United States Environmental Protection Agency Health Effects Research Laboratory Research Triangle Park NC 27711 EPA-600/1-80-009 January 1980 Research and Development Pilot Study Ambient Air Pollution and Survival from Cancer ------- RESEARCH REPORTING SERIES Research reports of the Office of Research and Development, U.S. Environmental Protection Agency, have been grouped into nine series. These nine broad cate- gories were established to facilitate further development and application of en- vironmental technology. Elimination of traditional grouping was consciously planned to foster technology transfer and a maximum interface in related fields. The nine series are: 1. Environmental Health Effects Research 2. Environmental Protection Technology 3. Ecological Research 4. Environmental Monitoring 5. Socioeconomic Environmental Studies 6. Scientific and Technical Assessment Reports (STAR) 7. Interagency Energy-Environment Research and Development 8. "Special" Reports 9. Miscellaneous Reports This report has been assigned to the ENVIRONMENTAL HEALTH EFFECTS RE- SEARCH series. This series describes projects and studies relating to the toler- ances of man for unhealthful substances or conditions. This work is generally assessed from a medical viewpoint, including physiological or psychological studies. In addition to toxicology and other medical specialities, study areas in- clude biomedical instrumentation and health research techniques utilizing ani- mals — but always with intended application to human health measures. This document is available to the public through the National Technical Informa- tion Service, Springfield, Virginia 22161. ------- EPA-600/1-80-009 January 1980 PILOT STUDY OF AMBIENT AIR POLLUTION AND SURVIVAL FROM CANCER Gregg S. Wilkinson Population Studies Division Health Effects Research Laboratory U.S. Environmental Protection Agency Research Triangle Park, North Carolina 27711 and Peter A. Reese Roger L. Priore Computer Center Roswell Park Memorial Institute New York State Department of Health 666 Elm Street Buffalo, New York 14263 Health Effects Research Laboratory Office of Research and Development U.S. Environmental Protection Agency Research Triangle Park, North Carolina 27711 ------- DISCLAIMER This report has been reviewed by the Health Effects Research Labora- tory, U.S. Environmental Protection Agency, and approved for publication. Mention of trade names or commercial products does not constitute endorse- ment or recommendation for use. 11 ------- FOREWORD The many benefits of our modern, developing, industrial society are accompanied by certain hazards. Careful assessment of the relative risk of existing and new man-made environmental hazards is necessary for the estab- lishment of sound regulatory policy. These regulations serve to enhance the quality of our environment in order to promote the public health and welfare and the productive capacity of our Nation's population. The Health Effects Research Laboratory, Research Triangle Park, conducts a coordinated environmental health research program in toxicology, epidemio- logy, and clinical studies using human volunteer subjects. These studies address problems in air pollution, non-ionizing radiation, environmental carcinogenesis and the toxicology of pesticides as well as other chemical pollutants. The Laboratory participates in the development and revision of air quality criteria documents on pollutants for which national ambient air quality standards exist or are proposed, provides the data for registra- tion of new pesticides or proposed suspension of those already in use, conducts research on hazardous and toxic materials, and is primarily respon- sible for providing the health basis for non-ionizing radiation standards. Direct support to the regulatory function of the Agency is provided in the form of expert testimony and preparation of affidavits as well as expert advice to the Administrator to assure the adequacy of health care and surveillance of persons having suffered imminent and substantial endanger- ment of their health. This report presents the results of a pilot study concerned with investigating the possible association between the length of survival of diagnosed cancer patients and ambient levels of particulates and sulfur dioxide characterizing their area of residence. Previous studies have shown increased mortality among elderly and chronically ill populations during air pollution disasters. There has also been increasing evidence of a possible influence exerted by air pollution upon cancer incidence and mortality. However, the influence that exposure to air pollutants may have upon the survival time of a severely stressed and especially suscep- tible population, such as diagnosed cancer patients, has yet to be evaluated. The results of this preliminary study suggest that high levels of ambient air pollution may adversely affect the health of certain types of cancer patients. Additional research of this nature is clearly warranted. F. G. Hueter, Ph.D. Di rector Health Effects Research Laboratory iii ------- ABSTRACT This study was concerned with investigating the potential influence exerted by ambient concentrations of particulate and sulfur dioxide air pollutants upon the length of survival for diagnosed cancer patients. Monitoring data from the National Aerometric Data Bank for particulates and sulfur dioxide were examined in conjunction with survival data from the Lakes Area Regional Tumor Service Registry. Length of survival for respiratory cancer patients was found to be inversely related to maximum particulate levels. Survival times for patients who resided in areas 3 where maximum particulate levels exceeded 240 |jg/m were significantly shorter than for similar patients who resided in areas with lower particu- late levels. Colorectal cancer patients demonstrated a similar trend that was not statistically significant. No association was found between survival of leukemia patients and particulate or SOp levels, nor was S02 related to survival of respiratory tract or colorectal cancer patients. These findings suggest that highly polluted air in residential areas may have a deleterious effect on the survival time of patients with certain types of neoplastic disease. Additional research is called for of the relationship between cancer survival and exposure to ambient air pollution, especially particulates. ------- TABLE OF CONTENTS Page Disclaimer ii Foreword iii Abstract v List of Tables and Figures vii Acknowledgment viii Section 1. Introduction 1 Section 2. Conclusions 4 Section 3. Recommendations 5 Section 4. Materials and Methods 7 Section 5. Results and Discussion 10 Section 6. References 22 VI ------- TABLES AND FIGURES Page Table 1: Cases Available for Analysis ........... 9 Table 2: Annual Averages of Mean and Maximum Particulates by Zip Code .................... ]1 Table 3: Annual Averages of Mean and Maximum Sulfur Dioxide Levels by Zip Code ................ 12 Table 4: Regression Model for Survival by Cancer Site, Mean and Maximum Levels of Particulates and Sulfur Dioxide ...................... 13 Table 5: Differences in Median Survival by Cancer Site, Mean and Maximum Particulate Levels ........ 15 Figure 1: Survival from Respiratory Cancer by Maximum Particulate Levels ................ 14 Figure 2: Survival from Respiratory Cancer by Mean Particulate Levels ................ 17 Figure 3: Survival from Leukemia by Mean Particulate Levels ...................... 18 Figure 4: Survival from Leukemia by Maximum Particulate Levels ...................... 19 Figure 5: Survival from Colorectal Cancer by Mean Particulate Levels ................ 20 Figure 6: Survival from Colorectal Cancer by Maximum Particulate Levels ................ 21 vn ------- ACKNOWLEDGMENT This investigation was a cooperative effort jointly conducted by the Epidemiology Branch, Health Effects Research Laboratory, U.S. Environ- mental Protection Agency, and the Computer Center, Roswell Park Memorial Institute, New York State Department of Health. The computer analyses were funded by USEPA Purchase Contract No. DA-8-6122J, Gregg S. Wilkinson, Project Officer. Gerald Nehls, Statistics and Data Management Office, Health Effects Research Laboratory, U.S. Environmental Protection Agency, contributed greatly to the study effort by obtaining and providing air quality data from the SAROAD system. Deborah Lorshbough aided in data entry activities involving both the Lakes Area Regional Tumor Service Registry and the SAROAD information. vi ii ------- SECTION 1. INTRODUCTION It has been recognized for many years that air pollution may have untoward consequences for human health. This concern has been reinforced by the health effects that have been observed pursuant to the occurrences of several major air pollution disasters. For instance, in 1930, a large number of residents in the Meuse Valley, Belgium, became severly ill after the Valley was blanketed for three days by a combination of industrial smoke and fog. Approximately sixty deaths from heart failure, mostly among the elderly and chronically ill, were attributed to this episode. Sulfur oxides and fluorine may have been the major culprits (1). More recent episodes that are thought to have had serious health consequences have occurred in Donora, Pennsylvania (2), London (3), Los Angeles and Piscataway, New Jersey (4). During the past decade, considerable attention has been directed toward potential environmental precursors of malignant neoplasms. Evidence of an environmental effect has come from several sources. Studies of migrants have shown their rates for several types of cancer to vary from those of their former homeland to those of their adopted country, and among succeeding generations (5,6,7). Several reports have demonstrated considerable variation in cancer incidence or mortality rates between industrialized and less developed countries (8,9). Within the United States, differences in county cancer mortality rates have also been shown (10). In addition, several studies have shown a tendency of rates for many types of cancers in urban areas to exceed rates in rural areas (11). ------- The contribution of exposure to air pollutants in the ambient air to the etiology of most cancers has yet to be demonstrated for most cancer sites. The effects of occupational exposures to such substances as asbestos, dust in uranium mines, vinyl chloride, and beta naphthylmine are well known. The urban excess for lung cancers as well as the results of several studies showing excess rates among residents of heavily polluted urban neighborhoods suggests that air pollution may exert a significant etiologic effect (12). Most considerations of a potential air pollution effect for neoplasms are concerned with an etiological influence. However, if we review the findings of studies concerned with the health consequences of air pollution disasters, we find that major effects occur mainly among the elderly and those suffering from a chronic illness. This suggests that rather than concentrating only upon the etiologic significance of air pollutants, it may be worthwhile to investigate health effects among those individuals who are already severely stressed (13). No investigations have yet been conducted of the possible influence of ambient air pollution levels upon the survival time of individuals who have been diagnosed and undergone treatment for cancer. Based upon the previously mentioned findings, it would appear that such individuals would comprise a population highly susceptible to contaminants in the ambient air. Approximately one-third of those who contract cancer survive for five years or more after being diagnosed. Furthermore, the treatments employed often carry such side effects as depressed immunity and decreased resistance to infection. These factors suggest that many ------- cancer patients residing in heavily polluted areas may be more highly susceptible to systemic infections, respiratory problems and other complications than are similar patients who reside in less polluted regions. If true, this would result in decreased survival times for patients from highly polluted areas, especially those with respiratory involvement such as lung cancer patients, or those with depressed immunity as a result of treatment such as leukemia patients. ------- SECTION 2. CONCLUSION The analyses performed in this pilot study revealed a significant association between length of survival from diagnosis for respiratory cancer patients and high maximum particulate levels characterizing area of residence. No significant effects for levels of particulates or sulfur dioxide upon survival were found for leukemia or colorectal cancer patients. However, the relationship of maximum particulate levels to the survival of these patients, although not statistically significant, was in the same direction as that of survival among respira- tory cancer patients. Since the methods employed in this pilot study to measure exposure to air pollution were crude, it is not surprising that more significant results were not found. Many assumptions were required and knowledge of the ambient pollutant levels under which cancer patients live is, at best, approximate. The results that were obtained indicate that more precise measurements may yield clear-cut detrimental influences of air pollution upon cancer survival after diagnosis and treatment. These findings imply that exposure to very high levels of particu- lates may prove harmful to patients with respiratory cancer as indicated by decreased survival times. The same may hold true for similar patients who are exposed to very high levels of sulfur dioxide and for colorectal patients exposed to high levels of these same pollutants. However, because of the crude manner in which exposure was measured in this pilot study, we may only conclude that such a possibility may exist and that additional research is clearly warranted. ------- SECTION 3. RECOMMENDATIONS Since this pilot study was a limited effort and primarily an assess- ment of feasibility, recommendations will be constrained to suggestions for future research. A large number of assumptions were necessary in order to obtain estimates of effluent levels representative of the environment in which a cancer patient resided. For example, it must be assumed that mean values of ambient pollution levels in the zip code area that included both the monitoring station and the patient's residence were representative of the exposures experienced by the patient after diagnosis and treatment of his condition. Fortunately, the precision of these estimates can be improved in several ways. First, annual isopleth maps for particulates and sulfur dioxide, as well as other pollutants, should be used to provide a more precise measure of mean and maximum levels in the immediate area of a given residence. Second, the residence of each cancer patient needs to be more accurately located than is possible by zip code alone. Paper records of patient residence addresses are available from the Lakes Area Regional Tumor Service Registry and will be used in conjunction with a follow-up effort. Third, variables that may affect survival such as stage of disease, tumor grade, type of treatment as well as socioeco- nomic status should be included in future analyses. In the present study, a lack of reliable information on some of these factors as well as further erosion of the amount of cases available for analysis precluded their inclusion. ------- Improved accuracy in evaluating the correlation of pollution to survival can be obtained by plotting patient residences on an accurate contaminant isopleth map. In addition, since no cases would be eliminated for lack of a pollutant reading in the zip code area where the patient resided on the year of diagnosis, more Registry cases would be available for analysis. If the above recommendations were adopted, the patient sample sizes would double. Although the findings of this pilot study do not allow definitive conclusions or recommendations regarding the association between pollutant levels and survival to be made, they do suggest that further examination of this problem is desirable. The additional expense and effort that is necessary to achieve an acceptable degree of accuracy does seem warranted on the basis of these preliminary findings. Thus, the primary recommenda- tion is to conduct additional investigations of this potential problem. ------- SECTION 4. MATERIALS AND METHODS The purpose of this pilot study was to assess the influence that air pollution may exert upon the survival of diagnosed cancer patients. It was hypothesized that length of survival would be inversely associated with levels of air .pollutants. Survival among respiratory cancer patients would be affected because of involvement of the respiratory system. Leukemia patients were selected because of the depressed immunity they experience as a result of treatment. Colorectal patients were chosen as a comparison group. Such patients do not have the direct involvement of the respiratory tract as do lung cancer patients, and they do not experience depressed immunity from therapeutic procedures to the same extent as do leukemia patients. Data Preparation Data from the Lakes Area Regional Tumor Service Registry were combined with pollution levels from the National Aerometric Data Bank to produce information sets for various cancer sites. Site by site analyses were then performed to determine the relationship between ambient pollutant levels and survival from date of diagnosis. The Lakes Area Regional Tumor Service Registry contains data on approximately 26,000 cancer patients who were treated at hospitals located in western New York and northern Pennsylvania. The Registry master file contains various elements of demographic data as well as treatment summary and follow-up information. For this study, residence zip code, diagnosis date, site of histology (ACS Red Book codes), date of last follow-up and patient status were the main parameters extracted from the master file. ------- The National Aerometric Data Bank contains mean and maximum readings for various sampler sites scattered about the catchment area of the Lakes Area Registry. The pollutants sampled and the years in which sampling was conducted varies widely between sampler locations. While particulates were generally sampled, the years in which sampling actually took place were somewhat variable. A visual inspection indicates that sulfur dioxide was the only other pollutant recorded consistently enough to allow meaningful determination of its affect on survival. The first step of the analysis was to determine the zip code zone in which the various samplers are located. It was then possible to construct data files containing records of sampler site, zip code, and mean and maximum pollutant levels for the years 1970 through 1976. The files were then sorted by zip code, and average values for maximum and mean ambient concentrations were computed by year within each zip code. This process was repeated for particulates and sulfur dioxide. Next a computer program was written to collate the pertinent informa- tion on each patient in the Lakes Area Registry with the average pollutant level in the residence zip area during the year of diagnosis. Cases were eliminated who were diagnosed before 1970, had a residence zip code outside of western New York, had no pollutant sample values in their zip code area for the year of diagnosis, or contained an obvious data error. The total number of cases and the number available for analysis by pollutant are given for the initial sites of interest in Table 1. 8 ------- TABLE 1. CASES AVAILABLE FOR ANALYSIS BY TYPE OF POLLUTANT Cases Available for Analysis Particulate Site Total Cases Matter Sp_2 Leukemia (ACS Red Book Histology) 577 315 154 Code 9800-9949 Respiratory (ACS Red Book Site) 2622 1463 774 Code 1600-1639 Colorectal (ACS Red Book Site) 3163 1687 865 Code 1530-1539 The reduced number of evaluable cases under sulfur dioxide is due to the smaller number of sampler recordings for that pollutant. Cox Modeling A series of Cox Modeling analyses were then performed on the various data sets. Cox Modeling is a multivariate nonlinear regression technique designed to accommodate censored data in the analysis of survival. The technique allows the assessment of the effect of multiple covariates on hazard function and, thus, survival under the assumption of exponential failures (14). Life Tables Life table analyses were conducted using mean and maximum particulate levels to form exposure groups. Breslow tests were completed in order to determine the significance of the difference in survival distributions between the two groups (15). ------- SECTION 5. RESULTS AND DISCUSSION Average mean and maximum levels of particulate matter for the years 1970 thru 1976 were categorized for the zip codes corresponding to the sampler locations. Tables 2 and 3 present these data. Several observations are worth discussion. First, it is obvious that considerably more data regarding particulates are available than for sulfur dioxide. This has a direct bearing on the types of analyses that may be conducted. Also, the range of variation tends to be much greater for maximum particulate levels than for mean levels by both sampler location and year of measurement. A problem that immediately surfaces concerns depletion of the number of patients available for analysis due to a lack of or inconsist- ency of monitoring data. Regarding particulate matter, this problem is especially observable for data collected during the early seventies. On the other hand, the number of stations measuring sulfur dioxide levels was much less than the number measuring particulate matter. Initially, a series of univariate regression analyses were conducted to determine the relationship between pollutant level and risk of death. As demonstrated by Table 4, the risk of death among leukemia and colorectal patients is not significantly associated with either mean or maximum particulate levels, nor mean or maximum levels of sulfur dioxide. However, for respiratory cancer patients, the risk is significantly associated with maximum particulate levels. 10 ------- TABLE 2. AVERAGES* OF MEAN AND MAXIMUM 'ARTICULATE COUNTS Bv HP CODE Zip Code 14006 14011 14020 14031 14043 14048 14063 14070 14072 14080 14086 14092 14094 14101 14105 14120 14131 14132 14136 1*150 1*174 14203 14206 14207 14210 14211 1*212 14213 14214 14215 14216 14217 14213 14219 14220 14221 14224 14225 14225 H301 14302 14303 14304 14305 14482 14569 14701 14706 14719 14733 14760 14772 14802 14895 1970 Mean 58 42 74 59 45 53 117 59 95 134 181 32 97 76 162 ICC 118 215 111 41 75 42 63 40 Max 131 91 188 141 94 140 263 117 199 162 592 156 250 144 425 210 259 512 276 53 195 120 393 89 1971 Mean 67 63 53 50 84 70 48 57 121 57 105 103 134 152 79 93 87 94 92 126 75 86 67 58 72 111 110 107 128 ;o7 62 81 50 52 64 45 Max 136 134 386 95 222 197 106 144 254 135 296 222 333 335 137 211 357 323 202 321 150 177 146 304 1*0 213 249 215 307 227 346 201 114 121 117 106 1972 Mean 38 26 58 64 38 51 85 64 45 51 82 53 42 82 95 117 70 137 76 78 72 81 37 117 78 102 76 92 74 108 104 103 109 98 53 78 25 44 42 56 41 27 Max 106 31 122 128 94 117 192 137 131 111 152 109 65 159 237 292 128 363 135 146 139 182 155 275 282 279 254 214 133 226 174 222 230 219 166 197 46 126 88 164 95 66 1973 Mean 39 46 53 57 41 53 31 59 45 56 74 50 57 72 37 112 74 136 79 75 65 73 125 68 104 65 72 70 101 101 71 96 93 48 75 54 30 44 54 29 49 Max 114 114 138 177 124 179 209 235 128 168 159 122 139 142 236 279 120 309 204 145 1*1 134 371 151 351 139 163 160 251 241 95 272 193 113 225 342 70 129 139 63 1J3 1974 Mean 44 31 45 17 58 58 46 34 48 68 57 38 47 54 47 76 81 34 99 72 136 61 70 62 74 69 13* 64 34 70 73 75 69 96 33 35 95 42 66 39 25 35 62 2* 23 34 Max 180 72 110 122 155 134 35 72 ill 167 126 115 96 124 119 718 151 266 259 136 312 108 128 108 157 123 385 174 236 145 201 212 148 224 153 195 293 119 172 121 58 31 164 57 14 'I 1975 Mean 47 40 47 48 58 60 49 45 49 68 59 45 57 63 54 55 113 56 82 74 74 103 60 63 55 79 69 137 71 36 34 66 71 75 99 75 93 39 55 73 36 33 34 18 37 23 40 Max 120 97 98 132 140 132 115 110 128 175 141 109 147 143 1-9 102 286 114 201 189 156 243 122 123 110 202 130 379 153 239 223 142 158 219 196 154 201 174 115 192 92 100 78 9* 82 6"1 103 1976 Mean 40 36 36 44 54 49 36 43 55 50 39 *6 56 *4 45 52 115 49 60 99 68 110 60 61 48 60 56 111 56 91 59 72 =3 75 64 76 63 44 43 38 36 39 49 32 25 29 Max 110 110 65 141 156 143 119 158 139 150 103 132 155 127 121 141 345 148 151 281 157 253 137 172 134 154 127 289 234 414 177 177 155 191 140 172 154 109 141 117 96 106 104 110 39 1-2 'Values are _g.-IT 11 ------- TABLE 3. AVERAGES* OF MEAN AND MAXIMUM SULFUR DIOXIDE COUNTS 9Y ZIP CODE Zip Code 14006 14011 14020 14031 14043 14048 14063 14070 14072 14080 14086 14092 14094 14101 14105 14120 14131 14132 14136 14150 14174 14203 14206 14207 14210 14211 14212 14213 14214 14215 14216 ua? 1421S 14219 14220 14221 14224 14225 14226 14253 14:01 14302 14303 143C4 14305 14432 14559 14701 14706 14719 14733 1*760 14772 1-202 14895 1970 1971 1972 1973 Mean Max Mean Max Mean Max Mean Max 1 39 150 29 150 35 196 42 14 36 22 73 41 33 26 78 30 73 42 54 10 10 4 25 22 40 290 33 480 34 10 16 40 8 40 35 22 13 30 2 10 10 24 10 20 1 30 16 24 38 2 1C 21 U3 2' 131 30 41 131 50 244 67 50 50 7 12 15 1 145 112 49 87 105 60 569 10 80 50 10 70 50 50 660 164 84 1974 Mean Max 1 10 8 19 24 22 31 29 12 14 28 26 12 14 13 11 17 14 13 20 34 15 14 7 3 3 39 28 111 120 139 164 172 50 45 279 110 50 40 50 46 42 60 60 220 159 69 87 23 17 1975 Mean Max 1 11 5 11 11 11 13 10 14 16 26 32 11 9 8 9 15 20 12 10 16 19 11 11 4 4 4 87 28 51 42 41 91 37 64 48 234 145 45 30 36 44 55 40 42 35 82 02 40 96 43 42 1976 Mean Max 1 3 6 9 13 9 18 11 13 10 24 37 11 12 11 15 21 19 13 10 12 17 11 13 4 1 10 12 32 56 47 31 80 65 70 38 183 157 60 41 42 79 67 51 42 33 67 74 38 100 35 6 ; /a1 j«s ars t,g/ n" 12 ------- TABLE 4. REGRESSION TABLE FOR CANCER SITE AND TYPE OF POLLUTANT Coefficient of Significance Site Covariate Covariate (pi) of Pi Leukemia Mean Particulate .1328E-02 .61 Max. Participate -.3950E-03 .62 Mean S09 -.9680E-02 .33 Max. SOg .1177E-02 .29 Respiratory Mean Particulate .6741E-03 .55 Max. Particulate .6671E-03 .05 Mean SO, -.2374E-02 .51 Max. SOg .2982E-03 .48 Colorectal Mean Particulate .1491E-02 .25 Max Particulate .5859E-03 .17 Mean S09 .5893E-02 .88 Max. SO .3495E-03 .45 This finding is further supported by Figure 1 which presents an actuarial survival comparison of respiratory cancer patients residing in areas with maximum particulate levels of 240 ug/m or less versus areas with higher levels. The difference between these two curves is statisti- cally significant at the a = .05 level. Individuals residing in areas o where maximum levels exceed 240 pg/m consistently display poorer survival than those residing in less polluted areas. Table 5 presents in somewhat greater detail the relationship between cancer site, particulate levels and median survival. The only significant difference in survival once again occurs for respiratory tract cancers. Median survival for patients residing in areas characterized by maximum o particulate levels less than 240 ug/m is 7.0 months compared to 5.2 months in higher pollution areas. 13 ------- Figure 1 SURVIVAL FROM RESPIRATORY CANCER BY. MAXIMUM PARTICULATE LEVELS I I I PARTICULATE LEVELS 0-240 >240 cc 3 CO 01 o cc HI BRESLOW TEST RESULTS: p < .05 14 ------- TABLE 5. MEDIAN SURVIVAL BY PARTICIPATE LEVELS AND CANCER SITE Median Significance of Difference Site Groups Survival in Survival Distributions Leukemia I - Mean Part. 0-80 15.2 mo. NS II - Mean Part. > 80 17.4 mo. Leukemia I - Max. Part. 0-240 15.9 mo. NS II - Max. Part. > 240 15.1 mo. Respiratory I - Mean Part. 0-80 6.7 mo. NS II - Mean Part. > 80 6.3 mo. Respiratory I - Max. Part. 0-240 7.0 mo. p < .05 II - Max. Part. > 240 5.2 mo. Colorectal I - Mean Part. 0-80 24.5 mo. NS II - Mean Part. > 80 22.8 mo. Colorectal I - Max. Part. 0-240 24.3 mo. NS II - Max. Part. > 240 22.6 mo. Qualifications It is important to understand the assumptions underlying the Cox Modeling performed. It must be assumed that the mean value of the ambient concentrations in the zip code area of residence during the year of diagnosis is representative of the conditions under which the cancer patient lived the remainder of his life. This is indeed a considerable supposition. A cursory inspection of the time progression of particulate and SO2 levels indicates a tendency for the mean reading to decline with time. Also, maximum values demonstrate no consistent trend which may be attributed to sampling being conducted on a periodic schedule such as 15 ------- every third day rather than daily. This indicates that even if a cancer patient remained at home after being diagnosed, the mean level to which he or she was exposed probably declined. Finally, it should be remembered that this was a pilot study designed to assess, in a preliminary manner, whether the hypothesis that length of survival among diagnosed cancer patients was associated with ambient pollutant levels is worthy of continued investigation. Although the only significant relationship found was between survival of respiratory cancer patients and maximum particulate levels, the same trend was also observed for both colorectal and leukemia patients. Given the crude measures consisting of available data that were employed in this investi- gation, one might argue that any bias that might exist would be against obtaining significant findings. Thus, it may be concluded that, although definitive statements about a possible association between the length of survival of cancer patients and ambient concentrations of particulate matter are not yet warranted, continued investigation of this potential problem is justified. 16 ------- C9 CC C/l H ui u oc IU a. 100 90 80 70 60 50 40 30 20 10 Figure 2 SURVIVAL FROM RESPIRATORY CANCER BY MEAN PARTICULATE LEVELS T I PARTICULATE LEVELS 0-80 — — — >80 10 20 30 MONTHS 40 50 60 BRESLOW TEST RESULTS: NOT SIGNIFICANT 17 ------- 100 90 80 70 60 50 z E 40 oc CO z LLJ O cc Ul a. 30 20 10 Figure 3 SURVIVAL FROM LEUKEMIA BY MEAN PARTICULATE LEVELS I I I PARTICULATE LEVELS 0-80 — >80 10 20 30 MONTHS 40 50 60 BRESLOW TEST RESULTS: NOT SIGNIFICANT 18 ------- Figure 4 SURVIVAL FROM LEUKEMIA BY MAXIMUM PARTICULATE LEVELS > cc M B oc 1U PARTICULATE LEVELS 0-240 >240 BRESLOW TEST RESULTS: NOT SIGNIFICANT 19 ------- Figure 5 SURVIVAL FROM COLORECTAL CANCER BY MEAN PARTICULATE LEVELS o cc V) I- III o cc UJ a. PARTICULATE LEVELS 0-80 — — >80 BRESLOW TEST RESULTS: NOT SIGNIFICANT 20 ------- Figure 6 100 90 80 70 60 O en Z 50 40 I o K £ 30 20 10 SURVIVAL FROM COLORECTAL CANCER BY MAXIMUM PARTICULATE LEVELS T I PARTICULATE_LEVELS 0-240 I 10 20 30 MONTHS 40 50 60 BRESLOW TEST RESULTS: NOT SIGNIFICANT 21 ------- REFERENCES 1. Roholm, K. The Fog Disaster in the Meuse Valley: A Fluorine Intoxication. J. Ind. Hyg. Toxicol. 19(3):126-137, 1937. 2. Ciacco, A. and D. J. Thompson. A Follow-up of Donora Ten Years After: Methodology and Findings. Am. J. Pub. Hlth. 51(2):155-164, 1961. 3. Wilkins, E. T. Air Pollution and the London Fog of December, 1952. J. R. San. Inst. 74(1):1-15, 1954. 4. Waldbott, G. Health Effects of Environmental Pollutants. The C. V. Mosby Company, St. Louis, Missouri, 1978. pp. 6-8. 5. Haenszel, W. Cancer Mortality Among the Foreign-Born in the United States. J. Natl. Cancer Inst. 26(1):37-132, 1961. 6. Haenszel, W. and M. Kurihara. Studies of Japanese Migrants. I. Mortality from Cancer and Other Diseases Among Japanese in the United States. J. Natl. Cancer Inst. 40(l):43-68, 1968. 7. Staszewski, J. and W. Haenszel. Cancer Among the Polish-Born in the United States. J. Natl. Cancer Inst. 35(2):291-297, 1965. 8. Waterhouse, J., C. Muir, P. Corres, and J. Powell. Cancer Incidence in Five Continents, Volume III. IARC Scientific Publications No. 15. International Agency for Research on Cancer, Lyon, France, 1976. 9. Levin, D. L., S. S. Devesa, J. D. Godwin, II, and D. T. Silverman. Cancer Rates and Risks. DHEW Pub. No. (NIH) 75-691. U.S. Govt. Printing Office, Washington, D.C., 1974. 22 ------- 10. Mason, T. J. and F. W. McKay. U.S. Cancer Mortality by County: 1950-1969. DHEW Pub. No. (NIH) 74-615. U.S. Govt. Printing Office, Washington, D.C., 1973. 11. Levin, M. L., W. Haenszel, B. E. Carroll, P. R. Gerhardt, V. H. Handy, and S. C. Ingraham, II. Cancer Incidence in Urban and Rural Areas of New York State. J. Natl. Cancer Inst. 24(6):1243-1257, 1960. 12. Henderson, B. E., R. J. Gordon, H. Mende, J. Soohoo, S. P. Martin, and M. C. Pike. Lung Cancer and Air Pollution in Southcentral Los Angeles County. Am. J. Epidemiol. 10(16):477-488, 1975. 13. Goldsmith, J. R. and L. Breslow. Epidemiological Aspects of Air Pollution. J. Air Pollution Control Assoc. 9(3):129-132, 1959. 14. Cox, D. R. Regression Models and Life Tables. J. Roy. Statist. Soc. 34:187-220, 1972. 15. Breslow, N. A Generalized Kruskal-Wailace Test for Comparing K Samples Subject to Unequal Patterns of Censorship. Biometrika 57:579-594, 1970. 23 ------- TECHNICAL REPORT DATA {Please read Instructions on the reverse before completing) REPORT NO. EPA-600/1-80-009 3. RECIPIENT'S ACCESSION1 NO. 4. TITLE AND SUBTITLE Pilot Study of Ambient Air Pollution And Survival From Cancer 5. REPORT DATE January 1980 6. PERFORMING ORGANIZATION CODE 7. AUTHOR(S) Gregg S. Wilkinson, Peter Reese, Roger Priore 8. PERFORMING ORGANIZATION REPORT NO. 9. PERFORMING ORGANIZATION NAME AND ADDRESS Health Effects Research Laboratory Environmental Protection Agency Research Triangle Park, NC 27711 and Roswell Park Memoria L Institute 666 Elm Street Buffalo, NY 14263 10. PROGRAM ELEMENT NO. 1HE775 11. CONTRACT/GRANT NO. DA-8-6122J 12. SPONSORING AGENCY NAME AND ADDRESS Environmental Protection Agency Research Triangle Park, NC 27711 13. TYPE OF REPORT AND PERIOD COVERED 14. SPONSORING AGENCY CODE EPA 600/11 15. SUPPLEMENTARY NOTES 16. ABSTRACT This study was concerned with investigating the potential influence exerted by ambient concentrations of particulate and sulfur dioxide air pollutants upon the length of survival for diagnosed cancer patients. Monitoring data from the National Aerometric Data Bank for particulates and sulfur dioxide were examined in conjunction with survival data from the Lakes Area Regional Tumor Service Registry. Length of survival for respiratory cancer patients was found to be inversely related to maximum particulate levels. Median sur- vival for those patients who resided in areas where maximum particulate levels exceeded 240 yg/m^ was significantly shorter than for similar patients who resided in areas with lower particulate levels. Colorectal cancer patients demonstrated a similar trend that was not statistically significant. No as- sociation was found between survival of leukemia patients and particulate or SC>2 levels, nor was SC>2 related to survival of respiratory tract or colorectal cancer patients. These findings suggest that highly polluted air in residential areas may have a deleterious effect on the survival time of patients with neo- plastic disease. Additional research is called for of the relationship between cancer survival and exposure to ambient air pollution, especially particulates. 17. KEY WORDS AND DOCUMENT ANALYSIS a. DESCRIPTORS b.lDENTIFIERS/OPEN ENDED TERMS C. COSATI Field/Group Sulfur Dioxide Particulates Aerometric Cancer 06.F.P 13. DISTRIBUTION STATEMENT RELEASE TO PUBLIC 19. SECURITY CLASS (ThisReport) UNCLASSIFIED 21. NO. OF PAGES 32 20. SECURITY CLASS (Thispage) UNCLASSIFIED 22. PRICE EPA Form 2220-1 (9-73) 24 ------- |