ISTITUTO Superiore di Sanità Istituto Superiore di Sanità

Ministero della Salute

Seminario “Prevenzione delle patologie

da amianto in Brasile” 9 settembre 2014

Benedetto Terracini

Incidenza dei mesoteliomi in Brasile e in altri paesi dell’America Latina (e una home made analisi della ricerca epidemiologica sulle malattie rausate dall’amianto in tali paesi)

International Classification of Diseases Xth revision: C45

• Mesothelioma of pleura excluding other malignant neoplasms of pleura • Mesothelioma of peritoneum excluding other malignant neoplasms of peritoneum • Mesothelioma of pericardium excluding other malignant neoplasms of pericardium • Mesotheliona of other sites • Mesothelioma, unspecified

International Classificatin of Diseases Xth revision: C37 and C38

C37 Malignant neoplasm of thymus C38 Malignant neoplasm of heart, mediastinum and pleura excluding mesothelioma C38.0 Heart C38.1-3 Mediastinum (anterior, posterior and unspecified) excluding great vessels) C38.4 Pleura C38.8 Overlapping lesion of heart, mediastinum and pleura

Why “pleural cancers excluding mesothelioma” are a nonsenseWh

Recent studies in France and the UK have shown that in those countries , even in recent times, a substantial proportion of mesotheliomas are registered as pleural cancers. To the best of my knowledge, I am not aware of any attempt mady in any country to verify that cases coded C 38.4 actually correspond to pleural cancers different from mesothelioma. Studies based on autopsy series have shown that a number of mesotheliomas may still go undiagnosed.

Forman D, Bray F, Brewster DH, Gombe Mbalawa C, Kohler B, Piñeros M, Steliarova-Foucher E, Swaminathan R and Ferlay J eds (2013)

Electronic version) Lyon, IARC. http://ci5.iarc.fr last accessed on August 12, 2014.

International Agency for Research on Cancer

International Association of Cancer Registries

Cancer Incidence in Five Continents vol X (CI5-X)

IARC Scientific Publication No. 164, 2013.

Absolute number of cancers registered as C 45 (mesothelioma) or C38.4 (pleural cancer excluding mesothelioma) in cancer registries In Latin America in 2003-2007 (source CI5-X)

Number of cases

Registries

80 + Sao Paulo (Br)

40-79 Cordoba (Ar), Mendoza (Ar) Cali (Co) , Puerto Rico, Uruguay

20-39 Antofagasta (Ch), Bucaramanga (Co), Costarica

< 20 Bahia Blanca (Ar), Tierra del Fuego (Ar), Aracaju (Br) Belo Horizonte (Br), Cuiaba (Br), Fortaleza (Br), Goiana (Br), Biobio (Ch), Valdivia (Ch), Manizales (Co), Pasto (Co), Villa Clara (Cu), Cuenca (Ec), Quito (Ec), Martinique (Fr), Kingston (Ja)

ASR (x 100.000/ys) in cancer registries in Latin American countries collecting at least 20 cases /C45+C38.4, men + women) in 2003-2007

mesothelioma cancer of pleura total

men women men women men women

Cordoba 0.9 (21) 0.5 (19) 0.6 (15) 0.4 (15) 1.5 (36) 0.9 (34)

Mendoza 0.6 (27) 0.2 (10) 0.1 (5) 0.1 (7) 0.7 (32) 0.3 (17)

Sao Paulo 0.2 (39) 0.1 (22) 0.1 (12) 0.0 (10) 0.3 (51) 0.1 (32)

Antofaga 0.3 (5) 0.3 (3) 1.3 (15) 0.4 (5) 1.6 (20) 0.7 (8)

Bucarama 0.2 (4) 0.1 (2) 0.3 (6) 0.2 (5) 0.5 (10) 0.3 (7)

Cali 0.4 (17) 0.2 (8) 0.1 (3) 0.3 (10) 0.5 (20) 0.5 (18)

Costarica 0.2 (13) 0.0 (5) 0.0 (1) 0.0 (1) 0.2 (14) 0.0 (6)

P . Rico 0.2 (27) 0.1 (12) 0.1 (7) 0.0 (6) 0.3 (34) 0.1 (18)

Uruguay 0.3 (19) 0.1 (10) 0.2 (13) 0.1 (11) 0.5 (32) 0.2 (21)

Canada 1.4 (1860)

0.3 (388)

0.1 (81)

0.0. (75)

1.5 (1941)

0.3 (463)

Absolute number of cases of mesothelioma + pleural cancer and cancer of the mediastinum (C38.1-3 in Brazilian cancer registries 2003-2007 (Source CI5-X)

C 45 + C 38.4 C 38.1-3

men women Men women

Aracaju

Belo H

8 4 11 6

Cuiaba 10 8 8 2

Fortaleza 13 4 10 7

Goiania 3 8 6 6

Sao Paulo 51 32 121 81

Men Women

rate number of cases (5 ys)

rate number of cases (5 ys)

Sao Paulo 0.5 122 0.3 81

Canada 0.2 180 0.1 91

US 42 states

0.2 1079 0.1 486

ICD-X C38.1-3 (cancer of the mediastinum) 2003-07

Age standardized rates (x 100.000/ys) and absolute number of cases registered in the quinquennium

Cancer in Brazil

Data from the Population Based Registries EXECUTIVE SUMMARY

Vol. IV Ministry of Health National Cancer Institute José Alencar Gomes da Silva (INA) Rio de Janeiro, RJ INCA 201313

Cancer registries operating in Brazil included in the INCA report 2013

Aracaju Joao Pessoa

Belem Manaus

Belo Horizonte Natal

Campogrande Palmas

Cuiaba Porto Alegre

Curitiba Recife

Fortaleza Salvador

Goiania Sao Paulo

Jau

Average yearly number of cases reported to the Sao Paulo Cancer Registry: Other Thoracic Organs (ICD-X C37-38) and Mesothelioma (ICD-X C45) according to CI5-X (2003-2007) and to INCA Report 2013 (2001-2005)

CI5-X (2003-2007) INCA (2001-2005)

men women men women

C37-38 30.2 24.2 38.8 40.4

C45 7.8 4.4 7.2 5.0

Some conclusions

• The incidence of mesothelioma in the Brazilian populations served by a cancer registry is low, not only in comparison with countries where industrialization started more than one century ago, but also in comparison with other Latin American countries.

• The limited quality of cancer registration in Brazil does not fully explain all of the difference. e of mesotheliomas

Factors which can be postulated as explanatory of the relatively low incidence of mesothelioma in Brazil

• Under diagnosis and under registration of cases. • Limited cancer registration in the areas experiencing the highest exposure to asbestos (but Sao Paulo ….). • Massive industrial use of asbestos in Brazil started decades later than in North American and European countries. • Contrary to other recently industrialized countries (eg Mexico), Brazil has used almost exclusively its own chrysotile. Imports of amphiboles have been negligible.

The best estimates for the relative potency of chrysotile ranged from zero to about 1/200th that of amphibole asbestos (depending on the width of the exposure metric used in the model). [The Working Group noted that there is a high degree of uncertainty concerning the accuracy of the relative potency estimates derived from the Hodgson & Darnton and Berman & Crump analyses because of the severe potential for exposure misclassification in these studies.]

IARC (vol 100) on the relative potency of amphiboles and chrysotile in terms of induction of mesotheliomas

1930 1940 1950 1960 1970 1980 1990 2000

USA 92 237 660 643 668 359 32 0

UK 23 95 108 163 149 93 15 0

Ita 7 13 24 73 132 181 62 0

Mex 0 1 5 13 40 79 39 36

Bra 0 1 9 26 38 195 163 172

India 0 5 11 23 50 163 119 145

Indon 0 0 0 1 - 119 29 43

Consumo annuo di amianto nel XX° secolo in alcuni paesi, in migliaia di tonnellate

(fonte: Virtas)

Mortality of pleural mesothelioma. Mexico 1979-2004

0

20

40

60

80

100

120

140

160

180

1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004

Nu

mb

er

death

Total Men Women

1346 Total death

The paucity of analytical epidemiological studies in Latin America

Number of entries in Medline with the term “pleural cancer” and the name of the country (July 31, 2014)

Country Number of entries

Country Number of entries

Mexico 49 Peru 1

Ecuador 2 Chile 3

Brazil 14 Argentina 5

United Kingdom

141 Italy 405

No entries for Nicaragua, Guatemala, Honduras, El Salvador, Cuba, Venezuela a, Bolivia, Uruguay, Costaricam Panama, Surinam, Colombia, Paraguay.

Case-control studies on asbestos-related cancer quoted in Medline

Mex meso ORs > 3 and up to 14

Aguilar Madrid G et al Amer J Industr Med 2010

Bra larynx No association with asb Sartor S et al Cad Saude Publ 2007

Bra lung No association with asb Wunsch-Filo V et al Scand J Wk Environ Hlth 1998

Uru lung No association with asb De Stefani E et al Scand J Wk Environ Hlth 1996

Arg lung No association with asb Matos E et al OEM 2000

Case series of mesothelioma published in the indexed literature

Number of cases

Reference

Mex 21 Mendez Vargas M et al Rev Med Inst Mex Seguro Soc 2010

Mex 85 Perez Guzman C et al Rev Med Inst Mex Seguro Soc 2008

Mex 45 Garcia Lopez MP et al Salud Publ Mex 2000

Pan 10 Briceno C et al Rev Med Panama 1990

Bra 17 Terra RM et al J Bras Pneumol 2008

Bra 7 Algranti E et al Occ Environ Med 2013

Bra 58 Motta AB et al J Bras Pneumol 2006

Bra 58 Cury PM et al J Pathol 1999

Bra 3 Capitani EM et al Rev Assoc Med Bras 1997

Arg 4 Zurbriggen R et al Medicina 2013

Arg 17 Mercurio S et al Medicina 1998

Other rlevant studies published in the indexed literature

Col Exposure in brake shops in Bogota Cely-Garcia et al Amer J Occ Hyg 2012

Bra Cross sectional study: Pleural plaques among chry miners

Mireilles G et al J Thoracic Imaging 2006

Bra Non neoplastic conditions among chrysotile miners

Bagatin et al Occup Environ Med 2005

Chi Lung and bladder cancer in a population exposed to arsenic

Ferreccio C et al Epidemiology 2013

A sine qua non for an adequate estimate of the burden of asbestos related cancers in Brazil

•Availability of adequate estimates of the Incidence not only of mesothelioma, but also of lung cancer and other cancers known to be target of the carcinogenicity of asbestos. •Implementation of properly designed epidemiological analytical studies designed in order to estimate the etimating relative and attributable risks for asbestos related multifactorial cancers

An additional conclusion

There is an urgent need for the implementation of analytical Epidemiological studies in Latin American countries, based on adequate diagnostic criteria and on proper estimates of exposure.