Using data on 1,860 bladder cancer cases and 3,934 population-based controls from the National Bladder Cancer Study, we examined associations between suspected bladder cancer risk factors and tumor stage and grade. Employment in a high-risk occupation was associated with the entire clinical spectrum of bladder cancer rather than a particular tumor stage or grade. For example, relative risks (RR) were similar for noninvasive and invasive disease (1.5 and 1.6, respectively). Cigarette smoking also increased risk of the entire clinical spectrum of bladder cancer, but the more advanced the stage, the stronger the effect. For example, relative risks of noninvasive and invasive bladder cancer for current heavy smokers were 3.0 and 5.2, respectively. Cigarette smoking was associated with higher risk of low-grade than high-grade tumors, once stage of disease was taken into account. Compared with whites, nonwhites were at a lower risk of noninvasive bladder cancer (RR = 0.4) but at similar risk of invasive bladder cancer (RR = 1.1), a pattern indicating racial differences in health practices related to bladder cancer detection. History of urinary tract infections and bladder stones was associated with increasing relative risks for advanced tumor stage. Heavy artificial sweetener use was associated with higher-grade, poorly differentiated tumors. Coffee consumption and family history of bladder cancer were not consistently associated with tumor stage or grade. Overall, different clinical presentations of bladder cancer share most suspected bladder cancer risk factors, including employment in a high-risk occupation and cigarette smoking.

The frequency with which diabetes mellitus was mentioned on the death certificates of 18,733 patients dying from bladder cancer has been compared with that of 19,709 patients dying from other cancers (excluding cancer of the lung and pancreas). The estimated relative risk of bladder cancer in diabetics was 0-98 with 95% confidence limits 0-70-1-38. There was no increase in risk of bladder cancer in patients with diabetes of long duration. Diabetics were shown by questionnaire to consume substantially more saccharin than non-diabetics, and the duration of regular saccharin use by diabetics was highly correlated with the duration of diabetes. There was therefore no evidence from this study that consumption of above average amounts of saccharin had led to bladder cancer in diabetics. The proporation of current smokers among diabetics was significantly less than among non-diabetics, and this may account for a low relative risk of lung cancer in the former (0-72).

The effects of sodium saccharin and caffeine on urinary bladder carcinogenesis in Wistar strain rats treated with N-butyl-N-(4-hydroxybutyl)nitrosamine (BBN) were studied. Animals were given 0.01% BBN as an initiator for 4 weeks and then sodium saccharin and/or caffeine as promoters for 32 weeks (Experiment I), or were treated simultaneously with 0.001% BBN, sodium saccharin and/or caffeine for 40 weeks (Experiment II). The urinary bladders were then removed and examined by light and electron microscopy. Sequential administration of sodium saccharin after BBN significantly enhanced the induction of hyperplasias compared with administration of BBN alone (Experiment I), and simultaneous administration of sodium saccharin with BBN significantly enhanced the induction of hyperplasia and papillomas compared with BBN alone (Experiment II). Two types of hyperplasias developed in the urinary bladder of rats treated with sodium saccharin alone in both experiments. Caffeine alone had no effect on the rat urinary bladder epithelium, and either sequential or simultaneous administration of caffeine with BBN caused no marked enhancement of carcinogenesis in these experiments.

Artificial sweeteners are added to a wide variety of food, drinks, drugs and hygiene products. Since their introduction, the mass media have reported about potential cancer risks, which has contributed to undermine the public's sense of security. It can be assumed that every citizen of Western countries uses artificial sweeteners, knowingly or not. A cancer-inducing activity of one of these substances would mean a health risk to an entire population. We performed several PubMed searches of the National Library of Medicine for articles in English about artificial sweeteners. These articles included 'first generation' sweeteners such as saccharin, cyclamate and aspartame, as well as 'new generation' sweeteners such as acesulfame-K, sucralose, alitame and neotame. Epidemiological studies in humans did not find the bladder cancer-inducing effects of saccharin and cyclamate that had been reported from animal studies in rats. Despite some rather unscientific assumptions, there is no evidence that aspartame is carcinogenic. Case-control studies showed an elevated relative risk of 1.3 for heavy artificial sweetener use (no specific substances specified) of >1.7 g/day. For new generation sweeteners, it is too early to establish any epidemiological evidence about possible carcinogenic risks. As many artificial sweeteners are combined in today's products, the carcinogenic risk of a single substance is difficult to assess. However, according to the current literature, the possible risk of artificial sweeteners to induce cancer seems to be negligible.

Saccharin, first synthesized in 1879, eventually became popular as an inexpensive substitute for sugar, particularly as a non-caloric sweetner. The dispute concerning the safety of saccharin for human consumption is almost as old as saccharin itself. In this article, the history concerning the uses of saccharin and the accompanying controversy are reviewed. In addition, the spectrum of toxicological and epidemiological studies to which saccharin has been subjected are also examined. While the toxicological data indicate that saccharin is probably the agent solely responsible for the bladder tumors observed in second generation male rats, the epidemiological studies provide, at best, an equivocal relationship between the consumption of saccharin and bladder cancer. A benefit-risk evaluation for saccharin showed few, if any documentable benefits from the use of saccharin and much genuine uncertainty concerning the potential risks for ingestion by man. This element of genuine uncertainty as to the extent of human risk posed to man is the crux of saccharin's past and its foreseeable future.

The mortality experience of 5971 members of the British Diabetic Association (BDA) was followed-up for between five and eight years to mid-1973. Overall, 1207 deaths occurred compared with 778 expected from the mortality of the population of England and Wales in 1972. This excess of deaths was due almost entirely to diabetes mellitus and ischaemic heart disease. Deaths from cancer (128) were significantly fewer than expected (168), mainly because of a deficit in the number of deaths from cancers related to smoking (cancers of the buccal cavity and pharynx, oesophagus, respiratory system, and bladder). There was also a lower than expected mortality from chronic bronchitis and emphysema. Data on saccharin consumption by BDA members showed that more than half of them used saccharin tablets daily, with an overall daily intake of three to six tablets, depending on age and sex. Information on a small sample of survivors from the mortality study suggested that about 23% of them would have taken saccharin daily for 10 years or more and 10% for 25 years or more by the end of the follow-up. It was concluded that these relatively high levels of saccharin intake had not increased the risk of cancer in general among BDA members.

Male and female Wistar rats were administered sodium saccharin for life (2 yr) either in the drinking water or diet. The maximum palatable dose of saccharin in the drinking water was found to be 2 g/kg/day and, even then, there was some voluntary restriction of fluid intake in the males. By contrast, double this dose--namely 4 g/kg/day, was palatable in the diet. A control group of rats of both sexes received saccharin-free diet and drinking water. Mild urothelial hyperplasias developed from 85 weeks in rats of both sexes receiving saccharin either in the drinking water or diet; the incidence was statistically significant in both the bladders and kidneys of rats receiving the higher dose of saccharin in the diet, but in the kidneys only of rats receiving the lower dose of saccharin in the drinking water. Telangiectasia of the vasa recta was significant in saccharin-treated rats of both sexes at both doses. A very low incidence of bladder tumours, exclusively in males receiving the higher saccharin dose in the diet was seen from 95 weeks. No consistent relationship between bladder epithelial hyperplasias and crystalluria could be demonstrated, although all 3 bladder tumours were associated with some form of mineralisation. Results suggest a particular susceptibility of males to saccharin treatment. The possibility that saccharin may promote, or enhance, the development of latent tumour cells already present in the experimental population, rather than initiate carcinogenesis per se is considered.

Exposure of male Charles River CDI rats to a 5% saccharin diet in utero and throughout weaning, conditions associated with tumor induction, did not induce detectable metabolism (less than 0.4% of the oral dose) of tritiated saccharin in vivo. No metabolites (less than 0.06 microgram per kilogram per 24 hours) were detected in the urine of normal rats given a tracer dose. Pretreatment with 3-methylcholanthrene did not induce saccharin metabolism.