Kristina Kjærheim Cancer Registry of Norway 29. August 2011 Mariehamn, Åland

Transcription

1 NOCCA - description and findings Kristina Kjærheim Cancer Registry of Norway 29. August 2011 Mariehamn, Åland 1

2 NOCCA > What is it? Background, populations, data, methods > What do we find? Results by occupation and by site > How can it be used further? Descriptive epidemiology, analytical epidemiology 2

3 What is it? in a nutshell: > Five countries > 15 million subjects > Included if aged at any computerized census > Followed-up from 1961 (earliest) until 2005 (latest) > Categorized into 53 occupational groups + 1 inactive > 200 million person-years accumulated > 2.8 million cancer cases belonging to 52 diagnostic main groups and 24 subgroups observed > 76x6x54x2 SIRs and confidence intervals calculated (~50 000) 3

4 Background: Aage I Occupation Cancer /1991 Gender, age 53+1 occupational groups 32 broad diagnostic groups 10 million people 1 million cancers 4

5 Pukkala E, Martinsen JI, Lynge E, Gunnarsdottir HG, Sparén P, Tryggvadottir L, Weiderpass E, Kjærheim K. Occupation and cancer follow up of 15 million people in five Nordic countries. Acta Oncologica, 2009; 48: Kauppinen T, Heikkilä, Plato N, Woldbæk T, Lenvik K, Hansen J, Kristjansson V, Pukkala E. Construction of job-exposure matrices for the Nordic Occupational Cancer Study (NOCCA). Acta Oncologica, 2009; 48:

6 What is it? - in detail > Census information, cohort definition > Economic activity > Occupational classification > Information in cancer registries > Linkage and follow-up in cancer registries > Cancer classification > Calculation of SIRs > Additional information 6

7 Study base = census information No. (mill.) Info. available Denmark X 2.0 Finland X X X 3.4 Iceland X 0.1 Norway X X X 2.6 Sweden X X X X 6.8 PID, occupation, age, sex, (++ for diff. countries) 7

8 Follow-up - the work-experience of the cohort 8

9 Economic activity Denmark Finland Iceland Norway Sweden Definition Employed at time of census or temporarily absent from work due to illness, unemployment, vacation or military service. Employed for at least half of normal working hours or temporarily absent from work. Employed the week before the census or temporarily absent from work that week In 1960 no specific criteria used (later estimated to be >1000 hours). Married women in family businesses were not counted as economically active. At later censuses employment for at least 100 working hours during last 12 months was required. Employed at time of census or temporarily absent from work due to illness, unemployment, vacation or military service. 9

10 Occupational classification Denmark NYK / ISCO 58 ISCO 68 National NOCCA X Back-coded to NYK Finland X X Iceland X Back-coded to NYK Norway X X Sweden X X No. of > categories 3-digit codes 2-digit X X 10

11 (Some) occupational groups defined by NYK-codes and ISCO-1958 codes NOCCA NYK ISCO Bricklayers Printers and related workers Chemical process workers Food manufacture workers 82 (except 824) , Beverage manufacture workers Tobacco manufacture workers Glass, ceramic, tile workers and others 81, 85 81, Packers, loaders and warehouse workers 86, 88 86, Engine and motor operator workers Public safety and protection workers Cooks and stewards 911, , Home-helpers 914, , 91930, Waiters Building caretakers and cleaners 93 (except 933) 93120, 93230, Chimney sweeps Hairdressers , 94150, 941,

12 Coding of wood workers F- code S- code N- code Occupational group Comment Plywood and fiberboard workers Wooden boat builders, coach-body builders etc. Bench carpenters and cabinet makers Not used in Sweden 676 Cabinetmakers and joiners etc. Only used in Finland Woodworking machine operators Not used in Sweden 678 Wooden surface finishers Only used in Finland 679 Woodworking occupations, nec Only used in Finland 12

13 Validity of occupational classification > Economically active or not: some deficit in women; specifically agriculture and service sector, part-time employees > Occupational codes: good agreement with interview data at 2-digit NYK > Occupational stability rate: overall %, varies between occupations, highest in work requiring long education, dependent on societal changes and individual career patterns 13

14 Sources of information in the cancer registries Denmark Finland Clinical hospital depts. X (+ specialists in gyn. & dermatology) X (+ private clinics and GPs) Pathology depts. X (autopsies only) Death certificates X Hospital discharge register X (from 1988) X X - Iceland X X X - X X X X (from 1998) Norway Sweden X (+ private clinicians from 1983) X

15 Information in cancer registries Topography Morphology Denmark ICD-7 ( ) ICD-O-1 (1978-) ICD-O-1 (from 1978-) Finland ICD-7 MOTNAC 1951 Iceland ICD-7 ICD-O-1 Norway Sweden ICD-7 (until 1993) ICD-O-2 (from 1993) ICD-7 (from ) ICD-9 (from ) ICD-O-2 (from 1993-) MOTNAC 1951 (until 1993) ICD-O-2 (from 1993) Statistical codes for human tumours, WHO

16 Cancer classification: 52 main groups 140 Lip 141 Tongue 142 Salivary glands Oral cavity Pharynx 145 Oropharynx 146 Nasopharynx 150 Oesophagus 151 Stomach Cardia 152 Small intestine 153 Colon 154 Rectum, rectosigma 155 Primary liver Gall bladder, biliary tract 157 Pancreas 160 Nose 161 Larynx 162,163 Lung 158, Mesothelioma (pleura/ peritoneum) 170 Breast 171 Cervix uteri (invasive) 172 Corpus uteri 173 Choriocarcinoma 175 Ovary Fallopian tube 176 Vulva Vagina 177 Prostate 178 Testis 179 Penis 180 Kidney Kidney, renal pelvis 181 Bladder, ureter, urethra 190 Melanoma 191 Non-melanoma skin cancer 192 Eye 193 Brain 194 Thyroid 195 Glandula suprarenalis Glandula parathyreioeda Thymus Hypophysis Corpus pineale 196 Bone 197 Soft tissue 200,202 Non-Hodgkin lymphoma 201 Hodgkin lymphoma 203 Multiple myeloma 204 Leukaemia 191/205 Mycosis fungoides (lymphoma) 199 Other/unknown site 16

17 Cancer classification: 24 sub-groups Main group Oesophagus Liver Nose Lung Breast Ovary Testis Skin melanoma Non-melanoma skin cancer Upper limbs Eye Melanoma Brain Thyroid Bone Soft tissue Leukaemia, Sub-group Adenocarcinoma Hemangiosarcoma Adenocarcinoma Adenocarcinoma, small cell, squamous cell, other Ductal, lobular Borderline tumour Seminoma, non-seminoma Upper limbs Glioma, meningeoma Follicular, pappilary Chondrosarcoma, fibrosarcoma Liposarcoma Chronic lymphatic, acute myeloid 17

18 Validity of cancer information Denmark 95 % in 1977 Finland Completeness 99 % in for most sites 90 % for specific sites Deficits Lymphohaematopoietic, breast, digestive organs, female genitals CLL, multiple myeloma, benign brain tumors Iceland 99 % in 2005 study - Norway 98 % in 1976 (two counties) Leukemia, multiple myeloma Sweden > 96.5 % in 1984 and 1998 Leukemia, multiple myeloma, prostate, stomach 18

19 Linkage and follow-up in cancer registries From Until P.yrs. Denmark Finland 1971, 1981, Iceland Norway 1961,1971, Sweden 1961,1971, 1981,

20 Validity of denominator data > Requires complete follow-up data on death and emigration in the Nordic population to give precise person-year calculations > Choice of comparison population: national or Nordic? > For Finland: only 20% balanced sample of the denominator > For Denmark: data cannot be exported from Statistics Denmark to be analysed outside. Danish data can thus not be used in analyses with sophisticated methodology or individual-level anonymous data 20

21 Calculation of Standardized Incidence Ratios (SIRs) > Observed no of cases/expected > Calculated for each gender, country, and occupation > For 5- year age groups (30-34, 35-39,.., 80-84, 85+) and > For 5-year time periods ( , ) 21

22 Cautionary remarks > Descriptive study interpretations require substantial knowledge of exposures and risks > Misclassification of occupation/exposure > Many O/E comparisons - chance findings; consider also consistency between countries, biological plausibility, what is know about specific occupations, etc.. > Large size: even slight deviations may be statistically significant 22

23 Additional information > Nordic Job Exposure Matrix (311 occupations) Tobacco smoking (prevalence/lung emphysema SMR) Alcohol consumption (liver cirrhosis SMR) > Reproductive history (women) 23

24 What do we find? > Caution! Careful interpretations! > Results by cancer site: - Lung cancer - Mesothelioma - Nose and sinuses > Results by occupation: > High and low risk groups 24

25 Descriptive epidemiology > Variation in cancer risk by for instance geography, socio economic status (SES), or occupational group > Such observations indicate that a large proportion of cancer cases are attributable to external factors, and thus in principle avoidable > Such observations may guide the setting up of screening programs or preventive interventions towards specific groups > Such observations may also lead to testable hypotheses of etiological factors 25

26 Interpretation of results Occupation and Cancer Risk in NOCCA Socioeconomic status Work-related health behaviour Occupational exposure 26

27 Evaluation of SIRs > Comparison of SIRs?. National incidence rates. Age distribution in exposed group may differ > Consider consistency between countries > Consider consistency between genders > Consider occupational stability, career paths, etc. 27

28 Age distribution at start of follow-up Male wood workers Male plumbers Finland Iceland 30.0 Finland Iceland Norway Norway 20.0 Sweden 20.0 Sweden

29 Age distribution at start of follow-up Male physicians Male waiters Finland 40.0 Finland 20.0 Iceland Norway 30.0 Iceland Norway 15.0 Sweden 20.0 Sweden

30 Attributable risks occupational cancer Site AF Exposures Lung +/- 20 % Asbestos, arsenic, PAHs, nickel compounds, chromium 6+, cadmium,.. Mesothelioma +/- 85 % Asbestos Nose and sinuses +/- 30 % Nickel compounds, wood dust, leather dust Larynx +/- 6 % Asbestos, strong organic acids Bladder +/- 2 % PAHs, Leukemia +/- 1 % Benzene 30

31 Lung cancer incidence in men 31

32 High and low lung cancer SIRs in men 32

33 Lung cancer among men, SIRs 1.20 Occupational group Obs Exp SIR 95% CI Waiters Tobacco workers Seamen Miners and quarry workers Cooks and stewards Chimney sweeps Plumbers Beverage workers Smelting workers Welders Economically inactive "Other construction workers" Packers Drivers Launderers Bricklayers Mechanics Painters Hairdressers Printers Engine operators

34 Lung cancer incidence in women 34

35 High and low lung cancer SIRs in women 35

36 Occupational exposure or tobacco? > Compare with other tobacco related cancers > Adjust for tobacco smoking if possible.. 36

37 Consistency between countries: lung cancer Waiters Plumbers Wood workers Obs SIR 95% CI Obs SIR 95% CI Obs SIR 95% CI Denmark Finland Iceland Norway Sweden Total

38 Consider occupational stability Waiters Plumbers Wood workers Period N % N % N % Finland Norway Sweden

39 Occupational exposure or tobacco? - Compare with other tobacco related cancers Waiters Hairdr. Plumbers Chimney sw. Miners Wood w. Tongue Oral cavity Pharynx Oesophagus Larynx Lung Kidney Bladder Pancreas Liver

40 Occupational exposure or tobacco? - Adjust for tobacco smoking (Data from Norway) Unadj. Adj. Obs. SIR SIR 95% CI Administrators Farmers Waiters Hairdressers Plumbers Chimney sweeps Miners and quarry w Wood workers Haldorsen et al

41 Mesothelioma incidence in men 41

42 High and low mesothlioma SIRs in men 42

43 Mesothelioma among men, SIRs 1.20 Occupational category Obs Exp SIR 95% CI Plumbers Seamen Mechanics Chimney sweeps Smelting workers Electrical workers Welders Painters Wood workers Bricklayers "Other construction workers" Chemical process workers Technical workers, etc Glass makers etc Engine operators

44 Mesothelioma incidence in women 44

45 High and low mesothelioma SIRs in women Bricklayers (1) Fishermen (1) The 5 highest and lowest SIR values for mesothelioma in the pleura/peritoneum with 95% confidence intervals Engine operators (4) Wood workers (11) Artistic workers (6) Religious workers etc (10) Farmers (26) Gardeners (35) Chemical process workers (2) Hairdressers (3) Pukkala et al SIR 45

46 Mesothelioma among women, SIRs 1.20 Occupational group Obs Exp SIR 95% CI Wood workers Artistic workers Glass makers etc Laboratory assistants Textile workers Sales agents Food workers Waiters Postal workers Building caretakers Cooks and stewards

47 Incidence of cancer of the nose and sinuses in men 47

48 High and low SIRs of cancer of the nose and sinuses in men 48

49 Insidence of cancer of the nose and sinuses in women 49

50 High and low SIRs of cancer of the nose and sinuses in women Beverage workers (3) The 5 highest and lowest SIR values for nasal cancer with 95% confidence intervals Wood workers (10) Drivers (6) Packers (26) Electrical workers (10) Tobacco workers (1) Other construction workers (1) Religious workers etc (9) Administrators (6) Laboratory assistants (1) Pukkala et al SIR 50

51 Insidence of bladder cancer in men 51

52 High and low SIRs of bladder cancer in men Waiters (249) Chimney sweeps (105) The 5 highest and lowest SIR values for cancer of the bladder. ureter. and urethra with 95% confidence intervals Hairdressers (359) Assistant nurses (159) Seamen (1478) Gardeners (2491) Forestry workers (1599) Nurses (11) Home helpers (7) Farmers (9447) SIR Pukkala et al

53 Insidence of larynx cancer in men 53

54 High and low SIRs of larynx cancer in men Waiters (102) The 5 highest and lowest SIR values for laryngeal cancer with 95% confidence intervals Beverage workers (59) Cooks and stewards (96) Seamen (378) Hairdressers (66) Physicians (47) Gardeners (291) Teachers (253) Laboratory assistants (11) Farmers (1052) SIR Pukkala et al

55 Insidence of leukemia in men 55

56 High and low SIRs of leukemia in men Tobacco workers (9) The 5 highest and lowest SIR values for leukaemia with 95% confidence intervals Waiters (66) Dentists (74) Beverage workers (44) Public safety workers (523) Hairdressers (72) Assistant nurses (34) Fishermen (312) Launderers (37) Nurses (2) Pukkala et al SIR 56

57 Insidence of breast cancer in women 57

58 High and low SIRs of breast cancer in women Military personnel (26) The 5 highest and lowest SIR values for breast cancer with 95% confidence intervals Dentists (538) Journalists (550) Physicians (702) Administrators (3167) Forestry workers (85) Fishermen (44) Seamen (8) Bricklayers (4) Chimney sweeps (1) Pukkala et al SIR

59 Insidence of lip cancer in men 59

60 High and low SIRs of lip cancer in men 60

61 Socially discriminating cancers 61

62 Socially discriminating cancers 62

63 Main findings and conclusions - NOCCA 1st phase > Most of established associations between occupations and site specific cancers were also demonstrated in this study > Wide variation in risk between occupations specifically in men > Some high-risk occupations are characterized by work-related risk factors more than occupational exposure > Farmers, forestry workers, gardeners and wood workers belong to occupations with low-risk profiles for most cancer sites in both genders > The risk of cancer is highly dependent on the persons position in society > Direct occupational hazards seem to explain only a small fraction of the observed variation while indirect factors such as need for longer education and decreasing physical activity appear more important 63

64 Further use of NOCCA data > Investigation of time trends and country specific differences > Investigation of specific occupations of interest > Linkage of cancer file to exposure matrix > Development of covariate matrices 64