REVIEW Received: 03/27/2019

Accepted: 12/18/2019
ARTICLE Funding: none

Cervical cancer related to

occupational risk factors: review*
Câncer de colo uterino associado a fatores de risco ocupacional
Arthur Brito-Marcelino1, Rodrigo Japur Duarte-Tavares2,
Katienne Brito Marcelino3, Julio Alves Silva-Neto4

ABSTRACT | Background: Occupational risk factors are associated with many types of neoplasms including cervical cancer.
Objective: To review the specialized literature for evidence on the relationship between cervical cancer and exposure to occupational
hazards. Methods: Literature search in electronic databases using keywords cervical cancer and occupational risk. Results: Workers
occupationally exposed to tobacco, fungi or bacteria, metalworking fluids and tetrachloroethylene used in dry cleaning and for metal
degreasing exhibited higher susceptibility to cervical cancer. Conclusion: Few studies sought to investigate relationships between
cervical cancer and occupational hazards, which hinders the attempts at establishing a causal link.
Keywords | cancer; cervical cancer; occupational health; occupational diseases.

RESUMO | Introdução: Fatores de risco associados ao trabalho podem causar, entre outros, câncer de colo uterino. Objetivo: Identificar na
literatura especializada a associação entre câncer de colo de útero e a exposição aos fatores ocupacionais de risco. Métodos: Realizou-se um
levantamento bibliográfico em bases de dados eletrônicos com os seguintes descritores: câncer de colo uterino e riscos ocupacionais.
Resultados: Trabalhadores expostos ao tabaco nas fábricas de cigarro, fluidos de motores, exposição ocupacional a fungos e bactérias
e ao tetracloroetileno, presente em produtos de limpeza usados em lavanderias e para desengraxar metais, estariam mais susceptíveis
ao desenvolvimento de câncer de colo uterino. Conclusão: Há poucos estudos que identificam a relação entre o câncer de colo de
útero e os fatores de risco ocupacional, dificultando a associação entre o carcinogênese e o fator de risco.
Palavras-chave | câncer; câncer de colo uterino; saúde do trabalhador; doenças profissionais.

*This article derives from the final essay presented to Oswaldo Cruz Foundation (FIOCRUZ) as part of the requirements to earn the degree of specialist in health
care management.
Emergency Hospital of Sergipe – Aracaju (SE), Brazil.
1

2
Oswaldo Cruz Foundation – Rio de Janeiro (RJ), Brazil.
3
Department of Medicine, Universidade de Gurupi – Gurupi (TO), Brazil.
4
Department of Pharmacology, Universidade de São Paulo – Ribeirão Preto (SP), Brazil.
DOI: 10.5327/Z1679443520200419

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 Brito-Marcelino A, et al.
INTRODUCTION
About 20% of cancers are associated with occupa-
tional hazards, with 1.3 million deaths worldwide 1.
Reports in the literature allow inferring that expo-
sure to chemicals, such as benzene, silica, pesticides
and ionizing radiation, can lead to several types of
cancer 2. Occupational cancer surveillance guidelines
describe a relationship between several neoplasms—
including skin, lung, peritoneal, nasal cavity, pharyn-
geal and laryngeal cancer, leukemia, myeloma, gastric,
esophageal, liver, bladder, pancreatic, brain and breast
cancer—and work environments and occupational
hazards3. However, cervical cancer is seldom mentioned
in this regard.
Cervical cancer is the seventh leading neoplasm world-
wide, and the second most frequent among women 4.
It exhibits strong association with the human papilloma-
virus (HPV) which while sexually transmitted4,5 might also
be related to occupational risk factors5.
Just as other neoplasms, also mortality by cervical cancer
is higher in underdeveloped and developing countries, to a
total of 275,000 deaths worldwide in 20085. India, namely,
the second most populous country, exhibits one of the
highest rates, 27%5.
Although HPV is necessary to cause changes in the
cell genome, it does not suffice to account for the full
development of cervical cancer. Also other intrinsic
viral aspects are relevant, such as infection by onco-
genic (high-risk) strains, persistent and recurrent
infection, and high viral load. Sexual behavior, early
onset sexual activity, multiple sexual partners, smoking
and immune factors influence the mechanisms that
underlie carcinogenesis 5.
According to data available at TABNET-DATASUS
(Informatics Department, Unified Health System–SUS)
mortality by cervical cancer was 5.5/100,000 women
in Brazil in 2014. The highest rates corresponded
among regions to the North (9.34) and among states
to Amazonas (16.09)6.
Establishing a causal relationship between cancer
and work is difficult for reasons such as heterogeneity in
the criteria to grant social security benefits and under-
reporting 7,8. To this we may add the large number of
workers with informal jobs, poor or no information on
Rev Bras Med Trab. 2020;18(1):103-8
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the occupational history of workers, lack of nationwide
surveys, and scarcity of studies on the etiology of some
types of cancer in Brazil2,8,9.
As a function of the abovementioned considerations,
the aim of the present study was to perform an integrative
review of the literature on the association between cervical
cancer and occupational risk factors.
METHODS
We reviewed studies included in databases PubMed
(United States National Library of Medicine), Scientific
Electronic Library Online (SciELO) and Latin American
and Caribbean Health Sciences Literature (LILACS)
using search terms cervical cancer AND occupational
risk. The time frame was set to 10 years (2009 to
2019). Original articles, PhD and master’s disserta-
tions, review articles and meta-analyses published in
English, Portuguese or Spanish were considered eligible.
We excluded abstracts and studies on cervical cancer
that did not analyze its relationship with occupational
risk factors.
RESULTS
We initially retrieved 168 studies, 71 of them
published within the set time frame; only nine addressed
the relationship between cervical cancer and exposure
to occupational hazards. Three studies analyzed expo-
sure to tetrachloroethylene, to wit, a metal degreasing
solvent and dry cleaning agent 10-12. One study investi-
gated risk of cervical cancer among tobacco industry
workers, and another exposure to metalworking fluids
among autoworkers13,14. One study performed in Finland
analyzed the association between cer vical cancer
and occupational exposure to fungi and bacteria 15 .
The  other three studies investigated exposure to
asbestos, night work, changes in the circadian rhythm
and cosmic radiation, but did not find any relation-
ship with cervical cancer 16-18.
A review and a cohort study reported association
between exposure to tetrachloroethylene and cervical
cancer10-11. While also occupational exposure to tobacco
 Cervical cancer and occupational risk

dust exhibited a relationship with the outcome, poor
working conditions emerged as one of the factors with
negative impact on the health and well-being of the
analyzed population12. Also water-based metalworking
fluids were found to possibly have some role in the etiology
of cervical cancer, however, the authors observed that
further studies with larger cohorts are needed to estab-
lish such relationship more clearly13. Occupational expo-
sure to fungi and bacteria proved to be little significant
for occurrence of cancer in general. Nevertheless, it is
associated with higher risk of some type of neoplasms,
including cervical cancer14 (Table 1).
DISCUSSION
The literature reflects a concern among the global scien-
tific community with the exposure of workers to carcino-
genic chemicals1. According to the International Agency
for Research on Cancer, 29 agents and 13 occupational
exposures are potentially liable to trigger cancer in human
beings. However, there is appropriate toxicology infor-
mation for only 20% of them. Measuring these agents is
difficult, while length of exposure is essential to establish
their actual carcinogenic potential1.
Carcinogenesis is a highly complex process that
involves genetic and environmental risk factors, including
smoking, diet, exposure to radiation and occupational
hazards. It might be triggered by physical, chemical and
biological factors3.
Biological carcinogenesis involves integration of viral
DNA into the DNA of a host cell; then the virus becomes
able use cell resources to replicate. Such changes in the
host cell DNA favor mutations during the transcription
of the involved genes. This phenomenon is illustrated,
for instance, by the case of the human papillomavirus
(HPV)3. While the available evidence indicates that all
cervical cancers are associated to HPV10, infection is not
the single factor involved. Early onset sexual activity,
multiple sexual partners and frequency of sexual activity
are additional factors that contribute to increase the rate
of cervical cancer19. This profile matches that of a partic-
ular population of workers, scarcely considered in the
scientific literature and socially discriminated and margin-
alized, namely that of sex workers20. These individuals
have resource to sex as a means to earn their living. As a

Table 1. Studies on the relationship between cervical cancer and occupational risk factors published in the past 10 years: analyzed
risk factors, authors, year of publication, study type, results and population.
Risk factors Authors Year Study type Results Population

Tetrachloroethylene Slack et al.10 2012 Review Positive association Workers in general

Positive association,
Workers exposed to
Tetrachloroethylene Hansen et al.11 2013 Cohort but confusion with
tetrachloroethylene
other risk factors

Workers exposed to
Tetrachloroethylene Charbotel et al.12 2013 Case-control Nonsignificant risk
tetrachloroethylene

Tobacco Joseph et al.13 2016 Case-control Positive association Tobacco industry workers

Metalworking fluids Betenia et al.14 2012 Cohort Positive association Autoworkers

Workers in several
Fungi and bacteria Laakkonen et al.15 2008 Cohort Positive association
occupations

Workers exposed
Asbestos Reid et al.16 2009 Case-control No evidence
to asbestos

Cosmic radiation and

Pinkerton et al.17 2018 Cohort No association Flight attendants
sleep/wake disorders

Workers in several
Night work Schwarz et al.18 2018 Review No association
occupations

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 Brito-Marcelino A, et al.
function of the nature of their job, they are exposed to
long working hours, sexual and physical violence and
poor working conditions, in addition to difficult access
to health care and lack of public occupational health
policies which take them into account20.
Chemical carcinogenesis follows direct or indirect
exposure to toxic or nontoxic environmental chemicals.
Diet, medications, lifestyle and occupational exposure may
contribute to chemical carcinogenesis3.
While occupational hazards might cause or increase the
risk of cancer among workers, the rates in Brazil—attribut-
able risk of 2.3% for men and 0.3% for women—are lower
by comparison to other countries9.
Cervical cancer is the least mentioned in the liter-
ature on the relationship between work and cancer1-3.
Lung and mesothelial cancer are the most frequently
associated with occupational hazards, with attributable
risk of 5.44–15.63% and 100% respectively21. In addition
to a strong association with tobacco, many other inhaled
substances present in the workplace exhibit considerable
carcinogenic potential3.
The rate of work-related cervical cancer was estimated
as 0.68% (95% confidence interval—CI95% 0.03–2.13)
in the United Kingdom. Workers at highest risk were elec-
tricians, pharmacists, tobacco industry workers, waitresses
and cleaners4.
Smoking is frequently mentioned in the literature
as a risk factor for cancer, particularly lung, respiratory
tract and oral cavity neoplasms. Carcinogenesis was
also reported among workers exposed to tobacco dust.
According to some studies, smoking is associated with
higher rate of cervical cancer even when HPV infection
has been controlled. Tobacco contains chemicals such as
nitrosamines, which hinder the treatment and healing of
cervical lesions. Nitrosamines were detected in cervical
tissue, where they might induce specific local effects leading
e.g. to cervical cancer12-13. In addition, the poor working
conditions to which tobacco industry workers are exposed
and lack of use of personal protective equipment (PPE)
contribute to make their situation worse12.
Autoworkers are exposed to metalworking fluids
which contain carcinogenic agents, some of them
similar to those found in tobacco, as e.g. nitrosamines.
The results of the included study13 point to a possible
relationship between cervical cancer and exposure to
Rev Bras Med Trab. 2020;18(1):103-8
106
metalworking fluids, although the mechanism of carcino-
genesis is still unknown.
Tetrachloroethylene—also known as perchloroeth-
ylene and a metal degreasing solvent and dry cleaning
agent—was described as a risk factor for cervical cancer.
It is considered a carcinogen and might be found within
several occupational settings, including industries,
machinery manufacture, personal and home services,
and metallurgy 4,10. Exposure is rated low in industry
and construction as a function of available PPE. In any
case, construction jobs do not contribute much to the
rate of cervical cancer given the small number of female
employees4. A review study found that the rate of cervical
cancer among 189,605 women exposed to tetrachloro-
ethylene along 40 years was 0.68% (95%CI 0.03–2.13)
with seven deaths (95%CI 0–22) in 2005 and 18 (95%CI
1–56) in 2014 attributable to this chemical10.
Several jobs involve handling fungi and bacteria, for
instance, fermentation in the food industry—bread and
cakes, dairy, wine and beer, among others14. The analyzed
cohort study with exposed workers failed to demon-
strate that fungi and bacteria are significant risk factors
for most cancers. Nevertheless, they may increase the
risk of lung cancer among males and of cervical cancer
among females15.
Some hints suggest that circadian rhythms disorders
might behave as risk factors for cancer17,18. Night shift
workers and those subjected to jet lag are susceptible
to changes in the melatonin homeostasis, with conse-
quent impact on the hypothalamic-pituitary-gonadal
axis 18. Circadian misalignment-related estrogen and
melatonin suppression may increase the risk of breast
cancer18. However, a similar association was not found
for cervical cancer.
Occupational exposure to asbestos is known to cause
lung, laryngeal, gastric and ovarian cancer1,21. However, risk
of cervical or breast cancer was not higher for female workers
at Wittenoom mines by comparison to other women in
Western Australia16.
CONCLUSION
Few studies reported association between occu-
pational risk factors and some neoplasms 2, cervical
 Cervical cancer and occupational risk
cancer in particular. Establishing a causal relationship
between cancer and work is a complex process, espe-
cially when a large number of occupational hazards
are involved.
Occupational exposure to tobacco dust, metal-
working fluids in the automotive industry, fungi and
bacteria, and tetrachloroethylene in dry cleaning and
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Correspondence address: Arthur Brito-Marcelino – Rua Cinco, n. 55, ap. 802 –
Jabotiana – CEP: 49095-803 – Aracaju (SE), Brazil. E-mail: arthur_amf@yahoo.com.br

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