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IntroductionInorganic lead is considered a probable carcinogen by IARC (brain, lung, and stomach).MethodsWe conducted internal analyses via Cox regression of cancer incidence in two cohorts of lead-exposed workers with blood lead data (Finland, UK ), including almost 30 000 workers (20 752 in Finland and 9122 in the UK) and over 10 000 incident cancers. Our exposure metric was maximum annual blood lead (BL) test.ResultsThe combined cohort had a median maximum blood lead of 29 ug/dl, a mean first year BL test of 1977, and was 87% male. Forty-seven percent had more than 1 BL test. Significant (p<0.05) positive trends, using the log of each worker’s maximum BL, were found for brain cancer (malignant and benign combined), Hodgkins’s lymphoma, lung cancer, and rectal cancer, while significant negative trends were found for colon cancer and melanoma. A borderline significant positive trend (0.05≤p≤0.10) was found for esophageal cancer. Significant interactions by country were found only for lung cancer, with Finland showing a strong positive trend and the UK showing only a modest trend. However, in general trends were marked in Finland and weak or inconsistent in the UK.ConclusionsWe found strong positive incidence trends with increasing blood lead level, for several outcomes in internal analysis. Two of these, lung and brain cancer, were a priori suspected sites. Two of these outcomes are associated with smoking (lung and esophageal cancer), for which we had no data; however, we had no a priori reason to believe smoking differed between workers with different BL levels.

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164 Background: Kentucky is the epicenter of smoking and lung cancer in the U.S.: over half the population is a current or former smoker (second only to WV); and it has the highest annual lung cancer incidence—89.6 per 100,000 population—according to the most recent CDC data. While offering a significant, double-digit death benefit due to early recognition and improved therapies, LDCT lung cancer screening of at-risk individuals remains extremely low. Helping primary care practices identify their at-risk patients, promote reduced tobacco use, and refer for screening is critical. Methods: In this pilot, family practice and internal medicine practices, residency programs, and federally qualified health centers (FQHCs) were recruited in rural regions of Eastern Kentucky with populations at highest risk. The Sustainable Healthy Communities Quality Improvement Education (SHC-QIE) model—which engages multidisciplinary practice leaders, rapid cycle improvement or a PDSA approach to QI, geoanalytics, and community engagement support—was implemented to promote better screening while enhancing clinician satisfaction. Results: Each practice significantly improved their identification of smokers and patients qualifying for lung cancer screening in the Medicare program as well as screening referrals by nearly 2-fold. For example, in one FQHC, accurate reporting of tobacco history data in the medical record increased from 34.6% to 56.9%. Another example showed referrals for LDCTs increased from 230 in 2017 to 412 in 2018, with a 71% increase over baseline. While survey data from the participating clinics conceded challenges in implementing a QI initiative, significant satisfaction with the initiative, ongoing plans for activities building on the program, and community engagement were found as well. Pre-, post-survey data also revealed significant improvement in screening, tobacco counseling, and LDCT referral. Conclusions: In spite of EMR barriers, significant increases in smoking history taking, counseling for tobacco cessation, and referral for lung cancer screening was achieved over the course of 9 months.