0
Review |

Personal Use of Hair Dyes and Risk of Cancer:  A Meta-analysis FREE

Bahi Takkouche, MD, PhD; Mahyar Etminan, PharmD, MSc; Agustín Montes-Martínez, MD, PhD
[+] Author Affiliations

Author Affiliations: Department of Preventive Medicine, University of Santiago de Compostela, Santiago de Compostela, Spain (Drs Takkouche and Montes-Martínez); Division of Clinical Epidemiology, Royal Victoria Hospital, Montreal, Quebec (Dr Etminan); and Center for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Institute, Vancouver, British Columbia (Dr Etminan).

More Author Information
JAMA. 2005;293(20):2516-2525. doi:10.1001/jama.293.20.2516.
Text Size: A A A
Published online

Context Use of hair dyes has been suggested recently as a risk factor for several types of cancer in epidemiologic studies. This alarming news and controversial declarations by scientific organizations and general media have made necessary a systematic evaluation of the epidemiologic evidence.

Objective To examine the association between personal use of hair dyes and relative risk of cancer.

Data Sources We retrieved studies published in any language by systematically searching the MEDLINE (1966–January 2005), EMBASE, LILACS, and ISI Proceedings computerized databases and by manually examining the references of the original articles, reviews, and monographs retrieved.

Study Selection We included cohort and case-control studies reporting relative risk estimates and 95% confidence intervals (CIs) (or data to calculate them) of personal hair dye use and cancer. We excluded studies that dealt with occupational exposure. We carried out separate analyses for bladder, breast, and hematopoietic cancers and cancers of other sites. Seventy-nine studies were included of 210 articles identified in the search.

Data Extraction Data were extracted independently by 2 investigators. We used a standardized questionnaire to record information on study design, sample size, type of controls, year of publication, adjustment factors, and relative risks of cancer among ever users of hair dyes. When possible, we extracted association measures on use of permanent dyes and extensive use (>200 lifetime episodes of dye use).

Data Synthesis Study-specific relative risks were weighted by the inverse of their variance to obtain fixed- and random-effects pooled estimates. The pooled relative risk for ever users of hair dyes was 1.06 (95% CI, 0.95-1.18) for breast cancer (14 studies), 1.01 (95% CI, 0.89-1.14) for bladder cancer (10 studies), and 1.15 (95% CI, 1.05-1.27) for hematopoietic cancers (40 studies). Other cancers were examined by only 1 or 2 studies, of which the pooled or single relative risk was elevated for brain cancer, ovarian cancer, and cancer of the salivary glands. No effect was observed for use of permanent dyes or for extensive use.

Conclusions We did not find strong evidence of a marked increase in the risk of cancer among personal hair dye users. Some aspects related to hematopoietic cancer and other cancers that have shown evidence of increased risk in 1 or 2 studies should be investigated further.

There is growing concern worldwide about a possible increase in the risk of cancer among users of hair dyes. Some aromatic amines contained in hair dyes are mutagenic in vitro1 and are carcinogenic in animals and humans.2,3 Prompted by the publication of a study that showed a positive relation between hair dyes and bladder cancer,4 the Scientific Committee on Cosmetic Products and Non-food Products (European Commission) called for an urgent review of the information and concluded in 2004 that “bladder cancer may be caused by carcinogenic arylamines in the hair dye solutions.”5 The US Food and Drug Administration declared recently that “FDA continues to follow research in this field,”6 while the International Agency for Research on Cancer has stated that there is “inadequate evidence of carcinogenicity” of hair dyes.7 In 2002, the British Broadcasting Corporation (BBC) caused alarm by reporting that “the Cancer Research Society advised consumers not to use hair products until further research has been completed.”8 However, it was not possible to confirm the authorship and veracity of this declaration.

As indicated by these statements, health organizations are concerned about the carcinogenicity of hair dyes, although their position sways between skeptical vigilance and official calls for bans of these products.

An association between hair dyes and cancer would be an important public health concern since about one third of women in Europe and North America, along with 10% of men older than 40 years, use some type of hair dye.9 Permanent dyes, the most aggressive type, represent 70% of the market share—even more in Asia.7

Recent reviews have commented on the association between dye use and cancer.7,911 However, no meta-analysis has been carried out so far. We therefore summarized the scientific evidence following the Meta-analysis of Observational Studies in Epidemiology (MOOSE) guidelines for meta-analyses of observational studies.12

Systematic Search

We conducted a computerized MEDLINE search from 1966 to January 2005 to identify potentially eligible studies. A study was defined as an analysis of a specific cancer-exposure association; thus, a single article or publication could report several studies. We applied the following algorithm both in Medical Subject Heading and in free-text words: (hair) and (dye* or colour* or color*) and (cancer* or neoplasm* or carcinogen*). To check whether every article on the topic was retrieved, we performed a second search, introducing the words cancer, neoplasms, and hair dye in an unstructured fashion. We used similar strategies to search EMBASE (1980-2004) and LILACS (Latin America and Caribbean) databases. We searched meeting abstracts using the ISI Proceedings database from its inception in 1990 to 2004. We also examined the references of every article retrieved and those of recent reviews and monographs of hair dyes and cancer.911 We considered including any relevant article, independent of the language of the publication. Unpublished studies were not considered. Formal translation was necessary in only 1 article published in Japanese.13 All searches were carried out independently by 2 epidemiologists (B.T. and A.M.-M.) and results were merged.

Inclusion Criteria and Data Collection

Studies were included if (1) they presented original data from case-control or cohort studies; (2) the outcome of interest was clearly defined as cancer of an anatomical site; (3) the exposure of interest was personal hair dye use; and (4) they provided relative risk (RR) estimates and their confidence intervals (CIs) or provided enough data to calculate them (raw data, P value, or variance estimate). We did not consider studies that dealt with occupational exposure to hair dyes or those that concerned childhood cancers related to use of hair dye by the mother. If data were duplicated in more than 1 study, the most recent study was included in the analysis. We contacted the authors of the publications when further explanations were necessary to assess whether the information provided in more than 1 article concerned the same study. When RRs of cancer of different anatomical sites were available in the same publication, we considered each cancer separately.

We developed a questionnaire and recorded study name, year of publication, study design, sample size (cases and controls or cohort size), type of controls for case-control studies (patients with other diseases or population-based controls), variables used for adjustment or matching, and association measures that compared ever users of hair dyes with never users for any (or unspecified) type of dye. When available, we also extracted association measures and CIs corresponding to the exclusive use of permanent dye and carried out a separate analysis for this type of dye. If a study provided information on permanent dye only and not on use of hair dye of any kind, we included this information in the pooled analysis of hair dye of any type. To check for possible changes in the result, we later recalculated our pooled estimate for hair dye of any type excluding studies that provided information on permanent dye only. Results were similar in both analyses, so only the former was presented in the tables. When possible, we also extracted RRs for intensive use of hair dye, defined as 200 or more lifetime episodes of dyeing. If not directly available in the publications, we calculated this magnitude assuming an average frequency of hair dyeing of 11.7 times per year among women. This number was obtained from the distribution of hair dye use among the control group of 1 of the studies included in our meta-analysis, which provided detailed information on frequency of use.14

Quality Assessment

We assessed study quality based on a 10-point scale that included elements of previous published scales adapted to the needs of the present meta-analysis.15 Each study was scored according to 5 characteristics of methods and presentation of results. Each item was scored from 0 to 2. Specifically, for case-control studies, we determined whether participation rate was at least 80% in both groups; whether cases were incident, prevalent, or dead; whether controls were taken from 1 or various hospitals or from the general population; whether potential confounding for sex, age, and smoking was corrected or prevented through matching or adjustment; and whether duration of exposure to hair dye was accurately measured. For cohort studies, in addition to the criteria listed above that were not specific to case-control designs, we determined whether loss to follow-up was less than 20% of the initial cohort size and whether efforts were made to ensure that the cohort did not change exposure during follow-up. (The complete protocol for quality scoring is available on request from the authors.) For stratification purposes, studies that scored 7 or higher of 10 were considered to be of high quality and the rest to be of low quality. Quality scoring was performed independently by 2 reviewers (B.T. and A.M.-M.) and the average score between reviewers was assigned to the studies. Disagreement was measured by the Bland-Altman limits-of-agreement method.16 The average disagreement was close to zero (−0.22; 95% CI, −2.42 to 1.98). The fact that the 95% CI is symmetric around zero suggests that there was no systematic disagreement.

Statistical Analysis

We weighted the study-specific adjusted log odds ratios for case-control studies and log RRs for cohort studies by the inverse of their variance to compute a pooled RR and its 95% CI. We presented both fixed- and random-effects pooled estimates but preferentially used the latter when heterogeneity was present.

We used a parametric bootstrap version (1000 replications) of the DerSimonian and Laird Q test to check for heterogeneity.17 The null hypothesis of this test is absence of heterogeneity. To quantify this heterogeneity, we calculated the proportion of the total variance due to between-study variance (Ri statistic).17 To further explore the origin of heterogeneity, we restricted the analysis to subgroups of studies defined by study characteristics such as case-control/cohort design, adjustment factors, and type of controls (hospital-based or population-based).

We used funnel plots to assess publication bias visually. Because funnel plots have several limitations and represent only an informal way to detect publication bias,18 we carried out more formal testing using the test proposed by Egger et al.19 All analyses were performed with the software HEpiMA, version 2.1.3,20 and STATA, version 8.0 (Stata Corp, College Station, Tex).

We identified 79 studies, carried out in 11 countries, on personal hair dye use and cancer that met our inclusion criteria and were included in the analysis.

We found 14 studies on breast cancer,2134 10 studies on bladder cancer,4,14,25,3541 and 40 studies on hematopoietic cancers.25,34,4258 Furthermore, 2 studies provided data on adult brain tumors,59,60 2 on skin cancer,6163 2 on ovarian cancer,25,64 and 2 on cervical cancer.25,51 We also found 1 study for each of the following cancer sites: salivary gland,65 endometrium,25 vagina,51 oral cavity,51 soft tissue sarcoma,58 digestive system,51 and respiratory system.51

Among the studies that could have been relevant to our meta-analysis, 1 was excluded because it presented cross-sectional data66 and another because it did not present any measure of uncertainty of the RR.67

Breast Cancer

The 12 case-control studies (involving 5019 cases and 8486 controls) and 2 cohort studies that dealt with breast cancer were published between 1977 and 2002 (Table 1). Seven case-control studies used population-based controls and 5 used hospital-based controls.

Table Graphic Jump LocationTable 1. Study-Specific RRs of Female Breast Cancer and Hair Dye Use

Compared with never use of hair dyes, the random-effects pooled RR of breast cancer for any type of dye use was 1.06 (95% CI, 0.95-1.18). The pooled RR for exclusive use of permanent dye was 1.00 (95% CI, 0.94-1.05) and was 0.99 (95% CI, 0.89 to 1.11) for intensive exposure (Table 2). There was no substantial difference in pooled RRs across designs (cohort, hospital-based case-control, and population-based case-control studies). Restricting the analysis to the 7 studies that scored 7 points or higher on the quality scale did not alter the results (RR, 1.06; 95% CI, 0.93-1.20). Heterogeneity of the study-specific RRs was moderate to large for case-control studies (Ri = 0.62) and all studies analyzed together (Ri = 0.68). This was explained mainly by the result of 1 population-based case-control study32 with an RR of 8.62 and a wide 95% CI, which might be considered as an influential point. Excluding this study resulted in low heterogeneity (Ri = 0.36). The funnel plot did not provide evidence for publication bias (data not shown). The Egger test of asymmetry of the funnel plot yielded a P value of .90, which did not change substantially when the outlier was excluded (P = .72).

Table Graphic Jump LocationTable 2. Pooled RRs of Female Breast Cancer and Hair Dye Use
Bladder Cancer

The 10 studies, presented in Table 3, that provided data on bladder cancer (9 case-control studies comprising 5740 cases and 9290 controls and 1 cohort study with 336 cases) did not show substantial heterogeneity. The only exception was for intensive exposure, the heterogeneity of which was high but based on only 3 studies.

Table Graphic Jump LocationTable 3. Study-Specific RRs of Bladder Cancer and Hair Dye Use

The pooled RR (Table 4) did not show any effect of hair dye on bladder cancer (RR, 1.01; 95% CI, 0.89-1.14 for all studies). This absence of effect was constant across study designs, types of exposure (permanent dyes and intensive exposure), and sex (RR, 1.03; 95% CI, 0.90-1.17 for women and RR, 0.93; 95% CI, 0.77-1.13 for men). Since smoking is an important risk factor for bladder cancer, we recalculated our pooled estimates for studies that provided data explicitly adjusted for tobacco consumption.4,14,3841 The pooled RR was 1.05 (95% CI, 0.93-1.19).

Table Graphic Jump LocationTable 4. Pooled RRs of Bladder Cancer and Hair Dye Use

Stratifying the analysis by quality scoring did not show any difference in the pooled RRs between studies with good quality scores and the remainder. We could not detect any evidence of publication bias on the funnel plot (P = .75 by Egger symmetry test).

Hematopoietic Cancers

Table 5 and Table 6 show the specific RRs for the 40 studies that dealt with hematopoietic cancers and the pooled RRs for different types of these cancers. When all hematopoietic cancers were analyzed together, we observed a borderline increase in the risk (RR, 1.15; 95% CI, 1.05-1.27) for ever users of hair dye. This increase is restricted to case-control studies (RR, 1.23; 95% CI, 1.09-1.39) and, more specifically, to the 17 case-control studies with data on men (RR, 1.57; 95% CI, 1.33-1.84). No cohort study with data on men was available for comparison. In these categories, heterogeneity was large. On the contrary, we did not observe any risk increase when we restricted our analysis to women (RR, 1.04; 95% CI, 0.97-1.11), to exclusive use of permanent dyes (random-effects RR, 1.14; 95% CI, 0.99-1.29), or to intensive exposure to hair dyes. Stratification by quality scoring or by adjustment for smoking did not produce any change in the results. The funnel plot showed substantial asymmetry (data not shown), confirmed by statistical testing (P value of the intercept = .02 by Egger test). Apparently, there is a deficit of studies that show a slightly protective but imprecise effect in their results. Our calculations show that only 5 such unpublished case-control studies, with an RR of 0.8 and a 95% CI of 0.6 to 1.1, would be sufficient to cancel the association between hair dye use and risk of hematopoietic cancers and render it nonsignificant (RR, 1.09; 95% CI, 0.99-1.20).

Table Graphic Jump LocationTable 5a. Study-Specific RRs of Hematopoietic Cancers and Hair Dye Use
Table Graphic Jump LocationTable 6. Pooled RRs of Hematopoietic Cancers and Hair Dye Use

Separate analyses by cancer site show a slight increase in the risk of non-Hodgkin lymphoma for ever users of hair dye (RR, 1.23; 95% CI, 1.07-1.42), which seems to be restricted to case-control studies. However, the results of intensive exposure do not show any association.

Case-control studies of multiple myeloma and lymphocytic leukemia show a slight increase of the risk.

Other Cancers

Table 7 presents the study-specific RRs of other cancer sites for hair dye users vs never users. The single study on cancers of salivary glands shows a 3-fold increase of the risk.65 The pooled RRs of the 2 studies available for each site were 1.83 (95% CI, 1.16-2.89) for brain tumors, 1.71 (95% CI, 1.15-2.53) for ovarian cancer, 0.74 (95% CI, 0.51-1.07) for skin cancer, and 0.89 (95% CI, 0.53-1.9) for cervical cancer.

Table Graphic Jump LocationTable 7. Study-Specific RRs of Other Cancers and Hair Dye Use

Our results indicate that, globally, there is no effect of personal hair dye use on the risk of breast and bladder cancer.

There is a borderline effect for hematopoietic cancers. However, the evidence of a causal effect is too weak to represent a major public health concern. The fact that the restriction of the analysis to intensive exposure to hair dyes and to exclusive use of permanent hair dye does not strengthen the risk further is consistent with the absence of causal effect. Furthermore, there is room for publication bias as shown by the funnel plot, the result of the corresponding hypothesis test, and the fact that only a small number of negative studies, unpublished so far, would cancel the association. Nonetheless, the intriguing risk increase for male users of hair dyes deserves further consideration.

A plausible explanation for the lack of effect may be the low concentration of potential carcinogens in the hair dyes and the fact that the use of some dye ingredients, such as 2,4-diaminotoluene and 2,4-diaminoanisole, was discontinued in the mid 1970s after they were found to be carcinogenic in rodents.7 The overwhelming majority of the studies were carried out several years after this ban went into effect.

There is potential for recall bias from case-control studies, which represent the majority of the studies included in this meta-analysis. However, the effect produced by this bias would be an exaggeration of the effect. Presence of misclassification bias of the exposure to hair dyes is not unlikely. Because exposure is generally measured at baseline and may change during follow-up, the potential for misclassification is higher for cohort studies, as mentioned by Miller and Bartsch.68 If exposure is measured on a dichotomous scale (exposed vs nonexposed), the consequence of nondifferential misclassification would be to bias the estimates toward the absence of effect. However, globally in our meta-analysis, we did not detect substantial differences between pooled results from case-control and cohort studies.

One possible limitation of our meta-analysis is that several case-control studies use the same comparison group for different outcomes and, therefore, might not be considered as completely independent. This raises a multiple comparison issue that would result in finding more statistically significant associations than they actually exist.42 This is particularly true for hematopoietic cancers because in several studies, the same control population was used to calculate relative risks for Hodgkin and non-Hodgkin lymphoma, leukemia, and multiple myeloma (Table 5).42,43,46,54,58 This may partially explain the positive results for hematopoietic cancers. However, it should be noted that pooling results from studies that share the same control group should yield similar results as pooling results from studies that use independent control groups, provided that controls are selected independent of the exposure. Restricting our analysis to studies that used different comparison sets yielded identical results (Table 6).

Another possible limitation is that individual studies may have failed to control for potential known or unknown confounders or to take into account potential effect modifiers. A study has shown that bladder cancer among hair dye users is restricted to the specific genotype/phenotype of slow acetylators of N-acetyltransferase, an enzyme involved in the detoxification of aromatic amines.4 This and other genetic factors are potential effect modifiers that were not addressed in the individual studies. Furthermore, it is remarkable that fewer than half of the studies explicitly adjusted for smoking, an established risk factor for cancer, although some authors decided not to adjust for it after having ruled out confounding in their data. Failure to adjust for confounders may bias the results in either direction, toward exaggeration or underestimation of the effect of personal hair dyes on cancer.

The borderline effect observed for brain tumors and ovarian cancer is based on the pooling of only 2 studies and does not permit a meaningful assessment of the risk. However, these results are based on reasonably sized case-control studies, although largely prone to bias (large proportion of proxy respondents,60 large number of dead cases,60 and imprecise exposure assessment59). Future studies may shed more light on the effect of hair dyes on these types of tumors.

In conclusion, we did not find strong evidence of a marked increase in the risk of cancer among personal hair dye users. Some aspects related to hematopoietic cancer should be investigated further. Efforts should be targeted toward the assessment of the risk of cancer in occupational settings where exposure to hair dyes is more prolonged and has a higher concentration and frequency than personal exposure.

Corresponding Author: Bahi Takkouche, MD, PhD, Department of Preventive Medicine, Faculty of Medicine, University of Santiago de Compostela, 15782 Santiago de Compostela, Spain (mrbahi@usc.es).

Author Contributions: Dr Takkouche had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Takkouche, Etminan.

Acquisition of data: Takkouche, Montes-Martinez.

Analysis and interpretation of data: Takkouche, Etminan, Montes-Martinez.

Drafting of the manuscript: Takkouche, Montes-Martinez.

Critical revision of the manuscript for important intellectual content: Etminan.

Statistical analysis: Takkouche, Etminan, Montes-Martinez.

Administrative, technical, or material support: Montes-Martinez.

Study supervision: Takkouche.

Financial Disclosures: None reported.

Funding/Support: Dr Etminan is supported by a Canadian Institutes of Health Research postdoctoral fellowship award.

Ames BN, Kammen HO, Yamasaki E. Hair dyes are mutagenic: identification of a variety of mutagenic ingredients.  Proc Natl Acad Sci U S A. 1975;72:2423-2427
PubMed   |  Link to Article
Sontag JM. Carcinogenicity of substituted-benzendiamines (phenylenediamines) in rats and mice.  J Natl Cancer Inst. 1981;66:591-602
PubMed
Silverman DT, Morrison AS, Devesa SS. Bladder cancer. In: Schottenfeld D, Fraumeni JF, eds. Cancer Epidemiology and Prevention. New York, NY: Oxford University Press; 1996:1156-1179
Gago-Dominguez M, Castelao JE, Yuan JM, Yu MC, Ross RK. Use of permanent hair dyes and bladder-cancer risk.  Int J Cancer. 2001;91:575-579
PubMed   |  Link to Article
Scientific Committee on Cosmetic Products and Non-food Products.  Opinion Concerning Use of Permanent Hair Dyes and Bladder CancerAdopted on April 23, 2004. SCCNFP/0797/04. Available at: http://www.europa.eu.int/comm/health/ph_risk/committees/sccp/documents/out272_en.pdf. Accessed May 3, 2005
Meadows M. Heading off hair-care disasters: use caution with relaxers and dyes.  FDA ConsumerJanuary-February 2001. Available at: http://www.fda.gov/fdac/features/2001/101_hair.html. Accessed December 29, 2004
 Occupational exposures of hairdressers and barbers and personal use of hair colourants.  IARC Monogr Eval Carcinog Risks Hum. 1993;57:43-118
PubMed
 Hair dye cancer alert. BBC News. April 17, 2002. Available at: http://news.bbc.co.uk/1/hi/health/1934496.stm. Accessed December 29, 2004
La Vecchia C, Tavani A. Epidemiological evidence on hair dyes and the risk of cancer in humans.  Eur J Cancer Prev. 1995;4:31-43
PubMed   |  Link to Article
Correa A, Jackson L, Mohan A, Perry H, Helzlsouer K. Use of hair dyes, hematopoietic neoplasms, and lymphomas: a literature review, I: leukemias and myelodysplastic syndromes.  Cancer Invest. 2000;18:366-380
PubMed   |  Link to Article
Correa A, Jackson L, Mohan A, Perry H, Helzlsouer K. Use of hair dyes, hematopoietic neoplasms, and lymphomas: a literature review, II: lymphomas and multiple myeloma.  Cancer Invest. 2000;18:467-479
PubMed   |  Link to Article
Stroup DF, Berlin JA, Morton SC.  et al.  Meta-analysis of observational studies in epidemiology: a proposal for reporting.  JAMA. 2000;283:2008-2012
PubMed   |  Link to Article
Nakata S, Sato J, Ohtake N, Imai K, Yamanaka H. Epidemiological study of risk factors for bladder cancer [in Japanese].  Hinyokika Kiyo. 1995;41:969-977
PubMed
Hartge P, Hoover R, Altman R.  et al.  Use of hair dyes and risk of bladder cancer.  Cancer Res. 1982;42:4784-4787
PubMed
Bhutta AT, Cleves MA, Casey PH, Cradock MM, Anand KJ. Cognitive and behavioral outcomes of school-aged children who were born preterm: a meta-analysis.  JAMA. 2002;288:728-737
PubMed   |  Link to Article
Bland JM, Altman DG. Statistical methods for assessing agreement between two methods of clinical measurement.  Lancet. 1986;1:307-310
PubMed   |  Link to Article
Takkouche B, Cadarso-Suarez C, Spiegelman D. Evaluation of old and new tests of heterogeneity in epidemiologic meta-analysis.  Am J Epidemiol. 1999;150:206-215
PubMed   |  Link to Article
Sutton AJ, Abrams KR, Jones DR, Sheldon TA, Song F. Methods for Meta-analysis in Medical ResearchChichester, England: John Wiley & Sons; 2000:115
Egger M, Davey Smith G, Schneider M, Minder C. Bias in meta-analysis detected by a simple, graphical test.  BMJ. 1997;315:629-634
PubMed   |  Link to Article
Costa-Bouzas J, Takkouche B, Cadarso-Suarez C, Spiegelman D. HEpiMA: software for the identification of heterogeneity in meta-analysis.  Comput Methods Programs Biomed. 2001;64:101-107
PubMed   |  Link to Article
Kinlen LJ, Harris R, Garrod A, Rodriguez K. Use of hair dyes by patients with breast cancer: a case-control study.  BMJ. 1977;2:366-368
PubMed   |  Link to Article
Shore RE, Pasternack BS, Thiessen EU, Sadow M, Forbes R, Albert RE. A case-control study of hair dye use and breast cancer.  J Natl Cancer Inst. 1979;62:277-283
PubMed
Nasca PC, Lawrence CE, Greenwald P, Chorost S, Arbuckle JT, Paulson A. Relationship of hair dye use, benign breast disease, and breast cancer.  J Natl Cancer Inst. 1980;64:23-28
PubMed
Stavraky KM, Clarke EA, Donner A. Case-control study of hair dye use by patients with breast cancer and endometrial cancer.  J Natl Cancer Inst. 1979;63:941-945
PubMed
Stavraky KM, Clarke EA, Donner A. A case-control study of hair-dye use and cancers of various sites.  Br J Cancer. 1981;43:236-239
PubMed   |  Link to Article
Wynder EL, Goodman M. Epidemiology of breast cancer and hair dyes.  J Natl Cancer Inst. 1983;71:481-488
PubMed
Koenig KL, Pasternack BS, Shore RE, Strax P. Hair dye use and breast cancer: a case-control study among screening participants.  Am J Epidemiol. 1991;133:985-995
PubMed
Nasca PC, Baptiste MS, Field NA, Metzger BB, DeMartino R. An epidemiologic case-control study of breast cancer and exposure to hair dyes.  Ann Epidemiol. 1992;2:577-586
PubMed   |  Link to Article
Boice JD Jr, Mandel JS, Doody MM. Breast cancer among radiologic technologists.  JAMA. 1995;274:394-401
PubMed   |  Link to Article
Cook LS, Malone KE, Daling JR, Voigt LF, Weiss NS. Hair product use and the risk of breast cancer in young women.  Cancer Causes Control. 1999;10:551-559
PubMed   |  Link to Article
Zheng T, Holford TR, Mayne ST.  et al.  Use of hair colouring products and breast cancer risk: a case-control study in Connecticut.  Eur J Cancer. 2002;38:1647-1652
PubMed   |  Link to Article
Petro-Nustas W, Norton ME, al-Masarweh I. Risk factors for breast cancer in Jordanian women.  J Nurs Scholarsh. 2002;34:19-25
PubMed   |  Link to Article
Green A, Willett WC, Colditz GA.  et al.  Use of permanent hair dyes and risk of breast cancer.  J Natl Cancer Inst. 1987;79:253-257
PubMed
Altekruse SF, Henley SJ, Thun MJ. Deaths from hematopoietic and other cancers in relation to permanent hair dye use in a large prospective study (United States).  Cancer Causes Control. 1999;10:617-625
PubMed   |  Link to Article
Jain M, Morgan RW, Elinson L. Hair dyes and bladder cancer.  Can Med Assoc J. 1977;117:1131-1133
PubMed
Neutel CI, Nair RC, Last JM. Are hair dyes associated with bladder cancer?  Can Med Assoc J. 1978;119:307-308
PubMed
Howe GR, Burch JD, Miller AB.  et al.  Tobacco use, occupation, coffee, various nutrients, and bladder cancer.  J Natl Cancer Inst. 1980;64:701-713
PubMed
Ohno Y, Aoki K, Obata K, Morrison AS. Case-control study of urinary bladder cancer in metropolitan Nagoya.  Natl Cancer Inst Monogr. 1985;69:229-234
PubMed
Nomura A, Kolonel LN, Yoshizawa CN. Smoking, alcohol, occupation, and hair dye use in cancer of the lower urinary tract.  Am J Epidemiol. 1989;130:1159-1163
PubMed
Andrew AS, Schned AR, Heaney JA, Karagas MR. Bladder cancer risk and personal hair dye use.  Int J Cancer. 2004;109:581-586
PubMed   |  Link to Article
Henley SJ, Thun MJ. Use of permanent hair dyes and bladder-cancer risk.  Int J Cancer. 2001;94:903-906
PubMed   |  Link to Article
Cantor KP, Blair A, Everett G.  et al.  Hair dye use and risk of leukemia and lymphoma.  Am J Public Health. 1988;78:570-571
PubMed   |  Link to Article
Zahm SH, Weisenburger DD, Babbitt PA, Saal RC, Vaught JB, Blair A. Use of hair coloring products and the risk of lymphoma, multiple myeloma, and chronic lymphocytic leukemia.  Am J Public Health. 1992;82:990-997
PubMed   |  Link to Article
Linos A, Kiamouris C, Foukanelis T, Kourousis C, Hatzis C, Stefanoudaki K. A case-control study of non-Hodgkin’s lymphoma.  J Epidemiol. 1994;139:S46
Holly EA, Lele C, Bracci PM. Hair-color products and risk for non-Hodgkin’s lymphoma: a population-based study in the San Francisco Bay Area.  Am J Public Health. 1998;88:1767-1773
PubMed   |  Link to Article
Miligi L, Seniori Costantini A, Crosignani P.  et al.  Occupational, environmental, and life-style factors associated with the risk of hematolymphopoietic malignancies in women.  Am J Ind Med. 1999;36:60-69
PubMed   |  Link to Article
Schroeder JC, Olshan AF, Dent RB.  et al.  A case-control study of tobacco use and other non-occupational risk factors for t(14;18) subtypes of non-Hodgkin’s lymphoma (United States).  Cancer Causes Control. 2002;13:159-168
PubMed   |  Link to Article
Zhang Y, Holford TR, Leaderer B.  et al.  Hair-coloring product use and risk of non-Hodgkin’s lymphoma: a population-based case-control study in Connecticut.  Am J Epidemiol. 2004;159:148-154
PubMed   |  Link to Article
Chiu BC, Weisenburger DD, Zahm SH.  et al.  Agricultural pesticide use, familial cancer, and risk of non-Hodgkin lymphoma.  Cancer Epidemiol Biomarkers Prev. 2004;13:525-531
PubMed
Grodstein F, Hennekens CH, Colditz GA, Hunter DJ, Stampfer MJ. A prospective study of permanent hair dye use and hematopoietic cancer.  J Natl Cancer Inst. 1994;86:1466-1470
PubMed   |  Link to Article
Thun MJ, Altekruse SF, Namboodiri MM, Calle EE, Myers DG, Heath CW Jr. Hair dye use and risk of fatal cancers in US women.  J Natl Cancer Inst. 1994;86:210-215
PubMed   |  Link to Article
Brown LM, Everett GD, Burmeister LF, Blair A. Hair dye use and multiple myeloma in white men.  Am J Public Health. 1992;82:1673-1674
PubMed   |  Link to Article
Herrinton LJ, Weiss NS, Koepsell TD, Daling JR, Taylor JW, Lyon JL. Exposure to hair-coloring products and the risk of multiple myeloma.  Am J Public Health. 1994;84:1142-1144
PubMed   |  Link to Article
Mele A, Szklo M, Visani G.  et al.  Hair dye use and other risk factors for leukemia and pre-leukemia: a case-control study.  Am J Epidemiol. 1994;139:609-619
PubMed
Markovic-Denic L, Jankovic S, Marinkovic J, Radovanovic Z. Brick mortar exposure and chronic lymphocytic leukemia.  Neoplasma. 1995;42:79-81
PubMed
Bjork J, Albin M, Welinder H, Tinnerberg H, Mauritzson N, Kauppinen T. Are occupational, hobby, or lifestyle exposures associated with Philadelphia chromosome positive chronic myeloid leukaemia?  Occup Environ Med. 2001;58:722-727
PubMed   |  Link to Article
Rauscher GH, Shore D, Sandler DP. Hair dye use and risk of adult acute leukemia.  Am J Epidemiol. 2004;160:19-25
PubMed   |  Link to Article
Tavani A, Negri E, Franceschi S, Talamini R, Serraino D, La Vecchia C. Hair dye use and risk of lymphoid neoplasms and soft tissue sarcomas.  Int J Cancer. 2005;113:629-631
PubMed   |  Link to Article
Ahlbom A, Navier IL, Norell S, Olin R, Spännare B. Nonoccupational risk indicators for astrocytomas in adults.  Am J Epidemiol. 1986;124:334-337
PubMed
Burch JD, Craib KJ, Choi BC, Miller AB, Risch HA, Howe GR. An exploratory case-control study of brain tumors in adults.  J Natl Cancer Inst. 1987;78:601-609
PubMed
Holman CDJ, Armstrong BK. Hutchinson’s melanotic freckle melanoma associated with non-permanent hair dyes.  Br J Cancer. 1983;48:599-601
PubMed   |  Link to Article
Holman CD, Armstrong BK. Hutchinson’s melanotic freckle melanoma and the use of non-permanent hair dyes.  Br J Cancer. 1985;52:135
PubMed   |  Link to Article
Osterlind A, Tucker MA, Stone BJ, Jensen OM. The Danish case-control study of cutaneous malignant melanoma, IV: no association with nutritional factors, alcohol, smoking or hair dyes.  Int J Cancer. 1988;42:825-828
PubMed   |  Link to Article
Tzonou A, Polychronopoulou A, Hsieh CC, Rebelakos A, Karakatsani A, Trichopoulos D. Hair dyes, analgesics, tranquilizers and perineal talc application as risk factors for ovarian cancer.  Int J Cancer. 1993;55:408-410
PubMed   |  Link to Article
Spitz MR, Fueger JJ, Goepfert H, Newell GR. Salivary gland cancer: a case-coontrol investigation of risk factors.  Arch Otolaryngol Head Neck Surg. 1990;116:1163-1166
PubMed   |  Link to Article
Hennekens CH, Rosner B, Belanger C, Speizer FE, Bain CJ, Peto R. Use of permanent hair dyes and cancer among registered nurses.  Lancet. 1979;1:1390-1393
PubMed   |  Link to Article
Markowitz JA, Szklo M, Sensenbrenner LL, Warm S. Hair dyes and acute nonlymphocytic leukemia [abstract].  Am J Epidemiol. 1985;122:523
Miller AB, Bartsch H. Hair dye use and bladder cancer.  Int J Cancer. 2001;94:901-902
PubMed   |  Link to Article

Figures

Tables

Table Graphic Jump LocationTable 1. Study-Specific RRs of Female Breast Cancer and Hair Dye Use
Table Graphic Jump LocationTable 2. Pooled RRs of Female Breast Cancer and Hair Dye Use
Table Graphic Jump LocationTable 3. Study-Specific RRs of Bladder Cancer and Hair Dye Use
Table Graphic Jump LocationTable 4. Pooled RRs of Bladder Cancer and Hair Dye Use
Table Graphic Jump LocationTable 5a. Study-Specific RRs of Hematopoietic Cancers and Hair Dye Use
Table Graphic Jump LocationTable 6. Pooled RRs of Hematopoietic Cancers and Hair Dye Use
Table Graphic Jump LocationTable 7. Study-Specific RRs of Other Cancers and Hair Dye Use

References

Ames BN, Kammen HO, Yamasaki E. Hair dyes are mutagenic: identification of a variety of mutagenic ingredients.  Proc Natl Acad Sci U S A. 1975;72:2423-2427
PubMed   |  Link to Article
Sontag JM. Carcinogenicity of substituted-benzendiamines (phenylenediamines) in rats and mice.  J Natl Cancer Inst. 1981;66:591-602
PubMed
Silverman DT, Morrison AS, Devesa SS. Bladder cancer. In: Schottenfeld D, Fraumeni JF, eds. Cancer Epidemiology and Prevention. New York, NY: Oxford University Press; 1996:1156-1179
Gago-Dominguez M, Castelao JE, Yuan JM, Yu MC, Ross RK. Use of permanent hair dyes and bladder-cancer risk.  Int J Cancer. 2001;91:575-579
PubMed   |  Link to Article
Scientific Committee on Cosmetic Products and Non-food Products.  Opinion Concerning Use of Permanent Hair Dyes and Bladder CancerAdopted on April 23, 2004. SCCNFP/0797/04. Available at: http://www.europa.eu.int/comm/health/ph_risk/committees/sccp/documents/out272_en.pdf. Accessed May 3, 2005
Meadows M. Heading off hair-care disasters: use caution with relaxers and dyes.  FDA ConsumerJanuary-February 2001. Available at: http://www.fda.gov/fdac/features/2001/101_hair.html. Accessed December 29, 2004
 Occupational exposures of hairdressers and barbers and personal use of hair colourants.  IARC Monogr Eval Carcinog Risks Hum. 1993;57:43-118
PubMed
 Hair dye cancer alert. BBC News. April 17, 2002. Available at: http://news.bbc.co.uk/1/hi/health/1934496.stm. Accessed December 29, 2004
La Vecchia C, Tavani A. Epidemiological evidence on hair dyes and the risk of cancer in humans.  Eur J Cancer Prev. 1995;4:31-43
PubMed   |  Link to Article
Correa A, Jackson L, Mohan A, Perry H, Helzlsouer K. Use of hair dyes, hematopoietic neoplasms, and lymphomas: a literature review, I: leukemias and myelodysplastic syndromes.  Cancer Invest. 2000;18:366-380
PubMed   |  Link to Article
Correa A, Jackson L, Mohan A, Perry H, Helzlsouer K. Use of hair dyes, hematopoietic neoplasms, and lymphomas: a literature review, II: lymphomas and multiple myeloma.  Cancer Invest. 2000;18:467-479
PubMed   |  Link to Article
Stroup DF, Berlin JA, Morton SC.  et al.  Meta-analysis of observational studies in epidemiology: a proposal for reporting.  JAMA. 2000;283:2008-2012
PubMed   |  Link to Article
Nakata S, Sato J, Ohtake N, Imai K, Yamanaka H. Epidemiological study of risk factors for bladder cancer [in Japanese].  Hinyokika Kiyo. 1995;41:969-977
PubMed
Hartge P, Hoover R, Altman R.  et al.  Use of hair dyes and risk of bladder cancer.  Cancer Res. 1982;42:4784-4787
PubMed
Bhutta AT, Cleves MA, Casey PH, Cradock MM, Anand KJ. Cognitive and behavioral outcomes of school-aged children who were born preterm: a meta-analysis.  JAMA. 2002;288:728-737
PubMed   |  Link to Article
Bland JM, Altman DG. Statistical methods for assessing agreement between two methods of clinical measurement.  Lancet. 1986;1:307-310
PubMed   |  Link to Article
Takkouche B, Cadarso-Suarez C, Spiegelman D. Evaluation of old and new tests of heterogeneity in epidemiologic meta-analysis.  Am J Epidemiol. 1999;150:206-215
PubMed   |  Link to Article
Sutton AJ, Abrams KR, Jones DR, Sheldon TA, Song F. Methods for Meta-analysis in Medical ResearchChichester, England: John Wiley & Sons; 2000:115
Egger M, Davey Smith G, Schneider M, Minder C. Bias in meta-analysis detected by a simple, graphical test.  BMJ. 1997;315:629-634
PubMed   |  Link to Article
Costa-Bouzas J, Takkouche B, Cadarso-Suarez C, Spiegelman D. HEpiMA: software for the identification of heterogeneity in meta-analysis.  Comput Methods Programs Biomed. 2001;64:101-107
PubMed   |  Link to Article
Kinlen LJ, Harris R, Garrod A, Rodriguez K. Use of hair dyes by patients with breast cancer: a case-control study.  BMJ. 1977;2:366-368
PubMed   |  Link to Article
Shore RE, Pasternack BS, Thiessen EU, Sadow M, Forbes R, Albert RE. A case-control study of hair dye use and breast cancer.  J Natl Cancer Inst. 1979;62:277-283
PubMed
Nasca PC, Lawrence CE, Greenwald P, Chorost S, Arbuckle JT, Paulson A. Relationship of hair dye use, benign breast disease, and breast cancer.  J Natl Cancer Inst. 1980;64:23-28
PubMed
Stavraky KM, Clarke EA, Donner A. Case-control study of hair dye use by patients with breast cancer and endometrial cancer.  J Natl Cancer Inst. 1979;63:941-945
PubMed
Stavraky KM, Clarke EA, Donner A. A case-control study of hair-dye use and cancers of various sites.  Br J Cancer. 1981;43:236-239
PubMed   |  Link to Article
Wynder EL, Goodman M. Epidemiology of breast cancer and hair dyes.  J Natl Cancer Inst. 1983;71:481-488
PubMed
Koenig KL, Pasternack BS, Shore RE, Strax P. Hair dye use and breast cancer: a case-control study among screening participants.  Am J Epidemiol. 1991;133:985-995
PubMed
Nasca PC, Baptiste MS, Field NA, Metzger BB, DeMartino R. An epidemiologic case-control study of breast cancer and exposure to hair dyes.  Ann Epidemiol. 1992;2:577-586
PubMed   |  Link to Article
Boice JD Jr, Mandel JS, Doody MM. Breast cancer among radiologic technologists.  JAMA. 1995;274:394-401
PubMed   |  Link to Article
Cook LS, Malone KE, Daling JR, Voigt LF, Weiss NS. Hair product use and the risk of breast cancer in young women.  Cancer Causes Control. 1999;10:551-559
PubMed   |  Link to Article
Zheng T, Holford TR, Mayne ST.  et al.  Use of hair colouring products and breast cancer risk: a case-control study in Connecticut.  Eur J Cancer. 2002;38:1647-1652
PubMed   |  Link to Article
Petro-Nustas W, Norton ME, al-Masarweh I. Risk factors for breast cancer in Jordanian women.  J Nurs Scholarsh. 2002;34:19-25
PubMed   |  Link to Article
Green A, Willett WC, Colditz GA.  et al.  Use of permanent hair dyes and risk of breast cancer.  J Natl Cancer Inst. 1987;79:253-257
PubMed
Altekruse SF, Henley SJ, Thun MJ. Deaths from hematopoietic and other cancers in relation to permanent hair dye use in a large prospective study (United States).  Cancer Causes Control. 1999;10:617-625
PubMed   |  Link to Article
Jain M, Morgan RW, Elinson L. Hair dyes and bladder cancer.  Can Med Assoc J. 1977;117:1131-1133
PubMed
Neutel CI, Nair RC, Last JM. Are hair dyes associated with bladder cancer?  Can Med Assoc J. 1978;119:307-308
PubMed
Howe GR, Burch JD, Miller AB.  et al.  Tobacco use, occupation, coffee, various nutrients, and bladder cancer.  J Natl Cancer Inst. 1980;64:701-713
PubMed
Ohno Y, Aoki K, Obata K, Morrison AS. Case-control study of urinary bladder cancer in metropolitan Nagoya.  Natl Cancer Inst Monogr. 1985;69:229-234
PubMed
Nomura A, Kolonel LN, Yoshizawa CN. Smoking, alcohol, occupation, and hair dye use in cancer of the lower urinary tract.  Am J Epidemiol. 1989;130:1159-1163
PubMed
Andrew AS, Schned AR, Heaney JA, Karagas MR. Bladder cancer risk and personal hair dye use.  Int J Cancer. 2004;109:581-586
PubMed   |  Link to Article
Henley SJ, Thun MJ. Use of permanent hair dyes and bladder-cancer risk.  Int J Cancer. 2001;94:903-906
PubMed   |  Link to Article
Cantor KP, Blair A, Everett G.  et al.  Hair dye use and risk of leukemia and lymphoma.  Am J Public Health. 1988;78:570-571
PubMed   |  Link to Article
Zahm SH, Weisenburger DD, Babbitt PA, Saal RC, Vaught JB, Blair A. Use of hair coloring products and the risk of lymphoma, multiple myeloma, and chronic lymphocytic leukemia.  Am J Public Health. 1992;82:990-997
PubMed   |  Link to Article
Linos A, Kiamouris C, Foukanelis T, Kourousis C, Hatzis C, Stefanoudaki K. A case-control study of non-Hodgkin’s lymphoma.  J Epidemiol. 1994;139:S46
Holly EA, Lele C, Bracci PM. Hair-color products and risk for non-Hodgkin’s lymphoma: a population-based study in the San Francisco Bay Area.  Am J Public Health. 1998;88:1767-1773
PubMed   |  Link to Article
Miligi L, Seniori Costantini A, Crosignani P.  et al.  Occupational, environmental, and life-style factors associated with the risk of hematolymphopoietic malignancies in women.  Am J Ind Med. 1999;36:60-69
PubMed   |  Link to Article
Schroeder JC, Olshan AF, Dent RB.  et al.  A case-control study of tobacco use and other non-occupational risk factors for t(14;18) subtypes of non-Hodgkin’s lymphoma (United States).  Cancer Causes Control. 2002;13:159-168
PubMed   |  Link to Article
Zhang Y, Holford TR, Leaderer B.  et al.  Hair-coloring product use and risk of non-Hodgkin’s lymphoma: a population-based case-control study in Connecticut.  Am J Epidemiol. 2004;159:148-154
PubMed   |  Link to Article
Chiu BC, Weisenburger DD, Zahm SH.  et al.  Agricultural pesticide use, familial cancer, and risk of non-Hodgkin lymphoma.  Cancer Epidemiol Biomarkers Prev. 2004;13:525-531
PubMed
Grodstein F, Hennekens CH, Colditz GA, Hunter DJ, Stampfer MJ. A prospective study of permanent hair dye use and hematopoietic cancer.  J Natl Cancer Inst. 1994;86:1466-1470
PubMed   |  Link to Article
Thun MJ, Altekruse SF, Namboodiri MM, Calle EE, Myers DG, Heath CW Jr. Hair dye use and risk of fatal cancers in US women.  J Natl Cancer Inst. 1994;86:210-215
PubMed   |  Link to Article
Brown LM, Everett GD, Burmeister LF, Blair A. Hair dye use and multiple myeloma in white men.  Am J Public Health. 1992;82:1673-1674
PubMed   |  Link to Article
Herrinton LJ, Weiss NS, Koepsell TD, Daling JR, Taylor JW, Lyon JL. Exposure to hair-coloring products and the risk of multiple myeloma.  Am J Public Health. 1994;84:1142-1144
PubMed   |  Link to Article
Mele A, Szklo M, Visani G.  et al.  Hair dye use and other risk factors for leukemia and pre-leukemia: a case-control study.  Am J Epidemiol. 1994;139:609-619
PubMed
Markovic-Denic L, Jankovic S, Marinkovic J, Radovanovic Z. Brick mortar exposure and chronic lymphocytic leukemia.  Neoplasma. 1995;42:79-81
PubMed
Bjork J, Albin M, Welinder H, Tinnerberg H, Mauritzson N, Kauppinen T. Are occupational, hobby, or lifestyle exposures associated with Philadelphia chromosome positive chronic myeloid leukaemia?  Occup Environ Med. 2001;58:722-727
PubMed   |  Link to Article
Rauscher GH, Shore D, Sandler DP. Hair dye use and risk of adult acute leukemia.  Am J Epidemiol. 2004;160:19-25
PubMed   |  Link to Article
Tavani A, Negri E, Franceschi S, Talamini R, Serraino D, La Vecchia C. Hair dye use and risk of lymphoid neoplasms and soft tissue sarcomas.  Int J Cancer. 2005;113:629-631
PubMed   |  Link to Article
Ahlbom A, Navier IL, Norell S, Olin R, Spännare B. Nonoccupational risk indicators for astrocytomas in adults.  Am J Epidemiol. 1986;124:334-337
PubMed
Burch JD, Craib KJ, Choi BC, Miller AB, Risch HA, Howe GR. An exploratory case-control study of brain tumors in adults.  J Natl Cancer Inst. 1987;78:601-609
PubMed
Holman CDJ, Armstrong BK. Hutchinson’s melanotic freckle melanoma associated with non-permanent hair dyes.  Br J Cancer. 1983;48:599-601
PubMed   |  Link to Article
Holman CD, Armstrong BK. Hutchinson’s melanotic freckle melanoma and the use of non-permanent hair dyes.  Br J Cancer. 1985;52:135
PubMed   |  Link to Article
Osterlind A, Tucker MA, Stone BJ, Jensen OM. The Danish case-control study of cutaneous malignant melanoma, IV: no association with nutritional factors, alcohol, smoking or hair dyes.  Int J Cancer. 1988;42:825-828
PubMed   |  Link to Article
Tzonou A, Polychronopoulou A, Hsieh CC, Rebelakos A, Karakatsani A, Trichopoulos D. Hair dyes, analgesics, tranquilizers and perineal talc application as risk factors for ovarian cancer.  Int J Cancer. 1993;55:408-410
PubMed   |  Link to Article
Spitz MR, Fueger JJ, Goepfert H, Newell GR. Salivary gland cancer: a case-coontrol investigation of risk factors.  Arch Otolaryngol Head Neck Surg. 1990;116:1163-1166
PubMed   |  Link to Article
Hennekens CH, Rosner B, Belanger C, Speizer FE, Bain CJ, Peto R. Use of permanent hair dyes and cancer among registered nurses.  Lancet. 1979;1:1390-1393
PubMed   |  Link to Article
Markowitz JA, Szklo M, Sensenbrenner LL, Warm S. Hair dyes and acute nonlymphocytic leukemia [abstract].  Am J Epidemiol. 1985;122:523
Miller AB, Bartsch H. Hair dye use and bladder cancer.  Int J Cancer. 2001;94:901-902
PubMed   |  Link to Article
CME
Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).

Multimedia

Some tools below are only available to our subscribers or users with an online account.

Web of Science® Times Cited: 62

Related Content

Customize your page view by dragging & repositioning the boxes below.

Articles Related By Topic
Related Topics
PubMed Articles
JAMAevidence.com

The Rational Clinical Examination
Make the Diagnosis: Cancer, Family History

The Rational Clinical Examination
Original Article: Does This Patient Have a Family History of Cancer?