Position statement - Alcohol and cancer risk

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Position statement - Alcohol and cancer risk


Key messages and recommendations

  • Alcohol use is a cause of cancer. Any level of alcohol consumption increases the risk of developing an alcohol-related cancer; the level of risk increases in line with the level of consumption.
  • Cancer Council Australia estimates that anywhere between 2,182 and 6,620 new cases of cancer in Australia (or 1.9–5.8% of all cancers) in 2009 were attributable to long-term, chronic use of alcohol
  • There is convincing evidence that alcohol use increases the risk of cancers of the mouth, pharynx, larynx, oesophagus, liver, bowel (in men) and breast (in women), and probable evidence that it increases the risk of bowel cancer (in women). ('Convincing' and 'probable' are the highest levels of evidence as determined by the World Cancer Research Fund and American Institute for Cancer Research and denote that the relationship is causal or probably causal in nature).
  • Together, smoking and alcohol have a synergistic effect on cancer risk, meaning the combined effects of use are significantly greater than the sum of individual risks.
  • Alcohol use may contribute to weight (fat) gain, and greater body fatness is a convincing cause of cancers of the oesophagus, pancreas, bowel, endometrium, kidney and breast (in post-menopausal women).
  • Cancer Council recommends that to reduce their risk of cancer, people limit their consumption of alcohol.
  • For individuals who choose to drink alcohol, Cancer Council recommends that they drink only within the National Health and Medical Research Council (NHMRC) guidelines for alcohol consumption.

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Introduction

Alcohol use is widespread in Australia and has had a dominant role in defining Australian culture for more than 200 years[1]. However, it is also an important cause of illness, injury and death, whether resulting from short-term episodes of intoxication or from long-term, chronic use[2].

Addressing the health and social damage resulting from risky drinking is one of the three key priority areas identified by the Australian National Preventative Health Taskforce[3]. Levels of harm from alcohol use are increasing, and a range of policy measures have been proposed to address the current drinking 'culture‘ in Australia[3].

In this position statement, Cancer Council Australia provides a brief overview of the evidence concerning alcohol use and cancer, and gives its current recommendations regarding alcohol consumption.

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Evidence linking alcohol and cancer

It has been known for more than 20 years that long-term chronic use of alcohol can cause cancer. In 1988, the International Agency for Research on Cancer (IARC) stated that 'the occurrence of malignant tumours of the oral cavity, pharynx, larynx, oesophagus and liver is causally related to the consumption of alcoholic beverages‘ and classified alcoholic beverages as Group 1 carcinogens—known to cause cancer in humans[4]. Ethanol, the chemical present in all alcoholic beverages and which induces the altered physical and mental responses experienced with alcohol use, has also been listed as a Group 1 carcinogen[5].

The most recent comprehensive review of the scientific evidence by the World Cancer Research Fund (WCRF) and the American Institute for Cancer Research (AICR) concluded that there is convincing evidence that alcohol is a cause of cancer of the mouth, pharynx, larynx, oesophagus, liver, bowel (in men) and breast (in women), and probable evidence that alcohol increases the risk of bowel cancer (in women)[6][7]. 'Convincing' and 'probable' are the two highest levels of evidence set by the World Cancer Research Fund and American Institute for Cancer Research that identify a causal relationship between a particular aspect of food, nutrition, physical activity or body composition, and cancer[6]. Scientific research is continuing to identify other cancers that could be associated with alcohol use. For example, there is initial evidence (currently insufficient to draw a link) that heavy alcohol consumption may be associated with a higher risk of prostate cancer[8][9].

There is a dose-response relationship between alcohol and cancer risk for men and women, with studies showing that the risk of cancer increases with increasing consumption of alcohol on a regular basis[6][10][11][12].

There are a number of biological mechanisms that may explain alcohol‘s contribution to cancer development. Ethanol may cause cancer through the formation of acetaldehyde, its most toxic metabolite. Acetaldehyde has mutagenic and carcinogenic properties, and bonds with DNA to increase the risk of DNA mutations and impaired cell replication[13][14]. Ethanol may also cause direct tissue damage by irritating the epithelium and increasing the absorption of carcinogens through its effects as a solvent[6]. In addition, alcohol can increase the level of hormones such as oestrogen, thereby increasing breast cancer risk[6], and increase the risk of liver cancer by causing cirrhosis of the liver, increased oxidative stress, altered methylation and reduced levels of retinoic acid[13]. Lifestyle factors such as smoking, poor oral hygiene, and certain nutrient deficiencies (folate, vitamin B6, methyl donors) or excesses (vitamin A/ß-carotene), owing to poor diet or self-medication, may also increase the risk for alcohol-associated tumours[13].

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Estimates of cancer incidence attributable to alcohol use in Australia

Several estimates of the numbers of cases of cancer attributable to alcohol use in Australia have been calculated using different methods[4][15][16][17]. However, these calculations pre-date the confirmation of alcohol use as a convincing cause of bowel cancer in men. Because the incidence of bowel cancer in Australia is high[18], calculations which exclude bowel cancer are likely to lead to a substantial underestimate of the true burden of alcohol-caused cancer in Australia.

Cancer Council Australia estimates that anywhere between 2,182 and 6,620 new cases of cancer in Australia (or 1.9–5.8% of all cancers) in 2009 were attributable to long-term, chronic use of alcohol (see Table 1 below).

These estimates are based on the methodology published by Winstanley et al. in the Medical Journal of Autralia in 2011[9]. The latest (2007) World Cancer Research Fund (WCRF) and American Institute of Cancer (AICR) analyses[6][19], and more recent findings from the European (EPIC)[20] and UK (Parkin) studies[21] provide a range of the percentages of different cancers that are attributable to alcohol consumption. These percentages have been paired with Australian cancer incidence data[22].

Attributable fractions for Europe and the UK have been used here, on the assumption that Australian patterns of drinking more closely mirror those in Europe and the UK, than those in the USA, Brazil or China, the other countries for which the World Cancer Research Fund presented prevention estimate data.

Using this method, it is estimated that between 2,182 and 6,620 new cases of cancer are attributable to long-term, chronic use of alcohol each year in Australia. This figure includes cancers for which there is convincing evidence that alcohol use increases the risk of disease. When cancers for which the risk is probably increased by alcohol use are included, the tally rises to between 2,564 and 7,445 (or 2.2–6.5% of all cancers in Australia) (see Table 1).


Table 1. Estimated incidence of cancers caused by alcohol use in Australia

Type of cancer Population attributable fraction Total incidence (2009)[22] Incidence attributed to alcohol use
WCRF AICR[19] EPIC[20] Parkin[22]
Cancers linked to alcohol use by convincing evidence
Mouth, pharynx


41%

25–44% 16.9–37.3% 3,005 508–1,322
Larynx in men 44% 27.3% 537 147–236
Larynx in women 25% 12.2% 69 8–28
Oesophagus in men
51%
44% 25.3% 917 232–468
Oesophagus in women 25% 11.3% 397 45–202
Bowel in men 7% 17% 15.5% 7,982 559–1,357
Breast in women 22% 5% 6.4% 13,668 683–3,007
Subtotal 2,182–6,620
% of all cancers 1.9 – 5.8%
Cancers linked to alcohol use by probable evidence
Bowel in women 7% 4% 6.9% 6,428 257–450
Liver in men
17%*
33% 11.4% 936 107–309
Liver in women 18% 5.0% 368 18–66
Subtotal 382–825
Percentage of all cancers 0.3–0.7%
Total cancers linked to alcohol use by convincing and probable evidence
Total 2,564–7,445
Percentage of all cancers 2.2–6.5%


* WCRF reviewed the evidence in 2015 and upgraded alcohol use from probable to convincing evidence, however, has not yet release data on percentage of liver cancer linked to alcohol use[7]

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Burden of disease and injury

Australian data show that alcohol is an important contributor to the overall burden of disease and injury in Australia[23]. Burden of disease and injury is measured in disability-adjusted life years (DALYs), which calculate the amount of time lost due to both fatal and non-fatal events; that is, years of life lost due to premature death coupled with years of “healthy” life lost due to disability[4]. In 2003, alcohol was ranked sixth after tobacco, high blood pressure, high body mass, physical inactivity and high blood cholesterol as a cause of burden of disease and injury in Australia[4]. Alcohol was responsible for 3.1% of the burden of disease and injury due to cancer[4]. These data pre-date confirmation that bowel cancers are caused by alcohol use and are therefore likely to be an underestimate.

Because alcohol is frequently consumed in excess by young people, it is responsible for many lost years of life[24]. The financial cost of disease, injury and crime caused by alcohol in Australia has been estimated to be about $15.3 billion[15]. The proportion of these costs which can be attributed to alcohol-related cancer is not specified[15].

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Combined effects of drinking and smoking

For some cancers the combined effects of drinking alcohol and smoking tobacco greatly exceed the risk from either factor alone. Smoking and alcohol together have a synergistic effect on upper gastrointestinal and aero-digestive cancer risk[25]. Compared with non-smoking non-drinkers, the approximate relative risks for developing mouth and throat cancers are up to seven times greater for people who smoke tobacco, up to six times greater for those who drink alcohol, but more than 35 times greater for those who are regular, heavy users of both substances (consuming more than four alcoholic drinks and smoking forty or more cigarettes daily)[26]. The synergistic effect of alcohol and smoking has been estimated to be responsible for more than 75% of cancers of the upper aero-digestive tract in developed countries[26].

See the Tobacco control chapter of the National Cancer Prevention Policy for more information.

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Alcohol and weight gain

The relationship between alcohol consumption and body weight and fat is complex and appears to vary with sex and drinking pattern[27]. From a nutritional viewpoint, alcoholic drinks represent 'empty kilojoules‘ – that is, alcoholic drinks are high in kilojoules but low in nutritional value, especially when added to sugary mixer drinks. Alcohol itself has a comparatively high energy content (29 kilojoules per gram) compared with other macronutrients[28].

If people drink alcohol in addition to their normal dietary intake – that is, without a compensatory reduction in energy intake – they are liable to gain weight. Alcohol provides extra kilojoules and slows fat and carbohydrate oxidation. On the other hand, if drinking replaces healthy eating patterns, it can lead to nutritional deficiencies and serious illness[27][29].

Therefore as well as being a direct cause of several cancers, alcohol might also contribute indirectly to those cancers associated with excess body fatness. There is convincing evidence that body fatness increases the risk of cancers of the oesophagus, pancreas, bowel, breast (in post menopausal women), endometrium and kidney, and probable evidence that body fatness increases the risk of gallbladder cancer[6].

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Alcohol and heart disease

The potential benefit of light to moderate alcohol consumption on cardiovascular disease is the subject of ongoing scientific debate. A number of population studies, including a 2011 systematic review[30] have suggested light to moderate alcohol consumption may reduce the risk of cardiovascular disease. However, other reviews have suggested unmeasured confounding in epidemiological studies on alcohol and heart disease is widespread and that randomised controlled trials may be the only way to obtain more consistent evidence about the effects of moderate alcohol consumption on cardiovascular disease risk[31].

Conclusive evidence shows higher levels of alcohol consumption confer no cardiovascular health benefits[31]. The 2011 review that suggested moderate alcohol consumption may reduce cardiovascular disease risk also linked higher alcohol consumption levels with an increased risk of stroke[30]. Neither the World Health Organization nor the National Heart Foundation of Australia recommend consuming red wine or any other alcoholic beverage to prevent cardiovascular disease[31][32].

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Alcohol consumption in Australia

Australia's relatively high burden of alcohol-related cancer reflects high levels of alcohol consumption in Australia by world standards; Australia ranks within the top 30 highest alcohol consuming nations out of 180 countries on a per capita basis[33].

The 2011-2012 National Nutrition and Physical Activity Survey reported that alcohol was consumed by almost one in three people (32%) aged 19 years and over on the day before interview[34]. The most commonly consumed alcoholic drinks were wines (13%) and beers (11%), followed by spirits (2.1%)[34]. Among these people, alcoholic beverages contributed 16% of daily energy intake[34].

According to the National Drug Strategy Household Survey, the percentage of people reporting that they drink daily was 6.5% in 2013, declining from 7.2% in 2010[35]. Over the same period there was a significant increase in the proportion of people who had never consumed a full serve of alcohol (12.1% in 2010 to 13.8% in 2013)[35]. In 2013, daily drinking rates were at the lowest level seen since 1991[35].

In 2012-13, there was 9.9 L of pure alcohol available for consumption per person aged 15 and over[36]. This was 1.6% less than the amount in 2011-12 and 8.2% less than 2007-08[36]. However, increases in wine consumption, and mistaken assumptions about the alcohol content in wine, resulted in an underestimate of overall alcohol consumption levels between 1990-91 and 2008-09[37]. A revised analysis published in the Medical Journal of Australia in 2010 shows consumption levels since the early 1990s have increased significantly over that time[37].

In 2013, 18.2% of people aged 14 or older exceeded the lifetime risk guidelines, down from 20% in 2010[35]. Males were more than twice as likely as females to exceed the lifetime risk guidelines (26% compared with 10%)[35].

Data on personal alcohol consumption is likely to be understated, as it is based on self-report and falls significantly short of consumption data based on sales, taxation and customs statistics[38][39]. Alcohol policy should be informed by data on alcohol use and harms, including credible consumption estimates based on sales data and well-targeted surveys[37].

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Children and youth

Alcohol consumption among children and youth is significant in a cancer context because the more alcohol consumed over time the higher the risk of cancer[40]; moreover, young people who drink at high-risk levels are more likely to become long-term high-risk drinkers[41] and, therefore, at significantly higher risk of alcohol-related cancer.

Analyses of national survey data show that the proportion of 12-15 year-olds consuming alcohol at risky levels for short-term harm approximately doubled from 1990 (circa 2.5%) to 2005 (circa 5%) and rose from 15% to around 20% for 16-17 year-olds[42]. By 18 years of age, approximately 50% of both males and females consume alcohol at high-risk levels; of all age groups, Australians aged 18-24 report the highest prevalence of high-risk drinking[42].

However, the age at which 14–24 year olds first tried alcohol has increased from 14.4 since 1998 to 15.7 years in 2013[35]. Between 2010 and 2013, there was a significant increase in the proportion of people who had never consumed a full serve of alcohol (from 12.1% to 13.8%) and the proportion abstaining from alcohol increased significantly (from 64% to 72%[35].

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Indigenous Australians

Indigenous Australians are twice as likely as non-Indigenous Australians to drink at short-term risky or high-risk levels[43]; rates of alcohol-related deaths are two and a half times higher in the Indigenous population[44]. Although Aboriginal and Torres Strait Islander Australians are more likely to abstain from alcohol use than the non-Indigenous population, of those who do drink, a higher proportion drink at risky or high-risk levels[45]. In 2004-05, 29% of Indigenous Australians had not had a drink in the previous 12 months, about twice the prevalence of non-Indigenous Australians (15%)[45]. Among the populations who had consumed alcohol, however, 34% of Indigenous Australians had consumed at long-term risky or high-risk levels, compared with 22% of non-Indigenous Australians[45].

The effects of alcohol use are felt especially heavily in this population. In 2003, drinking caused 8% of all Indigenous deaths and was responsible for 6% of the total burden of disease and injury for Indigenous Australians[46], approximately double that for the total Australian population[4]. Liver cancer, and cancers of the lip, mouth and pharynx occur at more than twice the rate in Indigenous Australians compared with non-Indigenous Australians[47]. (This estimate is based on combined data from Cancer Registries in Western Australia, Northern Territory and South Australia, and together provide the most detailed picture of Indigenous age-specific cancer incidence rates currently available.)

The higher rates of liver cancer are likely to be attributable to elevated rates of infection with the hepatitis B virus and excessive alcohol consumption in some Indigenous males[47]. The likelihood of developing cancers of the lip, mouth and pharynx is elevated in people who use tobacco and who drink alcohol; and the risk is much higher in people who use both substances[47]. As well as risky drinking, smoking is more prevalent among Indigenous people than in the non-Indigenous population[45].

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Cancer Council Australia's recommendations on alcohol use

Alcoholic drinks and ethanol are carcinogenic to humans[5][6]. There is no evidence that there is a safe threshold of alcohol consumption for avoiding cancer, or that cancer risk varies between the type of alcoholic beverage consumed[6].

Cancer Council recommends that to reduce their risk of cancer, people limit their consumption of alcohol. For individuals who choose to drink alcohol, consumption should occur within in the Australian NHMRC guidelines[48]. Cancer Council Australia‘s key recommendations are summarised at the beginning of this statement and outlined in Appendix 1.

Cancer Council Australia is a strong advocate for evidence-based action to reshape social attitudes concerning drinking, and to reduce the burden of morbidity and mortality caused by alcohol use.

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Appendix 1. Key evidence-based points and recommendations

  • Alcohol use is a cause of cancer in humans (Group 1 carcinogen, highest level of evidence, classified by IARC)[4][5].
  • Ethanol, the chemical present in all alcohol beverages, is also a cause of cancer in humans (Group 1 carcinogen, classified by IARC)[5].
  • There is convincing evidence that alcohol use increases the risk of cancers of the mouth, pharynx, larynx, oesophagus, liver, bowel (in men) and breast. Convincing evidence, as classified by the WCRF and the AICR, is the strongest level of evidence and denotes a causal relationship[6][7].
  • Alcohol use probably increases the risk of bowel cancer (in women). A 'probable' relationship, as classified by the WCRF and the AICR, is the second highest level of evidence and denotes that the relationship is probably causal in nature[6].
  • Alcohol use may contribute to weight (fat) gain, and therefore contribute in an indirect way to those cancers which are associated with overweight and obesity.
  • Greater body fatness is a convincing cause of cancers of the oesophagus, pancreas, bowel, endometrium, kidney and breast (in postmenopausal women). This is WCRF and AICR‘s strongest level of evidence, denoting a causal relationship[6].
  • Cancer Council recommends that people limit their consumption of alcohol to reduce their cancer risk.
  • For people who choose to drink alcohol, Cancer Council Australia recommends individuals drink only within the NHMRC Australian guidelines to reduce health risks from drinking alcohol[48].
  • The NHMRC guidelines[48] are listed in abridged form in Appendix 2.
  • Cancer Council bases its recommendations about alcohol use on the weight of scientific evidence which has accumulated about the relationship between alcohol consumption and cancer.

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Appendix 2. NHMRC alcohol guidelines, abridged

The Australian standard drink contains 10 g of alcohol (equivalent to 12.5 mL of pure alcohol). In Australia a standard drink is 100 mL wine (13.5% alcohol), a 285 mL glass of beer (~5% alcohol) or a 30 mL nip of spirits.

Guideline 1: Reducing the risk of alcohol-related harm over a lifetime

The lifetime risk of harm from drinking alcohol increases with the amount consumed. For healthy men and women, drinking no more than two standard drinks on any day reduces the lifetime risk of harm from alcohol-related disease or injury.

Guideline 2: Reducing the risk of injury on a single occasion of drinking

On a single occasion of drinking, the risk of alcohol-related injury increases with the amount consumed. For healthy men and women, drinking no more than four standard drinks on a single occasion reduces the risk of alcohol-related injury arising from that occasion.

Guideline 3: Children and young people under 18 years of age

For children and young people under 18 years of age, not drinking alcohol is the safest option.

Guideline 4: Pregnancy and breastfeeding

Maternal alcohol consumption can harm the developing foetus or breast feeding baby.

A -For women who are pregnant or planning a pregnancy, not drinking is the safest option.

B -For women who are breast feeding, not drinking is the safest option.

The NHMRC states that, "the advice in the guidelines cannot be ascribed levels of evidence ratings as occurs with other NHMRC guidelines, due to the analytic approach taken in their development". Guidelines one and four however are underpinned by evidence equivalent to NHMRC level III-1.

The full text of the guidelines is available from the NHMRC website.

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Position statement details

This statement was developed by Cancer Council Australia‘s Alcohol Working Group with input from its Nutrition and Physical Activity Committee and reviewed by the organisation‘s principal Public Health Committee. It was approved for publication by Cancer Council Australia‘s Board June 2011.

The statement was updated and approved by the Public Health Committee in October 2012 and November 2014.

Cancer Council Australia wishes to acknowledge Associate Professor Tanya Chikritzhs, who assisted in drafting the section on alcohol and heart disease, and Professor Jeanette Ward and Professor Dallas English, who kindly reviewed an earlier draft of the position statement.

A previous version of this statement was been peer-reviewed by the Medical Journal of Australia and, following amendments to the content as part of that process, was published by the MJA in April 2011. It can be accessed on the MJA website.

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