exposures (coal tar and pitches, soots, coal gasification, coke production,
asphalt workers and roofers, and creosotes) where dermal contact could occur. In a meta-analysis
14
Total
79,469
[-0.10 - 0.24]
1,580,931
Higher
84,405
of asphalt workers and roofers a combined RR of 1.74 (95%CI 1.07-2.65) was obtained (Pavers
and Road Maintenance: RR 2.18 (95% CI 1.19-3.66); Roofers: RR 4.00 (95%CI 0.83-11.7);
Other workers: RR 0.82 (95% CI 0.22-2.09) (Partanen & Boffetta, 1994). In a case-control study
of BCC and SCC cases in Canada an OR of 1.2 (95% CI 0.7-2.1) for BCC and 0.9 (0.5-1.7) for
SCC was found for those ever exposed to pitch tar and tar products (Gallagher et al., 1996).
(b) Numbers exposed: There are only two sites engaged in coal tar distillation with
approximately 80 workers potentially exposed. The number of workers exposed to coal tar and
pitches for 2002-2004 is shown in Table 9.
Table 9: Average number of workers with potential exposure to coal tar and pitches, bitumens,
asphalt, etc. between 2002-2004.
SIC code Description
Male Female Total
LFS 1979
139.7
Foremen of Road Surfacers Concreters
254
-
254
139.8
Foremen of Roadmen
6807
-
6807
139.9
Foremen of Paviors Kerb Layers
140.4
Roofers Glaziers
141.2
141.3
141.4
Paviors Kerb Layers
246
-
246
51796
485
52281
Road Surfacers Concreters
8615
-
8615
Roadmen
13622
-
13622
86403
485
86888
-
-
-
5063
TOTAL
159.3
Foremen of Labourers and Unskilled Workers in Coke Ovens and Gas
Works
160.3
Labourers and Other Unskilled Workers in Coke Ovens and Gas Works
TOTAL
5063
802
-
802
87205
485
87690
For the calculation of AF, asphalt workers and roofers are taken as those in the 1979 LFS key
occupation (KOS) categories 139.4 to 141.4 included in the table above, and those exposed in
coal gasification and coke production are taken as those in the 1979 LFS KOS categories 159.3
and 160.3 above.
(c) AF calculation: The AF is 2% for men, resulting in 547 registrations in the target year, and
0.01% for women (only 3 registrations) (see Table 10).
A parallel calculation, using data from the Canadian population based case-control study (males
only, basal cell carcinomas only), and Miettinen’s formula for AF (i.e. based on the proportion of
study cases exposed) resulted in a similar AF for men, confirming that this is probably a realistic
estimate.
15
Table 10: Summary of estimates of numbers exposed, proportion exposed, relative risks and
attributable fractions for PAH, coal tars and pitches.
Occupational exposure
PAHs - Coal tars and pitches
'Best study' for RR estimate
Partanen and Boffetta (1994)
Independent data:
PAHs - Coal tars and
pitches
Gallagher et al (1996)
Type of study
Meta-analysis of cohort studies in asphalt workers
Sex
Male
Industry Sectors
LFS 1979 numbers
exposed
Coal
gasification
and coke
production
(C-E)
Asphalt
pavers
and
roofers
(F)
Total
Female
`
Coal
gasification
and coke
production
(C-E)
Asphalt
pavers and
roofers (F)
0
485
0.14
0.16
802
86,643
Annual employment
turnover
0.09
0.13
Numbers exposed in
the REP
2,771
424,614
427,385
0
0.00
0.02
0.02
0
Proportion of the population exposed
87,445
Case-control study in
Canada
Male
Female
Total
All
All
485
87,445
3,086
3,086
427,385
3,086
0.0001
0.0001
0.02
0.0001
Proportion of cases exposed
Relative risks
Attributable
fraction
0.14
1.74
1.74
0.0001
0.016
0.02
[0.0000 0.0002]
[0.002 0.035]
[0.002 0.035]
Attributable deaths
0
5
5
Attributable registrations
Attributable
Meittinen's
fraction
4
544
547
Levin's
Random error 95%
confidence interval
485
1.74
1.74
1.20
1.20
0
0.0001
0.0001
0.004
0.00003
[0.0000 0.0002]
[0.0000 0.0002]
[-0.007 0.024]
[0.0000 0.0002]
0
0
0
0
0
0
3
3
106
1
0.02
Random error 95%
confidence interval
[-0.05 0.09]
Attributable registrations
566
3.5 Solar Radiation
(a) Risk estimate: The risk for NMSC caused by exposure to solar radiation is difficult to estimate
because everyone at some time is exposed to sunlight to a greater or lesser degree depending on
residential location and leisure time activities. Epidemiological evidence suggests that excess risk for
occupational UV-radiation exposure could only be demonstrated for SCC (Diepgen & Mahler, 2002),
mainly because the majority of these tumours occur on the head and neck areas of the body most
exposed to sunlight. Population-based case-control studies of BCC and SCC have shown an increased
risk of NMSC in individuals whose occupation entails many hours outside (Gallagher et al., 1995a;
Gallagher et al., 1995b), results suggesting that sun exposure in the 10 years prior to diagnosis may be
important in accounting for the individual risk of SCC. A US-based case-control study of 6565 cases of
NMSC compared occupations with predominantly indoor work, work that combined indoor and outdoor
work, outdoor work by non-farmers, and farming (Freedman et al., 2002), and found the odds ratio
(ORs) (with 95%CIs) given below:
•
Mixed indoor and outdoor
1.01, 0.93 - 1.09
•
Mainly outdoor
1.30, 1.14 - 1.47
•
Farmer
1.15, 1.00 - 1.32
16
A meta-analysis of 19 studies that investigated cancer among farmers found a similar RR of 1.15
(95%CI 1.00-1.33) (Acquavella et al., 1998).
The Freedman et al., (2002) estimate for outdoor workers will be used for the ‘higher exposed’
group, the mixed estimate will be used for the ‘lower exposed’ groups, and the farmers estimate
will be applied to those exposed in agriculture, hunting and forestry and fishing.
(b) Numbers exposed: The numbers exposed to solar radiation according to CAREX for 199093 are given in Table 11. The percentage of males is taken as that for all occupations from the
1990 census within the grouped main industry sectors.
Table 11: Numbers of workers exposed to solar radiation according to CAREX in 1990-1993
Industry
CAREX Data 1990-1993
Number
Exposed
Agriculture and hunting
Number in
Industry
159,533
419,825
Forestry and logging
9,860
14,500
Fishing
8,079
16,150
Metal ore mining
405
1,225
11,260
28,150
Food manufacturing
8,288
414,150
Manufacture of wearing apparel, except footwear
5,685
189,500
Manufacture of wood and wood and cork products, except furniture
17,287
132,975
Printing, publishing and allied industries
31,922
354,750
Petroleum refineries
2,528
18,075
Manufacture of pottery, china and earthenware
8,144
54,450
Other mining
Manufacture of glass and glass products
6,484
43,275
10,633
70,875
Iron and steel basic industries
1,937
48,425
Non-ferrous metal basic industries
3,173
79,325
Manufacture of fabricated metal products, except machinery and equipment
8,769
292,200
Manufacture of transport equipment
54,828
456,900
Electricity, gas and steam
18,330
140,975
Manufacture of other non-metallic mineral products
Water works and supply
9,035
45,175
350,701
1,753,450
Wholesale and retail trade and restaurants and hotels
85,349
4,459,525
Land transport
84,287
671,050
Construction
Water transport
8,864
68,175
Services allied to transport
37,950
180,725
Communication
66,984
459,425
Financing, insurance, real estate and business services
50,081
2,830,800
117,245
1,557,875
32,910
274,225
Research and scientific institutes
7,288
91,100
Medical, dental, other health and veterinary services
8,864
1,435,675
Welfare institutions
3,727
741,375
14,231
133,075
Public administration and defence
Sanitary and similar services
Business, professional and other organisations
17
Industry
CAREX Data 1990-1993
Number
Exposed
Recreational and cultural services
26,732
Personal and household services
6,592
Total
1,277,985
Main Industry Sector
Number in
Industry
534,600
686,750
18,698,725
% Male
Agriculture, hunting and forestry; fishing
Higher
177472
79%
Mining/quarrying, electricity/gas/steam,
manufacturing industry
Higher
198,708
71%
Construction
Higher
350701
91%
Armed forces
117245
93%
Higher
433,859
46%
Service industries
All the CAREX exposed workers are assumed to be ‘outdoor’ workers and therefore a higher
exposed category.
Using Local Authority statistics it is estimated that between 10% and 30% of the working
population work outdoors. These fractions have been applied to the LFS estimate of men and
women employed in 1979, to obtain upper and lower estimates of AF to compare with the
CAREX-based estimates.
Estimates of numbers of men and women employed in agriculture, forestry and fishing from the
LFS have also been used to give an alternative estimate to the CAREX-based figure for these
sectors. A smoothed and extrapolated estimate for 1975 is used, which is not out of line with
estimates from the ‘June’ Agricultural and Horticultural Census data. In 1987 (the earliest year
currently available from the June Census) there were 528,000 employed in full-time or part-time
employment (not including seasonal or casual labour), 413,000 men and 115,000 women.
(c) AF calculation: The estimated AF for men is 5.4% resulting in 1,824 skin cancer
registrations, and for women is 3.0%, resulting in 733 registrations. This estimate is based on
CAREX numbers exposed (see Table 12).
18
Table 12: Summary of estimates of numbers exposed, proportion exposed, relative risks and
attributable fractions for solar radiation.
Occupational exposure
Solar Radiation
'Best study' for RR
estimate
Reference
Freedman et al (2002)
Type of study
Death certificate based case-control study, US
Sex
Male
Exposure level
Farmer
Outdoors
TOTAL
Industry Sectors
A-B
C-E
F
G-Q
Armed
forces
CAREX numbers
exposed
139,738
141,800
319,129
108,857
200,350
1.00
1.40
1.00
0.90
0.90
0.09
0.09
0.13
0.11
0.11
482,800
685,894
1,563,962
409,314
753,336
3,412,506
Proportion of the population exposed
0.025
0.036
0.081
0.021
0.039
0.178
Relative risks
1.15
1.30
0.004
0.051
Independent data:
CAREX
adjustment factor
Annual
employment
turnover
Numbers exposed
in the REP
Attributable fraction
Levin's
Random error
95% confidence
interval
G-Q
Other
Total
770,136
[0.000 - 0.008]
Attributable deaths
Attributable registrations
909,874
3,895,306
0.203
0.054
[0.024 - 0.077]
1
16
17
127
1,709
1,824
Occupational exposure
Solar Radiation
'Best study' for RR
estimate
Reference
Freedman et al (2002)
Type of study
Death certificate based case-control study, US
Sex
Female
Exposure level
Farmer
Outdoors
TOTAL
Industry Sectors
A-B
C-E
F
G-Q
Armed
forces
CAREX numbers
exposed
37,734
56,908
31,572
8,388
233,509
0.75
1.50
0.67
0.80
0.80
0.10
0.14
0.16
0.15
0.15
116,038
478,748
134,590
40,163
1,118,133
1,771,634
1,887,673
Proportion of the population exposed
0.006
0.023
0.006
0.002
0.053
0.085
0.09
Relative risks
1.15
1.30
0.001
0.025
Independent data:
CAREX
adjustment factor
Annual
employment
turnover
Numbers exposed
in the REP
Attributable fraction
Levin's
19
G-Q Other
Total
330,377
368,111
0.026
Random error
95% confidence
interval
[0.012 0.038]
[0.000 - 0.002]
Attributable deaths
0
5
5
Attributable registrations
24
711
733
A-B = Agriculture, hunting and forestry; fishing
C-E = Mining and quarrying, electricity, gas and water; manufacturing industry
F = Construction
G-Q = Service industries
The alternative estimate based on the range of between 10% and 30% of all workers working
outdoors gives an AF of between 2% and 6% for men. The estimate for women is also from 2%
to 5%, much higher than the CAREX-based estimate, with the difference due mainly to the
assumption that all are exposed at the ‘high’ level (see Table 13).
The estimated AF for farmers in the second part of Table 13 is based on LFS exposed numbers in
industry sectors A-B extrapolated back to 1975, to account for the decline that is known from
Agricultural Census data to have occurred across the period 1955 – 1994 in this industry. The AF
is close to the AF from the CAREX estimate.
Table 13:
Occupational exposure
'Best study' for RR estimate
Type of study
Sex
Independent data:
Industry Sectors
LFS 1979 numbers
exposed
Annual employment
turnover
Numbers exposed in
the REP
Solar Radiation
Solar Radiation
Freedman et al (2002)
Freedman et al (2002)
Death certificate based case-control study, US
Death certificate based case-control
study, US
Male
Female
Male
10%
'outdoors'
Female
30%
'outdoors'
10%
'outdoors'
30%
'outdoors'
LFS Farmers 1975 estimate
1,516,516
4,549,548
974,761
2,924,282
489,360
102,433
0.020
0.020
0.022
0.022
0.020
0.022
1,402,903
4,208,710
1,138,032
3,414,097
452,699
119,590
Proportion of the population exposed
0.07
0.22
0.05
0.16
0.024
0.006
Relative risks
1.30
1.30
1.30
1.30
1.15
1.15
0.02
0.06
0.02
0.05
0.004
0.001
[0.01 - 0.03]
[0.03 - 0.09]
[0.01 - 0.02]
[0.02 - 0.07]
[0.000 - 0.007]
[0.000 - 0.002]
Attributable fraction
Levin's
Random error 95%
confidence interval
Attributable deaths
Attributable registrations
7
20
3
9
1
0
724
2,083
461
1,339
119
25
20
4. OVERALL ATTRIBUTABLE FRACTION
4.1 Comparison of exposure AFs
Figure 1 below shows the proportion of the population exposed for each exposure, and Figure 2
shows the attributable fraction estimated for each exposure for men and for women.
Figure 1:
Proportion of the population exposed
Exposure
Mineral oils
PAHs - Coal tars
and pitches
M
F
Solar Radiation
0.00
0.05
0.10
0.15
Pr(E)
21
0.20
0.25
0.30
Figure 2:
NMSC: Occupational attributable fraction
Exposure
Mineral oils
PAHs - Coal tars and pitches
M
Solar Radiation
F
Overall AF
0.00 0.02 0.04 0.06 0.08 0.10 0.12 0.14
AF
4.2 Exposure Map
The exposure map (Figure 3) gives an indication of how exposures overlap in the working
population. It illustrates the potential for double counting of the exposed population to occur
when an overall AF is calculated, and facilitates strategies to avoid this. For a given cancer, the
map entries consist of either an agent (or group of agents such as PAHs), or an exposure scenario
(i.e. an industry or occupation in which such exposure occurs). Agents are in plain type, exposure
scenarios in italics, from Table 4. Lines joining boxes then indicate where overlap would occur
were all the entries in the map simply considered separately. For example, if solar radiation and
coal tars/pitches were considered separately, overlap would occur in outdoor workers such as
paviors and roofers and asphalt workers (these exposure scenarios are indicated in the smaller
print, again based on information in Table 4). For substances and occupations shown in dotted
boxes a separate AF has not been estimated, as these exposure scenarios are included with
another exposure (see Table 5).
There is no overlap between workers exposed to mineral oils and to coal tars and pitches. The
AFs for these two exposures can therefore be summed directly. There is certainly overlap
between workers exposed to solar radiation and pavers and roofers exposed to coal tars and
pitches (PAHs), and most other workers also who may have changed between indoor and outdoor
jobs over a working lifetime.
It will be assumed therefore that solar radiation acts independently of and multiplicatively with
the other two exposures in the causation of NMSC. If it is known that overlapping exposures are
22
independent and their joint effect on initiating or promoting cancer is multiplicative, the AFs for
each overlapping exposure can be combined into an overall AF for the set by taking the
complement of the product of complements:
AFoverall = 1 – Πk(1-AFk) for the k exposures in the set.
Figure 3: Non-melanoma skin cancer exposure map
Dermal or ingestion exposure
to: Wood preservatives
Arsenical pesticides
(farmers)
Solar radiation
Paviors
Roofers
Asphalt workers
Coal-tar and pitches
Soots
Creosote
Coal gasification
Coke production
Arsenic and
arsenic compounds
Copper smelting
Mining ores
containing arsenic
Benzo[a]anthracene
Mineral oils, shale oils
and shale -derived
lubricants
Benzo[a]pyrene
Dibenz[a,h]anthracene
Machinists exposed
to Metal -working
fluids
4.3 Overall AF
Where possible, the AFs for non-melanoma skin cancer exposures have been estimated on RRs
for cancer incidence, as NMSC has a very good survival rate so that RR estimates for mortality
alone could grossly underestimate AF. However, with the exception of coal tars and pitches, for
which a meta-analysis was used which included some incidence estimates, only mortality studies
were available for the RR estimates.
The overall AF is calculated as follows:
For the exposures Mineral oils, PAHs and Solar radiation
AFOverall = 1-(1-AFS)* (1-(AFM + AFPAH))
= 1 – (1 – 0.054)*(1 – (0.052 + 0.016))
23
= 0.118
and
for men
AFOverall = 1 – (1 – 0.026)*(1 – (0.004 + 0.0001))
= 0.030
for women
All the exposures for which an AF has been calculated are considered to have strong evidence for
carcinogenicity for NMSC. The overall AF for these exposures is 11.8% for men and 3.0% for
women (see Table 16).
Other author’s estimates of overall attributable fraction for NMSC are in Table 14.
Table 14: Other estimates of occupational attributable fraction for NMSC.
Reference
Location
Men
Men & Women
Doll & Peto (1981)
US
10%
2%
Nurminen & Karjalainen (2001)
Finland
13%
4%
Steenland et al. (2003)
US
1.5%-6.0%
24
Women
4.4 Summary of results
Table 15: Source data
Agent
Mineral
oils
Level of
exposure
Dermal
exposure
to soluble
MWF
Source study data
Data for the proportion of the population exposed
Refere
nce
Study type
Male/
Female
Mortality
/ Cancer
incidence
Exposure
scenario
RR (95%
CI) ~
Source
Eisen
et al
(2001)
Cohort mortality
study in US
automobile
industry
M+F
Mortality
Exposure
to metal
working
fluids in
automobi
le
industry
1.20
[0.67 2.15]
LFS
1979
Groupe
d main
industr
y
sector
C-E
Industry /Occupation classes
111.1 Foremen of Press and Machine Tool Setters
Numbers:
Female
Num
bers:
Total
2,164
-
2,164
111.2 Foremen of other Centre Lathe Turners
736
-
736
111.3 Foremen of Machine Tool Setter Operators
581
-
581
111.4 Foremen of Machine Tool Operators
111.5 Foremen of Press Stamping and Automatic
Machine Operators
8,947
252
9,199
1,498
-
112.1 Press and Machine Tool Setters
64,157
740
112.2 Other Centre Lathe Turners
49,774
-
112.3 Machine Tool Setter Operators
10,818
232
112.4 Machine Tool Operators
113.1 Press Stamping and Automatic Machine
Operators
114.1 Foremen of Toolmakers Tool Fitters
Markers-Out
114.4 Foremen of Metal Working Production
Fitters and Fitter/Machinists
114.5 Foremen of Motor Mechanics Auto
Engineers
114.6 Foremen of Maintenance Fitters (Aircraft
Engines)
335,097
50,424
34,002
18,281
1,498
64,89
7
49,77
4
11,05
0
385,5
21
52,28
3
4,319
-
27,544
-
13,825
-
4,319
27,54
4
13,82
5
522
-
522
114.7 Foremen of Office Machinery Mechanics
-
-
92,886
510
93,39
6
115.0 Toolmakers Tool Fitters Markers-Out
25
Numbers:
Male
117.0 Metal Working Production Fitters and
Fitter/Machinists
546,544
6,933
118.1 Motor Mechanics Auto Engineers
269,925
1,271
3,957
-
11,506
-
15,469
567
21,276
1,515,54
7
259
79,469
3,957
11,50
6
16,03
6
21,53
5
1,595
,016
265
-
265
111.7 Foremen of Fettlers Dressers
-
-
-
111.8 Foremen of Shot Blasters
-
-
113.2 Metal Polishers
11,112
1,425
113.3 Fettlers Dressers
12,391
1,619
12,53
7
14,01
0
6,049
-
6,049
969
-
969
-
-
28,071
1,667
29,73
8
6,527
225
65,384
1,580,93
1
4,936
84,405
6,752
70,32
0
1,665
,336
240
-
240
118.2 Maintenance Fitters (Aircraft Engines)
119.0 Office Machinery Mechanics
Labourers and Other Unskilled Workers in
Foundries in Engineering
Labourers and Other Unskilled Workers in
Engineering and Allied Trades
High Total
'Low or
Backgrou
nd
exposure
1.00
111.6 Foremen of Metal Polishers
Low
exposure
131.8 Shot Blasters
114.2 Foremen of Precision Instrument Makers
and Repairers
114.3 Foremen of Watch and Chronometer Makers
and Repairers
1.00
116.1 Precision Instrument Makers and Repairers
116.2 Watch and Chronometer Makers and
Repairers
Low Total
TOTAL
All
PAHs Coal tars
and
pitches
553,4
77
271,1
96
Partane
n and
Boffett
a
(1994)
Meta-analysis of
cohort studies in
asphalt workers
Not
stated
Mortality
and
incidence
Asphalt
workers
1.74
[1.07 2.65]
LFS
1979
F
139.4 Foremen of Roofers Glaziers
139.7 Foremen of Road Surfacers Concreters
139.8 Foremen of Roadmen
139.9 Foremen of Paviors Kerb Layers
26
254
-
254
6,807
-
6,807
246
-
246
140.4 Roofers Glaziers
485
8,615
-
13,622
-
5,063
-
Sub-total
159.3 Foremen of Labourers and Unskilled
Workers in Coke Ovens and Gas Works
160.3 Labourers and Other Unskilled Workers in
Coke Ovens and Gas Works
86,643
485
5,063
87,12
8
-
-
-
802
-
TOTAL
87,445
485
802
87,93
0
125,613
33,920
159,5
33
Forestry and logging
7,764
2,096
9,860
Fishing
6,361
1,718
139,738
37,734
8,079
177,4
72
289
116
Other mining
8,035
3,225
405
11,26
0
Food manufacturing
5,914
2,374
8,288
Manufacture of wearing apparel, except footwear
Manufacture of wood and wood and cork products,
except furniture
4,057
1,628
12,336
4,951
Printing, publishing and allied industries
22,780
141.2 Road Surfacers Concreters
141.3 Roadmen
141.4 Paviors Kerb Layers
C-E
Solar
Radiatio
n
Gallag
her et
al
(1996)
Population based
case-control study
in Canada
Freedm
an et al
(2002)
Death certificate
based case-control
study, US
Farmer
M
Incidence
(BCC
only)
M+F
Mortality
Ever
exposed
to pitch
tar and
tar
products
Farmer
Outdoor
occupatio
n
8,615
13,62
2
1.20
[0.70 2.10]
[A*]
1.15
[1.00 1.32]
[A**]
CARE
X
A-B
Agriculture and hunting
Farmer Total
Outdoors
52,28
1
51,796
1.30
[1.14 1.47]
[A**]
CARE
X
C-E
Metal ore mining
27
9,142
5,685
17,28
7
31,92
2
Petroleum refineries
1,804
724
2,528
Manufacture of pottery, china and earthenware
5,812
2,332
8,144
Manufacture of glass and glass products
4,627
1,857
6,484
F
G-Q
Manufacture of other non-metallic mineral
products
7,588
3,045
10,63
3
Iron and steel basic industries
1,382
555
1,937
Non-ferrous metal basic industries
Manufacture of fabricated metal products, except
machinery and equipment
2,264
909
3,173
6,258
2,511
Manufacture of transport equipment
39,126
15,702
Electricity, gas and steam
13,080
5,250
8,769
54,82
8
18,33
0
Water works and supply
6,447
2,588
Sub-total
141,800
56,908
Construction
Wholesale and retail trade and restaurants and
hotels
319,129
31,572
39,413
45,936
Land transport
38,923
45,364
Water transport
4,093
4,771
Services allied to transport
17,525
20,425
Communication
Financing, insurance, real estate and business
services
30,932
36,052
23,127
26,954
108,857
8,388
15,197
17,713
8,864
37,95
0
66,98
4
50,08
1
117,2
45
32,91
0
Research and scientific institutes
Medical, dental, other health and veterinary
services
3,365
3,923
7,288
4,093
4,771
8,864
Welfare institutions
1,721
2,006
Business, professional and other organisations
6,572
7,659
Recreational and cultural services
12,344
14,388
3,727
14,23
1
26,73
2
Personal and household services
3,044
3,548
Sub-total
309,208
241,896
Outdoor Total
770,136
330,377
Public administration and defence
Sanitary and similar services
28
9,035
198,7
08
350,7
01
85,34
9
84,28
7
6,592
551,1
04
1,100
,513
TOTAL
~=
[A*]=
[A**] =
LFS =
Male and female unless otherwise stated
RR adjusted for age, skin colour, hair colour, mother's ethnic origin
RR adjusted for age, sex, race, place of residence and birth, physical activity and socio-economic status
Labour Force Survey
Industry sectors:
A-B = Agriculture, hunting and forestry; fishing
C-E = Mining and quarrying, electricity, gas and water; manufacturing industry
F = Construction
G-Q = Service industries
29
909,874
368,111
1,277
,985
Table 16: Results
Established/
uncertain
evidence for
carcinogenicity
Exposure
Numbers exposed
(1955-94)
M
F
Pr(E)
M
AF (& its 95% CI)
F
M
Attributable
deaths
F
M
F
Attributable
registrations
M
F
E
Mineral oils
5,462,177
473,380
0.28
0.02
0.052
[-0.10
0.24]
0.004
[-0.007
- 0.02]
17
1
1,745
122
E
PAHs - Coal
tars and
pitches
427,385
3,086
0.02
0.0001
0.016
[0.002
0.03]
0.0001
[0.0000
0.0002]
5
0
547
3
E
Solar
Radiation
3,895,305
1,887,673
0.20
0.09
0.054
0.026
17
5
1,824
733
Overall AF
0.118
0.030
38
6
3992
855
Exposures in
Construction
only
0.040
0.002
13
0
1,336
58
4.5 Exposures in construction
Exposures to workers in the construction industry were responsible for 33% of male NMSC
registrations in 2003 (Figure 4), but just 7% of female registrations.
Figure 4: NMSC Registrations attributable to work in the construction industry
NMSC Registrations attributable to work in Construction, 2003,
Male
Mineral oils
Exposure
PAHs - Coal tars
and pitches
Construction only
Solar Radiation
Other sectors
Overall AF
0
1,000
2,000
3,000
Number of registrations
30
4,000
5,000
4.6 Exposures by industry /job: Numbers of people exposed by job or industry, are shown in Figure 5.
Figure 5: Numbers of people exposed by job or industry for men and women combined
NMSC: Numbers exposed 1955-1994
Metal workers
Mechanics
Labourers in Engineering
Solar
Radiation
Exposure
Roofers/glaziers
Road workers
PAHs Coal tars
and pitches
Coke ovens and gas works
Agriculture, forestry, fishing (A-B)
Mining, Manufacturing, Utilities (C-E)
Mineral oils
Construction (F)
Armed Forces
0
4.7
2,000,
000
4,000,
000
6,000,
000
8,000,
000
Other Service Industries (G-Q)
High versus low exposures
All attributable registrations were estimated to be due to higher level exposure (see Table 17). For
allocations to the higher and lower level categories see Section 3.
Table 17: Numbers ever exposed to an occupational carcinogen for NMSC in the period 1955-1994,
and attributable registrations, by level of exposure
Exposure
Higher Level Exposure
Numbers exposed
Attributable
(1955-94)
registrations
M
F
M
F
Mineral oils
5,236,273
445,697
1,745
122
PAHs - Coal
tars and
pitches
427,385
3,086
547
3
3,895,305
1,887,673
1,824
733
3992
855
Solar
Radiation
Combined
exposures
31
Lower and Background Level exposure
Numbers exposed
Attributable registrations
(1955-94)
M
F
M
F
225,904
27,683
0
0
0
0
32
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37
Published by the Health and Safety Executive 10/07
Health and Safety Executive
The burden of occupational cancer
in Great Britain
Technical Annex 3: Non­melanoma skin cancer The aim of this project was to produce an updated estimate of the
current burden of occupational cancer specifically for Great Britain.
The primary measure of the burden of cancer used was the
attributable fraction (AF), ie the proportion of cases that would not
have occurred in the absence of exposure. Data on the risk of the
disease due to the exposures of interest, taking into account
confounding factors and overlapping exposures, were combined with
data on the proportion of the target population exposed over the
period in which relevant exposure occurred. Estimation was carried
out for carcinogenic agents or exposure circumstances that were
classified by the International Agency for Research on Cancer (IARC)
as Group 1 or 2A carcinogens with strong or suggestive human
evidence. Estimation was carried out for 2004 for mortality and 2003
for cancer incidence for cancer of the bladder, leukaemia, cancer of
the lung, mesoth elioma, non­melanoma skin cancer (NMSC), and
sinonasal cancer.
The proportion of cancer deaths in 2004 attributable to occupation
was estimated to be 8.0% in men and 1.5% in women with an overall
estimate of 4.9% for men plus women. Estimated numbers of deaths
attributable to occupation were 6,259 for men and 1,058 for women
giving a total of 7,317. The total number of cancer registrations in
2003 attributable to occupational causes was 13,338 for men plus
women. Asbestos contributed the largest numbers of deaths and
registrations (mesothelioma and lung cancer), followed by mineral oils
(mainly NMSC), solar radiation (NMSC), silica (lung cancer) and diesel
engine exhaust (lung and bladder cancer). Large numbers of workers
were potentially exposed to several carcinogenic agents over the risk
exposure periods, particularly in the construction industry, as farmers
or as other agricultural workers, and as workers in manufacture of
machinery and other equipment, manufacture of wood products, land
transport, metal working, painting, welding and textiles. There are
several sources of uncertainty in the estimates, including exclusion of
other potential carcinogenic agents, potentially inaccurate or
approximate data and methodological issues. On balance, the
estimates are likely to be a conservative estimate of the true risk.
Future work will address estimation for the remaining cancers that
have yet to be examined, together with development of methodology
for predicting future estimates of the occupational cancers due to
more recent exposures.
This report and the work it describes were funded by the Health
and Safety Executive (HSE). Its contents, including any opinions
and/or conclusions expressed, are those of the authors alone and
do not necessarily reflect HSE policy.
RR595
www.hse.gov.uk