Term Paper

Cancer due to Para-Occupational Asbestos Exposure

Rachel Penner
Dr. Mark Hanson
ENVR 2270 A01
December 7, 2016


























Introduction:

Asbestos is a type of fibrous mineral comprised mainly of silicon and oxygen.

The thin, resilient threads of fiber contained in the mineral are fire, heat, and electricity

resistant, which allows them to be utilized in over three thousand manufactured products

The mining of this mineral began around 1870, with peak use occurring near the Second

World War. There are two major categories of asbestos minerals, one being serpentine

with long, wavy fibers and the other being amphibole with straight, thin fibers. (National

Cancer Institute, 2009). Chrysotile is the only type of asbestos under serpentine. Amosite,

crocidolite, tremolite, anthrophyllite, and actinolite are all types of asbestos under

amphibole mineral category (LaDou, 2004). The disturbance of these minerals allows

their fibrous material to be released into the atmosphere. Humans exposed to this run the

risk of allowing the fibrous material to be confined in their lungs for an undisclosed

amount of time. With the classification of asbestos as a known human carcinogen,

inhalation of fibrous material can lead to lung cancer as well as mesothelioma.

Mesothelioma is a rare cancer that affects the thin membranes that line the chest and

abdomen (National Cancer Institute, 2009). In addition, inconclusive evidence has found

that asbestos fiber exposure can increase the chance of throat, kidney, esophagus,

gallbladder, gastrointestinal, and colorectal cancers. With increased exposure,

accumulation of fiber in the lungs rises, which leads to inflammation and scarring. One

form of inflammation is known as asbestosis, which can be a cause of nonmalignant

pleural disorders. Although nonmalignant, evidence suggests that an individual with a

pleural disorder has an increased chance of developing lung cancer. Consistent exposure

to asbestos fibers through work environments such as mining increases the risk of these
cancers occurring. The risk level an individual faces is dependent on the type, chemical

makeup, amount, as well as the length of time they were exposed to a certain kind of

asbestos fiber. The manifestation of a condition relating to asbestos exposure does not

normally appear until around ten to forty years after exposure. (National Cancer Institute,

2009). One of the first published reports concerning the relation between asbestos fibers

and cancer came out in the 1950’s by British, South African and Italian investigators. It

was not until 1986 that the World Health Organization came out with a publication that

recommended that asbestos have a protective exposure standard. It is estimated that

around ten million lives will be taken by an asbestos related illness before they are

banned worldwide and exposure is terminated. These ten million include not only

asbestos workers themselves, but also individuals exposed para-occupationally and

environmentally. (LaDou, 2004). Para-occupational exposure, which is exposure to a

material, in this case asbestos, due to it being brought into the home by a worker, can

occur due to various instances. Depending on the profession that an individual works, the

amount of exposure they occur will differ. An asbestos fiber, which collectively has an

appearance of white dust, has the ability to latch onto the clothing, hair, or other items

belonging to the workers. (National Cancer Institute, 2009). Certain facilities have

showers for workers to utilize after their shift, which would therefore decrease the

amount of fibers on their bodies, however this is not practiced at all facilities. The

amount of exposure an individual had to asbestos fibers is directly related to the exposure

family members would encounter. The para-occupational exposure is due to the fibers

now being airborne in the worker’s dwelling area. Further exposure is often a result of

wives washing their husband’s work clothes, directly handling and therefore being
exposed to the asbestos fibers. (LaDou, 2004). Therefore, the families of asbestos

workers have significantly greater chances of developing cancer than those who are not

workers.

Supporting Material:

Most commonly, it was found that males were the working individuals in an

asbestos related profession. Therefore, in determining the affects asbestos had on family

members due to para-occupational exposure, it is often most beneficial to base studies on

the wives of asbestos workers. Although the term ‘family members’ includes the kids of

workers as well, exposure has improved documentation if just focusing on wives because

of the improved reliability that they are present in the household for the majority of the

study. Ferrante D. (et. all) conducted a study that focused on a cohort of wives of

individuals working in the Eternit Factory of Casale Monferrato, Italy producing

asbestos-cement goods. All women who had a husband employed at the factory between

Janurary 1st 1950 until 1986 were included in the study. The town’s Registrar’s Office

was consulted to gather the marital status of Eternit Factory residents, which determined

that 2,347 were either married, widowed, or divorced. Through a refining process,

women who themselves worked at the Eternit Factory, and any slight unknown

discrepancies regarding marital status dates, and their husband’s employment, were

removed from the study. The exposure period was estimated based on the day marriage

began and concluded either when the marriage was terminated, or the husband retired

from the factory. After this refining process, 1,780 women were considered for the study.

Standardized mortality ratios and 95% confident intervals were computed comparing the
 observed to expected deaths within the cohort. The expected death number was provided

by the National Institute of Statistics for Piedmont, which were age and sex specific. The

results, shown in Table 1, indicate that the observed number of women that died of

cancer was higher than the expected value in every category other than uterus and breast

cancers. Of highest concern was malignant neoplasm of the respiratory organs, which had

a standardized mortality ratio value of 2.69, and the pleura with a standardized mortality

ratio value of 18.00, both being statistically significant. This is convincing evidence that

individuals who are para-occupationally exposed to asbestos are at greater risk of

developing cancer, especially pleura and malignant neoplasm of the respiratory organs,

than those not affiliated with individuals employed in an asbestos related occupation.

(Ferrante D et. all, 2007)

Table 1: . Cause-specific mortality before 80 years of age

of the cohort of wives of AC workers in Casale
Monferrato, Italy, during 1965–2003.

(Ferrante D et. all, 2007)

Another study conducted by Nicholas de Klerk (et. all), assessed the additional

risk of malignant mesothelioma in family members of asbestos miners exposed to

crocidolite (blue asbestos). While the previous study focused specifically on wives, this

study focused on all primary and secondary family members exposed para-

occupationally, in addition to spouses. Primary family members include parents, siblings,

and children, while secondary family members include the likes of aunts, uncles, cousins,

and grandparents. The cohort was compiled by consulting the National Death Index and

the Western Australian Registrar for information regarding mortality, births, deaths, and

marriages. Being that this study focused specifically on malignant mesothelioma, the

Australian Mesothelioma Registry was also consulted for specific statistics on individuals

in the cohort. Individuals were assessed based the duration, and intensity level of

exposure based on fibers/ milliliter years. There were 1,022 families found to have

singular cases of malignant mesothelioma, while 142 families had multiple cases. More

than 97% of individuals in the cohort were exposed for less than 10 years. The

comparison of the observed to expected number of cases was evaluated by computing a

risk ratio. This expected number was determined by individually assessing the risk each

member of either the primary or secondary family groups would occur in terms of the

time of diagnosis, and the amount of exposure. It was determined that 18 cases were

found for primary family while only 10.2 cases were predicted. Secondary family

members were also found to have a higher number of cases found then predicted, with 7

cases found, while only 2.7 predicted. These instances computed a risk ratio of 1.8 and

2.6 respectively. All cases observed in this study were only malignant mesothelioma, and

did not include any other cancers. This indicates that the risk of developing cancer

increases not only for primary para-occupationally exposed indivduals, but also for

secondary family members. Commonly, secondary family members are known to live

separate from the dwelling area of the asbestos worker, and therefore would only be para-

occupationally exposed periodically. The increased risk of cancer they occur further

supports the notion of this paper. (De Klerk N et. all, 2012)
 Evaluating the results of asbestos exposure is significant to the understanding of

the subject, however it is also beneficial to analyze the specifics of asbestos exposure. By

identifying the certain type of asbestos fiber and its effects, one can come to determine

the possible increase in risk encountering said fiber. The type of asbestos mineral fibers

found in the lung tissues of para-occupationally exposed individuals, and gas mask

workers who had direct exposure to asbestos were assessed in A. R. Gibbs’ (et. all) study.

There were 10 para-occupationally exposed individuals, and 7 gas mask workers

compared, each having undergone a necropsy to determine the cause of death being

pleural mesothelioma. The para-occupationally exposed individuals had partners

employed at a shipyard, lagging, building, or ordnance and therefore differ in their

exposure in terms of type and quantity of asbestos fibers. Each subject in the study had

lung tissue obtained, and the fiber type, length, and diameter were noted. It was found

that the para-occupational exposed individuals had asbestos fibers at similar levels in

their lungs as groups of workers with little direct exposure. In addition, in 8 out of the 10

case studies, crocidolite or amosite asbestos fibers were found to have increased

concentrations, which suggests that they are of highest concern. Therefore, individuals

exposed para-occupationally to those specific types of asbestos fibers have a significantly

higher chance of developing cancer. It was determined that 9 out of the 10 individuals

exposed para-occupationally developed carcinogenic tumors by part of being exposed to

asbestos fibers brought home by their partner’s work clothes. (Gibbs AR, 1900).
 To fully comprehend the effects of asbestos exposure para-occupationally, one

can compare these effects to those that individuals occur by part of being

environmentally exposed. The comparison between para-occupational, environmental,

and occupationally exposed individuals was evaluated in Méndez-Vargas M.M (et. all)

study. The subjects included all had developed lung cancer incidents from 2000 to 2004

in Mexico City. Cases of malignant pleural mesothelioma were included in the cohort.

Environmentally exposed individuals were defined in this study as those who did not

have any known occupational or para-occupational exposure, while para-occupationally

exposed individuals were defined in accordance to the previous studies. The study

examined 3,700 cases of lung cancer, upon which 21 cases were found to be malignant

pleural mesothelioma. On average, tumors were diagnosed after 8.25 months for para-

occupational exposed individuals, in comparison to by 6.75 months for environmentally

exposed individuals. Therefore, tumor lethality was found to be higher in para-

occupationally exposed individuals having a surviving period of around 10 months, in

comparison to environmentally exposed individuals having a 16 month surviving period

on average. The total lung capacity of exposed individuals was also assessed. After being

diagnosed with malignant pleural mesothelioma, it was found that environmentally

exposed individuals had 74% of their total lung capacity, while para-occupationally

exposed individuals had only 59% on average. These results signify the increased risk

that para-occupationally exposed individuals have in developing a life threatening form

of cancer in comparison to those exposed environmentally if both happen to develop

cancer. (Méndez-Vargas M.M et. all, 2010)

 The effect para-occupational exposure to asbestos has on an individual is

analogous to the quantity of fibers encountered. A Reid (et. all) conducted a study that

focused on not only the examination of women who died in Witternoom exposed para-

occupationally to asbestos, but additionally the speculated quantity of fibers they

encountered. Through the consultation of school, hospital, birth, and death records of

Wittenoom, 5097 individuals were recognized as being former residents, but not

employed in an asbestos related setting. By having said individuals complete a

questionnaire it was determined who had lived with an asbestos worker and its

implications, and whether they had smoked. Through a refining process, those who did

not return the questionnaire, or information about the individual was inconclusive were

excluded and therefore the total number of subjects in the cohort were 2608 women. The

questionnaire results were interpreted, and found that between 1966 and 1992,

individuals were exposed to 0.5 f/mL – 0.0010 f/mL of asbestos fibers on average for a

24 hour exposure period. 425 deaths in the cohort were analyzed from 1950 – 2004, and a

standardized mortality ratio was computed for numerous instances noted in table 2. It was

found that para-occupationally exposed individuals had a standardized mortality ratio of

1.18 (1.00 to 1.39). This indicates that said individuals have a higher chance of

developing cancer than the average population. The specific type of cancer mortalities

were further investigated (table 3), and it was found that lung and trachea, breast, ovary,

cervix, aerodigestive, and lymphomic cancers all had standardized mortality ratios above

1. This indicating again a higher risk of developing cancer in comparison to the Western

Australian population of women in that time period and therefore a higher risk for para-

occupationally exposed individuals in general. (Reid et. all, 2008).

Table 2: Mortality from all causes and chapters of
the International Classification of Diseases for the Table 3: Specific causes of mortality among former
Wittenoom women who did not work directly with Wittenoom women, 1950 to 2004 (Reid et. all, 2008).
asbestos, 1950 to 2004 (Reid et. all, 2008).

Refuting Material:

Ferrante D. (et. all) conducted a study that evaluated the incidence of mesothelioma in a

cohort of wives in Casale Monferrato, Italy. Although it was found that the observed

number of cancer cases was higher than that of the expected for many varieties of

cancers, referring to table 1 indicates that breast and uterus cancer have a standard

mortality rate of 0.69 and 0.46 respectively. This indicates that wives para-occupationally

exposed to asbestos fibers are less likely to develop said cancers. Although all other

cancers were found to increase in probability, the observed number of breast and uterus

cancers was approximately half of what was expected in each case, which discounts the

credibility of asbestos increasing the risk of cancers. In addition, the latency period of

less than 30, 30-39, and more than 40 were assessed on the incidence of malignant

mesothelioma. It was found that for a latency of less than 20 years there were 0 observed

cases of mesothelioma when 0.10 were expected for 0-9 years of exposure. 0 observed
cases were also found for latency’s over 40 for 0-9 and 10-19 years of exposure when

expected values were 0.04 and 0.07 respectively, and latency’s 20-29 for over 20 years of

exposure when the expected value was 0.06. Although the difference in the observed to

expected value is small, it refutes the idea that para-occupational exposure significantly

increases the chance of developing cancer. (Ferrante D et. all, 2007)

In N. de Klerk’s (et. all) study, the presence of malignant mesothelioma was

evaluated in spouses, primary, and secondary relatives who were exposed para-

occupationally. Supporting material found that primary and secondary relatives had a

higher risk ratio for developing cancer, however it was further reported that spouses were

found to have the opposite. The predicted number of mesothelioma cases in spouses was

3.4, where the observed value was only 2. The risk ratio that was computed from these

results was found to be 0.6, which indicates that developing mesothelioma is less likely to

occur if para-occupationally exposed to asbestos fibers. The doubling of risk found in

primary and secondary relatives para-occupationally exposed, but no increase in spouses

indicates that development of mesothelioma cancer may be genetically inclined.

Although the genetic element is not assumed to be large, it suggests that being genetically

susceptible slightly increases ones chances of developing cancer when para-

occupationally exposed, which may be a more significant contributing factor than the

exposure level itself. (De Klerk N et. all, 2012)

A. R. Gibbs’ (et. all) study presented findings on the type of asbestos fiber found

in the lungs of para-occupationally exposed individuals in comparison to occupationally

exposed individuals. It was determined that crocidolite and amosite were of highest

concern in terms of cancer causing asbestos fibers. However, the study also reports that

although crocidolite and chrysotile asbestos have similar widths and were both found to

be present at low or within control levels, crocidolite was found to be more carcinogenic.

This indicates that not all asbestos fibers are of equal concern, and therefore exposure to

chrysotile para-occupationally may not increase the risk of developing cancer at which it

is statistically significantly.

In Méndez-Vargas M.M (et. all) study, supporting material focused on the

increased risk of mortality and severity of cancer that para-occupational individuals had

in comparison to that of environmentally exposed individuals. This study also presented

information regarding the incidence rates found between para-occupational and

environmentally exposed individuals. This study presented that there were 21 cases of

malignant pleural mesothelioma out of 3,700 cases of lung cancer in Mexico City. It was

found that of the 21 cases, 19% (4) were from occupational exposure, 33% (or 7) were

from para-occupational exposure, and 48% (10) were from environmental exposure. This

indicates that although the cancer that develops from para-occupational exposure is more

severe, cancer is more prominent in an environmentally exposed individual. In addition,

it was found that 14 of the 21 cases included cancers that metastasized. Of these 14 it was

found that 20% (4) were from occupational exposure, 21% (3) from para-occupational

exposure, and 50% (7) from environmental exposure. This suggests that regardless of

survival rate being longer, malignant pleural mesothelioma is more aggressive in terms of
the dispersal rate in environmentally exposed individuals compared to that of para-

occupationally exposed individuals.

Although Reid’s (et. all) study reported convincing information regarding the

increase in the liklihood of developing cancer if para-occupationally exposed, evidence

was also presented that indicated the opposite. When referring to table 3, it is found that

uterus, oesophagus, stomach, intestine, pancreas, and colon and recutum cancers were

found to have lower standardized mortality ratios. This indicates that in comparion to the

Western Australian population, these cancers are found to be less prominent in para-

occupationally exposed individuals. If asbestos exposure increases the risk of developing

cancer, it can be expected that types of cancer should increase in their occerenc rate. In

additon, through the questionarre adressed to all women in the study, not all were fully

assessed on cigarette habits. Cigarettes being an indisputable cause of lung cancer would

cause an adjustment to the existing standardized mortality ratio reported for lung cancer

in table 3, as a portion of the reported statistics may have been attributed to smoking

cigarettes and not asbestos exposure. It is estimated that this value might have incrased

by a factor of 1.42, therefore decreasing the standardized mortality ratio down to 1.23.

Although this is still indicates an increase in the occerence of cancer in comparison to the

Western Australian population, it is much less statistically significant, and therefore is

less validated. (Reid et. all, 2008).

Conclusion:

The families of asbestos workers have significantly greater chances of developing

cancer than those who are not workers. Through the observation and analysis of the five

paper’s supporting and refuting material, one can determine that this original statement

holds validity. The first paper by Ferrante D’s (et. all) analyzed discussed the occurrence

of mesothelioma in family members of asbestos miners exposed to crocidolite. Although

it was determined that breast and ovary cancer was less prominent for para-

occupationally exposed individuals, the extreme increase in respiratory organs and plural

cancers both being quite statistically significant, along with all other forms of cancer

occurring more frequently further validates the original statement than refutes it. The

second paper by N. de Klerk’s (et. all) analyzed the differences between spousal,

primary, and secondary para-occupational asbestos exposure. Though the observed

spousal risk rate was lower than expected, there is only slight validity behind the

genetically prone reasoning for this decrease. Further, the primary and secondary family

members were determined to have a higher risk rate. The third paper by A. R. Gibbs’ (et.

all) determined crocidolite and amosite asbestos fibers to be of the highest concern.

Although chrysotile might not have a same effect para-occupationally as other fibers, the

disproval of it causing cancer has not been validated, and thus is not effective motive to

disprove the original statement. The fourth and most convincing paper for the refuting

material, Méndez-Vargas M.M (et. all) evaluated the differences between para-

occupationl and environmental exposure to asbestos. Although it was found that there

was a higher rate of cancer in environmental exposed individuals than para-occupational,

in order the fully validate the information, the determination that environmentally
exposed individuals were not unknowingly exposed para-occupationally is unknown,

which slightly discredits the information. The fifth and final paper by Reid’s (et. all)

evaluated the occurrence of various types of cancers. While it was found that numberous

cancers had a lower rate of occurrence than expected, breast, uterus, trechea, cervix,

aerodigestive, and lymphomic cancers all had a stadardized mortality ratio above the

observed value. Breast and uterus cancers being oberved as having a higher mortality

ratio whereas in Ferrante D’s (et. all) paper occurring lower indicates that results of these

test vary from locations. Being that the most prominent occurrence was a rise in the risk

rate of cancer in para-occupationally exposed individuals, one can conclude that the

original statement holds validity.

References:

De Klerk N, Alfonso H, Olsen N, Reid A, Sleith J, Palmer L, Berry G, Must AW(Bill).

2012. Familial aggregation of malignant mesothelioma in former workers and

residents of Wittenoom, Western Australia. International Journal of Cancer, 132

(6): 1423-1428.

Ferrante D, Bertolotti M, Todesco A, Mirabelli D, Terracini B, Magnani C. 2007. Cancer

Mortality and Incidence of Mesothelioma in a Cohort of Wives of Asbestos

Workers in Casale Monferrato, Italy, 115; 1401- 1405

Gibbs AR., Griffiths D.M., Pooley FD., Jones JSP. 1900. Comparison of fibre types and

size distributions in lung tissues of paraoccupational and occupational cases of

malignant mesothelioma. British Journal of Industrial Medicine, 47; 621-626.

LaDou J. 2004. The Asbestos Cancer Epidemic. Environmental Health Perspectives, 112;

285-286.

Méndez-Vargas MM, López-Rojas P, Campos-Pujal GA, Marír-Cotoñieto IA, Salinas-

Tovar S, Fernández-Muñoz MdJ. 2010. Pleural mesothelioma in

paraoccupational, environmental and occupational patients exposed to asbestos.

Revista Medica del IMSS, 48 (4): 361-366.

National Cancer Institute. 2009. Asbestos Exposure and Cancer Risk. United States of
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Reid A, Heyworth J, Klerk N de, Musk AW. 2008. The mortality of women exposed

environmentally and domestically to blue asbestos at Wittenoom Western

Australia. Occupational & Environmental Medicine, 65; 743-749.