Author response: Extended follow-up of lung cancer and non-malignant respiratory disease mortality among California diatomaceous earth workers

We will address the comments offered by Mundt and Boffetta1 on our manuscript describing findings from an update of mortality among California diatomaceous earth (DE) workers.2 We regard the sustained dose–response trends for lung cancer and non-malignant respiratory disease (NMRD) (tables 3 and 4, respectively) as the most important findings regarding risks associated with crystalline silica. The reduction of overall mortality for these outcomes, indicated by reduced standardised mortality ratios (SMR), is more likely to be a 'depletion of susceptibles' phenomenon than a 'balancing out' effect. We agree that a healthy worker effect is an unlikely explanation for the reduced lung cancer SMR. However, support for the assertion that the healthy worker effect generally declines with employment duration could only be obtained in occupational cohorts where exposure effects and survival effects are sufficiently taken into account, a condition rarely achieved in published studies.

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