TABLE 4.

Quality Review of Included Papers

Brief description	Source (Ref.)	Type of dosimetry	Mean dose	Comment on dosimetry	Statistical methods	Statistical models evaluated	Covariate adjustment factors
Sellafield Females	McGeoghegan et al. 2003 (29)	Annualized external doses for film badges used for external monitoring. Plutonium doses calculated using urinalysis and the Jones function. Doses from other known areas of employment included.	12.8 mSv; 23.3 mSv in plutonium workers	Uncertainty in film badge quality	SMR calculations, adjusted for age and calendar year, with female England/Wales Comparison population for the years 1971–1994. Rate ratios calculated for SMRs between radiation workers and non-radiation workers; trend tests conducted. Different latency periods assessed. Linear excess relative risk model stratifying on age and calendar year with a 10-year lag, using cumulative external dose, but only cancers were assessed with this model.	Linear model.	Stratified on age, calendar year, and industrial worker status; but only cancers were assessed with this model.
Male Colorado Plateau Millers	Pinkerton et al. 2004 (30)	No dosimetry. Assessed early vs. late period of exposure to determine whether higher doses assumed in early periods may be relevant.	Unknown	No dosimetry	SMRs calculated using the NIOSH modified life table analysis system (LTAS) using US rates and rates for Colorado, New Mexico, Utah, and Arizona state rates. Assessed underlying cause of death and other contributing causes. SIRs were used for end-stage renal disease.	SMRs/SIRs only.	SMRs/SIRs specific to age, calendar time, sex, and (White) race; stratified (with trend tests) on duration of employment, time since first employment, and year of first employment.
French Nuclear Workers (CEA & AREVA)	Telle-Lamberton 2007 (31)	Annualized external doses for film badges used for external monitoring. Doses were lagged by 2 years for leukemia and 10 for all other causes of death.	8.3 mSv; 16.9 mSv in exposed workers	Dosimetry data were validated for CEA (computer and paper records compared for a 1% random sample of the data and all doses above 3 mSv; corrections were made to doses above 3 mSv where appropriate)	SMR analysis with French national comparison (cancers only). Observed vs. expected rates with test of trend over dose-groups was the only analysis that included NMRD. For dose-response analyses, photon doses were classified into 11 groups and treated as time-dependent variables. Trend tests were calculated, and Poisson regression was conducted.	Only observed vs. expected (with trend tests) assessed NMRD; linear and log-linear models assessed cancers and broad noncancer causes of death. SMRs with confidence intervals only conducted for cancers and broad mortality groups.	SMRs adjusted for sex and 5-year age group. Fully stratified by total dose group, with test of trend. Poisson regression and tests for trend stratified on sex, 5-year age groups, 5-year periods, company, socioeconomic status, and duration of employment.
15-Country Study	Vrijheid et al. 2007 (32)	Annualized film badges/TLDs; correction factor database used, with many efforts to harmonize data across countries. Colon, RBM, and lung doses estimated in the study.	17.8 mSv (lung dose)	Dropped individuals with neutron and internal exposures, which reduces sample size considerably. Known errors in Canadian dosimetry data that biased studies.	Relative risk Poisson models with a 10-year lag (sensitivity analyses explored lag). Used mortality from COPD, liver cirrhosis, and external causes as sensitivity analyses to assess whether there was confounding from smoking, alcohol, and other lifestyle related factors, respectively.	Linear and log-linear models.	Stratified on sex, age and calendar period, facility, duration of employment, and SES. Interaction with dose tested for sex, cohort, facility type, and age.
Grants Miners and Millers	Boice et al. 2008 (33)	No dosimetry. Classified by potential exposure to radon (underground), uranium products (milling activities), or no/minimal exposure. Duration of employment also classified.	Unknown	No dosimetry.	SMRs calculated for the general US population and to the general New Mexico population (with race weightings of 90% White and 10% non-White).	SMRs only.	SMRs specific to age, calendar year, and sex; stratified by duration of employment and work experience at a uranium mine or mill.
Male British Nuclear Fuels Workers	McGeoghegan et al. 2008 (34)	Film badges for external exposure, a flag for internal exposure. Not much detail on dosimetry beyond that.	53.0 mSv	Assume doses annualized since Poisson regression was used.	SMRs for males with a comparison population mortality statistic from the northwest region of England. Poisson regression for male radiation workers using 15-year lagged dose.	Linear model.	SMRs specific to age and calendar year. The main Poisson analysis is stratified on birth cohort, attained age, employment status, site of employment, and radiation exposure status (external only, internal, none). Supplementary Poisson models allow effect modification by attained age and use excess additive risk models.
French Nuclear Contract Workers	Guerin et al. 2009 (35)	Personal dosimeters issued monthly provided information on external radiation; data was only collected through 2000 to accommodate a 3-year lag period.	33.5 mSv	Individuals with only one monthly record were excluded.	SMR calculated for the general French population. Their ERR analysis modeled SMR based on cumulative radiation dose (in categories where motivation is unclear) with a two-year lag period.	Linear model. Odd ERR analysis using SMR as the endpoint.	SMRs specific to sex, age, and calendar period. Stratified by year of study entry, age at study entry, specific exposure such as internal contamination, and time since hiring. They conducted test of trend for calendar period, attained age, and time-since-hire. Their ERR analysis adjusted for sex and attained age.
French Nuclear Fuel Company Cohort	Metz-Flamant 2009 (36)	Monitoring from AREVA or from CEA if individuals had prior exposures before coming to AREVA, lagged 2 years for leukemia and 10 years for all other outcomes. Internal irradiation possible but dosimetry not included.	20.2 mSv; 28.9 mSv in exposed workers	Dosimetry data were validated for CEA (computer and paper records compared for a 1% random sample of the data and all doses above 3 mSv; corrections were made to doses above 3 mSv where appropriate)	SMR calculated for the general French population. Trend tests were conducted over dose and duration of employment groups.	SMRs and trend tests only.	SMRs specific to sex, 5-year age groups, and 5-year calendar intervals. Trends in SMRs adjusted for sex, attained age, calendar year, and SES.
British National Registry for Nuclear Workers	Muirhead et al. 2009 (37)	Personal dosimeters provided information; correction factors were applied to arrive at more accurate dose estimates. Doses were lagged 2 years for leukemia and 10 years for all other outcomes.	24.9 mSv	Doses varied by individual site. Estimates for internal doses were not generally available, but workers monitored for exposure were identified.	SMRs calculated for the general population of England and Wales; tests for trend were conducted by dose. Internal dose-response analyses were conducted. Excess relative risk per Sv was estimated by maximum likelihood methods using categorical dose, with test of trend and confidence intervals calculated.	Linear model.	SMR analyses were fully stratified to account for social class (using industrial classification as a surrogate for the workers); these results not reported for NMRD. Dose-response analyses adjusted for age, sex, calendar period, industrial classification, and first employer.
Colorado Plateau Miners	Schubauer-Berigan et al. 2009 (38)	Exposure levels recorded in WLM, which was categorized into 9 exposure levels. Daily rates of exposure were interpolated for each worker. Exposure to radon progeny was included in these interpolations.	794 WLM	Doses categorized to be used in SMR/SIR analyses.	SMR analyses conducted with LTAS.NET, a modified life table analysis program. Expected mortality rates were calculated for White miners using combined White rates in Arizona, Colorado, New Mexico, and Utah, and for Native American miners using combined non-White rates for Arizona and New Mexico. SIR analyses were conducted for ESRD, with a US background incidence rate. Internal comparisons were conducted by using directly standardized rate ratios: miners exposed to higher radon levels (≥ 120 WLM) were compared to those exposed to lower radon levels (< 120 WLM).	SMRs/SIRs only.	SMRs specific to age, race, and calendar year; stratified by cumulative radiation exposure and smoking category.
French Uranium Processing Workers	Guseva Canu et al. 2010 (39)	External exposure assessed with individual dosimeters; external exposure was used as a proxy for internal exposure.	Not reported	Internal alpha emission from uranium intakes were measured at the Pierrelatte in vitro with fecal and urine samples and in vivo, but these records were not computerized so dosimetric software couldn’t be used at this time.	SMRs calculated for the general male French population for 1968–2005. Mortality rates of the four regions closest to the Pierrelatte plant (Gard, Drôme, Ardèche, and Vaucluse) were used as a second reference. Due to uneven deposition of uranium in the body, for deaths from target organs localized in a priori known uranium-target organs (including the lung), the SMRs for national mortality rates were calculated for: first year of Pierrelatte hire, SES, employment duration, time since recruitment, radiation exposure monitoring status, and cumulative external radiation dose. Trends and heterogeneity tests were conducted for each of these variables. Only the overall SMRs were calculated for NMRD.	SMRs only.	SMRs specific to age and calendar period.
Eldorado Workers	Lane et al. 2010 (40)	Gamma ray doses calculated from average film badge doses for the sample of workers who wore them and time on the job. Radon decay measurements were calculated differently by cohort. Port Radium used workplace monitoring augmented with ventilation data to calculate average WLMs which were applied to employees based on duration of work. Beaverlodge had individual radon decay measurements beginning in 1966; before that, methods similar to Port Radium were used. Port Hope had no radon decay information available and used dose reconstruction based on quantities of radium present in the plant in ore and at various refinement stages, measured radon emanation from various radium-bearing materials, and building air volumes and estimates of air exchange rates	100 WLM	Doses from other sites workers may have worked estimated or recorded and included. Dose used in regression analysis was the person-year weighted mean dose in each cross-classified cell.	SMRs and SIRs (cancer) compared to the general Canadian population. For internal analyses, grouped Poisson regression was conducted using time-dependent cumulative WLM and a 5 year lag. Internal analyses were also used to assess gamma rays instead of radon exposures.	Linear model. Quadratic term tested only for lung cancer.	SMRs/SIRs specific to sex, age, and calendar year at risk. Person years were cross classified by age at risk, sub-cohort, total duration of employment, age at first exposure, cumulative exposure, and years since first exposure. Further adjustment was only made in lung cancer models. Models did not adjust for additional radiation types (e.g., radon analyses did not include gamma doses).
French Electric Company Staff	Laurent et al. 2010 (41)	Film badges for external exposure; these were calibrated differently over time and were harmonized for the analysis. Organ doses were estimated for the RBM, lung, and colon. Flag for whether neutron dose exceeded 10% of the photon dose between 1967–2003.	21.5 mSv	Uncertainty in how dose calibration was harmonized and in neutron doses (for which a flag was used due to uncertainty).	RR per 100 mSv calculated for dose categories using Poisson regression, lagged by 2 years for leukemia and 10 years for all other causes of death; main analysis excluded workers with neutron exposures. Sensitivity analyses considered alternative lag times and alternative stratification strategies.	Log-linear model.	Analyses stratified on age, calendar period, and sex (except when sex was studied as a potential confounder); further assessed potential confounders by describing mortality and exposure to photon radiation and using a test of heterogeneity: gender, educational and job levels at hiring, first region of employment, length of employment and potential for substantial exposure to neutrons. Main Poisson analyses stratified on age, gender, calendar period and educational level at hiring (except for leukemia because of SES confounding)
Sellafield Windscale Accident Workers	McGeoghegan et al. 2010 (42)	Annualized film badge readings for external dose, with doses from other sites at which workers were employed included. External dose in 1957 was used as a proxy for internal dose (high dose = above median dose in fire or comparison cohort, respectively).	390.2 mSv in radiation exposed fire workers; 538.4 mSv in fire worker high dose group; 277.4 mSv in the fire worker low dose group	Doses not included for internal exposures. Film badge doses were used for regulatory compliance, so dosimetry may be inaccurate.	SMRs used to separately compare the 470 fire workers and the 2926 non-fire workers with the population of England and Wales and with the population of Northwest England for the study period. Rate ratios were used to compare the mortality (and cancer morbidity) rates of the fire workers with the non-fire workers. Rate ratios were also calculated for high vs. low dose workers. Multivariate matching using propensity scores conducted to match fire workers to the nearest individual in the non-fire cohort on age at entry, cumulative internal plutonium lung dose and external dose on 10 October 1957, industrial status, radiation status and age on 10 October 1957. Average exposure effect (AEE) for fire workers calculated via the ‘‘Matching’’ package in R after this matching; AEE was not calculated for NMRD.	SMRs, rate ratios, and average exposure effect calculated, but none of these represent a dose-response.	SMRs stratified on age and calendar year. Fully stratified analyses conducted by decade after the fire for the fire cohort and non-fire cohorts. Rate ratios stratified on attained age, calendar year, final radiation status and industrial status (paid monthly if non-industrial; weekly if industrial).
Rocketdyne Workers	Boice et al, 2011 (43)	Film badges/TLDs for external exposure; ~38% monitored for internal exposure to 14 isotopes with >30, 000 bioassays. Doses calculated for 16 organs/tissues.	19.0 mSv (lung dose)	Dose information for other sites collected and included. Uncertainties include exposure geometry, type of dosimeter used, and energy of the photons.	SMR and internal (Cox) analyses conducted. SMR comparison group was the age-, sex-, and race-matched California population in the same time period. Age at observation was used as the time scale. Dose treated as a continuous variable.	Cox proportional hazards model.	Analyses controlled for year of birth, year of hire, sex, pay type (hourly/salary), duration of employment and work as a test stand mechanic.
Male Wismut Miners	Kreuzer et al. 2013 (44)	Radon exposures reconstructed using a detailed job exposure matrix, which integrated calendar year, place of work, mining facility/mine shaft, and job type. No individual dosimetry was performed. Systematic area measurements were taken by the Wismut company beginning in 1955; before that, expert ratings were used to determine radon levels.	280 WLM	No individual dosimetry was performed for these miners.	Internal Poisson regression models were used, with cross-classifications made by age, calendar year, and cumulative radon exposure (categorical). A lag of 5 years was used in all analyses, though sensitivity analyses used lags of 0, 10, and 15 years. A sensitivity analysis was conducted expanding the definition of COPD to include contributing (as well as underlying) causes of death.	Linear model.	Silica exposure and duration of employment were controlled for in sensitivity analyses only.
Fernald Workers	Silver et al. 2013 (45)	Internal dose assessments using uranium concentration data from 1952 onward, with the latest (at the time) biokinetic and dosimetric models: urine bioassays were used to calculate organ doses. Organ doses were calculated for the lung, pancreas, lower large intestine, kidney and RBM. Film badge doses were used for external exposure; whole body equivalent dose was reported. External dose from other facilities was included. Hornung et al. methods used to estimate exposure to radon decay products using a matrix of radon decay product concentrations and employment information; these exposures are recorded in WLM. Thorium exposures were qualitatively assessed by work assignment examination and recorded with a dichotomous flag.	Mean lung dose ranged 34.5 microGy for hourly non-White females to 1552 micgroGy for hourly White males.	Heterogeneous sources of radiation exposure were not combined into a single metric. Radon decay product dose estimates involve considerable assumptions about worker location, seasonality, product levels inside and outside of buildings, etc.	SMRs compared to the general US population from 1940–2004; for several outcomes not available before 1960 used US rates from 1960–2004. Since Fernald is in Ohio, Ohio mortality rates were also used. Directly standardized rate ratios (SRR) were used to investigate differences by pay code (males only; female data was too sparse). Regression models assessed White males only; risk sets were defined using incidence density matching by attained age. Conditional logistic regression was used to estimate ERRs (equivalent to Cox). Univariate and multivariable models; multivariable models included both organ dose and external dose (and radon decay products when investigating lung cancer and NMRD). 0-, 10-, and 15-year lags investigated (only 10-year lag when data was sparse); leukemia used 0-, 2-, and 5-year lags.	Linear model preferred. Categorical and restricted cubic spline models also investigated. Log-linear models were applied where linear estimates were not within bounds.	SMRs specific to sex, age, race, and calendar year. ERR models adjusted for other types of exposure, age, birth year, and pay code. Non-radiologic confounders were assessed in univariate and multivariable models where there were at least 30 cases. Thorium data was only used in lung cancer and COPD analyses. Confounding was assessed with 20% change in estimate models adding in a covariate at a time.
Male Port Hope Workers	Zablotska et al. 2013 (46)	Gamma ray doses were recorded from badges when available (available for all workers starting ~1970) and calculated from average dose-rates and time on the job otherwise. No radon decay information was available; used dose reconstruction based on quantities of radium present in the plant in ore and at various refinement stages, measured radon emanation from various radium-bearing materials, and building air volumes and estimates of air exchange rates.	Radon decay products: 15.9 WLM; photons: 134.4 mSv	Both the company and Health Canada had dose records; company records were used if available. Workers further classified as primarily uranium or radium workers.	SMRs and SIRs (cancer) compared to the general Canadian population. Poisson regression used for internal analyses, ERRs calculated. Analyses conducted separately for internal and external exposures; sensitivity analyses used both in one model. All outcomes lagged by 5 years; sensitivity analyses tested 10- and 15-year lag times (for CVD outcomes only).	Linear model.	SMRs/SIRs specific to age and calendar year. Stratification on age at risk, calendar year at risk, total duration of employment, age at first exposure, cumulative exposure, and years since first exposure.
Male German Uranium Non-Miners	Kreuzer et al. 2015 (47)	Doses reconstructed using a job-exposure matrix that assigned an average annual exposure to each facility, workplace, and job type; applied to workers using payroll information: annualized workplace, facility, and job type, plus duration of employment. Ambient measurements were used to estimate dose. Retrospective estimates considered production, milling techniques, spatial arrangement, and available measurements. A software program calculated organ doses to the lung, stomach, kidney, liver, and RBM separately for each exposure type.	Radon progeny: 8 WLM; long-lived radionuclides: 3.9 kBqh/m^3; photons: 26 mSv	Estimates were used for photon, radon progeny, and long-lived radionuclide exposures. Exposure to silica dust was measured and estimated for workers, as well.	SMRs for the period 1970–2008 (missing 46% of deaths prior to 1970) compared to the general population in Eastern Germany. Poisson regression for relative risk analyses to assess the effects of cumulative exposures to radon progeny, external gamma radiation, LLR and silica dust on pre-defined causes of death. A 5-year lag was used. Sensitivity analyses with lag times of 0, 10, and 15. Regression was limited to outcomes with at least 12 deaths. For three cancer outcomes, sensitivity analyses adjusting for other types of exposure.	Linear model.	SMRs specific to age and calendar year. Poisson analyses were stratified on calendar year and age.
Male French Atomic Energy Commission Miners	Rage et al. 2015 (48)	For radon, retrospective dose reconstruction by an expert group for the years 1946–1955 using environmental measurements with job type, place of work, and duration of work. Individual monitoring began in 1956 and was improved in 1983. For long-lived radionuclides, dose reconstruction from ambient measurements was used for 1959–1982. From 1983 onward, individual measurements were collected. For photons, individual film badge monitoring began in 1956.	Full cohort: 36.6 WLM radon; post 1955 subcohort: 17.8 WLM radon, 1.64 kBq/m^3 long-lived radionuclides, 54.9 mGy photons	Unclear whether any estimates of photon exposures occurred before 1956. A post-1955 cohort was created to assess the time period during which all exposures were recorded individually.	SMRs compared to the general French male population. Tests for SMR trend over radon exposure categories and duration of employment categories were conducted (and for all exposure types in the post-1955 cohort). Poisson regression with a lag time of 5 years. Poisson regression only conducted for causes of death with an SMR > 1 or a significant test of trend.	Linear model.	SMRs specific to age and calendar period. Poisson stratification on calendar period, attained age, and duration of employment. The post-1955 cohort adjusted for other types of exposure (radon, long-lived radionuclides, photons).
TRACY Cohort	Samson et al. 2016 (49)	No dosimetry. Time since hire, time since end of employment, and total duration of employment were used as pseudo-surrogates.	Unknown	No dosimetry.	SMRs compared to the general French population. Only assessed causes of death with at least 5 occurrences in the cohort. Primary analyses considered men and women grouped together.	SMRs only.	SMRs specific to sex, age, and calendar period. Further stratification in sensitivity analyses for time since hire, time since end of employment, total duration of employment, and attained age. Men and women assessed separately in a sensitivity analysis. A sensitivity analysis stratified by company group for step in the uranium cycle (conversion, enrichment by gaseous diffusion and manufacturing of oxide fuel).
French Uranium Enrichment Workers	Zhivin et al. 2016 (50)	For external exposures, annualized doses from individual monitors were used. For internal exposures, a job-exposure matrix (JEM) was used that determined exposure to soluble uranium (ICRP definition; AREVA, CEA, and Eurodif) and for Eurodif distinguished between natural, depleted, and enriched uranium. JEM used to assign exposure levels of frequency and intensity of an exposure on a four-level scale for each hazard. A multiplicative product of the frequency, intensity, and duration of employment was used to derive an individual score for analyses.	External median dose: 0.8; external median dose among monitored workers: 0.75 mGy	AREVA JEM validated with 64% sensitivity and 80% specificity. Due to identical nature of work, AREVA JEM assigned to CEA. Eurodif JEM had more information on current occupational exposure limits, which validated intensity and frequency of exposure. AREVA and Eurodif JEM created with the same strategy	SMRs compared to the general French population. Within-cohort analyses using Poisson regression on grouped data, with time-dependent exposure quartiles (unexposed, low exposed, medium exposed, high exposed) grouped using quartiles of each cumulative exposure score weighted by person-years. Log-linear risk models used to obtain RRs, and linear models used to obtain ERRs. Only SMRs conducted for NMRD.	Only SMR assessed NMRD; log-linear RR model and linear ERR model assessed cancers and specific noncancer diseases.	SMRs specific to sex, age, and 5-year calendar period. Poisson analyses stratified person-years on sex, age, calendar period, socio-professional status at hire, subcohort, and 5-year lagged cumulative exposures to soluble uranium, external gamma radiation, trichloroethylene, heat, and noise. RR and ERR models stratified on age, sex, attained age, calendar period, SES at hire, and subcohort.
INWORKS	Gillies et al. 2017 (6)	Annualized dosimetry based on film badges/TLDs. Dose expressed in Sv defined as equivalent dose at a 10 mm tissue depth. Phantoms employed to reconstruct dose using different geometries and energies. Uncertainty in measurements examined to normalize exposures for bias.	25.2 mSv	Neutron exposures expressed as a time-varying indicator variable. Incorporated radionuclide exposures recorded as an indicator variable. Too little information available on early doses to evaluate impact of ‘‘missed’’ doses.	Poisson regression using time-varying cumulative dose. Fully parametric, semiparametric, and stratified models were considered for the baseline hazard function. Main analyses used a linear model. Cumulative dose was lagged by 10 years in the main analysis. Sensitivity analyses compared LQ, quadratic, and linear exponential models.	Linear model for NMRD (other shapes tested for circulatory disease)	Analyses assessed effect modifiers: employer/facility of employment, sex, SES, duration of employment, and attained age. To assess residual confounding, restricted analyses to those with known SES and detailed individual monitoring data attributable to site during study. Further sensitivity analyses assessed occupational neutron and internal exposures. Age at exposure and time since exposure further interrogated, as was lag period. None of these sensitivity analyses were applied to NMRD, but their application to circulatory diseases helps determine whether confounding was present.
French Cohort of Nuclear Workers	Leuraud et al. 2017 (51)	Annualized photon dosimetry lagged 10 years based on individual monitoring and validated for a percentage of the cohort (validated in CEA, EDF).	Full cohort: 18.4 mSv; Exposed workers: 25.7 mSv	Neutron exposures expressed as a time-varying indicator variable (before 1967: year any positive neutron dose first recorded; after 1967: year when estimated neutron dose exceeded 10% of total external dose). Internal radionuclide dosimetry not conducted for the present analysis.	SMRs compared to the general French population. For significant excess of death, calculated SMRs over professional categories (employing company, socioeconomic status, year of hiring, age at hiring, duration of employment, and cumulative dose) — didn’t include NMRD. Poisson regression for dose-response analysis; ERRs calculated. Sensitivity analyses were used to investigate the influence of adjustment for the neutron flag.	Linear model.	SMRs specific to calendar period, sex, and 5-year age intervals. ERRs stratified by calendar period, sex, 5-year age intervals, company (where worker spent a majority of time employed), duration of employment, and SES.
U.S. Uranium Gaseous Diffusion Workers	Yiin et al. 2017 (52)	For internal dosimetry, annual absorbed organ doses were calculated for all individuals presumed exposed to uranium using bioassay data combined with facility- and department-specific enrichment information estimated from the ratio of activity concentration to gravimetric concentration. For external dosimetry, annual absorbed organ dose was calculated from individual dosimetry information extracted from facilities, the U.S. Department of Energy’s (DOE) Radiation Exposure Monitoring System, the Nuclear Regulatory Commission’s (NRC) Radiation Exposure Information and Reporting System, and previous studies. Some workers at K-25 had non-negligible X rays that were included in external organ doses. 10-year lag used in main analyses.	Internal dose (lung): 0.07 mGy; External dose (lung): 40 mGy (with X rays), 4.5 mGy (without X rays)	Internal dosimetry was imputed for workers presumed exposed who did not have reported records. Job-exposure matrices were used for external photon dose during periods where personal monitoring was incomplete. Non-radiological exposures from nickel and trichloroethylene calculated from job exposure matrices for workers with probable exposures. 5- and 15-year lags used in sensitivity analyses. Correlation analysis was conducted between types of doses and duration of employment.	SMRs calculated using the NIOSH modified life table analysis system (LTAS) using US rates. A sensitivity analysis calculated SMRs with state-specific rates (Tennessee, Ohio, and Kentucky, as appropriate), and the three states combined for the pooled cohort. Internal regression analyses for uranium dose used incidence density sampling to draw risk sets matched on sex, race, birth date (within 5 years), and facility. General relative risk models analogous to Cox models used to calculate excess relative risk. ERR/mGy was restricted to individuals whose exposures were within the 95th percentile of uranium dose. Sensitivity analyses used a categorical exposure and calculated risks relative to an unexposed group (including lag).	Linear model.	SMRs specific to sex, race (White vs. other), 5-year age categories, and 5-year calendar period. Confounding in internal regression analyses was assessed by including one covariate at a time in the main model and examining the percent change relative to the width of the confidence interval; included covariates were external radiation with or without X rays, nickel, trichloroethylene, and duration of employment.
F-Millers Cohort	Bouet et al. 2018 (53)	No dosimetry. Attempt made to approximate dosimetry using type of activity at work.	Unknown	No dosimetry.	SMRs compared to the general French population or to French regional populations. Only assessed causes of death with at least 5 occurrences in the cohort. Analyses considered men and women grouped together.	SMRs only.	Analyses examined the effect of using different reference populations; national or regional background populations (French departments where the sites were located and adjacent to sites) were used. For regional analyses, SMRs were stratified by department (extrapolated to yearly rates for 1969–1974). Fully stratified analyses by socio-professional category (blue collar and other) and type of activity at hire (manufacturing, maintenance, other). Also conducted analyses adjusting for work site at hiring, time since hiring, the duration of employment, and attained age, with the last three considered time-dependent. For NMRD analyses, only stratified by type of activity at work (at time of first hire).
Male French Miners plus Jouac	Rage et al. 2018 (54)	CEA-AREVA: Radon monitoring from 1983 with reconstruction from 1946–1955 for the CEA-AREVA cohort; uranium exposure monitoring from 1959 with retrospective reconstruction prior; external monitoring from 1956 with reconstruction prior. Jouac: Exposure information from 1977 onward.	Post-1977 Jouac: 3.9 WLM among exposed miners; Extended cohort (miners + post-1977 Jouac): 35.1 WLM among exposed miners	Unclear if Jouac dosimetry includes only radon or also includes external and uranium monitoring.	SMRs compared to the general French male population. ERRs per WLM for radon exposure using Poisson regression with non-exposed miners as an internal reference group.	Linear model.	Cross-classification in DATAB by 5-year calendar period, attained age, duration of employment, cumulative radiation exposure (different categories for full vs. Jouac cohort). Baseline risk for Poisson regression stratified by calendar year and attained age. A sensitivity analysis considered lung cancer SMR variation by calendar year, attained age, and duration of employment (extended cohort and Jouac cohort).
Canadian and German Uranium Processing Workers	Zablotska et al. 2018 (55)	Port Hope: Individual annual exposures in WLM were assigned from calculated WL given each type of workplace, proportion of employees in each occupation, and proportion of time spent in each type of workplace by employees in each occupation. RDP estimates were calculated with this information, as well. Some individuals had film badges; for those that did not, personal gamma ray doses were calculated from the average dose-rates and time on the job. Wismut: Information from payroll on date of hire, date of term, and for each year, type of workplace, facility, and job type was used to create a job exposure matrix. The matrix was used to assign an average annual exposure value to each facility, workplace, and job type for radon progeny, long-lived radionuclides, and gamma irradiation. All doses lagged 5 years.	All Workers RDP: 10.0 WLM; All workers gamma: 61.5 mSv; Port Hope Males RDP: 13.3 WLM; Port Hope Males gamma: 116.3 mSv; Port Hope Females RDP: 4.9 WLM; Port Hope Females gamma: 36.2 mSv; Wismut Males RDP: 8.5 WLM; Wismut Males gamma: 30.8 mSv; Wismut Females RDP: 7.4 WLM; Wismut Females gamma: 31.1 mSv	In Port Hope, any individuals who worked with radium were considered radium workers; otherwise, they were considered uranium workers. Working level estimates were calculated from quantities of radium present in the plant in ore and at various stages of refinement, measured radon emanation rates from radium-bearing materials, building air volumes, and estimates of air exchange rates. 10-, 15-, and 20-year lags tested in sensitivity analyses. Exposure rate for effect modification analyses estimated as a time-dependent ratio of cumulative dose and cumulative duration of employment.	Grouped Poisson regression analysis used to estimate ERRs. In main analyses, gamma ray and RDP results estimated separately. In sensitivity analyses, gamma and RDP included in the model simultaneously. Deviance used to assess model fit. Most sensitivity analyses only addressed CVD.	Linear model. A series of categorical analyses were conducted to examine the shape of the dose-response. When gamma and RDP were assessed together, multiple model fits were tested.	Person-years at risk were stratified on 5-year age interval, 5-year calendar interval, total duration of employment (< or ≥6 months), and cumulative exposure (separately for RDP and gamma). Background rate was stratified to include potential confounders, which were included in the model if they produced a ≥10% change in the point estimate of the ERR. Potential confounders included age at risk, calendar year, duration of employment, and predominant exposures to radium/uranium (Port Hope) and cumulative exposures to long-lived radionuclides, silica or fine dust and arsenic (Wismut cohort). Effect modification of age at risk, exposure rate, age at first exposure, and duration of employment tested with time-window analyses.
French Nuclear Fuel Production Workers	Bouet et al. 2019 (56)	Annual organ doses calculated from internal exposures, estimated from bioassay data using biokinetic models and dosimetric models recommended by the ICRP. A maximum likelihood approach estimated intake. For workers with doses less than the threshold, two doses were calculated: zero dose (‘‘operational dose’’), and a maximum value calculated by setting the last bioassay data in the period as equal to the value of the threshold while other bioassay data remained censored. External gamma exposure from individual monitoring was annualized for whole body doses. Doses were lagged by 10 years.	Internal dose (lung): 4.22 mGy; External dose: 11.12 mGy (‘‘operational dose’’), 10.90 mGy (‘‘maximum dose’’)	Uranium bioassay was available for 83% of workers; information on physiochemical forms of uranium compounds reconstructed from career history files and documents describing workplace operations. Information on abnormal events and accidental intakes by inhalation or wounds collected from medical files and from collective incident registries documenting the specific circumstances of unusual events. For external, some workers only had external doses for some years and were not included in associations between external dose and mortality. Sensitivity analyses lagged doses by 5 and 15 years (AIC assessed lags).	SMRs calculated for the general French population. Poisson regression used to calculate RRs and ERRs. The ‘‘operational’’ dose was used in main analyses with sensitivity analyses to explore the ‘‘maximum’’ dose. Miners and millers were excluded from dose-response analyses. Assessed three subgroups of workers: 1) workers who at some point only had external dose available, 2) subset of subset 1 who had computerized medical files, 3) all workers whose medical records were computerized at the time of the study (excluded subjects recruited at companies before data were sufficiently complete). These three groups were used for external dose-response and internal dose-response analyses with adjustment for potential confounders as data completeness allowed. Only SMRs and external dose-response analysis (with Subgroup 1) assessed NMRD.	Log-linear risk models were used to calculate RRs and explore shape. Linear risk models were used to calculate ERRs; linear-quadratic and quadratic functions were also tested.	SMRs adjusted for 5-year age category, 5-year calendar interval, and sex. Person-years cross-classified on sex, age, year of birth, SES, and categories of lagged cumulative external and internal radiation. A number of medical variables were available for personnel with complete medical records (smoking, BMI, high blood pressure, elevated glycemic value) and were used in internal analyses, which did not include NMRD analyses.
Male Mallinckrodt Workers	Golden et al. 2019 (57)	Annualized external organ doses were based on film badges from 1945 onward; an algorithm assigned doses for years prior (20.8% working years). Annualized organ doses for medical X-rays required annually for workers were calculated based on X-ray parameters. Annualized internal organ doses were calculated using ICRP recommended biokinetic models based on urine samples, radon breath samples, and ambient radon measurements. Total dose included annualized organ dose from all dose sources, lagged 2 years for leukemia and 10 years for all other outcomes.	69.9 mGy	Doses from other sites of work were included (REMS, REIRS, Landauer, and other DOE sites). Uncertainty from 1942–1944; neutron doses unknown. Silica dust exposure reconstructed, as well. Primary analysis used a dose weighting factor of 1; sensitivity analyses used 10 and 20 for alpha doses (uranium and radium).	SMRs calculated for the US White male population for underlying cause of death (additionally, SIRs calculated for kidney disease incidence). Cox proportional hazards models with age as the underlying time scale estimated HRs and ERRs, which included underlying and contributing causes of death. Dose was a categorical variable with categories based on dose distribution for organ of interest. Cox analyses for dust were also conducted (not for NMRD).	Cox proportional hazards model.	SMRs adjusted for 5-year age category and 5-year calendar interval (race and sex already considered as this is just White males). Cox regression adjusted for year of birth and pay type. Sensitivity analyses adjusted for year of hire, duration of employment, SES, and cumulative dust exposure (not for NMRD).
Czech Republic Uranium Miners	Kelly-Reif et al. 2019 (58)	No dosimetry.	Unknown	No dosimetry.	SMRs calculated for the male Czech Republic population. Expected cases calculated with a lognormal Poisson model. SIRs calculated for cancers, and causal mortality rates (CMRs) calculated for select causes of death (not for NMRD). Random effects were used to assess changes in standardization over time (testing for heterogeneity of person-time distribution by age across calendar periods).	SMRs only.	SMRs adjusted for 5-year age category and calendar period. Age-specific data at different calendar periods were used to examine birth cohort effects, age effects, and period effects. Duration of employment, time since exposure, age at exposure, birth cohort, and hire cohort were examined. Only basic adjustment (age and calendar year) for NMRD.