Talcum powder's links to cancer: What it really means

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talc ovarian cancer cases orig mg_00000904

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Ford Vox is a physician specializing in rehabilitation medicine and a journalist. He is a medical analyst for NPR station WABE-FM 90.1 in Atlanta. He writes frequently for CNN Opinion. Follow him on Twitter @FordVox. The opinions expressed in this commentary are solely those of the author. This commentary adds an update to an earlier column about lawsuits over the effects of talcum powder use.

(CNN)With yet another eye-popping talcum powder verdict against Johnson & Johnson, the healthcare product giant is making the headlines. I last wrote about the issue in 2016, in a column (which appears below this update) about a ruling against Johnson & Johnson related to a claim that the powder caused ovarian cancer.

But in this new verdict, reached last week, a New Jersey jury agreed with a man suffering from mesothelioma, a form of lung cancer, that the baby powder he'd used for decades was to blame. The jury awarded him $30 million in compensatory damages and his wife $7 million in damages.
Americans' use of talcum powder has dropped off precipitously since the early 1980s, and the continuing legal battles over its links to cancer will ensure that trend continues. Johnson & Johnson is offering a cornstarch alternative, while vigorously attempting to defend itself from an onslaught of lawsuits, with few successes. Johnson & Johnson vehemently denies that its powder has anything to do with cancer.
The naturally occurring mineral compounds we call talc can sometimes be contaminated with asbestos, another group of minerals that are undisputed carcinogens. American talc products have had no detectible asbestos in testing for many decades now, but the scientific controversy over whether "pure" forms of talc can kick off cancers of the ovaries and lungs continues.
    Most of the research is of a sometimes frustrating variety of "epidemiological" work where medical researchers try to compare similar groups of people who have just one important difference, like daily baby powder use, or working in a talc mine.
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    It's not ethical or even technically feasible to perform more direct forms of research on humans about the effects of a suspected carcinogen. Taiwanese researchers recently tabulated data from 14 such studies that looked at talc miners, finding a link between pure talc and lung cancer.
    They made a point to include Chinese research that had been excluded in other studies, such as one published by employees of ChemRisk, a firm that is helping the talc industry defend itself from these product liability lawsuits.
    Another group of scientists from Australia recently evaluated 27 studies looking for links between ovarian cancer and talc, concluding that women who use talc on their genital areas face "a 24%--39% increased risk of ovarian cancer."
    While the lawsuits rage on, an agency charged with making clear determinations on the carcinogenicity of consumer products hasn't stepped up to the plate. The United States National Toxicology Program didn't add talc to its 2005 Congressional Report on Carcinogens despite meetings concluding that women's use of talc in the genital area is "reasonably anticipated to be a human carcinogen," and while they couldn't determine if talc caused lung cancer too, they did agree it remains in the lungs for years.
    The bottom line: You'll keep seeing these headlines. I hope these lawsuits will convince the consumer products industry to openly share what it knows, when it knows it, about the potential dangers of what it's selling.
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    Original column, published May 3, 2016:
    Does talcum powder — powder that many have slathered on babies for generations -- really cause cancer?
    There are more than 1,000 women lined up to sue Johnson & Johnson over just that: cancer diagnoses they attribute to the company's talcum powder products.
    In early 2016, a St. Louis jury ordered the company to pay $55 million to a South Dakota woman who had used talcum powder for years and has ovarian cancer.
    But why did it take rainmaker attorneys to educate a jury from square one all the way to the point of ringing up a jackpot verdict? Johnson & Johnson positioned itself well as their target: Even though scientists have been publishing concerning studies for years, the company didn't forthrightly warn its customers there could be a major safety issue.
    Talcum powder also managed to escape the oversight of federal agencies many consumers might imagine are always on high alert, surveilling the published literature for product safety concerns.
    So what's the big problem with a product millions of people have considered so safe they put it on babies during diaper change?
    The theory is that talcum powder, when applied in the genital region, manages to work its way up through the vagina, the cervix, the uterus, the fallopian tubes and into the ovaries.
    The female reproductive system has, after all, evolved to facilitate the upward mobility of sperm in order to fertilize eggs that have descended into the uterus, and the microscopic particles of talcum powder may well keep traveling all the way up.
    Indeed, doctors have identified talc particles inside cancerous ovarian tissue. Talc has also been found in pelvic lymph nodes, indicating that it made it all the way out of the fallopian tubes and into the abdominal space.
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    In 2013, Deane Berg of Sioux Falls, South Dakota, was the first woman diagnosed with ovarian cancer to take on the medical and consumer products giant.
    She came away without a dime awarded to her even though she won her suit; instead of awarding monetary damages the jury told Johnson & Johnson that it should affix a warning to its talc products like Johnson's Baby Powder and Shower to Shower, one that says the product could cause cancer.
    And Berg's lawsuit laid historic legal groundwork: The company will now have to pay a combined $127 million in damages awarded in two cases by St. Louis juries this year if its appeals aren't successful.
    In the Berg lawsuit, Brigham and Women's Hospital obstetrician and gynecologist Dr. Daniel Cramer testified to his opinion that upwards of 10,000 women a year are developing ovarian cancer in part due to their use of talcum powder.
    Pathologist Dr. John Godleski, also at Brigham, found talc particles inside Berg's ovarian tumor tissue.
    I don't have records from the two St. Louis cases where juries have penalized Johnson & Johnson with megamillion-dollar awards to the plaintiffs, but I'd expect those juries saw similar evidence to what Berg presented in 2013.
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    In fact, Cramer and his colleagues at Brigham just published a large study looking back at over 2,000 women diagnosed with ovarian cancer and comparing their use of talcum powder with that of a similar group of women who didn't have ovarian cancer.
    In showing a strong link between talc use and ovarian cancer, a 33% higher risk overall, the Brigham group specifically faulted another large study published in 2014 that didn't identify a risk. That study, Cramer wrote, didn't look at premenopausal women who seem to be at higher risk, and didn't properly weigh the role of estrogen use, which seems to be a necessary ingredient in upping the risk for ovarian cancer in postmenopausal women.
    The medical debate over whether talcum powder causes ovarian cancer goes back many decades, and the attorneys in these cases are demonstrating, through internal documents they've subpoenaed, that Johnson & Johnson knew about this research.
    They allege that Johnson & Johnson is akin to the tobacco companies that knew about research linking smoking to lung cancer but kept this information from the public and fought off attempts to regulate their product.
    I don't think Johnson & Johnson deserves quite the opprobrium we reserve for the tobacco companies, since conflicting research did exist, but they and companies like them are setting themselves up for these kinds of lawsuits if they're not open and transparent with consumers.
    A smarter approach would have been to acknowledge the worrisome research studies in their consumer literature, on their websites, and to have flagged customers somehow on their product labeling to review this material with their doctors and decide for themselves whether and how to use the products.
    But it's not all Johnson & Johnson's responsibility. Federal agencies like the Food and Drug Administration, the Centers for Disease Control and Prevention and the Consumer Products Safety Commission need the authority and the funding to keep up with reported and published adverse effects of all consumer products, and actively weigh when mandatory warnings are necessary.
    Companies should welcome the federal agencies taking off some of the load -- Johnson & Johnson could have shared some of its liability with such an agency by regularly checking in about how it should act, or what warning it should issue, in light of recent research.
    We have a problem when it falls to trial juries to weigh the scientific data on a given product against a particular medical case and decide whether a company should be adding warning labels, or paying out large sums in the hopes the companies will learn a lesson.
    That's one way to get the job done, but it's after the fact, it's messy, and it's prone to error and excess. We can expect that appeals will significantly reduce these headline-grabbing jury awards.