Opportunities for cancer prevention: lifestyle choices vs. unavoidable exposures
April 30, 2012 at 2:25 pm | Posted in H&E Features | Leave a commentTags: Cancer, cancer prevention, environment, female cancers, health, medicine, public health
Cancer prevention strategies are based on what is known about attributable causes of cancer. But does focusing on existing knowledge advance or hamper efforts to reduce cancer incidence? We evaluate two opposing perspectives to conclude that demanding highly robust data may in fact limit our ability to prevent cancers beyond the proportion caused by lifestyle choices.
In December, the British Journal of Cancer published an analysis of the fraction of cancers in the UK in 2010 which were attributable to lifestyle and environmental factors (Parkin 2011). Among the main findings were that 23% of male and 15% of female cancers were caused by tobacco use, that alcohol consumption was responsible for 3-5% of cancers in both males and females, and that obesity was responsible for 6% of female cancers [chart here].
Casual readers may be puzzled by two features of the report: firstly, although the report states it is about environmental causes of cancer, it deals almost exclusively with lifestyle choices; and secondly, although the report only identifies causes for 40% of cancers, it makes a clear statement that these factors ought to be prioritised as part of a cancer prevention programme.
Why so little discussion of the environment?
Lay readers (not epidemiologists) are likely to understand the term “environmental” as referring to anything with which the body involuntarily interacts with in the world, in particular pollutants, while lifestyle factors are likely to be interpreted as encompassing people’s choices, such as what they eat and how much they exercise.
There is a simple explanation as to why the report equates environmental causes of cancer with lifestyle causes, as Professor Max Parkin, lead author of the BJC report, explains: “Epidemiologists just split things up into environmental or genetic. Genetic is something built in from the word go, that you are born with. Everything else is an external influence, which is referred to as environmental.”
Of course, what many environmental organisations are interested in is the specific contribution which inadvertent exposure to environmental pollutants makes to the burden of cancer and other disease. On this, the report has very little to say, devoting only one chapter to occupational causes of cancer, and no space at all to environmental pollutants and chemicals as a potential cause of cancer.
Instead, the BJC report satisfies itself with identifying lifestyle causes of cancer and leaving the causes of the other 60% of cancers unaccounted for. Since most lifestyle factors are accounted for in the study, this leaves a significant proportion which must be environmental in the conventional sense. So why are they not in the report?
There is a simple explanation for this as well: there are no specific environmental causes of cancer for which there are sufficient data to calculate attributable risk. For calculating attributable risk, the BJC report required sufficient evidence on the presence and magnitude of likely causal associations with cancer risk from high-quality epidemiological studies, and data on risk factor exposure from nationally representative surveys.
“We could have written a little bit about air pollution,” says Parkin. “However, it is likely to be a minor component compared to those other things [assessed in the report]. It could be doubling the risk of cancer, but we don’t really have a very good hold on that.”
“It’s possible there are things we don’t know about which are substantial contributors to cancer,” Parkin adds. “But never say never: 35 years ago we didn’t know about HPV [human papilloma virus, a major risk factor in cervical cancer] so there might be something out there. It’s a bit odd that non-Hodgkin’s lymphoma is going up, and testicular cancer likewise. However, it is unlikely we will find [another major factor] like smoking.”
If only 40% of cancers are accounted for, why are these the most important causes to address?
The BJC figures are clearly intended to inform the UK’s cancer prevention strategy and place the emphasis on people’s choices about diet, exercise, alcohol consumption and so forth. Cancer Research UK’s Chief Executive, Dr Harpal Kumar, describes these “healthy habits” as the priority for cancer prevention (CRUK 2011). Tobacco cessation therefore continues to be the number-one priority, with reducing alcohol intake and encouraging more exercise and better diet next in the queue.
Some argue this approach does more harm than good. Professors Andrew Watterson and Rory O’Neill of the University of Stirling, Scotland, argue forcefully against the “victim-blaming” they see as implicit in a healthy habits strategy, diverts attention away from the broader, societal roots of many cases of cancer, in which “income and social class connect directly to […] poor diet […] poor housing near busy, polluting roads and […] dusty, dirty, chemical-laden jobs and long hours” play into cancer incidence.
Not everybody sees things this way, however. In a Personal View in March’s Lancet Oncology, Professor Bernard Stewart of the University of New South Wales, Australia, acknowledges that although a focus on lifestyle does not recognise the burden caused by the chemical industry and associated pollution, no intervention based around reducing involuntary exposure to pollutants (except for air pollution) should be prioritised over lifestyle choices in a cancer prevention strategy (Stewart 2012).
Stewart argues that public health strategies aimed at cancer prevention have to be based in solid data. To be solid enough, the data has to show (1) the circumstances of exposure; (2) a calculation the consequential risk of cancer; and (3) the effectiveness of measures in reducing that risk of cancer. Only if all three boxes are ticked can an intervention be properly described as preventive.
For Stewart, only air pollution has adequate data for describing exposure and establishing the burden of cancer. He describes industrial pollution and pesticide findings as “not unequivocal”. For EDCs, their role in human breast cancer is “mainly inferential” and as yet unsupported by epidemiological evidence. Nor, he says, is there any evidence that there is a case of cancer which would have been avoided had a consumer decided not to buy a particular product, or had regulators been more diligent.
This is the interpretation of the data on which the established view that personal choices provide the greatest opportunities for reducing cancer incidence, while controls on specific pollutants are understood to be individually so causally insignificant they cannot be interpreted as part of a cancer prevention strategy.
Does this lead to an effective prevention strategy?
Professor Richard Clapp of Boston (US) University’s School of Public Health is unimpressed with the findings of the BJC report and is opposed to the view that lifestyle choices should be a priority in a cancer prevention strategy. Although Professor Richard Peto says the BJC report will focus attention on the high priority areas, such as refocusing on tobacco and the continuing importance of tobacco control and efforts to change the UK diet (Peto 2011), to Clapp, this is “just more of the same”.
“The 60% unknown is the elephant in the room,” says Clapp, reiterating Parkin’s and Stewart’s view that, beyond obvious causes such as smoking, it is very difficult to attribute percentages to causes of cancer. However, he draws a very different conclusion, saying it is “counterproductive and pointless” to assign certain exposures as causing a specific fraction of cancer when it is clear that preventable occupational and environmental exposure fuel excess cancer cases and deaths. (See e.g. Clapp et al. 2007)
Clapp argues this is because the fundamental mechanism of cancer is both environmental and genetic. Exposures from outside the body combine with inherited genes and genetic mutations, all of which converge to produce cancer. Overall, there are six essential alterations which need to happen in order for the body’s defences against cancer to be overwhelmed (Hanahan & Weinberg 2011).
Clapp describes this as an integrated circuit, in which a combination of exposures is required to produce a tumour, then prevention of any one of these will prevent the tumour. While preventing any of the single major factors, such as a carcinogenic exposure, is therefore a preventive measure, it becomes impossible to calculate what proportion of cancers any particular such measure prevents.
That the effectiveness of an intervention cannot be measured is unimportant for Clapp, who says we do not need a hierarchy of interventions or to play one cause off against another; exposures from all sources should be systematically reduced: “It doesn’t matter if tobacco is responsible for 20% or 30% of cancers; if it’s a carcinogen, we should minimise the exposure.”
Conclusion
Is Stewart’s position of holding out on action until the data is certain help set the right priorities for a cancer strategy, or does it limit our ability to prevent cancer?
For one thing, human exposure to chemicals is uncontrolled. In the instance we find a control group, exposure is usually so thoroughly confounded with other chemicals, lifestyle choices, occupation, economic status etc. that it becomes extremely difficult to prove an association which could pass as causal.
It is therefore hard to see how we can attain Stewart’s required level of proof for preventive action, beyond the 40% we already know about (and have known about for over 30 years). Waiting for proof for a set of factors which Stewart and Parkin both acknowledge may remain unproven for many years to come, seems a missed opportunity for preventing many cancers – even if we do not know how many cancers such action will prevent.
So although Stewart argues against use of the precautionary principle, it seems if we are to progress beyond the 40% of cancers attributed to lifestyle choices, we will ultimately have no choice but to work with limited data: being measurable is important, but only if your measurements help you make the optimal decision, rather than simply the optimal measurable decision.
“It is probable that limiting exposure to tobacco smoke has reduced incidence of lung cancer; there are lots of opportunities to expand that approach,” says Clapp. Watterson and O’Neill say that “social, political and physical environmental factors all play into cancer incidence and prevalence, and should form part of a coherent cancer prevention strategy.”
Although individual exposures are unlikely to make much difference to cancer risk, if there are hundreds of exposures which can be eliminated through general pollution control programmes, then significant further progress could be made. As Parkin acknowledges, “healthy habits” will not help the majority of people who don’t smoke, aren’t overweight and will get cancer anyway.
Are moves toward threshold-based chemicals risk assessment premature? (TTCs part 3)
March 17, 2012 at 2:37 pm | Posted in H&E Features | Leave a commentTags: environment, health, research, science
Because of the possible far-reaching consequences of their adoption, the adoption of thresholds of toxicological concern (TTCs) in regulatory risk assessment needs to be discussed in a broad, democratic environment where all affected parties are involved in a final decision. Moves to implement TTCs should not be made in isolation by small committees in single European authorities.
Introduction

It may be necessary to speed up risk assessment and use fewer animals in toxicity testing, but if proposals to do so could have far-reaching implications, they need to be agreed on by all affected parties before they are implemented.
Thresholds of toxicological concern (TTCs) are a proposal to reduce the amount of data needed for the risk assessment of chemicals. The theory is that, for any given class of substances, there is an exposure level (a TTC) below which the chance of harm from any substance in that class is very small. Toxicological testing of the substances below the TTC is then virtually worthless as it is so unlikely to find an effect.
This greatly simplifies the risk assessment process for substances present below a TTC, as it merely becomes a matter of making sure the threshold for the substance in question is not exceeded. TTCs therefore remove all specific toxicological data requirements for below-threshold substances, speeding up the decision-making process and eliminating any need for animal testing.
Last month we looked at whether or not the proposed thresholds are likely to be adequately protective of health and concluded this may not be the case, as the age and methods used in the tests on which the TTCs are based mean their safety could easily be overestimated.
This month, our concern is with the regulatory implications of setting of a threshold below which toxicity data is not required for a chemical risk assessment. We pose four questions on TTCs and conclude they may be profoundly at odds with the driving principles of the on-going modernisation of chemicals policy in the EU.
- Could TTCs create an uneven regulatory playing-field?
- What happens to low-dose testing under TTCs?
- Could TTCs confuse liability in the event a substance is toxic below a threshold?
- Do TTCs undermine the principle of the producer being responsible for proving a product is safe?
Could TTCs create an uneven
regulatory playing-field?
TTCs are supposed to only be applied in very specific regulatory contexts, when a metabolite, breakdown product or unexpected contaminant is detected in a foodstuff, item of packaging, or so forth. The argument is that, because these substances are too numerous and unpredictable to risk assess individually, a threshold of concern has to be set in order to make the problem manageable.
There do not appear, however, to be any formal attempts (at least at the time of writing this) to specify when TTCs are applicable and when not. In its draft opinion on the use of TTCs (EFSA 2011, p2 PDF) the European Food Safety Authority simply states that they “would not normally be applied when there is a legislative requirement for submission of toxicity data.”
The problem is, it is not clear why this should not turn into a slippery slope: if controlling a substance’s concentration to keep it below a threshold is deemed sufficient for risk management in one context, why should it not be so in all contexts?
A manufacturer is unlikely to be happy with a situation in which they have to produce detailed toxicological data on a product but a competitor does not, simply because of some quirk of circumstance or contingency unrelated to the product’s design or intended use. It seems more likely they will argue that, regardless of whether a substance in a product is deliberately added or is an unexpected contaminant, everyone should have identical data obligations in proving that a product is safe – in the extreme case, TTCs would have to be used either universally or not at all.
At this stage, we are not in a position to predict how the adoption of TTC might work in practice. However, if there genuinely is a slippery slope, then the scope of application of TTCs ought to be carefully defined before they are introduced, lest a decision on TTCs made by one part of the EU regulatory apparatus have consequences more far-reaching than initially anticipated.
What happens to low-dose
testing under TTCS?
One would have to be very confident that one is correct in setting a threshold, if it is to be written into law that testing below this threshold is unnecessary. This is not merely a matter of deciding that some data is not relevant to making a risk assessment decision; it is deciding that the data does not need to be generated.
Do we really know enough about low-dose effects of substances to no longer need to generate the data? The consensus view of EFSA’s TTC panel seems to be in the affirmative, but the fact is low dose effects are the subject of intensive on-going research and controversy.
Although studies based on globally-harmonized test protocols (incidentally the only studies to which EFSA referred in validating its proposed TTCs (EFSA 2011, p3 PDF)) have failed to reproduce the effects under examination, their failure to do so could reflect the inadequacy of the tests as a lack of low-dose effects.
Indeed, the most recent state-of-the-art report on endocrine disruptors (EDCs) concluded the globally-harmonised studies are unlikely to be as clearly definitive as EFSA would have us believe (Kortenkamp et al. 2011, p7 PDF), precisely because they capture only a limited range of potential EDC effects, while a new review citing 845 studies has found that “low-dose effects are remarkably common in studies of natural hormones and EDCs” (Vandenberg et al. 2012).
Even if EFSA was correct and little of the low-dose data turned out to be sound, surely it would still be inappropriate to legislate against the relevance of new toxicological research to the risk assessment of a substance? Ordinarily one would give the science the chance to speak for itself; even if the data is not expected to alter the risk assessment, it would be rather irregular to exclude the data from the assessment before examining it.
Are we overstating the problem? It could of course be argued that concerns here are overstated, because under TTCs toxicity testing is triggered in the event that threshold levels are exceeded.
It is difficult, however, to foresee how this could result specifically in low-dose testing: why, in a system which assumes a threshold is safe, would exceeding the threshold trigger testing at doses below the threshold? If harm is unlikely enough that testing low-dose testing is not worth doing before the threshold is exceeded, why would exceeding the threshold make it any more likely the low-dose testing is worthwhile?
What seems more likely is that exceeding a TTC will be dealt with in one of two ways: either by reducing exposure to below the threshold level; or by testing the substance to ensure it is safe at the level at which it is present. Neither alternative will generate low dose data.
Indeed, if the low-dose testing did take place, it would have to be on the assumption that substances can be toxic below TTCs – but it is this assumption which the use of TTCs explicitly rejects.
The overall concern, then, is use of TTCs may result in legal prohibition on the generation of data which might falsify the assumptions on which the use of TTCs is based. This situation might be prevented by including a safety-net mechanism in risk assessment regulation which guarantees generation of the low-dose data which would allow the basic assumptions of TTCs to be reviewed, but as things stand such proposals are absent – at least from EFSA’s draft opinion on TTCs.
Could TTCs confuse liability in the event a
substance is toxic below a threshold?
Because TTCs determine safety based not on the intrinsic properties of a substance, but instead on structural similarity to other substances, it creates a situation in which a manufacturer can claim it has taken sufficient steps to ensure a substance is safe simply by determining its structure and ensuring its exposure threshold is not exceeded.
This is not a universally compelling line of argument, however: for example, it would hardly be offered as proof of safety of a car. An individual model has to demonstrate it is safe by passing the minimum required safety tests, and it would never be assumed a car is safe simply because it is similar in design to other cars which have passed the safety tests.
Nor if there was a fault in a car which results in an accident, would a manufacturer be likely to argue that it was not liable because nearly all similar cars are safe – it is the specific car and its specific failure to be safe which is the problem. For chemicals one might think the same rationale should apply, but under TTCs it is not clear how this can be the case.
Admittedly, duty of care is a complex matter in chemicals regulation; analogies drawn from vehicle manufacture do not necessarily apply to chemical manufacture. However, there are good reasons for regulating a substance according to its specific properties rather than the properties of its class – as things stand toxicity tests are carried out to determine the specific hazards a substance may present.
Dropping toxicity tests may therefore have implications for liability in the event of harm. How this is so may be unclear, but it surely needs examination before TTCs are introduced – especially if TTCs represent a slippery slope when it comes to data requirements and risk assessment of chemicals in general.
Do TTCs undermine the principle of the
producer being responsible for proving safety?
For our final concern, we will return to the question of where the low-dose data will come from: in the event that a substance is suspected of being harmful, who will be responsible for generating the data to prove it is safe?
Since the use of TTCs has already absolved a producer of this responsibility, it seems it would be up to society, reversing a basic principle of modern chemicals regulation that producers are responsible for proving that a substance is safe. That is, unless simply being below the threshold is adequate proof of safety – but we have already argued this may not be satisfactory.
Conclusion
Substance-specific risk assessment will always have a failure rate for setting a safe TDI for a substance, regardless of the quality and quantity of data involved in the assessment. Probabilistic risk assessment under TTCs, with its acknowledgement of the inevitability of failure, looks like a pragmatic alternative. It may even be possible to implement a probabilistic assessment process with a failure rate lower than a substance-specific system.
Similarity in failure rate, however, does not mean the two approaches are legislatively equivalent. The fundamental differences between probabilistic and substance-specific risk assessment, and the consequences of a move from the latter to the former for liability, the principle of no-data no-market, the generation of low dose data and the maintenance of a level playing field for all producers, are notably under-discussed.
It might therefore be worth asking: is it just simpler to avoid these problems by basing regulatory approval on substance-specific toxicity data?
Currently, chemicals risk assessment is supposed to be moving forward; is it appropriate to set in stone a threshold-based approach which has complex consequences at a time when the relevance of thresholds for risk assessment is being questioned (NRC 2009) and there is evidence that e.g. endocrine disruptors may be having an effect at low doses? Or should we be reflecting on the effectiveness of chemicals RA and concentrate on developing effective reforms in line with the latest science and political intent?
We have to draw the line on toxicity testing somewhere. TTCs may even have a limited role in prioritising chemicals for rigorous testing. However, because of the possible far-reaching consequences of adopting TTCs, if they are to have a substantial role in regulatory risk assessment, this needs to be discussed in a far broader, democratic environment where all affected parties are involved in a final decision. Moves to implement TTCs should certainly not be made in isolation by a small committee in a single European authority.
Are TTCs the best way to reduce animal testing? (Part 2)
February 23, 2012 at 7:59 am | Posted in H&E Features | 1 Comment
Limitations in the toxicological tests used to calculate the NOAELs on which TTCs are based could result in thresholds of effect being greatly over-estimated. Click to enlarge.
Part 2: Reasons for doubting that TTCs are adequately protective of health
Last month, we explained how thresholds of toxicological concern (TTCs) are a proposal to reduce the amount of data which needs to be generated in order to perform chemical risk assessments, by requiring toxicological testing of a substance of unknown toxicity (such as a food contaminant or pesticide metabolite) only in the event that humans are exposed to it above a certain threshold.
The claim is that TTCs are a viable alternative to standard chronic toxicity-based risk assessments because they set an exposure threshold low enough that risk to health posed by an unidentified substance at or below that level is negligible. Risk assessors should therefore have confidence in the safety of the substance, even though no chronic toxicity data on the substance is available.
Interest in substituting TTCs for toxicity testing is driven by many factors, including: the need for risk management decisions in the face of an overwhelming lack of toxicity data on the multitude of chemicals and their breakdown products present in the environment; the EU’s commitment to ending animal tests for cosmetics by 2013; understandable support from some animal welfare groups; and support from industry itself, which is happy to emphasise the animal welfare benefits of the proposal, yet must also see substantial financial benefits in facing reduced toxicological test requirements before bringing their products to market.
The European Food Safety Authority has published a draft opinion on the application of TTCs to food contaminants (EFSA 2011) while the EU non-food Scientific Committees have also drafted a recommendation on TTCs for cosmetics (SCHER/SCCP/SCENIHR 2008). A search of the published literature indicates they are being considered for use in a range of risk assessment and regulatory forums, including: prenatal developmental toxicity (van Ravenzwaay et al. 2011), substances regulated under REACH (Rowbotham & Gibson 2011, Marquart et al. 2011), tobacco smoke (Talhout et al. 2011), pesticide metabolites (Dekant et al. 2010), hormonally-active substances (Gross et al.2010), aerosol ingredients (Carthew et al. 2010), household and personal care products (Blackburn et al. 2005) and food additives (Pratt et al. 2009).
Last month we explained that TTCs are calculated by creating a database of existing chronic toxicity data for a representative subset of a structural class of chemicals; ranking them from lowest to highest lowest-found no observed adverse effect level (NOAEL); and identifying the 5th percentile NOAEL for the sub-set. This means that, in theory, there is only a 1 in 20 chance that a random chemical in the class is toxic at a dose equal to or less than this level. TTCs are then set by dividing this dose by an uncertainty factor of 100
As a probabilistic method, it is always possible that a chemical is toxic at the TTC. The contention is that there are so few chemicals which are toxic at this dose, there likelihood of harm is insignificant. Proponents of TTCs are therefore effectively offering policy-makers a trade-off: society foregoes the lesser advantages accrued from generating specific toxicological data on substances to reap the greater rewards of reduced cost and use of fewer animals in toxicological testing.
The acceptability of this trade-off turns on two questions. Firstly, can risk assessors be confident that the health risk posed by a substance below the TTC exposure thresholds really is negligible? And secondly, are the benefits of detailed toxicological testing really so marginal that they are outweighed by the benefits of waiving specific data requirements for risk assessment?
We will address the second question next month. Regarding the first question, one would imagine risk assessors would lose confidence in TTCs if there was a compelling evidence that the threshold doses are too high to reliably prevent harm to health, and/or if any substances which are toxic at the threshold dose could pose significant health threats, so that even if relatively few substances are toxic at the threshold dose, the potential consequences of exposure for population health are too severe to afford the risk of waiving toxicity data requirements.
Note on exposure. TTCs also require exposure levels for substances to be accurately determined, since one has to know the degree of exposure in order to know if an exposure threshold is exceeded. Biomonitoring programmes to measure actual exposures are rare in Europe, so exposure will likely be modelled rather than measured.
Exposure models, however, typically struggle both with multiple routes of exposure to single substances, and with the possibility that chemicals can have a combined, additive toxic effect. Determining if thresholds are exceeded or not is therefore challenging. Proponents of TTCs will at least have to prove that substances do not have cumulative toxic effects at the proposed threshold doses; as for overall accuracy of modelling, it is beyond the scope of this article to comment.

There are many studies finding that chemicals have effects at doses below the NOAELs identified in the TTC databases. Click to enlarge.
Are the thresholds
low enough?
The effectiveness of the TTC methodology depends entirely upon how few substances are toxic at the threshold doses. The more conservative the 5th percentile is, the fewer substances will be toxic below the threshold; the more consistently the TTC database over-estimates the NOAELs for a given class of substances, the more substances there will be which are toxic at the threshold dose.
Standard critiques of risk assessment give plenty of reason to hypothesise that the NOAELs on which TTCs are based may well be overestimated. We have covered these shortcomings a number of times in H&E (see e.g. #42, #34) and there are detailed critiques in the peer-reviewed literature (e.g. Myers at al. 2009). Current concerns with how NOAELs are determined which may lead to their over-estimation include: the failure to test full dose ranges; the use of insensitive assays inappropriate for detecting many toxic effects; the failure to test during specific developmental windows; and the sacrifice of animals before disease manifests.
The age of many of the studies used in the Munro databases on which TTCs are based (Munro et al. 1996) makes them especially susceptible to these concerns, although it has been claimed that TTCs derived from this data have been validated against newer studies and for a greater range of substances (Barlow 2005).
Additionally, there are doubts that thresholds of effect truly even exist, with the US National Research Council recommending a move away from risk assessments based on no-effect levels (National Research Council 2009). If there are no thresholds of effect, TTCs are necessarily over-estimated.
Direct evidence for the hypothesis that NOAELs are underestimated would come from studies showing effects at doses lower than the 5th percentile NOAELs in the TTC databases. And such studies are straightforward enough to find.
For example, PFOA, deltamethrin and BPA would have TTCs based on a 5th percentile NOAEL of 0.15mg/kgbw/day, yet there is evidence that PFOA has effects at 0.01mg/kgbw/day (Macon et al. 2011), deltamethrin at 0.003mg/kgbw/day (Issam at al. 2009), and BPA from less than 0.05mg/kgbw/day to lower than 0.025mg/kgbw/day (Richter et al. 2007). The TTC for DEHP would be based on a 5th percentile NOAEL of 3mg/kgbw/day, yet effects have been observed at doses as low as 0.045mg/kgbw/day (Andrade et al. 2006).
A few counterexamples do not, of course, prove broken a system which only claims to be right in most cases. However, the more counterexamples there are, the more it should undermine confidence in the accuracy of TTCs, as each example is evidence that the databases of NOAELs set the TTC at too high a dose. At the very least, however, one would think this toxicity data ought to be incorporated into the TTC databases from which the 5th percentile NOAEL is calculated; if these data are not part of the databases, it would be interesting to know why not.
Note on uncertainty factors: Proponents of TTCs might argue that the uncertainty factors used to create a TTCs from a 5th percentile NOAEL are sufficient to cover potential toxic effects from any substance which is toxic at the 5th percentile NOAEL or less, and that TTCs are not falsified by effects being found below the 5th percentile threshold, but instead below the TTCs themselves.
The use of uncertainty factors in TTCs, however, is different from their use in risk assessment in a subtle but important way. How this is so, and what this means for the trade-off which regulators are being offered, we will explore in next month’s article.
What about potential magnitude of harm
from substances toxic at low doses?
Our second concern with TTCs is the assumption that all we need to know for risk assessment is the likelihood of harm at a threshold dose, not the potency of the substances which are harmful at the dose. Proponents of TTCs are effectively saying that the potential magnitude of harm posed by the unknown substances which are toxic below the threshold of toxicological concern does not need to be calculated.
The problem is, risk of harm is not only a function of the likelihood of harm, it is also a function of the magnitude of effect. Even a small effect from a dose below a TTC could have substantial impact if a large population is exposed; for example, exposure to an unidentified substance which causes 10 instances of cancer per 1,000,000 lifetimes would cause 600 cancers in a population the size of the UK.
It is the need to estimate this potential impact which determines a risk assessor’s need for chemical-specific toxicological data. It is hard to understand, therefore, how a method such as TTCs, which provides only data on the probability of harm, can possibly be interpreted as a substitute for risk assessment based on chronic toxicity data: it is a completely different approach to managing risk from substances of unknown toxicity, which looks badly at odds with current standards in risk assessment.
In conclusion, it is far from clear that risk assessors should accept the TTC trade-off: not only is there substantial evidence that thresholds are set at a level which will fail to protect population health; without specific chronic toxicity data, the potential magnitude of effect of a chemical exposure on a population cannot be anticipated. Therefore TTCs do not look like a viable substitute for risk assessment based on chronic toxicity data.
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