Exposures to numerous substances designated by the International Agency for Research on Cancer (IARC) as known, probable and possible carcinogens may occur in pulp and paper operations. Asbestos, known to cause lung cancer and mesothelioma, is used to insulate pipes and boilers. Talc is used extensively as a paper additive, and can be contaminated with asbestos. Other paper additives, including benzidine-based dyes, formaldehyde and epichlorohydrin, are considered probable human carcinogens. Hexavalent chromium and nickel compounds, generated in stainless-steel welding, are known lung and nasal carcinogens. Wood dust has recently been classified by IARC as a known carcinogen, based mainly on evidence of nasal cancer among workers exposed to hardwood dust (IARC, 1995). Diesel exhaust, hydrazine, styrene, mineral oils, chlorinated phenols and dioxins, and ionizing radiation are other probable or possible carcinogens which may be present in mill operations.

Few epidemiological studies specific to pulp and paper operations have been conducted, and they indicate few consistent results. Exposure classifications in these studies have often used the broad industrial category “pulp and paper”, and even the most specific classifications grouped workers by types of pulping or large mill areas. The three cohort studies in the literature to date involved fewer than 4,000 workers each. Several large cohort studies are currently under way, and IARC is coordinating an international multicentric study likely to include data from more than 150,000 pulp and paper workers, allowing much more specific exposure analyses. This article will review the available knowledge from studies published to date. More detailed information may be obtained from earlier published reviews by IARC (1980, 1987, and 1995) and by Torén, Persson and Wingren (1996). Results for lung, stomach and haematological malignancies are summarized in table 1.

Table 1. Summary of studies on lung cancer, stomach cancer, lymphoma and leukaemia in pulp and paper workers

C = cohort study, CR = case-referent study, PM = proportionate mortality study.
* Statistically significant. ^§ = Where separately reported, NHL = non Hodgkin lymphoma and HD = Hodgkin’s disease. X = 0 or 1 case reported, no risk estimate calculated, — = No data reported.

A risk estimate exceeding 1.0 means the risk is increased, and a risk estimate below 1.0 indicates decreased risk.

Source: Adapted from Torén, Persson and Wingren 1996.

Respiratory System Cancers

Maintenance workers in paper and pulp mills experience an increased risk of lung cancer and malignant mesotheliomas, probably because of their exposure to asbestos. A Swedish study showed a threefold increased risk of pleural mesothelioma among pulp and paper workers (Malker et al. 1985). When the exposure was further analysed, 71% of the cases had been exposed to asbestos, the majority having worked in mill maintenance. Elevations in lung cancer risk among maintenance workers have also been shown in Swedish and Finnish pulp and paper mills (Torén, Sällsten and Järvholm 1991; Jäppinen et al. 1987).

In the same Finnish study, a twofold increased risk of lung cancer was also observed among both paper mill and board mill workers. The investigators made a subsequent study restricted to pulp mill workers exposed to chlorine compounds, and found a threefold increased risk of lung cancer.

Few other studies of pulp and paper workers have shown increased risks for lung cancer. A Canadian study showed an increased risk among those exposed to paper dust (Siemiatycki et al. 1986), and US and Swedish studies showed increased risks among paper mill workers (Milham and Demers 1984; Torén, Järvholm and Morgan 1989).

Gastro-intestinal Cancers

Increased risk of stomach cancer has been indicated in many studies, but the risks are not clearly associated with any one area; therefore the relevant exposure is unknown. Socio-economic status and dietary habits are also risk factors for stomach cancer, and might be confounders; these factors were not taken into account in any of the studies reviewed.

The association between gastric cancer and pulp and paper work was first seen in a US study in the 1970s (Milham and Demers 1984). The risk was found to be even higher, nearly doubled, when sulphite workers were examined separately. US sulphite and groundwood workers were also found in a later study to run an increased risk of stomach cancer (Robinson, Waxweiller and Fowler 1986). A risk of the same magnitude was found in a Swedish study among pulp and paper mill workers from an area where only sulphite pulp was produced (Wingren et al. 1991). American paper, paperboard and pulp mill workers in New Hampshire and Washington state ran an increased mortality from stomach cancer (Schwartz 1988; Milham 1976). The subjects were probably a mixture of sulphite, sulphate and paper mill workers. In a Swedish study, threefold increased mortality due to stomach cancer was found in a group comprising sulphite and paper mill workers (Wingren, Kling and Axelson 1985). The majority of pulp and paper studies reported excesses of stomach cancer, though some did not.

Due to the small number of cases, most studies of other gastrointestinal cancers are inconclusive. An increased risk of colon cancer among workers in the sulphate process and in paper board production has been reported in a Finnish study (Jäppinen et al. 1987), as well as among US pulp and paper workers (Solet et al. 1989). The incidence of biliary tract cancer in Sweden between 1961 and 1979 was linked with occupational data from the 1960 National Census (Malker et al. 1986). An increased incidence of cancer of the gallbladder among male paper mill workers was identified. Increased risks of pancreatic cancer have been observed in some studies of paper mill workers and sulphite workers (Milham and Demers 1984; Henneberger, Ferris and Monson 1989), as well as in the broad group of pulp and paper workers (Pickle and Gottlieb 1980; Wingren et al. 1991). These findings have not been substantiated in other studies.

Haematological Malignancies

The issue of lymphomas among pulp and paper mill workers was originally addressed in a US study from the 1960s, where a fourfold increased risk of Hodgkin’s disease was found among pulp and paper workers (Milham and Hesser 1967). In a subsequent study, the mortality among pulp and paper mill workers in the state of Washington between 1950 and 1971 was investigated, and a doubled risk of both Hodgkin’s disease and multiple myeloma was observed (Milham 1976). This study was followed by one analysing mortality among pulp and paper union members in the United States and Canada (Milham and Demers 1984). It showed almost a threefold increased risk for lymphosarcoma and reticulum cell sarcoma among sulphite workers, while sulphate workers had a fourfold increased risk of Hodgkin’s disease. In a US cohort study, sulphate workers were observed to have a twofold risk of lymphosarcoma and reticulosarcoma (Robinson, Waxweiller and Fowler 1986).

In many of the studies where it was possible to investigate the occurrence of malignant lymphomas, an increased risk has been found (Wingren et al. 1991; Persson et al. 1993). Since the increased risk occurs both in sulphate and sulphite mill workers, this points towards a common source of exposure. In the sorting and chipping departments, the exposures are rather similar. The workforce is exposed to wood dust, terpenes and other extractable compounds from the wood. In addition, both pulping processes bleach with chlorine, which has the potential to create chlorinated organic by-products, including small amounts of dioxins.

Compared with lymphomas, studies on leukaemias show less consistent patterns, and the risk estimates are lower.

Other Malignancies

Among US paper mill workers with presumed exposure to formaldehyde, four cases of urinary tract cancer were found after 30 years’ latency, although only one was expected (Robinson, Waxweiller and Fowler 1986). All of these individuals had worked in the paper-drying areas of the paper mills.

In a case-control study from Massachusetts, central nervous system tumours in childhood were associated with an unspecified paternal occupation as a paper and pulp mill worker (Kwa and Fine 1980). The authors regarded their observation as a random event. However, in three subsequent studies, increased risks were also found (Johnson et al. 1987; Nasca et al. 1988; Kuijten, Bunin and Nass 1992). In studies from Sweden and Finland, two- to threefold increased risks of brain tumours were observed among pulp and paper mill workers.

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