This article is written in response to a recent report on Alcohol and Cancer published by the American Society of Clinical Oncology and asks whether we, as physicians, have difficulty talking honestly about alcohol with our patients, because of our own attitudes towards it.
It is not unimaginable that bottles of Château Mouton Rothschild, which once bore the artwork of Salvador Dali and Pablo Picasso, might one day be required to have plain packaging and images of oesophageal cancer or a cirrhotic liver. (1)
So concludes a lead article in a recent edition of the Lancet, reporting on a newly published statement on alcohol and cancer from the American Society of Clinical Oncologists or ASCO. (2)
Alcohol and cancer
In 2012, it was estimated that 5.5% of all new cancers and 5.8% of cancer deaths worldwide were attributable to alcohol (3) and yet the contribution of alcohol to cancer has been generally underestimated by the medical world.
The ASCO publication reviews and summarises current research, and makes recommendations for prevention. Alcohol is causally associated with oropharyngeal and larynx cancer, oesophageal cancer, hepatocellular carcinoma, breast cancer, and colon cancer. Even modest use of alcohol may increase cancer risk, but the greatest risks are observed with heavy, long-term use. The associations between alcohol drinking and cancer risk have been observed consistently regardless of the specific type of alcoholic beverage. The strongest associations were observed for upper aero-digestive tract cancers (i.e. larynx, oesophagus, and oral cavity/pharynx), which involve tissues that come into direct contact with ingested alcohol. As well as being a causative agent, alcohol may affect response to treatment and rates of recurrence. (2)
World Cancer Research Fund/AICR made the following recommendation: “If alcoholic drinks are consumed, limit consumption to two drinks a day for men and one drink a day for women.” They also recommend that, “for cancer prevention, it’s best not to drink alcohol.” (4)
Risks of harmful use of alcohol
Approximately 3.3 million deaths worldwide result from the harmful use of alcohol each year. (5)
In the UK in 1999, liver disease surpassed lung cancer and breast cancer as the leading cause of years of working life lost and it is estimated that in 2-3 years, liver disease will overtake ischaemic heart disease in this regard. (6) While the epidemiological factors implicated in severe liver disease are multifactorial, including hepatitis, alcohol remains the major modifiable risk factor.
The Australian Institute of Health and Welfare reported that in 2011, alcohol was responsible for:
- 28% of the burden due to road traffic injuries
- 24% of the burden due to chronic liver disease
- 23% of the burden due to suicide and self-inflicted injuries
- 19% of the burden due to stroke. (7)
In 2013, 26% of people a consumed five or more standard drinks on a single drinking occasion at least once a month, and 47% of pregnant women reported consuming alcohol during their pregnancy. Over the previous 12 months, 21% of recent drinkers reported they had put themselves or others at risk of harm while under the influence of alcohol – driving a vehicle, or verbally or physically abusing someone or undertaking some other risky activity.
Not only are those choosing to drink in excess at risk, but in our society, all the people around them are at risk. In 2013, 26% of Australians had been a victim of an alcohol related incident, most commonly verbal abuse. (7)
As the Lancet says: “alcohol is an undeniable menace to health” and goes on to say: “moves towards safer drinking need to be led by health professionals.” Routine surveillance, health education, and cancer prevention provide contexts for doing so within any consultation.” (1)
Doctors and Alcohol
As a young doctor, I attended a teaching session on the then, ground-breaking surgery for micro-penis. A middle aged female paediatrician stood up and asked why there was all this bother when really sex was overrated. Of course, there were guffaws of laughter. Writing about doctors and alcohol makes me feel like that middle-aged paediatrician.
I learned to drink at medical school, having been a quiet teenager. We used alcohol to socialise, to blot out the unpleasantness of dissecting cadavers in the anatomy lab, to overcome shyness and inhibitions and to have what we thought was a lot of fun. As a young doctor, I enjoyed a drink or two, but gave it up a long time ago. In our hospitals then our doctors’ lounge always had a bar for the use of doctors on duty. It was a part of our medical culture. How many of us were delighted to have the “scientific evidence” that alcohol in moderation is cardio-protective, but are less willing to look at its inherent harm?
The ASCO report suggests that lack of clinician knowledge about the risks of alcohol, particularly as a carcinogen, prevents physicians delivering effective preventative care and that in fact many doctors do not routinely ask about alcohol use at all. (2) It is easy to say “don’t smoke” when you do not smoke yourself, to discuss the dangers of obesity when you are a super-fit cyclist, but how do we feel when we talk about alcohol?
A GP friend of mine who has been diagnosed with both diabetes and hypertension explained how both of his specialists had recommended he has no more than 2 standard glasses of red a night, and went on to joke how he now dutifully drank 2 for the cardiologist and 2 for the endocrinologist!
Is it possible that as a profession we have been unwilling to honestly look at the effects of alcohol on health? Could this be because as a profession it has been our own “drug of choice”?
The Australian Beyond Blue study (8) reported on the mental health of doctors. Self-reporting (always at risk of under-reporting) showed that younger doctors had the highest levels of moderate or high-risk alcohol use. Across all ages males had significantly higher levels of moderate or high-risk use compared to females (18.1%, and 10.9%, respectively).
The ASCO report suggest that just as overweight or obese physicians are less likely to counsel their patients about obesity, alcohol use among physicians may make them less likely to counsel patients about the risks of alcohol use. (2)
In Australia, our society was weaned on alcohol. In the early days of colonisation rum was used as currency – people were paid for their labour with alcohol. In a somewhat deluded attempt to curb drunkenness, breweries were built to introduce beer and later vineyards planted in the sole attempt to curb the drinking of spirits.
Alcohol is an integral part of our social gatherings and celebrations; any change will be a slow change but our relative success with reducing smoking suggests it is not impossible. Alcohol is widely used and accepted in moderation, but we see the results of over-use of alcohol not only in disease but in the carnage of traffic accidents, domestic violence and assaults. Those working in emergency settings are all too familiar with this and are often themselves put at risk.
Both the ASCO report and the Lancet editorial ask that as clinicians, we start to talk with our patients about the broader risks of alcohol use. Perhaps if we were to gently explore why we may have difficulty talking about alcohol and our own relationship with it and if, at the very least, we address harmful and hazardous drinking, in ourselves and in our patients, we could start to turn the tide. References:
1. Alcohol and cancer. The Lancet Volume 390, No. 10109, p2215, 18 November 2017
- LoConte N, Brewster A et al. Alcohol and Cancer: A Statement of the American Society of Clinical Oncology
- Praud D, Rota M, Rehm J, et al: Cancer incidence and mortality attributable to alcohol consumption. Int J Cancer 138:1380-1387, 2016
- World Cancer Research Fund International: Alcoholic drinks
- World Health Organization: Alcohol Fact Sheet.
- The 21st Century Mortality Files—deaths dataset, England and Wales.
7. Alcohol – Australian Institute of Health and Welfare
8. Beyond Blue