Genital Powder Use and Risk of Ovarian Cancer: A Pooled Analysis of 8,525 Cases and 9,859 Controls

Kathryn L. Terry; Stalo Karageorgi; Yurii B. Shvetsov; Melissa A. Merritt; Galina Lurie; Pamela J. Thompson; Michael E. Carney; Rachel Palmieri Weber; Lucy Akushevich; Wei-Hsuan Lo-Ciganic; Kara Cushing-Haugen; Weiva Sieh; Kirsten Moysich; Jennifer A. Doherty; Christina M. Nagle; Andrew Berchuck; Celeste L. Pearce; Malcolm Pike; Roberta B. Ness; Penelope M. Webb; for the Australian Cancer Study (Ovarian Cancer), and the Australian Ovarian Cancer Study Group;; Mary Anne Rossing; Joellen Schildkraut; Harvey Risch; Marc T. Goodman

doi:10.1158/1940-6207.CAPR-13-0037

DOI: 10.1158/1940-6207.CAPR-13-0037 Published August 2013

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Figure 1.
Association between genital powder use and ovarian cancer risk in eight studies, P_{heterogeneity} = 0.61. Adjusted for age (continuous), oral contraceptive duration (never use, <2, 2–<5, 5–<10, or ≥10 years), parity (0, 1, 2, 3, or 4+ children), tubal ligation history, BMI (quartiles), race/ethnicity (non-Hispanic White, Hispanic White, Black, Asian, or other) and non-genital powder use. Studies listed in decreasing order of effect size SE (funnel plot). No evidence of heterogeneity based on Conchran's Q statistic (P = 0.61).
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Figure 2.
Association between genital powder use and subgroups of ovarian cancer defined by behavior and histology (A. Borderline, B. Invasive, C. Invasive serous, D. Invasive endometrioid, E. Invasive clear cell, F. mucinous.). Estimates are adjusted for the same covariates as in the model presented in Fig. 1.

Table 1.

Characteristics of eight studies included in the analysis of genital powder use and ovarian cancer

				Histology^b				Behavior^c
Study^a	Diagnosis years	Controls	Cases	Serous	Mucinous	Endometrioid	Clear cell	Invasive	Borderline	Question used to define genital powder use
AUS^g	2002–2006	1,449	1,432	889 (62%)	174 (12%)	132 (9%)	78 (5%)	1,158 (81%)	274 (19%)	Have you ever used any sort of powder or talc on your genital area, in your underwear or on a sanitary pad or diaphragm?
DOV^g	2002–2009	1,841	1,565	905 (58%)	186 (12%)	201 (13%)	87 (6%)	1,153 (74%)	412 (26%)	Before (reference date) did you ever use any of the following products routinely during 1 month or more? Powder on sanitary napkins or pads? Vaginal deodorant spray? Before (reference date) did you usually apply any powder to your genital (perineal) area after bathing? We are only interested in times when you did this for at least 1 year or longer.^d
HAW	1993–2008	755	481	222 (46%)	87 (18%)	69 (14%)	47 (10%)	392 (82%)	89 (19%)	Before (month/year of diagnosis^e) did you ever use talc, baby, or deodorizing powder dusted or sprayed on your body? By regularly I mean at least once a month for 6 months or more. Did you ever use talc, baby, or deodorizing powder as a dusting powder to the genital or rectal area? As a dusting powder to sanitary napkins? As a dusting powder to underwear? On a diaphragm or cervical cap?
HOP	2003–2008	1,489	735	433 (59%)	53 (7%)	75 (10%)	47 (6%)	568 (88%)	80 (12%)	As an adult and before (reference month/year) did you ever use talc or baby powder or deodorizing powder with talc at least once a month for 6 months or more in any of the following ways: as a dusting powder or deodorizing spray to your genital or rectal areas? On your sanitary napkin? On your underwear? On your diaphragm or cervical cap?
NCO^g	1999–2008	650	786	489 (62%)	71 (9%)	100 (13%)	65 (8%)	636 (81%)	148 (19%)	Did you ever regularly use cornstarch, talc, baby, or deodorizing powders (dusted or sprayed) at least 1 time per month for at least 6 months? If yes, please tell me if you used cornstarch, talc, baby, or deodorizing powders in any of the following ways: directly to your genital or rectal areas? Applied to your sanitary napkins or tampons? Applied to birth control devices such as cervical cap or diaphragm? Applied to your underwear?
NEC^g	1992–2008	2,329	2,305	1,234 (54%)	281 (12%)	352 (15%)	276 (12%)	1,659 (77%)	486 (23%)	Did you ever regularly use powder on your body or your underwear (at least once per month for any amount of time)? If yes, did you apply powder directly to your genital or rectal areas? To your sanitary napkins or tampons? To your underwear?^f
SON^g	1989–1992	564	449	254 (57%)	80 (18%)	71 (16%)	29 (6%)	365 (81%)	84 (19%)	Have you ever used sanitary napkins/tampons? If yes, could you tell me over what ages you have used them, for how many years, what percentage of periods you have used them for, the usual number you have used for each period, whether they were deodorant pads/tampons, and if you used talcum powder or starch on them? Have you ever regularly used talcum powder or starch on your vaginal area after showering or bathing?
USC	1993–1997	782	772	396 (52%)	131 (17%)	75 (10%)	32 (4%)	549 (73%)	205 (27%)	Before (reference month/year), did you ever regularly use talc, baby, or deodorizing powder dusted or sprayed on your body? By regularly I mean at least once a month for 6 months or more. Did you ever use talc, baby, or deodorizing powder as a dusting powder to the genital or rectal area? As a dusting powder to sanitary napkins? As a dusting powder to underwear? On a diaphragm or cervical cap?

↵^aAUS, Australian Cancer Study; DOV, Diseases of the Ovary and their Evaluation Study; HAW, Hawaii Ovarian Cancer Study; HOP, Hormones and Ovarian Cancer Prediction Study; NCO, North Carolina Ovarian Cancer Study; NEC, New England Case Control Study; SON, Southern Ontario Ovarian Cancer Study; and USC, University of Southern California Study of Lifestyle and Women's Health.
↵^bCases listed by histology do not sum because mixed, other, undifferentiated, and unknown are not included.
↵^cCases listed by behavior do not sum to the total number of cases because 267 cases are missing behavior information.
↵^dIn a separate series of questions, participants were asked about powder use with diaphragm storage. Duration was calculated from ages of use. Information on duration, frequency, and timing of use was only collected on genital/perinal powder use after bathing.
↵^eControls were asked “Have you ever regularly used…”
↵^fNEC question varied slightly between the three study phases. Between 1992 and 1997 participants were asked, “As an adult and before (reference month/year), did you regularly use talc, baby, or deodorizing powders dusted or sprayed to your body in any of the following ways:”. Between 1998 and 2003, women were asked “Did you regularly apply cornstartch, talc, baby, or deodorizing body powder at least one time per month for 6 months or longer? If yes, please tell me if you regularly applied cornstarch, talc, baby or deodorizing body powders in any of the following ways:” Between 2003 and 2008 participants were asked the question listed above.
↵^gThese studies previously published on genital powder use and ovarian cancer risk. AUS, DOV, and NEC provided new data to the pooled analyses presented here that were not included in previous publications.

Table 2.

Characteristics of cases and controls included in the pooled analysis^a

	Controls (N = 9,859)	Cases (N = 8,525)
	Mean (STD) or N (%)	Mean (STD) or N (%)
Age	55 (12)	55 (12)
Oral contraceptive use
Never	2,995 (30)	3,411 (40)
Ever	6,864 (70)	5,114 (60)
Parous
No	1,468 (15)	2,196 (26)
Yes	8,391 (85)	6,329 (74)
Tubal ligation
No	7,359 (75)	6,994 (82)
Yes	2,500 (25)	1,531 (18)
BMI	26.5 (6.1)	27.0 (6.6)
Race/ethnicity
Non-Hispanic White	8,629 (88)	7,433 (87)
Hispanic White	197 (2)	214 (3)
Black	273 (3)	268 (3)
Asian	350 (4)	313 (4)
Other^b	407 (4)	291 (4)
Powder use^c
Never use	5,815 (59)	4,643 (54)
Non-genital use only	1,533 (16)	1,282 (15)
Genital use	2,511 (25)	2,600 (31)

↵^aAll characteristics listed except age differed significantly (<0.01) between cases and controls. Cases include both borderline and invasive ovarian cancers.
↵^bThere are 6 cases and 3 controls missing race/ethnicity information.
↵^cCategories for non-genital and genital powder use are mutually exclusive.

Table 3.

Association between powder use and risk of ovarian cancer (borderline and invasive combined) by study site

Site	Controls (%) (N = 9,859)	Cases (%) (N = 8,525)	Age-adjusted OR (95% CI)^a	Multivariate OR (95% CI)^a
AUS
No powder use	305 (21)	300 (21)	1.00	1.00
Non-genital use only	486 (34)	427 (30)	0.85 (0.69–1.05)	0.92 (0.74–1.14)
Genital use	658 (45)	705 (49)	1.04 (0.85–1.26)	1.13 (0.92–1.38)
DOV^b
No powder use	1,544 (83)	1,293 (83)	1.00	1.00
Genital use	297 (16)	272 (17)	1.14 (0.95–1.37)	1.13 (0.93–1.36)
HAW
No powder use	489 (65)	326 (68)	1.00	1.00
Non-genital use only	154 (20)	81 (17)	0.79 (0.58–1.07)	0.69 (0.50–0.96)
Genital use	112 (15)	74 (15)	0.99 (0.72–1.37)	0.99 (0.70–1.41)
HOP
No powder use	989 (66)	439 (60)	1.00	1.00
Non-genital use only	184 (13)	102 (14)	1.23 (0.94–1.61)	1.23 (0.93–1.62)
Genital use	316 (21)	194 (26)	1.37 (1.11–1.69)	1.34 (1.07–1.67)
NCO
No powder use	391 (60)	469 (60)	1.00	1.00
Non-genital use only	137 (21)	122 (16)	0.75 (0.57–0.99)	0.74 (0.56–0.99)
Genital use	122 (19)	195 (25)	1.33 (1.03–1.74)	1.37 (1.05–1.80)
NEC
No powder use	1,239 (53)	1,129 (49)	1.00	1.00
Non-genital use only	454 (19)	421 (18)	1.02 (0.87–1.19)	1.04 (0.88–1.22)
Genital use	636 (27)	755 (33)	1.30 (1.14–1.49)	1.28 (1.12–1.47)
SON^b
No powder use	364 (65)	252 (56)	1.00	1.00
Genital use	200 (35)	197 (44)	1.43 (1.11–1.85)	1.35 (1.03–1.76)
USC
No powder use	494 (63)	435 (56)	1.00	1.00
Non-genital use only	118 (15)	129 (17)	1.25 (0.94–1.66)	1.14 (0.85–1.52)
Genital use	170 (22)	208 (27)	1.39 (1.10–1.77)	1.36 (1.06–1.74)
Pooled^c
No powder use	5,815 (59)	4,643 (54)	1.00	1.00
Non-genital use only	1,533 (16)	1,282 (15)	0.98 (0.90–1.07)	0.98 (0.89–1.07)
Genital use	2,511 (25)	2,600 (31)	1.25 (1.16–1.34)	1.24 (1.15–1.33)

↵^aStudy-specific estimates were determined using unconditional logistic regression and pooled ORs were estimated using conditional logistic regression conditioned on 5-year age groups and study. Multivariate models are adjusted for age (continuous), oral contraceptive duration (never use, <2, 2–<5, 5–<10, or ≥10 years), parity (0, 1, 2, 3, or 4+ children), tubal ligation history (no or yes), BMI (quartiles), race/ethnicity (non-Hispanic White, Hispanic White, Black, Asian, or other).
↵^bInformation on non-genital powder use was not collected in the SON and DOV study.
↵^cP value for heterogeneity between multivariate study specific ORs equal to 0.61; calculated using Conchran's Q statistic test.

Table 4.

Association between powder use and risk of ovarian cancer by behavior and histology

	Model 1^a			Model 2^a
	No powder use	Genital powder use		No genital powder use	Genital powder use
	n (%)	n (%)	OR (95% CI)^b	n (%)	n (%)	OR (95% CI)^b
Controls	5,815 (59)	2,511 (25)		7,348 (75)	2,511 (25)
All borderline cases	1,035 (58)	504 (28)	1.29 (1.14–1.48)	1,247 (72)	504 (28)	1.30 (1.15–1.47)
Serous	567 (57)	300 (30)	1.46 (1.24–1.72)	700 (70)	300 (30)	1.45 (1.24–1.69)
Mucinous	409 (60)	184 (27)	1.17 (0.96–1.42)	502 (73)	184 (27)	1.19 (0.98–1.43)
All invasive cases	3,470 (54)	2,009 (31)	1.21 (1.12–1.32)	4,471 (69)	2,009 (31)	1.23 (1.14–1.32)
Serous	1,952 (53)	1,197 (32)	1.20 (1.09–1.32)	2,519 (68)	1,197 (32)	1.24 (1.13–1.35)
Mucinous	206 (57)	94 (26)	1.09 (0.84–1.42)	269 (74)	94 (26)	1.06 (0.82–1.36)
Endometrioid	568 (55)	304 (30)	1.22 (1.04–1.43)	723 (70)	304 (30)	1.20 (1.03–1.40)
Clear Cell	327 (54)	187 (31)	1.24 (1.01–1.52)	420 (69)	187 (31)	1.26 (1.04–1.52)

↵^aIn model 1, the reference group is restricted to women with no powder use except for the DOV and SON studies as these did not collect data on non-genital powder use. The number of cases who reported non-genital powder use was 212 (13%) of all borderline cases, 133 (13%) serous borderline, 93 (14%) mucinous borderline, 1,001 (15%) of all invasive, 567 (15%) serous invasive, 63 (17%) mucinous invasive, 155 (15%) endometrioid invasive, 93 (15%) clear cell invasive. In model 2, the reference group includes all women who did not use genital powders (nonusers and non-genital users combined).
↵^bORs were estimated using conditional logistic regression conditioned on 5-year age groups and adjusted for age (continuous), oral contraceptive duration (never use, <2, 2–<5, 5–<10, or ≥10 years), parity (0, 1, 2, 3, or 4+ children), tubal ligation history (no or yes), BMI (quartiles), race/ethnicity (non-Hispanic White, Hispanic White, Black, Asian, or other).

Table 5.

Association between estimated lifetime applications of genital powder and risk of ovarian cancer (borderline and invasive combined)

Lifetime number of applications^a		All cases (N = 7,587)		Nonmucinous cases (N = 6,361)
	Controls (%)	Cases (%)	OR^b (95% CI)	Cases (%)	OR^b (95% CI)
Never users	6,175 (76)	5,384 (71)	1.00	4,472 (70)	1.00
Quartile 1	509 (6)	534 (7)	1.14 (1.00–1.31)	467 (7)	1.18 (1.02–1.36)
Quartile 2	512 (6)	541 (7)	1.23 (1.08–1.41)	456 (7)	1.22 (1.06–1.41)
Quartile 3	497 (6)	542 (7)	1.22 (1.07–1.40)	457 (7)	1.22 (1.06–1.40)
Quartile 4	486 (6)	586 (8)	1.32 (1.16–1.52)	509 (8)	1.37 (1.19–1.58)
P_trend^c			0.17		0.17

↵^aAge-specific 25^th, 50^th, and 75^th percentile cutoff points are 612, 1,872, and 5,400 for participants < 40 years old; 612, 2,160, and 7,200 for 41–50 years; 720, 3,600, and 10,800 for 51–60 years; 1,440, 5,760, and 14,440 for 61–70; 840, 7,200, and 18,000 for > 70 years.
↵^bORs were estimated using conditional logistic regression conditioned on 5-year age groups and adjusted for age (continuous), oral contraceptive duration (never use, <2, 2–<5, 5–<10, or ≥10 years), parity (0, 1, 2, 3, or 4+ children), tubal ligation history (no or yes), BMI (quartiles), race/ethnicity (non-Hispanic White, Hispanic White, Black, Asian, or other).
↵^cTrend excludes never users.