Academic journal article Scandinavian Journal of Work, Environment & Health

Non-Occupational Exposure to Asbestos Is the Main Cause of Malignant Mesothelioma in Women in North Jutland, Denmark

Academic journal article Scandinavian Journal of Work, Environment & Health

Non-Occupational Exposure to Asbestos Is the Main Cause of Malignant Mesothelioma in Women in North Jutland, Denmark

Article excerpt

Diffuse malignant mesothelioma (MM) is an aggressive malignancy that derives from the mesothelial lining of the pleura (MPM), peritoneum (MPeM), pericardium and tunica vaginalis testis and is mainly caused by asbestos inhalation (1). Asbestos is classified into two major categories: the amphiboles, including crocidolite, amosite and tremolite, and the serpentines, namely chrysotile (2). Asbestos exposure is not only occupational but can also be domestic, by sharing a residence with an asbestos worker, as well as environmental, by living in proximity to an asbestos-emitting facility. All such exposures are carcinogenic (3-6). MM incidence among men is significantly higher than among women, but it seems to be a matter of exposure pattern and extent, since the male:female MM ratio is close to 1:1 when equally exposed to asbestos (2).

The North Jutland region in Denmark and particularly the largest city in the region, Aalborg, has a long-term history of large-scale asbestos use from two enterprises: the major Danish asbestos cement product factory (DAF) that has operated in the city of Aalborg since 1928, and a large shipyard (AaS) that used asbestos until 1986 (7). The predominant type of asbestos used in DAF was chrysotile (89%), while smaller quantities of amosite (10%) and crocidolite (1%) were used between 1946-1968 (8, 9). The factory was located in a densely inhabited area in the city of Aalborg, even neighboring four primary schools, and employed approximately 8000 male and 590 female workers (9, 10). Therefore, not only occupational, but domestic and environmental asbestos exposure, as well as combinations thereof might be expected as a cause of MM in that area.

In general, MM is a rare disease among men and even rarer among women, and there are only few detailed epidemiological studies of women with MM (5, 6, 11). Thus, the aim of this observational study was to investigate the scale of domestic and environmental asbestos exposure for the female MM patients.


All archival histological and cytological specimens obtained from female patients diagnosed with MM during 1974-2015 in the Institute of Pathology, Aalborg University Hospital, were reviewed. Two experienced pathologists individually reclassified the diagnoses based on available slides supplemented (when relevant and possible) with additional immunostains according to the international guidelines for mesothelioma diagnosis (12). For standardized classification, a 5-tiered scheme was applied: (i) definitely, (ii) probably, (iii) likely, (iv) unlikely and (v) definitely not MM. All the biopsies classified as unlikely and definitely not MM were excluded from the study, as these patients had probably or definitely other diagnoses.

The asbestos exposure information was obtained by linking individual identification numbers applied to all residents in Denmark from the Danish Supplementary Pension Fund Register (SPFR), the Danish Civil Registration System (CRS), medical journals and the national statistical service of Denmark (Statistics Denmark). The SPFR contains information on all employments, including company name and a unique company code, start and end dates for each employment since 1964, as well as a unique personal identification number, which makes it possible to link information on employment history to information on individuals in nationwide registers (13). The CRS was established in 1968 and covers information for all residents living in Denmark that includes among others the unique personal identification number, family relations (father, mother, siblings and children), and historical address since 1971 and parish at birth (14). Supplementary information about occupational and domestic exposure to asbestos was acquired from the medical journals, and particularly the assessments of occupational health specialist and pulmonologist were used accordingly.

The type of potential asbestos exposure was classified into four categories. …

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