Bladder cancer mortality reduction after installation of a tap-water supply system in an arsenious-endemic area in southwestern Taiwan

Arsenic has been well documented as the major risk factor for blackfoot disease (BFD), a unique peripheral vascular disease that was endemic in the southwestern coast of Taiwan, where residents had consumed high-arsenic artesian well water for more than 50 years. Long-term arsenic exposure has also been reported to be associated with bladder cancer mortality in a dose–response relationship. A tap water supply system was implemented in the early 1960s in the BFD endemic areas. Artesian well water was no longer used for drinking and cooking after the mid-1970s. The objective of this study is to examine whether bladder cancer mortality decreased after the improvement of the drinking water supply system through elimination of arsenic exposure from artesian well water. Standardized mortality ratios (SMRs) for bladder cancer were calculated for the BFD endemic area for the years 1971–2000. The study results show that mortality from bladder cancer declined gradually after the improvement of the drinking water supply system to eliminate arsenic exposure from artesian well water. Based on the reversibility criterion, this finding strengthened the likelihood of the observed association between arsenic exposure and bladder cancer being causal.