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                    <text>torn ID Number

01439

Author

Shepard, Barclay M.

Corporata Author
RODOrt/ArtiClB Titfe Typescript: Non-Hodgkin's Lymphoma: a Brief
Overview, March 31, 1987

Journal/Book Title
Year
Month/Day

March 31

Color

°

Number of Images

46

Descripton Notes

Tuesday, May 15, 2001

Page 1439 of 1514

�Non-Hodgkin's Lymphoma
A Brief Overview

The term non-Hodgkin's lymphoma refers to a group of
malignant neoplasms within the larger category of malignant
lymphomas. These tumors arise from the lymphoreticular system
which consits primarily of lymph nodes and collections of
specialized cells in many organs including the spleen, liver,
bone marrow, and portions of the gastrointestinal system. The
annual incidence of malignant lymphomas in the United States is
approximately 33,000 of which 25% are classified as Hodgkin's
disease and the remaining 75% are called non-Hodgkin's lymphoma.
The diagnosis of non-Hodgkin's lymphoma depends on a careful
microscopic examination of the actual tumor tissue and frequently
requires additional histo-chemical studies. There is a wide
range of cell types and the appropriate classification of a
particular tumor requires considerable skill on the part of an
experienced pathologist. Accurate diagnosis and correct
classification are very important since these determine the most
effective course of treatment and the prognosis of the tumor.
As is the case with many malignant neoplasms, the causative
factors for this group of tumors are largely unknown.
Considerable evidence does exist, however, that certain viruses
which have the potential for altering the immune system play a
key role in the development of certain types of non-Hodgkin 1 s
lymphoma. In addition, a number of recent epidemiological
studies are showing a positive association between non-Hodgkin's
lymphoma and exposure to chlorophenols and agricultural chemicals
such as the phenoxy acid herbicides and nitrogen-containing
fertilizers. It is too early to state that this represents a
definite cause-and-effect relationship, but the evidence seems to
be increasing to suggest such a conclusion.

Prepared by:

BARCLAY M. SHEPARD, M.D.
Director, Agent Orange Projects Office
March 31, 1987

�ABSTRACT

A population-based case-control study was conducted 1n western Washington
State to evaluate the relationship between occupational exposure of men aged
20 to 79 to phenoxy acetic acid herbicides and chlorinated phenols and the
risks of developing soft tissue sarcoma (STS) and non-Hodgkins lymphoma
(NHL). Occupational histories and other data were obtained by personal
interviews for 128 STS cases and 576 NHL cases, diagnosed between 1981 and
1984, and for 694 randomly selected controls without cancer. Among the study
subjects with any past occupational exposure to phenoxy herbicides, the
estimated relative risk and 952 confidence interval of developing STS was 0.80
(0.5-1.2), and of developing NHL, 1.07 (0.8-1.4). Risk estimates of
developing STS and NHL associated with past chlorophenol exposure were 0.99
(0.7-1.5) and 0.99 (0.8-1.2), respectively. No increasing risk of either
cancer was associated with overall duration or intensity of chemical exposure
or with exposure to any specific phenoxy herbicide per se. However, estimated
risks of NHL were elevated among men who had been fanners, 1.33 (1.03-1.7),
forestry herbicide applicators, 4.80 (1.2-19.4) and for those potentially
exposed to phenoxy herbicides in any occupation for 15 years or more during
the period prior to 15 years before cancer diagnosis, -1.71 (1.04-2.8).
Increased risks of NHL were also observed among those with occupational
exposure to organochlorine insecticides such as DDT, 1.82 (1.04-3.2), organic
solvents 1.35 (1.06-1.7), and to other chemicals typically encountered in the
agricultural, forestry or wood products industries. These results demonstrate
small but significantly increased risks of developing NHL in association with
some occupational activities involving exposure to phenoxy herbicides,
particularly for prolonged periods, and possibly in combination with other

Page 2

�chemicals. They do not demonstrate a positive association between increased
cancer risks and exposure to any specific phenoxy herbicide product alone.
Moreover, these findings provide no evidence of increased risks of developing
NHL associated with chlorinated phenol exposure or of developing STS
associated with exposure to either class of chemical.

Page 3

�INTRODUCTION
Recent studies from Sweden (1-5) and elsewhere (6-10) have reported an
increased risk of soft tissue sarcomas (STS) or non-Hodgkins lytnphomas (NHL)
in association with occupational exposures to phenoxy acetic acid herbicides
and/or chlorinated phenols.
appeared (11-15).

Negative studies of this association have also

Implicated as the putative carcinogen in most of these

studies is 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD) (CAS:1746-01-6), a trace
contaminant formed during the manufacture of chemicals which are derived from
alkaline hydrolysis of 1,2,4,5-tetrachlorobenzene.

Of particular concern in

this respect are 2,4,5-trichlorophenol and the phenoxy herbicides,
2,4,5-trichlorophenoxy acetic acid (2,4,5-T) (CAS:93-76-5) and
2-(2,4,5-trichlorophenoxy) propionic acid (Si!vex), which have been reported
to be contaminated with TCDD as high as 30 ppm (16).

Moreover, TCDD is the

prototype of a larger series of halogenated aromatic hydrocarbons including
other polychlorinated dibenzo-p-dioxins (PCDD), dibenzofurans and biphenyls,
all of which share similar biochemical properties and which may also
contaminate phenoxy herbicide or chlorophenol products in commercial use.
Hence, concern exists regarding the possible health risks from exposure to
chemical products in which any such contaminants may be present.
The present study was conducted to investigate the relationship between
the incidence of soft tissue sarcomas and non-Hodgkins lymphomas and past
exposure to phenoxy herbicides and chlorinated phenols using a
population-based case-control approach. Subjects were drawn from the male
population of western Washington state, where phenoxy acetic acid herbicides
and chlorophenols have been widely utilized during the past 40 years by
agricultural, forestry and wood products industries. Specific emphasis was
placed on identification of intervening factors or conditions which may

Page 4

�influence human susceptibility to the risk of cancer in association with
exposure to phenoxy acetic acids, chlorophenols or PCDDs.

METHODS
Acquisition of Cases and Controls
From 1983 through 1985 men with either STS or NHL were identified through
the Cancer Surveillance System (CSS), a population-based tumor registry that
has covered 13 counties of western Washington since 1974. Men eligible to
participate in the study were between the ages of 20 and 79 at diagnosis and
had been diagnosed during the years 1981-1984 as having either STS or NHL, as
classified histologically by the World Health Organization International
Classification of Diseases for Oncology, First Revision (17). Case
definitions of eligibility for STS by ICD-0 codes are 8800-8804, 8810-8813,
8830-8832, 8840, 8850-8860, 8890-8920, 8990-8991, 9040-9044, 9120, 9130, 9150,
9170, 9251, 9260, 9503, 9540-9560 and 9580-9581.

Case definitions of

eligibility for NHL by ICD-0 codes are 9590-9642, 9690-9701 and 9750. The CSS
obtains data from all hospitals throughout a 13 county region, and essentially
complete population coverage is attained.
During 1983-1985 a control group without STS or NHL was also selected.
Live control subjects aged 20-64 were chosen using a random digit dialing
procedure as described by Waksberg (18). Because the elderly are relatively
sparse in the general population, it was not economical to locate all older
controls by random digit dialing. Thus, additional live control subjects aged
65-79 were chosen at random from data supplied by the Health Care Financing
Administration covering social security recipients in the study area.
Controls were group-matched to NHL-cases by vital status and 5-year age group
with a ratio of 1.2 controls per case.

Deceased controls exclusive of

Page 5

�homicides and suicides were identified from non-cancer death certificates for
persons aged 20-79 with a date of death occurring during the study period and
with a residence within the 13-county study area.

The disposition of case and

control subjects according to vital status, interview outcome and pathologic
review of STS is presented in Table 1.
Interview Procedure
All study subjects, including proxies, were interviewed in-person by
experienced interviewers at a time and location of their choice. The
interview lasted approximately one hour and covered the participant's
residential, military and medical histories with a detailed section on
occupational exposures to herbicides, chlorophenols and other chemicals prior
to diagnosis or interview.

Detailed information on known or suspected risk

factors for STS and NHL including past history of immunosuppressive disorders,
use of immunosuppressant medication or family history of cancer or immune
disease, was also obtained.

Additional information, including pathology,

stage, extent of disease and date of diagnosis, was collected for each case
from data supplied by the CSS. "Exposure" for all variables refers to that
occurring prior to the date of diagnosis for the cases and prior to the date
of interview for controls. The effect of recall differences on cancer risk
owing to the difference in lapse time between diagnosis and interview for the
cases (about 1 year) versus initial contact and interview.for controls (about
1 month) was evaluated and found to be negligible. Risk estimates among
living and deceased cohorts were comparable for essentially all associations;
hence, living and deceased groups were combined in all analyses.
The questionnaire utilized in the interview was designed after identifying
the principal occupations and activities undertaken within the study area
which have involved the manufacture or use of phenoxy herbicides and/or

Page 6

�chlorophenols.
&lt;

Such occupations and activities were identified in

consultation with local industrial and university representatives who had had
long term experience with forestry, wood products and agricultural industries
in the Pacific Northwest. This consultation resulted in identification of 34
specific job titles (e.g., wood products worker, herbicide applicator) and 17
specific job activities (e.g., spray weeds with phenoxy herbicides;
manufacture chlorophenols) involving potential exposure to either phenoxy
herbicides or chlorophenols. In addition, 14 specific phenoxy herbicide or
chlorophenol preparations in common commercial use in the study area were
identified. Each job title or activity was then assigned to a "high,"
"medium," "low" or "no" exposure category for both phenoxy herbicides and
chlorophenols, reflecting the consensus of the consultant group of the likely
intensity of exposure to each chemical received in that occupation.

Examples

of occupational activities in each exposure category are given in the tables.
In the interview, cue questions referring to each specific job title,
activity or chemical preparation were asked to determine whether a subject had
worked in an occupation involving probable exposure to phenoxy herbicides or
chlorophenols. If an affirmative response to any cue question was elicited, a
series of additional inquiries was made to acquire detailed information
i

regarding the extent of exposure to specific chemicals of interest and the
precise time intervals during which each exposure episode had occurred. Among
the additional questions asked was an inquiry regarding the name and address
of the supervisor or a close co-worker in each job episode where possible
chemical exposure had occurred. This information was used with subject's
permission to corroborate self-reported exposure to specific chemicals and to
verify exposure histories in instances where the subject or his proxy was .
uncertain regarding the actual exposure circumstances in that job.

Paae 7

Additional

�measures taken to reduce the likelihood of recall bias with respect to the
reporting of phenoxy herbicide or chlorophenol exposure included avoiding a
deliberate focus on these specific chemicals in the interview and conducting
the interview during a period (1983-1985) of relatively low local or national
media attention to the herbicide-cancer issue. The study was not advertised
locally, and subjects were not made aware of the focus of the investigation
except that it had broad immplications with respect to environmental factors
related to cancer etiology.
In coding occupational exposure to phenoxy herbicides or chlorophenols
based on job descriptions, the inclusive dates during which a person was
employed in any specific occupation or activity were recorded in the
questionnaire. In the analysis, however, occupational exposure to phenoxy
herbicides and chlorophenols was considered to have begun no earlier than 1946
and 1937, respectively, the years when these chemicals first came into
widespread commercial use in the study area. The coding of each job episode
held by a study subject according to intensity and duration of exposure
permitted evaluation of the exposure history of each subject in terms of
duration of continuous or cumulative exposure at each dose level. Thus, a
complete exposure profile on each subject for each class of chemical under
evaluation was obtained.
Quality Control Procedures
Several quality control procedures were employed to verify the accuracy of
the data collected by interview. First, 145 respondents from a total of 1444
who completed interviews were randomly selected and were recontacted by
telephone approximately one month after the interview date.

Interview and

reinterview responses to 7 questions were compared. Five of the 7 questions
reflected an 88 percent or higher agreement with the original interview, and

�one item had an 81 percent agreement rate. The remaining item, cups of coffee
consumed per week, had a 34 percent agreement rate, although 55 percent of the
discrepancies involved minor disagreements regarding the precise number of
cups consumed.
A second quality control procedure consisted of independent receding of a
random sample of 238 coded interviews. The overall agreement rate between
codes and recedes was 99 percent. The agreement rate was 98.9 percent for
codes pertaining to phenoxy herbicides and 98.3 percent for codes pertaining
to chlorophenols.
Pathologic Review of Soft Tissue Sarcoma Case Materials
Pathologic review of histologic slides and/or sections prepared from
tissue blocks of STS cases was conducted in order to verify the initial
diagnosis of STS.

Reviews were performed by a pathologist (BK) with expertise

in soft tissue tumors.

For the review of STS, specimen materials were

acquired from each participating hospital where the initial diagnosis of STS
was made, and were then coded, and sent "blind" to the project pathologist.
In all, histoligic material from 155 cases was obtained for review. Twenty
percent of the slides or sections were resuomitted to the pathologist as an
internal check of his first diagnosis. In a few circumstances the project
pathologist disagreed with either the CSS or himself regarding the diagnosis
of either STS per se or the specific histological classification of STS.

In

these instances a sample of the disparate slides was sent to the Armed Forces
Institute of Pathology in Washington, DC for resolution of STS and/or
histologic type classification. This 3 tier STS evaluation procedure resulted
in retention of 45% of the STS cases in the study with histologic diagnosis as
originally determined, and an additional 34« of cases retained with STS
confirmed although of a different histologic classification than originally

Paae 9

�made. Twenty one percent of original cases were determined either not likely
to be STS, or of indeterminate pathology, and, consequently, were excluded
from the study. Many of these were primary bone tumors.

In light of the

widely accepted high level of reliability associated with the accurate
identification of NHL according to broad histologic classifications,
pathologic materials from NHL cases were not reviewed for verification in this
study.
Statistical Methods
The data analysis includes estimates of relative risks as odds ratios and
their 95* confidence intervals for a number of variables of interest.

The

most common confounding variable was age; thus, all relationships were
age-adjusted by 5 or 10-year age groups, where possible. Pooled odds ratios
were calculated using the Mantel-Haenszel method (19). Test-based confidence
intervals were calculated using the method of Miettinen (20).

In addition,

logistic regression analysis (21) was employed to evaluate the joint effect of
several variables and possible interactions between chemical exposure and
other potential risk factors on cancer risks. The total number of subjects
represented in each analysis varies according to the rate of unknown
responses; for occupational assessments unknowns were omitted from the
analyses. In all other analyses unknowns were included in the "none" or "no
exposure" category.

The percentage of the total study population responding

affirmatively with respect to specific job titles, exposures or other
characteristic is presented in the Tables. "Significance" in all analyses was
determined at the five percent level.

Paae 10

�RESULTS

Characteristics of the Study Population
Table 2 presents a comparison of NHL and STS cases and controls for
selected demographic attributes. The three groups were similar in most
respects. Notable differences included a higher proportion of STS cases than
controls among subjects in the 20-39 age group and a higher percentage of STS
cases in the "other" race category. Asians account principally for this
difference.
Risks Related to Intensity of Chemical Exposure
When estimates of relative risks of both STS and NHL were determined for
various levels of phenoxy herbicide or chlorophenol exposure among the entire
study population, no increasing trend nor risk estimates significantly
different from unity for any exposure level were seen (Table 3). However,
elevations in risk were observed for several specific occupations involving
chemical exposure. Estimates of relative risks of STS and NHL for various
occupations involving exposure principally to phenoxy herbicides are shown in
Table 4. When viewed across job categories involving increasing levels of
exposure, no clear indication of increasing risk is observed. No
significantly increased risks of either cancer were seen among those in
occupations involving low exposure to phenoxy herbicides, although a nearly
significant 1.70 (0.9-3.1) odds ratio for NHL was observed among landscapers.
Among those in medium exposure occupations, no significantly elevated
risks of STS were seen. A small but significantly increased risk of NHL, 1.33
(1.03-1.7), was observed among farmers, an occupation traditionally associated
with regular use of weed killers. This observation is consistent with reports
from other studies which have identified agricultural occupational groups at
increased NHL risk (22-25). Further evaluation of this observation with

Pace 11

�regard to duration of exposure and to use of specific substances indicated
that the risk of NHL increased from 1.02 (0.7-1.5) among those working as
fanners from 1 to 9 years to 1.62 (0.9-2.9) among farmers with 10 to 19 years
in that occupation.

However, no increased risks of developing NHL were

observed among those with more than 20 years as farmers, 0.92 (0.5-1.6).
Additionally, there were no increased risks of NHL among farmers who reported
having "regularly worked with" 2,4-D (0.68 [0.3-1.4]), 2,4,5-T (0.74
[0.3-2.1]), or phenoxy herbicides per se (0.71 [0.3-1.5]) when compared with
study subjects reporting no phenoxy herbicide exposure.

The estimated risk of

developing NHL among farmers who reported having regularly sprayed weed
killers by knapsack, tractor or aircraft was 1.13 (0.7-1.9). A risk of
developing NHL equal to 1.46 (0.8-2.8) was observed among farmers who reported
having worked with the specific organochlorine insecticides DDT and chlordane.
In occupations associated with high herbicide exposure, none was
associated with a statistically significant increased risk of developing STS.
A substantially increased risk of developing NHL, 4.80 (1.2-19.4), was noted
for persons who claimed to have worked regularly in jobs involving spraying of
weed killers in national, state or commercial forests.

However, increased

risks of this magnitude were not observed among those engaged in other
herbicide spraying activities or among those who worked as herbicide
f emulators or applicators per se. Further evaluation of-the increased risk
of NHL observed among forestry herbicide sprayers with respect to specific
chemicals used and duration of exposures indicated that all forestry sprayers
reported the combined use of 2,4-D and 2,4,5-T as well as various commercial
herbicide preparations containing these and other chemicals. An infinite risk
estimate was attained for developing NHL among forestry herbicide applicators
specifically in association with phenoxy herbicide exposure, inasmuch as tnere

Paae 12

�were no control subjects who served as forestry herbicide sprayers and did not
use phenoxy herbicides.
p = 0.004.
involved.

This association was statistically significant with

However, only a very small number of exposed subjects (7) were
The risks of STS and NHL associated with all occupations involving

potential exposure to phenoxy herbicides considered together were 0.80
(0.5-1.2) and 1.07 (0.8-1.4), respectively.

The risks of developing NHL

associated with exposure specifically to 2,4-D and 2,4,5-T and to phenoxy
herbicides in general among the entire study population were 0.73 (0.4-1.3),
0.98 (0.5-2.0) and 0.87 (0.5-1.5), respectively.
Table 5 presents risk estimates of STS and NHL for various occupations and
activities involving chlorophenol exposure.

As in the case of phenoxy

herbicides, no clear indication of increasing risks of either STS or NHL is
apparent when viewed across job categories involving increasing levels of
exposure to chlorophenols.

Somewhat elevated risks of developing STS are

suggested for lumber graders, 2.66 (1.1-6.4), and log/lumber inspectors, 4.83
(0.6-38.2), although other jobs involving comparable chlorophenol exposure
offer no suggestion of substantially increased STS risks.

No specific jobs

involving chlorophenol exposure were associated with increased risks of
developing NHL. When all occupations involving potential exposure to
chlorophenols were considered together, the risks of developing STS and NHL
were 0.99 (0.7-1.5) and 0.99 (0.8-1.2), respectively.
Results of Supervisor/Co-worker Survey
Corroboration of self-reported occupational exposure to phenoxy
herbicides, chlorophenols and other chemicals was sought through telephone
contact with employer supervisors or co-workers of subjects who had been
employed in jobs involving potential exposure to such substances.
Confirmation of subjects' responses regarding exposure was provided in

, Paae 13

�essentially all instances where employers or co-workers could be reached.
There were no significant differences between agreement rates for cases or
controls. The ability to acquire corroborative evidence of exposure (about
802 of contacts attempted) was greatest for most recent occupations held.
Risks Related to Duration of Chemical Exposure
Inasmuch as cancer risks may vary with length of exposure to specific
carcinogens or tumor promoting agents, it was of interest to estimate the
relative risks of STS and NHL for various lengths of cumulative exposure to
either phenoxy herbicides or chlorophenols. Hence, risk estimates of both
cancer types for 10-year durations (1-10, 11-20, 20+) of exposure to phenoxy
herbicides or chlorophenols were calculated. In this context, "exposure"
refers to any level of occupational phenoxy or chlorophenol exposure during
any portion of the time period since 1946 or 1937, respectively, up to the
date of diagnosis (cases) or interview (controls). "Duration" refers to the
total length of cumulative exposure during this time period. From these
calculations, it was determined that the risk of neither STS nor NHL increased
with the duration of phenoxy herbicide or chlorophenol exposure for periods of
20 years or more when all levels of exposure are considered concomitantly.
Moreover, no increased risks of either cancer were seen when increasing
lengths of exposure to only high levels of phenoxy herbicides or chlorophenols
were considered.
Evaluation of a Latency Period for Cancer Development
The average latency period for a carcinogenic effect of aromatic
hydrocarbons in humans has been postulated to be on the order of 15 to 30
years (26).

It was, therefore, of interest to determine if exposure to either

phenoxy herbicides or chlorophenols prior to an assumed latency period of 15
years before cancer diagnosis was associated with an increased risk of STS or

Page 14

�NHL. For these determinations, the risks of each cancer type were calculated
for two durations of cumulative exposure (1-14 and 1 5+ years) during the
period between 1946 or 1937 for phenoxy herbicides and chlorophenols,
respectively, and 15 years prior to diagnosis or interview.

The results

revealed a significant increase in the risk of NHL, 1.71 (1.04-2.8), among
those with cumulative exposures to phenoxy herbicides of more than 15 years
during the period preceding 15 years before diagnosis. When a 5 year latency
period for cancer development was assumed, the risk of NHL among those with 15
or more years of prelatency phenoxy exposure dropped to 1.29 (0.9-2.0). In
contrast, the risk of developing NHL was 2.51 (0.5-13.0) among subjects with
more than 15 years of herbicide exposure prior to a 25 year assumed latency
period. No increased risks of STS for either chemical or of NHL for
chlorophenols were observed in relation to chemical exposure for any latency
period or cummulative exposure assumption.
Evaluation of Other Risk Factors for STS and NHL
Since autoimmune diseases, primary immunodeficiency syndromes and other
conditions which compromise immune competence may act as independent risk
factors of STS or NHL, it was of interest to determine the risks of either
type of cancer associated with such conditions existing prior to the year of
cancer diagnosis (or interview). Table 6 presents risk estimates of STS and
NHL for a number of such conditions or factors. All assessments were made
from subject interviews, not from medical records. Immunosuppressant drug
therapy received for any reason prior to the year of diagnosis of NHL was the
greatest risk factor for either cancer.

Immune defficiency in a blood

relative was also associated with an increased (although non-significant) risk
of NHL. In contrast, the use of corticosteroids for observed periods of use
up to 29 years was not associated with an increased risk of either cancer type.

Paqe 15

�Of specific note is the 1.38-fold increased risk of NHL observed in
relation to a history of rheumatoid arthritis.

Although not statistically

significant, this observation is interesting in light of the current
controversy surrounding the question of increased risks of NHL among persons
afflicted with autoimmune diseases (27).

Preexisting skin cancer was also

associated with a slightly increased risk of both STS and NHL. Although the
type of skin cancer was not ascertained in this study, several histological
types of STS and NHL can have dermal manifestations which could have been
misreported as "skin cancer". Among these are the soft tissue tumors,
dermatofibrosarcoma (8832/3) and Kaposi's sarcoma (9140/3), and the
non-Hodgkins lymphoma, mycosis fungoides (9700-9701/3).

Kaposi's sarcoma was

excluded from evaluation in this study, and none of those reporting skin
cancer was found to have this form of STS. Among those 12 STS cases reporting
a prior history of skin cancer, none was found to have dermatofibrosarcoma,
and among 53 NHL cases, none had confirmed mycoides fungoides.
Malaria was evaluated as a potential risk factor for STS and NHL in light
of studies suggesting an etiologic association between malarial infection and
the risks of developing sarcomas or lymphomas through mechanisms involving
plasmodial suppression of immune defenses against malignant diseases (28,29).
The risk of developing neither STS nor NHL was significantly elevated in
association with a self-reported prior history of malaria alone.
Finally, Table 7 presents risk estimates associated with various
occupational and/or lifestyle factors which were observed in the present study
to independently alter the risk of STS or NHL and which might, therefore, be
considered as potential modifiers of the effect of chemical exposure on cancer
risks.

Of particular note is the significantly increased risk of NHL seen

among men with previous exposure to organic solvents, lead or lead arsenate

Paae 16

�pesticides, and welding and metal fumes. The risk of NHL was also elevated
among men reporting previous exposure to the organochlorine insecticides,
chlordane and DDT. Also of note is the increased risk of both STS and NHL
observed among those reporting a prior incidence of chloracne.

Although this

condition was not clinically confirmed in this study, this observation is of
considerable interest inasmuch as chloracne is an important clinical
manifestation of exposure to high levels of chlorinated dibenzodioxins and
furans in humans (30). The statistical association of reported chloracne with
phenoxy herbicide exposure was of borderline significance (p &lt; 0.075) in this
study.

Neither cigarette -smoking nor coffee drinking was a risk factor for

either cancer.
Not shown in Table 7 are a number of other factors or conditions which
were also evaluated as potential risks factors, but for which no significant
or suggestive associations with either STS or NHL were found.

These include:

exposure to radiation, X-rays or radioactive materials; exhaust fumes from
motorized equipment; home use of phenoxy herbicides; residency near areas
sprayed with weed killers; TB vaccination; consumption of multiple vitamins;
eating fish caught in Puget Sound; and, use of alcohol.
Logistic regression analysis was employed to estimate the potential
interaction between phenoxy herbicides or chlorophenols and various other
single variables appearing in Tables 6 or 7 as well as others of interest.
Intervening variables for which the interaction with phenoxy herbicides or
chlorophenols were determined included:

organochlorine pesticides (DDT +

Chlordane), lead/lead arsenate, welding or metal fumes, inherited or acquired
diseases of the immune system, any prior cancer, prior skin cancer, home use
of phenoxy herbicides, family history of cancer, and family history of
diseases of the imnune system.

All analyses were controlled for age. Results

�of the logistic regression analysis for these variables confirmed the
magnitude of the risks shown in Tables 6 and 7.

None of the interactions

between chlorinated phenol or phenoxy herbicide exposure and these variables
was statistically significant, with the exception of that between phenoxy
herbicides and organic solvents as a risk factor for NHL. The odds ratio for
joint exposure compared with exposure to neither substance was 1.50 with a 95«
confidence interval of 1.03-2.18.

The odds ratio estimates from the model for

exposure solely to organic solvents or phenoxy herbicides were
non-significantly 1.12 and 0.85, respectively.

The significance of the joint

exposure in this case may be a result of the large number of comparisons made
in this study or, possibly, due to a genuine synergistic effect.
Positive although non-significant interactions were also observed between
exposure to-either phenoxy herbicides or chlorophenols and co- or preexisting
autoimmune diseases or immune deficiency syndromes when those listed on
Table 6 and others (mononucleosis, celiac sprue, Sjogrens syndrome) were
considered jointly.

This interaction was most notable with chlorophenols

where the odds ratio for joint exposure (compared with neither) was 1.40
(0.95-2.07), as compared with 0.91 (0.72-1.14) and 1.32 (0.99-1.78),
respectively, for chlorophenol or immune deficiency alone.

These observations

are worthy of note in light of the widely held theory (31) that the etiology
of malignant lyraphomas involves failure of immunoregulation in the face of a
persistent stimulus for lymphocyte proliferation.

In autoimmune diseases,

chronic antigenie stimulation is provided by the constant exposure to
self-antigens, whereas in primary immunodeficiency syndromes, recurrent
infections are the likely source for antigenic stimulation.

In contrast, T2DD

is well recognized as a suppressant of both humoral and cell-mediated immunity
in animals (32-34), and has been recently characterized as a depressant of

Paae 18

�cell-mediated immunity in humans during prolonged, low-level exposure ( 3 5 ) .
Immunosuppression by other PCDDs has also been described (36). The
possibility that the statistical interactions, however slight, observed in
this study between phenoxy herbicides or chlorophenols and immunosuppressive
disorders may have biological relevance with respect to the etiology of NHL in
humans, therefore, deserves further consideration.

DISCUSSION
The results of the present study demonstrate significantly increased risks
of developing NHL among men in occupations involving farming and forestry
herbicide spraying and for occupations involving.regular exposure to phenoxy
acetic acid herbicides for prolonged periods. However, neither phenoxy
herbicides nor chlorophenols alone appear to constitute a sufficient cause of
either NHL or STS when evaluated within a population residing in western
Washington state, since increased cancer risks were not observed for numerous
other occupations or activities involving comparable opportunity for exposure
to these substances. In this regard, the present findings are not consistent
with results of studies conducted in Swedish and other populations which
report consistent and substantially increased risks of both types of cancer in
association with occupational exposure to specific chlorophenols or phenoxy
acetic acids or to combinations of these chemicals.
In consfderation of possible reasons underlying the apparent lack of
consi stency between the results of Swedish studies and those conducted here
and elsewto?*:, three issues which have not received major attention with
regard to •Slis question include: (1) differences in the intensities or dosages
of chemicals received by workers in comparable occupational activities, (2)
differences in the extent of environmental (non-occupational) exposure to the

ha ae 1 9

�chemicals received by the respective study populations, and (3) differences
between study populations with respect to the proportional distribution of
other risk factors which in combination with phenoxy herbicides or
chlorophenols contribute causally to the cancers putatively associated with
chemical exposure alone.
In addressing the question of differences in dosages of chemicals received
by workers engaged in comparable job activities, it is likely that, should the
chemicals under investigation independently increase cancer risks in humans,
this effect should be more apparent among persons receiving higher dosages.
In considering this possibility as it pertains specifically to application of
phenoxy herbicides, it is known that spraying activities, as well as work in
sprayed areas, extend over substantially shorter periods of the year in Sweden
than occur in western Washington, owing largely to climatic differences in the
length of the growing season. Thus, Swedish workers participate in activities
in which phenoxy herbicide exposure is typically consolidated within a 2-3
month period annually, during which spraying activities involving intensive
herbicide exposures which extend over several consecutive weeks at a time are
not uncommon (1,37). In contrast, the annual spraying season in the Pacific
korthwest extends over 6 to 7 months, during which individual spraying
episodes usually span only a few days at a time and may be separated by weeks
or even months during which no spraying is performed. Such differences in
herbicide use patterns could conceivably lead to Swedish applicators receiving
appreciably higher cumulative exposures to biologically active substances than
occurs among workers engaged in less intensive use patterns, as supported by
several studies of this questions (38,39).
To analyze this possibility quantitatively, we have employed the
pharmacokinetic model developed by Gehring (40) from the oral study of 2,4,5-7

Paae 20

�in humans to calculate maximum absorbed daily dosages of herbicide received by
Swedish and American workers.

The workers in question engaged in activities

with comparable job description, namely, herbicide applicator using
tractor-drawn equipment.

Calculations, based on urinary herbicide

concentrations using data derived from studies of applicators under actual
field conditions (37,41), indicate that the maximum daily dose of 2,4,5-T
absorbed by American workers in an application operation involving 2
sprayings, 2 weeks apart, is in the range of 12 to 86 ug/kg of body weight,
with a mean maximum daily dose of 45 ug/kg.

In contrast, calculated maximum

daily dosages received by Swedish workers, doing the same type of work but
involving spraying for 3 to 4 hours/day over a consecutive 2 week period
ranged from 11 to 315 ug/kg, with a mean maximum daily dosage of 90 ug/kg.
Maximum daily dosages received by American workers involved in other modes of
herbicide application were backpack crew, 19-104 ug/kg; helicopter crew, 17-23
ug/kg; and mixers, 12-138 ug/kg.

These results suggest that maximum daily

dosages of herbicides received by Swedish applicators could substantially
exceed those received by American counterparts as well as those engaged in
other modes of spraying operations.

From the pharmacokinetic studies in

humans (40) it is known that 2,4,5-T is absorbed and excreted in the urine
with a half-life of about one day following a single oral exposure.

Moreover,

from measurements of urinary 2,4,5-T, the maximum dose which can be absorbed
on repeated exposures is estimated to be about 100 ug/kg/day, with the
expected maximum concentration in plasma of individuals receiving repeated
daily doses reaching a plateau after 3 days of such exposure. Based on these
considerations, the calculated mean maximum daily dose of 2,4,5-T received by
Swedish workers under the occupational circumstances described above (90
ug/kg) would approximate that required to produce the maximum plasma

Paae 21

�concentration of 2,4,5-T which could be sustained during spraying operations.
Thus, Swedish applicators would experience higher sustained tissue levels
during repeated frequent exposure episodes, as well as higher tissue
concentrations of any PCDDs or other contaminants which would be concomitantly
absorbed, than would be experienced by American counterparts, who receive
lower exposures on a more sporadic basis.
Although the implications of these calculations with respect to human
cancer risks are difficult to estimate, they are nevertheless of interest in
light of findings from recent studies of Swedish subjects (42) involving
analysis of PCDDs in abdominal fat from both cases of STS and NHL as well as
control subjects. These studies reported that cancer cases exposed to
phenoxy herbicides 16 to 31 years previously had levels of highly chlorinated
PCDDs significantly higher than control subjects unexposed to phenoxy
herbicides. Interestingly, no differences in case or control TCDD levels were
seen. These findings are consistent with the observations from both Swedish
(2) and Danish (7) studies of increased cancer risks among persons exposed to
phenoxy herbicides and chlorophenols which do not contain detectable levels of
TCDD per se, but which are most likely contaminated with a variety of other
chlorinated dibenzodioxins and furans (43,44), some of which have been shown
to have carcinogenic potential (45,46). Moreover, the capacity of TCDD, and
presumably its approximate isostereoisomers, to act as a cocarcinogen (47) and
a tumor promoter (48,49) have been well characterized. These properties are
highly dose-dependent.

Thus, the exposure of Swedish workers to potentially

higher concentrations of biologically active substances associated with the
use or manufacture of phenoxy herbicides or chlorinated phenols is a
consideration possibly consistent with the higher cancer risks observed in
studies on such subjects. A recent study by Hoar et al (25) showing that the

Page 22

�relative risk of NHL dramatically increased with the number of days of phenoxy
herbicide use per year among agricultural workers in the U.S. supports this
view.
Differences in risk estimates observed between this and the Swedish
studies might also be accounted for on the basis of variation in the extent of
non-occupational exposure received by the general populations in areas where
the studies were conducted. Several investigators (50,51) have recently
reported widespread contamination of the general population in the United
States and Canada with PCDDs and PCDFs, based on analysis of human fat
samples.

The findings indicate that, while higher levels of total dioxins and

other contaminants may be seen in some exposed persons, there is considerable
overlap in actual tissue concentrations of such substances between some
persons with confirmed occupational exposures and others who are not
previously known to have been exposed through job-related activities. These
observations suggest that epidemiologic studies conducted in areas where the
extensive use of phenoxy herbicides and chlorophenols has occurred may have
inadvertently included subjects who have experienced significant exposure to
the chemicals of concern outside of the occupational setting.

Should this be

the case, it is possible that estimates of actual risk based on recall of
occupational exposures alone may be underestimated, owing to non-differential
misclassification of subjects according to exposure status (52).
To estimate the extent to which non-occupational exposure to phenoxy
herbicides may have occurred"in the present investigation, we have evaluated
data from several air monitoring studies (53,54) conducted during the spraying
season in the Pacific Northwest. These data indicate that phenoxy acetic
acids as well as PCDDs can be transported in the atmosphere, either as vapor
or adsorbed on particles, for distances ranging from several hundred feet up

Paae 23

�to a mile from the application area (54), depending on weather conditions and
mode of dispersion. The maximum concentration of 2,4,5-T, for example, found
in 24-hour collections from sampling stations in one study (55) was 3.4
o
3
ug/m . Concentrations of up to 10 ug/m of other phenoxy herbicides have
been detected at sampling sites in agricultural regions of Washington state
3
(57). If it is assumed that a 70 kg person inhales 30 m of air per day, a
person residing in the proximity of a sprayed area could conceivably receive a
dosage of 2,4,5-T equal to 1.5 ug/kg/day during the spraying operation solely
from atmospheric sources. These levels are on the order of 10 to 50 times
less than those received from occupational sources, as described above, and
moreover, are received via a different route of exposure (inhalation versus
dermal), which could alter absorption rates appreciably. However, it is
noteworthy that 24% of STS cases, 23% of NHL cases and 21% of control subjects
in the present study responded positively to the question "Have you ever lived
in an area where weed spraying was routinely done by truck or airplane?",
suggesting that considerable population exposure to phenoxy herbicides and
their contaminants from environmental sources could have occurred over the 40
year exposure assessment period. Eliminating subjects who reported
residential or home use exposures to phenoxy herbicides or chlorophenols in
the present study did not alter the estimated risks of developing STS or NHL.
Hence, it is unlikely that bias due to such exposures could account for the
large differences in risk estimates observed between these and the Swedish
studies. Nevertheless, should phenoxy herbicides and/or their contaminants
increase the risk of cancer at environmental exposure levels, or, as recently
suggested, produce subclinical immune system alterations which may predispose
to such risks (35), it is possible that risk estimates based solely on
assessment of occupational exposures could be attenuated as a result of

Pace 24

�exposure misclassification. Confirmation of this possibility awaits further
investigations based on direct analysis of tissue chemical content or the
development of a reliable surrogate measure of past chemical exposure.
A third possible reason for a lack of consistency between the results of
this and the Swedish studies may be differences between the study populations
with respect to the proportional distribution of factors or conditions other
than chemical exposure which contribute to the cancers under evaluation. If,
for example, a specific inherited, lifestyle or environmental condition which
independently predisposes to increased risks of the cancer(s) associated with
chemical exposure is more prevalent among Scandinavians than among other
populations, increased cancer risks could be observed in the former group,
even if the prevalence of phenoxy herbicide or chlorophenol exposure were the
same or even less than that occurring elsewhere. In this regard it is
interesting to note in the present study that exposure to the insecticides,
DDT and lead arsenate, as well as to agricultural and industrial chemicals
such as organic solvents and welding/metal fumes are associated with
significantly increased risks of developing NHL (Table 7). Compromise of the
immune system (31), exposure to zoonotic viruses (24,57) and chronic mitogenic
stimuli (24,31) have also been suggested as etiologic factors for NHL.
The extent to which differences in the proportional distribution of such
factors between Swedish and the local study population might account for the
inconsistencies observed between the results of this and the Swedish studies
cannot be currently estimated, since neither the specific conditions which
modify the effects of chemical exposure on cancer risks nor their prevalence
among the respective populations have as yet been identified.

However,

information based on interview responses from existing studies (4) indicates
that Swedish populations may have had as much as twice tne frequency of

Paoe 25

�exposure to DDT (5.8-7.8? versus 3.8°*. locally) as well as to total
insecticides (14.6% versus 7.9%), and this higher exposure may underlie some
increased risk of developing cancer, particularly NHL, independently of or in
combination with the chemicals currently under study.

On the other hand, the

frequency of exposure to organic solvents, for which a small but significant
interaction with phenoxy herbicides was observed in this study, was
approximately equal (28.2% versus 29.9%) between Swedish and local study
populations. Similarly, the frequency of cigarette smoking, now or ever,
among Swedish and local study populations was comparable (71* versus 73%).
Little or no data are available regarding population differences in
nutritional, medical or other lifestyle factors which might serve as component
causes of STS or NHL or which modify the effect of chemical exposures on
cancer risks.
The prospect that inherited factors or conditions among Scandinavians
might contribute to increased risks of developing cancer in that population
when exposed to the chemicals under investigation is another possibility that
might account for differences in risk estimates observed. Although specific
studies of this question have as yet to be accomplished, laboratory
investigations have shown that the binding affinity of the TCDD receptor, as
we'll as subsequent receptor-mediated events, are genetically determined and
may vary considerably even among different strains of the same animal soecies
(58).

That such variations are also a characteristic of human geneaology is

suggested by recent studies (59) which demonstrate both the presence of the Ah
(TCDD) receptor in human lung as well as considerable heterogenity in the
human population in regard to lung Ah receptor concentrations.

Moreover,

evidence of heritable differences in aryl hydrocarbon hydroxylase induction
among humans (60) has been presented.

Recently, a hereditary predisposition

Pace 26

�for the development of STS has been described in tne study of Danish phenoxy
herbicide manufacturers (7). However, no attempt has been made to determine
the frequency of this condition among Scandinavian or other populations, or to
investigate the extent to which the presence of such a condition could modify
the effect of chemical exposure on cancer risks.
In the present investigation we have taken advantage of the fact that
approximately 6% of the population of the study area is of Scandinavian
heritage (61) to make a crude evaluation as to the extent to which this factor
(Scandinavian heritage) might constitute an increased risk of STS or NHL in
association with phenoxy herbicide or chlorophenol exposure.

For this

assessment, the surnames of all study subjects were segregated into
Scandinavian or "other" categories by a member of the University of Washington
Department of Scandinavian Languages and Literature who had expertise in
Scandinavian genealogy. Through this effort 169 subjects with Scandinavian
surnames were identified including 15 STS cases, 66 NHL cases and 88
controls. No increased cancer risks were associated with having Scandinavian
as compared with non-Scandinavian names. However, when the analysis was
restricted to Scandinavians only, the risk estimates for STS in relation to
past occupational chemical exposures were substantially greater than those
observed among the study population as a whole both for high level phenoxy
herbicide (2.8[0.5-15.6]) and high level chlorophenol (7.2[2.1-24.7])
exposures. These estimates are comparable in magnitude to those reported
among subjects in Swedish (1-5) and Danish (7) studies. Moreover, the
distribution of predominant histologic types of STS was comparable to that
reported from the Swedish studies (2). No increased risks of NHL in relation
to chemical exposures were observed among persons with Scandinavian surnames.
While the assignment of Scandinavian ancestry in these studies remains

�unconfirmed, the results are interesting inasmuch as they suggest that factors
specific to Scandinavian descent, as opposed to residency or occupation in
Scandinavian countries, may contribute to increased risks of STS when exposed
to the chemicals under evaluation in this study.

Further investigation of

this issue may be warranted to help resolve the inconsistency between Swedish
studies and those conducted elsewhere.
In conclusion, the results of the present investigation demonstrate
increased risks of NHL in several specific occupations in which phenoxy acetic
acid herbicides are employed, as well as for prolonged occupational exposure
to these substances.

However, they are not consistent with results from

Swedish and other studies reporting substantially increased risks of either
STS or NHL associated with phenoxy herbicides or chlorophenols as sole or
major component causes of these diseases. Since methods of study design and
analysis in this and the Swedish studies were similar in most respects, it is
possible that factors specific to the populations under evaluation account for
the inconsistencies observed.

Concerns which bear further consideration in

this regard include possible differences in the intensity or distribution of
chemical exposures between the study populations, and variations in the
proportional distribution of specific inherited, lifestyle and/or
environmental factors which modify the effect of chemical exposure on the
risks of cancer development.

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exposure to 2,3,7,8-tetrachlorodibenzo-p-dioxin.

0 Amer Med Assoc 1986;

255:2031-2038.

(36) Holsapple MP, KcCay JA, Barnes DM. Immunosuppression without liver
induction by subchronic exposure to 2,7-dichlorodibenzo-p-dioxin in
adult female B5C3F1 mice. Toxicol Appl Pharmacol 1986; 83:445-455.

(37) Kolmodin-Hedman B, Erne K, Engqvist A. Testing of professional exposure
to phenoxy acids (2,4-D and 2,4,5-T). Arbete och Halsa, Vetenskaplig
1070; 17 ( i n Swedish).

�(38) Newton N, Norn's LA. Potential exposure of humans to 2,4,5-T and TCDD
in the Oregon coastal ranges.

Fund Appl Toxicol 1981; 1:339-346.

(39) Taskar PK, Das YT, Trout JR, Chattopadhyay SK, Brown HD. Measurement of
2,4-dichlorophenoxyacetic acid (2,4-D) after occupational exposure.
Bull Environ Contain Toxicol 1982; 29:586-591.

(40) Gehring PJ, Kramer CG, Schwetz BA, Rose JQ, Rowe, VK.

The fate of

2,4,5-trichlorophenoxyacetic acid (2,4,5-T) f o l l o w i n g oral
administration to man. Toxicol Appl Pharmacol 1973; 26:352-361.

(41) Leng ML, Ramsey JC, Braun WH.

Review of studies with

2,4,5-trichlorophenoxyacetic acid in humans including applicators under
field conditions.

ACS Symposium Series 182. 1982; pp 135-156.

(42) Hardell L, Axel son 0.
etiology of cancer.
Prevention.

Phenoxy herbicides and other pesticides in the
Some comments on the Swedish experiences in Cancer

Strategies in the Workplace.

University of California, San

Francisco, December 1984.

(43) Norstrom A, Rappe C, Lindall R, Baser HR. Analysis of some older
Scandinavian formulations of 2,^-dichlorophenoxy acetic arid and
2,4,5-trichlorophenoxy acetic acid for contents of chlorinated
dibenzo-p-dioxins and dibenzofurans.

Scand J Work Environ Health 1579;

5:375-378.

Page 34

�(44) Dickson, D. PCP dioxins found to pose health risks.

Nature 1980; 282:416.

(45) NIH Bioassay of 2,7-dichlorodibenzo-p-dioxin for possible
carcinogenicity.

Nat! Tox Pgm, Technical Report Series No. 123, 1979.

(46) NIH Bioassay of a mixture of 1,2,3,6,7,8 and
1,2,3,7,8,9-hexachlorodibenzo-p-dioxins for possible carcinogenicity
(gavage study).

Nat! Tox Pgm, Technical Report Series No. 198, 1980.

(47) Kouri RE, Rude TH, Joglekar R, Dansette PM, Jerina DM, Atlas SA,
Owens IS, Nebert DW.

2,3,7,8-Tetrachlorodibenzo-p-dioxin as carcinogen

causing 3-methylcholanthrene-initiated subcutaneous tumors in mice
genetically "nonresponsive" at Ah locus.

Cancer Res 1978; 38:2777-2783.

(48) Pi tot HC, Goldsworthy T, Campbell HA, Poland A.

Quantitative evaluation

of the promotion by 2,3,7,8-tetrachlorodibenzo-p-dioxin of
hepatocarcinogenesis from diethylnitrosamine.

Cancer Res 1980;

40:3616-3620.

(49) Abernathy DJ, Green!ee WF, Huband JC, Boreiko CJ.
2,3,7,S-Tetrachlprodibenzo-p-dioxin (TCDD) promotes the transformation
of C3K/1071/2 cells.

Carcinogenesis 1985; 6: 651-553.

(50) Ryan JJ, Williams DT, Lau BP-Y, Sakuma T.
Dibenzofurans in the Total Environment II,
C. eds, Butterworth, MA 1984; pp 205-214.

In Chiorinoted Dioxins and
Keith LH, Choudhary G, Rappe

�(58) Gasiewicz TA. Evidence for a homologous nature of Ah receptors among
various mammalian species in Biological Mechanisms of Dioxin Action.
Banbury Report 18. Poland A, Kimbrough RD, eds., Cold Spring Harbor
Laboratory 1984; pp 161-175.

(59) Roberts EA, Golas CL, Okey AB. Ah receptor mediating induction of aryl
hydrocarbon hydroxylase: detection in human lung by binding of
2
2,3,7,8,-[H ] tetrachlorodibenzo-p-dioxin. Cancer Res. 1986;
46:3739-3743

(60) Nebert DW, Jensen NM. The Ah locus: genetic regulation of the metabo
of carcinogens, drugs and other environmental chemicals by cytochrome
P-450-mediated monooxygenases. CRC Crit. Rev. Biochem. 1979;
pp.401-437.

(61) 1980 Census of Population, Vol 1, Characteristics of the Population,
Chapter C, General Social and Economics Characteristics, Part 49
Washington, US Department of Commerce, August, 1983.

�Table 1.

A case-control study of soft tissue sarcoma (STS) and non-Hodgkins
lymphoma (NHL) in relation to phenoxy herbicide and chlorophenol
exposure in Western Washington: Subject disposition.

STS

Subject

NHL

Living

Disoosition

Dead

Controls

Living

N

%

N

%

150

-

56

-

U

%

Dead
K

Living
%

N

%

Dead
N

:

Total identified

as eligible
Physician refusal

20 13

Respondent refusal

43

527 - 219

-

7 13

80 15

23 11

24

1 5 3

84

622 - 288 -

9 5 15

2 9 10

51

4 0 14

Other reasons for
non-interview
Total Interviewed

6

4

120 80

4

7

43 77

24

5

10

5

408 77 178 81

8

476 77 219 76
I

Excluded by pathologic
review

'

21 18* 12 28*

Excluded as non-eligible
post-interview**

2 - 0 -

6 - 4 -

1

- 0

Total Subjects
for analysis

97 -

31

-

402 - 174

* Percent of Total interviewed
**Based on diagnosis, age, "residence or date of diagnosis.

-

475 - 219

-

�Table 2.

Selected characteristics of 128 STS case men, 576 NHL case men
(diagnosed 1981-1984) and 694 interviewed population control men
(1983-1985).

STS (?)

NHL (?)

Controls (?)

Age

20-29

28.1

10.9

10.2

40-59

29.7

34.4

34.0

60-79

42.2

54.7

55.8

Less than High. School

21.1

26.3

26.4

High School graduate

76.6

72.0

70.6

2.3

1.7

3.0

White

89.8

94.4

95.1

Black

2.3

2.1

2.3

Other

7.0

3.4

2.6

Unknown

0.8

0.0 .

0.0

Education

Unknown

Race

Annual Income Level
Less than 515,000/year

25.8

28.0

24.1

$15, 000-530, OOD/year

32.8

37.3

35.2

30,000+/year

33.6

*»«••• 0

34.3

Refused

3.9

0.5

0.7

Unknown

3.9

0.7

1.7

�Table 3.

Risk (pooled odds ratio) of developing STS or NHL in men aged
20-79 by estimated intensity of past occupational exposure to
phenoxy herbicides or chlorophenols:

128 STS cases and 576 NHL

cases (diagnosed 1981-1984) and 694 population control men
(interviewed 1983-1985)in Western Washington.

The percentage of

the total study population in each exposure category is also
presented.

PHENOXY HERBICIDES
EXPOSURE

STS

NHL

CATEGORY

OR (95? CI)

OR ( 5 CI)
9?

PERCENT
STUDY
POPULATION

None

1.0

1.0

63.3

Low

0.56 (0.3-1.1)

0.90 (0.6-1.3)

12.0

Medium

0.99 (0.6-1.7)

0.95 (0.7-1.3)

16.5

High

0.89 (0.4-1.9)

1.24 (0.6-1.9)

8.2

CHLOROPHENOLS
EXPOSURE

STS

NHL

CATEGORY

OR ( 5 CI)
9?

OR ( 5 CI)
9?

Pr.Rwr.KT
STUDY
POPULATION

None

1.0

1.0

41.5

Low

0.90 (0.5-1.6)

0.97 (0.7-1.3)

16.5

Medium

0.93 (0.6-1.5)

0.92 (C.7-1.2)

31.8

High

0.93 (0.5-1.8)

0.92 (0.9-1.4)

10.2

�Table 4.

Risk (pooled odds ratio) of developing STS or NHL in men aged 20-79 for
specific occupations and activities involving potential phenoxy
herbicide exposure:

128 men with STS and 576 men with NHL in Western

Washington (diagnosed 1981-1984) and 694 population control men
(interviewed 1983-1985).

The precentage of the total study population

in each occupation or activity is also presented.

PHENOXY HERBICIDES
OCCUPATION
OR
ACTIVITY

STS

NHL

OR (95£ CD

OR (9Si CD

PERCENT
STUDY
POPULATION

Low Exposure:
landscaper

0.92 (0.3-2.8)

1.70

(0.9-3.1)

3.6

railway worker

1.14 (0.6-2.2)

1.06 (0.7-1.5)

10.7

telephone lineman

0.73

1.28 (0.6-2.6)

2.4

0.83

6.1

(0.1-3.6)

Medium Exposure:

gardner/grou ndskeeper

1.07 (0.5-2.2)

fanner

1.25 (0.8-1.9)

working in sprayed area

1.34 (0.7-2.6)

1.33

herbicide forma lator/mixer

1.24 (0.3-5.3)

1.53 (0.7-313)

2.1

herbicide applicator

1.77 (0.5-5.6)

1.33 (0.8-3.9)

2.2

spraying herbicides from backpack

0.80 (0.3-2.4)

0.82

(0.4-1.5)

2.3

spraying herbicides from tractor
or aircraft

1.27 (C. 5-3.1)

1.51 (0.9-2.5)

4.9

spraying farmlands with herbicides

1.35 (0.5-2.3)

1.35 (C.8-2.4)

4.3

spraying forests with herbicides

- - --

*4.80 (1.2-19.4)

1.0

spraying near utility lines or
railroad tracks

_ _ _ _

(0.5-1.4)

*1.33 (1.03-1.7)
(0.9-2.0)

30.0
8.4 -

High Exposure:

* D

n nc

1.03

(0.3-3.1)

0.9

�CHLOROPHENOL

OCCUPATION
OR
ACTIVITY

STS

NHL

OR (95% CD

OR (95? CD

PERCENT
STUDY
POPULATION'

Low Exposure:

planer mill worker

1.55 (0.5-4.7)

1.39 (0.7-2.7)

3.1

feeder man

1.31 (0.4-4.7)

1.44 (0.7-2.81)

2.9

bander man

0.90 (0.2-4.4)

1.45 (0.6-3.4)

1.8

log/lumber inspector

4. 83 (0.6-38.2)

0.40

(0.0-3.6)

"0.4

sawmill worker

0.97 (0.5-1.8)

1.03 (0.7-1.4)

15.0

wood products worker

1.27 (0.7-2.3)

0.88 (0.6-1.3)

12.0

fork lift driver in mill

1.52 (0.6-3.6)

1.44 (0.8-2.6)

4.2

lumber grader

*2.66 (1.1-5.4)

0.94 (0.5-1.9)

3.1

wood preserver

0.79 (0.1-5.9)

1.64 (0.6-4.2)

1.4

manufacturer of chlorophenols

1.37 (0.4-4.3)

1.72 (0.9-3.4)

3.0

Medium Exposure:

High Exposure:

* P •* 0.05

Paoe 42

�Table 6.

Risks (pooled odds ratio) of developing STS and NHL among men aged 20-79
with factors or conditions associated with compromise of immune
competence:

128 men with STS and 576 men with NHL (diagnosed 1981-1984)

and 694 population controls (interviewed 1983-1985) in Western
Washington.

The precentage of the total study population with each risk

factor is also presented.

STS
RISK
FACTOR

Malaria

NHL

OR (95% CI

OR (95% CI)

PERCENT
STUDY
POPULATION

1.14 (0.4-3.1)

1.47 (0.9-2.5)

4.7

non-skin

0.88 (0.3-2.5)

1.24 (0.7-2.1)

4.8

skin

1.47 (0.7-3.1)

*1.57 (1.03-2.4)

7.5

0.70 (0.4-1.1)

0.91 (0.7-1.2)

27.5

Rheumatoid arthritis

1.38 (0.9-2.2)

5.9

Low gamma or immunoglobulin

1.59 (0.5-4.6)

1.0

*10.97 (2.1-57.3)

0.7

1.51 (0.4-5.6)

0.6

Preexisting Cancer:

Corticosteroids

Imnunosuppressant drug therapy**
Immune deficiency in a
blood relative

* P &lt;0.05
** Azathioprine, Cyclophosphamide, Chlorambucil and/or Mercaptopurine.

�Table 7.

Risks (pooled odds ratio) of developing STS and NHL among men aged 20-79
associated with nicellaneous occupational factors or conditions among
128 men with STS and 576 men with NHL (diagnosed 1981-1984} and 694
population controls (interviewed 1983-1985) in Western Washington. The
precentage of the total study population with each condition or factor
is also presented.

STS
CONDITION

NHL

OR (95* CI)

OR (95% Ci:

PERCENT
STUDY
POPULATION

Insecticides:
Chlordane

0.96 (0.2-4.8)

DDT

1.10 (0.4-3.2) *1.82 (1.04-3.2)

1.61 (0.7-3.8)

1.6
4.0

Industrial Chemicals:
Organic solvents

1.10 (0.7-1.7)

*1.35 (1.06-1.7)

29.8

lead/lead arsenate

1.51 (0.9-2.6)

*1.60 (1.1-2.3)

12.0 •

welding/metal fumes

1.30 (0.9-2.0)

*1.31 (1.03-1.7)

31.1

Chloracne

3.32 (0.8-14.0)

2.12 (0.6-7.0)

1.0

Skin blisters from chemicals

1.72 (0..9-3.2)

1.06 (0.7-1.6)

7.8

Cigarette smoking

0.93 (0.6-1.4)

0.85 (0.7-1.1)

73.5

Coffee drinking

0.49 (0.4-1.2)

1.28 (0.9-1.9)

8°.8

* P &lt; 0.05

�Table 7.

Risks (pooled odds ratio) of developing STS and NHL. among men aged 20-79
associated with micellaneous occupational factors or conditions among
128 men with STS and 576 men with NHL (diagnosed 1981-1984) and 694
population controls (interviewed 1983-1985) in Western Washington. The
precentage of the total study population with each condition or factor
is also presented.

STS

CONDITION

NHL

OR (95* CD

OR (95£ CD

PERCENT
STUDY
POPULATION

Insecticides:
Chlordane

0.96 (0.2-4.8)

1.61 (0.7-3.8)

1.6

DDT

1.10 (0.4-3.2)

*1.82 (1.04-3.2)

4.0

Organic solvents

1.10 (0.7-1.7)

*1.35 (1.06-1.7)

29.8

lead/lead arsenate

1.51 (0.9-2.6)

*1.60 (1.1-2.3)

12.0

welding/metal fumes

1.30 (0.9-2.0)

*1.31 (1.03-1.7)

31.1

Chloracne

3.32 (0.8-14.0)

2.12 (0.6-7.0)

1.0

Skin blisters from chemicals

1.72 (0..9-3.2)

1.06 (0.7-1.6)

7.8

Cigarette smoking

0.93 (0.6-1.4)

0.85 (0.7-1.1)

73.5

Coffee drinking

0.49 (0.4-1.2)

1.28 (0.9-1.9)

89.8

Industrial Chemicals:

* P &lt; 0.05

�FOOTNOTES

1.

Supported by U.S. Public Health Service Grant CA-29900.

2.

We are indebted to the staff of the Epidemiologic Research Unit of the
Fred Hutchinson Cancer Research Center for their assistance in the
conduct of this study.

3.

We gratefully thank Frans M. Enzinger, M.D., Chairman, Department of
Soft Tissue Pathology, Armed Forces Institute of Pathology, Washington,
DC, for assisting in the confirmation and histological classification of
soft tissue sarcoma case materials in this study.

i

/! r

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&lt;p&gt;For more about this collection, &lt;a href="/exhibits/speccoll/exhibits/show/alvin-l--young-collection-on-a"&gt;view the Agent Orange Exhibit.&lt;/a&gt;&lt;/p&gt;</text>
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&lt;p&gt;For more about this collection, &lt;a href="/exhibits/speccoll/exhibits/show/alvin-l--young-collection-on-a"&gt;view the Agent Orange Exhibit.&lt;/a&gt;&lt;/p&gt;</text>
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&lt;p&gt;For more about this collection, &lt;a href="/exhibits/speccoll/exhibits/show/alvin-l--young-collection-on-a"&gt;view the Agent Orange Exhibit.&lt;/a&gt;&lt;/p&gt;</text>
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&lt;p&gt;For more about this collection, &lt;a href="/exhibits/speccoll/exhibits/show/alvin-l--young-collection-on-a"&gt;view the Agent Orange Exhibit.&lt;/a&gt;&lt;/p&gt;</text>
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                  <text>&lt;p style="margin-top: -1em; line-height: 1.2em;"&gt;The Alvin L. Young Collection on Agent Orange comprises 120 linear feet and spans the late 1800s to 2005; however, the bulk of the coverage is from the 1960s to the 1980s and there are many undated items. The collection was donated to Special Collections of the National Agricultural Library in 1985 by Dr. Alvin L. Young (1942- ). Dr. Young developed the collection as he conducted extensive research on the military defoliant Agent Orange. The collection is in good condition and includes letters, memoranda, books, reports, press releases, journal and newspaper clippings, field logs and notebooks, newsletters, maps, booklets and pamphlets, photographs, memorabilia, and audiotapes of an interview with Dr. Young.&lt;/p&gt;&#13;
&lt;p&gt;For more about this collection, &lt;a href="/exhibits/speccoll/exhibits/show/alvin-l--young-collection-on-a"&gt;view the Agent Orange Exhibit.&lt;/a&gt;&lt;/p&gt;</text>
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&lt;p&gt;For more about this collection, &lt;a href="/exhibits/speccoll/exhibits/show/alvin-l--young-collection-on-a"&gt;view the Agent Orange Exhibit.&lt;/a&gt;&lt;/p&gt;</text>
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&lt;p&gt;For more about this collection, &lt;a href="/exhibits/speccoll/exhibits/show/alvin-l--young-collection-on-a"&gt;view the Agent Orange Exhibit.&lt;/a&gt;&lt;/p&gt;</text>
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