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Evidence of a paradoxical relationship between endotoxin and lung cancer after accounting for left truncation in a study of Chinese female textile workers
  1. Katie M Applebaum1,2,
  2. Roberta M Ray3,
  3. George Astrakianakis4,
  4. Dao Li Gao5,
  5. David B Thomas3,6,
  6. David C Christiani2,
  7. Michael P LaValley7,
  8. Wenjin Li3,
  9. Harvey Checkoway6,8,
  10. Ellen A Eisen2,9
  1. 1Department of Epidemiology, School of Public Health, Boston University, Boston, Massachusetts, USA
  2. 2Department of Environmental Health, Harvard School of Public Health, Boston, Massachusetts, USA
  3. 3Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
  4. 4School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
  5. 5Zhong Shan Hospital Cancer Center, Shanghai, China
  6. 6Department of Epidemiology, University of Washington, Seattle, Washington, USA
  7. 7Department of Biostatistics, School of Public Health, Boston University, Boston, Massachusetts, USA
  8. 8Department of Environmental and Occupational Health Sciences, University of Washington, Seattle, Washington, USA
  9. 9Department of Environmental Health Sciences, School of Public Health, University of California, Berkeley, California, USA
  1. Correspondence to Dr Katie M Applebaum, Department of Epidemiology, Boston University School of Public Health, 715 Albany St., T322E, Boston, MA 02118, USA; kappleba{at}


Introduction Occupational exposure to endotoxin, found in Gram-negative bacteria in organic material, has been associated predominantly with a reduced risk of lung cancer among workers. An inverse exposure–response gradient among women textile workers in Shanghai, China, has been reported previously. In this case–cohort study, we investigated the influence of left truncation, which can itself induce a downward trend, on the observed association.

Methods Subjects were enrolled between 1989 and 1991 and followed until 1998. The data were left-truncated as all subjects were hired before baseline. An analysis was performed with 3038 subcohort members and 602 cases of incident lung cancer. To evaluate left truncation, we compared lung cancer rates in those hired longer ago with those hired more recently among unexposed subjects. Cox proportional hazards modelling was used to estimate incident rate ratios (IRRs) and 95% CIs.

Results Among those who were never exposed to workplace endotoxin, we compared lung cancer rates in those hired >35 years before enrolment with workers hired ≤35 years before enrolment and observed a reduced risk in the former group, IRR=0.74, 95% CI (0.51 to 1.07). After accounting for this downward bias from left truncation, the reduced risk associated with endotoxin remained among those hired ≤50 years before enrolment. In contrast, there was suggestion of an increased risk of lung cancer among those hired >50 years ago.

Conclusions After examination of left truncation bias, an inverse dose–response between endotoxin and lung cancer remained for all subjects except those hired longest ago.

  • Lung neoplasm
  • Endotoxin
  • Truncation bias

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