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Epidemiological Studies of Cancer in Humans

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Epidemiological Studies of Cancer in Humans 5. EPIDEMIOLOGleAL STUDIES OF eANeER lN HUMANS As early as 1910, it was observed in Paris, France, that about 80% of patients with cancer of the oesophagus and cardiac region of the stomach were alcoholics, who drank mainly absinthe (Lamy, 1910). ln the first half of this century, it was also noted from mortality statistics in various countries that high risks for cancers of the oral cavity, pharynx, oesophagus and larynx occurred among persons employed in the production and distribution of alcoholIc beverages (Young & RusselI, 1926; Clemmesen, 1941; Kennaway & Kennaway, 1947; Versluys, 1949). Later studies showed that cancers at these sites occur at lower rates of incidence (and mortality) in religious groups that proscribe alcohol intake, such as Seventh-day Adventists (Wynder et aL., 1959; Lemon et al., 1964; Philips et al., 1980), compared with corresponding national populations. Although many aspects of the life style of such populations are particular, differences in drinking (and smoking) habits may contribute to the differences in disease rates. Subsequent to these historical observations and studies of religious groups, analytical studies of the cohort and case- control type have been carried out. 5.1 Measurement of alcohol intake in epidemiological studies ln descriptive studies, discussed below, a very crude level of a1cohol intake is typically inferred for a group of individuals, on the basis of characteristics such as treatment for a1coholism. Frequently, even measurements of average a1cohol intake in these groups and in the groups with which they are compared are not avaIlable. ln case-control and cohort studies involving individual subjects, measurements of a1cohol intake are usually obtained by structured interview or questionnaire. The questions asked vary widely among studies, providing markedly different levels of detail about alcohol intake (Room, 1979). ln some studies, a single question was asked that provided only a few categories of alcohol consumption. ln many studies, separate questions were asked regarding the average frequency (usually in terms of standard units) of drinking beer, wine, spirits and other specific beverages. This information allows a calculation of usual total ethanol intake as weIl as an estimation of that from the specific beverages. ln some studies, further information was colIected about a1cohol consumption at different ages. ln genera1, details about intraindividual variations, such as 'binge drinking', have not been incorpo- rated in the studies reviewed. -153- 154 IARC MONOGRAPHS VOLUME 44 The validity of self-reported alcohol consumption has been reviewed by Midanik (1982). ln some populations (Pernanen, 1974), but not necessarily all, self reporting of alcohol intake results in a lower total than that for alcohol sales. However, even if a population as a whole tends to underestimate intake, this may not necessarily be true of participants in epidemiological studies, such as those who volunteer to enrol in a cohort study. Moreover, there is some evidence that underestimation tends to be proportional to consumption, so that the broad ordering of respondents is maintained (Boland & Roizen, 1973). The reproducibility and valIdity of the measurements of alcohol consumption used in epidemiological investigations have been examined in several recent studies. Rohan and Potter (1984) interviewed 37 men and 33 women in Australia regarding food and beverage intake twice at a three-year interval; mean intakes were reported almost identicalIy on the two questionnaires, and the correlation between the original report and recalled intake was 0.87 for men and 0.79 for women. ln a comparison of intake measured by diet record and a dietary history interview four years later among 79 Dutch men and women, mean alcohol consumption was found to be identical using the two methods, and the correlation among individual subjects was 0.82 (van Leeuwen et al., 1983). Riboli et al. (1986) compared wine intake as assessed by an interviewer-administered questionnaire among 29 Italian adults with consumption reported in a one-week dietary record. The estimate from the questionnaire was about 40% higher than that determined from the diary, and the correlation between the methods was 0.57. ln a valIdation study of a self-administered dietary questionnaire conducted among 173 participants in a large US cohort of women, Wilett et al. (1987) compared alcohol intake computed from two administrations of a questionnaire at a one-year interval with intake assessed by four one-week diet records collected during the interviewing year. Mean alcohol intake by this group of women was nearly identical whether assessed by either of the two questionnaires or the dietary record: the correlation between the two questionnaires was 0.90, that between the first questionnaire and the diet record, 0.86, and that between the second questionnaire and diet record, 0.90. Furthermore, significant correlations were observed between the questionnaire measure of alcohol intake and plasma high-density lipoprotein-cholesterol levels (which is known to be sensitive to alcohol ingestion), providing qualItative evidence of a physiological response to alcohol intake. It thus appears that a1cohol intake can be measured in a reproducible and valId manner by .the relatively simple questionnaires employed in many epidemiological studies. Additional characterization of drinking habits, including use of a1cohol at different ages and shorter-term patterns of individual variation, may provide useful information and improve the classification of subjects according to long-term alcohol use. ln case-control studies, errors in recall of alcohol intake that are different between cases and controls could distort the relation with cancer risk; it is possible that the occurrence of a grave ilness cou1d affect recall. ln several studies of dietary recall, it has been noted that current dietary intake has a major influence on the reporting of earlIer diet (Jensen et al., 1984). Since alcohol intake may be altered by serious ilness or by its treatment, it is possible that studies of prevalent cases of cancer are less relIable than studies of newly diagnosed cases, even if alcohol does not influence prognosis. EPIDEMIOLOGICAL STUDIES OF CANCER lN HUMANS 155 5.2 Descriptive studies Descriptive studies (also referred to as ecological or correlation studies) of the relation- ship between alcohol consumption and cancer risk enta il analysis of the co-variation of population-based measures of those two variables. Variations (known or inferred) in alcohol consumption by time, geographic location and category of person are examined in relation to variations in cancer incidence or mortality rates. Since alcohol consumption tends to be associated with other forms of behaviour that might also influence the risk of developing cancer (especially cigarette smoking and aspects of diet), and for which equivalent measures of exposure are frequently not available, it is not possible in descriptive studies to infer a causal relationship between a1cohol consumption and cancer risk. ln addition, in descriptive studies, average values of a1cohol consumption are attributed to population groups as a whole; depending on the actual distribution of exposures within the population, this can result in considerable misc1assification of exposure and consequent errors in estimation of effects. (a) Geographical and temporal studies Geographical and temporal variations in alcohol consumption are usually estimated from systematic records (governmental or commercial) of production and sales, or from changes in the rates of other acknowledged diseases of 'alcohol abuse' (especially alcoholIc liver cirrhosis). ln some cross-sectional, regional, ecological studies, a1cohol consumption in different population subgroups has been estimated by direct survey(e.g., Hinds et al., 1980). Intrapopulation studies, in which identifiable groups of people with known differences in a1cohol consumption (e.g., abstainers, relIgious groups, ethnie groups) or with known or presumed changes in drinking habits (e.g., migrants) are studied, are also a usefu1 source of descriptive epidemiologica1 data. Again, however, measures of confounding variables are often not available, or, if avai1able, may be difficult to 'control for' in data analysis at the population leveL. Descriptive studies have been used most frequently to study a1cohol consumption in relation to specifie cancers orthe upper alimentary tract and larynx. Oesophageal cancers, in particular, have been studied in this way in both developed and developing countries. Many geographic correlation studies have been carried out to examine mortality from alimentary tract cancer in relation to mortality from liver cirrhosis and alcoholIsm within the departments of France (Lasserre et al., 1967). These studies have consistently shown a strong correlation of oesophageal cancer with the index of alcohol consumption; less strong correlations have been seen for cancers of the mouth, pharynx and stomach. Geographie studies have also been carried out in eastern and southern Africa to examine the substantial local variations in oesophageal cancer mortality in relation to alcohol consumption and to brewing practices (Day et al., 1982). Several international studies have demonstrated a 156 IARC MONOGRAPHS VOLUME 44 positive correlation between national consumption of beer per head and mortality from cancer of the rectum (Breslow & Enstrom, 1974; Potter et al., 1982). Time
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