the links between non-hodgkin's lymphoma and exposures to pesticides and other environmental...
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The links between non-Hodgkin's lymphoma and
exposures to pesticides and other environmental agents
Yutaka AokiLynn Goldman
Johns Hopkins School of Public HealthDepartment of Environmental Health Sciences
APHA Annual Meeting, October 24, 2001
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Non-Hodgkin’s Lymphoma (NHL)What is it and why bother?
• A group of cancers arising in lymph system– Distinguished from Hodgkin’s Disease (HD)– Treatments limited
• NHL incidence is rising
• Need to control the rise in incidence
• Emerging knowledge on environmental exposures as risk factor
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Non-Hodgkin’s Lymphoma (NHL)Foci of this presentation
• A group of cancers arising in lymph system– Distinguished from Hodgkin’s Disease (HD)– Treatments limited
• NHL incidence is rising
• Need to control the rise in incidence
• Emerging knowledge on environmental exposures as risk factor
• What should we do?
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Trends in USA: 1973-1998
Based on Surveillance, Epidemiology and End Results (SEER) Data
An
nu
al I
nci
de
nce
pe
r 1
00
,00
0A
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ua
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10
0,0
00
Trend in age-adjusted annual incidence for NHLTrend in age-adjusted annual incidence for NHLYearYear
19701970 19801980 19901990 2000200000
55
1010
1515
2020
2525 All Males All Males
All Females All Females
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Clues for the Causes of the Rise
• Similar increasing pattern (3~4% annual increase) all over world
• The rise is real, i.e., can not be attributed solely to artifact of– Increased detection– Change in classification
• Only a part of increase is due to HIV • Incidence higher in developed areas, e.g.,
USA and Europe
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NHL Mortality MAP for USA
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Farming-related Exposures
• Higher incidence for Midwest states• Farming as occupation increases risk
(RR of 1.1 in a meta-analysis)• Farming is related to exposure to various agents
– Pesticides– Hay/Dust – Diesel exhaust – Sunlight– Zoonotic viruses– Healthy life style, etc
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Pesticides• Phenoxy herbicides (2,4-D, 2,4,5-T, etc)
– Dioxin as a contaminant – Among farmers, more exposurehigher risk– RR=2.6 in manufacturing workers– Agent orange (largely negative)
• Organochlorine insecticides– Chlordane remains to be a suspect– DDT & lindane unlikely
• Organophosphate & carbamate insecticides– Use increased after organochlorine regulations
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Other Persistent Chemicals
• PCB – mixed results w/ a positive result from a nested
case-control study
• PBB (high risk seen in Michigan study)• Dioxins (Manufacturing workers, Seveso)• Polybrominated Diphenyl Ether (PBDE)
– Used as flame retardant for plastics and fabrics– One positive study from Sweden
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Swedish human breast milk monitoring results reported by Noren & Meironyte (2000)
T
EQ
(p
g/g
fa
t)
Year
PB
DE
(p
g/g
fa
t)
1970 1980 1990 20000
20
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0
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D
DD
DDD
D
D
D P
P
P
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PP
PP
Dioxins PBDE <===== ====>
Polybrominated Diphenyl Ether (PBDE)
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Other Environmental Exposures
• Nitrate in groundwater– Connection with use of fertilizer– Mixed results
• Solvents (mixed results)– trichloroethylene, tetrachloroethylene, benzene
(controversial), other solvents, painter as occupation
• Wood dusts & wood-related work– Potential roles of chlorinated phenol wood
preservatives
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Other aspects of suspected or known risk factors
• Disruption of immune system confer high risk– HIV(RR~200)– Immunosuppressive therapies (RR~50)
• Suspected chemicals such as organophosphates and carbamates are immunotoxic
• Some agents found in occupational setting as well as in non-occupational setting with increasing use, e.g.,– Persistent chemicals in diet– Herbicides for crops and lawn– Solvents
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Contribution of genetic factors
• Gene pool is stable over a few decades• Contribution of genetically inherited factors,
that act alone, is negligible (Scandinavian twin study)
• Possibility for synergetic gene-environment interaction
• Polymorphisms in metabolic enzymes may be important as found in childhood leukemia
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Ann
ual I
ncid
ence
(1/1
00,0
00)
Year0
10
20
1970 1990
How much of increase is explained by known factors?
• Let’s think of a period of 20 years, 1970-90, with doubling of incidence
• A factor solely responsible for the increase– would explain 50% of
incidence in 1990; and– should have become more
common over time
• No such factors found
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How much of increase is explained by known factors? (cont’d)
• Each of environmental factors studied accounts only 5~10 % of the risk in each study
• Combined effects not thoroughly assessed yet– In a single study, not all of them considered
– Exposure trend unknown, e.g., for PBDE
• Prevalence of some factors has decreased, e.g., farming
• General consensus: the known/suspected factors can explain only a part of increase
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Policy issues
• “Epidemic” detected• Policy development
– Identify and reduce causal exposure FURTHER SEARCH FOR CAUSES
• Once policies implemented Assessment– Have we been successful in reducing exposures?– Have we been successful in preventing disease?– Need to “track” changes PREPARE FOR FUTURE ASSESSMENT
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Conclusions
• Causes of NHL remain elusive with some promising leads regarding roles of environmental exposures
• For sound policy development and assessment, we should– Continue further search for causes and– Keep improving disease and exposure tracking,
especially exposure tracking
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NHL Mortality MAP for USA
Use this map when printing in black & white
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Contact information and acknowledgement
Yutaka Aoki 615 N. Wolfe Street, Box 1249 Baltimore, MD 21205 email: [email protected]
This project was funded by Physicians for Social Responsibility.