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Exposures to respirable crystalline silica (RCS) occur at a variety of workplaces, especially in mining and quarrying. The International Agency for Research on Cancer (IARC) has classified RCS in the form of quartz or cristobalite dust as carcinogenic to humans (Group 1). But the role of silicosis for the development of lung cancer is still unclear: is silicosis a simple marker for a high cumulative exposure or is it an intermediate factor on the pathway to lung cancer?A review of published epidemiological studies in occupational settings with known exposure to RCS was performed.The lung cancer risk among silicotics is in general higher than among subjects with unknown silicosis status. But epidemiological studies on non-silicotics, which can refer to data of silicosis registries, are scarce and often have only low statistical power. Therefore, even if the pooled lung cancer risk estimate for these studies is not significantly elevated, an independent contribution of RCS to lung cancer risk cannot be ruled out.The question remains whether RCS increase the lung cancer risk even in the absence of silicosis. Future studies on lung cancer mortality should include data from silicosis registries and/or information on contributing causes of death. The impact of competing occupational risk factors like radon or arsenic should also be taken into account.