Childhood Leukemia Causation

1. Childhood Leukemia Causation By Terry Nordbrock, MPH student Mel & Enid Zuckerman College of Public Health Tucson, AZ December 2005

2. Overview of presentation • What is leukemia? • What are the known causes in adults? • What are the known causes in children? • What are the causal mechanisms? • What are the theories of causation?

3. What is leukemia?

4. Leukemia basics • Leukemia is cancer of the blood and bone marrow • In the U.S. there are approximately 3,250 children diagnosed each year with leukemia and 2,400 with acute lymphoblastic leukemia (ALL). • Leukemia is the most common cancer of childhood. • There has been a steady increase of 1% per year in the incidence of ALL in the past 25 years. • Etiology is not well understood

5. Types of Leukemia Myeloid Lymphoid Adults, ++ Children, + Adults, + Children, ++ Acute Chronic Adults, + Children, rare Adults, ++ Children, never

6. Types of Leukemia

7. Leukemogenesis • Multistep process • Involves one renegade cell - a hematopoietic pleuripotent stem cell or early myeloid cell • Disregulation of cell growth and differentiation (associated with mutations) • Proliferation of the leukemic clone

8. Normal blood cells

9. myeloblast promyelocyte myelocyte metamyelocyte band neutrophil Myeloid maturation MATURATION

10. Bone marrow Normal Leukemic (ALL)

11. Growth signal protein switched on

12. What are the known causes in adults?

13. Radiation causes leukemia • Scientists studying radioactive substances developed leukemia • Uranium miners • Atomic bomb survivors • Downwinders now receiving compensation

14. Above-ground Nuclear Testing • From 1945 to 1962, the US conducted 235 above ground nuclear weapons tests, primarily in Nevada and the Pacific • 200,000 Department of Defense (DoD) military and civilian participants.

15. Benzene • Known leukemogen in occupational settings • Clusters of leukemia in shoemakers, rubber workers, refinery workers

16. What are the known causes in children?

17. Prenatal Exposure to X-Rays • 1954 British researcher Alice Stewarts finds 50% higher risk of childhood leukemia following maternal x-ray • Findings repeated in multiple studies • Almost no pregnant women have abdominal radiography now

18. Postnatal Exposure to Radiation • Previously used for conditions such as tinea capitis and thymus enlargement • From 1924 to 1946, 1131 newborns in a Boston hospital irradiated for enlarged thymus • Atomic bomb survivors

19. Leukemia in atomic bomb survivors

20. Cancer treatments cause leukemia • AML is a common secondary cancer, caused by chemotherapy and radiation • Various antitumor agents have been strongly implicated, including procarbazine, melphalan, thio-TEPA, chlorambucil, and cyclophosphamide • Antibiotic chloramphenicol and analgesic phenylbutazone

21. What are the known causal mechanisms?

24. DNA damage

26. Molecular epidemiology • Benzene exposure causes chromosome damage • Chromosomes are cellular structures that contain DNA • Chromosome damage is a known precursor to cancer Courtesy Randa ElZein, MD Anderson Hospital

27. Double Strand DNA Break

28. Chromosomal translocations • A translocation is a condition where a fragment of one chromosome is broken off and is then attached to another.

29. Linus’ translocation • t(1;19)(q23;p13)

31. Tumor Suppressor Genes • Act in normal cells to regulate cell death or apoptosis, suppress tumors, regulate the cell cycle, and stop the cell from dividing when the DNA is damaged • when inactivated (as by mutation) place the cell at increased risk for malignant proliferation • called also anti-oncogene • Two tumor suppressor gene in leukemia: P53 and AML1

32. DNA Repair • Think of DNA as a zipper, and picture our cells as having tiny scavenger proteins that spend all of their time searching for and eliminating stray threads and foreign matter and broken teeth that have made their way into our DNA zippers. • There is a high incidence of leukemia in children with inherited defects in DNA repair mechanisms • Two DNA damage sensors defective in leukemia are ATM and FANC

33. Topoisomerase II • Topo II is an enzyme that allows the double helix of DNA to untangle during cell division so the chromosomes can replicate and segregate properly. • Inhibiting topo II can cause cell cycle blocks and DNA breakage. And these DNA disruptions can lead to cancer. • Benzene is a suspected topo II inhibitor

34. Topo II inhibitors • Many common chemotherapies are topo II inhibitors • 2-12% of patients who take topo II inhibitors go on to develop AML

35. In Utero Beginning • Newborn heelstick cards show leukemic chromosomal translocations present at birth • About 60-70% of diagnosed childhood ALL had the clone at birth • These chromosomal translocations are DNA damage probably caused by chemical, infectious or pesticide exposure

36. Two-hit theory • Approximately 1% of all umbilical cord blood studied have ETV6-AML1 (translocation common with ALL) • Only some of these children develop leukemia • Another “hit,” or damage to the gene, is needed to develop full blown leukemia

37. Second hit a virus? • Many leukemia researchers suspect the second “hit” may be a virus • Feline leukemia is a virus. • Human T-cell Leukemia Virus (HTLV) • Suspicions on common viruses • Timing is important. Luck plays a role.

38. What are the theories of causation

39. ALL peaks at age 2-4 years • Age peak absent in non-industrialized countries • Higher incidence in middle and high income families

40. Does modern living give 2 year-olds leukemia? • Hygiene hypothesis? • Electromagnetic frequency? • Automotive exhaust? Jet planes? • Rise of chemical industry? • Radiation from power plants? • Nuclear testing? • Monetary interests lead to bad science

41. Population Mixing Theory? • In the 1980’s England had two childhood leukemia clusters near nuclear power plants • Kinlen proposed this was due to the influx of workers to build the plants, bringing new exposures to the local rural population • Kinlen proposed the same theory to explain Fallon, as they had increased from 20,000 to 50,000 trainees during the cluster period

42. TCE and solvents • Woburn, Mass. And Toms River, NJ childhood leukemia clusters were associated with wells with TCE

43. Pesticides • 12+ studies found elevated rates of leukemia among children whose parents were occupationally exposed to pesticides or who used pesticides in their home or garden. • Children 5-6x more likely to develop brain cancer or leukemia if pesticides used at home

44. Low level exposure to benzene? • Benzene is a known leukemogen given large exposures in an occupational setting. But are current exposures safe? • Benzene is ubiquitous in low levels, from sources such as automotive exhaust, cigarettes smoke, gasoline vapors, paints and dyes and glues. • There are leukemia clusters near active airfields

45. Non ionizing radiation? • Many studies on EMF exposure and leukemia • Conflicting results • Recent ~12 studies have shown positive association with childhood leukemia

46. Other bad signs • Childhood brain tumors increasing • Chronic diseases higher than ever - asthma, ADD, autism, Parkinsons, birth defects, infertility • Biomonitoring results - we are all exposed to a host of toxics and carcinogens

47. Solutions - “Louisville Charter” • Require safe substitutes and solutions • Phase-out persistent, bioaccumulative or highly toxic chemicals • Give the public/workers full right-to-know • Act on early warnings • Require comprehensive safety data for all chemicals • Take immediate action to protect communities and workers

48. Some good news • Progress toward a national cancer registry for childhood cancer • 20,000 samples from childhood cancer tumor registries being analyzed for gene expression signatures • REACH law in Europe will require analysis of health impacts of new chemicals