REGULATORY

TOXICOLCSY

AND

PHARMACOLOGY

4, 107-129 (1984)

An Analysis of Potential Carcinogenic

ROBERT A.
SQUIRE AND LORRAINE

Risk from Formaldehyde

L. CAMERON

Division of Comparative Medicine, Johns Hopkins University School of Medicine, and Department of Environmental Health Sciences, Division of Occupational Medicine, Johns Hopkins University School of Hygiene and Public Health, Baltimore, Maryland 21205

Received December 22, 1983

Formaldehyde was recently shown to be carcinogenic in the nasal cavities of rats and mice following chronic inhalation at vapor concentrations which were cytotoxic. The epidemiological, physiological, and toxicological data on formaldehyde are evaluated as they pertain to the analysii of carcinogenic risk. It is concluded that humans are likely to be less susceptible than test rodents to potential carcinogenic effects and that the risk at low-level exposure would not be linearly related to that observed at the higher levels which were found to be carcinogenic in animals. Risk assessmentprocedures and risk management decisions should incorporate all of the relevant biological information, such as that discussed, rather than rely solely on a mathematical approach which is likely to yield inaccurate and misleading conclusions.

1. INTRODUCTION In the absence of adequate human data, chemical carcinogen policyin the United has been based upon the principle that a positive and valid animal bioassay provides presumptive evidence for human carcinogenic risk. This evidence is regarded as largely qualitative, although it has further been presumed that no-effect, or threshold, exposure levels for populations cannot be established. The evidence for these presumptions is indirect and/or based upon hypothetical assumptions. Thus, when a chemical as important as formaldehyde is found to induce cancer in test animals, particularly since there is widespread exogenous and endogenous exposure, it is necessary to reexamine these presumptions. The recent demonstration in rats and, to a lesser extent, in mice that chronic inhalation of formaldehyde at toxic levels induced squamous cell carcinomas of the nasal cavities has prompted extensive interest and discussion on possible carcinogenic hazards for man. Although formaldehyde was first discovered in 1859 and has been commercially manufactured since the early 19OOs, there has been no prior concern for carcinogenic risk based upon evidence in either man or animals. The acute toxicity and irritability of formaldehyde are well known, but evidence for progressive or
States

This paper was supported in part by USPHS

Grant 107

RR00 130.

0273-2300184 $3.00
Copvisbt 6 1984 by Acadanii Press, Inc. All rights of reproduction in any form resewed

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irreversible toxicity has not been available. The fact that formaldehyde has also been demonstrated to be genotoxic in certain tests has heightened the concern for potential carcinogenicity. It is the objective of this review to bring together and assessthe available scientific evidence that is relevant to carcinogenesis risk assessment of formaldehyde. The findings of carcinogenic effects in rats and mice have prompted several new research projects aimed at elucidating possible mechanisms of formaldehyde carcinogenicity and comparing the relative risks among man and test animals. The early results from these experiments as well as the considerable accumulated information on the metabolism and toxicity of formaldehyde, if viewed in the total perspective, allow for an objective and rational appraisal of potential carcinogenic risk to humans. This risk analysis is based upon a review of sources and levels of human exposure; human effects which have been confirmed; chronic and subchronic animal bioassays using the inhalation route; animal studies which may elucidate possible carcinogenic or protective mechanisms; comparative anatomical and physiological data; and shortterm in vivo and in vitro studies. Finally, discussions of mathematical and biological considerations in human risk assessment based upon the relevant toxicological data are presented. 2. NATURE A. Chemistry Formaldehyde (CAS No. 50-00-00) is the simplest of the aldehydes, with the molecular formula HCHO, and molecular weight of 30.3. It is a colorless, pungent gas at ordinary temperatures and is highly reactive. Aqueous formaldehyde, called Formalin, is a solution of 37% (by weight) formaldehyde gas in water, usually with lo- 15% methanol added to prevent polymerization (Merck Index, 1976). Formaldehyde is also commercially available as polymers, such as the solid pamformaldehyde (HCHO),, and the stable cyclic polymer trioxane or trioxymethylene (HCHO), (Meyer, 1979). B. Sources And Uses There are two major categories of sources of formaldehyde: direct commercial production and indirect production. Formaldehyde is produced by 15 companies at 52 plants, located in the eastern United States, along the Gulf Coast, and in the Pacific Northwest (SRI 1983). Almost all (99+%) of the 2710 million kg of formaldehyde directly produced in the United States in 1979 was consumed domestically (IARC, 1982a). indirect production of formaldehyde may occur through the photochemical oxidation of airborne hydrocarbons from vehicle exhausts, the incomplete combustion of hydrocarbons in fuels, and other sources. In 1978, an estimated 107 million kg of formaldehyde was released into the air from stationary sources such as oil refineries, power plants, incinerators, homes, and businesses, and approximately 223 million kg was released from mobile sources, primarily buses, trucks, and jet engines (Kitchens et al., 1976); these releases occur primarily in urban and industrial areas. Emissions of unburned hydrocarbons, such as those from auto and diesel OF THE CHEMICAL

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109 (NBC, 1976); the million kg (EPA, cigarette smoking microbes (Sawyer

exhausts, are a major source of formaldehyde in the atmosphere EPA estimates formaldehyde production from this source at 180 1980). Other sources of formaldehyde in the atmosphere include (Weber et al., 1976) and anaerobic decomposition of methane by and McCarty, 1978).

3. COMPARATIVE

ANATOMY,

PHYSIOLOGY

AND

METABOLISM

A. Comparative Anatomy and Physiology

As described in a recent report on safety assessment (Food Safety Council, 1980), an important procedure in risk assessment is an evaluation of the comparative anatomy and physiology of the test species and man. Particularly relevant is pharmacokinetics since determination of potential carcinogenic risk at any tissue site requires consideration of the actual target dose. The precise cellular or subcellular targets for carcinogenic transformation by formaldehyde in rodents are not known, although it is postulated that DNA is the ultimate target for most, if not all, chemical carcinogens. In any event, the determination of the dose of a chemical delivered to the target tissue is an initial step in estimating actual exposure levels. This is generally very difficult to measure or estimate following systemic exposure because of the uncertainties and complexities involved in absorption, tissue distribution, metabolism, and excretion. In the case of formaldehyde-induced cancer in rodents, however, the effect was a local one, comparable to the induction of skin cancer in skin painting experiments. Exposure at the target site may, therefore, be determined by such measurements as airflow to surface relationships, mucociliary activity, vapor absorption, and particle deposition in the nasal cavities. It is apparent that there are major species differences with respect to nasal anatomy and physiology, and these have recently been reviewed in a comprehensive chapter by Proctor and Chang (1983). The nasal cavities in most animals except man and other primates are adapted to their primary function of olfaction. Thus, the rat and mouse are obligatory nose breathers due to the close apposition of the epiglottis and soft palate. However, in man the anatomy of the nasal and oral cavities is arranged in such a manner that breathing can readily occur both nasally and orally. At the outset, then, one may conclude that the rat and mouse have more in common with each other than with man. They have proportionally greater nasal exposure to material in inspired air. There are other significant differences between man and animals in the functional anatomy of the nasal passages which can influence doses of chemical vapors or particulates deposited on nasal surfaces. For example, the distance from the nostrils to the nasopharynx is usually proportional to the head and snout length which varies widely. Total surface area varies with nasal complexity and shape, and total body size, and there are differences in amounts of respiratory versus olfactory epithelium which determine air filtering capacity per unit volume in the nasal cavity. The structural differences that exist between man and animals influence the course of air currents which, in turn, affect deposition on epithelial surfaces. For example, mouse and rat have atrioturbinates in the nasal vestibule that act as ballles which deflect large volumes of air. Man lacks these structures.

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All of these differences influence the airflow to surface relationships that are basic to estimating possible adverse health effects of inhaled materials (Proctor and Chang, 1983). Comparisons between the B6C3Fl mouse, the F344 rat, and man, based on normal minute ventilation and the surface area of the nasal epithelium, indicate that both rodents have approximately twice the relative surface area than man for filtering inspired air. This difference may be interpreted to indicate that man would receive a smaller target dose than rodents if both were exposed to similar concentrations. It does demonstrate that, in all probability, direct interspecies extrapolation is not appropriate in the case of inhalation exposures. Furthermore, it suggests that rat and mouse are more susceptible than man to the local nasal effects of formaldehyde or other inhaled materials at any given concentration. Because of the partial mouth breathing in humans, one may assume that relatively more formaldehyde may reach the trachea and bronchi. This is probably the case, although levels sufficient to cause irritation in the lower respiratory tract are high, i.e., 5-30 ppm (NAS, 1981), and even higher levels would probably be required to produce cytotoxicity. Furthermore, it has been shown that sulfur dioxide, another highly water-soluble gas, is virtually entirely removed by the nose in human volunteers at concentrations of up to 25 ppm (Anderson et al., 1974).

B. Metabolism With regard to formaldehyde metabolism studies in general, it should be recognized that measurements are of the radiolabel and not the intact molecule, which is very rapidly broken down. Formaldehyde can enter the body through inhalation, ingestion, or dermal absorption. Absorption through the respiratory route in dogs has been estimated to exceed 95% (Egle, 1972). Absorption through ingestion produces comparable blood levels, but dermal absorption is relatively small. Inhalation studies in rats at levels of 15 ppm also demonstrated absorption to be primarily in the upper respiratory tract, which would be expected due to high aqueous solubility of formaldehyde (Heck et al., ,1983). Absorption was directly proportional to the airborne concentration and was not influenced by prior exposures. Species differences in the absorption of formaldehyde in the nasal cavities are apparently related to minute volumes of air inspired, at least in the case of mice and rats. Because of greater sensitivity to the irritant effects of formaldehyde, mice decrease their respiratory rates and, thus, the effective exposures to about one-half that of rats (Jaeger and Gearhart 1982; Chang et al., 1983). This correlates well with the observed carcinogenic responses which were considerably less in mice. Formaldehyde is a normal metabolite and necessary component in the synthesis of certain essential biochemical substances in man and other animals and, thus, is not considered to be toxic at low levels of exposure (NAS, 198 1). Following systemic exposure, it is rapidly metabolized to formic acid, largely in the liver, but also in erythrocytes, brain, kidney, and muscle. Formic acid is subsequently either oxidized to carbon dioxide and water, eliminated in urine as a sodium salt, or enters the singlecarbon metabolic pool. The single-carbon pool is a biosynthetic pathway leading to formation of amino acids such as serine, choline, and glycine. The conversion of formaldehyde to formic acid is very rapid, the half-life being estimated at 1.5 min. The half-life of formate is approximately 80-90 min (McMartin et al., 1979).

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Following inhalation in rat, metabolic profiles as determined by radioactivity in plasma and tissues are similar to those following other systemic exposure routes (Heck et al., 198 3). Tissue distributions were also determined following inhalation exposure, and radioactivity was much higher in nasal mucosa than in any other tissue examined, with levels in the trachea not differing widely from those in plasma. There are species differences in metabolism but these are largely quantitative. For example, formaldehyde oxidation is greater in human than in rat liver (NAS, 198 l), whereas the rat converts formate to carbon dioxide at more than twice the rate of man or monkey and, thus, has lower blood formate levels (McMartin et al., 1977). There are several endogenous, as well as exogenous metabolic sources of formaldehyde. These include degradation of certain amino acids such as hi&dine, tryptophan, serine, and glycine. Formaldehyde or formic acid can also result from the metabolism of certain drugs or chemicals, e.g., aminopyrine and dihalomethanes (Palese and Tephly, 1975). A recent report describes the formation by nasal microsomes in rat of formaldehyde as the result of nasal exposure to several substances including nasal decongestants, cocaine, nicotine, essences, and solvents (Dahl and Hadley, 1983). Formaldehyde is a highly reactive compound and, in addition to its oxidation to formic acid, may react with amines through methyl01 and methylene bridges to form adducts with proteins, histones, and nucleic acids (Williams, 1959). Formaldehyde reacts with proteins and RNA more readily than with DNA because of the stability of the DNA double helix. In fact, formaldehyde does not react with double-stranded DNA and it is likely that unwinding of the double helix, as during cell division, is necessary for formaldehyde to form DNA adducts (Singer and Kusmierik, 1982). This may be particularly relevant to considerations of no-effect or threshold levels in carcinogenesis risk assessment. A recent study by Casanova-Schmitz et al. (1984) examined covalent binding of formaldehyde to DNA in rat nasal mucosa following exposure to vapor concentrations of 0.3,2,6, 10 or 15 ppm. The results indicate covalent binding to respiratory mucosal DNA at concentrations of 2 ppm and above. The extent of formaldehyde binding at 6 ppm was 10.5 fold higher than at 2 ppm, indicating significant non-linearity with respeti to vapor concentrations. This may be an important consideration in quantitative risk assessment. 4. EFFECTS A. Exposure Levels Formaldehyde is ubiquitous in the human environment and there is widespread exposure. A large percentage of the formaldehyde released from mans activities and from natural sources enters the outdoor or indoor air. Although it is continually being formed as an intermediate in the oxidation of methane in the atmosphere as well, formaldehyde does not persist, for it is rapidly photolyzed into hydrogen and carbon monoxide, or photoxidized to formyl radicals and water. The half-life of formaldehyde in the sunlight-irradiated lower troposphere is estimated at 75 min; therefore no accumulation occurs in the outdoor atmosphere (Calvert et al., 1972). Formaldehyde is also a natural metabolite and is generated and degraded by living organisms in the environment (NRC, 1976). In water, formaldehyde is rapidly hydrated and converted into glycols, which are biodegraded (Walker, 1975). IN HUMANS

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In reviewing the above information, the U. S. Environmental Protection Agency concluded that formaldehyde released outdoors will not build up in concentration, as about 95% of a point source emission would be degraded within 5 hr of emission. Therefore outdoor concentrations of formaldehyde will be dependent upon continual emission of point sources, such as auto and diesel exhaust in urban areas. However, in the indoor atmosphere photodegradation would not occur. Based on the above information on exposure and environmental fate, it appears that the predominant exposure route to formaldehyde in humans is through inhalation (EPA, 1980). In its review of the available monitoring data, the EPA concluded that the highest potential exposures to formaldehyde for humans are the result of its production and use, or the production and use of its products; and certain workplace levels are typically one to two orders of magnitude above outdoor ambient levels. As a consequence, major concern and interest have been focused on the workplace environment. Based on information obtained by NIOSH in a series of walk-through surveys of the workplaces utilizing formaldehyde or its products, the EPA has estimated typical atmospheric concentrations of formaldehyde by industry (Table 1). In addition, it has estimated the number of workers in these industries most likely to be exposed, utilizing data from the Bureau of the Census on numbers of establishments in an industry, and number of workers employed in these establishments. These estimates have been modified incorporating information from industrial hygiene and engineering. Although the figures are considered by many to be controversial, they are cited in this report to provide some perspective of occupational exposures. The total number of U. S. workers occupationally exposed to formaldehyde, including industries that use formaldehyde or its derivatives, ranged from 1.4 to 1.75 million in one recent estimate (Booz, Allen and Hamilton, Inc., 1979). Consumers in the general population may also be exposed to many of the same sources of formaldehyde. Formaldehyde may occur in indoor air as an emission from urea-formaldehyde foam insulation or from particle board containing adhesive bond or urea-formaldehyde resins. The EPA, in their integrated exposure analysis, attempted to estimate airborne
TABLE 1 ESTIMATED TYPICAL WORKPLACE" FORMALDEHYDE LEVELSAND NUMBERS OF WORKERS POTENTUALLY EXPOSED Industry a. b. c. d. e. f. g. h. Production of formaldehyde Production of formaldehyde resins Production of plywood and particle board Production, handling, and installation of urea-formaldehyde foam insulation Cotton textile manufacture and storage Paper products manufacture Embalmers and pathologists Biological and health sciences Mean cone hm-n) 1.12-1.6 0.11-1.71 up to 5.5 0.19-1.5 (production only) 0.31-0.85 0.05-0.59 0.52-4.8 8.3 Not available Not available Not available Estimated no. exoosed 416 2,050-6,150 20,768-29,778 2,032-15,080 1,687 7,150 82,600 35,000 (instructors) 1,487,500 (students) 6,128-27,584 3,003 800-3,075

i. Rubber and pk+stic.,products j. Leather products k. Metal products Abstracted from Tables 4.and 8 (EPA, 1981).

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exposure levels in several populations. They concluded in their analysis of the available data that there were no data from which to get a realistic estimate of the average typical exposures in this category [residential exposures] (EPA, 198 1). Thus, although it appears that urea-formaldehyde foam insulation does contribute some to indoor formaldehyde air concentrations, the magnitude of its contribution is difficult to assess. For additional information on this matter, see U. S. Court of Appeals Fifth Circuit (1983). Other sources of airborne formaldehyde in the home, besides urea-formaldehyde foam insulation and particle board, include consumer products containing formaldehyde and combustion products from heating fuels and cooking (NAS, 198 1). Gas stoves can generate extremely high formaldehyde levels. A gas stove operated without vent or hood for 1 hr at 350F emitted 233 ppm, with hood alone, 217 ppm, and with both hood and fan, 29 ppm (Hollowell et al., 1979). Consumers are exposed to formaldehyde through many of the products they use, such as textiles, paper, pharmaceuticals, wood products, etc. Smoking can be a significant source of formaldehyde exposure. The side stream smoke of cigarettes can also contribute to indoor air pollution; levels over 0.2 ppm have been observed (Weber et al., 1976). Exposures can also occur through food (as both a natural constituent or contaminant or food additive). These exposures of course would be through ingestion, not airborne. B. Epidemiologic Studies of Carcinogenicity

Epidemiology is the study of the distribution of human disease and of the factors which influence its distribution (Lilienfeld, 1976). There are two principal methods in epidemiology for exploring associations between an exposure and a disease. One method, the cohort study, is appropriate when the exposure is rare but the disease is not. The cuse-control study is better suited for studying an uncommon disease and a common exposure. (Clinical observations or case reports will sometimes suggest a relationship between an exposure and a human disease. However, this type of anecdotal information is of itself insufficient to demonstrate an association; epidemiologic studies are necessary for this.) The carcinogenicity of formaldehyde in humans has been studied using both methods. Because there is approximately 80% correlation between chemically induced carcinogenic sites in man and test animals to date (Tomatis et al., 1978) and the primary exposure sites for formaldehyde are similar, one would look for increased incidences of tumors of the nasal or nasopharyngeal epithelium if formaldehyde were carcinogenic in humans. The primary route of exposure in humans is through inhalation, and since formaldehyde is so reactive, one would expect almost all absorption to take place in the upper respiratory tract, primarily the anterior nose. This has, in fact, been demonstrated to be the case in rats (Heck et al., 1983). Since humans are also mouth breathers, other cancers of the respiratory system may also be considered. It is unlikely, however, that formaldehyde exposure will induce cancer at more distant sites, because of its high solubility and reactivity at the site of exposure. Cancers of the nose and paranasal sinuses are rare in the United States with about 1300 cases occurring per year (Redmond et al., 1982). Risk increases with age and is greater in males than females at all ages over 45 years. Data from the United States and Europe indicate that the incidence has remained stable or decreased slightly since the 1950s. Increased risk has been associated with low social class and with exposure to nickel, chrome pigments, mustard gas, wood, and other organic dusts.

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Nasopharyngeal cancer is also an uncommon disease in the Western world. Its incidence is highest in Asians, especially those who are of southern Chinese descent (Hirayama, 1978). Genetic factors and viral agents, especially Epstein-Barr virus, appear to be important global determinants of this type of cancer (Ablashi et al., 1983). The age-adjusted incidence of nasopharyngeal cancer for U. S. males from 1973 to 1977 was 0.4 per 100,000, a rate similar to that of male breast cancer; for nasal cancer (nose, nasal cavities, middle ear, and accessory sinuses), the rate was 0.8 per 100,000 (NCI, 1981). Numerous epidemiologic studies have been and are being conducted on formaldehyde-exposed populations. Several case-control studies of nasal cancer have been done in Europe and the United States which examined environmental and occupational exposures as risk factors (Bross et al., 1978; Decoufle, 1979; Moss and Lee, 1974; Ulitsky et al., 1981; Acheson et al., 1981; Roush et al., 1980; Tola et al., 1980; Hemberg et al., 1983). Cohort studies of workers in jobs with high potential formaldehyde exposure have also been carried out (Harrington and Shannon, 1975; Doll and Peto, 1977; Jenson, 1980; Anderson et al., 1982; Jenson and Anderson, 1982; Kreiger, 1983; Goldmann et al., 1982; Marsh, 1982; Walrath and Fraumeni, 1983; Wang, 1983; Bierre et al., 1981; Fayerweather et al., 1982, 1983; Matanowski, 1980). In reviewing the epidemiologic evidence on formaldehyde carcinogenicity, the Federal Panel on Formaldehyde (1982) concluded that the results suggest the possibility of formaldehyde being carcinogenic in humans; but the lack of information on exposure, coupled with confounding due to multiple exposures, hampered interpretation of the data. The Second IARC Working Group on Formaldehyde, however, reached a different conclusion. It reviewed all relevant epidemiologic data in 198 1, including the (then) unpublished studies by Marsh, Wong, and Walrath and Fraumeni (IARC, 1982a). They noted that none of the studies reported measurements of formaldehyde exposure and that all three of the cohort studies had short durations of possible exposure. They calculated the power to detect a doubling in lung cancer mortality for these studies to be relatively good (71 to 99%); however, none of the studies had sufficient power to detect a trebling of nasal cancer mortality (7 to 12%). (Nasal cancer is so rare that it would be difficult to detect an increase in risk or odds using a cohort design.) The conclusion of the IARC Working Group was that there was sufficient evidence that formaldehyde gas is carcinogenic to rats, but inadequate evidence to evaluate its carcinogenicity to humans. C. Other Toxic Effects in Humans Because formaldehyde has been known and used for many years, much is known of its acute toxicity in humans. The reader is referred to two review articles (NAS, 198 1; NIOSH 1976). Acute effects of exposure to formaldehyde gas relate primarily to its irritative effect. Although the severity of symptoms appears related to dose, there is wide variability among individual responses at any given dose level. Symptoms of eye irritation have been reported at concentrations as low as 0.05 ppm and of nose and throat irritation as low as 0.1 ppm. These reports are controversial and difficult to confirm; there is more firm evidence for symptoms at levels of l-l 1 ppm (NAS, 198 1). In addition, some persons develop tolerance to the irritative effects on the eye, nasal, or upper respiratory tract (NAS, 198 1).

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5. EFFECTS

IN ANIMALS

The present interest in the carcinogenic potential of formaldehyde was stimulated largely on the basis of chronic inhalation assays in rodents. The initial study showing the induction of nasal tumors in rats and mice was conducted for the Chemical Industry Institute of Toxicology (CIIT). No other compound-related tumors were reported. The results were subsequently reproduced in another study in rats. There was initially great controversy surrounding the validity of these positive studies and questions about the accuracy of tumor diagnoses. This controversy has subsided and interest has settled upon possible mechanisms and the relevance of the findings to human risk. This section briefly reviews the pertinent animal studies, plus short-term studies which contribute to an understanding of possible carcinogenic mechanisms.

A. Chronic Animal Bioassays

Several chronic inhalation bioassays of formaldehyde have been conducted in laboratory animals. In an early study by Horton et al. (1963), C3H mice were exposed to 0,40.4, 80.8, or 161.7 ppm 1 hr per day for 35 weeks. Mice exposed to the lowest concentration were subsequently exposed to 12 1 ppm for 29 weeks. Animals exposed to the higher concentration showed severe toxicity and treatment was discontinued after 11 days. Remaining animals were killed and examined after 35 or 70 weeks. Nasal cavities were not examined; however, tracheas and bronchi showed hyperplasia and metaplasia in treated animals. No lung tumors were induced. A recent study in rodents, conducted for the CIIT, first demonstrated a carcinogenic potential for formaldehyde and is the basis for the current interest (Swenberg et al., 1980; Kerns et al., 1983). Fischer 344 rats and B6C3Fl mice [120 per species per sex] were exposed to formaldehyde by inhalation for 6 hr per day, 5 days per week for 24 months. Doses administered were 0,2,6, or 15 ppm (actual mean concentrations and standard deviations were 0,2.0 + 0.6,5.6 -+ 1.2, 14.3 f 2.8, respectively). Selected animals were observed for extended periods following the 24-month exposure period, i.e., female mice were terminated at 27 months and male and female rats at 27 and 30 months, respectively. Male and female rat survival was adversely affected only at the 15 ppm level, and mouse survival was apparently unaffected at any exposure level. This may be related to the reduced minute volume of air inspired by mice exposed to formaldehyde, as described in Section 3, which reduces the effective exposures actually received. The only clinical abnormality noted was dyspnea in rats of both sexes at the 15 ppm level. The pathological findings of interest were squamous cell carcinomas in the nasal cavities. These occurred in 2 male mice in the 15 ppm group, 2 rats [ 1 maIe and 1 female] in the 6 ppm groups, and 103 rats [5 1 males and 52 females] in the 15 ppm groups. Two nasal carcinomas, one carcinosarcoma, one undifferentiated carcinoma, and one undifferentiated sarcoma were also found in rats in the 15 ppm groups. There was also a formaldehyde-related increase in polypoid adenomas in male rats at all dose levels, although there was no indication of progression to carcinomas in these benign lesions. In addition, epithelial hyperplasia, dysplasia, and

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metaplasia were noted in some animals at all exposure levels in rats, and at 6 and 15 ppm in mice. The 2 ppm level was apparently a no-effect level for mice. All of these observations reflect very steep dose-response curves for carcinogenic effects in both species. An important finding recently reported was regression of the rhinitis, dysplasia, and metaplasia at all exposure levels in both species at the 27-month (3month postexposure) sacrifice period (Kerns et al., 1983). At the high exposure level in rats (14.3 ppm), epithelial hyperplasia, dysplasia, and metaplasia were also seen in the proximal trachea. These were all reversible after the 24-month exposure, and no lesions were observed at lower exposures. In another study, rats were exposed by inhalation to mixtures of formaldehyde and hydrochloric acid (HCl) or to either chemical alone (Albert et al., 1982). Exposure levels of formaldehyde were approximately 14.0 ppm, which was similar to the high dose employed in the CIIT study. Both formaldehyde alone and in combination with HCl produced squamous cell carcinomas in the nasal cavities, but exposure to HCl alone at 10 ppm was not carcinogenic. The authors indicate that these results suggest that irritation alone may not be responsible for the carcinogenic effects of formaldehyde, since HCl did not enhance the effect nor was it carcinogenic alone. However, no comparison of the irritant levels induced by the two chemicals was reported. Formaldehyde was also tested by chronic inhalation in male Syrian golden hamsters (Dalbey, 1982). Animals were exposed to 10 ppm five times per week for life (length of exposure periods was not given), or to 30 ppm 1 day per week for 5 hr for life. Minimal hyperplastic and metaplastic changes in the nasal cavity were noted, but no tumors were observed. In the same experiment, some animals received injections of diethylmtrosamine following the 30 ppm formaldehyde exposures. It is stated that these animals had more tracheal tumors than did animals receiving diethylmtrosamine alone, indicating an apparent cocarcinogenic effect of the formaldehyde on the trachea. B. Other Animal Studies

A 26-week inhalation study with formaldehyde in monkeys, rats, and hamsters provides some useful information on dose response in different species (Rusch et al., 1983). Six male cynomolgus monkeys, 29 male and 20 female Fischer 344 rats, and 10 male and 10 female Syrian golden hamsters were exposed to formaldehyde vapor 22 hr per day, 7 days per week, for 26 weeks. Cumulative mean exposure groups were 0,O. 19,0.98, and 2.95 ppm. In monkeys, hoarseness, congestion, and squamous cell metaplasia and epithelial hyperplasia in the nasal turbinates were present in the 2.95 ppm group, with no clinical or pathological abnormalities at the lower levels. Similar results were noted in rats. Hamsters showed no evidence of toxicity at any level. When these results are compared to the 6-month findings in the CIIT study, it appears that formaldehyde concentration is more critical than cumulative dose. Exposure time in the 26-week study was approximately 5 times as long as in the CIIT study; thus, the total dose at 1.0 ppm was 2.5 times higher than the 2.0 ppm level in the CIIT study. Yet, squamous metaplasia was present at 2.0 ppm in the CIIT study, but not at 1.0 ppm in the 26-week study. It is important to note here that specific signs of irritation occur in humans at levels as low as 1.2 ppm (WeberTschopp et al., 1977), or even lower (NAS, 1981), levels which induced no cellular

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alterations in monkeys, rats, or hamsters, as detected by either light or electron microscopic examination. Apparently sensory irritation has a lower threshold than cellular alteration which would lead to avoidance of cytotoxic exposures. In another study, rats were exposed to continuous formaldehyde vapor for 45-90 days at levels to 8.0 ppm (Dubreuil et al., 1976), but histopathological examination of the nasal cavities was not reported. Coon et al. (1970) exposed rats, guinea pigs, rabbits, dogs, and monkeys continuously to 3.8 ppm of formaldehyde for 90 days. Interstitial inflammation was reported in the lungs in all species, but nasal cavities were apparently not examined. Swenberg et al. (1983) investigated possible mechanisms of formaldehyde toxicity in rats and mice subsequent to the findings of nasal cavity carcinogenesis. Using 14C-labeled formaldehyde, it was shown that the main deposition was in the anterior nasal cavity of rats and mice where the lesions were also most severe, except for the ventral cavity where deposition was noted with minimal lesions. This suggests the normal squamous epithelium in this area is protective. Morphometric studies of rat and mouse nasal cavity surfaces and measurements of minute volumes of inspired air showed that, at a level of 15 ppm, the nasal mucosa in mice is exposed to approximately one-half the amount of formaldehyde as rats, which correlates with the observed tumor response data. Dose-response relationships with formaldehyde with respect to nasal toxicity are, therefore, dependent upon nasal anatomic and physiological factors, as well as ambient air levels. Based upon known species differences, as discussed in Section 3, this is not unexpected. The toxicological responses in nasal cavities of rats exposed for 1 to 9 days to 15 ppm formaldehyde were cellular degeneration, necrosis and inflammation. Squamous metaplasia also occurred with as little as 5 days exposure. Responses in mice were similar, but less severe. The authors report that, based upon their work and that of Rusch et al. (1983), adaptive changes apparently occur and the extent and severity of the toxicity diminish with time. Other studies have shown inhibition of mucocihary action and mucous flow at toxic levels of exposure, i.e., 20-100 ppm (Dalhamn and Rosengren, 197 1). Recently, mucociliary clearance in rats has been studied more extensively (Morgan et al., 1983). Ciliastasis occurred in several areas of the nasal cavity at concentrations of 15 ppm. At 2 and 6 ppm, the effect was more focal and there was no impaired mucociliary function at 0.5 ppm. Extensive evidence derived from experimental carcinogenesis studies and human observations indicate that cellular proliferation is an essential step in the pathogenesis of neoplasms (Farber, 1982). The effects of formaldehyde on cellular proliferation in the nasal cavity may, therefore, be helpful in assessing potential carcinogenic risk. Swenherg et al. (1983) demonstrated that 5 days exposure to formaldehyde at 15 ppm resulted in a 7 l-fold increase over control levels in [3H]thymidine labeling in the nasal epithelium. A IO- to 20-fold increase in cell replication occurred when rats were exposed to 6 or 15 ppm or when mice were exposed to 15 ppm for only 3 days. However, at lower rates, i.e., 0.5 or 2.0 ppm in rats and 0.5, 2.0, or 6.0 ppm in mice, there was no increase in cell proliferation. As stated by Swenberg, The fact that only exposure concentrations associated with squamous cell carcinoma in rats and mice resulted in increased cell proliferation lends strong support to the hypothesis that increased cell proliferation is a critical event in formaldehyde carcinogene& It is,also stated in the International Agency for Research on Cancer Monograph,

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Levels of formaldehyde that cause nasal tumors also cause acute degeneration, necrosis, inflammation and increased cell replication in the nasal mucosa of rats and mice following inhalation exposure (IARC, 1982a). Such observations may provide useful markers for apparent no-effect levels which may impact on carcinogenesis risk assessment. Two recent initiation-promotion studies in mice, using traditional two-stage skin painting techniques, have been reported. In one study (Krivanek et al., 1983), formaldehyde lacked either initiator or promoter activity after 180 days of observation. In the second study, Spangler and Ward (1983) reported that through 48 weeks of observation, formaldehyde showed no activity as an initiator or as a complete carcinogen, but may have had weak promoting activity. In both studies, acetone was used as the vehicle and the formaldehyde was applied at levels which produced skin irritation. 6. SHORT-TERM
IN VITRO

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IN VZVO TESTS

A review of the genotoxicity of formaldehyde was presented by Auerbach et al. ( 1977), and the International Agency for Research on Cancer more recently reviewed the results of short-term tests with formaldehyde ( 1982). Mutations have been reported in several bacteria, including Escherichiu cob, psuedomonas, and staphylococcus; however, both positive and negative results have been noted with salmonella. Mutations have also been reported in several species of yeast. Several studies have been conducted in mammalian cells in vitro using formaldehyde solutions. Mutagenic effects were not induced in Chinese hamster ovary (CHO) cells; however, sister chromatid exchanges were induced in CHO cells and were also reported in human lymphocytes in culture. Unscheduled DNA synthesis was induced in HeLa cells, and DNA-protein crosslinks were produced in Ll2 10 and Chinese hamster V79 cells. These crosslinks were repaired, however, in both cell lines within 24 hr after removal of the formaldehyde. Recently, Grafstrom et al. (1983) reported that formaldehyde inhibited methylguanine excision repair in human bronchial cells in culture, and Goldmacher and Thilley (1983) demonstrated forward mutations in a human lymphoblastoid cell line. Formaldehyde has caused x-chromosome breakages in grasshopper spermatocytes, but did not cause mutations in silkworm. In Drosophila melanogaster, exposure to formaldehyde in food but not aerosol induced dominant lethal mutations and chromosomal aberrations. In Swiss mice, intraperitoneal injections of formaldehyde failed to induce dominant lethal effects (IARC, 1982a,b). In another mouse, strain (Q strain), formaldehyde solution injected intraperitoneally gave an increased frequency of dominant lethal effects, although analysis of spermatocytes failed to reveal any lesions (Fontingine-Housbrechts, 198 1). In vitro cell transformation studies using formaldehyde solutions have provided supportive evidence for formaldehyde carcinogenicity in animals. In experiments using C3H/lOT1/2 cells formaldehyde alone did not induce cellular transformation; however, enhanced transformation did occur when formaldehyde exposure was followed by continuous incubation with 12-0-tetradecanoylphorbol 13-acetate (TPA) (Ragan and Boreiko, 1981). Formaldehyde also had weak promoting activity in the same cells following initiation with N-methyl-N-nitro-N-nitrosoguanidine (Frazelle et

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al., 1983). Sivak reported dose-dependent transformation of mouse Balb/c3T3 cells by exposure to formaldehyde alone at levels of 2-20 clg/ml (IARC, 1982a,b). Brusick recently reported results of a series of short-term tests of formaldehyde (1983). His findings were interpreted as follows: The Ames test was negative at concentrations up to 1000 &plate, both with and without activation. The mouse lymphoma forward mutation assay produced activity at 7.5 &ml without activation and at 1.9 pdml with activation. The sister chromatid exchange assay (SCE) produced non-dose-related effects starting at 1.0 &ml without activation and at 0.5 &ml with activation. No chromosome aberrations were observed in Chinese hamster ovary cells with or without activation. Cell transformation using Balb/c3T3 cells was reported as positive over a range of 0.5-2.5 Clg/ml. It appears that only two species have been tested with formaldehyde vapor. In Drosophilia, the results were negative for dominant lethal mutations and chromosomal aberrations (IARC, 1982a,b), and Brusick (1983) conducted an in vivo assay for genotoxicity in mice exposed to formaldehyde vapor. He reported that SCE was negative at levels up to 25 ppm. Higher, toxic levels produced elevated SCE over negative controls. Chromosome aberration and somatic mutation assays (mouse spot test) were negative at all levels. In summary, although there are conflicting results, formaldehyde solutions are apparently capable of inducing in vitro DNA damage, chromosome aberrations, mutations, and cell transformation in some mammalian and nonmammalian systems. Whether or not such effects occur at noncytotoxic levels is not clear. Furthermore, neither mutagenic effects nor chromosomal aberrations have been demonstrated in an intact mammalian system utilizing the inhalation route. 7. RISK A. Introduction Evidence for carcinogenicity in humans derived from analytical epidemiological studies, which is the most direct and persuasive, is lacking in the case of formaldehyde. In fact, relatively high exposures in several occupational settings over many years have provided no evidence of human carcinogenic potential and nasal cancer is rare despite the ubiquitous presence of formaldehyde in the environment (see Table 1). At present, analysis of potential human carcinogenic risk from formaldehyde must rely upon analysis of the experimental animal data, which is a very inexact exercise. All such risk assessments are based upon assumptions concerning interspecies extrapolation (Food Safety Council, 1980). Initially, the relevance of the animal study must be determined. In this case, because of the qualitative similarities of exposure, metabolism, and tissue response between man and the test species, the animal studies may be considered to be relevant. The question to be addressed in risk assessment is, thus, mainly a quantitative one related to interspecies di&rences and dose-response relationships. For noncarcinogenic risks, safety factors are traditionally applied which take some fraction of the highest no-effect level in animals, e.g., l/100, and consider this to be an adequate margin of safety for an acceptable human daily intake (ADI). Since ASSESSMENT

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passage of the Delaney Clause to the Food, Drug, and Cosmetic Act in 1958, regulatory policy has tended to assume no threshold or no-effect levels for the human population for substances which are carcinogenic in animals. However, in the two and one-half decades since the enactment of the Delaney Clause, many more substances have been shown to be animal carcinogens than anticipated, including materials which occur naturally in our food supply and environment or are essential to society as presently structured. These substances have varied widely in their chemical and biological properties and their carcinogenic potencies and effects. The strength of evidence incriminating different chemicals as carcinogens, therefore, indicates that they do not pose equal hazards to man, and a uniform approach to carcinogen regulation is difficult to support (Squire, 198 1). Furthermore, analytical techniques have advanced to the point of detecting very minute amounts (e.g., parts per trillion) of chemicals where previously their presence would not be suspected. All of this has prompted the development of alternatives to the Delaney approach which attempt to estimate carcinogenic risks at actual exposure levels by extrapolation from effects observed in animals receiving high test doses. It is important to recognize that this process of risk assessment should involve both mathematical and biological considerations, taking into account all available information on biochemical reactivity, pharmacokinetics, and toxicity and repair mechanisms as they apply to man and the test species. Recent attempts to apply one of several mathematical models to animal tumor incidences without considering all of the available biological data constitute an oversimplification which cannot help but yield inaccurate and misleading results. B. Mathematical Considerations

Risk assessment has been defined by the Commission on Life Sciences, National Academy of Sciences, as the quantitative or qualitative characterization of the adverse health effects of human exposure to an agent (Committee on the Institutional Means for Assessment of Risks to Public Health, 1983). Quantitative risk assessment attempts to calculate the risk of disease or death in exposed populations, based upon assumed dose-response relationships. However, the necessary principles or techniques for quantitative cancer risk assessment are not yet well developed (IARC, 1982). Often, critical information is not available. Therefore, there are many points in the risk assessment process where the analyst must choose among alternatives, relying only upon his subjective judgment. These choices are often arbitrary and are based upon hypothetical assumptions. Yet they can radically influence the final risk estimate and the conclusions drawn therefrom (see Table 2). In the case of carcinogenic risk assessment performed for regulatory purposes, there has been a policy that, whenever uncertainty exists at any point in a risk assessment, the decision or assumption is made that will most likely avoid underestimating the risk. The effect of these policies has been to produce carcinogenic risk assessments that consistently overstate the true risk, sometimes substantially (Rodricks and Taylor, 1983). Many mathematical models have been developed for low-dose extrapolation. These include: (a) models based on the frequency distribution of responses in the test population, such as the log normal or probit model, or the log logistic or logit model; (b) models derived from assumptions of the mechanisms of cancer induction and

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include the linear or single-hit model, the multihit model, the multistage model, and the Weibull or multicell model (Crump et al., 1976); (c) the newest models based upon theories of nonlinear pharmacokinetics in the metabolism of carcinogens (Hoe1 et al., 1983); (d) selection of a mathematical model which will provide an upper confidence limit to the true response curve (Mantel and Bryan, 196 1; Hoe1 et al., 1975), these upper confidence limits being approximately linear if one assumes an additive effect of a direct-acting carcinogen (Guess et al., 1977). Although all models can give an equally good fit to data in the observed range, the estimates of risk at low dose can vary widely. Particularly, the linear model gives a very extreme measure of risk as illustrated in Table 2. A fact often overlooked in the use of mathematical models for quantitative risk estimation is that the results apply to the test animals, not to humans. Models predict low-dose risks in the tested species; they do not consider interspecies differences in biological responses, which, in the case of formaldehyde, are significant. Models are most useful to indicate relative potency of a chemical in a defined species as compared to other chemicals tested under equal conditions. There is little biological basis to assume they can predict the actual levels of risk in a human population. In addition to the biological uncertainties in interspecies comparisons, there are also several uncertainties in mathematical extrapolation from high- to low-dose risks in the test species themselves. With respect to carcinogenesis, there are several dosedependent differences which current mathematical models do not take into consideration. They include: (a) dose-dependent changes in metabolic handling of chemicals; (b) dose-dependent differences in efficiency of DNA or of other repair systems; (c) contributions to carcinogenesis of cell division induced by overt toxic doses of chemicals; (d) number of sequential mutations or other events within a cell population required to produce carcinogenic transformation. All of the above variables, which have been demonstrated to exist in biological systems, are overlooked, particularly in assumptions of low-dose, linear responses.
TABLE 2
DOSEPOFFORMALDEHYDE INCURRINGARISKOF 1 PERMILLIONFORNASAL CARCINOMAINRATSUSING SEVERAL MODELS

Model Probit Multihit Logit Weibull Multistage Linear Adapted from Gibson ( 1983, Table 4). a Inhalation 6 hr/day, 5 days/week for 24 months.

Ihe

(mm)

2.14 1.52 0.89 0.76 0.65 0.00059

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Quantitative risk assessment generally assumes that humans will respond to chemicals similarly to the test animals, both qualitatively and quantitatively. From the point of view of protecting the public health, this assumption may be justified where there are no available data indicating otherwise. Under such circumstances, it may be a reasonable and prudent regulatory position. However, the availability of specific comparative data on a chemical with which to predict interspecies differences in potential toxicity can permit a more accurate estimation of actual risk and should be applied. In the case of formaldehyde, there are considerable data relating to mechanism of action and interspecies differences in respiratory anatomy and physiology which are discussed in previous sections, and a simple mathematical approach which ignores these data is not appropriate. Formaldehyde presents a difficult challenge in risk assessment. It appears to be genotoxic in certain in vitro systems, and therefore may be considered to have the capacity to damage DNA. According to present operational definitions, formaldehyde would, therefore, be a potential initiator. Because of its ability to cause cellular toxicity and regenerative proliferation, it could also be a promoter, and as described earlier, formaldehyde solution acts both as a weak initiator and promoter in in vitro cell transformation. However, as indicated in Section 5, in vivo initiation-promotion studies using mouse skin have demonstrated only possible weak promoter activity, and no evidence of initiation. Present theories on carcinogenic mechanisms allow that nongenotoxic compounds, i.e., promoters or modifiers, are likely to have exposure levels which would not increase cancer risks, so-called threshold levels (Weisburger and Williams, 198 1). They are presumed to increase cancer risks only secondary to some prerequisite effect on cells which includes stimulation of cellular proliferation. It should be recognized, however, that certain so-called initiators may also have threshold levels of exposure if it can be demonstrated that, below certain target exposure levels, DNA damage either does not occur or is repaired prior to cell division. Swenberg et al. ( 1983) point out that, in V79 cells, DNA-protein crosslinks, which can be rapidly repaired before cell division, appear to be the adduct formed with formaldehyde. Even following actual mutagenic effects induced by low doses of a potent material, repair may also occur (Russell et al., 1982). In this study, specific-locus mutations in mouse spermatogonia induced by ethylnitrosourea were shown to be repaired at exposures below 100 mg/kg. As discussed in Section 3, it is apparent that formaldehyde-DNA adduct formation may require single-stranded DNA, as would be present during cell proliferation. Studies in several species of experimental animals, including monkey, have shown that increased celiular proliferation in the nasal cavity occurs only if critical levels of toxicity occur, and there are apparent thresholds for such cytotoxicity. At levels of 6 ppm or below in mice, and 2 ppm or below in rats, no increased cellular proliferation occurs and these are also noncarcinogenic doses. Absolutely no cellular alterations as determined by light or electron microscopic examination were observed in monkey, rat, or hamster at 1.0 ppm. Evidence of no-effect levels for genotoxic chemicals may also be derived from indirect observations of several substances. Formaldehyde is a normal metabolite in mammalian tissues. Recently studies have shown that acetaldehyde, a chemical with

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wide exposure and a significant intermediary metabolite in the catabolism of amino acids and of alcohol, is also carcinogenic in the nasal cavities of hamsters and rats following chronic inhalation exposure at high, toxic levels (Feron et al., 1983). In an in vitro system, acetaldehyde, metabolically derived from ethanol, has recently been shown to form adducts with proteins in rat liver homogenates at levels in the range of reported hepatic ethanol oxidation in vivo (Donohue et al., 1983). Major essential metabolic constituents have also recently been shown to be mutagenic under certain experimental conditions. Both glutathione and cysteine were reported to be positive mutagens in the Ames assay, even at concentrations found in mammalian tissues (Glatt et al., 1983). In light of such observations, it seems to be an inescapable conclusion that threshold levels for genotoxic and carcinogenic effects in animal tissues must exist for certain chemicals. The counterargument is often presented that, although this may be true for most individuals, no threshhold levels can be established for an entire population, including particularly susceptible individuals. If one concedes this point for carcinogenic effects, it must also be conceded for other forms of toxicity. No AD1 can be set for the entire population for any toxic effect if zero-risk levels are required. It must also be stressed that the nonthreshhold assumptions for carcinogenicity are theoretical and based upon a presumption of single-hit, irreversible, and cumulative events in the genetic material of cells. The existence of such cellular events as a result of exposure to chemicals has not been directly demonstrated, and based upon our knowledge of dose-dependent repair systems and the multistage progression and reversibility of the early stages of neoplasia, there is sufficient basis to question whether such phenomena indeed occur. In fact, there is no more direct evidence for absence of threshholds for carcinogenic effects than for any other toxic effect. The distinction between risks posed by genotoxic and nongenotoxic chemicals is further obscured by the evidence that promoters or modifiers may indirectly damage DNA, e.g., through the generation of free oxygen radicals, which is an ubiquitous process associated with inflammation and cytotoxicity (Freeman and Crapo, 1982; Birnboim, 1982). Evidence linking chromosomal defects and the activation or expression of oncogenes, already present in human and animal tissues, with the carcinogenic process also raises questions about the relevance of a chemicals genotoxicity (Yunis, 1983). Nongenotoxic chemicals, i.e., promoters, as well as genotoxins are capable of inducing chromosome damage which may permit oncogene expression (Rigby, 198 1). One or more of these mechanisms may be the basis for the induction of relatively rare forms of cancer in animals by nongenotoxic chemicals, such as saccharin and bladder cancer, 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD) and tongue cancer, and butylated hydroxyanisole (BHA) and stomach cancer. The often cited notion that promoters only cause an increase in background tumors ignores these and other examples of promoters apparently acting as complete carcinogens. The genotoxicity of a chemical or its metabolites as demonstrated in short-term tests may, therefore, have less relevance for carcinogenic risk than a determination of the levels of cytotoxicity in vivo which cause DNA or chromosomal damage. The biological evidence relating to the potential carcinogenic effects of formaldehyde does not support assumptions of low-dose linearity in risk assessment. In fact, a recent study by Casanova-Schmitz (1984) demonstrates that levels of covalent binding to DNA in rat nasal mucosa are not linear with respect to formaldehyde vapor concentrations. Formaldehyde gas does not reach the lungs to any degree, and the rare

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occurrence of upper respiratory cancer in humans does not support assumptions of background additivity. These observations, plus the steep dose-response curves in chronic animal studies, and the evident requirements for critical levels of cytotoxicity to induce neoplastic transformation, indicate that carcinogenic threshholds or, at least, nonlinear, low-dose responses prevail. If mathematical models are to be used to estimate human risk, they should take into consideration all of the available biological data, not only dose-response relationships in test animals. With formaldehyde, models that do not a priori assume low-dose linearity as the prevailing phenomenon would appear to be most appropriate.

8. SUMMARY

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CONCLUSION

Evidence for potential carcinogenic risk from environmental chemicals derives from three sources: epidemiological studies in humans, animal experiments, and short-term assays for genotoxicity or cell transformation. Although there are limitations associated with the available studies in humans, mainly relating to lack of quantitative exposure information, several well-defined human populations have been exposed to unusually high concentrations of formaldehyde for many years. Among certain occupational groups, particularly in fields of biology, medicine, mortuary science, and some manufacturing processes, exposures have been among the highest that can be tolerated without severe irritation. Yet, there is no adequate evidence of increased cancer risks at any tissue site, including the upper and lower respiratory tracts. The site of greatest exposure is the nasal cavity, where tumors are normally rare in humans, and sensory irritation generally occurs at concentrations below those that cause cytotoxicity in the nasal cavity, which would provide a protective mechanism. Because of mouth breathing in man, one may suspect that the lungs may also be at increased risk. However, it has been demonstrated that, because of the high solubility and reactivity of formaldehyde, virtually none reaches the lungs except at very high exposure levels and such levels also induce severe irritation to the eyes and upper respiratory passages. Animal studies have demonstrated that formaldehyde is carcinogenic in the nasal cavities of rodents when chronically administered at levels which are cytotoxic and result in increased cellular proliferation. At lower levels, carcinogenicity has not been demonstrated. Because of similarities of metabolism and routes of exposure between test animals and humans, the results of these studies must be considered relevant to human risk. The issues to be addressed in a proper risk assessment concern interspecies differences in respiratory anatomy and physiology as well as differences in toxic responses at various exposure levels. An important question in the risk assessment of formaldehyde is the possibility of a carcinogenic threshhold, or no-effect level, which is suggested by both the human and animal studies. The terms initiator and promoter are operational definitions which may or may not reflect actual mechanisms of neopiastic transformation; yet, threshhold assumptions are more readily accepted for promoters (or modifiers) than for initiators. As discussed in Section 7, however, such distinctions are becoming less apparent and arguments for or against threshholds for either type of carcinogen can be presented. The fact is that there is no direct evidence to rule out either possibility.

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Formaldehyde exhibits properties of both an initiator and a promoter. It is positive in several short-term assays for genotoxicity although it has not been shown to be positive in a mammalian in vivo system by inhalation. It is also a strong irritant which stimulates cellular proliferation at certain exposure levels-a characteristic of promoters. In two-stage initiation-promotion studies on mouse skin, there was evidence of weak promotion but no initiator activity was seen. DNA adducts can be formed with formaldehyde, but they appear to be limited to single-stranded DNA which would be available during cell replication. The extent of DNA covalent binding in rat nasal mucosa increases with exposure levels above 2 ppm, but in less than linear fashion. Thus, even if one assumes that DNA damage is the mechanism of neoplastic transformation, the effect is apparently limited to cytotoxic concentrations which result in enhanced cell proliferation. Concentrations which were carcinogenic in test animals were also levels which induced cell proliferation, i.e., greater than 2 ppm in rats and greater than 6 ppm in mice. No pathological alterations at all were induced at 1 ppm in either rats, hamsters, or monkeys. Since humans generally exhibit nasal or eye irritation at 1 ppm or even less, chronic exposures to cytotoxic levels are unlikely. There is additional circumstantial evidence for threshholds for carcinogenic effects by formaldehyde and a related compound. Specifically, formaldehyde and acetaldehyde, both normal and ubiquitous metabolites in mammalian systems, are carcinogenic in animals at the site of chronic exposure when administered at cytotoxic levels. It is difficult to reconcile assumptions of low-dose linearity with materials which are normally present and functional in mammalian tissues. Comparative anatomical and physiological studies have shown that tissue effects from formaldehyde are related to target dose, which depends upon airflow to surface relationships, rather than simply vapor concentrations of the chemical. There are major species differences in responses which influence target dose, as indicated by the difference in responses between rats and mice exposed to similar concentrations. Based upon actual comparisons of normal minute ventilation and surface areas, it is estimated that humans have approximately one-half the nasal capacity to filter inspired air than either mice or rats. In conclusion, evidence presently available on formaldehyde carcinogenic risk generally supports a threshhold. At the least, an assumption of nonlinearity at low exposure levels is warranted. Also, based upon comparative studies, humans are likely to be less rather than more susceptible than rodents to the potential carcinogenic effects. The use of any risk assessment procedures which fail to incorporate such evidence should explicitly describe the basis for the assessment and the likely overestimates of risk. REFERENCES
E. D., COWDELL, R. H., AND RANG, E. H. (1981). Nasal cancer in England and Wales: An occupational survey. Brit. J. Ind. Med. 38,2 18-224. ALBASHI, D. V., LEVINE, P. H., PRASED, U., AND PEARSON, G. R. (1983). Meeting report: Fourth International Symposium on Nasopharyngeal Carcinoma; Application of Field and Laboratory Studies to the Control of WC. Cancer Res. 43,23X-2318. ACHESON, ALBERT, R. E., SELLAKUMAR, A. R., LASKIN, S., KUSCHNER, M., AND NELSON, N. (1982). Gaseous

formaldehyde and hydrogen chloride induction of nasal cancer in the rat. J. Natl Cancer Inst. 68,597603.

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S. K., JENSON,0. M., AND OLIVA, D. (1982). [Exposure to formaldehyde and cancer of the lung in Danish physicians.] Ugeskr. L&g. 144, 1571-1573. [In Danish, English Abstmct] ANDERSON, I., LUNDQUIST, G. R., JENSON, P. L., AND PROCTOR, D. F. (1974). Human response to controlled levels of sulfur dioxide. Arch. Environ. Health 28, 3 l-39. AUERBACH, C., MOUTSCHEN-DAHMEN, M., AND MOUTXHEN, J. (1977). Genetic and cytogenet& effects of formaldehyde and related compounds. Mutut. Res. 39, 3 17-62; 1977. BIERRE, T. H., TUNNICLIFF, M. J., AND DARBY, F. W. (1981). A Review of the Occupational Health Problems Associated with Formaldehyde Exposure, unpublished report. Department of Health, Southern Regional Occupational Health Unit, New Zealand. BIRNBOIM, H. C. (1982). DNA strand breakage in human leucocytes exposed to a tumor promoter, phorbol myristate acetate. Science 215, 1247-1249. Booz, Allen and Hamilton, Inc. (1979). Preliminary Study of the Costs of Increased Regulation of Formaldehyde Exposure in the V. S. Workplace. Prepared for the Formaldehyde Task Force, Synthetic Organic Chemical Manufacturers Association, Florham Park, N. J. BROSS, I. D., VIADANA, E., AND HOUTEN, L. (1978). Occupational cancer in men exposed to dust and other environmental hazards. Arch. Environ. Health 33, 300-307. BRUSICK, D. J. (1983). Genetic and transforming activity of formaldehyde. In Formaldehyde Toxicity (J. E. Gibson, ed.). Hemisphere, Washington, D. C. CALVERT, J. G., KERR, J. A., DEMERJIAN, K. L., AND MCQUIGG, R. D. (1972). Photolysis of formaldehyde as a hydrogen atom source in the lower atmosphere. ScienCe 175, 75 l-752. CASANOVA-SCHMITZ, M., STARR, T., AND HECK, H. Differentiation Between Metabolic Incorporation and Covalent Binding in the Labeling of Macromolecules in the Rat Nasal Mucosa and Bone Marrow By Inhaled [I%]- And [HI Formaldehyde, Toxicol. Appl. Pharmacol. In press. CHANG, J. C. F., GROIN, E. A., SWENBERG,J. A., AND BARROW, C. S. (1983). Nasal cavity deposition, histopathology, and cell proliferation after single or repeated formaldehyde exposures in B6C3Fl mice and F-344 rats. Toxicol. Appl. Pharmacol. 68, 161-116. CIIT (Chemical Industry Institute of Toxicology) (1980). Progress Report on CIIT Formaldehyde Studies, Docket No. 112D0, Dec. 12. Committee on the Institutional Means for Assessment of Risks to Public Health ( 1983). Risk Assessment in the Federal Government: Managing the Process. Nat. Acad. Sci., Washington, D. C. COON, R. A., JONES, R. A., JENKINS, L. J., JR., AND SIEGEL, J. (1970). Animal inhalation studies on ammonia, ethylene glycol, formaldehyde, dimethylamine, and ethanol. Toxicol. Appl. Pharmacol. 16,
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CRUMP, K. S., HOEL, D. G., LANGLEY, C. H., AND PETO, R. (1976). Fundamental carcinogenic processes and their implications for low-dose risk assessment. Cancer Res. 36, 973-979. DAHL, A., AND HADLEY, W. (1983). Formaldehyde production promoted by rat nasal cytochrome P-450dependent monooxygenascs with nasal decongestants, essences, solvents, air pollutants, nicotine, and cocaine as substrates. Toxicol. Appl. Pharmacol. 67,2CQ-205. DALBEY, W. E. (1982). Formaldehyde and tumors in hamster respiratory tract. Toxicology 24,9-14. DALHAMN, T., AND ROSENGREN,A. (1971). Effect of different aldehydes on tracheal mucosa. Arch. Otolaryngol. 93, 496-500. DECOUFLE,P. (1979). Cancer risks associated with employment in the leather and leather products industry. Arch. Environ. Heafth 34, 33-37. DOLL, R., AND PETO, R. (1977). Mortality among doctors in difR.rent occupations. Brit. Med. J. 1, 14331436. DONOHUE, T. M., JR., TUMA, D. J., AND SORRELL, M. F. (1983). Binding of metabolically derived acetaldehyde to hepatic proteins in vitro. Lnb. Invest. 49, 226-229. DUBREUIL, A., I~XJLEY, G., GODIN, J., BOUDENE, C. (1976). Inhalation en continu, de faibles doses de formaldehyde: Etude experimentale chez le rat. J. Eur. Toxicol. 9, 245-250. F!.GLE, J. L. (1972). Retention of inhaled formaldehyde, propionaldehyde, and acrolein in the dog. Arch. Environ. Health 25, 119- 124. EPA (U. S. Environmental Protection Agency) (1980). Carcinogen assessment group. Fed. Regist. 45(231),
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EPA (1981). Technical Document: Formaldehyde, Nov. 16. Office of Toxic Substances, Washington, D. C. FARBER, E. (1982). Chemical carcinogenesia: A biologic perspective. Amer. J. Pathol. 106, 272-296. FAYERWEATHER, W. E., PELL, S., AND BENDER, J. R. (1982). Case-Control Study of Cancer Deaths in DuPont Workers with Potential Exposure to Formaldehyde, unpublished report.

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