Cancer incidence and cause-specific
mortality following Balkan deployment

RIVM Report 630450001/2011

RIVM Report 630450001

Colophon

© RIVM 2011
Parts of this publication may be reproduced, provided acknowledgement is given
to the 'National Institute for Public Health and the Environment', along with the
title and year of publication.

D. Schram-Bijkerk
R.P. Bogers
Contact:
D. Schram-Bijkerk
Centre for Environmental Health
dieneke.schram@rivm.nl

This study has been reviewed by a Scientific Advisory Board with Prof. Dr. F.E.
van Leeuwen (chairman, The Netherlands Cancer Institute), Dr. L.J. Schouten
(Maastricht University) and Prof. Dr. L.A.L.M. Kiemeney (Radboud University
Nijmegen Medical Centre).

This investigation has been performed by order and for the account of the Dutch
Ministry of Defence, within the framework of 'Epidemiologisch onderzoek Balkan'.

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Abstract

Cancer incidence and cause-specific mortality following Balkan
deployment
A study performed by the National Institute for Public Health and the Environment (RIVM) found no association between the deployment of Dutch military
personnel in the Balkan region and the incidence of cancer, including leukaemia.
There were fewer new cases of cancer and deaths between 1993 and 2008
among Balkan deployed Dutch military personnel than among those who were
not deployed to this region. Male military personnel of both groups had a lower
chance of developing cancer or dying than men of similar age in the general
Dutch population. In 2000, cases of leukaemia among Balkan deployed soldiers
were reported in both the international and national media. This study, however,
did not identify any increases in the number of cases of leukaemia among Balkan deployed soldiers.
The number of new cases of cancer among the 18,000 men who were deployed
to the Balkans was 15% lower than expected based on rates in the general population. The cancer incidence was also lower among Balkan deployed soldiers as
compared to the 135,000 soldiers who had not been deployed to the Balkans.
The number of lung tumours was half that in the general population, but the
underlying factors for this low incidence are unknown as data on smoking habits
and other lifestyle factors were not available. The number of leukaemia cases
among Balkan deployed military personnel was also lower than expected, but it
was not significantly different from the expected number based on the Dutch
population. No elevated risk of cancer was observed among the relatively small
number of women military personnel who were deployed to the Balkans.
The total number of deaths among soldiers deployed to the Balkans was 33%
lower than in the general population on a whole. The mortality rate was also
lower among Balkan deployed soldiers than among non-Balkan deployed soldiers. The difference with the general population can be explained by the
‘healthy worker effect’ phenomenon that considers the working population, and
the military population in particular, to be healthier than the general population
on a whole due to health examinations at the time of enlistment and the physical demands of the profession. With regard to causes of death, those due to
cancer and to diseases of the circulatory system were particularly lower among
Balkan deployed military personnel as compared to the general population.
Keywords:
cancer, deployment, Balkans, military, death

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Rapport in het kort

Cancer incidence and cause-specific mortality following Balkan deployment
Er blijkt geen verband te zijn tussen uitzending van militairen naar de Balkan en
het optreden van verschillende typen kanker, waaronder leukemie. Het aantal
nieuwe gevallen van kanker en het aantal sterfgevallen in de periode 1993-2008
was onder Nederlandse Balkanmilitairen lager dan onder militairen die niet op de
Balkan zijn geweest. Zowel de Balkanmilitairen als de niet-Balkanmilitairen hadden een lagere kans op kanker en sterfte vergeleken met even oude mannen uit
de Nederlandse bevolking. Dit blijkt uit onderzoek van het RIVM, dat is uitgevoerd naar aanleiding van een vermeend verband tussen uitzending naar de
Balkan en het optreden van leukemie.
Het aantal nieuwe gevallen van kanker onder de ruim 18.000 mannen die in de
onderzochte periode naar de Balkan zijn uitgezonden, lag in totaal 15 procent
lager dan onder even oude mannen uit de Nederlandse bevolking. Het aantal lag
ook lager dan onder de 135.000 niet-Balkanmilitairen. Het aantal tumoren in de
luchtwegen en borstholte lag de helft lager onder Balkanmilitairen dan onder de
Nederlandse bevolking. De reden voor dit lage aantal is onbekend – er waren
geen gegevens over roken en andere leefstijlfactoren beschikbaar. Ook het aantal leukemiegevallen lag lager, maar het verschil met de Nederlandse bevolking
was niet significant. Voor het relatief kleine aantal vrouwen dat naar de Balkan
is uitgezonden, is ook geen verhoogd aantal kankergevallen gevonden.
Het totale aantal sterfgevallen onder Balkanmilitairen in de periode 1993-2008
lag 33 procent lager dan onder even oude mannen uit de Nederlandse bevolking.
Het aantal lag ook lager dan onder de 135.000 niet-Balkanmilitairen. Ook de
niet-Balkanmilitairen hadden een lager sterftecijfer dan andere Nederlandse
mannen. Dit kan verklaard worden met het ‘healthy worker effect’: de werkende
bevolking, en uitgezonden militairen in het bijzonder, zijn vanwege bijvoorbeeld
de selectie op gezondheid door de dienstkeuring gezonder dan de algemene bevolking. Vooral sterfte aan kanker en hart- en vaatziekten lag lager onder Balkanmilitairen dan onder de Nederlandse bevolking.
Trefwoorden:
kanker, uitzending, Balkan, militairen, sterfte

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Contents

Summary—9
1
1.1
1.2
1.3
1.4

Introduction—13
Background—13
Objectives—14
The Dutch military contribution to Balkan missions—14
Organization of the report—15

2
2.1
2.2
2.3

Previous epidemiological studies on cancer and mortality in veterans—
17
Previous studies on cancer in veterans—17
Previous studies on post-deployment mortality in veterans—21
Summary—21

3
3.1
3.1.1
3.1.2
3.1.3
3.1.4
3.2
3.2.1
3.2.2
3.2.3

Methods—23
Design, study population and data collection—23
Inclusion criteria—23
No consent and privacy agreement—24
Cancer incidence—24
Cause-specific mortality data—25
Data-analysis—25
Differences between Balkan deployed military and their peers—25
Standardization to Dutch population—26
Additional analyses—27

4
4.1
4.1.1
4.2
4.2.1
4.2.2
4.3
4.3.1
4.3.2

Results—29
General characteristics of the study population—29
Characteristics of Balkan deployment—30
Cancer incidence—33
Comparison between Balkan deployed military and their peers—33
Comparison between Balkan deployed military and the Dutch population—34
Mortality—37
Comparison between Balkan deployed military and their peers—37
Comparison between Balkan deployed military and the Dutch population—37

5
5.1
5.2
5.3
5.4
5.5
5.6

Discussion—41
Main findings—41
The healthy soldier effect—41
Cause-specific mortality and cancer incidence—43
Lower risk of respiratory tumours—44
Completeness of study data—44
Methodological issues—45

6

Conclusions—47
Acknowledgement—49
References—51
Appendix 1. Letter to participants and no-consent form—55
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Appendix 2. Analyses in women—57
Appendix 3. Analyses in men non-deployed to the Balkans—59
Appendix 4. Analyses without conscripts—61
Appendix 5. Standardized mortality and cancer incidence ratios with follow-up
starting in 2001—63
Appendix 6. Hazard ratios of cancer incidence excluding cases in the first 18
months—65
Appendix 7. Index of tables—67
Appendix 8. Index of figures—69

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Summary
Background
In 2000 the international and national lay-press media reported on cases of leukaemia among Balkan deployed soldiers, which some attributed to alleged exposure to depleted uranium (DU), originating from DU-containing ammunition used
by NATO (North Atlantic Treaty Organization) Forces. These media reports
prompted questions in the Netherlands and other NATO countries about the occurrence of leukaemia, and its relationship with Balkan deployment and DU exposure in particular. Although the NATO reasoned the DU-related health risk to
be very low, it was nevertheless recommended that the NATO countries would
perform epidemiological studies on cancer among Balkan veterans. This report
describes the analyses for the Dutch military population. Although the study
originated from concerns about DU exposure, it is important to note that this
epidemiological study does not address any specific causative factors such as
exposure to DU, but rather explores associations between deployment status
and mortality and cancer incidence.
Aim
The aim of this study was to describe the cancer incidence and cause-specific
mortality up to 2008 among Dutch military personnel deployed to the Balkans
between 1993 and 2001, compared to:
− military personnel who were in service in the same time period but were not
deployed to the Balkans; and
− the general Dutch population of comparable age and sex.
Methods
The study population consisted of military personnel who:
− were in service any time between January 1, 1993 and March 1, 2001;
− worked in the Army or Military Police;
− did not return their no-consent form1;
− did not die during Balkan deployment, because this was a study on postdeployment mortality.
Cancer incidence and mortality data were collected for the years 1993-2008
from the Netherlands Cancer Registry (NCR) of the Association of Comprehensive Cancer Centres (IKNL) and the Dutch causes of death registry of Statistics
Netherlands (CBS), respectively. To study differences in mortality and cancer
incidence between Balkan- and non-Balkan deployed military personnel, survival
analyses (Cox proportional hazard models) were performed with adjustments for
age, appointment, rank and branch of military services. Analyses were performed for men and women separately. For the comparison with the Dutch
population, observed numbers of deaths and cases of cancer in Balkan deployed
personnel were compared with numbers that would be expected in the Balkan
deployed personnel based on the age- and sex-specific incidence and mortality
rates in the Dutch population in the same time period.

1

(Ex-)military personnel was given the opportunity to refuse matching their personal data with the Netherlands
Cancer Registry and cause of death registry. Only 2% returned their no-consent card.

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Results
The study population consisted of 19,167 Balkan deployed and 138,309 nonBalkan deployed persons. The Balkan deployed group included 992 women. The
majority (81%) of the non-Balkan deployed military male personnel were conscripts, whereas the Balkan-group included relatively few conscripts (15%). The
median age of both groups was 21 years in 1993. The median follow-up time of
Balkan deployed military personnel was 11 years.
The total cancer incidence rate among Balkan deployed military men was 17%
lower than the cancer incidence rate among non-Balkan deployed military men
(hazard ratio (RR) 0.83 (95% confidence interval (CI) 0.69-1.00)). The cancer
incidence rate was also lower (15%) as compared to the Dutch male population
of comparable age (Standardized Incidence Ratio (SIR)=0.85 (95% CI 0.730.99)). For the main cancer sites separately, cancer incidences were similar,
with the exception of tumours in the respiratory system and intrathoracic organs, of which the incidence was half that in the Dutch population (SIR=0.48
(95% CI 0.25-0.84)). Also for leukaemia, the observed number (n=5) appeared
to be lower than the expected number (n=8), based on the Dutch population,
but the difference was not statistically significant. For Balkan deployed women,
no significant elevations as compared to non-Balkan deployed women or the
Dutch female population were observed either.
The total mortality rate of Balkan deployed military men was 38% lower than
the mortality rate of non-Balkan deployed military men (RR=0.62 (95% CI 0.520.75)). The mortality rate was also lower (33%) as compared to the Dutch male
population of comparable age (Standardized Mortality Ratio (SMR)=0.67
(95% CI 0.57-0.78)). The risk of death from cancer and diseases of the circulatory system was significantly lower in the Balkan deployed group as compared to
the Dutch population, whereas death due to other causes was similar in both
groups. For Balkan deployed women, the numbers were too small to perform
meaningful analyses by cause of death, but the overall mortality appeared to be
similar to the expected mortality (SMR 0.74 (95% CI 0.15-2.16)).
The low cancer incidence and mortality rates were not restricted to the Balkangroup; relatively low rates as compared to the Dutch population were observed
for the non-Balkan deployed group as well, particularly for mortality. Results
were similar in analyses without conscripts.
Conclusion
This study showed that the cancer incidence and all-cause mortality in Balkan
deployed men was lower than in non-Balkan deployed men in the study period
of 15 years. This study also showed that Dutch military men, Balkan deployed or
not, had a lower risk of developing cancer and mortality as compared to the
general population of comparable age. For women, no elevated risk of developing cancer following Balkan deployment was observed either.
The results of the present study are in line with results of similar studies regarding cancer in Balkan deployed military personnel in Denmark, Sweden and Italy.
Furthermore, the results of this study support the conclusion of a previous report, i.e. that ‘it was unlikely that exposure of Dutch soldiers to DU-containing
particles during the 1999 Kosovo War would have had a significant health effect’, because exposure levels were minimal.
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The lower cancer incidence and mortality rate observed in Dutch military men as
compared to the Dutch population are generally attributed to a better health and
fitness of military personnel because of the health examination at the time of
enlistment and the physical demands of the profession. This is known as the
‘healthy soldier effect’. A possible explanation for the lower cancer incidence and
mortality rate in Balkan deployed vs. non-Balkan deployed military personnel is
that those who are ill are less likely to be deployed (the ‘healthy warrior effect’).
However, the finding of a lower risk of developing tumours in respiratory organs
in Balkan deployed military men as compared to the Dutch population was remarkable as it is generally assumed that smoking is more common in the military population than in the general population. Unfortunately, information regarding smoking habits of this population was unavailable.
This study is the largest study in Balkan veterans performed to date, with the
longest period of follow-up. However, because of potential long latency times,
future effects of deployment on cancer incidence cannot be completely ruled out.
For myeloid leukaemia, which has frequently been associated with radiation,
however, the latency time is relatively short (5-10 years). Furthermore, health
effects by DU-exposure in the Balkan deployed group have previously been reported to be ‘unlikely’2. Therefore, future health effects are not expected.

2

TNO assessed the fate of depleted uranium in the 1999 Kosovo War, potential DU exposure, and the radiological and chemical health risks associated with that among Dutch military personnel deployed to Kosovo (1).

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1

Introduction

1.1

Background
In 2000 the international and national lay-press media reported on cases of leukaemia among Balkan deployed soldiers or peacekeepers, which some attributed
to alleged exposure to depleted uranium (DU), originating from DU-containing
ammunition used by NATO Forces (2). These media reports prompted questions
in the Netherlands and other NATO countries about the occurrence of leukaemia,
and its relationship with Balkan deployment and DU-exposure in particular (2-4).
In response to the mounting concern in the military and the public, a first preliminary evaluation (the so-called ‘quick scan’) was made by the Military Medical
Service Agency of the Netherlands (3). No indication was found in this quick
scan for a higher incidence of leukaemia among Dutch military personnel in active duty in the first eight years following deployment to Kosovo (3). In addition,
the Military Medical Service Agency reasoned the DU-related health risk to be
very low, based on an estimated level of DU-exposure through inhalation of DUcontaining material during the Dutch deployment in Kosovo (3). The Chiefs of
Military Medical Services (COMEDS) of the NATO came to similar conclusions in a
meeting in January 2001, based on available international data (2)
(http://www.nato.int/du/docu/d010115a.htm, visited December 24, 2010). In
the same COMEDS meeting it was nevertheless recommended that the NATO
countries would perform epidemiological studies on cancer among Balkan veterans.
Early 2001, the Dutch ministry of Defence decided to commission two studies by
independent bodies (3). Firstly, the Netherlands Organisation for Applied Scientific Research (TNO) performed a desk-top study on depleted uranium in the Kosovo War. TNO assessed the fate of depleted uranium in the 1999 Kosovo War,
potential DU-exposure, and the radiological and chemical health risks associated
with that among Dutch military personnel deployed to Kosovo (1). It was concluded that, even if a worst-case approach was considered throughout the entire
calculation cascade, “it appears to be unlikely that exposure of Dutch soldiers to
DU-containing particles during the 1999 Kosovo War would have had a significant health effect” (1).
Secondly, the Dutch National Institute for Public Health and the Environment
(RIVM) was commissioned to perform the present epidemiological study (3).
RIVM was asked to describe the incidence of cancer and mortality up to 2008
among Dutch military personnel deployed to the Balkans between 1993 and
2001 and their peers. Such comparisons of large cohorts are important to detect
any adverse health effects, from whatever cause in a particular deployment (5).
It is important to note from the start, however, that this epidemiological study
does not address any specific causative factors such as exposure to DU, but
rather explores associations between deployment status and mortality and cancer incidence. This is because there was no information available about DUexposure or any other determinants of health. Therefore, a full review of possible health risks related to (military use of) DU or any other potential natural or
man-made hazards attributed to Balkan deployment is beyond the scope of the
present study. Those interested in the topic are referred to a number of publications, for example references (1, 6-10).

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1.2

Objectives
The aim of this study was to describe the cancer incidence and cause-specific
mortality up to 2008 among Dutch military personnel of the Army and Military
Police deployed to the Balkans between 1993 and 2001, based on health and
mortality registry data. Comparisons were made with military personnel who
were in service in the same time period, but who were not deployed to the Balkans, and the general Dutch population of comparable age and sex. Deployments before 1993 were not included because of lack of digitalized historical military data. Deployments after 2001 were not included because of extended latency periods associated with most types of cancer. Personnel of the Navy and
Air Force could not be included because of the lack of complete historical data on
all military personnel in these branches. Also leukaemia was evaluated, as concerns regarding leukaemia led to this study.

1.3

The Dutch military contribution to Balkan missions
The conflicts at the Balkans started when Croatia and Slovenia declared their
independence mid-1991, which resulted in combats with the Yugoslavian Federal
Army. The international interference commenced with the ‘European Community
Monitoring Mission’ in 1991, which also involved Dutch military personnel. A
number of missions followed, mainly in Bosnia-Herzegovina and Kosovo, when
the conflicts spilled over to other regions of the Former Yugoslavia
(http://www.defensie.nl/missies/bosnie/waarom_naar_bosnie/, visited November 24, 2010). This study focuses on Dutch deployments for missions in the Balkans between 1993 and 2001 (see chapter 3). According to the Dutch Veteran
Registration System of the Ministry of Defence, a total of 25,000 Dutch military
(from all branches) were involved in missions on land between 1993 and 2001.
Figure 1.1 shows the main Balkan missions in former Yugoslavia in which personnel from the Army and Military Police were involved during this period. After
2001, approximately 8,000 Dutch military personnel were sent to the Balkans.

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Figure 1.1. Map of main Balkan missions of the Army and Military Police in former Yugoslavia (including double counting of military personnel if deployed more
than once).
1.4

Organization of the report
Chapter two provides a literature review on cancer and mortality in veterans.
Chapter three describes the methods of this study, including study design, study
population, data collection and data analysis. In chapter 4, the results are described for cancer and mortality separately. The results are discussed in chapter
5, and chapter 6 provides the conclusions which have been drawn based on this
study.

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2

Previous epidemiological studies on cancer and mortality in
veterans

This study focuses on military personnel deployed to the Balkans. Some of the
Dutch Balkan (UNPROFOR) veterans have (also) participated in other studies, for
example on perceived health (e.g. (11, 12)) or on posttraumatic stress symptoms (e.g. (13, 14)). However, cancer and mortality have not yet been studied
in Dutch Balkan veterans. In light of the still limited international literature on
Balkan veterans, epidemiological studies on cancer and mortality in relation to
military deployment to other wars and peacekeeping missions are also briefly
considered here. Most of the previous studies compared a group of military personnel who were deployed to a certain mission to either the general population
or to military personnel who were in service in the same period, yet not deployed to that particular mission (a so called Era group). In the present study
both these comparisons will be made.
2.1

Previous studies on cancer in veterans
Although the lay-press media suggested a higher leukaemia incidence among
Balkan veterans in 2000, to date this has not been confirmed in the international
peer-reviewed literature. A recent study in Italy (15) showed a lower cancer incidence than expected in military personnel deployed to Kosovo, Bosnia, and
non-deployed personnel, as compared to the general population over the years
1996-2007. However, although this was not the case for the entire study period,
the standardized incidence ratio (SIR) was significantly higher than expected in
the year 2000 for Hodgkin’s lymphoma among troops deployed in Bosnia and
non-deployed personnel and in 2001 for thyroid cancer among troops deployed
in Bosnia. For the Kosovo group and other years, no such elevations were observed. Therefore, the authors concluded that these findings represented chance
findings. These analyses were an update of the provisional analysis performed
by the ‘Mandelli committee’ (see Table 2.1) which was published in a report (not
a peer-reviewed publication) (16) . Like the Mandelli analysis, the analysis by
Peragallo et al. (15) is of limited value because of incomplete collection of cancer cases and non-representative reference data from the general population.
With respect to Balkan veterans from other countries, there are only two epidemiological studies on cancer incidence available in the peer-reviewed scientific
literature: one from Sweden (17) and one from Denmark (18). Both studies did
not demonstrate an increased incidence of all cancers or leukaemia among Balkan veterans compared to their national rates for the general population of
comparable age and sex. It was noted, however, that the follow-up period in
these studies (1989-1999 and 1992-2002, respectively) was still short compared
to the latency time of cancer development in association with ionising radiation.
In another study on post-deployment hospitalisation of US military veterans,
comparisons between different cohorts of US active duty military personnel suggested that those who were exclusively deployed to Bosnia were at lower risk of
neoplasms compared to those who were exclusively deployed to the Gulf War
(19). However, follow-up time in the Bosnia-deployed group was only five years
compared to ten years in the Gulf War group, and thus latent disease in the
former group might have been inadequately captured.

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Others have also studied cancer in Gulf War veterans, which might be of particular relevance here because questions also arose on health risks of exposure to
DU from ammunition deployed during the Gulf War. A study on cancer incidence
among UK Gulf veterans (Gulf cohort) up to 11 years since the end of the war
showed no increased overall or site-specific cancer incidence as compared with
service personnel not deployed to the Gulf War back then (20). A report of the
US Committee on Gulf War Veterans’ Illnesses (21) concluded that depleted
uranium was not likely to have caused Gulf War Illness. Instead, use of pyridostigmine bromide pills (given to protect troops from effects of nerve agents)
and pesticide use (to combat the region’s ubiquitous insect and rodent populations) during deployment were found to be causally associated with this illness.
The Committee highlighted the need for information on cancer rates, which have
only minimally been assessed in Gulf War veterans so far.
Cancer (incidence, mortality, and hospitalization) has also been studied in military servicemen after other missions by means of various epidemiological approaches. Most of these studies refer to specific exposures attributed to a particular deployment and selected types or sites of cancer, and are therefore not
extensively considered here. This concerns, for example, exposure to Agent
Orange in Vietnam veterans [e.g. (22-29)], and exposure to ionizing (radioactive) radiation among UK and New Zealand participants in the UK atmospheric
nuclear weapon tests in the Pacific between the 1950s and 1960s, e.g. (30, 31).

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Table 2.1. Previously reported studies on cancer incidence among UN Balkan veterans.
Country

Study design

Outcome

Population

Follow-up/time period

Results
(total cancer and leukaemia)
(n among Balkan deployed and SIR
(95%CI))1

Conclusion (authors)

Storm ea
2006 (18)

Denmark

Populationbased historical
cohort study

Cancer incidence (registry-based)

Comparison of Danish Balkan deployed
military personnel
(n=14,012, 13,552
men, 460 women)
with the general Danish population

Follow-up period from
first Balkan deployment
(deployments between 1
Jan, 1992 and 31 Dec,
2001) until death, loss to
follow-up or the end of
the study (Dec 31, 2002).

Total cancer in men
(n=84) 0.9 (0.7-1.1) and
in women (n=12) 1.7
(0.9-3.0).
Leukaemia in men (n=4)
1.4 (0.4-3.5) and in
women (n=0)

‘Cancer incidence is not increased among Danish military
personnel deployed to the Balkans.’

Gustavsson
ea 2004 (17)

Sweden

Populationbased historical
cohort study

Cancer incidence (registry-based)

Comparison of Swedish Balkan deployed
military service personnel (n=8,347
men, 433 women)
with the general
Swedish population

Follow-up period from
first Balkan deployment
(involved in UN missions
in the Balkans from 1989
to 1999) until death, emigration, a diagnosis of
cancer, or the end of the
study (Dec 31, 1999).

Total cancer in men
(n=26) 1.2 (0.8-1.8) and
in women (n=4) 1.5 (0.43.9).
Chronic myeloid leukaemia in men (n=1) and in
women (n=0)

‘Swedish personnel involved in
UN missions in the
Balkans showed no statistically
significantly increased risk of
cancer relative to national
rates.’
‘…the period of follow up is too
short for an assessment of the
long term risk of cancer.’

Table continued on next page…

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Table 2.1 continued…
Country

Study design

Outcome

Population

Followup/time
period

Results
(total cancer and leukaemia)
(n among Balkan deployed and SIR
(95%CI))1

Conclusion (authors)

‘Mandelli
Committee’
(16)

Italy

Provisional
comparison
without
taking account of
latency
time

Detected cancer
cases among the
Balkan deployed
military group and
male reference
rate in selected
regional cancer
registries

Comparison of Italian Balkan deployed military and civilian personnel (N=43,058) employed by
the Ministry of Defence in the
period Dec 1995-2001 and general male population covered in
12 selected Italian regional tumour registries, with data for
1993-1997.

See ‘population’ (19952001).

All tumours (n=44) 0.48
(0.35-0.64).
Acute Lymphatic leukaemia (n=2)
1.78 (0.21-6.44)

1) The overall number of malignant tumours (haematological
and otherwise) observed is lower
than expected (…).
2) There is a statistically significant excess of Hodgkin’s lymphoma
(SIR 2.36 (1.22-4.13), n=12)

Peragallo et
al. 2010 (update of Mandelli Committee report)
(15)

Italy

Historical
cohort
study using
number of
persons
instead of
personyears

Cancer incidence
based on preliminary army cancer
surveillance activity

Comparisons of cancer incidence
in military personnel (n=130.275
in
1996 to 40.967 in 2007) deployed in Kosovo, Bosnia and
non-deployed personnel. All compared with national pooled incidence rates.

1996-2007.

Troops (men 20-59 y)
deployed firstly in Bosnia
all cancers (n=98) 0.48
(0.39–0.59), leukaemia
(n=9) 0.99 (0.45–1.87).
Troops (men 20-59 y)
deployed firstly in Kosovo all cancers (n=66)
0.47 (0.36–0.59), leukaemia (n=5) 0.75
(0.24–1.75).

‘… no indication of an increased
risk of cancer for Italian soldiers
who were stationed in Bosnia and
Kosovo. The cluster of Hodgkin’s
lymphoma in 2000 and of thyroid
cancer in 2001 were sporadic
events, they did not specifically
affect deployed personnel and are
unlikely to be related to environmental exposures in the Balkans.’

1. n=number, SIR=Standardized Incidence Ratio, 95% CI= 95% Confidence Interval

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2.2

Previous studies on post-deployment mortality in veterans
There are currently no scientific papers available with respect to postdeployment mortality in Balkan veterans. An epidemiological study among Norwegian former peacekeepers, including Balkan veterans, showed that the overall
(‘all-cause’) and disease-related mortality rates were lower as compared with
National figures of the general population of comparable age and sex (SMR 0.85
(0.8-1.0)) between 1978 and 1997 (32). These decreased mortality rates are
generally attributed to a better health and fitness of military personnel, which is
known as the ‘healthy soldier effect’ (33). However, in the Norwegian study
mortality from external causes such as suicide and motor vehicle accidents was
suggested to be higher among these former peacekeepers (32). Nevertheless, a
meta-analysis of 12 studies on mortality rates of military personnel showed that
compared with the general population, mortality rates from external causes are
10% and 20% lower in deployed and non-deployed military personnel, respectively (33). In comparisons with non-deployed Era military personnel, studies on
mortality in US and UK Gulf War veterans consistently showed lower diseaserelated mortality rates and higher mortality rates from external causes, in particular from (motor vehicle) accidents (34-38). In the present study, therefore,
also relative risks of mortality from external causes were calculated.

2.3

Summary
Studies in Italy, Denmark and Sweden do not suggest a higher risk of developing cancer in military personnel deployed to the Balkan region as compared to
the general population. These studies had a follow-up period of around 10 years.
Elevations of some tumours in the years 2000 and 2001 in some subgroups in
Italy were classified as chance findings in a subsequent analysis, because in the
whole time span of 11 years the risk of these tumours was not increased. Studies on post-deployment mortality in Balkan veterans are not available so far,
but a study among Norwegian peacekeepers showed a lower risk of diseaserelated mortality as compared to the general population. The present study, described in this report, is unique in the sense that it includes two comparison
groups; not only the general population, but also non-deployed military personnel, and because of the relatively long observation period of maximal 15 years.

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3

Methods

3.1

Design, study population and data collection
The objectives, mentioned in the introduction, were addressed by performing a
historical cohort study, which means that Balkan deployment occurred before
the beginning of the study and that military personnel was identified from information that was recorded in the past. Because a central registry of military personnel was lacking, military personnel in service between January 1, 1993 and
March 1, 2001 had to be identified from several registers of the Dutch Armed
Forces, including employee registers from the Army, Military Police, Air Force
and Navy and ‘care-for-relatives’ records. Available data included:
− Balkan deployment and deployment to other areas, including start and end
dates of deployment;
− dates of entrance and termination of service;
− branch of military service;
− rank before and during deployment;
− appointment;
− sex;
− birth year;
− personal details (for data linkages only - see section 3.1.2).
Data of deployments to the Balkans and to other areas were verified using the
Netherlands Veteran Registration System (VRS), which was established in 2006.
All who had ever been deployed for at least 28 days to the Balkans between
1993 and March 2001 – according to VRS – were included in the ‘Balkan deployed’ group. Available data in VRS includes for each deployment: name of the
mission, mission area, start and end date and rank during the mission.
To check the completeness of the study population, and add military personnel if
missing, several additional sources of information were consulted, including staff
magazines for changes in the number of employees over the years, salary records and data from the National Civil Pension Fund (in Dutch: ABP).
Addresses, place of birth and follow-up status by January 1, 2008 and personal
ID numbers, given to all Dutch citizens (municipal ‘A-numbers’), were obtained
through the Central Population Registry files by matching on name, birth date
and, if necessary, (old) addresses. If matching failed, personal details were
checked by sending a letter to the municipality where the person concerned
(had) lived. If matching failed for a person who had died, identification through
Statistics Netherlands (cause of death registry) was performed. Still, for 3-4% of
those who died the cause of death could not be retrieved. Most of these people
died while being stationed (not necessarily deployed) abroad, in which case the
cause of death was not always registered at Statistics Netherlands. Altogether,
almost all of the military personnel (97%) were identified.

3.1.1

Inclusion criteria
The cohort was restricted to people who:
− were in service any time between January 1, 1993 and March 1, 2001;
− worked in the Army or Military Police;
− did not return their no-consent form;
− did not die during Balkan deployment, because this is a study on postdeployment mortality.
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The rationale for these criteria was that Balkan deployment started in 1991, but
employee records were available from 1993 onwards3. Personnel from the Navy
and Air Force could not be included because despite an extensive search for
their data, no complete historical employee records could be found for these
branches of the military services. However, personnel of the Air Force and most
Navy personnel did not execute ground missions, and therefore exposure to DU
was unlikely. Civil personnel were excluded, because personnel were militarized
when deployed.
3.1.2

No consent and privacy agreement
Use of personal data of military personnel was required in this study, to enable
matching with the Central (Municipal) Population Registry and the Netherlands
Cancer Registry (NCR) of the Association of Comprehensive Cancer Centres
(IKNL). The (ex-)military personnel in the cohort was given the opportunity to
refuse matching their personal data with the Netherlands Cancer Registry, by
sending them a letter describing the study and by asking them to send back a
no-consent form if they did not want their registered data to be used in this
study (see Appendix 1). Current addresses were obtained by the Central (Municipal) Population Registry. Two percent (3,261 out of 160,737) returned their
no-consent form4 and were excluded from matching with the Netherlands Cancer
Registry and the study as a whole.
Operating procedures for confidential and careful handling of data of those who
did not return their no-consent form, were described in detail in a privacy
agreement between the Ministry of Defence, the Netherlands Cancer Registry
(NCR) and the research institute (RIVM). Central element of this agreement was
that none of the involved parties had access to data which was not strictly required for performing the study. The Ministry of Defence, for instance, did not
have access to current addresses, cancer incidence and mortality data, the dataanalysis unit of RIVM did not have access to any personal data and NCR did not
have access to military data (e.g. rank, deployment, appointment). Matching
with the anonymous causes of death registry of CBS followed CBS privacy conducts. Analysis of these data took place at CBS hardware, only accessible to two
researchers of RIVM by a Remote Access System using fingerprinting. In addition, handling of personal data complied with the Personal Data Protection Act
[in Dutch: Wet bescherming persoonsgegevens (Wbp)] and the Municipal Database Act [in Dutch: Wet gemeentelijke basisadministratie persoonsgegevens
(Wet GBA)].

3.1.3

Cancer incidence
Cancer incidence and mortality data were collected for the years 1993-2008.
Using sex, names and birth dates, cross-linkage with the Netherlands Cancer
Registry of the Association of Comprehensive Cancer Centres (IKNL) was performed. Addresses and place of birth, and if applicable, date of death, were used
to check the matches. The registry contains data on all new cancer cases in the
Netherlands; the sensitivity was reported to be 98% (39). Observed cancer cases were extracted from the registry and recoded from ICD-O, which is the Inter3

The early missions were restricted to monitoring and there is no information showing that DU was used in the
years before 1993.
4
Although reasons for refusal were not asked, some persons nevertheless indicated a reason, i.e. written on
returned forms. Reasons were not exclusively related to privacy – e.g. some (30% of those who described their
reasons) non-Balkan deployed military erroneously returned their form because they had never been deployed
to the Balkans.

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national Classification of Diseases for Oncology, into the general International
Classification of Diseases (ICD-10). As agreed upon in the privacy agreement
(section 3.1.2), the IKNL provided year of incidence instead of the exact date of
cancer incidence. Benign and non-invasive tumours were excluded, with the exception of non-invasive bladder tumours. Only first cancers were counted. Focus
was on the following main cancer site categories (ICD-10 codes in parentheses):
− digestive organs (C15-C26);
− respiratory system and intrathoracic organs (C30-C39);
− urinary tract and genital organs (C60-C68);
− breast (C50);
− heamatolymphopoetic system (including leukaemia; C81-C85, C88, C91C96).
In the comparisons with the Dutch population, all tumours were evaluated separately as well.
3.1.4

Cause-specific mortality data
Using unique, anonymous, Dutch personal ID-numbers (municipal ‘A-numbers’),
cross-linkage with the Dutch causes of death registry of Statistics Netherlands
(CBS) by January 1, 2008, was performed. Causes of death were grouped into
the 17 main categories of ICD-10, see
http://apps.who.int/classifications/apps/icd/icd10online/ visited December 24,
2010. The reliability of cause-of-death statistics has been reported to be high
(>90%) for the major causes of death (40).

3.2

Data-analysis
All statistical analyses were performed using SPSS for Windows version 14.0.

3.2.1

Differences between Balkan deployed military and their peers
To study differences in mortality and cancer incidence between Balkan- and nonBalkan deployed military, survival analyses were performed. Cox proportional
hazard models were used, in which age was defined as the follow-up variable.
Through this, an optimal adjustment for the possible confounding effect of age is
obtained. Time under study (follow-up) was included as a time-dependent variable, starting at the beginning of the study (January 1, 1993) or at entrance
into duty (if > January 1, 1993) and ending at death, emigration, a diagnosis of
cancer or the end of the study (January 1, 2008). Deployment to the Balkans
was included as a separate time-dependent variable, depending on end date of
the first deployment. Thus, person-time between entrance in the cohort and end
of first Balkan deployment was not considered as time at risk of developing cancer or dying, and corresponding person-years were added to the control group,
i.e. non-Balkan deployed military personnel. This was done because deaths during deployments were excluded from the study population, and therefore, time
at risk of dying could not start before the end of the deployment. For similarity
reasons, also time at risk for developing cancer started at the end of the first
deployment. Almost always, the duration of deployments was 6 months. Time
after end date of first Balkan deployment was counted in the Balkan deployed
group, regardless of subsequent deployments to the Balkans or other areas (see
Figure 3.1). The analyses provided ‘hazard ratios’, that is, the ratio between the
predicted hazard (i.e. risk of dying or developing cancer) for a member of the
Balkan-group and that for a member of the non-Balkan-group, holding
everything else constant. Hazard ratios are broadly equivalent to relative risks, a
more commonly reported outcome of epidemiological studies, and therefore, will
be referred to as relative risks in the results section.
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Control time

1, 1, 1993 1st deployment

Time at risk

2nd deployment

1, 1, 2008

Figure 3.1. Calculation of time at risk for a virtual Balkan deployed soldier who
was deployed to the Balkans twice.
All analyses were run for men and women separately. However, the number of
women was small, and separate analyses were not always possible. Therefore,
the tables of the results section include men only. Results for women are presented in tables in the appendices.
Analyses were adjusted for branch of military service (Army or Military Police),
rank (commissioned or non-commissioned officers) and appointment (permanent, temporary or conscription). Chaplains were not considered a separate
group but were grouped under ‘permanent appointment’. Branch of military service was included as a (crude) indicator of type of work during deployment (and
thereby possibly occupational exposures) and rank and appointment as crude
measures of socioeconomic status (SES). Adjustment for SES is common in
these types of analyses, because there are substantial differences in health and
lifestyle across socioeconomic classes, also in the Netherlands
(http://www.nationaalkompas.nl/bevolking/segv/sociaaleconomischegezondheidsverschillen-samengevat/, visited November 29, 2010). For example,
lower-educated men die, on average, 7 years earlier than higher-educated men.
As data on education level and income were not available for the military personnel under study, rank and appointment were used as measures of SES instead.
3.2.2

Standardization to Dutch population
Expected numbers of deaths and cases of cancer in the study population were
computed according to the person-year method, based on cause-specific death
and cancer incidence rates for the general population in the Netherlands, stratified by age (five year classes), sex and time period (two or three year classes).
Standardized mortality (SMR) and incidence rate ratios (SIR) were computed by
dividing the observed numbers by the expected numbers. Confidence intervals
were calculated using the Poisson distribution. The computational programme
for the calculation of SMR and SIR was developed by the Netherlands Cancer
Institute, and has been described previously (41). Mortality rates in the Dutch
population, from 1993 to 2007, were obtained from Statistics Netherlands. Cancer incidence rates, from 1996 to 2007, were obtained from the Netherlands
Cancer Institute (NKI). Cancer incidence rates between 1993 and 1996 were
available, but coded according to ICD-9, which does not completely match with
coding of some specific tumours in ICD-10 after 1996. Therefore, rates in the
Dutch population between 1993 and 1996 were not used. For those cancers
which occurred between 1993 and 1996 in the study population (ca. 10%), rates
in the Dutch population in 1996 were used as a reference instead.

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Standardisation to Dutch population does not provide information on differences
between Balkan deployed personnel and their peers
The standardisation to the Dutch population was performed for Balkan and nonBalkan deployed personnel separately. The SMR and SIR cannot be compared
across these groups, because this ‘indirect’ comparison is biased by differences
in the distributions of age and other characteristics between these groups. The
Cox regression, see section 3.2.1, which provided estimates for Balkan versus
non-Balkan deployed personnel, was adjusted for age and some other characteristics. Therefore, results of that analysis provide the best available information
on differences across Balkan deployed military and their peers.
3.2.3

Additional analyses
All analyses were also conducted without conscripts, because conscription was
abolished in August 1996. Also, because conscripts are relatively young, rank
may be a less stable indicator for SES in this group (see section 3.2.1). For cancer, analyses without cases occurring within 18 months from the ending date of
the mission were performed, as most cancers have a longer latency period. In
order to study possible trends over time, SIRs for cancer were calculated separately for the follow-up periods 0-5 years, 5-10 years and 10-15 years.

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4

Results

4.1

General characteristics of the study population
The study population included 19,167 persons who had been deployed to the
Balkans between 1993 and 2001 (18,175 men and 992 women; 12% of the total
study population). The number of non-Balkan deployed military personnel was
138,309, of which 2,954 were women. Of the Balkan deployed military personnel, 928 had also been deployed to other areas. Of the non-Balkan deployed
group, 1,308 had been deployed to other areas.
Table 4.1. General characteristics of male military personnel deployed and nondeployed to the Balkans.
Balkan deployed1
(N=18,175)
Median age at January 1, 1993
(p25-p752)

Non-Balkan deployed
(N=135,355)

21 (18-28)

21 (19-23)

13.1

5.3

Army

94.0

94.9

Military Police

6.0

5.1

Rank (% commissioned officers)3
Branch (%)

Appointment (%)
Permanent

37.2

8.9

Temporary

47.1

10.3

15.3

80.8

Conscription
4

Other (chaplains)

0.3

0.05

181 (166-185)

-

1 (%)

77.1

-

2 (%)

19.1

-

3 or more (%)

3.8

-

Duration of 1st deployment (median
number of days (p25-p752)) 5
Number of deployments

1.

2.
3.
4.
5.

All characteristics were significantly different between Balkan vs. non-Balkan deployed
military at p< 0.01. This was tested by using Chi-Square (sex, rank, appointment,
branch of military service) and Wilcoxon statistics (age))
25th and 75th percentiles
Rank was available for n=18,157 Balkan deployed and 128,077 non-Balkan deployed
men
Categorised in the analyses as permanent appointment
Available for n=18,155

Table 4.1 presents general characteristics of Balkan and non-Balkan deployed
military personnel. The majority of the non-Balkan deployed military personnel
were conscripts working in the Army. Balkan deployed personnel included more
commissioned officers and much less conscripts as compared to the non-Balkan
deployed military personnel. Most Balkan deployed military personnel worked in
the Army. The median age of both groups was 21 years in 1993. Figure 4.1
shows the age distribution of the study population at the start and end of the
study period. At the end of the study period, still only 13% of Balkan deployed
personnel was older than 50, and 16% between 40 and 50. For non-Balkan deployed personnel, 5% was older than 50 and 5% was between 40 and 50.

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A. Age distribution in 1993
120000
100000
80000
Balkandeployed
Non-Balkandeployed

60000
40000
20000
0
< 15

16-25 26-35

36-45 46-55 56-65

> 65

B. Age distribution in 2008
80000
70000
60000
50000

Balkandeployed
Non-Balkandeployed

40000
30000
20000
10000
0
< 15

16-25

26-35

36-45

46-55

56-65

> 65

Figure 4.1. Number of military personnel across different age groups among
Balkan and non-Balkan deployed military personnel at January 1, 1993 (A) and
January 1, 2008 (B).5
4.1.1

Characteristics of Balkan deployment
The majority of the Balkan deployed military personnel was deployed only once
(77%), but 19% was sent twice and 4% 3 times or more to the Balkans. The
median duration of first Balkan deployment was approximately 6 months. Figure 4.2 shows the total number of Balkan deployments over time in the Balkan
deployed group.
Table 4.2 gives an overview of the main missions the study population were involved in. The highest numbers of deployments were within SFOR, UNPROFOR,
IFOR and KFOR. All missions shown in the table took place in Former Yugoslavia,
with the exception of Operation Allied Harbour, which was in Albania. For more
details of the missions, see
http://www.defensie.nl/nimh/geschiedenis/internationale_operaties/missieoverzi
cht/, visited December 16, 2010.

5

Because some persons were not in military service in 1993, the graphs include persons of less than 15 years
of age.

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No. of deployments

RIVM Report 630450001

5000
4500
4000
3500
3000
2500
2000
1500
1000
500
0
1993

1994

1995

1996

1997

1998

1999

2000

2001

Starting date of deployment
Figure 4.2. Total number of Balkan deployments over time (includes double
counting of military personnel if deployed more than once).
Of the non-Balkan deployed personnel, 86% could be followed for at least
10 years and 48% for the complete follow-up time of 15 years. Median follow-up
time was 14.8 years. As follow-up of Balkan deployed personnel started later
than January 1, 1993, i.e. after the date of first Balkan deployment, 60% could
be followed for at least 10 years, but by definition, no one could be followed for
the complete follow-up period of 15 years. Median follow-up time for Balkan deployed personnel was 10.9 years.

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Table 4.2. Balkan missions of the study population between 1993 and 2001 with at least 50 deployments.
Mission

Abbreviation

Starting date

End date

Type of mission

No. of deployments1

European Community Monitoring Mission

ECMM/EUMM/
EUFOR

15-07-1991

7-1-2007

Observing

265

United Nations Protection Force / United
Nations Peace Force

UNPROFOR / UNPF

01-11-1992

31-12-1996

Peacekeeping, observing, peace enforcement (safe areas)

6,556

Inzet Luchtwapen

DENY FLIG / delib
gua

12-04-1993

20-12-1995

Air Force

230

Sharp Guard and WEU/Donau

SHARP GUAR /WEU
Donau

15-06-1993

27-06-1996

Embargo Adriatic Sea and Danube

156

Task Force Mostar

WEU MOSTAR

01-07-1994

31-10-1996

Peacekeeping

54

Implementation Force

IFOR

20-12-1995

20-12-1996

Peace enforcement

3,232

United Nations Mission in Bosnia and Herzegovina

UNMIBH / UNIPTF

01-03-1996

01-01-2003

Peacekeeping

752

Stabilization Force

SFOR

20-12-1996

02-12-2004

Peace enforcement

8,370

Extraction Force

EF

13-02-1999

24-03-1999

Peace enforcement

120

Operation Allied Force / Allied Harvest

OAF

24-03-1999

20-06-1999

Combat without UN Mandate

144

Kosovo Force

KFOR

12-04-1999

08-08-2000

Peace enforcement

2,737

Operation Allied Harbour

OAH

14-04-1999

10-07-1999

Humanitarian intervention

223

1. including double counting of military personnel if deployed more than once

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Relative risk (RR) and confidence interval (CI)
The ratio of the absolute risk of cancer or mortality in Balkan deployed military
personnel and the absolute risk in non-Balkan deployed military personnel is
called the relative risk. If the absolute risk in the former group is higher than the
absolute risk in the latter group, the relative risk is higher than 1, and thus Balkan deployed personnel have a greater risk of cancer or mortality.
Due to mere chance the calculated relative risk may differ from the true relative
risk. This occurs more often if the number of observations is rather small. Because the true relative risk is unknown, it is common practice to indicate a range
of values in which the true relative risk is located with 95% certainty. This range
is called the 95%-confidence interval (95% CI). If the entire 95% CI is above or
below 1, the relative risk is considered to be statistically significantly increased
or decreased. However, a statistically significantly increased or decreased relative risk is no guarantee that the finding is no ‘chance finding’. If multiple comparisons are made, like in this study, which includes many different tumours for
instance, it becomes more likely that only by chance the Balkan-group differs
from the other groups for at least one tumour site. This effect has been taken
into account in the interpretation of results, by focusing on categories of cancer
sites instead of single tumour sites and by disregarding tumours with observed
and expected numbers lower than 3.
4.2

Cancer incidence

4.2.1

Comparison between Balkan deployed military and their peers
In Balkan deployed men, 175 new cases of cancer were observed up till 2008. In
non-Balkan deployed men, 1,337 new cases of cancer were observed. The total
cancer incidence rate among Balkan deployed military personnel was lower than
the cancer incidence rate among non-Balkan deployed military personnel (relative risk (RR)=0.83 (95% confidence interval (CI) 0.69-1.00; see Figure 4.3).
For the 4 main cancer sites separately, cancer incidences were similar in both
groups. For breast cancer, numbers were too low for comparisons across groups.
The additional analyses without conscripts showed similar results, for example
for cancer in total the relative risk was 0.86 (95% CI 0.70-1.05). Twenty cases
occurred within 18 months from the ending date of the mission. Results of
analyses excluding these cases were similar to the overall results (see Appendix
6).
In Balkan deployed women, 10 cases of cancer were observed and the corresponding relative risk was 1.48 (95% CI 0.69-3.18).

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2,0

1,5

1,0

0,5

0,0
Total

Digestive

Respiratory

Urogenital Haematological

Figure 4.3. Relative risks1 of total and site-specific incidence of cancer in Dutch
male military personnel deployed to the Balkans (N= 18,175) compared with
non-Balkan deployed personnel.
1
Adjusted for rank, appointment and branch of military service.
4.2.2

Comparison between Balkan deployed military and the Dutch population
In men, the observed number of new cancer cases among Balkan deployed military personnel (n=175), was 15% lower than the expected number of cases
(n=205), based on the cancer incidence rates in the Dutch population (see Table 4.3). The SIR was close to unity in the first 5 years of follow-up and then
declined to 0.65 in the last 5 years of follow-up. For the 4 main cancer sites
separately, cancer incidences were similar, with the exception of tumours of the
respiratory system and intrathoracic organs, which showed a significantly lower
incidence among Balkan deployed military personnel (SIR=0.48 (95% CI 0.250.84)) than among the age- and sex-matched Dutch population (see Table 4.3).
Most common tumours in this group are bronchus and lung tumours. For leukaemia, the observed number (n=5) appeared to be lower than the expected
number (n=8.0), based on the rates in the Dutch population (see Table 4.3).
Among Balkan deployed professional military personnel (i.e. without conscripts;
Appendix 4) the SIR for all tumours was 0.87 (95% CI 0.74-1.01) and the SIR
for tumours of the respiratory system and intrathoracic organs was 0.49
(95% CI 0.25-0.86). Among non-Balkan deployed military men (Appendix 3) a
lower incidence of all tumours (SIR=0.91 (95% CI 0.87-0.96)) and tumours of
the respiratory system and intrathoracic organs (SIR=0.64 (95% CI 0.51-0.79))
was observed as compared to the Dutch population. In Balkan- and non-Balkan
deployed women, the SIR for all tumours were 1.31 (95% CI 0.63-2.41) and
1.15 (95% CI 0.77-1.64), respectively (Appendix 2).

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Table 4.3. Cancer incidence among Dutch military personnel deployed to the Balkans (N= 18,175) as compared to the age- and sex-matched
Dutch population.
Cancer site

ICD-10 codes

All cancers
total period
0-5 y
5-10 y
10-15 y

All

Digestive organs
total period
0-5 y
5-10 y
10-15 y

C15-C26

Respiratory system and intrathoracic organs

C30-C39

total period
0-5 y
5-10 y
10-15 y
Bronchus and Lung
Urinary tract and genital organs
total period
0-5 y
5-10 y
10-15 y

C34

Observed

Expected

SIR (95% CI)

175
74
74
27

205.3
70.7
93.3
41.3

0.85 (0.73-0.99)
1.05 (0.82-1.31)
0.79 (0.62-1.00)
0.65 (0.43-0.95)

30
7
16
7

36.5
11.1
17.1
8.2

0.82 (0.56-1.17)
0.63 (0.25-1.30)
0.93 (0.53-1.52)
0.85 (0.34-1.76)

12
8
3
1
10

25.0
8.0
11.6
5.5
20.8

0.48 (0.25-0.84)
1.00 (0.43-1.97)
0.26 (0.05-0.76)
0.18 (0.00-1.01)
0.48 (0.23-0.89)

55
22
27
6

54.1
17.9
25.1
11.2

1.02 (0.77-1.32)
1.23 (0.77-1.86)
1.08 (0.71-1.57)
0.54 (0.20-1.17)

C60-C68

Table continued on next page…

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Table 4.3 continued…
Cancer site

ICD-10 codes

Haematolymphopoetic system
total period
0-5 y
5-10 y
10-15 y
Leukaemia
total period1

C81-C96 (C81-C85, C88, C91-C96)

1

Observed

Expected

SIR (95% CI)

28
13
8
7

29.3
11.8
12.6
4.9

0.95 (0.63-1.38)
1.10 (0.59-1.88)
0.63 (0.27-1.25)
1.43 (0.58-2.96)

5

8.0

0.63 (0.20-1.46)

C91-C96

Total number too low to stratify analyses by follow-up period (0-5, 5-10, 10-15 years).

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4.3

Mortality

4.3.1

Comparison between Balkan deployed military and their peers
In the total population, 165 deaths were observed during the 15 years of followup. The total mortality rate of Balkan deployed military personnel was lower
than the mortality rate of non-Balkan deployed military personnel (RR=0.62
(95% CI 0.52-0.75), Figure 4.4). The risk of death from cancer was lower
among Balkan deployed military personnel (RR=0.66 (95% CI 0.46-0.97). Mortality of diseases of the circulatory system and digestive system was similar in
both groups. Mortality due to external causes was significantly lower among Balkan deployed than non-Balkan deployed military personnel (RR=0.56 (95% CI
0.42-0.76). This was mainly caused by fewer fatal transport accidents in Balkan
deployed personnel; the risk of suicide was non-significantly lower. For the other
main categories of causes of deaths, hazard ratios could not be calculated because of small numbers of deaths.
In professional military personnel only (i.e. without conscripts), results were
similar to the results of the overall analyses, for example for all-cause mortality
the relative risk was 0.65 (95% CI 0.53-0.79), and for external causes 0.51
(95% CI 0.36-0.72). For Balkan deployed women, the mortality rate was too low
to perform analyses.

2,0

1,5

1,0

0,5

0,0
Total

Cancer

Circulatory
system

Digestive
system

External
Causes

Not
elsewhere
classified

Figure 4.4. Relative risks1 of mortality2 in Dutch military personnel deployed to
the Balkans (N= 18,175) compared with non-Balkan deployed personnel during
15 years of follow-up.
1
Adjusted for rank, appointment and military branch.
2
Cox regression could not be performed for other main causes of death, because of low numbers of observed deaths.
4.3.2

Comparison between Balkan deployed military and the Dutch population
Table 4.4 shows cause-specific observed versus expected numbers of deaths
and standardized mortality rates (SMRs) for male Balkan deployed military personnel. The observed number of deaths (n=165) after deployment to the Balkans was 33% lower than the expected rate, based on the age- and sexmatched Dutch population (SMR=0.67 (95% CI 0.57-0.78)). The expected top 3
causes of death in a young male population are external causes, cancer and diseases of the circulatory system. This was in line with the observed numbers
(same ‘top 3’) among Balkan deployed military personnel. The risks of mortality
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due to cancer (SMR=0.61 (95% CI 0.43-0.82)) and diseases of the circulatory
system (0.71 (95% CI 0.50-0.98)) were lower in Balkan deployed personnel
than in the Dutch population, whereas the risk of mortality due to external
causes was similar in both groups.
In non-Balkan deployed military personnel, the SMR for all causes of death was
0.57 (95% CI 0.54-0.61; Appendix 3). Because of larger numbers of observed
cases due to the much larger population, SMRs could be calculated for more
main death categories than in Balkan deployed personnel. For all main categories, death rates were lower than the expected rates based on the Dutch population. SMRs ranged from 0.08 for congenital malformations, deformations and
chromosomal abnormalities to 0.72 for cancer.
In professional Balkan deployed military personnel, SMRs were similar to those
found in the overall analyses (Appendix 4). SMRs for all causes, cancer and diseases of the circulatory system were 0.65 (95% CI 0.55-0.76), 0.59 (95% CI
0.42-0.81) and 0.73 (95% CI 0.51-1.01), respectively. The SMR for external
causes of death was 0.85 (95% CI 0.63-1.14). In Balkan deployed women, the
number of deaths (n=3) appeared to be similar to the expected number (n=4)
(Appendix 2).

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Table 4.4. Mortality among Dutch military men deployed to the Balkans (N= 18,175) as compared to the age-matched Dutch male population,
summarized in main causes of death categories.
Cause of death

ICD-10 code

Observed

Expected

SMR (95% CI)

Total

All

165

246.9

0.67 (0.57-0.78)

Certain infectious and parasitic diseases

A00-B99

1

5.0

0.20 (0.01-1.10)

Cancer

C00-C97

41

67.7

0.61 (0.43-0.82)

Diseases of the blood and blood-forming organs and certain disorders
involving the immune mechanism

D50-D89

0

0.7

Endocrine, nutritional and metabolic diseases

E00-E90

0

6.0

Mental and behavioural disorders

F00-F99

1

3.0

Diseases of the nervous system

G00-H95

0

6.6

Diseases of the circulatory system

I00-I99

36

50.6

0.71 (0.50-0.98)

Diseases of the respiratory system

J00-J99

1

6.2

0.16 (0.00-0.90)

Diseases of the digestive system

K00-K93

5

9.4

0.53 (0.17-1.25)

Diseases of the skin and subcutaneous tissue

L00-L99

0

0.2

Diseases of the musculoskeletal system and connective tissue

M00-M99

0

0.8

Diseases of the genitourinary system

N00-N99

0

1.2

Pregnancy, childbirth and the puerperium

O00-O99

0

0

Certain conditions originating in the perinatal period

P00-P96

0

0.02

Congenital malformations, deformations and chromosomal abnormalities

Q00-Q99

0

2.4

Symptoms, signs and abnormal clinical and laboratory findings, not
elsewhere classified

R00-R99

13

18.6

0.70 (0.37-1.20)

External causes of morbidity and mortality

V01-Y89

62

66.5

0.93 (0.71-1.19)

Suicide

X60-X84

31

28.4

1.09 (0.74-1.55)

Transport accidents

V01-V99

24

21.4

1.12 (0.72-1.67)

0.33 (0.01-1.85)

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5

Discussion

5.1

Main findings
This study showed that the cancer incidence and all-cause mortality in Balkan
deployed men were lower than in non-Balkan deployed men in the study period
of 15 years. This study also showed that Dutch military men, Balkan deployed or
not, had a lower risk of developing cancer and mortality as compared to the
general population of comparable age. This can be explained by the fact that the
working population, and the military population in particular, is healthier than
the general population on a whole due to health examinations at the time of
enlistment and the physical demands of the profession (see section 5.2). For
women, no elevated risk of developing cancer following Balkan deployment was
observed either.
The results of the present study are in line with results of similar studies regarding cancer in Balkan deployed military personnel in Denmark, Sweden and Italy
(15, 17, 18), see Table 5.1. Furthermore, the results support the conclusion of a
previous report, i.e. that ‘it was unlikely that exposure of Dutch soldiers to DUcontaining particles during the 1999 Kosovo War would have had a significant
health effect’ (1).
Table 5.1. Results of this study, compared to previous studies on development
of cancer following Balkan deployment.
Study

Obs

Exp

SIR

95 % CI

Netherlands (‘93-08)

175

205.3

0.85

0.73-0.99

Denmark (’92-01)

84

0.9

0.7-1.1

Sweden (’89-99)

26

21.8

1.2

0.8-1.8

Italy(’96-07)

164

344.9

0.48

0.39-0.57

The sources of the concern about a possible increased risk of cancer following
Balkan deployment, which led to this study, were reports in 2000/2001 on an
elevated risk of haematological tumours among Balkan deployed personnel in
Italy. This elevated risk was attributed to the supposed exposure to depleted
uranium. However, a more thorough analysis in 2010 on cancer over a longer
time period categorized these findings in Italy as chance findings (15).
5.2

The healthy soldier effect
The lower cancer incidence and mortality observed in the Dutch military personnel can be explained by the so-called ‘healthy worker effect’. The healthy worker
effect was probably first described by William Ogle at the end of the 19th century
(42). It refers to the observation that the working population is healthier than
the general population on a whole. Ogle identified two kinds of selection responsible: one working at the time of hire, and the other working throughout employment. The first selectively attracts or rejects new workers depending on
physical demands of the job and health selection, by for instance occupational
physicians. The second forces people to leave their job because their health is
too much impaired for the job they are in. This ‘healthy worker effect’ is relatively strong for military personnel, due to health examinations at the time of
enlistment and the physical demands of the profession. Physical exercise reduces the risk of some site-specific cancers (43) and cardiovascular mortality
(44, 45). The risk reduction is at least in part attributed to the favourable effect
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of physical activity on the risk factors blood pressure, diabetes mellitus (risk factors for mortality (46)) and obesity (risk factor for mortality (46) and some sitespecific cancers (47)). For military personnel, a third selection effect at the time
of deployment can be distinguished, as those who are ill are less likely to be deployed (48). Therefore, the ‘healthy worker effect’ is called the ‘healthy soldier
effect’ or even ‘healthy warrior effect’ (referring to the third selection effect) in
military populations. A meta-analysis of 12 studies showed that the mortality in
military populations was 10-25% lower as compared to the general population,
depending on cause of death and the period of follow-up (33). Meta-analyses
were performed separately for deployed and non-deployed soldiers, resulting in
similar estimates of the ‘healthy soldier effect’ for all-cause and cancer mortality. Figure 5.1 shows the reported pooled meta-standardized mortality ratios for
deployed soldiers. The size of the ‘healthy soldier effect’ in our study was somewhat larger (33% for all-cause mortality, 39% for cancer mortality) than in the
meta-analysis (24% and 22% respectively). However, even larger effects have
been observed, for instance by Kang et al. (49) in veterans deployed to Iraq and
Afghanistan (44% for all-cause mortality, not included in the meta-analysis).
Our study did not only compare Balkan veterans with the general population,
but also with their non-deployed peers, which evens out part of the selection
effects. The lower mortality and cancer incidence in the Balkan veterans suggested the presence of a ‘healthy warrior effect’. Another option would be to
compare Balkan deployed personnel with personnel deployed to other areas, i.e.
to compare warriors with warriors. However, the number of personnel deployed
to other areas between 1993 and 2001 was too low to make this comparison.
Further, personnel deployed to other areas has also been exposed to different
environmental factors specific to those areas.
In women, relative risks of cancer and mortality were generally higher than in
men, and thus there were less indications of a healthy soldier effect in comparisons with the general Dutch, female population. This may be explained by the
fact that women without children, who form the majority of the female military
personnel, on average have a higher risk of breast cancer than women with children (49). In the Balkan-group in particular, the number of women with children
is probably relatively low, because women with young children are not deployed
to military missions. However, the higher amount of physical activity in military
personnel probably reduces the risk of breast cancer. The overall risk of developing breast cancer in female military populations is not known.

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Figure 5.1. Standardized mortality ratios for all causes and for cancer for deployed military personnel, according to the meta-analysis of McLaughlin (33).
5.3

Cause-specific mortality and cancer incidence
Because of the large study population and considerable length of follow-up, this
study was not subject to power problems when considering overall mortality and
cancer incidence, in the sense that small relative risks remain unnoticed because
of low numbers. However, when focusing on rare tumours in subgroups, numbers were limited. In the Balkan deployed group, 5 cases of leukaemia were observed, which appeared to be lower than expected based on the Dutch population (n=8), although the difference was not statistically significant. This number
was too low to analyze common characteristics of the personnel that developed
that disease, but it could be ruled out that they had been involved in one and
the same mission in the same time period.
For veterans deployed to the Gulf War, an elevated risk of post-deployment
death by external causes, like suicide, and particularly transport accidents as
compared to their non-deployed peers has been shown (34-38). In the present
study, no such elevations in the deployed compared to the non-deployed group
or the Dutch population were found. However, the number of transport accidents
was higher in non-deployed, professional military personnel as compared to the
Dutch population (see Table A4.2). This finding, which was not observed for the
non-deployed group as a whole (see Table A3.1), is actually outside the scope of
this study and the underlying factors are unknown. We cannot compare our finPage 43 of 69

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dings on mortality in the deployed group with previous studies, as to our knowledge, this is the first study of mortality in a large cohort of Balkan veterans. A
modest, but significant increase in the risk of suicide was observed in Norwegian
peacekeepers, including Balkan veterans, involved in missions between 1978
and 1995 (32). However, no elevated suicide risks were observed in other studies in peacekeepers (50, 51). Differences in population characteristics, reference groups, time period and deployment-related stressors and hazards might
explain the differences in results across studies.
5.4

Lower risk of respiratory tumours
Despite the healthy soldier effect described above, the lower risk of developing
tumours in respiratory organs that we found in Balkan deployed military personnel as compared to the Dutch population was against our expectations. Data on
smoking habits were not available for this study population, but it was generally
assumed that smoking (an important risk factor for respiratory tumours) is more
common in the military population than in the general population. A previous
study (12) in 1,124 Dutch veterans deployed to some specific areas of the Balkans (Lukavac, Santici and Busovaca) showed that 58% of them smoked during
deployment, which is considerably higher than in men of similar age in the general Dutch population
(http://www.nationaalkompas.nl/gezondheidsdeterminanten/leefstijl/roken/hoev
eel-mensen-roken/ visited December 24, 2010). Smoking rates before and after
deployment were not reported, but it was stated that ‘both current smoking
rates and rates during deployment were substantially higher than smoking rates
of the Dutch population’ (12). However, comparison of smoking rates across
studies is complicated, because smoking rates highly depend on the age of the
population, the time period and the way smoking habits are assessed. In the
United States, relatively high smoking rates have been reported for the military
population (52, 53), but a decreasing trend was observed between 1980 and
1998 (54).
Latency time should be taken into account when considering the risk of developing lung cancer, but because it is likely that most smokers in the study population started smoking many years before the onset of the study, an effect of
smoking on the development of lung cancer should have been detected.
However, our cohort was relatively young, and lung cancer in men is most observed among 65-80 year olds. Another explanation might be the relatively high
amount of physical activity among military personnel. However, despite strong
evidence for a protective role of physical activity on cancers of the breast and
endometrium, for lung cancer the evidence is weaker (55).

5.5

Completeness of study data
It took a long time to perform this study – nearly 10 years. Most time was spent
retrieving and validating historical employment data. This is inherent in the
study design, i.e. that data were collected many years after the first deployments, which is common in historical cohort studies which examine the health
effects of deployments. Hotopf and Wessely discussed the methodological difficulties associated with this, like tracing the (ex)military population, which is
highly mobile because of their job and young age (56). In 2001, each of the 4
branches of military service had its own administration, and each administration
had a different format. Deployment data were not recorded centrally either. In
addition, records of military personnel who died during active service were removed from the regular administration. It took a long time to build a comprehensive database with data from all different sources, and moreover, to validate
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the completeness of the data. Data registry has been much improved in the
meantime at the Dutch Ministry of Defence. In 2006, the Veteran Registration
System (VRS) was established, which includes detailed data on each mission
completed by each veteran. Deployment data collected in 2001 were replaced
with the deployment data of the VRS, because the latter had been validated,
e.g. by sending letters to veterans. Also, a new employee registry, covering personnel from all branches of service, was established (‘PeopleSoft’). Much effort
was put into validating the data, e.g. by comparisons with data of the Dutch
State Employees’ Pension Scheme (ABP). However, the Navy and Air Force could
not be included in this study because their data was not complete, e.g. not digitally available for the beginning of the study period. In addition, effects of Balkan deployments before 1993 could not be evaluated. However, there is no information showing that DU-containing ammunition was used in those years, and
given the type of the early missions (monitoring) this is unlikely.
In the data-analysis, difficulties in retrieving data were taken into account by
performing an analysis restricted to the years after 2001 (see Appendix 5),
which was the year of the start of the data collection. Theoretically, people who
were in service between 1993 and 2001 and who died during that time period
could have been missed because of removal of their data from employee records. However, results of the analysis with the restricted time period were similar to the results over the entire study period, suggesting that the overall results
were not biased by missing data on mortality in the early years of follow-up.
Bias by missing persons in the cohort because of the no-consent procedure is
also unlikely. Only 2% returned their no-consent card and the general characteristics of these persons (rank, appointment, age) were similar to those who were
included in the cohort. None of the Balkan veterans returned their no-consent
card, and of the non-deployed personnel that returned their card and described
a reason for refusal, some (approximately 30%) did so because they thought
that Balkan deployment was required to be included in the study, which was not
the case. Theoretically, the group who returned their card could differ from the
study population with respect to the incidence of cancer, but it is unlikely that
this influenced the results, because of the relatively small number of returned
cards.
5.6

Methodological issues
The advantage of the long time it took to perform this study was that more
years could be added to the follow-up period, resulting in a study period of
15 years. However, as the follow-up started at the end date of the first mission,
Balkan veterans have generally been followed for a shorter period of time. Late
effects of Balkan deployment on the development of cancer cannot be excluded,
as many cancers do not become apparent until 10-20 years after an initiating
event. For myeloid leukaemia, however, which has frequently been associated
with radiation, the latency time is relatively short. For Japanese A-bomb survivors at the ages of young soldiers, for instance, the incidence peaked at
5-10 years after irradiation (57).
Of note, ‘Balkan deployment’ is a very crude indicator of potential exposure to
uranium and other hazards. Effects might have been ‘evened out’ because of
looking at the entire population instead of focusing on people who were exposed. However, this kind of exposure data was not available. Another limitation
of this study is the inability to control for other risk factors for the development
of cancer and mortality, such as smoking, alcohol consumption, genetic factors
and job history after deployment to the Balkans. If one or more of these risk
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factors would show a relationship with Balkan deployment, the observed relative
risks may be biased due to confounding. For example, if Balkan deployed personnel had a lower risk of developing cancer because of genetic factors, the potential effects of exposures related to Balkan deployment would have been underestimated. A way to obtain information on confounding variables without the
need to question the entire study population would have been to conduct a
‘nested’ case-control study (58). In such a study additional information on lifestyle factors could have been obtained, which could have been used in the comparisons between Balkan deployed and non-Balkan deployed personnel.
As concluded by Hotopf, epidemiological studies should be planned before military action is contemplated, to avoid difficulties in assessing exposures and
health effects afterwards (56). Nevertheless, in the present study several methods were applied to deal with those difficulties. These included adjustment for
different sets of potential indicators of socioeconomic status, which did not affect
the outcomes of the study. In addition, in contrast to previous studies on Balkan
veterans, comparisons with non-deployed personnel were made and not only
cancer data, but also mortality data were included.

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6

Conclusions

This study showed that the cancer incidence and all-cause mortality in Balkan
deployed men was lower than in non-Balkan deployed men in the study period
of 15 years. This study also showed that Dutch military men, Balkan deployed or
not, had a lower risk of developing cancer and mortality as compared to the
general population of comparable age. This can be explained by the fact that the
working population, and the military population in particular, is healthier than
the general population. Also for women, no elevated risk of developing cancer
following Balkan deployment was observed.
This study is the largest study in Balkan veterans performed to date, with the
longest period of follow-up. The findings do not change conclusions drawn from
previous epidemiological studies – that there are no indications of an elevated
risk of developing cancer following Balkan deployment. Furthermore, since
health effects by DU-exposure in the Balkan deployed group have previously
been reported to be ‘unlikely’, future health effects are not expected.

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Acknowledgement

In the period 2001-2011, many persons have contributed to the study presented
in this report. The authors are grateful to Bas Verhagen, Jeanne van Loon, Diane
Houweling and Linda Grievink, who coordinated the project during different time
periods, Jeroen de Hartog and Leontien Korteweg, who contributed to the data
cleaning and analysis and Pauline Slottje, who wrote a first draft of the introduction. From RIVM, also Ellis Franssen, Ingrid van Kuilenburg, Adriaan van Kessel,
Bennie Bloemberg, Ben Bom, Dirk-Jan Griffioen, Wil Lokhorst, Caroline Ameling
and Hendriek Boshuizen contributed to this study. We thank Otto Visser, who
reviewed the study as a member of the initial Scientific Advisory Board, and Iris
Engelhard, who was an external advisor in the end stage of the project. We
would like to thank the members of the Scientific Advisory Board for the interesting discussions during our meetings: Floor van Leeuwen (chairman), Bart
Kiemeney and Leo Schouten. Floor van Leeuwen and her colleagues of the Netherlands Cancer Institute also provided the computer programme for standardization. We would also like to thank the persons at the Ministry of Defence who
contributed to this study; in particular Ad de Koning, Angelique Hardij, Tjalling
Leenstra and Peter Krab, who was the manager of the Veteran Registration System. We thank Jos van Dijck, Rob Verhoeven and colleagues of the Association
of Comprehensive Cancer Centres (VIKC), Leo Engberts, Ingeborg Deerenberg,
Ronald Blokzijl, Ruurd Schoonhoven and colleagues of the Centre for Policy Related Statistics of Statistics Netherlands (CBS) and Hans Jongen of the National
Civil Pension Fund (ABP).

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the Gulf War. Philos Trans R Soc Lond B Biol Sci. 2006;361(1468):553-69.
Kang HK, Bullman TA. Mortality among US veterans of the Persian Gulf
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Kang HK, Bullman TA, Macfarlane GJ, Gray GC. Mortality among US and
UK veterans of the Persian Gulf War: a review. Occup Environ Med.
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Long-term mortality amongst Gulf War Veterans: is there a relationship
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Macfarlane GJ, Thomas E, Cherry N. Mortality among UK Gulf War veterans. Lancet. 2000;356(9223):17-21.
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the 1990-91 Gulf War. Int J Epidemiol. 2005 Aug;34(4):791-800.
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Rothman KJ, Greenland S. Modern Epidemiology. 2nd ed. Philadelphia:
Lippincott-Raven Publishers; 1998.

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Appendix 1. Letter to participants and no-consent form

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Appendix 2. Analyses in women

Table A2.1. Mortality among Dutch military women deployed to the Balkans (N= 992) as compared to the age-matched Dutch female population.
Cause of death

ICD-10 code

Obs

Exp

SMR (95% CI)

Total

All

3

4.1

0.74 (0.15-2.16)

Table A2.2. Mortality among Dutch military women non-deployed to the Balkans (N= 2,954) as compared to the age-matched Dutch female
population.
Cause of death

ICD-10 code

Obs

Exp

SMR (95% CI)

Total

All

17

15.6

1.09 (0.63-1.74)

External causes of morbidity and mortality
Suicide6
Transport accidents

V01-Y89
X60-X84
V01-V99

8
2
5

3.8
1.7
1.2

2.10 (0.91-4.14)
4.17 (1.35-9.72)

Table A2.3. Incidence of cancer among Dutch military women deployed to the Balkans (N= 992) as compared to the age-matched Dutch female
population.
Type of cancer

ICD-10 code

Obs

Exp

SIR (95% CI)

Total

All

10

7.6

1.31 (0.63-2.41)

Breast

C50

3

2.5

1.19 (0.24-3.48)

6

SMR not calculated because of low numbers (observed and expected lower than 3)

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Table A2.4. Incidence of cancer among Dutch military women non-deployed to the Balkans (N=2,954) as compared to the age-matched Dutch
female population.
Type of cancer

ICD-10 code

Obs

Exp

SIR (95% CI)

Total

All

30

26.2

1.15 (0.77-1.64)

Breast

C50

12

8.1

1.48 (0.77-2.59)

Melanome of skin

C43

6

4.6

1.30 (0.48-2.82)

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Appendix 3. Analyses in men non-deployed to the Balkans

Table A3.1. Mortality among Dutch military men non-deployed to the Balkans (N= 135,355) as compared to the age-matched Dutch male population, summarized in main causes of death categories, lifting out suicide and transport accidents.
Cause of death

ICD-10 code

Obs

Exp

SMR (95% CI)

Total

All

1,080

1,890.5

0.57 (0.54-0.61)

Certain infectious and parasitic diseases

A00-B99

11

39.9

0.28 (0.14-0.49)

Cancer

C00-C97

305

423.3

0.72 (0.64-0.81)

Diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism

D50-D89

3

5.7

0.53 (0.11-1.54)

Endocrine, nutritional and metabolic diseases

E00-E90

10

38.6

0.26 (0.12-0.48)

Mental and behavioural disorders

F00-F99

7

18.0

0.39 (0.16-0.80)

Diseases of the nervous system

G00-H95

15

52.7

0.28 (0.16-0.47)

Diseases of the circulatory system

I00-I99

183

315.9

0.58 (0.50-0.67)

Diseases of the respiratory system

J00-J99

14

44.5

0.31 (0.17-0.53)

Diseases of the digestive system

K00-K93

25

53.6

0.47 (0.30-0.69)

Diseases of the skin and subcutaneous tissue7

L00-L99

1

1.1

Diseases of the musculoskeletal system and connective tissue

M00-M99

3

6.1

0.49 (0.10-1.44)

Diseases of the genitourinary system

N00-N99

4

7.9

0.50 (0.14-1.29)

Pregnancy, childbirth and the puerperium

O00-O99

0

0

Certain conditions originating in the perinatal period

P00-P96

0

0.1

Congenital malformations, deformations and chromosomal abnormalities

Q00-Q99

2

23.9

0.08 (0.01-0.30)

Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere

R00-R99

94

152.1

0.62 (0.50-0.76)

7

SMR not calculated because of low numbers (observed and expected lower than 3)

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Cause of death

ICD-10 code

Obs

Exp

SMR (95% CI)

V01-Y89
X60-X84
V01-V99

381
140
178

690.2
272.5
252.3

0.55 (0.50-0.61)
0.51 (0.43-0.61)
0.71 (0.61-0.82)

classified
External causes of morbidity and mortality
Suicide
Transport accidents

Table A3.2. Incidence of cancer among Dutch military men non-deployed to the Balkans (N=135,355) as compared to the age-matched Dutch
male population, summarized in cancer categories.
Type of cancer

ICD-10 code

Obs

Exp

SIR (95% CI)

Total

All

1,337

1,463.1

0.91 (0.87-0.96)

Digestive organs

C15-26

168

203.6

0.83 (0.71-0.96)

Respiratory organs

C30-39

86

135.2

0.64 (0.51-0.79)

Urogenital organs

C60-68

464

429.5

1.08 (0.98-1.18)

Haematological tumours

C81-C96 (C81-85, C88 C91-96)

194

237.4

0.82 (0.71-0.94)

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Appendix 4. Analyses without conscripts

Table A4.1. Mortality among Dutch professional military men deployed to the Balkans (N= 15,387) as compared to the age-matched Dutch male
population, summarized in main causes of death categories, lifting out suicide and transport accidents.
Cause of death

ICD-10 code

Obs

Exp

SMR (95% CI)

Total

All

144

222.4

0.65 (0.55-0.76)

Cancer

C00-C97

38

64.3

0.59 (0.42-0.81)

Diseases of the circulatory system

I00-I99

35

48.1

0.73 (0.51-1.01)

Diseases of the digestive system

K00-K93

5

8.9

0.56 (0.18-1.32)

Symptoms, signs and abnormal clinical and laboratory
findings, not elsewhere classified

R00-R99

12

16.4

0.73 (0.38-1.28)

External causes of morbidity and mortality

V01-Y89

46

53.9

0.85 (0.63-1.14)

Suicide
Transport accidents

X60-X84
V01-V99

26
15

23.5
16.6

1.11 (0.72-1.62)
0.90 (0.51-1.49)

Table A4.2. Mortality among Dutch professional military men non-deployed to the Balkans (N=26,029) as compared to the age-matched Dutch
male population, summarized in main causes of death categories, lifting out suicide and transport accidents.
Cause of death

ICD-10 code

Obs

Exp

SMR (95% CI)

Total

All

661

793.1

0.83 (0.77-0.90)

Certain infectious and parasitic diseases

A00-B99

7

16.7

0.42 (0.17-0.86)

Cancer

C00-C97

214

268.9

0.80 (0.69-0.91)

Endocrine, nutritional and metabolic diseases

E00-E90

4

20.6

0.19 (0.05-0.50)

Mental and behavioural disorders

F00-F99

4

9.0

0.44 (0.12-1.13)

Diseases of the nervous system

G00-H95

11

18.0

0.61 (0.31-1.10)

Diseases of the circulatory system

I00-I99

132

199.2

0.66 (0.55-0.79)

Diseases of the respiratory system

J00-J99

11

25.9

0.42 (0.21-0.76)

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Cause of death

ICD-10 code

Obs

Exp

SMR (95% CI)

Diseases of the digestive system

K00-K93

24

30.3

0.79 (0.51-1.18)

Symptoms, signs and abnormal clinical and laboratory
findings, not elsewhere classified

R00-R99

49

53.7

0.91 (0.68-1.21)

External causes of morbidity and mortality
Suicide
Transport accidents

V01-Y89
X60-X84
V01-V99

186
60
100

130.0
53.7
43.5

1.43 (1.23-1.65)
1.12 (0.85-1.44)
2.30 (1.87-2.79)

Table A4.3. Incidence of cancer among Dutch professional military men deployed to the Balkans (N=15,387) as compared to the age-matched
Dutch male population, summarized in cancer categories.
Type of cancer

ICD-10 code

Obs

Exp

SIR (95% CI)

Total

All

162

187.1

0.87 (0.74-1.01)

Digestive organs

C15-26

29

35.1

0.83 (0.55-1.19)

Respiratory organs

C30-39

12

24.5

0.49 (0.25-0.86)

Urogenital organs

C60-C68

53

48.1

1.10 (0.83-1.44)

Haematological tumours

C81-C96 (C81-85, C88, C9196)

22

25.6

0.86 (0.54-1.30)

Table A4.4. Incidence of cancer among Dutch professional military men non-deployed to the Balkans (N=26,029) as compared to the agematched Dutch male population, summarized in cancer categories.
Type of cancer

ICD-10 code

Obs

Exp

SIR (95% CI)

Total

All

649

663.9

0.98 (0.90-1.06)

Digestive organs

C15-26

132

139.8

0.94 (0.79-1.12)

Respiratory organs

C30-39

69

110.7

0.62 (0.48-0.79)

Urogenital organs

C60-68

213

175.3

1.22 (1.06-1.39)

Haematological tumours

C81-C96 (C81-85, C88 C9196)

81

73.9

1.10 (0.87-1.36)

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Appendix 5. Standardized mortality and cancer incidence ratios with follow-up starting in 2001

Table A5.1. Mortality among Dutch military men deployed to the Balkans (N= 18,175) after 2001 as compared to the age-matched Dutch male
population, summarized in main causes of death categories, lifting out suicide and transport accidents.
Cause of death

ICD-10 code

Obs

Exp

SMR (95% CI)

Total

All

117

170.7

0.69 (0.57-0.82)

Cancer

C00-C97

31

50.7

0.61 (0.42-0.87)

Diseases of the circulatory system

I00-I99

25

36.7

0.68 (0.44-1.01)

Diseases of the digestive system

K00-K93

3

6.9

0.44 (0.09-1.27)

Symptoms, signs and abnormal clinical and laboratory
findings, not elsewhere classified

R00-R99

9

12.1

0.74 (0.34-0.41)

External causes of morbidity and mortality

V01-Y89

42

40.3

1.04 (0.75-1.41)

Suicide
Transport accidents

X60-X84
V01-V99

19
17

18.6
11.0

1.02 (0.62-1.60)
1.54 (0.90-2.47)

Table A5.2. Mortality among Dutch military men non-deployed to the Balkans (N= 135,355) after 2001 as compared to the age-matched Dutch
male population, summarized in main causes of death categories, lifting out suicide and transport accidents.
Cause of death

ICD-10 code

Obs

Exp

SMR (95% CI)

Total

All

678

982.9

0.69 (0.64-0.74)

Cancer

C00-C97

218

254.3

0.86 (0.75-0.98)

Diseases of the circulatory system

I00-I99

120

187.3

0.64 (0.53-0.77)

Diseases of the digestive system

K00-K93

16

32.5

0.49 (0.28-0.80)

Symptoms, signs and abnormal clinical and laboratory
findings, not elsewhere classified

R00-R99

62

72.2

0.86 (0.66-1.10)

External causes of morbidity and mortality
Suicide
Transport accidents

V01-Y89
X60-X84
V01-V99

207
92
74

296.9
133.7
82.7

0.70 (0.61-0.80)
0.69 (0.55-0.84)
0.89 (0.70-1.12)

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Table A5.3. Incidence of cancer among Dutch military men deployed to the Balkans (N=18,175) after 2001 as compared to the age-matched
Dutch male population, for the total number and haematological tumours.
Type of cancer

ICD-10 code

Total
Haematological tumours

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C81-C96 (C81-85, C88,
C91-96)

Obs

Exp

SIR (95% CI)

128

154.7

0.83 (0.69-0.98)

20

20.8

0.96 (0.59-1.48)

RIVM Report 630450001

Appendix 6. Hazard ratios of cancer incidence excluding
cases in the first 18 months

2,0

1,5

1,0

0,5

0,0
Total

Digestive

Respiratory

Urogenital Haematological

Figure A6.1. Relative risks1 of total and site-specific incidence of cancer in Dutch
male military personnel deployed to the Balkans (N= 18,175) compared with
non-Balkan deployed personnel, excluding cases in the first 18 months.
1
Adjusted for rank, appointment and military branch.

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Appendix 7. Index of tables

Table 2.1. Previously reported studies on cancer incidence among UN
Balkan veterans.

19

Table 4.1. General characteristics of male military personnel deployed and non-deployed to the Balkans.

29

Table 4.2. Balkan missions of the study population between 1993
and 2001 with at least 50 deployments.

32

Table 4.3. Cancer incidence among Dutch military personnel deployed to the Balkans (N= 18,175) as compared to the age- and
sex-matched Dutch population.

35

Table 4.4. Mortality among Dutch military men deployed to the Balkans (N= 18,175) as compared to the age-matched Dutch male
population, summarized in main causes of death categories.

39

Table 5.1. Results of this study, compared to previous studies on
development of cancer following Balkan deployment.

41

Table A2.1. Mortality among Dutch military women deployed to the
Balkans (N= 992) as compared to the age-matched Dutch female
population.

57

Table A2.2. Mortality among Dutch military women non-deployed to
the Balkans (N= 2,954) as compared to the age-matched Dutch female population.

57

Table A2.3. Incidence of cancer among Dutch military women deployed to the Balkans (N= 992) as compared to the age-matched
Dutch female population.

57

Table A2.4. Incidence of cancer among Dutch military women nondeployed to the Balkans (N=2,954) as compared to the age-matched
Dutch female population.

58

Table A3.1. Mortality among Dutch military men non-deployed to the
Balkans (N= 135,355) as compared to the age-matched Dutch male
population, summarized in main causes of death categories, lifting
out suicide and transport accidents.

59

Table A3.2. Incidence of cancer among Dutch military men nondeployed to the Balkans (N=135,355) as compared to the agematched Dutch male population, summarized in cancer categories.

60

Table A4.1. Mortality among Dutch professional military men deployed to the Balkans (N= 15,387) as compared to the age-matched
Dutch male population, summarized in main causes of death categories, lifting out suicide and transport accidents.

61

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Table A4.2. Mortality among Dutch professional military men nondeployed to the Balkans (N=26,029) as compared to the agematched Dutch male population, summarized in main causes of
death categories, lifting out suicide and transport accidents.

61

Table A4.3. Incidence of cancer among Dutch professional military
men deployed to the Balkans (N=15,387) as compared to the agematched Dutch male population, summarized in cancer categories.

62

Table A4.4. Incidence of cancer among Dutch professional military
men non-deployed to the Balkans (N=26,029) as compared to the
age-matched Dutch male population, summarized in cancer categories.

62

Table A5.1. Mortality among Dutch military men deployed to the
Balkans (N= 18,175) after 2001 as compared to the age-matched
Dutch male population, summarized in main causes of death categories, lifting out suicide and transport accidents.

63

Table A5.2. Mortality among Dutch military men non-deployed to the
Balkans (N= 135,355) after 2001 as compared to the age-matched
Dutch male population, summarized in main causes of death categories, lifting out suicide and transport accidents.

63

Table A5.3. Incidence of cancer among Dutch military men deployed
to the Balkans (N=18,175) after 2001 as compared to the agematched Dutch male population, for the total number and haematological tumours.

64

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Appendix 8. Index of figures

Figure 2.1. Map of main Balkan missions in former Yugoslavia (including double counting of military personnel if deployed more than
once).

15

Figure 3.1. Calculation of time at risk for a virtual Balkan deployed
soldier who was deployed to the Balkans twice.

26

Figure 4.1. Number of military personnel across different age groups
among Balkan and non-Balkan deployed military personnel at January 1, 1993 (A) and January 1, 2008 (B).

30

Figure 4.2. Total number of Balkan deployments over time (includes
double counting of military personnel if deployed more than once).

31

Figure 4.3. Relative risks of total and site-specific incidence of cancer
in Dutch male military personnel deployed to the Balkans (N=
18,175) compared with non-Balkan deployed personnel.

34

Figure 5.1. Standardized mortality ratios for all causes and for cancer for deployed military personnel, according to the meta-analysis
of McLaughlin (33).

43

Figure A6.1. Relative risks of total and site-specific incidence of cancer in Dutch male military personnel deployed to the Balkans (N=
18,175) compared with non-Balkan deployed personnel, excluding
cases in the first 18 months.

65

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