Ann Ig 2016; 28: 208-217 doi:10.7416/ai.2016.2099 Incidence of oncological pathologies 2002-2010 in the southwestern area, province of , neighbouring municipalities of former nuclear sites

C. Salerno*, P. Marciani**, K. Vanhaecht***, L.A. Palin*, M. Panella*

Key words: Nuclear power plants; cancer; ; oncological incidence Parole chiave : Centrali nucleari, neoplasie, provincia di Vercelli, incidenza oncologica

Abstract

The Vercelli Province counts two former nuclear installations: a radioactive waste disposal area in Salug- gia and a former nuclear power plant in . This study takes also into account four other neighbouring municipalities, counting 20,000 total inhabitants. We studied the incidence of neoplastic pathologies in the 2002-2010 period. The data sources were Hospital Discharge Form (SDO), histological reports from the Registry of Hospital Charts (RHC) and ’s National Statistics Institute (ISTAT) reports, and the Cancer Register of . The research highlights the excesses for all type of cancers (SIR=1,11; IC 1,04-1,18), including the ones of nervous system (SIR=2,23 IC 1,47-2,98), leukaemia (SIR=1,94 IC 1,35-2,52), and bones (SIR=12,0 IC 9,22-14,7), according to different aggregation levels by age, sex and housing area. Considering such results, previous studies, and the environmental and occupational risk factors in the area, we believe that further epidemiological and environmental studies should be conducted in this area.

Introduction morphological and functional alterations. In most cases, the damage is repaired by Ionizing radiations produce different the regular biological defence mechanisms, pathogenic effects in relation to dose, in other cases, the interested cells may be exposure time, exposure area and type of totally compromised, so they die or transform radiation. The interaction of radiations with themselves. In the latter case, exposure may biological tissues may cause phenomena turn into healthcare consequences that can that induce possible cell damage with become clinically relevant (1-9).

* Department of Translational Medicine, University of Eastern Piedmont “Amedeo Avogadro, Novara, Italy ** Department of Pharmacological and Biomolecular Sciences, University of Milan, Milan, Italy *** Health Services Research Group, School of Public Health Center for Health Services and Nursing Research, Faculty of Medicine, Leuven, Belgium All individuals designated as Authors are qualified for authorship: all of them meet the three required conditions. The present Research Project was not sponsored by any grant/financial support. The Authors declare that they have no conflict of interest. Submitted manuscript is a Qualitative Research. Incidence of oncological pathologies in municipalities neighbouring former nuclear sites 209

Knowledge of the health effects (National Agency for Atomic Energy) in exposed people first derived from Research Centre. epidemiological studies carried on survivors The Avogadro Depot is a depot for of the atomic explosions in Hiroshima elements of irradiated nuclear fuel, placed and Nagasaki (10, 7), on soldiers and the in the pool of the Avogadro RS1 research population exposed to radiations of the reactor that terminated its activities in nuclear tests in the 1950s-1960s, on the 1971. At present, it contains elements of populations exposed after accidents at irradiated nuclear fuel. Until 2004, the Sorin nuclear plants - in particular at Chernobyl installation produced radio-medications. (1, 5, 9, 11) - on the population living close The site includes a depot area for solid to nuclear power plants (Sellafield) and radioactive, category I and II wastes derived radioactive wastes disposal sites, on exposed from both manufacturing activities and workers - mines, nuclear industry (4, 5, previous collections. The depot contains 11, 12) - and the recent data on soldiers also two hot cells that have been used in the exposed to depleted uranium (13). The past to manipulate high-activity sources. In immediate or short-term effects manifest 2009, Sorin Biomedica, according to the themselves after exposure to very high prescriptions of the Ministry of Industry, threshold such as, after a nuclear explosion Commerce, and Artisanship, concluded the or the Chernobyl or Fukushima accidents, adjustments of the depot and began moving on the power plant operators and the people the radioactive wastes into it. who gave first-aid assistance; these effects EUREX - SO.G.I.N. is an installation induce, immediately or in a very short time, for re-processing elements of U-235 high- anatomical lesions and loss of functionality enrichment irradiated fuel, M.T.R. (Material of organs and tissues (8). Testing Reactor) typology. The installation The stochastic effects might show up is not active anymore, during its life it years after irradiation, sometimes decades or produced a great amount of both solid and more, they are probabilistic in nature, and do liquid nuclear wastes, now stored inside not exhibit require a threshold value (8). the area. In June 2004, a partial leakage The Province of Vercelli, and specifically from the storage pool took place. After this its southwestern area on the border with accident, ARPA Piemonte (Regional Agency the Provinces of Alessandria and Turin, for Environmental Protection) immediately hosts two former nuclear sites. The first started an extraordinary radiological one is located in the area of the monitoring activity that, in July 2006, municipality and it is active as temporary highlighted a Sr-90 contamination on the storage site for radioactive wastes, the superficial water layer. This situation forced second one is a former nuclear power plant the immediate draining of the pool. Therefore, operating until 1987, in the area of the in May-July 2007, all the irradiated fuel municipality of Trino. stored in the pool nearby Avogadro Depot The Saluggia area is bordered by the was moved. In a second time, a drainage of Farini Canal at East, the Cavour Canal the EUREX pool was performed. at South, Dora Baltea river at West, and The second site is the former “E. Fermi” private properties at North. It can be electronuclear power plant located in divided into two separate areas: the Sorin Trino municipality (13-16), the first Italian installation plus the Avogadro Depot, and industrial activity in the nuclear field. On the EUREX - SO.G.I.N. (Enriched Uranium 21 June 1964, the reactor reached the first Extraction - Company for the Nuclear Plant critical phase and, operating with a 270 Management) installation, inside the ENEA MW power, produced electricity for sale, 210 C. Salerno et al. starting 22 October 1964. The reactor and the previous studies performed in the was stopped in 1967 because of technical area (14-16), we opted for an epidemiological problems concerning the radial shield of study taking into account the two above- the core and it was restarted in 1970, after mentioned municipalities and the nearby repair. A second stop was forced in 1979, to ones belonging to the Vercelli Province and perform the adjustments required after the included in different Local Health Agencies Three Mile Island (USA) accident. These (ASLs): , , Fontanetto operations caused inactivity until 1982. Po and (Figure 1) for After the restart, the Trino reactor operated a total of about 20,000 inhabitants. until 1987. In 1987, after the last stop for This study has to be considered mainly re-fuelling, the Trino power plant was not descriptive; data involved were taken from restarted due to Governmental decision after the Registry of Hospital Charts (RHC) from the changes in the energy policies following 2002 up to 2010, individuals with a record the 1987 referendum. In July 1990, the of multiple hospitalizations were excluded Government ordered its permanent closure, to avoid prevalence (17). The integration assigning to ENEL (National Agency for of the RHC flow with the relative intra- Electrical Power) the decommissioning and extra-regional passive mobility and plan. anatomopathological reports of the main Our study was aimed at verifying the hospitals specialized in cancer diagnosis and oncological incidence in the population treatment, allowed us to calculate incidence resident in the area of the two nuclear sites rates for a large number of oncological or close by. pathologies concerning the inhabitants of the municipalities under investigation. About 70% of cases show a double confirmation of the Materials and methods diagnosis, as the diagnosis specified by RCH was confirmed either by the pathologist report, Considering all problems, the worry of the or by the ISTAT death certificate, in case the population and of the local administrators, patient died. We calculated the Standardized

Figure 1. Province of Vercelli and Study Area (author’s image) Incidence of oncological pathologies in municipalities neighbouring former nuclear sites 211

Table 1 - Standardised Incidence Ratios SIR by sex and neoplasia, IC95% Interval of Confidence at 95%. Total area under examination

Total surveyed area Neoplasia Sex Obs SIR IC 95% Oral cavity M 17 2.11 1.41-2.80 F 10 2.81 1.80-3.81 Colon-rectum M 106 1.02 0.82-1.21 F 81 0.99 0.77-1.20 Liver/biliary tract M 36 1.05 0.72-1.38 F 22 0.98 0.56-1.39 Larynx M 17 1.18 0.66-1.69 F 3 3.12 1.12-5.11 Leukaemia M 32 1.72 1.26-2.17 F 22 1.94 1.35-2.52 Breast F 182 1.03 0.88-1.17 Melanoma M 9 0.58 0.08-1.08 F 12 0.86 0.33-1.38 Mesothelioma M 21 4.67 3.74-5.59 F (*)4 4.04 2.07-6.00 Myeloma m. M 17 1.72 1.10-2.34 F 9 0.88 0.26-1.49 Bone M 6 12.0 9.22-14.7 F 3 14.3 10.0-18.6 Pancreas M 16 0.93 0.46-1.40 F 22 1.19 0.73-1.64 Lung M 106 0.94 0.76-1.12 F 31 0.77 0.47-1.07 Prostate M 162 0.98 0.83-1.13 Kidney M 24 1.26 0.81-1.50 F 14 1.79 1.09-2.49 Nervous system M 15 2.23 1.47-2.98 F 18 1.89 1.25-2.52 Stomach M 27 1.14 0.73-1.54 F 15 0.90 0.41-1.38 Soft tissues M 9 1.64 0.80-2.47 F 7 1.69 0.72-2.65 Testicle M 3 0.81 0.0-1.82 Thyroid F 20 1.36 0.84-1.87 Bladder M 95 0.98 0.78-1.17 F 15 0.64 0.44-1.04 Ovary F 22 1.10 0.66-1.53 Uterus F 44 1.23 0.90-1.55 Total M 724 1.11 1.04-1.18 F 556 1.14 1.06-1.22 Tot. F+M 1280 1.12 1.07-1.17 (* all cases observed in Trino municipality) 212 C. Salerno et al.

Table 2 - Standardized Incidence Ratios SIR by total sex, area and neoplasia. IC95% Interval of Confidence at 95%. A=Crescentino; B=Fontaneto Po; C=Lamporo; D=Saluggia; E=Trino V.se; F=Palazzolo V.se

Analysis by single municipality under examination A B C D E F Neoplasy SEX SIR-IC95% SIR-IC95% SIR-IC95% SIR-IC95% SIR-IC95% SIR-IC95% 2.05 1.75 4.00 2.58 2.38 Oral cavity TOT --- (1.06-3.04) (0.00-4.34) (0.08-7.92) (1.29-3.86) (1.46-3.29) 0.96 0.81 1.32 0.80 1.11 1.20 Colon-rectum TOT (0.70-1.22) (0.25-1.36) (0.46-2.17) (0.46-1.13) (0.87-1.34) (0.64-1.75) 0.86 0.38 0.63 1.02 0.96 1.56 Liver/biliary tract TOT (0.40-1.32) (0.0-1.23) (0.0-1.73) (0.42-1.61) (0.54-1.38) (0.56-2.56) 0.83 10.0 1.24 1.61 1.06 Larynx TOT --- (0.0-1.72) (3.8-16.2) (0.15-2.33) (0.82-2.39) (0.0-3.08) 1.31 2.53 0.90 2.31 1.87 1.69 Leukaemia TOT (0.66-1.95) (0.30-4.73) (0.0-2.76) (1.48-3.13) (1.28-2.45) (0.0-3.49) 1.10 1.17 0.50 1.43 0.82 0.92 Breast F (0.83-1.36) (0.55-1.78) (0.0-1.48) (1.08-1.78) (0.57-1.06) (0.32-1.51) 0.39 1.57 0.66 0.70 Melanoma TOT ------(0.0-1.00) (0.14-2.99) (0.01-1.31) (0.12-1.28) 2.98 3.22 1.14 6.01 10.0 Mesothelioma TOT --- (1.28-4.67) (0.0-6.74) (0.0-3.23) (4.81-7.21) (6.42-13.6) 1.12 2.94 1.82 1.00 1.43 Myeloma m. TOT --- (0.33-1.90) (0.56-5.31) (0.82-2.82) (0.31-1.69) (0.0-3.09) 10.2 27.2 9.52 Bone TOT ------(7.06-13.3) (21.2-33.1) (5.24-13.8) 1.41 1.16 3.92 1.31 0.55 Pancreas TOT --- (0.82-1.99) (0.0-2.38) (1.17-6.66) (0.56-2.05) (0.04-1.06) 1.04 0.48 1.17 0.77 0.89 1.00 Lung TOT (0.75-1.32) (0.0-1.09) (0.11-2.23) (0.40-1.13) (0.63-1.14) (0.26-1.74) 0.68 1.62 0.94 1.17 0.75 Prostate M --- (0.40-0.95) (1.04-2.20) 0.60-1.28) (0.91-1.42) (0.15-1.35) 1.22 1.49 4.54 1.29 1.55 Kidney TOT --- (0.56-1.87) (0.0-3.18) (0.36-8.71) (0.44-2.14) (0.96-2.14) 3.00 1.69 3.84 2.0 1.33 1.63 Nervous system TOT (2.10-3.90) (0.0-4.24) (0.0-7.68) (0.94-3.06) (0.57-2.08) (0.0-4.13) 1.12 1.73 1.65 0.51 1.01 1.15 Stomach TOT (0.56-1.67) (0.57-2.88) (0.0-3.43) (0.0-1.21) (0.52-1.50) (0.23-1.78) Sarcoma+soft tis- 1.16 6.25 2.00 1.75 TOT ------sues (0.11-2.21) (1.35-11.1) (0.61-3.38) (0.76-2.73) 0.52 1.11 Testicle M ------(0.0-1.94) (0.0-2.57) 0.90 2.85 1.01 1.86 Thyroid F ------(0.07-1.73) (0.0-6.16) (0.0-2.14) (1.06-2.66) 0.93 1.10 0.33 0.67 1.03 0.90 Bladder TOT (0.60-1.25) (0.41-1.78) (0.0-1.45) (0.25-1.08) (0.73-1.32) (0.20-1.60) 1.48 0.78 0.86 1.45 Ovary F ------(0.72-2.23) (0.0-1.78) (0.18-1.36) (0.0-3.11) 0.91 2.34 1.20 1.26 1.43 0.45 Uterus F (0.31-1.50) (1.00-3.68) (0.0-3.35) (0.48-2.03) (0.90-1.96) (0.0-1.77) 1,03 1,29 1.23 1.06 1.12 1.07 Total TOT (0,93-1,13) (1,06-1,52) (0.81-1.65) (0.92-1.19) (1.03-1.21) (0.81-1.32) Incidence of oncological pathologies in municipalities neighbouring former nuclear sites 213

Incidence Ratios (SIR= observed/expected available to allow a precise reconstruction cases) by using specific rates for the various age of the professional exposure of each ranges, concerning the oncological incidence patient, we must consider the extrapolated of the Turin City in the period 2005-2007 as epidemiological data just hypothesis for reference population. The result is the number further studies that will better analyse the of expected ill people in the studied population. possible causes of carcinogenesis in the SIR is obtained calculating the observed to population under examination. Further expected ratio in the studied population; the studies should evaluate factors derived from 95% confidence intervals were calculated by many factors such as work-environments and Byar methodology (18). food habits. The excess for the high digestive tract and mesothelioma may be ascribed to Results the concrete factories placed in the area for decades, which exposed workers to Table 1 highlights excess ratios that higher risk for these pathologies (19-23). are statistically significant for both sexes, Although, higher SIR for mesothelioma concerning the oral cavity, leukaemia, might be connected to the “E. Fermi” nuclear mesothelioma, bones, nervous system, and power plant itself since it was built using total cancers; female-only excesses were found construction materials that contains asbestos as regards larynx and kidney. A single excess and synthetic derived from asbestos. Several for myeloma was found in male subjects. workers, in particular members of the The stratification as for living area (table maintenance stuff, have been exposed and 2) shows that the oral cavity and bones developed mesothelioma. are mainly referred to the Crescentino, The increased risk of tumours of the high Saluggia and Trino municipalities; excess for respiratory airways can have viral origin (24, leukaemia can be found in the Saluggia and 25). Still, taking into account the presence Trino municipalities. Excesses for all cancers of industries (concrete, chemicals, foundries, concern and Trino V.se. etc.), the occupational factors should be Besides statistically significant excesses, evaluated, among them, the exposure to the whole area shows SIR values that are asbestos that clearly links to these types strongly biased towards the risk, as regards of tumour (24), together with individual oral cavity, leukaemia, mesothelioma, bones, habits such as consumption of alcohol and/ nervous system, sarcoma, and uterus. or tobacco. We believe that leukaemia (26- Table 3, stratified by young age (0-44) 28) and the neoplasia of the nervous system and working age (36-69) ranges, globally (29, 30) should be considered on their shows that for neoplasia of the nervous own, as the medical literature, concerning system, bones, oral cavity and leukaemia, these pathologies, lists various potential the risk increase mainly refers to the younger risk factors, both professional and random/ population. The analysis by age range should environmental, including radiations. Other be assessed taking into account the exiguity researchers enlightened an increase in of the observed cases. leukaemia rates in particular, in paediatric age within 5 km from nuclear power plant (31-34). It is clear that emission of radiation Discussions and Conclusions from nuclear power plants due to accident and/or malfunctions may cause biological The study shows SIR excesses for various damage particularly in fast proliferative organs. Since specific researches are not tissues such as bone marrow and colon- 214 C. Salerno et al.

Table 3 - Standardized Incidence Ratios SIR, by sex, neoplasia site, for the main municipalities under examination. IC95% Interval of Confidence at 95%. (Because of the small numbers, this analysis is limited to the 3 larger municipalities)

Analysis by single municipality under examination Neoplasy Sex Crescentino Saluggia Trino Age 35-69 00-44 35-69 00-44 35-69 00-44 (IC 95%) (IC 95%) (IC 95%) (IC 95%) (IC 95%) (IC 95%) Oral cavity M 2.92 --- 1.05 --- 1.12 14.2 (1.42-4.41) (0.0-3.05) (0.0-2.58) (6.79-21.6) F ------8.10 25.0 3.89 --- (4.87-11.3) (15.2-34.8) (1.59-6.12) Colon-rectum M 1.25 2.98 0.91 --- 1.09 1.49 (0.71-1.78) (0.58-4.97) (0.21-1.61) (0.57-1.60) (0.0-3.88) F 0.56 3.12 1.45 --- 0.91 1.56 (0.0-1.21) (0.67-5.57) (0.55-2.34) (0.28-1.53) (0.0-4.00) Liver/biliary tract M 1.29 4.16 1.29 --- 1.02 --- (0.44-2.13) (0.16-8.16) (0.18-2.40) (0.22-1.82) F ------1.09 --- 0.53 --- (0.0-3.14) (0.0-1.95) Larynx M 1.36 --- 0.60 --- 1.28 --- (0.21-2.50) (0.0-2.13) (0.17-2.39) F ------3.44 --- (0.0-7.07) Leukaemia M 1.31 2.53 2.34 7.50 0.82 1.35 (0.02-2.60) (0.33-4.73) (0.60-4.07) (4.40-10.5) (0.0-2.07) (0.0-3.62) F 0.83 ------2.23 6.66 (0.0-2.61) (0.53-3.92) (3.73-9.58) Breast F 1.04 0.86 1.34 0.32 0.60 0.17 (0.71-1.36) (0.05-1.67) (0.90-1.78) (0.0-1.43) (0.29-0.91) (0.0-0.99) Melanoma M --- 1.33 2.13 --- 0.57 1.20 (0.0-3.59) (0.69-3.57) (0.0-1.62) (0.0-3.35) F 0.31 0.72 0.55 1.36 0.90 0.78 (0.0-1.40) (0.0-2.39) (0.0-2.00) (0.0-3.65) (0.0-1.97) (0.0-2.51) Mesothelioma M ------9.61 --- (6.89-12.3) F ------6.45 --- (2.92-9.97) Myeloma m. M 0.74 --- 2.59 (*) 50.0 1.36 --- (0.0-2.43) (0.35-4.82) (36.1-63.8) (0.0-2.97) F 0.99 --- 1.81 ------(0.0-2.94) (0.0-4.45) Bone M 9.0 --- 14.3 20.0 7.69 --- (4.10-14.9) (6.89-21.7) (13.8-26.2) (2.25-13.1) F 14.3 7.14 ------(6.89-21.7) (1.90-12.3) Pancreas M 1.39 --- 0.61 --- 0.63 14.2 (0.23-2.54) (0.0-2.14) (0.0-1.73) (6.79-21.6) F 0.58 ------1.04 --- (0.0-2.08) (0.0-2.45) (segue tabella 3) Incidence of oncological pathologies in municipalities neighbouring former nuclear sites 215

(continua tabella 3)

Analysis by single municipality under examination Neoplasy Sex Crescentino Saluggia Trino Lung M 1.13 --- 0.77 4.16 0.68 --- (0.63-1.62) (0.12-1.42) (0.16-8.16) (0.22-1.14) F 1.20 3.03 1.10 --- 0.90 --- (0.32-2.07) (0.0-6.44) (0.0-2.28) (0.07-1.73) Soft M --- 2.32 ------4.54 Tissue+sarc (0.0-5.30) (1.58-7.49) F 3.03 --- 2.77 5.55 1.40 --- (0.61-5.44) (0.0-6.03) (0.93-10.1) (0.0-3.72) Prostate M 0.57 --- 0.83 --- 0.94 --- (0.16-0.98) (0.28-1.37) (0.55-1.32) Kidney M 2.10 --- 0.92 4.44 0.97 --- (1.10-3.10) (0.0-2.25) (1.51-7.36) (0.01-1.93) F 0.76 --- 2.77 --- 2.72 --- (0.0-2.47) (0.46-5.07) (1.10-4.33) Nervous system M 2.61 4.65 1.14 --- 1.26 2.46 (1.02-4.19) (2.53-6.76) (0.0-3.24) (0.0-2.81) (0.28-4.65) F --- 5.88 ------0.59 3.12 (2.51-9.24) (0.0-2.09) (0.0-6.58) Stomach M 2.07 5.55 ------1.34 5.26 (0.65-3.48) (0.93-10.1) (0.33-2.35) (0.76-9.75) F 1.93 4.34 1.17 --- 1.67 --- (0.35-3.50) (0.26-8.42) (0.0-3.29) (0.20-3.13) Testicle M --- 0.51 --- 1.19 1.13 (0.0-1.92) (0.0-3.32) (0.0-2.60) Thyroid F 0.95 1.51 0.90 0.98 2.09 0.55 (0.0-1.90) (0.12-2.90) (0.0-2.21) (0.0-2.92) (1.14-3.03) (0.0-2.00) Bladder M 0.72 1.42 0.70 --- 1.17 2.85 (0.16-1.27) (0.0-3.76) (0.0-1.43) (0.63-1.70) (0.51-5.19) F 0.77 ------0.66 --- (0.0-1.99) (0.0-1.78) Ovary F 1.09 1.66 0.50 --- 1.02 1.78 (0.07-2.11) (0.0-4.19) (0.0-1.89) (0.04-1.96) (0.0-4.39) Uterus F 1.24 1.36 0.28 --- 1.83 2.81 (0.46-2.01) (0.0-3.65) (0.0-1.32) (1.10-2.56) (0.48-5.13) rectum. Moreover, some elements such as C, Table 3 refers to the oncological trend Cs, and I can be absorbed in the body, where in terms of incidence for oncological they may reach target tissues and exert their pathologies in the young and working age local specific activity. In our study, data refer ranges. The data show excesses that are mainly to adults with few cases in young/ still difficult to interpret, as we believe that adult age, for these reasons further studies specific studies should be conducted on the will possible take into account the impact of 0-44 age range, aimed at understanding occupational and lifestyle related factors as how much influence the hereditary/familiar well as time and distance of residence from components may have on aetiology (35). If a nuclear power plant, on SIRs. this factor proves to be weak and considering 216 C. Salerno et al. that the patients are very young (therefore, eccessi per tutti i tipi di tumori (SIR=1,11; IC 1,04-1,18), their working history should be absent or inclusi quelli del sistema nervoso (SIR=2,23 IC 1,47-2,98), just in its beginnings), research studies leucemia (SIR=1,94 IC 1,35-2,52) e delle ossa (SIR=12,0 IC 9,22-14,7). Alla luce di tali risultati, dei precedenti studi should be mainly focused on investigating e dei diversi fattori di rischio ambientali e occupazionali environmental factors. presente sull’area si considera l’area in studio meritevole As Table 1 shows statistically significant di approfondimenti epidemiologici e ambientali. excesses between 10% and 15% in the total cancer field for the total area under study, we suggest a larger monitoring activity, References extended to the nearby municipalities outside the Vercelli Province. 1. Cardis E, Howe G, Ron E, et al. 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Corresponding Author: Prof. Paola Marciani, PhD, Department of Pharmacological and Biomolecular Sciences Uni- versity of Milan, Via Trentacoste 1, 10134 Milan, Italy e-mail: [email protected]