The first study to estimate the alcohol-related cancer burden on a state-by-state basis provides more evidence that the drinking habits of Americans account for a “considerable” proportion of cancer diagnoses and deaths, researchers say.
“In the United States, on average, alcohol consumption accounts for 4.8% of cancer cases and 3.2% of cancer deaths,” concludes Farhad Islami, MD, PhD, of the American Cancer Society (ACS) and colleagues.
However, the proportion was higher for specific cancer types, with alcohol consumption accounting for an estimated 12.1% of female breast cancers, 11.1% of colorectal, 10.5% of liver, and 7.7% of esophageal cancers, the study showed.
The study was published online January 19 in Cancer Epidemiology.
“Implementing state-level policies and cancer control efforts to reduce alcohol consumption could reduce this cancer burden,” the researchers comment.
They noted that restrictive policies on alcohol sales are associated with a reduction in cancer mortality rates and that a recent study showed increasing alcohol controls by 10% was associated with an 8.3% relative decrease in the oropharyngeal cancer mortality rate.
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Separating Drinking From Smoking
The study is also one of a growing number to evaluate alcohol consumption and cancer risk in nonsmokers, said Mary Beth Terry, PhD, professor of epidemiology at Mailman School of Public Health, Columbia University, New York City, when approached for comment.
“This is important because the much larger effects of smoking and cancer risk have made it challenging in the past to evaluate the full impact of alcohol consumption,” she told Medscape Medical News. “In the past it was hard to calculate population-attributable fractions for alcohol because a large part of the population smoked and drank.”
“This was a very comprehensive analysis,” added Terry, who was not involved with the study. She pointed out that the authors used sales data in combination with self-reported alcohol consumption “to adjust for the fact that most alcohol consumption is severely underreported.”
For the study, researchers analyzed age-, sex-, and state-specific cancer incidence and mortality data (2013-2016) from the US Cancer Statistics database in adults 30 years of age and older. They also estimated state-level, self-reported age- and sex-stratified alcohol consumption using Behavioral Risk Factor Surveillance System surveys for 2003-2006 .
Large Variation Between States
The study also showed that state-specific estimates for incident cancer cases and cancer deaths varied widely, ranging from 2.1% to 5.0% in men, and from 1.4% to 4.4% in women.
The proportions of alcohol-attributable cancer tended to be higher in New England and the western states and lower in the midwestern and southern states, with two notable exceptions. Delaware had the highest number of alcohol-related cancer cases (6.7%) and deaths (4.5%) among men and women combined, and Utah had the lowest (2.9% and 1.9%, respectively).
The magnitude of the state-to-state variation in cancer burden left the researchers “a bit surprised,” Islami told Medscape Medical News.
“The proportion of cancer cases and deaths attributable to alcohol consumption among women was about three times higher in Delaware than in West Virginia,” he said.
He noted that in the last decade, alcohol consumption among women has increased. “This may make our results even more relevant,” Islami said.
Many adults have limited awareness of the cancer-related risks of alcohol consumption, Islami commented. Others may not take the association seriously but “many pay attention to their doctor’s health recommendations,” Islami said. “Clinicians could have an important role in increasing awareness of the cancer-related risks of alcohol consumption, which could result in a reduction in alcohol-related cancer burden.”
Overall, the proportion of alcohol-attributable cancer cases and deaths was not substantially different from that reported in their 2017 study of national-level estimates, the investigators said. That study was based on sales-adjusted 2013-2014 contemporary exposure data from the National Health Interview Survey. It showed that alcohol consumption accounted for an estimated 5.6% of incident cancer cases and 4.0% of cancer deaths.
“More research is needed to monitor alcohol consumption and the alcohol-related cancer burden to evaluate state-based policies and cancer control efforts,” said Islami. “Further research is also needed to fine-tune proven interventions to increase their efficacy and to identify other effective interventions.”
‘Best Not to Drink Alcohol‘
In the meantime, a new, stronger directive on alcohol consumption was issued by the ACS last year (June 2020) in an update of its Guideline for Diet and Physical Activity for Cancer Prevention, the first since 2012.
That guideline recommends “it is best not to drink alcohol,” as previously reported by Medscape Medical News, although it also included the previous recommendation, that men should limit their daily intake to two drinks and women to one drink.
“Guidelines are based on the best available data, but risk does depend on many things, including underlying susceptibility,” Columbia’s Terry told Medscape Medical News. Emerging epidemiological data indicates that independent of daily alcohol consumption, binge drinking may be associated with increased risk of some common cancers, such as breast cancer.
“Alcohol metabolites are known carcinogens. It may be easier to convey a public health message focused on the harmful effects of binge drinking than in a specific daily amount,” Terry said.
Until then, evidence is growing for another disturbing trend: increased alcohol consumption to cope with the SARS-CoV-2 pandemic. Last spring, with many parts of the country in lockdown, 14% of Americans who participated in a national survey said they were drinking significantly more alcohol compared with the same time in 2019. As previously reported by Medscape Medical News, the results showed these increases were most evident in adults aged 30-59, women, and non-Hispanic Whites.
“Alcohol consumption can have significant negative health consequences, so this information suggests another way that the pandemic may be affecting the physical and mental health of Americans,” lead investigator Michael Pollard, PhD, sociologist at the RAND Corporation, said at the time.
More recently, a commentary for Medscape Medical News by F. Perry Wilson, MD, Yale School of Medicine in New Haven, Connecticut, also highlighted increased drinking. Published in the American Journal of Drug and Alcohol Abuse, a survey of 1928 affluent Americans who sheltered in place for an average of 4 weeks showed 60% who self-identified as binge drinkers reported significantly increasing their alcohol intake, as did about 30% of nonbinge drinkers. Depression was the only common factor statistically linked to increased drinking among binge drinkers.
“I think we need to consider that increased alcohol abuse is a potential harm of the social isolation that COVID-19 has forced upon us,” Wilson commented.
And what about physicians? Are they drinking more during the pandemic?
Apparently not. Nearly half of the 12,000 physicians surveyed for Medscape’s Physician Lifestyle & Happiness Report 2021 said they consume less than one drink of alcohol per week and 24% who said they never touch the stuff.
The study was funded by the ACS. Islami and colleagues were all employed by the ACS at the time of the study. The study authors and Terry have also reported no relevant financial relationships.
Cancer Epidemiol. Published online January 19, 2021. Abstract