A Retrospective Study On Malignant Neoplasms Of Bladder, Lung And Liver In Blackfoot Disease Endemic Area In Taiwan.

Br. J. Cancer (1986), 53, 399-405

A retrospective study on malignant neoplasms of bladder,
lung and liver in blackfoot disease endemic area in Taiwan
C.-J. Chen, Y.-C. Chuang, S.-L. You, T.-M. Lin & H.-Y. Wu
Institute of Public Health, National Taiwan University College of Medicine, Taipei, Taiwan, Republic of China

Summary A total of 69 bladder cancer, 76 lung cancer and 59 liver cancerdeceased cases and 368 alive
community controls group-matched on age and sex were studied to evaluate the association between higharsenic artesian well water and cancers in the endemic area of blackfoot disease (BFD), a unique peripheral
vascular disease related to continuous arsenic exposure. According to a standardized structured questionnaire,
information on risk factors was obtainedthrough proxy interview of the cases and personal interview of the
controls. A positive dose-response relationship was observed between the exposure to artesian well water and
cancers of bladder, lung and liver. The age-sex-adjusted odds ratios of developing bladder, lung and liver
cancers for those who had used artesian well water for 40 or more years were 3.90, 3.39, and 2.67,
respectively, ascompared with those who never used artesian well water. Multiple binary logistic regression
analyses showed that the dose-response relationships and odds ratios remained much the same while other
risk factors were further adjusted.

Blackfoot disease (BFD) is an endemic peripheral
vascular disorder confined to a limited area on the
southwest coast of Taiwan (Wu et al., 1961). The
disease whichcommonly ends with spontaneous
amputation of the affected extremities has been
related to the water derived from artesian wells in
the area (Tseng et al., 1961). Substances including
organic cholorides and ergot alkaloids have been
identified in artesian well water; however, arsenic
has been suggested as the most important determinants of BFD (WHO, 1981).
Previous studies have shown thatcrude cancer
mortality rate was higher in the BFD endemic area
than in the general population in Taiwan (Wu &
Chen, 1965). It has also been found that the
prevalence rate of skin cancer in the BFD endemic
area was as high as 1.06 per 1,000 (Tseng et al.,
1968), and a dose-response relationship was
observed between the prevalance rate of skin cancer
and the arsenic concentration of the wellwater in
villages of the endemic area (Tseng, 1977). A recent
study showed that standardized mortality ratios
(SMRs) for cancers of bladder, kidney, skin, lung,
liver and colon in both males and females were
significantly greater in BFD endemic areas that in
the general population in Taiwan (Chen et al.,
1985).
This study was carried out to explore possible
risk factors attributable tothe significantly high
mortality of cancers of bladder, lung and liver in
Correspondence: C.-J. Chen
Received 19 August 1985; and in revised form, 8
November 1985

the BFD endemic area. The specific aim was to
examine the associations between the exposure to
high-arsenic artesian well water and these cancers
while other relevant risk factors were adjusted
through multiple logisticregression analyses.

Subjects and methods
Study area and defined population
The area covered in this study was limited to the
four neighbouring BFD-endemic townships of
Peimen, Hsuechia, Putai and Iche located on the
southwest coast of Taiwan. Because the soil and the
water from shallow wells (6 to 8 meters in depth) of
this area have a high salinity, some residents have
been using water fromartesian wells (100 to 200
meters deep) since the 1920s, especially those who
lived in villages along the coast. The aresenic
content of artesian well water in the BFD endemic
area ranged from 0.35 to 1.14ppm with a median
of 0.78 ppm, while the shallow well water in the
BFD endemic area had arsenic content between
0.00 and 0.30 ppm with a median of 0.04 ppm
(Chen et al., 1962). The...