Reply to the recent article by Boffetta et al. [28(5):913–915] on attribution of cancer to the environment
Department of Public Health and the Environment, World Health Organization, Geneva
* To whom correspondence should be addressed. Email: pruessa{at}who.int
In reference to our recent global estimate of attributable fraction of 19% (12–29%) of cancers to the environment (1), Boffetta et al. (2) argue that a systematic combination of errors in epidemiological study design may have ‘led to estimates of cancers attributable to pollution one order of magnitude larger than the range of reasonably accepted estimates’. We would like to point to various misunderstandings in the analysis of Boffetta et al.
First, there is a lack of understanding of the underlying method of our study. The estimate of 19% is not based on new epidemiological analyses, but rather a synthesis of existing results combined with a survey of expert opinion. Second, our estimate is not attributable to pollution alone, but to all environmental modifications in a broader sense. As clearly outlined in our work, the definition of environment included, in addition to pollution, (i) hygiene related to sanitation (e.g. link to Helicobacter pylori and gastric cancer), (ii) occupation (e.g. exposure to carcinogens, which also includes sex work and human papilloma virus linked to cervical cancer, needlestick injury in health-care workers and hepatitis B and C and liver cancer), (iii) ultraviolet radiation (e.g. excessive exposure linked to skin cancer) and (iv) the built environment (e.g. impacting on the level of physical activity linked to breast, colon and rectum cancer). In fact, adding up health impacts related to these risks would justify our estimate, in congruence with other published literature.
Despite having raised some general statements about epidemiological study designs, Boffetta et al. (2) misses the point about the method and definitions underlying our global estimate. We are well aware of the uncertainties for such a global estimate. An estimation of cancer that is preventable by environmental improvements provides, however, important information for policy considerations.
Acknowledgments
Conflict of Interest Statement: None declared.
References
- Prüss-Üstün A, et al. Preventing disease through healthy environments—towards an estimate of the environmental burden of disease (2006) Geneva: World Health Organization.
- Boffetta, et al. ‘Environment’ in cancer causation and etiological fraction: limitations and ambiguities. Carcinogenesis (2007) 28:913–1015.
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