Occupational diseases / carcinogenesis

FB 286: Development of exposure assessment for the risk of work-related bladder cancer from aromatic amines and assessment of the effects of bladder cancer on employment

In the expert assessment of bladder carcinomas in suspected cases of BK 1301 (changes to mucous membranes, cancers, or other new formations of the urinary tract from aromatic amines), exposure assessment presents a challenge. Since the general population is ubiquitously exposed to aromatic amines, the detection of exposure alone cannot prove that the causation of a bladder carcinoma can be significantly attributed to occupational factors. In this case, quantitative consideration of occupational risk with respect to risk-doubling appears reasonable and important. A generally obligatory convention may yield a contribution to the equal treatment of all insured parties. As long as there is no generally accepted convention for the contraction of a bladder carcinoma, risk assessment in individual cases remains the sole responsibility of the medical assessor in question.

The goal of this scientific project is, in cooperation with occupational physicians and urologists, to achieve a consensus in which a referential dosage for carcinogenic aromatic amines can be established which is deemed relevant for the occurrence of work-related bladder tumours as part of an expert medical assessment.

With statistic consultation from the Institute of Medical Informatics, Biometry, and Epidemiology of Friedrich-Alexander-Universität Erlangen-Nürnberg, a review of the scientific literature is being compiled which enables the derivation of a referential dosage of carcinogenic aromatic amines at which the risk for bladder tumours doubles:

• directly from available epidemiological studies,
• directly from available animal studies, or
• via comparison with the disease risk associated with tobacco consumption.

A workshop of occupational physicians and urologists will discuss the results of the literature review as well as the necessity of further research, all with the goal of reaching a consensus.

Furthermore, the conditions for the assessment of reduced ability to work in cases of work-related bladder tumours caused by carcinogenic aromatic amines (BK 1301) or polycyclic aromatic hydrocarbons (BK 1321: changes to the mucous membrane, cancers, or other new formations of the urinary tract from polycyclic aromatic hydrocarbons in cases of detection of the impact of a cumulative dosage of at least 80 benzo(a)pyrene years [(µgm³) × years]) are to be established.

This scientific results of this project will be published and are intended to be used for assessment recommendations in cases of work-related bladder cancer.

This project is financed by the DGUV (FB 286).

The literature review on the topic of “Development of exposure assessment for the risk of bladder cancer from aromatic amines – systematic review” was registered on the PROSPERO Server under No. 187862 https://www.crd.york.ac.uk/prospero/.

Contact person:

PD Dr. med. Wobbeke Weistenhöfer Dr. med. Teresa Schilling

Artificial UV radiation from welding and uveal melanoma – a scientific evaluation of the correlation based on German occupational-disease legislation

Summary

Background: The “International Agency for Research on Cancer” (IARC) has established a causal relationship between welding and the occurrence of uveal melanoma and it classified welding as a human carcinogen in its Monographs 100D (2012). A literature review has now been undertaken as to whether uveal melanoma caused by welding meets the requirements for being recognised as an occupational disease under German legislation.

Method: A systematic literature search was conducted on the association between the risk of a uveal melanoma and welding.

Findings: An association between welding or photokeratitis (inter alia through welding) and uveal melanoma was investigated in multiple case-control studies and one meta-analysis. Although predominantly positive associations were found, the causation was greatly limited by the frequent lack of statistical significance in the findings, the overlap of some study collectives, and uncertain pathomechanisms.

Conclusion: Current literature varies in terms of the nature and strength of a causal relationship between welding and the risk of a uveal melanoma and does not meet the scientific requirements of German occupational-disease legislation. Further critical monitoring and research is needed regarding the pathogenic agent, a mechanism of action, a dose-effect relationship, and the exact extent to which occupation is relevant.

Reference

Hiller J, Drexler H, Weistenhöfer W. Künstliche UV-Strahlung durch Schweißen und Aderhaut-Melanome. Arbeitsmed Sozialmed Umweltmed 2016; 51: 201-210 https://www.asu-arbeitsmedizin.com/originalia/kuenstliche-uv-strahlung-durch-schweissen-und-aderhaut-melanome

Contak person: Dr. med. Julia Hiller, PD Dr. med. Wobbeke Weistenhöfer

Alongside the introduction of BK 5103 (squamous cell carcinoma of the skin from natural UV radiation), the recommendations for the estimation of a person’s reduction in employment capacity (Minderung der Erwerbsfähigkeit, MdE) were revised as well. In order to draw a comparison with cases of BK 5103 assessed to date, the expert-assessment practice from 2010 to 2015 was analysed in a case collective and trends were analysed.

Publication

Hiller J, Braun M, Drexler H. Minderung der Erwerbsfähigkeit bei der Berufskrankheit 5103: Trends und Vergleich der Begutachtungspraxis von 2010 – 2015. Dermatologie in Beruf und Umwelt 2016; 64: 45-53

Contact person:

Dr. med. Julia Hiller

The web app “BK‑Check” is a project of the Next Generation working group at the German Society of Occupational and Environmental Medicine (Deutsche Gesellschaft für Arbeitsmedizin und Umweltmedizin, DGAUM) in cooperation with the IPASUM of FAU Erlangen-Nürnberg under inclusion of all interested medical organisations and patient representatives.

Project goal

The “BK-Check” web app aims to create a database in which all available knowledge on occupational diseases is presented in a way that enables laypeople to easily and independently access understandable information.

Development concept

The development of the web app is transparent, inclusive, and offers all interested occupational physicians as well as physicians from other disciplines and patient representatives the opportunity to participate directly. The current development status can be viewed at www.bkcheck.de. Doctors and patient representatives may report requests for changes, suggestions for improvements, and supplemental information back to the PASUM project team; this feedback will be actively incorporated into the development of the app (contact: ipasum-bkcheck@fau.de).

At the end of the development process, the aim is to provide an app that meets the needs and wishes of users (patients and practicing physicians) and, above all, that enables patients to obtain information about the possibility of an occupational disease from an easily accessible and comprehensible source.

Scientific background

The definition of the term “occupational disease” (“Berufskrankheit”, BK) and the obligation to report originate from the German Social Code VII (SGB VII) and are therefore of legal origin. The concretisation of individual “BKs” in the Occupational Diseases Ordinance (BKV) is of legal origin as well. Annex 1 of the BKV lists all illnesses that can be recognised as occupational diseases. This BK list has evolved over time and is not rigid – new diseases have been and continue to be added to the list depending on the state of scientific knowledge. In addition, its classification is not uniform: in some cases, it is classified according to the type of exposure and in others, according to organ systems. The focus is predominantly on harmful noxious agents.

For doctors subject to obligatory reporting, who focus on clinical thinking, and have no legal expertise and no special knowledge of the respective noxious substances, this focus can make access to the required information considerably more difficult and usually requires time-consuming research. For patients, who generally have neither legal nor medical expertise, it is practically impossible to access well-founded information and to form an independent opinion in the complex system of “occupational diseases.” Failure to report a well-founded suspicion of an occupational disease can be of significant importance to the patient concerned if, for example, possible preventive measures are not taken or financial benefits from the accident-insurance institutions go unclaimed.

The “BK-Check” web app

The “BK Check” web app is an easily accessible and comprehensible database designed to enable patients to find out whether or not they might have an occupational disease in just a few steps (“clicks”). If the web app is made freely accessible via a homepage, users can check whether they might have an occupational disease at any time, taking clinical presentation and specific occupation into account; if they wish, they may present the result to their doctor for further evaluation. The web app works completely without the patient needing to enter any personal data.

How can I participate?

• … as a patient, patient representative, or doctor in patient care:

View the current status of the web app in its demo version at www.bkcheck.de. Give us feedback as to whether the web app is easily usable, if anything is missing, or what may be improved (contact: ipasum-bkcheck@fau.de). The application should live up to your needs as a user!

• … as an occupational physician or expert from another field:

Share your knowledge about occupational diseases and specify what we program! The information must be prepared as follows: Affected organ system → exact disease → relevant exposure at the workplace (example: respiratory tract and lungs → lung cancer → chromium / chromium compounds). Progress can be tracked (and corrected!) at www.bkcheck.de. Give us feedback on whether the web app is easy to use in its current form, whether something is missing, or what could be improved (contact: ipasum-bkcheck@fau.de).

Project director:

Dr. med. Anna Wolfschmidt-Fietkau

Contact:

Email: ipasum-bkcheck@fau.de