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Environ Health Perspect. 2017 Aug 1;125(8):087001. doi: 10.1289/EHP577.

The Association of Arsenic Metabolism with Cancer, Cardiovascular Disease, and Diabetes: A Systematic Review of the Epidemiological Evidence.

Kuo CC1,2,3,4, Moon KA1,2,3, Wang SL5, Silbergeld E2, Navas-Acien A1,2,3,6.

Author information

Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health , Baltimore, Maryland, USA.
Department of Environmental Health Sciences, Johns Hopkins Bloomberg School of Public Health , Baltimore, Maryland, USA.
Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Medical Institutions , Baltimore, Maryland, USA.
Kidney Institute and Big Data Center, China Medical University Hospital and College of Medicine, China Medical University , Taichung, Taiwan.
National Institute of Environmental Health Sciences, National Health Research Institutes , Miaoli, Taiwan.
Department of Environmental Health Sciences, Columbia University Mailman School of Public Health , New York, New York, USA.



The available evidence on the role of arsenic metabolism in individual susceptibility to the development of cancer, cardiovascular disease, and diabetes has not been formally and comprehensively reviewed.


Our goal was to systematically investigate the association of arsenic metabolism with cancer, cardiovascular disease, and diabetes-related outcomes in epidemiologic studies. As a secondary objective, we characterized the variation of arsenic metabolism in different populations worldwide.


We searched Medline/PubMed and EMBASE from inception to January 2016 and applied predetermined exclusion criteria. Compositional data analysis was used to describe the distribution of arsenic metabolism biomarkers and evaluate the association between arsenic exposure and metabolism.


Twenty-eight studies met the inclusion criteria, 12 on cancer, nine on cardiovascular disease, and seven on diabetes-related outcomes. The median (interquartile range) for mean iAs%, MMA%, and DMA% was 11.2 (7.8-14.9)%, 13.0 (10.4-13.6)%, and 74.9 (69.8-80.0)%, respectively. Findings across studies suggested that higher arsenic exposure levels were associated with higher iAs% and lower DMA% and not associated with MMA%. For cancer, most studies found a pattern of higher MMA% and lower DMA% associated with higher risk of all-site, urothelial, lung, and skin cancers. For cardiovascular disease, higher MMA% was generally associated with higher risk of carotid atherosclerosis and clinical cardiovascular disease but not with hypertension. For diabetes-related outcomes, the pattern of lower MMA% and higher DMA% was associated with higher risk of metabolic syndrome and diabetes.


Population level of iAs% and DMA%, but not MMA%, were associated with arsenic exposure levels. Overall, study findings suggest that higher MMA% was associated with an increased risk of cancer and cardiovascular disease, while lower MMA% was associated with an increased risk of diabetes and metabolic syndrome. Additional population-based studies and experimental studies are needed to further evaluate and understand the role of arsenic exposure in arsenic metabolism and the role of arsenic metabolism in disease development.

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