Preview
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NYSCEF DOC. NO. 353 RECEIVED NYSCEF: 03/17/2023
EXHIBIT 142
FILED: ERIE COUNTY CLERK 03/17/2023 09:21 PM INDEX NO. 815818/2020
NYSCEF DOC. NO. 353 RECEIVED NYSCEF: 03/17/2023
Moline et al. Journal of Occupational
Journal of Occupational Medicine and Toxicology (2023) 18:1
https://doi.org/10.1186/s12995-023-00367-5 Medicine and Toxicology
RESEARCH Open Access
Exposure to cosmetic talc and mesothelioma
Jacqueline Moline1,2*, Kesha Patel1 and Arthur L. Frank3
Abstract
Aim Mesothelioma is associated with asbestos exposure. In this case series, we present 166 cases of individuals who
had substantial asbestos exposure to cosmetic talc products as well as some who had potential or documented addi-
tional exposures to other asbestos-containing products and who subsequently developed mesothelioma.
Methods Data were gathered for all subjects referred to an occupational and environmental medicine specialist as
part of medicolegal review. Years of total cosmetic talcum powder usage was noted as well as the latency from the
onset of talcum powder use to the mesothelioma diagnosis. Alternate asbestos exposure in addition to the exposure
from cosmetic talc was categorized as none, possible, likely, and definite.
Results In 122 cases, the only known exposure to asbestos was from cosmetic talc. For 44 cases, potential or docu-
mented alternate exposures in addition to the cosmetic talc were described.
Conclusion Cumulative exposure to asbestos leads to mesothelioma; for individuals with mixed exposures to asbes-
tos, all exposures should be considered. Use of cosmetic talc is often overlooked as a source of asbestos exposure. All
individuals with mesothelioma should have a comprehensive history of asbestos exposure, including cosmetic talc
exposure.
Keywords Malignant mesothelioma, Cumulative asbestos exposure, Cosmetic talcum powder
Introduction as “take-home” exposure has been well described in the
Mesothelioma, described as a sentinel tumor, is inti- literature [2–5]. An underappreciated source of exposure
mately associated with asbestos exposure. Asbestos has is the use of cosmetic talc products. The International
been used for decades in thousands of products, both in Agency for Research on Cancer (IARC) [6] states that
occupational and non-occupational settings, historically asbestos contaminated talc is carcinogenic and should be
accounting for the bulk of mesothelioma cases. Non- treated as if one were dealing with asbestos. Asbestos lev-
occupational exposures can be environmental in nature, els in talcum powder are significantly above background
from effluents from mines and factories, from para- ambient asbestos exposure levels [7–9]. Talc applica-
occupational exposures such as “shade-tree mechanics” tion simulation studies have been published [7, 8] where
using friction products, and from home renovations [1]. exposures to talcum powder were 1.9 f/cc and 2.57 f/cc,
Household exposures affecting family members, known respectively. According to the Gramond et al. [10] cate-
gorization of intensity, asbestos exposure at these levels
*Correspondence:
would be considered to be high (> 1–10 f/ml).
Jacqueline Moline Historically, asbestos exposures at work have been
jmoline@northwell.edu
1
linked to multiple products. The overall risk for asbes-
Department of Occupational Medicine, Epidemiology and Prevention,
Northwell Health, Great Neck, NY 11021, USA
tos related disease, including mesothelioma, is related
2
Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, to cumulative exposure. As agencies such as NIOSH,
Hempstead, NY 11549, USA
3
OSHA, the EPA, and others have recognized, there
Dornsife School of Public Health of Drexel University, Philadelphia, PA
19104, USA
is no known safe exposure to asbestos. Low doses of
exposure to asbestos contribute to mesothelioma [11].
© The Author(s) 2023. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which
permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the
original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or
other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line
to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory
regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this
licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativeco
mmons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.
FILED: ERIE COUNTY CLERK 03/17/2023 09:21 PM INDEX NO. 815818/2020
NYSCEF DOC. NO. 353 RECEIVED NYSCEF: 03/17/2023
Moline et al. Journal of Occupational Medicine and Toxicology (2023) 18:1 Page 2 of 13
Both time from first exposure (latency) and total expo- cleaning clothes), do-it-yourself home repair, domestic
sure (cumulative dose) to asbestos must be taken into (handling asbestos material or living in the presence
account when evaluating risk. With multiple repeated of asbestos material susceptible to damage at home),
incidences of exposure, all those above background level or environmental (living near and asbestos processing
should be thought of as “’substantial.” When considering plant). This study was conducted with approval from
the elevated risk of mesothelioma in sheet metal work- the Human Research Protection Program at North-
ers [12, 13], Zoloth and Michaels considered the multi- well Health Feinstein Institute for Medical Research
ple bystander exposures to different products, not simply (#21–0897-OTH).
one construction material. This case series presents 166
cases of individuals who had a minimum of five years and
a mean of 40.8 years of exposure to asbestos through cos- Results
metic talc products, some with possible other exposures, We identified 166 individuals with exposure to cosmetic
but all developed mesothelioma. talc who were diagnosed with a malignant mesothelioma
between 2014 and 2021. None of these individuals were
Methods previously included in publications by the authors [14]. A
Data were gathered for all subjects referred to an occu- summary of the case findings is found in Table 1. Overall,
pational and environmental medicine specialist, JM, the average age of diagnosis was 63.3 (age range 26–94)
as part of medicolegal review. All cases were reviewed years of age. The majority of cases were epithelioid meso-
personally by an occupational medicine specialist with thelioma (75.3%). The average length of exposure to cos-
experience evaluating asbestos exposure in thousands metic talc was 40.8 years (range 5–76 years of use), and
of individuals. The individual’s medical records were the average latency period from the onset of talcum pow-
reviewed and mesothelioma diagnoses were based on der use to the development of mesothelioma was 52.4
pathological reports that were performed as part of (20—83 years). We identified 122 individuals with asbes-
their diagnostic evaluation. Exposure data was obtained tos exposure solely through use of cosmetic talc. Expo-
by sworn testimony of the mesothelioma patients in sure to talcum powder could have been for personal use,
all cases, and/or from family members who had direct in an occupational setting (for example, a nurse applying
knowledge of the individual’s use of cosmetic talc and, talcum powder to a patient), or applying talcum powder
if present, other sources of asbestos exposure. Use of to others such as children. For 122 individuals, they either
talc was recorded as being diapered or powdered as a used cosmetic talc while diapering children or recalled
child; diapering or powdering children or others; apply- applying talc to others (such as their children). Overall,
ing talcum powder to oneself after bathing, or other 80.6% of women and 52.4% of men used talcum powder
personal applications of talc. Years of total cosmetic for diapering or applying talc to others. For 44 individu-
talcum powder usage was noted as well as the latency als, potential alternate asbestos exposure in addition to
from the onset of talcum powder use to the mesothe- cosmetic talc was reported. Table 1 presents the 44 cases
lioma diagnosis. Age was presented within a 10 year with alternate exposure ranked by possible, likely, and
window to maintain confidentiality. Data reviewed definite asbestos exposure. Twenty-two women (17.8%)
included family occupational histories (parents or any- and fifteen men (35.7%) had likely or definite alternate
one cohabitating with the individual), hobbies, resi- exposure to asbestos in addition to their talcum powder
dence, living with or laundering clothes of an asbestos usage. [Details of the exposure history of all 166 individu-
exposed worker, if indicated, home renovations that als with cosmetic talc exposure is presented in Table 2,
could have exposed the individual to asbestos contain- including a description of the alternate exposure.] Table 1
ing construction materials, residence close to a facility also shows the site of the tumor by gender. Of the 166
with environmental contamination, or other potential cases, 109 were pleural, 52 were peritoneal, 4 were dis-
asbestos exposures. In those individuals with potential covered in both the pleura and peritoneum and the origi-
asbestos exposure in addition to the cosmetic talc, cat- nal site could not be determined. One case of pericardial
egorization of these exposures was done by two occu- mesothelioma was noted out of the 166 cases, which
pational physicians, JM and ALF. Alternate asbestos reflects the rarity of this site for mesothelioma. The per-
exposure in addition to the exposure from cosmetic talc centages of peritoneal mesothelioma were similar for
was categorized as none, possible, likely, and definite women (29.8%) and men (35.7%). The high proportion
following the descriptions by Gramond et al. [10]. Non- of peritoneal mesothelioma tumors relative to pleural
occupational exposure to asbestos was characterized tumors, consistent with prior case series of patients with
as paraoccupational (living with an asbestos worker or malignant mesothelioma after cosmetic talc use [14, 15],
is unusual and deserves further investigation.
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Moline et al. Journal of Occupational Medicine and Toxicology (2023) 18:1 Page 3 of 13
Table 1 Characteristics of 166 mesothelioma cases with cosmetic talc usage
Total (N = 166) Female (n = 124) Male (n = 42)
Average Age (range) 63.3 (26 – 94) 64.3 (26 – 94) 60.9 (28 – 83)
Years of Talc Use* (range) 40.8 (5 – 76) 40.4 (6 – 76) 42.0 (5 – 74)
Talc Latency in Years (range) 52.4 (20 – 83) 53.3 (20 – 83) 49.9 (28 – 74)
Diapering or Applying Talc to Others** 122 (73.5%) 100 (80.6%) 22 (52.4%)
Talc Use Only 122 (73.5%) 97 (78.2%) 25 (59.5%)
Talc Use and Alternate Exposure 44 (26.5%) 27 (21.8%) 17 (40.5%)
Certainty of Alternate Exposure (n = 44) (26.5%) Possible 7 (4.2%) 5 (4.0%) 2 (4.8%)
Likely 17 (10.2%) 14 (11.3%) 3 (7.1%)
Definite 20 (12.0%) 8 (6.5%) 12 (28.6%)
Tumor Location Pleura 109 (65.7%) 83 (66.9%) 26 (61.9%)
Peritoneum 52 (31.3%) 37 (29.8%) 15 (35.7%)
Both Pleura & Peritoneum 4 (2.4%) 3 (2.4%) 1 (2.4%)
Pericardium 1 (0.6%) 1 (0.8%) 0
Tumor Subtype Biphasic 24 (14.5%) 18 (14.5%) 6 (14.3%)
Epithelial 125 (75.3%) 92 (74.2%) 33 (78.6%)
Sarcomatoid 16 (9.6%) 13 (10.5%) 3 (7.1%)
Not specified 1 (0.6%) 1 (0.8%) 0
*
Years of Talc Use: includes years of being diapered or powdered with talc as a child; years of diapering or powdering children or others with talc; and years applying
talcum powder to oneself after bathing or other personal use
**
Diapering or Applying Talc: restricted to diapering or powdering children with talc or applying talcum powder to others, including occupational use
Discussion [23] In some instances authors limited the characteriza-
This paper presents 166 individuals with malignant mes- tion of asbestos exposure in women to certain industries,
othelioma and asbestos exposure through documented such as shipbuilding during wartime [24], thus neglecting
use of cosmetic talcum powder. For 122 of 166, their only other potential sources and decreasing the attributable
known exposure to asbestos was their use of cosmetic tal- risk. Conversely, when non-occupational exposures were
cum powder. Without the recognition of asbestos expo- included for women, even with low-intensity domestic
sure through cosmetic talcum powder, 73.5% of the cases exposure considered, the attributable risk increased from
might well have been considered “idiopathic.” Similarly, 40% to 64.8% [21].
for those 26.5% of cases with additional asbestos exposure Given that all types of asbestos can cause mesothe-
along with the talc, those alternate exposures would have lioma [6], it is important to consider every source of
been mistakenly considered as the sole, and sufficient, exposure to asbestos in an individual. Talcum powder has
cause of the mesothelioma. Historically, the attributable been contaminated with both chrysotile and amphibole
risk of asbestos for mesothelioma in women ranged from asbestos (predominately anthophyllite and tremolite) [8,
around 20–50%. However as Baur et al. point out, mis- 25, 26]. Recently, Wong et al. (2021) found significantly
classification or inadequate exposure ascertainment has elevated risks of mesothelioma among individuals with
led to this low attributable risk for women compared to only chrysotile exposure and for mixed fiber exposure.
men. [16]. Data from occupationally exposed cohorts that [27]. Chrysotile alone (OR = 3.8) and in combination
included men and women actually show that compared with tremolite/anthophyllite asbestos (OR = 3.9) were
to similarly exposed men, women had higher mortality associated with similar increases in risk of mesothelioma.
rates from mesothelioma [17–20]. Lacourt found that These three fiber types are most commonly found in cos-
at low-level cumulative asbestos exposure ((0 – 0.1 f-cc/ metic talc, and given that different ore sources were used
year) women were more likely to develop mesothelioma in manufacturing over time, it is likely that many formu-
than men [21]. Magnani (2008) found the SMR for mes- lations and uses of talcum powder involved mixed fiber
othelioma was higher for women than for men among type exposure. There is no scientific basis to state that
workers at an asbestos cement plant [22]. Frank et al. one type of exposure was the sole cause of the mesothe-
(2009) found mesothelioma rates in the Qingdao region lioma in a mixed exposure scenario. For example, rates of
of China were correlated with a higher proportion of mesothelioma have been evaluated based on either job
women employed in asbestos manufacturing industries. type or locale (e.g., construction, shipping) rather than
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Table 2 Description of 166 mesothelioma cases
Age at Sex Tumor Tumor Occupation(s) Talc Years Diapering/ Certainty of Type of
Diagnosis Location Subtype Latency of Talc Applying Talc Alternate Alternate
(years) Use* to Others** Exposure Exposure
51–60 F Pleura Epithelial Cosmetics 41 36 Yes None
factory
31–40 F Peritoneal Biphasic Marketing 39 12 No None
91–100 F Pleura Epithelial Clerical worker 69 57 Yes Definite Smoked Kent
cigarettes in
1950s
51–60 M Pleura Biphasic Warehouse 54 22 No Definite Home renova-
supervisor tions as child
21–30 M Peritoneal Epithelial Aircraft techni- 28 5 No None
cian
41–50 F Pleura Biphasic Marketing 47 47 Yes Definite Automotive fric-
tion exposure
41–50 F Peritoneal Epithelial Operator 37 36 Yes Likely Parents worked
technician in chemical
plant/with
automotive
friction materials;
no work clothes
laundered at
home
61–70 F Peritoneal, Epithelial Hairdresser 65 57 Yes Definite Household expo-
pleura sures laundering
clothes (automo-
tive friction
materials)
41–50 F Pleura Epithelial Industrial 45 10 Yes None
engineer
71–80 M Pleura Biphasic Firefighter, 59 59 No Definite Occupational
painter exposures to
industrial talc,
firefighting
51–60 F Peritoneal Epithelial Dental assis- 58 57 Yes Definite Automotive
tant, secretary, friction product
logging busi- exposure
ness
51–60 F Peritoneal, Epithelial Nurse 50 20 Yes None
pleura
71–80 F Pleura Epithelial Secretary 60 61 No None
61–70 M Peritoneal Epithelial Software 53 53 No Likely Construc-
engineer tion work as
teenager;
family member
machinist
61–70 F Pleura Epithelial Secretary 61 20 Yes None
61–70 M Pleura Epithelial Law professor 46 45 No None
21–30 F Peritoneal Biphasic Customer ser- 26 12 No None
vice manager
51–60 F Pleura Epithelial Dental assis- 50 17 Yes Likely Dental tape used
tant, sales in office
21–30 F Pleura Epithelial Programmer 29 17 Yes None
51–60 F Pleura Epithelial Clerical worker 54 48 No None
71–80 F Pleura Biphasic Dental 64 34 Yes Possible Possible house-
assistant, hold exposure
receptionist from parental
occupations
61–70 F Pleura Epithelial Systems 62 61 Yes None
analyst
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Table 2 (continued)
Age at Sex Tumor Tumor Occupation(s) Talc Years Diapering/ Certainty of Type of
Diagnosis Location Subtype Latency of Talc Applying Talc Alternate Alternate
(years) Use* to Others** Exposure Exposure
51–60 F Peritoneal Epithelial Clerical worker 59 31 Yes Likely Asbestos shingle
exposure as child
71–80 F Peritoneal Epithelial Teacher’s aide, 46 46 No None
customer
service
51–60 M Pleura Epithelial Baked goods 55 49 Yes None
manufacturer
61–70 F Pleura Epithelial Housekeeping, 51 23 No None
packaging
41–50 M Peritoneal Epithelial Lawyer 46 23 Yes None
51–60 M Pleura Sarcomatoid IT 30 30 Yes None
61–70 F Peritoneal Epithelial Bookkeeper 62 15 Yes None
71–80 M Pleura Epithelial Engineer 71 20 No Definite Home renova-
tions, automotive
friction products,
cement in molds
41–50 F Pleura Epithelial Restaurant 46 12 No None
81–90 F Pleura Epithelial Not provided 62 62 Yes Likely Household expo-
sures laundering
clothes (automo-
tive friction
materials)
81–90 F Pleura Epithelial LPN 67 18 Yes Likely Household expo-
sures laundering
clothes (automo-
tive friction
materials)
31–40 F Peritoneal Epithelial Nanny, teacher 26 7 Yes Definite Home renova-
tions
61–70 M Peritoneal Epithelial Packaging, 48 48 Yes Definite Cut transite and
machine cement pipes;
operator, weld- automotive
ing friction exposure
(“shade tree”)
71–80 F Peritoneal Biphasic Clerical worker 61 39 Yes None
51–60 F Peritoneal Epithelial Lawyer 54 18 No None
41–50 F Pleura Sarcomatoid Research 44 45 Yes None
51–60 F Peritoneal Epithelial Variety of jobs 50 48 Yes Definite Home renova-
tion
41–50 M Peritoneal Epithelial Farrier, 41 35 Yes Definite Occupational
mechanic, exposure
general labor
81–90 M Pleura Epithelial Barber 50 36 Yes Likely Boiler work in rail
yards
71–80 M Pleura Biphasic Bus driver, fac- 47 47 Yes None
tory worker
51–60 F Peritoneal Epithelial Physician 20 12 Yes None
61–70 F Pleura Epithelial Cashier, sales, 53 53 No None
clerical worker,
wire assembler
51–60 F Peritoneal Epithelial Laborer 41 50 Yes Likely Home renova-
tions, family
member worked
with clay
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Table 2 (continued)
Age at Sex Tumor Tumor Occupation(s) Talc Years Diapering/ Certainty of Type of
Diagnosis Location Subtype Latency of Talc Applying Talc Alternate Alternate
(years) Use* to Others** Exposure Exposure
61–70 M Pleura Epithelial Accountant 69 69 Yes Definite Home renova-
tions during
1970s
81–90 F Pleura Biphasic Bookkeeping, 83 32 Yes None
rehab coun-
seling
71–80 F Pleura Sarcomatoid Office manager 75 75 Yes None
61–70 F Pleura Epithelial Merchandising 31 18 Yes None
manager
41–50 F Pleura, perito- Epithelial Teacher 46 22 Yes None
neal
51–60 M Pleura Epithelial Automechanic, 31 44 Yes Definite Occupational
pipefitter and take home
exposure (ship-
yard)
51–60 F Peritoneal Epithelial Clerical worker 40 38 Yes None
41–50 F Pericardium Sarcomatoid Medical center 50 31 Yes None
71–80 M Pleura Epithelial Mechanic, 61 50 No Definite Occupational
parts manager naval exposure
to asbestos,
automotive
friction material
handling
71–80 F Pleura Epithelial Secretary, 50 25 No Definite Household expo-
cosmetics, sures laundering
cashier clothes (automo-
tive friction
materials)
61–70 F Pleura Sarcomatoid Catering 45 40 Yes None
61–70 F Pleura Epithelial Cleaner, per- 52 50 Yes None
sonal assistant
51–60 M Pleura Epithelial Meat inspector 41 26 No None
71–80 F Pleura Epithelial Office manager 65 55 Yes Possible Household
exposure from
husband (drilling
wells, pipes)
71–80 F Pleura Epithelial Clerical worker 60 59 Yes Possible Family member
worked at ser-
vice station (no
details on work)
71–80 M Pleura Sarcomatoid Accountant 47 39 Yes None
61–70 F Pleura Epithelial Sales, business 60 16 No None
81–90 M Peritoneal Epithelial Accountant 68 56 No None
51–60 F Pleura Epithelial Social worker 40 6 No None
71–80 F Pleura Epithelial Hairdresser 60 49 Yes None
41–50 M Pleura, perito- Epithelial Warehouse 47 8 No Definite Automotive filler
neal worker exposure
51–60 F Pleura Epithelial Retail, banktel- 56 56 Yes None
ler, work at
school
61–70 F Pleura Biphasic Bakery 64 49 Yes None
71–80 F Pleura Epithelial Hospitality 61 58 Yes None
51–60 F Pleura Epithelial Cashier 57 56 Yes None
81–90 F Peritoneal Epithelial Teacher 40 50 Yes Possible Abatement done
at work
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Table 2 (continued)
Age at Sex Tumor Tumor Occupation(s) Talc Years Diapering/ Certainty of Type of
Diagnosis Location Subtype Latency of Talc Applying Talc Alternate Alternate
(years) Use* to Others** Exposure Exposure
81–90 F Pleura Epithelial Physical ther- 64 62 Yes None
apy assistant
31–40 M Peritoneal Epithelial IT 35 25 No None
51–60 F Pleura Epithelial Housekeeper 42 34 Yes None
81–90 F Pleura Epithelial Teacher 54 50 Yes Likely Home renova-
tions
61–70 M Pleura Epithelial Accounting 63 63 Yes None
71–80 M Pleura Epithelial Tractor driver, 62 60 No Likely Oil drilling
race track
71–80 F Pleura Epithelial Research 62 42 Yes None
51–60 F Peritoneal Epithelial Agriculture 53 53 Yes None
consultant
31–40 F Peritoneal Epithelial Clerical worker 39 27 Yes None
41–50 F Pleura
Preview
FILED: ERIE COUNTY CLERK 03/17/2023 09:21 PM INDEX NO. 815818/2020 NYSCEF DOC. NO. 353 RECEIVED NYSCEF: 03/17/2023 EXHIBIT 142 FILED: ERIE COUNTY CLERK 03/17/2023 09:21 PM INDEX NO. 815818/2020 NYSCEF DOC. NO. 353 RECEIVED NYSCEF: 03/17/2023 Moline et al. Journal of Occupational Journal of Occupational Medicine and Toxicology (2023) 18:1 https://doi.org/10.1186/s12995-023-00367-5 Medicine and Toxicology RESEARCH Open Access Exposure to cosmetic talc and mesothelioma Jacqueline Moline1,2*, Kesha Patel1 and Arthur L. Frank3 Abstract Aim Mesothelioma is associated with asbestos exposure. In this case series, we present 166 cases of individuals who had substantial asbestos exposure to cosmetic talc products as well as some who had potential or documented addi- tional exposures to other asbestos-containing products and who subsequently developed mesothelioma. Methods Data were gathered for all subjects referred to an occupational and environmental medicine specialist as part of medicolegal review. Years of total cosmetic talcum powder usage was noted as well as the latency from the onset of talcum powder use to the mesothelioma diagnosis. Alternate asbestos exposure in addition to the exposure from cosmetic talc was categorized as none, possible, likely, and definite. Results In 122 cases, the only known exposure to asbestos was from cosmetic talc. For 44 cases, potential or docu- mented alternate exposures in addition to the cosmetic talc were described. Conclusion Cumulative exposure to asbestos leads to mesothelioma; for individuals with mixed exposures to asbes- tos, all exposures should be considered. Use of cosmetic talc is often overlooked as a source of asbestos exposure. All individuals with mesothelioma should have a comprehensive history of asbestos exposure, including cosmetic talc exposure. Keywords Malignant mesothelioma, Cumulative asbestos exposure, Cosmetic talcum powder Introduction as “take-home” exposure has been well described in the Mesothelioma, described as a sentinel tumor, is inti- literature [2–5]. An underappreciated source of exposure mately associated with asbestos exposure. Asbestos has is the use of cosmetic talc products. The International been used for decades in thousands of products, both in Agency for Research on Cancer (IARC) [6] states that occupational and non-occupational settings, historically asbestos contaminated talc is carcinogenic and should be accounting for the bulk of mesothelioma cases. Non- treated as if one were dealing with asbestos. Asbestos lev- occupational exposures can be environmental in nature, els in talcum powder are significantly above background from effluents from mines and factories, from para- ambient asbestos exposure levels [7–9]. Talc applica- occupational exposures such as “shade-tree mechanics” tion simulation studies have been published [7, 8] where using friction products, and from home renovations [1]. exposures to talcum powder were 1.9 f/cc and 2.57 f/cc, Household exposures affecting family members, known respectively. According to the Gramond et al. [10] cate- gorization of intensity, asbestos exposure at these levels *Correspondence: would be considered to be high (> 1–10 f/ml). Jacqueline Moline Historically, asbestos exposures at work have been jmoline@northwell.edu 1 linked to multiple products. The overall risk for asbes- Department of Occupational Medicine, Epidemiology and Prevention, Northwell Health, Great Neck, NY 11021, USA tos related disease, including mesothelioma, is related 2 Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, to cumulative exposure. As agencies such as NIOSH, Hempstead, NY 11549, USA 3 OSHA, the EPA, and others have recognized, there Dornsife School of Public Health of Drexel University, Philadelphia, PA 19104, USA is no known safe exposure to asbestos. Low doses of exposure to asbestos contribute to mesothelioma [11]. © The Author(s) 2023. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativeco mmons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. FILED: ERIE COUNTY CLERK 03/17/2023 09:21 PM INDEX NO. 815818/2020 NYSCEF DOC. NO. 353 RECEIVED NYSCEF: 03/17/2023 Moline et al. Journal of Occupational Medicine and Toxicology (2023) 18:1 Page 2 of 13 Both time from first exposure (latency) and total expo- cleaning clothes), do-it-yourself home repair, domestic sure (cumulative dose) to asbestos must be taken into (handling asbestos material or living in the presence account when evaluating risk. With multiple repeated of asbestos material susceptible to damage at home), incidences of exposure, all those above background level or environmental (living near and asbestos processing should be thought of as “’substantial.” When considering plant). This study was conducted with approval from the elevated risk of mesothelioma in sheet metal work- the Human Research Protection Program at North- ers [12, 13], Zoloth and Michaels considered the multi- well Health Feinstein Institute for Medical Research ple bystander exposures to different products, not simply (#21–0897-OTH). one construction material. This case series presents 166 cases of individuals who had a minimum of five years and a mean of 40.8 years of exposure to asbestos through cos- Results metic talc products, some with possible other exposures, We identified 166 individuals with exposure to cosmetic but all developed mesothelioma. talc who were diagnosed with a malignant mesothelioma between 2014 and 2021. None of these individuals were Methods previously included in publications by the authors [14]. A Data were gathered for all subjects referred to an occu- summary of the case findings is found in Table 1. Overall, pational and environmental medicine specialist, JM, the average age of diagnosis was 63.3 (age range 26–94) as part of medicolegal review. All cases were reviewed years of age. The majority of cases were epithelioid meso- personally by an occupational medicine specialist with thelioma (75.3%). The average length of exposure to cos- experience evaluating asbestos exposure in thousands metic talc was 40.8 years (range 5–76 years of use), and of individuals. The individual’s medical records were the average latency period from the onset of talcum pow- reviewed and mesothelioma diagnoses were based on der use to the development of mesothelioma was 52.4 pathological reports that were performed as part of (20—83 years). We identified 122 individuals with asbes- their diagnostic evaluation. Exposure data was obtained tos exposure solely through use of cosmetic talc. Expo- by sworn testimony of the mesothelioma patients in sure to talcum powder could have been for personal use, all cases, and/or from family members who had direct in an occupational setting (for example, a nurse applying knowledge of the individual’s use of cosmetic talc and, talcum powder to a patient), or applying talcum powder if present, other sources of asbestos exposure. Use of to others such as children. For 122 individuals, they either talc was recorded as being diapered or powdered as a used cosmetic talc while diapering children or recalled child; diapering or powdering children or others; apply- applying talc to others (such as their children). Overall, ing talcum powder to oneself after bathing, or other 80.6% of women and 52.4% of men used talcum powder personal applications of talc. Years of total cosmetic for diapering or applying talc to others. For 44 individu- talcum powder usage was noted as well as the latency als, potential alternate asbestos exposure in addition to from the onset of talcum powder use to the mesothe- cosmetic talc was reported. Table 1 presents the 44 cases lioma diagnosis. Age was presented within a 10 year with alternate exposure ranked by possible, likely, and window to maintain confidentiality. Data reviewed definite asbestos exposure. Twenty-two women (17.8%) included family occupational histories (parents or any- and fifteen men (35.7%) had likely or definite alternate one cohabitating with the individual), hobbies, resi- exposure to asbestos in addition to their talcum powder dence, living with or laundering clothes of an asbestos usage. [Details of the exposure history of all 166 individu- exposed worker, if indicated, home renovations that als with cosmetic talc exposure is presented in Table 2, could have exposed the individual to asbestos contain- including a description of the alternate exposure.] Table 1 ing construction materials, residence close to a facility also shows the site of the tumor by gender. Of the 166 with environmental contamination, or other potential cases, 109 were pleural, 52 were peritoneal, 4 were dis- asbestos exposures. In those individuals with potential covered in both the pleura and peritoneum and the origi- asbestos exposure in addition to the cosmetic talc, cat- nal site could not be determined. One case of pericardial egorization of these exposures was done by two occu- mesothelioma was noted out of the 166 cases, which pational physicians, JM and ALF. Alternate asbestos reflects the rarity of this site for mesothelioma. The per- exposure in addition to the exposure from cosmetic talc centages of peritoneal mesothelioma were similar for was categorized as none, possible, likely, and definite women (29.8%) and men (35.7%). The high proportion following the descriptions by Gramond et al. [10]. Non- of peritoneal mesothelioma tumors relative to pleural occupational exposure to asbestos was characterized tumors, consistent with prior case series of patients with as paraoccupational (living with an asbestos worker or malignant mesothelioma after cosmetic talc use [14, 15], is unusual and deserves further investigation. FILED: ERIE COUNTY CLERK 03/17/2023 09:21 PM INDEX NO. 815818/2020 NYSCEF DOC. NO. 353 RECEIVED NYSCEF: 03/17/2023 Moline et al. Journal of Occupational Medicine and Toxicology (2023) 18:1 Page 3 of 13 Table 1 Characteristics of 166 mesothelioma cases with cosmetic talc usage Total (N = 166) Female (n = 124) Male (n = 42) Average Age (range) 63.3 (26 – 94) 64.3 (26 – 94) 60.9 (28 – 83) Years of Talc Use* (range) 40.8 (5 – 76) 40.4 (6 – 76) 42.0 (5 – 74) Talc Latency in Years (range) 52.4 (20 – 83) 53.3 (20 – 83) 49.9 (28 – 74) Diapering or Applying Talc to Others** 122 (73.5%) 100 (80.6%) 22 (52.4%) Talc Use Only 122 (73.5%) 97 (78.2%) 25 (59.5%) Talc Use and Alternate Exposure 44 (26.5%) 27 (21.8%) 17 (40.5%) Certainty of Alternate Exposure (n = 44) (26.5%) Possible 7 (4.2%) 5 (4.0%) 2 (4.8%) Likely 17 (10.2%) 14 (11.3%) 3 (7.1%) Definite 20 (12.0%) 8 (6.5%) 12 (28.6%) Tumor Location Pleura 109 (65.7%) 83 (66.9%) 26 (61.9%) Peritoneum 52 (31.3%) 37 (29.8%) 15 (35.7%) Both Pleura & Peritoneum 4 (2.4%) 3 (2.4%) 1 (2.4%) Pericardium 1 (0.6%) 1 (0.8%) 0 Tumor Subtype Biphasic 24 (14.5%) 18 (14.5%) 6 (14.3%) Epithelial 125 (75.3%) 92 (74.2%) 33 (78.6%) Sarcomatoid 16 (9.6%) 13 (10.5%) 3 (7.1%) Not specified 1 (0.6%) 1 (0.8%) 0 * Years of Talc Use: includes years of being diapered or powdered with talc as a child; years of diapering or powdering children or others with talc; and years applying talcum powder to oneself after bathing or other personal use ** Diapering or Applying Talc: restricted to diapering or powdering children with talc or applying talcum powder to others, including occupational use Discussion [23] In some instances authors limited the characteriza- This paper presents 166 individuals with malignant mes- tion of asbestos exposure in women to certain industries, othelioma and asbestos exposure through documented such as shipbuilding during wartime [24], thus neglecting use of cosmetic talcum powder. For 122 of 166, their only other potential sources and decreasing the attributable known exposure to asbestos was their use of cosmetic tal- risk. Conversely, when non-occupational exposures were cum powder. Without the recognition of asbestos expo- included for women, even with low-intensity domestic sure through cosmetic talcum powder, 73.5% of the cases exposure considered, the attributable risk increased from might well have been considered “idiopathic.” Similarly, 40% to 64.8% [21]. for those 26.5% of cases with additional asbestos exposure Given that all types of asbestos can cause mesothe- along with the talc, those alternate exposures would have lioma [6], it is important to consider every source of been mistakenly considered as the sole, and sufficient, exposure to asbestos in an individual. Talcum powder has cause of the mesothelioma. Historically, the attributable been contaminated with both chrysotile and amphibole risk of asbestos for mesothelioma in women ranged from asbestos (predominately anthophyllite and tremolite) [8, around 20–50%. However as Baur et al. point out, mis- 25, 26]. Recently, Wong et al. (2021) found significantly classification or inadequate exposure ascertainment has elevated risks of mesothelioma among individuals with led to this low attributable risk for women compared to only chrysotile exposure and for mixed fiber exposure. men. [16]. Data from occupationally exposed cohorts that [27]. Chrysotile alone (OR = 3.8) and in combination included men and women actually show that compared with tremolite/anthophyllite asbestos (OR = 3.9) were to similarly exposed men, women had higher mortality associated with similar increases in risk of mesothelioma. rates from mesothelioma [17–20]. Lacourt found that These three fiber types are most commonly found in cos- at low-level cumulative asbestos exposure ((0 – 0.1 f-cc/ metic talc, and given that different ore sources were used year) women were more likely to develop mesothelioma in manufacturing over time, it is likely that many formu- than men [21]. Magnani (2008) found the SMR for mes- lations and uses of talcum powder involved mixed fiber othelioma was higher for women than for men among type exposure. There is no scientific basis to state that workers at an asbestos cement plant [22]. Frank et al. one type of exposure was the sole cause of the mesothe- (2009) found mesothelioma rates in the Qingdao region lioma in a mixed exposure scenario. For example, rates of of China were correlated with a higher proportion of mesothelioma have been evaluated based on either job women employed in asbestos manufacturing industries. type or locale (e.g., construction, shipping) rather than FILED: ERIE COUNTY CLERK 03/17/2023 09:21 PM INDEX NO. 815818/2020 NYSCEF DOC. NO. 353 RECEIVED NYSCEF: 03/17/2023 Moline et al. Journal of Occupational Medicine and Toxicology (2023) 18:1 Page 4 of 13 Table 2 Description of 166 mesothelioma cases Age at Sex Tumor Tumor Occupation(s) Talc Years Diapering/ Certainty of Type of Diagnosis Location Subtype Latency of Talc Applying Talc Alternate Alternate (years) Use* to Others** Exposure Exposure 51–60 F Pleura Epithelial Cosmetics 41 36 Yes None factory 31–40 F Peritoneal Biphasic Marketing 39 12 No None 91–100 F Pleura Epithelial Clerical worker 69 57 Yes Definite Smoked Kent cigarettes in 1950s 51–60 M Pleura Biphasic Warehouse 54 22 No Definite Home renova- supervisor tions as child 21–30 M Peritoneal Epithelial Aircraft techni- 28 5 No None cian 41–50 F Pleura Biphasic Marketing 47 47 Yes Definite Automotive fric- tion exposure 41–50 F Peritoneal Epithelial Operator 37 36 Yes Likely Parents worked technician in chemical plant/with automotive friction materials; no work clothes laundered at home 61–70 F Peritoneal, Epithelial Hairdresser 65 57 Yes Definite Household expo- pleura sures laundering clothes (automo- tive friction materials) 41–50 F Pleura Epithelial Industrial 45 10 Yes None engineer 71–80 M Pleura Biphasic Firefighter, 59 59 No Definite Occupational painter exposures to industrial talc, firefighting 51–60 F Peritoneal Epithelial Dental assis- 58 57 Yes Definite Automotive tant, secretary, friction product logging busi- exposure ness 51–60 F Peritoneal, Epithelial Nurse 50 20 Yes None pleura 71–80 F Pleura Epithelial Secretary 60 61 No None 61–70 M Peritoneal Epithelial Software 53 53 No Likely Construc- engineer tion work as teenager; family member machinist 61–70 F Pleura Epithelial Secretary 61 20 Yes None 61–70 M Pleura Epithelial Law professor 46 45 No None 21–30 F Peritoneal Biphasic Customer ser- 26 12 No None vice manager 51–60 F Pleura Epithelial Dental assis- 50 17 Yes Likely Dental tape used tant, sales in office 21–30 F Pleura Epithelial Programmer 29 17 Yes None 51–60 F Pleura Epithelial Clerical worker 54 48 No None 71–80 F Pleura Biphasic Dental 64 34 Yes Possible Possible house- assistant, hold exposure receptionist from parental occupations 61–70 F Pleura Epithelial Systems 62 61 Yes None analyst FILED: ERIE COUNTY CLERK 03/17/2023 09:21 PM INDEX NO. 815818/2020 NYSCEF DOC. NO. 353 RECEIVED NYSCEF: 03/17/2023 Moline et al. Journal of Occupational Medicine and Toxicology (2023) 18:1 Page 5 of 13 Table 2 (continued) Age at Sex Tumor Tumor Occupation(s) Talc Years Diapering/ Certainty of Type of Diagnosis Location Subtype Latency of Talc Applying Talc Alternate Alternate (years) Use* to Others** Exposure Exposure 51–60 F Peritoneal Epithelial Clerical worker 59 31 Yes Likely Asbestos shingle exposure as child 71–80 F Peritoneal Epithelial Teacher’s aide, 46 46 No None customer service 51–60 M Pleura Epithelial Baked goods 55 49 Yes None manufacturer 61–70 F Pleura Epithelial Housekeeping, 51 23 No None packaging 41–50 M Peritoneal Epithelial Lawyer 46 23 Yes None 51–60 M Pleura Sarcomatoid IT 30 30 Yes None 61–70 F Peritoneal Epithelial Bookkeeper 62 15 Yes None 71–80 M Pleura Epithelial Engineer 71 20 No Definite Home renova- tions, automotive friction products, cement in molds 41–50 F Pleura Epithelial Restaurant 46 12 No None 81–90 F Pleura Epithelial Not provided 62 62 Yes Likely Household expo- sures laundering clothes (automo- tive friction materials) 81–90 F Pleura Epithelial LPN 67 18 Yes Likely Household expo- sures laundering clothes (automo- tive friction materials) 31–40 F Peritoneal Epithelial Nanny, teacher 26 7 Yes Definite Home renova- tions 61–70 M Peritoneal Epithelial Packaging, 48 48 Yes Definite Cut transite and machine cement pipes; operator, weld- automotive ing friction exposure (“shade tree”) 71–80 F Peritoneal Biphasic Clerical worker 61 39 Yes None 51–60 F Peritoneal Epithelial Lawyer 54 18 No None 41–50 F Pleura Sarcomatoid Research 44 45 Yes None 51–60 F Peritoneal Epithelial Variety of jobs 50 48 Yes Definite Home renova- tion 41–50 M Peritoneal Epithelial Farrier, 41 35 Yes Definite Occupational mechanic, exposure general labor 81–90 M Pleura Epithelial Barber 50 36 Yes Likely Boiler work in rail yards 71–80 M Pleura Biphasic Bus driver, fac- 47 47 Yes None tory worker 51–60 F Peritoneal Epithelial Physician 20 12 Yes None 61–70 F Pleura Epithelial Cashier, sales, 53 53 No None clerical worker, wire assembler 51–60 F Peritoneal Epithelial Laborer 41 50 Yes Likely Home renova- tions, family member worked with clay FILED: ERIE COUNTY CLERK 03/17/2023 09:21 PM INDEX NO. 815818/2020 NYSCEF DOC. NO. 353 RECEIVED NYSCEF: 03/17/2023 Moline et al. Journal of Occupational Medicine and Toxicology (2023) 18:1 Page 6 of 13 Table 2 (continued) Age at Sex Tumor Tumor Occupation(s) Talc Years Diapering/ Certainty of Type of Diagnosis Location Subtype Latency of Talc Applying Talc Alternate Alternate (years) Use* to Others** Exposure Exposure 61–70 M Pleura Epithelial Accountant 69 69 Yes Definite Home renova- tions during 1970s 81–90 F Pleura Biphasic Bookkeeping, 83 32 Yes None rehab coun- seling 71–80 F Pleura Sarcomatoid Office manager 75 75 Yes None 61–70 F Pleura Epithelial Merchandising 31 18 Yes None manager 41–50 F Pleura, perito- Epithelial Teacher 46 22 Yes None neal 51–60 M Pleura Epithelial Automechanic, 31 44 Yes Definite Occupational pipefitter and take home exposure (ship- yard) 51–60 F Peritoneal Epithelial Clerical worker 40 38 Yes None 41–50 F Pericardium Sarcomatoid Medical center 50 31 Yes None 71–80 M Pleura Epithelial Mechanic, 61 50 No Definite Occupational parts manager naval exposure to asbestos, automotive friction material handling 71–80 F Pleura Epithelial Secretary, 50 25 No Definite Household expo- cosmetics, sures laundering cashier clothes (automo- tive friction materials) 61–70 F Pleura Sarcomatoid Catering 45 40 Yes None 61–70 F Pleura Epithelial Cleaner, per- 52 50 Yes None sonal assistant 51–60 M Pleura Epithelial Meat inspector 41 26 No None 71–80 F Pleura Epithelial Office manager 65 55 Yes Possible Household exposure from husband (drilling wells, pipes) 71–80 F Pleura Epithelial Clerical worker 60 59 Yes Possible Family member worked at ser- vice station (no details on work) 71–80 M Pleura Sarcomatoid Accountant 47 39 Yes None 61–70 F Pleura Epithelial Sales, business 60 16 No None 81–90 M Peritoneal Epithelial Accountant 68 56 No None 51–60 F Pleura Epithelial Social worker 40 6 No None 71–80 F Pleura Epithelial Hairdresser 60 49 Yes None 41–50 M Pleura, perito- Epithelial Warehouse 47 8 No Definite Automotive filler neal worker exposure 51–60 F Pleura Epithelial Retail, banktel- 56 56 Yes None ler, work at school 61–70 F Pleura Biphasic Bakery 64 49 Yes None 71–80 F Pleura Epithelial Hospitality 61 58 Yes None 51–60 F Pleura Epithelial Cashier 57 56 Yes None 81–90 F Peritoneal Epithelial Teacher 40 50 Yes Possible Abatement done at work FILED: ERIE COUNTY CLERK 03/17/2023 09:21 PM INDEX NO. 815818/2020 NYSCEF DOC. NO. 353 RECEIVED NYSCEF: 03/17/2023 Moline et al. Journal of Occupational Medicine and Toxicology (2023) 18:1 Page 7 of 13 Table 2 (continued) Age at Sex Tumor Tumor Occupation(s) Talc Years Diapering/ Certainty of Type of Diagnosis Location Subtype Latency of Talc Applying Talc Alternate Alternate (years) Use* to Others** Exposure Exposure 81–90 F Pleura Epithelial Physical ther- 64 62 Yes None apy assistant 31–40 M Peritoneal Epithelial IT 35 25 No None 51–60 F Pleura Epithelial Housekeeper 42 34 Yes None 81–90 F Pleura Epithelial Teacher 54 50 Yes Likely Home renova- tions 61–70 M Pleura Epithelial Accounting 63 63 Yes None 71–80 M Pleura Epithelial Tractor driver, 62 60 No Likely Oil drilling race track 71–80 F Pleura Epithelial Research 62 42 Yes None 51–60 F Peritoneal Epithelial Agriculture 53 53 Yes None consultant 31–40 F Peritoneal Epithelial Clerical worker 39 27 Yes None 41–50 F Pleura