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120


EVALUATION OF CONFOUNDING BY CIGARETTE SMOKING

An evaluation of the effect of confounding by cigarette smoking for cancer of
the trachea, bronchus, .and lung was done for the major occupational groupings,
using a method suggested by Axelson (36) (Appendix K)- This method utilizes
independently collected data on smoking rates in the major occupational
groupings (37) and on lung cancer risk ratios for smokers and ex-smokers (38)
to calculate sMORs adjusted for differences in cigarette smoking among the
major occupational groupings. Certain limitations of this analysis should be
pointed out:

1) This is an indirect method. The smoking rates used were not
determined from the population under study, and therefore could be erroneous.

2) Age-specific data for the risk ratios for smokers and ex-smokers was
not available. Therefore the same risk ratios were used for all 5-year age
groups.

3) Reliable age-specific smoking rates were not available for ages 65
and over, so the analysis was restricted to ages 20-64.

4) The analysis is relatively simplistic, not taking into account
factors such as number of cigarettes smoked per day, degree of inhalation, age
began smoking, years since last smoked for ex-smokers, etc.

On the positive side, this analysis is relatively simple to perform, and given
the data at hand, is the only practical way to attempt to adjust for the
effect of cigarette smoking. It can be a valuable exercise if the results are
interpreted with the limitations kept in mind.

22


CODE

128
129
130
131
132
133

134
135
136
137
138

139
140
141
142
143
144
145
146
147
148
149
150

151
152
153
154
155
156

157
158
159
160
161
162
163
164
165
166
167
168
169
170
171
172
173
174
175
176

TITLE

cabinetmakers

carpenters

cement and concrete finishers, cement workers
compositors and typesetters

cranemen, derrickmen and hoistmen
decorators and window dressers; interior
decorators

electricians

electricians, shipyard

electrotypers and sterotypers

engravers, except photengravers

heavy equipment, construction equipment
operators

railroad foreman

construction foremen, etc. NEC

foremen NEC

forgemen and haimermen

furriers

glaziers, glass workers

heat treaters, annealers, temperers
inspectors, railroad

inspectors NEC

jewelers, watchmakers, silversmiths
jobsetters and die setters, metal
linemen, servicemen and installers-telegraph,
telephone, power (utility and gas)
locomotive engineers (railroad)
locomotive firemen

precision machine operatives

machinists NEC

machinists, shipyard

mechanics and repairmen, air conditioning,
heating, refrigeration appliances
mechanics and repairmen, airplane
mechanics and repairmen, automobile
mechanics and repairmen, automobile body
mechanics and repairmen, radio, television
mechanics and repairmen, railroad and car shop
loom fixers

mechanics and repairmen NEC

millers, grain

millwrights

molders, metal

motion picture projectionists

opticians; lens grinders and polishers
painters, construction and maintenance
painters, sign

painters, auto

painters, shipyard

pattern and model makers, metal
paperhangers

piano and organ tuners and repairmen
plasterers and lathers

151

CENSUS copg*

410
4ll
413
414
415
420

421
422
423
424
425,676

427

429

430

431

387
434,1321-323
435

447

450
451,1387,1391,1396
452

453

454
460
(650-653)
465
467
470

471
472
(472)
474
475
(483)
480
490
491
492
493
494
495
694

502
501
504
505

a
a
*

WWERWA AR AWHYERWERWERWYWWAW WHWWWWW WWWWWWWBWNYNUww WHWuUwWW woveee |


APPENDIX E

CAUSE OF DEATH CATEGORIES

CAUSE OF DEATH

malignant neoplasms

buccal cavity and pharynx

tongue

Salivary gland

mouth

pharynx

tonsils

digestive organs and peritoneum
esophagus

stomach

small intestine

large intestine and rectum

large intestine, except rectum
cecum, appendix, and ascending colon
transverse colon

descending colon

sigmoid colon

rectum and rectosigmoid junction
rectosigmoid junction

rectum

biliary passages and liver

liver

gallbladder, ducts, ampulla of vater
pancreas

peritoneum and retroperitoneal tissue
respiratory system

nose and nasopharynx

sinuses

larynx

trachea, bronchus, and lung

pleura and mediastinum

bone

connective and other soft tissue
malignant melanoma of skin

skin, other malignant neoplasms of
breast

prostate

testis

urinary organs

bladder

kidney

eye

brain and nervous system

brain

thyroid

supra-renal gland

secondary malignant neoplasms
multiple malignant neoplasms
lymphatic and hematopoietic tissue
lymphomas

ODMIKHRUBRWNH

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146

ICDA CODES

140-209
140-149
141

142
143-145
146-149
146.0
150-159
150

151

152
153-154
153.0-153.8
153.0
153.1
153.2
153.3

154

154.0
154.1
155-156
155.0

156

157

158
160-163
147,160.0
160.2,160.8,160.9
161

162
163.0,163.1
170

171

172

173

174

185

186
188-189
188
189.0,189.1
190
191-192
191

193

194.0
196-198
199.0
200-209
200-202


OCCUPATIONAL CHARACTERISTICS OF
CANCER VICTIMS IN MASSACHUSETTS
1971-1973

Robert Dubrow, M.D., Ph.D. and David H. Wegman, M.D.
Occupational Health Program
Harvard School of Public Health
665 Huntington Avenue
Boston, Massachusetts 02115

Purchase Order No. 81-1233

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Public Health Service
Centers for Disease Control
National Institute for Occupational Safety and Health

Division of Surveillance, Hazard Evaluations, and Field Studies

Cincinnati, Ohio 45226

September 1984


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116


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65


62
63
64
65

66

68
69

70
71
72
73

74

76
77

79
80
81
82
83
84
86
87
88

89

TITLE

hurses, professional

optometrists

pharmacists, druggists

photographers

physicians and surgeons

radio operators

recreation workers

religious workers

social and welfare workers, except group
economists, business consultants, analysts
psychologists, psychiatrists
statisticians and actuaries

sports instructors and officials
surveyors

vocational and educational counsellors
school administrators, elementary and
secondary school

teachers, elementary and secondary school
technicians, medical and dental
technicians, electrical and electronic
technicians, other engineering and physical
sciences

technicians NEC

therapists and healers NEC

veterinarians

students

MANAGERS, OFFICIALS, PROPRIETORS, EXCEPT FARM

assessors

treasurers, financial managers, bank officers

florists

buyers and shippers, farm products; produce
brokers

conductors, railroad

credit men

funeral directors

health administrators

hotel, motel owners, Managers, etc.

inspectors, investigators, public administra-

tion

managers and superintendents, building
newspaper owners, publishers, managers, etc.
officers-pilots-~pursers-engineers, ship
officials and administrators NEC, public
administration

officials, lodge, society, union, etc.
personnel and labor relations workers
postmasters

public relations men

public utility supervisors, officials,
Managers, etc.

purchasing agents and buyers; brokers NEC

149

#
CENSUS CODE

150
152
160
161
162
164
165
170
171
172
173
174
180
181
(174)
(240)

182
185
190
191

192
193
194
196

(202)
249
251

252
253
104
(212)
819
260

262
O76
265
270

275
154
280
163
364

285

Ito
la
*

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76


CLASSIFICATION SCHEMES

CAUSE OF DEATH CATEGORIES

Sixty-two malignancy categories (including overlapping categories) and
cirrhosis of the liver were investigated. All other causes of death were
grouped together into the “auxiliary causes of death" category, which was used
as the auxiliary cause of death group in the mortality odds ratio analyses
(see "METHODS OF ANALYSIS" section). Appendix E presents the cause of death
categories by their International Classification of Diseases (eighth revision)
codes.

We felt that it was desirable to do as detailed an investigation as possible
with respect to type and anatomic site of cancer. This is because many
carcinogens are known to have a high degree of target specificity. Thus the
classification system used in this study is as detailed as that used in any of
the other studies. At the same time, information would be lost by not
collapsing the most specific categories into broader categories, so this was
done as well. For example, reticulum cell sarcoma, lymphosarcoma, and
Hodgkin's disease were investigated individually, and were also collapsed,
along with unspecified and other lymphomas into the broader category of
lymphomas.

For some of the more specific cause of death categories, the potential for
bias is particularly noteworthy. For example, of the 1674 subjects who are

classified into the broader category large intestine, except rectum (ICD
153-0-153.8) only 536 are classified into the more specific categories of
cecum, appendix, and ascending colon (ICD 153.0), transverse colon (ICD

153.1), descending colon (ICD 153.2), or sigmoid colon (ICD 153.3). The

remainder are classified into the non-specific category large intestine
(including colon), part unspecified (ICD 153.8).

We do not know what factors determine whether a death certificate cause of
death statement will give the more specific or less specific diagnosis.
However, we would postulate that the probability of receiving a more specific
diagnosis would be social class, and therefore, occupation, dependent.

OCCUPATIONAL CODE

In designing the occupational code, we attempted to make the occupational
categories as homogeneous as possible, so as not to dilute or cancel out
possible effects. At the same time, we created grouped codes of occupations
which are likely to have similar exposures. ‘These provide the advantage of
larger numbers for analysis. :

Every subject is classified into one of 321 individual occupational categories
(Appendix F). (This includes industrial classifications (e.g., rubber
workers, shoe factory workers, fabricated metal products workers not elsewhere
classified (NEC)) as well as strictly occupational classifications such as
machinists. For simplicity, we are including "industrial" within the term

12


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125


C 5, 350 MACHINISTS AND RELATED OCCUPATIONS

Stomach Trachea, bronchus, and lung
age 20-54

Occupation Observed Expected sMOR_ Observed Expected sMOR
149 jobsetters and

diesetters, metal od S - 1 1 -
153 precision machine

operatives 3 3 96 3 2 172
154 machinists NEC 39 32 122 27 ab} 184++
155 machinists, shipyard 2 1 144 2 fo) -
165 millwrights 1 2 61 2 2 107
173 pattern and model

makers, metal 2 1 303 ie} 1 0
192 tool and die makers 9 5 176 8 3 269+
224 filers, grinders and

polishers, metal;

metal cutters 6 3 181 1 3 29
350 machinists and rela-

ted occupations 62 47 131+ 44 26 1714+

C 6. 351 PRINTING TRADES

Buccal cavity and pharyx

Occupation Observed Expected sMOR
131 compositors and typesetters 3 1 438
136 electrotypers and sterotypers 1 (0) -
177 photoengravers, lithographers,

and composers - - -
181 pressmen and plate printers, printing 9 4 257++
208 printing and publishing workers NEC 2 1 186-—-
351 printing trades 15 6 2524+

C 7, 359 WELDERS (expanded)
Prostate

Occupation Observed Expected sMOR
123 boilermakers 4 1 295
261 welders and flame cutters 9 4 244+
263 welders, shipyard 1 0 -
359 welders (expanded) 14 5 256++

131




Occupation

Deliverymen

Dentists

Derrickmen

Designers

Detectives

Die makers

Die setters, metal

Dieticians

Dishwashers

Dispatchers, vehicle

Doorkeepers

Draftsmen

Drivers NEC

Druggists

Drycleaning operatives, owners,
managers

Dyers

E

Economists

Editors

Egg farmers

Electrical machinery, equipment,
supplies workers NEC

Electricians

Electricians (expanded)

Electricians, shipyard

Electronic machinery, equipment,
supplies workers NEC

Electroplaters

Electrotypers

Elevator operators

Embalmers

Engineers

Engineers NEC

Engineers, chemical

Engineers, civil

Engineers, construction

Engineers, electrical

Engineers, industrial

Engineers, locomotive (railroad)

Engineers, marine

Engineers, mechanical

Engineers, metallurgical

Engineers, sales

Engineers, ship

Engravers, except photoengravers

Individual

Code Grouped Codes
222 372
23 330,331
132 352
24 336
288
192 350,361
149 350,361
25 330,331
274 368,383
101
287
26 322,324,325,329
257 372
48 330,331
230
223 365,378
55 325,329,341
27 337
296 389,391
205
134 345,387
345
135 345,377,395
205
225 361
136 351
275
39 328,329,342
323
36 323,324,325,329
28 323,324,325,327,329
29 323 324,325,329 ,385,387
29 323,324,325,329,385,387
30 323,324,325,329
31 . 323,324,325,329
151 354,356
33 323,324,325,329
32 323 ,324,325,329
34 323,324,325,327,329
35 323,324,325,329
82 371
137 361

175


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REFERENCES

1- Milham, S. 1976. NIOSH Research Report: Occupational Mortality in
Washington State 1950-1971. Vol. 1-3. National Institute for Occupational
Safety and Health (HEW Publication No. (NIOSH) 76-175), Cincinnati.

2. Petersen, G-R., Milham S. 1980. NIOSH Research Report: Occupational
Mortality in the State of California 1959-1961. National Institute for
Occupational Safety and Health (DHEW (NIOSH) Publication No. 80-104),
Cincinnati.

3. Registrar General. 1978. Decennial Supplement for England and Wales,
1970-72: Occupational Mortality. Her Majesty's Stationery Office, London.

4. Guralnick, L. 1963. Mortality by Occupation and Cause of Death Among Men
20 to 64 Years of Age, United States, 1950. Public Health Service (Vital
Statistics - Special Reports 53: numbers 1-5), Washington, D.C.

5. Williams, R.R., Stegens, N.L., Goldsmith, J.R. 1977. Associations of
cancer site and type with occupation and industry from the Third National
Cancer Survey Interview. J. Natl. Cancer Inst. 59:1147-1185.

6. Menck, H-R-, Mack, T.M. 1979. A proportional analysis of the anatomic
site distribution of cancer by occupation, males - Los Angeles County
1972-1977. Unpublished.

7. Decoufle, P., Stanislawczyk, K., Houten, L. Bross, I.D.J., Viadana, E.
1977. NIOSH Research Report: A Retrospective Survey of Cancer in Relation to

Occupation. National Institute for Occupational Safety and Health (DHEW
(NIOSH) Publication No. 77-178), Cincinnati.

8. Gute, D.M. 1981. The Association of Occupation and Industry with
Mortality in Rhode Island (1968-1972). Rhode Island Department of Health
(echnical Report No. 23, Health Planning and Development), Providence.

9. Registrar General. 1971. Decennial Supplement, England and Wales, 1961:
Occupational Mortality Tables. Her Majesty's Stationery Office, London.

10. Registrar General. 1972. Statistical Review of England and Wales for
the Two Years 1966-67. Supplement on Cancer.. Her Majesty's Stationery
Office, London.

ll. Registrar General. 1975. Statistical Review of England and Wales for

the Three Years 1968-70. Supplement on Cancer. Her Majesty's Stationery
Office, London.

12. Kendrick, M., Fuentes, R.- 1967. Occupational Characteristics of
Disabled Workers, by Disabling Condition: Disability Insurance Benefit Awards
Made in 1959-1962 to Men Under Age 65. Public Health Service and Social
Security Administration (PHS Publication No. 1531), Washington, D.C.

36


212 assemblers NEC

358 Foundry workers (expanded)

166 molders, metal
228 foundry workers NEC

359 Welders (expanded)

123 boilermakers
261 welders and flame cutters
263 welders, shipyard

360 Heated metal workers

122 blacksmiths

142 forgemen and hammermen

145 heat treaters, annealers, temperers
229 furnacemen, smeltermen and pourers
358 foundry workers (expanded)

359 welders (expanded)

361 Metal workers

137 engravers, except photoengravers

188 structural metal craftmen

190 tinsmiths, coppersmiths, and sheet metal workers
204 fabricated metal product workers NEC

206 primary metal industry workers NEC

225 electroplaters

244 steelworkers, wire workers

350 machinists and related occupations

360 heated metal workers

362 Paper workers (expanded)

240 paper, pulp mill workers
241 paperboard container and box factory workers

363 Leather product workers
185 shoemakers and repairers
249 shoe factory workers

250 factory workers, other leather goods

364 Leather and leather product workers

251 leather workers, tanners
363 leather product workers

365 Textile workers (expanded)

162 loom fixers
223 dyers
252 rope makers

161


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SOCIAL CLASS

DISEASE


groupings which might have substantial occupational exposures (craftsmen,
foremen, and kindred workers; operatives) had high sMORs after smoking
adjustment. The discrepancy for laborers (except farm) could be explained if
all of the results for this group were generally underestimated due to a high
mortality rate in the auxiliary disease group, as discussed earlier. In fact,
many of the results for this grouping seemed to be lower than one might
expect. The discrepancy for clerical and kindred workers is not readily
explainable.

A similar exercise in smoking adjustment was performed on data from California
deaths 1949-51 (27). Managers, and possibly professional and clerical workers
had fewer lung cancer deaths than expected by their smoking habits, while
laborers and service workers (mainly due to cooks) had more lung cancer deaths
than expected.

Doll and Peto have estimated that roughly 15 percent of the cases of lung
cancer in the United States can be attributed to occupational factors,
although they think that this estimate might be on the high side (71). They
propose a large scale national case-control study of lung cancer to address
this issue. We strongly support this proposal.

COMMENTS ON SELECTED ASSOCIATIONS
Truck and tractor drivers

Truck and tractor drivers (the vast majority being truck drivers) exhibited
cancer excesses over’ the entire respiratory system and upper alimentary tract
- buccal cavity and pharynx; esophagus; nose and nasopharynx; larynx; and
trachea, bronchus, and lung. The excesses for esophagus; nose and
nasopharynx; and trachea bronchus and lung were highly significant in both the
social class adjusted and unadjusted analyses (Appendix B), and the chi-square
value for respiratory cancers was the highest for any occupation-cancer
combination in the study with five or more observed deaths. The generalized
lung cancer excesses among other vehicle drivers (Appendix C.13), although not
as extreme, provides additional support for the association.

These excesses can be due to lifestyle (cigarette smoking and alcohol
consumption), occupational exposure to gasoline and diesel engine exhaust, or
a combination of the two. Cigarette smoking is causally related to all of the
above cancers, and truck drivers have been reported to be heavy cigarette
smokers (37). Alcohol consumption is causally related to cancers of the
buccal cavity and pharynx and esophagus. The excess of cirrhosis of the liver
seen in this study suggests excessive alcohol consumption among truck
drivers. On the other hand, diesel exhaust has been reported to contain
carcinogenic substances (72). Furthermore, the excess of lung cancer among
truck drivers seen in the Third National Cancer Survey study remained
unchanged after controlling for cigarette smoking based upon smoking histories
for each subject. Given the highly significant excesses and the support that
these. results have from other studies (especially for the lung cancer excess)
(Appendix A, Table 5), further investigation is clearly needed.

32


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270 barbers
285 hairdressers and cosmetologists

381 Hospital workers (expanded)

267 attendants, hospital
284 practical nurses

382 Bar workers

92 cocktail bar, tavern, owners, managers
271 bartenders

383 Restaurant workers (expanded)

91 restaurant and cafe owners, managers

273 cooks, chefs (except private household)
274 dishwashers

279 kitchen workers, restaurant employees NEC
290 waiters

384 Custodial, maintenance, cleaning workers

80 managers and superintendents, building

272 cleaners

276 housekeepers and stewards, except private households
277 window cleaners

278 janitors, sextons, maintenance workers

280 school custodians

385 Construction workers, management

29 engineers, civil and construction
126 building contractors, construction contractors

386 Construction workers (expanded)

140 construction foremen, etc. NEC
314 construction laborers NEC -
315 road construction and maintenance workers

387 Construction trades (all)

125 brickmasons, stonemasons, tile setters

129 carpenters

130 cement and concrete finishers; cement workers
134 electricians

138 heavy equipment, construction equipment operators
169 painters, construction and maintenance

174 paperhangers

176 plasterers and lathers

179 plumbers and pipefitters

183 roofers and slaters

191 floor layers, installers, workers

164


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123


APPENDIX A

ELEVATED AGE-STANDARDIZED MORTALITY ODDS RATIOS
BY OCCUPATION COMPARED WITH OTHER STUDIES

This table presents significant occupation-cancer associations, as well as
associations of borderline significance (defined below), for the 397
occupational categories and the 10 major occupational groupings. It also
compares these results with the results from the other studies listed in Table
1. The comparison is a qualitative one using symbols, so that one can quickly
assess to what degree a finding in the present study is supported by results
from other studies. "+" indicates that the result was significant in the
other study; "=" indicates that the result was of borderline significance; "-"
indicates that the result was elevated, although not significant or borderline
significant; and "0" indicates that there was no support for the finding in
the other study. If the particular occupation- cancer combination was not
examined in the other study or if there were no observed deaths, the entry was
left blank. The entry was also left blank if there was one observed death and
a mortality ratio greater than 100. Results are presented in occupational
code order. The results for the major occupational groupings are presented at
the end of the table. The number directly after the occupational category
title is the number of subjects who are classified into that category.

To be eligible for this table, an occupation-cancer association had to be
significant (p < .05) or borderline significant in one or more of the age
groupings 20-54, 20-64, 20-74, 55-74, and 20+ in either the standard or the
social class adjusted analysis. [A small number of entries in the table did
not fit these criteria. They were sub-classifications of broader cancer
classifications which did meet these criteria. (For example, leukemia and
aleukemia is a sub-classification of lymphatic and hematopoietic tissue).
They were included in the table because their sMORs were also raised and were
directly comparable to cancer categories in some of the other studies which
did not present data for the broader classification. Such entries are
enclosed in parentheses (e.g., (bladder) under code 36 "engineers NEC").]

For the sake of brevity, under a given occupational code, redundant results
were omitted from the table. For example, both "brain and nervous system" and
"brain" are significantly elevated under individual code 1 "accountants and
auditors". The results for cancer of the brain were omitted from the table.
In these Situations, the authors used their judgement as to which results
would be of most interest.

42


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CAUSE OF DEATH

51
52
53
54
55
56
57
58
59
60
61
62
63
64

reticulum cell sarcoma
lymphosarcoma

Hodgkin's disease
multiple myeloma

leukemia and aleukemia
lymphatic leukemia, acute
lymphatic leukemia, chronic
myeloid leukemia
monocytic leukemia

acute erythremia
polycythemia vera
myelofibrosis

cirrhosis of the liver
auxiliary causes of death

147

ICDA CODES

200.0

200.1

201

203

204-207

204.0

204.1

205

206

207.2

208

209

571

000-136, 210-570,
572-999 .


40. Ernster, V.L., Selvin, S., Brown, S.M., Sacks, S.T., Winkelstein, W.,
Austin, D.F 1979. Occupation and prostatic cancer: a review and
retrospective analysis based on death certificates in two California
counties. J. Occupational Medicine 21:175-183.

41. Sparks, P.J., Wegman, D.H. 1980. Cause of death among jewelry workers.
J. Occupational Medicine 22:733-736.

42. Hueper, W.-C. 1969. Occupational and Environmental Cancers of the
Urinary System. Yale University Press, New Haven.

43. Cole, P., Hoover, R., Friedell, G.H. 1972. Occupation and cancer of the
lower urinary tract. Cancer 29:1250-1260.

44. Howe, G-R., Burch, J.D., Miller, A.B., Cook, G.M., Esteve, J.,
Morrison, B., Gordon, P., Chambers, L.W., Fodor, G., Winsor, G.M. 1980.
Tobacco use, occupation, coffee, various nutrients, and bladder cancer. J.
Natl. Cancer Inst. 64:701-713.

45. McMichael, A.J., Spirtas, R., Kupper, L.L., Gamble, J.F. 1975. Solvent
exposure and leukemia among rubber workers: an epidemiologic study.
J. Occupational Medicine 17: 234-239.

46. Aksoy, M., Erdem, S., DinCol, G. 1974. Leukemia in shoeworkers exposed
chronically to benzene. Blood 44:837-841.

47. Wynder, E.L., Onderdonk, J., Mantel, N. 1963. An epidemiological
investigation of cancer of the bladder. Cancer 16:1388-1407.

48. Dunham, L.J., Rabson, A.S., Stewart, H.L., Frank, A.S., Young, J.L.
1968. Rates, interview, and pathology study of cancer of the urinary bladder
in New Orleans, Louisiana. J. Natl. Cancer Inst. 41:683-709.

49. Anthony, H.M., Thomas, G.M. 1970. ‘Tumors of the urinary bladder: an
analysis of the occupations of 1,030 patients in Leeds, England. J. Natl.
Cancer Inst. 45:879-895.

50. Milham, S- 1978. NIOSH Research Report: Mortality Experience of the
AFL-CIO United Brotherhood of Carpenters and Joiners of America 1969-1970 and

1972-1973. National Institute for Occupational Safety and Health (DHEW
(NIOSH) Publication No. 78-152), Cincinnati.

51. Kaminski, R., Geissert K.S., Dacey, E. 1980. Mortality analysis of
plumbers and pipefitters. J. Occupational Medicine 22:183-189.

52. Decoufle, P- 1978. Further analysis of cancer mortality patterns among
workers exposed to cutting oil mists. J. Natl. Cancer Inst. 61:1025-1030.

53. Jarvholm, B., Lillienberg, L., Sallsten, G., Thiringer, G., Axelson, 0.

1981. Cancer morbidity among men exposed to oil mist in the metal industry.
J. Occupational Medicine 23:333-337.

39


334

335

336

337

338

339

340

341

60 vocational and educational counsellors
61 school administrators, elementary and secondary school
62 teachers, elementary and secondary school

School professions

69 students
332 teachers and administrators, college and university
333 teachers and administrators, elementary and secondary school

Religious workers (expanded)

13 clergymen
53 religious workers

Artists (expanded)

7 artists and art teachers
24 designers
49 photographers
133 decorators and window dressers; interior decorators

Writers (expanded)

10 authors and writers
27 editors and reporters, journalists

Musical workers

42 musicians and music teachers
175 piano and organ tuners and repairmen

Entertainers (expanded)

3 actors, radio announcers, TV announcers
8 athletes

35 entertainers NEC
42 musicians and music teachers

Athletes (expanded)

8 athletes
52 recreation workers
58 sports instructors and officials

Financial workers

1 accountants and auditors

55 economists, business consultants, analysts
70 assessors

71 ‘treasurers, financial managers, bank officers
75 credit men
119 stock and bond salesmen, counsellors, etc.

158


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79


NGS

Occupational Characteristics of
Cancer Victims in Massachusetts

1971-1973

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Public Health Service

Centers for Disease Control

National Institute for Occupational Safety and Health


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Individual

Qccupation Code Grouped Codes
Maintenance workers 278 384
Maintenance, railrcad 235 355,356
Managers NEC 93
Manufacturers representatives. 115
Marine Corps, officers and enlisted

men 196 370
Market managers 97 368
Marshalls 288
Material handlers 307 388
Material handlers (expanded) 388
Mathematical professions 325
Mathematical, scientific and

technical professions 329
Meat cutters, except slaughter and

packing house 231 373
Meat processing workers 373
Mechanics and repairmen (all) 349
Mechanics and repairmen NEC 163 349
Mechanics and repairmen, air

conditioning 156 349
Mechanics and repairmen, airplane 157 348 ,349
Mechanics and repairmen, automobile 158 348,349
Mechanics and repairmen, automobile

body 159 348,349
Mechanics and repairmen, heating 156 349
Mechanics and repairmen, radio 160 349
Mechanics and repairmen, railroad

and car shop 161 348,349,355 ,356
Mechanics and repairmen, refriger-

ation appliances 156 349
Mechanics and repairmen, television 160 349
Mechanics and repairmen, vehicle 348
Medical workers 331
Merchant marine 200 371
Messengers 105
Metal products workers, fabricated

NEC 204 361
Metal workers 361
Millers, grain 164 368
Milliners 233 366
Millworkers 264 369
Millwrights 165 350,361
Model makers, metal 173 350,361
Molders, metal 166 358 ,360,361,379
Motel managers, owners, etc. 78
Movers, moving truck drivers 259 372,388
Music teachers 42 338,339
Musical workers 338
Musicians 42 338 ,339

179


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128


APPENDIX G

GROUPED OCCUPATIONAL CODES

322 Architects and draftmen

6 architects
26 draftsmen

323 Engineers

17 professors/instructors, engineering
28 engineers, chemical

29 engineers, civil and construction
30 engineers, electrical

31 engineers, industrial

32 engineers, mechanical

33 engineers, marine

34 engineers, metallurgical

35 engineers, sales

36 engineers NEC

324 Architects, draftsmen, and engineers

322 architects and draftsmen
323 engineers

325 Mathematical professions

1 accountants and auditors
18 professors/instructors, mathematics
22 computer and data processing specialists
55 economists, business consultants, analysts
57 statisticians and actuaries
59 surveyors
322 architects and draftsmen
323 engineers

326 Life and physical scientists

11 chemists

15 professors/instructors, biological sciences

16 professors/instructors, chemistry sciences

19 professors/instructors, physics

43 agricultural scientists

44 physicists

45 miscellaneous natural scientists and researchers

327 Chemists (expanded)

11 chemists
16 professors/instructors, chemistry sciences

156


ABSTRACT

This study examines cancer mortality patterns by occupation for white males in
the state of Massachusetts using death records for the years 1971-1973. Its
purpose is to identify occupation-cancer associations which, when interpreted
in conjunction with results from other studies and hypotheses about potential
occupational carcinogens, can serve as leads for more definitive etiological
investigations.

Sixty-two malignancy categories (including grouped categories) were
investigated for each of 397 occupational categories (including grouped

categories) using an age-standardized mortality odds ratio approach. Results
were adjusted for the effects of social class.

The results were compared with those of eleven other similar surveillance type
studies, as well as with other studies from the literature. The most
significant finding was the confirmation of lung cancer excesses among a large
number of occupations for which there are reasonable hypotheses as to possible
carcinogenic exposures, including truck drivers, painters, machinists,
automobile mechanics, plumbers, cooks, fishermen, heated metal workers, sheet
metal workers, and brickmasons, stonemasons, and tile setters.

This report was submitted in fulfillment of purchase order no. 81-1233 by the

Harvard School of Public Health under the sponsorship of the National
Institute for Occupational Safety and Health.

iii


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106


TABLE 4

SOME OCCUPATION-CANCER ASSOCIATIONS (OTHER THAN LUNG CANCER)

SUPPORTED BY STUDIES IN THE LITERATURE OTHER THAN THOSE IN TABLE 1*

Occupation

iL

131

148

202

243

249

251

285

331

344

347

350

351

359

389

393

chemists
compositors and typesetters

jewelers, watchmakers, silver-
smiths

chemical workers

xcubber workers

shoe factory workers

leather workers, tanners
hairdressers and cosmetologists
medical workers

carpenters (expanded)

plumbers (expanded)

machinists and related
occupations

printing trades
welders (expanded)
farmers

large employer B - abrasives
products

Cancer
Pancreas
prostate

Pancreas

bladder

myeloid leukemia
leukemia and aleukemia
bladder

bladder

bladder

stomach, leukemia, multiple
myeloma

esophagus, lymphatic and
hematopoietic tissue

stomach, large intestine,
and other digestive system

bladder

buccal cavity and pharynx
prostate

multiple myeloma

large intestine and rectum

References
(39)
(40)

(a1)*

(42-44)
(45)

(46)

(43),
(4447-49)
(44,49)

(50)
(51)
(27 52,53)

(44,48,49)
(54,55)
(56)

(57)

(sa) *

* This table was not based upon a thorough literature search , but upon the
author's current knowledge of the literature (Pebruary, 1982).

# The death certificate data used in these studies and this report overlap.

27


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8l


would expect that they would be more likely to be diagnosed accurately in
sindividuals who had access to the best diagnostic facilities, thus introducing
biases in the results.

Another problem with the use of death certificates for occupational cancer
studies is that ideally one would want.to know about all incident cancer
cases, not just those whose underlying cause of death was stated to be cancer
on the death certificate. Using mortality data, as opposed to incidence data,
introduces potential biases with respect to differential cure rates for
various types of cancer across occupations - again, due to unequal access to
high quality medical treatment.

A related problem is the assignment of underlying cause of death in a patient
with more than one major medical problem. Often, such an assignment is
arbitrary. However, if the probability of assigning a cancer as opposed to
another cause is the same from occupation to occupation, no bias will result
from this problem. No attempt was made in this study, or in any of the
previous studies which used death certificate data, to utilize information on
the death certificates with regard to secondary causes of death. This would
be a worthwhile project for future studies.

OCCUPATIONAL INFORMATION

No systematic attempt was made to assess the accuracy of the occupational
statement on Massachusetts death certificates. However, some limited
information is available from previous work done by the authors:

1) Ninety-one percent of the 423 death certificates for all of the active and

retired workers from a single large manufacturing plant who died from 1971 to
1973 in Massachusetts listed the correct name of the employer as the industry
or business (unpublished data).

2) In a study of oat cell lung cancer, 75 percent of the death certificate
statements of usual occupation corresponded with the information obtained
from interviews of next of kin (25).

The England and Wales 1959-63 and 1970-72 studies and the United States study
did direct comparisons, for a sample of the study population, between the
occupation reported on the death certificate and that reported in the census.
The United States study of deaths in 1950 found,71 percent to be reported in
the same major occupational group on the death certificate and the 1950 census
report, with only 61 percent in the same detailed occupational category.
However, some of the discrepancy would be explained by the fact that the death
certificate lists the decedent's usual occupation while the census lists the
last or current occupation.

In the British studies, both the death certificate and the census listed the
last or current occupation. A sample of deaths occurring shortly after the
census was used. The 1959-63 study reported that 74 percent were assigned to
the same occupational order on the death certificate and the census report,
and only 63 percent were assigned to the same occupational unit (the more


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51


APPENDIX J

COMPUTATION OF MORTALITY ODDS RATIO

Occupation Non-exposed
of interest Comparison Group!
Cancer of interest a b
Auxiliary causes of death? c d
Population at risk N,=? No=?
MOR =

Relationship of MOR to SHR :

_ = 2No_
SUR = 5 ‘a oN,

= ay, =
HOR=SUR (y—/

gc =
If No Wr then MOR = SMR

Relationship of MOR to exposure odds ratio (FOR):

fad
d bc

EOR = =/ = MOR

1 In this study, we performed the anelysis using two different comparison groups - all other indi-
viduals in the entire study population (standard or unadjusted analysis), and all other individuals
within the same social class (social class adjusted analysis).

® Causes of death other than malignant neoplasms and cirrhosis of the liver.

168


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o} of o 0 ofa} +cerost] (tatt] = (tV0zt (9) 94 unqoer deoxe ‘eutysequr ebxeT
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+ + olla] ttesetet| (setrsot] (69t) Itt] (eotystt]  (veyezt susetdosu jueubTTeu

98h STEAIOM TeZeUu_pezwou O9E|
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93


Individual
Occupation Code Grouped Codes

Public administration, officials

and administrators NEC 83
Public relations men 87
Public utility supervisors,

officials, managers, etc. 88
Public utility workers NEC

(gas, electric, telephone) 319
Public works employees NEC 320
Publishing workers NEC 208 351
Pulp mill workers 240 362,378
Purchasing agents 89
Pursers, ship 82 371
R
Radio announcers 3 339
Radio operators 51 328 ,329
Railroad brakemen 216 355,356
Railroad clerks 112 355,356
Railroad foremen 139 355,356
Railroad workers (all) 356
Railroad workers (off train) 355
Railroad workers (on train) 354
Railroad workers NEC 316 355,356
Ranchers, cattle, sheep, etc. 299 391
Real estate agents, brokers,

developers, executives 118
Receiving clerks 109
Recreation and amusement (cardroom,

poolhall, carnival) attendants 269
Recreation workers 52 340
Religious workers 53 335
Religious workers (expanded) 335
Reporters 27 337
Researchers, miscellaneous 45 326,329
Restaurant employees NEC 279 368 , 383
Restaurant owners and managers 91 368,383
Restaurant workers (expanded) 383
Riggers 184 352
Road construction and maintenance

workers 315 386,387
Roofers 183 387
Rope makers 252 365
Routemen — 222 372
Rubber workers 243 378
Ss
Sailors 246 371
Sailors 371

182


Social Class

APPENDIX I

SOCIAL CLASS CLASSIFICATION

Major Occupational Grouping

*professional, technical, and kindred workers
+managers, officials, proprietors, except farm
clerical and kindred workers
sales workers

professional, technical and kindred workers
managers, officials, proprietors, except farm
+clerical and kindred workers

*+sales workers

craftsmen, foremen, and kindred workers

clerical and kindred workers
toraftsmen, foremen, and kindred workers
operatives

service workers

craftsmen, foremen, and kindred workers
toperatives

tservice workers

+laborers

*
Duncan's sociceconomic index of occupations (31).

Socioeconomic*
Index

> 50
> SO
> 60
> 60

*mnaicates the main major occupational groupings which make up the social

class.

167


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72


Machinists and related occupations

The excesses of cancers of the stomach (see Appendix C.5), large intestine,
rectum, trachea, bronchus and lung, and bladder, as well as leukemia and
aleukemia, are supported by other studies in Table 1 (see 154 "machinists" and
192 "tool and die makers, tool makers, etc." in Appendix A). The excesses of
stomach, colorectal, lung and bladder cancer are also supported by other
studies from the literature (Tables 4 and 5). Possible etiologic agents
include cutting fluids and synthetic abrasives.

Of special interest are the results in the 20-54 age group. The excess of
lung cancer was concentrated in this group (Appendix C.5), as was the excess
of colorectal cancer among machinists, the dominant individual occupational
category in this group. In addition, colorectal cancer in the 20-54 age group
was highly significantly elevated among workers employed by large employer A,
whose manufacturing facilities include a large proportion of machining
operations. This elevation is largely independent of the excess among
machinists, with only three of the 12 large employer A's and the

15 machinists’ colorectal cancers overlapping.

Printing trades and cancers of the buccal cavity and pharynx

The highly significant excess of cancers of the buccal cavity and pharynx
found in the printing trades (Appendix C.6) was confirmed by other studies in
Table 1, and by other more in-depth studies from the literature (Table 4).
Printing workers have a variety of exposures, including oil and ink mists and
solvents. The highly significant excess of cancers of the buccal cavity and
pharynx among artists and art teachers, who also have exposure to inks, lends
added weight to this association.

Prostate cancer and exposure to cadmium

Three of the occupational categories with highly significant excesses of
cancer of the prostate (Appendix B) ~ compositors and typesetters; painters,
construction and maintenance; and welders (expanded) ~ have potential exposure
to cadmium. Cadmium exposure has been linked to prostate cancer (56,73).
While there was no support for the association between these occupations and
prostate cancer from the other studies in Table 1, studies from the literature
support the prostatic cancer excesses for compositors and typesetters (40) and
welders (56)+

Malignant neoplasms

The significant excess of all malignant neoplasms among chemical workers;
heated metal workers (Appendix C.8); and chemists (expanded) is of interest

because of the large number of potential carcinogenic exposures in each of
these groups.

33


Individual

Occupation Code Grouped Codes
a
Janitors 278 384
Jewelers 148
Jobsetters, metal 149 350,361
Journalists 27 337
Judges 40
Junk dealers, workers 309
K
Kitchen workers NEC 279 368 ,383
L
Labor relations workers 85
Laborers NEC 313
Landscapers 305 390
Large employer A - electrical equip-

ment; engines and turbines 392

Large employer C ~ electrical and
electronic machinery, equipment,

and supplies 394
Large employer B - abrasives products 393
Large employer D - mass transit 396
Large employer E - telephone company 397
Lathers 176 387
Laundry operatives, owners, managers 230
Lawyers 40
Leather and leather product workers 364
Leather goods - other, factory workers 250 363,364
Leather product workers 363
Leather workers 251 364,378
Lens grinders and polishers 168 367
Librarians 4l
Life and physical scientists 326
Linemen - telegraph, telephone, power

(utility and gas) 150 349
Lithographers 177 351
Longshoremen 306 388
Loom fixers 162 349,365
Lumbermen 310 369
M
Machine operatives, precision 153 350,361
Machine operators NEC 234
Machinists and related occupations 350
Machinists NEC 154 350,361
Machinists, si.ipyard AIS 5 350,361,377,395
Mail carriers 104 343

178


9. England and Wales 1959-63: ranked chi-square, p <.05. The test was
performed on the PMR results, ages 25-75, for the occupational orders (broader
classification) only (17). In addition, a chi-square test (chi-square > 6.25)
was performed on the SMR results, ages 15-64, for the occupational orders
only. No statistical test was performed on the occupational unit (more
detailed classification) results. We did not apply the Poisson test to these
results, as we did to the Los Angeles County results, because for ages 15-64
SMR results are presented, and SMRs generally are not as reliable as PMRs in
this type of study for the occupational units.

10. England and Wales 1966-67: chi-square, p < .0l. A few results were
indicated as p < .05, but a complete analysis for p < .05 was not presented.
It is not clear from the text whether the test was a standard a priori test or
a ranked chi-square a posteriori test (3).

ll. England and Wales 1968-70: chi-square, p <.0l. A few results were
indicated as p < .05, but a complete analysis for p < .05 was not presented.
It is not clear from the text whether the test was a standard a priori test or
a ranked chi-square a posteriori test (3).

"=" - the association was of borderline significance for four or more observed
deaths according to the criteria listed above. Since the statistical testing
in the England and Wales 1970-72, 1966-67, and 1968-70 studies was at the

Pp < -01 level, some of the results assigned to borderline significance from
these studies would have been found to be significant if they had been tested
at the p < .05 level. Since statistical testing was not done on the
occupational units in the England and Wales 1959-63 study, borderline
significance is the highest rating these results could achieve in this
comparison.

The Washington State and California studies presented results for the age
grouping 20-64, although no significance testing was done on this age
grouping. If the criteria for borderline significance were met for either the
20+ age grouping or the 20-64 age grouping, a "=" was assigned.

The England and Wales 1970-72 and 1959-63 studies presented SMR results for
ages 15-64, and PMR results for ages 65-74. If the criteria for borderline
significance were met for either age grouping, or for the weighted average of
the two results, a "=" was assigned.

As noted above, the Roswell Park study presents results for men ever employed
in the occupation, men employed at least five years, and smoking-adjusted
results. The Rhode Island study presents SMR and PMR results, ages 16-64, and
PMR results, ages 65+. In both of these studies, if the criteria for
borderline significance were met for any one of the three analyses, a "=" was
assigned. In the Rhode Island study, if the weighted average of either the
SMR or PMR results for ages'16-64 and the PMR results for ages 65+ was
borderline significant, a "=" was assigned as well.

45


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50


C 15.376 OIL AND GASOLINE EXPOSURE

Bladder, age 20-74

Occupation Observed Expected sMOR
94 fuel oil dealers, managers 2 1 154
95 garage, gas station owners, foremen,

managers 4 6 1 586++
158 mechanics and repairmen, automobile 4 2 162
209 oil and related industries workers NEC 2 0 899
213 attendants, auto service, gas station 1 Oo -
237 oilers and greasers, except auto 5 - -
256 fuel oil truck drivers and laborers S S -
376 oil and gasoline exposure ll 4 2674+

not included in grouped category 376 oil and gasoline exposure

C 16, 384 CUSTODIAL, MAINTENANCE, AND CLEANING WORKERS

Trachea, bronchus, and lung

age 20-54

Occupation Observed Expected _sMOR
80 managers and superintendents, building 3 10) 5
272 cleaners 2 i) 512
276 housekeepers and stewards, except

private household Oo Oo 0
277 window cleaners o) fe) -
278 janitors, sextons, maintenance workers 21 15 141
280 school custodians 6 6 107
384 custodial, maintenance, cleaning workers 32 21 152+

135


rate the association was not significant or borderline significant, but the
mortality index was 2 110 for four or more observed deaths, or > 120 for two
or three observed deaths.

In the Washington State and California studies, if the results for the 20+ age
grouping did not meet these criteria, but the PMR for age group 20-64 was >
120 with four or more observed deaths, while not being borderline significant,
a "-" was assigned.

In the England and Wales 1970-72 and 1959-63 studies, the weighted average of
the 15-64 and 65-74 age group results had to meet the criteria in order for a
"-"to be assigned. If either the 15-64 or 65-74 age group result was ? 120,
but not borderline significant or significant, a "-" was assigned as well.

In the Roswell Park study, the weighted average of the results for men ever
employed, men employed at least five years, and the smoking adjusted results
had to meet the criteria in order for a " to be assigned. If any one of the
three results was > 120, but not borderline significant or significant, a "-"
was assigned as well.

In the Rhode Island study, the weighted average of either the SMR or PMR
results for age group 16-64 and the PMR results for age group 65+ had to meet
the criteria in order for a "-" to be asigned. If any one of the three
results was 7120, but not borderline significant or significant, a "-" was
assigned as well.

7 "=", and

"0" - there was one or more observed death, and the criteria for "
"-""were not met.

While most of the cancer categories were directly comparable with those from
the other studies, a few adjustments had to be made. These are shown in Table
A-l.

The cases in which a cancer category from this study was compared with more
than one category from another study (see Table A-1) were handled as follows:
If the result for any one of the categories from the other study met the
criteria for significance or borderline significance, a "+" or "=" was
assigned, respectively. If the weighted average of the results for the
categories from the other study was borderline significant, a "=" was
assigned. Otherwise, if the result for any of the categories was 2 120 or the
weighted average was — 110, a "-" was assigned.

46


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85


54. Nicholson, W.J., Seidman, H., Hoos, D., Selikoff, I-J. 1981. ‘The
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124


CODE

WODMIDUARWNE

APPENDIX F

INDIVIDUAL OCCUPATIONAL CODES

TITLE

PROFESSIONAL, TECHNICAL

AND KINDRED WORKERS *

accountants and auditors
analysts and consultants NEC
actors, radio announcers, TV announcers

air traffic controllers

airplane pilots and navigators

architects

artists and art teachers

athletes

chiropodists (podiatrists)

authors and writers
chemists
chropractors
clergymen

college presidents, deans, administrators

professors/instructors,
professors/instructors,
professors/instructors,
professors/instructors,
professors/instructors,
professors/instructors,
professors/instructors,

biological sciences
chemistry sciences
engineering
mathematics

physics

nonscientific subjects
subject not specified

computer and data processing specialists

dentists
designers

dieticians and nutritionists

draftsmen

editors and reporters, jounalists

engineers, chemical

engineers, civil and construction

engineers, electrical
engineers, industrial
engineers, mechanical
engineers, marine

engineers, metallurgical

engineers, sales
engineers NEC
entertainers NEC

foresters and conservationists

embalmers

lawyers and judges, attorneys

librarians

musicians and music teachers

agricultural scientists

physicists

miscellaneous natural scientists and

researchers

148

CENSUS CODE u

000

010
oll
012
013
014
015
016
020
022
022
023
030
032
034
040
042
045
054
060
(003-005)
071
072
073
074
075
081
082
083
084
085
086
090
092
093
101
103
104
105
11
120
130
140

145

BRR RHP NN PB E EPP BBE EER EP EE PEE EEE ee

H


CODE
177
178
179
180
181
182
183
184
185
186
187
188
189
190

191
192
193
194

195
196
197
198
199
200
201
202
203

204
205

206
207
208
209
210
211
212
213
214
215
216
217
218

219
220

TITLE

photoengravers, lithographers and composers
steamfitters

plumbers and pipefitters

plumbers, shipyard

pressmen and plate printers, printing
power station operators

roofers and slaters

riggers and steeplejacks

shoemakers and repairers

stationary engineers

stonecutters and stone carvers
structural metal craftsmen

tailors

tinsmiths, coppersmiths, and sheet metal
workers

floor layers, installers, workers

tool and die makers, tool makers, etc.
upholsterers

craftsmen and kindred workers NEC

OPERATIVES

officers and enlisted men, Coast Guard
officers and enlisted men, Marine Corps
officers and enlisted men, Air Force
officers and enlisted men, Navy

officers and enlisted men, Army

Merchant Marine

officers and enlisted men, Armed Forces NEC
chemical workers

instrument workers NEC

fabricated metal products workers NEC

electrical and-electronic machinery, equip-
ment, supplies workers NEC

primary metal industries workers NEC
apparel workers NEC

printing and publishing workers NEC

oil and related industry workers NEC
abrasive workers

asbestos and insulation workers
assemblers NEC

attendants, auto service, gas station
parking attendants

brewery workers

railroad brakemen

bus drivers

checkers, examiners and inspectors, manu~
facturing

clothing pressers

conductors, bus and street railway

152

#
CENSUS CODE

a
a
*

(515)
508
510

512
7O1L
514

515
520
521
523
524
525

528
530
535
545

www weEuesuavouwen|

548

549

550

551

552

553

555

985,128 (except 1282)
I38 (except 1383,
1385.,1387)
134(except 1348)
I35,137(except 1373).
I36

b ARK RQAOQOooAH.B_

S

1333-339
I23

I27

r29

13291
630,13292
631

632

632
818,12082
640

641

643

ARWEERAWRWW ERA

(611)
645

oS


DISCLAIMER

Mention of company names or products does not constitute endorsement by the
National Institute for Occupational Safety and Health.

NIOSH Project Officer: John P. Sestito

DHHS (NIOSH) Publication No; 84-109


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49


where
Pas, A= proportion of non-smokers in major occupational group A.

P,

eran proportion of ex-smokers in major occupational group A.

Pom, Az proportion of smokers in major occupational group A.
z

Ig= lung cancer mortality rate for never-smokers.

fi, = cigarette smoking adjusted expected lung cancer mortality rate for
major occupational group i.

N A= number of subjects in major occupational group A.
Ni = number of subjects in major occupational group i.

4.71 is the lung cancer risk ratio for ex-smokers compared with never-
smokers.

10.88 is the lung cancer risk ratio for smokers compared with never-
smokers.

The P's were obtained from an analysis of smoking characteristics by major
occupational group using data from the 1970 Household Interview Survey (37)?
Reliable age-specific P’s were available for ages 20-84. However, most of the indi-
viduals who were older than 64 were classified as unemployed or retired. This is
why the analysis was restricted to ages 20-64.

The risk ratios for ex-smokers and smokers were taken from the Dorn Study of
Smoking and Mortality Among U.S. Verterans (38). There was insufficient infor-
mation to obtain age-specific risk ratios.

"We obtained the complete age-specific tables of P's from Dr. Theodore Sterling, Department of
Computing Science, Simon Fraser University, British Columbia, Canada.

170


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98


RESULTS

The basic occupational mortality tables are furnished in the microfiche
enclosed in the jacket on the back cover of this report. Complete tables are
presented for the following:

1) The standard analysis of the 397 occupational categories (321
individual occupational categories, 70 grouped categories, and 6
large employer categories).

2) The social class adjusted analysis of the 397 occupational categories.

3) The standard analysis of the ten major occupational groupings.

4) The standard analysis of the four social classes.

Observed and expected deaths and sMORs are presented by cause of death for
each age grouping. Table 3 is the first page of the printout and illustrates
the layout of the tables. Cause of death lines were printed only if there was
an observed death. Expected deaths in each age grouping were rounded to the
nearest whole number before printing (although they were kept exact for all of
the calculations) for convenience of the reader. sMORs are presented as
percentages. A dash (-) was printed in place of the sMOR value if the number
of observed deaths was one and the number of expected deaths was less than
one. This was done to avoid meaninglessly large sMORs. A dash was also
printed in the sMOR entry if the expected number of deaths was zero (before
rounding). sMOR values (four or more observed deaths) which were
significantly elevated or lowered were flagged with asterisks ~ a single
asterisk (*) if p< .05 (chi-square 7 3.84) and a double asterisk (**) if

p< .01 (chi-square > 6.63). N (top right of table) is the number of deaths
in the occupational category.

Appendix A presents significant occupation-cancer associations, as well as
associations of borderline significance, for the 397 occupational categories
and the 10 major occupational groupings. The definition (an arbitrary one) of
borderline significance is given in Appendix A. Appendix A also gives an
indication of how closely the social class adjusted and unadjusted results
corresponded (see explanation of "SC" column in Appendix A). Finally,
Appendix A compares the results with the results from the other studies listed
in Table 1. ‘The comparison is a qualitative one, using symbols, so that one
can quickly assess to what degree a finding in this study is supported by
results from other studies (see Appendix A for details).

Appendix B presents by cancer type the highly significant (p < .01 in the age
groupings 20-54, 20-64, 20-74, 55-74, or 20+) occupation-cancer associations
for the 397 occupational categories. Occupational categories are listed in
the table if the social class unadjusted or social class adjusted results were

highly significant. A comparison of the adjusted versus the unadjusted
results is presented.

Appendix C shows the mortality patterns, for selected cancer types, of the
individual occupational categories which comprise selected grouped
categories. Finding similar cancer mortality elevations in occupations with
similar exposures is suggestive of a causal association.

23


TABLE 2

SMRs FOR MAJOR OCCUPATIONAL GROUPINGS
AND SOCIAL CLASS GROUPINGS FROM OTHER STUDIES

SMR
+  U-S. 1960 Matghed
Major Occupational Grouping 1950 U.S. stud) Records Study
professional, technical, and kindred
workers 84 88
managers, officials, and proprietors,
except farm 87 91
clerical and kindred workers 81
102*
sales workers 95
craftsmen, foremen, and kindred workers 96 98
operatives and kindred workers 94 108
service workers, except private household 97 116
laborers, except farm and mine 127 116
farmers and farm laborers 85 82
SMR
England and Wales England and Wales California
Social Class 1959-63° 1970-72¢ 1g949-52*+
I professional, etc.
occupations 77 77 94
II intermediate occupations 81 82 89
IIIN skilled occupations
(non-manual) oot* 102 97**
IIIM skilled occupations (manual) 103
IV partly skilled occupation 102 113 98
Vv unskilled occupations 145 139 120

white males,age 20-64. Most of the SMRs are less than 100 because non-
white males, who have a higher mortality rate, were included in the
comparison group.
white males, age 25-74.
SMR for clerical and sales workers combined.
males, age 15-64.
males, age 20-64.
ws IIIN and ITIM combined.

sales, clerical, skilled workers.

19


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342

343

344

345

346

347

348

349

Funeral workers

39
76

embalmers
funeral directors

Postal workers (all)

86
104
107
318

postmasters

mail carriers
postal clerks
postal workers NEC

Carpenters (expanded)

127
128
129

boatbuilders; carpenters, shipyard
cabinet makers
carpenters

Electricians (expanded)

134
135

electricians
electricians, shipyard

Painters (expanded)

169
170
171
172

painters, construction and maintenance
painters, sigh

painters, auto

painters, shipyard

Plumbers (expanded)

178
179
180

steamfitters
plumbers and pipefitters
plumbers, shipyard

Mechanics and repairmen, vehicle

157
158
159
161

mechanics and repairmen, airplane

mechanics and repairmen, automobile

mechanics and repairmen, automobile body
mechanics and repairmen, railroad and car shop

Mechanics and repairmen (all)

150

156

160
162
163
175
348

linemen, servicemen, and installers - telegraph, telephone, power
(utility and gas)

mechanics and repairmen, air conditioning, heating, refrigeration
applicances

mechanics and repairmen, radio, television

loom fixers

mechanics and repairmen NEC

piano and organ tuners and repairmen
mechanics and repairmen, vehicle

159


260
266

weavers, textile
textile workers NEC

366 Apparel workers (expanded)

189
193
207
233
247

367 Glass
144

168
236

tailors

upholsterers

apparel workers NEC

milliners

sewers and stitchers, manufacturing; cutters

workers
glaziers, glass workers

opticians; lens grinders and polishers
optical workers NEC

368 Food workers

97 grocers and market managers
121 bakers
164 millers, grain
221 cannery and food processing workers
226 dairy workers, dairymen
308 grocery clerks
383 restaurant workers
369 Wood workers
264 woodworkers, mill workers, furniture workers
310 lumbermen
344 carpenters (expanded)

370 Armed

195
196
197
198
199
201

forces

officers and enlisted men, Coast Guard
officers and enlisted men, Marine Corps
officers and enlisted men, Air force
officers and enlisted men, Navy

officers and enlisted men, Army

officers and enlisted men, Armed Forces NEC

371 Sailors

82
195
198
200
246
303

officers-pilots-pursers-engineers, ship
officers and enlisted men, Coast Guard
officers and enlisted men, Navy
merchant marines

.Sailors and deckhands, seamen NEC

fishermen and oystermen

372 Vehicle drivers

217

bus drivers

162


CODE

392
393
394

395
396
397

*includes:

TITLE

large employer

APPENDIX H

LARGE EMPLOYER CODES

- electrical equipment; engines and turbines

A
large employer B - abrasives products
c

large employer

shipyards*

- electrical and electronic machinery, equipment,
and supplies

large employer D - mass transit
large employer E - telephone company

1) 5 large shipyards

2) listings of navy yard, shipyard, shipbuilding, etc., in the
“industry or business" entry on the death certificate.
3) all individuals with the following individual occupational codes:

127
135
155
172
180
248
263

boat builders; carpenters, shipyard
electricians, shipyard

machinists, shipyard

painters, shipyard

plumbers, shipyard

shipyard workers NEC

welders, shipyard

These overlap considerably with categories 1) and 2) above.

166


and steelworkers. In addition, support for the lung cancer elevations among
vehicle drivers (especially truck drivers); painters; heated metal workers;
brickmasons, stonemasons, and tilesetters; tinsmiths, coppersmiths, and sheet
metal workers; automobile mechanics and repairmen; cooks; machinists;
fishermen; and plumbers was particularly strong from the studies in Table 1.

The critical question which must be answered with regard to occupational
excesses in lung cancer mortality is whether the excesses are the result of
occupational exposures, or whether they can be explained by differences in
cigarette smoking habits among occupations. Given the large number of
occupations with potential carcinogenic exposures which have consistently
shown lung cancer elevations from study to study, and given the large number
of workers in these occupations, this is a pressing question. It has not yet
been adequately addressed, especially given that the scanty evidence which
does exist indicates that much of the excesses cannot be explained by
cigarette smoking. “For example, in the Third National Cancer Survey and
Roswell Park studies, which had smoking histories for each subject, most
associations between occupation and lung cancer remained unchanged upon
controlling for cigarette smoking. In addition, about half the
occupation-lung cancer associations in the 1970-72 England and Wales study
could not be explained by social class adjustment, which should at least
partially control for cigarette smoking.

In the present study, social class adjustment uniformly weakened significant
and borderline significant occupation-lung cancer associations with likely
occupational exposures (those in Table 5 as well as others). However, the
social class adjusted sMORs remained either significantly or borderline
significantly elevated in about 80 percent of the cases.

At least two factors can contribute to the effects of social class adjustment
on lung cancer sMORs. First, since virtually all of the occupations with
likely exposures are in Social Classes 3 and 4, which tend to have higher
smoking rates than Classes 1 and 2, social class adjustment should lower the
lung cancer sMORs by at least partially controlling for cigarette smoking.
Secondly, occupations with likely occupational exposures which have exhibited
lung cancer elevations in this and/or other studies include well over half the
total number of subjects in Social Classes 3 and 4. If, in fact, an
appreciable number of the lung cancer deaths in these occupations are
contributed to in some way by occupation, concentrating them in the comparison
group through the social class adjusted analysis would lower the sMORs as well.

There is no way, with the data available, to determine the relative importance
of these two factors. However, adjusting for differences in smoking habits
among the major occupational groupings does not explain most of the
differences in lung cancer sMORs among these groupings (Appendix L),
suggesting that these differences could be due to occupational exposures.
Except for clerical and kindred workers, the major occupational groupings
which one would expect to have little occupational exposure (professional,
technical, and kindred workers; managers, officials, proprietors, except farm;
sales workers; service workers; and farmers) had low sMORs after smoking
adjustment. And excluding laborers (except farm), the major occupational


INDEX OF OCCUPATIONAL TITLES

Occupation
A

Abrasive workers

Accountants

Actors

Actuaries

Adjustors

Administrators NEC

Advertising agents, salesmen,
Managers, executives

Agricultural scientists

Air Force, officers and enlisted men

Air traffic controllers

Airplane pilots and navigators

Analysts NEC

Animal workers

Animal workers NEC

Annealers

Apparel workers (expanded)

Apparel workers (NEC)

Architects

Architects and draftsmen

Architects, draftsmen, and engineers

Armed Forces

Armed Forces NEC, Officers and
enlisted men

Army, officers and enlisted men

Art teachers

Artists

Artists (expanded)

Asbestos €xposure

Asbestos Workers

Assemblers (expanded)

Assemblers NEC

Assessors

At home

Athletes

Athletes (expanded)

Attorneys

Auditors

Authors

Auto Service attendants

B

Bakers
Bank clerks, tellers, etc.

Individual
Code Grouped Codes
210
1 325,329,341
3 339
57 325,329
102
93
114
43 326,329
197 370
4 328,329
5 328,329
2
391
300 391
145 360,361
366
207 366
6 322,324,325,329
322
324
370
201 370
199 370
7 336
7 336
336
377
211 377
357
212 357]
70 341
282
8 339,340
340
40
1 325,329,341
10 337
213 374,376
121 368
98

172


APPENDIX B
HIGHLY SIGNIFICANT OCCUPATION~CANCER ASSOCIATIONS BY CANCER TYPE

This table presents occupation-cancer associations for which p S<.01 in the
age groupings 20-54, 20-64, 20-74, 55-74, and/or 20+ (highly significant
associations) for the 397 occupational categories. The result presented is
the largest age grouping for which p S-0l. The size ranking of the age
groupings are, in descending order: 20+, 20-74, 55-74, 20-64, 20-54.
Occupational categories are listed in the table if the unadjusted and/or
social class adjusted results were highly significant. For the sake of
brevity, under a given cancer type, redundant occupational category entries
were omitted from the table. For example, under biliary Passages and liver,
individual code 271 "bartenders" and grouped code 382 "bar workers" were both
highly significant. For the unadjusted results, bartenders had five observed
deaths, sMOR = 430, and bar workers had six observed deaths, sMOR = 479.
Bartenders therefore were omitted from the table.

In the table, the entry for age group was left blank if the result was for the
20+ age grouping. All of the results in the table are not significant at

p <.01 because for each occupational category, both the unadjusted and social
class adjusted results are presented, and only one of these must have p <.01
for the occupational category to be eligible for the table. In the MOR
columns, " indicates p < .05, and "~" indicates that the result was not
significantly elevated. The footnote "a" indicates that p S.01 in a lower age
grouping, and the footnote indicates that p < .05 in a lower. age grouping.

112


C 10. 364 LEATHER AND LEATHER PRODUCT WORKERS

Respiratory system,age 20-74

Occupation Observed Expected sMOR
185 shoemakers and repairers 4 3 141
249 shoe factory workers 60 43 140+
250 factory workers, other leather goods - - -
251 leather workers, tanners 23 17 133
364 leather and leather product workers 87 65 134+
C11, 366 APPAREL WORKERS (expanded)
Respiratory system

Occupation Observed Expected sMOR
189 tailors 21 11 188+
193  upholsterers 7 9 76
207 apparel workers NEC 6 3 215
233 milliners 1 3 32
247 sewers and stitchers, manufacturing;

cutters 11 5 211+
366 apparel workers 46 31 146+

C12. 371 SATLORS
Trachea, bronchus, and lung

Occupation Observed Expected sMOR
82 officers - pilots - pursers -

engineers, ship 3 1 421
195 officers and enlisted men, Coast Guard 3 2 160
198 officers and enlisted men, Navy 18 10 180+
200 Merchant Marines 6 8 74
246 sailors and deck hands, seamen NEC 6 4 157
303 fishermen and oystermen 26 19 137
371 sailors 62 43 143+

133


Occupation

Clergymen
Clerical and
Clothing pres

kindred workers NEC
sers

Individual
Code

13
113
219

Coast Guard, officers and enlisted men 195

Cocktail bar
College presi

owners and managers
dents and

administrators
Composers, printing

Compositors
Computer spec
Concrete fini

ialists
shers

Conductors, bus and street railway
Conductors, railroad

Conservationi
Constables
Construction
Construction
Construction
Construction
Construction
Construction
Construction
Consultants NI
Cooks (except
Coppersmiths

sts

contractors
equipment operators
foremen, etc. NEC
laborers NEC
trades (all)
workers (expanded)
workers, management
IEC

private household)

Correction officers

Cosmetologist:

Ss

92

14
177
131

22
130
220

74

38
288
126
138
140
314

273
190
287
285

Counselors, vocational and educational 60
Court officers

Craftsmen and kindred workers NEC
Cranberry farmers, laborers

Crane operators (expanded)

Cranemen
Credit men
Crossing and

bridge tenders

Custodial, maintenance, cleaning

workers

Cutters, cloth manufacturing

Cutters, metal

D

Dairy farmers
Dairy workers
Data processi:
Deans, colleg
Deck hands
Decorators

, dairymen
ng specialists
le

288
194
294

132
75
289

247
224

295
226
22

246
133

174

Grouped Codes
335

370,371
382

332,334
351
351
325,329
387
372
354,356
390

385,387
387
386,387
386,387
387
386
385

368,383
361

380
333,334

389,390
352
352
341

384
366
350,361

389,391
368
325,329
332,334
371
336


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Appendix D presents bar graphs of sMORs as a function of social class for each
cause of death category.

Appendix L presents the results of adjusting the lung cancer sMORs for the
effects of cigarette smoking in the major occupational groupings.

25


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91


Massachusetts complements the Washington State study in this respect, having a
large number of textile workers and shoe factory workers, but no plywood
workers or atomic energy workers.

5) Occupational cancer risks may be a function of geography. A given
industry may have its older plants concentrated in one geographical region,
and its more modern facilities in another. Differences between the processes
or materials used in the older versus the newer plants may result in
differences in exposure patterns to occupational carcinogens.

6) Finally, each of these studies has its own particular strengths and
limitations both with respect to the quality and quantity of the data, and the
methods of analysis used. These complement each other to some extent. It is
beyond the scope of this report to review the strengths and limitations of the
other studies - they are discussed to a greater or lesser degree in the
individual publications (See (3) and (8) in particular). One example will
suffice:

The quality of occupation information obtained from death certificates is
known to be mediocre, and disease information has its shortcomings (see "DEATH
CERTIFICATE DATA" section). This is a deficiency in the present study, as
well as in the Washington State, California, United States, Rhode Island, and
England and Wales 1970-72 and 1959-63 studies. On the other hand, the quality
of disease information is high in the studies which used cancer registries as
their data base (Third National Cancer Survey, Roswell Park, Los Angeles
County, England and Wales 1966-67 and 1968-70). The Third National Cancer
Survey and Roswell Park studies also have high quality occupational
information which was obtained from detailed personal interviews and
questionnaires, respectively. However, these are the two smallest studies;
many of the associations found are based on small numbers and are therefore
relatively unstable.

It was in the context of the need for multiple ongoing occupational cancer
surveillance studies that the present study of Massachusetts was undertaken.
Some of the distinguishing features of this study are:

1) The use of the age-standardized mortality odds ratio (sMOR) as the basic
measure of relative mortality. This has certain advantages over the more
commonly used proportionate mortality ratio (PMR), which are discussed in the
“METHODS OF ANALYSIS" section.

2) Analysis for occupation-cancer associations in a variety of age

groupings. This was done because some occupational cancers may concentrate in
a particular age grouping, and because possible inaccuracy of reporting of
cause of death and occupation for older subjects could serve to dilute out
real association when looking at all ages grouped together.

3) Control for potential confounding by social class. This was done using a
social class classification scheme based upon occupation. Because a whole
range of potential confounding factors - such as diet, cigarette smoking,
alcohol consumption, stress, and ethnicity - are related to social class,
controlling for social class has the effect of at least partially controlling
for these factors.


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Occupation
U

Unknown
Upholsterers

v

Vehicle drivers
Veterinarians

W

Waiters

Warehousemen NEC

Watchmakers

Watchmen

Watchmen, crossing and bridge
Weavers, textile

Welders

Welders (expanded)

Welders, shipyard

Welfare workers, except group
Winding operatives NEC
Window cleaners

Window dressers

Wire workers

Wood workers

Woodworkers

Wrappers NEC

Writers

Writers (expanded)

‘= US GOVERNMENT PRINTING OFFICE: 1084 ~ 761-726/11811

Individual

185

Code

321
193

68

290
312
148
287
289
260
261

263
54

227
277
133
244

264
238
10

Grouped Codes

366

372
330,331,391

368,383
388

365

359,360,361

359

359,360 ,361,377,395

384
336
361
369
369

337
337


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89


Individual

Occupation

Glaziers

Government workers NEC
Greasers, except auto
Greenskeepers
Grinders, metal
Grocers

Grocery clerks

Groundskeepers
Guards

H

Hairdressers

Hammermen

Healers NEC

Health administrators

Heat treaters

Heated metal workers

Heavy equipment operators
Hoistmen

Hospital attendants
Hospital workers (expanded)
Hotel managers, owners, etc.
Housekeepers, except private household
Housewives

I

Inspectors NEC

Inspectors, manufacturing

Inspectors, public administration

Inspectors, railroad

Installers - telegraph, telephone,
power (utility and gas)

Instructors, biological sciences

Instructors, chemistry sciences

Instructors, engineering

Instructors, mathematics

Instructors, non-scientific subjects

Instructors, physics

Instructors, subject not specified

Instrument workers NEC

Insulation workers

Insurance agents, brokers, under~
writers, executives, managers

Interior decorators

Investigators

Investigators, public administration

177

Code

144
317
237
305
224

97
308
305
287

138
132
267

78
276
282

147
218

79
146

150
15

17
18
20
19
21
203
211

116
133
102

79

Grouped Codes
367

375,376
390
350,361
368
368
390

380
360,361
330,331

360,361
360
387
352
331,381
381

384

355,356

349

326 , 329,332,334

326 ,327,329, 332,334
323,324,325, 329,332,334
325,329, 332,334

332,334

326 ,329, 332,334

332,334

377

336


Occupation
N

Natural scientists, miscellaneous

Navy, officers and enlisted men

Newspaper owners, publishers,
managers, etc.

None

Not stated

Nurserymen

Nurses, practical

Nurses, professional

Nutritionists

°

Office boys

Officers, ship

Qfficials NEC

Officials, lodge

Officials, society

Officials, union

Oil and gasoline exposure

Oil and related industry workers
NEC

Oil exposure

Oilers, except auto

Operatives and kindred workers NEC

Optical workers NEC

Opticians

Optometrists

Orchardists

Ordnance plant workers

Organ tuners and repdirmen

Oystermen

P

Packers NEC

Painters (expanded)

Painters, auto

Painters, construction and
maintenance

Painters, shipyard

Painters, sign

Paper workers

Paper workers (expanded)

Paperboard container workers

Paperhangers

Parking attendants

Pattern makers, metal

Individual

180

Code

45
198

81
321
321
297
284
46
25

105
82
93
84
84
84

209

237
262
236
168
47

298
265
175
303

238

171

169
172
170
240

241
174
214
173

Grouped Codes

326,329
370,371

389,390
331,381
330,331
330,331

371

376

375,376
375
375,376

367
367
330,331
389,390

338,349
371

346

346

346,387
346,377,395
346

362,378
362
362
387
374,376
350,361


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53


separate ratings for foremen in the textile industry, operatives in the
textile industry, and laborers in the textile industry. However, a small
number of these categories could only be partially rated.

Subjects who could not be rated were assigned to a social class solely on the
basis of the social class to which their major occupational grouping was
primarily assigned. The social class classification scheme is presented in
Appendix I. The social class assignments of the individual occupational
categories is presented in Appendix F.

15


and allied products" and "laborers (n.e.c.), chemical and allied products").
In these cases, the symbol entered in the "OTHER STUDIES" column was for the
comparison which yielded the most positive result.

In a few cases, more than one category from this study was compared with a
single category from another study. (For example, the category "carpenters
and joiners" from the 1970-72 England and Wales study was compared with
individual code 129 "carpenters" and grouped code 344 "carpenters
(expanded)"). Documentation on specific comparisons which were made is
available upon request.

The meaning of the symbols in the "OTHER STUDIES" columns is as follows:

"+" = the association was indicated to be significant in the other study, for
four or more observed deaths. The criteria for significance in the other
studies were as follows:

1. Washington State: chi-square, p < .05. The test was performed if
there were six or more observed deaths.

2. California: chi-square, p < .05. The test was performed if there
were six or more observed deaths.

3. England and Wales 1970-72: Poisson (74), or ranked chi-square (an a
posteriori test) (3), p <-0l- The test was performed on the PMR results for
ages 15-64. It is not clear from the text which test was used. In addition,
the ranked chi-square test was performed on SMR results for the occupational
orders (the broader classification) for ages 15-64.

4. United States: chi-square, p <.05. The test was performed on the
PMR results, 20 or more observed deaths.

5. Third National Cancer Survey: chi-square, p < .05 for the summary
relative odds in any of the six stratification sets used (age and race;
education, age and race; smoking, age and race; smoking, age, race, and
education; alcohol, smoking, age, race, and education; or age, race,
education, smoking, alcohol, and geographic location); or summary relative
odds > 2.0 based on five or more exposed patients with at least one
significant chi~square in any of the 27 strata subtotal results.

6. Los Angeles County: not tested. For the purposes of this
comparison, we applied the Poisson test (74), p < .05, to these results.

7. Roswell Park: chi-square, p <.05. The test was performed on the
results for men ever employed in the occupation, men employed at least five
years, and on the smoking-adjusted results. If the association was
significant in any one of these three analyses, a "+" was assigned.

8. Rhode Island: Poisson, p <.-05. The test was performed on both the
SMR and PMR results, ages 16-64, and the PMR results, ages 65+. If the
association was significant in any one of these cases, a " was assigned.

44


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C 8. 360 HEATED METAL WORKERS

sSMOR*
Large intes- Trachea, Respiratory
Malignant tine and bronchus, system,

Occupation neoplasms rectum and lung age 20-64
122 blacksmiths 117(17) 124 (3) 114 (4) - (1)
123 boilermakers 164 (26) 253(6)+ 215 (10)+ 200 (4)
142 forgemen and hammermen 353(19)++ 336 (3) 613 (9) ++ - (6)++
145 heat treaters, annea-

lers, temperers 121 (18) 89 (2) 133 (6) 478 (8)++
166 molders, metal 110 (42) 140 (8) 129(14° 129 (8)
228 foundry workers NEC 129 (34) 242 (10)+ 135 (9) 385 (7)+
229 furnacemen, smelter-

men, and pourers 80 (8) 130 (2) 140 (4) 290 (3)
261 welders and flame

cutters 91(70) 106 (11) 83 (21) 71 (14)
263 welders, shipyard 229(19)+ — 261(3) 110 (3) 122 (2)
360 heated metal workers 121(253)+ 157(48)++ 129 (80) 154 (53) +

* The numbers in parentheses indicate the number of observed deaths.

C 9. 361 METAL WORKERS

Occupation

Pancreas ,age 20-74

Observed Expected sMOR
137. engravers, except photoengravers 1 (e) -
188 structural metal craftsmen 2 1 169
190 tinsmiths, coppersmiths, sheet
metal workers 5) 2 236
204 fabricated metal product workers NEC 13 8 171
206 primary metal industries workers NEC 1 1 -
225 electroplaters 5 oS oS
244 steelworkers, wire workers 2 2 124
350 machinists and related occupations 35 30 117
360 heated metal workers 8 8 99
361 metal workers 67 51 130+

132


detailed classification). Another 9 percent were assigned to related
occupations. The most common discrepancy was thought to be individuals who
had at some point in their working life changed their occupation. In the

1970-72 study, 62 percent were assigned to the same order and 51 percent to
the same unit.

The Washington State study examined the accuracy of death certificate
occupational statements for men dying from Hodgkin's disease and bladder
cancer. Interviews with next of kin indicated that the death certificates
were accurate in 75 percent of the cases, and gave a related occupation in
another 10 percent of the cases. In addition, the occupational information on
the death certificates of 25 smelter workers known to have died from lung
cancer from smelter records was sufficient to identify 24 of them as smelter
workers.

Finally, a comparison of the death certificate statement of occupation with
comprehensive occupational histories obtained from interviews, primarily of
lung cancer patients, was performed in California in 1949-52 (26).
Seventy-eight percent of the death certificates stated an occupation which was

given in the occupational history, although only 52 percent stated the usual
occupation as determined from the history.

Synthesizing the above information, we would conservatively postulate that the
statements of usual occupation in the present study are at least 60 percent
accurate. In another 20-25 percent of the cases, the occupation listed is
probably related to the actual usual occupation of the decedent or is an
occupation in which the decedent worked at some point in his life, although
not the usual occupation.

The limited accuracy of the occupational statement on death certificates
should not be surprising. Firstly, the informant, especially if not a next of
kin, may not have detailed knowledge of the decedent's work history. It would
be especially difficult to assign a usual occupation in the case of a decedent
with a varied work history. Secondly, there seems to be a tendency for
relatives to "promote" the decedent into a higher level occupation than he had
in reality (3,27). Finally, the mortician as interviewer has no published
guidelines by which to collect this information.

If misclassification of occupation were random, the effect would be to dilute
the magnitude of any real occupation-cancer association, but no biases would
be introduced into the results. Most likely, however, some occupations are
selectively misclassified into others, creating biases. Such selective
misclassification is described in the 1970-72 England and Wales study.

Aside from the question of accuracy, there is an additional problem with using
the usual occupation statement. Many individuals have more than one
occupation during their working life time. Ideally, in an occupational cancer
study one would want to have a complete work history to use in the analysis.
For example, even short term employment is of significance if it exposed the
subject to a potent carcinogen.

10


C 13. 372 VEHICLE DRIVERS

Trachea, bronchus, and lung

Age group 20+ Age group 20-64

Occupation Observed Expected sMOR Observed Expected sMOR
138 heavy equipment ,con-

struction equipment

operators* 18 6 295++ 15 4 426++
217 bus drivers 24 18 132 15 8 183
220 conductors, bus and

street railway 10 4 259+ 5 ie} 1031++
222 deliverymen and

routemen 13 12 105 4 5 88
254 taxicab drivers and

chauffers 38 32 118 15 15 101
255 truck and tractor

drivers 176 102 173++ 101 iy) 177++
256 fuel oil truck drivers

and laborers ll 14 81 4 5 73
257 drivers NEC 23 20 115 10 7 141
258 fork lift drivers 6 4 142 6 2 262
259 movers, moving truck

drivers 4 7 59 4 2 165
372 vehicle drivers 305 211 1454++ 164 100 1634+

* not included in grouped category 372 vehicle drivers

C 14 373 MEAT PROCESSING WORKERS

Bladder Kidney

Occupation Observed Expected sMOR_ Observed Expected sMOR
231 meat cutters, except

slaughter and

packing house 5 3 163 2 2 121
232 slaughter house

butchers 4 1 276++ 4 1 4324+
373 meat processing

workers 9 5 200+ 6 3 234+

134


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52


CONTENTS

Abstract . . . O + - . . . .
Acknowledgements . . . . . . . . .
Introduction . . o . . . . . .
Death Certificate Data . . . . . . . : .
Classification Schemes . ° . . 9 . . . .

Methods of Analysis . . D 0 . 9 . D . . 0

Results . . . . . . . . . . . . . . . . .
Discussion . o o . . . o . . . . . . . 9
References . . D . . . . . . . . 5 . . .
Appendices

A. Elevated age-standardized mortality odds ratios in Massachusetts
study and comparison with other studies . . D D D

B. Highly significant occupation-cancer associations by cancer type

C. Mortality patterns of selected grouped occupational categories and
cancer types a 5 oO . - 8 . 9 .

D. Age-standardized mortality odds ratios by social class and cancer

site, age 20+ . . . . . . . . . . . . .
E. Cause of death categories a . . . . . . . . .
F, Individual occupational codes O O O D o O O ° .

G. Grouped occupational codes 9 . o 0 D ° 9
H. Large employer codes . . . . . . . . 0
I. Social class classification . . . . . . . .

3. Computation of mortality odds ratio . ° a O oO a ° o
K. Adjustment of lung cancer MORs for confounding by cigarette
smoking . D o a . o ° . ° . a oO O a .
L. SMORs for lung cancer in the major occupational groupings adjusted
for the effects of smoking, age 20-64 a 3 . Oo O°

eaist

23

26

37

42

112

129

137

146

148

156

166

167

168

169

171

Index of Occupational Titles . 9 5 #O o . . Oo ° . +172

Microfiche . . . . . . . . . . . . - Back Cover


APPENDIX L

sMORs FOR LUNG CANCER IN THE MAJOR OCCUPATIONAL GROUPINGS

ADJUSTED FOR THE EFFECTS OF SMOKING, AGE 20-64

Unadjusted Adjusted
Major Occupational Grouping Observed Expected sMOR Expected sMOR
professional, technical, and
kindred workers 150 225 67+#* 185 81+
managers, officials, propri- b
etors, except farm 204 254 80+ 234 87
clerical and kindred workers 122 114 107 110 111
sales workers 85 105 81 107 80
craftsmen, foremen, and
kindred workers 565 439 129++ 440 128++
operatives 469 391 120++ 410 115+
service workers 242 245 99 282 86
laborers, except farm 133 138 96 142 94
farmers 10 16 61 14 72
unknown 68 98 694+ 104 65++

° 44 indicates p< .01

» 4 indicates p< .05

171


350 Machinists and related occupations

149 jobsetters and die setters, metal

153 precision machine operatives

154 machinists NEC

155 machinists, shipyard

165 millwrights

173 pattern and model makers, metal

192 tool and die makers, tool makers, etc.

224 filers,grinders and polishers, metal; metal cutters

351 Printing trades

131 compositors and typesetters

136 electrotypers and sterotypers

177 photoengravers, lithographers, and composers
181 pressmen and plate printers, printing

208 printing and publishing workers NEC

352 Crane operators (expanded)

132 cranemen, derrickmen, and hoistmen
184 riggers and steeplejacks

353 Stationary engineers (expanded)

182 power station operators
186 stationary engineers
253 stationary firemen

354 Railroad worker (on train)

74 conductors, railroad
151 locomotive engineers (railroad)
152 locomotive firemen

355 Railroad workers (off train)

112 railroad clerks

139 railroad foremen

146 inspectors, railroad

161 mechanics and repairmen, railroad and car shop
216 railroad brakemen

235 maintenance, railroad

316 railroad workers NEC

356 Railroad workers (all)

354 railroad workers (on train)
355 railroad workers (off train)

357 Assemblers (expanded)

123 boilermakers

160


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67


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SUP-REN SEC MAL MUL MAL LYM&HEN  LYMPHOM

TT

143

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DISEASE
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60


relatively closely associated with social class and occupational level. These
include cigarette smoking habits, dietary habits, alcohol consumption habits,
stress, and ethnicity. In this sense, members of the same social class serve
as a better comparison group than all other individuals in the study
population.

Table 2 shows SMRs as a function of major occupational grouping (or social
class grouping based on occupation) from five previous studies (1950 United
States (4), 1970-72 and 1959-63 England and Wales (3,9), 1949-51 California
(27), and 1960 United States Matched Records Study (34)). These studies
calculated SMRs using death certificate data to obtain numerators and census
data to obtain denominators. The pitfalls of this approach have been
discussed. However, the SMRs calculated for major occupational groupings using
this approach should be more accurate than those calculated for detailed
occupational categories because there is a greater degree of correspondence
between death certificate data and census data for the major occupational
groupings (71 percent in the 1950 United States study, 83 percent in the
1959-63 British study, 73 percent in the 1970-72 British study, and 77 percent
in the 1949-51 California study). In the 1960 United States Matched Records
Study, the problem of discrepant reporting of occupation in the census and on
the death certificate was resolved by matching all the records, and using the
occupation stated on the census report.

For the 1950 United States study and the British studies, SMRs are shown for
the grouped auxiliary causes of death. This information was not available
from the 1960 Matched Records Study, so the SMRs for all causes combined are
shown. However, the other three studies revealed a close parallel between the
SMRs for all causes and that for the auxiliary diseases. The SMRs for all
causes except violent causes and certain cancer sites are presented from the
1949-51 California study.

These and other studies consistently reveal an inverse relationship between
mortality and occupational level (or social class) (34). Generally, there
tend to be relatively small differences among the upper and middle
occupational levels (or social classes), and a wider gap between the upper and
middle versus the lower levels. Prdéfessional, technical and kindred workers;
managers, officials, and proprietors, except farm; and farmers and farm
laborers consistently have the lowest SMRs, while laborers (except farm)
consistently have the highest SMRs. Differences in mortality among
occupational levels decrease with increasing age, and tend to disappear in the
older age groups (not shown in table) (34). Comparison of the 1950 and 1960
United States studies are consistent with the assertion that class differences
in mortality have narrowed over time (34). These considerations should be
kept in mind when interpreting the results of the standard analysis. To the
extent that these relationships between mortality and occupational level exist
in the Massachusetts study population, the results will be biased toward
systematically overestimating cancer mortality in the higher occupational
levels and farmers, and systematically underestimating it in the lower
occupational levels, especially in the younger age groups.

17


Cirrhosis of the liver

Cirrhosis of the liver is a disease highly associated with alcoholism.
Cancers of the buccal cavity and pharynx, esophagus, larynx, and biliary
passages and liver are also known to be associated with an excesive use of
alcohol (19). Alcohol is thought to act synergistically with cigarette smoke
in causing cancers of the buccal cavity and pharynx, esophagus, and larynx.
Thus bar workers and cooks and cHefs, both of whom have ready access to
alcoholic beverages, and have been reported to be heavy smokers (37) have
excesses of all of these alcohol-related diseases.

Occupations with excess cirrhosis of the liver which have potential exposure
to liver toxins are laundry and dry cleaning workers; paper and pulp mill
workers; and leather workers and tanners. The excess among laundry and dry
cleaning workers is supported by other studies in Table 1- Among the solvents
used in dry cleaning operations are carbon tetrachloride, perchloroethylene,
and trichloroethylene - known liver toxins.

SOCIAL CLASS AND CANCER MORTALITY

Appendix D shows mortality from all malignant neoplasms combined to be largely
social class independent, except for a small but highly significant elevation
in Social Class 3. However, for a number of specific cancer categories,
social class mortality gradients were seen.

Gradients increasing from Social Class 1 to Social Class 4 were seen for
buccal cavity and pharynx; esophagus; stomach; rectum; larynx; trachea,
bronchus, and lung; acute and chronic lymphatic leukemia; polycythemia vera;
and cirrhosis of the liver. The gradients for buccal cavity and pharynx;
larynx; trachea, bronchus, and lung; polycythemia vera; and cirrhosis of the
liver were particularly pronounced.

Gradients decreasing from Social Class 1 to Social Class 4 were seen for large
intestine, except rectum; connective and soft tissue; malignant melanoma;
prostate; eye; brain and nervous system; lymphomas; multiple myeloma; myeloid
leukemia; morocytic leukemia; and acute erythremia. All of these gradients,
except for prostate and multiple myeloma, were pronounced.

The gradients for esophagus; stomach; larynx; trachea, bronchus, and lung; and
brain and nervous system had strong support from other similar studies
(3,4,9,27,34)-

COMMENTS ON METHODOLOGY
Social class adjustment

In general, the social class adjusted and unadjusted results were surprisingly
similar. Seventy-seven percent of the associations presented in Appendix A
were significant or borderline significant in both the social class adjusted
and unadjusted analyses. Sixty-seven percent of the associations presented in
Appendix B were significant at the p <.-01 level in both analyses, with
ninety-six percent significant at either the p < .0l1 or p < .05 level in both

34


CODE

267
268

269

270
271
272
273
274
275
276

277
278
279
280
281

282
283
284
285
286
287

288
289

290
291

292
293
294
295
296
297
298
299
300

301
302

303

TITLE

SERVICE WORKERS

attendants, hospital

attendants, professional and personal service
NEC

attendants, recreation and amusement
(cardroom, poolhall, carnival)

barbers

bartenders

cleaners

cooks, chefs, (except private household)
dishwashers

elevator operators

housekeepers and stewards, except private
household

window cleaners

janitors, sextons, maintenance workers
kitchen workers, restaurant employees NEC
school custodians

private household workers, servants, butlers,
etc.

housewives, at home

porters

practical nurses

hairdressers and cosmetologists

firemen and fire protection

guards, watchmen and doorkeepers, correction
officers

policemen, detectives, marshalls, constables,
sheriffs, court officers

watchmen, crossing and bridge tenders, toll
collectors

waiters

service workers NEC

FARMERS

farm laborers

farm owners, managers, foremen
cranberry farmers, laborers
dairy farmers .

egg and poultry farmers
nurserymen

orchardists

ranchers, cattle, sheep, etc.
animal workers NEC

LABORERS, EXCEPT FARM
garbage collectors, sewerage workers
forestry workers; tree farmers, wardens,

surgeons, workers, etc.
fishermen and oystermen

154

CENSUS cops"

810
812

813

814
815
824
825
826
831
832

833
834
835
836
(982,984)

841
842
843
850
851

853,854
860

875
890

902
200,222,901

204
206
202
201
203

891
724

962

SARAH ware eR RAD

Ros. AD

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54


Aside from the general relationships between mortality and occupational level,
the possibility must be considered that a specific occupation has a high
mortality rate from the auxiliary causes of death due primarily to hazards
associated with the occupation. For example, many asbestos workers die from
asbestosis. For such occupations, cancer mortality will be systematically
underestimated in this study.

Even when the assumption that the mortality rate for the auxiliary diseases is
independent of occupation is valid, there are still numerous confounding
variables which can result in an occupation having an elevated sMOR for
reasons other than an occupational exposure.

There are both advantages and disadvantages to the standard analysis versus
the social class adjusted analysis with respect to the problem of

confounding. Smoking related cancers, such as lung cancer, “provide a good
example. On the one hand, since there tends to be an inverse relationship
between smoking and occupational level, the standard analysis will bias the
results toward systematically underestimating lung cancer due to occupational
exposures in the higher occupational levels, and systematically overestimating
it in the lower levels. ‘The social class adjusted analysis will control for
differences in smoking patterns, at least partially. On the other hand, it is
not unlikely that a measurable percent of lung cancer in Social Classes 3

and 4 is occupationally related. If this is the case, narrowing the
comparison group to the same social class will systematically underestimate
occupationally related lung cancer in Social Classes 3 and 4. Using all other
individuals in the study population as the comparison group serves to dilute
out the proportion of occupationally related lung cancers in the comparison
group and thus lessens this effect.

It would be attractive to refine the choice of both the auxiliary diseases and
comparison group further in order to increase the validity of the results.

One possibility might be the exclusion of accidents from the auxiliary causes
of death, since many occupationally related deaths are due to accidents.
Ideally, one would like to be able to give individualized consideration to the
most valid comparison group and auxiliary diseases for each occupation-cancer
type combination. However, this approach would be inordinately complex for a
multi-occupation, multi-disease surveillance type study such as this one,
although it could be a fruitful approach for selected occupations and cancer
types. A problem with overly restricting the auxiliary diseases or the
comparison group is the loss of stability due to smaller numbers.

The MOR approach is superior to the more commonly used proportionate mortality
ratio (PMR) approach (see (33) for a full discussion of this point). The MOR
has a clear quantitative interpretation as an SMR, with appropriate
assumptions. The PMR can be interpreted as an SMR only when the number of
deaths from the cause of interest is small in relation to the number of deaths
from the auxiliary causes. Thus, for a given cause, the PMR is dependent on
the size of the auxiliary cause of death group. The MOR, in contrast, is
independent of this factor. This has important practical implications. In
this study, we chose the auxiliary cases from a one in four sampling of male
deaths for the period under study. Because of the restriction of the size of

20


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87


APPENDIX K

ADJUSTMENT OF LUNG CANCER MORs FOR CONFOUNDING BY CIGARETTE SMOKING

Comparison Group
Major Occupational (All other individuals

Group A in the study group)
Lung cancer a b
Auxiliary causes of death c d
Ta
baajustes = Tele

where J Az cigarette smoking adjusted expected lung cancer mortality
rate for major occupational group A.

I= cigarette smoking adjusted expected lung cancer mortality rate
for the comparison group.

badiusted 18 the number of lung cancer deaths one would have
expected in the comparison group if it had the same cigarette smoking
adjusted expected lung cancer mortality rate as major occupational
group A. ba aiusteq WS calculated for each five year age group (ages 20-
64) and sus dusy ‘up over the age groups to obtain age-standardized sum-
mary odds ratios.

I, and I, were calculated as follows:

Ig = Pra a Ip + 4:71 Pees Io + 10.88P em aly

bY Nh — Nala
(zl

Ie=
. SMM

(zl

169


68. Frazier, T.M., Wegman, D.H. 1979. Exploring the use of death
certificates as a component of an occupational health surveillance system.
Am. J. Public Health 69: 718-720.

69. Palmer W.G., Scott W.D. 1981. Lung cancer in ferrous foundry workers: a
review. Am. Ind. Hyg. Assoc. J. 42:329-340.

70. Blot, W.J., Harrington, J.M., Toledo, A., Hoover, R., Heath, Cow,
Fraumeni, J-F. 1978. Lung cancer after employment in shipyards during World
War II. New England J. Med. 299:620-624.

71. Doll, Re, Peto, R- 1981. The causes of cancer: quantitative estimates
of avoidable risks of cancer in the United States today. J. Natl. Cancer
Inst. 66:1191-1308.

72. Schenker, M-B. 1980. Diesel exhaust - an occupational carcinogen? J.
Occupational Medicine 22:41-46.

73. Lemen, R.A., Lee, J-S., Wagoner, J.K., Blejer, H.P. 1976. Cancer
mortality among cadmium production workers. Ann. N.Y. Acad. Sci. 271:273-279.

74. Bailar, J.C., Ederer, F. 1964. Significance factors for the ratio of a
Poisson variable to its expectation. Biometrics 20:639-643.

41


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82


Individual

Occupation

Bank Officers

Bar workers

Barbers

Barbers (expanded)

Bartenders

Blacksmiths

Boatbuilders

Boilermakers

Bond salesmen, counsellors, etc.
Bookbinders

Bookkeepers

Box factory workers

Brewery workers

Brickmasons

Brokers NEC

Building contractors

Building managers and superintendents
Bus drivers

Business consultants and analysts
Butchers, slaughter house

Butlers

Buyers

Buyers, farm products

c

Cabinetmakers

Cafe owners and managers
Cannery workers

Car salesmen, dealers, managers
Car washers

Carpenters

Carpenters (expanded)
Carpenters, shipyard

Cashiers

Cement finishers

Cement workers

Chauffers

Checkers, manufacturing

Chefs (except private household)
Chemical exposure (operatives)
Chemical workers

Chemists

Chemists (expanded)
Chiropodists

Chiropractors

Cleaners

173

Code
71
270

271
122
127
123
119
124

99
241
215
125

126
80
217
55
232
281
89
73

128

91
221
117
304
129

127
100
130
130
254
218
273

202

12
272

Grouped Codes

341

382

380

380

382

360 , 361
344,369, 377,395
357, 359,360,361
341

362
387

385,387

384

372
325,329,341
373

344,369
368,383
368

344,369,387
344
344, 369,377,395

387
387
372

368 , 383

378

378
326,327,329
327
330,331
330,331

384


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28


CODE

222
223
224

225
226
227
228
229
230

231

232
233
234
235
236
237
238
239
240
241
242
243
244
245
246
247
248
249
250
251
252
253
254
255
256
257
258
259
260
261
262
263
264

265
266

TITLE

cannery and food processing workers

deliverymen and routemen

dyers

filers, grinders and polishers, metal;
metal cutters

electroplaters

dairy workers, dairymen

winding operatives NEC

foundry workers NEC

furnacemen, smeltermen and pourers

laundry and drycleaning operatives, owners,
managers

meat cutters, except slaughter and packing
house

slaughter house. butchers

milliners

machine operators NEC

maintenance, railroad

optical workers NEC

oilers and greasers, except auto

packers and wrappers NEC

pest control workers

paper, pulp mill workers

paperboard container and box factory workers
plastic workers

rubber workers

steelworkers, wire workers

signmakers

sailors and deck hands, seamen NEC

sewers and stitchers, manufacturing; cutters
shipyard workers NEC

shoe factory workers

factory workers, other leather goods
leather workers, tanners

rope makers

stationary firemen

taxicab drivers and chauffeurs

truck and tractor drivers

fuel oil truck drivers and laborers’
drivers, NEC

fork lift drivers

movers, moving truck drivers

weavers, textile

welders and flame cutters

operatives and kindred workers NEC
welders, shipyard

woodworkers, millworkers, furniture workers

ordnance plant workers
textile workers NEC

153

CENSUS coe"

527,1203-209
(except 2041,
2044, 2046 2082)
650, .
652

653

(635)

655 ,1202
(681)

1332

670

674 .

675

677, 12011-2016
680

(690 ,692)

469

I383,1385

692

693

986
500,1261-264, 1266
1265

1282 ,1307
1301-306
1331-332

(543)

703

705

507,1373

(664) ,1313-314
13157319

515, 1311

711

712

714

715

716

(706)
719
720
721
722

974,124,12511-12,
12517,12521, 12541
726, 1348

(670-6 72,674) ,122

we ja
is

Bob w

ob kk AO

FAL ALLA BH LALA AAA HA KAR eR RAR eRe RAR RWOeR FB

=

*


Occupation

Entertainers (expanded)
Entertainers NEC
Estimators

Examiners

Examiners, manufacturing
Expeditors

Express agents

F

Farm laborers

Farm owners, managers, foremen

Farmers

Filers, metal

Financial managers

Pinancial workers

Firemen and fire protection

Firemen, locomotive

Fishermen

Flame cutters

Floor layers, installers workers

Florists

Food processing workers

Food workers

Foremen NEC

Foresters

Forestry workers

Forgemen

Fork lift drivers

Foundry workers (expanded)

Foundry workers NEC

Freight handlers

Fuel oil dealers, managers

Fuel oil truck drivers and laborers

Funeral directors

Funeral workers

Furnacemen

Furniture store owners, managers,
dealers, salesmen

Furniture workers

Furriers

G

Garage owners, foremen, managers
Garbage collectors

Gardeners (except farm)

Gas station attendants

Gas station owners, foremen, managers

Gas station, garage workers
Glass workers
Glass workers

Individual
Code

37
102
102
218
103
111

292
293

224
71

286
152
303
261
191

72
221

141

302
142
258

228
307
94
256
76

229

96
264
143

95
301
305
213

95

144

176

Grouped Codes

339
339

389,390
389,390
389
350,361
341
341

354,356

371
359,360,361
387

390

368

368

390

390

360,361

372

358
358,360,361
388

375,376
372,375,376
342

342

360,361

369

374,376

390
374,376
374,376
374
367
367


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2.17. 391 ANIMAI, WORKERS

Occupation

Lymphatic and hematopoietic
tissue

Observed Expected sMOR

68 veterinarians

295 dairy farmers

296 egg and poultry farmers
299 ranchers, cattle, sheep
300 animal workers NEC

, etc.

391 animal workers

Gis

Occupation

. 395 SHIPYARD

5 2 214
2 2 123
2 1 208
9 5 167

Trachea, bronchus, and lung

Observed Expected _sMOR

127 boatbuilders; carpenters, shipyard

135 electricians, shipyard
155 machinists, shipyard
172 painters, shipyard
180 plumbers, shipyard
248 shipyard workers NEC
363 welders, shipyard

395 shipyards*

* includes shipyard workers
occupational categories.

in addition to

See Appendix C.

136

6 3 201
8 ) 92
18 7 270++
9 3 261+
5) 4 112
27 19 141
3 3 110
108 72 1524+

those in the above individual


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200
M
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100
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DISEASE
200
M
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R
100
SOCTAL CLass
DISEASE


CODE
90

92
93

94
95
96

97

98

100
lol
102

103
104
105
106
107
108
109
110
alla
112
113

114

115
116

117
118

119
120

121
122
123
124
125
126
127

TITLE

sales managers

restaurant and cafe owners, managers
cocktail bar, tavern owners, managers
managers, administrators, officials, and
proprietors NEC; supervisors NEC

fuel oil dealers, managers

garage, gas station owners, foremen, managers
furniture store owners, managers, dealers,
salesmen

grocers and market managers

CLERICAL AND KINDRED WORKERS

bank clerks, tellers, etc.
bookkeepers

cashiers

dispatchers and starters, vehicle
adjustors, examiners, investigators,
estimators

expeditors and production control
mail carriers

messengers and office boys
payroll and timekeeping clerks
postal clerks

secretaries

shipping and receiving clerks
stock clerks and storekeepers
ticket, station and express agents
railroad clerks

clerical and kindred workers NEC

SALES WORKERS

advertising agents, salesmen, managers,
executives

manufacturers and sales representatives
insurance agents, brokers, underwriters,
executives, managers

car salesmen, dealers, managers

real estate agents, brokers, developers,
executives

stock and bond salesmen, counsellors, etc.
sales clerks and salesmen NEC

CRAFTSMEN, FOREMEN AND KINDRED WORKERS

bakers

blacksmiths

boilermakers

bookbinders

brickmasons, stonemasons, tile setters
building contractors, construction contractors
boatbuilders; carpenters, shipyard

150

CENSUS cone*

285
817
816
290

291
293
297

298

305
310
312
314
321

(323)
323
324
333
340
342
343
350
354
361
370.

380

380
385

386
393

395
396

401
402
403
404
405
406
407

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Borderline significance is defined (arbitrarily) as follows:

Observed deaths sMOR
4-6 2 300, but not significant
7-9 2 200, but not significant

we
°
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i
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v

2 150, but not significant

Vv

N

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v

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In the "MORTALITY ODDS RATIO" columns, the number in parentheses indicates the
number of observed deaths, and a "+" indicates p <.05.

The "SC" column indicates whether the association was seen in the unadjusted
analysis (u), the social class adjusted anaylsis (a), or both (b). An
association was considered to be seen in both analyses if the results were at
least borderline significant in both. The results presented when the
association was seen in both analyses are the unadjusted results.

The other studies to which the results were compared are as follows:

1. Washington State 1950-71 (1)
2. California 1959-61 (2)

3. England and Wales 1970-72 (3)
4. United States 1950 (4)

5. Third National Cancer Survey 1969-71 (5)
6. Los Angeles County 1972-77 (6)
7. Roswell Park 1956-65 (7)

8. Rhode Island 1968-72 (8)

9. England and Wales 1959-63 (9)
10. England and Wales 1966-67 (10)
11. England and Wales 1968-70 (11)

Frequently, a comparable occupational category was not examined in some or all
of the other studies. Also, some of the cancer categories were not examined
in some of the other studies. This accounts for the many blanks in the "OTHER
STUDIES" columns of the table.

In many cases, the occupational title of the category in this study and that
in the study to which it was being compared did not exactly correspond. (For
example, code 138, "heavy equipment, construction equipment operators" was
compared with "operators of earth moving and other construction machinery
nee.c.e"” in the 1970-72 England and Wales study). In a few cases, comparison
was made with more than one category from another study. (For example,
individual code 202 "chemical workers" was compared with two categories from
the United States study: “operators and kindred workers (n.e.c.), chemical

43


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13. Kennedy J, Fischbach TJ, Green JH, Leihy RF. 1980. NIOSH Research
Report. Occupational Characteristics of Disabled Workers: Analysis of Social
Security Disability Benefit Awards to Workers During 1969-1972. National
Institute for Occupational Safety and Health (DHHS (NIOSH) Publication No.
80-145), Cincinnati.

14. Kaminski, R-, Spirtas, R. 1980. NIOSH Research Report: Industrial
Characteristics of Persons Reporting Morbidity During the Health Interview

Surveys Conducted in 1969-1974: An Exploratory Review. National Institute
for Occupational Safety and Health (DHHS (NIOSH) Publication No. 80-123),
Cincinnati.

15. Copplestone, J.F. 1967. Occupational Mortality Among Male Population,
Other Than Maori, 20 to 64 Years of Age (Based on Deaths, 1959-63 and

Population Census, 1961). National Health Statistics Centre (Special Report
No. 28), Wellington, New Zealand.

16. Society of Actuaries. 1967. 1967 Occupation Study. Society of
Actuaries, Chicago.

17. Adelstein, A.M. 1972. Occupational mortality: cancer. Ann. Occup.
Hyg. 15:53-57.

18. U.S. Department of Health, Education and Welfare. 1967. International
Classification of Diseases, Eighth Revision, Adapted for Use in the United
States. U.S. Government Printing Office (PHS Publication No. 1693),
Washington, D.C.

19. Rothman, K.J. 1975. Alcohol. In: Fraumeni, J.F., Ed. Persons at High
Risk of Cancer: An Approach to Cancer Etiology and Control. pp. 139-150.
Academic Press, New York.

20. Gittelsohn A., Senning J. 1979. Studies on the reliability of vital and
health records: I. Comparison of cause of death and hospital record
diagnoses. Am. J. Public Health 69:680-689.

21. Percy C-, Stanek E., Gloeckler L. 1981. Accuracy of cancer death
certificates and its effect on cancer mortality statistics. Am. J. Public
Health 71:242-250.

22. Bauer F.W., Robbins S.L. 1972. An autopsy study of cancer patients I.

Accuracy of the clinical diagnoses (1955 to 1965) Boston City Hospital. J.
Am. Med. Assoc. 221:1471-1474.

23. Engel, L.W., Strauchen, J.A., Chiazze, L., Heid, M. 1980. Accuracy of
death certification in an autopsied population with specific attention to
malignant neoplasms and vascular disease. Am. J. Epidemiology 111:99-112.

24. Heasman, M.A., Lipworth, Le 1966. Accuracy of Certification of Cause of
Death. Her Majesty's Stationery Office (Studies on Medical and Population
Subjects No. 20.), London.

37


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117


METHODS OF ANALYSIS

MORTALITY ODDS RATIO

The age-standardized mortality ratio (SMR) is a preferred index for measuring
occupational mortality. This index compares the death rate for a specific
cause in a given occupation with the death rate for that cause in the study
group as a whole. In practice it is very difficult to obtain accurate SMRs
using death certificate data. In the studies in which this has been done
(3,4,8,9,15), census data has been used to obtain age-specific number of
persons at risk of death in each occupation (the denominator in the rates).
However, the relatively poor correspondence between occupational statements on
death certificates and census records leads one to interpret the SMR results
with a great degree of caution. The 1970-72 British study presents an
analysis of the complex biases between death certificates and census data
which must be considered in interpreting the results.

Because of the problems in obtaining accurate SMRs, we felt that the extra
costs involved in incorporating census data into the analysis were not
warranted. Instead, we chose to use the age-standardized mortality odds ratio
(sMOR) as the measure of relative mortality in this study (33). The death
certificate data alorie is sufficient for calculation of sMORs.

The MOR is the ratio of mortality odds between the cancer of interest and
other (auxiliary) diseases for the occupation of interest compared with a
non-exposed comparison group (Appendix J). The MOR approach is essentially
equivalent to a case-control approach, where the cases are all of the deaths
from the cancer of interest, the controls are the auxiliary causes of death,
and the exposure of interest is occupation. The exposure odds ratio - the
ratio of the exposure odds between the occupation of interest and the
non-exposed comparison group for the cancer of interest compared with the
auxiliary diseases - is equal to the MOR (Appendix J).

sMOR can be interpreted as the SMR on the assumption that the mortality rate
for the auxiliary causes of death is the same in the occupation of interest
and the comparison group (Appendix J). ‘Thus the choice of the auxiliary
diseases and the comparison group should be a considered one. We performed
the sMOR analyses using two different comparison groups - all other
individuals within the same social class (social class adjusted analysis) and
all other individuals in the entire population (standard or social class
unadjusted analysis). In both analyses, causes of death other than malignant
neoplasms and cirrhosis of the liver were used as the auxiliary causes of
death.

Generally, it has been found that there is less variation in overall mortality
(and mortality from the grouped auxiliary causes of death) among occupations
within the same social class or major occupational grouping than among
occupations from different social classes or major occupational groupings
(34). This is because, apart from direct effects of the work environment
itself, there are other major determinants of mortality which are

16


On the positive side, for studies of occupational cancer usual occupation is
preferred to current or last occupation (used in the California, Los Angeles
County, and British studies). This is because of the long latent period (in
most cases 20 years or greater) between initial exposure to carcinogens and
the onset of clinical diseases. Thus, if a subject worked as a plumber for
30 years, and then as a truck driver for the last five years of his life,
Plumber would be the main occupation of interest in occupational cancer
studies.

In this section, we have concentrated on pointing out limitations in the use
of death certificates as the data base for occupational cancer studies. These
limitations must be kept in mind when interpreting the results from these
studies. An additional limitation should be noted - there is no information
on death certificates with regard to potential confounding factors such as
smoking habits, alcohol consumption habits, and dietary habits. (While
ethnicity can be inferred from death certificate information on the decedent's
birth place and the mother's and father's birth places and names, no attempt
was made in any of the studies to examine for confounding by ethnicity.
Another major confounding factor for which it is possible to control using
death certificate data is social class. This was done in the 1959-63 and
1970-72 British studies. We have controlled for social class in the present
Massachusetts study using a social class classification scheme based upon
occupation).

Yet, in spite of all of these caveats, a death certificate data base presents
the overriding advantage of easy accessibility to large numbers of death
records, with information on occupation and cause of death, which can be
analyzed relatively simply and cheaply. In the absence of cancer registries
in the United States which collect information on occupation and potential
confounding variables, which would represent a qualitative advance in the
field, death certificate analysis will most likely remain the principle means
for doing this type of broad-based occupational cancer surveillance.

11


ACKNOWLEDGEMENTS

We would like to express our gratitude to the following people for their work
on this study: Phillip Hogg added the information on occupation and industry
from the death certificates to the computer tapes. Bill Musk helped with the
occupational coding. Cindy Rubin and Donna Spiegelman provided assistance
with data management. Donna Spiegelman and Jim Meade provided assistance in
preparing the graphs in Appendix D. Jane McGowan, Susan Sheridan, and
Melinda Tuhus provided assistance in preparing the manuscript.

We wish to thank the Massachusetts Department of Health for providing the
computer tapes of the death certificate records. We would also like to thank
Dr. Theodor D. Sterling, Department of Computing Science, Simon Fraser
University, British Columbia, Canada for providing tables of age-specific
smoking patterns by major occupational group.

A portion of this study was supported by NIEHS Occupational and Environmental
Health Center Grant no. 5 P30 ES 00002. Robert Dubrow was a Fellow in the

Interdisciplinary Programs in Health, Harvard School of Public Health, during
a portion of this investigation.

vi


MORTALITY PATTERNS OF SELECTED GROUPED

OCCUPATIONAL CATEGORIES AND CANCER TYPES

+ indicates p< .05

++ indicates p< .01

APPENDIX C

The results are for the age group 20+ unless otherwise indicated.

C 1. 343 POSTAL WORKERS

Rectum and rectosigmoid junction

Occupation Observed Expected sSMOR
86 postmasters 2 2 107
104 mail carriers 3 3 115
107 postal clerks 9 3 264++
318 postal workers NEC 4 2 205
343 postal workers (all) 18 10 185+
C 2. 346 PAINTERS (expanded)
Respiratory system

Occupation Observed Expected sMOR
169 painters, construction

and maintenance 106 81 130+
170 painters, sign 5 3 157
171 painters, auto 3) 2 166
172 painters, shipyard 9 4 244+
346 painters (expanded) 123 90 137++

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66


the auxiliary group, the interpretation of a PMR analysis on this data would
have been seriously compromised. The PMR approach would have necessitated
including all male deaths in the study, resulting in a considerable increase
in costs.

AGE STANDARDIZATION

Age-standardized MOR analyses were performed for the entire matrix of 397 x 63
occupation-disease combinations, for the ten major occupational groupings, and
for the four social classes. The comparison group in the major occupational
grouping and social class analyses was all other individuals in the study
population. Age stratification was done by five year age groups (20-24,
25-29, etc.). sMORs (33) were calculated for the following age groups:

20-54, 55-64, 65-74, 75+, as well as for the summary age groups 20-64, 20-74,
and 55-74 and for the total age range. This was done in order to facilitate
looking at occupation-cancer associations as a function of age. This could be
valuable for several reasons:

1) Some occupational cancers may occur at an earlier than average age because
of a high intensity of exposure.

2) On the other hand, some occupational cancers may concentrate in the 55-74
age group, and not appear at younger ages, because of a long latent period or
a long duration of exposure necessary for cancer induction.

3) The accuracy of the cause of death statement and the occupational
statement on death certificates has been reported to decrease with increasing
age past retirement (9). Thus including the older age groups (especially 75+)
in the analysis could dilute out the magnitude of real occupation-cancer
associations. On the other hand, if, in fact, the death certificates in the
older age groups are not less accurate for many occupations and cancers,
excluding them from the analysis would mean a loss of information.

4) Some occupational cancers may occur selectively among younger or older
workers due to changes in exposures over the years.

One cannot predict a priori which age grouping would be optimal to examine for
a given occupation-cancer combination based on the above considerations. Thus
we deemed it valuable to examine the range of age groupings systematically.

In the social class adjusted analysis, summary odds ratios (33) were
calculated for mixed social class occupations by summing over the classes.
SIGNIFICANCE TESTING

Significance testing was done using the chi-square test, applying the
Mantel-Haenszel principle (35). Significance testing was done for each age

grouping studied, but only if four or more deaths were observed in the
grouping.

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4) An analysis of social class-cancer associations.

5) Control for potential confounding by cigarette smoking for the lung cancer
results in the major occupational groupings. This was done by a method which
utilized independent data on smoking habits in the major occupational
groupings and on lung cancer death rates among smokers, ex-smokers, and never
smokers.

6) A comprehensive comparison of the positive results in this Massachusetts
study with the other studies in Table l.


Abbreviation Cancer Site

MYE LEU myeloid leukemia

MON LEU monocytic leukemia

AC ERYT acute erythremia

POL VER polycythemia vera
MYELOFI myelofibrosis

CIRRHOS cirrhosis of the liver

Note: The overall sMORs for the four social classes combined differs from
100 because in the analysis subjects who were not assigned to a social
class (farmers and unknowns) were included in the comparison group.

138


Individual

Occupation

Payroll clerks

Personnel workers

Pest control workers,

Pharmacists

Photoengravers

Photographers

Physicians

Physicians, dentists, and
related practicioners

Physicists

Piano tuners and repairmen

Pilots, ship

Pipefitters

Plant and tree workers

Plasterers

Plastic workers

Plate printers, printing

Plumbers

Plumbers (expanded)

Plumbers, shipyard

Policemen

Polishers, metal

Porters

Postal clerks

Postal workers (all)

Postal workers NEC

Postmasters

Poultry farmers

Pourers

Power station operators

Pressmen, printing

Primary metal industries workers NEC

Printing trades

Printing workers NEC

Private household workers

Produce brokers,

Production control

Professional and personal
service attendants NEC

Professors, biolgocial sciences

Professors, chemistry sciences

Professors, engineering

Professors, mathematics

Professors, nonscientific subjects

Professors, physics

Professors, subject not specified

Projectionists, motion picture

Proprietors NEC

Psychiatrists

Psychologists

181

Code

106
85
239
48
177
49
50

44
175
82
179

176
242
181
179

180
288
224
283
107

318

296
229
182
181
206

208
281
73

103

Grouped Codes

378
330,331
351
336
330,331

330
326,329
338,349
371
347,377,387
390

387

378

351
347,377,387
347
347,377,395

350,361
388
343
343
343
343
389,391
360,361
353
351
361
351
351

326 ,329,332,334

326 ,327,329, 332,334
323,324,325 ,329,332,334
325 ,329, 332,334
332,334

326 ,329,332,334
332,334

330,331
330,331


DISCUSSION

In interpreting the results of this study, numerous factors need to be taken
into account. For a given occupation-cancer association, these include:

1) The level of significance of the association.
2) The effects of social class adjustment on the association.

3) The possibility of other confounding factors or biases explaining the
association.

4) Whether occupations with similar exposures have an excess of the
cancer of interest.

5) The degree to which the association is supported by the studies in
Table 1.

6) The degree to which the association is supported by other studies from
the literature.

7) Whether reasonable hypotheses can be made as to possible carcinogenic
exposures associated with the occupation of interest.

Appendices A-C are presented as aids in interpreting the complete results,
which are on the microfiche. Appendix A addresses points 1), 2) and 5);

Appendix B addresses points 1), 2), and 4); and Appendix C addresses point 4).

Table 4 presents occupation-cancer associations (other than lung cancer) from
this study, which are supported by other studies from the literature, thus
addressing point 6). (Table 4 was not based upon a thorough literature
search, but upon the authors’ current knowledge of the literature.) In
addition, Table 5 lists occupational categories which had excess cancer of
the trachea, bronchus, and lung in this study, which had substantial support
from the studies in Table 1 and other studies from the literature, and for
which there are reasonable hypotheses as to possible occupational
carcinogens. It thus addresses points 5), 6), and 7).

General principles for assessing the possibility of confounding and biases
(point 3)) are presented in the "DEATH CERTIFICATE DATA" and "METHODS OF
ANALYSIS" sections. Confounding of the lung cancer results by cigarette
smoking is assessed for the major occupational groupings in Appendix L.

We will not attempt to do an exhaustive interpretation of the results in this
section, as this would basically duplicate what is already presented in the
Appendices and Tables. However, we would like to highlight some results from
this study which, in our opinion, are particularly noteworthy.

LUNG CANCER - SMOKING OR OCCUPATION?

In our opinion, the most significant result of this study is the confirmation
of an association between cancer of the trachea, bronchus, and lung and a
large number of occupations for which there are reasonable hypotheses as to
possible occupational carcinogens (Table 5). These include the well
established lung cancer elevations among asbestos workers, shipyard workers,

26


373

374

376

377

378

379

380

220 conductors, bus and street railway
222 deliverymen and routemen

254 taxicab drivers and chauffeurs

255 truck and tractor drivers

256 fuel oil truck drivers and laborers
257 drivers NEC

258 fork lift drivers

259 movers, moving truck drivers

Meat processing workers

231 meat cutters, except slaughter and packinghouse
232 slaughter house butchers

Gas station, garage workers

95 garage, gas station owners, foremen, managers
213 attendants, auto service, gas station
214 parking attendants

Oil exposure

94 fuel oil dealers, managers

209 oil and related industry workers NEC
237 oilers and greasers, except auto
256 fuel oil truck drivers and laborers

Oil and gasoline exposure

374 gas station, garage workers
375 oil exposure

Asbestos exposure

211 asbestos and insulation workers
347 plumbers (expanded)

395 shipyard workers

Chemical exposure (operatives)

202 chemical workers

223 dyers

239° pest control workers
240 paper, pulp mill workers
242 plastic workers

243 rubber workers

251 Jleatherworkers, tanners

Silica exposure

166 molders, metal
187 stonecutters and stonecarvers

Barbers (expanded)

163


Individual

Occupation Code Grouped Codes
Sales clerks NEC 120
Sales managers 90
Sales representatives 115
Salesmen NEC 120
Salvage dealers, workers 309
School administrators, elementary

and secondary school 61 333,334
School custodians 280 384
School professions 334
Scrap metal dealers, workers 309
Seamen NEC 246 371
Secretaries 108
Servants 281
Service workers NEC 291
Servicemen-telegraph, telephone,

power (utility and gas) 150 349
Sewerage workers 301
Sewers, manufacturing 247 366
Sextons 278 384
Sheet metal workers 190 361
Sheriffs 288
Shippers, farm products 73
Shipping clerks 102
Shipyard workers NEC 248 377,395
Shipyards 377,395
Shoe factory workers 249 363,364
Shoe repairers 185 363,364
Shoemakers 185 363,364
Signmakers 245
Silica exposure 379
Silversmiths 148
Slaters 183 387
Smeltermen 229 360,361
Social workers, except group 54
Sports instructors 58 340
Sports officials 58 340
Starters, vehicle 101
Station agents 111
Stationary engineers 186 353
Stationary engineers (expanded) 353
Stationary firemen 253 353
Statisticians 57 325,329
Steamfitters 178 347,377
Steelworkers 244 361
Steeplejacks. 184 352
Sterotypers 136 351
Stevedores 306 388
Stewards, except private household 276 384
Stitchers, manufacturing 247 366
Stock clerks 110

183


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95


APPENDIX D

AGE-STANDARDIZED MORTALITY ODDS RATIOS
BY SOCIAL CLASS AND CANCER SITE, AGES 20+

P-VALUE HR nor sionsricont BALI aces
PCL
Abbreviation Cancer Site
MAL NEO malignant neoplasms
BUC & PHA buccal cavity and pharynx
SALIV salivary gland
DIGEST digestive organs and peritoneum
ESOPHAG esophagus
SMA INT small intestine
COL & REC large intestine and rectun
COLON large intestine, except rectum
CE,A,AC cecum, appendix, and ascending colon
TR COL transverse colon
DES COL descending colon
SIG COL sigmoid colon
REC & RSJ rectum, and rectosigmoid junction
RSJUN rectosigmoid junction
BIL & LIV biliary passages and liver
GALLBLA gallbladder, ducts, ampulla of vater
PANCREA pancreas
PER & RTP peritoneum and retroperitoneal tissue
RESPIR respiratory system
NOSE & NP nose and nasopharynx
LUNG trachea, bronchus, and lung
PLEU & MS pleura and mediastinum
CON & SFT connective and other soft tissue
MAL MEL malignant melanoma of skin
OT SKIN skin, other malignant neoplasms of
PROSTAT prostate
URINARY urinary organs
BRA & NER brain and nervous system
SUP-REN supra-renal gland
SEC MAL secondary malignant neoplasms
MUL MAL multiple malignant neoplasms
LYM & HEM lymphatic and hematopoietic tissue
LYMPHOM lymphomas
RET SAR reticulum cell sarcoma
LYMSARC lymphosarcoma
HODGKIN Hodgkin's Disease
MYELOMA. multiple myeloma
LEUKEMI leukemia
ALL lymphatic leukemia, acute
CLL lymphatic leukemia, chronic

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88


DEATH CERTIFICATE DATA

The initial data source for this study was the entire death file for
Massachusetts for the years 1971 to 1973. All adult males (20 years of age or
older) whose underlying cause of death was coded by the state nosologist as a
malignant neoplasm (International Classification of Diseases (eighth revision)
(18) codes 140-209) or as cirrhosis of the liver (ICD code 571) were chosen
for the study. (Because a number of industrial chemicals are potential liver
toxins, cirrhosis of the liver was studied as well. Cirrhosis of the liver
also serves as a good indicator of alcohol consumption, “which is known to be
related to certain forms of cancer (19)).

In addition, a sample of every fourth adult male death was chosen. The deaths
other than malignant neoplasms and cirrhosis of the liver from this sample
were used as the auxiliary disease group in the age-standardized mortality
odds ratio analyses (see "METHODS OF ANALYSIS" section). Because of the small
percentage of non-whites (3 percent), they were omitted from the analysis to
avoid confounding by race, and were not analyzed separately. Thus all results
are for adult white males only. A total of 34,879 adult white males were in
the final data base, including 16,629 who died from malignant neoplasms and
2177 who died from cirrhosis of the liver.

The items of information used from the death certificates to perform the
analysis were:

1) age at death.

2) underlying cause of death as coded by the state nosologist according
to the ICD (eighth revision) code.

3) usuai occupation. ‘The instruction on the death certificate reads,
"Kind of work done during most of working life."

4) industry or business.

CAUSE OF DEATH INFORMATION

Although no data is available from Massachusetts, several studies have been
published in the United States and Great Britain which assess the accuracy of
cause of death certification for specific forms of cancer. For most forms of
cancer, the accuracy of the cause of death statement has been found to be
between 70 and 90 percent when compared with hospital diagnoses (20,21),

although it has been found to be somewhat lower when compared with autopsy
findings (22-24).

The quality of cause of death certification presents problems for occupational
cancer mortality studies. At best, if misclassification of cause of death
occurs randomly across occupations, the magnitude of any real
occupation-cancer association will be diluted. However, it would not be
surprising if the accuracy of cause of death certification were social class,
and therefore occupation, dependent. This could be particularly true for
cancer types, such as pancreatic cancer, which are difficult to diagnose. One


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Individual

Occupation

Stock salesmen, counsellors, etc.
Stone carvers

Sonecutters

Stonemasons

Storekeepers

Structural metal craftsmen
Students

Supervisors NEC

Surgeons

Surveyors

T

Tailors

Tanners

Tavern owners and managers

Taxicab drivers

Teachers and administrators,
college and university

Teachers and administrators,
elementary and secondary school

Teachers, elementary and secondary
school

Teamsters

Technicians

Technicians NEC

Technicians, dental

Technicians, electrical

Technicians, electronic

Technicians, medical

Technicians, other engineering
and physical sciences

Temperers

Textile workers (expanded)

Textile workers NEC

Therapists NEC

Ticket agents

Tile setters

Timekeeping clerks

Tinsmiths

Toll collectors

Tool makers

Tractor drivers

Treasurers

Tree farmers, wardens, surgeons
workers, etc.

Truck drivers

TV announcers

Typesetters

184

Code

119
187
187
125
110
188
69
93
50
59

189
251
92

254

62
311

66
63
64
64
63

65
145

266

111
125
106
190
289
192
255

302
255

131

Grouped Codes

341
379
379
387

361
334

330,331
325,329

366
364,378
382
372

332
333
333,334

328

328 ,329
328,329,331
328,329
328,329

328 , 329,331

328 , 329
360,361
365
365
330,331

387
361

350,361
372
341

390
372
339
351


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68


“occupational"). In addition, individual occupations are collapsed into

70 grouped categories of similar occupations (Appendix G)- An individual
occupation can appear in more than one grouped category. Finally, we coded
six large employers who are named on the death certificates with sufficient
frequency to permit analysis (Appendix H). Subjects classified into one of
the large employer categories are also classified into an individual
occupation category.

The individual occupation classification is based on the modification of the
1960 U.S. Bureau of the Census classification used in the Washington State
study, with significant additional modifications. New categories added to the
classification include our own additions, additions taken from the 1970 Bureau
of the Census classification, and a number of industrial categories. The 1970
Census of Population Alphabetical Index of Industries and Occupations (28) was
relied on extensively as an aid in assigning occupational codes (those from
the 1960 classification as well as the additions).

Many death certificates list the name of the employer in the "industry or
business" entry. The 1974-75 Industrial Directory of Massachusetts
Manufacturers (29), which classifies Massachusetts manufacturing firms by
their Standard Industrial Classification (SIC) code (30), also proved to be
invaluable in assigning codes. Not only are a number of our categories
strictly industrial, but in the Bureau of the Census classification system the
assignment of codes is often dependent on both the occupation and the
industry. There was enough information on the death certificates to classify
96.4 percent of the subjects into a category other than "not stated, unknown,
none" (code 321).

For convenience, we assigned code numbers by consecutive numbering (1 to 321)
of the individual occupational categories. Appendix F shows the corresponding
Bureau of the Census and SIC codes. The grouped codes are further
consecutively numbered (322 to 391), as are the large employer codes (392 to
397).

All subjects were also grouped into ten major occupational groupings:

professional, technical and kindred workers
managers, officials, proprietors, except farm
clerical and kindred workers

sales workers

craftsmen, foremen, and kindred workers
operatives

service workers

laborers, except farm

farmers

unknown.

These groupings are mainly by individual occupational category, as indicated
in Appendix F. However, a number of individual occupational categories are
mixed with respect to major occupational grouping. For example, the category
fabricated metal product workers NEC includes foremen, operatives, and
laborers. In these situations subjects were coded into major occupational
groupings independently from their individual occupational codes.

13


28 engineers, chemical
34 engineers, metallurgical

328 Technicians (all)

4 air traffic controllers

5 airplane pilots and navigators

39 embalmers

51 radio operators

63 technicians, medical and dental

64 technicians, electrical and electronic

65 technicians, other engineering and physical science
66 technicians NEC

329 Mathematical, scientific, and technical professions

325 mathematical professions
326 life and physical sciences
328 technicians

330 Physicians, dentists, and related practitioners

9 chiropodists (podiatrists)
12 chiropractors

23 dentists

25 dieticians and nutritionists
46 nurses, professional

47 optometrists

48 pharmacists, druggists

50 physicians and surgeons

56 psychologists, psychiatrists
67 therapists and healer NEC
68 veterinarians

331 Medical Workers
63 technicians, medical and dental
330 physicians, dentists, and related practitioners

381 hospital workers

332 Teachers and administrators, college and university

14 college presidents, deans, administrators

15 professors/instructors, biological sciences
16 professors/instructors, chemistry sciences

17 professors/instructors, engineering

18 professors/instructors, mathematics

19 professors/instructors, physics

20 professors/instructors, nonscientific subjects
21 professors/instructors, subject not specified

333 Teachers and administrators, elementary and secondary schools

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96


TABLE 2

SMRs OF INTEREST FOR MAJOR OCCUPATIONAL GROUPINGS
AND SOCIAL CLASS GROUPINGS FROM OTHER STUDIES

For the 1950 United States study (4) and the two England and Wales studies (3,
9), the SMRs are for the auxiliary causes of death (all causes of death other
than malignant neoplasms and cirrhosis of the liver). They were calculated by
subtracting the observed and expected deaths from malignant neoplasms and
cirrhosis of the liver from the observed and expected deaths for all causes
combined. It was found that the SMRs for the auxiliary causes of death fairly
closely approximated the SMRs for all causes of death combined in these three
studies. Since information on specific causes of death was not available from
the 1960 United States Matched Records Study (34), SMRs presented from this
study are for all causes of death combined - a reasonable approximation of the
SMRs for the auxiliary causes of death. ‘The SMRs presented from the 1949-51
California Study (27) are for all causes except cancers of the upper
alimentary tract, stomach cancer, lung cancer, accidents, suicide, and
homicide.

18


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385 construction workers, management
386 construction workers (expanded)

388 Material handlers (expanded)

259 movers, moving truck drivers
283 porters

306 longshoremen and stevedores
307 freight and material handlers
312 warehousemen NEC

389 Farmers

292 farm laborers

293 farm owners, managers, foremen
294 cranberry farmers, laborers
295 dairy farmers

296 egg and poultry farmers

297 nurserymen

298 orchardists

390 Plant and tree workers

38 foresters and conservationists

72 florists

292 farm laborers

293 farm owners, managers, foremen

294 cranberry farmers, laborers

297 nurserymen

298 orchardists

302 forestry workers; tree farmers, wardens, surgeons, workers, etc.
305 gardeners (except farm), groundskeepers, greenskeepers, landscapers

391 Animal workers

68 veterinarians

295 dairy farmers

296 egg and poultry farmers

299 ranchers, cattle, sheep, etc.
300 animal workers NEC

165


C 3. 347 PLUMBERS (expanded)

Respiratory system

Occupation Observed Expected sMOR
178 steamfitters . 20 11 182+
179 plumbers and pipefitters 52 41 125
180 plumbers, shipyard 5 5 104
347 plumbers (expanded) 77 57 135+

C 4, 349 MECHANICS AND REPAIRMEN (all)

Respiratory system
Occupation Observed Expected SMOR

150 linemen, servicemen, and installers,

telegraph, telephone, power

(utility and gas) 24 20 122
156 mechanics and repairmen, air condi-

tioning, heating, refrigeration

appliances 13 3 3834+
157 mechanics and repairmen, airplane 6 1 432+
158 mechanics and repairmen, automobile 50 39 129
159 mechanics and repairmen, auto body 8 8 102
160 mechanics and repairmen, radio,

television 2 4 50
161 mechanics and repairmen, railroad

and car shop 8 6 126
162 loom fixers 13 13 101
163 mechanics and repairmen NEC 66 44 148+
175 piano and organ tuners and repairmen 1 2 64
347 mechanics and repairmen (all) 191 139 137++

130


The major grouping "unknown" is with respect to the other nine major
groupings, and not absolute. There is sufficient information on the death
certificates of many of the subjects to classify them into individual
occupational codes 316-320 (railroad workers NEC, government workers NEC,
postal workers NEC, public utility workers NEC, and public works employees
NEC), but insufficient information to classify many of them into a major
occupational grouping. For example, the following could be classified into
major occupational groupings: :

Usual Occupation Industry or Business

Signal man B and M Railroad

Laborer City of Boston

Laborer Post Office

Inspector Boston Edison Company

Foreman Massachusetts Department of Public Works

The following could not be classified into major occupational groupings:

Usual Occupation Industry or Business
Worker Railroad

City Employee Malden

Postal Worker Post Office

None Brockton Gas Company
None Cambridge Public Works

SOCIAL CLASS CLASSIFICATION

The social class classification scheme was based upon occupation. Subjects in
the major occupational groupings "farmers" and "unknown" were not assigned to
a social class- All other subjects were assigned to one of four social
classes, based primarily upon their major occupational grouping, and
secondarily upon the rating of their individual occupation in Duncan's
socioeconomic index of occupations (31) (Appendix I). This is a widely used
socioeconomic rating system for occupations, based upon U.S. Census education
and income data. ‘The index was first calculated using data from the 1950
census (31). Recently, an updated version, based upon 1970 census data, has
been published (32). While the 1950 and 1970 versions were generally in good
agreement, there were a few significant changes in ratings of occupations. We
relied primarily on the 1950 index. Although the subjects in this study died
in 1971-73, because of the generally long latent period of cancer, their
social class in 1950 is more relevant than that in 1970. However, some of the
occupational categories were given ratings in the 1970 version, but did not
appear in the 1950 version. For these we used the 1970 ratings.

The socioeconomic index was detailed enough so that, between the 1950 and 1970
versions, only 19 of our occupational categories could not be given any
rating. We were able to rate fully most of the categories which were mixed
with respect to major occupational grouping. For example, the 1950 index had

14


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113


INTRODUCTION

This study examines cancer mortality patterns by occupation for white males in
the state of Massachusetts using death records for the years 1971-1973. Its
purpose is to identify occupation-cancer associations which, when interpreted
in conjunction with results from other studies and hypotheses about potential
occupational carcinogens, can serve as leads for more definitive etiological
investigations.

A number of similar studies, which provide information on occupation-cancer
associations, based on either vital records data or cancer registry data, have
been published over the past twenty years (1-11). Table 1 summarizes some of
the basic features of these studies. (In the subsequent text these studies
will be referred to by the geographic base listed in the first column of
Table 1. The England and Wales studies will be distinguished by referring to
the years of the study (third column of Table 1) as well. The reader should
refer to Table 1 for the references for these studies.) The repetition of
this type of study is important for a number of reasons:

1) Many of the associations seen in any one study will be chance
associations. Any time a large number of statistical comparisons are made, a
certain number will achieve statistical significance by chance alone. In
addition, some of the associations will be artifacts resulting from problems
in the particular method of analysis or data base used. (For example, there
is always the possibility of selective occupational and/or disease
misclassification due to biases in the collection of information on death
certificates). However, if the same association is reproduced in several
different studies, the probability that the association is real is enhanced.
Of course, further investigation is necessary to determine whether the
association is causal or is due to a separate factor which is associated with
the occupation - such as socioeconomic status, ethnicity, cigarette smoking,
or consumption of alcoholic beverages.

2) For rare occupations, rare forms of cancer, or weak associations, the
numbers in any one study may not be sufficient to show statistical
significance. But if the same association is seen consistently from study to

study, even if it is statistically significant in none of them, it may point
to an occupational hazard.

3) Occupational cancer risks may change as a function of time. As old
processes or materials are replaced by new ones, exposure patterns to
occupational carcinogens may change. Thus an occupation-cancer association
may be observed in a study using a 1970 data base, but not ina study using a
1950 data base.

4) Certain occupations and industries are found concentrated in some
geographical areas, but not in others. For example, the Washington State
study has a large number of plywood workers and atomic energy workers, but
very few textile workers and no shoe factory workers. The present study of


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90


analyses. As one might expect, social class adjustment generally made the
greatest difference in the cancer categories which exhibited the steepest
social class mortality gradients.

Analysis by age groupings

Forty-three percent of the associations listed in Appendix B were significant
at the p < .01 level in the age groupings 20-54, 20-64, 20-74, and/or 55-74,
but not in the 20+ age grouping. Twenty-five percent of the associations
listed in Appendix B were significant at the p < .01 level in the age
groupings 20-54, 20-64, 20-74, and/or 55-74, but were significant neither at
the p < .01 nor the p < .05 level in the 20+ age grouping. Thus many
associations would have been missed if the analyses had been restricted to the
all 20+ age grouping. Undoubtedly, many of the associations found only in the
narrower age groupings were due to chance. However, a number of associations
with reasonable hypotheses as to possible occupational carcinogens and/or with
support from other studies were found to be highly significant in narrower age
groupings, but not significant at all in the all 20+ age grouping. For
example, the results for machinists and related occupations in the 20-54 age
grouping were discussed in the "DISCUSSION, OTHER SELECTED ASSOCIATIONS,
Machinists and related occupations" section.

Codes

Having detailed cause of death and occupational codes proved to be worthwhile,
as associations of interest were found which would have been missed if the
codes were less detailed. Two examples are the highly significant excesses of
myeloid leukemia among rubber workers and prostate cancer among compositors
and typesetters. The associations, which are supported by the literature, and
for which there are reasonable hypotheses as to possible carcinogenic
exposures, would have been missed if myeloid leukemia had not been examined
separately from leukemia and aleukemia and if compositors and typesetters had
not been examined separately from other printing trades.

On the other hand, significant associations of interest were seen in grouped
categories which were not significant in any of the individual categories
which make up the grouped categories. For example, while stomach cancer was
significantly elevated in grouped code 350 "machinists and related
occupations," it was not significantly elevated in any of the eight individual
occupational categories which make up this group.

Possible biases

Several occupational categories had surprisingly low or surprisingly high
mortality rates for all malignant neoplasms. In these cases, low or high
mortality rates for the auxiliary causes of death could be creating
artifactually high or low cancer mortality rates. Occupational categories
with surprisingly low cancer rates include fuel oil truck drivers and
laborers; stationary firemen; constuction laborers NEC; and roofers and
slaters. Occupational categories with surprisingly high cancer rates include
teachers and administrators, college and university; lawyers, judges, and
attorneys; and agricultural scientists.

35


CODE TITLE CENSUS cops! sc*

304 car washers 963 4
305 gardeners (except farm), groundskeepers, 964 4
greenskeepers, landscapers
306 longshoremen and stevedores 965 4
307 freight and material handlers (753) 4
308 grocery clerks 298 4
309 scrap metal, salvage, junk dealers, workers 892 4
310 lumbermen 970 4
311 teamsters 971 4
312 warehousemen NEC 973 4
313 laborers NEC 980 4
314 construction laborers NEC 982 4
315 road construction and maintenance workers 496 4
UNKNOWN.
316 railroad workers NEC 981
317 government workers NEC
318 postal workers NEC
319 public utility workers NEC (gas, electric, 363
telephone)
320 public works employees NEC
321 not stated, unknown, none 997-999

+ The individual occupational codes are grouped under ten major groupings.
However, the actual classification into major occupational groupings is more
complex than is indicated in this table. A number of individual occupational
categories contain subjects from several major occupational groupings. For
example, code 202, "chemical workers," is classified under the major grouping
"operatives" in this table. This code includes in it subjects which come
under three different major groupings - operatives in the chemical industry,
laborers in the chemical industry, and foremen in the chemical industry. The
major grouping "unknown" is in relation to the other nine major groupings,
and not absolute. There is sufficient information on many of the death cer-
tificates to classify them into individual occupational codes 316-320, but
insufficient information to assign many of these certificates to a major occu-
pational grouping. See the text (CLASSIFICATION SCHEMES - OCCUPATIONAL CODE)
for further discussion of these points.

# The census codes listed are from the modification of the 1960 Bureau of the
Census code used in the Washington State study. Codes in parentheses are
from the 1970 Bureau of the Census code. Codes with the prefix "I" are Stan-
dard Industrial Classification (SIC) codes. If no code is listed, the occu-
pation is our own addition to the classification scheme.

* The number indicates the social class into which the occupation has been
classified. See the text (CLASSIFICATION SCHEMES - SOCIAL CLASS CLASSIFICA-
TION) and Appendix E for the details of the social class classification
scheme.

155


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97


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38