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00004032-200902000-0000300004032_2009_96_128_boice_pennsylvaniaan_2article< 97_0_12_4 >Health Physics©2009Health Physics SocietyVolume 96(2)February 2009pp 128-137County Mortality and Cancer Incidence in Relation to Living near Two Former Nuclear Materials Processing Facilities in Pennsylvania—An Update[Paper]Boice, John D. Jr*†; Bigbee, William L.‡; Mumma, Michael T.*; Tarone, Robert E.*; Blot, William J.*†* International Epidemiology Institute, 1455 Research Boulevard, Suite 550, Rockville, MD 20850; † Vanderbilt University, Department of Medicine and Vanderbilt-Ingram Cancer Center, Nashville, TN 37232; ‡ University of Pittsburgh, Department of Pathology, School of Medicine, Department of Epidemiology, Graduate School of Public Health and University of Pittsburgh Cancer Institute/Hillman Cancer Center, Pittsburgh, PA 15213.For correspondence contact: J. D. Boice, Jr., International Epidemiology Institute, 1455 Research Blvd., Suite 550, Rockville, MD 20850, or email at john.boice@vanderbilt.edu.(Manuscript accepted 10 July 2008)Abstract—A previous county mortality study of populations living near two nuclear materials processing and fabrication facilities in Westmoreland and Armstrong counties in Pennsylvania (1950–1995) was extended through 2004. Noncancer mortality (1996–2004) and cancer incidence (1990–2004) were also evaluated. Among the Westmoreland and Armstrong populations, 10,547 cancer deaths occurred during the period 1996 through 2004 and the relative risk (RR) based on comparisons with six demographically similar counties in western Pennsylvania was 0.97, that is, almost exactly as expected, and no different from our previously published analyses covering the years 1950–1995. The results based on cancer incidence data were very similar to those based on cancer mortality data. Over the years 1990 though 2004, 39,350 incident cancers were reported among residents of Armstrong and Westmoreland counties and the RR based on the six demographically similar counties was 0.99, that is, almost exactly as expected. The number of deaths from nonmalignant conditions was 36,565 and very close to the number expected (RR 1.01). Overall, no increases in cancer or nonmalignant diseases could be attributed to living in counties with nuclear materials processing and fabrication facilities.INTRODUCTIONThere has been concern that living near nuclear installations might increase the risk of cancer in surrounding communities. Such concern has been voiced by residents in Armstrong and Westmoreland counties in western Pennsylvania in conjunction with the operation of two former nuclear materials processing facilities located in the Apollo borough and the Parks township, just three miles apart on the Kiskiminetas River which borders the two counties (PDH 1988). These facilities began operating in 1957 and 1960, respectively, and processed uranium and plutonium for commercial and naval applications. Nuclear fuel processing ceased during the 1980’s. Cancer incidence and mortality studies had been conducted by the Pennsylvania Department of Health and revealed no convincing evidence for excess cancers among residents of municipalities in close proximity to the nuclear facilities (PDH 1988, 1996).To evaluate further the possibility of increased cancer rates in communities around the Apollo and Parks nuclear materials processing facilities, a county mortality survey was also conducted (Boice et al. 2003b). Nearly 40,000 cancer deaths occurred in the population residing in Armstrong and Westmoreland counties from 1950 through 1995. Each of these two study counties was matched to three comparison counties in the same region on the basis of age, race, urbanization, and socio-economic factors available from the 1990 U.S. Census. There were over 77,000 cancer deaths in the six comparison counties during the 45 years studied. Following similar methods used by the National Cancer Institute (Jablon et al. 1991), Standardized Mortality Ratios (SMRs) were computed as the ratio of observed numbers of cancers in the study and comparison counties to the expected numbers derived from general population rates of the United States. Relative risks (RRs) were computed as the ratios of the SMRs of the study to the control counties. There were no statistically significant increases in the study counties for any cancer when comparisons were made with either the U.S. population or the comparison counties in western Pennsylvania. In particular, deaths due to cancers of a priori interest, i.e., cancers of the lung, bone, liver, and kidney, and non-Hodgkin lymphoma were not more frequent in the study counties than in the comparison counties. Deaths from all cancers combined also were not increased in the study counties, and the RRs of cancer mortality before the facilities operated or during start-up (1950–1964), during plant operations (1965–1979), and after plant closure (1980–1995) were similar, 0.96, 0.95, and 0.98, respectively. For childhood leukemia mortality, the RR comparing the study counties with the comparison counties before or during plant start-up was 1.02, while during operations (RR 0.81) and after closure (RR 0.57) the RRs were lower. Because there is a latency period of many years following an exposure to radiation before a cancer would develop (UNSCEAR 2000; NRC 2006), any excess occurrence would have been more likely to occur in the later years, but none was seen. Here we report an extension of our previous county study for an additional nine years from 1996 through 2004. In addition, noncancer mortality and cancer incidence at the county level over this period were also evaluated.METHODSCountiesThe selection of the study and comparison counties was described previously (Boice et al. 2003b) and is summarized below. The Apollo and Parks nuclear materials processing facilities are located in Armstrong county near the Kiskiminetas River which defines the border between the Armstrong and Westmoreland counties (Fig. 1). Armstrong and Westmoreland counties are the study counties whose populations are assumed to have had the potential for exposure to any radioactive materials associated with plant operations. Most of the population in each county resides within 20 miles of the Apollo-Parks facilities. Because the wind patterns were predominantly from the southwest (CHMR 1994), it is assumed that the greatest potential for any exposure would have been for residents of Armstrong county.Fig. 1. Map of western Pennsylvania showing the two study counties (Armstrong and Westmoreland) and the six comparison counties (Clarion, Clearfield, Somerset, Beaver, Washington, Erie). The Apollo and Parks nuclear materials processing facilities (designated with a star symbol) were three miles apart on the Kiskiminetas River, which forms the border between the two study counties.The comparison counties were selected based on socio-economic and demographic characteristics available from the Census Bureau and included Clarion, Clearfield, and Somerset counties (matched to Armstrong) and Beaver, Washington, and Erie counties (matched to Westmoreland) in western Pennsylvania (http://factfinder.census.gov ). Control counties were selected based on the following characteristics: percentages of persons in the population that were white, urban, rural, employed in manufacturing, below the poverty level, over age 64 y, and high school graduates, and by mean family income and population size. Differences among cancer death rates in different geographic areas cannot always be accounted for completely from routinely available population statistics. For example, data on diet, smoking, and other potential cancer risk factors are not readily available. Control counties were chosen from the same region as the study counties, i.e., western Pennsylvania, in an attempt to minimize differences in these and other factors.Mortality and cancer incidence dataMortality counts and age-adjusted rates for all causes of death and specific causes of death were extracted for Armstrong and Westmoreland counties, as well as the six comparison counties, using SEER*Stat software (http://seer.cancer.gov/seerstat/ ). Cancer incidence counts (by age, race, and sex) within each Pennsylvania county for all cancers and specific cancers were available from the Pennsylvania Department of Health EpiQMS Web site (http://app2.health.state.pa.us/epiqms/ ). County population estimates (by age, race and sex) from the 2000 Census were extracted from SEER*Stat software.Statistical methodsAge-, sex-, and race-adjusted incidence rates of specific cancers among residents of Armstrong and Westmoreland counties were computed using the corresponding incidence counts and census population estimates between 1990 and 2004. The rates among the residents of the six comparison counties were also computed in similar fashion over the same time period. An RR estimate for each cancer site was calculated as the ratio of the age-adjusted rate of the study counties to the comparison counties. Similarly, the age-adjusted mortality rates for specific causes of death for the years 1996 through 2004 among the residents of the two study counties were compared to those of the six comparison counties by calculating the RR. Standard errors and 95 percent confidence limits around the RR estimate were computed using standard methods for cohort studies (Breslow and Day 1987). The difference between each RR and 1.00 was assessed by calculation of the probability that a difference of the observed magnitude, or larger, might have arisen by chance. In general, not much attention is ascribed to associations that may be explained by random variation in statistical data. Statistical significance was assumed when the 95% confidence interval (CI) about the estimate of the RR did not include 1.00. It is noted that when many RRs are computed and presented, about 1 in 20 observations would be expected to be statistically significant based on chance alone when the level of statistical significance is taken as p = 0.05 (Breslow and Day 1987).RESULTSTable 1 presents the observed number of cancer and noncancer deaths among residents of Armstrong and Westmoreland counties for males, females and both sexes combined for the years 1996 through 2004. The RR of dying from specific causes is also presented as the ratio of the age-adjusted mortality rates for Armstrong and Westmoreland residents to those of residents within the six comparison counties selected to be similar on the basis of socio-economic and demographic factors. Adjustment is made for age and calendar year and 95% CI about the estimate of RR are presented. Based on 47,112 total deaths, the residents of Armstrong and Westmoreland counties are seen to have the same risk of dying as residents in the comparison counties (RR 1.00; 95% CI 0.99–1.01) and there was no difference among men (RR 0.99) or women (RR 1.01). Based on 10,547 cancer deaths, total deaths from cancer were also seen to be similar although slightly lower among residents of Armstrong and Westmoreland counties than residents of the comparison counties (RR 0.97; 95% CI 0.94–0.99). This RR estimate of 0.97 for the years 1996–2004 is exactly the same as the estimate of 0.97 for the years 1950–1995 reported previously (Boice et al. 2003b).Table 1. Observed number of deaths from cancer and non-cancer causes and relative risks (RR) in the two study counties (Armstrong and Westmoreland) compared with six comparison counties for the years 1996 through 2004, by sex and specific cause of death.Table 1. (Continued)For both sexes combined, there was no statistically significant excess of any cause of cancer death, including lung cancer (RR 0.93; 95% CI 0.89–0.98; n = 2,848), breast cancer (RR 1.01; 95% CI 0.92–1.10; n = 817), stomach cancer (RR 1.13; 95% CI 0.98–1.32; n = 286), liver cancer (RR 0.93; 95% CI 0.78–1.11; n = 193), urinary bladder cancer (RR 0.96; 95% CI 0.83–1.12; n = 260), kidney cancer (RR 0.94; 95% CI 0.79–1.10; n = 225), brain cancer (RR 1.03; 95% CI 0.88–1.22; n = 227), thyroid cancer (RR 0.99; 95% CI 0.60–1.64; n = 24), non-Hodgkin lymphoma (RR 1.08; 95% CI 0.96–1.20; n = 499), bone cancer (RR 0.89; 95% CI 0.52–1.54; n = 20), nonmelanoma skin cancer (RR 1.00; 95% CI 0.69–1.46; n = 44), all leukemia (RR 1.01; 95% CI 0.90–1.14; n = 427) and all leukemia excluding chronic lymphocytic leukemia (CLL) (RR 1.00; 95% CI 0.87–1.14; n = 330).Cancer deaths by sex were also evaluated. A statistically significant excess of stomach cancer was seen among men (RR 1.25) whereas a slight deficit was seen among women (RR 0.96), arguing against a common environmental exposure since an opposite effect by sex would be unlikely (Weiss 2008). The only other statistically significant associations were low risks among women for lung cancer (RR 0.91) and melanoma of the skin (RR 0.64). The pattern of increased and decreased RRs of specific causes of death is similar to the normal variations in population statistics commonly seen, i.e., for both sexes combined, 36 of the RRs in Table 1 were equal to or slightly above 1.00 and 37 of the RRs were slightly below 1.00.Overall, noncancer deaths for both sexes combined (RR 1.01) and for men (RR 0.99) and women (RR 1.02) separately were almost exactly as expected (Table 1). Among residents of Armstrong and Westmoreland counties, statistically significant increases were seen for septicemia (RR 1.14; n = 783), infectious and parasitic diseases (RR 1.29; n = 286), all diseases of the heart (RR 1.04; n = 15,733), and pneumonia and influenza (RR 1.11; n = 1,373). In contrast, statistically significant low risks were seen for AIDS (RR 0.65; n = 46), Alzheimer’s disease (RR 0.81; n = 690), chronic obstructive pulmonary disease (RR 0.93; n = 2,119), and ill-defined conditions (RR 0.69; n = 464). No statistically significant associations were seen for death due to diabetes (RR 0.96; n = 1,425), cerebrovascular disease (RR 0.99; n = 2,967), chronic liver disease (RR 0.90; n = 344), nephritis and other nonmalignant kidney diseases (RR 0.99; n = 990), congenital anomalies (RR 0.82; n = 120) or accidents (RR 1.03; n = 1,666). There was no evidence that chronic disease of the lung, liver, or kidney were increased among residents of Armstrong and Westmoreland counties.Table 2 presents the reported number of incident cancers among residents of Armstrong and Westmoreland counties for males, females and both sexes combined over the years 1990 through 2004. The RR of developing specific cancers is also presented in comparison with the cancer incidence rates of the six comparison counties selected to be similar on the basis of socio-economic and demographic variables. Adjustment is made for age and calendar year and 95% CIs about the estimate of RR are presented. Based on 39,350 total incident cancers occurring among both sexes combined, the residents of Armstrong and Westmoreland counties are seen to be at essentially the same risk of developing cancer as residents in the comparison counties (RR 0.99; 95% CI 0.97–1.00) and there was no difference among men (RR 0.98) or women (RR 0.99). These cancer incidence findings are essentially the same as those based on cancer mortality (Table 1).Table 2. Observed number of incident cancers and relative risk (RR) of cancer in the two study counties (Armstrong and Westmoreland) compared with six comparison counties for the years 1990 through 2004, by sex and specific cancer diagnosis.For both sexes combined, there were no statistically significant increases in the incidence of any cancer, including lung cancer (RR 0.98; 95% CI 0.95–1.01; n = 5,901), female breast cancer (RR 1.00; 95% CI 0.97–1.04; n = 5,526), stomach cancer (RR 1.09; 95% CI 1.00–1.20; n = 753), liver cancer (RR 0.97; 95% CI 0.84–1.12; n = 302), bladder cancer (RR 0.97; 95% CI 0.92–1.02; n = 2,141), kidney cancer (RR 1.03; 95% CI 0.95–1.11; n = 1,013), brain cancer (RR 0.95; 95% CI 0.85–1.07; n = 489), non-Hodgkin lymphoma (RR 1.01; 95% CI 0.95–1.08; n = 1,607), bone cancer (RR 1.26; 95% CI 0.92–1.72; n = 67), melanoma skin cancer (RR 0.95; 95% CI 0.87–1.04; n = 760), all leukemia (RR 1.06; 95% CI 0.98–1.15; n = 1,020) and all leukemia excluding CLL (RR 1.00; 95% CI 0.90–1.10; n = 629). CLL, a malignancy considered not to be caused by radiation (UNSCEAR 2000; NRC 2006), was significantly elevated among both sexes combined (RR 1.20; 95% CI 1.05–1.36; n = 391), whereas significantly low risks were seen for esophageal cancer (RR 0.80; 95% CI 0.70–91; n = 341) and thyroid cancer (RR 0.88; 95% CI 0.78–0.99; n = 433).Males, similar to the cancer mortality findings, showed a statistically significantly excess of stomach cancer (RR 1.13; 95% CI 1.01–1.27; n = 473) but were at significantly low risk of developing cancer of the esophagus (RR 0.77; 95% CI 0.67–0.89; n = 260). The occurrence of stomach cancer among females was as expected (RR 1.03), and the occurrence of esophageal cancer was lower than expected but the decrease was not statistically significant (RR 0.89; 95% CI 0.68–1.17). Females had a statistically significant excess of CLL (RR 1.42; 95% CI 1.17–1.72; n = 183) which was not seen among males (RR 1.05; 95% CI 0.89–1.25; n = 208) and argues against a common environmental exposure. Radiation is not considered a cause of CLL (IARC 2000; Boice 2006). The pattern or distribution of cancer incidence is as expected in a general population, i.e., of the 30 RRs presented for both sexes combined, 15 were equal to or slightly above 1.00 and 15 were slightly below 1.00.DISCUSSIONThe current study of residents of Armstrong and Westmoreland counties extends the previous publication of cancer mortality by an additional nine years (Boice et al. 2003a), i.e., from 1996 through 2004, and includes an analysis of noncancer mortality (1996–2004) and cancer incidence (1990–2004). Similar to the previously reported findings, residents living in counties with nuclear materials fabrication and processing facilities were not at increased risk of dying or developing cancer compared to the mortality and cancer incidence experience of residents in six comparable Pennsylvania counties. Similarly, cancer and noncancer causes of death of a priori interest were not increased significantly among Armstrong and Westmoreland residents, notably chronic diseases of the lung, liver, and kidney for which an effect from any environmental exposure might have been expected had it occurred (Leggett 1989; ICRP 1995a and b; ATSDR 1999; IOM 2000; IARC 2001).The Apollo and Parks facilities processed uranium and plutonium for nuclear fuel use in commercial and navy reactors. Uranium exposure has not been consistently found associated with statistically significant increases of cancer among workers (Harley et al. 1999; IOM 2000; Royal Society 2001; Brown and Bloom 1987; Boice et al. 2006; UNSCEAR 2008), millers (Pinkerton et al. 2004; Boice et al. 2007b, 2008), or populations potentially exposed to environmental sources of uranium (Mason et al. 1972; Boice et al. 2003a, b, and c, 2007a, 2009) or presumably exposed to environmental sources of uranium in drinking water (Auvinen et al. 2002, 2005; Kurttio et al. 2006b). Uranium millers have shown an increased risk of nonmalignant lung disease and kidney disease, although associations with duration of employment were not seen which reduced the likelihood that the associations were causal (Pinkerton et al. 2004; IOM 2000). Environmental exposure to uranium in drinking water has not significantly increased the risk of urinary cancers or bone and kidney diseases (Kurttio et al. 2005, 2006a and b). Gene mutations in somatic cells have not been associated with living near a uranium processing plant in Ohio (Wones et al. 1995). Our study is generally consistent with these previous observations in that no increase in cancer was seen and nonmalignant diseases of the lung, kidney, and liver were not increased among residents of Armstrong and Westmoreland counties.Workers occupationally exposed to plutonium in the United States and United Kingdom have not been found to have a statistically significant high risk of developing cancer (Voelz et al. 1997; Omar et al. 1999; IARC 2001). Workers in the former Soviet Union, however, were found to be at a statistically significant high risk of developing cancers of the lung, bone, and liver following enormous intakes of plutonium in the 1940’s and early 1950’s during the production of nuclear weapons at the Mayak facility (IARC 2001; Gilbert et al. 2000, 2004; Koshurnikova et al. 2000). The plutonium exposures among Mayak workers were so large that they caused sclerosis of the lung (IARC 2001). The plutonium body burdens estimated from urinary excretion data among Mayak workers were, on average, 12.9 kBq for men and 29.7 kBq for women (IARC 2001). In contrast, the mean body burden for the most heavily exposed plutonium workers at Los Alamos during the Second World War was 0.97 kBq (IARC 2001). The mean body burden among British plutonium workers was estimated to be below 0.05 kBq (IARC 2001). There was no evidence that cancers linked to the large plutonium exposures in Russia were elevated in residents of Armstrong and Westmoreland counties, i.e., cancers of the lung, liver, and bone as well as nonmalignant disease of the lung, liver, and kidney were not increased significantly above expectation based on rates in the demographically similar comparison counties. Further, there was little evidence that cancer excesses among Mayak workers occurred at plutonium body burdens below 3 kBq (IARC 2001).The occurrence of leukemia of all types combined and cancers of the breast, thyroid, and lung also were not increased among the Westmoreland and Armstrong county residents. The incidence of thyroid cancer occurred significantly less often than expected. Among females, but not males, a statistically significant increase occurred for one subtype of leukemia, CLL, but this is one of several cancers which have not been established as being caused by ionizing radiation (NRC 2006; UNSCEAR 2000; IARC 2000). A statistically significant excess of stomach cancer was seen only among males and not females, which argues against a common environmental exposure since it would be unlikely that any effect would differ by sex, i.e., it would not be expected that radiation would increase risk in one sex while reducing risk in the other sex.The statistically significant excess of stomach cancer among males but not females may be due to chance when so many comparisons are made, or perhaps to lifestyle factors that differed between men (but not women) living in the study and comparison counties. Similarly, the significant deficit in incident cases of esophageal cancer among males but not females may also reflect the role of chance and the variations in disease rates commonly seen in population data. A common environmental exposure to uranium and/or plutonium is unlikely to be the cause because such exposure would not be expected to affect one subgroup adversely and conversely to have no effect or a protective effect in another subgroup (Weiss 2008). Stomach cancer also was not a malignancy of a priori interest for several reasons. There was no increase in stomach cancer in these counties in the previous years studied, i.e., 1950–1995 (SMR 1.00; n = 2,203) (Boice et al. 2003b), and there were no increases in stomach cancer mortality (PDH 1988) or incidence (PDH 1996; Boice et al. 2003c) seen in the municipalities close to the nuclear facilities for which any environmental exposure to uranium or plutonium releases, had they occurred, would have been greater than for county residents living at greater distances. Further, there is no consistent evidence that stomach cancer can be caused by potentially large occupational exposure. No significant elevations in stomach cancer were seen in studies of workers involved with the processing, fabrication and manufacturing of uranium materials (Royal Society 2001), and studies of underground uranium miners are inconsistent (Darby et al. 1995; Kreuzer et al. 2004). Early reports of significant increases in stomach cancer (SMR 1.33; n = 217) among combined miner data from 11 studies were not linked to cumulative radon levels (Darby et al. 1995), and subsequent studies among a larger number of German miners found no increased risk (SMR 0.94; n = 454) (Kreuzer et al. 2004). There was also no association found between stomach cancer and intakes of plutonium among Mayak workers in the former Soviet Union (Zhuntova et al. 2000). Finally, high concentrations of uranium and other radionuclides in Finnish ground water and wells were not associated with increases in the incidence of stomach cancer in a large study of 144,627 persons (Auvinen et al. 2005).As with any descriptive epidemiologic study of geographic areas, the current study has certain limitations. These include the absence of measures of actual exposure to individuals to any radioactive materials, the potential dilution of any possible effect by including areas in the counties that are not in close proximity to the nuclear materials processing facilities, the absence of information on potential confounding factors, and the potential impact of migration into and out of the areas of interest. Soil samples taken around the Apollo nuclear processing facility, however, were stated in a 1994 report by the University of Pittsburgh to contain levels of radioactivity typical of levels found in this region (CHMR 1994). The strengths of the study include the large numbers of cancer deaths, the inclusion of cancer incidence data, the inclusion of noncancer deaths, the use of previously collected data by the Pennsylvania Department of Health and the U.S. National Cancer Institute, and the consistency of results compared with previous investigations conducted at the county and municipality level.The selection of six comparison counties based on socio-economic and demographic variables available from the U.S. Census Bureau allowed us to minimize the possible influence of potential confounding factors by comparing rates of populations in the same state and with the same general characteristics (Boice et al. 2003b). Although there has been migration into and out of the counties over the years, it has mainly been for young persons seeking employment or college education and not for long-term residents who would have been the most likely exposed to any environmental pollutants emanating from the nuclear materials processing facilities (see also Boice et al. 2003b). The eight municipalities [or minor civil divisions (MCD)] within one mile of the Apollo-Parks facilities had little change in their populations over the years 1990 to 2000 based on census records. There were 16,772 persons living in the proximal MCDs in 1990 and 15,956 in 2000, and the number of persons over age 65 increased. The potential dilution effect of including areas within the study counties, but still at some distance from the nuclear materials processing facilities, was addressed in incidence and mortality studies of cancer among residents of these municipalities in very close proximity to the facilities which confirmed the absence of any increase in cancer (PDH 1988, 1996; Boice et al. 2003c, 2009).Finally, these findings are consistent with what is known about the carcinogenicity of uranium and plutonium, i.e., uranium is not classified as a human carcinogen (IARC 2001), only very high intakes of uranium have been associated with nonmalignant diseases of the kidney and lung, and plutonium has been convincingly linked to only a few specific cancers following enormous intakes among workers fabricating nuclear weapons and only in Russia.CONCLUSIONThis extended county health survey provides no evidence that living in counties with uranium or plutonium fuel processing and fabrication facilities has resulted in excess cancer or nonmalignant disease. These county findings are consistent with investigations among residents living in municipalities near the facilities (PDH 1986, 1996; Boice et al. 2003c, 2009), and with what is known about the carcinogenicity of uranium and plutonium (IARC 2001; IOM 2000; ATSDR 1999).Acknowledgments—We thank the National Cancer Institute for providing statistical programs and databases used for these analyses, for which the American Nuclear Insurers provided financial support. J. D. Boice may be asked to testify as an expert in a lawsuit relating to the former nuclear materials processing facilities in Pennsylvania. The results presented herein represent the conclusions and opinions solely of the authors. Its publication does not imply endorsement by any of the acknowledged agencies or individuals.REFERENCESAgency for Toxic Substances and Disease Registry. Toxicological profile for uranium. Atlanta, GA: Centers for Disease Control; ATSDR; CAS#7440-61-1; 1999. 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Jr; Bigbee, William L.; Mumma, Michael T.; Tarone, Robert E.; Blot, William J.Paper296InternalHealth Physics10.1097/01.HP.0000334548.64581.f22009962118-127FEB 2009Cancer Incidence in Municipalities near Two Former Nuclear Materials Processing Facilities in Pennsylvania—An UpdateBoice, JD; Bigbee, WL; Mumma, MT; Heath, CW; Blot, WJhttp://journals.lww.com/health-physics/Fulltext/2009/02000/Cancer_Incidence_in_Municipalities_near_Two_Former.2.aspx549disablehttp://dx.doi.org/10.1097%2f01.HP.0000334548.64581.f2