- Email: [email protected]
Airborne dioxin exposure and breast cancer risk in a case-control study nested within the French E3 N prospective cohort
European Congress of Epidemiology – “Crises, epidemiological / Revue d’Épidémiologie et de Santé Publique 66S (2018) S233–S276 stress status providing new insights of the biological pathways central to fetal programming. Funding Instituto de Salud Carlos III (ISCIII), Spanish Ministry of Economy and Competitiveness and Fondos FEDER (Grant numbers: CP14/00046, PIE15/00051, and PI16/00422). Disclosure of interest est.
The authors declare that they have no competing inter-
https://doi.org/10.1016/j.respe.2018.05.032 S5.3
Circulating levels of perfluoroalkylated compounds and breast cancer risk: Evidence from a nested case-control study F.R. Mancini a,∗ , G. Cano-Sancho b , J. Gabaretti a , P. Marchand b , J.-P. Antignac b , M. Kvaskoff a a Centre for Research in Epidemiology and Population Health (CESP), Inserm, Villejuif, France b LABERCA, École Nationale Vétérinaire, Agroalimentaire et de l’Alimentation, Nantes, France ∗ Corresponding author. E-mail address: [email protected] (F.R. Mancini) Introduction The incidence of breast cancer is continuing to rise in Western countries, and there has been increasing interest in understanding the contribution of exposure to endocrine disrupting chemicals (EDCs) to this increase. A large group of EDCs, for which the long-term health effects remain uncharacterized with regards to breast cancer, are perfluoroalkyated compounds (PFAS). PFAS are a group of synthetic compounds that are stable, persistent and bioaccumulative. Among PFAS, perfluorooctane sulfonate (PFOS) and perfluorooctanoic acid (PFOA) are the most frequent compounds found in food and are ubiquitously present in the blood of Western populations. The objective of this study was to investigate the associations between serum levels of PFOS and PFOA and the risk of breast cancer in a nested case-control study. Methods E3 N (“Étude Épidémiologique auprès de femmes de l’Éducation Nationale”) is a French prospective cohort that enrolled 98,995 women aged 40–65 years at inclusion in 1990. After inclusion, women were followed-up every 2–3 years through self-administered questionnaires. We identified 198 cases of incident invasive breast cancer with available blood samples, collected between 1994 and 1999. For each case, one control was randomly sampled from women in the cohort who were free of breast cancer at the time of diagnosis of the corresponding case. Controls were matched to cases by age and menopausal status at blood collection, study center, and year of blood collection. Serum levels of PFOS and PFOA were measured for each woman included in the study (n = 396) by liquid chromatography coupled to tandem mass spectrometry. Women were divided into quintiles based on serum levels of PFOS and PFOA separately. Conditional logistic regression models were used to estimate odds ratios (ORs) and 95% confidence intervals (95% CIs). After running univariate models, all models were adjusted for total serum lipids, body mass index, smoking status, physical activity, education level, family history of breast cancer, history of benign breast disease, parity/age at first full-term pregnancy, total breastfeeding duration, age at menarche, age at menopause, current use of menopausal hormone therapy, use of hormonal contraceptives, adherence to a Western dietary pattern and adherence to a Mediterranean dietary pattern. Results The average serum levels of PFOS and PFOA were 19.08 ng/mL (Standard deviation [SD] 8.19) and 7.32 ng/mL (SD 3.49), respectively. Since serum levels were right skewed, all values were log-transformed in order to achieve a normal distribution. In univariate analyses, no statistically significant association was found between PFOS or PFOA serum levels and breast cancer risk. After adjustment, PFOS serum levels were positively and linearly associated with breast cancer risk (highest quintile: OR 3.46, 95% CI 1.40–8.52, compared with the lowest; Ptrend = 0.006). In contrast, when considering PFOA levels, only women in the 2nd quintile group had a significantly increased risk of breast cancer (OR 2.41, 95% CI 1.08–5.35), suggesting a non-monotonic dose-response pattern. Conclusions This study provides evidence of an association between circulating levels of PFAS and breast cancer risk. In particular, PFOS was linearly associated with breast cancer risk starting from internal values equal
S245
to 13.3 ng/mL, while only a low dose effect was highlighted for PFOA, with a increased risk for values between 4.7 and 5.8 ng/mL. This study reflects real-life exposure of a non-professionally exposed population of women in France. Our results highlight the importance of focusing on low-dose effects when studying EDCs, as well as the importance of considering exposure to EDCs, and in particular to PFAS, as a relevant risk factor for breast cancer, thus as a serious public health issue. Disclosure of interest est.
The authors declare that they have no competing inter-
https://doi.org/10.1016/j.respe.2018.05.033 S5.4
Airborne dioxin exposure and breast cancer risk in a case-control study nested within the French E3 N prospective cohort A. Danjou a,b,∗ , T. Coudon a,b , D. Praud a,c , E. Lévêque d , E. Faure a , P. Salizzoni e a Département cancer et environnement, centre Léon-Bérard, Lyon, France b Université Claude Bernard Lyon 1, université de Lyon, Villeurbanne, France c UMR Inserm 1052 CNRS 5286, équipe « Signalisation des hormones stéroïdes et cancer du sein », centre de recherche en cancérologie de Lyon, Lyon, France d Centre Inserm U1219 épidemiology and biostatistics, Institut de Santé publique, d’épidémiologie et de développement, université de Bordeaux, Bordeaux, France e Laboratory of Fluid Mechanics and Acoustics, École Centrale de Lyon, Ecully, France ∗ Corresponding author. E-mail address: [email protected] (A. Danjou) Introduction Dioxins are a mixture of related chemicals emitted by industrial chlorinated combustion processes, including chemical manufacturing of pesticides, and activities from metallurgy, steel and municipal solid waste incineration. TCDD (2,3,7,8-tetrachlorodibenzo-p-dioxin) is the most potent dioxin congener and has been classified as a group 1 carcinogen by the International Agency for Research on Cancer, with sufficient evidence for all cancers combined. As a persistent endocrine disrupting chemical, TCDD is suspected to be involved in breast cancer (BC) etiology and may influence estrogen- and progesterone-mediated pathways. The long-term nature of airborne dioxin exposure may imply variations in exposure intensities over time and given their tumor promoting properties, the impact of dioxin exposures close to the time of diagnosis needs to be considered. We aimed to estimate BC risk associated with airborne dioxin exposure in a case-control study nested within the E3 N cohort (“Étude Épidémiologique auprès de femmes de la Mutuelle Générale de l’Éducation Nationale”), improving the method for the assessment of low-dose airborne dioxin exposure and considering temporal dimensions of exposure in the risk estimates. Methods We designed a case-control study nested within the French E3 N prospective cohort and restricted to the Rhône-Alpes region, France. Between 1990 and 2008, 429 invasive BC cases were diagnosed and matched to 716 controls on relevant factors. Assessment of airborne dioxin exposure was based on a detailed inventory of dioxin emitting sources and residential history of the study subjects. Exposure was evaluated at the individual address level with a geographic information system (GIS)-based exposure metric that included proximity to dioxin emitting sources and their technical characteristics, exposure duration and wind direction. We first estimated odds ratios (OR) and 95% confidence intervals (CI) for BC in relation to cumulative airborne dioxin exposure using conditional logistic regression models adjusting for main BC risk factors. We then estimated time-dependent effects of annual airborne dioxin exposure on overall BC risk according to time prior to diagnosis with a flexible time-dependent weight function. Results We observed no linear trend across quintiles of airborne dioxin exposure (P = 0.81) and no increased risk of overall BC for higher dioxin exposure levels (OR for Q5 versus. Q1: 1.12, 95% CI: 0.69–1.82). We however observed a statistically significant OR for Q2 vs. Q1 (OR: 1.61, 95% CI: 1.04–2.49). For an increase of 0.1 g-TEQ/m2 in annual airborne dioxin exposure, risk estimates for overall BC according to time prior to diagnosis did not vary
S246
European Congress of Epidemiology – “Crises, epidemiological / Revue d’Épidémiologie et de Santé Publique 66S (2018) S233–S276
from 1.00 at each time point. No association was observed between airborne dioxin exposure and BC risk defined according to status of estrogen-receptor and progesterone-receptor. Conclusions No association was observed between airborne dioxin exposure and overall BC risk in our study population, as well as for hormone-receptor defined BC tumors. Our results suggested an increased risk in overall BC for Q2 vs Q1; this might be explained by the non-monotonic effect of dioxins, which has been suggested for other endocrine disruptor chemicals, meaning that the effect would be different depending on the dose and that stronger effects would be observed for lower levels of exposure. Confirmation of our findings is required in larger populations. Our study may provide a new tool for the assessment of longterm exposure with the GIS-based metric, as well as new ways of considering temporal dimensions for environmental exposures in disease risk assessment. Disclosure of interest est.
The authors declare that they have no competing inter-
https://doi.org/10.1016/j.respe.2018.05.034 S5.5
Impact of mean temperature on daily mortality in seven different bioclimatic regions in Tunisia, 1991–2011 H. Bellali a,b,∗ , K. Talmoudi a , W. Ettoumia c , C. Harizi a,d , N. Ben Alaya b,c , M. Chahed a,b a Epidemiology and statistic, A Mami Hospital, Ariana, Tunisia b Section of epidemiology and Public health, medical faculty of Tunis, Tunis-El-Manar University, Tunis, Tunisia c National Observatory of New and Emerging Diseases, Ministry of Health, Tunis, Tunisia d Medical Faculty of Tunis, Tunis-El-Manar University, Tunis, Tunisia ∗ Corresponding author. E-mail address: [email protected] (H. Bellali) Background It is well known that weather conditions influence the comfort and human health, in particular temperature variations and its extremes. Many studies showed cold and heat-related mortality mainly in infants and the elderly. In Tunisia, the effects of temperatures have never been estimated at a large scale. The objective of this study was to estimate the effect of extreme daily temperatures on the risk of death in 7 different bioclimatic regions. Methods Generalized additive model was applied to assess the exposureresponse relation and lag patterns of the association between mean temperature and the daily number of death from 1991 to 2011 in Tunis (North), Siliana and Jendouba (North West), Kairouan (Center West), Monastir (Center East), Gabes (South East) and Tozeur (South West). The analysis was adjusted for sex, age and population size, and controlled for long-term trend, seasonality and holidays. We did not adjust for the confounding effect of road traffic accident. The goodness-of-fit of the constructed model was assessed using generalized cross-validation (GCV) score and residual test. Results Tunis registered 153,926 deaths, Siliana 20,937, Jendouba 36,974, Monastir 46,625, Kairouan 51,409, Gabes 34,347 and Tozeur 10,658. The coldest period was in January and February and the hottest one was in July and August for all regions. The higher mortality rate was observed in cold season. The effect of temperatures in mortality was immediate, and presenting a 1–26days delay. The maximum risk of death was registered for under 10 degrees temperatures and for temperatures from 35 degrees and over. Conclusions Exposure to cold temperatures has more impact on mortality than hot weather. Climate in Tunisia is relatively warm; people are more sensitive to cold weaves. The health system should be prepared to reduce this impact mainly in vulnerable population such as children and old people. Disclosure of interest est.
The authors declare that they have no competing inter-
https://doi.org/10.1016/j.respe.2018.05.035
S5.6
PROPOUMON: Systematic screening for occupational exposures in lung cancer patients. A prospective French cohort O. Pérol a , B. Charbotel b , L. Perrier c , V. Avrillon d , M. Pérol d , B. Fervers a,∗ a Cancer et environnement, centre Léon-Bérard, Lyon, France b UMRESTTE, Université Lyon 1, Lyon, France c DRCI, Centre Léon-Bérard, Lyon, France d Oncologie médicale, centre Léon-Bérard, Lyon, France ∗ Corresponding author. E-mail address: [email protected] (B. Fervers) Introduction Although the population attributable fraction of lung cancer deaths due to occupational carcinogens has been estimated at between 8% and 24% worldwide, occupational lung cancers are largely under-reported and under-compensated. Several reasons can explain under-reporting, including the long latency between occupational exposures and cancer; the limited knowledge about occupational cancers and patients’ difficulties with administrative processes. We assessed systematic screening for occupational exposures to carcinogens combining a self-administered questionnaire and an occupational consultation to improve the detection of occupational lung cancers and their compensation. Social deprivation and the costs of this investigation were estimated. Methods Patients with a histologically confirmed lung cancer were identified through the weekly multidisciplinary lung cancer board; they received a self-administered questionnaire to collect their job history (job-title, start and end dates, employer and sector of activity and tasks performed), potential exposure to carcinogens and deprivation (EPICES score). When the patients had not returned the questionnaire after three weeks, a research technician called and offered help to complete it. At reception, a physician assessed the questionnaire and recommended an occupational consultation if necessary. During the consultation, a physician assessed if the lung cancer was work-related and, if it was, delivered a medical certificate to claim for compensation. Patients were offered help from a social worker for the claim process. The cost assessment was based on a bottom-up micro-costing approach from the healthcare providers perspective. Data on resource consumption during the process between the questionnaire administration and the consultation and social worker costs, if applicable were collected. Results Between March 2014 and September 2015, 440 patients received the self-administered questionnaire: 234 (53%) returned a completed questionnaire, including 105 (24%) after phone contact (average delay overall 47 days). Among the 206 patients who did not complete the questionnaire, 84 patients declared they did not feel concerned and 32 patients could not be contacted by phone after three attempts. Newly diagnosed patients returned the questionnaire more frequently within the first three weeks than those with disease progression. Of the 120 patients invited to the occupational consultation, 97 attended. Among them, 59 (61%) were considered to have occupational-related lung cancer. The main occupational exposures were asbestos (53%) and welding fumes (13%). A claim for compensation was judged possible under the French system for 41 patients and the medical certificate was delivered to 35 patients (five patients did not want to claim and one had already filed a claim). A compensation claim was judged unlikely to be successful for 18 patients. For the remaining 38 patients, lung-cancer was not considered to be work-related. Compensation was awarded to 19 patients (4.3% of the overall population and 8% of responders), five claims were rejected, three are still under assessment and eight patients did not submit a claim. The mean EPICES score was 28.7. Patients classified as deprived (46% with EPICES score > 30) took significantly longer to return the SAQ. The mean cost of the systematic screening of occupational exposures was D 62.65 per patient. Conclusions Our study confirms the frequency of occupational exposures among lung cancer patients, social deprivation in this population and the necessity to accompany patients during the compensation process. Our results showed a systematic self-administered questionnaire can be used to identify patients potentially exposed to carcinogens. In France, only 2.3% of lung cancers have been compensated in 2014; this percentage was doubled with our systematic screening which shows its capacity to improve the compensation of occupational lung cancers.
The authors declare that they have no competing inter-
https://doi.org/10.1016/j.respe.2018.05.032 S5.3
Circulating levels of perfluoroalkylated compounds and breast cancer risk: Evidence from a nested case-control study F.R. Mancini a,∗ , G. Cano-Sancho b , J. Gabaretti a , P. Marchand b , J.-P. Antignac b , M. Kvaskoff a a Centre for Research in Epidemiology and Population Health (CESP), Inserm, Villejuif, France b LABERCA, École Nationale Vétérinaire, Agroalimentaire et de l’Alimentation, Nantes, France ∗ Corresponding author. E-mail address: [email protected] (F.R. Mancini) Introduction The incidence of breast cancer is continuing to rise in Western countries, and there has been increasing interest in understanding the contribution of exposure to endocrine disrupting chemicals (EDCs) to this increase. A large group of EDCs, for which the long-term health effects remain uncharacterized with regards to breast cancer, are perfluoroalkyated compounds (PFAS). PFAS are a group of synthetic compounds that are stable, persistent and bioaccumulative. Among PFAS, perfluorooctane sulfonate (PFOS) and perfluorooctanoic acid (PFOA) are the most frequent compounds found in food and are ubiquitously present in the blood of Western populations. The objective of this study was to investigate the associations between serum levels of PFOS and PFOA and the risk of breast cancer in a nested case-control study. Methods E3 N (“Étude Épidémiologique auprès de femmes de l’Éducation Nationale”) is a French prospective cohort that enrolled 98,995 women aged 40–65 years at inclusion in 1990. After inclusion, women were followed-up every 2–3 years through self-administered questionnaires. We identified 198 cases of incident invasive breast cancer with available blood samples, collected between 1994 and 1999. For each case, one control was randomly sampled from women in the cohort who were free of breast cancer at the time of diagnosis of the corresponding case. Controls were matched to cases by age and menopausal status at blood collection, study center, and year of blood collection. Serum levels of PFOS and PFOA were measured for each woman included in the study (n = 396) by liquid chromatography coupled to tandem mass spectrometry. Women were divided into quintiles based on serum levels of PFOS and PFOA separately. Conditional logistic regression models were used to estimate odds ratios (ORs) and 95% confidence intervals (95% CIs). After running univariate models, all models were adjusted for total serum lipids, body mass index, smoking status, physical activity, education level, family history of breast cancer, history of benign breast disease, parity/age at first full-term pregnancy, total breastfeeding duration, age at menarche, age at menopause, current use of menopausal hormone therapy, use of hormonal contraceptives, adherence to a Western dietary pattern and adherence to a Mediterranean dietary pattern. Results The average serum levels of PFOS and PFOA were 19.08 ng/mL (Standard deviation [SD] 8.19) and 7.32 ng/mL (SD 3.49), respectively. Since serum levels were right skewed, all values were log-transformed in order to achieve a normal distribution. In univariate analyses, no statistically significant association was found between PFOS or PFOA serum levels and breast cancer risk. After adjustment, PFOS serum levels were positively and linearly associated with breast cancer risk (highest quintile: OR 3.46, 95% CI 1.40–8.52, compared with the lowest; Ptrend = 0.006). In contrast, when considering PFOA levels, only women in the 2nd quintile group had a significantly increased risk of breast cancer (OR 2.41, 95% CI 1.08–5.35), suggesting a non-monotonic dose-response pattern. Conclusions This study provides evidence of an association between circulating levels of PFAS and breast cancer risk. In particular, PFOS was linearly associated with breast cancer risk starting from internal values equal
S245
to 13.3 ng/mL, while only a low dose effect was highlighted for PFOA, with a increased risk for values between 4.7 and 5.8 ng/mL. This study reflects real-life exposure of a non-professionally exposed population of women in France. Our results highlight the importance of focusing on low-dose effects when studying EDCs, as well as the importance of considering exposure to EDCs, and in particular to PFAS, as a relevant risk factor for breast cancer, thus as a serious public health issue. Disclosure of interest est.
The authors declare that they have no competing inter-
https://doi.org/10.1016/j.respe.2018.05.033 S5.4
Airborne dioxin exposure and breast cancer risk in a case-control study nested within the French E3 N prospective cohort A. Danjou a,b,∗ , T. Coudon a,b , D. Praud a,c , E. Lévêque d , E. Faure a , P. Salizzoni e a Département cancer et environnement, centre Léon-Bérard, Lyon, France b Université Claude Bernard Lyon 1, université de Lyon, Villeurbanne, France c UMR Inserm 1052 CNRS 5286, équipe « Signalisation des hormones stéroïdes et cancer du sein », centre de recherche en cancérologie de Lyon, Lyon, France d Centre Inserm U1219 épidemiology and biostatistics, Institut de Santé publique, d’épidémiologie et de développement, université de Bordeaux, Bordeaux, France e Laboratory of Fluid Mechanics and Acoustics, École Centrale de Lyon, Ecully, France ∗ Corresponding author. E-mail address: [email protected] (A. Danjou) Introduction Dioxins are a mixture of related chemicals emitted by industrial chlorinated combustion processes, including chemical manufacturing of pesticides, and activities from metallurgy, steel and municipal solid waste incineration. TCDD (2,3,7,8-tetrachlorodibenzo-p-dioxin) is the most potent dioxin congener and has been classified as a group 1 carcinogen by the International Agency for Research on Cancer, with sufficient evidence for all cancers combined. As a persistent endocrine disrupting chemical, TCDD is suspected to be involved in breast cancer (BC) etiology and may influence estrogen- and progesterone-mediated pathways. The long-term nature of airborne dioxin exposure may imply variations in exposure intensities over time and given their tumor promoting properties, the impact of dioxin exposures close to the time of diagnosis needs to be considered. We aimed to estimate BC risk associated with airborne dioxin exposure in a case-control study nested within the E3 N cohort (“Étude Épidémiologique auprès de femmes de la Mutuelle Générale de l’Éducation Nationale”), improving the method for the assessment of low-dose airborne dioxin exposure and considering temporal dimensions of exposure in the risk estimates. Methods We designed a case-control study nested within the French E3 N prospective cohort and restricted to the Rhône-Alpes region, France. Between 1990 and 2008, 429 invasive BC cases were diagnosed and matched to 716 controls on relevant factors. Assessment of airborne dioxin exposure was based on a detailed inventory of dioxin emitting sources and residential history of the study subjects. Exposure was evaluated at the individual address level with a geographic information system (GIS)-based exposure metric that included proximity to dioxin emitting sources and their technical characteristics, exposure duration and wind direction. We first estimated odds ratios (OR) and 95% confidence intervals (CI) for BC in relation to cumulative airborne dioxin exposure using conditional logistic regression models adjusting for main BC risk factors. We then estimated time-dependent effects of annual airborne dioxin exposure on overall BC risk according to time prior to diagnosis with a flexible time-dependent weight function. Results We observed no linear trend across quintiles of airborne dioxin exposure (P = 0.81) and no increased risk of overall BC for higher dioxin exposure levels (OR for Q5 versus. Q1: 1.12, 95% CI: 0.69–1.82). We however observed a statistically significant OR for Q2 vs. Q1 (OR: 1.61, 95% CI: 1.04–2.49). For an increase of 0.1 g-TEQ/m2 in annual airborne dioxin exposure, risk estimates for overall BC according to time prior to diagnosis did not vary
S246
European Congress of Epidemiology – “Crises, epidemiological / Revue d’Épidémiologie et de Santé Publique 66S (2018) S233–S276
from 1.00 at each time point. No association was observed between airborne dioxin exposure and BC risk defined according to status of estrogen-receptor and progesterone-receptor. Conclusions No association was observed between airborne dioxin exposure and overall BC risk in our study population, as well as for hormone-receptor defined BC tumors. Our results suggested an increased risk in overall BC for Q2 vs Q1; this might be explained by the non-monotonic effect of dioxins, which has been suggested for other endocrine disruptor chemicals, meaning that the effect would be different depending on the dose and that stronger effects would be observed for lower levels of exposure. Confirmation of our findings is required in larger populations. Our study may provide a new tool for the assessment of longterm exposure with the GIS-based metric, as well as new ways of considering temporal dimensions for environmental exposures in disease risk assessment. Disclosure of interest est.
The authors declare that they have no competing inter-
https://doi.org/10.1016/j.respe.2018.05.034 S5.5
Impact of mean temperature on daily mortality in seven different bioclimatic regions in Tunisia, 1991–2011 H. Bellali a,b,∗ , K. Talmoudi a , W. Ettoumia c , C. Harizi a,d , N. Ben Alaya b,c , M. Chahed a,b a Epidemiology and statistic, A Mami Hospital, Ariana, Tunisia b Section of epidemiology and Public health, medical faculty of Tunis, Tunis-El-Manar University, Tunis, Tunisia c National Observatory of New and Emerging Diseases, Ministry of Health, Tunis, Tunisia d Medical Faculty of Tunis, Tunis-El-Manar University, Tunis, Tunisia ∗ Corresponding author. E-mail address: [email protected] (H. Bellali) Background It is well known that weather conditions influence the comfort and human health, in particular temperature variations and its extremes. Many studies showed cold and heat-related mortality mainly in infants and the elderly. In Tunisia, the effects of temperatures have never been estimated at a large scale. The objective of this study was to estimate the effect of extreme daily temperatures on the risk of death in 7 different bioclimatic regions. Methods Generalized additive model was applied to assess the exposureresponse relation and lag patterns of the association between mean temperature and the daily number of death from 1991 to 2011 in Tunis (North), Siliana and Jendouba (North West), Kairouan (Center West), Monastir (Center East), Gabes (South East) and Tozeur (South West). The analysis was adjusted for sex, age and population size, and controlled for long-term trend, seasonality and holidays. We did not adjust for the confounding effect of road traffic accident. The goodness-of-fit of the constructed model was assessed using generalized cross-validation (GCV) score and residual test. Results Tunis registered 153,926 deaths, Siliana 20,937, Jendouba 36,974, Monastir 46,625, Kairouan 51,409, Gabes 34,347 and Tozeur 10,658. The coldest period was in January and February and the hottest one was in July and August for all regions. The higher mortality rate was observed in cold season. The effect of temperatures in mortality was immediate, and presenting a 1–26days delay. The maximum risk of death was registered for under 10 degrees temperatures and for temperatures from 35 degrees and over. Conclusions Exposure to cold temperatures has more impact on mortality than hot weather. Climate in Tunisia is relatively warm; people are more sensitive to cold weaves. The health system should be prepared to reduce this impact mainly in vulnerable population such as children and old people. Disclosure of interest est.
The authors declare that they have no competing inter-
https://doi.org/10.1016/j.respe.2018.05.035
S5.6
PROPOUMON: Systematic screening for occupational exposures in lung cancer patients. A prospective French cohort O. Pérol a , B. Charbotel b , L. Perrier c , V. Avrillon d , M. Pérol d , B. Fervers a,∗ a Cancer et environnement, centre Léon-Bérard, Lyon, France b UMRESTTE, Université Lyon 1, Lyon, France c DRCI, Centre Léon-Bérard, Lyon, France d Oncologie médicale, centre Léon-Bérard, Lyon, France ∗ Corresponding author. E-mail address: [email protected] (B. Fervers) Introduction Although the population attributable fraction of lung cancer deaths due to occupational carcinogens has been estimated at between 8% and 24% worldwide, occupational lung cancers are largely under-reported and under-compensated. Several reasons can explain under-reporting, including the long latency between occupational exposures and cancer; the limited knowledge about occupational cancers and patients’ difficulties with administrative processes. We assessed systematic screening for occupational exposures to carcinogens combining a self-administered questionnaire and an occupational consultation to improve the detection of occupational lung cancers and their compensation. Social deprivation and the costs of this investigation were estimated. Methods Patients with a histologically confirmed lung cancer were identified through the weekly multidisciplinary lung cancer board; they received a self-administered questionnaire to collect their job history (job-title, start and end dates, employer and sector of activity and tasks performed), potential exposure to carcinogens and deprivation (EPICES score). When the patients had not returned the questionnaire after three weeks, a research technician called and offered help to complete it. At reception, a physician assessed the questionnaire and recommended an occupational consultation if necessary. During the consultation, a physician assessed if the lung cancer was work-related and, if it was, delivered a medical certificate to claim for compensation. Patients were offered help from a social worker for the claim process. The cost assessment was based on a bottom-up micro-costing approach from the healthcare providers perspective. Data on resource consumption during the process between the questionnaire administration and the consultation and social worker costs, if applicable were collected. Results Between March 2014 and September 2015, 440 patients received the self-administered questionnaire: 234 (53%) returned a completed questionnaire, including 105 (24%) after phone contact (average delay overall 47 days). Among the 206 patients who did not complete the questionnaire, 84 patients declared they did not feel concerned and 32 patients could not be contacted by phone after three attempts. Newly diagnosed patients returned the questionnaire more frequently within the first three weeks than those with disease progression. Of the 120 patients invited to the occupational consultation, 97 attended. Among them, 59 (61%) were considered to have occupational-related lung cancer. The main occupational exposures were asbestos (53%) and welding fumes (13%). A claim for compensation was judged possible under the French system for 41 patients and the medical certificate was delivered to 35 patients (five patients did not want to claim and one had already filed a claim). A compensation claim was judged unlikely to be successful for 18 patients. For the remaining 38 patients, lung-cancer was not considered to be work-related. Compensation was awarded to 19 patients (4.3% of the overall population and 8% of responders), five claims were rejected, three are still under assessment and eight patients did not submit a claim. The mean EPICES score was 28.7. Patients classified as deprived (46% with EPICES score > 30) took significantly longer to return the SAQ. The mean cost of the systematic screening of occupational exposures was D 62.65 per patient. Conclusions Our study confirms the frequency of occupational exposures among lung cancer patients, social deprivation in this population and the necessity to accompany patients during the compensation process. Our results showed a systematic self-administered questionnaire can be used to identify patients potentially exposed to carcinogens. In France, only 2.3% of lung cancers have been compensated in 2014; this percentage was doubled with our systematic screening which shows its capacity to improve the compensation of occupational lung cancers.