Risk of Gynecological and Breast Cancers in Workers Exposed to Diesel Exhaust: A Systematic Review and Meta-Analysis Of Cohort Studies

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Marika D'Agostini https://orcid.org/0000-0001-9998-8896
Giulia Collatuzzo
Federica Teglia
Paolo Boffetta


Gynecological cancers, Breast cancer, Diesel Exhaust, Occupational Health, Occupational Risk


Background: This study aimed to explore the association between occupational exposure to diesel exhaust (DE) and gynaecological and breast cancers. Methods: A systematic review was performed to identify cohort studies reporting results on the association between occupational exposure to DE and risk of gynaecological and breast cancers. STROBE guidelines and PECOS criteria were followed. We identified 6 studies for breast cancer (BC), 4 for cervical cancer (CC), 4 for endometrial cancer (EC) and 7 for ovarian cancer (OC). Random-effects meta-analyses were conducted on the relationship between DE exposure and BC, CC, EC, and OC risk; 95% confidence intervals (CI) and prediction intervals (PI) were reported. We investigated between-study heterogeneity and potential publication bias using Egger's test. Results: No associations were observed between occupational DE exposure and risk of BC [RR=0.93; CI: 0.77-1.13; PI:0.50-1.73, I2=80.31%], EC [RR=0.89; CI: 0.75-1.05; PI:0.61-1.30, I2=0.78%], and OC [RR=1.08; CI: 0.89-1.32, PI: 0.76-1.56, I2=11.87%]. A weak association was observed for CC [RR=1.41; CI: 1.17-1.17; PI:0.85-2.30, I2=6.44%]. No between-study heterogeneity or publication bias was detected. Conclusions: This study identified an association between DE exposure and CC, which was not adjusted for potential confounders. No evidence of an association was found with BC, EC, and OC.

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1. Pronk A, Coble J, Stewart PA. Occupational exposure to diesel engine exhaust: a literature review. J Expo Sci Environ Epidemiol. 2009 Jul;19(5):443-57. doi: 10.1038/jes.2009.21.
2. IARC Working Group on the Evaluation of Carcinogenic Risks to Humans. Diesel and gasoline engine ex-hausts and some nitroarenes. IARC Monogr Eval Carcinog Risks Hum. 1989;46:1-458.
3. IARC: diesel engine exhaust carcinogenic. Cent Eur J Public Health. 2012 Jun; 20(2):120, 138.
4. Soll-Johanning H, Bach E, Olsen JH, Tüchsen F. Cancer incidence in urban bus drivers and tramway em-ployees: a retrospective cohort study. Occup Environ Med. 1998 Sep;55(9):594-8. doi: 10.1136/oem.55.9.594.
5. Vasama-Neuvonen K, Pukkala E, Paakkulainen H et al. Ovarian cancer and occupational exposures in Fin-land. Am J Ind Med. 1999 Jul;36(1):83-9. doi: 10.1002/(sici)1097-0274(199907)36:1<83::aid-ajim12>3.0.co;2-q.
6. Guo J, Kauppinen T, Kyyrönen P et al. Risk of esophageal, ovarian, testicular, kidney and bladder cancers and leukemia among finnish workers exposed to diesel or gasoline engine exhaust. Int J Cancer. 2004 Aug 20;111(2):286-92. doi: 10.1002/ijc.20263.
7. Andersen A, Barlow L, Engeland A et al. Work-related cancer in the Nordic countries. Scand J Work Environ Health. 1999;25 Suppl 2:1-116. PMID: 10507118.
8. Pedersen JE, Strandberg-Larsen K, Andersson M, Hansen J. Breast cancer among Danish women occupa-tionally exposed to diesel exhaust and polycyclic aromatic hydrocarbons, 1964-2016. Scand J Work Envi-ron Health. 2021 Mar 1;47(2):154-162. doi: 10.5271/sjweh.3923.
9. IARC Working Group on the Evaluation of Carcinogenic Risks to Humans. Some non-heterocyclic polycyclic aromatic hydrocarbons and some related exposures. IARC Monogr Eval Carcinog Risks Hum. 2010; 92:1–853.
10. Weiderpass E, Boffetta P, Vainio H. Occupational causes of cancer. In: Alison, MR, editor. The cancer hand-book. Chichester (UK): JohnWiley & Sons Ltd; 2007. P. 443-52.
11. von Elm E, Altman DG, Egger M et al. The Strengthening the Reporting of Observational Studies in Epidemi-ology (STROBE) statement: guidelines for reporting observational studies. Bull World Health Organ. 2007 Nov;85(11):867-72. doi: 10.2471/blt.07.045120.
12. Morgan RL, Whaley P, Thayer KA, Schünemann HJ. Identifying the PECO: A framework for formulating good questions to explore the association of environmental and other exposures with health outcomes. Environ Int. 2018 Dec;121(Pt 1):1027-1031. doi: 10.1016/j.envint.2018.07.015.
13. Page MJ, Moher D, Bossuyt PM et al. PRISMA 2020 explanation and elaboration: updated guidance and exemplars for reporting systematic reviews. BMJ. 2021 Mar 29;372:n160. doi: 10.1136/bmj.n160.
14. Sidik K, Jonkman JN. A simple confidence interval for meta-analysis. Stat Med. 2002 Nov 15;21(21):3153-9. doi: 10.1002/sim.1262.
15. Borenstein M, Hedges LV, Higgins JPT, Rothstein HR. (2009). Prediction Intervals. In Introduction to Meta-Analysis (eds Borenstein M, Hedges LV, Higgins JPT, Rothstein HR). 2009. doi:10.1002/9780470743386.ch17
16. Higgins JP, Thompson SG. Quantifying heterogeneity in a meta-analysis. Stat Med. 2002 Jun 15;21(11):1539-58. doi: 10.1002/sim.1186.
17. Egger M, Davey Smith G, Schneider M, Minder C. Bias in meta-analysis detected by a simple, graphical test. BMJ. 1997 Sep 13;315(7109):629-34. doi: 10.1136/bmj.315.7109.629.
18. Van Den Eeden SK, Friedman GD. Exposure to engine exhaust and risk of subsequent cancer. J Occup Med. 1993 Mar;35(3):307-11.
19. Boffetta P, Dosemeci M, Gridley G et al. Occupational exposure to diesel engine emissions and risk of cancer in Swedish men and women. Cancer Causes Control. 2001 May;12(4):365-74. doi: 10.1023/a:1011262105972.
20. Pukkala E, Martinsen JI, Lynge E et al. Occupation and cancer - follow-up of 15 million people in five Nordic countries. Acta Oncol. 2009;48(5):646-790. doi: 10.1080/02841860902913546.
21. Matsuura Y, Yoshioka M, Nakata A et al. Trends in Uterine Cervical Cancer Screening at Physical Health Checkups for Company Employees in Japan. J UOEH. 2019;41(3):327-333. doi: 10.7888/juoeh.41.327.
22. Nyambe N, Hoover S, Pinder LF et al. Differences in Cervical Cancer Screening Knowledge and Practices by HIV Status and Geographic Location: Implication for Program Implementation in Zambia. Afr J Reprod Health. 2018 Dec;22(4):92-101. doi: 10.29063/ajrh2018/v22i4.10.
23. Collaborative Group on Hormonal Factors in Breast Cancer. Menarche, menopause, and breast cancer risk: individual participant meta-analysis, including 118 964 women with breast cancer from 117 epidemiological studies. Lancet Oncol. 2012 Nov;13(11):1141-51. doi: 10.1016/S1470-2045(12)70425-4.
24. Lambe M, Hsieh CC, Chan HW et al. Parity, age at first and last birth, and risk of breast cancer: a population-based study in Sweden. Breast Cancer Res Treat. 1996;38(3):305-11. doi: 10.1007/BF01806150.
25. Collaborative Group on Hormonal Factors in Breast Cancer. Breast cancer and breastfeeding: collaborative reanalysis of individual data from 47 epidemiological studies in 30 countries, including 50302 women with breast cancer and 96973 women without the disease. Lancet. 2002 Jul 20;360(9328):187-95. doi: 10.1016/S0140-6736(02)09454-0.
26. White ND. Hormonal Contraception and Breast Cancer Risk. Am J Lifestyle Med. 2018 Jan 31;12(3):224-226. doi: 10.1177/1559827618754833.
27. IARC Working Group on the Evaluation of Carcinogenic Risks to Humans. Painting, firefighting, and shiftwork. IARC Monogr Eval Carcinog Risks Hum. 2010;98:9-764.
28. Lie JA, Andersen A, Kjaerheim K. Cancer risk among 43000 Norwegian nurses. Scand J Work Environ Health. 2007 Feb;33(1):66-73.
29. Dimich-Ward H, Lorenzi M, Teschke K et al. Mortality and cancer incidence in a cohort of registered nurses from British Columbia, Canada. Am J Ind Med. 2007 Dec;50(12):892-900. doi: 10.1002/ajim.20505.
30. Hansen J, Stevens RG. Case-control study of shift-work and breast cancer risk in Danish nurses: impact of shift systems. Eur J Cancer. 2012 Jul;48(11):1722-9. doi: 10.1016/j.ejca.2011.07.005.
31. Chuang YS, Lee CY, Lin PC et al. Breast cancer incidence in a national cohort of female workers exposed to special health hazards in Taiwan: a retrospective case-cohort study of ~ 300,000 occupational records spanning 20 years. Int Arch Occup Environ Health. 2022 Dec;95(10):1979-1993. doi: 10.1007/s00420-022-01897-x.
32. Xiao W, Huang J, Wang J et al. Occupational exposure to organic solvents and breast cancer risk: a systematic review and meta-analysis. Environ Sci Pollut Res Int. 2022 Jan;29(2):1605-1618. doi: 10.1007/s11356-021-17100-6. Epub 2021 Oct 22. Erratum in: Environ Sci Pollut Res Int. 2021 Nov 20.
33. Costantini AS, Gorini G, Consonni D et al. Exposure to benzene and risk of breast cancer among shoe factory workers in Italy. Tumori. 2009 Jan-Feb;95(1):8-12. doi: 10.1177/030089160909500102.
34. Brito-Marcelino A, Duarte-Tavares RJ, Marcelino KB, Silva-Neto JA. Breast cancer and occupational exposures: an integrative review of the literature. Rev Bras Med Trab. 2021 Mar 3;18(4):488-496. doi: 10.47626/1679-4435-2020-595.
35. Mordukhovich I, Beyea J, Herring AH et al. Vehicular Traffic-Related Polycyclic Aromatic Hydrocarbon Exposure and Breast Cancer Incidence: The Long Island Breast Cancer Study Project (LIBCSP). Environ Health Perspect. 2016 Jan;124(1):30-8. doi: 10.1289/ehp.1307736.
36. Onstad MA, Schmandt RE, Lu KH. Addressing the Role of Obesity in Endometrial Cancer Risk, Prevention, and Treatment. J Clin Oncol. 2016 Dec 10;34(35):4225-4230. doi: 10.1200/JCO.2016.69.4638.
37. Raglan O, Kalliala I, Markozannes G et al. Risk factors for endometrial cancer: An umbrella review of the literature. Int J Cancer. 2019 Oct 1;145(7):1719-1730. doi: 10.1002/ijc.31961.
38. Wernli KJ, Ray RM, Gao DL et al. Occupational risk factors for endometrial cancer among textile workers in Shanghai, China. Am J Ind Med. 2008 Sep;51(9):673-9. doi: 10.1002/ajim.20614.
39. Olson SH, Vena JE, Dorn JP et al. Exercise, occupational activity, and risk of endometrial cancer. Ann Epidemiol. 1997 Jan;7(1):46-53. doi: 10.1016/s1047-2797(96)00071-3.
40. Koushik A, Grundy A, Abrahamowicz M et al. Hormonal and reproductive factors and the risk of ovarian cancer. Cancer Causes Control. 2017 May;28(5):393-403. doi: 10.1007/s10552-016-0848-9.
41. Whelan E, Kalliala I, Semertzidou A et al. Risk Factors for Ovarian Cancer: An Umbrella Review of the Literature. Cancers (Basel). 2022 May 30;14(11):2708. doi: 10.3390/cancers14112708.
42. Mori M, Harabuchi I, Miyake H et al. Reproductive, genetic, and dietary risk factors for ovarian cancer. Am J Epidemiol. 1988 Oct;128(4):771-7. doi: 10.1093/oxfordjournals.aje.a115030.
43. Le ND, Leung A, Brooks-Wilson A et al. Occupational exposure and ovarian cancer risk. Cancer Causes Control. 2014 Jul;25(7):829-41. doi: 10.1007/s10552-014-0384-4.
44. Shields T, Gridley G, Moradi T et al. Occupational exposures and the risk of ovarian cancer in Sweden. Am J Ind Med. 2002 Sep;42(3):200-13. doi: 10.1002/ajim.10099.
45. Reid A, de Klerk N, Musk AW. Does exposure to asbestos cause ovarian cancer? A systematic literature review and meta-analysis. Cancer Epidemiol Biomarkers Prev. 2011 Jul;20(7):1287-95. doi: 10.1158/1055-9965.EPI-10-1302.
46. Slomovitz B, de Haydu C, Taub M et al. Asbestos and ovarian cancer: examining the historical evidence. Int J Gynecol Cancer. 2021 Jan;31(1):122-128. doi: 10.1136/ijgc-2020-001672.
47. Ruder AM, Meyers AR, Bertke SJ. Mortality among styrene-exposed workers in the reinforced plastic boatbuilding industry. Occup Environ Med. 2016 Feb;73(2):97-102. doi: 10.1136/oemed-2015-102990.
48. Arm Armenian HK. Incubation periods of cancer: old and new. J Chronic Dis. 1987;40 Suppl 2:9S-15S. doi: 10.1016/s0021-9681(87)80004-8.
49. DerSimonian R, Laird N. Meta-analysis in clinical trials. Control Clin Trials. 1986 Sep;7(3):177-88. doi: 10.1016/0197-2456(86)90046-2.
50. Veroniki AA, Jackson D, Viechtbauer W et al. Methods to estimate the between-study variance and its uncertainty in meta-analysis. Res Synth Methods. 2016 Mar;7(1):55-79. doi: 10.1002/jrsm.1164.
51. Sidik K, Jonkman JN. A comparison of heterogeneity variance estimators in combining results of studies. Stat Med. 2007 Apr 30;26(9):1964-81. doi: 10.1002/sim.2688.
52. Szender JB, Cannioto R, Gulati NR et al. Impact of Physical Inactivity on Risk of Developing Cancer of the Uterine Cervix: A Case-Control Study. J Low Genit Tract Dis. 2016 Jul;20(3):230-3. doi: 10.1097/LGT.0000000000000210.
53. Collatuzzo G, Teglia F, Boffetta P. Role of Occupation in Shaping Cancer Disparities. Cancers (Basel). 2022 Aug 31;14(17):4259. doi: 10.3390/cancers14174259.
54. Wirtz C, Mohamed Y, Engel D et al. Integrating HPV vaccination programs with enhanced cervical cancer screening and treatment, a systematic review. Vaccine. 2022 Mar 31;40 Suppl 1:A116-A123. doi: 10.1016/j.vaccine.2021.11.013.
55. Warner EL, Martel L, Ou JY et al. A Workplace-Based Intervention to Improve Awareness, Knowledge, and Utilization of Breast, Cervical, and Colorectal Cancer Screenings Among Latino Service and Manual Labor Employees in Utah. J Community Health. 2019 Apr;44(2):256-264. doi: 10.1007/s10900-018-0581-2.
56. Huang HL, Chang M: Effects of Two Teaching Programs on Workplace Women’s Cervical Cancer Screening Knowledge, Health Beliefs and Behavior. Nurs Res. 2000, 8 (1): 111-123. In Chinese
57. Jensen KE, Hannibal CG, Nielsen A et al. Social inequality and incidence of and survival from cancer of the female genital organs in a population-based study in Denmark, 1994-2003. Eur J Cancer. 2008 Sep;44(14):2003-17. doi: 10.1016/j.ejca.2008.06.014.
58. Broberg G, Wang J, Östberg AL et al. Socio-economic and demographic determinants affecting participation in the Swedish cervical screening program: A population-based case-control study. PLoS One. 2018 Jan 10;13(1):e0190171. doi: 10.1371/journal.pone.0190171.
59. Akinyemiju T, Ogunsina K, Sakhuja S et al. Life-course socioeconomic status and breast and cervical cancer screening: analysis of the WHO's Study on Global Ageing and Adult Health (SAGE). BMJ Open. 2016 Nov 22;6(11):e012753. doi: 10.1136/bmjopen-2016-012753.
60. Singh H, Mahmud SM. Different study designs in the epidemiology of cancer: case-control vs. cohort studies. Methods Mol Biol. 2009;471:217-25. doi: 10.1007/978-1-59745-416-2_11.