Epidemiology of childhood leukemia in the presence and absence of Down syndrome

Down syndrome (DS) is a common congenital anomaly, and children with DS have a substantially higher risk of leukemia. Although understanding of genetic and epigenetic changes of childhood leukemia has improved, the causes of childhood leukemia and the potential role of environmental exposures in leukemogenesis remain largely unknown. Although many epidemiologic studies have examined a variety of environmental exposures, ionizing radiation remains the only generally accepted environmental risk factor for childhood leukemia. Among suspected risk factors, infections, exposure to pesticides, and extremely low frequency magnetic fields are notable. While there are well-defined differences between leukemia in children with and without DS, studies of risk factors for leukemia among DS children are generally consistent with trends seen among non-DS (NDS) children.We provide background on DS epidemiology and review the similarities and differences in biological and epidemiologic features of leukemia in children with and without DS. We propose that both acute lymphoblastic and acute myeloblastic leukemia among DS children can serve as an informative model for development of childhood leukemia. Further, the high rates of leukemia among DS children make it possible to study this disease using a cohort approach, a powerful method that is unfeasible in the general population due to the rarity of childhood leukemia.     

An in-host model of acute infection: measles as a case study

The epidemiology of acute infections is strongly influenced by the immune status of individuals. In-host models can provide quantitative predictions of immune status and can thus offer valuable insights into the factors that influence transmission between individuals and the effectiveness of vaccination protocols with respect to individual immunity. Here we develop an in-host model of measles infection. The model explicitly considers the effects of immune system memory and CD8 T-cells, which are key to measles clearance. The model is used to determine the effects of waning immunity through vaccination and infection, the effects of booster exposures or vaccines on the level of immunity, and the immune system characteristics that result in measles transmission (R(0)>1) even if an individual has no apparent clinical symptoms. We find that the level of immune system CD8 T-cells at the time of exposure to measles determines whether an individual will experience a measles infection or simply a boost in immunity. We also find that the infected cell dynamics are a good indicator of measles transmission and the degree of symptoms that will be experienced. Our results indicate that the degree of immunity in adults is independent of the source of exposure in early childhood, be it vaccine or natural infection.     

To respond or not to respond: T cells in allergic asthma

The incidence of allergic asthma has almost doubled in the past two decades. Numerous epidemiological studies have linked the recent surge in atopic disease with decreased exposure to infections in early childhood as a result of a more westernized lifestyle. However, a clear mechanistic explanation for how this might occur is still lacking. An answer might lie in the presently unfolding story of various regulatory T-cell populations that can limit adaptive immune responses, including T helper 2 (T(H)2)-cell-mediated allergic airway disease.     

Residential magnetic fields predicted from wiring configurations: II. Relationships To childhood leukemia.

Case-control data on childhood leukemia in Los Angeles County were reanalyzed with residential magnetic fields predicted from the wiring configurations of nearby transmission and distribution lines. As described in a companion paper, the 24-h means of the magnetic field's magnitude in subjects' homes were predicted by a physically based regression model that had been fitted to 24-h measurements and wiring data. In addition, magnetic field exposures were adjusted for the most likely form of exposure assessment errors: classic errors for the 24-h measurements and Berkson errors for the predictions from wire configurations. Although the measured fields had no association with childhood leukemia (P for trend=.88), the risks were significant for predicted magnetic fields above 1.25 mG (odds ratio=2.00, 95% confidence interval=1.03-3.89), and a significant dose-response was seen (P for trend=.02). When exposures were determined by a combination of predictions and measurements that corrects for errors, the odds ratio (odd ratio=2.19, 95% confidence interval=1.12-4.31) and the trend (p =.007) showed somewhat greater significance. These findings support the hypothesis that magnetic fields from electrical lines are causally related to childhood leukemia but that this association has been inconsistent among epidemiologic studies due to different types of exposure assessment error. In these data, the leukemia risks from a child's residential magnetic field exposure appears to be better assessed by wire configurations than by 24-h area measurements. However, the predicted fields only partially account for the effect of the Wertheimer-Leeper wire code in a multivariate analysis and do not completely explain why these wire codes have been so often associated with childhood leukemia. The most plausible explanation for our findings is that the causal factor is another magnetic field exposure metric correlated to both wire code and the field's time-averaged magnitude.     

Childhood leukemia mortality and farming exposure in South Korea: A national population-based birth cohort study

ObjectivesThe aim of this study was to evaluate the relationship between leukemia mortality and exposure to farming among children in South Korea.MethodsA retrospective cohort study of South Korean children was conducted using data collected by the national birth register between 1995 and 2006; these data were then individually linked to death data. A cohort of 6,479,406 children was followed from birth until either their death or until December 31, 2006. For surrogate measures of pesticide exposure, we used residence at birth, paternal occupation, and month of conception from the birth certificate. Farming and pesticide exposure indexes by county were calculated using information derived from the 2000 agricultural census. Poisson regression analyses were used to calculate rate ratios (RRs) of childhood leukemia deaths according to indices of exposure to agricultural pesticides after adjustment for potential confounders.ResultsIn total 585 leukemia deaths were observed during the study period. Childhood leukemia mortality was significantly elevated in children born in rural areas (RR = 1.43, 95%CI 1.09–1.86) compared to those in metropolises, and in counties with both the highest farming index (RR = 1.33, 95%CI 1.04–1.69) and pesticide exposure index (RR = 1.30, 95%CI 1.02–1.66) compared to those in the reference group. However, exposure–response associations were significant only in relation to the farming index. When the analyses were limited to rural areas, the risk of death from leukemia among boys conceived between spring and fall increased over those conceived in winter.ConclusionsOur results show an increase in mortality from childhood leukemia in rural areas; however, further studies are warranted to investigate the environmental factors contributing to the excess mortality from childhood leukemia in rural areas.     

Early‐life environment,developmental immunotoxicology,and the risk of pediatric allergic disease including asthma

Incidence of childhood allergic disease including asthma (AD‐A) has risen since the mid‐20th century with much of the increase linked to changes in environment affecting the immune system. Childhood allergy is an early life disease where predisposing environmental exposures, sensitization, and onset of symptoms all occur before adulthood. Predisposition toward allergic disease (AD) is among the constellation of adverse outcomes following developmental immunotoxicity (DIT; problematic exposure of the developing immune system to xenobiotics and physical environmental factors). Because novel immune maturation events occur in early life, and the pregnancy state itself imposes certain restrictions on immune functional development, the period from mid‐gestation until 2 years after birth is one of particular concern relative to DIT and AD‐A. Several prenatal‐perinatal risk factors have been identified as contributing to a DIT‐mediated immune dysfunction and increased risk of AD. These include maternal smoking, environmental tobacco smoke, diesel exhaust and traffic‐related particles, heavy metals, antibiotics, environmental estrogens and other endocrine disruptors, and alcohol. Diet and microbial exposure also significantly influence immune maturation and risk of allergy. This review considers (1) the critical developmental windows of vulnerability for the immune system that appear to be targets for risk of AD, (2) a model in which the immune system of the DIT‐affected infant exhibits immune dysfunction skewed toward AD, and (3) the lack of allergy‐relevant safety testing of drugs and chemicals that could identify DIT hazards and minimize problematic exposure of pregnant women and children. Birth Defects Res (Part B) 2008. © 2008 Wiley‐Liss, Inc.     

Recent developments in new and old viral infections

Until recently, concerns regarding viral infections and hematologic malignancies were primarily focused on the transplantation of an allogeneic graft. In the last years, the use of immunomodulatory agents such as monoclonal antibodies (e.g. anti CD20, anti CD52) directed against lymphocyte antigens in the treatment of hematopoietic malignancies (e.g. lymphoma, chronic lymphocytic leukemia) has added a great potential to impact on the incidence, severity and timing of viral infections. Patients may acquire viral infections through several mechanisms including transfusion, community exposure or via the donor origin in the case of stem cell transplant. Endogenous reactivation of latent viruses is also commonly observed. Viral replication may lead directly to viral diseases or induce indirect effects such as increased incidence of opportunistic infections and decreased patient survival. Traditionally, herpesviruses have been and are still today the most important viruses in patients with hematologic malignancies. Nowadays, several emerging viral infections have been highlighted as being of concern in this patients' population.     

Trends in childhood leukaemia in the Nordic countries in relation to fallout from atmospheric nuclear weapons testing.

OBJECTIVE--To obtain further information about the risks of childhood leukaemia after exposure to ionising radiation at low doses and low dose rates before or after birth or to the father''s testes shortly before conception. DESIGN--Observational study of trends in incidence of childhood leukaemia in relation to estimated radiation exposures due to fallout from atmospheric nuclear weapons testing during the 1950s and 1960s. SETTING--Nordic countries. SUBJECTS--Children aged under 15 years. MAIN OUTCOME MEASURES--Incidence rates of leukaemia by age at diagnosis, sex, country, and calendar year of diagnosis or year of birth; exposure category; relation between leukaemia and exposure for children aged 0-14 and 0-4 separately. RESULTS--During the high fallout period the average estimated dose equivalent to the fetal red bone marrow was around 140 mu Sv and the average annual testicular dose 140 mu Sv. There was little evidence of increased incidence of leukaemia among children born in these years. Doses to the red bone marrow of a child after birth were higher, and during the high exposure period children would have been subjected to an additional dose equivalent of around 1500 mu Sv, similar to doses received by children in several parts of central and eastern Europe owing to the Chernobyl accident and about 50% greater than the annual dose equivalent to the red bone marrow of a child from natural radiation. leukaemia incidence and red marrow dose was not related overall, but rates of leukaemia in the high exposure period were slightly higher than in the surrounding medium exposure period (relative risk for ages 0-14: 1.07, 95% confidence interval 1.00 to 1.14; for ages 0-4: 1.11, 1.00 to 1.24). CONCLUSIONS--Current predicted risks of childhood leukaemia after exposure to radiation are not greatly underestimated for low dose rate exposures.     

Exposure to sodium tungstate and Respiratory Syncytial Virus results in hematological/immunological disease in C57BL/6J mice

The etiology of childhood leukemia is not known. Strong evidence indicates that precursor B-cell Acute Lymphoblastic Leukemia (Pre-B ALL) is a genetic disease originating in utero. Environmental exposures in two concurrent, childhood leukemia clusters have been profiled and compared with geographically similar control communities. The unique exposures, shared in common by the leukemia clusters, have been modeled in C57BL/6 mice utilizing prenatal exposures. This previous investigation has suggested in utero exposure to sodium tungstate (Na2WO4) may result in hematological/immunological disease through genes associated with viral defense. The working hypothesis is (1) in addition to spontaneously and/or chemically generated genetic lesions forming pre-leukemic clones, in utero exposure to Na2WO4 increases genetic susceptibility to viral influence(s); (2) postnatal exposure to a virus possessing the 1FXXKXFXXA/V9 peptide motif will cause an unnatural immune response encouraging proliferation in the B-cell precursor compartment. This study reports the results of exposing C57BL/6J mice to Na2WO4 in utero via water (15 ppm, ad libetum) and inhalation (mean concentration PM5 3.33 mg/m3) and to Respiratory Syncytial Virus (RSV) within 2 weeks of weaning. Inoculation of C57BL/6J mice with RSV was associated with a neutrophil shift in 56% of 5-month old mice. When the RSV inoculation was combined with Na2WO4-exposure, significant splenomegaly resulted (p=0.0406, 0.0184, 0.0108 for control, Na2WO4-only and RSV-only, respectively) in addition to other hematological pathologies which were not significant. Exposure to Na2WO4 and RSV resulted in hematological/immunological disease, the nature of which is currently inconclusive. Further research is needed to characterize this potential leukemia mouse model.     

Childhood leukemia, electric and magnetic fields, and temporal trends

During the past 25 years concern has been raised about the possible health effects of extremely low frequency (ELF) electric and magnetic fields (EMFs), particularly regarding childhood leukemia. Comparison of changes in electricity consumption (a surrogate for exposure) to changes in childhood-leukemia rates, known as ecologic correlation, have been used to argue both for and against the association between magnetic fields and childhood leukemia. In this paper we explore what can be learned from such an ecologic approach. We first examine separately the evidence on trends in exposure to EMFs and on trends in leukemia rates, and then compare the two. Both incidence rates and exposures have increased, but there are so many approximations and assumptions involved in connecting the two trends that we cannot regard the ecologic evidence as providing any meaningful evidence for or against a causal link.     

The Childhood Leukemia International Consortium

Background: Acute leukemia is the most common cancer in children under 15 years of age; 80% are acute lymphoblastic leukemia (ALL) and 17% are acute myeloid leukemia (AML). Childhood leukemia shows further diversity based on cytogenetic and molecular characteristics, which may relate to distinct etiologies. Case–control studies conducted worldwide, particularly of ALL, have collected a wealth of data on potential risk factors and in some studies, biospecimens. There is growing evidence for the role of infectious/immunologic factors, fetal growth, and several environmental factors in the etiology of childhood ALL. The risk of childhood leukemia, like other complex diseases, is likely to be influenced both by independent and interactive effects of genes and environmental exposures. While some studies have analyzed the role of genetic variants, few have been sufficiently powered to investigate gene–environment interactions. Objectives: The Childhood Leukemia International Consortium (CLIC) was established in 2007 to promote investigations of rarer exposures, gene–environment interactions and subtype-specific associations through the pooling of data from independent studies. Methods: By September 2012, CLIC included 22 studies (recruitment period: 1962–present) from 12 countries, totaling approximately 31 000 cases and 50 000 controls. Of these, 19 case–control studies have collected detailed epidemiologic data, and DNA samples have been collected from children and child–parent trios in 15 and 13 of these studies, respectively. Two registry-based studies and one study comprising hospital records routinely obtained at birth and/or diagnosis have limited interview data or biospecimens. Conclusions: CLIC provides a unique opportunity to fill gaps in knowledge about the role of environmental and genetic risk factors, critical windows of exposure, the effects of gene–environment interactions and associations among specific leukemia subtypes in different ethnic groups.     

Intrauterine exposure to diagnostic X rays and risk of childhood leukemia subtypes.

The relationship between childhood leukemia and prenatal exposure to low-dose ionizing radiation remains debatable. This population-based case-control study investigated the association between prenatal exposure to diagnostic X-ray examinations (for different types of examinations and at different stages of pregnancy) and the risk of childhood lymphatic and myeloid leukemia. All children born and diagnosed with leukemia between 1973-1989 in Sweden (578 lymphatic and 74 myeloid) were selected as cases, and each was matched (by sex and year of birth) to a healthy control child (excluding Down's syndrome). Exposure data were abstracted blindly from all available medical records. Odds ratios (OR) and 95% confidence intervals (CI) were calculated by conditional logistic regression. It was found that prenatal X-ray examinations resulting in direct fetal exposure were not associated with a significant overall increased risk for childhood leukemia (OR = 1.11, 95% CI 0.83-1.47), for lymphatic leukemia (OR = 1.04, 95% CI 0.77-1.40), or for myeloid leukemia (OR = 1.49, 95% CI 0.48-4.72). There was little evidence of a dose response or variation in risk by trimester of exposure or age at diagnosis. Thus X-ray examinations performed during pregnancy in the 1970s and 1980s in Sweden did not affect the risk of childhood leukemia discernibly.     

Validity of Using Background Leukemia Incidence Rates with Cohort Mortality-Based Potency Estimates to Calculate Excess Lifetime Risk

Data from occupational cohort mortality studies have been used to derive exposure-response curves and general population excess lifetime cancer risks, given low-level, chronic exposure. Using an actuarial method, mortality-based rate ratios associated with cumulative exposures are applied to age-specific background cancer mortality rates for a theoretical population aged birth to 70 years. In one recent U.S. Environmental Protection Agency health assessment, a mortality-based leukemia relative rate model was used with background leukemia incidence rates, rather than mortality rates, to calculate excess lifetime risk of leukemia incidence. We examined the validity and implications of this novel approach, while considering possible bias if a potential leukemogen did not pose equal risk by cell type. Limited sensitivity analyses were also conducted. Our analyses show that using total leukemia mortality-based potency estimates with background incidence rates will introduce a biased estimate of excess lifetime risk, the direction of which varies by potency and the histological type of leukemia. These biases were somewhat increased on adjustment for possible greater susceptibility of children. For potent carcinogens, the traditional approach provides a reasonable approximation of excess lifetime mortality risk for both the more and less fatal forms of leukemia, even after adjustments for children and is, therefore, to be preferred. Less consistency by leukemia cell type and background rate was observed for flatter exposure-response curves. This evaluation illustrates the importance of carefully examining the impact of methodological changes to calculations of excess lifetime risk before implementation.     

Secondary malignancies in late periods after chemoradiotherapy for lymphogranulomatosis in children

The incidence of secondary malignancies (SM) was studied in a population of 219 patients in late periods (3-29 years) after childhood and adolescence chemoradiotherapy for Hodgkin's lymphoma (HL). SMs were found in 15 (6.8%) patients. These were solid neoplasms located in the irradiated areas in 12 of them, including 4 patients with thyroid cancer and 2 with gastric cancer. All 3 cases of acute leukemia had occurred after chemoradiotherapy performed by extended programs that consisted of a large number of chemotherapy cycles. The detection rate of SM did not significantly depend on the dose of radiation, age at start of treatment, and a child's gender. The findings suggest that there is a need for the maximum concentration of an irradiation beam in the area of thyroid lesion and exposure, for limited cytotoxic therapy programs, and lifetime medical observation of the patients treated for HL in childhood.     

Epidemiologic studies of exposure to prenatal infection and risk of schizophrenia and autism

In this review, we provide a synopsis of work on the epidemiologic evidence for prenatal infection in the etiology of schizophrenia and autism. In birth cohort studies conducted by our group and others, in utero exposure to infectious agents, prospectively obtained after biomarker assays of archived maternal sera and by obstetric records was related to an increased risk of schizophrenia. Thus far, it has been demonstrated that prenatal exposure to influenza, increased toxoplasma antibody, genital-reproductive infections, rubella, and other pathogens are associated with schizophrenia. Anomalies of the immune system, including enhanced maternal cytokine levels, are also related to schizophrenia. Some evidence also suggests that maternal infection and immune dysfunction may be associated with autism. Although replication is required, these findings suggest that public health interventions targeting infectious exposures have the potential for preventing cases of schizophrenia and autism. Moreover, this work has stimulated translational research on the neurobiological and genetic determinants of these conditions. ? 2012 Wiley Periodicals, Inc. Develop Neurobiol, 2012.     

The Urban Environment and Childhood Asthma (URECA) birth cohort study: design, methods, and study population

Background

The incidence and morbidity of wheezing illnesses and childhood asthma is especially high in poor urban areas. This paper describes the study design, methods, and population of the Urban Environment and Childhood Asthma (URECA) study, which was established to investigate the immunologic causes of asthma among inner-city children.

Methods and Results

URECA is an observational prospective study that enrolled pregnant women in central urban areas of Baltimore, Boston, New York City, and St. Louis and is following their offspring from birth through age 7 years. The birth cohort consists of 560 inner-city children who have at least one parent with an allergic disease or asthma, and all families live in areas in which at least 20% of the population has incomes below the poverty line. In addition, 49 inner-city children with no parental history of allergies or asthma were enrolled. The primary hypothesis is that specific urban exposures in early life promote a unique pattern of immune development (impaired antiviral and increased Th2 responses) that increases the risk of recurrent wheezing and allergic sensitization in early childhood, and of asthma by age 7 years. To track immune development, cytokine responses of blood mononuclear cells stimulated ex vivo are measured at birth and then annually. Environmental assessments include allergen and endotoxin levels in house dust, pre- and postnatal maternal stress, and indoor air nicotine and nitrogen dioxide. Nasal mucous samples are collected from the children during respiratory illnesses and analyzed for respiratory viruses. The complex interactions between environmental exposures and immune development will be assessed with respect to recurrent wheeze at age 3 years and asthma at age 7 years.

Conclusion

The overall goal of the URECA study is to develop a better understanding of how specific urban exposures affect immune development to promote wheezing illnesses and asthma.     

Developmental and transplacental genotoxicology: fluconazole

Over the last 40 years mankind has been facing new types of radiochemical environmental settings with every decade. During the last decade, biomonitoring was additionally focused on assessing associations between environmental exposure(s) and both early and late biological effects in children. Despite efforts to control and avoid child exposure to genotoxic agents the incidence of childhood cancers is increasing. Some cancers in adulthood may be the consequence of a multi-step process which starts with intrauterine and childhood exposure. This highlights the importance of a comprehensive interpretation of multiple health effects, especially considering recent studies suggesting that most health disorders are related to DNA changes. When exposed to genotoxic agents, a developing organism (fetus or child) is constantly being forced to reorganize into new equilibriums in order to adjust to a xenobiotic environment. In addition, the influence of sex hormones on radiochemical sensitivity is still unknown. For this reason special attention should be paid to puberty. The results of recent studies on animal models and follow up studies on children after nuclear accidents show long-lasting cytogenetic damage even after low dose exposures and their transgenerational persistance. To evaluate age-related difference and transplacental genotoxic potency fluconazole (FC) was investigated by in vivo micronucleus (MN) assay in adult mice, young mice and in transplacentally exposed newborn pups. Compared to the baseline values, FC caused no detectable genome damage in adult animals, but there was a significant increase in MN frequency in young animals and in newborn pups. Our study thus exemplifies an age-related chemosensitivity, and argues that cancer-promoting disturbances of complex prenatal developmental mechanisms and maturation during childhood require a new approach using systems biology.     

Non-cancer effects of chemical agents on children's health

This paper provides an overview about the non-cancer health effects for children from relevant chemical agents in our environment. In addition, a meta-analysis was conducted on the association between sudden infant death syndrome (SIDS) and maternal smoking during pregnancy as well as postnatal exposure to environmental tobacco smoke (ETS).In children, birth deformities, neurodevelopment, reproductive outcomes and respiratory system are mainly affected by chemical exposures. According to recent systematic reviews, evidence is sufficient for cognitive impairments caused by low lead exposure levels. Evidence for neurotoxicity from prenatal methylmercury exposure is sufficient for high exposure levels and limited for low levels. Prenatal exposure to polychlorinated biphenyls (PCB) and related toxicants results in cognitive and motor deficits.Maternal smoking during pregnancy is a risk factor for preterm birth, foetal growth deficit and SIDS. The meta-analytic pooled risk estimate for SIDS based on 15 studies is 2.94 (95% confidence interval: 2.43–3.57). Postnatal exposure to ETS was found to increase the SIDS risk by a factor of 1.72 (95% CI: 1.28–2.30) based on six studies which took into account maternal smoking during pregnancy. Additionally, postnatal ETS exposure causes acute respiratory infections, ear problems, respiratory symptoms, more severe asthma, and it slows lung growth. These health effects are also of concern for postnatal exposure to ambient and indoor air pollution.Children differ from adults with respect to several aspects which are relevant for assessing their health risk. Thus, independent evaluation of toxicity in childhood populations is essential.     

Evaluation of maternal health and labor and delivery conditions as risk factors for childhood leukemias in children with Down syndrome

Children with Down syndrome (DS) have a remarkably high risk of developing leukemia during childhood; the mechanisms driving that risk are not well understood, and no clear prevention strategies exist. We conducted a nested case-control study in a Texas DS birth cohort to investigate possible links between maternal health, labor/delivery conditions, and leukemia risk. For most of the factors studied there was no evidence of an increased risk of total leukemias, or the subtypes acute lymphoid or acute myeloid leukemia. Ultrasound use showed an almost 2-fold increased odds of leukemia, but this result is likely an example of confounding by indication. There was a pattern of increased risk seen for presence of co-occurring heart anomalies, including tetralogy of Fallot, ventricular septal defects, atrial septal defects, and patent ductus arteriosus. Further investigation of the links between co-occurring heart defects in children with DS and development of leukemia may provide new understanding of cancer mechanisms, and ultimately lead to prevention opportunities for this high-risk population.     

Childhood acute lymphocytic leukemia and perspectives on risk assessment of early-life stage exposures

Recognition that children are a potentially susceptible subpopulation has led to the development of child-specific sensitivity factors. Establishing reliable sensitivity factors in support of risk assessment of early-life stage exposures can be aided by evaluating studies that enhance our understanding both of the biological basis of disease processes and the potential role of environmental exposures in disease etiology. For these reasons, we evaluated childhood acute lymphocytic leukemia (ALL) studies from the point of view of mechanism and etiology. ALL is the most common form of childhood cancer proposed to result from a prenatal primary event and a postnatal second event. This multi-stage model is supported by the observation that chromosomal translocations/fusion genes (e.g., TEL-AML1) involved in producing ALL are detected at birth (prenatal event), and a postnatal event (e.g., TEL deletion) is required for disease manifestation. It appears that a proportion of ALL cases are the result of environmental exposures, in which case preconceptional, prenatal, and postnatal stages are likely to be critical exposure windows. To this end, we recognized postnatal infection-related risk factors as potential candidates associated with the ALL second event. Additionally, we discuss use of ALL-associated fusion genes and genetic polymorphisms, together or separately, as indicators of ALL susceptibility and increased risk. The possibility of using fusion genes alone as biomarkers of response is also discussed because they can serve as predictors of key events in the development of a mode of action (a sequence of key events, starting with interaction of an agent with a cell, ultimately resulting in cancer formation) for particular environmental exposures. Furthermore, we discuss use of an initiated animal model for ALL, namely transgenic mice with TEL-AML1 expression, for exploring mechanisms by which different classes of environmental exposures could be involved in inducing the postnatal step in ALL formation.