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Alcohol and Cancer: a Statement of the American Society of Clinical Oncology Noelle K

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Alcohol and Cancer: a Statement of the American Society of Clinical Oncology Noelle K VOLUME 36 • NUMBER 1 • JANUARY 1, 2018 JOURNAL OF CLINICAL ONCOLOGY ASCO SPECIAL ARTICLE Alcohol and Cancer: A Statement of the American Society of Clinical Oncology Noelle K. LoConte, Abenaa M. Brewster, Judith S. Kaur, Janette K. Merrill, and Anthony J. Alberg Author affiliations and support information ABSTRACT (if applicable) appear at the end of this article. Alcohol drinking is an established risk factor for several malignancies, and it is a potentially modi- Published at jco.org on November 7, fi 2017. able risk factor for cancer. The Cancer Prevention Committee of the American Society of Clinical Oncology (ASCO) believes that a proactive stance by the Society to minimize excessive exposure to Reprint requests: American Society of Clinical Oncology, 2318 Mill Rd, Suite 800, alcohol has important implications for cancer prevention. In addition, the role of alcohol drinking on Alexandria, VA 22314; e-mail: outcomes in patients with cancer is in its formative stages, and ASCO can play a key role by [email protected]. generating a research agenda. Also, ASCO could provide needed leadership in the cancer com- Corresponding author: Noelle K. LoConte, munity on this issue. In the issuance of this statement, ASCO joins a growing number of in- MD, University of Wisconsin Madison, ternational organizations by establishing a platform to support effective public health strategies in 600 Highland Ave, Madison, WI 53792; this area. The goals of this statement are to: e-mail: [email protected]. • Promote public education about the risks between alcohol abuse and certain types of cancer; © 2017 by American Society of Clinical • Support policy efforts to reduce the risk of cancer through evidence-based strategies that Oncology prevent excessive use of alcohol; 0732-183X/18/3601w-83w/$20.00 • Provide education to oncology providers about the influence of excessive alcohol use and cancer risks and treatment complications, including clarification of conflicting evidence; and • Identify areas of needed research regarding the relationship between alcohol use and cancer risk and outcomes. J Clin Oncol 36:83-93. © 2017 by American Society of Clinical Oncology INTRODUCTION with preventive interventions at both the policy and the individual levels. Here, we provide an overview of the evidence of the links between alcohol The importance of alcohol drinking as a con- drinking and cancer risk and cancer outcomes. The tributing factor to the overall cancer burden is areas of greatest need for future research are high- often underappreciated. In fact, alcohol drinking lighted. On the basis of this evidence and guide- is an established risk factor for several malig- lines adopted by other cancer-focused organizations, nancies. As a potentially modifiable risk factor for ASCO-endorsed strategies for the reduction of high- cancer, addressing high-risk alcohol use is one risk alcohol consumption are presented. strategy to reduce the burden of cancer. For ex- ample, in 2012, 5.5% of all new cancer occur- rences and 5.8% of all cancer deaths worldwide EPIDEMIOLOGY OF ALCOHOL USE were estimated to be attributable to alcohol.1 In the United States, it has been estimated that 3.5% of all cancer deaths are attributable to drinking Beyond oncology, alcohol use and abuse to- alcohol.2 Alcohol is causally associated with gether pose a significant public health problem. oropharyngeal and larynx cancer, esophageal According to the Centers for Disease Control and cancer, hepatocellular carcinoma, breast cancer, Prevention, approximately 88,000 deaths were and colon cancer.3 Even modest use of alcohol attributed to excessive alcohol use in the United may increase cancer risk, but the greatest risks are States between 2006 and 2010.4 Approximately observed with heavy, long-term use. 3.3 million deaths worldwide result from the Despite the evidence of a strong link between harmful use of alcohol each year.5 Population alcohol drinking and certain cancers, ASCO has surveys demonstrate that 12% to 14% of adults not previously addressed the topic of alcohol and have a current alcohol use disorder and that 29% DOI: https://doi.org/10.1200/JCO.2017. cancer. In addition, alcohol drinking is a poten- have had such a disorder at some point in their 6,7 76.1155 tially modifiable risk factor that can be targeted lifetime. In addition to alcohol use disorder, © 2017 by American Society of Clinical Oncology 83 Downloaded from ascopubs.org by 173.8.10.209 on March 11, 2019 from 173.008.010.209 Copyright © 2019 American Society of Clinical Oncology. All rights reserved. LoConte et al other measures used to assess the impact of alcohol are excessive ALCOHOL AND CANCER drinking, binge drinking, and heavy drinking. Excessive drinking includes binge drinking and is defined as consumption of four or more drinks during a single occasion for women, or five or more Evidence to Link Alcohol Consumption to Specific drinks during a single occasion for men. Binge drinking is the most Cancers common form of excessive drinking compared with heavy drinking, The relationship between drinking alcohol and cancer risk has which is defined as eight or more drinks per week or three or more been evaluated extensively in epidemiologic case-control and drinks per day for women, and as fifteen or more drinks per week or cohort studies. In a thorough systematic review of the world’s four or more drinks per day for men.8 Recent work has shown that evidence that adhered to prespecified criteria for drawing in- the prevalence of adults who drink more than four to five drinks per ferences, a World Cancer Research Fund/American Institute for occasion, defined as extreme binge drinking, has been increasing Cancer Research (AICR) report judged the evidence to be con- during the past decade.9 This study estimated that 13% of the US vincing that drinking alcohol was a cause of cancers of the oral adult population engaged in extreme binge drinking on at least one cavity, pharynx, larynx, esophagus, breast, and colorectum (in 23 occasion in the previous year. Moderate drinking is defined at up to men). Also, alcohol was judged to be a probable cause of in- 23 one drink per day for women and up to two drinks per day for creased risk of liver cancer and colorectal cancer (in women). An men.1,4 Most individuals who drink excessively do not meet the updated review of the evidence for liver cancer upgraded the clinical criteria for alcoholism or alcohol dependence.10 conclusion for an association between alcohol drinking and liver 24 Alcohol use during childhood and adolescence is a predictor cancer to convincing. The International Agency for Research on 25 of increased risk of alcohol use disorder as an adult.11 College-age Cancer (IARC), a branch of WHO, has assessed the evidence and and younger people who drink are prone to develop an alcohol use come to virtually identical conclusions: that alcohol is a cause of disorder later in life.7 Most adults who engage in high-risk alcohol cancers of the oral cavity, pharynx, larynx, esophagus, colorectum, drinking behavior started drinking before age 21 years. Among US liver (ie, hepatocellular carcinoma), and female breast. For youth age 12 to 20 years, 23% were current drinkers in the past esophageal cancer, the association with alcohol drinking is largely 25 30 days, 10% were episodic drinkers, 2% were heavy episodic specific to squamous cell carcinoma. The more that a person drinkers, and 6% met criteria for alcohol use disorder.11 Among drinks, and the longer the period of time, the greater their risk of 3 childhood cancer survivors, the prevalence of alcohol use in the development of cancer, especially head and neck cancers. past 30 days in adulthood (7.8 mean years since diagnosis of their A valid question is whether these associations are specificto cancer) was 25%, which was lower than that observed in the ethanol per se or whether they vary according to the type of al- general population.12 However, alcohol use among teenage patients coholic beverage (ie, beer, wine, or spirits/liquor). The answer is with cancer is a common occurrence overall and has been observed that the associations between alcohol drinking and cancer risk have to be as high among teens without cancer.13-15 been observed consistently regardless of the specific type of al- coholic beverage.25 The full range of cancers for which alcohol drinking repre- DRINKING GUIDELINES AND DEFINITIONS sents a risk factor remains to be clarified. For example, the index of suspicion is high that alcohol drinking leads to excess risk of 25 26 Internationally, more than 40 countries have issued alcohol pancreatic cancer and gastric cancer. For some malignancies, drinking guidelines; however, these vary substantially.16 The alcohol drinking clearly is statistically associated with increased American Heart Association, American Cancer Society, and US risk but, because of its strong correlation with other risk factors, it Department of Health and Human Services all recommend that is difficult to discern if alcohol drinking is truly an independent risk men drink no more than one to two drinks per day and that factor. For example, alcohol drinking consistently has been sta- 23 women drink no more than one drink per day.17-19 In addition, it is tistically strongly associated with increased lung cancer risk. recommended that drinking alcohol should only be done by adults However, cigarette smokers also are more likely to be alcohol of legal age. People who do not currently drink alcohol should not drinkers, and cigarette smoking is such an overwhelming lung start for any reason. cancer risk factor that confounding by cigarette smoking—rather Defining risk-drinking can be challenging, because the than a direct association with alcohol drinking—currently 27 amount of ethanol contained in an alcoholic beverage will vary cannot be ruled out as a possible explanation.
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