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What are the Alternatives to Traditional Radiation Therapy for Breast Cancer?

Dana Casciotti, PhD, Anna E. Mazzucco, PhD, and Danielle Shapiro, MD, MPH, Cancer Prevention and Treatment Fund

Almost all women with early-stage breast cancer will live just as long if they choose lumpectomy (also called breast conserving surgery) instead of mastectomy. However, traditional radiation treatment is recommended for lumpectomy patients because it lowers their chances of the cancer returning.

Traditional radiation therapy is given on an outpatient basis 5 days each week for 6-8 weeks, and that is a difficult schedule for many patients. Many women living in rural areas or far from the hospital choose to get a mastectomy because daily radiation is so inconvenient.

For some women, radiation to a smaller area of the breast over a shorter period of time may be a useful alternative. These options are called partial breast irradiation (PBI).

PBI can be given with just 5-10 treatments over about a week’s time, and researchers are testing if treatments can be shortened to 2 days. According to experts, PBI can reduce the chances of a tumor coming back in the area around the lumpectomy from 10-25% to 3-4%.[1]

Based on a comprehensive 2016 research review, women who had PBI were more likely to have their tumor come back or to have a new tumor form in the same breast than women who had whole breast radiation treatment (WBRT). However, women who had PBI were not more likely to die any sooner or to later need a mastectomy.[2] 

PBI is not for everyone (see considerations below). Each type of PBI carries a different potential risk than the other types. For example, PBI with brachytherapy carries a higher risk of infection or seroma (fluid filled pocket in the breast tissue after surgery) than PBI with external beam radiation.[3] However, PBI with external beam radiation, increases risk for harmful effects to the lungs and heart. Three-dimensional models can reduce the radiation exposure to normal tissue, but do not completely eliminate risk.[4]

Across many studies, it is not clear whether PBI is more harmful to skin tissue than traditional radiation therapies.[5, 6,7] Harmful effects on the skin are rated on a scale of 1 to 4, with 4 being the worst. The changes in skin appearance include wrinkling, shrinkage, color change, red blotches, thickening, skin loss and destruction, etc.[8]  

PBI has been studied in clinical trials lasting no longer than 5 years, which isn’t really long enough to know if the therapy works the same or better than traditional radiation treatment. Traditional radiation therapy has been proven to be safe and effective for women for at least 15 years after treatment.

Who Should Consider PBI?

The American Society of Therapeutic Radiology and Oncology (ASTRO) provides the following recommendations: [9]

  1. Women aged 50 and over
  2. Early-stage breast cancer that is confined to one defined area of one breast only
  3. Estrogen receptor-positive breast cancer
  4. Women who had a breast lump removed with “clean margins” (no cancer cells were found in the area that was removed surrounding the lump)
  5. Women who did not have chemotherapy prior to surgery

Who should not be given PBI?

  1. Women aged 40 and younger
  2. Women who had the cancer removed but the margins contained cancer cells (“positive margins”)

What are the Types of PBI?

PBI can be given in the following ways:

  1. Intracavitary brachytherapy or MammoSite- A radiation bead is placed in the surgical cavity (the space left in the breast tissue after the breast lump is removed). This can be done at the time of surgery or later.
  2.  Interstitial brachytherapy- Several catheters are placed into the surgical cavity. Radioactive beads can be put in the breast through the catheters.
  3. Intra-operative technique- During the surgery, a machine is used that gives local radiation to the surgical cavity before the wound is closed.
  4. External beam radiotherapy using 3D modeling- Beams of radiation are given from different directions to match the 3D shape of the tumor. This focuses the rays on the tumor while reducing damage to the rest of the breast.

What are the Benefits and Harms of PBI?

Advantages of PBI:

  1. Smaller area of breast is given radiation, which reduces damage to normal breast tissue.
  2. Treatments can be given over days instead of weeks, making it more convenient and easier to schedule with other medical appointments.
  3. Because of the more convenient schedule, more women may be able to choose to get lumpectomy instead of mastectomy.

Disadvantages of PBI:

  1. Increased chances of tumor coming back or new tumor forming in the same breast compared to traditional radiation therapy.
  2. Because PBI can give a bigger dose of radiation, women may have later toxic effects, which affect the way the breast looks.
  3. Invasive approaches (placing beads in the surgical wound or catheters in the wound) can increase the chance of infection and can slow wound healing, which may affect the way the breast looks.

The Bottom Line

Radiation treatment can help women to conserve breast and prevent cancer spread after lumpectomy. PBI can be more convenient in the short run, but in the long run, we do not know if it is as safe or effective as traditional radiation treatment.

All articles are reviewed and approved by Dr. Diana Zuckerman and other senior staff.

1. Kuznar, W. ASCO Reading Room: APBI: A Compromise Solution Following BCT–In low-risk breast cancer patients, recurrence rates equivalent to those for WBI. Medpage Today. (July 26, 2016). Available Online:

2. Hickey BE, Lehman M, Francis DP, See AM. Partial breast irradiation for early breast cancer. Cochrane Database of Systematic Reviews 2016, Issue 7. DOI: 10.1002/14651858.CD007077.pub3.

3. Lei RY, Leonard CE, Howell KT, et al. Four-year clinical update from a prospective trial of accelerated partial breast intensity-modulated radiotherapy (APBIMRT). Breast Cancer Research and Treatment. 2013;140(1):119-133. doi:10.1007/s10549-013-2623-x.

4. Jacobson GM, Siochi RA. Low-Energy Intraoperative Radiation Therapy and Competing Risks of Local Control and Normal Tissue Toxicity. Frontiers in Oncology. 2017;7:212. doi:10.3389/fonc.2017.00212.

5. Whelan TJ, Olivotto I, Parpia S, et al. Interim toxicity results from RAPID: a randomized trial of accelerated partial breast irradiation (APBI) using 3D conformal external beam radiation therapy (3D CRT) Int J Radiat Oncol Biol Phys. 2013;85:21–22. DOI: 10.1200/JCO.2013.50.5511

6. Keshtgar MRS, Williams NR, Bulsara M, et al. Objective assessment of cosmetic outcome after targeted intraoperative radiotherapy in breast cancer: results from a randomized controlled trial. Breast Cancer Res Treat. 2013;140:519–525. DOI: 10.1007/s10549-013-2641-8.

7. Akhtari M, Abboud M, Szeja S, et al. Clinical outcomes, toxicity, and cosmesis in breast cancer patients with close skin spacing treated with accelerated partial breast irradiation (APBI) using multi-lumen/catheter applicators. Journal of Contemporary Brachytherapy. 2016;8(6):497-504. doi:10.5114/jcb.2016.64830.

8. RTOG Foundation. RTOG/EORTC Late Radiation Morbidity Scoring Schema. Available online:

9. Correa C, et al. Accelerated Partial Breast Irradiation: Executive summary for the update of an ASTRO Evidence-based Consensus Statement. Practical Radiation Oncology 2017, Issue 7. DOI: 10.1016/j.prro.2016.09.007.

Can Girls Lower Their Breast Cancer Risk by Eating Peanut Butter?

Krista Kleczewski, Cancer Prevention and Treatment Fund

Peanut butter, a favorite food of so many kids and overwhelmed parents, may help ward off abnormal breast conditions linked to cancer, according to researchers from Harvard and Washington University School of Medicine. The study, funded by the National Institutes of Health (NIH) and the Breast Cancer Research Foundation, found that girls between the ages of 9 and 15 who regularly ate foods high in vegetable protein and fat had a significantly lower risk of developing non-cancerous (benign) breast conditions as young women than those who did not eat these foods.1 Peanut butter, peanuts and nuts were the main sources of vegetable protein and fat in the girls’ diets.

What is Benign Breast Disease and How is it Related to Breast Cancer?

Benign breast diseases are changes in the breast that sometimes have no symptoms and sometimes can cause pain or discomfort, but are not cancerous. Some benign breast diseases increase a woman’s risk of eventually developing breast cancer only slightly, while others can increase her risks more substantially.2<sup>,</sup>3 For example, women with simple cysts or fibrosis (scar-like tissue in the breasts) have almost the same risk of developing breast cancer as women who don’t have these benign breast conditions.<sup>4</sup> However, women who have fast-growing abnormal cells, called atypical hyperplasia, are 3-4 times more likely to develop breast cancer than women with normal breasts.4

Peanut Butter and Benign Breast Disease

The study enrolled 9,039 girls, ages 9 to 15, and kept in touch with them for 14 years. The girls regularly reported to the researchers what they ate and drank, and whether they had been diagnosed at any point between the ages of 18 and 30 with benign breast disease. Adolescent girls who ate peanut butter or any kind of nuts three times a week or more had a nearly 40% lower chance of developing benign breast disease.

Although all the girls who ate peanut butter and nuts were less likely to develop benign breast disease, the girls who benefited the most were those who had a family history of breast cancer. This is important because, in general, benign breast disease is riskier in women with a family history of breast cancer.

Many people think of peanuts as nuts, but they are actually legumes.  For that reason, it is not surprising that the researchers found that consumption of other legumes such as beans, lentils, soybeans, as well as corn, may help shield girls from these breast conditions. Although the researchers did not study the benefits of specific types of nuts, it is believed that regular consumption of most nuts, including tree nuts, such as almonds and walnuts, provide protection against benign breast disease. At least one study in 2011 found that a diet containing walnuts slowed breast cancer tumor growth in mice; more research is needed before we will know if this is true for humans.5

Should All Girls Eat More Peanut Butter, Nuts, and Beans?

Although this was a large study of over 9,000 girls living in all 50 states, 95% of the girls were non-Hispanic whites, primarily from middle and upper socioeconomic backgrounds. As a result, it is impossible to say whether the study’s findings would also apply to girls from other races, and ethnicities, or to girls of lower socioeconomic backgrounds.

The study had other limitations. Because the girls filled out questionnaires about their eating habits, the researchers did not observe what the girls actually ate, or how much. This means the researchers had to rely on the girls remembering and reporting their intake accurately.

Another important question is do these foods truly protect against benign breast disease and possibly even breast cancer, or do the girls who eat them eat fewer less nutritious foods that would increase the risk of cancer? Whichever the answer, it’s a good idea—particularly if you have breast cancer in your family— to eat snacks involving peanut butter or a handful of nuts instead of less healthy alternatives like cookies, candy, or chips. Nuts and nut butter are what nutritionists call “nutrient dense” foods. They are rich in protein and nutrients, but they are also high in calories. So eat them in moderation and don’t assume that the new study means you can eat Reese’s Peanut Butter Cups to your heart’s content! They are not a nutritious snack choice! Similarly, it is best to look for low-salt and peanut butter brands without added sugar or oils. Try peanut butter with an apple or banana, peanuts low in salt, or an old classic called “Ants on a Log,” which is a stick of celery with peanut butter and raisins sprinkled on top.

Spread the news, and spread the peanut butter (in moderation, of course)!


Drugs to Avoid for Women Taking Tamoxifen

Blossom Paravattil, Megan Cole, and Danielle Shapiro, MD, MPH, Cancer Prevention and Treatment Fund

The female hormone estrogen makes most cancer tumor cells grow and multiply. The drug tamoxifen was developed to block estrogen and therefore stop that growth, to help treat, prevent, and stop the recurrence of most breast cancer.  Breast cancer that is sensitive to estrogen is called “estrogen receptor-positive breast cancer.”

For tamoxifen to do its job, it needs to be broken down in the body by a key protein known as CYP2D6.  Unfortunately, many common medicines can block or slow down CYP2D6, and that would make tamoxifen less effective.

Certain medications used to treat depression should be avoided by women taking tamoxifen. The antidepressants paroxetine (Paxil) and fluoxetine (Prozac) have been found to increase women’s risk of dying of cancer if they are taking tamoxifen. Women who are on these medications should talk to their doctors about switching to other medicines that don’t affect how tamoxifen works.

The table below shows a list of drugs to avoid and alternative drugs that can be taken instead.


Classes of drugs Drugs that are likely to interfere with tamoxifen

Alternative drugs that should be safe to take with tamoxifen

Antidepressants (SSRI/SNRIs) Paxil, Prozac, Wellbutrin, and Cymbalta Effexor, Pristiq, Edronax, Lexapro, and Remeron
Antipsychotics Mellaril, Trilafon, and Orap Navane, Clozaril, Zyprexa, Geodon, and Seroquel
Cardiac Drugs Cardioquin and Ticlid Cardizem
Allergy medications Benadryl (diphenhydramine), Unisom (doxylamine), Dimetapp (Brompheniramine), Tagamet (cimetidine) Zyrtec (cetirizine), Claritin (Loratadine), Fexofenadine (Allegra), Ranitidine (Zantac)
Medications for Infectious Diseases Seldane and Cardioquin Crixivan, Invirase, Viracept, Rescriptor, Viramune, and Sustiva

The Bottom Line

If you are taking tamoxifen, talk to your doctor about any medications  that you are taking (including over-the-counter products, such as cold and allergy medications) to be sure that they don’t interfere with tamoxifen.

All articles are reviewed and approved by Dr. Diana Zuckerman and other senior staff.


  1. Zosia Chustecka. Medscape News. Drugs to Avoid in Women Taking Tamoxifen. May 05, 2010. Accessed December 2017 Available online:

Can Aspirin Prevent Cancer and Cancer Deaths?

Nyedra W. Booker, PharmD, Tracy Rupp, PharmD, MPH, RD, Laura Gottschalk, PhD, and Danielle Shapiro, MD, MPH, Cancer Prevention and Treatment Fund

Doctors have prescribed aspirin to prevent heart attacks and stroke for many years. There is now good evidence that regular aspirin use can also prevent cancer. Experts already recommend an aspirin a day to prevent colon cancer, but aspirin may also “play a strong role in reducing death from cancer.”[1]  

Recommending Aspirin for Cancer Prevention

The U.S. Preventative Service Task Force (USPSTF), an independent group of medical experts, recommend  that people between the ages of 50 and 59 should take 81 mg of aspirin daily (which is the typical dosage of “baby” or low-dose aspirin) to prevent colon cancer. Since colon cancer develops slowly overtime, aspirin should be taken for at least 10 years.[2]

Daily aspirin is not for everyone between 50 and 59, however. For example, if you have an increased risk of bleeding because of other medication you are taking or because of a history of stomach or intestinal ulcers, kidney disease, or severe liver disease, the risks of taking aspirin daily may outweigh the benefits. 

The benefits of aspirin in preventing death from cancer are based in part on a 2016 study published in the prestigious Journal of the American Medical Association (JAMA), which looked at the rate of cancer in two large long-term studies.  The Nurse’s Health Study and the Health Professionals Follow-up study included almost 48,000 men and more than 88,000 women.[3] The study found that people who took aspirin regularly had a slightly lower risk for overall cancer and a 19% lower risk for colon cancer. These benefits were seen after just five years of use and are statistically significant, which means they are almost definitely due to the aspirin and not to other factors.

The new study results were presented at a national cancer conference in April 2017 and go beyond the results published in 2016.[1] Women in the studies who took aspirin regularly had a 7% lower chance of dying of any cause than women who did not take regular aspirin. Men who took aspirin regularly had an 11% lower chance of dying of any cause than men who did not take regular aspirin. Dying from cancer was 7% lower in women and 15% lower in men who regularly took aspirin. Women who regularly took aspirin had an 11% lower risk of dying from breast cancer. Men who regularly took aspirin had a 23% lower risk of dying from prostate cancer.  

Aspirin can have many benefits, but since it also has risks more studies are needed to examine who is most likely to benefit and who is most likely to be harmed. The study was observational, which means that it evaluated the health of people in the “real world,” rather than a randomized clinical trial.  Since it is not possible to know as much about all the health habits and other possible influences of the thousands of people in these huge studies as is possible in a clinical trial, the conclusions are considered less certain.

What You Need to do Before Starting Aspirin Therapy

Remember that aspirin is a drug, and it has risks even at low doses. You should talk about whether taking a daily aspirin is a good idea with your doctor, so that you can discuss:

  • Your medical history and all the medicines you are currently using, whether they are prescription or over-the-counter
  • Any allergies or sensitivities you may have to aspirin
  • Any vitamins or dietary supplements you are currently taking

Aspirin should not be taken with certain other over-the-counter pain medications such as ibuprofen (Motrin and Advil) and naproxen (Aleve) because they can increase the risk of internal bleeding. These medications are called NSAIDS.  Aspiring should also not be taken daily by those who regularly use herbs and nutritional supplements.  Vitamin E, fish oil (omega-3 fatty acids) and what’s known as the “four Gs”– garlic, ginger, gingko, and ginseng– can all increase your risk for bleeding when taken with aspirin and other blood thinners.[4]

If taking aspirin is not a safe option for you, there are other ways to reduce your chance of developing heart disease and cancer, without any side effects!  They include quitting smoking, eating a diet rich in fruits and vegetables, and getting up from your chair or couch regularly rather than sitting for hours without moving around. Walking or other exercising for at least 20-30 minutes each day is also helpful. However, for people at highest risk of heart disease or cancer, aspirin could truly be a lifesaver.

The Bottom Line

Regular aspirin use may prevent deaths from many causes including cancer, heart attacks, and strokes.

All articles are reviewed and approved by Dr. Diana Zuckerman and other senior staff.


  1. American Association for Cancer Research News Release. Regular Aspirin Use in Associated with Lower Cancer Mortality. April 3, 2017. Available online:
  2. USPSTF. Final Update Summary: Aspirin Use to Prevent Cardiovascular Disease and Colorectal Cancer: Preventive Medication. April 2016. Available online:
  3. Cao Y, et al. Population-wide Impact of Long-term Use of Aspirin and the Risk for Cancer. JAMA Oncol. Published online March 03, 2016. DOI: 10.1001/jamaoncol.2015.6396
  4. U.S. National Library of Medicine. MedlinePlus: Drugs, Supplements, and Herbal Information. Accessed December 2017.

Patients Under 50 with Early-Stage Ovarian Cancer: Safe Treatment with no Loss of Fertility

Julie Bromberg and Danielle Shapiro, MD, MPH, Cancer Prevention and Treatment Fund

Ovarian cancer is especially traumatic for young women, because it is often diagnosed when the disease is advanced. Standard treatment usually includes having both ovaries, fallopian tubes, and the uterus removed. While this “radical” surgery was once considered the safe option, the procedure left younger women with early menopause and unable to become pregnant. Now, many young women have the option of “fertility sparing surgery,” which removes one ovary and one tube.

A 2017 study in the Journal of Obstetrics & Gynecology found that women below age 40 who have early-stage epithelial ovarian cancer can be safely treated without losing their fertility.  Women in the study had an 89% chance of surviving at least 10 years after their surgery, whether they had the standard surgery or the fertility-sparing surgery.[1]  

A similar 2017 study in the Journal of Gynecologic Oncology examined premenopausal women under age 50 with a more aggressive type of ovarian cancer called early-stage ovarian clear cell cancer. At 5 years after surgery, 90% of women who did not have their uterus removed were alive compared to 88% of women who did. Similarly, 93% of women who had one ovary removed were alive compared to 85% who had both ovaries removed.[2]

The traditional treatment approach for ovarian cancer was to remove the organs to prevent the cancer from coming back. The uterus was also removed, because it was assumed to be safer to remove a nearby organ where cancer could grow. Younger women who were treated for ovarian cancer underwent early menopause (known as surgical menopause) because of the greatly reduced level of estrogen hormones in their bodies, and lost their ability to have children.[3]

Since the 2017 studies only included pre-menopausal women under age 50 with Stage 1 ovarian cancer, it is impossible to know whether older women would have similar survival rates under similar circumstances. Fertility-preserving treatment is risky for women with stage II or later stage ovarian cancer.

Cancer surgery has evolved over the years, becoming less radical. For example, breast cancer used to be treated by removing the entire breast and the muscles underneath, instead of just the cancer and a small area of healthy tissue around it.  Eventually, research proved that women lived just as long with much less radical surgery, and now early-stage breast cancer is often treated by removing just the cancer, rather than one or both breasts. The latest research indicates that breast cancer patients’ survival is slightly better with the less radical surgeries. (Read more on breast conserving surgery here.)

What Happens after Ovarian Cancer Surgery?

After surgery, women need to see their physician frequently for clinical exams during the first 5 years. The Society of Gynecologic Oncologists (doctors specializing in women’s cancers) recommends the following [3]:

  • In the first 2 years after surgery, women should have a regular exam, including an exam of the pelvis and lymph nodes every 3 months (or 4 times a year).
  • In the third year, women should have exams every 4-6 months (or 2-3 times a year).
  • In the fourth and fifth year, women should have exams every 6 months (or twice a year).
  • After 5 years, women can resume annual exams.
  • A blood test that checks for a tumor marker (CA-125) is optional.
  • CT scan should be done only when the doctor is concerned the cancer has recurred.   

How can you Detect Ovarian Cancer Early?

For all cancers, early treatment greatly increases the chances of survival. Unfortunately, the early symptoms of ovarian cancer are easily confused with less serious problems, making it difficult for women to know if they need to be tested for ovarian cancer.

If a woman has any of the following symptoms every day for more than 2 weeks, or if the symptoms are more severe or unusual for her, she should talk to her doctor about being tested for ovarian cancer[4]:

  • Feeling bloated or swelling in the stomach area
  • Pain in the stomach area
  • Difficulty eating or feeling full
  • Gas, bloating, or constipation

The Bottom Line

Treatments that preserve the uterus and at least part of one ovary, instead of removing the uterus and both ovaries, can be safe for women younger than 50 who have Stage 1 epithelial ovarian cancer. Premenopausal women with early-stage ovarian cancer who want to preserve their fertility should find a doctor who is experienced in that treatment and find out whether it is a safe option for them.



  1. Melamed A, Rizzo AE, Nitecki R, Gockley AA, Bregar AJ, Schorge JO, delCarmen MG, and Rauh-Hain JA. (2017). All-Cause Mortality After Fertility-Sparing Surgery for Stage I Epithelial Ovarian Cancer. Obstetrics & Gynecology, 130 (1): 71-79. doi: 10.1097/AOG.0000000000002102
  2. Nasioudis, D., Chapman-Davis, E., Frey, M. K., Witkin, S. S., & Holcomb, K. (2017). Could fertility-sparing surgery be considered for women with early stage ovarian clear cell carcinoma? Journal of Gynecologic Oncology, 28(6), e71.
  3. Medscape. Ovarian Cancer Guidelines. (2016, Aug. 22). Available Online:
  4. National Cancer Institute. Ovarian Epithelial, Fallopian Tube, and Primary Peritoneal Cancer Treatment (PDQ®)–Patient Version. (2017, Oct. 13). Available Online:

† 85%-90% of all ovarian cancers are epithelial

Hormone Therapy and Menopause

Anna E. Mazzucco, PhD, Elizabeth Santoro, RN, MPH, Maushami DeSoto, PhD, and Jae Hong Lee, MD, MPH

 Do women need to “replace” hormones as they age? Millions of women struggle with the decision about hormones during and after menopause: should I go on, should I stay on, or should I go off?

For decades, women were told that hormone therapy was like a fountain of youth that would protect them against many of the diseases and symptoms of aging that increase after menopause. Since estrogen alone was known to increase the risk of uterine cancer, doctors usually prescribed a combination of estrogen and progestin, unless a woman had a hysterectomy and therefore was at no risk of uterine cancer.

In addition to its proven effectiveness for decreasing hot flashes, night sweats, and vaginal dryness, in the 1980’s and 1990’s hormone therapy was thought to decrease osteoporosis, prevent heart disease, improve memory and concentration, reduce wrinkles, and improve mood. Women were encouraged to start hormone therapy before menopause started and to continue to take it for years, if not decades, in order to improve their health and their quality of life.

However, the research evidence is now clear: the risks of hormones outweigh the benefits for the vast majority of women.

What the Research Says

In December 2017, the experts at the U.S. Preventive Services Task Force issued a clear recommendation:  post-menopausal women should NOT take hormones to prevent chronic health conditions, such as increasing bone strength to avoid fractures. The reason is that the risks of these hormones outweigh the benefits.

This recommendation is just the latest evidence that taking hormones to “replace” those that are reduced in menopause if often bad for your health. Previous evidence came from the Women’s Health Initiative (WHI), sponsored by the National Institutes of Health (NIH), which included more than 27,000 women in three different trials to study the effect of hormones on women’s bodies. The 3 trials were: 1) the Estrogen Plus Progestin Trial, 2) the Women’s Health Initiative Memory Study, and 3) the Estrogen-alone Trial.

The researchers found that women taking a combination of estrogen and progesterone hormones were more likely to develop breast cancer, stroke, and blood clots, and at least as likely to develop heart disease, compared to women taking placebo. Those on estrogen alone were at an increased risk for strokes and at a significantly increased risk for deep vein, thrombosis.† The memory Study revealed that women taking a combination of estrogen plus progesterone were twice as likely to develop Alzheimer’s Disease and other forms of dementia compared to women on placebo.

All the three trials were stopped early for ethical reasons when it became clear that women taking hormones were more likely to be harmed than helped. While there are some short-term benefits to taking hormones, the researchers concluded that for most women, the risks of hormone therapy outweigh the benefits.

Following release of these findings, use of hormone therapy in the U.S. dropped significantly.  Since then, several large studies have pointed out that breast cancer incidence also dropped a few years after the decline inHRT use.6,,7  This unexpected and unprecedented drop in breast cancer incidence suggests that HRT has a more dramatic impact on breast cancer risk than previously thought.8

In 2009, a study found that hormone therapy increased the risk of dying of lung cancer among women who smoked or previously smoked, compared to smokers or former smokers who did not take hormone therapy. For more information click here.

In 2010 the University of California at San Francisco did a study of nearly 700,000 women. The researchers found that taking hormones may actually promote the growth of tumors in the breast which increases the incidents of invasive cancer and the risk of ductal carcinoma in situ (DCIS), a form of non-invasive pre-cancer. You can read more about that study by clicking here.

Experts who promote the use of HRT have criticized the WHI for enrolling women after menopause rather than just before or in the earliest stages.  So, it is important to note that in 2014, a study of 727 women in early menopause showed that hormone therapy did not prevent atherosclerosis (artery thickening), as had been claimed previously.  Following women on HRT for 4 years, the researchers from the Kronos Longevity Research Institute, a pro-HRT research institute, and other institutions, found no difference in artery thickening between the women who took HRT and those who didn’t.9  In 2015, the same group published an article admitting that hormone therapy also had no impact on “cognitive decline,” despite claims that it would prevent Alzheimer’s and memory loss. 10  Although the authors focused on a small improvement in mood related to using hormone pills for 4 years (but not found with hormone creams), they downplayed the more important finding: no impact on depression as measured by the valid and reliable Beck Depression Inventory.

What are the Risks and Benefits of Hormone Therapy?

To emphasize that lost hormones don’t necessarily need to be replaced, the term “hormone replacement therapy” has been changed to “hormone therapy.” Experts now advise women to use hormone therapy only for severe symptoms of menopause that reduce the quality of life, such as severe hot flashes, night sweats, insomnia, and vaginal dryness. Women are urged to take hormones at the lowest dose that is effective and for the shortest possible period of time. However, even short-term use (less than one year) increases some risks; for example, the increase in heart disease comes primarily from the first year of hormone use.

Hormone therapy may be recommended in severe cases of vulvar and vaginal atrophy as well as for treating severe postmenopausal osteoporosis when non-estrogen medications or other strategies are unsuccessful or impossible. A decision to use any combination of estrogen and progestin should be discussed with a physician who is expert on the topic, and specific criteria for the indication, dose, and duration of these hormones must be met prior to their prescription and administration.


Compared to women taking placebo, within 5 years the women who received estrogen plus progestinexperienced:
— 41% more strokes
— 29% more heart attacks
— twice as many blood clots
— 22% more heart disease of all types
— 26% more breast cancer
— 37% fewer cases of colorectal cancer
— one-third fewer hip fractures
— 24% fewer bone fractures of any type
— no difference in the overall death rate

It’s important to note that only 2.5% of the women in the study experienced health problems. So, while the percentage increase in some diseases was rather large, the risk for most patients remained relatively small. That does not mean these risks are not important however.

To provide a better sense of the additional risks that come with combination hormone therapy, the study data can be summarized more simply. Compared to a group of 10,000 women taking placebo, 10,000 women taking combination hormone therapy will experience:
— 7 more heart attacks
— 8 more strokes
— 8 more cases of breast cancer
— 18 more blood clots
— 6 fewer cases of colorectal cancer
— 5 fewer hip fractures

Research Evidence

The Women’s Health Initiative was a major 15-year research program to address the most common causes of death, disability and poor quality of life in post-menopausal women – cardiovascular disease, cancer, and osteoporosis. The WHI was launched in 1991 and consisted of a set of clinical trials and an observational study. The clinical trials were designed to test the effects of post-menopausal hormone therapy, diet modification, and calcium and vitamin D supplements on heart disease, fractures, and breast and colorectal cancer.

The hormone trial had two studies: the estrogen-plus-progestin study of women with a uterus and the estrogen-alone study of women without a uterus. (Women with a uterus were given progestin in combination with estrogen, a practice known to prevent endometrial cancer.) In both hormone therapy studies, women were randomly assigned to either the hormone medication being studied or to placebo. Those studies ended several years ago, and the women are now participating in a follow-up phase, which will last until 2010.

Estrogen plus Progestin Trial (stopped in July 2002)

Compared with women in the placebo those on estrogen plus progestin had:

  • Increased risk of heart attack
  • Increased risk of stroke
  • Increased risk of blood clots
  • Increased risk of breast cancer
  • Reduced risk of colorectal cancer
  • Fewer fractures
  • No protection against mild cognitive impairment and increased risk of dementia (study included only women 65 and older)
  • Increased risk of dying of lung cancer
Women’s Health Initiative Memory Study (stopped in May 2003)
  • Women taking hormones had twice the risk for developing dementia
  • Hormones provided no protection against mild cognitive impairment/memory loss
Estrogen-alone Trial (stopped in February 2004)
  • Estrogen increased risk for stroke
  • Estrogen decreased risk for hip fracture
  • No positive or negative effect on breast cancer

Compared to placebo women on estrogen alone had:

  • Increased risk of stroke
  • Increased risk of blood clots
  • Uncertain effect for breast cancer
  • No difference in risk for colorectal cancer
  • No difference in risk for heart attack
  • Reduced risk of fracture

Links to Research Information

Estrogen Plus Progestin Trial: July 2002
The Women’s Health Initiative Memory Study: May 2003
The Estrogen-alone Trial: February 2004


† Deep vein thrombosis refers to a blood clot deep inside the veins, usually in the legs.
‡ Symptoms include thinning and inflammation of the vaginal walls and changes in the vulva.

Nearly a Dozen Artificial Turf Fields in DC Failed Last Round of Safety Tests

Evan Lambert, Fox 5 News: September 18, 2017

A parents’ group known as Tireless DC tells FOX 5 that 11 artificial turf fields in the District have failed their most recent round of testing, leading to closures and replacements, and igniting another debate over the safety of synthetic turf.

D.C.’s Department of General Services (DGS) maintains and tests the 50 synthetic turf fields in the city. DGS did not make a list of the 11 failing fields available to FOX 5, but a task order from DGS shared with us shows the city is spending nearly $1 million to replace four turf fields at Janney, Eaton, Ross and Tubman elementary schools.

Tireless DC tells FOX 5 those schools are among the 11 fields that failed an annual test by DGS, which essentially measures how hard the fields are. A number under 200G is considered safe by some industry experts and that is the guideline DGS uses. […]

Janney Elementary School’s principal sent a letter to parents at the start of the school year letting them know the field failed a safety test and that it would be closed for replacement. The field is nearing completion, according to a DGS spokeswoman.

Parents expressed frustration over not learning of the test results sooner and the timing of the repair during the school year.

“The timing is really what was the biggest frustration because if it was known last spring, there was a lot of downtime during the summer, and at this point, it has impacted the practices,” said Janney Elementary School parent Christine Lucy.

Dr. Diana Zuckerman, president of the National Center for Health Research, expressed concern about the fact that the synthetic turf industry faces little government regulation.

“We really know very little about what is in artificial turf, but when studies have been done, they find a wide range of very toxic materials, including materials that can cause children to have attention deficit problems, can exacerbate asthma or obesity and can even in the long run cause cancer,” Dr. Zuckerman said.

In Montgomery County, seven artificial turf fields used by the school system are tested twice yearly by the manufacturers.

Read the original article here.

Question: I Have Been Diagnosed with Breast Cancer. What Are My Options so That I Can Still Have Breasts?

Q: I have been diagnosed with breast cancer. What are my options so that I can still have breasts?

A. We’re not doctors and we don’t provide medical advice, but I can tell you what we know based on research and from speaking with many experts and with women who have had breast implants. If you have been diagnosed with early stage breast cancer (stage I, IIa, IIb, or IIIa) , you probably can keep your breasts, and have a lumpectomy rather than a mastectomy (which removes the entire breast). Early-stage breast cancer patients who undergo a lumpectomy (which removes only the cancer and a small area around it) that is followed by radiation will live just as long as women who have a mastectomy instead.  In fact, the latest research indicates that women with early-stage breast cancer who have a lumpectomy live significantly longer than women of the same age and diagnosis who undergo mastectomy.

Experts recommend a lumpectomy with radiation for most women because it is less traumatic physically and emotionally, and avoids the problems from reconstructing a breast. For more information about this, see a booklet printed by the National Cancer Institute, the NIH, AHRQ, and the National Research Center for Women & Families here.

If you have been diagnosed with a pre-cancerous condition such as Stage 0 breast cancer, including ductal carcinoma in situ (DCIS) or lobular carcinoma in situ (LCIS), it is very unlikely that you need a mastectomy. Women with LCIS do not have breast cancer and most will never get breast cancer. They do not need a mastectomy or even a lumpectomy, although they do need regular mammograms. Most women with DCIS can choose lumpectomy with radiation, rather than mastectomy. For more information, see our booklet here.

For women with breast cancer who want to have breasts, the preferred choice is usually to keep their breasts (rather than remove their breasts and create new ones). Although a lumpectomy can make the breast smaller or change the shape, it will still have the sensation of a natural breast. In contrast, a woman who has a mastectomy with reconstruction, either with implants or with tissue transferred from elsewhere in her body, will have “breast shapes” that do not have any feeling. They are numb. Reconstruction also requires at least two surgeries. Reconstructed breasts may look fuller or “younger” but when the options are explained to them, many women would prefer to have sensation in their breast (or breasts), and would prefer not to have to worry about complications and the need for additional surgery.

If a woman needs to have a mastectomy, because the DCIS has spread throughout the breast or the cancer is large, there are several choices for reconstruction: saline breast implants, silicone breast implants, and moving tissue to create a new breast, such as a TRAM flap (Transverse Rectus Abdominis Myocutaneous flap) or DIEP flap (Deep Inferior Epigastric Perforator flap).

Many plastic surgeons know how to reconstruct breasts using breast implants, but few are skilled at moving tissue (which is called autologous tissue transfer). That is one of the reasons why so many plastic surgeons recommend breast implants.

Saline or Silicone? Some surgeons prefer silicone gel breast implants to saline, because they feel more natural. However, saline breast implants are approved by the FDA as “reasonably safe” and silicone gel implants are not. That is why women getting silicone gel breast implants must agree to be in a study. The goal is to find out how many complications or problems arise in these women in order to decide whether they are safe enough to approve. You would be part of an experiment to find out if the implants are “safe enough” for other women.

One problem with silicone breast implants is that they can break without a patient knowing it. Although less embarrassing than an instant deflation (which is likely with saline), breakage without symptoms is a bad thing, not a good thing. If silicone gel breast implants break and leak, the silicone can get into lymph nodes and travel to the lungs, liver, and brain. No research has been done on those risks, but a study by scientists at the National Cancer Institute found that women with breast implants were twice as likely to die from brain cancer or lung cancer compared to other plastic surgery patients. More research is needed, but those findings are cause for concern.

If saline implants break they are usually easy to remove. If silicone implants break, they can leak and can be extremely difficult and expensive to remove carefully. For that reason, we believe that saline are safer than silicone, even though both have very high complication rates.

Risks. All breast implants, even saline implants, are enveloped in an outer shell made of silicone. The envelope also contains other chemicals and heavy metals, such as microscopic amounts of platinum or tin, which vary during the manufacturing process. Unfortunately, some women have a reaction to those substances. Although silicone is considered “biocompatible” and most people don’t have an immediate allergic or autoimmune response, some people do, and many more develop a response years later.

It’s impossible to predict who will have problems with breast implants, and who won’t. It’s important to know that all implants will eventually break, sometimes within a few months or years, and usually within 10 years. Sometimes women who have a mastectomy get breast implants to replace one breast and to make the other breast look more similar to the replaced breast. However, it’s important to know that either silicone or saline breast implants interfere with mammograms. They show up white on the film, hiding tumors that are above or below.

Alternatives to Implants. An alternative to breast implants is “autologous tissue transfer,” such as the TRAM flap and DIEP flap procedures. These procedures use a woman’s own fat and tissue is used to reconstruct the breast. Many women prefer it to implants because it feels more natural and apparently lasts for a very long time (possibly forever, although the procedure has mostly been done in the last 15 years so it’s impossible to say). However, both the TRAM flap and DIEP flap procedures are more expensive than implants, require an especially skilled surgeon for a good result, and the healing process usually takes at least several months and can be painful. Women are only able to get this surgery if they have enough body fat in their abdomen area or back to form breasts. And, like a breast implant reconstruction, the breast has no feeling. For a woman who has the tissue transferred from her abdomen area (in an operation that has been compared to a “tummy tuck”), there is some loss of muscle in that area. That can be a problem for athletic women, but many other women don’t mind.

The DIEP flap is a similar type of reconstruction but does not remove any muscle. Instead, for the DIEP flap, the surgeon only removes fat and other tissue and makes a small cut in the abdominal muscle. Since no part of the abdominal muscle is removed, patients are able to maintain abdominal strength, making this surgery a better option for most women, especially those who are physically active.

Fortunately, TRAM flaps and DIEP flaps are covered by some health insurance companies. These are complicated surgeries with long recovery times and you would need to find a physician who is very experienced doing these procedures, and we highly recommend asking the doctor to put you in touch with other patients who were happy with the reconstruction.


For examples of women who had less pain and other symptoms after their implants were removed, see the personal stories on our website at You also might want to check out to hear from women who have had their implants removed and not replaced. Many felt healthier, happier, and more attractive afterwards.

We hope this information is helpful. For more information, check out or feel free to write to us at /

The comments and statements of the National Research Center for Women & Families are believed and intended to be accurate, and where applicable, based on scientific literature. NRC’s statements do not constitute medical diagnoses, medical advice, plans of treatment, or legal opinion, and we are not responsible for the use or application of this information. All medical information should be reviewed with your health care practitioner.

We hope that the information we’ve provided is helpful. In order to maintain this free service to all women and their families, we invite your tax-deductible contributions to NRC (see )

Children and Athletes at Play on Toxic Turf and Playgrounds

 Nyedra W. Booker, PharmD, MPH and Stephanie Fox-Rawlings, PhD

Is your child playing on rubber instead of grass at the playground? The use of human-made surfaces on playgrounds has increased dramatically over the years. First developed during the 1960s primarily for athletic fields, these artificial surfaces were also part of a strategy to provide children with more opportunities for outdoor physical activity, particularly in the inner city where outdoor playgrounds were scarce.[1] The first artificial turf (marketed as “Chemgrass”) was made of plastic, yet looked a lot like natural grass.  Since then, these artificial surfaces have expanded and many look like colorful rubber surfaces.  But regardless of what they look like, all are made with materials that can be dangerous to children and adults.

As its use for various sports activities increased significantly over the years, so did the concerns. Athletes began to complain that the surface was much harder than natural grass, as some studies also began to show that the use of artificial turf could increase the risk for football and other sports-related injuries. This prompted a ban on the use of artificial turf by the English Football Association in 1988, while many ballparks and professional sports stadiums in the United States began converting back to using natural grass during the 1990s. Over time, material such as rubber was added to keep the blades of “grass” in place and provide more cushioning.[1] Artificial turf containing rubber and other cushioning materials was also assumed to reduce sports-related injuries, but study results have not always supported that assumption.[2] Even with modern fields, many professional athletes dislike playing on artificial turf. It increases the severity of abrasions due to sliding, puts additional stress on joints, and heats up much more than grass does in the sun – and can become dangerously hot.[3][4] Following their failure to force soccer’s international governing body (FIFA) to use sod instead of artificial turf for the 2015 Women’s World Cup, an international group of women players are suing the FIFA.[5]

Some of the benefits of artificial turf are that it’s a long-lasting “all-weather” material that does not require a lot of maintenance in the short-term or potentially dangerous pesticides. Artificial turf is currently used on more than 12,000 athletic fields in the U.S.[6] Unfortunately, these surfaces often don’t last as long as expected.

From the Tire Swings to Play Surfaces Made from Tires

Do you remember when children used to play on tire swings in the backyard or at the park? Those same tires are now being put to a new and possibly hazardous use! Recycled rubber tires have become one of the top choice materials for surfacing children’s playgrounds.[7] In 2013, approximately 233 million scrap tires were generated, of which 8% (approximately 17.5 million tires) was processed for playground surface cover and 4% (almost 10 million tires) for sports surfaces.[8] Logically, tire scraps seemed like a surface that would be less likely to harm children if they fell. Recycling tires for use in playgrounds also keeps them out of landfills where they take up space, harbor rodents and other animals, and trap standing water that serve as breeding grounds for mosquitoes and other disease-bearing insects. In addition, tires that have been thrown away can catch fire and that releases many different harmful chemicals into the air and ground water.[9]

The tire material and other rubber used on playgrounds can include the following:

  •    Loose tire shred (rubber mulch) or “crumb” on a surface that can be raked.
  •    Tire shreds that are combined with a binder and then poured onto a permanent surface
  •    Tiles made from tire shreds and binder that have been factory-molded, then glued to a playground surface.[7]
  •  Colorful rubber that is “poured in place” (PIP) that is not necessarily made from tires but contains many of the same dangerous materials.

Are Playground Surfaces Made with Rubber or Recycled Tires Safe?

There has been increasing evidence that raises concerns about the safety of recycled tire material as well as new rubber and other synthetic materials used on playground surfaces. While “rubber” includes natural rubber from rubber trees, it also contains phthalates (chemicals that affect hormones, see Phthalates and Children’s Products), polycyclic aromatic hydrocarbons (PAHs), volatile organic compounds (VOCs) and other chemicals known or suspected to cause adverse health effects.[10] PAHs, for example, are natural or human-made chemicals that are made when oil, gas, coal or garbage is burned.[11] According to the EPA, breathing air contaminated with PAHs may increase a person’s chance of developing cancer, and the Agency for Toxic Substances and Disease Registry (ATSDR) states that PAHs may increase the risk for cancer and also increase the chances of birth defects.[11][12]

What the Scientific Studies Say

The California Office of Environmental Health Hazard Assessment (OEHHA) conducted three laboratory studies in 2007 to investigate the potential health risks to children from playground surfaces made from recycled tires. One study evaluated the level of chemicals released that could cause harm to children after they have had contact with loose tire shreds, either by eating them or by touching them and then touching their mouth. The other two studies looked at the risk of injury from falls on playground surfaces made from recycled tires compared to wood chips, and whether recycled tire shreds could contaminate air or water.[7]

It would not be ethical to ask children to eat tire shreds, so the researchers created chemical solution that mimicked the conditions of a child’s stomach and placed 10 grams of tire shreds in it for 21 hours at a temperature of 37°C. Researchers then measured the level of released chemicals in the solution and compared them to levels EPA considered risky. The study also mimicked a child touching the tire shreds and then touching her mouth by wiping recycled tire playground surfaces and measuring chemical levels on the wipes. To evaluate skin contact alone, the researchers tested guinea pigs to see if rubber tire playground samples caused any health problems. This study assumed that children would be using the playground from the ages of 1 through 12. Results of the OEHHA studies showed that a single incident of eating or touching tire shreds would probably not harm a child’s health, but repeated or long-term exposure might. Five chemicals, including four PAHs, were found on wipe samples. One of the PAHs, “chrysene,” was higher than the risk level established by the OEHHA, and therefore, could possibly increase the chances of a child developing cancer.[7]

Out of the 32 playgrounds surfaced in recycled tires that the researchers in California looked at, only 10 met that state’s 2007 standard for “head impact safety” to reduce brain injury and other serious harm in children who fall while playing. In contrast, all five surfaces made of wood chips met the safety standard.[7]

A 2012 study analyzing rubber mulch taken from children’s playgrounds in Spain found harmful chemicals in all, often at high levels.[10] Twenty-one samples were collected from 9 playgrounds in urban locations. The results showed that all samples contained at least one hazardous chemical, and most contained high concentrations of several PAHs. Several of the identified PAHs can be released into the air by heat, and when that happens children are likely to inhale them. While the heat needed to do this was very high in some cases (140 degrees Fahrenheit/ 60 ºC), many of the chemicals also became airborne at a much lower temperature of 77 ºF (25 ºC). The authors concluded that the use of rubber recycled tires on playgrounds “should be restricted or even prohibited in some cases.”[10]

A 2015 report by Yale scientists analyzed the chemicals found in 5 samples of tire crumbs from 5 different companies that install school athletic fields, and 9 different samples taken from 9 different unopened bags of playground rubber mulch. The researchers detected 96 chemicals in the samples. A little under a half have never been studied for their health effects, so their risks are unknown, and the other chemicals have been tested for health effects, but those tests were not thorough. Based on the studies that were done, 20% of the chemicals that had been tested are considered to probably can cause cancer, and 40% are irritants that can cause breathing problems such as asthma, and/or can irritate skin or eyes.[13]

What the EPA Has Done

The EPA created a working group that collected and analyzed data from playgrounds and artificial turf fields that used recycled tire material. Samples were collected at six turf fields and two playgrounds in four study sites (Maryland, North Carolina, Georgia and Ohio). In a report released in 2009, the agency concluded that the level of chemicals monitored in the study and detected in the samples were “below levels of concern.” There were limitations to this study, however. The study did not measure the concentration of organic chemicals that are known to vaporize during summer heat (called SVOCs). SVOCs include PAH.

Due to the small number of samples and sampling sites used, the EPA stated that it is not possible to know if these findings are typical of other playgrounds or fields until additional studies are conducted.[14] When announcing the results of the study, EPA joined other organizations in recommending that as a precaution, young children wash their hands frequently after playing outside.[14]

A meeting was then convened by the EPA in 2010, bringing together various state and federal agencies to discuss safe levels of chemical exposure on playgrounds made from recycled tire rubber, and opportunities for additional research.[14] In the case of PAHs, the EPA has concluded that while there are currently no human studies available to determine their effects at various levels, based on laboratory findings, “breathing PAHs and skin contact seem to be associated with cancer in humans.”[11]

In February 2016, the U.S. government announced a new action plan to better understand the likely health risks of recycled tire crumb and similar artificial surfaces. This initiative involves 4 U.S. government agencies: the EPA, Centers for Disease Control and Prevention (CDC), Agency for Toxic Substances and Disease Registry (ATSDR) and Consumer Product and Safety Commission (CPSC). In December 2016, they released a status report.[15]

How to Protect Your Children

So how can you protect your child at the playground? Remember that children are much more likely to be harmed by exposure to chemicals in their environment than adults because they are smaller (so the exposure is greater) and because their bodies are still developing. This is why it’s important to significantly reduce (or try to eliminate) any contact your child may have with substances that are known or suspected to be harmful. If you have more than one playground in your area, choose the one that doesn’t have a recycled rubber play surface or other types of rubber or synthetic surface.

Parents can actively persuade local officials that playgrounds should use wood chips rather than rubber or other substances that are less safe when children fall, and more dangerous in terms of chemicals that they breathe or get on their hands.

The CDC, Consumer Product Safety Commission (CPSC) and EPA all recommend that you teach your child the importance of frequent hand washing, especially after playing outside and before eating.[14] The President’s Cancer Panel  advised to “minimize children’s exposure to toxics” and “both mothers and fathers should avoid exposure to endocrine-disrupting chemicals and known or suspected carcinogens prior to a child’s conception and throughout pregnancy and early life, when risk of damage is greatest.”[16]

The Consumer Product Safety Commission recommends the following precautions:

  1. Avoid mouth contact with playground surfacing materials, including mouthing, chewing, or swallowing playground rubber. This may pose a choking hazard, regardless of chemical exposure.
  2. Avoid eating food or drinking beverages while directly on playground surfaces, and wash hands before handling food.
  3. Limit the time at a playground on extremely hot days.
  4. Clean hands and other areas of exposed skin after visiting the playground, and consider changing clothes if evidence of tire materials (e.g., black marks or dust) is visible on fabrics.
  5. Clean any toys that were used on a playground after the visit.[17]

To learn more about artificial turf and concerns about cancer risks for kids and young adults, watch this ESPN news video here.

All articles on our website have been approved by Dr. Diana Zuckerman and other senior staff.

Related Articles

Helping Children Recover from Stomach Flu
Can cleanliness increase the risk of allergies and asthma?
Children and cell phones: is phone radiation risky for kids?


  1. Claudio L. Synthetic Turf-Health Debate Takes Root. Environmental Health Perspectives, 2008; 116(3):A117-22.
  2.  New York State Department of Health. . Fact Sheet: Crumb-Rubber Infilled Synthetic Turf Athletic Fields. August 2012 (last revised). Accessed May 2016.
  3. Dubois L Artificial turf controversy a constant in backdrop of Women’s World Cup. Sports Illustrated. June 24, 2015.
  4. Goff S Women’s World Cup will be played on lush, green artificial turf. Washington Post. June 5, 2015. Accessed May 2016.
  5. Dockterman E U.S. Women’s Soccer Team Refuses to Play on Turf. Time. Dec 8, 2015. Accessed May 2016.
  6. Synthetic Turf Council. About Synthetic Turf. Accessed May 2016.
  7. State of California-Office of Environmental Health Hazard Assessment (OEHHA), Contractor’s Report to the Board. Evaluation of Health Effects of Recycled Waste Tires in Playground and Track Products. January 2007. Accessed May 2016.
  8. Rubber Manufacturers Association. US Scrap Tire Markets 2013. Nov 2014. Accessed May 2016.
  9. US Environmental Protection Agency (EPA). Wastes-Resource Conversation-Common Wastes & Materials – Scrap Tires (Frequent Questions). Accessed May 2016.
  10. Llompart M, Sanchez-Prado L, Lamas JP, Garcia-Jares C, et al. Hazardous organic chemicals in rubber recycled tire playgrounds and pavers. Chemosphere. 2013;90(2):423-431.
  11. US Environmental Protection Agency (EPA). Polycyclic Aromatic Hydrocarbons (PAHs)-Fact Sheet. November 2009. Accessed May 2016.
  12. Agency for Toxic Substances and Disease Registry (ATSDR). Polycyclic Aromatic Hydrocarbons. September 1996. Accessed May 2016.
  13. Yale Study Reveals Carcinogens and Skin Irritants in Synthetic Turf.
  14. US Environmental Protection Agency (EPA). Fact Sheet – The Use of Recycled Tire Materials on Playgrounds & Artificial Turf Fields.
  15. EPA. Federal Research on Recycled Tire Crumbs Used on Playing Fields. December, 2016. Accessed August, 2017.
  16. CPSC. Crumb Rubber Information Center.


Letter from NCHR about Dangerous Playgrounds and Athletic Fields to the Mayor and City Council of Washington, DC

National Center for Health Research: July 19, 2017

Dear Mayor Bowser and Council Members,

I am writing as the president of the National Center for Health Research to express my strong concerns about the safety of the synthetic turf that the DC government has used and is continuing to use across the city, including installation that will soon be underway at Janney Elementary.

As a scientist who has worked on health policy issues for 30 years, I don’t shock easily. However, the fact that school athletic fields and playgrounds are exposing D.C. children on a daily basis to chemicals and materials that are known to increase obesity, cause early puberty, cause ADD and other attention problems, harbor deadly bacteria, and exacerbate asthma is very disturbing. Surely these are exactly the types of health problems that the DC government should be doing its best to reduce, not increase. Federal agencies are investigating the safety of these products – even during the Trump Administration – and yet neither District officials nor parents are being provided with accurate information about the products being used.

Whether natural grass or synthetic materials, all types of turf have risks and benefits. However, some materials are well known to have substantial risks. For example, DCPS is installing synthetic turf with Envirofill at Janney Elementary and possibly other schools, even though the Department of Parks and Recreation has already determined that product to be too unsafe to install at city parks. Envirofill was slated for installation at Friendship (Turtle) Park, but after local parents briefed DC officials about problems with the product on June 9th, the District revised its plans and did not install that material. Since children play on school fields five days a week, under the direction of their teachers, this is a particularly questionable decision on the part of DCPS, for safety reasons and in terms of legal liability. How does it make sense that a product is not safe enough for a public park but is safe enough for a school field or playground?

I don’t know if you are aware of the number of synthetic turf fields across the District that have been condemned because of failing safety tests. Gmax is a score that tests for hardness to determine if a surface is safe for playing. A Gmax over 200 is considered extremely dangerous and is considered by industry to pose a death risk. The synthetic turf industry and ASTM suggest that scores should be below 165 to ensure safety comparable to a grass field. It is my understanding that there are at least six fields in the city that are over the 200 level. That information should be made public to all parents, so that they understand why fields are closed and can protect their children’s safety. Since the Gmax score varies with the weather, synthetic fields should be tested at least quarterly, all scores should be posted publicly, and scores over 165 should have warning signs in order to prevent traumatic brain injuries.

This has not happened. For example, the Gmax score at Janney Elementary tested over 200 in June, and yet that information was not made public and the field was used by camp children all summer. Despite the repeated requests of concerned parents for the last few months, the field wasn’t closed until the day before school started last week. Parents were justifiably upset that the field was closed when school started, and some parents claimed to have been told by school staff that the Mayor’s office stated that the field would be closed all year and perhaps forever. It seems unlikely to me that the Mayor’s office would have said such a thing, but it resulted in ugly and unfair accusations. The many parents who were concerned about the safety of the synthetic field were bullied into silence, and a small number of parents who wanted the field available immediately erroneously claimed that all parents agreed that synthetic field was best.

As a result of that controversy, DC officials have recently stated that Envirofill will be used at Janney. Envirofill is basically a type of infill underneath a plastic carpet. It is composed of materials resembling plastic polymer pellets (similar in appearance to tic tacs) with silica inside. Silica is classified as a hazardous material according to OSHA regulations, and the American Academy of Pediatrics specifically recommends avoiding it on playgrounds. The manufacturers and vendors of these products claim that the silica is contained inside the plastic coating. However, sunlight and the grinding force from playing on the field breaks down the plastic coating. For that reason, even the product warranty admits that only 70% of the silica will remain encapsulated. The other 30% can be very harmful as children are exposed to it in the air; here’s a screen grab from a November 2016 Patriots vs. Seahawks game, which shows how the silica sand infill is kicked up when players dive on a synthetic surface with silica sand infill.

In addition, the Envirofill pellets are coated with an antibacterial called Microban, which is a trade name for triclosan. Triclosan is registered as a pesticide with the United States Environmental Protection Agency (EPA), and last year the FDA banned triclosan from soaps because manufacturers did not prove that that the ingredients are safe for long-term use, since it is associated with liver and inhalation toxicity and hormone disruption. In addition to microscopic particles of synthetic turf infill being inhaled by children, visible and invisible particles come off of the field, ending up in shoes, socks, pockets, and hair.

I have appreciated the opportunity to meet with several Councilmembers’ staff in the last few weeks, and I commend the Council for banning crumb rubber in FY 2018. Unfortunately, however, Envirofill, “poured in place” rubber (PIP), EPDM, and all the other synthetic materials currently on the market all share some of the same health risks. While the companies that sell these products claim they are safe and meet federal safety standards, the sad truth is that there are currently no federal safety tests required to prove that these products are safe, and as noted earlier, the Gmax safety tests have until recently been ignored by DC officials. Most important, none are proven to be as safe as natural grass in well-constructed fields such as the Maryland Soccerplex. Although a well-respected grass expert offered a free consultation on how to install well-engineered grass designed to withstand rain and play. DGS did not respond to his offer.

I am one of many parents and scientists in DC that are asking DC officials to provide essential safety information about the materials being used for fields and playgrounds. We are offering our expertise on these issues and would welcome the opportunity for public meetings so that parents across the city can be informed.


Diana Zuckerman, Ph.D.
National Center for Health Research
1001 Connecticut Ave, NW, Suite 1100
Washington, DC 20036