Reference: JAMA Netw Open. 2023 Aug 1;6(8):e2328328
Practice Point: Screening for alcohol consumption among cancer survivors has the potential to impact health outcomes.
EBM Pearl: Using a screening tool with diagnostic intent is misuse of the tool and will result in overdiagnosis.
Excessive alcohol consumption is a well-known risk factor for many types of cancer. It may be less well known, however, that alcohol has been linked to adverse health outcomes in patients with a diagnosis of cancer, including risk of recurrence, new primary cancers, and even death. There is good reason to identify modifiable risk factors, and so it makes sense to explore the prevalence and patterns of alcohol consumption in cancer patients as a first step.
A cross-sectional study recently published in JAMA examined alcohol consumption and drinking patterns among US adults diagnosed with cancer at least a year prior, termed “survivors” by these authors. Investigators evaluated EHR data from 15,297 individuals, 1,839 of whom had received treatment within the previous year. Participants were categorized as never, former, or current drinkers and their drinking patterns assessed. “Hazardous drinking” was defined by an AUDIT-C score of ≥ 3 for female patients and ≥ 4 for male patients. Among the 77.7% of participants who self-identified as current drinkers, 13.0% reported “exceeding moderate drinking” (consuming > 2 drinks/day on a typical drinking day), 23.8% reported “binge drinking” (consuming ≥ 6 drinks on ≥ 1 occasion within the prior year), and 38.3% met the hazardous level AUDIT-C criteria. The investigators went on to further break down demographic information based on the various drinking patterns. Health outcomes were not assessed.
These data suggest that at least a third of patients (in the US) who have a cancer diagnosis and have survived at least a year are engaging in “hazardous” drinking. Let’s give that some context: drinking 4 or more drinks/week gives an AUDIT-C score of 4 all by itself, so anyone who drinks one glass of wine with dinner 4 days a week is considered to be engaging in hazardous drinking according to this study. By way of comparison, a recent systematic review found rates of problematic drinking among physicians to be 26.8%, which is not so different from the cohort of cancer survivors studied. But if the point is to identify modifiable risk factors, (so that we can give patients the opportunity to potentially modify their health outcomes), we have a few problems with this study as a first step in that process.
First, the way “hazardous drinking” was assigned in this study, those individuals drinking a glass of wine with dinner, (which may actually be classified in other studies as beneficial), are lumped with those with very heavy drinking. Certainly those are different types of drinking behaviors with different health outcomes. We actually view this as a misuse of the AUDIT-C tool, which is meant to be used to screen for alcohol use problems, not to diagnose them. The “lumping” done in this study reflects more of a diagnostic intent with the AUDIT-C screening tool, and if extrapolated, would likely lead to many false positives. Second, data on health outcomes were not evaluated, so even from an association standpoint, we don’t know if the hazardous drinkers had worse health outcomes. And obviously we don’t have data to suggest whether alcohol is the cause of a patient's cancer or adverse health outcome, whether they drink to cope with their cancer diagnosis, or whether the two things are unrelated. Lastly, the cross-sectional study design only gives us information about a single point in time, limiting any understanding about how alcohol consumption patterns over time might impact health outcomes. The bottom line is that while we agree screening for excessive alcohol use or hazardous drinking behavior is likely worthwhile and a good jumping off point for further discussions, this study doesn’t move the needle very far in terms of identifying modifiable risk factors that would improve cancer survivorship and quality of life.
For more information, see the topic Risks and Benefits of Alcohol Consumption in DynaMed.
DynaMed EBM Focus Editorial Team
This EBM Focus was written by Elham Razmpoosh, PhD, Postdoctoral fellow at McMaster University. Edited by Alan Ehrlich, MD, Executive Editor at DynaMed and Associate Professor in Family Medicine at the University of Massachusetts Medical School; Katharine DeGeorge, MD, MS, Senior Deputy Editor at DynaMed and Associate Professor of Family Medicine at the University of Virginia; Dan Randall, MD, Deputy Editor at DynaMed; Nicole Jensen, MD, Family Physician at WholeHealth Medical; Vincent Lemaitre, PhD, Medical Editor at DynaMed; and Sarah Hill, MSc, Senior Associate Editor at DynaMed.