Tiny plastic particles may boost risk from major diseases – study

UNIVERSITY OF BIRMINGHAM

 

IMAGE: 

HUMAN EXPOSURE RATES ARE DETERMINED BY THE ENVIRONMENTAL FATE AND TRANSPORT OF MNPS THAT CONTROL THE CONNECTIVITY BETWEEN SPATIALLY AND TEMPORALLY DYNAMIC ENVIRONMENTAL POLLUTION SOURCES AND HUMAN EXPOSURES (BOTTOM). TOGETHER, THESE DYNAMIC EXPOSURE CONTROLS DETERMINE THE COMBINED UPTAKE OF MNPS AND THEIR ADDITIVES THAT MAY INFLUENCE THE RISK AND/OR SEVERITY OF NCDS. THE TEXT BOXES PROVIDE SOME EXAMPLE EXPOSURE RANGES ASSOCIATED WITH DIFFERENT MNP SOURCES.

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CREDIT: UNIVERSITY OF BIRMINGHAM

People may be at increased risk from cancer, diabetes, cardiovascular disease, and chronic lung disease – as rising global levels of micro- and nanoplastics (MnPs) are absorbed into the human body, a new study reveals.

Non-communicable diseases (NCD) such as these are linked to inflammatory conditions in the body’s organs, with the tiny particles increasing the uptake of MnPs and their leachates within digestive and respiratory systems – potentially boosting the risk and severity of NCDs in the future.

And MnP concentrations in infant faecal matter are significantly higher than in adults – possibly because plastic is commonly used in infant food preparation, presentation, and storage. Young children’s behaviour such as putting objects in their mouth may also account for this.

Publishing their findings in Cell Reports Medicine, an international group of researchers is now calling for a global integrated One Health approach to human health and environmental research that will reveal the environmental mechanisms that lie behind the rise in human MnP exposure and the particles links with NCDs.

Lead author Professor Stefan Krause, from the University of Birmingham, commented: “Plastic pollution has increased globally – making it critical that we understand the overall health risks associated with MnP exposure.

“We must tackle this pollution at its source to reduce further emissions, as the global dispersal of MnPs that has already happened will remain a cause of concern for centuries to come. For this, we need a systematic investigation into the environmental drivers of human MnP exposure and their impacts on the prevalence and severity of the main NCD groups of cancer, diabetes, cardiovascular disease, and chronic lung disease.”

The researchers highlight that the relationship between MnPs and NCDs resembles those of other particles, including natural sources such as pollen or human-made pollutants like diesel exhaust, and MnPs, and engineered nanomaterials, all acting in a similar biological manner. The body treats these as foreign entities triggering the same protective mechanisms – presenting a risk of bodily defences becoming overwhelmed and boosting the frequency and severity of NCDs.

The incidence of NCDs is increasing across the world with the four main types collectively responsible for 71% of all global deaths annually and creating a predicted economic impact of more than $30 trillion over the next two decades.

Co-author Semira Manaseki-Holland, from the University of Birmingham, commented: “We must better understand how MnPs and NCDs interact, if we are to progress global prevention and treatment efforts toward the UN Sustainable Development Goal on reducing premature mortality from NCDs and other conditions where inflammation are concerned through by 2030.

“This need is critical in low- and low-middle-income countries (LMICs) where NCD prevalence is rising, and plastic pollution levels and exposures are high. Whether we encounter them indoors or outdoors, MnPs are likely adding to global health risks.”

Global pollution trends show that micro- (smaller than 5 mm) and nanoplastic (smaller than 1 µm) particles are now found everywhere. MnPs have been detected in lungs, blood, breast milk, placenta, and stool samples confirming that the particles enter the human body from the environment.

Humans are exposed to MnPs in outdoor and indoor environments through food stuffs, drinks consumption, air and many other sources including cosmetics and human care products.

MnPs have been found in fish, salt, beer, and plastic bottled drinks or air, where they are released from synthetic clothing materials, plastic fabric bedding during sleep, plastic carpet or furniture. Other sources can include fertiliser, soil, irrigation, and uptake into food crops or produce.

Human exposure to MnPs varies significantly depending on location and exposure mechanism, with evidence of MnP pollution hotspots in indoor air containing up to 50 times the number of particles encountered outdoors.

Co-author Professor Iseult Lynch, from the University of Birmingham, commented: “We must understand the human health risks associated with MnPs and to do this, we will need to understand the environmental controls of individual exposures. This will require environmental and medical scientists to work very closely together.”

ENDS

Hypothesized uptake mechanisms of MnPs through human body 

(A) Hypothesized uptake mechanisms of MnPs through human biological barriers, including via (B) the olfactory bulb, (C) the lung-air barrier, and (D) the gastrointestinal tract, indicating also the systems and organs directly affected by MnPs and the associated MnP impacts and suspected adverse health out comes including NCDs. The suspected particle-size fractionation caused by differences in the uptake mechanisms (A–D) is highlighted in (E), with larger particles being ingested (up to 130 mm) rather than inhaled (less than 2.5 mm) and only the smallest (nanoscale) particles being able to penetrate the blood-brain barrier. MnP internalized by routes (C) and (D) reach the wider circulatory system and from there can reach all organs.

CREDIT

University of Birmingham

Infographic details

• Figure 1. Environmental exposure routes, transport, and sources of MnPs Environmental exposure routes and sources of MnPs in indoor (top) and outdoor environments (middle). Human exposure rates are determined by the environmental fate and transport of MnPs that control the connectivity between spatially and temporally dynamic environmental pollution sources and human exposures (bottom). Together, these dynamic exposure controls determine the combined uptake of MnPs and their additives that may influence the risk and/or severity of NCDs. The text boxes provide some example exposure ranges associated with different MnP sources.
• Figure 2. Hypothesized uptake mechanisms of MnPs through human body (A–D) (A) Hypothesized uptake mechanisms of MnPs through human biological barriers, including via (B) the olfactory bulb, (C) the lung-air barrier, and (D) the gastrointestinal tract, indicating also the systems and organs directly affected by MnPs and the associated MnP impacts and suspected adverse health out comes including NCDs. The suspected particle-size fractionation caused by differences in the uptake mechanisms (A–D) is highlighted in (E), with larger particles being ingested (up to 130 mm) rather than inhaled (less than 2.5 mm) and only the smallest (nanoscale) particles being able to penetrate the blood-brain barrier. MnP internalized by routes (C) and (D) reach the wider circulatory system and from there can reach all organs.

Notes to Editors

• The University of Birmingham is ranked amongst the world’s top 100 institutions, its work brings people from across the world to Birmingham, including researchers and teachers and more than 8,000 international students from over 150 countries. Discover Birmingham.
• ‘The potential of micro- and nanoplastics to exacerbate the health impacts and global burden of non-communicable diseases’ - Stefan Krause, Valerie Ouellet, Deonie Allen, Steven Allen, Kerry Moss, Holly A. Nel, Semira Manaseki-Holland, and Iseult Lynch is published by Cell Reports Medicine.
• Participating institutions:

• University of Birmingham, UK
• Universite´ Claude Bernard, Lyon, France
• University of Strathclyde, Glasgow, UK
• Northeast Fisheries Science Center, Orono, USA
• Dalhousie University, Halifax, Canada
• Imperial College of Science, Technology and Medicine, London, UK
• Center for Environment, Fisheries & Agriculture Science, Lowestoft, UK

 

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JOURNAL

Cell Reports Medicine

METHOD OF RESEARCH

Data/statistical analysis

SUBJECT OF RESEARCH

People

ARTICLE TITLE

The potential of micro- and nanoplastics to exacerbate the health impacts and global burden of non-communicable diseases

Plastics Are Fossil Fuel Industry’s Plan B.

 Fenceline Communities Pay the Price.

Production is concentrated in poor communities and communities of color, and residents face elevated health threats.

By Derek Seidman , 

TRUTHOUT

February 16, 2024

Oil facilities are seen past neighborhoods in Port Arthur, Texas,

MICHAEL S. WILLIAMSON / THE WASHINGTON POST VIA GETTY IMAGES

Scientists are increasingly alarmed over the soaring amounts of microplastics (small pieces of plastic less than five millimeters) and nanoplastics (extremely small, sub-micrometer plastic particles) being discovered throughout our planet, our bodies and our food. Just this past January, new studies found huge numbers of plastic particles in bottled water and microplastics in nearly 90 percent of sampled proteins like beef and tofu. These reports follow many others that have found microplastics and nanoplastics in nearly every crevice of our world: clouds and rivers, Arctic sea ice and sea mammals, heart tissue and breast milk and even placentas.

With global plastics waste on pace to nearly triple by 2060, the problem is only set to worsen. The proliferation of microplastics is an outgrowth of the larger perils associated with plastics production. Plastic contains many toxic chemicals, and plastic waste saturates our land and oceans. According to a 2022 OECD report, only 9 percent of plastic waste is recycled, with most of it “ending up in landfill, incinerated or leaking into the environment.”

Major corporations, from chemical companies to consumer brands, have a vested interest in perpetuating plastics production. Powerful industry organizations spend millions every year lobbying to expand plastics production and kill regulatory efforts to limit harms tied to plastics.

The oil and gas industry sees plastics, which are made from fossil fuels, as an expanding avenue for profits. Plastics production is interlocked with the climate crisis and environmental injustice. Refineries and petrochemical facilities that turn crude oil and natural gas into polymers to make plastic are concentrated in poor communities and communities of color, like along the Texas and Louisiana Gulf Coast, where residents face elevated threats of cancer and respiratory diseases.

The Same Billionaires Behind the Super Bowl Are Also Behind the Climate Crisis

The Kansas City Chiefs’ current owner, Clark Hunt, comes from one of the most powerful oil dynasties in US history.

By Derek Seidman , TRUTHOUT February 11, 2024

“These are toxic chemicals they use,” John Beard Jr., a resident of Port Arthur, Texas, and founder of the Port Arthur Community Action Network, told Truthout. “We’re poisoning ourselves with more and more pollution. This has to stop.”

Fossil Fuel Industry’s Plan B

The proliferation of microplastics across the world is so widespread that some scientists claim we’re living in a new historical epoch: the Plasticene.

“Microplastics are worth being concerned about, not just because our bodies are now containing plastic, but because that plastic contains a number of chemical additives, many of which we know to be toxic to human health,” said Melissa Valliant, communications director of Beyond Plastics, a nonprofit group working to reducing plastic pollution.

Numerous studies have raised alarm over dangers to public health associated with plastics production. A 2019 report by the Center for International Environmental Law extensively documented the ways that harmful toxins, chemicals and waste tied to numerous diseases, including cancer, pervade the entire production chain and life cycle. A recent study found endocrine-disrupting chemicals in plastics “pose a serious threat to public health” and “cost the U.S. an estimated $250 billion in increased health care costs in 2018.”

While scientists say there’s still a lot of investigating to be done into the health impacts of microplastics, there is general worry over the expanding amount of plastics waste in the environment, especially because we still know little about many chemical additives used in plastics.

“We’ve got about 13,000 different chemical additives that are used in different types of plastic,” Valliant told Truthout. “Many of those are known to be carcinogens or toxic chemicals that affect hormone regulation, fertility, diabetes and other health conditions.”

Production of single-use plastics is a major source of the industry’s profits. By one estimate, the plastics packaging market will amount to $365 billion by 2025. Around 44 percent of plastics globally are used for packaging.

Plastics production is also tied to the climate crisis. Plastics production involves refining and “cracking” fossil fuels like crude oil and natural gas into polymers that are combined with petrochemical additives to make different kinds of plastics. With diminishing oil- and gas-fired energy on the horizon, says Valliant, Big Oil is turning toward plastics as a way to keep ramping up production.

“Plastic is their Plan B,” said Valliant. “It’s an easy way to put their product into something that sells.” According to one report, if plastics production was a nation, it would be the fifth-largest greenhouse gas emitter in the world.

“Plastics are fossil fuels,” said Beard. The precursor chemicals for plastics are derived from fossil fuels and petrochemicals, he says, and these precursor chemicals “come from communities of color on the Texas-Louisiana Gulf Coast.”

Environmental Racism

At the very center of plastics production lie cities like Port Arthur, Texas, a key hub within the Gulf Coast corridor of refineries and petrochemical facilities that stretch from the Houston area through Louisiana’s “Cancer Alley.” Around 55,000 people — overwhelmingly Black and Brown, and disproportionately poor — live in Port Arthur. The city hosts the nation’s largest refinery and numerous other refineries, petrochemical facilities and ethane cracker plants.

Beard knows a lot about the industry and its impacts on Port Arthur. Now in his 60s, he worked for decades at a petrochemical refinery. He is a former Port Arthur city council member and mayor pro tempore. “I was born and raised on the fence line,” he told Truthout.

Beard is a community leader and award-winning fighter for environmental justice. He founded the Port Arthur Community Action Network (PACAN), now a nonprofit that organizes to improve conditions in the city.

According to U.S. Census data, 42.3 percent of people in Port Arthur identify as Black, 34 percent as Hispanic or Latino, 30.8 percent as White and 6.2 percent as Asian. Per capita income is $24,065. The poverty rate is 26.7 percent, nearly double Texas’s poverty rate.

Beard says that environmental racism is at the root of Port Arthur’s crisis. “They don’t locate these facilities in white communities,” he says. “They don’t put them on Madison Avenue or in Beverly Hills. But they do it here, in communities of color, where people don’t have much of an ability to fight back against these companies, and they do it with impunity.”

“We all have a right to breathe clean air,” he says.

Beard says Port Arthur is a “cancer cluster.” A 2017 Environmental Integrity Project (EIP) report found that “the cancer mortality rate for African Americans in Jefferson County, including the predominantly black community of Port Arthur, is consistently about 40 percent higher than Texas’ overall cancer mortality rate.” ProPublica found parts of Port Arthur to have “an estimated excess lifetime cancer risk from industrial sources of about 1 in 53,” which is 190 times the EPA’s acceptable risk.

The EIP report also noted “230 illegal air pollution ‘upset’ events from industries in Port Arthur” from 2012 to 2016, many of which “released toxic chemicals including benzene, a carcinogen,” and that asthma rates for children in the county are more than twice the national average.

To educate people about the industry’s impacts on the community, Beard gives regular “Toxic Tours” that highlight the refineries and chemical plants in the area, from Total’s massive petrochemical plant that spews cancer-causing benzine, to Saudi Aramco’s Motiva’s super-refinery, to Koch Industries’ polluting Oxbow Calcining plant, to the Valero refinery that’s faced numerous violations.

Beard rattles off a long list of chemicals and pollutants these operations release. “We’re basically being embalmed and bombarded,” he says. “We’re dead men walking here.”

Why Industry Touts Recycling

Behind the plastics industry rests a powerful machine that spends tens of millions of dollars annually on lobbying, campaign donations and public relations campaigns, all backed by corporate money. Key players include the Plastics Industry Association and American Fuel and Petrochemical Manufacturers, as well as industry-backed groups like the Alliance to End Plastic Waste, which critics say greenwash plastics production.

One of the biggest backers of plastics is the American Chemistry Council (ACC), whose website prominently features its advocacy for plastics production among interrelated industries such as fossil fuels and chemicals.

The ACC is backed by the fossil fuel and chemical industries. Its board includes oil and petrochemical giants like Chevron, Shell, Honeywell, Huntsman, and many others. Its members include dozens of industry powerhouses like BP, Chevron, Dow, DuPont, ExxonMobil and Shell, and corporate law, consulting and accounting firms like Deloitte, KPMG, McKinsey and Ernst & Young.

The ACC spends massive amounts of money to influence politics. From 2021 through 2023 alone it spent $58.25 million on federal lobbying efforts, according to Truthout’s analysis of lobbying filings.

This lobbying activity occurred through the ACC’s in-house lobbying time as well as 10 outside lobbying firms. The ACC lobbied on broad topics like “microplastics,” “plastics innovation and recycling,” and “PFAS,” as well as against specific legislation like the Break Free from Plastic Pollution Act of 2023, which would “reduce the production and use of certain single-use plastic products and packaging,” and the Protecting Communities From Plastics Act, which “sets forth a variety of requirements and incentives to reduce the production and use of plastics and other petrochemicals.”

The ACC relied on a host of revolving door lobbyists to push their agenda on these and other issues. For example, Ryan Jackson, the ACC’s vice president of federal affairs, served as the chief of staff of the Environmental Protection Agency for three years until 2020, while lobbyist Amy Swonger served as Donald Trump’s legislative affairs director and as an aide to Mitch McConnell.

As the Intercept’s Schuyler Mitchell and Sharon Lerner have shown, the ACC has also lobbied intensely at the state level against plastic bag bans and for chemical recycling. Promoted by the industry as a means to address plastics pollution, a recent report by Beyond Plastics and the International Pollutants Elimination Network calls chemical recycling a “false solution” that “has failed for decades” while producing toxic emissions and hazardous waste.

Valliant says the industry’s touting of recycling amounts to greenwashing aimed at maintaining the status quo. Levels of plastics recycling are very low, and the rate of plastics production, already huge, is set to vastly expand.

Valliant says we must address the plastics crisis at its point of production, “We can’t recycle our way out of this problem,” she says. “The only way to do it is to reduce plastic production.”

“There’s No Planet B”

Despite the powerful forces that PACAN is up against, Beard remains driven by “a sense of personal and moral outrage” over conditions in Port Arthur and elsewhere. PACAN has connected with environmental justice groups around the region, country, and even the world, and this larger framing of the local fight in Port Arthur motivates Beard.

“It’s a global struggle,” he says, listing off a chain of movement battles from Brownsville, Texas, to Appalachia, to the fight against the Dakota Access Pipeline, to organizing in Europe and the Pacific Rim. “It’s all one fight. We have to put ourselves in the position where there’s something salvageable for the human species, because there’s no planet B.”

Moreover, PACAN has made progress. The group has helped bring major attention from media, elected officials and regulators to Port Arthur. It testifies to regulators about conditions in the area and has filed complaints with the EPA. It has received EPA funding to monitor air emissions.

While Beard knows PACAN has powerful industry foes, he remains steadfast. “They got more money to spend on advertising,” he says, “but I believe we’ll win.”


DEREK SEIDMANis a writer, researcher and historian living in Buffalo, New York. He is a regular contributor for Truthout and a contributing writer for LittleSis.

 

More than 900 chemicals, many found in consumer products and the environment, display breast-cancer causing traits

New study advances understanding of how endocrine disrupting chemicals influence breast cancer risk

Peer-Reviewed Publication

SILENT SPRING INSTITUTE

With tens of thousands of synthetic chemicals on the market, and new ones in development all the time, knowing which ones might be harmful is a challenge both for the federal agencies that regulate them and the companies that use them in products. Now scientists have found a quick way to predict if a chemical is likely to cause breast cancer based on whether the chemical harbors specific traits.

“This new study provides a roadmap for regulators and manufacturers to quickly flag chemicals that could contribute to breast cancer in order to prevent their use in consumer products and find safer alternatives,” says lead author Dr. Jennifer Kay, a research scientist at Silent Spring Institute.

Breast cancer remains the most commonly diagnosed cancer in the United States. Recent data show rates increasing in young women, a trend that can’t be explained by genetics. “We need new tools to identify environmental exposures that could be contributing to this trend so we can develop prevention strategies and reduce the burden of the disease,” says Kay.

Hormone signals

Kay and her colleagues searched through multiple international and U.S. government databases to identify chemicals that have been found to cause mammary tumors in animals. The databases were from the International Agency for Cancer Research (IARC), the National Toxicology Program, the U.S. Environmental Protection Agency (EPA), and the National Cancer Institute, among others.

The researchers also looked at data from EPA’s ToxCast program to identify chemicals that alter the body’s hormones, or endocrine disruptors, in ways that could promote breast cancer. The team looked specifically for chemicals that activate the estrogen receptor—a receptor present in breast cells—as well as chemicals that cause cells to make more estrogen or progesterone, an established risk factor for breast cancer.

Reporting in Environmental Health Perspectives, the researchers identified a total of 921 chemicals that could promote the development of breast cancer. Ninety percent of the chemicals are ones that people are commonly exposed to in consumer products, food and drink, pesticides, medications, and workplaces.

A breakdown of the list revealed 278 chemicals that cause mammary tumors in animals. More than half of the chemicals cause cells to make more estrogen or progesterone, and about a third activate the estrogen receptor. “Breast cancer is a hormonal disease, so the fact that so many chemicals can alter estrogen and progesterone is concerning,” says Kay.

Since damage to DNA can also trigger cancer, the researchers searched additional databases and found 420 of the chemicals on their list both damage DNA and alter hormones, which could make them riskier. What’s more, the team’s analysis found that chemicals that cause mammary tumors in animals are more likely to have these DNA damaging and hormone-disrupting characteristics than ones that don’t.

“Historically, chemicals that cause mammary tumors in animals were seen as the best predictor of whether they might cause breast cancer in humans,” says co-author Ruthann Rudel, director of research at Silent Spring. “But animal studies are expensive and time consuming, which is why so many chemicals have not been tested. Our findings show that screening chemicals for these hormonal traits could be an effective strategy for flagging potential breast carcinogens.”

A roadmap for safety

Over the past decade, there has been growing evidence that environmental chemicals are important contributing factors in the development of cancer. A number of studies in people have found links between breast cancer and pesticides, hair dyes, and air pollution. Other studies suggest exposure to hormone-disrupting chemicals early in life, in the womb or during puberty, can alter breast development in ways that could increase the risk of cancer later on.

To observe those associations, however, scientists have to wait until hundreds or thousands of children and women have been exposed to a chemical and check, often many years later, to see who develops breast cancer. “It’s not feasible, nor is it ethical, to wait that long,” says Rudel. “And it’s another reason why we need better tools for predicting which chemicals are likely to lead to breast cancer so we can avoid those exposures.”

The Silent Spring study could have implications for how EPA assesses chemicals for safety. For instance, the chemicals identified in the study include more than 30 pesticides that EPA previously approved for use despite evidence linking the chemicals with mammary tumors.

This fall, EPA proposed a new strategic plan to ensure that pesticides are evaluated for their effects on hormones. The study authors hope their new comprehensive list of breast cancer-relevant chemicals, which includes hundreds of endocrine disruptors, will inform EPA’s plan and better protect the public from harmful exposures.

Additional co-authors of the new study include Megan Schwarzman at UC Berkeley and Julia Brody at Silent Spring Institute.

Funding for this project was provided by the California Breast Cancer Research Program (Grant #23QB-1881) and charitable donations to the Safer Chemicals Program at Silent Spring Institute.

Reference:

Kay, J.E., J.G. Brody, M. Schwarzman, R.A. Rudel. 2023. Application of the Key Characteristics framework to identify potential breast carcinogens using publicly available in vivo, in vitro, and in silico data. Environmental Health Perspectives. DOI: 10.1289/EHP13233

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JOURNAL

Environmental Health Perspectives

DOI

10.1289/EHP13233 

METHOD OF RESEARCH

Data/statistical analysis

SUBJECT OF RESEARCH

Cells

ARTICLE TITLE

Application of the Key Characteristics framework to identify potential breast carcinogens using publicly available in vivo, in vitro, and in silico data

ARTICLE PUBLICATION DATE

10-Jan-2024

COI STATEMENT

Silent Spring Institute is a scientific research organization dedicated to studying environmental factors in women’s health. The institute is a 501(c)3 public charity funded by federal grants and contracts, foundation grants, and private donations, including from breast cancer organizations. Study funders had no role in study design; in the collection, analysis, and interpretation of data; in the writing of the report; and in the decision to submit the article for publication.

Training a new generation of ‘climate doctors’

Caleb Hellerman, Global Health Reporting Center
Mon, December 11, 2023 


For Dr. Aaron Hultgren, the wake-up call was Hurricane Sandy in 2012, when the young emergency physician returned from an overseas trip and found his hospital without power, its doors closed to the public.

Dr. Lakshmi Balasubramanian, an oncologist in Austin, Texas, signed up to study climate medicine after the death of a patient who was trapped in her home during a freak winter storm two years ago.

Dr. Paul Charlton, a physician with the Indian Health Service in northwest New Mexico, was motivated by 2023’s summer heat wave, when temperatures cracked 100 degrees Fahrenheit for nearly a week straight in July, setting all-time records.

Hultgren, Charlton and Balasubramanian traded these stories in early November as they gathered in College Station, Texas, midway through a first-of-its-kind diploma program that will mint them as certified experts in “climate medicine.” The course is the brainchild of Dr. Jay Lemery, director of the Climate and Health Program at the University of Colorado School of Medicine.

“This is our first foray into training a climate-savvy health care workforce,” Lemery said. “We need credible, knowledgeable and effective leaders, and we want to send a message to clinicians that these are critically important skills for mitigating climate-driven health effects.”

This past weekend, at the UN climate conference in Dubai, 123 countries signed an acknowledgment that climate change is having a major impact on human health, along with announcements of nearly half a billion dollars in funding commitments to bolster health systems and reduce overall harms to human health.

Lemery, who was at the meeting, says, “We just saw huge pledges and initiatives to double down on resiliency and decarbonisation, and yet no one has been trained to do this.”

Awareness of climate’s harms has been building, especially since 2009, when the journal The Lancet called climate change the “biggest global health threat of the 21st century.” Warming temperatures extend the range of disease-carrying pests like mosquitoes. Heat and drought disrupt crop cycles, leading to food shortages. Between 2030 and 2050, according to a World Health Organization report in October, climate change will cause an extra 250,000 deaths per year just from malnutrition, malaria, diarrheal disease and heat stress.

Warnings like this are a growing part of US medical education. Since 2019, the number of US medical schools requiring coursework on the effects of climate change has more than doubled. Universities and public health graduate programs offer majors and concentrations, but the Colorado diploma program goes a step further and aims to turn working medical professionals into leading experts on climate and health.

“It’s specifically designed for working clinicians who are seeking a ‘heavyweight’ credential,” said Lemery, an emergency physician by training. “We wanted to build a program that has real gravitas.”

Lemery’s program offers five separate certificate programs, each of which satisfies requirements for continuing medical education credits.


To earn a diploma, students complete all five, over a period of more than two years. The most recent module was designed to help participants prepare for and simulate a response to a major weather disaster.

Following readings and class discussions — over Zoom, since participants live in all corners of the country — course directors Dr. Terry O’Connor and Dr. Bhargavi Chekuri booked two days at a unique training facility. “Disaster City” is sprawled across 52 acres near the Texas A&M campus, where visitors will find upside-down train cars, smashed cars and buses and pile after pile of concrete rubble. Physicians are not the usual clientele; firefighters, EMTs and disasters come for the facility’s world-renowned search-and-rescue training.

The November training didn’t include any rubble piles, but the climate medicine students ran through tabletop simulations posing challenges like: What does your hazard vulnerability assessment need to include? How do you convince hospital administrators to pay for expensive, disaster-proofing upgrades that may never be used? If your hospital’s backup generator runs out, do you evacuate all the patients?

Lemery says the simulations cut straight to the essence of medical training. “Practice makes perfect. We can’t possibly be good at something unless we flex those muscles, go through the paces and learn how to make it better. When disasters hit, we want our medical teams and hospitals to say, ‘Don’t worry, we got this.’ We don’t want them pacing around wondering where we keep the emergency action plan.”

The federal government and states have strict requirements for hospitals to avoid catastrophic power failures, but as the simulation exercise made clear, that may not be enough. Generators flood. Evacuation routes may be blocked.

Dr. Karen Glatfelter, a physician from Lawrence, Massachusetts, told the group that supply chain issues are common.

“After Hurricane Maria, hospitals across the country ran into IV saline shortages that took months to work through,” she said.

Arien Hermann, who oversees a regional hospital coordinating center in southern Illinois, noted that not all electrical outlets are connected to a generator. At one hospital in Hermann’s network, this included the entire kitchen.

“So if you lost power, you weren’t going to have a microwave; you weren’t going to have refrigeration; you weren’t going to have electric stoves; you weren’t even going to have lights.”

Feeding patients and staff, the group agreed, would be a problem.

Hurricane Sandy underscored the vulnerability of many major hospitals. The storm killed at least 147 people and caused $82 billion in damage, according to the US National Oceanic and Atmospheric Association. Even Sandy faded into a mere tropical storm, a massive storm surge flooded 51 square miles of New York City, put much of Lower Manhattan underwater, led six hospitals to close and forced the evacuation of 6,500 patients. Hultgren, like many others, was utterly unprepared. “I never in a million years imagined that we would even lose power. It was a complete shock.”

Since Sandy, the number of weather disasters causing $1 billion or more in damage has soared; this year alone has seen 23 such events. But a changing climate is only one reason. A major factor is the higher cost of rebuilding, due to inflation, coupled with increased housing density in flood-, fire- and storm-prone areas. As a 2022 report from NOAA points out, “Much of the growth has taken place in vulnerable areas like coasts, the wildland-urban interface, and river floodplains.”

But recent years have also seen an apparent rise in storms like Hurricane Harvey, which dropped nearly 60 inches of rain on Houston while barely moving for five days, and Hurricane Idalia, which shocked forecasters in September by growing into a Category 4 storm nearly overnight. Such storms put an additional premium on planning and flexibility.

Unpredictable hurricanes aren’t the only threat from climate change, but they are part of what many people describe as climate “weirding,” new weather patterns that upend patterns of sickness and health.

Charlton, the Indian Health Service physician, whose home base of Gallup, New Mexico, sits at 6,500 feet of elevation, says he never imagined he would see the kind of extended heat that baked the town this summer. “Until now, we haven’t had to have cooling centers.”

Dr. Hilary Ong, a pediatric emergency physician from San Francisco, says doctors are taught to expect a cold and flu season that lasts from October to February. “Now, what I see in the pediatric emergency room is that respiratory season is lasting from September up to August. There was no break.”

Ong regularly cares for young patients who are dehydrated from extreme heat or struggling with asthma flare-ups after being exposed to wildfire smoke. She wonders, “Why am I seeing kids with asthma exacerbations all year ‘round?”

Being “climate-informed” helps clinicians do their daily jobs better, Chekuri says. She offers the example of a patient who comes in with a nagging cough. “A climate-informed physician might be aware of the fact that our pollen seasons are longer, sometimes more intense” and unpredictable. “If you’re not thinking about that change in the environment, then you can’t ask whether someone has had allergies before.”

Most doctors don’t think about climate on a day-to-day basis.“The realization about climate impacts on everyday patients was slow to come to me,” said Dr. Joanne Leovy, a physician from Las Vegas who is pursuing the climate medicine diploma. “People come into the office all the time with climate-related disease that we don’t recognize. And until you learn about the connections, you’re not going to see it.”

Many of the first doctors to focus on climate were emergency physicians or disaster relief workers. Those specialties are well represented in the Colorado program, but the group at Disaster City also includes three oncologists, a psychiatrist, an infectious disease specialist, a pediatrician, a family practitioner, two nurses and Hermann, a paramedic, Marine Corps veteran and hospital system administrator. Several students are already deeply involved in efforts to reduce waste and reduce the carbon footprint of the hospitals where they work; they point out that the US health care system is responsible for nearly 9% of the country’s greenhouse gas emissions.

Glatfelter pushed her hospital to switch out the standard gases used for anesthesia - replacing desflurane, the use of which in hospitals produces greenhouse gas emissions equivalent to a million cars - with a less-harmful alternative.

Dr. Elizabeth Cerceo, a hospitalist who chairs the “green team” at Cooper University Hospital in southern New Jersey, says there’s a laundry list of improvements that most hospitals can make, from re-examining their supply chains to simply replacing standard light bulbs with LEDs. Often, she says, it’s simply inertia that blocks change.

Dr. Katie Lichter, an oncology resident at the University of California, San Francisco, co-founded the GreenHealth Lab at UCSF, which generates research reports about the environmental impact of health care practice and “how climate change may reduce patient access to essential care.”

Lichter’s big moment of clarity came during the first days of her residency training at UCSF. Just a few months after she moved to San Francisco in 2020, Northern California was struck with a string of severe wildfires that sent a heavy blanket of smoke across the region. Locals still refer to “orange-sky day,” when the thick smoke generated its most surreal views.

Lichter had just admitted a patient into the ICU with Covid-19 as well as worsening cancer and lung disease. “He had missed weeks of crucial chemo and radiation because he couldn’t travel because of the wildfires,” she said. Pulling off her mask and gloves and home that night, she had an epiphany: “Climate change was going to impact my patients directly. This would be part of my career in medicine.”

Indeed, Lichter’s published research shows that cancer patients treated during times of wildfires have worse outcomes. Although cancer isn’t the first thing that springs to mind when it comes to climate change, Lichter says it shows how climate’s effects ripple through everything the health system touches.

“It’s the whole continuum of care,” she said. “Climate change increases exposure to carcinogens through air pollution and increased exposure to viral causes of cancer. And with screening, climate disasters impact access, like a patient’s ability to go get a mammography.”

The ability to access treatment, too.

Balasubramanian, the Austin-based oncologist, can’t say for sure that a winter storm killed her patient, but the woman had been fine a few days earlier. “She was thriving and doing very well,” the doctor recalls. “She was an avid volunteer and an advocate for pets and other women with breast cancer.”

The Colorado team encourages participants in the diploma program to be advocates on climate-related issues. Says Ong, “That’s really my motivation [for taking this course], to learn about this kind of medicine, to be a better physician and in order to lead and advocate and educate my peers and colleagues.”

Lemery points out that even after the height of the Covid pandemic, doctors and nurses typically rank high as trusted sources of information. “It’s important to bring the best science forward with candid-evidence based risk assessments. Our job is to train practitioners to be confident and proficient in doing just that.”

Mike Bethel, a nurse in Fresno, California, says he feels a duty “to speak out, as that trusted source, about things we know are true. We know that climate change is happening, and we know that it’s impacting our health negatively. When we don’t speak out about that as a profession, I think we do a disservice.”

Bethel says air pollution blocks views of the coastal mountain range that were visible almost every day when he was a Boy Scout roaming the mountains not far from where he lives today. He goes on to list other ominous signs. In Fresno, he says, “summers are longer. Summers are hotter. Our wildfire seasons have extended; they’re starting earlier and ending later. I mean, we’re already beyond a point of no return. There’s some damage that is irreparable, and if we continue, we’re going to damage the planet to the point where maybe it’s just not habitable.”

This dark view is shared by many here, but it’s tempered by a strong streak of idealism. Hultgren, who was an elementary school teacher before going to medical school, says he’s excited about forging a new path.

“As an emergency medicine physician, you always want to be at the front line, and I feel like I am at the front line, really trying to do something. We’re trying to change and hopefully impact our future for the better.”

Correction: This story has been updated to reflect that Disaster City is located near the Texas A&M University campus in College Station, Texas.

‘Unbearable’: Lorry drivers and environment pay price of air pollution at Bulgaria-Romania border

By Cristian GherasimPublished on 26/11/2023 -

Hours-long border queues are taking a climate toll in Bulgaria and Romania. Could entry into the Schengen Area help?

Pollution is on the rise as lorries queue for kilometres on both sides of the crossing between Romania and Bulgaria.

People in Giurgiu, a border town in southern Romania have for years felt that the air they breathe is no longer as clean as it used to be. It gets worse nearest to the checkpoint with Bulgaria where hundreds of lorries wait for hours to be inspected and allowed passage.

Romania and Bulgaria have been EU member states since 2007. Their campaign to become part of the Schengen Zone - an area that allows people and goods to travel freely between member countries without going through border controls - however, is ongoing.

Being admitted into Schengen would slash border waiting times, congestion and emissions from running engines.

For tourists going on vacation, long queues are an inconvenience. But for drivers of heavy duty vehicles that transit EU borders on a daily basis, the economic and health impact is huge.
Slow-moving traffic makes air ‘unbearable’ at Bulgaria and Romania’s borders

“The seven kilometre bypass stretching from Giurgiu in Romania to the border with Bulgaria is packed day and night with hundreds of lorries,” Bogdan Priceputu, born and raised in Giurgiu, tells Euronews Green.

“Not only is the air dirtiest in that vicinity but the field nearby gets littered with garbage as drivers wait by the side of the road for hours, without amenities and sanitation facilities, to cross the border into Bulgaria.”

Until recently, Bogdan’s father worked as a customs officer on the Romanian side of the border. “I know that several times a day the air got unbearable due to the slow moving traffic,” he says.


Albania, Colombia, Moldova: Which countries are doing the most for air pollution and climate?

This English city is banning gas stoves in new homes. Here’s why

Things are not much better on the Bulgarian side of the border. For years the border town of Ruse has been trying to curb its air pollution problem but to no avail. People have taken to the streets to protest against the issue and it has even become a topic of debate in the European Parliament.

The river Danube acts as the border between Romania and Bulgaria. Bogdan explains that when he gets on his boat and goes out on the river he can sometimes see smog plumes gliding across the nearby canal. “I don’t know if it’s from the traffic, but the increasing number of lorries waiting nearby at the border sure doesn’t help.”

Lorry drivers don’t have it any easier.

“A couple of weeks ago I ended up waiting for over 24 hours to cross the border from Bulgaria into Romania,” a Romanian lorry driver tells Euronews Green. “Of course it was unbearable, of course there’s pollution. I am driving a chiller lorry and the engine needs to be running almost all of the time otherwise the shipment goes bad.”

What are the health risks of traffic pollution in Bulgaria and Romania?

According to Eurostat southeastern Europe has some of the EU's most polluted cities. Bulgaria and Romania have the first and third highest values of fine particulate matter - also known as PM2.5 - in the entire European Union.

This is only set to worsen as winter descends: studies show levels of the larger PM 10 rise as temperatures drop in Bulgaria, fuelled by transport, industry and domestic heating.

Pollutants such as particulate matter suspended in the air are particularly worrisome as they reduce people’s life expectancy, aggravating many chronic and acute respiratory and cardiovascular diseases, according to the European Environment Agency.

Excess traffic emissions put border communities at risk of pollution-related health problems.
Can the Balkans steer away from fossil fuels? Albania and Romania are banking on it

“Air pollution is one of the leading causes for pulmonary cancer,” oncologist Roxana Macarie, tells Euronews Green. “It also increases the risk of breast, liver and pancreatic cancer in all age groups.”

Roxana practises medicine in Bucharest, Romania’s capital, but travels frequently to the border city of Giurgiu where some of her relatives live.

“Traffic has increased significantly over the past years. There are hundreds of lorries waiting each day around the city, some with their engines running, to cross into Bulgaria. That can’t be good for air quality in the area,” she says.

PM 2.5 can also have long-term impacts on children’s lung function and development. This can lead to respiratory and cardiovascular diseases, including asthma, which affects nine per cent of young people in Europe.

The environmental toll of keeping Romania and Bulgaria outside the Schengen area is adding up.
What’s keeping Bulgaria and Romania out of the Schengen area?

Both Bulgaria and Romania met the necessary criteria to join the passport-free zone over a decade ago.

They have received backing from the European Commission and the European Parliament. But the final green light has to come from the Council of the European Union.

They need approval from all 27 EU countries but still face opposition from Austria and the Netherlands.

Austria’s resistance stems from a broader dissatisfaction with Schengen and flows of migrants that cross into the EU. The Netherlands has signalled it might approve Bulgaria's bid if a series of conditions on judicial reform and anti-corruption fight is met.

A new vote is slated to be held next month.
What is the environmental impact of border crossing delays?

In a statement calling for Bulgaria and Romania’s Schengen ascension by the end of 2023, the European Parliament highlights the environmental and health burden of delaying the decision.

MEPs say that queues faced at two countries’ border crossings can last from a few hours to even days. This translates into 46,000 tonnes of CO2 emitted each year, according to recent analysis by accounting organisation KPMG.

The added pollution inflicts “irreparable damages” on the environment and will have health repercussions for drivers, customs agents and people living near border crossings, the statement continues.

The European Parliament believes that limiting border crossings and obstructing the free flow of goods between EU member states do not align with the bloc’s climate neutrality goal, which aims for net-zero greenhouse gas emissions by 2050.

Already, the years of delays have led to half a million tonnes of excess CO2 emissions, according to KPMG. This is the equivalent of over 600 GWh of electricity produced from climate-wrecking coal sources, or enough to power 60,000 homes for a year.

 

Air pollution and breast cancer risk - a link that calls for political action

Reports and Proceedings

EUROPEAN SOCIETY FOR MEDICAL ONCOLOGY

Lugano, Switzerland, 17 October 2023 – Women living and working in places with higher levels of fine particle air pollution are more likely to get breast cancer than those living and working in less polluted areas. Results of the first study to take account of the effects of both residential and workplace exposure to air pollution on breast cancer risk are presented at the ESMO Congress 2023 in Madrid, Spain (1).  

“Our data showed a statistically significant association between long term exposure to fine particle air pollution, at home and at work, and risk of breast cancer. This contrasts with previous research which looked only at fine particle exposure where women were living, and showed small or no effects on breast cancer risk,” said Professor Béatrice Fervers, Head of Prevention Cancer Environment Department, Léon Bérard Comprehensive Cancer Centre, France. 

  In the study, home and workplace exposure to pollution in 2419 women with breast cancer was compared to that in 2984 women without breast cancer over the period 1990-2011. The results showed that breast cancer risk increased by 28% when exposure to fine particle (PM2.5) air pollution increased by 10 µg/m3 – approximately equivalent to the difference 

inPM2.5 particle concentration typically seen in rural versus urban areas of Europe. Smaller increases in breast cancer risk were also recorded in women exposed to high levels of larger particle air pollution (PM10 and nitrogen dioxide). Fervers and colleagues now plan to investigate the effects of pollution exposure during commuting to get a complete picture of effects on breast cancer risk. 

Professor Charles Swanton, the Francis Crick Institute, London, UK, whose research suggesting how PM2.5 particles may trigger lung cancer in non-smokers was presented at ESMO Congress 2022 (2), stressed the importance of the new findings with breast cancer. 

“These very small particles can penetrate deep into the lung and get into the bloodstream from where they are absorbed into breast and other tissues. There is already evidence that air pollutants can change the architecture of the breast (3,4). It will be important to test if pollutants allow cells in breast tissue with pre-existing mutations to expand and drive tumour promotion possibly through inflammatory processes, similar to our observations in non-smokers with lung cancer,” he said. “It is very concerning that small pollutant particles in the air and indeed microplastic particles of similar size are getting into the environment when we don’t yet understand their potential to promote cancer. There is an urgent need to set up laboratory studies to investigate the effects of these small air pollutant particles on the latency, grade, aggression and progression of breast tumours,” he added. 

“There is now strong epidemiological and biological evidence for the link between PM2.5 particle exposure and cancer, and there are good clinical and economic reasons for reducing pollution in order to prevent cancers,” said Professor Jean-Yves Blay, ESMO Director of Public Policy.  

Following on a proposal from the European Commission in October 2022 to reduce the limit for PM2.5 particles in the air from the current 25 µg/m3 to 10 µg/m3 by 2030, ESMO urged a reduction in the PM2.5 limit still further to 5 µg/m3, in line with the World Health Organisation’s air quality guidance (5). “Reducing PM2.5 particles in the air to the WHO recommended level is critical because of their association with a variety of tumour types, including breast cancer,” Blay added. “We have a responsibility to push for this change, not only for people in Europe but worldwide where there are big variations in the pollution landscape.” The lower limit was indeed adopted by the European Parliament’s Environment, Public Health and Food Safety Committee in June 2023.  

More recently, in September 2023, the European Parliament adopted in plenary session its report on the ongoing revision of the EU Ambient Air Quality Directives, which reflects ESMO’s recommendations to set the annual limit value for Fine Particulate Matter (PM2.5) at 5 µg/m³. This adoption opens interinstitutional negotiations between the co-legislators – European Parliament, European Commission and EU Council – to agree on the final text of the directive. (6,7) 

“By supporting our requests with solid scientific evidence, we are offering a new dimension to health public policy. The work is not over, and change will not happen overnight, but we are moving in the right direction,” the ESMO Public Policy Director concluded. 

 

-END- 

 

Notes to Editors 

Please make sure to use the official name of the meeting in your reports: ESMO Congress 2023 

Official Congress Hashtag: #ESMO23. Follow it to stay up to date and use it to take part in the conversation on X (Twitter), LinkedIn, Instagram, Facebook 

 

Disclaimer 

This press release contains information provided by the author of the highlighted abstract and reflects the content of this abstract. It does not necessarily reflect the views or opinions of ESMO who cannot be held responsible for the accuracy of the data. Commentators quoted in the press release are required to comply with the ESMO Declaration of Interests policy and the ESMO Code of Conduct. 

 

References 

1 Fervers B et al. Longterm residential and workplace exposure to air pollution and breast cancer risk: A case-control study nested in the French E3N cohort from 1990 to 2011 will be presented by Fervers B. during the Mini Oral Session on Monday, 23 October 2023, 16:30-18:00 CEST, at ESMO Congress 2023, Madrid (Bilbao Auditorium). 

2 Swanton C et al. Mechanism of action and an actionable inflammatory axis for air pollution induced non-small cell lung cancer: Towards molecular cancer prevention. Presented at ESMO Congress 2022, Paris, France Presidential Symposium 1, LBA1 

3 Niehoff NM et al. Outdoor air pollution and terminal duct lobular involution of the normal breast. Breast Cancer Res 2020; 22,100.  

4Kotake R et al. An association between mammographic breast density and fine particulate matter among postmenopausal women. Environ Sci Pollut Res Int. 2023 Feb;30(10):25953-25958.  

5 WHO global air quality guidelines: particulate matter (‎PM2.5 and PM10)‎, ozone, nitrogen dioxide, sulfur dioxide and carbon monoxide. https://www.who.int/publications/i/item/9789240034228 

6 European Parliament. Revision of the ambient air quality directives. https://www.europarl.europa.eu/legislative-train/theme-a-european-green-deal/file-revision-of-eu-ambient-air-quality-legislation 

7 European Parliament. Towards cleaner air for Europe. https://www.europarl.europa.eu/RegData/etudes/ATAG/2023/751388/EPRS_ATA(2023)751388_EN.pdf 

 

About the European Society for Medical Oncology (ESMO)    
Representing more than 33,000 oncology professionals from 170 countries worldwide, ESMO is a reference for oncology education and information. Driven by a shared determination to secure the best possible outcomes for patients, ESMO is committed to standing by those who care about cancer through addressing the diverse needs of #ONEoncologycommunity, offering #educationforLIFE, and advocating for #accessiblecancerCARE. www.esmo.org     

 LA REVUE GAUCHE - Left Comment: Search results for LUNG CANCER 

LA REVUE GAUCHE - Left Comment: Search results for AIR POLLUTION 

LONGTERM RESIDENTIAL AND WORKPLACE EXPOSURE TO AIR POLLUTION AND BREAST CANCER RISK: A CASE-CONTROL STUDY NESTED IN THE FRENCH E3N COHORT FROM 1990 TO 2011 

B. Fervers1, M. Duboeuf1, A. Amadou1, T. Coudon1, L. Grassot1, E. Faure2, G. Severi3, F. Mancini3, P. Salizzoni4, J. Gulliver5, D. Praud1 [Text Wrapping Break]1Cancer And Environment Department, Centre Léon Bérard, Lyon/FRANCE, 2Exposome, Hérédité, Cancer Et Santé, Gustave Roussy, Villejuif/FRANCE, 3Exposome, Hérédité, Cancer Et Santé Inserm 1018, Gustave Roussy, Villejuif/FRANCE, 4Mécanique Des Fluides, Ecole Centrale, Ecully/FRANCE, 5Centre For Environmental Health And Sustainability, University of Leicester, Leicester/UNITED KINGDOM 

Background: Air pollution, classified as carcinogenic to humans, is a major public health concern. Studies on breast cancer are scarce and remain inconsistent. We studied the association between breast cancer risk and long-term exposure to particulate matters (PM2.5, PM10) and nitrogen dioxide (NO2) estimated at the womens' residential and workplace addresses. Methods: We conducted a case-control study of 2419 cases and 2984 individually matched controls nested in the French prospective E3N cohort, over the period 1990-2011. Controls were matched to cases on department of residence, age (±1 year); date (±3 months), and menopausal status at blood collection. Annual mean PM2.5, PM10 and NO2 concentration levels were estimated using a Land Use Regression (LUR) model (resolution 50m x 50m) and were assigned to women based on their geocoded residential and workplace addresses. The mean exposure was calculated for each woman from their inclusion into the E3N cohort to their index date (date of diagnosis of cases). Odds ratios (OR) and 95% confidence intervals (CI) were estimated using multivariate logistic regression models, for a 10 µg/m3 increase in PM2.5, PM10 and NO2. Adjustment variables were selected from the literature, using a directed acyclic graph. Results: The results showed a statistically significant linear increase in breast cancer risk related to mean exposure to PM2.5 (adjusted OR 1.28; CI 1.00–1.63, for an increment of 10 µg/m3). A numerically increased risk was observed for PM10 (adjusted OR1.09; CI 0.92–1.30) and NO2 (adjusted OR 1.05; CI 0.97–1.13) for an increment of 10 µg/m3. No effect modification by menopausal status was observed (p interaction 0.99, 0.90, and 0.86 respectively for PM2.5PM10 and NO2). Analyses by hormone receptor status showed a positive but not significant association for PM2.5 for oestrogen receptor positive (ER+) breast cancer cases (adjusted OR 1.32; CI 0.97–1.79). Conclusions: To our knowledge, this study is the first to investigate breast cancer risk associated with long term air pollution exposure at both, the subjects’ residence and workplace, estimated using a very fine spatial resolution LUR model. Future studies should consider exposure during commuting. 

Legal entity responsible for the study: INSERM 

Funding: Foundation or academic group WITHOUT funding from a pharma, biotech, or other commercial company[Text Wrapping Break]- ARC Foundation for Cancer Research (CANCAIR201601245), ANSES, French League against Cancer, Fondation de France 

Disclosure: All authors have declared no conflicts of interest.