Bladder cancer and drinking water: a population-based case-control study in Washington County, Maryland (United States)

Chlorination by-products in drinking water and risk of bladder cancer - A population-based cohort study

Chlorination by-products have been consistently associated with risk of bladder cancer in case-control studies, but confirmation from large-scale cohort studies is lacking. We assessed the association of drinking water trihalomethanes (THM), a proxy for chlorination by-products, with risk of bladder cancer in 58,672 men and women. Data came from two population-based cohorts, parts of the Swedish Infrastructure for Medical Population-Based Life-Course and Environmental Research (SIMPLER). Individual exposure to THM was assessed by combining residential information with tap water monitoring data. Participants were categorized into non-exposed, low (<15 µg/L) or high (≥15 µg/L) THM exposure. Incident cases were ascertained from 1998 through 2019 via register linkage. During 16 years of follow-up (965,590 person-years), 831 bladder cancer cases were ascertained. We observed no overall association of THM with risk of bladder cancer, hazard ratio for the highest exposed compared to the non-exposed 0.90 (95% confidence interval: 0.73 - 1.11). The null association remained after restricting the analysis to long-term residents and across strata of smoking status and cancer stage. Our results indicate that chlorination by-product exposure at THM concentrations representative of chlorinated drinking waters in most European countries, is not associated with an increased risk of bladder cancer.

Cigarette smoking and risk of bladder cancer: a dose-response meta-analysis

INTRODUCTION

The disease burden of bladder cancer is increasing worldwide; therefore, to deal with this situation, many studies on bladder cancer have been carried out extensively. Among these studies, the risk factors studies may provide a possible way to reduce the incidence of bladder cancer. Meta-analyses and original researches have confirmed that smoking is a risk factor of bladder cancer. However, the specific dose-response relationship between smoking and bladder cancer risk was still unclear. This meta-analysis addresses this research gap by summarizing the accumulated evidences, quantitatively.

METHODS

Relevant studies were obtained by searching PubMed, Embase and Web of Science database since inception until August 10, 2021, without restrictions. To obtain more comprehensive data, reference lists of identified articles were also browsed. Studies that reported risk estimates (relative risks (RR) or odds ratio (OR)) with 95% confidence intervals (CIs) focusing on the association between cigarette smoking and risk of bladder cancer were included in a dose-response meta-analysis.

RESULTS

A non-linear dose-response relationship was confirmed between cigarette smoking and risk of bladder cancer on the basis of 8 cohorts and 44 case-control studies. The summary relative risk of developing bladder cancer for 1 more cigarettes/day (7 cohorts and 24 case-control studies) was 1.039 (95% CI 1.038-1.040, I² = 0%), for 1 more pack-year (3 cohorts and 21 case-control studies) was 1.017(95% CI 1.016-1.019, I² = 0%) and for 1 more year of exposure (16 case-control studies) was 1.021 (95% CI 1.020-1.023, I² = 0%).

CONCLUSION

A positive non-linear dose-response relationship is confirmed between all smoking intensity, pack-years of smoking, smoking duration(years) and the risk of bladder cancer, but the plateau only occurred when smoking intensity reached 20 cigarettes/day. Further studies should report more detailed results, including those for subtypes of gender, age, region and be stratified by other risk factors to rule out residual confounding.

Heterogeneity in the Relationship between Disinfection By-Products in Drinking Water and Cancer: A Systematic Review

The epidemiological evidence demonstrating the effect of disinfection by-products (DBPs) from drinking water on colon and rectal cancers is well documented. However, no systematic assessment has been conducted to assess the potential effect measure modification (EMM) in the relationship between DBPs and cancer. The objective of this paper is to conduct a systematic literature review to determine the extent to which EMM has been assessed in the relationship between DBPs in drinking water in past epidemiological studies. Selected articles (n = 19) were reviewed, and effect estimates and covariates that could have been used in an EMM assessment were gathered. Approximately half of the studies assess EMM (n = 10), but the majority of studies only estimate it relative to sex subgroups (n = 6 for bladder cancer and n = 2 both for rectal and colon cancers). Although EMM is rarely assessed, several variables that could have a potential modification effect are routinely collected in these studies, such as socioeconomic status or age. The role of environmental exposures through drinking water can play an important role and contribute to cancer disparities. We encourage a systematic use of subgroup analysis to understand which populations or territories are more vulnerable to the health impacts of DBPs.

Charting Uncertainty in Science-Policy Discourses: The Construction of the Chlorinated Drinking-Water Issue and Cancer

Drinking-water guidelines remain an ongoing issue within Canada, as elsewhere. Given recent epidemiological evidence concerning chlorinated disinfection byproducts in drinking water and cancer outcomes, some branches within Health Canada have been undertaking an extensive review of the issue. This paper examines what impact contested scientific authorities, as filtered through a regulatory agency, may have on the policymaking process in the setting of Canadian drinking-water guidelines. Using an agenda-setting framework, we rely on a textual analysis of a Health Canada expert panel report and a position paper written to accompany the panel report; Canadian print media translations of scientific evidence; and in-depth interviews with scientists (from the academy, industry, and government) and other interested stakeholders [for example, chlorine and water industry, and environmental nongovernmental organizations]. Through this analysis we reconstruct a discourse which suggests government-science in policy, rather than policymakers, is primarily and presently driving the issue. The issue itself appears to remain a debate which is largely over the strength of the scientific evidence from regulatory and public-health scientists (for example, in Health Canada), and their colleague research scientists (for example, leading researchers in the field). Although we argue that it is primarily cancer that drives the science-policy agenda, with respect to chlorinated drinking water, it is possible that reproductive effects are likely to be central to the debate for controlling chlorine use in the future.

Identifying unknown by-products in drinking water using comprehensive two-dimensional gas chromatography-quadrupole mass spectrometry and in silico toxicity assessment

Improvements in extraction and detection technologies have increased our abilities to identify new disinfection by-products (DBPs) over the last 40 years. However, most previous studies combined DBP identification and measurement efforts with toxicology to address concerns on a few expected DBPs, making it difficult to better define the health risk from the individual DBPs. In this study, a nontargeted screening method involving comprehensive two-dimensional gas chromatography-quadrupole mass spectrometry (GC × GC-qMS) combined with OECD QSAR Toolbox Ver. 3.2 was developed for identifying and prioritizing of volatile and semi-volatile DBPs in drinking water. The method was successfully applied to analyze DBPs formed during chlorination, chloramination or ozonation of the raw water. Over 500 compounds were tentatively identified in each sample, showing the superior performance of this analytical technique. A total of 170 volatile and semi-volatile DBPs representing fourteen chemical classes were then identified, according to the criteria that the DBP was presented in the duplicate treated samples. The genotoxicity and carcinogenicity of the DBPs were evaluated using Toolbox, and 58 DBPs were found to be actual or potential genotoxicants. The accuracy of the compound identification was determined by comparing 47 identified compounds with commercially available standards. About 90% (41 of the 47) of the compounds that were automatically identified using the library were correct. The results show that GC×GC-qMS coupled with a quantitative structure-activity relationship model is a powerful and fast nontargeted screening technique for compounds. The method and results provide us a new idea for identification and prioritization of DBPs.

Estimating Potential Increased Bladder Cancer Risk Due to Increased Bromide Concentrations in Sources of Disinfected Drinking Waters

Public water systems are increasingly facing higher bromide levels in their source waters from anthropogenic contamination through coal-fired power plants, conventional oil and gas extraction, textile mills, and hydraulic fracturing. Climate change is likely to exacerbate this in coming years. We estimate bladder cancer risk from potential increased bromide levels in source waters of disinfecting public drinking water systems in the United States. Bladder cancer is the health end point used by the United States Environmental Protection Agency (EPA) in its benefits analysis for regulating disinfection byproducts in drinking water. We use estimated increases in the mass of the four regulated trihalomethanes (THM4) concentrations (due to increased bromide incorporation) as the surrogate disinfection byproduct (DBP) occurrence metric for informing potential bladder cancer risk. We estimate potential increased excess lifetime bladder cancer risk as a function of increased source water bromide levels. Results based on data from 201 drinking water treatment plants indicate that a bromide increase of 50 μg/L could result in a potential increase of between 10(-3) and 10(-4) excess lifetime bladder cancer risk in populations served by roughly 90% of these plants.

Impact of groundwater surface storage on chlorination and disinfection by-product formation

The change in water quality arising from the open storage of groundwater (GW) and its impact on chlorination and chlorination by-product formation were investigated. Water quality descriptors, such as temperature, pH, chlorophyll, and dissolved oxygen contents of GW undergo substantial alteration when stored in a reservoir. Dissolved organic content (DOC) measured in the two water sources studied, i.e., GW and open reservoir water (RW), varied from 0.41 mg/L to 0.95 mg/L and 0.93 mg/L to 2.53 mg/L, respectively. Although DOC demonstrated wide variation, UV absorbance at 254 nm (UVA254) values for GW (0.022-0.067) and RW (0.037-0.077) did not display reciprocal variations. The chlorine demand (CD) of RW was always higher than that of GW for the corresponding sampling period. Average trihalomethane (THM) formation for RW was 50-80% higher compared to GW and thus poses an enhanced health risk. Appreciable amounts of bromide present in these water sources (0.15-0.26 mg/L in GW and 0.17-0.65 mg/L in RW) have resulted in the non-selective distribution of the four THM species. The formation of more toxic brominated THM due to chlorination of these near-coast drinking water sources must be regarded as a decisive factor for the choice of water disinfection regime.

Evaluating Evidence for Association of Human Bladder Cancer with Drinking-Water Chlorination Disinfection By-Products

Exposure to chlorination disinfection by-products (CxDBPs) is prevalent in populations using chlorination-based methods to disinfect public water supplies. Multifaceted research has been directed for decades to identify, characterize, and understand the toxicology of these compounds, control and minimize their formation, and conduct epidemiologic studies related to exposure. Urinary bladder cancer has been the health risk most consistently associated with CxDBPs in epidemiologic studies. An international workshop was held to (1) discuss the qualitative strengths and limitations that inform the association between bladder cancer and CxDBPs in the context of possible causation, (2) identify knowledge gaps for this topic in relation to chlorine/chloramine-based disinfection practice(s) in the United States, and (3) assess the evidence for informing risk management. Epidemiological evidence linking exposures to CxDBPs in drinking water to human bladder cancer risk provides insight into causality. However, because of imprecise, inaccurate, or incomplete estimation of CxDBPs levels in epidemiologic studies, translation from hazard identification directly to risk management and regulatory policy for CxDBPs can be challenging. Quantitative risk estimates derived from toxicological risk assessment for CxDBPs currently cannot be reconciled with those from epidemiologic studies, notwithstanding the complexities involved, making regulatory interpretation difficult. Evidence presented here has both strengths and limitations that require additional studies to resolve and improve the understanding of exposure response relationships. Replication of epidemiologic findings in independent populations with further elaboration of exposure assessment is needed to strengthen the knowledge base needed to better inform effective regulatory approaches.

Human health risk analysis from disinfection by-products (DBPs) in drinking and bathing water of some Indian cities

BACKGROUND

Human health risk assessment from exposure to disinfection by-products (DBPs) during drinking and bathing water vary from country to country as per life expectancy, body mass index, water consumption pattern and individual concentration of DBPs component, etc.

METHODS

Present study considered average direct water intake per person for adult males and females as 4 & 3 L/day, respectively as per Indian literature for risk evaluation from another component of pollutant. While other important factor like average life expectancy, body weight & body surface area for male and female were considered 64 & 67 years, 51.9 & 45.4 Kg and 1.54 & 1.38 m(2) respectively as per Indian Council of Medical Research and WHO report. The corresponding lifetime cancer risk of the formed THMs to human beings was estimated by the USEPA and IRIS method as per Indian population.

RESULTS

The total cancer risk reached 8.99 E-04 and 8.92 E-04 for males and females, respectively, the highest risk from THMs seems to be from the inhalation route followed by ingestion and dermal contacts.

CONCLUSIONS

The multipath way evaluations of lifetime cancer risks for THMs exposure through ingestion, dermal absorption, and inhalation exposure were examined at the highest degree of danger. Results reveals that water containing THMs of the selected water treatment plant of the eastern part of India was unsafe in terms of risk evaluation through inhalation and ingestion, while dermal route of risk was found very close to permissible limit of USEPA. Sensitivity analysis shows that every input parameter is sole responsible for total risk potential, whereas exposure duration playing important role for estimation of total risk.

EPA's Stage 2 Disinfection Byproducts Rules (DBPR) and Northern Kentucky Water: An Economic and Scientific Review

Implementation of EPA's Stage 2 Disinfection Byproducts Rules (DBPR) in Northern Kentucky will cause a water rate increase of over 25%. Hence a review was undertaken, considering both economics and science in the context of President Obama's 2009 scientific integrity directive. The rules purport to avoid up to 0.49% of new bladder cancers by reducing the levels of DBPs in drinking water - a benefit so small that failure to implement will not cause unreasonable risk to health (URTH). It suggests at most one Northern Kentucky death avoided over 17 years for a cost of $136,000,000 ($1700 per household). Even this small benefit is probably overstated. EPA finds no "causal link" between DBPs and bladder cancer, and EPA acknowledges problems with the epidemiological data used in their calculation: the data appear contradictory and inconsistent, may be skewed toward "positive" results, and suggest different cancer sites than animal studies. Two similar international agencies disagree with EPA's conclusions. The science is based on the Linear No Threshold (LNT) dose response model for DBPs, but this may not be the correct model. 83% of EPA's epidemiological data show a statistical possibility that low levels of DBPs might be beneficial or have no effect.

Chlorination disinfection by-products, public health risk tradeoffs and me

Since 1974 when trihalomethanes (THMs) were first reported as disinfection by-products (DBPs) in drinking water, there has been an enormous research effort directed at understanding how DBPs are formed in the chlorination or chloramination of drinking water, how these chlorination DBPs can be minimized and whether they pose a public health risk, mainly in the form of cancer or adverse reproductive outcomes. Driven by continuing analytical advances, the original DBPs, the THMs, have been expanded to include over 600 DBPs that have now been reported in drinking water. The historical risk assessment context which presumed cancer could be mainly attributed to exposure to environmental carcinogens played a major role in defining regulatory responses to chlorination DBPs which, in turn, strongly influenced the DBP research agenda. There are now more than 30 years of drinking water quality, treatment and health effects research, including more than 60 epidemiology studies on human populations, directed at the chlorination DBP issue. These provide considerable scope to reflect on what we know now, how our understanding has changed, what those changes mean for public health risk management overall and where we should look to better understand and manage this issue in the future.

The effect of smoking on the male excess of bladder cancer: a meta-analysis and geographical analyses

Smoking is considered the primary risk factor for bladder cancer. Although smoking prevalence and bladder cancer incidence vary around the world, bladder cancer is on average 4 times more common in males than in females. This article describes the observed male-female incidence ratio of bladder cancer for 21 world regions in 2002 and 11 geographical areas during the time period 1970-1997. A meta-analysis, including 34 studies, was performed to ascertain the increased risk for bladder cancer in males and females when smoking. The summary odds ratios (SORs) calculated in the meta-analysis were used to estimate the male-female incidence ratio of bladder cancer that would be expected for hypothetical smoking prevalence scenarios. These expected male-female incidence ratios were compared with the observed ratios to evaluate the role of smoking on the male excess of bladder cancer. The male-female incidence ratio of bladder cancer was higher than expected worldwide and over time, based on a smoking prevalence of 75% in males, 10% in females and an increased risk (SOR) of bladder cancer associated with smoking of 4.23 for males and 1.35 for females, respectively. This implied that, at least in the Western world, smoking can only partially explain the difference in bladder cancer incidence. Consequently, other factors are responsible for the difference in bladder cancer incidence.

Evaluation of the estrogenic potential of river and treated waters in the Paris area (France) using in vivo and in vitro assays

For many years, surface waters have been shown to be contaminated by endocrine-disrupting compounds (EDCs), which can cause adverse effects on human and wildlife growth, development, and reproduction. It is therefore of primary importance to determine if drinking water could be contaminated by EDCs when produced from polluted surface waters. It is also essential to determine if disinfection by-products can account for estrogenic activity in treated waters. The estrogenic potential of river and treated waters was investigated using an in vivo assay. Adult male zebrafish were placed in three drinking water treatment plants (DWTPs) in the Paris area and exposed for 1 month to the two types of waters. After exposure, vitellogenin (VTG) was measured in the plasma of fish using a competitive ELISA. In addition, an in vitro assay (MELN cells) was used to assess the estrogenic potential of 10 major chlorination by-products. No significant induction of VTG was observed in fish exposed to river or treated waters. Among the 10 chlorination by-products tested, only 2-chlorophenol was found to be weakly estrogenic at concentrations up to 1mg/L. Therefore, the risk for the three DWTPs studied to produce drinking water with significant level of estrogenic substances appears to be low.

Enhancement of renal carcinogenicity by combined inhalation and oral exposures to chloroform in male rats

Chloroform, ubiquitously present in indoor and outdoor air, drinking water, and some foodstuffs, enters the human body by inhalation, oral and dermal routes of exposure. In order to provide bioassay data for risk assessment of humans exposed to chloroform by multiple routes, effects of combined inhalation and oral exposures to chloroform on carcinogenicity and chronic toxicity in male F344 rats were examined. A group of 50 male rats was exposed by inhalation to 0 (clean air), 25, 50, or 100 ppm (v/v) of chloroform vapor-containing air for 6 h/d and 5 d/wk during a 104 w period, and each inhalation group was given chloroform-formulated drinking water (1000 ppm w/w) or vehicle water for 104 wk, ad libitum. Renal-cell adenomas and carcinomas and atypical renal-tubule hyperplasias were increased in the combined inhalation and oral exposure groups, but not in the oral- or inhalation-alone groups. Incidences of cytoplasmic basophilia and dilated tubular lumens in the kidney, as well as incidence of positive urinary glucose, were markedly increased by the combined exposures, compared with those after single-route exposures. It was concluded that combined inhalation and oral exposures markedly enhanced carcinogenicity and chronic toxicity in the proximal tubule of male rat kidneys, suggesting that carcinogenic and toxic effects of the combined exposures on the kidneys were greater than the ones that would be expected under an assumption that the two effects of single route exposures through inhalation and drinking were additive.

Preliminary Report of a Multicentric Study on Environmental Risk Factors in Ta-T1 Transitional Cell Carcinoma of the Bladder

OBJECTIVE

The distribution of potential environmental risk factors among patients affected by superficial transitional cell carcinoma of the bladder (TCCB) has been analyzed.

METHODS

Patients affected by superficial TCCB underwent TUR and early intravesical chemotherapy. Detailed data about age, sex, residence, employment, active and passive cigarette smoking, water resource and hair dye use were centralized. Analysis has been conducted on 474 patients affected by Ta-T1 G1-2 TCCB at medium risk for recurrence. Patients with primary single Ta G1-2, Tis or T1G3 tumors were excluded from the present analysis.

RESULTS

Over 80% of the patients lived in urban areas, 22% were employed in industries presumed at risk for bladder cancer, 8% used hair dye and 75% were smokers. Bottled water was the only water resource in 42% of the patients. Employment in industry at risk (p = 0.01) and cigarette smoking (p = 0.04) resulted in being statistically related to tumor multiplicity. Moreover, the period of cigarette smoking was significantly longer in patients with recurrent tumors (p = 0.026). The municipal water supply represented the main water source in never-smokers (p = 0.01) rather than in smokers and in patients harboring T1 rather than Ta tumors (p = 0.03).

CONCLUSIONS

Employment in industry at risk and cigarette smoking resulted in being related to tumor multiplicity. The length of exposure to cigarette smoking was related to the natural history of the tumor. A drinkable water source emerged as a risk factor in absence of cigarette smoking.

Disinfection byproducts and bladder cancer: a pooled analysis

BACKGROUND

Exposure to disinfection byproducts in drinking water has been associated with an increased risk of bladder cancer. We pooled the primary data from 6 case-control studies of bladder cancer that used trihalomethanes as a marker of disinfection byproducts.

METHODS

Two studies were included from the United States and one each from Canada, France, Italy, and Finland. Inclusion criteria were availability of detailed data on trihalomethane exposure and individual water consumption. The analysis included 2806 cases and 5254 controls, all of whom had measures of known exposure for at least 70% of the exposure window of 40 years before the interview. Cumulative exposure to trihalomethanes was estimated by combining individual year-by-year average trihalomethane level and daily tap water consumption.

RESULTS

There was an adjusted odds ratio (OR) of 1.24 in men exposed to an average of more than 1 microg/L (ppb) trihalomethanes compared with those who had lower or no exposure (95% confidence interval [CI] = 1.09-1.41). Estimated relative risks increased with increasing exposure, with an OR of 1.44 (1.20-1.73) for exposure higher than 50 microg/L (ppb). Similar results were found with other indices of trihalomethane exposure. Among women, trihalomethane exposure was not associated with bladder cancer risk (0.95; 0.76-1.20).

CONCLUSIONS

These findings strengthen the hypothesis that the risk of bladder cancer is increased with long-term exposure to disinfection byproducts at levels currently observed in many industrialized countries.

Transformation of effluent organic matter during subsurface wetland treatment in the Sonoran Desert

The fate of dissolved organic matter (DOM) during subsurface wetland treatment of wastewater effluent in a hot, semi-arid environment was examined. The study objectives were to (1) discern changes in the character of dissolved organics as consequence of wetland treatment (2) establish the nature of wetland-derived organic matter, and (3) investigate the impact of wetland treatment on the formation potential of trihalomethanes (THMs). Subsurface wetland treatment produced little change in DOM polarity (hydrophobic-hydrophilic) distribution. Biodegradation of labile effluent organic matter (EfOM) and internal loading of wetland-derived natural organic matter (NOM) together produced only minor changes in the distribution of carbon moieties in hydrophobic acid (HPO-A) and transphilic acid (TPI-A) isolates of wetland effluent. Aliphatic carbon decreased as a percentage of total carbon during wetland treatment. The ratio of atomic C:N in wetland-derived NOM suggests that its character is determined by microbial activity. Formation of THMs upon chlorination of HPO-A and TPI-A isolates increased as a consequence of wetland treatment. Wetland-derived NOM was more reactive in forming THMs and less biodegradable than EfOM. For both HPO-A and TPI-A fractions, relationships between biodegradability and THM formation potential were similar among EfOM and NOM isolates; the less biodegradable isolates exhibited greater THM formation potential.

Fluid intake and risk of bladder and other cancers

There are appreciable differences in total fluid intake at the individual and population level, and substantial difficulties in obtaining valid measures of fluid intake. Epidemiological studies have examined the association between fluid intake and different types of cancer. For bladder cancer, fluid consumption has been associated with a moderate increase of risk in some studies, including a multicentric case-control study from the United States, based on about 3000 cases, with a decrease in others, including the Health Professional Follow-up study, or with no material association. The evidence, therefore, is far from consistent. Sources and components of fluids were also different across different types studies. From a biological point of view, a decreased fluid intake could result in a greater concentration of carcinogens in the urine or in a prolonged time of contact with the bladder mucosa because of less frequent micturition. Carcinogenic or anticarcinogenic components of various beverages excreted in the urine may also play a role in the process. It has been suggested that fluid consumption has a favorable effect on colorectal cancer risk. Fluid intake may reduce colon cancer risk by decreasing bowel transit time and reducing mucosal contact with carcinogens. Low fluid intake may also compromise cellular concentration, affect enzyme activity in metabolic regulation, and inhibit carcinogen removal. However, epidemiological data are inadequate for evaluation. Data are sparse and inconsistent for other neoplasms, including breast cancer. The fluid constituent of foods, confounding, interactions and possible influences of specific types of beverages should be investigated further. In conclusion therefore the association between total fluid intake and cancer risk remains still open to debate.

Chlorinated drinking water and micronuclei in urinary bladder epithelial cells

BACKGROUND

Evidence for a causal relationship between disinfection byproducts in chlorinated water and cancer is not conclusive. This study investigates the association between disinfection byproducts in chlorinated water, as measured by trihalomethane concentration, and the frequency of micronuclei in urinary bladder epithelial cells, thereby assessing the carcinogenic potential of disinfection byproducts.

METHODS

A cohort study was undertaken in 1997 in 3 Australian communities with varying levels of disinfection byproducts in the water supply. Exposure was assessed using both available dose (total trihalomethane concentration in the water supply) and intake dose (calculated by adjusting for individual variations in ingestion, inhalation, and dermal absorption). Micronuclei in urinary bladder epithelial cells were used as a preclinical biomarker of genotoxicity.

RESULTS

Cells were scored for micronuclei for 228 participants, of whom 63% were exposed to disinfection by products and 37% were unexposed. Available dose of total trihalomethane for the exposed group ranged from 38 to 157 micro ;g/L, whereas intake dose ranged from 3 to 469 micro g/kg per day. Relative risk for DNA damage to bladder cells, per 10 micro g/L of available dose total trihalomethane, was 1.01 (95% confidence interval [CI] = 0.97-1.06) for smokers and 0.996 (CI = 0.961-1.032) for nonsmokers. Relative risk, per 10 micro g/kg per day of intake dose of total trihalomethane, was 0.99 (CI = 0.96-1.03) for smokers and 1.003 (CI = 0.984-1.023) for nonsmokers.

CONCLUSION

This study provides no evidence that trihalomethane concentrations, at the levels we investigated, are associated with DNA damage to bladder cells.

Bladder cancer prevention. Part I: what do I tell my patients about lifestyle changes and dietary supplements?

PURPOSE OF REVIEW

Comprehensive reviews of lifestyle changes and dietary supplements that may prevent bladder cancer are needed in order to facilitate discussions between clinicians and patients.

RECENT FINDINGS

Novel data exist that numerous lifestyle/diet and dietary supplements may lower the risk of this disease. For example, reducing arsenic exposure, incorporating dietary changes, and vitamin E supplements continue to accumulate research that supports their use with some patients at a higher risk for this disease. Regardless, smoking cessation seems to have the largest impact on reducing risk and incorporating these other changes after smoking cessation may reduce an individual's risk to an even greater extent.

SUMMARY

However, a large percentage of cases of individuals diagnosed with this cancer apparently have no known etiology. Diets lower in calories or possibly specific sub-types of fat, and higher in fruits and especially vegetables, seem to provide some protection. Other dietary/supplement options may affect risk, but these benefits could be seriously attenuated by smoking. Dietary selenium, but currently not selenium supplements, may also affect risk, especially in non-smokers. Dietary vitamin E, and vitamin E supplements, may provide some protection. Non-selective (e.g. non-steroidal anti-inflammatory drugs) and selective cyclooxygenase-2 inhibitors are generating interest because bladder tumors seem to contain higher concentrations of this enzyme. Drinking-water quality, especially arsenic concentrations, may seriously affect risk. Providing recommendations for patients with regard to some of these lifestyle modifications is currently recommended because the majority of these alterations are also recommended currently for cardiovascular or general oncology disease reduction.

Meta-analysis of studies on individual consumption of chlorinated drinking water and bladder cancer

STUDY OBJECTIVE

To evaluate whether consumption of chlorinated drinking water is associated with bladder cancer.

DESIGN

A bibliographic search was conducted and the authors selected studies evaluating individual consumption of chlorinated drinking water and bladder cancer. The authors extracted from each study risk estimates for intermediate and long term (>40 years) consumption of chlorinated water, stratified by sex when possible, and performed meta-analysis for the two exposure levels. A meta-analysis was also performed of the dose-response regression slopes.

SETTING

Populations in Europe and North America.

PARTICIPANTS

Those included in six case-control studies (6084 incident bladder cancer cases, 10,816 controls) and two cohort studies (124 incident bladder cancer cases) fulfilling the inclusion criteria.

MAIN RESULTS

Ever consumption of chlorinated drinking water was associated with an increased risk of bladder cancer in men (combined OR=1.4, 95%CI 1.1 to 1.9) and women (combined OR=1.2, 95%CI 0.7 to 1.8). The combined OR for mid-term exposure in both genders was 1.1 (95% CI 1.0 to 1.2) and for long term exposure was 1.4 (95%CI 1.2 to 1.7). The combined estimate of the slope for a linear increase in risk was 1.13 (95% CI 1.08 to 1.20) for 20 years and 1.27 (95% CI 1.15 to 1.43) for 40 years of exposure in both sexes.

CONCLUSIONS

This meta-analysis of the best available epidemiological evidence indicates that long term consumption of chlorinated drinking water is associated with bladder cancer, particularly in men. The observed relative risk is only moderately high, but the population attributable risk could be important as the vast majority of the population of industrialised countries is potentially exposed to chlorination byproducts for long time periods.

Potential lifestyle and dietary supplement options for the prevention and postdiagnosis of bladder cancer

Apart from smoking, certain occupational exposures, and schistosomiasis, little is known about other potential lifestyle risk factors for bladder cancer. Other investigations thus far have also been important because of the large number of individuals who are diagnosed with this cancer that apparently have no known risk factors. Preventing the recurrence of bladder cancer has generated some interest because several preliminary trials have found that a combination dietary supplement of vitamins and minerals or a probiotic agent (Lactobacillus casei) may impact this outcome favorably. Advising patients on some of these lifestyle modifications is currently recommended because the majority of them are also currently recommended for cardiovascular disease reduction.

A multiple-purpose design approach to the evaluation of risks from mixtures of disinfection by-products

Drinking water disinfection has effectively eliminated much of the morbidity and mortality associated with waterborne infectious diseases in the United States. Various disinfection processes, however, produce certain types and amounts of disinfection by-products (DBPs), including trihalomethanes (THM), haloacetic acids, haloacetonitriles, and bromate, among others. Human health risks from the ubiquitous exposure to complex mixtures of DBPs are of concern because existing epidemiologic and toxicologic studies suggest the existence of systemic or carcinogenic effects. Researchers from several organizations have developed a multiple-purpose design approach to this problem that combines efficient laboratory experimental designs with statistical models to provide data on critical research issues (e.g., estimation of human health risk from low-level DBP exposures, evaluation of additivity assumptions as useful for risk characterization, estimation of health risks from different drinking water treatment options). A series of THM experiments have been designed to study embryonic development, mortality and cancer in Japanese medaka (Oryzias latipes) and liver and kidney endpoints in female CD-1 mice. The studies are to provide dose-response data for specific mixtures of the 4 THMs, for the single chemicals, and for binary combinations. The dose-levels and mixing ratios for these experiments were selected to be useful for development and refinement of three different statistical methods: testing for departures from dose-additivity; development of an interactions-based hazard index; and use of proportional-response addition as a risk characterization method. Preliminary results suggest that dose-additivity is a reasonable risk assessment assumption for DBPs. The future of mixtures research will depend on such collaborative efforts that maximize the use of resources and focus on issues of high relevance to the risk assessment of human health.

[Bladder cancer in Asturias, Spain: incidence and trends (1982-1993)]

OBJECTIVES

To assess epidemiological aspects of bladder cancer in Asturias, as a preliminary step before undertaking epidemiological and genetic research of the etiology and survival of bladder neoplasm.

METHODS

cases from the Asturias Regional Cancer Registry, Spain were used to calculated annual incidence rates between 1982 and 1993 for Asturias and all its health areas. It has been Standardized incidence ratios with the indirect method for the Asturian areas and other Spanish regions were obtained our results are also compared with other european countries.

RESULTS

The trend in bladder cancer in Asturias has been increasing significantly in the last twelve years (11.03 to 15.10 age standardized rate per 100,000). For the different health areas no differences have been identified, while there were not significant differences between our region and other Spanish regions. Standardized rates for Asturian men are in the highest group among European countries, while women rates are at an intermediate level.

CONCLUSIONS

Between 1982 and 1993, bladder cancer incidence has been increasing in Asturias. The different behaviour of incidence ratios between men and women and the similar epidemiological factors between Asturias and other parts of Spain point at the need for further epidemiological research to look at the different occupational factors existing in an industrial area like Asturias.

Fluid intake and the risk of bladder cancer in men

BACKGROUND

Studies in animals have shown that the frequency of urination is inversely associated with the level of potential carcinogens in the urothelium. In humans, an increase in total fluid intake may reduce contact time between carcinogens and urothelium by diluting urinary metabolites and increasing the frequency of voiding. The data on fluid intake in relation to the risk of bladder cancer are inconclusive.

METHODS

We examined the relation between total fluid intake and the risk of bladder cancer over a period of 10 years among 47,909 participants in the prospective Health Professionals Follow-up Study. There were 252 newly diagnosed cases of bladder cancer during the follow-up period. Information on total fluid intake was derived from the reported frequency of consumption of the 22 types of beverages on the food-frequency questionnaire, which was completed by each of the 47,909 participants who were free of cancer in 1986. Logistic-regression analyses were performed to adjust for known and suspected risk factors for bladder cancer.

RESULTS

Total daily fluid intake was inversely associated with the risk of bladder cancer; the multivariate relative risk was 0.51 (95 percent confidence interval, 0.32 to 0.80) for the highest quintile of total daily fluid intake (>2531 ml per day) as compared with the lowest quintile (<1290 ml per day). The consumption of water contributed to a lower risk (relative risk, 0.49 [95 percent confidence interval, 0.28 to 0.86] for > or =1440 ml [6 cups] per day vs. <240 ml [1 cup] per day), as did the consumption of other fluids (relative risk, 0.63 [95 percent confidence interval, 0.39 to 0.99] for >1831 ml per day vs. <735 ml per day).

CONCLUSIONS

A high fluid intake is associated with a decreased risk of bladder cancer in men.