Abstract
Background:
Talc is a known risk factor for some lung diseases due to its small particle size, commonly aerosolized form, and possible contamination with asbestos, a known lung carcinogen. Personal talc-based body powder (talc) use is common among U.S. women, but the association of talc use and lung cancer has not been studied in non-occupational settings.
Methods:
At enrollment (2003–2009), Sister Study participants reported talc use in the last year and ages 10–13. We used Cox proportional hazards models to estimate covariate-adjusted hazards ratios (HRs) and 95% confidence intervals (CIs) for the associations between talc use and incident lung cancer.
Results:
Among 49,592 eligible women, 41% reported using talc in the last year and 641 reported a new lung cancer diagnosis. Self-reported talc use was not consistently associated with incident lung cancer: HR=0.91 (95% CI: 0.78–1.07) for talc use in the last year; HR=0.94 (0.80, 1.10) for talc use ages 10–13.
Conclusions:
No consistent associations were observed between talc use and lung cancer overall, though some suggestive positive associations observed among never-smokers and for lung adenocarcinomas may warrant further investigation.
Impact:
Population-based research on personal care product use is critical to improving our understanding of the impacts of potentially harmful substances, and their known or unknown contaminants, on human health.
Keywords: lung cancer, talc, talcum powder, personal care products
Introduction
Lung cancer is the leading cause of cancer death in the United States. In addition to smoking, risk factors include environmental exposures such as air pollution, radon, and asbestos.1 Talc-based body powder (talc) may contain asbestos, and its small aerosolized particles can be inhaled deep into the lung, potentially contributing to carcinogenesis.2 Women have reported using talc to prevent dampness and chafing, to feel clean, and to reduce vaginal odor.3 Talc use has been linked to non-lung cancers,4 and there is some evidence of excess lung cancer mortality among exposed workers,5 but no studies have considered personal talc use and lung cancer risk. We examined the association of self-reported talc exposure and incident lung cancer among women in the Sister Study.
Methods
The Sister Study is a prospective cohort of 50,884 women across the United States, enrolled between 2003–2009.6 Participants were aged 35–74 years and had never had breast cancer, but each had a sister diagnosed with breast cancer. The Institutional Review Board of the National Institutes of Health approved this study in accordance with the US Common Rule and all participants provided written informed consent. After excluding participants who withdrew (n=9), had pre-enrollment lung cancer or unknown status (n=70), or were missing talc (n=978) or follow-up data (n=235), 49,592 eligible participants remained. As of September 30, 2021 (data release 11.1; median follow-up 12.5 years), 641 incident primary lung or bronchus cancer diagnosis were self-reported. Those with pathology reports, death certificates or National Death Index records were considered medically confirmed (n=487). Mesotheliomas were excluded (n=11 incident cases).
At baseline, participants completed questionnaires regarding personal talc use in the 12 months prior to enrollment and between ages 10–13, including application site (vaginal area, underarms, and other), and frequency.4
Statistical Analyses
We used Cox proportional hazards models to estimate adjusted (HRs) and 95% confidence intervals (CIs), with age as the time scale. Participants were followed from enrollment to diagnosis, censoring at loss to follow-up, death, or end of follow-up.
Multivariable models for exposure at ages 10–13 were adjusted for childhood socioeconomic status, race/ethnicity, birth cohort, smoking status (incorporating pack-years), and environmental tobacco smoke. Models for adult talc use additionally adjusted for adult socioeconomic status, BMI, alcohol consumption, and region of residence.
We also conducted analyses limited to never smokers (N=27,814; 121 cases) and separately considered medically-confirmed lung cancer (n=487) or lung adenocarcinoma (n=211). All analyses were performed using SAS (v9.4; SAS Institute Inc.; RRID:SCR_008567).
Results
The average age at enrollment was 61.5 years (SD=7.7) among cases and 55.6 (SD=9.0) among non-cases. Median follow-up was 13.5 years. Talc use at any site was common both at ages 10–13 (48% of cases, 49% of non-cases) and the year before enrollment (40% of cases, 41% of non-cases) (Table 1). Self-reported talc use was not associated with lung cancer (HR=0.94, 95% CI: 0.80–1.10 for adolescent use; HR=0.91, 95% CI: 0.78–1.07 for adult use), with no evidence of differences by application site or frequency.
Table 1.
Self-reported talc use at ages 10–13 and in the 12 months prior to enrollment in relation to incident lung cancer, Sister Study (n=49,497a)
| No Lung Cancer | Lung Cancer | Age-adjusted | Multivariable-adjusted | p-trend, multivariable model | |
|---|---|---|---|---|---|
| n = 48,856; n (%) | n = 641; n (%) | HRb (95% CI) | HRb,c (95% CI) | ||
|
| |||||
| Talc use at ages 10–13 years | |||||
| Any talc use (all sites) | 23,801 (49) | 302 (48) | 0.95 (0.81, 1.11) | 0.94 (0.80, 1.10) | |
| Sometimes use | 20,027 (42) | 253 (40) | 0.94 (0.80, 1.11) | 0.97 (0.82, 1.15) | 0.25 |
| Frequent use | 3,774 (8) | 49 (8) | 0.96 (0.71, 1.30) | 0.81 (0.59, 1.11) | |
| Any genital talc use | 9,068 (19) | 119 (20) | 1.01 (0.82, 1.23) | 0.99 (0.81, 1.21) | |
| Sometimes use | 7,701 (16) | 104 (17) | 1.04 (0.84, 1.28) | 1.06 (0.86, 1.31) | 0.50 |
| Frequent use | 1,367 (3) | 15 (3) | 0.83 (0.50, 1.38) | 0.67 (0.39, 1.15) | |
| Any underarm talc use | 12,206 (27) | 169 (28) | 1.07 (0.89, 1.27) | 1.00 (0.83, 1.20) | |
| Sometimes use | 10,509 (23) | 151 (25) | 1.11 (0.92, 1.33) | 1.08 (0.89, 1.30) | 0.41 |
| Frequent use | 1,697 (4) | 18 (3) | 0.81 (0.50, 1.30) | 0.62 (0.38, 1.01) | |
| Any talc use in other areas | 20,349 (45) | 257 (43) | 0.93 (0.79, 1.09) | 0.90 (0.77, 1.07) | |
| Sometimes use | 17,904 (39) | 228 (38) | 0.93 (0.79, 1.10) | 0.93 (0.78, 1.10) | 0.13 |
| Frequent use | 2,445 (5) | 29 (5) | 0.87 (0.59, 1.26) | 0.74 (0.50, 1.09) | |
| Talc use in the 12 months prior enrollment | |||||
| Any talc use (all sites) | 19,843 (41) | 254 (40) | 0.90 (0.77, 1.05) | 0.91 (0.78, 1.07) | |
| Less than once a month | 8,488 (17) | 98 (15) | 0.86 (0.69, 1.07) | 0.89 (0.72, 1.12) | 0.34 |
| 1 or more times per month | 11,349 (23) | 156 (25) | 0.92 (0.77, 1.11) | 0.92 (0.76, 1.11) | |
| Any genital talc use | 7,029 (14) | 92 (15) | 1.03 (0.82, 1.28) | 1.02 (0.81, 1.27) | |
| Less than once a month | 3,035 (6) | 34 (5) | 0.93 (0.65, 1.31) | 0.99 (0.70, 1.39) | 0.84 |
| 1 or more times per month | 3,990 (8) | 58 (9) | 1.10 (0.84, 1.44) | 1.04 (0.79, 1.36) | |
| Any underarm talc use | 7,848 (16) | 112 (18) | 1.06 (0.87, 1.30) | 1.06 (0.86, 1.30) | |
| Less than once a month | 3,657 (8) | 42 (7) | 0.90 (0.66, 1.23) | 0.89 (0.65, 1.22) | 0.32 |
| 1 or more times per month | 4,187 (9) | 70 (11) | 1.19 (0.93, 1.53) | 1.19 (0.93, 1.53) | |
| Any talc use other areas | 17,985 (37) | 226 (36) | 0.87 (0.74, 1.02) | 0.87 (0.74, 1.02) | |
| Less than once a month | 8,145 (17) | 93 (15) | 0.84 (0.67, 1.05) | 0.85 (0.68, 1.07) | 0.10 |
| 1 or more times per month | 9,831 (20) | 133 (21) | 0.88 (0.73, 1.08) | 0.86 (0.71, 1.05) | |
| Any use of powder | 19,391 (40) | 248 (39) | 0.89 (0.76, 1.05) | 0.90 (0.77, 1.06) | |
| Any use of spray | <1% | <1% | NE | NE | |
Abbreviation: HR = hazard ratio, CI = confidence interval, NE = not evaluated
Missing: 774 any use ages 10–13; 1925 genital use ages 10–13; 3076 underarm use ages; 3318 other use ages 10–13; 191 any use 12 months prior to enrollment; 215 genital use 12 months prior to enrollment; 217 underarm use 12 months prior to enrollment; 227 other use 12 months prior to enrollment; 562 powder versus spray use in 12 months prior to enrollment
Limited to women with complete data for race/ethnicity, smoking status, smoking pack-years, environmental tobacco smoke exposure
Relative to common referent of never users
Models for exposure at ages 10–13 adjusted for race/ethnicity (non-Hispanic White, Black, Hispanic, other), smoking status at enrollment, total years of environmental tobacco smoke exposure (continuous), childhood household income (well off, middle income, low income, poor), highest attained education in household in childhood (high school or less, some college, college degree, postgraduate degree), birth cohort (1928–1945, 1946–1954, ≥1955) and a smoking status by pack-years (continuous) interaction term. Models for exposure in last 12 months adjusted for race/ethnicity (non-Hispanic White, Black, Hispanic, other), smoking status at enrollment, total years of environmental tobacco smoke exposure (continuous), adult household income (<$20,000, $20,000-<$50,000, $50,000-<$100,000, $100,000-<$200,000, $200,000+), highest attained education (high school or less, some college, college degree, postgraduate degree), birth cohort (1928–1945, 1946–1954, ≥1955), BMI (<25 kg/m2, 25-<30 kg/m2, ≥30 kg/m2), alcohol consumption (never, past, current non-regular, regular), geographic region of residence (Northeast, Midwest, South, West), and a smoking status by pack-years (continuous) interaction term.
Among never-smokers, however, underarm talc use at ages 10–13 was positively associated with incident lung cancer (HR=1.55, 95% CI: 1.04–2.32; Table 2), though associations were inconsistent by frequency of use. Among all women, frequent underarm talc use in the last year was suggestively positively associated with medically-confirmed adenocarcinoma (>1 time/month: HR=1.38, 95% CI: 0.91–2.10; p-for-trend=0.21). Underarm talc use during adolescence was also suggestively associated with adenocarcinoma (HR for ever use=1.21, 95% CI: 0.90–1.64).
Table 2.
Sensitivity Analyses of the talc use and incident lung cancer association, multivariable-adjusted hazard ratios (HRsa,b) and 95% confidence intervals (CIs)
| Analysis limited to non-smokers | Medical-confirmed cases onlyc | Adenocarcinomas onlyc | |
|---|---|---|---|
| Total n=27,814, with 121 cases | Total n=49,497, with 487 cases | Total n=49,497, with 211 cases | |
|
| |||
| Talc use at ages 10–13 years | |||
| Any talc use (all sites) | 0.95 (0.66, 1.39) | 0.96 (0.80, 1.15) | 1.07 (0.81, 1.42) |
| Sometimes use | 1.02 (0.70, 1.50) | 0.99 (0.82, 1.21) | 1.07 (0.80, 1.44) |
| Frequent use | 0.55 (0.22, 1.41) | 0.81 (0.57, 1.16) | 1.07 (0.64, 1.79) |
| p-trend | 0.43 | 0.38 | 0.65 |
| Any genital talc use | 0.94 (0.58, 1.52) | 0.98 (0.78, 1.25) | 1.10 (0.78, 1.56) |
| Sometimes use | 1.04 (0.64, 1.71) | 1.03 (0.81, 1.33) | 1.16 (0.80, 1.67) |
| Frequent use | NE | 0.75 (0.42, 1.36) | 0.81 (0.33, 1.99) |
| p-trend | 0.49 | 0.63 | 0.81 |
| Any underarm talc use | 1.55 (1.04, 2.32) | 0.95 (0.77, 1.18) | 1.21 (0.90, 1.64) |
| Sometimes use | 1.70 (1.13, 2.55) | 1.04 (0.83, 1.30) | 1.30 (0.95, 1.78) |
| Frequent use | 0.60 (0.15, 2.49) | 0.53 (0.29, 0.96) | 0.74 (0.32, 1.69) |
| p-trend | 0.10 | 0.21 | 0.47 |
| Any talc use in other areas | 0.98 (0.66, 1.45) | 0.91 (0.75, 1.10) | 1.04 (0.78, 1.39) |
| Sometimes use | 1.07 (0.72, 1.58) | 0.93 (0.77, 1.14) | 1.02 (0.75, 1.38) |
| Frequent use | 0.34 (0.08, 1.39) | 0.74 (0.47, 1.16) | 1.18 (0.65, 2.11) |
| p-trend | 0.46 | 0.19 | 0.69 |
| Talc use in the 12 months prior enrollment | |||
| Any talc use (all sites) | 0.75 (0.51, 1.10) | 1.02 (0.85, 1.23) | 1.04 (0.79, 1.37) |
| Less than once a month | 0.53 (0.29, 0.97) | 1.02 (0.79, 1.30) | 1.03 (0.71, 1.50) |
| 1 or more times per month | 0.91 (0.59, 1.40) | 1.03 (0.83, 1.28) | 1.05 (0.76, 1.46) |
| p-trend | 0.44 | 0.78 | 0.77 |
| Any genital talc use | 0.96 (0.55, 1.65) | 1.10 (0.86, 1.41) | 0.97 (0.65, 1.45) |
| Less than once a month | 0.71 (0.29, 1.76) | 0.93 (0.62, 1.41) | 0.68 (0.34, 1.38) |
| 1 or more times per month | 1.14 (0.60, 2.16) | 1.20 (0.89, 1.62) | 1.18 (0.74, 1.89) |
| p-trend | 0.90 | 0.30 | 0.77 |
| Any underarm talc use | 1.26 (0.80, 1.97) | 1.06 (0.84, 1.35) | 1.18 (0.83, 1.67) |
| Less than once a month | 1.04 (0.52, 2.09) | 0.90 (0.62, 1.30) | 0.93 (0.54, 1.62) |
| 1 or more times per month | 1.43 (0.82, 2.49) | 1.20 (0.90, 1.60) | 1.38 (0.91, 2.10) |
| p-trend | 0.23 | 0.36 | 0.21 |
| Any talc use other areas | 0.59 (0.39, 0.88) | 0.95 (0.79, 1.14) | 0.96 (0.72, 1.28) |
| Less than once a month | 0.42 (0.22, 0.81) | 0.96 (0.75, 1.24) | 0.97 (0.67, 1.42) |
| 1 or more times per month | 0.69 (0.43, 1.11) | 0.94 (0.75, 1.18) | 0.94 (0.67, 1.34) |
| p-trend | 0.05 | 0.58 | 0.73 |
Abbreviation: HR = hazard ratio, CI = confidence interval, NE = not evaluated
Missing: 774 any use ages 10–13; 1925 genital use ages 10–13; 3076 underarm use ages; 3318 other use ages 10–13; 191 any use 12 months prior to enrollment; 215 genital use 12 months prior to enrollment; 217 underarm use 12 months prior to enrollment; 227 other use 12 months prior to enrollment; 562 powder versus spray use in 12 months prior to enrollment; 187 ever lifetime use
Relative to common referent of never users
Models for exposure at ages 10–13 adjusted for race/ethnicity (non-Hispanic White, Black, Hispanic, other), total years of environmental tobacco smoke exposure (continuous), childhood household income (well off, middle income, low income, poor), highest attained education in household in childhood (high school or less, some college, college degree, postgraduate degree), and birth cohort (1928–1945, 1946–1954, ≥1955). Models for exposure in last 12 months adjusted for race/ethnicity (non-Hispanic White, Black, Hispanic, other), total years of environmental tobacco smoke exposure (continuous), adult household income (<$20,000, $20,000-<$50,000, $50,000-<$100,000, $100,000-<$200,000, $200,000+), highest attained education (high school or less, some college, college degree, postgraduate degree), birth cohort (1928–1945, 1946–1954, ≥1955), BMI (<25 kg/m2, 25-<30 kg/m2, ≥30 kg/m2), alcohol consumption (never, past, current non-regular, regular), and geographic region of residence (Northeast, Midwest, South, West).
Additionally adjusted for smoking status at enrollment and a smoking status by pack-years (continuous) interaction term
Discussion
Self-reported personal talc use was not consistently associated with incident lung cancer in a cohort of US women. The observed positive association between adolescent underarm talc use and overall lung cancer among never-smokers deserves further investigation, as do the adenocarcinoma-specific results, but considering imprecise effect estimates and inconsistent dose-response patterns, we observed little evidence to support a true effect.
Though dermal contact also occurs, inhalation is the primary route of talc exposure. Inhaled particles can penetrate deep into the lung, leading to granulomas in the alveoli and the potential to progress to cancer.2 Studies of talc workers suggest occupational exposure may be modestly associated with increased overall mortality, lung cancer specific-mortality and non-malignant respiratory disease.5,7,8 Talc-based personal care products are potentially contaminated with asbestos due to co-location, co-mining, and chemical detection challenges.2 Other potentially harmful chemicals in talc-based products, including phthalates and parabens, could also contribute to carcinogenesis.9
Since 80% of all lung cancers are attributed to smoking, identifying non-smoking-related risk factors has been historically difficult.1 Underarm talc use could increase inhalation of harmful particles, with age 10–13 representing an early window of susceptibility. Adenocarcinomas, which can arise from bronchoalveolar regions, are the most common subtype among never-smokers.
Strengths of the study include its prospective design and detailed data collection. Limitations include limited generalizability, small subgroup sample sizes, and potential exposure misclassification, including the absence of information on the chemical composition of talc-based products.
Conclusions
This analysis does not support an association between talc use and lung cancer, though some subgroup findings may warrant further investigation. Population-based research on personal care product use is critical to improving our understanding of the impacts of potentially harmful substances, and their known or unknown contaminants, on human health.
Acknowledgements
This research was supported by the Intramural Research Program of the National Institutes of Health (NIH) National Insittute of Environmental Health Sciences (Z01-ES044005 to D.P. Sandler). The contributions of the NIH authors are considered Works of the United States Government. The findings and conclusions presented in this paper are those of the authors and do not necessarily reflect the views of the NIH or the U.S. Department of Health and Human Services.
Footnotes
Conflicts of Interest
The authors declare no potential conflicts of interest.
Data Availability Statement
Requests for data, including the data used in this manuscript, are welcome. De-identified data can be made available upon request as described on the study website (https://sisterstudy.niehs.nih.gov/English/data-requests.htm). The data sharing policy was developed to protect the privacy of study participants and is consistent with study informed consent documents as approved by the NIEHS Institutional Review Board.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
Requests for data, including the data used in this manuscript, are welcome. De-identified data can be made available upon request as described on the study website (https://sisterstudy.niehs.nih.gov/English/data-requests.htm). The data sharing policy was developed to protect the privacy of study participants and is consistent with study informed consent documents as approved by the NIEHS Institutional Review Board.