Health Stream Literature Summary - Issue 55 - September 2009

Cigarette smoking and drinking water source: Correlation with clinical features and pathology of superficial bladder carcinoma.
Serretta, V., Altieri, V., Morgia, G., Allegro, R., Ruggirello, A., Di Lallo, A., Carrieri, G. and Melloni, D. (2009) Urologia Internationalis, 82(3); 318-323.

Transitional cell carcinoma of the bladder (TCCB) arises from cells in the bladder lining (urothelium), and is usually the most common form of bladder cancer. Cigarette smoking is a known cause of bladder cancer and the risk of TCCB increases with the number of cigarettes and the duration of smoking. A number of water contaminants including disinfection byproducts have also been suspected to play a role in TCCB but none have been proven as yet. This study investigated cigarette smoking and drinking water supply, comparing bottled mineral water to chlorinated water in the same geographic region and the correlation with clinical features and pathology of superficial bladder carcinoma.

This study was undertaken between May 2002 and August 2003 in southern Italy with 577 patients from forty urological units. Patients were undergoing transurethral resection (TUR) for Ta-Tl stage tumours grades G1-G3 and TCCB. Detailed information was collected about age, sex, active and passive cigarette smoking and water source via a structured questionnaire. Patients were excluded if they were unable to specify their smoking habits, the water source and length of consumption, or if they had not been living in southern Italy all their life. Data was also collected on residency, employment and hair dye use. The duration of smoking, the number of cigarettes per day and their type (with or without filter) were recorded. Information collected on water supply included the source of water, unique or mixed to other sources and the length of consumption from each source.

Of the 80 women in the study 33 (41.3%) were classified as current or former smokers and 396 (79.7%) of the 497 men were classed as current or former smokers. There were 88 (25.1%) patients who were exposed to passive smoke and 15 (17%) that had never smoked. Statistical analysis found that the percentage of patients with recurrent tumours increased from 24 (20.2%) to 44 (41.9%) (p less than 0.0001) among smokers for less or more than 30 years, respectively. There was no difference found between current and former smokers and no specific correlation with the number of cigarettes per day.

There were 249 (45%) patients who only drank bottled water, 177 (32%) who drank municipal water, 38 (7%) who drank artesian well water, 7 (1%) who drank spring water and 89 (16%) with a mixed water source. A chlorinated water supply was more frequent in never smokers than in smokers (p=0.015). T1 tumours (cancer that has begin to grow into the connective tissue beneath the bladder lining) occurred statistically more frequently (p=0.02) in patients drinking chlorinated municipal water than Ta tumours (cancer just in the innermost layer of the bladder lining), suggesting a possible role of disinfection by-products in promoting bladder cancer aggressiveness. Therefore patients drinking chlorinated water for a long period should also be considered at higher risk. The activity/effect of water pollution is possibly weaker than that of cigarette smoking and not easily detected in smokers due to a masking effect caused by the stronger factor.

The results of this study need to be confirmed by larger trials investigating bladder cancer outcome in relation to tumour risk factors as well as to several lifestyle factors. If the observations found in this study are confirmed then long-term smokers and patients drinking chlorinated water may be candidates for adjuvant therapy and a closer follow-up schedule due to the risk of cancer recurrence.

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