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Original research
Rate advancement measurement for lung cancer and pleural mesothelioma in asbestos-exposed workers
  1. Danila Azzolina1,
  2. Dario Consonni2,
  3. Daniela Ferrante3,
  4. Dario Mirabelli4,
  5. Stefano Silvestri3,
  6. Ferdinando Luberto5,
  7. Alessia Angelini3,
  8. Francesco Cuccaro6,
  9. Anna Maria Nannavecchia6,
  10. Enrico Oddone7,
  11. Massimo Vicentini5,
  12. Francesco Barone-Adesi8,
  13. Tiziana Cena3,
  14. Lucia Mangone5,
  15. Francesca Roncaglia5,
  16. Orietta Sala9,
  17. Simona Menegozzo10,
  18. Roberta Pirastu11,
  19. Sara Tunesi3,
  20. Elisabetta Chellini12,
  21. Lucia Miligi12,
  22. Patrizia Perticaroli13,
  23. Aldo Pettinari13,
  24. Vittoria Bressan14,
  25. Enzo Merler15,
  26. Paolo Girardi15,16,
  27. Lucia Bisceglia17,
  28. Alessandro Marinaccio18,
  29. Stefania Massari18,
  30. Corrado Magnani3
  31. The working group
    1. 1Università degli Studi di Ferrara, Ferrara, Italy
    2. 2Unit of Epidemiology, Fondazione IRCCS Ca' Granda—Ospedale Maggiore Policlinico, Milan, Italy
    3. 3Department of Translational Medicine, Unit of Medical Statistics and Cancer Epidemiology, Università degli Studi del Piemonte Orientale Amedeo Avogadro, Novara, Italy
    4. 4Unit of Cancer Epidemiology, CPO Piedmont and University of Turin, Turin, Italy
    5. 5Epidemiology Unit, Azienda Unità Sanitaria Locale—IRCCS di Reggio Emilia, Reggio Emilia, Italy
    6. 6Unit of Epidemiology and Statistics, Local Health Unit of Barletta-Andria-Trani, Barletta, Italy
    7. 7Department of Public Health, Experimental and Forensic Medicine, University of Pavia, and ICS Maugeri IRCCS, Pavia, Italy
    8. 8Unit of Public Health, Department of Translational Medicine, University of Eastern Piedmont, Novara, Italy
    9. 9Regional Agency for Protection, Environment and Energy Emilia-Romagna, Reggio Emilia, Italy
    10. 10National Cancer Institute IRCCS Fondazione Pascale, Napoli, Italy
    11. 11Department of Biology and Biotechnologies 'Charles Darwin', Sapienza University, Rome, Italy
    12. 12Occupational & Environmental Epidemiology Unit—Institute for Cancer Research, Prevention and Clinical Network (ISPRO), Firenze, Italy
    13. 13Prevention Department, ASUR Marche, Senigallia, Italy
    14. 14UOSD Servizio di Epidemiologia AULSS6 EUGANEA, Padua, Italy
    15. 15Mesothelioma Register of the Veneto Region, Regional Epidemiologic System, Local Health Unit 6, Padua, Italy
    16. 16Department of Developmental and Social Psychology Department of Statistical Sciences University of Padova, Padua, Italy
    17. 17Apulia Regional Agency for Health and Social Policies—ARESS Puglia, Bari, Italy
    18. 18Italian Workers' Compensation Authority (INAIL), Department of Occupational and Environmental Medicine, Epidemiology and Hygiene, Unit of Occupational and Environmental Epidemiology, Italian Mesothelioma Register, Roma, Italy
    19. 1Department of Epidemiology, Lazio Regional Health Service, Rome, Italy
    20. 2Occupational Medicine Unit, Careggi University Hospital, Florence, Italy
    21. 3Unit of Cancer Epidemiology, CPO Piedmont and University of Turin, Turin, -, Italy
    22. 4Occupational & Environmental Epidemiology Unit - Institute for Cancer Research, Prevention and Clinical Network (ISPRO), Florence, Italy
    23. 5Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
    24. 6Department of Public Health, Prevention and Security Area Work Environments, Local Health Authority, Bologna, Italy
    25. 7Interdisciplinary Department of Medicine, Occupational Medicine "B. Ramazzini", University of Bari, Bari, Italy
    26. 8Mesothelioma Register of the Veneto Region, Regional Epidemiologic System, Local Health Unit 6, Padua, -, Italy
    27. 9Unit of Medical Statistics and Cancer Epidemiology, Department of Translational Medicine, University of Eastern Piedmont, Novara, and CPO-Piedmont, Novara, Italy
    28. 10Epidemiology Unit, Azienda Unità Sanitaria Locale - IRCCS di Reggio Emilia, Reggio Emilia, Italy
    1. Correspondence to Dr Danila Azzolina, Environmental and Preventive Science, Università degli Studi di Ferrara, Ferrara, 44121, Italy; danila.azzolina{at}


    Introduction Exposure to asbestos increases the risk of lung cancer and mesothelioma. Few studies quantified the premature occurrence of these diseases in asbestos-exposed workers. Focus on premature disease onset (rate advancement or acceleration) can be useful in risk communication and for the evaluation of exposure impact. We estimated rate advancement for total mortality, lung cancer and pleural mesothelioma deaths, by classes of cumulative asbestos exposure in a pooled cohort of asbestos cement (AC) workers in Italy.

    Method The cohort study included 12 578 workers from 21 cohorts, with 6626 deaths in total, 858 deaths from lung cancer and 394 from pleural malignant neoplasm (MN). Rate advancement was estimated by fitting a competitive mortality Weibull model to the hazard of death over time since first exposure (TSFE).

    Result Acceleration time (AT) was estimated at different TSFE values. The highest level of cumulative exposure compared with the lowest, for pleural MN AT was 16.9 (95% CI 14.9 to 19.2) and 33.8 (95% CI 29.8 to 38.4) years at TSFE of 20 and 40 years, respectively. For lung cancer, it was 13.3 (95% CI 12.0 to 14.7) and 26.6 (95% CI 23.9 to 29.4) years, respectively. As for total mortality, AT was 3.35 (95% CI 2.98 to 3.71) years at 20 years TSFE, and 6.70 (95% CI 5.95 to 7.41) at 40 years TSFE.

    Conclusion The current study observed marked rate advancement after asbestos exposure for lung cancer and pleural mesothelioma, as well as for total mortality.

    • lung cancer
    • mesothelioma
    • asbestos induced lung disease

    Data availability statement

    Data are available on reasonable request.

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    • Collaborators The working group: Lisa Bauleo, Antonio Baldassarre, Carol Brentisci, Barbara Cortini, Stefania Curti, Manuela Gangemi, Giuseppe Gorini, Patrizia Legittimo, Francesco Marinelli, Pasqualina Marinilli, Stefano Mattioli, Marina Musti, Chiara Panato, Venere LedaMara Pavone, Alessandra Ranucci, Elisa Romeo, Corrado Scarnato, Cinzia Storchi, Antonella Stura, Simona Verdi.

    • Contributors CM, DC, DF and DM conceived the study and the analysis which was developed with input from all authors from inception. CM acts as the coordinator. Data analysis was performed by DA and CM and DA produced the first draft of the manuscript to which all other authors contributed in reading and editing. CM act as data guarantor. The final version of the manuscript has been fully reviewed and approved by all authors.

    • Funding The cohort study was conducted thanks to grants from the ‘Asbestos Project’ of the Italian National Institute of Health (ISS) (current research 2012: asbestos project. Operative Unit 2 'Amedeo Avogadro' University of Eastern Piedmont, Novara, Research Line 1.2) and from the INAIL (Piano Ricerca 2016-2018, 'Programma Speciale Amianto', Ricerca BRIC id 55 and Ricerca BRIC id 59), (Piano Attività di Ricerca 2019-2021, Programma Speciale Amianto, BRIC id 55).

    • Competing interests The authors declare that they have no competing interests. The following authors or working group components reported that they served as expert witness in court trials on asbestos related diseases: AA, AB, CM, DM, EM, EO, FB-A, LBi, LMa, LMi, MM, SMe, SS, VP.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.