Despite its widespread recognition in chemical toxicology, the adverse outcome pathway (AOP) framework has not been fully explored in the radiation field to guide relevant research and subsequent risk assessment. Development of a radiation relevant AOP is described here using a case example of lung cancer. Lung cancer is a major public health problem world-wide, causing the deaths of an estimated 1.5 million people annually; it imposes a major health-care burden. Numerous environmental factors are known contributors including both chemical (e.g. asbestos, air pollution and arsenic) and radiation stressors (e.g. radon gas). Radon gas is the second leading cause of lung cancer in North America. Evidence suggests that environmental and indoor radon exposure constitutes a significant public health problem. The mechanism of lung cancer development from exposure to radon gas is unclear. Data suggest that cytogenetic damage from radon decay progeny may be an important contributor. This AOP defines a path to cancer using key events related to DNA damage response and repair. The molecular initiating event (MIE) which represents the first chemical interaction with the cell is identified as the deposition of ionizing energy. Energy deposited onto a cell can lead to multiple ionization events to targets such as DNA. This energy will break DNA double strands (KE1) and initiate double strand break (DSB) repair machinery. In higher eukaryotes, this occurs through nonhomologous end joining (NHEJ) which is a quick and efficient, but error-prone process (KE2). If DSBs occur in regions of the DNA transcribing critical genes, then mutations (KE3) generated through faulty repair may alter the function of these genes or may cause chromosomal aberrations (KE4), resulting in genomic instability. These events will alter the functions of many gene products and impact cellular pathways such as cell growth, cell cycling, and apoptosis. With these alterations, cell proliferation (KE5) will be promoted by escaping the regulatory control and form hyperplasia in lung epithelial cells, leading eventually to lung cancer (AO) induction and metastasis. The overall weight of evidence for this AOP is strong. The uncertainties and inconsistencies surrounding this AOP are centred on dose-response relationships associated with dose, dose-rates and radiation quality. The proposed AOP will act as a case example to motivate more researchers in the radiation field to use the AOP framework to effectively exchange knowledge and identify research gaps in the area of low dose risk assessment. 5
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