Body mass, tobacco smoking, alcohol drinking and risk of cancer of the small intestine--a pooled analysis of over 500,000 subjects in the Asia Cohort Consortium.

BACKGROUND: The evidence for a role of tobacco smoking, alcohol drinking, and body mass index (BMI) in the etiology of small intestine cancer is based mainly on case-control studies from Europe and United States. SUBJECTS AND METHODS: We harmonized the data across 12 cohort studies from mainland China, Japan, Korea, Singapore, and Taiwan, comprising over 500,000 subjects followed for an average of 10.6 years. We calculated hazard ratios (HRs) for BMI and (only among men) tobacco smoking and alcohol drinking. RESULTS: A total of 134 incident cases were observed (49 adenocarcinoma, 11 carcinoid, 46 other histologic types, and 28 of unknown histology). There was a statistically non-significant trend toward increased HR in subjects with high BMI [HR for BMI>27.5 kg/m2, compared with 22.6-25.0, 1.50; 95% confidence interval (CI) 0.76-2.96]. No association was suggested for tobacco smoking; men drinking>400 g of ethanol per week had an HR of 1.57 (95% CI 0.66-3.70), compared with abstainers. CONCLUSIONS: Our study supports the hypothesis that elevated BMI may be a risk factor for small intestine cancer. An etiologic role of alcohol drinking was suggested. Our results reinforce the existing evidence that the epidemiology of small intestine cancer resembles that of colorectal cancer.

From mechanisms to risk estimation--bridging the chasm.

We have a considerable amount of work ahead of us to determine the importance of the wealth of new information emerging in the fields of sub-cellular, cellular and tissue biology in order to improve the estimation of radiation risk at low dose and protracted dose-rate. In this paper, we suggest that there is a need to develop models of the specific health effects of interest (e.g., carcinogenesis in specific tissues), which embody as much of the mechanistic (i.e., biological) information as is deemed necessary. Although it is not realistic to expect that every radiation-induced process should or could be included, we can hope that the major factors that shape the time dependence of evolution of damage can be identified and quantified to the point where reasonable estimations of risk can be made. Regarding carcinogenesis in particular, the structure of the model itself plays a role in determining the relative importance of various processes. We use a specific form of a multi-stage carcinogenic model to illustrate this point. We show in a review of the application of this model to lung cancer incidence and mortality in two exposed populations that for both high- and low-LET radiation, there is evidence of an "inverse dose-rate" or protraction effect. This result could be of some considerable importance, because it would imply that risk from protracted exposure even to low-LET radiation might be greater than from acute exposure, an opinion not currently held in the radiation protection community. This model also allows prediction of the evolution of the risk over the lifetimes of the exposed individuals. One inference is that radiation-induced initiation (i.e., the first cellular carcinogenic event(s) occurring in normal tissue after the passage of the radiation) may not be the driving factor in the risk, but more important may be the effects of the radiation on already-initiated cells in the tissue. Although present throughout the length of the exposure, radiation-induced initiation appears to play a dominating role only very late in life, and only for those individuals who began their exposure early in life. These conclusions are very dependent, of course, on the hypotheses embodied in the initiation-promotion-conversion paradigm of carcinogenesis. We suggest that recently identified processes, such as the "bystander effect", might affect initiation, promotion, and malignant conversion in different ways. Finally, the manner in which the quality of radiation affects these processes must be understood in the context of the mixed high- and low-LET radiations that are found in the space environment. Important directions in critical experiment definition are suggested, including a renewed emphasis on well-designed animal experiments over extended periods of time.

The use of biologically based cancer risk models in radiation epidemiology.

Biologically based risk projection models for radiation carcinogenesis seek to describe the fundamental biological processes involved in neoplastic transformation of somatic cells into malignant cancer cells. A validated biologically based model, whose parameters have a direct biological interpretation, can also be used to extrapolate cancer risks to different exposure conditions with some confidence. In this article biologically based models for radiation carcinogenesis, including the two-stage clonal expansion (TSCE) model and its extensions, are reviewed. The biological and mathematical bases for such models are described, and the implications of key model parameters for cancer risk assessment examined. Specific applications of versions of the TSCE model to important epidemiological datasets are discussed, including the Colorado uranium miners' cohort; a cohort of Chinese tin miners; the lifespan cohort of atomic bomb survivors in Hiroshima and Nagasaki; and a cohort of over 200,000 workers included in the National Dose Registry (NDR) of Canada.

A new perspective of carcinogenesis from protracted high-LET radiation arises from the two-stage clonal expansion model.

When applied to the Colorado Plateau miner population, the two-stage clonal expansion (TSCE) model of radiation carcinogenesis predicts that radiation-induced promotion dominates radiation-induced initiation. Thus, according to the model, at least for alpha-particle radiation from inhaled radon daughters, lung cancer induction over long periods of protracted irradiation appears to be dominated by radiation-induced modification of the proliferation kinetics of already-initiated cells rather than by direct radiation-induced initiation (i.e., mutation) of normal cells. We explore the possible consequences of this result for radiation exposures to space travelers on long missions. Still unknown is the LET dependence of this effect. Speculations of the cause of this phenomenon include the suggestion that modification of cell kinetics is caused by a "bystander" effect, i.e., the traversal of normal cells by alpha particles, followed by the signaling of these cells to nearby initiated cells which then modify their proliferation kinetics.

Analysis of a historical cohort of Chinese tin miners with arsenic, radon, cigarette smoke, and pipe smoke exposures using the biologically based two-stage clonal expansion model.

Hazelton, W. D., Luebeck, E. G., Heidenreich, W. F. and Moolgavkar, S. H. Analysis of a Historical Cohort of Chinese Tin Miners with Arsenic, Radon, Cigarette Smoke, and Pipe Smoke Exposures Using the Biologically Based Two-Stage Clonal Expansion Model. Radiat. Res. 156, 78-94 (2001).The two-stage clonal expansion model is used to analyze lung cancer mortality in a cohort of Yunnan tin miners based on individual histories with multiple exposures to arsenic, radon, cigarette smoke, and pipe smoke. Advances in methodology include the use of nested dose-response models for the parameters of the two-stage clonal expansion model, calculation of attributable risks for all exposure combinations, use of both a fixed lag and a gamma distribution to represent the time between generation of the first malignant cell and death from lung cancer, and scaling of biological parameters allowed by parameter identifiability. The cohort consists of 12,011 males working for the Yunnan Tin Corporation, with complete exposure records, who were initially surveyed in 1976 and followed through 1988. Tobacco and arsenic dominate the attributable risk for lung cancer. Of 842 lung cancer deaths, 21.4% are attributable to tobacco alone, 19.7% to a combination of tobacco and arsenic, 15.8% to arsenic alone, 11% to a combination of arsenic and radon, 9.2% to a combination of tobacco and radon, 8.7% to combination of arsenic, tobacco and radon, 5.5% to radon alone, and 8.7% to background. The models indicate that arsenic, radon and tobacco increase cell division, death and malignant conversion of initiated cells, but with significant differences in net cell proliferation rates in response to the different exposures. Smoking a bamboo water pipe or a Chinese long-stem pipe appears to confer less risk than cigarette use, given equivalent tobacco consumption.

The role of promotion in carcinogenesis from protracted high-LET exposure.

Recent analysis of epidemiological studies using the two-stage clonal expansion (TSCE) model has shown that radiation-induced promotion dominates radiation-induced initiation for protracted exposures to radon. This strong promotion effect (i.e. enhanced proliferation of already-initiated cells) causes a pronounced 'inverse dose-rate effect', but by a mechanism completely different from those usually discussed in this connection. This rather startling result is discussed along with implications to extended space missions that include a significant amount of high-LET radiation. It is suggested that the effect might be caused by a 'Bystander Effect' by which normal cells in the vicinity of initiated cells are hit by alpha particles and send out signals that modify the cell kinetics of the already-initiated clones.

Biologically based analysis of the data for the Colorado uranium miners cohort: age, dose and dose-rate effects.

This study is a comprehensive analysis of the latest follow-up of the Colorado uranium miners cohort using the two-stage clonal expansion model with particular emphasis on effects related to age and exposure. The model provides a framework in which the hazard function for lung cancer mortality incorporates detailed information on exposure to radon and radon progeny from hard rock and uranium mining together with information on cigarette smoking. Even though the effect of smoking on lung cancer risk is explicitly modeled, a significant birth cohort effect is found which shows a linear increase in the baseline lung cancer risk with birth year of the miners in the cohort. The analysis based on the two-stage clonal expansion model suggests that exposure to radon affects both the rate of initiation of intermediate cells in the pathway to cancer and the rate of proliferation of intermediate cells. However, in contrast to the promotional effect of radon, which is highly significant, the effect of radon on the rate of initiation is found to be not significant. The model is also used to study the inverse dose-rate effect. This effect is evident for radon exposures typical for mines but is predicted to be attenuated, and for longer exposures even reversed, for the more protracted and lower radon exposures in homes. The model also predicts the drop in risk with time after exposure ceases. For residential exposures, lung cancer risks are compared with the estimates from the BEIR VI report. While the risk estimates are in agreement with those derived from residential studies, they are about two- to fourfold lower than those reported in the BEIR VI report.