Effective interventions

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Effective interventions

Greater coordination across sectors is pivotal to reducing occupational cancer risk through regulation, informed by more research to help ensure policy decisions are evidence-based. In cases where occupational exposures and their effects are consistent across developed economies, international evidence and policy can provide guidance. However, addressing conditions specific to Australian workplaces – such as high levels of sun exposure, the impact of mining and agriculture and a climate both unique and diverse – requires targeted Australian data to underpin policy.

A joint commitment to building the evidence base itself is therefore one of the key challenges to reducing occupational cancer burden in Australia.

Monitoring and surveillance

Comprehensive monitoring of exposure to carcinogens in the workplace and health monitoring of workers potentially exposed to carcinogens are both important strategies in reducing the burden of occupational cancers[1].

Recent research has provided comprehensive data on the extent of potential carcinogen exposure in occupational settings in Australia[2]. However, there are no systems in place for routine, systematic assessment of exposure, awareness, compliance with regulations, cancer incidence or prevention activities with respect to occupational cancers[3]. Improved data on the circumstances of occupational exposure to carcinogens and their effect over lengthy time periods is essential to reduce the burden of occupational cancers[4].

Occupational exposure matrices such as the CAREX (CARcinogen EXposure) database provide exposure data and estimates of exposed workers by carcinogen and industry for Group 1 (carcinogenic to humans), Group 2A (probably carcinogenic) and selected Group 2B (possibly carcinogenic) carcinogens for 19 countries in the European Union [5] and Canada[6].

Documentation of all carcinogens and carcinogenic processes used in Australian workplaces by statutory authorities such as Safe Work Australia and the National Industrial Chemicals Notification and Assessment Scheme (NICNAS) would facilitate research on occupational exposures. However, this would require considerable resources, and the most effective way to accomplish such monitoring is unclear.

Surveillance strategies in addition to monitoring of exposures in the workplace include biological monitoring of the uptake of potential carcinogens in the body, monitoring of conditions related to carcinogen exposure, testing DNA for interactions with carcinogens and screening for pre-clinical or early cancer[7].

Improved health monitoring of workers who may have been exposed to occupational carcinogens should assist both in the collection of data and in increasing opportunities for earlier detection which should lead to improved survival. State-based agencies, such as the Dust Diseases Board of NSW, run occupational respiratory screening services. Currently, no systematic collection of exposure data occurs in Australia however, several possible sources of data exist:

  • NICNAS are responsible for assessing (but not regulating) health and environmental impacts of industrial chemicals.
  • The National Pollutant Inventory publishes data on annual emissions of 93 specific chemicals identified as important due to their possible effect on human health and the environment.
  • Safe Work Australia publishes some research relating to workplace health, but does not provide ongoing estimates of the number of workers exposed to particular carcinogens.

There are limitations to undertaking carcinogen exposure and cancer surveillance. A number of cancers linked to occupation, such as lung cancer and mesothelioma, cannot be detected early through the screening of asymptomatic people. Moreover, current diagnostic technology cannot distinguish between cancers potentially caused by occupational exposures and those that would have occurred irrespective of workplace carcinogens. Examples include cancers in nurses who have worked with cytotoxic drugs and smelter workers who are diagnosed with lung cancer.

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Inter-sectoral partnerships

Effective cancer control policy, particularly where exposures are widespread, requires cross-sectoral partnerships across a range of sectors such as health, industry, trade, and environment[8]. Building on this type of partnership approach is integral to reducing the incidence of occupational cancers.

Occupational health and safety in Australia is the remit of a range of organisations, offering abundant opportunities for joint approaches to policy and industry compliance. Overall occupational safety is in the remit of every state and territory government (through occupational health and safety agencies and workers’ compensation authorities) and several federal regulatory authorities, including Safe Work Australia, NICNAS and specialist agencies concerned with the maritime, petroleum and transport industries. Recent examples of collaboration include:

  • the establishment of the Nanotechnology Work Health and Safety Advisory Group involving Safe work Australia, NICNAS, the Australian Council of Trade Unions (ACTU) and Australian Chamber of Commerce and Industry (ACCI), among others;
  • the ACTU joining the International Metalworkers’ Federation and other international union bodies in 2008 to support the Occupational Cancer/Zero Cancer campaign[9]; and
  • the ACTU and Cancer Council Australia’s joint national forum, kNOw Cancer in the Workplace held in December 2009[10].

Greater collaboration across these inter-sectoral groups should be sought. More broadly, peak business organisations such as ACCI and the Australian Industry Group, along with professional groups like the Faculty of Occupational and Environmental Medicine (within the Australasian College of Physicians) and the Australian Institute of Occupational Hygienists are potential partners.

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Integrated health protection and health promotion programs

The workplace provides a structured framework for delivering health messages, whether relating to hazardous exposures and harmful work practices or to individual health behaviours, such as smoking, nutrition and physical activity.

Recent approaches to health promotion in the workplace have been based on the premise that home and work life both contribute to individual health and that best results are achieved when behaviours in both settings are addressed. Integrated programs that target both workplace safety and individual health have the potential to increase the effectiveness of separate programs in each setting[11]. Employees who see that management is making a genuine attempt to improve workplace safety may also be more likely to engage in safe work practices and other wellness programs, particularly blue collar workers[11][12].

The World Health Organisation’s Global Plan of Action on Workers’ Health 2008-2017[13] endorses integrated programs for occupational safety and health promotion initiatives for individual health, including support for smoking cessation, healthy diet and physical activity, and promoting mental and family health. In the US, the national WorkLife Initiative (an alliance between the US Department of Health and Human Services, the Centres for Disease Control and the National Institute for Occupational Health and Safety) calls for the same approach[14]. In Australia, the Government’s National Preventive Health Taskforce identified an opportunity for introducing and evaluating integrated workplace health improvement programs along the lines of the WorkLife Initiative[15]. However, the evidence base supporting the effectiveness of such programs is required.

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Evaluating potential risks

While evidence is clear that a number of industries and materials cause occupational cancer (see the Links section of this chapter), there may be other widespread current work practices that have not yet been identified as increasing cancer risk. The potential time lag between carcinogen exposure and cancer diagnosis underscores this potential problem, particularly in relation to practices and technologies that have been introduced in recent years. It is therefore critical to evaluate the potential health risks of new work practices, materials and technologies as they are introduced, while recognising that evaluation is difficult to perform comprehensively.

For example, little is known about the long-term health risks for workers using nanotechnology (the manipulation of particles so small that they can penetrate human cellular structures). Under the Nanotechnology Work Health and Safety Program, Safe Work Australia conduct nanotechnology research and provide guidance on the potential work safety and health implications of nanotechnology applications[16]. Ongoing monitoring and evaluation will be key to building the evidence base around nanotechnology, to determine if there is an increase in cancer risk associated with the industry.

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Legislation to improve policy

Regulation has an important role to play in preventing occupational cancer. Currently, the scope and design of relevant regulations in Australia is inherently complex because of Federal and State Government relationships, and does not comprehensively addressing all recognised hazards.

Both legislative and common law impose a duty of care on employers to provide a safe workplace. Regulations in a range of state-based industrial and other legislative frameworks underpin employers’ responsibilities for preventing work-related injury and limiting exposure to workplace carcinogens.

Legislation changes in 2012 have provided a platform for harmonisation of health and safety laws between Australian jurisdictions, as well as with international standards. The Model work health and safety laws were introduced under the Intergovernmental Agreement for Regulatory and Operational Reform in Occupational Health and Safety. All jurisdictions have committed to adopting the legislation. The model work health and safety laws include implementation of the Globally Harmonized System of Classification and Labelling of Chemicals (GHS) for occupational and environmental hazardous substances. GHS is an internationally agreed system which harmonises classification systems and hazard communication globally.

See Policy context for more information on legislation.

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Compensation to improve policy

Compensation can be payable to individuals deemed to have developed cancer as the result of occupational exposures, with cancers related to the use of asbestos the most prevalent example. Authorities such as the Dust Diseases Board of NSW have been involved in such compensation cases.

As well as providing some financial compensation to affected individuals, a potential benefit of litigation is that the disincentive of paying damages may prompt employers to improve occupational health and safety practices and contribute to tighter laws. The recent work on deemed diseases by Safe Work Australia should streamline legitimate claims for occupational cancer and raise awareness of the risk as well as increase the incentives to adequately work-related exposure to carcinogens[17].

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Primary prevention

Primary prevention of cancers through removal of carcinogens or reductions in exposure has proven effective in a range of occupational settings[18][19]. Despite this, there is a tendency for primary prevention to be under-resourced and uncoordinated, and to not make full use of existing knowledge[8].

Primary prevention of occupational cancers requires explicit legislation across health, social security and labour sectors[8]. See the section on legislation to improve policy for more information.

Banning carcinogenic substances or practices and replacing them with less hazardous alternatives is potentially the most effective way to eliminate occupational cancers. However, this may not always be feasible[7]. Where the use of carcinogens cannot be avoided, there is an established hierarchy of preventive measures for limiting exposures. Engineering controls may be introduced to isolate substances or reduce exposure through the use of robotics, enclosed working systems or ventilation. Work practices may also be altered – for example by limiting outdoor work when UV radiation is at its peak or introducing procedures to dampen down dusty environments.

Personal protective equipment (PPE) in the form of respirators, gloves and other special clothing also have an important place, but must be regularly checked, properly maintained and correctly used. Barriers to the effectiveness of PPE include that it can be uncomfortable to wear and make tasks more difficult or dangerous. PPE also places the onus for compliance on the employee. For these reasons, PPE should not be relied upon as the only form of exposure protection. Unfortunately, it is often the first line of defence used in the workplace against hazardous substances, including occupational carcinogens[3].

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Comprehensive research is essential to develop a strong evidence base to underpin policy across the cancer control spectrum. This is a critical priority in relation to occupational cancers, where there are significant gaps in the evidence base on the nature and extent of exposure to carcinogens in Australian workplaces, and on their impact on cancer occurrence. This significantly restricts the development of evidence-based occupational health and safety policy. Building the evidence base is therefore a major public health policy priority in itself.

Some data on occupational cancer in Australia has been collected for more than 50 years, preceding the establishment of population-based cancer registries[3]. Studies have typically involved job descriptions, or carcinogenic exposures identified elsewhere, and attempts to apply the findings to Australian workplaces.

Compared with occupational cancer studies in more populous North American and Western European settings, numbers of Australians in particular industries tend to be smaller. Despite this limitation, results of local research provide clear justification for further studies.

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  1. Kauppinen T, Saalo A, Pukkala E, Virtanen S, Karjalainen A, Vuorela R. Evaluation of a national register on occupational exposure to carcinogens: effectiveness in the prevention of occupational cancer, and cancer risks among the exposed workers. Ann Occup Hyg 2007 Jul;51(5):463-70 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/17625219.
  2. Carey RN, Driscoll TR, Peters S, Glass DC, Reid A, Benke G, et al. Estimated prevalence of exposure to occupational carcinogens in Australia (2011-2012). Occup Environ Med 2014 Jan;71(1):55-62 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/24158310.
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  4. National Health and Hospitals Reform Commission. A healthier future for all Australians – final report of the National Health and Hospitals Reform Commission. Canberra: NHHRC; 2009 Jun Available from: http://www.health.gov.au/internet/nhhrc/publishing.nsf/content/nhhrc-report.
  5. Finnish Institute of Occupational Health. Description of CAREX. [homepage on the internet] Helsinki, Finland: Finnish Institute of Occupational Health; 2010 Jun 21 Available from: http://www.ttl.fi/en/chemical_safety/carex/description_of_carex/pages/default.aspx.
  6. Peters CE, Ge CB, Hall AL, Davies HW, Demers PA. CAREX Canada: an enhanced model for assessing occupational carcinogen exposure. Occup Environ Med 2014 Jun 26 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/24969047.
  7. 7.0 7.1 Australasian Faculty of Occupational Medicine. Occupational Cancer, a guide to prevention, assessment and investigation. Sydney: AFOM; 2003 Available from: http://www.racp.edu.au/index.cfm?objectid=5DEC24B4-9AA9-1BEE-C65E0F6B0DF34C3B.
  8. 8.0 8.1 8.2 Espina C, Porta M, Schüz J, Aguado IH, Percival RV, Dora C, et al. Environmental and occupational interventions for primary prevention of cancer: a cross-sectorial policy framework. Environ Health Perspect 2013 Apr;121(4):420-6, 426e1-7 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/23384642.
  9. Australian Council of Trade Unions. International workers memorial day 2009. Melbourne: ACTU; 2009 Apr 28 [cited 2009 Nov 9] Available from: http://www.actu.org.au/Images/Dynamic/attachments/6514/factsheet_death_at_work_0409.pdf.
  10. Cancer Council Australia. kNOw cancer in the workplace. Sydney: CCA; 2009 [cited 2009 Nov 9] Available from: http://www.cancer.org.au/content/pdf/HealthProfessionals/CancerInTheWorkPlace/Cancer-in-the-Workplace2012-Program.pdf.
  11. 11.0 11.1 LaMontagne AD, Barbeau E, Youngstrom RA, Lewiton M, Stoddard AM, McLellan D, et al. Assessing and intervening on OSH programmes: effectiveness evaluation of the Wellworks-2 intervention in 15 manufacturing worksites. Occup Environ Med 2004 Aug;61(8):651-60 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/15258270.
  12. Sorensen G, Stoddard A, Ockene JK, Hunt MK, Youngstrom R. Worker participation in an integrated health promotion/health protection program: results from the WellWorks project. Health Educ Q 1996 May;23(2):191-203 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/8744872.
  13. World Health Assembly. Workers’ health: global plan of action. WHA60.26. 2007 May 23; Geneva. Sixtieth World Health Assembly; 2007 Available from: http://apps.who.int/gb/ebwha/pdf_files/WHA60/A60_R26-en.pdf.
  14. National Institute for Occupational Safety and Health. WorkLife initiative. [homepage on the internet] Centers for Disease Control and Prevention; 2017 Nov 18 Available from: http://www.cdc.gov/niosh/docs/2009-146/.
  15. National Preventative Health Taskforce. Australia: the healthiest country by 2020. National preventative health strategy – the roadmap for action. Canberra: Commonwealth of Australia; 2009 Jun 30 Available from: http://www.preventativehealth.org.au/internet/preventativehealth/publishing.nsf/Content/nphs-roadmap/$File/nphs-roadmap.pdf.
  16. Safe Work Australia. Nanotechnology and work health and safety. [homepage on the internet] Canberra: SWA; 2017 Nov 18 Available from: http://www.safeworkaustralia.gov.au/sites/swa/whs-information/nanotechnology/pages/nanotechnology.
  17. Safe Work Australia. Deemed Diseases in Australia. Canberra: Safe Work Australia; 2015 Aug Available from: http://www.safeworkaustralia.gov.au/sites/SWA/about/Publications/Documents/931/deemed-diseases.pdf.
  18. Hayes RB, Gerin M, Raatgever JW, de Bruyn A. Wood-related occupations, wood dust exposure, and sinonasal cancer. Am J Epidemiol 1986 Oct;124(4):569-77 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/3752051.
  19. Hemminki K, Hussain S. Mesothelioma incidence has leveled off in Sweden. Int J Cancer 2008 Mar 1;122(5):1200-1 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/17973259.

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