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Industries at risk of bladder cancer within Europe

Submitted by on 30 Sep 2016 – 17:10

Several occupations have an elevated risk of bladder cancer. The highest risks occur in workers within tobacco manufacture, dye and rubber production, nurses, hairdressers and radiation workers. Prof James W.F. Catto, Professor of Urology at the University of Sheffield, surveys the occupations at risk of developing bladder cancer and those at risk of death

Bladder cancer (BC) is the fourth commonest malignancy worldwide and one of the most prevalent in the European Union. (1). The incidence of BC varies greatly around EU member states reflecting patterns of exposure to the main two risk factors; namely tobacco smoke and occupational exposure to cancer forming agents (carcinogens). (1,2) Around half of all BC is caused by tobacco smoke. The impact of smoking upon an individual’s risk of BC varies with the directness of their exposure (self-smoking or inhalation of environmental tobacco smoke), the type of tobacco (black or blonde), gender and the inherited genetic profile (3,4). Legislation to prohibit smoking in public and workplaces is likely to reduce the rate of BC that arise through this route. (2)

The second most common cause of BC is exposure to carcinogens through occupational tasks. This route has been known for many years and has been reduced through workplace health and safety regulations, such as European Union directives (e.g. 90/394/EEC and 98/24/EC) and the 2002 Control of Substances Hazardous to Health Regulations in the UK. The fraction of BCs that arises through occupational carcinogens is estimated to be around 5.3% in total and 7.1% for males. (5) This is lower than the 10% estimated by Doll and Peto in 1981 (6) and fits the estimated 20-30 year latency from exposure to cancer. (7, 8)

Historical occupational bladder cancer

Bladder Cancer was one of the earliest cancers to be linked to occupation. For example, it was known in the 1920s that workers in the rubber industry had an elevated risk of BC. (9) Subsequent evidence identified the anti-oxidant-naphthylamine (2-naphthylamine) as a bladder carcinogen and lead to its restriction and replacement in rubber manufacture. (8,10) Similar observations were made in the dye, textile and printing industries, and lead to restrictions in the use of Benzidine and 4-Aminobiphenyl.

The rubber, dye, textile and printing industries were characterised by high exposures of workers to aromatic amines, usually through the skin contact or inhalation. (7) Workplace legislation and changing manufacturing processes (e.g. digital publishing rather than printing presses using mineral oils and benzidine pigments, robotic automation within car manufacture) have now reduced aromatic amine exposures and BC risk in these industries. However, current workers still appear to have a higher than expected rate of BC, probably through either unknown agents (11) or continued exposure to known carcinogens (e.g. in recycled tyres). (12)

Contemporary occupational bladder cancer

Given changes in manufacturing and workplace health and safety, we recently undertook a systematic review of occupational BC from 1930 to 2010. (13) We reported outcomes in 5 million persons and found significantly elevated BC risks in 42 occupational classes. More worryingly, we also saw an increased risk of mortality from BC in 16 occupational classes. Occupations at risk varied and appeared to differ for BC incidence (new cases) and BC mortality (death from BC).

Occupations at risk

Many occupations have an elevated risk of BC. The highest risks occur in workers within tobacco manufacture, dye and rubber production, nurses, hairdressers and radiation workers. The causative chemicals differ between aromatic amines, polycyclic aromatic hydrocarbons (PAHs) and radiation. Tobacco workers are exposed to aromatic amines such as 2-napthylamine, 4-aminobiphenyl (4-ABP). Dye manufacture, leather and textile workers contact aromatic amines used as dyes and pigments (such as 2-napthylamine, 4-ABP, nitrobiphenyl, benzidine, direct black 58 and blue 6). (14, 15). BC risk in Hairdressers has declined from 3.2-9.15 fold (14, 16), compared to 1.25 fold [13] following the removal of 4-ABP in hair products. Nursing staff are exposed to PAHs through coal tar dressings and the medical use of radiation. Plastic manufacture uses a variety of urothelial carcinogens (e.g. 1,1-dichloroethane is a solvent for 1,1,1-trichloroethane production, MBOCA is a curing agent in polyurethane production and 4,4’-methylenedianiline is used to make polyurethane foams or epoxy resins).

Occupations at risk of death from bladder cancer

The risks of BC in the rubber, dye and chemical industries has lead to health education and worker screening programs of ‘at risk’ workers in various countries. (17) These measures appear successful, as elevated BC risks do not necessarily transfer into higher mortality rates. Similar observations occur in medical staff, suggesting rapid BC diagnosis can alter its prognosis. In contrast, there appears to be a number of occupations, e.g. metal, aluminum and glass manufacture, with higher than expected risks of BC death. (13)

Many of these workers are exposed to PAHs through inhalation of atmospheric pollutants or skin contact from lubricants. PAHs are recognised carcinogens graded according to composition (e.g. naphthalene (IARC 2b), benzo[a]pyrene (IARC 1)) and exposure.(18) Metal, machine and automobile workers are exposed to mineral oil metalworking fluids (MWFs), solder/welding fumes, solvents, paints and greases. MWFs are colorless, odorless, light alkane mixtures from a non-vegetable (mineral) source (often a distillate of petroleum), and include paraffinic oils (based on n-alkanes), naphthenic oils (based on cycloalkanes) and aromatic oils (aromatic hydrocarbons).

Mineral oils are known (IARC 1) carcinogens due to their high PAH content. (5, 14) BC risk increases proportionally with the intensity, duration and accumulation of exposure, (19) and the type of mineral oil: straight (high-risk) versus soluble/synthetic fluids (low-risk) [20]. PAH exposure during aluminum manufacture arises from coal tar/pitch anode evaporation during electrolysis to produce benzo[a]pyrene vapour (IARC 1) (18). PAH inhalation also occurs in firefighters and bar/entertainment industries staff. Many workers are exposed to diesel fumes, known to contain PAHs and other mutagenic particles [21], including drivers, miners, marine workers and seamen. (22-24) The toxicity of fume inhalation is enhanced by the low volumes of fluid drunk by drivers and the high prevalence of cigarette smoking within these occupations. (25)


Many workers are at elevated risks of BC. Geographic patterns will reflect local industries, e.g. Italy, Bulgaria, Greece, Spain and Poland are the main tobacco manufacturers (26), metal workers in the Netherlands, Germany and the UK, and smoking patterns. Health improvement measures should be targeted to workers with higher BC mortality, such as those exposed to PAHs and diesel fumes


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