Perineal use of talcum powder and endometrial cancer risk

Systematic review of the association between talc and female reproductive tract cancers

Talc is a hydrous magnesium sheet silicate used in cosmetic powders, ceramics, paints, rubber, and many other products. We conducted a systematic review of the potential carcinogenicity of genitally applied talc in humans. Our systematic review methods adhere to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and incorporated aspects from the US Institute of Medicine (IOM, now the National Academy of Medicine) and several US EPA frameworks for systematic reviews, evaluating and integrating the epidemiological, animal, and mechanistic literature on talc and cancer. We conducted a comprehensive literature search. Detailed data abstraction and study quality evaluation, adapting the Toxic Substances Control Act (TSCA) framework, were central to our analysis. The literature search and selection process identified 40 primary studies that assessed exposure to talc and female reproductive cancer risks in humans (n = 36) and animals (n = 4). The results of our evaluation emphasize the importance of considering biological plausibility and study quality in systematic review. Integrating all streams of evidence according to the IOM framework yielded classifications of suggestive evidence of no association between perineal application of talcum powders and risk of ovarian cancer at human-relevant exposure levels. We also concluded that there is suggestive evidence of no association between genital talc application and endometrial cancer, and insufficient evidence to determine whether a causal association exists between genital talc application and cervical cancer based on a smaller but largely null body of literature.

Douching or Perineal Talc Use and Prevalent Fibroids in Young African American Women

Background: Black women are at an increased risk of developing fibroids, but the cause is unclear. Douching and perineal talc use are common lifestyle exposures among Black women, and may be risk factors for fibroid development. Materials and Methods: This cross-sectional study consisted of Black women 23-35 years of age in the metropolitan Detroit area (n = 1693) without prior diagnoses of fibroids and intact uteri. Main exposures were ever douching (yes/no) and any perineal talc use (ever/never). Main outcomes were prevalent fibroids at baseline (yes/no) and total fibroid volume at baseline (no fibroids/ Collapse

Key Words

• Women's Health
• douching
• health disparities
• talc
• uterine leiomyoma

Collapse

MESH Headings

• Black or African American
• Cross-Sectional Studies
• Female
• Humans
• Leiomyoma/epidemiology
• Prospective Studies
• Talc/adverse effects
• Therapeutic Irrigation
• Uterine Neoplasms

Collapse

Grants

• R00 NR017191 NINR NIH HHS

Collapse

Affiliation(s)

Maya A. Wright Department of Epidemiology, University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Chapel Hill, North Carolina, USA
Kristen R. Moore Epidemiology Branch, National Institute of Environmental Health Sciences, Research Triangle Park, North Carolina, USA
Kristen Upson Department of Epidemiology and Biostatistics, College of Human Medicine, Michigan State University, East Lansing, Michigan, USA
Donna D. Baird Epidemiology Branch, National Institute of Environmental Health Sciences, Research Triangle Park, North Carolina, USA
Helen B. Chin Epidemiology Branch, National Institute of Environmental Health Sciences, Research Triangle Park, North Carolina, USA

Collapse

Talc, body powder, and ovarian cancer: A summary of the epidemiologic evidence

Many women apply powder to the genital area as a drying agent. Talc, an inert mineral with a high capacity to absorb water, has historically been a major component of body powders. Due to its similarity and co-occurrence with asbestos, the association of body powder/talc use and gynecological cancer risk, specifically ovarian cancer risk, has been a long-standing research question. Retrospective case-control studies have shown associations between genital powder use and ovarian cancer risk, with summary relative risk estimates from meta-analyses and pooled analyses ranging from 1.24 to 1.35 for ever versus never use. In contrast, prospective cohort studies have not shown a statistically significant association until recently, when a pooled analysis of four large cohorts demonstrated a weak, but statistically significant association among women with patent reproductive tracts (hazard ratio 1.13). Taken together, the epidemiological data from case-control studies and cohort studies suggest that there may be a small, positive association between genital powder use and ovarian cancer. The causal factors underlying this association are not clear. Proposed factors include talc, other minerals, such as asbestos or quartz, that are known carcinogens and may contaminate talc products, or other powder ingredients that could cause inflammation of the reproductive tracts. Given the rarity of ovarian cancer in the general population, the small increase in relative risk translates to a very low increase in absolute risk. Further research is needed to understand the underpinnings of the observed association between genital powder use and ovarian cancer risk.

The association between douching, genital talc use, and the risk of prevalent and incident cervical cancer

While human papillomavirus is the primary cause of cervical cancer, other factors may influence susceptibility and response to the virus. Candidates include douching and talcum powder applied in the genital area. We used Cox proportional hazards models to estimate confounder-adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) in the Sister Study (2003-2009), a US cohort of women aged 35-74. We considered pre-baseline (n = 523) and incident (n = 31) cervical cancers. Douching at ages 10-13 was positively associated with pre-baseline cervical cancer (HR 1.32, 95% CI 0.86-2.03), though the association was not statistically significant. We did not observe an association between adolescent talc use and pre-baseline cervical cancer (HR 0.95, 95% CI 0.76-1.19). Douching in the year before enrollment was positively associated with incident cervical cancer (HR 2.56, 95% CI 1.10-5.99). The association between recent genital talc use and incident cervical cancer was positive, but not statistically significant (HR 1.79, 95% CI 0.78-4.11). The observed positive association between douching and incident cervical cancer is consistent with previous retrospective case-control studies. In the first study to examine genital talc use and cervical cancer, we did not see evidence of an association.

Genital powder use and risk of uterine cancer: A pooled analysis of prospective studies

When powder is applied to the genital area, it has the potential to reach internal reproductive organs and promote carcinogenesis by irritating and inflaming exposed tissues. Although many studies have considered the association between genital powder use and ovarian cancer risk, the relationship between genital powder use and uterine cancer is less well-studied. We pooled data from four large, prospective cohorts (the Nurses' Health Study, the Nurses' Health Study II, the Sister Study and the Women's Health Initiative - Observational Study). We used Cox proportional hazards models to estimate hazard ratios (HRs) and 95% confidence intervals (CIs), adjusting for prespecified confounders. In total, 209 185 women were included, with 37% reporting ever genital powder use. Over a mean 14.5 years of follow-up, 3272 invasive uterine cancers were diagnosed. There was no overall association between ever genital powder use and uterine cancer (HR = 1.01, 95% CI: 0.94-1.09), with little difference observed for frequent (≥1 times/week) vs never use (HR = 1.05, 95% CI: 0.95-1.16; P-for-trend = .46). Long-term use (>20 years; HR = 1.12, 95% CI: 0.96-1.31; P-for-trend = 0.14) was associated with a small, but not statistically significant, increase in risk, compared to never use. There were not clear differences by uterine cancer histologic subtypes or across strata of relevant covariates, including race/ethnicity, follow-up time, menopausal status and body mass index. The results of this large, pooled analysis do not support a relationship between the use of genital powder and uterine cancer, although the positive associations observed for long-term use may merit further consideration.

Perineal Talc Use, Douching, and the Risk of Uterine Cancer

BACKGROUND

Perineal talc use and douching could affect the risk of uterine cancer through several possible pathways, including inflammation response, microbiota changes, or endocrine disruption. Two previous cohort studies of the association between talc use and uterine cancer have reported weak positive associations, but we know of no previous evaluations of the relationship between douching and uterine cancer.

METHODS

Using a large prospective cohort, we examined the relationship between incident uterine cancer and self-reported use of talc or douche using Cox proportional hazards models.

RESULTS

After excluding those with prior hysterectomy, 271 of 33,609 women reported incident uterine cancer (mean follow-up = 8.3 years in noncases; maximum 12.6 years). Overall, 26% of women reported ever using talc and 15% reported ever having douched. Ever talc use was associated with an increase in risk of uterine cancer (adjusted hazard ratio [HR] = 1.2; 95% confidence interval [CI] = 0.94, 1.6), with some evidence of a dose-response for frequency of talc use (P-for-trend = 0.07). Ever douching was not associated with uterine cancer risk (HR = 1.0; 95% CI = 0.72, 1.5), with no evidence of a frequency dose-response (P = 0.96). The estimates were similar when we restricted to invasive endometrial cancers, but not when we further restricted to endometroid adenocarcinomas.

CONCLUSION

The positive association we observed between talc use and uterine cancer risk is consistent with findings from previous prospective cohort studies of endometrial cancer. The relationships between uterine cancer and both douching and talc use merit further consideration, particularly as both exposures are preventable.

Talc Pleurodesis: A Medical, Medicolegal, and Socioeconomic Review

BACKGROUND

Talcum has been used in pleurodesis for more than 8 decades. Despite a wealth of research, controversy remains over the optimal sclerosant for pneumothorax and pleural effusions. Talc's historical primacy has been challenged because of its potential for pulmonary toxicity, possible carcinogenicity, and recent concerns surrounding availability and legal liability, thus making this an ideal time for a review.

METHODS

This systematic review of the talc literature, focused on publications after the year 2000, evaluated mechanism of action, efficacy, side effect profile, and alternative sclerosants; included is an overview of current socioeconomic and legal controversies.

RESULTS

The data support talc as the most effective agent for pleurodesis. There is evidence to suggest that mean particle size has a direct relationship with the side effect profile and that significant hypoxemic events after talc administration are exceedingly rare when using available graded talc preparations. Concerns regarding the development of malignant diseases after topical talc application remain incompletely resolved but appear related to cosmetic powder preparations that were contaminated with asbestos. Purified talc in the pleural space has not been implicated. Recent difficulties accessing commercial talc preparations have been solved. Although safe and effective talc alternatives do exist, these agents are not as well studied.

CONCLUSIONS

Talc pleurodesis with modern, purified, graded talc preparations is safe and highly effective. Talc is an inexpensive and accessible option that remains appropriate for pleurodesis despite existing controversies.

Rapid detection of talcum powder in tea using FT-IR spectroscopy coupled with chemometrics

This paper investigated the feasibility of Fourier transform infrared transmission (FT-IR) spectroscopy to detect talcum powder illegally added in tea based on chemometric methods. Firstly, 210 samples of tea powder with 13 dose levels of talcum powder were prepared for FT-IR spectra acquirement. In order to highlight the slight variations in FT-IR spectra, smoothing, normalize and standard normal variate (SNV) were employed to preprocess the raw spectra. Among them, SNV preprocessing had the best performance with high correlation of prediction (R_P = 0.948) and low root mean square error of prediction (RMSEP = 0.108) of partial least squares (PLS) model. Then 18 characteristic wavenumbers were selected based on a hybrid of backward interval partial least squares (biPLS) regression, competitive adaptive reweighted sampling (CARS) algorithm and successive projections algorithm (SPA). These characteristic wavenumbers only accounted for 0.64% of the full wavenumbers. Following that, 18 characteristic wavenumbers were used to build linear and nonlinear determination models by PLS regression and extreme learning machine (ELM), respectively. The optimal model with R_P = 0.963 and RMSEP = 0.137 was achieved by ELM algorithm. These results demonstrated that FT-IR spectroscopy with chemometrics could be used successfully to detect talcum powder in tea.

Prospective study of body size throughout the life-course and the incidence of endometrial cancer among premenopausal and postmenopausal women

Although adult obesity is known to increase endometrial cancer risk, evidence for childhood obesity is limited. We prospectively examined the association between body fatness throughout life and endometrial cancer risk. 47,289 participants in the Nurses' Health Study (NHS) and 105,386 of the Nurses' Health Study II (NHS II) recalled their body fatness at ages 5, 10 and 20 using a pictogram. Childhood and adolescent body fatness were derived as the average at ages 5 and 10 and ages 10 and 20, respectively. We obtained adult weight from concurrent questionnaires. We calculated hazard ratios (HR) of endometrial cancer using Cox proportional hazards models. During follow-up, 757 incident cases of endometrial cancer were diagnosed. Body fatness in childhood, at age 10, in adolescence and at age 20 were positively associated with endometrial cancer risk (HR for ≥ Level 5 versus ≤ Level 2 in adolescence: 1.83 (95% CI 1.41-2.37). After adjusting for most recent BMI, none of the associations persisted. Weight change since age 18 was positively associated with endometrial cancer risk [HR for ≥ 25 kg gain versus stable: 2.54 (95% CI 1.80-3.59). Adult BMI was strongly associated with endometrial cancer risk [HR BMI ≥ 35 kg/m(2) versus BMI ≤ 25 kg/m(2) : 4.13 (95% CI 3.29-5.16)]. In postmenopausal women, the association with BMI was significantly stronger among non-users of hormone therapy. In conclusion, obesity throughout life is positively associated with endometrial cancer risk, with adult obesity one of the strongest risk factors. Maintaining a healthy weight throughout life remains important.

Safety Assessment of Talc as Used in Cosmetics

The Cosmetic Ingredient Review Expert Panel (Panel) assessed the safety of talc for use in cosmetics. The safety of talc has been the subject of much debate through the years, partly because the relationship between talc and asbestos is commonly misunderstood. Industry specifications state that cosmetic-grade talc must contain no detectable fibrous, asbestos minerals. Therefore, the large amount of available animal and clinical data the Panel relied on in assessing the safety of talc only included those studies on talc that did not contain asbestos. The Panel concluded that talc is safe for use in cosmetics in the present practices of use and concentration (some cosmetic products are entirely composed of talc). Talc should not be applied to the skin when the epidermal barrier is missing or significantly disrupted.

Contemporary clinical management of endometrial cancer

Although the contemporary management of endometrial cancer is straightforward in many ways, novel data has emerged over the past decade that has altered the clinical standards of care while generating new controversies that will require further investigation. Fortunately most cases are diagnosed at early stages, but high-risk histologies and poorly differentiated tumors have high metastatic potential with a significantly worse prognosis. Initial management typically requires surgery, but the role and extent of lymphadenectomy are debated especially with well-differentiated tumors. With the changes in surgical staging, prognosis correlates more closely with stage, and the importance of cytology has been questioned and is under evaluation. The roles of radiation in intermediate-risk patients and chemotherapy in high-risk patients are emerging. The therapeutic index of brachytherapy needs to be considered, and the best sequencing of combined modalities needs to balance efficacy and toxicities. Additionally novel targeted therapies show promise, and further studies are needed to determine the appropriate use of these new agents. Management of endometrial cancer will continue to evolve as clinical trials continue to answer unsolved clinical questions.

Detection of toxic metals (lead and chromium) in talcum powder using laser induced breakdown spectroscopy

A laser induced breakdown spectroscopic (LIBS) system was developed using a 266 nm laser and a high-resolution spectrograph (Andor SR 500 i-A) to detect the trace levels of the highly toxic metals such as lead and chromium present in different brands of talcum powder available in the local market. The strongest atomic transition lines of lead (Pb) (405.7 nm) and chromium (Cr) (425.4 nm) were used as spectral markers to simultaneously detect lead and chromium. The LIBS system was calibrated for these two heavy metals, and the system was able to detect 15-20 parts per million (ppm) of lead and 20-30 ppm of chromium in the talcum powder sample. The limits of detection of the LIBS system were also estimated, and they are 1.96 and 1.72 ppm per million respectively for lead and chromium. This study is highly significant due to the use of cosmetic products that could affect the health of millions of people around the globe.

Perineal powder use and risk of endometrial cancer in postmenopausal women

BACKGROUND

Most known endometrial cancer risk factors involve genetics or exposure to unopposed estrogens; less is known about risk due to environmental exposures. While several studies have found an increased risk of ovarian cancer associated with perineal powder use, only two studies have addressed perineal powder use and endometrial cancer risk.

METHODS

We used Cox proportional hazards regression to examine the association between perineal powder use and endometrial cancer risk using the Women's Health Initiative Observational Study Research Materials obtained from the National Heart, Lung, and Blood Institute Biological Specimen and Data Repository Coordinating Center.

RESULTS

Of the 48,526 women in our primary analysis, 25,181 (52 %) reported ever use of perineal powder. During 364,134 person-years of follow-up, 447 participants were diagnosed with endometrial cancer. Ever use of perineal powder was not associated with increased risk of endometrial cancer (multivariable-adjusted hazard ratio, 1.06; 95 % confidence interval, 0.87-1.28). External use of powder on the genitals and/or on sanitary napkins was also not significantly associated with risk of endometrial cancer. However, use of powder on a diaphragm for twenty or more years was associated with a threefold increase in risk of endometrial cancer compared to women who never used perineal powder (multivariable-adjusted hazard ratio, 3.06; 95 % CI, 2.00-4.70).

CONCLUSIONS

Any duration of external use of perineal powder was not associated with increased risk of endometrial cancer; however, long-term use of powder on a diaphragm may increase the risk of endometrial cancer.

Use of talcum powder and endometrial cancer risk

PURPOSE

Use of talcum powder in the perineal area has been associated with an increased risk of ovarian cancer, and a recent cohort study found a positive association with endometrial cancer. We sought to confirm this association using data from the Australian National Endometrial Cancer Study (ANECS).

METHODS

ANECS was a population-based case-control study conducted from 2005 to 2007, in which 1,399 women with newly diagnosed histologically confirmed primary endometrial cancer and 740 control women provided risk factor information via telephone interview. Unconditional logistic regression was used to estimate odds ratios adjusting for potential confounders.

RESULTS

We found no significant association between ever use of talc in the perineal area (OR 0.88, 95% CI: 0.68-1.14) or upper body area (OR 0.90, 95% CI: 0.71-1.14) and risk of endometrial cancer. The results were similar when stratified by subtype. Composite variables combining frequency and duration of talc use were also not significantly associated with risk (any perineal area use p = 0.07 and any upper body use p = 0.49).

CONCLUSIONS

The absence of any increase in risk and the similarity of our results for talc use on the upper body and in the perineal area do not support the hypothesis that use of talc in the perineal area is associated with an increased risk of endometrial cancer. Our data do not confirm the positive association between perineal talc use and endometrial cancer observed in the only previous study.

The epidemiology of endometrial and ovarian cancer

This review highlights similarities in the epidemiology of endometrial and ovarian cancer, including highly correlated incidence rates and similar risk factor profiles. Factors that decrease risk for both cancers include a late menarche, early age at first birth, giving birth and breastfeeding, and use of oral contraceptives. Short or irregular cycles and late menopause are associated with increased risk for both. Other risk factors that appear to operate in a similar direction include decreased risk associated with IUD use or a tubal ligation, and increased risk associated with obesity, lack of exercise, and use of talc powders in genital hygiene. Estrogen excess is proposed as the underlying mechanism for most endometrial cancers, whereas incessant ovulation has been suggested as the explanation for ovarian cancer. However, an increased number of estimated ovulatory cycles correlates directly with risk for both endometrial and ovarian cancer, suggesting that reproductive tissue turnover with an accumulation of PTEN or p53 mutations represents a possible common mechanism. An immune-based explanation involving mucin proteins represents another common mechanism that could explain additional risk factors. Maintenance of ideal weight, breastfeeding children, use of oral contraceptives, and avoidance of talc powders in genital hygiene are measures that could lower the risk for both types of cancer. Careful selection of patients for prophylactic oophorectomy for those women who are coming to hysterectomy for benign disease is an additional measure to consider for ovarian cancer.

Epidemiologic perspective on immune-surveillance in cancer

Common 'themes' in epidemiology related to cancer risk beg a comprehensive mechanistic explanation. As people age, risk for cancer increases. Obesity and smoking increase the risk for many types of cancer. History of febrile childhood diseases lowers the risk for melanomas, leukemias, non-Hodgkin's lymphoma (NHL), and ovarian cancer. Increasing number of ovulatory cycles uninterrupted by pregnancies correlate positively with breast, endometrial, and ovarian cancer risk while pregnancies and breastfeeding lower the risk for these cancers as well as cancers of the colon, lung, pancreas, and NHL. Chronic inflammatory events such as endometriosis or mucosal exposure to talc increase the risk for several types of cancer. Mechanisms so far considered are site specific and do not explain multiple associations. We propose that most of these events affect cancer immunosurveillance by changing the balance between an effective immune response and immune tolerance of an emerging cancer. We review recently published data that suggest that immune mechanisms underlie most of these observed epidemiologic associations with cancer risk.