THRESHOLDS FOR ENVIRONMENTAL CANCER: BIOLOGIC AND STATISTICAL CONSIDERATIONS

Thresholds for carcinogens

Current regulatory cancer risk assessment principles and practices assume a linear dose-response relationship-the linear no-threshold (LNT) model-that theoretically estimates cancer risks occurring following low doses of carcinogens by linearly extrapolating downward from experimentally determined risks at high doses. The two-year rodent bioassays serve as experimental vehicles to determine the high-dose cancer risks in animals and then to predict, by extrapolation, the number of carcinogen-induced tumors (tumor incidence) that will arise during the lifespans of humans who are exposed to environmental carcinogens at doses typically orders of magnitude below those applied in the rodent assays. An integrated toxicological analysis is conducted herein to reconsider an alternative and once-promising approach, tumor latency, for estimating carcinogen-induced cancer risks at low doses. Tumor latency measures time-to-tumor following exposure to a carcinogen, instead of tumor incidence. Evidence for and against the concept of carcinogen-induced tumor latency is presented, discussed, and then examined with respect to its relationship to dose, dose rates, and the dose-related concepts of initiation, tumor promotion, tumor regression, tumor incidence, and hormesis. Considerable experimental evidence indicates: (1) tumor latency (time-to-tumor) is inversely related to the dose of carcinogens and (2) lower doses of carcinogens display quantifiably discrete latency thresholds below which the promotion and, consequently, the progression and growth of tumors are delayed or prevented during a normal lifespan. Besides reconciling well with the concept of tumor promotion, such latency thresholds also reconcile favorably with the existence of thresholds for tumor incidence, the stochastic processes of tumor initiation, and the compensatory repair mechanisms of hormesis. Most importantly, this analysis and the arguments presented herein provide sound theoretical, experimental, and mechanistic rationales for rethinking the foundational premises of low-dose linearity and updating the current practices of cancer risk assessment to include the concept of carcinogen thresholds.

Do dose response thresholds exist for genotoxic alkylating agents?

The demonstration and acceptance of dose response thresholds for genotoxins may have substantial implications for the setting of safe exposure levels. Here we test the hypothesis that direct-acting DNA reactive agents may exhibit thresholded dose responses. We examine the potential mechanisms involved in such thresholded responses, particularly in relation to those of alkylating agents. As alkylating agents are representative model DNA reactive compounds with well characterized activities and DNA targets, they could help shed light on the general mechanisms involved in thresholded dose responses for genotoxins. Presently, thresholds have mainly been described for agents with non-DNA targets. We pay particular attention here to the contribution of DNA repair to genotoxic thresholds. A review of the literature shows that limited threshold data for alkylating agents are currently available, but the contribution of DNA repair in thresholded dose responses is suggested by several studies. The existence of genotoxic thresholds for alkylating agents methylmethanesulfonate is also supported here by data from our laboratory. Overall, it is clear that different endpoints induced by the same alkylator, can possess different dose response characteristics. This may have an impact on the setting of safe exposure levels for such agents. The limited information available concerning the dose response relationships of alkylators can nevertheless lead to the design of experiments to investigate the mechanisms that may be involved in threshold responses. Through using paired alkylators inducing different lesions, repaired by different pathways, insights into the processes involved in genotoxic thresholds may be elucidated. Furthermore, as alkyl-guanine-DNA transferase, base excision repair and mismatch repair appear to contribute to genotoxic thresholds for alkylators, cells deficient in these repair processes may possess altered dose responses compared with wild-type cells and this approach may help understand the contribution of these repair pathways to the production of thresholds for genotoxic effects in general. Finally, genotoxic thresholds are currently being described for acute exposures to single agents in vitro, however, dose response data for chronic exposures to complex mixtures are, as yet, a long way off.

Dose-response and threshold-mediated mechanisms in mutagenesis: statistical models and study design

The objective of this paper is to review the use, in mutagenesis, of various mathematical models to describe the dose-response relationship and to try to identify thresholds. It is often taken as axiomatic that genotoxic carcinogens could damage DNA at any level of exposure, leading to a mutation, and that this could ultimately result in tumour development. This has led to the assumption that for genotoxic chemicals, there is no discernible threshold. This assumption is increasingly being challenged in the case of aneugens. The distinction between 'absolute' and 'pragmatic' thresholds is made and the difficulties in determining 'absolute' thresholds using hypothesis testing approaches are described. The potential of approaches, based upon estimation rather than statistical significance for the characterization of dose-response relationships, is stressed. The achievement of a good fit of a mathematical model to experimental data is not proof that the mechanism supposedly underlying this model is operating. It has been argued, in the case of genotoxic chemicals, that any effects produced by a genotoxic chemical which augments that producing a background incidence in unexposed individuals will lead to a dose-response relationship that is non-thresholded and is linear at low doses. The assumptions underlying this presumption are explored in the context of the increasing knowledge of the mechanistic basis of mutagenicity and carcinogenicity. The possibility that exposure to low levels of genotoxic chemicals may induce and enhance defence and repair mechanisms is not easily incorporated into many of the existing mathematical models and should be an objective in the development of the next generation of biologically based dose-response (BB-DR) models. Studies aimed at detecting or characterizing non-linearities in the dose-response relationship need appropriate experimental designs with careful attention to the choice of biomarker, number and selection of dose levels, optimum allocation of experimental units and appropriate levels of replication within and repetition of experiments. The characterization of dose-response relationships with appropriate measures of uncertainty can help to identify 'pragmatic' thresholds based upon biologically relevant criteria which can help in the regulatory process.

Dose-response relationships in chemical carcinogenesis: superposition of different mechanisms of action, resulting in linear-nonlinear curves, practical thresholds, J-shapes

The shape of a carcinogen dose-cancer incidence curve is discussed as the result of a superposition of dose-response relationships for various effects of the carcinogen on the process of carcinogenesis. Effects include direct DNA damage, e.g., by covalent binding, indirect DNA damage, e.g., by increased formation of reactive oxygen species or interaction with DNA replication or chromosome integrity. The 'fixation' of a DNA adduct as a heritable mutation depends on its pro-mutagenic potency and on the rates of DNA repair and DNA replication. Endogenous and unavoidable DNA damage is responsible for a background rate of the process of mutagenesis and carcinogenesis and forms the basis of spontaneous cancer incidence. For DNA-reactive carcinogens, linearity of the dose response at the low-dose end is expected. With increasing dose, saturation of DNA repair can introduce a sublinearity (example: dimethylnitrosamine). Stimulation of cell division as a result of high-dose toxicity and regenerative proliferation also results in a sublinear deviation from low-dose linearity. If the DNA-damaging potency of the carcinogen is low in comparison with the high-dose effects, the linear part of the low dose-cancer incidence curve might be hidden within the background variability. Under such conditions, 'practical thresholds' could be discussed (formaldehyde). If a carcinogen increases the rate of cell division or the level of oxidative stress at high dose but has an antimitogenic or antioxidative effect at low dose, a J-shaped (or: U-shaped) curve with a decrease of the spontaneous tumor incidence at low dose could result (caffeic acid; TCDD). This phenomenon has been observed even under conditions of a genotoxic contribution (ionizing radiation; diesel exhaust particles). For a mechanism-based assessment of a low-dose cancer risk, information on the various modes of action and modulations should be available over the full dose range, and models should be refined to incorporate the respective information.

Statistical models for low dose exposure

Extrapolation of health risks from high to low doses has received a considerable amount of attention in carcinogenic risk assessment over decades. Fitting statistical dose-response models to experimental data collected at high doses and use of the fitted model for estimating effects at low doses lead to quite different risk predictions. Dissatisfaction with this procedure was formulated both by toxicologists who saw a deficit of biological knowledge in the models as well as by risk modelers who saw the need of mechanistically-based stochastic modeling. This contribution summarizes the present status of low dose modeling and the determination of the shape of dose-response curves. We will address the controversial issues of the appropriateness of threshold models, the estimation of no observed adverse effect levels (NOAEL), and their relevance for low dose modeling. We will distinguish between quantal dose-response models for tumor incidence and models of the more informative age/time dependent tumor incidence. The multistage model and the two-stage model of clonal expansion are considered as dose-response models accounting for biological mechanisms. Problems of the identifiability of mechanisms are addressed, the relation between administered dose and effective target dose is illustrated by examples, and the recently proposed Benchmark Dose concept for risk assessment is presented with its consequences for mechanistic modeling and statistical estimation.

Carcinogens in Israeli milk: a study in regulatory failure

The potential danger to humans of exposure to chemicals shown to be carcinogenic in animals has become increasingly clear in the last 20 years. A gap still exists, however, between the appreciation of the risk by scientists and the willingness of public health authorities to reduce it. Three pesticides, shown repeatedly to produce over a dozen different types of cancer in rats and mice, were discovered in inordinately high concentrations in Israeli milk and dairy products. The three pesticides--alpha-BHC, gamma-BHC (lindane), and DDT--had been shown to be present for ten years or more at mean concentrations up to 100 times those found in U.S. dairy products--with resultant concentrations in breast milk being possibly 800 times greater than those in the United States--yet neither the Ministry of Health nor the Israel Cancer Association made any apparent moves either to warn the public or to rectify the situation. A small consumer organization, Consumer Shield, brought the issue into the open. Through public pressure, court action, and the threat of further legal redress--and despite repeated attacks in the media by the milk producers, the Ministry, and the Cancer Association--Consumer Shield forced the authorities to outlaw the use of alpha-BHC and lindane (DDT no longer being in general use). The ban resulted in a precipitous drop in the concentrations of these substances in Israeli milk. Recent epidemiological and laboratory findings suggest that the dramatic drop in breast cancer mortality rates subsequent to the pesticide ban could be a direct result of that ban.

Making decisions from numbers

Regulatory agencies require numbers to provide health protection. The manner in which these numbers are derived from animal experiments and human epidemiology is considered together with the limitations and inadequacies of these numbers. Some recent examples of risk assessment in Canada are given including asbestos, drinking water, and indoor air quality. The value of these numbers in providing a measure of the hazard in a wider perspective is stressed, although they can never be the sole determinant of public policy.

Formaldehyde risk assessment for occupationally exposed workers

Formaldehyde has been shown to be carcinogenic in animals and should be considered potentially carcinogenic in humans. The mechanism of action is unknown but formaldehyde is weakly genotoxic and also may act as a late stage carcinogen or promoter. An estimated 1.3 million workers are potentially exposed to formaldehyde through their occupation. Of those exposed workers, about 3.5% were found to be exposed to formaldehyde air concentrations greater than the 3 ppm set by OSHA as a permissible exposure level. Fewer than 12% were exposed to concentrations greater than 1 ppm, but over 88% were exposed to concentrations of 0.5 ppm or more. A quantitative risk assessment, using the multistage low-dose extrapolation model, found the (maximum likelihood) estimate of lifetime risk for excess cancers to be 620 per 100,000 at the OSHA permissible exposure level. The estimated risk is 23 per 100,000 at 1 ppm and 2.8 per 100,000 at 0.5 ppm. Reduction of the OSHA permissible exposure level to 1 ppm would significantly decrease risk with minor economic disruption for most industries involved. However, reduction of risk to levels which have been generally regarded by other regulatory agencies as acceptable, i.e., 10(-5) to 10(-6), would require increased control by all the industries reviewed.

The New York City fire epidemic as a toxic phenomenon

Reductions in the fire service in New York City from 1972 to 1976 appear to have caused a disproportionate increase in fire-fighter work load through several unexpected mechanisms of fire contagion. In turn, the work load increase has itself had a disproportionate physiologic impact: A classic dose-response relation has been observed between a composite measure of per capita structural fire work load and the percentage of the fire-fighting work force retiring under conditions of disability. After 1974, the increase in work load seems to have caused entry to the 'linear' portion of the dose-response curve. Implications of this synergism are explored for both New York City and other American urban areas now suffering 'fiscal crises' or planning fire service reductions.