A population-based case-control study of childhood leukemia in Shanghai

Mutagenic lifestyles? A review of evidence of associations between germ-cell mutations in humans and smoking, alcohol consumption and use of 'recreational' drugs

In humans, associations between germ-cell mutations and hypothetical aetiological factors can be investigated by (1) examining the relationship between the factor of interest and conditions known to be of genetic aetiology; (2) examining the relationship between conditions of unknown aetiology and route of exposure, especially paternal preconceptional exposure. As regards smoking, alcohol and 'recreational' drugs, the first approach has been applied in studies of retinoblastoma, Wilms' tumour and chromosomal anomalies. Only Down's syndrome has received intensive investigation, in relation to maternal smoking during pregnancy; the relative risks would be compatible with there being no association in all recognized conceptuses. The second approach has been applied in studies of sperm quality, miscarriage, congenital anomalies and childhood cancer. The available studies do not show a consistent relationship between smoking and sperm quality; there are few data on the effects of the other exposures. There are a substantial number of studies of childhood cancer and smoking by the father; the majority do not indicate any relationship. Some studies of childhood cancer suggest a positive association with use of 'recreational' drugs by the parents, but it has not been possible to clarify which route of exposure, or the specific type of drug which may be involved. Use of molecular techniques to detect individual genetic changes should enable progress to be made in elucidating the origin of mutation. In the meantime, public health actions are justified on the basis of the known non-genetic effects of these agents.

Diagnostic X-ray and ultrasound exposure and risk of childhood cancer

In a population-based case-control study of 642 childhood cancer cases and the same number of matched controls in Shanghai, China, we evaluated the relationship between diagnostic X-ray (preconception, pre- and post-natal) and antenatal ultrasound exposure and the subsequent risk of developing three major types of childhood cancer (acute leukaemia, lymphoma and brain tumours) and all childhood neoplasms combined. Consistent with previous studies, prenatal X-ray exposure was found to be associated with an 80% increased risk of childhood cancers, although the estimation was based on 4% and 2% exposed cases and controls and was only marginally statistically significant (P = 0.08). Post-natal X-ray exposure was also linked with a small elevation in the risk of all cancers and the major categories of malignancies in children. Little evidence, however, was found to relate parental preconception X-ray exposure with the subsequent cancer risk in offspring, regardless of the exposure window and the anatomical site of X-ray exposures. This study adds further to the growing literature indicating that antenatal ultrasound exposure is probably not associated with an increased risk of childhood cancer.

Exposure to passive smoking during pregnancy and childhood, and cancer risk: the epidemiological evidence

There are relatively few studies on the association between environmental tobacco smoke (ETS) during pregnancy and childhood, and cancer in childhood, adolescence or adulthood. The associations between maternal smoking during pregnancy and childhood cancer have been studied intensively, but there is no clear association overall, or for specific sites. The association between childhood cancer and smoking by the father in the preconceptional period, and by either parent during the child's lifetime, has been little studied. Again, no clear associations have been identified. However, evidence from studies of exposure to known carcinogens from ETS, and of genotoxic effects indicates that any effect, if present, is expected to be weak, and therefore could not have been detected by most of the studies which have been performed, due to the small number of cases included. There is some consistency of association between ETS exposure in childhood and the risk of lung cancers in adulthood. There is therefore a need for further epidemiological studies on ETS exposure during pregnancy and childhood and the occurrence of cancers.

Risk of childhood leukemia in areas passed by high power lines

There has been an emerging concern about possible health risks posed by exposure to extremely low frequency electromagnetic fields (EMF). The incidence of childhood leukemia near high-power transmission lines has only rarely been investigated. A total of 67 cases of childhood leukemia (aged 0-14 years) were reported to the Cancer Registration Center in Taiwan between 1979 and 1988 from the five districts in the Taipei Metropolitan Area, where at least one elementary school campus is passed over by a high power transmission line (69-345 KV). The standardized incidence ratio (SIR) of childhood leukemia in the five districts was found to be significantly elevated (SIR = 1.49, 95% confidence interval: 1.16-1.91). Younger children seemed more susceptible to EMF exposure as indicated by the fact that children aged 0-4 years in two of the five districts showed significantly elevated SIRs compared to older ones. The unusually high SIRs for children of age 5-9 and 10-14 years in one of these districts (SIR = 4.38 and 3.68 respectively) deserves further investigation.

Fouling one's own nest revisited

Transport of hazards from the workplace to the home by workers is a previously recognized but poorly addressed public health problem. Particularly disturbing are the childhood intoxications which may result from such paraoccupational exposure. Work clothes and shoes appear to be a common vehicle for hazard transport in recently reported cases as they were in the past, although other "markers" for potential paraoccupational exposure may be derived from case reviews. These include: poor workplace hygiene, occupational intoxications in adult workers, and the "cottage industry" phenomenon. These markers are reviewed in the context of recently reported cases and strategies are suggested to mitigate these easily preventable exposures.

Prior medical conditions and the risk of adult leukemia in Shanghai, People's Republic of China

A population-based case-control interview study of 486 adult leukemia cases and 502 healthy controls was carried out in Shanghai, People's Republic of China during 1987-89 to evaluate the etiologic role of prior medical conditions, medications, and diagnostic X-rays. Risks were examined separately for 236 cases with acute non-lymphocytic leukemia (ANLL), 79 with chronic myeloid leukemia (CML), 81 with acute lymphocytic leukemia (ALL), and 21 with chronic lymphocytic leukemia (CLL). Little difference was found between cases and controls for prior history of diabetes, hypertension, allergic conditions, most medications, and diagnostic X-rays. A few significant associations were observed for appendectomy, tuberculosis, and for several other chronic disorders with specific leukemia cell types, but the odds ratio estimates for most of these ranged from two to three and, with the exception of the two specified above, were based generally on five or fewer exposed controls. In contrast to an association with childhood leukemia in Shanghai, prior use of chloramphenicol was not linked with ANLL or other forms of adult leukemia. Further research is needed to clarify the relation of specific medical conditions and exposures with particular subtypes of leukemia, and to examine reasons for the low incidence of CLL in China and other Asian populations.

Human health effects of agrichemical use

The use of pesticides and nitrogen fertilizers in agriculture has grown dramatically over the past 30 years. Currently, approximately 600 active pesticide ingredients are used, but adequate toxicologic data are available for only approximately 100 of these. Environmental exposure of humans to agrichemicals is common and results in both acute and chronic health effects, including acute and chronic neurotoxicity (insecticides, fungicides, fumigants), lung damage (paraquat), chemical burns (anhydrous ammonia), and infant methemoglobinemia (nitrate in groundwater). A variety of cancers also have been linked to exposure to various pesticides, particularly hematopoietic cancers. Immunologic abnormalities and adverse reproductive and developmental effects due to pesticides also have been reported. The health effects associated with pesticides do not appear to be restricted to only a few chemical classes. Therefore, enhanced efforts are needed to control or eliminate human exposures wherever possible. Research also is needed to better characterize and quantitate the adverse effects of agrichemicals on human health.

Viruses, clusters and clustering of childhood leukaemia: a new perspective?

Clusters of childhood leukaemia have, during a lengthy and controversial history, focussed attention on two alternative putative aetiological agents: infections and localised environmental pollution. In the United Kingdom emphasis is currently placed on the latter because of reports of localised clusters in the vicinity of two nuclear reprocessing plants. Now the most recent studies of spatial clustering in the United Kingdom also support the hypothesis that a substantial population of cases of childhood acute lymphoblastic leukaemia (ALL) arise as a rare host response to certain patterns of exposure to common infectious agents--the aberrant response model. Relevant aspects of the epidemiology of ALL are reviewed from this perspective and the hypothesis shown to be capable of unifying reported associations with different types of risk factor. It is probable that specific agent(s) are involved though none have been identified and these may share many epidemiological characteristics of herpes viruses. The possible relevance of these results to associations with prenatal parental occupational exposures to dusts and ionising radiation is explored.

Major histocompatibility complex, t-complex, and leukemia

In experimental models, leukemia was the first disease shown to have an association with the major histocompatibility complex (MHC) genes. In humans, several allelic human-leukocyte antigen (HLA) associations also have been recognized. In addition to allelic associations, atypical HLA segregation patterns have been observed in leukemic families. These include a higher frequency of HLA-identical unaffected siblings, increased HLA homozygosity and increased maternal HLA-DR identity. These observations suggest preferential transmission of disease-associated haplotypes and a male transmission bias in leukemic families. The lack of disease-specific segregation, however, supports the idea that the HLA system is not directly relevant in leukemogenesis. Therefore, the existence of another genetic region linked to the MHC, causing segregation distortion, and containing recessive leukemia susceptibility genes may be postulated. The mouse t-complex would fit this model. This gene complex has recessive (semi-) lethal genes, is transmitted preferentially through fathers, and both the mouse t-complex and its rat homolog, growth and reproduction complex grc, confer susceptibility to carcinogenesis. This model could also explain the increased spontaneous abortion rate in mothers of leukemic patients, epidemiologic associations of leukemia with oral clefts and neuroectodermal tumors, and the transmission of a radiation-induced leukemia risk through fathers. Such segregation distortion might be the reason behind the maintenance of a gene(s) with a lethal effect in the population.

Use of a job-exposure matrix to evaluate parental occupation and childhood cancer

We examined the association between parental occupation and childhood cancer among 252 incident cases of childhood cancer (ages 0-14, diagnosed 1976-83) and 222 controls selected by random digit dialing in Denver, Colorado (USA). A job-exposure matrix was used to assign parental exposures based on job titles, emphasizing chemicals that were implicated in previous studies. All cancers, acute lymphocytic leukemia (ALL), and brain cancer were examined in relation to parental occupation during the year prior to the birth of the child. Elevated odds ratios (OR), all with confidence intervals extending below the null, were found for maternal exposure to benzene (OR = 1.9), petroleum/coke pitch/tar (OR = 2.2), and soot (OR = 3.3) in relation to total cancers. The ORs for total cancer and paternal exposure to all hydrocarbons combined was 1.0. Results for individual hydrocarbons and ALL showed larger odds ratios, including aniline (OR = 2.1), benzene (OR = 1.6), and petroleum/coke pitch/tar (OR = 1.6). Potential exposure to creosote was strongly associated with brain cancer (OR = 3.7) based on five exposed cases (95 percent confidence interval = 0.8-16.6). Control for other potential childhood cancer risk factors did not alter the results substantially. In spite of uncertainties due to small numbers and errors in exposure classification, results tend to corroborate past research that suggests an association between specific parental occupational exposures and childhood cancer.

Protective effect of medroxyprogesterone acetate plus testosterone against radiation-induced damage to the reproductive function of male rats and their offspring

This study attempted to protect spermatogenesis and the reproductive performance of rats against the effects of acute scrotal exposure to x-rays. Daily subcutaneous injections of medroxyprogesterone acetate (8 mg/kg) plus testosterone (1 mg/kg) (MT group) were administered for 55 days (experiment A) or 15 days (experiment B). The rats were irradiated (3 grays) on the last day of MT pretreatment (MTX group). In both experiments, on days 1 and 130 posttreatment, rats from each of the four groups (control, x-irradiated, MT, and MTX groups) were killed to measure the weight of the reproductive organs and the number of epididymal spermatozoa. Breeding was started 3 days posttreatment by housing all males from the four groups each with two virgin females for six successive periods of 19 days, separated by a period of 2 days. The percentage of fertile males, the litter size, postimplantation losses, and dominant lethal mutations were calculated. In experiment A, in the last fertility trial, animals of both sexes were selected at random from the progeny of each group (F1). When they were adults, their fertility was tested in a mating trial. A fertility trial was also performed with the F2 males. Our data essentially reveal that (i) in addition to their adverse quantitative effects on spermatogenesis, x-rays also produce a significant increase in dominant lethal mutations in all germ cell classes, including stem spermatogonia; (ii) the F1 and F2 male descendants of irradiated male rats provoked abnormal rates of postimplantation losses in their female mates; (iii) the short as well as the long MT pretreatment protects testicular function of irradiated rats; and (iv) in experiment A, MT pretreatment totally prevented qualitative damage to spermatozoa and protected the descendants of the irradiated animals against altered spermatogenesis as well as against genetic damage in germ cells. In conclusion, pretreatment with MT, even for a short period of time, offers a method for potentially reducing the toxic and genotoxic effects of irradiation on the male reproductive system.

Maternal reproductive history and birth characteristics in childhood acute lymphoblastic leukemia

Using birth-registration data, a case-control study was done to investigate the possible associations of childhood acute lymphoblastic leukemia (ALL) with birth characteristics and maternal reproductive history. The data included cases born and diagnosed in Minnesota since 1969. Matched analyses were conducted using 337 cases and 1336 birth year-matched controls. There was a statistically significant increased odds of ALL for birth to older (greater than 35 years) mothers (odds ratio (OR) = 2.14, 95% confidence interval (CI) = 1.28, 3.58), older fathers (OR = 1.62, 95% CI = 1.14, 2.30), mothers with at least a high school education (OR = 1.61, 95% CI = 1.05, 2.48), and larger intervals (greater than 5 years) between the birth of the proband and the preceding sibling (OR = 1.86, 95% CI = 1.12, 3.09). The increased odds of ALL for birth by Caesarean section approached significance (OR = 1.42, P = 0.06). No overall association was found for: gender, race, paternal education, fetal-loss history, birth order, prenatal care history, pregnancy complications, inducement of labor, multiple birth, gestational age, or birth weight. Age at diagnosis was an important effect modifier of some analyses. For cases diagnosed before age 2 years, there was a 2.7-fold increased odds of ALL if the last pregnancy had resulted in a fetal loss (P = 0.03). For cases diagnosed before age 4 years, birth weight greater than 3800 g was associated with a significant 2.05-fold increased odds of ALL. These data strengthen the hypothesis that prenatal events may play a causative role in childhood ALL, particularly in those cases diagnosed at a younger age.

Parental occupations of children with leukaemia in west Cumbria, north Humberside, and Gateshead

OBJECTIVE

To determine whether parental occupations and chemical and other specific exposures are risk factors for childhood leukaemia.

DESIGN

Case-control study. Information on parents was obtained by home interview.

SETTING

Three areas in north England: Copeland and South Lakeland (west Cumbria); Kingston upon Hull, Beverley, East Yorkshire, and Holderness (north Humberside), and Gateshead.

SUBJECTS

109 children aged 0-14 born and diagnosed as having leukaemia or non-Hodgkin's lymphoma in study areas during 1974-88. Two controls matched for sex and date and district of birth were obtained for each child.

MAIN OUTCOME MEASURES

Occupations of parents and specific exposure of parents before the children's conception, during gestation, and after birth. Other adults living with the children were included in the postnatal analysis.

RESULTS

Few risk factors were identified for mothers, although preconceptional association with the food industry was significantly increased in case mothers (odds ratio 2.56; 95% confidence interval 1.32 to 5.00). Significant associations were found between childhood leukaemia and reported preconceptional exposure of fathers to wood dust (2.73, 1.44 to 5.16), radiation (3.23, 1.36 to 7.72), and benzene (5.81, 1.67 to 26.44); ionising radiation alone gave an odds ratio of 2.35 (0.92 to 6.22). Raised odds ratios were found for paternal exposure during gestation, but no independent postnatal effect was evident.

CONCLUSION

These results should be interpreted cautiously because of the small numbers, overlap with another study, and multiple exposure of some parents. It is important to distinguish periods of parental exposures; identified risk factors were almost exclusively restricted to the time before the child's birth.

[Tobacco and leukemia]

Although some epidemiological studies have published findings supporting the hypothesis that smokers are at a higher risk of developing leukemia, the causal relationship between tobacco and leukemia has not been considered conclusive due to the weak association found, to the lack of a dose-response relationship and to the inconsistencies found throughout the different studies. However, most of these studies were not specifically designed to establish the tobacco-leukemia relationship and therefore their capacity to evaluate this hypothesis is rather limited. This hypothesis could be supported by the fact that tobacco causes cancer in sites which are not in direct contact with tobacco smoke. Likewise, the presence of benzene and radioactive compounds would provide some biologic plausibility to the hypothesis that tobacco could be a cause of leukemia. However, since the etiology of leukemia is not well understood, the small excess risk detected may be confounded by some uncontrolled factor.

Acute lymphoblastic leukaemia among Spanish children and mothers' occupation: a case-control study

STUDY OBJECTIVE

The aim was to investigate the association between mothers' occupational exposure during pregnancy and the incidence of acute lymphoblastic leukaemia in children.

DESIGN

The study was a case-control investigation. A face to face interview was used to assess exposures at work and relevant confounding variables.

SETTING

The study was community based and was carried out in five provinces of Spain.

SUBJECTS

128 cases less than 15 years of age were interviewed (91% of those eligible). Controls (one for each case) were chosen from the census lists and were matched on year of birth, sex and municipality.

MEASUREMENTS AND MAIN RESULTS

Children of mothers working at home had a relative risk (RR) of 7.0 (95% CI = 1.59-30.79) of developing acute lymphoblastic leukaemia. Exposure to organic dust was associated with a RR of 5.5 (95% CI = 1.21-24.8). There was a statistically significant interaction between exposure to organic dust and working at home. The majority of women working at home were hired by local industries to sew different types of tissues (cotton, wool, synthetic fibres) on a machine.

CONCLUSION

A similar association has not been reported before: if confirmed, this finding may suggest a new health concern.

Adult leukemia and farm practices: an alternative approach for assessing geographical pesticide exposure

Many studies have attempted to show a significant relationship between leukemia and farm practices, and some of them mention the potential responsibility of pesticide exposure. In this study, a pesticide exposure index (PEI) is established for geographical units at a small scale. It measures, as accurately as possible, the exposure of the farming population to pesticides, taking into account differential practices in the treatment of different crops as well as an estimate of the time per inhabitant spent cultivating each crop. This approach was developed in southern Normandy, an area of France exhibiting strong contrasts of agricultural activities, and where the necessary agricultural surveys at a small geographical level were available. Statistically significant increasing trends between leukemia mortality of males over 15 on one hand and the PEI and the proportion of agricultural land growing cereals on the other hand were found.

Parental occupational exposures and risk of childhood cancer: a review

We reviewed the literature in order to summarize the present knowledge on the association between parental occupational exposures to chemicals and the risk of childhood malignancy. The 32 studies pertaining to this topic were evaluated by considering various study qualities such as sample size, specificity of outcome, confounding, exposure specificity, and control selection. When evaluating the findings from any epidemiologic study, the potential sources of bias have to be considered. The selection of subjects, misclassification of exposure or outcome, and confounding from extraneous factors can contribute to a biased estimate of effect. Studies done to minimize these potential biases will be more valid, and these studies should be given the most weight when parental occupational exposures are evaluated as risk factors for childhood malignancy. We conclude that the preponderance of evidence supports the hypothesis that occupational exposure of parents to chemicals increases the risk of childhood malignancy. The parental occupational exposures implicated in childhood malignancy risk are exposure to chemicals including paints, petroleum products, solvents (especially chlorinated hydrocarbons) and pesticides, and exposure to metals. The available data do not allow the identification of specific etiologic agents within these categories of compounds. Future epidemiologic and toxicologic studies should be designed to pursue these leads.

Parental occupation and intracranial neoplasms of childhood: anecdotal evidence from a unique occupational cancer cluster

Near the end of the data-collection phase of a case-control interview study of environmental factors and childhood brain tumors, an unusual space-time cluster was revealed. Not only had six genetically unrelated children been diagnosed with a primary intracranial tumor in a recent 2.4 year period in a rural county in Ohio, but each child had one parent employed by the same company (two mothers, four fathers). This represents an observed/expected ratio greater than 70 (p much less than 0.001). All tumors were microscopically confirmed, and all case parents worked at the facility in question for at least 1 year prior to conception, during the index pregnancy, and for at least 6 months after birth. The place of parental employment was an electronics firm (Standard Industrial Classification [SIC] group number 367, electronic components and accessories), where more than 100 chemical compounds are used by the company in a manufacturing process. Results of the cluster investigation are described, including a description of the case series. This cancer cluster is unique in that the index case series is composed of the offspring of workers, not the workers themselves.

Ionising radiations from nuclear establishments and childhood leukaemias--an enigma

The Gardner report, recently published in the UK, showing a correlation between incidence of childhood leukaemia and paternal exposure to ionising radiations (amongst fathers working in nuclear power plants) has added a new element to debates about both the risk factors in nuclear power plants and the relationships between ionising radiations and leukaemogenesis. The epidemiologic and genetic evidence concerning leukaemias is reviewed here and it is concluded that the leukaemogenic agent, whose existence is indicated in the Gardner report, is unlikely to be paternal radiation dose per se but rather exposure to another factor that is correlated with parternal radiation dose received.

Energy balance, body size, and cancer

Increased energy intake and physical inactivity have been shown to heighten the risk of breast, large bowel, and other cancers. Large body size and fatness, as measured by adult stature, body weight and body mass indices, are positively related to a variety of cancers, including breast, colorectum, prostate, endometrium, kidney, and ovary, as well as to total cancer incidence or mortality in many investigations, although conflicting reports exist. Adult weight gain has also been specifically implicated in a few etiologic studies of breast and large bowel cancer. Furthermore, increased birthweight and childhood stature have been linked to increased risk of leukemia, lymphoma, osteogenic sarcoma, and central nervous system malignancies between infancy and young adulthood. Greater body weight also adversely affects breast cancer survival. These findings are complementary and support a role for positive energy balance in promoting human carcinogenesis. Potential mechanisms are discussed.