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Cancer Mortality in an Area of
Campania (Italy) Characterized
by Multiple Toxic Dumping Sites
PIETRO COMBA,aFABRIZIO BIANCHI,bLUCIA FAZZO,aLUCIA
MARTINA,cMASSIMO MENEGOZZO, dFABRIZIO MINICHILLI,b
FRANCESCO MITIS,eLOREDANA MUSMECI,aRENATO PIZZUTI,c
MICHELE SANTORO,cSTEFANIA TRINCA,aMARCO MARTUZZI,eAND
“HEALTH IMPACT OF WASTE MANAGEMENT CAMPANIA”WORKING GROUP∗
aDepartment of Environment and Primary Prevention, Istituto Superiore di
Sanit`a, 00161 Rome, Italy
bUnit of Epidemiology, CNR Institute of Clinical Physiology, 56127 Pisa, Italy
cCampania Region Health Authority—Regional Epidemiological Observatory,
80100 Naples, Italy
dCampania Region Environmental Protection Agency, 80100 Naples, Italy
eWHO European Centre for Environment and Health, Rome Office,
00187 Rome, Italy
ABSTRACT: Several recent studies have documented that a widespread
practice of dumping toxic wastes has taken place for many years in the
Provinces of Naples and Caserta. Extensive programs of environmental
monitoring are currently ongoing in the area. In this frame, the Depart-
ment of Civil Defence of the Italian Government has appointed an ad hoc
study group in order to assess the health status of the population resi-
dent in the area of interest. The first investigation performed by the study
group has been a geographic study on cancer mortality and occurrence of
malformations in 196 municipalities constituting the two Provinces. The
study detected an area located in the southeastern part of the Province
∗Members of the working group are: R. Bertollini, M. Martuzzi, F. Mitis (WHO European Centre for
Environment and Health), C. Carboni, P. Comba, L. Cossa, P. De Nardo, L. Fazzo, L. Musmeci, S. Trinca
(Istituto Superiore di Sanit`a), F. Bianchi, N. Linzalone, F. Minichilli, A. Pierini (National Research
Council), E. Lorenzo, L. Martina, R. Pizzuti, M. Santoro (Campania Region Health Authority), E.
Lionetti, M. Menegozzo (Campania Region Environmental Protection Agency), M. Fusco (Naples
Cancer Registry), G. Scarano (Campania Region Birth Defects Registry), S.Menegozzo (Campania
Region Mesothelioma Registry), G. Doddi, M. Leonardi, L. Madeo, G. Martini, N. Mazzei, R. Pizzi
(Department of Civil Defence), A. Savarese (Legambiente Campania), C. Bove (Local Health Unit
Caserta1), A. D’Argenzio (Local Health Unit Caserta2), A. Simonetti (Local Health Unit Naples1),
A. Parlato (Local Health Unit Naples2), F. Peluso (Local Health Unit Naples3), R. Palombino (Local
Health Unit Naples4), and F. Giugliano (Local Health Unit Naples5).
Address for correspondence: Pietro Comba, Department of Environment and Primary Prevention,
Istituto Superiore di Sanit`a, Viale Regina Elena 299, 00161 Roma, Italy. Voice: 39-06-49902249; fax:
39-06-49387083.
e-mail: comba@iss.it
Ann. N.Y. Acad. Sci. 1076: 449–461 (2006). C
2006 New York Academy of Sciences.
doi: 10.1196/annals.1371.067
449
450 ANNALS NEW YORK ACADEMY OF SCIENCES
of Caserta and in the northwestern part of the Province of Naples, where
cancer mortality and congenital malformations show significantly in-
creased rates with respect to expected figures derived from the regional
population. The area highlighted by the study is, in general terms, over-
lapping with the area where most illegal dumping of toxic wastes took
place. It is now recommended that mortality studies be extended to take
into account other health outcomes, to search for correlations with envi-
ronmental exposures, and consider possible confounding factors.
KEYWORDS: toxic wastes; dumping sites; cancer; malformations
INTRODUCTION
The possible health effects associated with residential proximity to waste
disposal sites have been the object of many epidemiological studies over the
last 20 years. Several reports of increased risk of different diseases are avail-
able, but causal links have not been adequately proven; for a comprehensive
review the reader is referred to Vrijheid,1who examines 50 papers published
from 1980 through 1998. Difficulties of conducting epidemiological studies
around waste disposal sites include exposure assessment, because many dif-
ferent chemicals released in the environment may be absorbed by contact,
inhalation, and ingestion of food and water.2Furthermore, the sites of interest
are often located in areas characterized by other sources of environmental pol-
lution, and the resident population is often sparse. Finally, some of the reported
increases in risk are small, making their interpretation difficult.
Different study designs have been adopted in epidemiological studies of
waste disposal sites. Ecological and geographical studies have reported in-
creases in lung cancer risk in men3–5and in women,5bladder cancer in both
sexes6,7and in men only,3,5leukemia,8childhood leukemia,9liver cancer in
men,4prostate cancer,4gastric cancer in both sexes3and in men only,4uter-
ine cancer,4rectum cancer,3breast cancer,3perinatal mortality,10 and birth
defects.10,11
Cohort studies have reported increases of low birth weight12,13 and birth
defects.14–17 Case–control studies have reported increases in the risk of low
birth weight,18 birth defects,19–21 bladder cancer, and leukemia in women,22
and cancer of the pancreas, liver, prostate, and non-Hodgkin’s lymphoma.23
The issue of possible health effects of waste disposal sites was specifically
addressed in Campania, a Region of Southern Italy, where Naples is located.
Since the 1980s, thousands of illegal and uncontrolled sites of urban, toxic, and
industrial waste disposal, including land filling and unauthorized incineration,
have been known to be active in this region (FIGS. 1 and 2). The issue of waste
treatment in Campania has been constantly surrounded by controversy and so-
cial conflict, periodically making national headlines. Local communities are
worried about severe health effects and express frustration over their compro-
mised level of well-being and quality of life. A Commissioner appointed by the
COMBA et al.: CANCER MORTALITY NEAR MULTIPLE TOXIC DUMPING SITES 451
FIGURE 1. Waste disposal site.
FIGURE 2. Treatment of waste that was illegally burnt.
452 ANNALS NEW YORK ACADEMY OF SCIENCES
national government and holding special power has held executive authority
for waste treatment and disposal policy in the region since 1994. For a review,
the reader is referred to the annual report on “Ecomafia.”24 A census of waste
dumping sites has been made available by Campania Region’s Environmental
Protection Agency since 2003.25
Possible adverse health effects of the waste cycle in Campania were first
investigated with respect to childhood cancer mortality in the Province of
Caserta.26 More recently, two papers published in Lancet Oncology have ad-
dressed the question of waste and health in Campania. A first report27 identified
a “triangle of death” consisting of three municipalities; subsequently, Bianchi
et al.28 revealed a more complex picture and advocated a different and wider
approach.
The Department of Civil Defence of the Italian Government requested the
World Health Organization (WHO) to design and conduct an epidemiological
study on the health impact of the waste cycle in Campania. To this end, a work-
ing group comprising WHO, National Research Council, Istituto Superiore di
Sanit`a, Campania Region Health Authority Epidemiologic Observatory, and
Campania Region Environmental Protection Agency was appointed, and a net-
work of cooperation has been constructed with local health authorities, cancer
and malformation registries, and environmental organizations. The working
group was set up to include technical expertise, access to local information,
and the ability to establish a dialogue with the numerous stakeholders involved.
The purpose of this article is to present the findings of the first phase of the
study, concerning the distribution of cancer mortality and birth defects in the
Provinces of Naples and Caserta, the part of Campania most severely affected
by illegal waste dumping sites.
MATERIALS AND METHODS
Mortality
The geographical distribution of mortality in the 196 municipalities of the
Provinces of Naples and Caserta, with a population of around 4 million people,
was analyzed using data from ISTAT (National Bureau of Statistics); mortal-
ity records were provided by the Regional Epidemiological Observatory of
Campania. A total of 20 causes of death were studied for the period 1994–
2001, including all-cause mortality, all-cancer mortality, and a set of cancer
causes reported in excess in previous epidemiological studies conducted in the
surroundings of waste landfills or incinerators. Availability of such data at the
municipality level, relatively small units on average with the exception of large
cities, allows the analysis of risk variability by small area and in relation to the
spatial occurrence of exposures produced by known sources. The analyses were
carried out separately for men and women. At the provincial level, analyses
COMBA et al.: CANCER MORTALITY NEAR MULTIPLE TOXIC DUMPING SITES 453
were carried out using standardized mortality rates with national reference
and through standardized mortality ratios (SMRs) with regional reference.
At the municipality level, analyses were carried out using SMRs, with 95%
confidence intervals, and hierarchical Bayesian estimators (BMRs, and 95%
uncertainty intervals), calculated as suggested by Besag et al29 and Molli´e.30
BMRs improve the quality of the risk estimates by removing part of the large
random variability due to sparseness of data, and the possible “confounding by
location” from unknown, spatially structured determinants.31 Risk estimates
(SMRs and BMRs) were mapped at the municipality level.
Congenital Malformations
This component of the study is based on data recorded by the Campania
Region Birth Defects Registry, which include data for the population residing in
the Provinces of Naples and Caserta, 1996–2002. For a long time the Campania
registry has been part of the EUROCAT & ICBDMS networks of Congenital
anomalies.32,33 Cases have been ascertained at birth and during the postnatal
period; fetal deaths after the 20th week and therapeutic abortion prior to week
24 have also been included. The number of observed birth defects in each
municipality is contrasted to the corresponding number of expected cases
based on regional demographic figures. As in the mortality analysis, both
SMRs and BMRs are computed and mapped.
RESULTS
Results show that the cancer mortality profile of the area is characterized by
numerous excesses, as summarized in TABLE 1. In the Province of Naples, 8 of
19 (42%) of all the risks that were estimated are in significant excess for men,
and 11 of 19 (58%) for women. Excess risks range from 6.1% (mortality for all
causes) to 32.9% (cancer of pleura) in men, and from 7.3% (all-cause mortality)
to 27.3% (cancer of esophagus) in women. Fewer excesses were found for the
Province of Caserta (16% for men, 11% for women) even though some risk
estimates are high (cancer of the stomach: 29.3% for men, 18.2% for women).
At the municipality level, results indicate the occurrence of increased risks for
several causes of cancer death, in 11 municipalities of the southeastern part of
the Province of Caserta and 13 adjacent municipalities of the northern part of
the Province of Naples. In 19% of the municipalities of the Province of Caserta
and in 43% of the municipalities of the Province of Naples all-cause mortality
is statistically significantly elevated in men; in 23% of the municipalities of
the Province of Caserta and in 47% of municipalities of the Province of Naples
all-cause mortality is statistically significantly elevated in women (FIG. 3).
The specific cancer causes frequently in excess in these municipalities (can-
cer of the stomach, kidney, liver, trachea, bronchus and lung, pleura, bladder)
454 ANNALS NEW YORK ACADEMY OF SCIENCES
TABLE 1. Mortality in the provinces of Naples and Caserta, 1994–2001.
Province of Naples Province of Caserta
Men Women Men Women
Causes of death Deaths SMR Deaths SMR Deaths SMR Deaths SMR
All-cause mortality 95,951 106.1∗91,888 107.3∗27,676 102.5∗24,984 102.9∗
All cancers 29,185 108.7∗20,206 109.2∗8,158 102.3∗5,179 98.2
All cancers (0–14) 137 101.9 95 102.6 37 100.3 30 118.3
Cancer of the esophagus 262 98.8 126 127.3∗76 97.425 88.6
Cancer of the stomach 1,696 100.3 1,090 98.1 649 129.3∗375 118.2∗
Cancer of rectum 655 101.6 584 106.8 191 99.1 158 101.3
Cancer of the liver and biliar ducts 1,910 117.6∗1,572 114.1∗490 102 417 105.5
Cancer of the pancreas 821 103.4 840 108.9∗231 98.5 202 91.5
Cancer of the larynx 728 111.8∗66 126.6 203 105.610 67.4
Cancer of the trachea, bronchus, and lung 9,681 114.1∗1,845 126.5∗2,566 102.1 345 82.7
Cancer of the pleura 212 132.9∗109 125.8∗30 64.121 85.3
Soft Tissues Sarcoma 107 114.487 88.626 95.824 86.5
Cancer of the breast 3,475 110.7∗871 98.1
Cancer of the testis 34 93.8768.6
Cancer of the bladder 1,745 110.7∗348 117.5∗445 93.381 95.5
Cancer of the kidney 494 105.7 304 120.7∗128 92.756 77.6
Cancer of the brain 526 98.6 416 97.3 176 114.2 116 96
Non-Hodgkin lymphomas 682 100 649 109.1∗182 91.4 142 83.6
Leukemias 894 95.9 789 103.7 288 105 214 98.8
Ill-defined causes 2,860 125.4∗1,246 104.8 434 66.7 299 90.2
∗lower limit of 95% confidence interval >100.
COMBA et al.: CANCER MORTALITY NEAR MULTIPLE TOXIC DUMPING SITES 455
FIGURE 3. Municipalities with significant excesses of mortality and congenital mal-
formations and waste disposal sites in the provinces of Naples and Caserta.
have, as main determinants, risk factors linked to lifestyle and individual cir-
cumstances (diet, tobacco smoke, infections) and to occupational exposures.
However, in several epidemiological studies they have been observed in re-
lation to residence near waste treatment sites, even though causality remains
unconfirmed.
Two sets of municipalities with significant excesses in the total of congenital
malformations and on some specific groups were identified. First, the south-
ern part of the Province of Caserta, where there are frequent excesses for con-
genital malformations overall and for the group of urogenital malformations;
second, Naples and its northeastern neighboring municipalities, where there
are frequent excesses for the total of congenital malformations, cardiovascular
malformations and, to a lesser extent, urogenital malformations (FIG. 3).
DISCUSSION
Consistently with previously published data,34 residents in the Provinces of
Naples and Caserta have cancer mortality significantly raised compared to
the Campania region. Increased risks are observed for several cancers; sim-
ilarly, the occurrence of congenital malformations is significantly in excess.
The reliability of the malformation data collected, in terms of accuracy and
completeness, is documented by the comparability of the Campania data with
other European and International registries.32,33
Analysis of mortality data by municipalities entails multiple comparison
of observed counts with expected numbers of deaths. Even under the null
456 ANNALS NEW YORK ACADEMY OF SCIENCES
hypothesis of uniform risk across municipalities, using a 5% threshold for
statistical significance would result in approximately 5% of the municipali-
ties (around 10 of them) differing statistically from the null. However, even
discounting for this proportion of spurious significance, the statistically signif-
icant large risks observed in the municipalities of the two provinces far exceed
what can be expected by chance alone. In addition, BMRs remove substantial
part of the random variability and are not subject to the inflation of statistically
significant risk estimates due to multiple comparison. Thus, the occurrence
of excesses is unlikely to be due to chance. On the other hand, the number of
expected cases may be systematically overestimated, compared to the value of
real interest, that is, the number of cases that would be expected in a situation
of no exposure to environmental risk factors linked to waste management. Ex-
pected numbers were calculated using, as reference, the regional rates. These
are based, in turn, on the data for the whole population of Campania, which
includes the exposed areas and whose average exposure, therefore, is nonzero.
Hence, it is likely that a comparison between exposed municipalities with un-
exposed ones, rather than with the regional average, could produce generally
higher risk estimates.
Within the two Provinces, there is geographical variability in mortality across
municipalities, by cause of cancer death. The distributions of these excesses
might provide some indication as to the possible role of environmental expo-
sures, in particular those associated with the cycle of waste treatment. Increased
risks in cancer mortality tend to be more frequent in municipalities in the south-
ern part of the Caserta Province and in the northern part of the Naples Province.
A similar pattern is also shared by the distribution of risk of congenital mal-
formations (FIG. 3). This similarity may be casual or may be explained, in part,
by the presence of one or more risk factors occurring with more intensity in
the area between the two Provinces. The area where municipalities at higher
risk of mortality and congenital malformations aggregate overlaps with the
presence of landfills and sites of uncontrolled disposal of waste (FIG. 3).
These recurring patterns of mortality and congenital malformations that
were observed are suggestive, but the underlying complexity should be empha-
sized; concern is more than justified, even without the support from epidemi-
ological findings, but oversimplifications are likely to result in sensationalism
and be of little help in dispelling the social controversy.28
The Province of Caserta and some municipalities of the northern part of
the Province of Naples show high rates of mortality from gastric cancer, a
disease that is decreasing in industrialized societies, but still frequent in rural
areas. The most important risk factors of gastric cancer are infection from
Helicobacter pylori.35–37 A diet poor in fresh vegetables and fruit, and rich in
salt and nitrites adds to gastric cancer risk,38–42 while occupational exposures
do not seem to play an appreciable role.43 Increases in gastric cancer risk near
landfills were reported by Griffith et al.3and Goldberg et al.4as previously
mentioned.
COMBA et al.: CANCER MORTALITY NEAR MULTIPLE TOXIC DUMPING SITES 457
The southern part of Caserta Province and some municipalities in the north-
ern part of Naples Province show high mortality rates from kidney cancer.
Tobacco smoking, diet, and some drugs have been associated with kidney can-
cer; among occupational risk factors an etiologic role has been suggested, but
not confirmed, for combustion products, heavy metals, and solvents.44–48 An
increased risk of renal cancer for the population resident in the neighborhood
of landfills has been reported by Goldberg et al.23 Several municipalities in the
southern part of Caserta Province and in the northern part of Naples Province
are characterized by high mortality rates from liver cancer. Figures produced
by the Naples Cancer Registry indicate a high occurrence of hepatocellular
carcinoma in this area, where both B and C type hepatitis show high incidence
rates.49,50 Exposure to hepatotoxic chemicals may have particularly strong ad-
verse effects among subjects who are seropositives for hepatitis virus, as has
recently been shown by Mastrangelo et al.51 with reference to vinyl chloride.
An increased risk of liver cancer near landfills has been reported by Gold-
berg et al.4,23 Elevated mortality from lung cancer has been described in the
southern part of Caserta Province and in the northern part of Naples Province.
Tobacco smoking, and several occupational carcinogens (namely arsenic, as-
bestos, chromates, chloromethylethers, nickel, and polyciclic aromatic hydro-
carbons) are established causes of lung cancer; recently the etiologic role of
urban air pollution has been documented.52–55 An increased risk of lung cancer
near landfills has been reported by Griffith et al.,3Goldberg et al.,4and Mitis
et al.5
Several municipalities of the northwestern part of the Province of Naples
have high mortality rates from pleural mesothelioma, which can be attributed to
a variety of occupations with exposure to asbestos, which have been described
in the area.56 High mortality from bladder cancer occurs in the south of Caserta
Province and in the north of Naples Province. Cigarette smoking is the main
cause of this disease, followed by occupational exposure to aromatic amines in
textile and rubber industries and by exposure to solvents, paints, leather dust,
inks, some metals, polycyclic aromatic hydrocarbons, combustion products,
diesel exhaust, and environmental exposure to water chlorination.57,58 An in-
creased risk of bladder cancer in areas close to landfills has been reported by
Budnick et al.,6Griffith et al.,3Mallin,7Lewis-Michl et al.,22 and Mitis et al.5
The findings of the present study indicate the presence of an area character-
ized by elevated cancer mortality rates and by the elevated occurrence of birth
defects, corresponding with the area where most waste disposal sites are con-
centrated. In the area under study, in addition, there are many environmental
stressors, deriving from intensive agriculture, widespread industrial activities,
and a very high population density.
These preliminary findings are consistent with a possible contributory role
of waste-related exposures in determining ill health in the area over time. The
consistency of the patterns may reflect an effect on cancer mortality, which re-
quires a long latency time (variable by cancer type) to become manifest, while
458 ANNALS NEW YORK ACADEMY OF SCIENCES
congenital malformations might be affected by concurrent exposures. Given
the sizeable excesses observed, the past and present waste disposal activities,
legal and illegal, and considering that waste disposal facilities are being built
or planned, more detailed investigation is warranted. Besides further epidemi-
ological analysis, it seems advisable to continue and optimize the existing
biomonitoring activities. More generally, it is desirable to strengthen the par-
ticipation of public health officials in indentifying and adopting appropriate
policies on waste management in the region. Above all, immediate action is
essential to ensure that the most extreme instances of population exposure to
environmental contamination due to waste treatment are prevented.
ACKNOWLEDGMENTS
The authors are very grateful to Colin Soskolne for his support and helpful
comments to previous draft versions of this article. The study has been com-
missioned and partly funded by the Department of Civil Defence of the Italian
Government.
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