Noelle K. LoConte, MD
As reported in the Journal of Clinical Oncology by Noelle K. LoConte, MD, of the University of Wisconsin, Madison, and colleagues, ASCO has issued a statement on the association of alcohol consumption with cancer risk that outlines proposals for promoting awareness of the association, supporting research on the association, and reducing alcohol-related cancer risk.1
As stated by the authors: “[ASCO] believes that a proactive stance … to minimize excessive exposure to alcohol has important implications for cancer prevention. In addition, the role of alcohol drinking on outcomes in patients with cancer is in its formative stages, and ASCO can play a key role by generating a research agenda. Also, ASCO could provide needed leadership in the cancer community on this issue. In the issuance of this statement, ASCO joins a growing number of international organizations by establishing a platform to support effective public health strategies in this area.”
Statement Goals
The specific goals of the statement are to:
- romote public education about the association between alcohol abuse and the risk of certain types of cancer
- upport policy efforts to reduce the risk of cancer through evidence-based strategies that prevent excessive use of alcohol
- Provide education to oncology providers about the influence of excessive alcohol use on cancer risks and treatment complications, including clarification of conflicting evidence
- Identify areas of needed research regarding the relationship between alcohol use and cancer risk and outcomes.
Burden of Alcohol-Related Cancers
Alcohol consumption is an established and potentially modifiable risk factor for several malignancies. It is estimated that 5.5% of all new cancers and 5.8% of all cancer deaths worldwide in 2012 were attributable to alcohol; in the United States, it has been estimated that 3.5% of all cancer deaths are attributable to alcohol consumption. Alcohol consumption has been causally associated with oropharyngeal and laryngeal cancers, esophageal cancer, hepatocellular carcinoma, breast cancer, and colorectal cancer.
Results of a large-scale meta-analysis cited in the statement indicate that the risk for malignancy is significantly increased with modest use of alcohol, and that risk increases further with heavy, long-term consumption. In particular, the meta-analysis found statistically significant increases in relative risk (RR) for specific cancers according to the magnitude of alcohol consumption vs no consumption, as follows:
- Oral cavity and pharynx: RR = 1.13 for light drinker, 1.83 for moderate drinker, and 5.13 for heavy drinker
- Esophageal squamous cell carcinoma: RR = 1.26 for light drinker, 2.23 for moderate drinker, and 4.95 for heavy drinker
- Larynx: RR = 1.44 for moderate drinker and 2.65 for heavy drinker
- Liver: RR = 2.07 for heavy drinker
- Female breast: RR = 1.04 for light drinker, 1.23 for moderate drinker, and 1.61 for heavy drinker
- Colorectum: RR = 1.17 for moderate drinker and 1.44 for heavy drinker.
In addition, some cancers have been causally linked to both alcohol consumption and cigarette smoking, with synergistic risk being observed in some cases. Various studies have identified strong associations between alcohol drinking and cigarette smoking in cancers of the oral cavity, pharynx, larynx, and esophagus.
Research Needs
The statement emphasizes that the most urgent research needed regarding risks associated with alcohol consumption is better understanding of the effects of concurrent alcohol use on the delivery of cancer treatments, including chemotherapy, radiotherapy, and surgery, and the effects of such use on cancer outcomes. Rigorous studies are needed to accurately define such effects.
[ASCO] believes that a proactive stance … to minimize excessive exposure to alcohol has important implications for cancer prevention.— Noelle K. Loconte, MD, and colleagues
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The statement notes that underexplored research areas also include the mechanistic effects of alcohol on postoperative morbidity, the efficacy of chemotherapy and radiation, and novel targeted therapies including immunotherapy and radiotherapy. Improved understanding of the mechanisms of effects of alcohol use on cancer-related pathways and treatments may improve knowledge of the roles they play in disease progression, response to treatments, and toxicities.
Public Health Strategies
The ASCO committee stresses that excessive alcohol use can delay or have a negative impact on cancer treatment and that reducing high-risk alcohol consumption constitutes cancer prevention. Joining other cancer care and public health organizations, ASCO supports strategies to prevent high-risk alcohol consumption, including the following measures:
- Development of clinical strategies for alcohol screening and brief intervention provided in clinical settings
- Regulation of alcohol outlet density
- Increases in alcohol taxes and prices
- Maintenance of limits on days and hours of sale
- Enhanced enforcement of laws prohibiting sales to minors
- Restriction of youth exposure to advertising of alcoholic beverages
- Resistance to further privatization of retail alcohol sales in communities with current government control
- Inclusion of alcohol control strategies in comprehensive cancer control plans.
In addition, the statement cites ASCO’s support of efforts to eliminate “pinkwashing” from the marketing of alcoholic beverages. Pinkwashing is a form of “cause marketing” characterized by a company using the color pink or pink ribbons to show commitment to finding a cure for breast cancer. As stated by the authors: “Given the consistent evidence that shows the link between alcohol consumption and an increased risk of breast cancer, alcoholic beverage companies should be discouraged from using the symbols of the battle against breast cancer to market their products.”
Role of the Oncologist
The ASCO statement stresses that oncologists are situated to play a major role in efforts to reduce alcohol-related risks, both as front-line providers who can help patients reduce high-risk alcohol use, and potentially avoid adverse effects on treatment, and as community advisors and leaders who can help raise awareness of alcohol consumption as a cancer risk factor. ■
DISCLOSURE: Dr. LoConte has a consulting or advisory role with Celgene. For full disclosures of the statement authors, visit ascopubs.org/doi/full/10.1200/JCO.2017.76.1155.
REFERENCE
Alcohol Consumption
- The National Institute of Alcohol Abuse and Alcoholism defines a standard drink as one that contains roughly 14 g of pure alcohol, which is the equivalent of 1.5 ounces of distilled spirits (approximately 40% alcohol by volume); 5 ounces of wine (approximately 12% alcohol by volume); or 12 ounces of regular beer (approximately 5% alcohol by volume).
- In the ASCO Statement, a moderate drinker is defined as up to 1 drink/day for women and up to
2 drinks/day for men. - A heavy drinker defined as 8 or more drinks/week or 3 or more drinks/day for women, and as 15 or more drinks/week or 4 or more drinks/day for men.
