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私密护理产品可能含有干扰内分泌的化学物质，例如邻苯二甲酸盐、对羟基苯甲酸酯和双酚，可以改变内源性激素水平，并且可能影响患乳腺癌、卵巢癌或子宫癌等激素相关疾病的风险。私密护理产品还可能含有其他已知或可疑的致癌物质，例如挥发性有机化合物和石棉。冲洗剂和粉剂是两种常用的私密护理产品。冲洗是使用产生向上水流的装置将液体注入阴道，最初宣传冲洗是为避孕，女性还通过冲洗提高清洁度并减少异味，尤其性交或者月经之后。虽然一些冲洗液仅仅含有水或醋，但是在市售产品中已经检测到干扰内分泌的化学物质和挥发性有机化合物，并且使用者尿中邻苯二甲酸盐含量升高。冲洗还与不良生殖卫生结局相关，包括盆腔炎、细菌性阴道病和宫外孕，也被认为是宫颈癌风险因素以及可能的卵巢癌风险因素。由滑石粉或者玉米淀粉组成的粉末可以涂在生殖器区域，防止潮湿和擦伤，促进清洁感或减少异味。由于滑石粉与石棉天然共存，使用生殖器爽身粉已成为公共卫生问题。虽然最近监测发现某些滑石产品存在石棉颗粒，但是由于缺乏常规监测，石棉污染的普遍程度尚不明确。在生殖器区域使用粉末可能通过直接接触石棉以外的机制促进致癌，包括接触其他化学物质或生殖道的刺激和炎症。在考虑私密护理产品潜在致癌性时，生殖器粉末与卵巢癌的关联得到深入研究，虽然结果尚不一致。最初的病例对照研究表明存在很强的正相关性，但是即使汇总之后，前瞻研究并未重复该关联。根据数据收集回顾研究，已患和未患卵巢癌的女性报告暴露情况可能不同，从而导致回忆偏倚。前瞻研究虽然不受回忆偏倚的影响，但是往往病例数较少且暴露评估简化，导致统计学精度较低，并且非差异暴露错误分类的可能性增加。 2024年5月15日，美国临床肿瘤学会《临床肿瘤学杂志》在线发表美国国家卫生研究院、国家环境卫生科学研究所、国家癌症研究所、北卡罗来纳大学吉林斯全球公共卫生学院《姐妹研究》分析报告，利用该史诗级超大样本美国队列研究数据，分析私密护理产品与女性激素相关癌症的关联，并且考虑可能存在的偏倚。 《姐妹研究》于2003年至2009年入组姐妹患乳腺癌但是自己尚未患癌女性50884例，并于2017年至2019年进行随访，入组时和随访时收集生殖器滑石粉使用和冲洗的数据，采用多因素比例风险模型对种族、学历、身高体重指数、初次月经年龄、激素避孕时间、分娩次数、绝经状态、激素治疗使用情况、吸烟情况、饮酒情况以及地理区域等其他影响因素进行校正后，比较私密护理产品使用与否，对乳腺癌、卵巢癌和子宫癌风险的影响。为了解释可能存在的暴露错误分类和回忆偏倚，在各种暴露重新分配假设下进行定量偏倚分析。 
结果，对其他影响因素进行校正前，用过冲洗剂和生殖器滑石粉的比例分别为41%和35%，对其他影响因素进行校正后，最高分别达64%和56%。 对暴露错误分类进行校正后，用过与从未用过生殖器滑石粉相比，卵巢癌风险高达1.17～3.34倍。冲洗次数越多、年龄越早，卵巢癌风险越高。但是，无论冲洗剂，还是滑石粉，都对乳腺癌或子宫癌风险影响不大。
按病例和非病例对滑石粉使用情况进行差异化报告可能产生正偏倚，但是纠正错误仍可导致风险比高于1.0。例如，当25%的暴露病例和10%的未暴露非病例重新比较是否用过滑石粉时，风险仍然高达1.40倍（95%置信区间：1.04～1.89）。 因此，该研究结果表明，虽然回忆差异可导致估计值出现向上偏倚，但是校正后仍然支持私密护理产品（包括生殖器滑石粉）与卵巢癌风险存在显著关联。J Clin Oncol. 2024 May 15. IF: 45.3 Intimate Care Products and Incidence of Hormone-Related Cancers: A Quantitative Bias Analysis. O'Brien KM, Wentzensen N, Ogunsina K, Weinberg CR, D'Aloisio AA, Edwards JK, Sandler DP. National Institute of Environmental Health Sciences, National Institutes of Health, Research Triangle Park, NC; National Cancer Institute, Rockville, MD; DLH Holdings Corporation, Durham, NC; Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC. PURPOSE: Intimate care products may contain substances associated with increased risk of hormone-related cancers. The relationship between genital talc use and ovarian cancer, in particular, has been well studied, but concerns about recall bias and exposure misclassification have precluded conclusions. We examined the association between intimate care products and female hormone-related cancers, accounting for potential biases, using data from a US-based cohort study. METHODS: The Sister Study enrolled 50,884 women who had a sister with breast cancer. Data on genital talc use and douching were collected at enrollment (2003-2009) and follow-up (2017-2019). We used Cox proportional hazards models to estimate hazard ratios (HRs) for associations between intimate care product use and breast, ovarian, and uterine cancers. To account for potential exposure misclassification and recall bias, we conducted quantitative bias analyses under various exposure reassignment assumptions. RESULTS: Across considered scenarios, 41%-64% of participants douched and 35%-56% used genital talc. In models adjusted for exposure misclassification, genital talc use was positively associated with ovarian cancer (HR range, 1.17-3.34) Frequent douching and douching during young adulthood were positively associated with ovarian cancer, but neither douching nor talc was associated with breast or uterine cancer. Differential reporting of talc use by cases and noncases likely produces positive biases, but correcting for error still resulted in HRs above 1.0. For example, HR, 1.40 (95% CI, 1.04 to 1.89) when 25% of exposed cases and 10% of unexposed noncases had talc status reassigned. CONCLUSION: Although results show how differential recall would upwardly bias estimates, corrected results support a positive association between use of intimate care products, including genital talc, and ovarian cancer. KEY OBJECTIVE: Are history of genital talc use and douching associated with breast, ovarian, or uterine cancer after correcting for likely biases? KNOWLEDGE GENERATED: Genital talc use was positively associated with ovarian cancer for a range of plausible bias-correction scenarios, with higher rates seen for frequent and long-term users. Douching frequently and during young adulthood were also positively associated with ovarian cancer, but neither douching nor talc was associated with breast or uterine cancer. RELEVANCE: These findings support the hypothesis that there is a positive association between genital talc use and development of ovarian cancer, but unmeasured confounding could still be present. PMID: 38748950 DOI: 10.1200/JCO.23.02037
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