Finnish Cancer Registry, Institute for Statistical and Epidemiological Cancer Research, Pieni Roobertinkatu 9, FI-00130, Helsinki, Finland.
Acta Oncol. 2009;48(5):646-790. doi: 10.1080/02841860902913546.
We present up to 45 years of cancer incidence data by occupational category for the Nordic populations. The study covers the 15 million people aged 30-64 years in the 1960, 1970, 1980/1981 and/or 1990 censuses in Denmark, Finland, Iceland, Norway and Sweden, and the 2.8 million incident cancer cases diagnosed in these people in a follow-up until about 2005. The study was undertaken as a cohort study with linkage of individual records based on the personal identity codes used in all the Nordic countries. In the censuses, information on occupation for each person was provided through free text in self-administered questionnaires. The data were centrally coded and computerised in the statistical offices. For the present study, the original occupational codes were reclassified into 53 occupational categories and one group of economically inactive persons. All Nordic countries have a nation-wide registration of incident cancer cases during the entire study period. For the present study the incident cancer cases were classified into 49 primary diagnostic categories. Some categories have been further divided according to sub-site or morphological type. The observed number of cancer cases in each group of persons defined by country, sex, age, period and occupation was compared with the expected number calculated from the stratum specific person years and the incidence rates for the national population. The result was presented as a standardised incidence ratio, SIR, defined as the observed number of cases divided by the expected number. For all cancers combined (excluding non-melanoma skin cancer), the study showed a wide variation among men from an SIR of 0.79 (95% confidence interval 0.66-0.95) in domestic assistants to 1.48 (1.43-1.54) in waiters. The occupations with the highest SIRs also included workers producing beverage and tobacco, seamen and chimney sweeps. Among women, the SIRs varied from 0.58 (0.37-0.87) in seafarers to 1.27 (1.19-1.35) in tobacco workers. Low SIRs were found for farmers, gardeners and teachers. Our study was able to repeat most of the confirmed associations between occupations and cancers. It is known that almost all mesotheliomas are associated with asbestos exposure. Accordingly, plumbers, seamen and mechanics were the occupations with the highest risk in the present study. Mesothelioma was the cancer type showing the largest relative differences between the occupations. Outdoor workers such as fishermen, gardeners and farmers had the highest risk of lip cancer, while the lowest risk was found among indoor workers such as physicians and artistic workers. Studies of nasal cancer have shown increased risks associated with exposure to wood dust, both for those in furniture making and for those exposed exclusively to soft wood like the majority of Nordic woodworkers. We observed an SIR of 1.84 (1.66-2.04) in male and 1.88 (0.90-3.46) in female woodworkers. For nasal adenocarcinoma, the SIR in males was as high as 5.50 (4.60-6.56). Male waiters and tobacco workers had the highest risk of lung cancer, probably attributable to active and passive smoking. Miners and quarry workers also had a high risk, which might be related to their exposure to silica dust and radon daughters. Among women, tobacco workers and engine operators had a more than fourfold risk as compared with the lung cancer risk among farmers, gardeners and teachers. The occupational risk patterns were quite similar in all main histological subtypes of lung cancer. Bladder cancer is considered as one of the cancer types most likely to be related to occupational carcinogens. Waiters had the highest risk of bladder cancer in men and tobacco workers in women, and the low-risk categories were the same ones as for lung cancer. All this can be accounted for by smoking. The second-highest SIRs were among chimney sweeps and hairdressers. Chimney sweeps are exposed to carcinogens such as polycyclic aromatic hydrocarbons from the chimney soot, and hairdressers' work environment is also rich in chemical agents. Exposure to the known hepatocarcinogens, the Hepatitis B virus and aflatoxin, is rare in the Nordic countries, and a large proportion of primary liver cancers can therefore be attributed to alcohol consumption. The highest risks of liver cancer were seen in occupational categories with easy access to alcohol at the work place or with cultural traditions of high alcohol consumption, such as waiters, cooks, beverage workers, journalists and seamen. The risk of colon cancer has been related to sedentary work. The findings in the present study did not strongly indicate any protective role of physical activity. Colon cancer was one of the cancer types showing the smallest relative variation in incidence between occupational categories. The occupational variation in the risk of female breast cancer (the most common cancer type in the present series, 373 361 cases) was larger, and there was a tendency of physically demanding occupations to show SIRs below unity. Women in occupations which require a high level of education have, on average, a higher age at first child-birth and elevated breast cancer incidence. Women in occupational categories with the highest average number of children had markedly lower incidence. In male breast cancer (2 336 cases), which is not affected by the dominating reproductive factors, there was a suggestion of an increase in risk in occupations characterised by shift work. Night-shift work was recently classified as probably carcinogenic, with human evidence based on breast cancer research. The most common cancer among men in the present cohort was prostate cancer (339 973 cases). Despite the huge number of cases, we were unable to demonstrate any occupation-related risks. The observed small occupational variation could be easily explained by varying PSA test frequency. The Nordic countries are known for equity and free and equal access to health care for all citizens. The present study shows that the risk of cancer, even under these circumstances, is highly dependent on the person's position in the society. Direct occupational hazards seem to explain only a small percentage of the observed variation - but still a large number of cases - while indirect factors such as life style changes related to longer education and decreasing physical activity become more important. This publication is the first one from the extensive Nordic Occupational Cancer (NOCCA) project. Subsequent studies will focus on associations between specific work-related factors and cancer diseases with the aim to identify exposure-response patterns. In addition to the cancer data demonstrated in the present publication, the NOCCA project produced Nordic Job Exposure Matrix (described in separate articles in this issue of Acta Oncologica) that transforms information about occupational title histories to quantitative estimates of specific exposures. The third essential component is methodological development related to analysis and interpretation of results based on averaged information of exposures and co-factors in the occupational categories.
我们展示了北欧人群按职业类别的癌症发病数据,时间跨度长达 45 年。本研究涵盖了丹麦、芬兰、冰岛、挪威和瑞典 1960 年、1970 年、1980/1981 年和/或 1990 年普查中年龄在 30-64 岁的 1500 万人口,以及这些人群中约 280 万例在随访期间确诊的癌症病例。该研究采用队列研究设计,通过个人身份码将个体记录进行链接,这些身份码在所有北欧国家都有使用。在普查中,每个人的职业信息通过自我管理问卷中的自由文本提供。数据由各国的统计部门集中编码和计算机化。对于本研究,原始职业代码被重新分类为 53 个职业类别和一组无经济活动人员。所有北欧国家在整个研究期间都对癌症发病进行了全国范围的登记。对于本研究,发病癌症病例被分为 49 个初级诊断类别。一些类别根据亚部位或形态类型进一步细分。在国家、性别、年龄、时期和职业定义的人群中,观察到的癌症病例数与根据分层特定人群年和全国人口发病率计算的预期病例数进行比较。结果以标准化发病比(SIR)表示,定义为观察到的病例数除以预期病例数。对于所有癌症(不包括非黑色素瘤皮肤癌),该研究表明,在男性中,从家庭佣人的 SIR 为 0.79(95%置信区间 0.66-0.95)到服务员的 1.48(1.43-1.54),存在广泛的差异。SIR 最高的职业还包括生产饮料和烟草、海员和烟囱清洁工。在女性中,海员的 SIR 为 0.58(0.37-0.87),而烟草工人的 SIR 为 1.27(1.19-1.35)。农民、园丁和教师的 SIR 较低。我们的研究能够重复大多数已确认的职业与癌症之间的关联。众所周知,几乎所有间皮瘤都与石棉暴露有关。因此,水暖工、海员和机械师是本研究中风险最高的职业。间皮瘤是显示出职业间最大相对差异的癌症类型。渔民、园丁和农民等户外工作者患唇癌的风险最高,而医生和艺术工作者等室内工作者的风险最低。鼻癌的研究表明,接触木尘会增加风险,包括从事家具制造的人和大多数北欧木工中仅接触软木的人。我们观察到男性木工的 SIR 为 1.84(1.66-2.04),女性木工的 SIR 为 1.88(0.90-3.46)。男性鼻腺癌的 SIR 高达 5.50(4.60-6.56)。男性服务员和烟草工人患肺癌的风险最高,可能归因于主动和被动吸烟。矿工和采石工人的风险也很高,这可能与他们接触二氧化硅粉尘和氡子体有关。与农民、园丁和教师相比,女性烟草工人和发动机操作员的肺癌风险高出四倍以上。在所有主要组织学肺癌亚型中,职业风险模式非常相似。膀胱癌被认为是最有可能与职业致癌物有关的癌症类型之一。男性中,服务员的膀胱癌风险最高,女性中烟草工人的膀胱癌风险最高,而肺癌风险最低的类别则相同。这一切都可以归因于吸烟。烟囱清洁工和理发师的 SIR 位居第二。烟囱清洁工接触来自烟囱烟灰的多环芳烃等致癌物质,理发师的工作环境也富含化学物质。在北欧国家,乙型肝炎病毒和黄曲霉毒素等已知肝癌致癌物的暴露非常罕见,因此很大一部分原发性肝癌可归因于饮酒。在工作场所容易接触酒精或具有高酒精消费文化传统的职业类别中,如服务员、厨师、饮料工人、记者和海员,肝癌风险最高。结肠癌与久坐不动的工作有关。本研究的结果并没有强烈表明任何体力活动的保护作用。结肠癌是职业类别中发病率相对变化最小的癌症类型之一。女性乳腺癌(本系列中最常见的癌症类型,373361 例)的职业风险变化较大,体力要求高的职业 SIR 低于 1。需要高水平教育的女性平均初育年龄较高,乳腺癌发病率也较高。职业类别中平均子女数量较高的女性发病率明显较低。在男性乳腺癌(2336 例)中,生殖因素没有主导作用,有迹象表明,轮班工作会增加患病风险。夜班工作最近被归类为可能致癌,其人类证据基于乳腺癌研究。本队列中男性最常见的癌症是前列腺癌(339973 例)。尽管病例数量巨大,但我们无法证明任何与职业相关的风险。观察到的职业变化很小,可以通过 PSA 测试频率的变化很容易解释。北欧国家以平等和公民自由获得全民医疗保健而闻名。本研究表明,即使在这种情况下,癌症的风险也高度取决于个人在社会中的地位。直接职业危害似乎只能解释观察到的变异的一小部分-但仍然是大量病例-而间接因素,如与较长的教育和减少体力活动相关的生活方式变化变得更加重要。本出版物是广泛的北欧职业癌症(NOCCA)项目的第一份出版物。随后的研究将重点关注特定工作相关因素与癌症疾病之间的关联,旨在确定暴露-反应模式。除了本出版物中展示的癌症数据外,NOCCA 项目还产生了北欧职业暴露矩阵(在本期《肿瘤学》中单独的文章中描述),该矩阵将职业史的职业标题信息转换为特定暴露的定量估计。第三个重要组成部分是基于职业类别中的暴露和协变量的平均信息进行分析和解释的方法开发。
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