Geography of Mesothelioma: An Overview

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1 Table of Contents PL-1-02 Claudio Bianchi Geography of Mesothelioma: An Overview Claudio Bianchi, Tommaso Bianchi Center for the Study of Environmental Cancer Italian League against Cancer, Monfalcone, Italy Abstract The principal feature in mesothelioma geography is the lack of data. Reliable figures on the incidence/mortality of/from mesothelioma are available for about 15% only of the world population. In particular, mesothelioma epidemiology is scarcely known for a majority of the big asbestos producer/consumer countries. Where data are available, marked variations in incidence are observed. During the last decades mesothelioma incidence showed a progressive increase in various industrialized countries, reaching the highest values in Australia, Belgium, and the UK. In such countries, annual crude incidence rates are around 30 cases per million. At the other extreme, crude incidence rates of 0.6 and 0.7 cases per million are reported respectively from Tunisia and Morocco. Japan showed a tremendous rise in mortality from mesothelioma during the last few years. In all the countries a high ratio pleural/peritoneal is generally observed. Incidence is markedly higher among men than among women, and it varies substantially from one occupational category to another. Some occupational groups (for instance maritime trades, non asbestos textile industries) have only recently been recognized as categories at risk for mesothelioma. At the national level, wide variations are observed among the different areas. The above characteristics may largely be explained by differences in the asbestos use. The latency periods (time intervals between first exposure to asbestos and diagnosis of mesothelioma) are considerably longer than previously reported and currently appreciated. In large series mean latency periods were around 50 years. An inverse relationship between intensity of exposure to asbestos and duration of latency period has been observed. Predictions on the future trend of the mesothelioma epidemic should take into account the fact that generally latency periods are longer than years. The mesothelioma wave consequent to the very high world asbestos consumption that occurred in the1970s has yet to be seen. Numerous studies have recently been devoted to mesothelioma epidemiology Nevertheless, for a vast majority of countries, data on mesothelioma incidence/mortality are not available. In particular, mesothelioma epidemiology is scarcely known for various of the major asbestos producers, such as the Russian Federation, China, Kazakhstan, Brazil, and Zimbabwe. In addition, the situation is unknown for some major asbestos consumers, such as Thailand. Data are only available for about 15% of the world population. The degree of reliability such data show, varies substantially from one country to another. In fact, for some countries (e.g. Australia, Scandinavian countries, UK), the data are based on cancer registries or mesothelioma registries. In other countries, however, only limited parts are covered by registries, or mortality data only are available. Where incidence is known or may be estimated with some reliability, the rates are extremely various (Fig. 1). The highest values are reported or estimated for Australia, Belgium, and the UK.

2 In such countries the annual crude incidence rates are around 30 cases per million. The Netherlands also show high incidence (21 cases per million). A second group of countries is characterized by crude incidence rates comprised between 11 and 20 cases per million. This group includes various countries of Western and Northern Europe (France, Germany, Italy, Scandinavian countries), and New Zealand. Incidence rates below 11 cases per million are reported or estimated for many countries of Europe (Central and Eastern Europe, Iberian peninsula, Ireland), of North America (Canada, USA), Asia (Cyprus, Israel, Japan, Turkey), and Africa (Morocco, Tunisia). In a majority of countries mesothelioma incidence showed a progressive increase during the last decades. In particular, such increase was tremendous in Japan 6. The lowest crude incidence rates are estimated for Morocco (0.7 cases per million), and for Tunisia (0.6 cases per million). The principal primary site of mesothelioma is the pleura, cases originating from peritoneum being only a small percentage. The pleura/peritoneum ratio is 13:1 in Australia 11 ; 8:1 in Japan 6, and 7.3:1 in Sweden 8-9. Mesothelioma incidence is markedly higher among men than among women. This fact has consistently been confirmed by studies conducted in Europe 7, 9, 10, Québec 4, USA 5, Australia 11, and Japan 6. Incidence substantially varies from one occupational category to another In The Netherlands, Burdorf et al. 12 have estimated that in the insulation industry, the overall risk of mesothelioma was 5 out of 100 workers, and in the shipbuilding industry, 1 out of 100 workers; in the construction industry the risk was by far lower (7 per 10,000 workers). Some occupational groups have only recently been recognized as categories at risk for mesothelioma. Epidemiological studies conducted in Finland 13, Iceland 14, and Sweden 9 confirmed the risks existing among seafarers. Studies conducted in Italy 15 show a previously unrecognized risk among non-asbestos textile industry workers. A striking feature in mesothelioma epidemiology is the strong heterogeneity in distribution at a national level. Italy offers a good example of such an irregular distribution 16 (Fig. 2). When the principal characteristics of mesothelioma epidemiology are considered in the frame of asbestos use history, a clear relationship emerges between asbestos consumption and mesothelioma incidence Moreover the mesothelioma distribution in a given country reflects the location of the asbestos using industries. Again Italy represents a clear example. In Italy, shipyard and port areas as well as asbestos industry areas show the highest mortality rates from pleural cancer (Fig. 2). Interestingly, in some provinces of Northern Italy with large shipyards (Genoa, Trieste, La Spezia), the high mortality rates from pleural tumors were already reported in the period The marked gender difference, generally observed in mesothelioma incidence, is also adequately explained by differences in exposure to asbestos the two sexes had in various countries in the past 10, 21. In many mesothelioma series, the percentages of asbestos-related cases among women are markedly lower than the cases among men. In fact, major difficulties are often encountered in reconstructing occupational and social histories in women 21. However, when objective markers of asbestos exposure (pleural plaques, lung asbestos bodies) are investigated, a relationship asbestos mesothelioma may be established also among women 21. In interpreting the relationship asbestos mesothelioma, it should be remembered that in mesothelioma, latency periods (time intervals between first exposure to asbestos and diagnosis of the tumor) may be considerably longer than previously reported and currently appreciated. In large series mean latency periods of 50 years have been reported Discrepancies among the values of latency periods in the various series may be explained by the fact that latency periods at least partly depend on the intensity of

3 asbestos exposure People severely exposed to asbestos such as insulators show latency periods of about 30 years At the other extreme, occupational groups with less heavy exposures, such as sailors, show mean latency periods of 55 years (Figs. 3-4). Given these premises, it is clear that the effects of the highest world asbestos consumption, occurring in 1970s, remain to be seen. References 1. Hillerdal G. Mesothelioma: cases associated with non occupational and low dose exposures. Occup Environ Med 1999; 56, Giarelli L, Bianchi C. Geography of mesothelioma: expected findings and paradoxes. Eur J Oncol 2000; 5: Giarelli L, Bianchi C, Bianchi T. Geografia del mesotelioma. Eur J Oncol 2003; 8: De Guire L, Lajoie P, Lemieux C, Paulin M. Épidémiologie des maladies reliées à l exposition à l amiante au Québec. Institut National de Santé Publique du Québec 2003; 5. Price B, Ware A. Mesothelioma trends in the United States: an update based on Surveillance, Epidemiology, and End Results Program data for 1973 through Am J Epidemiol 2004; 159: Furuya S, Natori Y, Ikeda R. Asbestos in Japan. Int J Occup Environ Health 2003; 9: Montanaro F, Bray F, Gennaro V, et al.. Pleural mesothelioma incidence in Europe: evidence of some deceleration in the increasing trends. Cancer causes and control 2003; 14: Hemminki K, Li X. Time trends and occupational risk factors for peritoneal mesothelioma in Sweden. J Occup Environ Med 2003; 45: Hemminki K, Li X. Time trends and occupational risk factors for pleural mesothelioma in Sweden. J Occup Environ Med 2003; 45: Ulvestad B, Kjaerheim K, Moller B, Andersen A. Incidence trends of mesothelioma in Norway, Int J Cancer 2003; 107: Leigh J, Driscoll T. Malignant mesothelioma in Australia, Int J Occup Environ Health 2003; 9: Burdorf A, Dahhan M, Suste P. Occupational characteristics of cases with asbestos-related diseases in The Netherlands. Ann Occup Hyg 2003; 47: Saarni H, Pentti J, Pukkala E. Cancer at sea: a case-control study among male Finnish seafarers. Occup Environ Med 2002; 59: Rafnsson V, Sulem P. Cancer incidence among marine engineers, a population-based study (Iceland). Cancer causes control 2003; 14: Chiappino G, Mensi C, Riboldi L, Rivolta G. Il rischio amianto nel settore tessile: indicazioni dal Registro Mesoteliomi Lombardia e definitiva conferma. Med Lav 2003; 94: Mastrantonio M, Belli S, Binazzi A, et al.. La mortalità per tumore maligno della pleura nei comuni italiani, Rapporti ISTISAN 2002; 02/ Tossavainen A. National mesothelioma incidence and the past use of asbestos. Monaldi Arch Chest Dis 2003; 59: Tossavainen A. Global use of asbestos and the incidence of mesothelioma. Int J Occup Environ Health 2004; 10: White C. Annual deaths from mesothelioma in Britain to reach 2000 by BMJ 2003; 326: Facchini U, Marcazzan MG, Camnasio M, Branzaglia P. Studio sulla mortalità per mesotelioma della pleura del decennio con riferimento alle province italiane. Med Lav 1986; 77: Bianchi C, Bianchi T, Ramani L. Mesotelioma maligno della pleura nella donna. Med Lav 2004; 95:

4 22. Bianchi C, Brollo A, Ramani L, Bianchi T, Giarelli L. Asbestos exposure in malignant mesothelioma of the pleura: a survey of 557 cases. Ind Health 2001; 39: Bianchi C, Ramani L, Bianchi T, Giarelli L. Latency periods in asbestos-related mesothelioma of the pleura (abstract). Med. Lav 2002; 93: Hilliard AK, Lovett JK, McGavin CR. The rise and fall in incidence of malignant mesothelioma from a British Naval Dockyard, Occup. Med 2003; 53:

5 cases per million cases per million cases per million no data available Fig. 1. Estimated annual crude incidence rates of mesothelioma Standardized rate per 100,000 (fig. based on data by Mastrantonio et al., 2002). = 4-12 cases per 100,000 = 1-4 cases per 100,000 < 1 case per 100,000 Fig. 2. Mortality from pleural cancer among men in Italy,

6 Fig. 3. Latency periods in 400 cases No. cases Men Women Years Fig 3. Latency periods in 400 cases of pleural mesothelioma, Trieste-Malfacone area, Fig. 4. Latency periods by occupation in 400 cases No. cases Shipyard workers Years No. cases Insulators Dock workers Sailors Other industries Domestic exposure Various Years Fig.4. Latency periods in 400 cases of pleural mesothelioma by occupation, Trieste-Malfacone area, Next