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Noelle K. LoConte, MD

Associate Professor of Medicine

University of Wisconsin

Madison, WI

Alcohol and Cancer: The Risk Factor We Aren’t Talking About

THE SCOPE OF THE PROBLEM

Public Health Impact

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Alcohol and Cancer

• Alcohol use has been shown to cause at least 7 different cancers: – Mouth & Throat

– Larynx

– Esophagus

– Breast

– Liver

– Colorectal

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What cancers are associated with alcohol use? (RR)• Head and neck cancer – SCC

– Oropharynx (5.13)– Larynx (2.65)

• Esophageal cancer – SCC, GI (4.95)• Gallbladder – GI (2.64)• Liver – GI (2.07)• Breast (1.61)• Colorectal – GI (1.44)• Pancreas – GI (1.19)• Lung (1.15)

Bagnardi V et al, 2014 Br J Cancer 112: 580.

How significant is the risk?

• Approximately 3.5% of all cancer deaths, and 15% of breast cancer deaths, in the U.S. are attributed to alcohol.

• That’s more than 1 death per day in Wisconsin.

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How many people are we talking about?

• Estimated 18,200-21,300 alcohol attributable cancer deaths in the United States in 2009– Based off BRFSS and National Alcohol Survey (NAS)

• 3.2-3.7% of all cancer deaths

• By amount of consumption– >40 g/day (3+ drinks) = 48-60% of deaths

– 20-40 g/day (1 ½ - 3 drinks) = 14-17% of deaths

– <20g/day (less than 1 ½ drinks) = 25-33% of deaths (larger “n”)

Nelson DE 2013 Am J Public Health 103:641-48.

Bagnardi V et al, 2014 Br J Cancer 112: 580.

With higher levels of drinking, higher likelihood that cancer is from alcohol

Alcohol-attributable Cancers in Wisconsin

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Cancer Type Average Annual Cases Average Annual Deaths

Mouth & Throat 790* 164*

Larynx 234* 55

Esophagus 352* 321*

Breast 4,312 767

Liver 428 355

Colorectal 2,570 950

*Rate is at or above national average

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2010 data: Attributable risks

Alcohol Use in Wisconsin

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• 65% of Wisconsinites drink alcohol– 23% binge drinkers (18% youth)

– 8% heavy drinkers

• Alcohol is a common avoidable risk factor. Compare to:– 17% tobacco use

– 22% no physical activity

– 24% <1 veggie

The little known risk factor…

• Only 11% of U.S. adults knew alcohol was a cancer risk factor.– Same study supported a connection between awareness and

behavior.

• Low health professional knowledge.

• Cancer community (in the U.S.) has been relatively quiet.

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Hawkins, et al, 2003

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How much is too much?

• Even moderate drinking can increase your cancer risk.

• But in general, for most cancers, the more you drink, the greater your risk.

• Bottom line: to reduce your cancer risk, drink less or don’t drink at all.

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MECHANISMS OF ACTION

How does alcohol increase cancer risk?• WHO International Agency for Research on Cancer Group

1 Carcinogen “Definitely carcinogenic in humans”

• Ethanol metabolized to acetaldehyde (carcinogen)

• Generating reactive O2 species

• Cirrhosis (liver, biliary)

• Interrupts folate metabolism (colorectal)

• Increased estrogen levels (breast)

• Alcohol can increase the absorption of carcinogens from tobacco

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Slide courtesy of S Gapstur, NY Alcohol Policy Conference 2017

Slide courtesy of S Gapstur, NY Alcohol Policy Conference 2017

WHAT CAN BE DONE?

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What can be done?

• Alcohol control efforts in state-based comprehensive cancer control programs– Review of 69 comp cancer programs

– 45% (31) at least one goal/strategy addresses EtOH

• National efforts – American Society of Clinical Oncology (ASCO)

Henley SJ, Alcohol and Alcoholism (2014)

Date of download: 3/15/2017Published by Oxford University Press on behalf of Medical Council on Alcohol 2014. This work is

written by (a) US Government employee(s) and is in the public domain in the US.

From: Alcohol Control Efforts in Comprehensive Cancer Control Plans and Alcohol Use Among Adults in the USA

Content related to alcohol use in state comprehensive cancer control plans 2003–2020. Map depicts whether the state comprehensive cancer control plan addressed alcohol use as a cancer risk factor in at least one goal, objective or strategy; as background information only; or not at all.

Alcohol Alcohol. 2014;49(6):661-667. doi:10.1093/alcalc/agu064

WI Comprehensive Cancer Control Plan 2015-2020

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Comprehensive Cancer Control

A collaborative and strategic approach that brings partners together to combine, share, and coordinate resources to reduce the burden of cancer across the whole continuum from prevention through end of life.

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Partners coming together to:Reduce cancer risk * Find cancer earlier

Improve cancer treatments * Reduce death and suffering from cancer * Improve survivors’ quality of life

Comprehensive Cancer Control in Wisconsin

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WI CCC ProgramThe state's cancer prevention and control program that facilitates the development, implementation and evaluation of the WI CCC Plan.

WI Cancer CouncilCoalition of organizations dedicated to the development, implementation and evaluation of the WI CCC Plan.

WI CCC Plan 2015-2020Serves as a common framework for action for all working on cancer prevention and control in Wisconsin.

WI Comprehensive Cancer Control PROGRAMThe state's cancer prevention and control program

• Coordinates the development of the WI CCC Plan.

• Promotes the implementation of the WI CCC Plan.

• Facilitator of and staffing for the Wisconsin Cancer Council.

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Wisconsin CancerCOUNCILEngages diverse partners to develop, implement and promote a statewide comprehensive approach to cancer control.

– Established in late 1980s

– Partners ready to come together to develop the WI CCC Plan in 2003-2005.

– Developed and implementing WI CCC Plan for the last 10+ years.

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WI CCC Plan 2015-2020

• Common framework for action in cancer prevention and control to be implemented over 5 years

• Includes 13 Priorities and 4 Cross Cutting Issues

• Interactive version available online at www.wicancer.org/plan

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WI CCC Plan 2015-2020

Priority 3: Decrease high risk alcohol consumption

Strategies:a. Increase awareness of the connection between alcohol

consumption and cancer riskb. Create environments that discourage excessive use of

alcoholc. Increase screening and treatment for high risk alcohol

consumption

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Wisconsin Comprehensive Cancer Control Plan 2015-2020

Significance of Underage Drinking

• Underage drinking is a risk factor for heavy drinking later in life.

• Heavy drinking across the lifetime increases the risk for cancer.

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Alcohol and Smoking

• People who smoke and drink have a higher cancer risk than those who just smoke, or those who just drink.

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Source: Hashibe M et al, Cancer Epi Bio Prev. 2009;18(2):541-50

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Education

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• Educate membership

• Increase awareness

• Encourage healthy decision making

Education

Why focus on policy change?

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Policy

National

• Less efforts in US than similar groups in Europe, UK, Australia, New Zealand– AICR, ACS, ASCO

• Growing area of interest to limit alcohol as a means of cancer prevention

Ziegler, APHA 2015

International Cancer Community

• Public awareness campaigns in UK and Australia.

• Policy recommendations from many international cancer associations: – Pricing policy

– Restricting alcohol marketing to youth

– “Pink-washing” (South Africa)

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Impact of Public Awareness Campaigns

• Australian participants were 30-60% more likely to support alcohol policies like: – Increasing price and taxation

– Reducing availability

– Restricting marketing

– Labeling

• Similar results seen in the U.K.

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Major Takeaway

Increasing awareness of the connection between alcohol and cancer may encourage individual

behavior change and increase support for public policies that impact the alcohol environment.

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ASCO

• Network of more than 40,000 oncology professionals

• 30% international members (120 countries)

• Practicing oncologists, nurses, research staff, industry, advocacy, public health

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ASCO’s Cancer Prevention Committee

Goals:

• Advance the education of the oncology community in the area of cancer prevention

• Advocate public policy to assure patients the benefits of ongoing cancer prevention research

• Promote clinical, behavioral, and translational research in cancer prevention and control

Major Areas of Focus

• Tobacco Cessation & Control

• Inherited Cancer Susceptibility

• Energy Balance & Obesity

• Vaccination to Prevent Cancer

• Cancer Screening

Cancer Prevention Policy Objective

• Develop policies and advocate legislation that support cancer prevention research as well as access to cancer prevention services, including coverage and reimbursement models that support risk assessment and management interventions.

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Development of alcohol and cancer statement

• Similar to recent HPV vaccine statement (Bailey, JCO 2016)

• Expect release in summer 2017 in JCO

• Written by experts in:– Medical Oncology

– Cancer Disparities

– Epidemiology

– Public Health

– Cancer Prevention

Goals in the proposal• Promoting public education

• Detailing policy efforts to reduce the risk of cancer through evidence-based strategies that prevent excessive use of alcohol

• Providing education to oncology providers about the influence of excessive alcohol use and cancer risks and treatment complications, including clarification of conflicting evidence

• Identifying areas of needed research

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Research needs, the low hanging fruit

• Effect of alcohol cessation on cancer risk and treatment

• Effect of alcohol use on cancer treatment delivery– Effect of EtOH on posop morbidity

– Effect of EtOH on chemotherapy, hormonal therapy and supportive medication metabolism

• Systems based research into identification of patients with alcohol use issues

• Appropriate clinical interventions for alcohol use reduction

POTENTIAL BARRIERS

Barriers to Limiting Alcohol to Reduce Cancer

• “Heart health” of moderate drinking

• Industry pushback

• Pink-washing

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Isn’t alcohol good for your heart…?

• Relationship between moderate drinking (red wine) and heart disease risk has been largely debunked.

• American Heart Association does not recommend drinking wine or any other form of alcohol to gain benefits.

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Industry Pushback

• “[Public health officials] want to tell you that alcohol causes cancer…”

- American Beverage Institute

• “We can’t let them gain traction.”

- Beer Institute

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Pink-washing

“Pink-washing” = Using the color pink or the pink ribbon to market products associated with breast cancer.

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Slide from D Journigan, Wisconsin Alcohol Policy Webinar

Where to go from here?

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• Continuing professional and public education.

• Sharing educational materials with partners.

• Develop specific education around pink-washing and cancer fundraising practices.

Conclusions

• Prevention is a key strategy to controlling cancer

• Alcohol intake is a target for a modifiable risk factor for cancer

• State CDC Comprehensive Cancer Control programs can be a useful alcohol control strategy

• American cancer societies (like ASCO) are increasing their efforts around alcohol