AMERICAN JOURNAL OF INDUSTRIAL MEDICINE 301383-391 (1 996)

Lung Cancer Mortality in Stainless Steel and Mild

Steel Welders: A Nested Case-Referent Study

Jens M. Lauritsen, MD, PhD, and Klaus 5. Hansen, MD, PhD

The association between welding and lung cancer has been studied in a nested case-referent
study within a cohort of 8,372 metal workers. Lifetime exposure data on welding and other
occupational exposures, as well as alcohol and smoking habits, were obtained by interviewrs
of spouses and colleagues. Analysis was based on 139 deceased referents and 94 deceased
cases. There was a 70% excess of lung cancer associated with “welding exposure ever” (OR
k 95% C.I.: 1.68, 1.02-2.78). Overall OR for “mild steel (MS)welding ever” was 1.64,
0.99-2.72. The risk estimates for welding exposures showed an increasing tendency up to 15
years of e.uposure. The pattern of stainless steel (SS) welding resembles that of mild steel with
an estimated OR of 1.65, 0.88-3.0. The general conclusion is that MS welding as well as SS
welding seems to be associated with an increased risk of lung cancer. Further followup of the
cohort will enhance precision of the estimates. @ 1996 Wiley-Liss, Inc.

KEY WORDS: risk estimation, occupational health, welding, occupational exposures,

surrogate data sources

INTRODUCTION modes of retrieval of exposure data in living (self-adminis-

A large proportion (1-2%) of the work force world
wide is occupied in welding. The International Agency for
Research on Cancer (IARC) has recently reviewed all stud-
ies on welding and cancer [IARC, 19901. There was a con-
sistent pattern in the results of most of the lung cancer
studies showing an excess lung cancer risk of 30-50%
[IARC, 19901. The review gave the overall classification:
‘‘Welding fumes are possibly carcinogenic to humans’ ’
(group 2B). However, there is still some uncertainty about
the significance of the association. Is the excess lung cancer
mortality associated with welding exposure as such or with
specific welding settings [Stem, 1983; Peto, 1986]?
The present study is based on a large cohort study of
cancer occurrence in welders, grinders, and other metal
workers [Hansen et al., 19961. The cohort study carried a
possibility of introducing information bias through different
tered questionnaire) and deceased persons (interview of
spouses and colleagues). This possible bias is excluded in
the present nested case-referent analyses, which concerns
only deceased cohort members. The only source of exposure
data is surrogate interviews given by spouses and col-
leagues.
SUBJECTS AND METHODS
The study base for the nested case-referent study was
the work forces of 79 Danish welding companies. Pure or
predominant stainless steel welding is rather uncommon.
Therefore, the majority of the welding companies were sam-
pled among companies employing stainless steel welding.
Formation of the Cohort, Which Served
as a Base for the Present nested
Case-Referent Study

Faculty of Health Sciences, institute of Community Health, Odense, Denmark.
Address reprint requests to Jens M. Lauritsen, Faculty of Health Sciences,
Institute of Community Health, Winskawparken 17,l,DK-5000 Odense C, Den-
mark.
Accepted for publication September 26, 1995.
A brief description of the formation of the originating
cohort will be given here [see Hansen et al., 1996 for de-
tails). Inclusion criteria were: (1) male; (2) at least 1 year of
employment between 1964 and 1984 in one of the 79 com-
panies; (3) alive by April 1968. The cohort was identified,

0 1996 Wiley-Liss, Inc.

384 Lauritsen and Hansen

TABLE I. Distribution of Underlying Cause of Death Among Steel Welders and Referents,
Denmark, 1964-1984*

Excluded controls

Included inanalysis Other/unclear Younger than

respiratory youngest
Cause of death Cases Controls cause of death case Total

Malignant neoplasm
Digestive system 46 46
Lung 94 94
Mesothelioma 2 2
Other respiratory 4 4
Urogenital system 30 8 38
Lymphatic systems 13 2 15
Other neoplasms 6 6
Circulatory system 266 14 280
Respiratory system 48 48
Digestive system 8 3 11
Suicide 12 17 29
Other violent causes 15 17 32
Other causes 49 21 70
Total 94 439 60 82 675

*Numbers in table are based on grouping of the major underlying cause of death (supplied by the National
Cause of Death Registry).

classified according to job description, and verified in sev-
eral steps. The steps were based on a combination of ( 1 )
incomplete personnel records in the involved companies;
(2) registrations in the Public Supplementary Pension Fund
(the Danish so-called ATP registry); recognition of persons
by former long-time colleagues and supervisors.
Attempts were made to retrieve information on lifetime
exposure for the whole cohort. Information was supplied
either by the cohort members themselves (all alive) or by
spouses/colleagues (all deceased and emigrated). Response
rates for living and deceased cohort members were similar
(87% vs. 83%). Information was received for 8,372 persons,
of whom 675 had died in the period April 1, 1968 to De-
cember 31, 1985 (i.e., the persons who were alive on April
1, 1968 and died before the end of the exposure period of
interest). The present nested case-referent study is based on
the 675 deceased persons.
Cases and Referents in the Study
Cases
Cases were defined as the 94 subjects who died from
lung cancer (ICD8 code 162.0-1). Causes of death were
collected from the Danish National Death Register at the
Danish Institute for Clinical Epidemiology (coded accord-
ing to the WHO International Classification of Diseases in
use at the time).
Referents
Sixty subjects who had died from respiratory diseases
other than lung cancer (including six with secondary respi-
ratory or unknown malignancies as cause of death) were
excluded. These exclusions were made because welding ex-
posure has been described as a possible cause of respiratory
diseases other than lung cancer [IARC, 19901. Eighty-two
of the remaining 521 referents who were younger than the
youngest case were excluded, because they had not lived
long enough to develop lung cancer (diagnosable).All anal-
yses have been made using the remaining 439 referents plus
the 94 cases. A different sampling approach, splitting the
data into a grid defined by age and calendar year of death,
has been applied as well. Through linkage to the Danish
Cancer Registry, we have assured correct case ascertain-
ment (lung cancer diagnosis) and exclusion of related inci-
dent cancer diagnosis for referents. The distribution of main
cause of death among cases and referents is shown in Ta-
ble I.
Exposure Assessment
Data on lifetime exposures were obtained for every
case and referent by telephone interviews of spouses, and
 Lung Cancer Mortality in Welders 385

telephone or (a few) personal interviews of long-term col- one in which all missing values were replaced by the null
leagues. The interviews covered questions on lifetime work value (baseline) for the covariate under consideration.
exposures with emphasis on welding, grinding, asbestos,
and cutting oil exposures, as well as alcohol and smoking Information Used in Analysis
habits. Whenever possible, both spouses and colleagues
were interviewed. When both interviews were obtained, Variables entered the analysis in this form: welding
data on smoking and alcohol history were extracted from exposures (welding unspecified, MS, and SS): “time from
the spouse interviews and data on lifetime work exposures first to last exposure,” welding ever, yesho. Asbestos:
were extracted from the colleague interviews. When data none, 1-9 years, 10 or more years. Smoking data were
from only one interview were available, all those data were grouped based on overall lifetime exposure allocating indi-
used in the analysis. Interviews with both spouses and col- viduals to the highest average (as indicated in the interview)
leagues were obtained for 274 ( 5 I %) cases and referents. In category as: (1) smoking data from spouses: non+rarely
49 (9%) and 210 (40%) instances, respectively, there were smokers, light to medium daily smokers (corresponding to
data from only spouse or colleague interviews available. 1-19 cigarettes per day), and heavy smokers (20 cigarettes
or more per day); ( 2 ) smoking data for whole study:
Exposure Information non+rarely smokers, daily smokers. Asbestos: none, some
but less than 10 years, 10 years or more. Latency was de-
Simple exposure (ever exposed, yesho) information fined as time (years) since first welding exposure (which
and time-related data on first and last years exposed were might be before 1964) until year of death.
collected for each type of welding (MS, mild steel welding;
SS, stainless steel welding) and stainless steel grinding. For Statist ical Methods
each decade (grouped as before 1950, 1950-1959, 1960-
1969, 1970-1979, 1980-1985), persons interviewed were Analysis of the data was based on principles described
asked to indicate the actual number of years and average by Breslow and Day [ 19801. Estimation of crude odds ratios
daily welding time for the cohort member. For lifetime as- (OR) k 95% confidence intervals and analysis for trend
bestos and cutting oil exposure, data on first year and num- were made using the exact procedures implemented in Egret
ber of years exposed were collected. The smoking history [ 1990-19951. Adjustment for smoking in Tables III-VI was
was covered with questions on type and amount of tobacco made with an unconditional logistic regression model using
smoked, first and last year of smoking, and number of years Egret. In the adjusted analysis, all missing data have been
smoked. Alcohol history was described through data on replaced with the null value tie., the lowest category of the
number of years and the average weekly alcohol consump- variables). Assessment of interaction and effect modifica-
tion. No attempts were made to collect data on other pos- tion was done using recursive graphical modeling [Klein et
sible work-related confounding exposures. al., 19951. The same approach was applied in parallel sub-
group analysis of the data split by source of data, missing
Missing Data data, etc.
Conditional analysis using matched sets of cases and
Unfortunately (but expectedly), there were problems in referents has also been performed (based on a grid defined
retrieving information on exposures dating several decades by year of death in 5 year groups and age at death in 5 year
back in time for the deceased population. The analysis is intervals, resulting in a variable number of referents per
therefore based on overall exposure measures as “welding case). The results were similar to those obtained with the
ever” and number of years welding rather than “intensity unconditional analysis. All results were rounded to one digit
of welding-related measures,” which was the intention at precision. Rounded 95% confidence intervals which ex-
time of data collection. In the presented tables, missing data cluded values above or below one were considered statisti-
are marked in each subtable. Simple exposure information cally significant.
(“welding ever, yesho,” etc.) was missing from 28 of the
49 (57%) spouses, where no colleague interview was avail- RESULTS
able. From the colleague interviews, only 21 of 484 (4%)
could not provide this information. The relative distribution of 94 lung cancer cases and
As a consequence of the missing data, formal adjust- 439 referents in five job groups, representing job titles based
ment (confounder control) is limited to smoking history. on lifetime welding exposure, is shown in Figure 1. The
Information on asbestos exposure and other potential con- persons designated nonwelders are persons holding other
founders was lacking for many persons (see Table 11). jobs in direct relation to the production (departments of
Where appropriate, tables will have two sets of risk esti- storage, delivery, and office personnel have been excluded
mates; one based on the individuals with complete data, and in the cohort formation).
3 86 Lauritsen and Hansen
400 c
Non Welder
Lifetime Job Title
FIGURE 1. Study group composition. Number of persons in each subgroup by exposure. Denmark, 1964-1 984. MS, mild
steel: SS, stainless steel.
The crude risk estimates of smoking and asbestos are
presented in Table 11. As expected, the risk estimate in-
creases with increasing tobacco smoke exposure (one-sided
p value for trend = 0.008). More than 10 years of asbestos
exposure was associated with an increased lung cancer risk
(OR = 7.26, C.I. 1.2-5 1 .O). A statistically significant trend
of lung cancer by asbestos exposure was seen (one-sided p
= 0.019). Exposure to SS grinding dust, alcohol, and cutting
oil exposure did not show odds ratios significantly elevated
above unity.
“Welding ever,” yesino, was associated with a 70%
statistically significant increase in lung cancer risk (Table
111). When stratifying by duration, the same exposure is
associated with an increasing tendency in the risk up to 15
years of exposure. For exposure longer than 1.5 years, the
risk estimates decrease. The risk associations with duration
of exposure to mild steel welding and stainless steel weld-
ing show the same pattern (Tables IV, V). Stratification
with years since first exposure shows a similar pattern. An
increased effect is seen (Table VI) in the groups of less than
10 years for both mild steel and stainless steel welding
exposure, but estimates are imprecise because of small
numbers.
Search for hidden interactions and effect modification
has shown no confounding effects (based on welding expo-
sure, age, smoking, and asbestos), which would require fur-
ther adjustment than the simple one presented in Tables
111-VI. In subgroup analysis, where data were split by
source of data or missing values, the same tendencies as
described above (but with less precision because of the
smaller numbers) were seen,
No important differences in smoking habits in welders
and nonwelders were seen. The frequencies of heavy smok-
MS Only SS Only M S and SS welder
ers were 10.3%, 10.2%, and 10.5% among MS, SS, and
mixed MSiSS welders, respectively, and 10.3% among non-
welding metal workers. This is reflected in the practically
unchanged risk estimates following adjustment for smoking
in Tables 111-VI. Additionally, Tables 11-VI show that the
estimates change only to a small degree following missing
value imputation to the null level.
DISCUSSION
Most earlier epidemiological studies on welding and
lung cancer exhibited an overall excess risk of lung cancer
in the order of 40% [IARC, 19901. In our study, “welding
ever, yesino” is associated with a crude 70% statistically
significant increase in risk of lung cancer (adjusted OR 1.S,
95% C.I. 1.0-2.4). Risk estimates for mild and stainless
steel welding show the same pattern. These estimates are
adjusted for smoking in a logistic regression model. Since
the graphical modeling approach revealed no signs of effect
modification or confounding, there seem to be no important
differences in smoking habits or other confounding expo-
sures between welders and nonwelders in relation to cases
and controls.
The risk shows an increasing tendency for exposure
groups of MS, S S , and “welding ever” with years of weld-
ing. This is regarded as favoring the traditional causal cri-
teria of a dose-response effect. The increasing tendency is,
however, seen only up to a certain point (5-10 years for SS
and 1.5 for MSiwelding ever). This weakens the causal in-
terpretation, but could be a reflection of a selection effect
among welders who had been exposed for 20 (15) years or
more and began as welders before 1968 (the start of fol-
lowup of the present cohort): i.e., only those sufficiently
 Lung Cancer Mortality in W e l d e r s 387

TABLE 11. Crude Odds Ratio (OR) Estimates and 95% Confidence Intervals for Lung Cancer and Some Possible
Confounding Exposures in Study of Steel Welders, Denmark, 1964-1984

Crude ORb Crude OR and 95% C.I.

(One-sided p All missing values
Exposure factor No. casesa value for trend) 95% C.I. given baseline value

Smokingc
(Spouse information, 323 persons)
Nevertrarely 3 1.o (No missing)
Daily, 1-19 cigarettes 33 1.6 0.5-8.6
Daily, 20t cigarettes 16 3.7 0.9-21.2
(0.008)
Smoking
(Whole study)
Nevertrarely 11 1.o
Daily smoker 76 1.6 0.8-2.8 1.5 0.8-2.7
(7140)
Asbestos
None 53 1.o 1.o
Low ( 4 0 year) 3 1.18 0.2-4.4 1.o 0.2-3.8
High ( l o t year) 4 7.26 1.2-51 .O 6.4 1.l-44.7
(34/131) (0.019)

aMissing answers on exposures are indicated as # case/# referent in parentheses, in column two from left.
bExact confidence intewal estimation. Exact p values for trend indicated in parentheses where appropriate.
'Based on casestreferents, for whom information was given by spouses (i.e., excluding those based solely on colleagues' information)

TABLE 111. Crude and Adjusted Odds Ratio (OR) Estimates and Exact 95% Confidence Intervals for Lung Cancer and Welding
Exposure (of Any Kind), Denmark, 1964-1984

Crude ORC 95% C.I.

Crude ORc 95% C.I. All missing assumed baseline Adjusted ORb
Welding exposure No. casesa (One-sided p value for trend) (One-sided p value for trend) 95% c.1.

Ever
No 38
Yes 46 1.7 1.O-2.8 1.6 1.O-2.5 1.5 1.0-2.4
(10140)
Years exposed
(Last-first calendar year)
Unexposed 38 1
1-5 8 1.7 0.6-4.1 1.6 0.6-3.8 1.5 0.7-3.5
6-1 0 7 2.1 0.7-5.7 2.0 0.7-5.2 1.9 0.8-4.7
11-15 10 3.2 1.2-7.9 3.0 1.2-7.2 2.9 1.3-6.6
16-20 7 1.5 0.5-3.9 1.4 0.5-3.6 1.4 0.5-3.3
21 t 14 1.2 0.6-2.5 1.2 0.6-2.3 1.1 0.6-2.1
(10142) (0.10) (0.13)

aMissing answers on exposures are indicated as # case/# referent, in parentheses.

adjusted OR all missing values replaced by null value (baseline). Adjusted for smoking
CExactp values for trend indicated in parentheses.
388 Lauritsen and Hansen

TABLE IV. Crude and Adjusted Odds Ratio (OR) Estimates and Exact 95% Confidence Intervals for Lung Cancer and Welding in
Mild Steel, Denmark, 1964-1984

Crude ORC95% C.I.

Crude ORc95% C.I. All missing assumed baseline
Welding in mild steel No. casesa (One-sided p value tor trend) (One-sided p value tor trend) Adjusted OR 95% C.l.b

Ever mild steel

No 41
Yes 42 1.6 1.O-2.7 1.5 0.9-2.5 1.5 0.9-2.3
(11143)
Mild steel only
No 57
Yes 26 1.3 0.8-2.3 1.3 0.7-2.1 1.3 0.8-2.1
(11/43)
Years exposed
(Last-first calendar year)
Unexposed 41
1-5 5 1.6 0.4-4.7 1.5 0.4-4.3 1.4 0.5-4.0
6-1 0 6 1.8 0.6-5 .O 1.7 0.5-4.5 1.6 0.6-4.2
11-15 10 3.0 1.1-7.2 2.8 2.1-6.6 2.6 1.2-5.9
16-20 5 1.o 0.3-2.9 1.o 0.3-2.7 0.9 0.3-2.5
21 t 16 1.5 0.8-3 .O 1.4 0.7-2.7 1.4 0.8-2.6
(11145) (0.059) (0.082)

aMissing answers on exposures are indicated as # case/# referent, in parentheses.

bAdjusted for smoking. In adjusted OR all missing values replaced by null value (baseline)
'Exact p values for trend indicated in parentheses.

healthy to continue employment until the start of the cohort
formation period were included. Those already ill or with
deteriorated health-possibly as a consequence of expo-
sure-left the companies before the start of this study.
Those with long-term exposure in the study would therefore
be expected to be in a relatively healthier state. When com-
pared to those who left the companies before the start of the
study, it is plausible to state that the decreasing effect with
long exposure is a consequence of the lack of long-term
followup of a sufficient part of the cohort. Only a few cohort
members who entered the cohort after 1968 had been ex-
posed for enough time to contribute to the high (long time)
exposure groups. The same explanation applies to the de-
crease in the risk estimate with increasing latency.
An alternative explanation might be that duration of
welding is not a sufficient measure of cumulative dose of
exposure for more than the first decade of welding. Welders
with high and therefore more irritating exposures may have
been more likely to change to nonwelding jobs. If this is the
case, the risk of cancer is underestimated in the long-term
exposed in the current study.
The precision of information on work history and spe-
cific occupational exposures is low in the majority of earlier
studies on welding and cancer, where exposure categoriza-
tion has been based on information from death certificates
or union membership. A more detailed assessment of weld-
ing exposure, such as a differentiation by type of welding
(MS/SS), has not been possible in most studies. Moreover,
in many studies there is information on welding exposures
for only a portion of the subject's lifetime work history.
Only one or two studies have been large enough to be able
to analyze a dose-response relationship and the effect of
latency. In the present nested case-referent study, informa-
tion on lifetime welding exposure as well as other occupa-
tional exposures and smoking habits has been collected with
considerable success from spouses and long-term col-
leagues for several decades. The accuracy of surrogate data
has been studied in the originating cohort of the present
study [Hansen, 19961. A fairly correct classification of MS
welding exposure (80-100% of welders and nonwelders
correct) and smoking (approximately 90% correct) was
found, whereas a moderately correct classification of SS
welding exposure (60-95% of welders and nonwelders
classified correctly) was found. This might result in an un-
derestimation of the risk. Despite this suggested surrogate
source precision, missing data and the resulting possible
information bias have been a concern. Several covariates
had to be left out of the adjusted analysis (asbestos, alcohol
consumption, grinding dust, and cutting oil) because no in-
formation was available. These excluded covariates were
 Lung Cancer Mortality in Welders 389

TABLE V. Crude and Adjusted Odds Ratio (OR) Estimates and Exact 95% Confidence Intervals for Lung Cancer and Welding in
Stainless Steel Welders, Denmark, 1964-1 984

Crude ORc95% C.I.

Welding in Crude ORE950/0 C.I. All missing assumed baseline
stainless steel No. casesa (One-sided p value for trend) (One-sided p value for trend) Adjusted OR 95% C.1.”

Ever stainless steel

No 59
Yes 20 1.7 0.9-3 .O 1.6 0.8-2.8 1.5 0.8-2.6
(15/57)
Stainless steel only
No 75
Yes 4 1.3 0.3-4.3 1.3 0.3-4.1 1.2 0.4-3.8
(15/57)
Years exposed
(Last-first calendar year)
Unexposed 59
1-5 7 2.9 0.9-8.2 2.7 0.9-7.6 2.6 1&6.7
6-1 0 3 1.6 0.3-6.5 1.5 0.3-6.1 1.4 0.4-5.3
11-1 5 3 1.8 0.3-7.4 1.7 0.3-7.0 1.6 0.4-6.2
16-20 4 1.4 0.3-4.7 1.3 0.3-4.4 1.3 0.4-3.9
21t 3 1.o 0.2-3.4 0.9 0.2-3.2 0.8 0.2-2.9
(15/59) (0.226) (0.27)

aMissing answers on exposures are indicated as # case/# referent, in parentheses.

hAdjusted for smoking. In adjusted OR all missing values replaced by null value (baseline).
CExact p values for trend indicated in parentheses.

consequently used only in the part of the analysis where
patterns of association were looked at in subgroups. Missing
value imputation has been made by giving the individual the
reference category for that variable, a principle which is
known to produce conservative estimates (underestimation)
of the risk. In the analysis, association patterns were stable
regardless of using data from individuals with complete
data, data with replacement of missing values, or in partic-
ular subgroups. Additionally, the proportion of missing data
was similar in cases and controls. It is therefore most likely
that the missing data contribute only to less precise but
otherwise unbiased estimates.
The question of whether welding as such, or specific
welding settings such as MS and SS welding, is associated
with an excess of lung cancer has been a matter of discus-
sion for some years. SS welders are exposed to chromium
and nickel compounds, which have been shown to be car-
cinogenic to humans. This has led to the hypothesis that
“the moderate elevation of lung cancer risk among all
welders is due to a particularly increased risk in the SS
group of welders” [Stern, 1983; IARC, 19901. Only a few
studies have had sufficient data to investigate the effect of
different kinds of welding exposures. Two cohort studies
have shown a moderately increased risk of lung cancer in
SS welders [Sjogren et al., 1987; Becker et al., 1985, 19911
and two case-referent studies have shown a strongly in-
creased risk of lung cancer in SS welders [Gerin et al., 1984;
Kjuus et al., 19861. Additionally, a large American cohort
study found a relationship between duration of MS exposure
and increasing risk of lung cancer [Beaumont and Weiss,
19811.
When looking at Tables IV and V, it is seen that for
both MS and SS welding the risk estimates are slightly
higher for “MS and SS ever” than for “MS and SS only.”
The explanation for this is probably that the estimate for
“MS ever” is an effect of MS welding exposure as well as
some SS welding exposure and vice versa for the “ S S
ever” estimate. The numbers for “SS only” are small,
casting doubt on the risk estimation, while the estimate for
“MS only” is more solid. However, the results point to the
conclusion that MS as well as SS welding exposures are
associated with an increased risk of lung cancer. In order to
get more solid estimates for SS welding exposure, a further
followup of the cohort is desirable.
The analysis confirms smoking and asbestos exposure
as lung cancer carcinogens with a dose-response pattern.
This indicates that the data of the present study are reliable.
According to the analyses in the originating cohort study,
very few had been exposed to asbestos to any significant
degree, most likely because no shipyards were among the
390 Lauritsen and Hansen

TABLE VI. Crude and Adjusted Odds Ratio (OR) Estimates and 95% Confidence Intervals for Lung Cancer With Reference to Latency in
Mild Steel and Stainless Steel Welders, Denmark, 1964-1984

Crude ORC95% C.I.

Latency in years Crude OflC95% C.I. All missing assumed baseline
(Years since first exposure) No. casesa (One-sided p value far trend) (One-sided p value far trend) Adjusted OR 95% C.I.”

Mild Steel Welding

Unexposed 41
1-5 2 1.7 0.2-9.3 1.6 0.2-8.6 1.4 0.3-7.2
6-1 0 6 3.2 0.9-10.2 3.0 0.9-9.3 2.8 1 .O-8.0
11-15 7 1.4 0.5-3.6 1.3 0.5-3.3 1.3 0.5-3.1
16-20 6 1.9 0.6-5.3 1.7 0.5-4.8 1.7 0.7-4.5
21 t 21 1.5 0.8-2.8 1.4 0.8-2.5 1.3 0.8-2.4
(11/45) (0.055) (0.078)
Stainless Steel Welding
Unexposed 59
1-5 4 4.3 0.8-20.4 4.0 0.8-1 9.1 3.7 1.O-14.2
6-1 0 3 2.3 0.4-10.4 2.2 0.4-9.7 2.0 0.5-8.1
11-15 3 1.I 0.2-4.0 1.o 0.2-3.7 1.o 0.3-3.5
16-20 3 2.7 0.4-12.9 2.5 0.4-1 2.1 2.4 0.6-9.8
21 t 7 1.2 0.4-3.0 1.2 0.4-2.8 1.I 0.5-2.5
(15/59) (0.163) (0.198)

aMissing answers on exposures are indicated as #’ case/# referent, in parentheses.

adjusted OR all missing values replaced by null value (baseline). Adjusted for smoking.
‘Exact p values for trend indicated in parentheses

companies from which the cohort was established. Two
cases of mesothelioma, one in a mild steel welder and one
in a non-welder, were found in the total cohort. This is not
statistically significantly different from expected (based on
national age, gender, and period-specific rates from the
Danish Cancer Registry; RR = 1.17, 95% C.I. 0.14-4.23)
and indicates no significant asbestos exposure in the origi-
nating total cohort [Hansen et al., 19961.
When following the cohort in the future it will be nec-
essary to collect supplementary exposure data for the
elapsed years after the primary data collection. In order to
minimize the consumption of resources, we find it appro-
priate to repeat the nested case-referent approach in due
course. A continuous followup of the study population will
probably enable us to cope with the problem of selection
bias and, therefore, to study the effect of duration and la-
tency more precisely. Adding 10 years to the followup of
the cohort is expected to increase the number of lung cancer
cases to between 200 and 300.
the Danish Medical Research Council, the Danish Cancer
Society, the Danish Health Foundation, the Jacob Madsen
Foundation, and the Wedell-Wedellsborg Foundation.
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ACKNOWLEDGMENTS Gerin M, Siemiatycki J, Richardson L, Pellerin J, Lakhani R, Dewar R

Thanks to Doug Easton and Professor Julian Peto, In-
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valuable advice. This study was supported by grants from
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