Research discussing potential environmental toxins that may be related to the etiology of childhood leukemia has been growing. The suspected environmental contaminants include solvents, air pollutants, pesticides, and tobacco smoke. Exposure to various pesticides has come under particular scrutiny, with positive associations with childhood leukemia [1]. Poynter et al. [2] conducted a population-based study assessing the association between self-reported chemical exposures and odds of acute myeloid leukemia (AML) and myelodysplastic syndromes (MDS). The authors found no clear association between pesticides and AML or MDS; however, they did report significant associations of AML and MDS with other chemicals, including benzene, vinyl chloride, and fertilizers [2]. While it is certainly important to identify exposure to pesticides as a potential etiological factor in leukemia onset, it is also important to address confounding variables, such as fertilizers, that may be both strongly associated with pesticide use and empirically associated with leukemic outcomes.

We have previously identified environmental exposure to nitrous oxide (N₂O), an agricultural and combustion pollutant, as a likely effect modifier to the proposed relationship between the use of the herbicide, glyphosate, and neurodevelopmental outcomes like attention-deficit hyperactivity disorder (ADHD) [3]. We found that use of glyphosate was closely tied to the use of nitrogen fertilizers in agriculture at a county urbanization level [3]. Therefore, it is possible that pesticide exposures may act as a proxy for air pollutants (i.e., N₂O) directly related to the use of anthropogenic nitrogen in agriculture. Prior studies have identified pre-morbid ADHD and other developmental abnormality in children newly diagnosed with leukemia [4]. Therefore, if environmental N₂O is a trigger for neurodevelopmental disorders, as we have suggested, and developmental abnormalities may precede childhood leukemia, we hypothesize that chronic exposure to N₂O in the environment, and not necessarily pesticide exposures, may foster both neurodevelopmental and hematologic abnormalities.

Including an interaction term of time with farm use of fertilizer heightens the significance of the main effect considerably, while the interaction itself significantly increases annual hospitalization risk for leukemia by 12% (results not shown). These data suggest that a 1-year lagged indicator of farm use of nitrogen fertilizer protects against hospitalization for leukemia, but that compensatory biological mechanisms may be induced over the longer term, soon increasing risk of hospitalizations for leukemia, as supported by Poynter et al. [2].

Biological evidence indicates that N₂O may be protective against leukemic cell growth via the role of N₂O in oxidizing the cobalt ion within cobalamin, inactivating vitamin B12 [5]. Also, N₂O exposure may increase leukocyte DNA damage in patients who underwent surgery, as evidenced by a two-fold increase in the percentage of DNA intensity in the comet tail using digital fluorescence microscopy [6]. The extent of DNA damage was also positively correlated with the duration of N₂O exposure [6]. Therefore, the current epidemiological finding of a significantly protective effect of farm use of nitrogen fertilizers (an environmental proxy of N₂O emissions and exposures) against hospitalization for leukemia is consistent with the prevailing biological evidence. It is interesting to note, however, that elevated blood cobalamin has been acknowledged as a diagnostic marker for leukemia [7], although the significance of this metabolic abnormality in blood cancers is not well characterized. Moreover, the use of methylphenidate, a psychostimulant used to manage premorbid neuropsychiatric conditions like ADHD, has been found to be associated with increased risk of leukemia [8], although evidence of cytogenetic damage attributed to the use of methylphenidate is not consistent [9], suggesting that factors related to the use of psychostimulants and neurodevelopmental impairment, including environmental N₂O exposure, may increase risk of leukemia. These data point to both endogenous and pharmacologic compensatory mechanisms, including leukemic outcomes and methylphenidate use respectively, which may reverse the hematologic and neuropsychiatric effects of chronic N₂O exposure.

The present longitudinal findings provide a more nuanced perspective regarding the significantly increased odds of AML from self-reported exposure to fertilizer [2]. We suggest here that leukemic outcomes, including elevated blood cobalamin levels, may reflect compensatory mechanisms to reverse the hematologic depression from chronic environmental exposure to N₂O emissions associated with nitrogen fertilizer use [10]. Additional investigations are therefore warranted to better characterize the metabolic role of increased serum vitamin B12 in hematologic cancers. As confirmed by Poynter et al. [2], future investigations exploring links between pesticides and leukemia should consider the associated use of nitrogen fertilizers and chronic exposure to related air pollutants, such as N₂O, which has been empirically shown to affect not only leukemic outcomes but also neurodevelopmental abnormality that may often precede a leukemia diagnosis. Therefore, we think that nitrogen fertilizers and their influence on nitrous oxide emissions should be considered.