The prognosis of gallbladder cancer is poor, and the 5-year survival rate of 390 patients with resected gallbladder cancer in Shanghai from 1997 to 2001 was only 31.3% to 40.7% [1]. The literature reports that 80% of gallbladder cancer patients have local infiltration or distant metastases at the time of definite diagnosis, and 30% of patients terminate resection when metastases are detected intraoperatively. The median survival of patients with symptomatic gallbladder cancer is less than six months, and the overall 5-year survival rate is less than 5%. According to the French Surgical Association, the median survival of 724 patients with gallbladder cancer was 3 months, with a 1-year survival rate of 14%. Potential risk factors for gallbladder cancer include gallstone disease, diet, obesity, women and their multiple births, anatomical abnormalities of the hepatobiliary system, and inherited molecular abnormalities. The significance of recognizing factors in the development of gallbladder cancer lies in the prevention and treatment of gallbladder cancer, especially in assessing the need for prophylactic cholecystectomy. The presence of gallbladder stones in patients with gallbladder cancer was recognized as early as the late 19th century, and in the 1930s, Graham suggested that gallbladder stones were associated with gallbladder cancer based on the fact that 69% to 100% of gallbladder cancer patients had gallbladder stones and 4.5% to 14.0% of gallstone patients had gallbladder cancer, and recommended cholecystectomy for gallbladder stone patients to prevent gallbladder cancer. A population-wide case-control biliary cancer study conducted in Shanghai in collaboration with NCI showed that gallbladder stones were a factor in the development of gallbladder cancer. Among 3922 gallbladder cancer cases in the National Gallbladder Cancer Clinical Epidemiological Survey in 2000, 49.7% were combined with gallbladder stones, and the relative risk of gallbladder cancer in patients with gallbladder stones was 13.7. In the Shanghai Large Sample Biliary Cancer Study, 368 cases of gallbladder cancer, 191 cases of extrahepatic bile duct cancer, and 68 cases of jugular cancer were included in the study. The study showed that gallstone disease is a strong risk factor for biliary tract cancer, using 1,037 gallstone patients as case controls and 959 randomized healthy individuals from the long-term resident population as normal controls. Up to 83.7% of gallbladder cancer patients had a history of gallbladder stones, including history of cholecystectomy, symptomatic gallstone disease, and asymptomatic gallstone disease. It was calculated that 80% of gallbladder cancer cases were attributed to gallstone disease (95% confidence interval 0.75-0.84), while the proportion of bile duct cancer and jugular cancer cases attributed to gallstone disease were relatively small, 59% (95% confidence interval 0.50-0.61) and 42% (95% confidence interval 0.29-0.57), respectively. Gallstone disease had the highest odds ratios (odds ratios) for gallbladder cancer, with 23.8 for gallbladder cancer, 8.0 for bile duct cancer, and 4.2 for jugular cancer for the three. Family history of gallbladder stone disease was correlated with gallbladder cancer, further supporting gallbladder stones as a factor in the development of gallbladder cancer. The family history of gallbladder stone disease was 9.5% (91/868) in the control population and 19.3% (71/297) in gallbladder cancer patients. Family history of gallstone disease significantly increased the risk of gallbladder cancer (up to 2.1-fold, 95% confidence interval 1.4 to 3.3). Women with a family history of gallstone disease had an increased risk of gallbladder cancer with a ratio of 2.9 (95% confidence interval 1.9-4.5), significantly higher than men with a family history of gallstone disease (ratio 1.8, 95% confidence interval 0.9-3.4), which is consistent with the increased risk of gallstone disease in women. The correlation between the number and nature of gallbladder stones and gallbladder cancer also supports the role of gallbladder stones on tumors. The Shanghai data showed that gallbladder cancer patients tended to have multiple gallstones (72% vs. 58%, P=0.08) and larger and heavier gallstones. The mean weight of gallstones in gallbladder cancer patients was significantly higher than that in gallstone patients (4.9g vs. 2.9g, P=0.006) The process of gallbladder stones leading to gallbladder carcinogenesis may be the irritation of the gallbladder mucosa by gallstones leading to trauma, affecting the mechanical contraction and emptying function of the gallbladder, recurrent chronic inflammation of the gallbladder with prolonged microbial infection (e.g. S. typhi), followed by mucosal metaplasia, through atypical proliferation, carcinoma in situ A 1964 cohort study of typhoid outbreaks in Scotland found that the risk of gallbladder cancer in carriers of S. typhi and S. paratyphi was 167 times higher than that of controls, and also involved other tumors, including pancreatic, colorectal, and lung cancers. The risk of gallbladder cancer was significantly higher in chronic carriers than in acute patients. Case-control studies have shown that bacterial degradation of primary bile acids can lead to gallbladder cancer, and patients with gallbladder cancer contain higher levels of secondary bile acids (deoxycholic acid vs. lithotriptic acid). A case-control study from northern India concluded that S. typhi carriers are risk factors for gallbladder cancer. Chronic infection of gallbladder tissues as well as serum and bile of gallbladder cancer patients was studied and chronic Salmonella carriers were found to be significantly associated with gallbladder cancer and gallbladder stones. In addition, patients with gallbladder cancer had significantly more bacteria in their bile than patients with gallbladder stones. The concealment of bacteria within gallstones has been confirmed in most studies, calling gallstones a nest of bacteria. In conclusion, these case-control studies support that biliary tract infection is a risk factor for gallbladder cancer. In addition to S. typhi and Salmonella, Helicobacter gallinarum infections are also present in the biliary system of gallbladder cancer patients. Japanese and Thai researchers have detected DNA fragments of Helicobacter gallinarum from bile and gallbladder tissue using PCR with 16sRNA as a universal primer. In conclusion, by studying the relationship between biliary tract infections of microorganisms such as S. typhi and H. gallinarum and gallbladder cancer, it is suggested that gallbladder stones induce gallbladder cancer through the pathological mechanism of bacterial infection. The pathogenic mechanism of gallstone cholesterol-induced gallbladder cancer Venniyoor concluded that among several risk factors contributing to the development of gallbladder cancer, two factors, cholesterol stones and women, have been consistent and important in many studies. While the mechanism of carcinogenesis involves mechanical stimulation of gallstones leading to atypical hyperplasia of the gallbladder, cholesterol itself produces atypical hyperplasia of the gallbladder epithelium. Furthermore, Venniyoor suggests that gallbladder cancer may be the result of environmental toxins excreted into the gallbladder via bile, and that cholesterol stone formation is an indicator of excessive activation of nuclear receptors and ABC transporters. Recently it has been recognized that the two systems of xenobiotic and hepatic excretion of substances from the body and cholesterol secretion mechanisms are closely related and interconnected. Cholesterol excretion and toxin excretion (environmental toxins, food toxins, drugs, etc.) in the body are regulated by nuclear receptors and the ABC transporter family. Cholesterol transport involves the liver X receptor and ABCG5/G8, while xenobiotic transport involves the pregnane X receptor and transporters such as ABCB1, and the authors have confirmed these carcinogenic mechanisms in more animal studies. The xenobiotics involve carcinogens excreted from the bile, including the liver carcinogen, aflatoxin B in food, which is also a strong carcinogen for gallbladder cancer. Most of the evidence supporting gallbladder stones as a factor in the development of gallbladder cancer comes from areas with a high incidence of gallbladder cancer. Because of the presence of a high-risk population for gallbladder cancer in Chile and northern and northeastern India, some authors have suggested the use of cholecystectomy to prevent gallbladder cancer in young female patients with asymptomatic gallbladder stones there. The natural course of asymptomatic gallbladder stones was thought to be good, with less than 20% developing symptomatic gallbladder stones, thus questioning whether it is worthwhile to use 100 cholecystectomies to prevent 1 case of gallbladder cancer. However, in the Italian 10-year follow-up data, 38.5% had symptomatic attacks or required surgical treatment. Ten percent of asymptomatic gallbladder stones in the Swedish population study required surgical intervention within 5 years, suggesting that asymptomatic gallbladder stones are not such a good course as reported in the literature. Furthermore, questions are raised about the treatment strategy of using cholecystectomy to prevent gallbladder cancer by removing the site of tumor occurrence and not by targeting gallstones, the cause of gallbladder cancer. In the author’s opinion, asymptomatic gallbladder stone patients with good gallbladder function, low number and moderate size of gallstones (bold stones are prone to cancer, small gallstones or sediment-like gallstones are prone to develop into secondary bile duct stones and biliary pancreatitis) can be followed up or undergo biliary stone removal surgery; however, once symptoms appear, or gallbladder malfunction, gallbladder is full of stones or occupies more than 50% of the gallbladder cavity, gallstones >2-3 cm in diameter gallbladder atrophy, etc., early cholecystectomy is recommended, and treatment should not be delayed. Targeted treatment of gallbladder stone disease should be an active and appropriate strategy to prevent gallbladder cancer.