How much can we say about site-specific cancer radiation risks?

Impact of Advanced Radiotherapy on Second Primary Cancer Risk in Prostate Cancer Survivors: A Nationwide Cohort Study

Purpose

External Beam Radiotherapy (EBRT) techniques dramatically changed over the years. This may have affected the risk of radiation-induced second primary cancers (SPC), due to increased irradiated low dose volumes and scatter radiation. We investigated whether patterns of SPC after EBRT have changed over the years in prostate cancer (PCa) survivors.

Materials and Methods

PCa survivors diagnosed between 1990-2014 were selected from the Netherlands Cancer Registry. Patients treated with EBRT were divided in three time periods, representing 2-dimensional Radiotherapy (RT), 3-dimensional conformal RT (3D-CRT), and the advanced RT (AdvRT) era. Standardized incidence ratios (SIR) and absolute excess risks (AER) were calculated to estimate relative and excess absolute SPC risks. Sub-hazard ratios (sHRs) were calculated to compare SPC rates between the EBRT and prostatectomy cohort. SPCs were categorized by subsite and anatomic region.

Results

PCa survivors who received EBRT had an increased risk of developing a solid SPC (SIR=1.08; 1.05-1.11), especially in patients aged <70 years (SIR=1.13; 1.09-1.16). Pelvic SPC risks were increased (SIR=1.28; 1.23-1.34), with no obvious differences between the three EBRT eras. Non-pelvic SPC were only significantly increased in the AdvRT era (SIR=1.08; 1.02-1.14), in particular for the 1-5 year follow-up period. Comparing the EBRT cohort to the prostatectomy cohort, again an increased pelvic SPC risk was found for all EBRT periods (sHRs= 1.61, 1.47-1.76). Increased non-pelvic SPC risks were present for all RT eras and highest for the AdvRT period (sHRs=1.17, 1.06-1.29).

Conclusion

SPC risk in patients with EBRT is increased and remained throughout the different EBRT eras. The risk of developing a SPC outside the pelvic area changed unfavorably in the AdvRT era. Prolonged follow-up is needed to confirm this observation. Whether this is associated with increased irradiated low-dose volumes and scatter, or other changes in clinical EBRT practice, is the subject of further research.

Somatic mutation signatures in primary liver tumors of workers exposed to ionizing radiation

Liver cancer is associated with genetic mutations caused by environmental exposures, including occupational exposure to alpha radiation emitted by plutonium. We used whole exome sequencing (WES) to characterize somatic mutations in 3 histologically distinct primary liver tumors (angiosarcoma of the liver (ASL), cholangiocarcinoma (CCA) and hepatocellular carcinoma (HCC)) from Mayak worker subjects occupationally exposed to ionizing radiation (IR) to investigate the contribution of IR to the mutational landscape of liver cancer. DNA sequence analysis revealed these tumors harbor an excess of deletions, with a deletions:substitutions ratio similar to that previously reported in radiation-associated tumors. These tumors were also enriched for clustered mutations, a signature of radiation exposure. Multiple tumors displayed similarities in abrogated gene pathways including actin cytoskeletal signaling and DNA double-strand break (DSB) repair. WES identified novel candidate driver genes in ASL involved in angiogenesis and PIK3CA/AKT/mTOR signaling. We confirmed known driver genes of CCA, and identified candidate driver genes involved in chromatin remodeling. In HCC tumors we validated known driver genes, and identified novel putative driver genes involved in Wnt/β-catenin signaling, chromatin remodeling, PIK3CA/AKT/mTOR signaling, and angiogenesis. This pilot study identifies several novel candidate driver mutations that are likely to be caused by IR exposure, and provides the first data on the mutational landscape of liver cancer after IR exposure.

Bioavailable serum estradiol may alter radiation risk of postmenopausal breast cancer: a nested case-control study

PURPOSE

Ionizing radiation and high levels of circulating estradiol are known breast cancer carcinogens. We investigated the risk of first primary postmenopausal breast cancer in relation to the combined effects of whole-body ionizing radiation exposure and prediagnostic levels of postmenopausal sex hormones, particularly bioavailable estradiol (bE2).

MATERIALS AND METHODS

A nested case-control study of 57 incident breast cancer cases matched with 110 controls among atomic bomb survivors. Joint effects of breast radiation dose and circulating levels of sex hormones were assessed using binary regression and path analysis.

RESULTS AND CONCLUSION

Radiation exposure, higher levels of bE2, testosterone and progesterone, and established reproductive risk factors were positively associated with postmenopausal breast cancer risk. A test for mediation of the effect of radiation via bE2 level suggested a small (14%) but significant mediation (p = 0.004). The estimated interaction between radiation and bE2 was large but not significant (interaction = 3.86; p = 0.32). There is accumulating evidence that ionizing radiation not only damages DNA but also alters other organ systems. While caution is needed, some portion of the radiation risk of postmenopausal breast cancer appeared to be mediated through bE2 levels, which may be evidence for cancer risks due to both direct and indirect effects of radiation.

Site-specific Solid Cancer Mortality After Exposure to Ionizing Radiation: A Cohort Study of Workers (INWORKS)

BACKGROUND

There is considerable scientific interest in associations between protracted low-dose exposure to ionizing radiation and the occurrence of specific types of cancer.

METHODS

Associations between ionizing radiation and site-specific solid cancer mortality were examined among 308,297 nuclear workers employed in France, the United Kingdom, and the United States. Workers were monitored for external radiation exposure and follow-up encompassed 8.2 million person-years. Radiation-mortality associations were estimated using a maximum-likelihood method and using a Markov chain Monte Carlo method, the latter used to fit a hierarchical regression model to stabilize estimates of association.

RESULTS

The analysis included 17,957 deaths attributable to solid cancer, the most common being lung, prostate, and colon cancer. Using a maximum-likelihood method to quantify associations between radiation dose- and site-specific cancer, we obtained positive point estimates for oral, esophagus, stomach, colon, rectum, pancreas, peritoneum, larynx, lung, pleura, bone and connective tissue, skin, ovary, testis, and thyroid cancer; in addition, we obtained negative point estimates for cancer of the liver and gallbladder, prostate, bladder, kidney, and brain. Most of these estimated coefficients exhibited substantial imprecision. Employing a hierarchical model for stabilization had little impact on the estimated associations for the most commonly observed outcomes, but for less frequent cancer types, the stabilized estimates tended to take less extreme values and have greater precision than estimates obtained without such stabilization.

CONCLUSIONS

The results provide further evidence regarding associations between low-dose radiation exposure and cancer.

Hierarchical regression for analyses of multiple outcomes

In cohort mortality studies, there often is interest in associations between an exposure of primary interest and mortality due to a range of different causes. A standard approach to such analyses involves fitting a separate regression model for each type of outcome. However, the statistical precision of some estimated associations may be poor because of sparse data. In this paper, we describe a hierarchical regression model for estimation of parameters describing outcome-specific relative rate functions and associated credible intervals. The proposed model uses background stratification to provide flexible control for the outcome-specific associations of potential confounders, and it employs a hierarchical "shrinkage" approach to stabilize estimates of an exposure's associations with mortality due to different causes of death. The approach is illustrated in analyses of cancer mortality in 2 cohorts: a cohort of dioxin-exposed US chemical workers and a cohort of radiation-exposed Japanese atomic bomb survivors. Compared with standard regression estimates of associations, hierarchical regression yielded estimates with improved precision that tended to have less extreme values. The hierarchical regression approach also allowed the fitting of models with effect-measure modification. The proposed hierarchical approach can yield estimates of association that are more precise than conventional estimates when one wishes to estimate associations with multiple outcomes.

Radiation effects on mortality from solid cancers other than lung, liver, and bone cancer in the Mayak worker cohort: 1948-2008

Radiation effects on mortality from solid cancers other than lung, liver, and bone cancer in the Mayak worker cohort: 1948-2008. The cohort of Mayak Production Association (PA) workers in Russia offers a unique opportunity to study the effects of prolonged low dose rate external gamma exposures and exposure to plutonium in a working age population. We examined radiation effects on the risk of mortality from solid cancers excluding sites of primary plutonium deposition (lung, liver, and bone surface) among 25,757 workers who were first employed in 1948-1982. During the period 1948-2008, there were 1,825 deaths from cancers other than lung, liver and bone. Using colon dose as a representative external dose, a linear dose response model described the data well. The excess relative risk per Gray for external gamma exposure was 0.16 (95% CI: 0.07 - 0.26) when unadjusted for plutonium exposure and 0.12 (95% CI 0.03 - 0.21) when adjusted for plutonium dose and monitoring status. There was no significant effect modification by sex or attained age. Plutonium exposure was not significantly associated with the group of cancers analyzed after adjusting for monitoring status. Site-specific risks were uncertainly estimated but positive for 13 of the 15 sites evaluated with a statistically significant estimate only for esophageal cancer. Comparison with estimates based on the acute exposures in atomic bomb survivors suggests that the excess relative risk per Gray for prolonged external exposure in Mayak workers may be lower than that for acute exposure but, given the uncertainties, the possibility of equal effects cannot be dismissed.

Radiation effects on mortality from solid cancers other than lung, liver, and bone cancer in the Mayak worker cohort: 1948-2008

Radiation effects on mortality from solid cancers other than lung, liver, and bone cancer in the Mayak worker cohort: 1948-2008. The cohort of Mayak Production Association (PA) workers in Russia offers a unique opportunity to study the effects of prolonged low dose rate external gamma exposures and exposure to plutonium in a working age population. We examined radiation effects on the risk of mortality from solid cancers excluding sites of primary plutonium deposition (lung, liver, and bone surface) among 25,757 workers who were first employed in 1948-1982. During the period 1948-2008, there were 1,825 deaths from cancers other than lung, liver and bone. Using colon dose as a representative external dose, a linear dose response model described the data well. The excess relative risk per Gray for external gamma exposure was 0.16 (95% CI: 0.07 - 0.26) when unadjusted for plutonium exposure and 0.12 (95% CI 0.03 - 0.21) when adjusted for plutonium dose and monitoring status. There was no significant effect modification by sex or attained age. Plutonium exposure was not significantly associated with the group of cancers analyzed after adjusting for monitoring status. Site-specific risks were uncertainly estimated but positive for 13 of the 15 sites evaluated with a statistically significant estimate only for esophageal cancer. Comparison with estimates based on the acute exposures in atomic bomb survivors suggests that the excess relative risk per Gray for prolonged external exposure in Mayak workers may be lower than that for acute exposure but, given the uncertainties, the possibility of equal effects cannot be dismissed.

FISH analysis of translocations induced by chronic exposure to Sr radioisotopes: second set of analysis of the Techa River Cohort

Fluorescent in situ hybridisation analysis of stable translocations was performed for 26 residents living along the Techa River (Russia), who were predominantly (95%) exposed to ingested strontium radioisotopes ((89)Sr and (90)Sr) resulting in exposure of their red bone marrow (RBM). Analysis was conducted at the Urals Research Center for Radiation Medicine, Public Health England and Leiden University Medical Center. Each laboratory scored 1000 cells per donor, which resulted in ∼1000 genome equivalents (GE) per donor. The age-dependent spontaneous level of translocations for each donor was evaluated on the basis of data published by Sigurdson et al. (International study of factors affecting human chromosome. Mutat. Res. 2008;652: :112-121). Reconstruction of doses was performed with the 'Techa River Dosimetry System' developed in 2009. In the studied donors, the range of individual cumulated RBM dose was from 0.3 to 3.7 Gy. Analysis of the yield of stable translocations dependent on the individual RBM dose from (89,90)Sr showed a linear dose-response relationship of 0.007 ± 0.002 translocation/GE cell/Gy (R = 0.61, p = 0.001). This set of results was in a good agreement with the previous data reported for 18 donors by Vozilova et al. (Preliminary FISH-based assessment of external dose for residents exposed on the Techa River.

What radiation dose does the FISH translocation assay measure in cases of incorporated radionuclides for the Southern Urals populations?

The fluorescence in situ hybridisation (FISH) technique is now well established for retrospective dosimetry in cases of external radiation exposure that occurred many years ago. However, the question remains as to whether FISH provides valid estimates of cumulative red bone marrow radiation doses in cases of incorporation of radionuclides or combined external and internal exposures. This question has arisen in connection with the interpretation of results of dose assessments for epidemiological studies of plutonium workers at the Russian Mayak plant and of members of the public exposed to strontium radioisotopes and external radiation as a result of discharges from Mayak to the Techa River. Exposures to penetrating external radiation result in fairly uniform irradiation of body tissues, and hence similar doses to all tissues, for which FISH dosimetry can provide a reliable measure of this whole body dose. However, intakes of radionuclides into the body by inhalation or ingestion may result in retention in specific organs and tissues, so that the distribution of dose is highly heterogeneous. For radionuclides emitting short-range radiations (e.g. alpha particles), this heterogeneity can apply to dose delivery within tissues and between cells within tissues. In this paper, an attempt is made to address the question of what FISH measures in such circumstances by considering evidence regarding the origin and lifetime dynamics of lymphocyte subsets in the human body in relation to the localised delivery of dose from the internal emitters (90)Sr and (239)Pu, which are of particular interest for the Southern Urals Mayak and Techa River populations, and for which most evidence is available in these populations. It is concluded that the FISH translocation assay can be usefully applied for detecting internal and combined external gamma and internal doses from internally deposited (90)Sr, albeit with fairly large uncertainties. The same may be true of (239)Pu, as well as other radionuclides, although much work remains to be done to establish dose-response relationships.

A reanalysis of cancer mortality in Canadian nuclear workers (1956-1994) based on revised exposure and cohort data

Background:

A 15-country study of nuclear workers reported significantly increased radiation-related risks of all cancers excluding leukaemia, with Canadian data a major factor behind the pooled results. We analysed mortality (1956–1994) in the updated Canadian cohort and provided revised risk estimates.

Methods:

Employment records were searched to verify and revise exposure data and to restore missing socioeconomic status. Excess relative risks per sievert (ERR/Sv) of recorded radiation dose and 95% confidence intervals (CIs) were estimated using Poisson regression.

Results:

A significant heterogeneity of the dose–response for solid cancer was identified (P=0.02), with 3088 early (1956–1964) Atomic Energy of Canada Limited (AECL) workers having a significant increase (ERR/Sv=7.87, 95% CI: 1.88, 19.5), and no evidence of radiation risk for 42 228 workers employed by three nuclear power plant companies and post-1964 AECL (ERR/Sv=−1.20, 95% CI: <−1.47, 2.39). Radiation risks of leukaemia were negative in early AECL workers and non-significantly increased in other workers. In analyses with separate terms for tritium and gamma doses, there was no evidence of increased risk from tritium exposure. All workers had mortality lower than the general population.

Conclusion:

Significantly increased risks for early AECL workers are most likely due to incomplete transfer of AECL dose records to the National Dose Registry. Analyses of the remainder of the Canadian nuclear workers (93.2%) provided no evidence of increased risk, but the risk estimate was compatible with estimates that form the basis of radiation protection standards. Study findings suggest that the revised Canadian cohort, with the exclusion of early AECL workers, would likely have an important effect on the 15-country pooled risk estimate of radiation-related risks of all cancer excluding leukaemia by substantially reducing the size of the point estimate and its significance.

Solid cancer incidence other than lung, liver and bone in Mayak workers: 1948-2004

BACKGROUND

Cancer incidence in the Mayak Production Association (PA) cohort was analysed to investigate for the first time whether external gamma-ray and internal plutonium exposure are associated with raised incidence of solid cancers other than lung, liver and bone (other solid cancers).

METHODS

The cohort includes 22,366 workers of both sexes who were first employed between 1948 and 1982. A total of 1447 cases of other solid cancers were registered in the follow-up period until 2004. The Poisson regression was used to estimate the excess relative risk (ERR) per unit of cumulative exposure to plutonium and external gamma-ray.

RESULTS

A weak association was found between cumulative exposure to external gamma-ray and the incidence of other solid cancers (ERR/Gy=0.07; 95% confidence intervals (CIs): 0.01-0.15), but this association lost its significance after adjusting for internal plutonium exposure. There was no indication of any association with plutonium exposure for other solid cancers. Among 16 individual cancer sites, there was a statistically significant association with external exposure for lip cancer (ERR/Gy=1.74; 95% CI: 0.37; 6.71) and with plutonium exposure for pancreatic cancer (ERR/Gy=1.58; 95% CI; 0.17; 4.77).

CONCLUSION

This study of Mayak workers does not provide evidence of an increased risk of other solid cancers. The observed increase in the risk of cancer of the lip and pancreas should be treated with caution because of the limited amount of relevant data and because the observations may be simply due to chance.

Solid cancer mortality in the techa river cohort (1950-2007)

Our understanding of cancer risk from ionizing radiation is largely based on studies of populations exposed at high dose and high dose rates. Less certain is the magnitude of cancer risk from protracted, low-dose and low-dose-rate radiation exposure. We estimated the dose-response relationship for solid cancer mortality in a cohort of 29,730 individuals who lived along the Techa River between 1950 and 1960. This population was exposed to both external γ radiation and internal (90)Sr, (137)Cs and other radionuclides after the release of radioactive waste into the river by the Mayak Radiochemical Plant. The analysis utilized the latest individualized doses from the Techa River Dosimetry System (TRDS) 2009. We estimated excess relative risks (ERRs) per Gy for solid cancer mortality using Poisson regression methods with 95% confidence intervals (CIs) and P values based on likelihood ratio tests. Between 1950 and 2007, there were 2,303 solid cancer deaths. The linear ERR/Gy = 0.61 (95%; CI 0.04-1.27), P = 0.03. It is estimated that approximately 2% (49.7) of solid cancers deaths were associated with the radiation exposure. Our results, based on 2,303 solid cancer deaths and more than 50 years of follow-up, support an increased risk of solid cancer mortality following protracted radiation exposure from the Techa River contamination. The wide confidence interval of our estimate reflects the challenges of quantifying and describing the shape of the dose-response relationship in the low dose range. Nevertheless, the risk estimates provide important information concerning health risks from whole-body radiation exposure that can occur from accidents that result in wide-scale environmental contamination.

Reconstruction of the contamination of the Techa River in 1949-1951 as a result of releases from the "Mayak" Production Association

More accurate reconstruction of the radioactive contamination of the Techa River system in 1949-1951 has been made on the basis of refined data on the amounts and the rate of discharge of radionuclides into the Techa River from the Mayak Production Association; this has led to the development of a modified Techa River model that describes the transport of radionuclides through the up-river ponds and along the Techa River and deposition of radionuclides in the river-bottom sediments and flooded areas. The refined Techa River source-term data define more precisely the time-dependent rates of release and radionuclide composition of the releases that occurred during 1949-1951. The Techa River model takes into account the time-dependent characteristics of the releases and considers (a) the transport of radionuclides adsorbed on solid particles originally contained in the discharges or originating in the up-river ponds as a result of stirring up of contaminated bottom sediments and (b) the transport of radionuclides in soluble form. The output of the Techa River model provides concentrations of all source-term radionuclides in the river water, bottom sediments, and floodplain soils at different distances from the site of radioactive releases for the period of major contamination in 1950-1951. The outputs of the model show good agreement with historical measurements of water and sediment contamination. In addition, the river-model output for (90)Sr concentration in the river water is harmonized with retrospective estimates derived from the measurements of (90)Sr in the residents of the Techa Riverside villages. Modeled contamination of the floodplain soils by (137)Cs is shown to be in agreement with the values reconstructed from late measurements of this radionuclide. Reconstructed estimates of the Techa River contamination are being used for the quantification of internal and external doses received by residents of the Techa Riverside communities.