Background: Acetaminophen (paracetamol) is a widely used over-the-counter drug, but concerns of genotoxic effects have been raised. After we recently found an almost two-fold increased risk of hematologic malignancies associated with high use of acetaminophen in the prospective VITamins And Lifestyle (VITAL) study, we herein further examined the association between acetaminophen use and cancer risk in the VITAL cohort.

Methods: A total of 62,841 men and women aged 50 to 76 years were recruited from 2000 to 2002, and incident malignancies other than nonmelanoma skin cancer (n = 5,750) were identified through December 2008 via linkage to the Surveillance, Epidemiology, and End Results cancer registry. HRs associated with acetaminophen use for incidence of total cancers and nonhematologic cancer subcategories were estimated with Cox proportional hazards models that were adjusted for age, demographics, cancer risk factors, and medical conditions that may be indications for acetaminophen use.

Results: Use of acetaminophen was not associated with total cancer risk. We also observed no associations for most major nonhematologic cancer sites, including cancers of the gastrointestinal system, lung, urinary tract, skin, prostate, or female organs.

Conclusion: This study failed to provide evidence of an association between acetaminophen use and total cancer risk or incidence of nonhematologic malignancies.

Impact: Together with our previous findings, the analyses from the VITAL study suggest a particular sensitivity of the hematopoietic system to the mutagenic effects of acetaminophen. Cancer Epidemiol Biomarkers Prev; 20(12); 2637–41. ©2011 AACR.

Acetaminophen (paracetamol) is one of the most widely used over-the-counter analgesic antipyretics. However, as the active metabolite of phenacetin, which is considered carcinogenic to humans (1), significant genotoxic effects have long been a concern. This possibility has been investigated by a number of epidemiologic studies, primarily with case–control design, with inconsistent results (2–4). Recently, we found an almost 2-fold increased risk of hematologic malignancies other than chronic lymphocytic leukemia/small lymphocytic lymphoma associated with high use of acetaminophen in the prospective VITamins and Lifestyle (VITAL) study (5). We have now examined the association of acetaminophen use with incidence of total cancers and individual solid tumors in this cohort.

Study cohort

Details of the VITAL study have been published previously (6). Among 77,719 men and women deemed eligible for study participation, 11,463 were excluded because of a prior history of any cancer other than nonmelanoma skin cancer or missing cancer information at baseline. We additionally excluded 3,394 participants with missing exposure information and 21 cases with postbaseline cancer on death certificate only without a diagnosis date, leaving 62,841 participants, aged 61.5 ± 7.3 (mean ± SD), available for study.

Data collection

Participants completed a baseline questionnaire on demographics, health history, cancer risk factors, diet, and medications that encompassed questions on regular use, defined as ≥1 d/wk for ≥1 years, of acetaminophen and other analgesics, including frequency and duration of use over the previous 10 years. Ten-year use was categorized as “no use,” “low use” (<4 d/wk or <4 years), and “high use” (≥4 d/wk and ≥4 years).

Case ascertainment

After a mean follow-up of 6.5 ± 1.7 years, a diagnosis of incident, invasive malignancy other than nonmelanoma skin cancer was identified in 5,750 (9.2%) participants via annual linkage to the Surveillance, Epidemiology, and End Results (SEER) cancer registry (6). The remainders were censored at the earliest date of the following events: withdrawal from study (n = 19), emigration from the SEER region (n = 4,290), death (n = 1,900), or December 31, 2008 (the date of complete case ascertainment at time of linkage to the SEER registry; n = 50,882).

Statistical analysis

Cox proportional hazards models using participants' age as the time metric estimated HRs and 95% confidence intervals (95% CI) for the associations between acetaminophen use and incident malignancies. For analyses of individual tumor types, various cancer entities were treated as separate outcomes, and cases of other malignancies were censored at their respective time of diagnosis. P values for trend were computed by using the categorized 10-year acetaminophen use variable as ordinal in regression models. All reported P values are 2-sided, and P < 0.05 was considered statistically significant.

High use of acetaminophen was not associated with total cancer risk either overall [HR 1.02 (0.89–1.17)], or by gender [for women, HR 0.97 (0.80–1.17); for men, HR 1.08 (0.88–1.31; Table 1]. The associations between acetaminophen use and risk of individual solid tumors, stratified by site and gender, are summarized in Table 2. There were no statistically significant associations with risks of total gastrointestinal, lung, urinary tract, female, prostate, or melanoma skin cancers. We additionally conducted exploratory cancer subgroup analyses, acknowledging the low power to detect significant associations because of the small number of cases of individual cancer types. With this limitation in mind, high use of acetaminophen was associated with statistically nonsignificantly increased risk of bladder cancer [HR = 1.50 (0.57–3.89)] and decreased risk of aggressive prostate cancer [HR = 0.74 (0.45–1.21)] or pancreatic cancer [HR = 0.40 (0.12–1.31)].

Table 1.

Associations between acetaminophen use and total cancer incidence, stratified by gender

10-y use prior to baselinea
No useLow useHigh usePtrend
All participants (n = 62,841) 
 Cases (n = 5,750) 4,467 (77.7%) 978 (17.0%) 305 (5.3%) 0.25 
 Noncases (n = 57,091) 44,467 (77.9%) 9,671 (16.9%) 2,953 (5.2%)  
 HR (95% CI)b 1.00 (reference) 1.08 (0.99–1.17) 1.02 (0.89–1.17)  
Women (n = 32,059) 
 Cases (n = 2,441) 1,741 (71.3%) 523 (21.4%) 177 (7.3%) 0.97 
 Noncases (n = 29,618) 21,620 (73.0%) 6,002 (20.3%) 1,996 (6.7%)  
 HR (95% CI)b 1.00 (reference) 1.04 (0.92–1.17) 0.97 (0.80–1.17)  
Men (n = 30,782) 
 Cases (n = 3,309) 2,726 (82.4%) 455 (13.8%) 128 (3.9%) 0.11 
 Noncases (n = 27,473) 22,847 (83.2%) 3,669 (13.4%) 957 (3.5%)  
 HR (95% CI)b 1.00 (reference) 1.18 (0.99–1.26) 1.08 (0.88–1.31)  
   P interaction = 0.88  
10-y use prior to baselinea
No useLow useHigh usePtrend
All participants (n = 62,841) 
 Cases (n = 5,750) 4,467 (77.7%) 978 (17.0%) 305 (5.3%) 0.25 
 Noncases (n = 57,091) 44,467 (77.9%) 9,671 (16.9%) 2,953 (5.2%)  
 HR (95% CI)b 1.00 (reference) 1.08 (0.99–1.17) 1.02 (0.89–1.17)  
Women (n = 32,059) 
 Cases (n = 2,441) 1,741 (71.3%) 523 (21.4%) 177 (7.3%) 0.97 
 Noncases (n = 29,618) 21,620 (73.0%) 6,002 (20.3%) 1,996 (6.7%)  
 HR (95% CI)b 1.00 (reference) 1.04 (0.92–1.17) 0.97 (0.80–1.17)  
Men (n = 30,782) 
 Cases (n = 3,309) 2,726 (82.4%) 455 (13.8%) 128 (3.9%) 0.11 
 Noncases (n = 27,473) 22,847 (83.2%) 3,669 (13.4%) 957 (3.5%)  
 HR (95% CI)b 1.00 (reference) 1.18 (0.99–1.26) 1.08 (0.88–1.31)  
   P interaction = 0.88  

aLow use, use for either less than 4 d/wk or less than 4 years; high use, use for at least 4 d/wk and at least 4 years.

bA priori potential confounders were selected, including known and suspected cancer risk factors and medical conditions that may be indications for use of acetaminophen, for adjustment in multivariable regression models. Specifically, all models were adjusted for age, education, race, marital status, height, body mass index, physical activity, pack-years of smoking, alcohol intake at 45 years, fruit and vegetable intake, red meat intake, multivitamin use, self-rated health, family history of colon, lung, and hematologic cancers (as separate terms), sigmoidoscopy in the past 10 years, diabetes, osteoarthritis/chronic joint pain, migraine/chronic headaches, and use of nonsteroidal anti-inflammatory drugs. The models were additionally adjusted for family history of breast cancer, mammogram in the past 2 years, age at menarche, age at menopause, age at first birth, years of estrogen therapy, years of combined hormone therapy, and hysterectomy (for women); and family history of prostate cancer and prostate-specific antigen test in the past 2 years (for men).

Table 2.

Associations between acetaminophen use and cancer incidence, stratified by cancer site and gender

10-y use prior to baselinea
Cancer sitebNo useLow useHigh usePtrend
Gastrointestinal (n = 783)c 
Cases/noncases 623/48,311 120/10,529 40/3,218 0.24 
HR (95% CI)d 1.00 (reference) 0.90 (0.71–1.14) 0.84 (0.57–1.22)  
 Women 
  Cases/noncases 265/23,096 72/6,453 20/2,153 0.29 
  HR (95% CI)d 1.00 (reference) 0.93 (0.67–1.29) 0.75 (0.45-1.26)  
 Men 
  Cases/noncases 358/25,215 48/4,076 20/1,065 0.53 
  HR (95% CI)d 1.00 (reference) 0.86 (0.60–1.23) 0.94 (0.54–1.64)  
   P interaction = 0.35  
Colon and rectum (n = 419) 
 Cases/noncases 344/48,590 56/10,593 19/3,239 0.18 
 HR (95% CI)d 1.00 (reference) 0.79 (0.56–1.12) 0.80 (0.46–1.37)  
Pancreas (n = 132) 
 Cases/noncases 105/48,829 21/10,628 6/3,252 0.16 
 HR (95% CI)d 1.00 (reference) 0.90 (0.51–1.58) 0.40 (0.12–1.31)  
Lung (n = 622) 
Cases/noncases 458/48,476 122/10,527 42/3,216 0.32 
HR (95% CI)d 1.00 (reference) 1.22 (0.95–1.55) 1.06 (0.73–1.54)  
 Women 
  Cases/noncases 170/23,191 67/6,458 28/2,145 0.36 
  HR (95% CI)d 1.00 (reference) 1.18 (0.83–1.67) 1.18 (0.72–1.95)  
 Men 
  Cases/noncases 288/25,285 55/4,069 14/1,071 0.64 
  HR (95% CI)d 1.00 (reference) 1.24 (0.88–1.75) 0.93 (0.52–1.67)  
   P interaction = 0.65  
Urinary tract (n = 282)e 
Cases/noncases 214/48,720 50/10,599 18/3,240 0.72 
HR (95% CI)d 1.00 (reference) 1.10 (0.76–1.59) 1.05 (0.60–1.83)  
 Women 
  Cases/noncases 57/23,304 21/6,504 8/2,165 0.89 
  HR (95% CI)d 1.00 (reference) 1.07 (0.58–1.97) 0.89 (0.38–2.11)  
 Men 
  Cases/noncases 157/25,416 29/4,095 10/1,075 0.53 
  HR (95% CI)d 1.00 (reference) 1.17 (0.73–1.87) 1.15 (0.54–2.41)  
   P interaction = 0.88  
Kidney (n = 161) 
 Cases/noncases 120/48,814 30/10,619 11/3,247 0.91 
 HR (95% CI)d 1.00 (reference) 1.11 (0.69–1.79) 0.96 (0.46–1.98)  
Bladder (n = 101) 
 Cases/noncases 76/48,858 19/10,630 6/3,252 0.24 
 HR (95% CI)d 1.00 (reference) 1.39 (0.74–2.60) 1.50 (0.57–3.89)  
Melanoma (n = 279) 
Cases/noncases 229/48,705 38/10,611 12/3,246 0.42 
HR (95% CI)d 1.00 (reference) 0.90 (0.60–1.33) 0.79 (0.39–1.58)  
 Women 
  Cases/noncases 84/23,277 17/6,508 6/2,167 0.26 
  HR (95% CI)d 1.00 (reference) 0.76 (0.42–1.39) 0.63 (0.22–1.82)  
 Men 
  Cases/noncases 145/25,428 21/4,103 6/1,079 0.92 
  HR (95% CI)d 1.00 (reference) 1.02 (0.61–1.71) 1.04 (0.41–2.62)  
   P interaction = 0.33  
Female cancers (n = 1,225)f 
Cases/noncases 880/22,481 269/6,256 70/2,103 0.68 
HR (95% CI)d 1.00 (reference) 1.07 (0.91–1.26) 0.85 (0.64–1.13)  
Breast (n = 901) 
 Cases/noncases 646/22,715 196/6,329 53/2,120 0.74 
 HR (95% CI)d 1.00 (reference) 1.10 (0.91–1.33) 0.83 (0.59–1.15)  
Uterus (n = 214) 
 Cases/noncases 156/23,205 47/6,478 11/2,162 0.88 
 HR (95% CI)d 1.00 (reference) 1.07 (0.71–1.63) 0.99 (0.48–2.01)  
Prostate cancer (n = 1,587) 
Cases/noncases 1,321/24,252 216/3,908 50/1,035 0.51 
HR (95% CI)d 1.00 (reference) 1.10 (0.93–1.30) 1.00 (0.73–1.37)  
Aggressive prostate cancer (n = 768)g 
 Cases/noncases 649/48,285 99/10,550 20/3,238 0.32 
 HR (95% CI)d 1.00 (reference) 0.97 (0.76–1.25) 0.74 (0.45–1.21)  
10-y use prior to baselinea
Cancer sitebNo useLow useHigh usePtrend
Gastrointestinal (n = 783)c 
Cases/noncases 623/48,311 120/10,529 40/3,218 0.24 
HR (95% CI)d 1.00 (reference) 0.90 (0.71–1.14) 0.84 (0.57–1.22)  
 Women 
  Cases/noncases 265/23,096 72/6,453 20/2,153 0.29 
  HR (95% CI)d 1.00 (reference) 0.93 (0.67–1.29) 0.75 (0.45-1.26)  
 Men 
  Cases/noncases 358/25,215 48/4,076 20/1,065 0.53 
  HR (95% CI)d 1.00 (reference) 0.86 (0.60–1.23) 0.94 (0.54–1.64)  
   P interaction = 0.35  
Colon and rectum (n = 419) 
 Cases/noncases 344/48,590 56/10,593 19/3,239 0.18 
 HR (95% CI)d 1.00 (reference) 0.79 (0.56–1.12) 0.80 (0.46–1.37)  
Pancreas (n = 132) 
 Cases/noncases 105/48,829 21/10,628 6/3,252 0.16 
 HR (95% CI)d 1.00 (reference) 0.90 (0.51–1.58) 0.40 (0.12–1.31)  
Lung (n = 622) 
Cases/noncases 458/48,476 122/10,527 42/3,216 0.32 
HR (95% CI)d 1.00 (reference) 1.22 (0.95–1.55) 1.06 (0.73–1.54)  
 Women 
  Cases/noncases 170/23,191 67/6,458 28/2,145 0.36 
  HR (95% CI)d 1.00 (reference) 1.18 (0.83–1.67) 1.18 (0.72–1.95)  
 Men 
  Cases/noncases 288/25,285 55/4,069 14/1,071 0.64 
  HR (95% CI)d 1.00 (reference) 1.24 (0.88–1.75) 0.93 (0.52–1.67)  
   P interaction = 0.65  
Urinary tract (n = 282)e 
Cases/noncases 214/48,720 50/10,599 18/3,240 0.72 
HR (95% CI)d 1.00 (reference) 1.10 (0.76–1.59) 1.05 (0.60–1.83)  
 Women 
  Cases/noncases 57/23,304 21/6,504 8/2,165 0.89 
  HR (95% CI)d 1.00 (reference) 1.07 (0.58–1.97) 0.89 (0.38–2.11)  
 Men 
  Cases/noncases 157/25,416 29/4,095 10/1,075 0.53 
  HR (95% CI)d 1.00 (reference) 1.17 (0.73–1.87) 1.15 (0.54–2.41)  
   P interaction = 0.88  
Kidney (n = 161) 
 Cases/noncases 120/48,814 30/10,619 11/3,247 0.91 
 HR (95% CI)d 1.00 (reference) 1.11 (0.69–1.79) 0.96 (0.46–1.98)  
Bladder (n = 101) 
 Cases/noncases 76/48,858 19/10,630 6/3,252 0.24 
 HR (95% CI)d 1.00 (reference) 1.39 (0.74–2.60) 1.50 (0.57–3.89)  
Melanoma (n = 279) 
Cases/noncases 229/48,705 38/10,611 12/3,246 0.42 
HR (95% CI)d 1.00 (reference) 0.90 (0.60–1.33) 0.79 (0.39–1.58)  
 Women 
  Cases/noncases 84/23,277 17/6,508 6/2,167 0.26 
  HR (95% CI)d 1.00 (reference) 0.76 (0.42–1.39) 0.63 (0.22–1.82)  
 Men 
  Cases/noncases 145/25,428 21/4,103 6/1,079 0.92 
  HR (95% CI)d 1.00 (reference) 1.02 (0.61–1.71) 1.04 (0.41–2.62)  
   P interaction = 0.33  
Female cancers (n = 1,225)f 
Cases/noncases 880/22,481 269/6,256 70/2,103 0.68 
HR (95% CI)d 1.00 (reference) 1.07 (0.91–1.26) 0.85 (0.64–1.13)  
Breast (n = 901) 
 Cases/noncases 646/22,715 196/6,329 53/2,120 0.74 
 HR (95% CI)d 1.00 (reference) 1.10 (0.91–1.33) 0.83 (0.59–1.15)  
Uterus (n = 214) 
 Cases/noncases 156/23,205 47/6,478 11/2,162 0.88 
 HR (95% CI)d 1.00 (reference) 1.07 (0.71–1.63) 0.99 (0.48–2.01)  
Prostate cancer (n = 1,587) 
Cases/noncases 1,321/24,252 216/3,908 50/1,035 0.51 
HR (95% CI)d 1.00 (reference) 1.10 (0.93–1.30) 1.00 (0.73–1.37)  
Aggressive prostate cancer (n = 768)g 
 Cases/noncases 649/48,285 99/10,550 20/3,238 0.32 
 HR (95% CI)d 1.00 (reference) 0.97 (0.76–1.25) 0.74 (0.45–1.21)  

aLow use, use for either less than 4 d/wk or less than 4 years; high use, use for at least 4 d/wk and at least 4 years.

bMajor categories do not add to 5,750 due to exclusion of 571 cases with hematologic malignancies and 393 cases with cancers of the head and neck, connective tissue, brain, thyroid, and unspecified primary site.

cBesides cancers of colon/rectum and pancreas, contains cancers of esophagus (n = 56), stomach (n = 56), liver (n = 47), small intestines (n = 21), anus and anal canal (n = 15), gall bladder (n = 11), biliary tract (n = 9), and other or ill-defined digestive organs (n = 17).

dAll models were adjusted as described in footnote to Table 1.

eBesides cancers of kidney and bladder, contains cancers of renal pelvis (n = 10), ureter (n = 5), and other or unspecified urinary organs (n = 5).

fBesides cancers of breast and uterus, contains cancers of ovary (n = 74), cervix (n = 11), vulva (n = 7), vagina (n = 3), and other or unspecified female genital organs (n = 15).

gTo compare our findings on prostate cancer risk with those from Jacobs and colleagues (8), we considered aggressive prostate cancers to be those with a Gleason grade ≥7, American Joint Committee on Cancer (AJCC) stages III/IV, or fatal prostate cancer. For cancers diagnosed between 2000 and 2003, Gleason grade was identified using a SEER differentiation variable. From 2000 to 2002, well- or moderately differentiated tumors were those with Gleason grades of 2 to 7, whereas poorly differentiated tumors had scores between 8 and 10. In 2003, this coding scheme changed so that a Gleason grade of 7 was considered poorly differentiated. We therefore reabstracted Gleason scores from the original SEER reports for cancers diagnosed from 2000 to 2002 to properly classify Gleason grades of ≥7 as poorly differentiated. AJCC stage was not available from SEER until 2004. Before 2004, we classified aggressive tumors as those with distant SEER summary stage, which identifies metastatic AJCC stage IV tumors. Prostate cancers diagnosed from 2004 to 2008 were classified as aggressive using Gleason grade (≥7) and AJCC stage (III/IV) data. Fatal prostate cancer was defined by cause of death and was available for all years.

In our study, there was no evidence for an association between acetaminophen use and total cancer risk overall or by gender. This finding is comparable to that from a retrospective population-based cohort study showing no association for overall cancers [SIR = 1.1 (1.06–1.15)] with acetaminophen use (7). We also found no statistically significant association with cancer development for most cancer subgroups other than hematologic malignancies. Of note, some studies on acetaminophen suggested a decreased risk with certain cancers. Most prominently, Jacobs and colleagues recently reported a decreased risk of overall prostate cancer [RR = 0.62 (0.44–0.87)] and aggressive prostate cancer [RR = 0.49 (0.27–0.88)] among long-term regular users of acetaminophen (as defined as current use of ≥ 30 pills per month for ≥ 5 years) in the Cancer Prevention Study II Nutrition Cohort (8). In our study, which had 80% power to detect a HR of 0.74 for overall prostate cancer and 0.64 for aggressive subforms, there was no association with overall prostate cancer, although there was a statistically nonsignificant trend toward reduced risk for aggressive prostate cancer; this comparison may be limited given the differences in definition of acetaminophen use between the 2 studies.

Despite the large cohort size, however, our study had limited power in detecting associations between acetaminophen use and risk of individual cancers or cancer subtypes. Nonetheless, it is reassuring that we did not find an association between high acetaminophen use and specific cancers other than hematologic malignancies. The latter observation suggests a particular sensitivity of the hematopoietic system to acetaminophen. The reason for this predisposition is unclear and will deserve further study.

No potential conflicts of interest were disclosed.

All authors designed and carried out research, analyzed and interpreted data, and drafted the manuscript.

This study was supported by grants P30-CA015704-35S6 (to R.B. Walter), K05-CA154337 (to E. White), R01-CA142545 (to E. White), and R25-CA094880 (to E. White) from the National Cancer Institute and Office of Dietary Supplements/NIH.

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