In 2023, the World Health Organization (WHO) declared that “no level of alcohol consumption is safe for our health.”1 The warning came decades after the International Agency for Research on Cancer classified alcohol as a Group 1 carcinogen, which is the highest risk group, and also includes asbestos, radiation, and tobacco.1 Worldwide, 3 million deaths each year are attributed to alcohol use, including more than 400,000 deaths from cancer2—19,000 deaths from cancer in the United States alone.3
Although alcoholic beverages have been linked to the development of at least seven cancers—oral cavity, pharynx, larynx, esophagus, colon and rectum, liver, and female breast3—most American adults are unaware of the alcohol-cancer association. In a 2017 ASCO National Cancer Opinion Survey, just 30% of the more than 4,000 Americans polled identified alcohol as a risk factor for cancer.4 More recently, a study found that 20% of 3,900 U.S. adults surveyed were aware that wine increases cancer risk; 25% said that beer increases cancer risk; and 31% associated cancer risk with overall liquor consumption, despite the fact that research shows any alcohol intake increases cancer risk, regardless of whether it is from wine, beer, or liquor.5
Outlining the Health Consequences of Excessive Drinking
In 2018, ASCO released a statement on the role alcohol plays in the development of cancer and its recommendations to reduce cancer risk through evidence-based approaches to prevent alcohol abuse and modify behavior.6 Here are some of the goals outlined in ASCO’s statement:
- Promote public education about the risks between alcohol abuse and certain types of cancer
- Support 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 and 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.
Noelle K. LoConte, MD, FASCO
“We need to ask our patients about their drinking history during our initial meeting,” explained Noelle K. LoConte, MD, FASCO, Associate Professor of Medicine at the University of Wisconsin School of Medicine and Public Health and Carbone Cancer Center in Madison, and a coauthor of ASCO’s alcohol and cancer statement. “Normalizing asking patients about their drinking history, and not just asking a simple, ‘Do you drink, yes or no,’ is crucial because regularly consuming even modest amounts of alcohol during therapy can reduce its effectiveness and may raise the risk of a cancer recurrence. In addition to collecting alcohol consumption information, oncologists should also inform survivors of the potential harms in an effort to reduce risky alcohol use,” she said.
Researching the Scope of Alcohol Consumption Among Cancer Survivors
In a large cross-sectional study of 15,199 adult cancer survivors, Dr. LoConte and her colleagues investigated the prevalence of current alcohol consumption and risky alcohol consumption; 77.7% of about 12,000 participants self-reported as current drinkers. Among these participants, 1,541 (13.0%) exceeded moderate drinking levels; 2,812 (23.8%) reported binge drinking; and 4,527 (38.3%) engaged in hazardous drinking (defined as more than three drinks a day for women or more than four drinks a day for men). In addition, among the nearly 2,000 cancer survivors receiving cancer treatment, the prevalences of current drinking and risky drinking were similar to those in the overall cohort and across treatment types.7
In an interview with The ASCO Post, Dr. LoConte discussed the findings from her study, steps policymakers can take to curb alcohol abuse, and how oncologists can help their patients reduce alcohol use during cancer treatment and in long-term survivorship to decrease alcohol-related cancer recurrence.
Supporting Patients During Treatment
The findings from your study on the number of cancer survivors who continue alcohol use during and after treatment are disturbing. What surprised you most about the study results?
I assumed that patients undergoing cancer treatment would drink less, mostly because alcohol can worsen the side effects of treatment, especially chemotherapy. These patients may experience greater changes in the taste of food and drink and may have more fatigue and nausea. Alcohol can also decrease the effectiveness of therapy, so continuing to drink during cancer treatment is not a good idea.
Since drinking is so ingrained in our societal norms and rituals, and considering the limited awareness of how alcohol consumption is associated with cancer outcomes, it is imperative that we provide support to our patients and offer them guidance.
Preventing High-Risk Alcohol Consumption
The American Cancer Society guideline on nutrition and physical activity states it is best not to drink alcohol, and individuals who choose to drink should limit intake to one drink or fewer a day for women and two drinks per day for men.8 Despite reporting about the health risks of alcohol consumption, studies consistently show that most Americans are unaware of the alcohol-cancer link. What needs to be done to raise public awareness of this connection? Will adding warning labels on alcoholic beverages, increasing alcohol taxes and prices, limiting the number of days alcohol can be sold, and reducing advertising and sales to minors improve public awareness of the health dangers of alcohol?
I don’t think just raising public awareness about the health risks will solve the problem. The best way out of this situation is through public policy. I live in Wisconsin, where alcohol is readily available in grocery stores, at work events, and even in clothing boutiques while people shop.
If we could implement culturally sensitive and equitable public health strategies, such as the ones you mentioned, including reducing alcohol advertising, raising taxes and prices on alcoholic beverages, and putting health warning labels on products, they could help prevent high-risk alcohol consumption. However, the messaging has to be nuanced to be successful. I would like to see oncologists support measures that will decrease drinking and alcohol-related cancers.
We also have to dispel the long-held perception that light alcohol use, especially red wine, is healthy for the heart. Differences in alcohol dehydrogenase variants are associated with nondrinking, and research shows that nondrinkers have lower rates of coronary heart disease and stroke than even light drinkers. So, alcohol consumption should not be recommended to prevent cardiovascular disease or all-cause mortality.
Understanding the Impact of -Drinking on Cancer Outcomes
In addition to the cancer risk alcohol poses, drinking during cancer treatment may be associated with worsening cognition and cardiotoxicity among patients undergoing chemotherapy, increasing the risk of surgical complications and higher mortality, raising the risk of osteonecrosis of the jaw among patients with head and neck cancers receiving radiation therapy, and reducing the effectiveness of chemotherapy. Do you know how alcohol may affect the efficacy of immunotherapy?
We don’t have enough research about the impact of alcohol on the effectiveness of immunotherapy. In general, we know that people with heavy alcohol use disorder have a compromised immune system, so it is reasonable to assume that immunotherapy will not be as effective in those individuals, but we don’t know for sure.
We said in the 2018 ASCO statement on alcohol and cancer that the effect of alcohol consumption on cancer treatment is an area in desperate need of research. We know alcohol use complicates treatment outcomes among patients with cancer and contributes to longer hospitalizations, increased surgical procedures, prolonged recovery, higher health-care costs, and higher mortality.6
Helping Patients Reduce Risky Drinking Behaviors
What can oncologists do to help their patients reduce their alcohol consumption or quit drinking altogether during and after cancer treatment?
In addition to serving as community advisors and leaders to help raise awareness of alcohol as a cancer-risk behavior, we need to have direct conversations with our patients to explain how drinking could affect their treatment and cancer outcome. We need to support patients in identifying the most effective strategies to reduce their alcohol use, take blame out of the conversation, and provide them with resources (such as behavioral interventions). We also need to partner with other medical specialists, including mental health professionals, to develop ways to reduce risky drinking behaviors and recruit family members to help manage a patient’s drinking.
It’s a difficult problem, because oncologists are already stretched so thin and rarely have the time or training to appropriately deal with these issues.
Making Reduction in Alcohol -Consumption a Priority
The WHO has declared that no level of alcohol consumption is safe for our health. Should oncologists make reducing or quitting alcohol the same priority they give to quitting smoking and weight reduction to decrease the risk of cancer recurrence?
Yes, especially for patients diagnosed with one of the seven alcohol-related cancers. Given the limited amount of time oncologists have with their patients, just explaining the health risks drinking poses and how much better patients’ overall health would be if they stopped drinking would be helpful.
DISCLOSURE: Dr. LoConte has served as a consultant or advisor to AbbVie and Personal Genome Diagnostics and has received research funding from Exact Sciences.
REFERENCES
1. World Health Organization: No level of alcohol consumption is safe for our health. Available at www.who.int/europe/news/item/04-01-2023-no-level-of-alcohol-consumption-is-safe-for-our-health. Accessed July 11, 2024.
2. American Cancer Society: Alcohol Use and Cancer. Available at www.cancer.org/cancer/risk-prevention/diet-physical-activity/alcohol-use-and-cancer.html. Accessed July 11, 2024.
3. Hopkins A: Study Probes Awareness of Alcohol’s Link to Cancer. National Cancer Institute, January 18, 2023. Available at www.cancer.gov/news-events/cancer-currents-blog/2023/cancer-alcohol-link-public-awareness. Accessed July 11, 2024.
4. National Cancer Opinion Survey: Prepared for the American Society of Clinical Oncology, October 2017. Available at https://society.asco.org/sites/new-www.asco.org/files/content-files/research-and-progress/documents/2017-ASCO-National-Cancer-Opinion-Survey-Results.pdf. Accessed July 11, 2024.
5. American Institute for Cancer Research: Most Americans Still Unaware That Alcohol Is a Cause of Cancer. Available at www.aicr.org/news/most-americans-still-unaware-that-alcohol-is-a-cause-of-cancer. Accessed July 11, 2024.
6. LoConte NK, Brewster AM, Kaur JS, et al: Alcohol and cancer: A statement of the American Society of Clinical Oncology. J Clin Oncol 36:83-93, 2018.
7. Shi M, Luo C, Oduyale OK, et al: Alcohol consumption among adults with a cancer diagnosis in the All of Us Research program. JAMA Netw Open 6: e2328328, 2023.
8. Rock CL, Thomson C, Gansler T, et al: American Cancer Society guideline for diet and physical activity for cancer prevention. CA Cancer J Clin 70:245-271, 2020.
