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O c c u p a t i o n a l a n d E n v i r o n m e n t a l M e d i c i n e 1 9 9 7 ; 5 4 : 7 2 9 - 7 3 3

R i s k o f cancer among paper r e c y c l i n g w o r k e r sBo A n d r e a s s e n R i x , E b b e V i l l a d s e n , G e r d a E n g h o l m , E l s e b e t h L y n g e

A b s t r a c tO b j e c t i v e s - S t u d i e s i n t r a d i t i o n a l paperm i l l s have i n d i c a t e d an excess cancer r i s k ,and mutagenic compounds h a v e beeni d e n t i f i e d i n t h e i n d u s t r y . No s t u d i e s h a v er e p o r t e d on r i s k o f cancer i n paperr e c y c l i n g . T h e r e f o r e t h e cancer i n c i d e n c ei n Danish paper r e c y c l i n g m i l l s was i n v e s -t i g a t e d .Methods-5377 e m p l o y e e s i n f i v e paperr e c y c l i n g p l a n t s were i n c l u d e d i n a h i s -t o r i c a l c o h o r t s t u d y . The workers hadbeen employed i n paper r e c y c l i n g i n 1 9 6 5 -9 0 , and t h e c o h o r t was f o l l o w e d up u n t i l 3 1December 1 9 9 3 . Th e e x p e c t e d number o fcancer cases was c a l c u l a t e d from n a t i o n a lr a t e s .Results-There was s i g n i f i c a n t l y morep h a r y n g e a l cancer among male w o r k e r s( s e v e n o b s e r v e d s t a n d a r d i z e d d i n c i d e n c er a t i o ( S I R ) 3 . 3 3 , 95% c o n f i d e n c e i n t e r v a l(95% C I ) 1 . 3 4 t o 6 . 8 7 ) ) . There was s l i g h t l ymore l u n g cancer among male w o r k e r s i np r o d u c t i o n ( 3 9 o b s e r v e d , SIR 1 . 2 1 , 95% CI0 . 8 6 t o 1 . 6 5 ) . R i s k o f H o d g k i n ' s d i s e a s e wasdoubled i n male p r o d u c t i o n worker ( f o u ro b s e r v e d , SIR 1 . 9 0 , 95% CI 0 . 5 1 t o 4 . 8 5 ) .Conclusions-The i n c r e a s e d r i s k o f p h a -r y n g e a l cancer found i n t h i s s t u d y i si n t e r e s t i n g but may be i n f l u e n c e d by con-f o u n d e r s such as smoking and a l c o h o li n t a k e . T h i s s t u d y a l s o i n d i c a t e s an excessr i s k o f H o d g k i n ' s d i s e a s e , which i s i naccordance w i t h some s t u d i e s i n t h et r a d i t i o n a l paper m i l l s . As t h i s i s the f i r s treport on r i s k o f cancer i n paper recy-c l i n g , f u r t h e r s t u d i e s are n e e d e d .( O c c u p E n v i r o n Med 1 9 9 7 ; 5 4 : 7 2 9 - 7 3 3 )K e y w o r d s : n e o p l a s m s ; o c c up at i o na l exposure; paperi n d u s t r y

Th e Danish CancerS o c i e t y , C o p e n h a g e n ,DenmarkB A R i xE V i l l a d s e nG EngholmE L y n g eC o r r e s p o n d e n c e t o :Dr B o A n d r e a s s e n R i x ,D a n i s h C a n c e r S o c i e t y ,S t r a n d b o u l e v a r d e n 4 9 ,DK-2 1 0 0 C o p e n h a g e n ,Denmark.A c c e p t e d 5 J u n e 1 9 9 7

Many c h e m i c a l compounds are u s e d i n t h ep u l p and paper i n d u s t r y , a n d some o f t h e com-p o u n d s h a v e b e e n shown t o b e m u t a g e n i c . ' I ne f f l u e n t water and s l u d g e f r o m paper m i l l s , 2 ,3 , 7 , 8 - t e t r a c h l o r o d i b e n z o - p - d i o x i n ( 2 , 3 , 7 , 8 -TCDD), o t h e r d i o x i n s , a n d p o l y c h l o r i n a t e dd i b e n z o f u r a n s ( P C D F s ) h a v e b e e n f o u n d . 2 AS t u d i e s o f p o l y c h l o r i n a t e d d i b e n z o d i o x i n s(PCDDs) a n d P C DFs i n paper p r o d u c t s h a v eshown t h e h i g h e s t c o n c e n t r a t i o n s i n p u l p fromr e c y c l e d p a p e r , ' and a h i g h i n c i d e n c e o fchromosomal m u t a t i o n s was f o u n d i n f e r n s i na r i v e r c o n t a m i n a t e d b y paper r e c y c l i n ge f f l u e n t . '

S t u d i e s o f w o r k e r s from t h e p u l p and paperi n d u s t r y h a v e i n d i c a t e d an i n c r e a s e d r i s k o fl u n g cancer, s t o m a c h cancer, a n d m a l i g n a n t

l y m p h o m a s , 6 b u t n o s t ud y h as p r e v i o u s l y b e e nu n d e r t a k e n t o i n v e s t i g a t e t h e r i s k o f c a nc e r i nt h e p a p e r r e c y c l i n g i n d u s t r y . D e - i n k i n g a n dr e c y c l i n g o f p a pe r w i l l b e c o m e a n i m po r t a n ti n d u s t r y i n t h e f u t u r e a s p a p e r c o n s u m p t i o ni n c r e a s e s . 7 A s D e n m a r k h a s a n o l d p a p e r r e c y -c l i n g i n d u s t r y 8 a n d a n a t i o n a l c o m p u l s o r y c a n -c e r r e g i s t r a t i o n , we c o n d u c t e d a h i s t o r i c a lc o ho r t s t ud y o f i n c i d e n c e o f c a n c e r i n D a n i s hp a p e r r e c y c l i n g p l a n t s .M a t e r i a l s and methodsDESCRIPTION OF THE PAPER RECYCLING PLANTSF i v e D a n i s h p a p e r r e c y c l i n g p l a n t s w e r ei n c l u d e d . Th e o l d e s t p l a n t s t a r t e d p r o d u c t i o ni n 1 9 5 6 a n d t h e n e w e s t i n 1 9 6 9 . I n t h r e ep l a n t s , p a p e r w a s t e w a s m i x e d w i t h w a t e r , a n ds l i m i c i d e s , s i z i n g a g e n t s , f l o c k i n g c h e m i c a l s ,f i l l e r s , a n d o t h e r c h e m i c a l s w e r e a d d e d t o t h ep a p e r s t o c k .Tw o p l a n t s u s e d a d e - i n k i n g p r o c e s s t or e m o v e p r i n t i n g i n k f r o m n e w s p a p e r s a n dm a g a z i n e s . I n a f l o t a t i o n d e - i n k i n g s y s t e m ,p a p e r w a s t e w a s d i s s o l v e d i n w a t e r , f a t t y a c i d sa n d o t h e r c o m p o u n d s w e r e a d d e d , a n d p r i n t -i n g i n k a n d i m p u r i t i e s w e r e s e p a r a t e d b y a n a i rf l o w i n a f o a m s e p a r a t o r .Th e m o s t co m m on c h e m i c a l s u s e d i n t h eD a n i s h r e p u l p i n g a n d d e - i n k i n g i n d u s t r y w e r ef a t t y a c i d d e r i v a t i v e s , h y d r o g e n p e r o x i d e ,s o d i u m b i s u l p h i t e , s o d i u m h y d r o x i d e , s o d i u ms i l i c a t e , s o d i u m d i t h i o n i t e , a l u m i n u m s u l p h a t e ,c h l o r i n e , h y p o c h l o r i t e , p o l y e t h y l e n i m i n e ,( d i e t h y l e n e t r i n i t r i l o ) p e n t a - a c e t i c a c i d , b e n -t o n i t e , k a o l i n , r e s i n s , a n d a c r y l a m i d e p o l y m e r s .S e v e r a l s l i m i c i d e s - f o r e x a m p l e , t h i a z o l e com-p o u n d s , b r o m i n e c o m p o u n d s , a n d c o p p e rc o m p o u n d s - w e r e a l s o u s e d . I n d u s t r i a l h y -g i e n e m e a s u r e m e n t s i n t h e p a p e r r e c y c l i n gi n d u s t r y i n Denmark s h o w e d t h a t d u s t c o n c e n -t r a t i o n s i n t h e i n d u s t r y may h a v e e x c e e d e d 5m g / m ' , a n d m i c r o - o r g a n i s m s a n d e n d o t o x i n sw e r e o f t e n m e a s u r e d i n t h e w o r k e n v i r o n m e n t . 9R e p u l p i n g a n d d e - i n k i n g t o o k p l a c e i n o p e np o n d s , b u t f r o m t h e m i d - 1 9 7 0 s w o r k e r s s p e n tp a r t o f t h e w o r k i n g h o u r s i n c l o s e d c o n t r o lr o o m s .REGISTRATION OF THE PAPER RECYCLINGINDUSTRY COHO RTNo h i s t o r i c a l a r c h i v e on f o r m e r e m p l o y e e s wasa v a i l a b l e a t f o u r o f t h e f i v e p l a n t s i n c l u d e d . Ther e g i s t r a t i o n w a s t h e r e f o r e b a s e d on companyr e c o r d s o f a c t i v e w o r k e r s a n d d a t a f r o m an a t i o n a l s u p p l e m e n t a r y p e n s i o n s c h e m e c a l l e dA T P . T h i s w a s s t a r t e d on 1 A p r i l 1 9 6 4 , a n d i sb a s e d on c o m p u l s o r y q u a r t e r l y c o n t r i b u t i o n sf r o m e m p l o y e e s a n d e m p l o y e r s . I n f o r m a t i o non c o n t r i b u t i o n s a n d p e r i o d s o f e m p l o y m e n ta r e s t o r e d i n a d a t a b a n k t o g e t h e r w i t h n a m e s ,

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R i x , V i l l a d s e n , E n g h o l m , L y n g e

d a t e s o f b i r t h , p e r s o n a l i d e n t i f i c a t i o n n u m b e r so f e m p l o y e e s , a n d u n i q u e i d e n t i f i c a t i o nn u m b e r s o f e m p l o y e r s . D a t a on a l l p e o p l ee m p l o y e d i n t h e p l a n t s f r o m 1 A p r i l 1 9 6 4 u n t i l3 1 D e c e m b e r 1 9 9 0 were r e t r i e v e d . A s somef o r m e r e m p l o y e e s were m i s s i n g i n t h e e a r l yp e r i o d o f t h e p e n s i o n s c h e m e i n 1 96 4 , o n l yp e o p l e e m p l o y e d on 1 J a n u a r y 1 9 6 5 or l a t e rwere i n c l u d e d . L i s t s o f f o r m e r e m p l o y e e s weres e n t t o t h e p l a n t managers f o r f u r t h e r i n f o r -m a t i o n on j o b t i t l e s a n d d e p a r t m e n t s . T h i si n f o r m a t i o n was s u p p l e m e n t e d f r o m v a r i o u ssources, a n d f o r most f o r m e r e m p l o y e e s i t wasp o s s i b l e t o f i n d i f t h e y h a d b e e n i n p r o d u c t i o n ,m a i n t e n a n c e a n d s t o r a g e , or a d m i n i s t r a t i o n .

I n p l a n t No 5 , 2 5 4 a c t i v e a n d f o r m e r w o r k e r swere r e g i s t e r e d i n t h e p l a n t f i l e s . From t h e ATPs u p p l e m e n t a r y p e n s i o n s c h e m e , 1 8 4 a d d i t i o n a lw o r k e r s were r e t r i e v e d . D a t a c o n c e r n i n g t h e s ep e o p l e were s e n t t o t h e company a n d t o r e t i r e df o r e m e n f o r c o m p l e t i o n o f i n f o r m a t i o n a b o u tj o b t i t l e s a n d d e p a r t m e n t s . O n l y 3 7 6 w o r k e r se m p l o y e d f r o m 1 J a n u a r y 1 9 7 0 were i n c l u d e di n t h e f i n a l c o h o r t , as p r o d u c t i o n was c h a n g e dt o paper r e c y c l i n g f r o m t h a t d a t e .A t o t a l o f 5 3 7 9 p e o p l e were r e g i s t e r e d i n t h eD a n i s h paper r e c y c l i n g i n d u s t r y c o h o r t ( t a b l e1 ) .FOLLOW UP OF THE COHORTFrom 1 A p r i l 1 9 6 8 , a l l D a n i s h c i t i z e n s h a v eb e e n g i v e n a u n i q u e p e r s o n a l i d e n t i f i c a t i o nnumber a n d a l l d a t e s o f d e a t h s , e m i g r a t i o n s ,a n d d i s a p p e a r a n c e s h a v e b e e n r e c o r d e d i n t h ec e n t r a l p o p u l a t i o n r e g i s t e r . P e o p l e w i t h ap e r s o n a l i d e n t i f i c a t i o n number were s e a r c h e df o r i n t h e C e n t r a l P o p u l a t i o n R e g i s t e r f o r v i t a ls t a t u s . P e o p l e w i t h o u t a p e r s o n a l i d e n t i f i c a t i o nn u m b e r were s e a r c h e d f o r i n t h e n a t i o n a lm o r t a l i t y r e g i s t r y f o r d a t e o f d e a t h . A t o t a l o f5 3 7 7 p e o p l e ou t o f 5 3 7 9 i n t h e c o h o r t werei d e n t i f i e d . Tw o were e x c l u d e d f r o m t h e a n a l y -s i s ( t a b l e 1 ) . F o r e a c h person, person-years a tr i s k were c a l c u l a t e d f r o m t h e r e g i s t e r e d s t a r t o fe m p l o y m e n t , u n t i l d e a t h , e m i g r a t i o n , d i s a p -pearance, or e n d o f f o l l o w up on 3 1 December1 9 9 3 , w h i c h e v e r came f i r s t .The D a n i s h cancer r e g i s t e r s t a r t e d i n 1 9 4 3 .Members o f t h e D a n i s h paper r e c y c l i n g c o h o r tw i t h o u t a p e r s o n a l i d e n t i f i c a t i o n number weres e a r c h e d f o r m a n u a l l y on l i s t s o f cancerp a t i e n t s w i t h e q u i v a l e n t sex a n d d a t e o f b i r t h i nt h e cancer r e g i s t e r . Members w i t h a p e r s o n a li d e n t i f i c a t i o n number w ere s e a r c h e d f o r i n t h ecancer r e g i s t e r on 1 J u n e 1 9 9 6 .A l l t u m o u r s d i a g n o s e d i n t h e i n d i v i d u a l r i s kp e r i o d s were i n c l u d e d . The e x p e c t e d number

o f cancer cases were c a l c u l a t e d f r o m person-years a t r i s k a n d t h e cancer i n c i d e n c e s f o r t h et o t a l D a n i s h p o p u l a t i o n f o r sex, f i v e - y e a r ag egroups, a n d c a l e n d a r p e r i o ds ( 1 9 6 3 - 6 7 , 1 9 6 8 -7 2 , . . . 1 9 8 8 - 9 2 ) w i t h t h e PYRS p r o g r a m . " 0A s t an da r di z e d i n c i d e n c e r a t i o ( S I R ) wasc a l c u l a t e d b y d i v i d i n g t h e o b s e r v e d number o fcancer cases i n a g i v e n g r o u p b y t h e e x p e c t e dn u m b e r , a n d a 95 % c o n f i d e n c e i n t e r v a l ( 9 5 %C I ) was c a l c u l a t e d . "C a n c e r s i t e s o f s p e c i f i c i n t e r e s t were ana-l y s e d w i t h P o i s s o n r e g r e s s i o n m o d e l s . D u r a t i o no f e m p l o y m e n t , years s i n c e f i r s t e m p l o y m e n t ,a n d year o f f i r s t e m p l o y m e n t w ere u s e d as t h ei n d e p e n d e n t f a c t o r s , a n d t h e l o g o f t h ee x p e c t e d number o f cases b a s e d on p o p u l a t i o nr a t e s was u s e d as an o f f s e t v a r i a b l e . " Th em o d e l l i n g was d o n e w i t h t h e s t a t i s t i c a l p a c k a g eE p i c u r e . 1 2

R e s u l t sAmong men, t h e o v e r a l l i n c i d e n c e o f cancerwas s i g n i f i c a n t l y l o w e r t ha n e xp e c t e d ( 2 0 6o b s e r v e d c a s e s , SIR 0 . 8 5 , 9 5 % C I 0 . 7 3 t o 0 . 9 7 ,t a b l e 2 ) . The r i s k o f p h a r y n g e a l cancer wasi n c r e a s e d more t h a n t h r e e f o l d ( s e v e n o b s e r v e d ,2 . 1 0 e x p e c t e d , S I R 3 . 3 3 , 95% C I 1 . 3 4 t o 6 . 8 7 ) .Th e r i s k o f l u n g cancer was m a r g i n a l l y i nexcess ( 4 7 o b s e r v e d , SIR 1 . 1 1 , 95 % C I 0 . 8 1 t o1 . 4 7 ) , a n d an excess o f H o d g k i n ' s d i s e a s e wasi n d i c a t e d ( f o u r o b s e r v e d cases, 2 . 5 7 e x p e c t e d ,SIR 1 . 5 6 , 95 % C I 0 . 4 2 t o 3 . 9 8 ) .When a n a l y s e d b y l a t e n c y t i m e a n d d u r a t i o no f e m p l o y m e n t ( t a b l e 3 ) , no c l e a r t r e n d wasseen f o r t h e o v e r a l l r i s k o f cancer. Th e r i s k o fl u n g cancer was h i g h e r t h a n e x p e c t e d f o r s h o r tt i m e w o r k e r s a n d w o r k e r s w i t h a t l e a s t 10 yearso f e m p l o y m e n t . Th e r i s k o f H o d g k i n ' s d i s e a s ei n c r e a s e d w i t h d u r a t i o n o f e m p l o y m e n t , b a s e don very f e w cases ( t a b l e 3 ) .

I n t h e P o i s s o n a n a l y s i s , t h e r i s k o f l u n g can-cer i n c r e a s e d w i t h t i m e s i n c e f i r s t e m p l o y m e n t( r e l a t i v e r i s k ( R R ) 1 . 2 8 , 95% C I 0 . 5 8 t o 2 . 8 2f o r 1 0 - 1 9 years o f l a t e n c y , RR 1 . 8 0 , 95 % C I0 . 7 3 t o 4 . 4 3 f o r 2 0 - 2 4 years o f l a t e n c y , a n d R R3 . 2 3 , 95% C I 1 . 2 8 t o 8 . 1 3 f o r a l a t e n c y o f >25y e a r s , P f o r t r e n d 0 . 0 7 , c o m p a r e d w i t h 25 years o f l a t e n c y , P f o r t r e n d0 . 0 4 .The r i s k o f p h a r y n g e a l cancer among menw o r k i n g i n p r o d u c t i o n o f r e c y c l e d paper wass i g n i f i c a n t l y i n excess ( f i v e o b s e r v e d , 1 . 4 5e x p e c t e d , SIR 3 . 4 5 , 95% C I 1 . 1 1 t o 8 . 0 5 ) ,

T a b l e 1 N u m b e r o f p e o p l e * a n d p e r s o n - y e a r s i n t h e D a n i s h p a p e r r e c y c l i n g p l a n t s t u d yMen W o m e n T o t a lR e g i s t e r e d I n c l u d e d R e g i s t e r e d I n c l u d e d R e g i s t e r e d I n c l u d e dP l a n t p e o p l e i n P e r s o n - p e o p l e i n P e r s o n - p e o p l e i n P e r s o n -No ( n ) U n t r a c e d c o h o r t y e a r s ( n ) U n t r a c e d c o h o r t y e a r s ( n ) U n t r a c e d c o h o r t y e a r s

1 6 2 9 1 6 2 8 1 1 2 2 3 1 1 9 0 1 1 9 1 3 4 2 7 4 8 1 7 4 7 1 2 5 6 52 3 0 0 0 0 3 0 0 0 4 4 9 2 6 7 3 4 0 7 3 4 8 6 4 6 3 7 3 4 0 3 7 3 4 5 3 5 7 23 3 4 4 0 3 4 4 4 6 8 4 2 6 0 2 6 2 7 2 3 7 0 0 3 7 0 4 9 5 64 1 4 2 1 1 4 1 1 1 6 2 9 0 9 7 6 1 5 1 1 1 5 0 1 2 3 85 3 3 7 0 3 3 7 5 1 0 8 3 9 0 3 9 5 3 3 3 7 6 0 3 7 6 5 6 4 1T o t a l 4 4 5 2 2 4 4 5 0 6 7 1 0 3 9 2 7 0 927 1 0 8 6 9 5 3 7 9 2 5 3 7 7 7 7 9 7 2* S e v e n p e o p l e e m p l o y e d i n tw o p l a n t s w e r e r e g i s t e r e d i n t h e p l a n t o f f i r s t e m p l o y m e n t .

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R i s k o f cancer amongpaper r e c y c l i n g w o r k e r s

T a b l e 2 O b s e r v e d ( 0 ) a n d e x p e c t e d ( E ) n u m b e r o f c a n c e r c a s e s a m o n g e m p l o y e e s i n t h e D a n i s h p a p e r r e c y c l i n g i n d u s t r yb y d i a g n o s t i c g r o u pMen W o m e nD i a g n o s i sI C D - 7 S i t e 0 E S I R ( 9 5 % C I ) 0 E S I R ( 9 5 % C I )

1 0 4 - 2 0 5 A l l c a n c e r 2 0 6 2 4 3 . 5 9 0 . 8 5 ( 0 . 7 3 t o 0 . 9 7 ) 3 9 3 6 . 6 2 1 . 0 6 ( 0 . 7 6 t o 1 . 4 6 )1 4 0 - 1 4 4 B u c c a l c a v i t y 5 5 . 7 6 0 . 8 7 ( 0 . 2 8 t o 2 . 0 3 ) - 0 . 2 9 -1 4 5 - 1 4 8 P h a r y n x 7 2 . 1 0 3 . 3 3 ( 1 . 3 4 t o 6 . 8 7 ) - 0 . 1 1 - -1 5 0 O e s o p h a g u s 1 3 . 0 6 0 . 3 3 ( 0 . 0 0 t o 1 . 8 2 ) - 0 . 1 3 - -1 5 1 S t o m a c h 8 8 . 6 0 0 . 9 3 ( 0 . 4 0 t o 1 . 8 3 ) - 0 . 5 8 - -1 5 3 C o l o n 1 2 1 5 . 3 4 0 . 7 8 ( 0 . 4 0 t o 1 . 3 7 ) 5 2 . 1 8 2 . 2 9 ( 0 . 7 4 t o 5 . 3 5 )1 5 4 R e c t u m 6 1 1 . 5 8 0 . 5 2 ( 0 . 1 9 t o 1 . 1 3 ) 1 1 . 0 4 0 . 9 6 ( 0 . 0 1 t o 5 . 3 5 )1 5 5 L i v e r , p r i m a r y 2 2 . 4 3 0 . 8 2 ( 0 . 0 9 t o 2 . 9 7 ) - 0 . 2 0 - -1 5 5 . 1 G a l l b l a d d e r 1 1 . 3 7 0 . 7 3 ( 0 . 0 1 t o 4 . 0 6 ) - 0 . 2 7 - -1 5 7 P a n c r e a s 8 6 . 4 4 1 . 2 4 ( 0 . 5 3 t o 2 . 4 5 ) - 0 . 6 91 6 1 L a r y n x 3 4 . 4 4 0 . 6 8 ( 0 . 1 4 t o 1 . 9 7 ) - 0 . 1 4 - -1 6 2 L u n g 4 7 4 2 . 5 2 1 . 1 1 ( 0 . 8 1 t o 1 . 4 7 ) 4 2 . 6 3 1 . 5 2 ( 0 . 4 1 t o 3 . 8 9 )1 7 0 B r e a s t 1 0 . 3 8 2 . 6 3 ( 0 . 0 3 t o 1 4 . 6 4 ) 9 9 . 4 2 0 . 9 6 ( 0 . 4 4 t o 1 . 8 1 )1 7 1 C e r v i x u t e r i - - - - 2 2 . 7 5 0 . 7 3 ( 0 . 0 8 t o 2 . 6 3 )1 7 2 C o r p u s u t e r i - - - 1 1 . 8 5 0 . 5 4 ( 0 . 0 1 t o 3 . 0 1 )1 7 5 O v a r y - - - - 1 1 . 9 3 0 . 5 2 ( 0 . 0 1 t o 2 . 8 8 )1 7 7 P r o s t a t e 1 4 1 8 . 3 5 0 . 7 6 ( 0 . 4 2 t o 1 . 2 8 ) - -1 7 8 T e s t i s 7 9 . 5 7 0 . 7 3 ( 0 . 2 9 t o 1 . 5 1 ) - - - -1 8 0 K i d n e y 7 7 . 7 3 0 . 9 1 ( 0 . 3 6 t o 1 . 8 7 ) 2 0 . 6 9 2 . 9 0 ( 0 . 3 3 t o 1 0 . 4 7 )1 8 1 B l a d d e r 1 4 1 9 . 9 9 0 . 7 0 ( 0 . 3 8 t o 1 . 1 8 ) 2 0 . 7 9 2 . 5 3 ( 0 . 2 8 t o 9 . 1 4 )1 9 0 Melanoma o f s k i n 7 7 . 0 5 0 . 9 9 ( 0 . 4 0 t o 2 . 0 5 ) - 1 . 5 3 - -1 9 1 S k i n , o t h e r 2 5 3 4 . 5 6 0 . 7 2 ( 0 . 4 7 t o 1 . 0 7 ) 6 4 . 2 2 1 . 4 2 ( 0 . 5 2 t o 3 . 0 9 )1 9 3 B r a i n 8 9 . 0 6 0 . 8 8 ( 0 . 3 8 t o 1 . 7 4 ) 2 1 . 2 8 1 . 5 6 ( 0 . 1 8 t o 5 . 6 4 )1 9 6 B o n e - 0 . 5 5 - - - 0 . 0 4 - -1 9 7 C o n n e c t i v e t i s s u e 2 1 . 1 6 1 . 7 2 ( 0 . 1 9 t o 6 . 2 2 ) - 0 . 1 2 - -2 0 0 , 2 0 2 N o n - H o d g k i n ' s 5 6 . 3 9 0 . 7 8 ( 0 . 2 5 t o 1 . 8 3 ) - 0 . 6 7l y m p h o m a2 0 1 H o d g k i n ' s d i s e a s e 4 2 . 5 7 1 . 5 6 ( 0 . 4 2 t o 3 . 9 8 ) - 0 . 2 6 - -2 0 4 L e u k a e m i a 1 6 . 5 5 0 . 1 5 ( 0 . 0 0 t o 0 . 8 5 ) 1 0 . 6 0 1 . 6 7 ( 0 . 0 2 t o 9 . 2 7 )w h e r e a s t h e r i s k o f l u n g cancer was m o d e r a t e l yi n c r e a s e d ( 39 o b s e r v e d, SIR 1 . 2 1 , 9 5 % C I 0 . 8 6t o 1 . 6 5 ) ( t a b l e 4 ) . The r i s k o f H o d g k i n ' sd i s e a s e was d o u b l e d , b a s e d on f o u r cases ( SIR1 . 9 0 , 95% C I 0 . 5 1 t o 4 . 8 5 ) .Among women, t h e o v e r a l l r i s k o f cancer wasc l o s e t o t h e e x p e c t e d ( 3 9 o b s e r v e d , SIR 1 . 0 6 ,95% C I 0 . 7 6 t o 1 . 4 6 ) ( t a b l e 2 ) . The r i s k o fc o l o n cancer was d o u b l e d b a s e d on f i v eo b s e r v e d cases ( S I R 2 . 2 9 , 95% C I 0 . 7 4 t o5 . 3 5 ) , a n d t h e r i s k o f l u n g cancer was i n c r e a s e d( f o u r o b s e r v e d , SIR 1 . 5 2 , 9 5 % CI 0 . 4 1 t o 3 . 8 9 )( t a b l e 2 ) .D i s c u s s i o nTh e o v e r a l l r i s k o f cancer w as l o w e r t h a ne x p e c t e d among men a n d c l o s e t o t h a te x p e c t e d among women i n t h e D a n i s h c o h o r to f paper r e c y c l i n g w o r k e r s , a n d t h i s i s i na c c o r d a n c e w i t h c o h o r t s t u d i e s i n t h et r a d i t i o n a l p u l p a n d paper i n d u s t r y . 1 " 1 6 Ah e a l t h y w o r k e r e f f e c t may e x p l a i n t h e l o w over-a l l cancer i n c i d e n c e i n men. As t h e i n d u s t r y i snew, t h e average f o l l o w u p p e r i o d was o n l y 1 4 . 5y e a r s .

P h a r y n g e a l cancer was s i g n i f i c a n t l y i n excessi n t h i s D a n i s h paper r e c y c l i n g c o h o r t . P h a r y n -g e a l cancer i s r e l a t e d t o s m o k i n g and a l c o h o l

c o n s u m p t i o n . ' 7"" A l c o h o l was n o r m a l l y no ta l l o w e d a t t h e p l a n t s , b u t s m o k i n g was a l l o w e di n s p e c i a l rooms. I n a D a n i s h h e a l t h surveys t u d y i n 1 9 7 2 , ' 9 s m o k i n g a n d a l c o h o l con-s u m p t i o n among m a l e paper w o r k e r s d i d no td i f f e r much f r o m t h a t o f o t h e r w o r k e r s , b u tc o n f o u n d i n g b y t h e s e f a c t o r s cannot b e r u l e do u t . H o w e v e r , c o n f o u n d i n g b y s m o k i n g mayno t a l o n e e x p l a i n a t h r e e f o l d excess r i s k o fp h a r y n g e a l cancer.20 R i s k o f cancer o f t h e b u c -c a l c a v i t y a n d p h a r y n x c o m b i n e d was i n c r e a s e di n some p r o p o r t i o n a t e m o r t a l i t y s t u d i e s amongp u l p a n d paper w o r k e r s , 2 ' 2 2 b u t c o h o r t s t u d i e sh a v e shown t h e c o m b i n e d r i s k o f b u c c a l c a v i t ya n d p h a r y n g e a l cancer t o b e c l o s e t o or l o w e rt h a n e x p e c t e d . ' 3 " 1 6

T h i s s t u d y s u g g e s t e d t h a t t h e i n c i d e n c e o fl u n g cancer w as s l i g h t l y i n c r e a s e d amongmeni n p r o d u c t i o n a n d m o d e r a t e l y i n c r e a s e d i ns h o r t term w o r k e r s w i t h l e s s t h a n one year o fe m p l o y m e n t . O c c u p a t i o n a l exposures may b eh i g h i n t h i s s u b g r o u p , as members may h a v eo c c u p i e d t h e l e a s t q u a l i f i e d j o b s . O t h e r e x p l a -n a t i o n s s u c h a s s m o k i n g i n a more m a r g i n a l -i s e d group o f w o r k e r s may a l s o b e r e l e v a n t . ' 3F o r m a l e e m p l o y e e s w i t h a t l e a s t one year o fe m p l o y m e n t , t h e s t u d y i n d i c a t e d an i n c r e a s i n g

T a b l e 3 O b s e r v e d ( O ) c a n c e r i n c i d e n c e f o r a l l m a l i g n a n t n e o p l a s m s p h a r y n g e a l c a n c e r , l u n g c a n c e r , a n d H o d g k i n ' s d i s e a s e a m o n g m en b y l a t e n c y a n db y d u r a t i o n o f e m p l o y m e n t i n D a n i s h p a p e r r e c y c l i n g p l a n t sA l l c a n c e r s P h a r y n g e a l c a n c e r L u n g c a n c e r H o d g k i n ' s d i s e a s e0 S I R ( 9 5 % C I ) 0 S I R ( 9 5 % C I ) 0 S I R ( 9 5 % C I ) 0 S I R ( 9 5 % C I )

Y e a r s s i n c e f i r s t e m p l o y m e n t ( y ) :0 - 9 5 8 0 . 8 0 ( 0 . 6 1 t o 1 . 0 3 ) 3 4 . 7 6 ( 0 . 9 6 t o 1 3 . 9 1 ) 9 0 . 7 6 ( 0 . 3 5 t o 1 . 4 4 ) 3 2 . 0 1 ( 0 . 4 0 t o 5 . 8 8 )1 0 - 1 9 9 1 0 . 8 4 ( 0 . 6 8 t o 1 . 0 3 ) 3 3 . 1 3 ( 0 . 6 3 t o 9 . 1 3 ) 1 9 0 . 9 7 ( 0 . 5 8 t o 1 . 5 1 ) 1 1 . 1 9 ( 0 . 0 2 t o 6 . 6 2 )> 2 0 5 7 0 . 9 1 ( 0 . 6 9 t o 1 . 1 8 ) 1 1 . 9 6 ( 0 . 0 3 t o 1 0 . 9 1 ) 1 9 1 . 7 2 ( 1 . 0 4 t o 2 . 6 9 ) 0 - -D u r a t i o n o f e m p l o y m e n t ( y ) :< 1 5 5 0 . 8 5 ( 0 . 6 4 t o 1 . 1 0 ) 3 5 . 0 0 ( 1 . 0 0 t o 1 4 . 6 1 ) 1 4 1 . 4 2 ( 0 . 7 8 t o 2 . 3 9 ) 1 0 . 8 9 ( 0 . 0 1 t o 4 . 9 7 )1 - 9 9 6 0 . 8 3 ( 0 . 6 7 t o 1 . 0 2 ) 4 4 . 1 7 ( 1 . 1 2 t o 1 0 . 6 7 ) 1 5 0 . 7 3 ( 0 . 4 1 t o 1 . 2 1 ) 2 1 . 7 5 ( 0 . 2 0 t o 6 . 3 3 )1 0 - 1 9 44 0 . 8 2 ( 0 . 6 0 t o 1 . 1 0 ) 0 - - 1 4 1 . 3 6 ( 0 . 7 4 t o 2 . 2 8 ) 1 3 . 8 5 ( 0 . 0 5 t o 2 1 . 4 0 )B 2 0 1 1 1 . 1 3 ( 0 . 5 6 t o 2 . 0 3 ) 0 - - 4 2 . 1 3 ( 0 . 5 7 t o 5 . 4 5 ) 0 - -

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T a b l e 4 O b s e r v e d ( 0 ) a n d e x p e c t e d ( E ) n u m b e r o f c a n c e r c a s e s a m o n g m a l e w o r k e r s i n t h e D a n i s h p a p e r r e c y c l i n gi n d u s t r y by d i a g n o s t i c g r o u p a n d w o r k p r o c e s s *R e c y c l e d p u l p a n d p a p e r p r o d u c t i o n M a i n t e n a n c e a n d s t o r a g eD i a g n o s i sI C D - 7 S i t e 0 E S I R ( 9 5 % C I ) 0 E S I R ( 9 5 % C I )

1 0 4 - 2 0 5 A l l c a n c e r 1 6 9 1 8 6 . 9 3 0 . 9 0 ( 0 . 7 7 t o 1 . 0 5 ) 3 4 4 3 . 0 9 0 . 7 9 ( 0 . 5 5 t o 1 . 1 0 )1 4 0 - 1 4 4 B u c c a l c a v i t y 5 4 . 4 3 1 . 1 3 ( 0 . 3 6 t o 2 . 6 3 ) - 1 . 0 01 4 5 - 1 4 8 P h a r y n x 5 1 . 4 5 3 . 4 5 ( 1 . 1 1 t o 8 . 0 5 ) 1 0 . 3 3 3 . 0 3 ( 0 . 0 4 t o 1 6 . 8 6 )1 5 0 O e s o p h a g u s 1 2 . 3 4 0 . 4 3 ( 0 . 0 1 t o 2 . 3 8 ) - 0 . 5 5 -1 5 1 S t o m a c h 7 6 . 4 7 1 . 0 8 ( 0 . 4 3 t o 2 . 2 3 ) 1 1 . 5 8 0 . 6 3 ( 0 . 0 1 t o 3 . 5 2 )1 5 3 C o l o n 9 1 1 . 5 9 0 . 7 8 ( 0 . 3 5 t o 1 . 4 7 ) 2 2 . 8 1 0 . 7 1 ( 0 . 0 8 t o 2 . 5 7 )1 5 4 R e c t u m 6 8 . 7 6 0 . 6 8 ( 0 . 2 5 t o 1 . 4 9 ) - 2 . 1 1 -1 5 5 L i v e r , p r i m a r y 2 1 . 8 4 1 . 0 9 ( 0 . 1 2 t o 3 . 9 2 ) - 0 . 4 41 5 5 . 1 G a l l b l a d d e r 1 1 . 0 3 0 . 9 7 ( 0 . 0 1 t o 5 . 4 0 ) - 0 . 2 6 -1 5 7 P a n c r e a s 7 4 . 8 6 1 . 4 4 ( 0 . 5 8 t o 2 . 9 7 ) 2 1 . 1 7 1 . 7 1 ( 0 . 1 9 t o 6 . 1 7 )1 6 1 L a r y n x 2 3 . 4 1 0 . 5 9 ( 0 . 0 7 t o 2 . 1 2 ) - 0 . 7 8 - -1 6 2 L u n g 3 9 3 2 . 2 3 1 . 2 1 ( 0 . 8 6 t o 1 . 6 5 ) 9 7 . 7 5 1 . 1 6 ( 0 . 5 3 t o 2 . 2 0 )1 7 7 P r o s t a t e 1 1 1 3 . 3 8 0 . 8 2 ( 0 . 4 1 t o 1 . 4 7 ) 2 3 . 5 7 0 . 5 6 ( 0 . 0 6 t o 2 . 0 2 )1 7 8 T e s t i s 6 8 . 1 1 0 . 7 4 ( 0 . 2 7 t o 1 . 6 1 ) 1 1 . 2 3 0 . 8 1 ( 0 . 0 1 t o 4 . 5 2 )1 8 0 K i d n e y 7 5 . 9 1 1 . 1 8 ( 0 . 4 7 t o 2 . 4 4 ) - 1 . 3 71 8 1 B l a d d e r 1 0 1 5 . 1 6 0 . 6 6 ( 0 . 3 2 t o 1 . 2 1 ) 5 3 . 6 2 1 . 3 8 ( 0 . 4 5 t o 3 . 2 2 )1 9 0 M e l a n o m a o f s k i n 7 5 . 6 4 1 . 2 4 ( 0 . 5 0 t o 2 . 5 6 ) - 1 . 1 11 9 1 S k i n , o t h e r 1 8 2 6 . 5 7 0 . 6 8 ( 0 . 4 0 t o 1 . 0 7 ) 3 6 . 1 4 0 . 4 9 ( O . l O t o 1 . 4 3 )1 9 3 B r a i n 8 7 . 2 6 1 . 1 0 ( 0 . 4 7 t o 2 . 1 7 ) 1 1 . 4 3 0 . 7 0 ( 0 . 0 1 t o 3 . 8 9 )1 9 6 B o n e - 0 . 4 5 - - - 0 . 0 81 9 7 C o n n e c t i v e t i s s u e 2 0 . 9 3 2 . 1 5 ( 0 . 2 4 t o 7 . 7 6 ) - 0 . 1 7 -2 0 0 , 2 0 2 N o n - Ho d g k i n' s 3 5 . 0 2 0 . 6 0 ( 0 . 1 2 t o 1 . 7 5 ) 1 1 . 0 7 0 . 9 3 ( 0 . 0 1 t o 5 . 2 0 )l y m p h o m a2 0 1 H o d g k i n ' s d i s e a s e 4 2 . 1 1 1 . 9 0 ( 0 . 5 1 t o 4 . 8 5 ) 1 0 . 3 5 2 . 8 6 ( 0 . 0 4 t o 1 5 . 9 0 )2 0 4 L e u k a e m i a 1 5 . 0 6 0 . 2 0 ( O . O O t o 1 . 1 0 ) - 1 . 1 4* A p e r s o n may h a v e b e e n e m p l o y e d i n m o r e t h a n o n e w o r k p r o c e s s .

r i s k o f l u n g c a n c e r w i t h i n c r e a s i n g d ur a t i o n o fe m p l o y m e n t , b a s e d o n a f e w c a s e s . I n a F i n n i s hc o h o r t s t u d y , w o r k e r s i n p a p e r m i l l s h a d a d o u -b l e d r i s k o f l u n g c a n c e r w i t h 1 2 o b s e r v e d c a s e s( S I R 1 9 7 , 95 % C I 1 0 2 t o 3 4 5 ) . ' 4 S m o k i n gc o u l d n o t e x p l a i n t h e e x c e s s r i s k o f l u n g c a n c e ramong p a p e r m i l l w o r k e r s i n F i n l a n d . ' 4 Th er i s k o f l u n g c a n c e r w a s i n c r e a s e d i n t h e p u l pa n d p a p e r i n d u s t r y i n p r o p o r t i o n a t e m o r t a l i t ys t u d i e s , 2 5 2 6 a n d a C a n a d i a n c a s e - c o n t r o l s t u d yi n d i c a t e d a n OR f o r l u n g c a n c e r o f 1 . 4 f o rw o r k e r s e x p o s e d t o p a p e r d u s t . ' 7 I t h a s b e e ns u g g e s t e d t h a t e x p o s u r e t o a s b e s t o s u s e d a s a na d d i t i v e i n p a p e r p r o d u c t s a n d i n i n s u l a t i o n i np a p e r m i l l s may e x p l a i n t h e e x c e s s r i s k o f l u n gc a n c e r . ' 8 I n t he D a n i s h p a p e r r e c y c l i n g i n d u s -t r y , no a s b e s t o s w a s a d d e d t o t h e p a p e r , b u ta s b e s t o s h a s b e e n u s e d i n i n s u l a t i o n o f p i p e s i nt h e D a n i s h p a p e r r e c y c l i n g p l a n t s . One c a s e o fm e s o t h e l i o m a w a s f o u n d among m e n , w h i c hw a s a s e x p e c t e d .None o f t h e c h e m i c a l s w i d e l y u s e d i n t h eD a n i s h p a p e r r e c y c l i n g i n d u s t r y a r e knownc a r c i n o g e n s , b u t s m a l l a m o u n t s o f a c r y l a m i d emay b e r e l e a s e d i n t h e w o r k e n v i r o n m e n t , 9 a n da c r y l a m i d e h a s b e e n e v a l u a t e d a s a p r o b a b l ec a r c i n o g e n . ' 9 V a r i o u s c h l o r i n a t e d o r g a n i c c o m -p o u n d s may a l s o b e r e l e a s e d i n t h e w o r k e n v i -r o n m e n t , b u t t h e a m o u n t s a r e s m a l l . ' ~ ' Somes t u d i e s i n o c c u p a t i o n a l s e t t i n g s w i t h e x p o s u r e st o c h l o r o p h e n o x y h e r b i c i d e s a n d c h l o r o p h -e n o l s h a v e i n d i c a t e d a n e x c e s s r i s k o f l u n g c a n -c e r w h e r e a s o t h e r s t u d i e s h a v e n o t . " ' "Tw o s t u d i e s h a v e s h o w n a r e d u c e d r i s k o fl u n g c a n c e r i n w o r k e r s i n c o t t o n t e x t i l ep l a n t s , 3 4 3 5 a n d i t h a s b e e n p r o p o s e d t h a t e n d o -t o x i n s i n t h e w o r k e n v i r o n m e n t may p r o t e c ta g a i n s t l u n g c a n c e r . 3 6 T h i s h y p o t h e s i s w a s n o tc o n f i r m e d i n t h e p r e s e n t s t u d y .F e m a l e w o r k e r s h a d a d o u b l e d r i s k o f c o l o nc a n c e r . R i s k o f c o l o n c a n c e r w a s s h o w n t o b ei n c r e a s e d among m en i n s u l p h a t e m i l l s a n db o a r d m i l l s i n F i n l a n d , ' 4 a n d i n a p a p e r m i l l i n

t h e U n i t e d S t a t e s , ' 5 a s w e l l a s i n s o m e p r o p o r -t i o n a t e m o r t a l i t y s t u d i e s . 3 7 ' 8 A s f e m a l e w o r k e r si n t h e D a n i s h p a p e r r e c y c l i n g i n d u s t r y p r o b -a b l y h a d l o w e r e x po s u r e s t h a n m e n , t h e e x c e s sr i s k i n women may b e d u e t o c h a n c e .B a s e d o n o nl y f o ur c a s e s , t h i s s t u d y i n d i -c a t e d a n i n c r e a s e d r i s k o f H o d g k i n ' s d i s e a s eamong m en w o r k i n g i n r e c y c l e d p u l p a n dp a p e r p r o d u c t i o n . Th e r i s k o f H o d g k i n ' sd i s e a s e w a s i n c r e a s e d among e m p l o y e e s i np a p e r m i l l s i n a n A m e r i c a n c o h o r t s t u dy (SMR2 . 3 3 , 95% C I 0 . 7 5 t o 5 . 4 4 ) 6 a n d i n p r o p o r -t i o n a t e m o r t a l i t y a n d c a s e - c o n t r o l s t u d i e samong p u l p a n d p a p e r w o r k e r s . " " - l I n a C a n a -d i a n c a s e - c o n t r o l s t u d y , 4 ' H o d g k i n ' s d i s e a s ew a s s i g n i f i c a n t l y i n c r e a s e d among m en e x -p o s e d t o c e l l u l o s e , e i g h t c a s e s ( OR 4 . 2 , 90% C I2 . 0 t o 8 . 8 ) . C e l l u l o s e i s t h e m a j o r c o m p o n e n ti n p a p e r d u s t . 4 '

I n c o n c l u s i o n , t h i s s t u d y o f t h e r i s k o f c a n c e ri n t h e D a n i s h p a p e r r e c y c l i n g i n d u s t r y i n d i -c a t e d a n i n c r e a s e d r i s k o f p h a r y n g e a l c a n c e ra n d H o d g k i n ' s d i s e a s e i n m e n , a n d t o s o m ee x t e n t a l s o o f l u n g c a n c e r . H o w e v e r , d u e t o t h ef e w c a s e s , t h e r e s u l t s a r e o n l y s u g g e s t i v e .A l t h o u g h t h e c o h o r t i n c l u d e d m o r e t h a n 5 0 0 0p e o p l e , t h e n u m b e r s o f c a n c e r s o f s p e c i f i c s i t e sw e r e l o w a s t h e i n d u s t r y i s new a n d t h e f o l l o wu p p e r i o d s h o r t . F u r t h e r m o r e , s o m e m i s c l a s s i -f i c a t i o n o f d e p a r t m e n t o f w o r k may h a v e t a k e np l a c e a n d b i a s e d t h e r e s u l t s . F u r t h e r e v i d e n c eo f a p o s s i b l e r i s k o f c a n c e r i n t h e p a p e rr e c y c l i n g i n d u s t r y w i l l a w a i t a l o n g e r f o l l o w u po f t h e p r e s e n t c o h o r t a n d r e s u l t s f r o m o t h e rc o u n t r i e s . S u c h s t u d i e s a r e n e e d e d a s p a p e rr e c y c l i n g i s no w a n i m p o r t a n t i n d u s t r y .T h i s s t u d y w a s s u p p o r t e d f r o m g r a n t s No 9 1 - 7 5 9 0 a n d9 3 - 7 6 2 7 b y t h e D a ni s h C a n c e r S o c i e t y . TS p a r t i c i p a t e d i n t h ei n i t i a l p h a s e o f t he d a t a c o l l e c t i o n .

1 I n t e r n a t i o n a l A g e n c y f o r R e s e a r c h o n C a n c e r . IARC m o n o -g r a ph s o n t h e e v a l u a t i o n o f t h e c a r c i n o g e n i c r i s k o f c h e m i c a l s t oh u m a n s . W o o d , l e a t h e r a n d s o m e a s s o c i a t e d i n d u s t r i e s . L y o n :I A R C , 1 9 8 1 .

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R i s k o f c a n c e r among p a p e r r e c y c l i n g w o r k e r s2 V a i n i o H , H e s s o A , J a p p i n e n P . C h l o r i n a t e d d i o x i n s a n dd i b e n z o f u r a n s i n t h e e n v i r o n m e n t : a h a z a r d t o p u b l i ch e a l t h . S c a n d J 7 W o r k E n v i r o n H e al t h 1 9 8 9 ; 1 5 : 3 7 7 - 8 2 .3 R a p p e C . E n v i r o n m e n t a l s t a b l e c h l o r i n a t e d c o n t a m i n a n t sf r o m t h e p u l p a n d p a p e r i n d u s t r y . I n : V a i n i o H , S o r s a M,M c M i c h a e l A J , e d s . C o m p l e x m i x t u r e s a n d c a n c e r r i s k . L y o n :I n t e r n a t i o n a l A g e n c y f o r R e s e a r c h o n C a n c e r , 1 9 9 0 : 3 4 1 -5 3 . ( I A R C S c i P u b l v o l 1 0 4 . )4 F i e d l e r H , H u t z i n g e r 0 . D i o x i n s : s o u r c e s o f e n v i r o n m e n t a ll o a d a n d human e x p o s u r e . T o x i c o l o g i c a l a n d E n v i r o n m e n t a lC h e m i s t r y 1 9 9 0 ; 2 9 : 1 5 7 - 2 3 4 .5 K l e k o w s k i E , L e v i n DE. M u t a g e n s i n a r i v e r h e a v i l yp o l l u t e d w i t h p a p e r r e c y c l i n g w a s t e s : r e s u l t s o f f i e l d a n dl a b o r a t o r y m u t a g e n a s s a y s . E n v i r o n m e n t a l M u t a g e n e s i s1 9 7 9 ; 1 : 2 0 9 - 1 9 .6 T o r e n K , P e r s s o n B , W i n g r e n G . H e a l t h e f f e c t s o f w o r k i n gi n p u l p a n d p a p e r m i l l s : m a l i g n a n t d i s e a s e s . Am J f I n d Med1 9 9 6 ; 2 9 : 1 2 3 - 3 0 .7 G u p t a N , K e n n e t t R L . R e c y c l i n g a n d r e c y c l e d p a p e r .J A A ' I A 1 9 9 2 ; 2 6 7 : 3 3 3 3 - 4 .8 T h e D a n i s h M i ni s t r y o f E n v i r o n m e n t . E c o n o m y a n d p a p e rr e c y c l i n g . R e p o r t No 2 9 4 . C o p e n h a g e n : Th e D a n i s hM i n i s t r y o f E n v i r o n m e n t , 1 9 9 5 . ( I n D a n i s h . )9 R i x B A , L y n g e E . I n d u s t r i a l h y g i e n e m e a s u r e m e n t s i n a newi n d u s t r y : t he r e p u l p i n g a n d d e i n k i n g o f p a p e r w a s t e . AmJI n d Med 1 9 9 6 ; 3 0 : 1 4 2 - 7 .1 0 C o l e m a n M, D o u g l a s A , Hermon C , P e t o J . C o h o r t s t u d ya n a l y s i s w i t h a F o r t r a n c o m p u t e r p r o g r a m . I n t J E p i d e m i o l1 9 8 6 ; 1 5 : 1 3 4 - 7 .1 1 B r e s l o w NE, Day NE. S t a t i s t i c a l m e t h o d s i n c a n c e r r e s e a r c h .V o l I I . L y o n : I n t e r n a t i o n a l A g e n c y f o r R e s e a r c h o n C a n c e r ,1 9 8 7 .1 2 P r e s t o n D L , L u b i n J H , P i e r c e DA, McConney ME. E p i c u r e .S e a t t l e : H i r o s o f t , 1 9 9 3 .

1 3 R o b i n s o n C F , W a x w e i l e r R J , F o w l e r D P . M o r t a l i t y amongp r o du c t i o n w o r k e r s i n p u l p a n d p a p e r m i l l s . S c a n d J f W o r kE n v i r o n H e al t h 1 9 8 6 ; 1 2 : 5 5 2 - 6 0 .1 4 J a p p i n e n P , H a k u l i n e n T , P u k k a l a E , T o l a S , K u r p p a K .C a n c e r i n c i d e n c e o f w o r k e r s i n t h e F i n n i s h p u l p a n d p a p e ri n d u s t r y . S c a n d J W o r k E n v i r on H e al t h 1 9 8 7 ; 1 3 : 1 9 7 - 2 0 2 .1 5 H e n n e b e r g e r P K , F e r r i s J R B G , Monson R R . M o r t a l i t yamong p u l p a n d p a p e r w o r k e r s i n B e r l i n , Ne w H a m p s h i r e .B r J I n d Med 1 9 8 9 ; 4 6 : 6 5 8 - 6 4 .1 6 M a t a n o s k i G , K a n c h a n a r a k s a S . L a n t r y D . H e a l t h p r o f i l e o fl o n g - t e r m w o r k e r s i n t h e p u l p a n d p a p e r i n d u s t r y . B a l t i m o r e :J o h n s H o p k i n s U n i v e r s i t y , 1 9 9 5 .1 7 I n t e r n a t i o n a l A g e n c y f o r R e s e a r c h o n C a n c e r . IARC m o n o -g r a p h s o n t h e e v a l u a t i o n o f t h e c a r c i n o g e n i c r i s k o f c h e m i c a l s t oh u m a n s . T o b a c c o s m o k i n g . L y o n : I A R C , 1 9 8 6 .1 8 I n t e r n a t i o n a l A g e n c y f o r R e s e a r c h o n C a n c e r . IARC m o n o -g r a p h s o n t h e e v a l u a t i o n o f t h e c a r c i n o g e n i c r i s k o f c h e m i c a l s t oh u m a n s . A l c o h o l d r i n k i n g . L y o n : I A R C , 1 9 8 8 .1 9 L y n g e E , R i x B A , V i l l a d s e n E , A n d e r s e n I , H i n k M, O l s e nE , e t a l . C a n c e r i n p r i n t i n g w o r k e r s i n D e n m a r k . O c c u pE n v i r o n Med 1 9 9 5 ; 5 2 : 7 3 8 - 4 4 .2 0 A x e l s o n 0 . A s p e c t s o n c o n f o u n d i n g i n o c c u p a t i o n a l h e a l t he p i d e m i o l o g y . S c a n d J W o r k E n v i r o n H e a l t h 1 9 7 8 ; 4 : 8 5 - 9 .2 1 S c h w a r t z E . A p r o p o r t i o n a t e m o r t a l i t y r a t i o a n a l y s i s o f p u l pa n d p a p e r m i l l w o r k e r s i n Ne w H a m p s h i r e . B r J I n d Med1 9 8 8 ; 4 5 : 2 3 4 - 8 .2 2 D e c o u f l e P , S t a n i s l a w c z y k KA r e t r o s p e c t i v e s u r v e y o f c a n c e ri n r e l a t i o n t o o c c u p a t i o n . C i n c i n n a t i : US D e p a r t m e n t o fH e a l t h , E d u c a t i o n , a n d W e l f a r e , 1 9 7 7 .2 3 S t e w a r t P A , S c h a i r e r C , B l a i r A . C o m p a r i s o n o f j o b s , e x p o -s u r e s , a n d m o r t a l i t y r i s k s f o r s h o r t - t e r m a n d l o n g - t e r mw o r k e r s . J o u r n a l o f O c c u p a t i o n a l M e d i c i n e 1 9 9 0 ; 3 2 : 7 0 3 - 8 .

2 4 J a p p i n e n P , T o l a S . S m o k i n g among F i n n i s h p u l p a n d p a p e rw o r k e r s - e v a l u a t i o n o f i t s c o n f o u n d i n g e f f e c t o n l u n g c a n -c e r a n d c o r o n a r y h e a r t d i s e a s e r a t e s . S c an d J7 W o r k E n v i r o nH e a l t h 1 9 8 6 ; 1 2 : 6 1 9 - 2 6 .2 5 Menck HR , H e n d e r s o n B E . O c c u p a t i o n a l d i f f e r e n c e s i nr a t e s o f l u n g c a n c e r . J o u r n a l o f O c c u p a t i o n a l M e d i c i n e 1 9 7 6 ;1 8 : 7 9 7 - 8 0 1 .2 6 S o l e t D , Z o l o t h S R , S u l l i v a n C , J e w e t t J , M i c h a e l s D M. P a t -t e r n s o f m o r t a l i t y i n p u l p a n d p a p e r w o r k e r s . J o u r n a l o fO c c u p a t i o n a l M e d i c i n e 1 9 8 9 ; 3 1 : 6 2 7 - 3 0 .2 7 S i e m i a t y c k i J , R i c h a r d s o n L, G e r i n M, G o l d b e r g M, D e w a rR , D e s y M, e t a l . A s s o c i a t i o n b e t w e e n s e v e r a l s i t e s o f c a n-c e r a n d n i ne o r ga ni c d u s t s : r e s u l t s f r o m a n h y p o t h e s i s -g e n e r a t i n g c a s e - c o n t r o l s t u d y i n M o n t r e a l 1 9 7 9 - 8 3 . AmJE p id e m io l 1 9 8 6 ; 1 2 3 :2 3 5 - 4 9 .2 8 Thorn K , J a r v h o l m B , H a g b e r g S . Comment o n t h ei n t e r p r e t a t i o n o f J a p p i n e n e t a l c o n c e r n i n g i n c r e a s e d l u n gc a n c e r i n c i d e n c e among b o a r d m i l l w o r k e r s . S c a n d J W o r kE n v i r o n H e a l t h 1 9 8 8 ; 1 4 : 5 2 .2 9 I n t e r n a t i o n a l A g e n c y f o r R e s e a r c h o n C a n c e r . IARC m o n o -g r a p h s o n t h e e v a l u a t i o n o f t h e c a r c i n o g e n i c r i s k o f c h e m i c a l s t oh u m a n s . S o m e i n d u s t r i a l c h e m i c a l s . L y o n : I A R C , 1 9 9 4 .3 0 F i n g e r h u t MA, H a l p e r i n WE, M a r l o w D A , P i a c i t e l l i L A ,H o n c h a r P A , S w e e n e y MH, e t a l . C a n c e r m o r t a l i t y i nw o r k e r s e x po s e d t o 2 , 3 , 7 , 8 - t e t r a c h l o r o d i b e n z o - p - d i o x i n . NE n g l j M e d 1 9 9 1 ; 3 2 4 : 2 1 2 - 8 .3 1 B e c h e r H . , F l e s c h - J a n y s D , K a u p p i n e n T , K o g e v i n a s M,S t e i n d o r f K , Manz A , W a h r e n d o r f J . C a n c e r m o r t a l i t y i nGerman m a l e w o r k e r s e x p o s e d t o p h e n o x y h e r b i c i d e s a n dd i o x i n s . C a n c e r C a u s e s C o n t r o l 1 9 9 6 ; 7 : 3 1 2 - 2 1 .3 2 S a r a c c i R , K o g e v i n a s M, B e r t a z z i P - A , B u e n o d e M e s q u i t aB H , C o g g o n D , G r e e n LM, e t a l . C a n c e r m o r t a l i t y i nw o r k e r s e x p o s e d t o c h l o r o p h e n o x y h e r b i c i d e s a n d c h l o -r o p h e n o l s . L a n c e t 1 9 9 1 ; 3 3 8 : 1 0 2 7 - 3 2 .3 3 Bond GG, W e t t e r s t r o e m NH, R o u s h G J , McLaren E A ,L i p p s T E , Cook R R . C a u s e s p e c i f i c m o r t a l i t y amonge m pl o y e e s e n g a g e d i n t h e m a n u f a c t u r e , f o r m u l a t i o n , o rp a c k a g i n g o f 2 , 4 - d i c h l o r o p h e n o x y a c e t i c a c i d a n d r e l a t e ds a l t s . B r J t I n d Med 1 9 8 8 ; 4 5 : 9 8 - 1 0 5 .3 4 L e v i n L I , Gao Y - T , B l o t W J , Z h e n g W , F r a u m e n i J F .D e c r e a s e d r i s k o f l u n g c a n c e r i n t h e c o t t o n t e x t i l e i n d u s t r yi n S h a n g h a i . C a nc e r R e s 1 9 8 7 ; 4 7 : 5 7 7 7 - 8 1 .3 5 H e n d e r s o n V , E n t e r l i n e P E . An u n u s u a l m o r t a l i t ye x p e r i e n c e i n c o t t o n t e x t i l e w o r k e r s . J o u r n a l o f O c c u p a t i o n a lM e d i c i n e 1 9 7 3 ; 1 5 : 7 1 7 - 9 .3 6 E n t e r l i n e P E , K e l e t i G . S y k o r a J L , L a n g e J H . E n d o t o x i n s ,c o t to n d us t a n d c a n c e r . L a n c e t 1 9 8 5 ; i i : 9 3 4 - 5 .3 7 M i l h a m S , D e m e r s R Y M o r t a l i t y among p u l p a n d p a p e rw o r k e r s . J o u r n a l o f O c c u p a t i o n a l M e d i c i n e 1 9 8 4 ; 2 6 : 8 4 4 - 6 .3 8 S o l e t D , Z o l o t h S R , S u l l i v a n C , J e w e t t J . M i c h a e l s D M. P a t -t e r n s o f m o r t a l i t y i n p u l p a n d p a p e r w o r k e r s . J o u r n a l o fO c c u p a t i o n a l M e d i c i n e 1 9 8 9 ; 3 1 : 6 2 7 - 3 0 .3 9 Milham S . O c c u p a t i o n a l m o r t a l i t y i n W a s h i n g t o n s t a t e1 9 5 0 - 7 9 , U S . C i n c i n n a t i : US D e p a r t m e n t o f H e a l t h a n dHuman S e r v i c e s , 1 9 9 3 .4 0 P e r s s o n B . F r e d r i k s s o n M, O l s e n K , B o e r y d B , A x e l s o n 0 .Some o c c u pa t i o na l e x po s u r e s a s r i s k f a c t o r s t o m a l i g n a n tl y m p h o m a s . C a n c e r 1 9 9 3 ; 7 2 : 1 7 7 3 - 8 .4 1 M i l h a m S , H e s s e r J E . H o d g k i n ' s d i s e a s e i n w o o d w o r k e r s .L a n c e t 1 9 6 7 ; 1 5 : 1 3 6 - 7 .4 2 S i e m i a t y c k i J . R i s k f a c t o r s f o r c a n c e r i n t h e w o r k p l a c e . B o c aR a t o n : C R C P r e s s , 1 9 9 1 .4 3 S a h l e W , S a l i s t e n G . Thorn K . C h a r a c t e r i z a t i o n o f a i r b o r n ed u s t i n a s o f t p a p e r m i l l . Ann O c c u p Hy g 1 9 9 0 ; 3 4 : 5 5 - 7 5 .

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