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To the Editor Dr O’Brien and colleagues combined data on powder use in the genital area and ovarian cancer from 4 cohort studies and reported an overall hazard ratio (HR) of 1.08 (95% CI, 0.99-1.17). Except for data from the Nurses’ Health Study II and additional follow-up, little new information was presented. Previously, combined data from 3 of the cohorts showed an odds ratio (OR) for perineal powder use and ovarian cancer of 1.06 (95% CI, 0.90-1.25). In the latter study, the cohort data did not outweigh the evidence from 24 case-control studies, with a combined OR of 1.31 (95% CI, 1.24-1.39).
To the Editor We disagree with the analysis and interpretation of the findings presented by Dr O’Brien and colleagues. The increased risk of ovarian cancer in women with intact genital tracts exposed to powder (HR, 1.13) is actually greater than the estimated 10% increased incidence of ovarian cancer attributable to cumulative talc exposure with 10 000 or more applications previously reported in women with intact genital tracts. The lack of association in women without an intact genital tract is consistent with their curtailed exposure. O’Brien and colleagues discounted the results because their statistical test for heterogeneity was not statistically significant. No statistical test is needed to know that women without an intact genital tr.
In Reply As pointed out by Dr Cramer, the cohorts in our pooled analysis assessed powder use with less detail compared with prior case-control studies. He is also correct that most participants were postmenopausal at enrollment, although ever use included premenopausal time and we considered menopausal status and hormone use as effect modifiers. We noted that genital powder exposure was likely misclassified for some individuals, especially with regard to frequency and duration, and we did not have data on changes in use over time, use during specific exposure windows, or use of different types of powder. This lack of detail may have biased our effect estimates toward the null.

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