Multiple risk factors associated with arsenic-induced skin cancer: effects of chronic liver disease and malnutritional status

Abstract

Organization, 1980; IARC, 1987). Exposures to inorganic arsenic from medicinal (Sommers and McManus, 1953;Frost, 1967), environmental (Neubauor, 1947;Tseng et al.. 1968;Yeh et al., 1968;Yeh, 1973; Cebnran et al., 1983) and occupational (Roth, 1957;Nelson et al., 1973;Brown and Rabinowitz, 1979) sources have been found to be associated with the development of skin cancer. Blackfoot disease (BFD) is a unique peripheral vascular disorder confined to an area on the south-west coast of Taiwan (Wu et al., 1961). The prevalence of BFD has been found to increase with the arsenic content of drinking water in a dose-response relation (Chen and Wu, 1962). The prevalence of skin cancer, hyperkeratosis and hyperpigmentation in the BFD endemic area was as high as 10.6, 71.0 and 183.5 per 1000 respectively (Tseng et al., 1968). A dose-response relation was also observed between the occurrence of skin cancer and the arsenic concentration in drinking water (Tseng et al., 1968;Tseng, 1977;Chen et al., 1985 Chen et al., , 1988Wu et al., 1989;Chen et al., 1992). Furthermore, a significant ecological correlation beween the arsenic level in well water and ageadjusted mortality from skin cancer in 314 townships all over Taiwan island was reported in a recent study (Chen and Wang, 1990). All these findings were obtained in ecological correlation studies on the association between arsenic exposure and skin cancer prevalence studies at the village level. They might be subject to the bias of ecological fallacy, i.e. the association observed at the village level may not hold at the individual level.Artesian wells have been used in the BFD endemic area since the decade 1900-10. In the 1960s a tap water supply Correspondence: C-J Chen Received 31 January 1994; revised 26 July 1994: accepted 16 August 1994 system was implemented in the endemic area, but the coverage was not high until the 1970s. This study was camred out at the individual level to assess the prevalence of skin cancer among residents in the BFD-endemic area who had not drunk high-arsenic artesian well water for more than 15 years.Despite a large number of residents having consumed higharsenic artesian well water, only a small fraction were affected with skin cancer (Tseng et al., 1968). Furthermore, residents with the same exposure to high-arsenic artesian well water were of different ages at the onset of skin cancer. Such discrepancies in individual susceptibility suggest the existence of some other co-factors in the induction of arsenic-related skin cancer. Multiple risk factors other than chronic arsenic exposure were also explored in this study. Material and methodsStud} area Three villages, Homei, Fuhsin and Hsinming of Putai Township on the south-western coast of Taiwan island, were selected as the study area. These three villages include approximately 5% of the total population of the BFD endemic area. BFD was hyperendemic in this area with a prevalence as high as 13.6% in Homei, 9.6% in Fuhsin and 10.3% in Hsinming (Wu et al., 1961). Residents in the area ha...

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