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Bozigar M, Konstantinoudis G, Zilli Vieira CL, Li L, Alwadi Y, Jones RR, Koutrakis P. Domestic radon exposure and childhood cancer risk by site and sex in 727 counties in the United States, 2001-2018. THE SCIENCE OF THE TOTAL ENVIRONMENT 2024; 954:176288. [PMID: 39278504 DOI: 10.1016/j.scitotenv.2024.176288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/28/2024] [Revised: 08/07/2024] [Accepted: 09/12/2024] [Indexed: 09/18/2024]
Abstract
BACKGROUND Childhood cancer has few established risk factors and environmental influences are underexplored. This ecologic study investigated the association between domestic radon exposure and childhood cancer risk in a large sample of United States (U.S.) counties. METHODS Monthly ZIP code-level basement radon estimates from a geographic machine learning model were aggregated annually to counties, analyzed as continuous and dichotomized (cut point: 74 Bq/cubic meter (Bq/m3) or 2.0 picocuries/L (pCi/L)) versions, and lagged by one year. Annual county-level counts of sex- and site-specific (all, leukemia, brain and central nervous system [CNS], and other sites) incident cancer diagnoses among those 0-19 years from 2001 to 2018 were obtained from the National Cancer Institute's Surveillance, Epidemiology, and End Results Program database. Sex- and site-specific counts were modeled as zero-inflated Poisson distributions in a Bayesian spatiotemporal framework and sequentially adjusted for random and fixed confounder effects. RESULTS In 727 counties across 14 states, the average population aged 0-19 years was 41,599 people at baseline. Results from fully adjusted spatiotemporal statistical models indicated 1.05 (95% credible interval, CrI: 1.00, 1.09) times higher relative risks (RRs) of leukemia among both sexes and a RR of 1.06 (95%CrI: 1.00, 1.12) in males from a 50 Bq/m3 (1.35 pCi/L) increase in radon concentration the year prior. For radon exposures ≥74 Bq/m3 (2.00 pCi/L) the year prior, RRs were 1.08 (95%CrI: 1.02, 1.15) for both sexes and 1.12 (95%CrI: 1.04, 1.22) for females. No associations were found with other cancer sites or sexes from prior year radon exposures. CONCLUSIONS County-level childhood leukemia risk in both sexes were associated with average radon levels below U.S. Environmental Protection Agency guidelines recommending mitigation (148 Bq/m3 or 4.00 pCi/L). These findings warrant further investigation using population-based and individual-level study designs.
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Affiliation(s)
- Matthew Bozigar
- School of Nutrition and Public Health, College of Health, Oregon State University, 160 SW 26(th) Street, Corvallis, Oregon 97331, USA.
| | - Garyfallos Konstantinoudis
- MRC Centre for Environment and Health, Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, London, UK
| | - Carolina L Zilli Vieira
- Department of Environmental Health, Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Longxiang Li
- Department of Environmental Health, Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Yazan Alwadi
- Department of Environmental Health, Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Rena R Jones
- Occupational and Environmental Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD, USA
| | - Petros Koutrakis
- Department of Environmental Health, Harvard TH Chan School of Public Health, Boston, MA, USA; Exposure Epidemiology and Risk Program, Harvard TH Chan School of Public Health, Boston, MA, USA
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2
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Little MP, Bazyka D, de Gonzalez AB, Brenner AV, Chumak VV, Cullings HM, Daniels RD, French B, Grant E, Hamada N, Hauptmann M, Kendall GM, Laurier D, Lee C, Lee WJ, Linet MS, Mabuchi K, Morton LM, Muirhead CR, Preston DL, Rajaraman P, Richardson DB, Sakata R, Samet JM, Simon SL, Sugiyama H, Wakeford R, Zablotska LB. A Historical Survey of Key Epidemiological Studies of Ionizing Radiation Exposure. Radiat Res 2024; 202:432-487. [PMID: 39021204 PMCID: PMC11316622 DOI: 10.1667/rade-24-00021.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 04/23/2024] [Indexed: 07/20/2024]
Abstract
In this article we review the history of key epidemiological studies of populations exposed to ionizing radiation. We highlight historical and recent findings regarding radiation-associated risks for incidence and mortality of cancer and non-cancer outcomes with emphasis on study design and methods of exposure assessment and dose estimation along with brief consideration of sources of bias for a few of the more important studies. We examine the findings from the epidemiological studies of the Japanese atomic bomb survivors, persons exposed to radiation for diagnostic or therapeutic purposes, those exposed to environmental sources including Chornobyl and other reactor accidents, and occupationally exposed cohorts. We also summarize results of pooled studies. These summaries are necessarily brief, but we provide references to more detailed information. We discuss possible future directions of study, to include assessment of susceptible populations, and possible new populations, data sources, study designs and methods of analysis.
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Affiliation(s)
- Mark P. Little
- Radiation Epidemiology Branch, National Cancer Institute, Bethesda, MD 20892-9778, USA
- Faculty of Health and Life Sciences, Oxford Brookes University, Headington Campus, Oxford, OX3 0BP, UK
| | - Dimitry Bazyka
- National Research Center for Radiation Medicine, Hematology and Oncology, 53 Melnikov Street, Kyiv 04050, Ukraine
| | | | - Alina V. Brenner
- Radiation Effects Research Foundation, 5-2 Hijiyama Park, Minami-ku, Hiroshima 732-0815, Japan
| | - Vadim V. Chumak
- National Research Center for Radiation Medicine, Hematology and Oncology, 53 Melnikov Street, Kyiv 04050, Ukraine
| | - Harry M. Cullings
- Radiation Effects Research Foundation, 5-2 Hijiyama Park, Minami-ku, Hiroshima 732-0815, Japan
| | - Robert D. Daniels
- National Institute for Occupational Safety and Health, Cincinnati, OH, USA
| | - Benjamin French
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Eric Grant
- Radiation Effects Research Foundation, 5-2 Hijiyama Park, Minami-ku, Hiroshima 732-0815, Japan
| | - Nobuyuki Hamada
- Biology and Environmental Chemistry Division, Sustainable System Research Laboratory, Central Research Institute of Electric Power Industry (CRIEPI), 1646 Abiko, Chiba 270-1194, Japan
| | - Michael Hauptmann
- Institute of Biostatistics and Registry Research, Brandenburg Medical School Theodor Fontane, 16816 Neuruppin, Germany
| | - Gerald M. Kendall
- Cancer Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Richard Doll Building, Old Road Campus, Headington, Oxford, OX3 7LF, UK
| | - Dominique Laurier
- Institute for Radiological Protection and Nuclear Safety, Fontenay aux Roses France
| | - Choonsik Lee
- Radiation Epidemiology Branch, National Cancer Institute, Bethesda, MD 20892-9778, USA
| | - Won Jin Lee
- Department of Preventive Medicine, Korea University College of Medicine, Seoul, South Korea
| | - Martha S. Linet
- Radiation Epidemiology Branch, National Cancer Institute, Bethesda, MD 20892-9778, USA
| | - Kiyohiko Mabuchi
- Radiation Epidemiology Branch, National Cancer Institute, Bethesda, MD 20892-9778, USA
| | - Lindsay M. Morton
- Radiation Epidemiology Branch, National Cancer Institute, Bethesda, MD 20892-9778, USA
| | | | | | - Preetha Rajaraman
- Radiation Effects Research Foundation, 5-2 Hijiyama Park, Minami-ku, Hiroshima 732-0815, Japan
| | - David B. Richardson
- Environmental and Occupational Health, 653 East Peltason, University California, Irvine, Irvine, CA 92697-3957 USA
| | - Ritsu Sakata
- Radiation Effects Research Foundation, 5-2 Hijiyama Park, Minami-ku, Hiroshima 732-0815, Japan
| | - Jonathan M. Samet
- Department of Epidemiology, Colorado School of Public Health, Aurora, Colorado, USA
| | - Steven L. Simon
- Radiation Epidemiology Branch, National Cancer Institute, Bethesda, MD 20892-9778, USA
| | - Hiromi Sugiyama
- Radiation Effects Research Foundation, 5-2 Hijiyama Park, Minami-ku, Hiroshima 732-0815, Japan
| | - Richard Wakeford
- Centre for Occupational and Environmental Health, The University of Manchester, Ellen Wilkinson Building, Oxford Road, Manchester, M13 9PL, UK
| | - Lydia B. Zablotska
- Department of Epidemiology and Biostatistics, School of Medicine, University of California, San Francisco, 550 16 Street, 2 floor, San Francisco, CA 94143, USA
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3
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Little MP, Wakeford R, Zablotska LB, Borrego D, Griffin KT, Allodji RS, de Vathaire F, Lee C, Brenner AV, Miller JS, Campbell D, Pearce MS, Sadetzki S, Doody MM, Holmberg E, Lundell M, French B, Adams MJ, Berrington de González A, Linet MS. Radiation exposure and leukaemia risk among cohorts of persons exposed to low and moderate doses of external ionising radiation in childhood. Br J Cancer 2023; 129:1152-1165. [PMID: 37596407 PMCID: PMC10539334 DOI: 10.1038/s41416-023-02387-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 07/12/2023] [Accepted: 07/27/2023] [Indexed: 08/20/2023] Open
Abstract
BACKGROUND Many high-dose groups demonstrate increased leukaemia risks, with risk greatest following childhood exposure; risks at low/moderate doses are less clear. METHODS We conducted a pooled analysis of the major radiation-associated leukaemias (acute myeloid leukaemia (AML) with/without the inclusion of myelodysplastic syndrome (MDS), chronic myeloid leukaemia (CML), acute lymphoblastic leukaemia (ALL)) in ten childhood-exposed groups, including Japanese atomic bomb survivors, four therapeutically irradiated and five diagnostically exposed cohorts, a mixture of incidence and mortality data. Relative/absolute risk Poisson regression models were fitted. RESULTS Of 365 cases/deaths of leukaemias excluding chronic lymphocytic leukaemia, there were 272 AML/CML/ALL among 310,905 persons (7,641,362 person-years), with mean active bone marrow (ABM) dose of 0.11 Gy (range 0-5.95). We estimated significant (P < 0.005) linear excess relative risks/Gy (ERR/Gy) for: AML (n = 140) = 1.48 (95% CI 0.59-2.85), CML (n = 61) = 1.77 (95% CI 0.38-4.50), and ALL (n = 71) = 6.65 (95% CI 2.79-14.83). There is upward curvature in the dose response for ALL and AML over the full dose range, although at lower doses (<0.5 Gy) curvature for ALL is downwards. DISCUSSION We found increased ERR/Gy for all major types of radiation-associated leukaemia after childhood exposure to ABM doses that were predominantly (for 99%) <1 Gy, and consistent with our prior analysis focusing on <100 mGy.
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Affiliation(s)
- Mark P Little
- Radiation Epidemiology Branch, National Cancer Institute, 9609 Medical Center Drive, Bethesda, MD, 20892-9778, USA.
| | - Richard Wakeford
- Centre for Occupational and Environmental Health, Faculty of Biology, Medicine and Health, The University of Manchester, Ellen Wilkinson Building, Oxford Road, Manchester, M13 9PL, UK
| | - Lydia B Zablotska
- Department of Epidemiology & Biostatistics, School of Medicine, University of California, San Francisco, 550 16th Street, 2nd floor, San Francisco, CA, 94143, USA
| | - David Borrego
- Radiation Epidemiology Branch, National Cancer Institute, 9609 Medical Center Drive, Bethesda, MD, 20892-9778, USA
| | - Keith T Griffin
- Radiation Epidemiology Branch, National Cancer Institute, 9609 Medical Center Drive, Bethesda, MD, 20892-9778, USA
| | - Rodrigue S Allodji
- Equipe d'Epidémiologie des radiations, Unité 1018 INSERM, Bâtiment B2M, Institut Gustave Roussy, Villejuif, Cedex, 94805, France
| | - Florent de Vathaire
- Equipe d'Epidémiologie des radiations, Unité 1018 INSERM, Bâtiment B2M, Institut Gustave Roussy, Villejuif, Cedex, 94805, France
| | - Choonsik Lee
- Radiation Epidemiology Branch, National Cancer Institute, 9609 Medical Center Drive, Bethesda, MD, 20892-9778, USA
| | - Alina V Brenner
- Radiation Epidemiology Branch, National Cancer Institute, 9609 Medical Center Drive, Bethesda, MD, 20892-9778, USA
| | - Jeremy S Miller
- Information Management Services, Silver Spring, MD, 20904, USA
| | - David Campbell
- Information Management Services, Silver Spring, MD, 20904, USA
| | - Mark S Pearce
- Institute of Health and Society, Newcastle University, Sir James Spence Institute, Royal Victoria Infirmary, Queen Victoria Road, Newcastle upon Tyne, NE1 4LP, UK
- NIHR Health Protection Research Unit in chemical and radiation threats and hazards, Newcastle University, Newcastle upon Tyne, UK
| | - Siegal Sadetzki
- Israel Ministry of Health, Jerusalem, Israel
- Cancer & Radiation Epidemiology Unit, Gertner Institute for Epidemiology & Health Policy Research, Sheba Medical Center, Tel-Hashomer, Israel & Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv-Yafo, Israel
| | - Michele M Doody
- Radiation Epidemiology Branch, National Cancer Institute, 9609 Medical Center Drive, Bethesda, MD, 20892-9778, USA
| | - Erik Holmberg
- Department of Oncology, Sahlgrenska University Hospital, S-413-45, Göteborg, Sweden
| | - Marie Lundell
- Department of Medical Radiation Physics and Nuclear Medicine, Karolinska University Hospital, S-17176, Stockholm, Sweden
| | - Benjamin French
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Michael Jacob Adams
- University of Rochester School of Medicine and Dentistry, 265 Crittenden Boulevard, CU 420644, Rochester, NY, 14642-0644, USA
| | - Amy Berrington de González
- Radiation Epidemiology Branch, National Cancer Institute, 9609 Medical Center Drive, Bethesda, MD, 20892-9778, USA
- Division of Genetics and Epidemiology, Institute of Cancer Research, London, UK
| | - Martha S Linet
- Radiation Epidemiology Branch, National Cancer Institute, 9609 Medical Center Drive, Bethesda, MD, 20892-9778, USA
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Ngoc LTN, Park D, Lee YC. Human Health Impacts of Residential Radon Exposure: Updated Systematic Review and Meta-Analysis of Case-Control Studies. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 20:97. [PMID: 36612419 PMCID: PMC9819115 DOI: 10.3390/ijerph20010097] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 12/13/2022] [Accepted: 12/19/2022] [Indexed: 05/27/2023]
Abstract
This study investigated the impact of residential radon exposure on human cancers (i.e., lung cancer and childhood leukemia) through a systematic review and meta-analysis of case−control studies. A total of 9724 articles obtained from electronic databases were assessed; however, only 55 case−control studies were eligible after manually screening and eliminating unnecessary studies. The causal associations were addressed by determining the meta-analysis’s estimated size effects (i.e., ORs/RRs) of the meta-analysis. Residential radon was revealed to significantly increase the incidence of lung cancer and childhood leukemia with pooled ORs of 1.38 [1.19; 1.60] (I2 = 90%; p < 0.00001) and 1.43 [1.19; 1.72] (I2 = 0% and p = 0.51), respectively. In addition, subgroup analyses were performed to reduce the heterogeneity of the initial meta-analyses. The results provided strong evidence that inhaling radon in the indoor environments is closely associated with the development of lung cancer and childhood leukemia in patients living in Europe and areas with high radon levels (≥100 Bq/m3).
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Affiliation(s)
- Le Thi Nhu Ngoc
- Department of Industrial and Environmental Engineering, Graduate School of Environment, Gachon University, 1342 Seongnam-daero, Seongnam-si 13120, Republic of Korea
| | - Duckshin Park
- Korea Railroad Research Institute (KRRI), 176 Cheoldobakmulkwan-ro, Uiwang-si 16105, Republic of Korea
| | - Young-Chul Lee
- Department of BioNano Technology, Gachon University, 1342 Seongnam-daero, Seongnam-si 13120, Republic of Korea
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5
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Folly CL, Mazzei-Abba A, Coste A, Kreis C, Spycher BD. Measurements and determinants of children's exposure to background gamma radiation in Switzerland. JOURNAL OF RADIATION RESEARCH 2022; 63:354-363. [PMID: 35349709 PMCID: PMC9124624 DOI: 10.1093/jrr/rrac006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 12/26/2021] [Indexed: 06/14/2023]
Abstract
Epidemiological studies of children's cancer risks associated with background gamma radiation exposure have used geographic exposure models to estimate exposure at their locations of residence. We measured personal exposure to background gamma radiation, and we investigated the extent to which it was associated with children's whereabouts. We collected data on whereabouts and exposure to background gamma radiation over a 5-day period among children aged 4-15 years in Switzerland. We used D-Shuttle dosimeters to measure children's exposure, and we asked parents to write their children's activities in diaries. We used Poisson mixed-effects and linear regression models to investigate the association of hourly and overall doses, respectively, with children's reported whereabouts. During the observed time, 149 participating children spent 66% indoors at home; 19% indoors away from home; and 15% outdoors. The mean personal exposure was 85.7 nSv/h (range 52.3 nSv/h-145 nSv/h). Exposure was 1.077 (95% CI 1.067, 1.087) times higher indoors than outdoors and varied by building material and (predicted) outdoor dose rates. Our study provides detailed information about children's patterns of exposure to background gamma radiation in Switzerland. Dwelling building materials and outdoor dose rates are important determinants of children's exposure. Future epidemiological studies may benefit from including information about building materials.
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Affiliation(s)
- Christophe L Folly
- Institute of Social and Preventive Medicine (ISPM), University of Bern, 3012 Bern, Switzerland
- Graduate School for Health Sciences (GHS), University of Bern, 3012 Bern, Switzerland
| | - Antonella Mazzei-Abba
- Institute of Social and Preventive Medicine (ISPM), University of Bern, 3012 Bern, Switzerland
- Graduate School for Health Sciences (GHS), University of Bern, 3012 Bern, Switzerland
| | - Astrid Coste
- Institute of Social and Preventive Medicine (ISPM), University of Bern, 3012 Bern, Switzerland
- INSERM UMR 1296, Radiation : Defense, Health,Environment, Centre Léon Bérard, Bâtiment Cheney A 1er étage 28 rue Laennec, 69008 Lyon, France
| | - Christian Kreis
- Institute of Social and Preventive Medicine (ISPM), University of Bern, 3012 Bern, Switzerland
| | - Ben D Spycher
- Institute of Social and Preventive Medicine (ISPM), University of Bern, 3012 Bern, Switzerland
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6
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Little MP, Wakeford R, Bouffler SD, Abalo K, Hauptmann M, Hamada N, Kendall GM. Review of the risk of cancer following low and moderate doses of sparsely ionising radiation received in early life in groups with individually estimated doses. ENVIRONMENT INTERNATIONAL 2022; 159:106983. [PMID: 34959181 PMCID: PMC9118883 DOI: 10.1016/j.envint.2021.106983] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 10/16/2021] [Accepted: 11/13/2021] [Indexed: 05/28/2023]
Abstract
BACKGROUND The detrimental health effects associated with the receipt of moderate (0.1-1 Gy) and high (>1 Gy) acute doses of sparsely ionising radiation are well established from human epidemiological studies. There is accumulating direct evidence of excess risk of cancer in a number of populations exposed at lower acute doses or doses received over a protracted period. There is evidence that relative risks are generally higher after radiation exposures in utero or in childhood. METHODS AND FINDINGS We reviewed and summarised evidence from 60 studies of cancer or benign neoplasms following low- or moderate-level exposure in utero or in childhood from medical and environmental sources. In most of the populations studied the exposure was predominantly to sparsely ionising radiation, such as X-rays and gamma-rays. There were significant (p < 0.001) excess risks for all cancers, and particularly large excess relative risks were observed for brain/CNS tumours, thyroid cancer (including nodules) and leukaemia. CONCLUSIONS Overall, the totality of this large body of data relating to in utero and childhood exposure provides support for the existence of excess cancer and benign neoplasm risk associated with radiation doses < 0.1 Gy, and for certain groups exposed to natural background radiation, to fallout and medical X-rays in utero, at about 0.02 Gy.
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Affiliation(s)
- Mark P Little
- Radiation Epidemiology Branch, National Cancer Institute, Bethesda, MD 20892-9778, USA.
| | - Richard Wakeford
- Centre for Occupational and Environmental Health, Faculty of Biology, Medicine and Health, The University of Manchester, Ellen Wilkinson Building, Oxford Road, Manchester M13 9PL, UK
| | - Simon D Bouffler
- Radiation Effects Department, UK Health Security Agency (UKHSA), Chilton, Didcot OX11 0RQ, UK
| | - Kossi Abalo
- Laboratoire d'Épidémiologie, Institut de Radioprotection et de Sûreté Nucléaire, BP 17, 92262 Fontenay-aux-Roses Cedex, France
| | - Michael Hauptmann
- Institute of Biostatistics and Registry Research, Brandenburg Medical School Theodor Fontane, Fehrbelliner Strasse 38, 16816 Neuruppin, Germany
| | - Nobuyuki Hamada
- Radiation Safety Unit, Biology and Environmental Chemistry Division, Sustainable System Research Laboratory, Central Research Institute of Electric Power Industry (CRIEPI), 2-11-1 Iwado-kita, Komae, Tokyo 201-8511, Japan
| | - Gerald M Kendall
- Cancer Epidemiology Unit, Oxford Population Health, University of Oxford, Richard Doll Building, Old Road Campus, Headington, Oxford, OX3 7LF, UK
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7
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Rühm W, Laurier D, Wakeford R. Cancer risk following low doses of ionising radiation - Current epidemiological evidence and implications for radiological protection. MUTATION RESEARCH. GENETIC TOXICOLOGY AND ENVIRONMENTAL MUTAGENESIS 2022; 873:503436. [PMID: 35094811 DOI: 10.1016/j.mrgentox.2021.503436] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Revised: 12/09/2021] [Accepted: 12/11/2021] [Indexed: 01/05/2023]
Abstract
Recent studies suggest that every year worldwide about a million patients might be exposed to doses of the order of 100 mGy of low-LET radiation, due to recurrent application of radioimaging procedures. This paper presents a synthesis of recent epidemiological evidence on radiation-related cancer risks from low-LET radiation doses of this magnitude. Evidence from pooled analyses and meta-analyses also involving epidemiological studies that, individually, do not find statistically significant radiation-related cancer risks is reviewed, and evidence from additional and more recent epidemiological studies of radiation exposures indicating excess cancer risks is also summarized. Cohorts discussed in the present paper include Japanese atomic bomb survivors, nuclear workers, patients exposed for medical purposes, and populations exposed environmentally to natural background radiation or radioactive contamination. Taken together, the overall evidence summarized here is based on studies including several million individuals, many of them followed-up for more than half a century. In summary, substantial evidence was found from epidemiological studies of exposed groups of humans that ionizing radiation causes cancer at acute and protracted doses above 100 mGy, and growing evidence for doses below 100 mGy. The significant radiation-related solid cancer risks observed at doses of several 100 mGy of protracted exposures (observed, for example, among nuclear workers) demonstrate that doses accumulated over many years at low dose rates do cause stochastic health effects. On this basis, it can be concluded that doses of the order of 100 mGy from recurrent application of medical imaging procedures involving ionizing radiation are of concern, from the viewpoint of radiological protection.
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Affiliation(s)
- W Rühm
- Helmholtz Center Munich German Research Center for Environmental Health, Neuherberg, Germany.
| | - D Laurier
- Institut de Radioprotection et de Sûreté Nucléaire (IRSN), Fontenay-aux-Roses, France
| | - R Wakeford
- Centre for Occupational and Environmental Health, The University of Manchester, Manchester, M13 9PL, UK
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8
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Schmidt JA, Hornhardt S, Erdmann F, Sánchez-García I, Fischer U, Schüz J, Ziegelberger G. Risk Factors for Childhood Leukemia: Radiation and Beyond. Front Public Health 2021; 9:805757. [PMID: 35004601 PMCID: PMC8739478 DOI: 10.3389/fpubh.2021.805757] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Accepted: 12/06/2021] [Indexed: 12/20/2022] Open
Abstract
Childhood leukemia (CL) is undoubtedly caused by a multifactorial process with genetic as well as environmental factors playing a role. But in spite of several efforts in a variety of scientific fields, the causes of the disease and the interplay of possible risk factors are still poorly understood. To push forward the research on the causes of CL, the German Federal Office for Radiation Protection has been organizing recurring international workshops since 2008 every two to three years. In November 2019 the 6th International Workshop on the Causes of CL was held in Freising and brought together experts from diverse disciplines. The workshop was divided into two main parts focusing on genetic and environmental risk factors, respectively. Two additional special sessions addressed the influence of natural background radiation on the risk of CL and the progress in the development of mouse models used for experimental studies on acute lymphoblastic leukemia, the most common form of leukemia worldwide. The workshop presentations highlighted the role of infections as environmental risk factor for CL, specifically for acute lymphoblastic leukemia. Major support comes from two mouse models, the Pax5+/- and Sca1-ETV6-RUNX1 mouse model, one of the major achievements made in the last years. Mice of both predisposed models only develop leukemia when exposed to common infections. These results emphasize the impact of gene-environment-interactions on the development of CL and warrant further investigation of such interactions - especially because genetic predisposition is detected with increasing frequency in CL. This article summarizes the workshop presentations and discusses the results in the context of the international literature.
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Affiliation(s)
- Janine-Alison Schmidt
- Department of Effects and Risks of Ionizing and Non-ionizing Radiation, Federal Office for Radiation Protection (BfS), Neuherberg, Germany
| | - Sabine Hornhardt
- Department of Effects and Risks of Ionizing and Non-ionizing Radiation, Federal Office for Radiation Protection (BfS), Neuherberg, Germany
| | - Friederike Erdmann
- Division of Childhood Cancer Epidemiology, Institute of Medical Biostatistics, Epidemiology and Informatics (IMBEI), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
- Environment and Lifestyle Epidemiology Branch, International Agency for Research on Cancer, World Health Organization (IARC/WHO), Lyon, France
| | - Isidro Sánchez-García
- Experimental Therapeutics and Translational Oncology Program, Instituto de Biología Molecular y Celular del Cáncer, CSIC/Universidad de Salamanca, Salamanca, Spain
| | - Ute Fischer
- Department of Pediatric Oncology, Hematology and Clinical Immunology, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany
| | - Joachim Schüz
- Environment and Lifestyle Epidemiology Branch, International Agency for Research on Cancer, World Health Organization (IARC/WHO), Lyon, France
| | - Gunde Ziegelberger
- Department of Effects and Risks of Ionizing and Non-ionizing Radiation, Federal Office for Radiation Protection (BfS), Neuherberg, Germany
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9
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Moon J, Yoo H. Residential radon exposure and leukemia: A meta-analysis and dose-response meta-analyses for ecological, case-control, and cohort studies. ENVIRONMENTAL RESEARCH 2021; 202:111714. [PMID: 34274332 DOI: 10.1016/j.envres.2021.111714] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 07/12/2021] [Accepted: 07/14/2021] [Indexed: 06/13/2023]
Abstract
INTRODUCTION In this study, the authors conducted a comprehensive systematic review and meta-analysis (including a dose-response meta-analysis) for a possible causal association between residential radon exposure and leukemia. All 3 types of study design, including ecological, case-control, and cohort studies, were included in this study. In particular, different measurement units of radon exposure among studies were dealt with and analyzed thoroughly. METHODS A medical librarian searched MEDLINE (PubMed), EMBASE, and the Cochrane Library (from January 01, 1970 to November 05, 2020). For ecological studies, a conventional meta-analysis and subgroup analyses with meta-ANOVA analyses were conducted. For case-control and cohort studies, a two-stage dose-response meta-analysis was conducted. RESULTS A total of 8 ecological, 9 case-control, and 15 ecological-cohort studies were analyzed. For ecological studies, the pooled correlation coefficient was 0.48 (95% CI 0.41-0.54). In the meta-analysis of variance (ANOVA) analyses, the age group (childhood vs. adult) showed a statistically significant result (Q = 7.93 and p = 0.019) with the pooled correlation coefficient for childhood, adult, and all age group of 0.67 (95% CI 0.53-0.77), 0.46 (95% CI 0.05-0.74), and 0.44 (95% CI 0.36-0.51), respectively. For case-control studies, the dose-response meta-analysis showed the pooled OR increase of 1.0308 (95% CI 1.0050-1.0573) for each 100 Bq/m3 increase of radon dose. The pooled OR increase was 1.0361 (95% CI 1.0014-1.0720) for each 100 Bq/m3 increase of radon dose for lymphoid leukemia subgroup and 1.0309 (95% CI 1.0050-1.0575) for each 100 Bq/m3 increase of radon dose for childhood leukemia subgroup. Because of the inclusion of ecological studies with larger exposure assessment units, the pooled RR from ecological-cohort studies should be interpreted conservatively (a tendency towards a higher risk estimate). The overall pooled RR increase for each 100 Bq/m3 increase of radon dose was 1.1221 (95% CI 1.0184-1.2363). The pooled RR increase was 1.2257 (95% CI 1.0034-1.4972) for each 100 Bq/m3 increase of radon dose for the myeloid leukemia subgroup and 1.2503 (95% CI 1.0233-1.5276) for each 100 Bq/m3 increase of radon dose for adult leukemia subgroup. DISCUSSION A number of epidemiologic concepts, including the issue of sample size justification, the possibility of differential participation selection bias for case-control studies, the possibility of random and systematic errors in radon measurement, ecological fallacy for ecological studies, were discussed. The effect of age group, socioeconomic status, and gamma radiation exposure was also discussed. Future more accurate and conclusive large-scale case-control and cohort studies are needed.
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Affiliation(s)
- Jinyoung Moon
- Department of Environmental Health Science, Graduate School of Public Health, Seoul National University, Gwanak-ro 1, Gwanak-gu, Seoul, 08826, Republic of Korea; Department of Occupational and Environmental Medicine, Seoul Saint Mary's Hospital, Banpo-daero 222, Seocho-gu, Seoul, 06591, Republic of Korea.
| | - HyeKyoung Yoo
- Department of Environmental Health Science, Graduate School of Public Health, Seoul National University, Gwanak-ro 1, Gwanak-gu, Seoul, 08826, Republic of Korea
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10
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Berlivet J, Hémon D, Cléro É, Ielsch G, Laurier D, Faure L, Clavel J, Goujon S. Residential exposure to natural background radiation at birth and risk of childhood acute leukemia in France, 1990-2009. JOURNAL OF ENVIRONMENTAL RADIOACTIVITY 2021; 233:106613. [PMID: 33895630 DOI: 10.1016/j.jenvrad.2021.106613] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 03/26/2021] [Accepted: 04/02/2021] [Indexed: 06/12/2023]
Abstract
BACKGROUND The role of natural background radiation (NBR) in childhood acute leukemia (AL) remains unclear. Several large record based studies have recently reported heterogeneous results. Differences in exposure assessment timing may explain this heterogeneity. OBJECTIVES In a previous ecological study we did not observe any association between childhood AL incidence in France and NBR exposure at the time of diagnosis. With the same methodology, the present study focused on NBR exposure at the time of birth. Based on data from the French national registry of childhood cancer, we analyzed all AL together, and lymphoblastic and myeloid AL, separately. METHODS We included 6,059 childhood AL cases born and diagnosed in mainland France between 1990 and 2009. NBR levels in municipalities of residence at birth were estimated by cokriging models, using NBR measurements and precise geological data. The incidence rate ratio (IRR) per unit variation of exposure was estimated with Poisson regression models, with adjustment for socio-demographic indicators and ultraviolet radiation levels. NBR exposures were considered at the time of birth, and cumulatively from birth to diagnosis. We also estimated a total NBR dose to red-bone marrow (RBM). RESULTS There was no evidence for an association between NBR exposure at birth and childhood AL incidence, neither overall (gamma radiation: IRR = 0.99 (0.94,1.05) per 50 nSv/h; radon: IRR = 0.97 (0.91,1.03) per 100 Bq/m3) nor for the main AL types. The conclusions were similar with the cumulative exposures, and the total RBM dose. CONCLUSIONS The study was based on high quality incidence data, large numbers of AL cases, and validated models of NBR exposure assessment. In all, the results further support the hypothesis that NBR are not associated to childhood AL in France.
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Affiliation(s)
- Justine Berlivet
- Inserm, UMR 1153 Epidemiology and Biostatistics Sorbonne Paris Cité Research Center (CRESS), Epidemiology of Childhood and Adolescent Cancers Team (EPICEA), Paris University, Villejuif, F-94807, France
| | - Denis Hémon
- Inserm, UMR 1153 Epidemiology and Biostatistics Sorbonne Paris Cité Research Center (CRESS), Epidemiology of Childhood and Adolescent Cancers Team (EPICEA), Paris University, Villejuif, F-94807, France
| | - Énora Cléro
- Institute for Radiological Protection and Nuclear Safety (IRSN), Health and Environment Division, Fontenay-aux-Roses, F-92262, France
| | - Geraldine Ielsch
- Institute for Radiological Protection and Nuclear Safety (IRSN), Health and Environment Division, Fontenay-aux-Roses, F-92262, France
| | - Dominique Laurier
- Institute for Radiological Protection and Nuclear Safety (IRSN), Health and Environment Division, Fontenay-aux-Roses, F-92262, France
| | - Laure Faure
- Inserm, UMR 1153 Epidemiology and Biostatistics Sorbonne Paris Cité Research Center (CRESS), Epidemiology of Childhood and Adolescent Cancers Team (EPICEA), Paris University, Villejuif, F-94807, France; French National Registry of Childhood Hematological Malignancies (RNHE), Villejuif, F-94807, France
| | - Jacqueline Clavel
- Inserm, UMR 1153 Epidemiology and Biostatistics Sorbonne Paris Cité Research Center (CRESS), Epidemiology of Childhood and Adolescent Cancers Team (EPICEA), Paris University, Villejuif, F-94807, France; French National Registry of Childhood Hematological Malignancies (RNHE), Villejuif, F-94807, France
| | - Stéphanie Goujon
- Inserm, UMR 1153 Epidemiology and Biostatistics Sorbonne Paris Cité Research Center (CRESS), Epidemiology of Childhood and Adolescent Cancers Team (EPICEA), Paris University, Villejuif, F-94807, France; French National Registry of Childhood Hematological Malignancies (RNHE), Villejuif, F-94807, France.
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11
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Folly CL, Konstantinoudis G, Mazzei-Abba A, Kreis C, Bucher B, Furrer R, Spycher BD. Bayesian spatial modelling of terrestrial radiation in Switzerland. JOURNAL OF ENVIRONMENTAL RADIOACTIVITY 2021; 233:106571. [PMID: 33770702 DOI: 10.1016/j.jenvrad.2021.106571] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 02/23/2021] [Accepted: 02/24/2021] [Indexed: 06/12/2023]
Abstract
The geographic variation of terrestrial radiation can be exploited in epidemiological studies of the health effects of protracted low-dose exposure. Various methods have been applied to derive maps of this variation. We aimed to construct a map of terrestrial radiation for Switzerland. We used airborne γ-spectrometry measurements to model the ambient dose rates from terrestrial radiation through a Bayesian mixed-effects model and conducted inference using Integrated Nested Laplace Approximation (INLA). We predicted higher levels of ambient dose rates in the alpine regions and Ticino compared with the western and northern parts of Switzerland. We provide a map that can be used for exposure assessment in epidemiological studies and as a baseline map for assessing potential contamination.
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Affiliation(s)
- Christophe L Folly
- Institute for Social and Preventive Medicine (ISPM), University of Bern, Switzerland; Graduate School for Health Sciences, University of Bern, Switzerland.
| | - Garyfallos Konstantinoudis
- Institute for Social and Preventive Medicine (ISPM), University of Bern, Switzerland; MRC Centre for Environment and Health, Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, London, UK.
| | - Antonella Mazzei-Abba
- Institute for Social and Preventive Medicine (ISPM), University of Bern, Switzerland; Graduate School for Health Sciences, University of Bern, Switzerland.
| | - Christian Kreis
- Institute for Social and Preventive Medicine (ISPM), University of Bern, Switzerland.
| | - Benno Bucher
- Swiss Nuclear Safety Inspectorate, Brugg, Switzerland.
| | - Reinhard Furrer
- Department of Mathematics and Department of Computational Science, University of Zurich, Zurich, Switzerland.
| | - Ben D Spycher
- Institute for Social and Preventive Medicine (ISPM), University of Bern, Switzerland.
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12
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Poulalhon C, Vignon L, Idbrik L, Bernier-Chastagner V, Fabre M, Schleiermacher G, Dijoud F, Perrin C, Varlet P, Faure L, Guissou S, Désandes E, Hémon D, Berger C, Lacour B, Clavel J. Data Resource Profile: The French Childhood Cancer Observation Platform (CCOP). Int J Epidemiol 2021; 49:1434-1435k. [PMID: 32642766 DOI: 10.1093/ije/dyaa048] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 03/10/2020] [Indexed: 01/07/2023] Open
Affiliation(s)
- Claire Poulalhon
- Epidémiologie des Cancers des Enfants et des Adolescents (EPICEA), Centre de Recherche en Epidémiologie et Statistiques (CRESS), INSERM, UMR 1153, Université de Paris, Paris, France.,Registre National des Cancers de l'Enfant, Hôpital Paul Brousse, Groupe Hospitalier Universitaire Paris-Sud, Assistance Publique Hôpitaux de Paris (AP-HP), Villejuif, and Centre Hospitalier Régional Universitaire de Nancy, Vandœuvre-lès-Nancy, France
| | - Lucie Vignon
- Epidémiologie des Cancers des Enfants et des Adolescents (EPICEA), Centre de Recherche en Epidémiologie et Statistiques (CRESS), INSERM, UMR 1153, Université de Paris, Paris, France
| | - Latifa Idbrik
- Epidémiologie des Cancers des Enfants et des Adolescents (EPICEA), Centre de Recherche en Epidémiologie et Statistiques (CRESS), INSERM, UMR 1153, Université de Paris, Paris, France
| | | | - Monique Fabre
- Service d'Anatomie et Cytologie Pathologiques, Hôpital Necker-Enfants Malades, AP-HP, and Faculté de Médecine, Université de Paris, Paris, France
| | | | - Frédérique Dijoud
- Service d'Anatomie et Cytologie Pathologiques, Groupement Hospitalier Est, Hospices Civils de Lyon, and Université Claude Bernard Lyon 1, Lyon, France
| | - Corinne Perrin
- Centre de Pathologie et de Neuropathologie Est, Hospices Civils de Lyon, Lyon, France
| | - Pascale Varlet
- Service de Neuropathologie, Hôpital Sainte-Anne, Groupe Hospitalier Universitaire Paris Psychiatrie et Neurosciences, and Université de Paris, Sorbonne Paris Cité, Paris, France
| | - Laure Faure
- Epidémiologie des Cancers des Enfants et des Adolescents (EPICEA), Centre de Recherche en Epidémiologie et Statistiques (CRESS), INSERM, UMR 1153, Université de Paris, Paris, France.,Registre National des Cancers de l'Enfant, Hôpital Paul Brousse, Groupe Hospitalier Universitaire Paris-Sud, Assistance Publique Hôpitaux de Paris (AP-HP), Villejuif, and Centre Hospitalier Régional Universitaire de Nancy, Vandœuvre-lès-Nancy, France
| | - Sandra Guissou
- Epidémiologie des Cancers des Enfants et des Adolescents (EPICEA), Centre de Recherche en Epidémiologie et Statistiques (CRESS), INSERM, UMR 1153, Université de Paris, Paris, France.,Registre National des Cancers de l'Enfant, Hôpital Paul Brousse, Groupe Hospitalier Universitaire Paris-Sud, Assistance Publique Hôpitaux de Paris (AP-HP), Villejuif, and Centre Hospitalier Régional Universitaire de Nancy, Vandœuvre-lès-Nancy, France
| | - Emmanuel Désandes
- Epidémiologie des Cancers des Enfants et des Adolescents (EPICEA), Centre de Recherche en Epidémiologie et Statistiques (CRESS), INSERM, UMR 1153, Université de Paris, Paris, France.,Registre National des Cancers de l'Enfant, Hôpital Paul Brousse, Groupe Hospitalier Universitaire Paris-Sud, Assistance Publique Hôpitaux de Paris (AP-HP), Villejuif, and Centre Hospitalier Régional Universitaire de Nancy, Vandœuvre-lès-Nancy, France
| | - Denis Hémon
- Epidémiologie des Cancers des Enfants et des Adolescents (EPICEA), Centre de Recherche en Epidémiologie et Statistiques (CRESS), INSERM, UMR 1153, Université de Paris, Paris, France
| | - Claire Berger
- Epidémiologie des Cancers des Enfants et des Adolescents (EPICEA), Centre de Recherche en Epidémiologie et Statistiques (CRESS), INSERM, UMR 1153, Université de Paris, Paris, France.,Service d'Hématologie-Oncologie Pédiatrique, Centre Hospitalier Universitaire de Saint-Etienne, Saint-Priest-en-Jarez, France
| | - Brigitte Lacour
- Epidémiologie des Cancers des Enfants et des Adolescents (EPICEA), Centre de Recherche en Epidémiologie et Statistiques (CRESS), INSERM, UMR 1153, Université de Paris, Paris, France.,Registre National des Cancers de l'Enfant, Hôpital Paul Brousse, Groupe Hospitalier Universitaire Paris-Sud, Assistance Publique Hôpitaux de Paris (AP-HP), Villejuif, and Centre Hospitalier Régional Universitaire de Nancy, Vandœuvre-lès-Nancy, France
| | - Jacqueline Clavel
- Epidémiologie des Cancers des Enfants et des Adolescents (EPICEA), Centre de Recherche en Epidémiologie et Statistiques (CRESS), INSERM, UMR 1153, Université de Paris, Paris, France.,Registre National des Cancers de l'Enfant, Hôpital Paul Brousse, Groupe Hospitalier Universitaire Paris-Sud, Assistance Publique Hôpitaux de Paris (AP-HP), Villejuif, and Centre Hospitalier Régional Universitaire de Nancy, Vandœuvre-lès-Nancy, France
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Milder CM, Kendall GM, Arsham A, Schöllnberger H, Wakeford R, Cullings HM, Little MP. Summary of Radiation Research Society Online 66th Annual Meeting, Symposium on "Epidemiology: Updates on epidemiological low dose studies," including discussion. Int J Radiat Biol 2021; 97:866-873. [PMID: 33395353 PMCID: PMC8165006 DOI: 10.1080/09553002.2020.1867326] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 12/04/2020] [Accepted: 12/16/2020] [Indexed: 12/19/2022]
Affiliation(s)
- Cato M Milder
- Space Radiation Analysis Group, NASA Johnson Space Center, 2101 E NASA Pkwy, Houston, TX 77058 USA
| | - Gerald M Kendall
- Cancer Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Richard Doll Building, Old Road Campus, Headington, Oxford, OX3 7LF, UK
| | - Aryana Arsham
- Radiation Epidemiology Branch, National Cancer Institute, Bethesda, MD 20892-9778, USA
| | - Helmut Schöllnberger
- Department of Radiation Sciences, Institute of Radiation Medicine, Helmholtz Zentrum München, Ingolstädter Landstrasse 1, 85764 Neuherberg, Germany
| | - Richard Wakeford
- Centre for Occupational and Environmental Health, Faculty of Biology, Medicine and Health, The University of Manchester, Ellen Wilkinson Building, Oxford Road, Manchester, M13 9PL, UK
| | - Harry M Cullings
- Department of Statistics, Radiation Effects Research Foundation, 5-2 Hijiyama Park, Minami-ku, Hiroshima, Japan 732-0815
| | - Mark P Little
- Radiation Epidemiology Branch, National Cancer Institute, Bethesda, MD 20892-9778, USA
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14
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Kendall GM, Little MP, Wakeford R. A review of studies of childhood cancer and natural background radiation. Int J Radiat Biol 2021; 97:769-781. [PMID: 33395329 PMCID: PMC10686050 DOI: 10.1080/09553002.2020.1867926] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 12/16/2020] [Accepted: 12/17/2020] [Indexed: 12/22/2022]
Abstract
PURPOSE The projected existence and magnitude of carcinogenic effects of ionizing radiation at low doses and low-dose rates is perhaps the most important issue in radiation protection today. Studies of childhood cancer and natural background radiation have the potential to throw direct light on this question, into a dose range below a few tens of mSv. This paper describes the studies that have been undertaken and their context, discusses some problems that arise and summarizes the present position. CONCLUSIONS Many such studies have been undertaken, but most were too small to have a realistic chance of detecting the small effects expected from such low doses, based on risk projections from higher exposures. Case-control or cohort studies are to be preferred methodologically to ecological studies but can be prone to problems of registration/participation bias. Interview-based studies of the requisite size would be prohibitively expensive and would undoubtedly also run into problems of participation bias. Register-based studies can be very large and are free of participation bias. However, they need to estimate the radiation exposure of study subjects using models rather than individual measurements in the homes of those concerned. At present, no firm conclusions can be drawn from the studies that have been published to date. Further data and perhaps pooled studies offer a way forward.
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Affiliation(s)
- Gerald M Kendall
- Cancer Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Headington, Oxford, UK
| | - Mark P Little
- Radiation Epidemiology Branch, National Cancer Institute, Bethesda, MD, USA
| | - Richard Wakeford
- Centre for Occupational and Environmental Health, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
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15
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Hauptmann M, Daniels RD, Cardis E, Cullings HM, Kendall G, Laurier D, Linet MS, Little MP, Lubin JH, Preston DL, Richardson DB, Stram DO, Thierry-Chef I, Schubauer-Berigan MK, Gilbert ES, Berrington de Gonzalez A. Epidemiological Studies of Low-Dose Ionizing Radiation and Cancer: Summary Bias Assessment and Meta-Analysis. J Natl Cancer Inst Monogr 2020; 2020:188-200. [PMID: 32657347 PMCID: PMC8454205 DOI: 10.1093/jncimonographs/lgaa010] [Citation(s) in RCA: 95] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 03/26/2020] [Indexed: 07/27/2023] Open
Abstract
BACKGROUND Ionizing radiation is an established carcinogen, but risks from low-dose exposures are controversial. Since the Biological Effects of Ionizing Radiation VII review of the epidemiological data in 2006, many subsequent publications have reported excess cancer risks from low-dose exposures. Our aim was to systematically review these studies to assess the magnitude of the risk and whether the positive findings could be explained by biases. METHODS Eligible studies had mean cumulative doses of less than 100 mGy, individualized dose estimates, risk estimates, and confidence intervals (CI) for the dose-response and were published in 2006-2017. We summarized the evidence for bias (dose error, confounding, outcome ascertainment) and its likely direction for each study. We tested whether the median excess relative risk (ERR) per unit dose equals zero and assessed the impact of excluding positive studies with potential bias away from the null. We performed a meta-analysis to quantify the ERR and assess consistency across studies for all solid cancers and leukemia. RESULTS Of the 26 eligible studies, 8 concerned environmental, 4 medical, and 14 occupational exposure. For solid cancers, 16 of 22 studies reported positive ERRs per unit dose, and we rejected the hypothesis that the median ERR equals zero (P = .03). After exclusion of 4 positive studies with potential positive bias, 12 of 18 studies reported positive ERRs per unit dose (P = .12). For leukemia, 17 of 20 studies were positive, and we rejected the hypothesis that the median ERR per unit dose equals zero (P = .001), also after exclusion of 5 positive studies with potential positive bias (P = .02). For adulthood exposure, the meta-ERR at 100 mGy was 0.029 (95% CI = 0.011 to 0.047) for solid cancers and 0.16 (95% CI = 0.07 to 0.25) for leukemia. For childhood exposure, the meta-ERR at 100 mGy for leukemia was 2.84 (95% CI = 0.37 to 5.32); there were only two eligible studies of all solid cancers. CONCLUSIONS Our systematic assessments in this monograph showed that these new epidemiological studies are characterized by several limitations, but only a few positive studies were potentially biased away from the null. After exclusion of these studies, the majority of studies still reported positive risk estimates. We therefore conclude that these new epidemiological studies directly support excess cancer risks from low-dose ionizing radiation. Furthermore, the magnitude of the cancer risks from these low-dose radiation exposures was statistically compatible with the radiation dose-related cancer risks of the atomic bomb survivors.
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Affiliation(s)
- Michael Hauptmann
- Correspondence to: Michael Hauptmann, Institute of Biostatistics and Registry Research, Brandenburg Medical School Theodor Fontane. Fehrbelliner Straße 38, 16816 Neuruppin, Germany (e-mail: )
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16
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Berrington de Gonzalez A, Daniels RD, Cardis E, Cullings HM, Gilbert E, Hauptmann M, Kendall G, Laurier D, Linet MS, Little MP, Lubin JH, Preston DL, Richardson DB, Stram D, Thierry-Chef I, Schubauer-Berigan MK. Epidemiological Studies of Low-Dose Ionizing Radiation and Cancer: Rationale and Framework for the Monograph and Overview of Eligible Studies. J Natl Cancer Inst Monogr 2020; 2020:97-113. [PMID: 32657348 PMCID: PMC7610154 DOI: 10.1093/jncimonographs/lgaa009] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Accepted: 03/13/2020] [Indexed: 12/21/2022] Open
Abstract
Whether low-dose ionizing radiation can cause cancer is a critical and long-debated question in radiation protection. Since the Biological Effects of Ionizing Radiation report by the National Academies in 2006, new publications from large, well-powered epidemiological studies of low doses have reported positive dose-response relationships. It has been suggested, however, that biases could explain these findings. We conducted a systematic review of epidemiological studies with mean doses less than 100 mGy published 2006-2017. We required individualized doses and dose-response estimates with confidence intervals. We identified 26 eligible studies (eight environmental, four medical, and 14 occupational), including 91 000 solid cancers and 13 000 leukemias. Mean doses ranged from 0.1 to 82 mGy. The excess relative risk at 100 mGy was positive for 16 of 22 solid cancer studies and 17 of 20 leukemia studies. The aim of this monograph was to systematically review the potential biases in these studies (including dose uncertainty, confounding, and outcome misclassification) and to assess whether the subset of minimally biased studies provides evidence for cancer risks from low-dose radiation. Here, we describe the framework for the systematic bias review and provide an overview of the eligible studies.
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Affiliation(s)
| | - Robert D Daniels
- National Institute for Occupational Safety and Health, Cincinnati, OH, USA
| | - Elisabeth Cardis
- Barcelona Institute for Global Health (ISGlobal), Barcelona, Catalonia, Spain
- Universitat Pompeu Fabra (UPF), Barcelona, Catalonia, Spain
- CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| | | | - Ethel Gilbert
- Division of Cancer Epidemiology & Genetics, Radiation Epidemiology Branch, Bethesda, MD, USA
| | - Michael Hauptmann
- Department of Epidemiology and Biostatistics, Netherlands Cancer Institute, Amsterdam, the Netherlands
- Brandenburg Medical School Theodor Fontane, Institute of Biostatistics and Registry Research, Neuruppin, Germany
| | | | | | - Martha S Linet
- Division of Cancer Epidemiology & Genetics, Radiation Epidemiology Branch, Bethesda, MD, USA
| | - Mark P Little
- Division of Cancer Epidemiology & Genetics, Radiation Epidemiology Branch, Bethesda, MD, USA
| | - Jay H Lubin
- Division of Cancer Epidemiology & Genetics, Radiation Epidemiology Branch, Bethesda, MD, USA
| | | | | | - Daniel Stram
- University of Southern California, Los Angeles, CA
| | - Isabelle Thierry-Chef
- Barcelona Institute for Global Health (ISGlobal), Barcelona, Catalonia, Spain
- Universitat Pompeu Fabra (UPF), Barcelona, Catalonia, Spain
- CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
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Konstantinoudis G, Schuhmacher D, Ammann RA, Diesch T, Kuehni CE, Spycher BD. Bayesian spatial modelling of childhood cancer incidence in Switzerland using exact point data: a nationwide study during 1985-2015. Int J Health Geogr 2020; 19:15. [PMID: 32303231 PMCID: PMC7165384 DOI: 10.1186/s12942-020-00211-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 04/11/2020] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND The aetiology of most childhood cancers is largely unknown. Spatially varying environmental factors such as traffic-related air pollution, background radiation and agricultural pesticides might contribute to the development of childhood cancer. This study is the first investigation of the spatial disease mapping of childhood cancers using exact geocodes of place of residence. METHODS We included 5947 children diagnosed with cancer in Switzerland during 1985-2015 at 0-15 years of age from the Swiss Childhood Cancer Registry. We modelled cancer risk using log-Gaussian Cox processes and indirect standardisation to adjust for age and year of diagnosis. We examined whether the spatial variation of risk can be explained by modelled ambient air concentration of NO2, modelled exposure to background ionising radiation, area-based socio-economic position (SEP), linguistic region, duration in years of general cancer registration in the canton or degree of urbanisation. RESULTS For all childhood cancers combined, the posterior median relative risk (RR), compared to the national level, varied by location from 0.83 to 1.13 (min to max). Corresponding ranges were 0.96 to 1.09 for leukaemia, 0.90 to 1.13 for lymphoma, and 0.82 to 1.23 for central nervous system (CNS) tumours. The covariates considered explained 72% of the observed spatial variation for all cancers, 81% for leukaemia, 82% for lymphoma and 64% for CNS tumours. There was weak evidence of an association of CNS tumour incidence with modelled exposure to background ionising radiation (RR per SD difference 1.17; 0.98-1.40) and with SEP (1.6; 1.00-1.13). CONCLUSION Of the investigated diagnostic groups, childhood CNS tumours showed the largest spatial variation. The selected covariates only partially explained the observed variation of CNS tumours suggesting that other environmental factors also play a role.
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Affiliation(s)
- Garyfallos Konstantinoudis
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland.
- Epidemiology and Biostatistics Department, School of Public Health, Imperial College London, London, UK.
| | - Dominic Schuhmacher
- Institute for Mathematical Stochastics, University of Göttingen, Göttingen, Germany
| | - Roland A Ammann
- Department of Paediatrics Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Tamara Diesch
- Division of Paediatric Oncology/Haematology, University Children's Hospital Basel, Basel, Switzerland
| | - Claudia E Kuehni
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland
| | - Ben D Spycher
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland
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Mazzei-Abba A, Folly CL, Coste A, Wakeford R, Little MP, Raaschou-Nielsen O, Kendall G, Hémon D, Nikkilä A, Spix C, Auvinen A, Spycher BD. Epidemiological studies of natural sources of radiation and childhood cancer: current challenges and future perspectives. JOURNAL OF RADIOLOGICAL PROTECTION : OFFICIAL JOURNAL OF THE SOCIETY FOR RADIOLOGICAL PROTECTION 2020; 40:R1-R23. [PMID: 31751953 PMCID: PMC10654695 DOI: 10.1088/1361-6498/ab5a38] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
The empirical estimation of cancer risks in children associated with low-dose ionising radiation (<100 mSv) remains a challenge. The main reason is that the required combination of large sample sizes with accurate and comprehensive exposure assessment is difficult to achieve. An international scientific workshop, 'Childhood cancer and background radiation', organised by the Institute of Social and Preventive Medicine of the University of Bern, brought together researchers in this field to evaluate how epidemiological studies of background radiation and childhood cancer can best improve our understanding of the effects of low-dose ionising radiation. This review summarises and evaluates the findings of these studies with regard to their methodological differences, identifies key limitations and challenges, and proposes ways to move forward. Large childhood cancer registries, such as those in Great Britain, France and Germany, now permit the conducting of studies that should have sufficient statistical power to detect the effects predicted by standard risk models. Nevertheless, larger studies or pooled studies will be needed to investigate disease subgroups. The main challenge is to accurately assess children's individual exposure to radiation from natural sources and from other sources, as well as potentially confounding non-radiation exposures, in such large study populations. For this, the study groups should learn from each other to improve exposure estimation and develop new ways to validate exposure models with personal dosimetry.
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Affiliation(s)
- Antonella Mazzei-Abba
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland
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Rühm W, Breckow J, Dietze G, Friedl A, Greinert R, Jacob P, Kistinger S, Michel R, Müller WU, Otten H, Streffer C, Weiss W. Dose limits for occupational exposure to ionising radiation and genotoxic carcinogens: a German perspective. RADIATION AND ENVIRONMENTAL BIOPHYSICS 2020; 59:9-27. [PMID: 31677018 DOI: 10.1007/s00411-019-00817-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Accepted: 10/14/2019] [Indexed: 06/10/2023]
Abstract
This paper summarises the view of the German Commission on Radiological Protection ("Strahlenschutzkommission", SSK) on the rationale behind the currently valid dose limits and dose constraints for workers recommended by the International Commission on Radiological Protection (ICRP). The paper includes a discussion of the reasoning behind current dose limits followed by a discussion of the detriment used by ICRP as a measure for stochastic health effects. Studies on radiation-induced cancer are reviewed because this endpoint represents the most important contribution to detriment. Recent findings on radiation-induced circulatory disease that are currently not included in detriment calculation are also reviewed. It appeared that for detriment calculations the contribution of circulatory diseases plays only a secondary role, although the uncertainties involved in their risk estimates are considerable. These discussions are complemented by a review of the procedures currently in use in Germany, or in discussion elsewhere, to define limits for genotoxic carcinogens. To put these concepts in perspective, actual occupational radiation exposures are exemplified with data from Germany, for the year 2012, and regulations in Germany are compared to the recommendations issued by ICRP. Conclusions include, among others, considerations on radiation protection concepts currently in use and recommendations of the SSK on the limitation of annual effective dose and effective dose cumulated over a whole working life.
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Affiliation(s)
- Werner Rühm
- Helmholtz Zentrum München, Institute of Radiation Therapy, Ingolstädter Landstr. 1, 85764, Oberschleißheim, Germany.
| | | | - Günter Dietze
- Physikalisch-Technische Bundesanstalt, Braunschweig, Germany
| | - Anna Friedl
- Department of Radiation Oncology, University Hospital, LMU Munich, Munich, Germany
| | | | - Peter Jacob
- Helmholtz Zentrum München, Neuherberg, Germany
| | | | | | | | - Heinz Otten
- Deutsche Gesetzliche Unfallversicherung, Berlin, Germany
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Berlivet J, Hémon D, Cléro É, Ielsch G, Laurier D, Guissou S, Lacour B, Clavel J, Goujon S. Ecological association between residential natural background radiation exposure and the incidence rate of childhood central nervous system tumors in France, 2000-2012. JOURNAL OF ENVIRONMENTAL RADIOACTIVITY 2020; 211:106071. [PMID: 31600676 DOI: 10.1016/j.jenvrad.2019.106071] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 08/01/2019] [Accepted: 09/23/2019] [Indexed: 06/10/2023]
Abstract
BACKGROUND High-dose ionizing radiation is an established risk factor for childhood central nervous system tumors (CNST) but the role of low doses remains debated. In particular, there are few studies of natural background radiation (NBR, gamma radiation and radon) and childhood CNST, and their results are inconclusive. OBJECTIVES This study aimed to investigate the ecological association between NBR exposure and childhood CNST incidence in France, considering childhood CNST overall and by subgroups. METHODS Incidence data were provided by the French national registry of childhood cancers, which has high completeness. We included 5471 childhood CNST cases registered over the period 2000-2012, and their municipality of residence at diagnosis was recorded. Municipality NBR exposures were estimated by cokriging models, using NBR measurements and additional geographic data. The incidence rate ratio (IRR) per unit variation of exposure was estimated with Poisson regression models. NBR exposures were considered at the time of diagnosis, and cumulatively from birth to diagnosis. In an exploratory analysis, the total brain dose due to NBR was used. RESULTS Overall, there was no association between NBR exposure and childhood CNST incidence (IRR = 1.03 (0.98,1.09) per 50 nSv/h for gamma radiation, and IRR = 1.02 (0,96,1.07) per 100 Bq/m3 for radon). An association was suggested between pilocytic astrocytomas and gamma radiation (IRR = 1.12 (1.00,1.24) per 50 nSv/h) but not with radon (IRR = 1.07 (0.95,1.20) per 100 Bq/m3). Upward trends for this CNST subtype were also suggested with the cumulative exposures to gamma radiation and the total brain dose. NBR exposure was not associated with other CNST subgroups (ependymomas, embryonal tumors, and gliomas other than pilocytic astrocytomas). Adjustment for socio-demographic factors did not change the findings. CONCLUSIONS Our study was based on high quality incidence data, large numbers of CNST cases, and validated models of NBR exposure assessment. Results suggest an association between gamma radiation, as a component of NBR, and pilocytic astrocytomas incidence in France.
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Affiliation(s)
- Justine Berlivet
- Inserm, UMR 1153 Epidemiology and Biostatistics Sorbonne Paris Cité Research Center (CRESS), Epidémiologie des Cancers de l'enfant et de l'adolescent Team (EPICEA), Villejuif, F-94807, France; Paris Descartes University, Sorbonne Paris Cité, France.
| | - Denis Hémon
- Inserm, UMR 1153 Epidemiology and Biostatistics Sorbonne Paris Cité Research Center (CRESS), Epidémiologie des Cancers de l'enfant et de l'adolescent Team (EPICEA), Villejuif, F-94807, France; Paris Descartes University, Sorbonne Paris Cité, France
| | - Énora Cléro
- Institut de Radioprotection et de Sûreté Nucléaire, IRSN, PSE-SANTE/SESANE, Fontenay aux Roses, F-92262, France
| | - Géraldine Ielsch
- Institut de Radioprotection et de Sûreté Nucléaire, IRSN, PSE-ENV/SEREN, Fontenay aux Roses, F-92262, France
| | - Dominique Laurier
- Institut de Radioprotection et de Sûreté Nucléaire, IRSN, PSE-SANTE/SESANE, Fontenay aux Roses, F-92262, France
| | - Sandra Guissou
- Inserm, UMR 1153 Epidemiology and Biostatistics Sorbonne Paris Cité Research Center (CRESS), Epidémiologie des Cancers de l'enfant et de l'adolescent Team (EPICEA), Villejuif, F-94807, France; Paris Descartes University, Sorbonne Paris Cité, France; CHU Nancy, French National Registry of Childhood Solid Tumors (RNTSE), Faculté de Médecine, Vandoeuvre-lès-Nancy, F-54500, France
| | - Brigitte Lacour
- Inserm, UMR 1153 Epidemiology and Biostatistics Sorbonne Paris Cité Research Center (CRESS), Epidémiologie des Cancers de l'enfant et de l'adolescent Team (EPICEA), Villejuif, F-94807, France; Paris Descartes University, Sorbonne Paris Cité, France; CHU Nancy, French National Registry of Childhood Solid Tumors (RNTSE), Faculté de Médecine, Vandoeuvre-lès-Nancy, F-54500, France
| | - Jacqueline Clavel
- Inserm, UMR 1153 Epidemiology and Biostatistics Sorbonne Paris Cité Research Center (CRESS), Epidémiologie des Cancers de l'enfant et de l'adolescent Team (EPICEA), Villejuif, F-94807, France; Paris Descartes University, Sorbonne Paris Cité, France; French National Registry of Childhood Hematological Malignancies (RNHE), Villejuif, F-94807, France
| | - Stéphanie Goujon
- Inserm, UMR 1153 Epidemiology and Biostatistics Sorbonne Paris Cité Research Center (CRESS), Epidémiologie des Cancers de l'enfant et de l'adolescent Team (EPICEA), Villejuif, F-94807, France; Paris Descartes University, Sorbonne Paris Cité, France; French National Registry of Childhood Hematological Malignancies (RNHE), Villejuif, F-94807, France
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Chen J, Xie L. DOMESTIC RADON EXPOSURE AND CHILDHOOD LEUKAEMIA AND LYMPHOMA: A POPULATION-BASED STUDY IN CANADA. RADIATION PROTECTION DOSIMETRY 2019; 184:486-492. [PMID: 31034559 DOI: 10.1093/rpd/ncz068] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
In this paper, we revisit the possibility, first raised using a data set collected in the 1970s, that there is a link between average radon concentrations and the incidence of childhood leukaemia and lymphoma in Canada. Following the launch of the National Radon Program in 2007, Health Canada completed a long-term radon survey in 33 census metropolitan areas (CMAs), which covers about 70% of the Canadian population. We used this data, together with leukaemia and lymphoma incidence rates among children (0-14 years of age) in the past decade (2006-15), and tried to link the city-level average radon concentrations to the leukaemia and lymphoma incidence rates in 33 major Canadian cities. Analyses were conducted for six subtypes (ALL, AML, CMD, HL, NHL and BL) of leukaemia and lymphoma. Estimated doses to red bone marrow from domestic radon exposure were low and we did not find any association between radon exposure at home and the increased risk for developing leukaemia among children under 15 years of age living in the CMAs. The results indicate a slight positive association for AML among 1-4 year males in CMAs of Peer Group C and NHL among 5-9 year females in CMAs of Peer Group A; however, these should be interpreted with caution owing to the crude exposure assessment and possibilities of other confounding factors.
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Affiliation(s)
- Jing Chen
- Radiation Protection Bureau, Health Canada, 775 Brookfield Road, Ottawa, Ontario, Canada
| | - Lin Xie
- Centre for Surveillance and Applied Research, Public Health Agency Canada, 785 Carling Avenue, Ottawa, Ontario, Canada
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Boice JD, Held KD, Shore RE. Radiation epidemiology and health effects following low-level radiation exposure. JOURNAL OF RADIOLOGICAL PROTECTION : OFFICIAL JOURNAL OF THE SOCIETY FOR RADIOLOGICAL PROTECTION 2019; 39:S14-S27. [PMID: 31272090 DOI: 10.1088/1361-6498/ab2f3d] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Radiation epidemiology is the study of human disease following radiation exposure to populations. Epidemiologic studies of radiation-exposed populations have been conducted for nearly 100 years, starting with the radium dial painters in the 1920s and most recently with large-scale studies of radiation workers. As radiation epidemiology has become increasingly sophisticated it is used for setting radiation protection standards as well as to guide the compensation programmes in place for nuclear weapons workers, nuclear weapons test participants, and other occupationally exposed workers in the United States and elsewhere. It is known with high assurance that radiation effects at levels above 100-150 mGy can be detected as evidenced in multiple population studies conducted around the world. The challenge for radiation epidemiology is evaluating the effects at low doses, below about 100 mGy of low-linear energy transfer radiation, and assessing the risks following low dose-rate exposures over years. The weakness of radiation epidemiology in directly studying low dose and low dose-rate exposures is that the signal, i.e. the excess numbers of cancers associated with low-level radiation exposure, is so very small that it cannot be seen against the very high background occurrence of cancer in the population, i.e. a lifetime risk of incidence reaching up to about 38% (i.e. 1 in 3 persons will develop a cancer in their lifetime). Thus, extrapolation models are used for the management of risk at low doses and low dose rates, but having adequate information from low dose and low dose-rate studies would be highly desirable. An overview of recently conducted radiation epidemiologic studies which evaluate risk following low-level radiation exposures is presented. Future improvements in risk assessment for radiation protection may come from increasingly informative epidemiologic studies, combined with mechanistic radiobiologic understanding of adverse outcome pathways, with both incorporated into biologically based models.
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Affiliation(s)
- J D Boice
- National Council on Radiation Protection and Measurements, Bethesda, Maryland, United States of America. Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
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23
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Pawel D, Boyd M. Studies of radiation health effects inform EPA actions. JOURNAL OF RADIOLOGICAL PROTECTION : OFFICIAL JOURNAL OF THE SOCIETY FOR RADIOLOGICAL PROTECTION 2019; 39:S40-S57. [PMID: 31085816 PMCID: PMC7158982 DOI: 10.1088/1361-6498/ab2197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
In 1970, the US Environmental Protection Agency (EPA) was given the responsibility to provide guidance to other federal agencies in the formulation of radiation protection standards. To carry out its federal guidance responsibilities and protect human health, the EPA must estimate risk at low doses to limit the risk of radiogenic cancers from environmental exposures. These risk estimates are based on models which conform to the linear no threshold (LNT) hypothesis. A cancer risk model conforms to the LNT hypothesis if the excess risk of cancer at low doses increases approximately proportional to dose, with no threshold. Risk models with a linear-quadratic dose response can satisfy the LNT hypothesis. Based on careful review of evidence from epidemiological and radiobiological studies, authoritative scientific bodies have repeatedly endorsed the use of LNT models for estimating and regulating risk and concluded that despite uncertainties at low dose and dose rates, the LNT model remains the most practical and implementable model for radiation protection. This article describes the rationale underlying the use of LNT models for calculating risk for low dose and dose rate exposures and discusses some of the epidemiological evidence which inform on its continued use.
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Kendall GM, Chernyavskiy P, Appleton JD, Miles JCH, Wakeford R, Athanson M, Vincent TJ, McColl NP, Little MP. Modelling the bimodal distribution of indoor gamma-ray dose-rates in Great Britain. RADIATION AND ENVIRONMENTAL BIOPHYSICS 2018; 57:321-347. [PMID: 30132159 DOI: 10.1007/s00411-018-0752-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Accepted: 08/04/2018] [Indexed: 06/08/2023]
Abstract
Gamma radiation from naturally occurring sources (including directly ionizing cosmic-rays) is a major component of background radiation. An understanding of the magnitude and variation of doses from these sources is important, and the ability to predict them is required for epidemiological studies. In the present paper, indoor measurements of naturally occurring gamma-rays at representative locations in Great Britain are summarized. It is shown that, although the individual measurement data appear unimodal, the distribution of gamma-ray dose-rates when averaged over relatively small areas, which probably better represents the underlying distribution with inter-house variation reduced, appears bimodal. The dose-rate distributions predicted by three empirical and geostatistical models are also bimodal and compatible with the distributions of the areally averaged dose-rates. The distribution of indoor gamma-ray dose-rates in the UK is compared with those in other countries, which also tend to appear bimodal (or possibly multimodal). The variation of indoor gamma-ray dose-rates with geology, socio-economic status of the area, building type, and period of construction are explored. The factors affecting indoor dose-rates from background gamma radiation are complex and frequently intertwined, but geology, period of construction, and socio-economic status are influential; the first is potentially most influential, perhaps, because it can be used as a general proxy for local building materials. Various statistical models are tested for predicting indoor gamma-ray dose-rates at unmeasured locations. Significant improvements over previous modelling are reported. The dose-rate estimates generated by these models reflect the imputed underlying distribution of dose-rates and provide acceptable predictions at geographical locations without measurements.
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Affiliation(s)
- G M Kendall
- Cancer Epidemiology Unit, NDPH, University of Oxford, Richard Doll Building, Old Road Campus, Headington, Oxford, OX3 7LF, UK.
| | - P Chernyavskiy
- Radiation Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, DHHS, NIH, Bethesda, MD, 20892-9778, USA
- Department of Mathematics and Statistics, Ross Hall 331, University of Wyoming, Laramie, WY, 82071-3036, USA
| | - J D Appleton
- British Geological Survey, Kingsley Dunham Centre, Nicker Hill, Keyworth, Nottingham, NG12 5GG, UK
| | - J C H Miles
- , Nobles Close, Grove, Oxfordshire, OX12 0NR, UK
| | - R Wakeford
- Centre for Occupational and Environmental Health, Institute of Population Health, The University of Manchester, Ellen Wilkinson Building, Oxford Road, Manchester, M13 9PL, UK
| | - M Athanson
- Bodleian Library, University of Oxford, Broad Street, Oxford, OX1 3BG, UK
| | - T J Vincent
- Childhood Cancer Research Group, University of Oxford, New Richards Building, Old Road, Oxford, UK
| | - N P McColl
- Centre for Radiation, Chemical and Environmental Hazards, Public Health England, Chilton, Didcot Oxon, OX11 0RQ, UK
| | - M P Little
- Radiation Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, DHHS, NIH, Bethesda, MD, 20892-9778, USA
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Nikkilä A, Kendall G, Raitanen J, Spycher B, Lohi O, Auvinen A. Effects of incomplete residential histories on studies of environmental exposure with application to childhood leukaemia and background radiation. ENVIRONMENTAL RESEARCH 2018; 166:466-472. [PMID: 29945121 DOI: 10.1016/j.envres.2018.06.035] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 06/13/2018] [Accepted: 06/16/2018] [Indexed: 06/08/2023]
Abstract
When evaluating environmental exposures, residential exposures are often most relevant. In most countries, it is impossible to establish full residential histories. In recent publications, childhood leukaemia and background radiation have been studied with and without full residential histories. This paper investigates the consequences of lacking such full data. Data from a nationwide Finnish Case-Control study of Childhood Leukaemia and gamma rays were analysed. This included 1093 children diagnosed with leukaemia in Finland in 1990-2011. Each case was matched by gender and year of birth to three controls. Full residential histories were available. The dose estimates were based on outdoor background radiation measurements. The indoor dose rates were obtained with a dwelling type specific conversion coefficient and the individual time-weighted mean red bone marrow dose rates were calculated using age-specific indoor occupancy and the age and gender of the child. Radiation from Chernobyl fallout was included and a 2-year latency period assumed. The median separation between successive dwellings was 3.4 km and median difference in red bone marrow dose 2.9 nSv/h. The Pearson correlation between the indoor red bone marrow dose rates of successive dwellings was 0.62 (95% CI 0.60, 0.64). The odds ratio for a 10 nSv/h increase in dose rate with full residential histories was 1.01 (95% CI 0.97, 1.05). Similar odds ratios were calculated with dose rates based on only the first dwelling (1.02, 95% CI 0.99, 1.05) and only the last dwelling (1.00, 95% CI 0.98, 1.03) and for subjects who had lived only in a single dwelling (1.05, 95% CI 0.98, 1.10). Knowledge of full residential histories would always be the option of choice. However, due to the strong correlation between exposure estimates in successive dwellings and the uncertainty about the most relevant exposure period, estimation of overall exposure level from a single address is also informative. Error in dose estimation is likely to cause some degree of classical measurement error resulting in bias towards the null.
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Affiliation(s)
- Atte Nikkilä
- Faculty of Medicine and Biosciences, University of Tampere, Tampere, Finland.
| | - Gerald Kendall
- Cancer Epidemiology Unit, NDPH, University of Oxford, Old Road Campus, Oxford OX3 7LF, UK
| | - Jani Raitanen
- Faculty of Social Sciences, University of Tampere, Tampere, Finland; UKK Institute, Tampere, Finland
| | - Ben Spycher
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland
| | - Olli Lohi
- Tampere Center for Child Health Research, University of Tampere and Tampere University Hospital, Tampere, Finland
| | - Anssi Auvinen
- Faculty of Social Sciences, University of Tampere, Tampere, Finland; Radiation and Nuclear Safety Authority, Helsinki, Finland
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Abstract
For stochastic effects such as cancer, linear-quadratic models of dose are often used to extrapolate from the experience of the Japanese atomic bomb survivors to estimate risks from low doses and low dose rates. The low dose extrapolation factor (LDEF), which consists of the ratio of the low dose slope (as derived via fitting a linear-quadratic model) to the slope of the straight line fitted to a specific dose range, is used to derive the degree of overestimation (if LDEF > 1) or underestimation (if LDEF < 1) of low dose risk by linear extrapolation from effects at higher doses. Likewise, a dose rate extrapolation factor (DREF) can be defined, consisting of the ratio of the low dose slopes at high and low dose rates. This paper reviews a variety of human and animal data for cancer and non-cancer endpoints to assess evidence for curvature in the dose response (i.e. LDEF) and modifications of the dose response by dose rate (i.e. DREF). The JANUS mouse data imply that LDEF is approximately 0.2-0.8 and DREF is approximately 1.2-2.3 for many tumours following gamma exposure, with corresponding figures of approximately 0.1-0.9 and 0.0-0.2 following neutron exposure. This paper also cursorily reviews human data which allow direct estimates of low dose and low dose rate risk.
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Affiliation(s)
- M P Little
- Radiation Epidemiology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD 20892-9778, USA
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Little MP, Wakeford R, Borrego D, French B, Zablotska LB, Adams MJ, Allodji R, de Vathaire F, Lee C, Brenner AV, Miller JS, Campbell D, Pearce MS, Doody MM, Holmberg E, Lundell M, Sadetzki S, Linet MS, Berrington de González A. Leukaemia and myeloid malignancy among people exposed to low doses (<100 mSv) of ionising radiation during childhood: a pooled analysis of nine historical cohort studies. LANCET HAEMATOLOGY 2018; 5:e346-e358. [PMID: 30026010 DOI: 10.1016/s2352-3026(18)30092-9] [Citation(s) in RCA: 99] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Revised: 05/29/2018] [Accepted: 06/01/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Substantial evidence links exposure to moderate or high doses of ionising radiation, particularly in childhood, with increased risk of leukaemia. The association of leukaemia with exposure to low-dose (<100 mSv) radiation is less certain, although this is the dose range most relevant to the general population. We aimed to estimate the risk of leukaemia associated with low-dose radiation exposure in childhood (age <21 years). METHODS In this analysis of historical cohort studies, we pooled eligible cohorts reported up to June 30, 2014. We evaluated leukaemia and myeloid malignancy outcomes in these cohorts with the relevant International Classification of Diseases and International Classification of Diseases for Oncology definitions. The cohorts included had not been treated for malignant disease, had reported at least five cases of the relevant haematopoietic neoplasms, and estimated individual active bone marrow (ABM) doses. We restricted analysis to individuals who were younger than 21 years at first irradiation who had mean cumulative ABM doses of less than 100 mSv. Dose-response models were fitted by use of Poisson regression. The data were received in fully anonymised form by the statistical analyst. FINDINGS We identified nine eligible cohorts from Canada, France, Japan, Sweden, the UK, and the USA, including 262 573 people who had been exposed to less than 100 mSv enrolled between June 4, 1915, and Dec 31, 2004. Mean follow-up was 19·63 years (SD 17·75) and mean cumulative ABM dose was 19·6 mSv (SD 22·7). 154 myeloid malignancies were identified (which included 79 acute myeloid leukaemias, eight myelodysplastic syndromes, and 36 chronic myeloid leukaemias, in addition to other unspecified myeloid malignancies) and 40 acute lymphoblastic leukaemias, with 221 leukaemias (including otherwise unclassified leukaemias but excluding chronic lymphocytic leukaemia) identified overall. The fitted relative risks at 100 mSv were 3·09 (95% CI 1·41-5·92; ptrend=0·008) for acute myeloid leukaemia and myelodysplastic syndromes combined, 2·56 (1·09-5·06; ptrend=0·033) for acute myeloid leukaemia, and 5·66 (1·35-19·71; ptrend=0·023) for acute lymphoblastic leukaemia. There was no clear dose-response for chronic myeloid leukaemia, which had a relative risk at 100 mSv of 0·36 (0·00-2·36; ptrend=0·394). There were few indications of between-cohort heterogeneity or departure from linearity. For acute myeloid leukaemia and myelodysplastic syndromes combined and for acute lymphoblastic leukaemia, the dose-responses remained significant for doses of less than 50 mSv. Excess absolute risks at 100 mSv were in the range of 0·1-0·4 cases or deaths per 10 000 person-years. INTERPRETATION The risks of acute myeloid leukaemia and acute lymphoblastic leukaemia were significantly increased after cumulative doses of ionising radiation of less than 100 mSv in childhood or adolescence, with an excess risk also apparent for cumulative radiation doses of less than 50 mSv for some endpoints. These findings support an increased risk of leukaemia associated with low-dose exposure to radiation and imply that the current system of radiological protection is prudent and not overly protective. FUNDING National Cancer Institute Intramural Research Program, National Cancer Institute, and US National Institutes for Health.
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Affiliation(s)
- Mark P Little
- Radiation Epidemiology Branch, National Cancer Institute, Bethesda, MD, USA.
| | - Richard Wakeford
- Centre for Occupational and Environmental Health, Institute of Population Health, The University of Manchester, Manchester, UK
| | - David Borrego
- Radiation Epidemiology Branch, National Cancer Institute, Bethesda, MD, USA
| | | | - Lydia B Zablotska
- Department of Epidemiology & Biostatistics, School of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - M Jacob Adams
- School of Medicine and Dentistry, University of Rochester, Rochester, NY, USA
| | - Rodrigue Allodji
- Centre for Research in Epidemiology and Population Health, INSERM Unit 1018, Institut Gustave Roussy, University of Paris-Saclay, Villejuif, France
| | - Florent de Vathaire
- Centre for Research in Epidemiology and Population Health, INSERM Unit 1018, Institut Gustave Roussy, University of Paris-Saclay, Villejuif, France
| | - Choonsik Lee
- Radiation Epidemiology Branch, National Cancer Institute, Bethesda, MD, USA
| | - Alina V Brenner
- Radiation Epidemiology Branch, National Cancer Institute, Bethesda, MD, USA
| | | | | | - Mark S Pearce
- Institute of Health and Society, and National Institute for Health Research Health Protection Research Unit for Chemical and Radiation Threats and Hazards, Newcastle University, Newcastle-upon-Tyne, UK
| | - Michele M Doody
- Radiation Epidemiology Branch, National Cancer Institute, Bethesda, MD, USA
| | - Erik Holmberg
- Department of Oncology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Marie Lundell
- Department of Medical Radiation Physics and Nuclear Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Siegal Sadetzki
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Gertner Institute, Tel Hashomer, Israel
| | - Martha S Linet
- Radiation Epidemiology Branch, National Cancer Institute, Bethesda, MD, USA
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Kendall GM, Little MP, Wakeford R. Comment on "Indoor terrestrial gamma dose rate mapping in France: A case study using two different geostatistical models" by Warnery et al. (J. Environ. Radioact. 2015, 139, 140-148). JOURNAL OF ENVIRONMENTAL RADIOACTIVITY 2018; 182:172-173. [PMID: 29208339 DOI: 10.1016/j.jenvrad.2017.11.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Accepted: 11/23/2017] [Indexed: 06/07/2023]
Affiliation(s)
- G M Kendall
- Cancer Epidemiology Unit, NDPH, University of Oxford, Oxford, OX3 7LF, UK.
| | - M P Little
- Radiation Epidemiology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD, 20892-9778, USA
| | - R Wakeford
- Institute of Population Health, University of Manchester, Manchester, M13 9PL, UK
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Fournier L, Cléro E, Samson E, Caër-Lorho S, Laurier D, Leuraud K. Impact of considering non-occupational radiation exposure on the association between occupational dose and solid cancer among French nuclear workers. Occup Environ Med 2017; 75:199-204. [PMID: 29055886 DOI: 10.1136/oemed-2017-104341] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Revised: 08/25/2017] [Accepted: 10/05/2017] [Indexed: 11/03/2022]
Abstract
OBJECTIVES The French nuclear worker cohort allows for the assessment of cancer risk associated with occupational radiation exposure, but workers are also exposed to medical and environmental radiation which can be of the same order of magnitude. This study aims to examine the impact of non-occupational radiation exposures on the dose-risk analysis between occupational radiation exposure and cancer mortality. METHODS The cohort included workers employed before 1995 for at least one year by CEA, AREVA NC or EDF and badge-monitored for external radiation exposure. Monitoring results were used to calculate occupational individual doses. Scenarios of work-related X-ray and environmental exposures were simulated. Poisson regression was used to quantify associations between occupational exposure and cancer mortality adjusting for non-occupational radiation exposure. RESULTS The mean cumulative dose of external occupational radiation was 18.4 mSv among 59 004 workers. Depending on the hypotheses made, the mean cumulative work-related X-ray dose varied between 3.1 and 9.2 mSv and the mean cumulative environmental dose was around 130 mSv. The unadjusted excess relative rate of cancer per Sievert (ERR/Sv) was 0.34 (90% CI -0.44 to 1.24). Adjusting for environmental radiation exposure did not substantially modify this risk coefficient, but it was attenuated by medical exposure (ERR/Sv point estimate between 0.15 and 0.23). CONCLUSIONS Occupational radiation risk estimates were lower when adjusted for work-related X-ray exposures. Environmental exposures had a very slight impact on the occupational exposure risk estimates. In any scenario of non-occupational exposure considered, a positive but insignificant excess cancer risk associated with occupational exposure was observed.
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Affiliation(s)
- Lucie Fournier
- Institut de Radioprotection et de Sûreté Nucléaire (IRSN), Fontenay-aux-Roses, France
| | - Enora Cléro
- Institut de Radioprotection et de Sûreté Nucléaire (IRSN), Fontenay-aux-Roses, France
| | - Eric Samson
- Institut de Radioprotection et de Sûreté Nucléaire (IRSN), Fontenay-aux-Roses, France
| | - Sylvaine Caër-Lorho
- Institut de Radioprotection et de Sûreté Nucléaire (IRSN), Fontenay-aux-Roses, France
| | - Dominique Laurier
- Institut de Radioprotection et de Sûreté Nucléaire (IRSN), Fontenay-aux-Roses, France
| | - Klervi Leuraud
- Institut de Radioprotection et de Sûreté Nucléaire (IRSN), Fontenay-aux-Roses, France
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Kheifets L, Swanson J, Yuan Y, Kusters C, Vergara X. Comparative analyses of studies of childhood leukemia and magnetic fields, radon and gamma radiation. JOURNAL OF RADIOLOGICAL PROTECTION : OFFICIAL JOURNAL OF THE SOCIETY FOR RADIOLOGICAL PROTECTION 2017; 37:459-491. [PMID: 28586320 DOI: 10.1088/1361-6498/aa5fc7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
In this paper we compare the findings of epidemiologic studies of childhood leukemia that examined at least two of ELF magnetic fields and/or distance to power lines, and exposure to radon and gamma radiation or distance to nuclear plants. Many of the methodologic aspects are common to studies of non-ionising (i.e. ELF-MF) and ionising radiation. A systematic search and review of studies with more than one exposure under study identified 33 key and 35 supplementary papers from ten countries that have been included in this review. Examining studies that have looked at several radiation exposures, and comparing similarities and differences for the different types of radiation, through the use of directed acyclic graphs, we evaluate to what extent bias, confounding and other methodological issues might be operating in these studies. We found some indication of bias, although results are not clear cut. There is little evidence that confounding has had a substantial influence on results. Influence of the residential mobility on the study conduct and interpretation is complex and can manifest as a selection bias, confounding, increased measurement error or could also be a potential risk factor. Other factors associated with distance to power lines and to nuclear power plants should be investigated. A more complete and consistent reporting of results in the future studies will allow for a more informative comparison across studies and integration of results.
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Affiliation(s)
- Leeka Kheifets
- University of California Los Angeles, United States of America
| | - John Swanson
- National Grid, 1-3 Strand, London, United Kingdom
| | - Yingzhe Yuan
- University of California Los Angeles, United States of America
| | - Cynthia Kusters
- University of California Los Angeles, United States of America
| | - Ximena Vergara
- University of California Los Angeles, United States of America
- Electric Power Research Institute, Palo Alto, CA, United States of America
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Spix C, Grosche B, Bleher M, Kaatsch P, Scholz-Kreisel P, Blettner M. Background gamma radiation and childhood cancer in Germany: an ecological study. RADIATION AND ENVIRONMENTAL BIOPHYSICS 2017; 56:127-138. [PMID: 28337585 DOI: 10.1007/s00411-017-0689-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Accepted: 03/11/2017] [Indexed: 06/06/2023]
Abstract
The relationship of low-dose background gamma radiation and childhood leukaemia was investigated in a number of studies. Results from these studies are inconclusive. Therefore, in the present study 25 years of German childhood cancer data were analyzed using interpolated background annual gamma dose rate per community in an ecological study. The main question was leukaemia; as exploratory questions we investigate central nervous system (CNS) tumours, thyroid carcinomas and diagnoses less likely to be related to radiation. A Poisson regression model was applied and a fractional polynomial model building procedure. As the main sensitivity analysis a community deprivation index was included as a potential confounder. It was found that outdoor background gamma annual dose rates in Germany range roughly from 0.5-1.5 mSv/a with an average of 0.817 mSv/a. No association of annual ambient gamma dose rates with leukaemia incidence was found. Amongst the exploratory analyses, a strong association was found with CNS tumour incidence [rate ratio for 1.5 vs 0.5 mSv/a: 1.35; 95% confidence interval (1.17, 1.57)]. The community level deprivation index was not a confounder. It is concluded that the present study did not confirm an association of annual outdoor ambient gamma dose rate and childhood leukaemia, corresponding to some studies and contrasting others. An association with CNS incidence was found in the exploratory analyses. As this is an ecological study no causal interpretation is possible.
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Affiliation(s)
- Claudia Spix
- German Childhood Cancer Registry at the Institute for Medical Biometry, Epidemiology and Informatics, University Medical Center of the Johannes Gutenberg-University Mainz, 55101, Mainz, Germany.
| | - Bernd Grosche
- Federal Office for Radiation Protection, 85764, Oberschleissheim, Germany
| | - Martin Bleher
- Federal Office for Radiation Protection, 85764, Oberschleissheim, Germany
| | - Peter Kaatsch
- German Childhood Cancer Registry at the Institute for Medical Biometry, Epidemiology and Informatics, University Medical Center of the Johannes Gutenberg-University Mainz, 55101, Mainz, Germany
| | - Peter Scholz-Kreisel
- Institute for Medical Biometry, Epidemiology and Informatics, University Medical center of the Johannes Gutenberg-University Mainz, 55101, Mainz, Germany
| | - Maria Blettner
- Institute for Medical Biometry, Epidemiology and Informatics, University Medical center of the Johannes Gutenberg-University Mainz, 55101, Mainz, Germany
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Facteurs de risque environnementaux des cancers de l’enfant. ONCOLOGIE 2016. [DOI: 10.1007/s10269-016-2673-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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