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Alcohol and Cancer: State of the Science Christine L. Molmenti PhD, MPH, RD
AICR Science Analyst
Assistant Professor
Hofstra-Northwell School of Medicine
Northwell Health
April 11, 2018
As required by the Alcohol Policy 18 Conference,
I/we have signed a disclosure statement and note the following conflict(s) of interest:
None
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Outline
Background on the American Institute for Cancer
Research (AICR) and Continuous Update Project
(CUP)
Recommendations for alcohol and cancer
prevention
Scientific evidence behind the recommendations
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The World Cancer Research Fund Network
World Cancer Research Fund International (est. 1999)
Leads and unifies a network of cancer charities with a global reach, dedicated to the prevention of cancer through diet,
weight and physical activity.
American Institute for
Cancer Research
Washington DC (est. 1982)
World Cancer Research Fund UK London
(est. 1990)
World Cancer Research Fund NL Amsterdam
(est.1994) World Cancer
Research Fund HK
Hong Kong (est.1997)
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1997 2007 2018
New Expert Report
www.wcrf.org/cup
Third expert report
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13 CUP reports so far
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People involved in the CUP
More than 100 scientists
17 countries
Team of researchers for the CUP at Imperial College London
Includes CUP Expert Panel,
researchers, peer reviewers,
advisers and more
CUP Panel of independent experts
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Grading the evidence
Decreases risk Increases risk
Strong evidence
Convincing
Probable
Limited evidence
Limited - suggestive
Limited – no conclusion
Strong evidence
Substantial effect on risk unlikely
Basis for recommendations
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Grading criteria
Predefined requirements for
Number and types of studies
Quality of exposure and outcome assessment
Heterogeneity within and between study types
Exclusion of chance, bias or confounding
Biological gradient
Evidence of mechanisms
Size of effect
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For cancer prevention, don’t drink alcohol
ALCOHOLIC DRINKS
DECREASES RISK INCREASES RISK
Convincing Mouth/throat; oesophagus (SCC); liver; colorectum (men); breast (pre & post)
Probable Kidney Stomach; colorectum (women)
Substantial effect on risk unlikely
None identified
Alcohol consumption linked to an increased risk of 6 cancers
If you do, limit alcoholic drinks to two drinks per day for men and one drink per day for women
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Strength of association varies by site
Cancer RR per 10g/d Number of
cohort
studies
Oropharynx, larynx, pharynx n/a 2
Oesophagus (squamous cell carcinoma) 1.25 (1.12-1.41) 6
Colorectum 1.10 (1.06-1.13) 8
Breast (premenopause) 1.09 (1.01-1.17) 10
Breast (postmenopause) 1.08 (1.05-1.11) 25
Liver 1.04 (1.02-1.06) 14
Stomach 1.02 (1.00-1.04) 23
Kidney 0.92 (0.86-0.97) 7
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Association strongest for cancers of the upper aerodigestive tract
Cancer RR per 50g/d
Oral cavity, pharynx, larynx, esophagus
4-7
Colorectum 1.5
Breast 1.5
Liver 1.5
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Esophageal squamous cell carcinoma
Steeper increase in risk for lower intakes
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Esophageal squamous cell carcinoma
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• Synergistic effects of smoking and alcohol – Smoking is a significant confounder/effect modifier
• Risk holds even among non-smokers
– Meta-analysis (15 studies) found consumption of ≥4 drinks/d most strongly associated with pharynx but also oropharynx, larynx, esophageal SCC
– Pooled analysis of case-control studies, heavy alcohol consumption (≥3 drinks/d) associated with oropharynx and larynx cancer
Zeka et al, 2003 Hashibe et al, 2007
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Colorectal cancer
– 8 (all) cohort studies showed increased risk with increased intake (dose-response relationship)
– Greater effect in men than women • 11% vs 7% increased risk respectively per 10g/d
– Pooled analysis of >4600 colorectal cancer cases among >475000 participants followed for 6-16 years • 41% increased risk for groups that drank the most alcohol
– Interaction with smoking unclear
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Breast cancer 2017 CUP report
– 119 studies (from both the US and internationally)
– >12 million women
– >260,000 cases of breast cancer.
Consumption of alcoholic drinks is a probable cause of premenopausal breast cancer and a convincing cause of postmenopausal breast cancer.
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Breast cancer
Dose-response meta-analysis – 3 cohort studies, 7 case-control studies
– 10 g ethanol per day (4 oz glass of wine or 12oz of beer)
• Statistically significant increased risks:
• All ER+ (12%)
• All ER- (7 %)
• ER+, PR+ (11 %)
• ER+, PR- (15%)
• Not ER-, PR-
Each drink/d associated with 11% increase in postmenopausal breast cancer risk
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0.6 0.8 1.0 1.2 1.4
Alcohol intake*Breast Cancer
Beer
Wine
Spirits
*per 10g ethanol /day
1.6 1.8
Premenopausal
breast cancer
Postmenopausal
breast cancer
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Breast cancer
Pooled analysis of 53 studies, >58,000 women with breast cancer (included in IARC 2010 review) – Linear dose response association
– 7.1% increase risk per 10g/d increase in ethanol consumption
– No effect modification by numerous factors including age at dx, parity, age at first birth, breast feeding, race, country, education, BMI, OC use, menopausal status, FDR with breast cancer
High risk women should avoid alcohol
– Binge drinking specially deleterious in younger women
Hamajima et al, 2002
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Liver cancer (hepatocellular carcinoma)
Alcohol is a cause of cirrhosis – predisposes to liver cancer
– Excluded patients with cirrhosis, HBV, HBC, history or alcoholism
14 studies included in dose response analysis
– 4% increased risk per 10 g/d
Meta-analysis of 19 prospective cohort studies
– 16% increased risk compared to non-drinkers (3 drinks/d)
– Pooled relative risk among 6 drinks/d = 1.22(1.10, 1.35)
Turati et al, 2014
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Pancreatic cancer
Evidence considered “limited-suggestive”
Dose response analyses revealed a suggestion of an increased risk in heavier drinkers (> ~3 drinks/day)
ACS CPS-II
– 1 million US adults, 24 years follow up, 7000 pancreatic cancer deaths • ≥3 drinks/d associated with increased risk of pancreatic
cancer death [RR=1.36 (1.13, 1.62)
Gapstur et al, 2011
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Cancer survivors Evidence unclear
Pre diagnostic alcohol in take
– 18 total studies published through 2012
– No associations of pre-diagnostic alcohol intake with total mortality or risk of second primary breast cancer
Post diagnostic alcohol intake
– Inconsistent results
– Not dose related
Premenopausal vs postmenopausal
– Post-menopausal women who consume at least ≥6/d, 19% higher risk
– No association found among pre-menopausal women
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• Summary
– Alcoholic drinks are a cause of cancers of the oral cavity, pharynx, larynx, esophagus, liver, colorectum (men), and breast.
– Probable cause of stomach cancer and colorectal cancer (women).
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Recommendation
For cancer prevention, it’s best not to drink alcohol. If you do, limit alcoholic drinks to two drinks per day for men and one drink per day for women
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For further information Christine L. Sardo Molmenti, PhD, MPH, RD
Science Analyst
American Institute for Cancer Research
Assistant Professor
Feinstein Institute for Medical Research | Northwell Health
Donald and Barbara Zucker School of Medicine at Hofstra/Northwell
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@aicrtweets
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