Failla memorial lecture. Risk, research, and radiation protection

Radiation protection concerns the risk of stochastic late effects, especially cancer, and limits on radiation exposure both occupationally and for the public tend to be based on these risks. The risks are determined, mainly by expert committees, from the steadily growing information on exposed human populations, especially the survivors of the atomic bombs dropped in Japan in 1945. Risks of cancer estimated up to the early 1980s were in the range 1 to 5 X 10(-2)/Sv, but recent revisions in the dosimetry of the Japanese survivors and additional cycles of epidemiological information suggest values now probably at the high end of this range. These are likely to require an increase in the values used for radiation protection. A major problem with risk estimation is that data are available only for substantial doses and must be extrapolated down to the low-dose region of interest in radiation protection. Thus the shape of the dose-response curve is important, and here we must turn to laboratory research. Of importance are studies involving (1) dose rate, which affects the response to low-LET radiation and often to high-LET radiation as well; (2) radiation quality, since the shapes of the dose-response curves for high- and low-LET radiation differ and thus the RBE, the ratio between them, varies, reaching a maximum value RBEM at low doses; and (3) modifiers of the carcinogenic response, which either enhance or reduce the effect of a given dose. Radiation protection depends both on risk information, and especially also on comparisons with other occupational and public risks, and on research, not only for extrapolations of risk to low doses but also in areas where human information is lacking such as in the effects of radiation quality and in modifications of response.     

Value of a multinational approach in determining the causation of cancer

MacMahon and Pugh define epidemiology as the use of knowledge on the frequency and distribution of disease to search for determinants. This paper demonstrates that a multinational approach in cancer epidemiology can be of great value in at least four circumstances: namely, the compilation and standardization of data, the assessment of risk, the pooling of study populations to obtain interpretable results, and the provision of resources for specific epidemiologic investigations. One or two examples are given for each category--the determination of international cancer incidence patterns, the evaluation of the risk posed by chemicals to man, assessment of the effects of low doses of ionizing radiation, determination of the long-term effects of exposure to asbestos substitutes, and studies on the influence of diet on esophageal cancer.     

Radiation Hormesis and Cancer

Despite the long history of radiation hormesis and the public health concerns with low-level exposures to ionizing radiation, there has been surprisingly little formal evaluation of whether hormetic effects are displayed with respect to radiation exposure and cancer incidence (i.e., reduced cancer risk at low radiation doses compared to controls, enhanced cancer risk at higher doses) until relatively recently. This paper reviews data relevant to the question of radiation hormesis and cancer with particular emphasis on experimental studies in animal models exposed to low levels of ionizing radiation. Data exist that provide evidence both consistent with and/or supportive of radiation hormesis. Other biomedical research provides potentially important mechanistic insight: low dose exposures have the capacity to activate immune function to prevent the occurrence of tumor development and metastasis; low doses of radiation have been shown to reduce mutagenic responses and induce endogenous antioxidant responses. These findings are consistent with epidemiological data suggesting an inverse relationship between background radiation and cancer incidence and with occupational epidemiological investigations in which low-dose exposure groups display markedly lower standardized mortality rates than the referent or control group.     

Molecular epidemiology of the late radiation effects

The scientific bases, problems, methods and prospects for the development of a new scientific direction "Molecular epidemiology of late consequences of ionizing radiation influence on the man" are reviewed. It is marked, that for two decades on the basis of achievements in the field of molecular biology, biochemistry, genetics and genomics it has arisen and is developing the important direction in infectious and non-infectious epidemiology--molecular epidemiology. Molecular epidemiology is a new section of epidemiology on border with molecular biology and genetics, integrating efforts of epidemiologists, molecular biologists, genetics and researchers from many other areas of knowledge in a direction of an estimation of individual risk of development of chronic diseases at practically healthy people, development of recommendations on their preventive maintenance in cohorts of risk and, hence, in all population by studying by molecular methods of an etiology of illnesses, mechanisms of a susceptibility to them, and also biological mechanisms and frequency of their development in human cohorts. Special development in molecular epidemiology was noticed for the methods named biomarkers, subdivided on 4 categories: 1) markers of an internal dose; 2) markers of an effective dose; 3) markers of preclinical biological effects; 4) markers of a susceptibility. Use of biomarkers in molecular-epidemiological researches appeared especially productive in oncology. As radiogenic cancers are the main remote consequence of exposure to ionizing radiations, approaches and achievements of molecular epidemiology of nonradiation cancers are perspective at becoming of molecular epidemiology of radiation effects, with an object to solve problems concerning mechanisms and features of radiation carcinogenesis, risk assessment, distribution and preventive maintenance of radiogenic cancers in cohorts of professionals of the various branches having contact to sources of ionizing radiation, and the population, exposed to radiation medically.     

Ionizing radiation biomarkers for potential use in epidemiological studies

Ionizing radiation is a known human carcinogen that can induce a variety of biological effects depending on the physical nature, duration, doses and dose-rates of exposure. However, the magnitude of health risks at low doses and dose-rates (below 100mSv and/or 0.1mSvmin(-1)) remains controversial due to a lack of direct human evidence. It is anticipated that significant insights will emerge from the integration of epidemiological and biological research, made possible by molecular epidemiology studies incorporating biomarkers and bioassays. A number of these have been used to investigate exposure, effects and susceptibility to ionizing radiation, albeit often at higher doses and dose rates, with each reflecting time-limited cellular or physiological alterations. This review summarises the multidisciplinary work undertaken in the framework of the European project DoReMi (Low Dose Research towards Multidisciplinary Integration) to identify the most appropriate biomarkers for use in population studies. In addition to logistical and ethical considerations for conducting large-scale epidemiological studies, we discuss the relevance of their use for assessing the effects of low dose ionizing radiation exposure at the cellular and physiological level. We also propose a temporal classification of biomarkers that may be relevant for molecular epidemiology studies which need to take into account the time elapsed since exposure. Finally, the integration of biology with epidemiology requires careful planning and enhanced discussions between the epidemiology, biology and dosimetry communities in order to determine the most important questions to be addressed in light of pragmatic considerations including the appropriate population to be investigated (occupationally, environmentally or medically exposed), and study design. The consideration of the logistics of biological sample collection, processing and storing and the choice of biomarker or bioassay, as well as awareness of potential confounding factors, are also essential.     

Human exposure to endocrine disrupters: carcinogenic risk assessment

Human exposure to endocrine disrupters (EDs) is widespread and is considered to pose a growing threat to human health. Recent advances in molecular and genetic research and better understanding of mechanisms of blastic cell transformation have led to efforts to improve cancer risk assessment for populations exposed to this family of xenobiotics. In risk assessment, low dose extrapolation of cancer incidence data from both experimental animals and epidemiology studies has been largely based on models assuming linear correlation at low doses, despite existence of evidence showing otherwise. Another weakness of ED risk assessment is poor exposure data in ecological studies. Those are frequently rough estimates derived from contaminated items of local food basket surveys. Polyhalogenated hydrocarbons are treated as examples. There is growing sense of urgency to develop a biologically based dose response model of cancer risk, integrating emerging data from molecular biology and epidemiology to provide more realistic data for risk assessors, public, public health managers and environmental issues administrators.     

The effect of dose rate on radiation-induced neoplastic transformation in vitro by low doses of low-LET radiation

The dependence of the incidence of radiation-induced cancer on the dose rate of the radiation exposure is a question of considerable importance to the estimation of risk of cancer induction by low-dose-rate radiation. Currently a dose and dose-rate effectiveness factor (DDREF) is used to convert high-dose-rate risk estimates to low dose rates. In this study, the end point of neoplastic transformation in vitro has been used to explore this question. It has been shown previously that for low doses of low-LET radiation delivered at high dose rates, there is a suppression of neoplastic transformation frequency at doses less than around 100 mGy. In the present study, dose-response curves up to a total dose of 1000 mGy have been generated for photons from (125)I decay (approximately 30 keV) delivered at doses rates of 0.19, 0.47, 0.91 and 1.9 mGy/min. The results indicate that at dose rates of 1.9 and 0.91 mGy/min the slope of the induction curve is about 1.5 times less than that measured at high dose rate in previous studies with a similar quality of radiation (28 kVp mammographic energy X rays). In the dose region of 0 to 100 mGy, the data were equally well fitted by a threshold or linear no-threshold model. At dose rates of 0.19 and 0.47 mGy/min there was no induction of transformation even at doses up to 1000 mGy, and there was evidence for a possible suppressive effect. These results show that for this in vitro end point the DDREF is very dependent on dose rate and at very low doses and dose rates approaches infinity. The relative risks for the in vitro data compare well with those from epidemiological studies of breast cancer induction by low- and high-dose-rate radiation.     

Animals as sentinels: using comparative medicine to move beyond the laboratory

The comparative medicine approach, as applied to the study of laboratory animals for the betterment of human health, has resulted in important medical and scientific progress. Much of what is known about the human health risks of many toxic and infectious hazards present in the environment derives from experimental studies in animals and observational (epidemiological) studies of exposed human populations. Yet there is a third source of "in vivo" knowledge about host-environment interactions that may be underused and -explored: the study of diseases in naturally occurring animal populations that may signal potential human health threats. Just as canaries warned coal miners of the risk of toxic gases, other nonhuman animals, due to their greater susceptibility, environmental exposure, or shorter life span, may serve as "sentinels" for human environmental health hazards. Traditionally, communication between human and animal health professionals about cross-species sentinel events has been limited, but progress in comparative genomics, animal epidemiology, and bioinformatics can now provide an enhanced forum for such communication. The "One Health" concept involves moving toward a comparative clinical approach that considers "shared risks" between humans and animals and promotes greater cooperation and collaboration between human and animal health professionals to identify and reduce such risks. In doing so, it also creates new opportunities for the field of comparative medicine that can supplement traditional laboratory animal research.     

Genomic damage in children accidentally exposed to ionizing radiation: a review of the literature

During the last decade, our knowledge of the mechanisms by which children respond to exposures to physical and chemical agents present in the environment, has significantly increased. Results of recent projects and programmes focused on children's health underline a specific vulnerability of children to environmental genotoxicants. Environmental research on children predominantly investigates the health effects of air pollution while effects from radiation exposure deserve more attention. The main sources of knowledge on genome damage of children exposed to radiation are studies performed after the Chernobyl nuclear plant accident in 1986. The present review presents and discusses data collected from papers analyzing genome damage in children environmentally exposed to ionizing radiation. Overall, the evidence from the studies conducted following the Chernobyl accident, nuclear tests, environmental radiation pollution and indoor accidental contamination reveals consistently increased chromosome aberration and micronuclei frequency in exposed than in referent children. Future research in this area should be focused on studies providing information on: (a) effects on children caused by low doses of radiation; (b) effects on children from combined exposure to low doses of radiation and chemical agents from food, water and air; and (c) specific effects from exposure during early childhood (radioisotopes from water, radon in homes). Special consideration should also be given to a possible impact of a radiochemical environment to the development of an adaptive response for genomic damage. Interactive databases should be developed to provide integration of cytogenetic data, childhood cancer registry data and information on environmental contamination. The overall aim is to introduce timely and efficient preventive measures, by means of a better knowledge of the early and delayed health effects in children resulting from radiation exposure.     

Sensitivity of germ cells and embryos to ionizing radiation

Experiments performed in laboratory animals suggest that ionizing radiation can induce DNA damage in the germ cells of exposed individuals and lead to various deleterious effects in their progeny, including miscarriage, low birth weight, congenital abnormalities and perhaps cancer. However, no clear evidence for such effects has been found in epidemiological studies of people exposed to radiation. The predicted risks of hereditary effects of any kinds resulting from parental exposure to relatively low doses of ionizing radiation remain very low, compared to the spontaneous risks in the absence of irradiation. Irradiation of the mouse embryo can lead to various effects (lethality, growth retardation, congenital abnormalities), depending on the period of gestation at which irradiation occurs. In humans, prenatal irradiation has only been exceptionally associated with congenital abnormalities, but irradiation between weeks 8-25 has been shown to be able to induce severe mental retardation. Although being not proven, the risk of developing a childhood cancer following prenatal irradiation may also not be excluded. Like for genetic effects, the risk of adverse effects following exposure of the embryo to relatively low doses remains quite low compared to the natural risks.     

Low doses of ionizing radiation and circulatory diseases: a systematic review of the published epidemiological evidence

Recent analyses of mortality among atomic bomb survivors have suggested a linear dose-response relationship between ionizing radiation and diseases of the circulatory system for exposures in the range 0-4 Sv. If confirmed, this has substantial implications. We have therefore reviewed the published literature to see if other epidemiological data support this finding. Other studies allowing a comparison of the rates of circulatory disease in individuals drawn from the same population but exposed to ionizing radiation at different levels within the range 0-5 Gy or 0-5 Sv were identified through systematic literature searches. Twenty-six studies were identified. In some, disease rates among those exposed at different levels may have differed for reasons unrelated to radiation exposure, while many had low power to detect effects of the relevant magnitude. Among the remainder, one study found appreciable evidence that exposure to low-dose radiation was associated with circulatory diseases, but five others, all with appreciable power, did not. We conclude that the other epidemiological data do not at present provide clear evidence of a risk of circulatory diseases at doses of ionizing radiation in the range 0-4 Sv, as suggested by the atomic bomb survivors. Further evidence is needed to characterize the possible risk.     

Comparing different methods of estimating cosmic radiation exposure of airline personnel

In Europe, several studies are currently underway to investigate the cancer risk of pilots and cabin crew exposed to low-level ionizing radiation of cosmic origin. Although no individualized exposure measurements of airline personnel are available, exposure assessment based on job history data is feasible. However, there is a marked variability in the level of detail of these data between studies in different countries and between subcohorts in national studies raising the issue of comparability of exposure estimation. In this paper we investigate the comparability of several methods of exposure assessment in a large German cohort of pilots and cabin crew. We found that the correlation between the estimates obtained by the four approaches analysed, is relatively high, ranging from 0.85 to 0.97. The precision attainable in the exposure assessment is higher than in many other epidemiological studies but can be refined further with simulation studies and comparison with ongoing and future on-board measurement programmes.     

Cancer risk from chronic exposures to chemicals and radiation: a comparison of the toxicological reference value with the radiation detriment

This article aims at comparing reference methods for the assessment of cancer risk from exposure to genotoxic carcinogen chemical substances and to ionizing radiation. For chemicals, cancer potency is expressed as a toxicological reference value (TRV) based on the most sensitive type of cancer generally observed in animal experiments of oral or inhalation exposure. A dose–response curve is established by modelling experimental data adjusted to apply to human exposure. This leads to a point of departure from which the TRV is derived as the slope of a linear extrapolation to zero dose. Human lifetime cancer risk can then be assessed as the product of dose by TRV and it is generally considered to be tolerable in a 10^–6–10^–4 range for the public in a normal situation. Radiation exposure is assessed as an effective dose corresponding to a weighted average of energy deposition in body organs. Cancer risk models were derived from the epidemiological follow-up of atomic bombing survivors. Considering a linear-no-threshold dose-risk relationship and average baseline risks, lifetime nominal risk coefficients were established for 13 types of cancers. Those are adjusted according to the severity of each cancer type and combined into an overall indicator denominated radiation detriment. Exposure to radiation is subject to dose limits proscribing unacceptable health detriment. The differences between chemical and radiological cancer risk assessments are discussed and concern data sources, extrapolation to low doses, definition of dose, considered health effects and level of conservatism. These differences should not be an insuperable impediment to the comparison of TRVs with radiation risk, thus opportunities exist to bring closer the two types of risk assessment.

     

Non-malignant thyroid diseases after a wide range of radiation exposures

The thyroid gland is one of the most radiosensitive human organs. While it is well known that radiation exposure increases the risk of thyroid cancer, less is known about its effects in relation to non-malignant thyroid diseases. The aim of this review is to evaluate the effects of high- and low-dose radiation on benign structural and functional diseases of the thyroid. We examined the results of major studies from cancer patients treated with high-dose radiotherapy or thyrotoxicosis patients treated with high doses of iodine-131, patients treated with moderate- to high-dose radiotherapy for benign diseases, persons exposed to low doses from environmental radiation, and survivors of the atomic bombings who were exposed to a range of doses. We evaluated radiation effects on structural (tumors, nodules), functional (hyper- and hypothyroidism), and autoimmune thyroid diseases. After a wide range of doses of ionizing radiation, an increased risk of thyroid adenomas and nodules was observed in a variety of populations and settings. The dose response appeared to be linear at low to moderate doses, but in one study there was some suggestion of a reduction in risk above 5 Gy. The elevated risk for benign tumors continues for decades after exposure. Considerably less consistent findings are available regarding functional thyroid diseases including autoimmune diseases. In general, associations for these outcomes were fairly weak, and significant radiation effects were most often observed after high doses, particularly for hypothyroidism. A significant radiation dose-response relationship was demonstrated for benign nodules and follicular adenomas. The effects of radiation on functional thyroid diseases are less clear, partly due to the greater difficulties encountered in studying these diseases.     

The Southern Urals radiation studies. A reappraisal of the current status

In the late 1940s and early 1950s the nuclear workers of the Mayak Production Association in the Southern Urals were exposed to high doses from gamma-rays and from incorporated plutonium. In addition, the population of the Techa riverside downstream of the plutonium-production sites received continued exposures from external gamma-rays due to fission products released into the river and from the internal radiation due to incorporation of the fission products. Based on two international coordination meetings in 1998 and 2000, a synopsis has been given recently in this journal of the radioepidemiological studies on these exposed populations. This commentary describes the current status of these singular investigations with regard to the dosimetry, the assessment of late health effects, and the risk estimation both for the Mayak nuclear workers and the Techa riverside population. A central issue are newly published reduced estimates of the external dose to the Techa riverside population which imply substantially increased risk coefficients for solid cancer. Unless the new dosimetry system, TRDS-2000, has missed a major dose contribution, there is now conspicuous disagreement with current risk estimates. Unaccounted doses from atmospheric releases of fission products and from radiological screening of the Techa riverside population need to be explored, but underestimation of the short lived fission products released into the river appears to be a more critical factor. It is furthermore argued that even if TRDS-2000 were confirmed it would remain questionable whether risk estimates can be based on organ-specific doses when they are obtained in a population with a much higher bone-marrow exposure that may possibly have caused an 'abscopal' radiation effect.     

Secondary carcinogenesis in patients treated with radiation: a review of data on radiation-induced cancers in human, non-human primate, canine and rodent subjects

Concern for risk of radiation-induced cancer is growing with the increasing number of cancer patients surviving long term. This study examined data on radiation transformation of mammalian cells in vitro and on the risk of an increased cancer incidence after irradiation of mice, dogs, monkeys, atomic bomb survivors, occupationally exposed persons, and patients treated with radiation. Transformation of cells lines in vitro increased linearly with dose from approximately 1 to approximately 4-5 Gy. At <0.1 Gy, transformation was not increased in all studies. Dose-response relationships for cancer incidence varied with mouse strain, gender and tissue/organ. Risk of cancer in Macaca mulatta was not raised at 0.25-2.8 Gy. From the atomic bomb survivor study, risk is accepted as increasing linearly to 2 Sv for establishing exposure standards. In irradiated patients, risk of cancer increased significantly from 1 to 45 Gy (a low to a high dose level) for stomach and pancreas, but not for bladder and rectum (1-60 Gy) or kidney (1-15 Gy). Risk for several organs/tissues increased substantially at doses far above 2 Gy. There is great heterogeneity in risk of radiation-associated cancer between species, strains of a species, and organs within a species. At present, the heterogeneity between and within patient populations of virtually every parameter considered in risk estimation results in substantial uncertainty in quantification of a general risk factor. An implication of this review is that reduced risks of secondary cancer should be achieved by any technique that achieved a dose reduction down to approximately [corrected] 0.1 Gy, i.e. dose to tissues distant from the target. The proportionate gain should be greatest for dose decrement to less than 2 Gy.     

International Commission for Protection against Environmental Mutagens and Carcinogens. ICPEMC publication No. 13. The need for biological risk assessment in reaching decisions about carcinogens

The prudent assumption that carcinogen bioassays in rodents predict for human carcinogenicity is examined. It is suggested that in certain cases, as for example the induction of tumors against a high incidence in controls, or in situations in which high dose toxicity may be a critical factor in the induction of cancer, the probability that animal bioassays predict for humans may be low. The term 'biological risk assessment' is introduced to describe that part of risk assessment concerned with the relevance of specific animal results to the induction of human cancer. Biological risk assessment, which is almost entirely dependent on an understanding of carcinogenesis mechanisms, is an important addition to present mathematical modeling used to predict the effects of animal carcinogens that have been demonstrated after high dose exposure, to the effects of the much smaller doses to which humans are perceived to be exposed. Evidence for the conclusions reached by biological risk assessment may sometimes be supported by a careful review of human epidemiological data.     

Updates to astronaut radiation limits: radiation risks for never-smokers

New epidemiology assessments of the life span study (LSS) of the atomic bomb survivors in Japan and of other exposed cohorts have been made by the U.S. National Academy of Sciences, the United Nations Committee on the Effects of Atomic Radiation, and the Radiation Research Effects Foundation in Japan. The National Aeronautics and Space Administration (NASA) uses a 3% risk of exposure-induced death (REID) as a basis for setting age- and gender-specific dose limits for astronauts. NASA's dose limits originate from the report of the National Council on Radiation Protection and Measurements (NCRP) in the year 2000 based on analysis of older epidemiology data. We compared the results of the recent analysis of the LSS to the earlier risk projections from the NCRP. Using tissue-specific, incidence-based risk transfer from the LSS data to a U.S. population to project REID values leads to higher risk and reduced dose limits for older astronauts (>40 years) compared to earlier models that were based on mortality risk transfer. Because astronauts and many other individuals should be considered as healthy workers, including never-smokers free of lifetime use of tobacco, we considered possible variations in risks and dose limits that would occur due to the reference population used for estimates. After adjusting cancer rates to remove smoking effects, radiation risks for lung and total cancer were estimated using a mixture model, with equal weights for additive and multiplicative transfer, to be 20% and 30% lower for males and females, respectively, for never-smokers compared to the average U.S. population. We recommend age- and gender-specific dose limits based on incidence-based risk transfer for never-smokers that could be used by NASA. Our analysis illustrates that gaining knowledge to improve transfer models, which entail knowledge of cancer initiation and promotion effects, could significantly reduce uncertainties in risk projections.     

Cancer incidence and mortality after low-dose radiation exposure: epidemiological aspects

Current recommendations for limiting exposure to ionizing radiation are based on the linear-no-threshold (LNT) model for radiation carcinogenesis under which every dose, no matter how low, carries with it some cancer risk. In this review, epidemiological evidences are discussed that the LNT hypothesis is incorrect at low doses. A large set of data was accumulated that showed that cancer risk after ordinarily encountered radiation exposure (natural background radiation, medical X-rays, etc.) is much lower than projections based on the LNT model. The discovery of the low-level radiation hormesis (stimulating effect) implies a non-linear dose-response curve in the low-dose region. The further studies in this field will provide new insights about the mechanisms of radiation carcinogenesis.     

Cancer incidence and mortality after low-dosage radiation exposure: Epidemiological aspects

Current recommendations for limiting exposure to ionizing radiation are based on the linear no-threshold (LNT) model for radiation carcinogenesis under which every dose, no matter how low, bears some cancer risk. In this review, epidemiological evidence is discussed that the LNT hypothesis is incorrect at low doses. A large set of data was accumulated that show that cancer risk after ordinarily encountered radiation exposure (natural background radiation, medical X-rays, etc.) is much lower than estimates based on the LNT model. The discovery of low-level radiation hormesis (stimulating effect) implies a non-linear dose-response curve in the low-dosage region. Further studies in this field will provide new insights into the mechanisms of radiation carcinogenesis.