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Summary
Background Ambient air pollution is suspected to cause lung cancer. We aimed to assess the association between
long-term exposure to ambient air pollution and lung cancer incidence in European populations.
Methods This prospective analysis of data obtained by the European Study of Cohorts for Air Pollution Eects used
data from 17 cohort studies based in nine European countries. Baseline addresses were geocoded and we assessed air
pollution by land-use regression models for particulate matter (PM) with diameter of less than 10 m (PM10), less than
25 m (PM25), and between 25 and 10 m (PMcoarse), soot (PM25absorbance), nitrogen oxides, and two trac indicators.
We used Cox regression models with adjustment for potential confounders for cohort-specic analyses and random
eects models for meta-analyses.
Findings The 312 944 cohort members contributed 4 013 131 person-years at risk. During follow-up (mean 128 years),
2095 incident lung cancer cases were diagnosed. The meta-analyses showed a statistically signicant association between
risk for lung cancer and PM10 (hazard ratio [HR] 122 [95% CI 103145] per 10 g/m). For PM25 the HR was 118
(096146) per 5 g/m. The same increments of PM10 and PM25 were associated with HRs for adenocarcinomas of the
lung of 151 (110208) and 155 (105229), respectively. An increase in road trac of 4000 vehicle-km per day within
100 m of the residence was associated with an HR for lung cancer of 109 (099121). The results showed no association
between lung cancer and nitrogen oxides concentration (HR 101 [095107] per 20 g/m) or trac intensity on the
nearest street (HR 100 [097104] per 5000 vehicles per day).
Interpretation Particulate matter air pollution contributes to lung cancer incidence in Europe.
Funding European Communitys Seventh Framework Programme.
Introduction
Lung cancer is one of the most common cancers and has a
poor prognosis. Active smoking is the main cause, but
occupational exposures, residential radon, and environmental tobacco smoke are also established risk factors.
Furthermore, lower socioeconomic position has been
associated with a higher risk for lung cancer.1 Ambient air
pollution, specically particulate matter with absorbed
polycyclic aromatic hydrocarbons and other genotoxic
chemicals, is suspected to increase the risk for lung cancer.
Results of several epidemiological studies have shown
higher risks for lung cancer in association with various
measures of air pollution211 and suggested an association
mainly in non-smokers4,12 and never-smokers13,14 and in
individuals with low fruit consumption.4,13 In developed
countries, overall lung cancer incidence rates have
stabilised during the past few decades, but major shifts
have been recorded in the frequencies of dierent
histological types of lung cancer, with substantial relative
increases in adenocarcinomas and decreases in squamouscell carcinomas.15 Changes in tobacco blends15 and ambient
air pollution16,17 might have contributed to these shifts.
Within the European Study of Cohorts for Air Pollution
Eects (ESCAPE), we aimed to analyse data from
17 European cohort studies with a wide range of exposure
levels to investigate the following hypotheses:
that ambient air pollution at the residence (specically
particulate matter) is associated with risk for lung cancer;
that the association between air pollution and risk for
lung cancer is stronger for non-smokers and people with
low fruit intake; and that the association with air pollution
is stronger for adenocarcinomas and squamous-cell
carcinomas than for all lung cancers combined.
Methods
Study design and participants
This study is a prospective analysis of data obtained by
ESCAPEan investigation into the long-term eects of
Published Online
July 10, 2013
http://dx.doi.org/10.1016/
S1470-2045(13)70279-1
See Online/Comment
http://dx.doi.org/10.1016/
S1470-2045(13)70302-4
*Joint last authors
See Online for related
multimedia content
Danish Cancer Society Research
Center, Copenhagen, Denmark
(O Raaschou-Nielsen PhD,
Z J Andersen PhD,
K T Eriksen PhD, M Srensen PhD,
A Tjnneland DMSc); Center for
Epidemiology and Screening,
Department of Public Health,
University of Copenhagen,
Copenhagen, Denmark
(Z J Andersen); Institute for Risk
Assessment Sciences, Utrecht
University, Utrecht,
Netherlands (R Beelen PhD,
Prof B Brunekreef PhD,
M Eeftens MSc, K Meliefste BSc,
M Wang MSc, G Hoek PhD);
Department of Hygiene,
Epidemiology and Medical
Statistics, Medical School,
National and Kapodistrian
University of Athens, Athens,
Greece (E Samoli PhD,
Prof K Katsouyanni PhD,
K Dimakopoulou MSc,
Prof A Trichopoulou MD,
C Bamia PhD); Department of
Epidemiology, Lazio Regional
Health Service, Local Health
Unit ASL RME, Rome, Italy
(M Stafoggia MSc,
G Cesaroni MSc, C Badaloni MSc,
F Forastiere PhD); Institute of
Epidemiology and Medical
Biometry, Ulm University, Ulm,
Germany (G Weinmayr PhD,
G Nagel PhD); IUFLeibniz
Research Institute for
Environmental Medicine,
Dsseldorf, Germany
(G Weinmayr,
Articles
Ume
Oslo
Stockholm
Copenhagen
London/Oxford
Netherlands
Vorarlberg
Turin
Basque country
Varese
Rome
Athens
Procedures
The association between long-term exposure to air
pollution and incidence of lung cancer was analysed in
each cohort separately at the local centre by common
standardised protocols for exposure assessment,
outcome denition, confounder models, and statistical
analyses. Cohort-specic eect estimates were combined
by meta-analysis at the Danish Cancer Society Research
Center, Copenhagen, Denmark. A pooled analysis of all
cohort data was not possible due to data transfer and
privacy issues.
The main outcome was all cancers of the lung; secondary
analyses addressed adenocarcinomas and squamous-cell
carcinomas of the lung. We included cancers located in
the bronchus and the lung (International Statistical
Classication of Diseases and Related Health Problems,
10th revision [ICD10] and International Classication of
Diseases for Oncology, 3rd edition [ICDO3] C340C349).
We only included primary cancers (ie, not metastases).
Each cancer was histologically characterised, and data for
squamous-cell carcinomas (ICDO3 80508084; fth
digit morphology code 3) and adenocarcinomas
(ICDO3 81408384; fth digit morphology code 3) in
particular were obtained. Lymphomas in the lung
(ICDO3 morphology codes 9590/39729/3) were not
included. The characterisation of histology was based on
routine pathology; this study did not include verication
of tumour histology. The cohort members were followed
up for cancer incidence in national or local cancer
registries, except for EPIC-Athens, in which cancer cases
were identied by questionnaires and telephone
interviews followed by verication of medical records, and
the SIDRIA cohorts, for which hospital discharge and
mortality register data were used.
Exposure assessment
Figure 1: Areas where cohort members lived, measurements were taken, and land-use regression models for
prediction of air pollution were developed
NO2=nitrogen dioxide. NOx=nitrogen oxides (the sum of nitric oxide and nitrogen dioxide). PM=particulate matter.
Articles
All lung
Age at
baseline cancer
(years)
Adenocarcinoma*
Squamouscell
carcinoma*
PM10
(g/m3)
18 (008%) NA
Trac load on
major streets
within 100 m
(vehicle-km
per day)
PMcoarse PM25
PM25absorbance NO2
(g/m3) (g/m3) (105/m)
(g/m3)
NOx
Trac on
(g/m3) nearest
street
(vehicles per
day)
NA
NA
NA
52 (25)
87
(57)
845 (1530)
102 (417)
EPIC-Ume,
Sweden
22 136
460
(122)
69
(031%)
34 (015%)
HUBRO, Oslo,
Norway
17 640
478
(150)
75
(043%)
25 (014%)
135
(31)
40
(20)
89
(13)
12 (03)
209 (80)
383
(155)
2502 (5117)
821 (1840)
SNAC-K,
Stockholm,
Sweden
2384
731
(107)
18
(076%)
13 (055%)
164
(60)
86
(48)
80
(13)
08 (02)
175 (49)
335
(126)
3888 (9886)
2298 (3699)
SALT, Stockholm,
Sweden
4732
579
(102)
29
(061%)
12 (025%)
149
(39)
73
(30)
73
(13)
06 (02)
109 (42)
189
(94)
1460 (3351)
587 (1623)
Sixty, Stockholm,
Sweden
3813
604
(01)
38
(100%)
22 (058%)
5 (013%)
150
(38)
73
(29)
73
(13)
06 (02)
107 (42)
186
(94)
1453 (3466)
512 (1446)
SDPP, Stockholm,
Sweden
7116
471
(50)
35
(049%)
22 (031%)
5 (007)
136
(32)
63
(24)
66
(12)
05 (01)
84 (17)
144
(33)
861 (1621)
110 (423)
DCH,
Copenhagen,
Denmark
37 447
568
(44)
638
(170%)
236 (063%)
106 (028%)
171
(19)
57
(10)
113
(09)
12 (02)
163 (70)
267
(184)
2991 (7209)
1221 (2332)
EPIC-MORGEN,
Netherlands
15 993
437
(107)
92
(058%)
32 (020%)
24 (015%)
256
(17)
86
(11)
169
(06)
14 (02)
238 (70)
365
(118)
1535 (4084)
917 (1979)
EPIC-PROSPECT,
Netherlands
14 630
576
(60)
112
(077%)
43 (029%)
16 (011%)
253
(12)
85
(07)
168
(05)
14 (02)
267 (46)
396
(105)
1020 (3433)
678 (1513)
EPIC-Oxford, UK
36 832
453
(136)
78
(021%)
19 (005%)
9 (002%)
161
(20)
64
(09)
98
(11)
11 (03)
245 (80)
409
(156)
1381 (4345)
373 (1287)
VHM&PP,
108 018
Vorarlberg, Austria
428
(149)
678
(063%)
223 (021%)
157 (015%)
207
(24)
67
(09)
136
(12)
17 (02)
199 (55)
400
(95)
1687 (3582)
294 (991)
EPIC-Varese, Italy
9506
516
(82)
43
(045%)
17 (018%)
12 (013%)
NA
NA
NA
NA
438 (173)
868
(419)
EPIC-Turin, Italy
7216
504
(76)
48
(067%)
23 (032%)
466
(46)
166
(30)
301
(20)
31 (04)
530 (109)
962
(215)
3903 (9164)
465 (912)
SIDRIA-Turin, Italy
4816
440
(62)
19
(039%)
481
(41)
170
(25)
310
(17)
32 (04)
598 (106)
1073
(243)
810 (1379)
SIDRIA-Rome,
Italy
9105
443
(60)
53
(058%)
365
(50)
167
(34)
194
(18)
27 (05)
391 (91)
820
(239)
2956 (6728)
1392 (2825)
EPIC-San
Sebastian, Spain
7464
494
(77)
52
(070%)
NA
NA
NA
NA
238 (66)
471
(125)
EPIC-Athens,
Greece
4096
490
(117)
18
(044%)
6 (015%)
452
(137)
208
(26)
204
(27)
23 (05)
380 (137)
755
(410)
NA
NA
NA
673 (2614)
Data are n, mean (SD), and n (%). PM10=particulate matter with diameter <10 m. PMcoarse=particulate matter with diameter 2510 m. PM25=particulate matter with diameter <25 m. PM25absorbance=soot.
NO2=nitrogen dioxide. NOx=nitrogen oxides (the sum of nitric oxide and nitrogen dioxide). EPIC=European Prospective Investigation into Cancer and Nutrition. NA=not available. HUBRO=Oslo Health Study.
SNAC-K=Swedish National Study on Aging and Care in Kungsholmen. SALT=Screening Across the Lifespan Twin study and TwinGene. Sixty=Stockholm 60 years old and IMPROVE. SDPP=Stockholm Diabetes
Prevention Program. DCH=Diet, Cancer and Health study. MORGEN=Monitoring Project on Risk Factors and Chronic Diseases in the Netherlands. VHM&PP=Vorarlberg Health Monitoring and Prevention
Programme. SIDRIA=Italian Studies of Respiratory Disorders in Childhood and Environment. =No data or too few cases for the model to converge. *Of the lung. Contributed to results for adenocarcinomas of
the lung in participants who lived at the same residence during the whole follow-up, but did not contribute to the results for all participants because the model did not converge.
Table 1: Participants, lung cancer cases, mean air pollution concentrations, and trac in each cohort
Articles
P E Schwarze PhD,
Prof P Nafstad MD); Institute of
Health and Society, University
of Oslo, Oslo, Norway
(Prof P Nafstad); Institute of
Environmental Medicine
(Prof U De Faire PhD,
J Penell PhD, M Korek MSc,
Prof G Pershagen PhD),
Department of Medical
Epidemiology and Biostatistics
(Prof N L Pedersen PhD),
Department of Molecular
Medicine and Surgery
(Prof C-G stenson PhD), and
Aging Research Center,
Department of Neurobiology,
Statistical analyses
Proportional hazards Cox regression models were tted
for each cohort, with age as the underlying timescale.
Participants were followed up for lung cancer from
enrolment until the time of a lung cancer diagnosis or
censoring. Participants with a cancer (except nonmelanoma skin cancer) before enrolment were excluded.
Censoring was done at the time of death, a diagnosis of
A
HUBRO
SNAC-K
SALT
Sixty
SDPP
DCH
EPIC-MORGEN
EPIC-PROSPECT
EPIC-Oxford
VHM&PP
EPIC-Turin
SIDRIA-Turin
SIDRIA-Rome
EPIC-Athens
20
40
60
PM10 concentration (g/m3)
80
100
B
HUBRO
SNAC-K
SALT
Sixty
SDPP
DCH
EPIC-MORGEN
EPIC-PROSPECT
EPIC-Oxford
VHM&PP
EPIC-Turin
SIDRIA-Turin
SIDRIA-Rome
EPIC-Athens
0
10
15
20
25
30
35
40
Figure 2: Distribution of particulate matter air pollution at participant addresses in each cohort
PM10 concentration (A) and PM25 concentration (B) in each of the cohort studies. Pink boxes show median (central
vertical line) and 25th and 75th percentiles (ends of box); lines extending from the left of each box show the
concentration range from the 10th to the 25th percentile; lines extending from the right of each box show the
concentration range from the 75th to the 90th percentile. The black circles show each concentration below the
10th percentile and above the 90th percentile. PM10=particulate matter with diameter <10 m. PM25=particulate
matter with diameter <25 m.
Articles
Results
The 17 cohorts in nine European countries that
contributed to this study contained 312 944 cohort
members and contributed 4 013 131 person-years at risk
and 2095 incident lung cancer cases that developed
during follow-up (average follow-up was 128 years).
More details of each cohort, including characteristics of
the participants, available variables, and their distribution
are provided in the appendix (pp 218). Most of the
cohort studies recruited participants in the 1990s
(appendix, pp 218). The number of participants and the
Increase
Number
of
cohorts
HR (95% CI)
Measures of heterogeneity
between cohorts
(model 3)
Model 1*
Model 2
Model 3
I2
p value
PM10
10 g/m
14
132 (112155)
121 (103143)
122 (103145)
00%
083
PM25
5 g/m
14
134 (109165)
117 (095145)
118 (096146)
00%
092
PMcoarse
5 g/m
14
119 (099142)
108 (089131)
109 (088133)
338%
011
PM25absorbance
105/m
14
125 (105150)
109 (087137)
112 (088142)
190%
025
NO2
10 g/m
17
107 (100114)
099 (093106)
099 (093106)
00%
070
NOx
20 g/m
17
108 (102114)
101 (095106)
101 (095107)
00%
062
5000 vehicles
per day
15
102 (098106)
100 (097104)
100 (097104)
00%
090
4000 vehicle-km 16
per day
110 (100121)
107 (097118)
109 (099121)
00%
092
We included only participants without missing data in any of the variables included in model 3, so the datasets were identical for analyses with all three models.
See appendix (p 25) for numbers of participants and lung cancer cases contributing to each meta-analysis result. HR=hazard ratio. PM10=particulate matter with
diameter <10 m. PM25=particulate matter with diameter <25 m. PMcoarse=particulate matter with diameter 2510 m. PM25absorbance=soot. NO2=nitrogen dioxide.
NOx=nitrogen oxides (the sum of nitric oxide and nitrogen dioxide). *Model 1: age (timescale in Cox model), sex, calendar time. Model 2: model 1 + smoking
status, smoking intensity, square of smoking intensity, smoking duration, time since quitting smoking, environmental tobacco smoke, occupation, fruit intake,
marital status, education level, and employment status. Model 3: model 2 + area-level socioeconomic status.
Correspondence to:
Dr Ole Raaschou-Nielsen, Danish
Cancer Society Research Center,
2100 Copenhagen, Denmark
ole@cancer.dk
Table 2: Meta-analyses of associations between air pollutants and trac indicators and the risk for lung cancer
Articles
A
Weight (%)
Study
HR (95% CI)
HUBRO
106 (050227)
SNAC-K
089 (037212)
371
SALT
069 (032147)
482
Sixty
163 (072367)
429
SDPP
117 (040340)
248
DCH
110 (069176)
1277
EPIC-MORGEN
036 (008157)
133
EPIC-PROSPECT
189 (0351031)
098
EPIC-Oxford
164 (050539)
199
VHM&PP
120 (087166)
2770
EPIC-Turin
145 (069304)
511
SIDRIA-Turin
141 (046431)
227
SIDRIA-Rome
135 (085216)
1285
EPIC-Athens
155 (100240)
1479
025
05
492
B
HUBRO
083 (035200)
574
SNAC-K
073 (012437)
138
SALT
124 (023676)
154
Sixty
156 (041598)
245
SDPP
201 (0401001)
DCH
091 (052160)
1409
EPIC-MORGEN
049 (008321)
126
EPIC-PROSPECT
109 (017699)
128
EPIC-Oxford
053 (015191)
273
VHM&PP
132 (097181)
4456
EPIC-Turin
160 (067381)
587
SIDRIA-Turin
194 (054700)
267
SIDRIA-Rome
133 (069258)
1012
EPIC-Athens
090 (034240)
458
025
05
171
Figure 3: Risk for lung cancer according to concentration of particulate matter in each cohort study
HRs for lung cancer according to PM10 concentration (A) and PM25 concentration (B) in each of the cohort
studies, based on confounder model 3. Weights are from random eects analysis. Datapoints show HR; lines
show 95% CI; boxes show the weight with which each cohort contributed to the overall HR; vertical dashed line
shows overall HR. HR=hazard ratio. PM10=particulate matter with diameter <10 m. PM25=particulate matter with
diameter <25 m.
Discussion
This analysis of 17 European cohort studies shows
associations between residential exposure to particulate
matter air pollution at enrolment and the risk for lung
cancer. The associations were stronger for adenocarcinomas of the lung and in participants who lived at
their enrolment address throughout follow-up.
The strengths of our study include the use of 17 cohort
studies in several locations in Europe with very dierent
air pollution exposure levels and also the use of
standardised protocols for exposure assessment and data
analysis. A comprehensive set of pollutants was assessed,
by contrast with many previous studies; few European
studies have assessed particulate matter air pollution
(panel). Individual exposure assessment was based on
actual measurements made in the development of
land-use regression models for the detection of withinarea contrasts. The study benets from standardised
exposure assessment, a large number of participants,
Articles
Number of cohorts
PM10
PM25
PM10
PM25
All participants
All lung cancers
14
122 (103145)
118 (096146)
122 (103145)
118 (096146)
Adenocarcinomas
11
151 (110208)
155 (105229)
122 (101147)
116 (092145)
084 (050140)
146 (043490)
119 (094151)
118 (091152)
Squamous-cell carcinomas
Participants who did not change residence
All lung cancers
10
148 (116188)
133 (098180)
122 (102146)
120 (096151)
Adenocarcinomas
8||
227 (132391)
165 (093295)
119 (098145)
117 (092149)
Squamous-cell carcinomas
3**
064 (028148)
065 (016257)
121 (094155)
122 (093160)
Meta-analysis results based on confounder model 3. See appendix (p 25) for numbers of participants and lung cancer cases contributing to each meta-analysis result. HRs are
per 10 g/m of PM10 and per 5 g/m of PM25. HR=hazard ratio. PM10=particulate matter with diameter <10 m. PM25=particulate matter with diameter <25 m. *Standard
analysis, disregarding histological cancer subtype (ie, with all lung cancers as the endpoint and including all participants in the same cohorts as used in the histological cancer
subtype analysis). HUBRO, SNAC-K, SALT, Sixty, SDPP, DCH, EPIC-MORGEN, EPIC-PROSPECT, EPIC-Oxford, VHM&PP, EPIC-Turin, SIDRIA-Turin, SIDRIA-Rome, EPIC-Athens.
HUBRO, SALT, Sixty, SDPP, DCH, EPIC-MORGEN, EPIC-PROSPECT, EPIC-Oxford, VHM&PP, EPIC-Turin, EPIC-Athens. Sixty, SDPP, DCH, EPIC-MORGEN, EPIC-PROSPECT, EPICOxford, VHM&PP. HUBRO, SNAC-K, SALT, Sixty, SDPP, DCH, VHM&PP, SIDRIA-Turin, SIDRIA-Rome, EPIC-Athens. ||HUBRO, SNAC-K, SALT, Sixty, SDPP, DCH, VHM&PP, EPICAthens. **Sixty, DCH, VHM&PP.
Table 3: Associations between PM10 and PM25 and risk for lung cancer for all participants and those who did not change residence during follow-up,
according to histological cancer subtype
Number of
cohorts
PM10
15 g/m3
134 (051352)
121 (087168)
20 g/m3
131 (094182)
113 (092140)
25 g/m3
10
117 (093147)
112 (091138)
30 g/m3
10
113 (092140)
112 (091138)
35 g/m3
11||
111 (090137)
115 (095139)
40 g/m3
12**
113 (092139)
117 (097141)
No threshold
14 (all)
122 (103145)
122 (103145)
PM25
10 g/m3
120 (055266)
097 (063149)
15 g/m3
111 (085145)
115 (090147)
20 g/m3
11
114 (090145)
116 (092145)
25 g/m3
11
113 (090143)
116 (092145)
No threshold
14 (all)
118 (096146)
118 (096146)
Meta-analysis results based on confounder model 3. See appendix (p 25) for numbers of participants and lung cancer
cases contributing to each meta-analysis result. HRs are per 10 g/m3 of PM10 and per 5 g/m3 of PM25. HR=hazard ratio.
PM10=particulate matter with diameter <10 m. PM25=particulate matter with diameter <25 m. *Participants living at
addresses (at baseline) with air pollution above these thresholds were excluded from the analysis. Standard analysis,
disregarding thresholds (ie, including all participants in the same cohorts as used in the threshold analysis). HUBRO,
Sixty, SDPP, DCH, EPIC-Oxford. HUBRO, SNAC-K, SALT, Sixty, SDPP, DCH, EPIC-Oxford, VHM&PP. HUBRO, SNAC-K,
SALT, Sixty, SDPP, DCH, EPIC-MORGEN, EPIC-PROSPECT, EPIC-Oxford, VHM&PP. ||HUBRO, SNAC-K, SALT, Sixty, SDPP,
DCH, EPIC-MORGEN, EPIC-PROSPECT, EPIC-Oxford, VHM&PP, SIDRIA-Rome. **HUBRO, SNAC-K, SALT, Sixty, SDPP, DCH,
EPIC-MORGEN, EPIC-PROSPECT, EPIC-Oxford, VHM&PP, EPIC-Turin, SIDRIA-Rome. HUBRO, SNAC-K, SALT, Sixty, SDPP,
DCH, EPIC-MORGEN, EPIC-PROSPECT, EPIC-Oxford, VHM&PP, EPIC-Turin, SIDRIA-Turin, SIDRIA-Rome, EPIC-Athens.
SNAC-K, SALT, Sixty, SDPP, DCH, EPIC-Oxford. HUBRO, SNAC-K, SALT, Sixty, SDPP, DCH, EPIC-Oxford, VHM&PP.
HUBRO, SNAC-K, SALT, Sixty, SDPP, DCH, EPIC-MORGEN, EPIC-PROSPECT, EPIC-Oxford, VHM&PP, SIDRIA-Rome.
Table 4: Associations between PM10 and PM25 and risk for lung cancer, according to air pollution thresholds*
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Acknowledgments
This study was funded by the European Communitys Seventh
Framework Programme (FP7/20072011) under grant agreement
number 211250.
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