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FILE NAME Talc TALC DATE 1997 DOC TALC027 DOCUMENT DESCRIPTION Journal Letter to the Editor RE Perineal Powder Exposure and the Risk of Ovarian Cancer NE : NE American Journal of Epidemiology Copyright '1997 by The Johns Hopkins University School of Hygiene and Public Health All rights reserved Vol 146 No. 9 Printed in U.S.A. LETTERS TO THE EDITOR law Copyright ' U.S. RE PERINEAL POWDER EXPOSURE AND THE RISK OF OVARIAN CANCER Cook et al 1 suggest that their data support the hypothesis that talcum powder use causes ovarian cancer We groups Reliability studies on genital hygienic practices are needed . by_ believe that the current biologic and epidemiologic data do not provide strong evidence for a causal association It is REFERENCES unknown how talcum powder could migrate to the ovaries or whether the physical aspects of talcum powder protected can induce ovarian cancer The cited paper by Egli and be Newton 2 showed migration of carbon black particles from vaginal deposition to the oviducts in two of three may : patients Different results were obtained by Deboer 3 who and . found carbon black translocation from the vagina to the uterus in only 2 of 37 surgical patients Based on a previ- ously published paper 4 the authors state that like party particles are found more frequently in ovarian tumors than third + in normal tissue However in that study the amount of a ~ particles ranged from 6,900-55,100 g wet tissue in tissues by * from three healthy ovaries to 6,400-24,500 g wet tissue : from three malignant ovaries 4 Further efforts are needed Medicineto determine whether and how like particles can migrate up the reproductive tract to confirm findings of talc * particles in healthy and malignant ovarian tissue and to of _ explore possible mechanisms of induced ovarian carci- 1. 1. Cook LS Kamb ML Weiss NS Perineal powder exposure and the risk of ovarian cancer Am J Epidemiol 1997 459-65 2. Egli GE Newton M. The transport of carbon particles in the human female reproductive tract Fertil Steril 151 5 3. Deboer CH Transport of particulate matter through the human female genital tract J Reprod Fertil 295--7 4. Henderson WJ Joslin CA Turnbull AC et al Talc and carcinoma of the ovary and cervix J Obstet Gynaecol Br Commonw 266-72 5. Wynder EL Guidelines to the epidemiology of weak associ- ations Prev Med 211 12 6. Harlow BL Weiss NS A control study of borderline ovarian tumors the influence of perineal exposure to talc Am J Epidemiol 390-4 7. Chen Y Wu PC Ge WJ et al Risk factors for epithelial ovarian cancer in Beijing China Int J Epidemiol 1992 23-9 8. Booth M Beral V Smith P. Risk factors for ovarian cancer a control study Br J Cancer 592-8 Library nogenesis In epidemiologic studies of weak associations dose- response trends are especially important to demonstrate National - causality 5 Cook et al ) found no trend in the odds ratios with increasing number of perineal applications despite a fivefold difference between the lowest and highest the , exposure categories Other studies either did not determine 9. Whittemore AS Wu ML Paffenbarger RS Jr et al Personal and environmental characteristics related to epithelial ovarian cancer Am J Epidemiol 1228-40 10. Cramer DW Welch WR Scully RE et al Ovarian cancer and talc Cancer 372-6 11. Harlow BL Cramer DW Bell DA Perineal exposure to talc and ovarian cancer risk Obstet Gynecol 1992 19 26 of the duration and frequency of perineal dusting 6-9 or Joshua E. Muscat = showed no trend in risk with duration of exposure 9 10 or colection a suggestive trend 11 The lack of a trend in several studies argues against a biologic effect The modest positive findings may be due to greater awareness and recall among the the cases This seems possible given the numerous questions on from talc use in these epidemiologic surveys and the considerable differences in exposure percentages between the control Ernst L. Wynder American Health Foundation 320 East 43rd Street New York NY 10017 Editor's note In accordance with Journal policy Dr. Cook and her coauthors were given the opportunity to reply to the above letter but they chose not to do so x copied was RE ASSESSING THE DIRECTION OF CAUSALITY IN SECTIONAL STUDIES page . We read with some concern the paper by Flanders et al this 1 in which they question the direct causality of the rela- tion between dioxin exposure shown in studies 2 3 that on were carried out among veterans of Operation Ranch Hand who were participants in the ongoing Air Force Health material Study AFHS As Flanders et al correctly note in their first example the exposed E and control C ) group triglyceride The means are nearly identical in the AFHS Therefore we believe that any model relating triglyceride and dioxin in the AFHS should accommodate equal triglyceride group means Using the same notation used by Flanders et al let Y Y2 andX denote the dioxin exposure level the mea- sured exposure level and the triglyceride level respectively Without loss of generality we have dropped the subject subscript from the notations Then a model to study triglycerides should accommodate the condition ...= ... 1 where ...Cand ...E respectively are the overall triglycgroups eride means for the control and exposed Flanders et al consider two models Their model 1 is a direct causation model to study the effect of dioxin exposure on health and model 2 is a reverse causation model to study the effect of triglycerides on measured dioxin In both models they assume that the exposed group is stratified by dioxin categories E low E2 medium and E3 high and MIO < MII < M12 < M13 2 786 wl re su gl W the pa W ex au an al an wh Th and and are dir the sib lyc bo law Copyright U.S. U.S. by protected be may and party third a by Medicne of Library National the of colection the from copied was page this on |NA7R.: material The OMNES, diabetologists and in major medical centers where funduscopic examination is done routinely and competently However in the office of the primary care physicians where most diabetics in this country receive much of their care annual examination of the fundi through dilated pupils regrettably is performed infrequently if at all Given that circumstance an abnormal tourniquet test result demands a competent funduscopic examination to rule out proliferative retinopathy often by referral to an ophthalmologist I wish to emphasize that I am not advocating that the tourniquet test replace regular funduscopic examination If Drs Aaby and Zegarra have a effective strategy to ensure ade- quate annual examination of the 11 million diabetics in the United States by a physician who can recognize early proliferative diabetic retinopa- . thy I would happily endorse it and discard the tourniquet test until then the tourniquet test will identify nine of every ten patients with diabetic retinopathy who need to be referred to such a physician Many of these patients conditions are currently undiagnosed until loss of vision occurs Decrease in capillary fragility with improved diabetic control noted in several patients was not meant to imply regression of diabetic retinopathy Histological study however may confirm that the tourniquet test does accurately reflect the progression or regression of diabetic dermal microangiopathy At present the vascular or platelet abnormality causing capillary fragility in diabetes is unknown I am currently involved in a study correlating the tourniquet test with fluorescein retinal angiography in those patients who do not have identifiable diabetic retinopathy on ophthalmoscopic examination WILLIAM A. REYNOLDS MD Western Montana Clinic Missoula 1. Cartwright GE Diagnostic Laboratory Hematology ed 4. New York Grune & Stratton Inc 1968 p 367 2. Stobbe H R^...rupC Zum Nachweis von Kapillarschaden im Rahmen der Mikroangiopathie beim Diabetes mellitus mittels Strauversuchs Schweiz Med Wochenschr 1808-1810 3. Rodriguez R Root HF Capillary fragility and diabetic retinitis N Engl J Med 391-397 Talc and Ovarian Cancer To the Cramer and work- ers recently reported observing an association between talc use and risk of ovarian cancer We therefore examined data on talc use that two of us L.M. and L.P.L. had collected as part of a control interview study Estimated Relative Risk of Ovarian Cancer According to Reported Use of Talc No talc mentioned , Any talc mentioned No diaphragm used Diaphragm used no talc Diaphragm with talc No body talc Some body talc All over Genital Legs only Not genital Unknown where Cases 62 87 92 14 25 77 54 37 7 1 8 3 Controls 61 100 118 11 41 84 78 57 3 0 8 10 On genitals sanitary napkins or underwear Estimated Relative Risk 1.0 0.7 1.0 1.8 0.8 1.0 0.8 0.7 2.5 ... 0.8 0.3 95 Confidence Interval see 0.4-1.1 wee 0.7-3.7 0.4-1.4 tee 0.5-1.2 0.4-1.2 0.7-10.0 wee 0.3-2.5 0.1-1.2 of epithelial ovarian cancer conducted from 1974 to 1977 in the Washington DC area The cases were 197 women with pathologically confirmed primary epithelial ovarian cancers treated in participating hospitals The controls were 197 women treated at the same hospitals for conditions other than gynecologic psychiatric or malignant diseases or pregnancy The controls were frequency matched to the cases on age race and hospital The interviewers asked questions about reproductive and sexual history medical history drug use and other exposures Questions about tale use were added to the questionnaire after the study began so 135 cases and 171 controls were asked about talc exposure The reported talc use among cases and controls is given in the Table We estimated the relative risk to talc users as 0.7 95 confidence interval 0.4 to 1.1 The estimate was unaffected by adjustment for race age and gravidity Neither women who used talc on their diaphragms nor those who used it as body powder seemed to be at excess risk Women who used talc as a body powder were asked how they used it Among the ten who specifically mentioned use on sanitary napkins underwear or the genital area the relative risk was estimated as 2.5 but the small number of exposed women yielded an unreliable estimate 95 0.7 to 10.0 Our data thus indicate no overall association between talc use and risk of ovarian cancer Although a small group of women who specifically reported genital use of body talcum . powders showed an excess relative risk use of talc on a diaphragm which would be the closest exposure to the ovaries did not seem to elevate risk Chance bias in selection or obser- vation or confounding may have influenced these estimates One im- portant potential bias to consider in this and Cramer's study is a difference between cases and controls in recollecting or reporting talcum powder use especially in the genital area Talc exposure was not a major focus of this study and few data are avail- able to assess the likelihood of recall bias Such a bias could stem from cases heightened awareness or from the fact that controls were inter- viewed in the hospital while most cases were interviewed at home On the other hand the questions about talc use were rather simple and unambiguous Also we noted that cases and controls were equally likely to report douching Since reporting of use of douches might be subject to the same recall biases as talc use this observation suggests that little recall bias operated Another possible interpretation of our findings of no apparent effect of using talc on the diaphragm but some effect of perineal use of powder is that talc itself does not increase risk of ovarian cancer but that patients with ovarian cancer have or perceive a greater need for using body powder in the genital area for reasons related either to the biolo- gy of the disease or to style We agree with Cramer and workers that other epidemiologic data will be useful PATRICIA HARTGE MSC ROBERT HOOVER MD National Cancer Institute Bethesda Md LINDA P. LESHER MPH LARRY MCGOWAN MD George Washington University Medical Center Washington DC 1. Cramer DW Welch WR Scully RE et al Ovarian cancer and tale Cancer 372-376 2. McGowan L Parent L Lednar W et al The woman at risk for developing ovarian cancer Gynecol Oncol 325-344 1844 JAMA Oct 14 1983 250 No. 14 Letters an duty a expens prove in you you m part of Guard earthq you'll challe New tunitie inforn tunitie Guard Nation The