Occupational respiratory cancer in Korea.
ABSTRACT Malignant mesothelioma and lung cancer are representative examples of occupational cancer. Lung cancer is the leading cause of cancer death, and the incidence of malignant mesothelioma is expected to increase sharply in the near future. Although information about lung carcinogen exposure is limited, it is estimated that the number of workers exposed to carcinogens has declined. The first official case of occupational cancer was malignant mesothelioma caused by asbestos exposure in the asbestos textile industry in 1992. Since then, compensation for occupational respiratory cancer has increased. The majority of compensated lung cancer was due to underlying pneumoconiosis. Other main causative agents of occupational lung cancer included asbestos, hexavalent chromium, and crystalline silica. Related jobs included welders, foundry workers, platers, plumbers, and vehicle maintenance workers. Compensated malignant mesotheliomas were associated with asbestos exposure. Epidemiologic studies conducted in Korea have indicated an elevated risk of lung cancer in pneumoconiosis patients, foundry workers, and asbestos textile workers. Occupational respiratory cancer has increased during the last 10 to 20 yr though carcinogen-exposed population has declined in the same period. More efforts to advance the systems for the investigation, prevention and management of occupational respiratory cancer are needed.
- [show abstract] [hide abstract]
ABSTRACT: Cancer mortality and morbidity are described for the first time in all Korean workers exposed to ionizing radiation. Based on hospital admissions, Standardized Rate Ratios (SRR) and Standardized Mortality Ratios (SMR) were modeled with Poisson regression. Cancer admissions during 2000 to 2005 were low compared with autoworkers with the exception of nuclear power workers (SRR = 1.13, 95% CI = 0.94-1.36). Thyroid cancer was statistically significantly elevated in women radiation workers in medical (SRR = 2.90, 95% CI = 1.05-7.94) and research institutions (SRR = 3.91, 95% CI = 1.36-11.0) and industry (SRR = 5.07, 95% CI = 1.56-15.6), and in all nuclear power workers (SRR = 2.59, 95% CI = 1.33-5.13), and there was a significant association with dose (ERR = 20.4 per Sv, 90% CI = -8 to 60, one-tailed P = 0.049). The 935 deaths revealed a healthy worker effect for all causes (SMR = 0.58, 95% CI = 0.54-0.62) and all-cancer (SMR = 0.73, 95% CI = 0.64-0.82). Lung cancer (SMR = 0.77, 95% CI = 0.55-1.05) and leukemia (SMR = 0.59, 95% CI = 0.28-1.06) mortalities were also less than expected. Compared with autoworkers, radiation workers displayed decreased all-cause mortality except for nuclear power workers (statistically not significant). ERRs as high as 300 per Sv appear to be ruled-out in this population with regulated exposure to ionizing radiation while ERRs as high as 100 per Sv are not.Journal of occupational and environmental medicine / American College of Occupational and Environmental Medicine 08/2008; 50(7):791-803. · 1.88 Impact Factor
- Analysis of occupational disease by approved Korea Labor Welfare Corporation in 1999. 449-60..
- Occupational lung cancer surveillance in South Ko-rea. 134-9..
© 2010 The Korean Academy of Medical Sciences.
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Occupational Respiratory Cancer in Korea
Malignant mesothelioma and lung cancer are representative examples of occupational
cancer. Lung cancer is the leading cause of cancer death, and the incidence of malignant
mesothelioma is expected to increase sharply in the near future. Although information
about lung carcinogen exposure is limited, it is estimated that the number of workers
exposed to carcinogens has declined. The first official case of occupational cancer was
malignant mesothelioma caused by asbestos exposure in the asbestos textile industry in
1992. Since then, compensation for occupational respiratory cancer has increased. The
majority of compensated lung cancer was due to underlying pneumoconiosis. Other main
causative agents of occupational lung cancer included asbestos, hexavalent chromium, and
crystalline silica. Related jobs included welders, foundry workers, platers, plumbers, and
vehicle maintenance workers. Compensated malignant mesotheliomas were associated
with asbestos exposure. Epidemiologic studies conducted in Korea have indicated an
elevated risk of lung cancer in pneumoconiosis patients, foundry workers, and asbestos
textile workers. Occupational respiratory cancer has increased during the last 10 to 20 yr
though carcinogen-exposed population has declined in the same period. More efforts to
advance the systems for the investigation, prevention and management of occupational
respiratory cancer are needed.
Key Words: Occupational; Lung Cancer; Mesothelioma; Asbestos; Carcinogenic Substances
Hye-Eun Lee1,2, and Hyoung Ryoul Kim3
Occupational Safety and Health Research Institute1,
KOSHA, Inchoen; Department of Environmental
Health, School of Public Health2, Seoul National
University, Seoul; Department of Preventive
Medicine and Industrial Medical Center3, The
Catholic University of Korea, College of Medicine,
Received: 24 March 2010
Accepted: 27 September 2010
Address for Correspondence:
Hye-Eun Lee, M.D.
Occupational Safety and Health Research Institute,
Korea Occupational Safety and Health Agency,
478 Munemi-ro, Bupyong-gu, Inchoen 403-711, Korea
Tel: +82.32-510-0832, Fax: +82.32-518-0862
E-mail : firstname.lastname@example.org
DOI: 10.3346/jkms.2010.25.S.S94 • J Korean Med Sci 2010; 25: S94-98
Occupation & Environmental Medicine
Cancer has been the most common cause of death in Korea since
1983, and lung cancer is the leading site among cancer deaths.
In 2005, 16,949 new cases of lung cancer occurred in Korea, and
the age-standardized incidence rates were 50.2 and 13.2 per
100,000 for males and females, respectively (1). Although its
predominant cause is now clearly known to be tobacco smok-
ing, lung cancer is the most common cancer associated with
occupational exposures (2). The proportion of lung cancer cases
to which occupational exposure contributes is reported to be in
the range of 9%-15% (3). In Korea, that was estimated at 7% (4).
In reference to the respiratory cancers, malignant mesotheli-
oma is a well-known occupational cancer caused by asbestos
exposure. Malignant mesothelioma is a very rare cancer, and its
incidence in Korea was 70-90 new cases per year during 2004-
2007 (5-8). However, the mortality rate has increased by more
than double in recent years, from 0.4 in 1998 to 0.9/100,000 in
2008 (1). Also, the number of cases detected by a nationwide
malignant mesothelioma surveillance system has also increased
by nearly three-fold. Thus, Korean society is concerned that a
surge of malignant mesothelioma occurrence may begin soon
(9, 10). The aim of this review is to overview occupational respi-
ratory cancer including malignant mesothelioma in Korea.
EXPOSURE TO OCCUPATIONAL LUNG
In Korea, 14 agents are listed as carcinogens by the Ministry of
Employment and Labor (Table 1) (11). The list is not exactly the
same as the list of agents proposed by the International Agency
for Research on Cancer (IARC) Group 1. Among those in the
former list, carcinogens known to be associated with respirato-
ry cancer include asbestos, bis(choloromethyl)ether, chromium
(VI) compound, coaltar pitch volatiles, and nickel compound.
In order to use or manufacture these agents, one must obtain
permission from the authorities. The manufacturing, import,
and use of all kinds of asbestos were banned in 2009.
The Korean Occupational Safety and Health Agency (KOSHA)
performs the Work Environment Survey every five years. The
subjects of this survey are limited to the private sector and in-
clude all manufacturers employing more than five workers and
some portion of all other companies. Some lung carcinogen-
exposed populations were presented in the survey (Table 2) (12).
Other useful data include the number of workers who received
the special health examination because of exposure to desig-
nated hazardous agents (Table 3) (13). The list of agents and the
coverage of medical check-ups are specified by law. According
to a study using these data, from 2000 to 2004, 2,098 workers
were exposed to cokes, and 5,789 to asbestos (14). In a similar
Lee H-E, et al. • Occupational Respiratory Cancer in Korea
study using these data from 2000 to 2002, it was reported that
the carcinogenic heavy metal (including arsenic, beryllium, cad-
mium, chromium, nickel)-exposed population was 32,096 (15).
It shows big gap between the number of exposed workers of
Work Environment Survey data and that of Special Health Ex-
amination data. Main reason is because Work Environment Sur-
vey did not cover small-scale enterprises (less than five work-
ers), public sector and majority of non-manufacturing industry.
In case of asbestos, use of any form of asbestos is banned from
2009, but quite many workers are still exposed to asbestos in
buildings and facilities. Such exposure due to deconstruction
and repair was beyond the scope of Work Environment survey.
COMPENSATION FOR OCCUPATIONAL
Some criteria for granting compensation for occupational dis-
eases are stated in the Enforcement Decree under the Industri-
al Accident Compensation Insurance (IACI) Act. For example,
if primary lung cancer develops in a pneumoconiosis patient
whose radiograph defines profusion of 1/0 or greater by the In-
ternational Labor Organizaion (ILO) classification, the worker
will be compensated automatically by this regulation. Another
example is asbestos-related diseases. Asbestos-exposed work-
ers who have primary lung cancer or malignant mesothelioma
could be compensated if they have asbestosis, signs of asbestos
exposure such as pleural plaque, or a history of asbestos expo-
sure for more than 10 yr (16). However, most cases claimed for
occupational diseases are evaluated on a case-by-case basis by
the Korea Workers’ Compensation and Welfare Service (COM-
WEL), and some of them are investigated in depth by the Occu-
pational Safety and Health Research Institute (OSHRI) in KO-
SHA to determine whether they are work-related. The official
statistics of compensation for occupational injuries and diseas-
es are reported annually by KOSHA. About 10-13 million work-
ers per year were covered by IACI, and the total number of com-
pensated occupational diseases (excluding work-related disease
like musculoskeletal, cardiovascular, and cerebrovascular dis-
ease) ranged about 2,000-2,500 cases per year in the past five
years (17). No data specific to lung cancer or malignant meso-
thelioma were presented. A number of asbestos related cancer
is available since 2006. A few studies have analysed the charac-
teristics of compensated occupational diseases including respi-
ratory cancer using the database of COMWEL; these are sum-
marized as below.
Ahn et al. (18) analyzed 575 compensated occupational disease
cases that occurred in 1999. Among them were 17 cases of can-
cer, and 11 of these were lung cancer. Six cases of lung cancer
were compensated because they were recognized as complica-
tions of pneumoconiosis (9). In a similar study of another period
using the COMWEL database, Ahn et al. (19) analyzed 4,240
cases of compensated occupational disease that occurred from
2001 to 2003. Sixty-seven cases of lung cancer were approved
based on underlying pneumoconiosis, and another 22 lung
cancer cases were compensated. Another study collected 120
cases of compensated lung cancer during 1994-2008 (20); cases
approved for underlying pneumoconiosis were excluded in their
analysis. The number of compensated occupational lung cancer
cases increased from 15 during 1994-1999 to 105 cases during
Table 1. List of confirmed carcinogen (A1) by the Ministry of Employment and Labor,
Asbestos, all forms
Beryllium & compounds
Chloroethylene or vinyl chloride
0.001 ppm or
Chromite ore processing (Chromate), as Cr
Chromium(VI) compounds as Cr
Certain water-insoluble inorganic compounds
Coaltar pitch volatiles, as Benzene solubles
Nickel sulfide roasting fume & dust, as Ni
Particulate polycyclic aromatic hydrocarbons,
as benzene solubles
Zinc chromates, as Cr
TLV-TWA, Threshold limit value-Time weighted average; STEL, Short term exposure
Table 2. Lung carcinogen-exposed population person (0) reported in the Work Environ-
Zinc chromates, as Cr
Beryllium & compounds
Arsenic & inorganic compound
Chromium (VI) compounds
Nickel sulfide & compounds
Coaltar pitch volatiles & compounds
Table 3. Number of workers exposed to lung cancer related hazardous agents by the
Special Health Examination data
Agents 2008 2007 2006 2005
Lee H-E, et al. • Occupational Respiratory Cancer in Korea
2000-2008. The majority of occupational lung cancers (93.3%)
were male. The average age at the time of diagnosis was 51.9 yr,
and 63% of the patients were diagnosed in their fifties. The most
common pathologic findings were adenocarcinoma (35%), fol-
lowed by squamous cell carcinoma (19%). The mean duration
of occupational exposure was 19.6 yr. The average latency was
21.3 yr, and nearly half of the cases (44.2%) had a latent period
of 20-30 yr. The major lung carcinogen was asbestos (45%), fol-
lowed by hexavalent chromium (30%) and crystalline silica (19%).
Prevalent occupations among these cases were welders (14%)
and foundry workers (14%), and the rest included painters, plat-
ers, plumbers, and vehicle maintenance workers.
Ahn et al. (10) analyzed 60 cases of occupational cancer com-
pensated from 1993 to 2007. Among them, 19 cases were malig-
nant mesothelioma. The mean duration of asbestos exposure
was 16.0 yr, and the mean latency was 22.6 yr. The types of ex-
posure included the manufacture of asbestos-containing prod-
ucts, use of asbestos-containing products in the manufacturing
process, and handling of asbestos-containing products in the
course of work. The most common industries related to occu-
pational malignant mesothelioma were shipbuilding and repair
(4 cases) and the manufacturing of asbestos textiles (3 cases).
Case investigation by OSHRI
At the request of COMWEL, OSHRI has investigated workers
and the workplaces of involved in claims of occupational dis-
ease to evaluate work-relatedness since 1992. Cases having a
probability of work-relatedness greater than 50% have been rec-
ognized as occupational disease. Kang et al. (21) analyzed the
data of this investigation from 1992 to 2000. The total number of
cancer cases claimed was 108. Fourteen of 46 cases (30.4%) of
lung cancer and 6 of 6 cases (100%) of malignant mesothelioma
were accepted as occupational cancer. The most common caus-
ative agent of lung cancer was asbestos, followed by hexavalent
chromium, polycyclic aromatic hydrocarbons (PAHs), and crys-
talline silica. Asbestos exposure was related to all cases of malig-
nant mesothelioma. Other types of respiratory cancer that have
been investigated include laryngeal cancer, nasal cancer, and
OCCUPATIONAL DISEASE SURVEILLANCE SYSTEM
An occupational disease surveillance system have been estab-
lished to monitor trends in occupational disease and to identify
sentinel cases since 1999, supported by OSHRI. In Korea, two
types of surveillance systems are used. The first is the regional
occupational surveillance system for preventing occupational
hazards at the local level. The second is a nation-wide occupa-
tional surveillance system for specific target diseases, such as
occupational lung cancer, occupational asthma, and malignant
Occupational Lung Cancer Surveillance System
The Occupational Lung Cancer Surveillance System is a hospi-
tal-based system covering nine general hospitals in six regions.
The investigators at member hospitals report all cases of first-
diagnosed lung cancer in their hospital during a specified peri-
od and check the occupational history of the patient. Then, the
cases are classified into four groups according to the possibility
of work-relatedness: definite, probable, possible, and suspicious.
A total of 3,353 cases were reported during 2006-2009, and the
number in the definite and probable groups combined was 393
(11.7%). The probable carcinogens to which these patients had
been exposed were asbestos (20%), diesel engine exhaust (17%),
crystalline silica (14%), and PAHs (10%) (22).
Malignant Mesothelioma Surveillance System
The Mesothelioma Surveillance System began operation in Korea
in 2000. When the members of the Korean Society of Pathology
confirm malignant mesothelioma, they report it to the surveil-
lance center, and then information about occupational and en-
vironmental exposure is collected by telephone interview. Ac-
curacy is the strength of this data because only pathologically
confirmed cases are collected. Kim et al. (23) reported that un-
der this system, only 18 cases were reported before 1995, but
this increased to 42 in 2004, 37 in 2005, and 53 in 2006 and 55 in
2007. The incidence rate, calculated using the total population
of Korea as the denominator, increased rapidly from 0.25 per
million in 2001 to 1.14 per million in 2007. The most common
occupation among these cases was construction worker, and
others included asbestos textile industry workers, welders at a
shipbuilding, soldiers, and manufacturing workers. Some pa-
tients had histories of environmental exposure, such as resi-
dence near a mine or repair the asbestos slate roof of their own
house (24, 25).
OCCUPATIONAL RESPIRATORY CANCER
An elevated risk of respiratory cancer among several occupa-
tional cohorts was observed. Choi (26) reported that lung can-
cer was significantly elevated in non-miners with pneumoco-
niosis (standardized incidence ratio [SIR], 2.6; 95% confidence
interval [CI] 1.8-3.8), underground mine workers with pneumo-
coniosis (SIR, 1.9; 95% CI, 1.8-2.1), and underground mine work-
ers without pneumoconiosis (SIR, 1.9; 95% CI, 1.7-2.2). Based
on this result, the criteria for compensation of occupational lung
cancer in the IACI. Act were revised in 1999 to compensate pri-
mary lung cancer of pneumoconiosis patients with profusion of
Lee H-E, et al. • Occupational Respiratory Cancer in Korea
1/0 or greater by the ILO classification of pneumoconiosis.
Ahn et al. (27) used the National Health Insurance data to
evaluate the risk of lung cancer in foundry workers; a signifi-
cant positive association was reported between foundry work
and the risk of lung cancer (Odds ratio, 10.04; 95% CI, 3.95-25.55;
cases=7 foundry workers).
An elevated risk of lung cancer was found among cohorts of
male workers exposed to carcinogenic heavy metals including
arsenic, beryllium, cadmium, chromium, and nickel, but the
association was not significant (SIR, 1.47; 95% CI, 0.67-2.80;
cases=9) (15). An analysis of a cohort of carcinogen-exposed
workers indicated an excess of lung cancer in asbestos-exposed
workers (standardized rate ratio [SRR], 7.87; 95% CI, 1.87-33.15;
cases=6 exposed workers) (14).
Kim (28) investigated the occurrence and mortality of malig-
nant mesothelioma and lung cancer among retired workers of
a asbestos textile company. Of the 222 subjects, three died of
malignant mesothelioma, and six died of lung cancer. An ex-
tremely elevated risk of malignant mesothelioma was observed
in males (standardized mortality ratio [SMR], 517.1; 95% CI,
130.9-28813.0, case=1) and in females (SMR, 4501.7; 95% CI,
545.2-16262.0; cases=2). The risk of lung cancer was not signifi-
cantly elevated in males (SMR, 1.4; 95% CI, 0.0-7.6; case=1), but
it was significantly elevated in females (SMR, 41.4; 95% CI 13.5-
Although not targeting respiratory cancer, several occupa-
tional cohort studies have been conducted to examine the risk
of cancer. Park et al. (29) reported no significant association be-
tween the iron and steel industry employment and lung cancer
(SMR, 0.81; 95% CI, 0.85-2.28; cases=31). Morbidity analysis of
the same cohort showed an elevated lung cancer risk among
workers in subcontract plants compared with those in parent
plants (SRR, 2.35; 95% CI, 1.07-4.92) (30). Non-significant nega-
tive associations with lung cancer risk among workers exposed
to ionizing radiation were reported in a cohort study (SMR, 0.77;
95% CI, 0.55-1.05; cases=38) (31).
In a study based on patients in one university hospital, 4.6%
of primary lung cancer was identified as probable or definite
occupational lung cancer, and the presumptive carcinogens in-
cluded asbestos, heavy metal, inorganic dust, and PAHs (32).
In Korea, the first officially reported case of occupational cancer
was mesothelioma caused by asbestos exposure in the asbestos
textile industry in 1992 (33). This report confirmed high expo-
sure to asbestos associated with a high count of asbestos fiber
in pleural tissue. Following that report, lung cancer with pleural
asbestosis in a worker exposed to asbestos in manufacturing
insulation (34) and malignant pleural mesothelioma in a boil-
ermaker and a plumber (35) were reported in the 1990s. Since
2000, reports have identified lung cancer associated with expo-
sure to coke oven emissions (36), lung cancer in an asbestos-
exposed shipyard repairman (37), and lung cancer with silicosis
in a plasterer exposed to cement dust contained silica (38).
Interest in occupational cancer is growing in Korea. Especially,
lung cancer and malignant mesothelioma are well known oc-
cupational cancers. We have reviewed the results of scientific
articles about compensated occupational respiratory cancer,
but the national official statistics did not report the status and
trends of compensation for respiratory cancer. Also, a nation-
wide investigation of the hazardous agent-exposed population
was quite limited, so more efforts are needed to estimate the
lung carcinogen-exposed population. Few epidemiological
studies have examined occupational respiratory cancer, and
long-term cohort studies are thus far very limited. Nonetheless,
it is expected that more research will be conducted in response
to the increasing interest in occupational cancer.
It is difficult to predict the trend for the future incidence of
occupational respiratory cancer, but this review demonstrates
that occupational respiratory cancer has increased during the
last 10 to 20 yr. At present, important programs and regulations
are in place to prevent and control occupational cancer, such as
banning all forms of asbestos, workplace exposure monitoring,
and occupational disease surveillance systems. Indeed, more
efforts to advance the systems for the prevention and manage-
ment of occupational cancer are needed in response to chang-
ing technology and work environments.
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