Urinary aflatoxin levels, hepatitis-B virus infection and hepatocellular carcinoma in Taiwan.

Using a urinary immunoassay to measure aflatoxin metabolites, we examined the associations between exposure to aflatoxin, chronic infection with the hepatitis-B virus (HBV) and background rates of hepatocellular carcinoma (HCC) mortality in a cross-sectional survey of 250 residents from 8 areas of Taiwan with a 4-fold variation in age-adjusted HCC mortality. Specimens of fasting blood and overnight urines were used to determine HBV carrier status and excretion of aflatoxin in the subjects surveyed. While the prevalence of hepatitis-B virus carriers showed moderate variability, there was a 500-fold range in urinary aflatoxin levels. Mean log-transformed levels of aflatoxin metabolites were similar in males and females and in HBV carriers and non-carriers. In the 8 townships, HCC mortality correlated positively with both area HBV carrier prevalence and mean aflatoxin levels. The primary analyses, however, were conducted at the individual level. Each subject's aflatoxin level was treated as the response variable in a multiple regression model, and the corresponding sex-specific area HCC rate was included as a predictor along with the individual's carrier status, age and sex; alcohol consumption and cigarette smoking were also considered. In these analyses, a significant association was again observed between the marker of aflatoxin exposure and the background rate of HCC mortality. In females, the slope of the regression line was somewhat steeper in HBV carriers, but this pattern was not seen in males and formal testing yielded no statistically significant evidence of an interaction. Our findings are consistent with the hypothesis that aflatoxin plays an independent role in hepatocellular carcinoma in Taiwan.