Alcohol intake and cancer of the upper digestive tract

Ethanol versus Phytochemicals in Wine: Oral Cancer Risk in a Light Drinking Perspective

This narrative review aims to summarize the current controversy on the balance between ethanol and phytochemicals in wine, focusing on light drinking and oral cancer. Extensive literature search included PUBMED and EMBASE databases to identify in human studies and systematic reviews (up to March 2015), which contributed to elucidate this issue. Independently from the type of beverage, meta-analyses considering light drinking (≤1 drinks/day or ≤12.5 g/day of ethanol) reported relative risks (RR) for oral, oro-pharyngeal, or upper aero-digestive tract cancers, ranging from 1.0 to 1.3. One meta-analysis measured the overall wine-specific RR, which corresponded to 2.1. Although little evidence exists on light wine intake, phytochemicals seem not to affect oral cancer risk, being probably present below the effective dosages and/or due to their low bioavailability. As expected, the risk of oral cancer, even in light drinking conditions, increases when associated with smoking habit and high-risk genotypes of alcohol and aldehyde dehydrogenases.

Esophageal cancer risk by type of alcohol drinking and smoking: a case-control study in Spain

Background

The effect of tobacco smoking and alcohol drinking on esophageal cancer (EC) has never been explored in Spain where black tobacco and wine consumptions are quite prevalent. We estimated the independent effect of different alcoholic beverages and type of tobacco smoking on the risk of EC and its main histological cell type (squamous cell carcinoma) in a hospital-based case-control study in a Mediterranean area of Spain.

Methods

We only included incident cases with histologically confirmed EC (n = 202). Controls were frequency-matched to cases by age, sex and province (n = 455). Information on risk factors was elicited by trained interviewers using structured questionnaires. Multiple logistic regression was used to estimate adjusted odds ratios and 95% confidence intervals (CI).

Results

Alcohol drinking and tobacco smoking were strong and independent risk factors for esophageal cancer. Alcohol was a potent risk factor with a clear dose-response relationship, particularly for esophageal squamous-cell cancer. Compared to never-drinkers, the risk for heaviest drinkers (≥ 75 g/day of pure ethanol) was 7.65 (95%CI, 3.16–18.49); and compared with never-smokers, the risk for heaviest smokers (≥ 30 cigarettes/day) was 5.07 (95%CI, 2.06–12.47). A low consumption of only wine and/or beer (1–24 g/d) did not increase the risk whereas a strong positive trend was observed for all types of alcoholic beverages that included any combination of hard liquors with beer and/or wine (p-trend<0.00001). A significant increase in EC risk was only observed for black-tobacco smoking (2.5-fold increase), not for blond tobacco. The effects for alcohol drinking were much stronger when the analysis was limited to the esophageal squamous cell carcinoma (n = 160), whereas a lack of effect for adenocarcinoma was evidenced. Smoking cessation showed a beneficial effect within ten years whereas drinking cessation did not.

Conclusion

Our study shows that the risk of EC, and particularly the squamous cell type, is strongly associated with alcohol drinking. The consumption of any combination of hard liquors seems to be harmful whereas a low consumption of only wine may not. This may relates to the presence of certain antioxidant compounds found in wine but practically lacking in liquors. Tobacco smoking is also a clear risk factor, black more than blond.

Carcinogenetic impact of alcohol intake on squamous cell carcinoma risk of the oesophagus in relation to tobacco smoking

Consumption of alcohol and tobacco, separately or jointly, can increase the risk of oesophageal squamous cell carcinoma (OSCC). It is unclear whether the amount of alcohol consumption by individual drinkers affects the joint carcinogenetic action of both agents. To demonstrate how the intensity of alcohol intake determines the risk of OSCC in relation to tobacco smoking, we conducted a multicentre case-control study. A total of 652 patients with pathology-proven OSCC, as well as 1127 gender, age, and study hospital matched controls were recruited. To identify a possible curvature in the continuous relationship between exposure and risk, we applied the generalised additive models to the collected data. Both non-drinkers who smoked tobacco and non-smokers who drank heavy alcohol (>30 g/day) were observed to have elevated cancer risks. A smoking habit-specific, non-linear increase in oesophageal cancer risk was recognised. Tobacco was found to interact with light-to-moderate alcohol (0.1-30 g/day) to increase the risk of oesophageal cancer in a supra-multiplicative way (Odds ratio (OR) ratio=5.5-5.7, p<0.05), whereas with heavy alcohol consumption in a simple multiplicative model (OR ratio=1.7-2.3, p>0.05). Weekly intake frequency had the strongest influence on the risk of neoplasm development. Alcohol consumption was responsible, respectively, for 18% and 77% of nonsmoking and smoking OSCC cases in this population. In conclusion, both light-to-moderate and heavy alcohol intake interact separately with tobacco in differently synergistic processes that can determine the development of this type of cancer.

Prospective Study of Alcohol Consumption and Risk of Oral Premalignant Lesions in Men

Recent case-control studies indicate that alcohol increases the risk of oral premalignant lesions (OPL) among tobacco users, but the independent association between alcohol and OPL remains unclear. We prospectively evaluated the association between alcohol consumption and the incidence of OPL. Participants were 41,458 men in the Health Professionals Follow-up Study. Alcohol consumption was assessed every 4 years using validated food frequency questionnaires. We confirmed clinically or histopathologically diagnosed OPL events occurring between 1986 and 2002 by medical record review (193 cases). Multivariate-adjusted relative risks of OPL were calculated from Cox proportional hazards models. With detailed control for tobacco and other variables, multivariate relative risks (95% confidence intervals) were 1.7 (0.9-3.2) for drinkers of 0.1 to 14.9 g/d, 2.9 (1.5-5.6) for 15 to 29.9 g/d, and 2.5 (1.3-5.1) for > or =30 g/d, compared with nondrinkers. Approximately one additional drink per day (12.5 g) was associated with a 22% increase in risk (P < 0.001). The associations did not vary by beverage type, frequency, or consumption with meals. Results were similar when restricted to cases of oral epithelial dysplasia. Alcohol increased OPL risk in never-users of tobacco as well as in past or current users. An interaction between alcohol and tobacco was apparent by their more-than-additive joint effects. Alcohol is an independent risk factor for OPL, regardless of beverage type or drinking pattern. Recommendations to reduce alcohol intake have the potential to reduce incidence of OPL in nonsmokers and smokers alike.

Type of alcoholic beverage and the risk of laryngeal cancer

A few studies have investigated whether the risk of laryngeal cancer depends on the types of alcoholic beverage consumed, providing conflicting results. We investigated this issue using the data from two case-control studies conducted in Italy between 1986 and 2000. These included 672 cases of laryngeal cancer and 3454 hospital controls, admitted for acute, non-neoplastic conditions, unrelated to smoking and alcohol consumption. Significant trends in risk were found for total alcohol intake, with multivariate odds ratios (ORs) of 1.12 for drinkers of 3-4 drinks/day, 2.43 for 5-7, 3.65 for 8-11, and 4.83 for > 12 drinks/day, as compared to abstainers or light drinkers. Corresponding ORs for wine drinkers were 1.12, 2.45, 3.29 and 5.91. After allowance was made for wine intake, the ORs for beer drinkers were 1.65 for 1-2 drinks/day, and 1.36 for > or = 3 drinks/day, as compared to non-beer drinkers; corresponding values for spirits drinkers were 0.88 and 1.15. This study thus indicates that in the Italian population characterized by frequent wine consumption, wine is the beverage most strongly related to the risk of laryngeal cancer.

Wine, beer and spirits and risk of oral and pharyngeal cancer: a case-control study from Italy and Switzerland

We examined the relation between consumption of different types of alcoholic beverages and the risk of oral and pharyngeal cancer, using data from a case-control study conducted in Italy and Switzerland between 1992 and 1997. This included a total of 749 cases of oral and pharyngeal cancer and 1,772 hospital controls, admitted for acute, non-neoplastic conditions, unrelated to alcohol and smoking consumption. Significant trends in risk were found with increasing total alcohol intake, with multivariate odds ratios (OR) of 2.1 for drinkers of 3-4 drinks/day, as compared to abstainers or light drinkers (< or = 2 drinks/day), 5.0 for 5-7, 12.2 for 8-11 and 21.1 for > or = 12 drinks/day. Similar increased risks for subsequent levels of consumption were found for wine drinkers. After allowance for wine intake, the ORs for beer drinkers were 1.2 for 1-2 drinks/day, and 2.3 for > or = 3 drinks/day. Corresponding values for spirit drinkers were 1.0 and 1.9. Patterns of risk for wine drinkers were similar for wine only drinkers and drinkers of wine, plus beer and spirits. Our study indicates that in populations with frequent wine consumption, wine per se can strongly increase the risk of cancer of the oral cavity and pharynx, and confirms that the most prevalent alcoholic beverage in each population tends to be the one with the highest risk.

Trends in oral cancer mortality in Europe

Mortality from oral cancer has been rising appreciably in most European countries up to the late 1980s, essentially for men. To update trends in oral cancer, death certification data from oral and pharyngeal cancer for 27 European countries were abstracted and analysed from the WHO mortality database over the period 1980-99. Oral cancer mortality in men has started to decline since the late 1980s in most western countries, although some persisting upward trends were registered for Belgium, Denmark, Greece, Portugal, or Scotland. Persisting rises were observed for most central and eastern Europe up to the mid 1990s, reaching exceedingly high rates in Hungary (20.2/100000 at all ages, 51.4 at age 35-64), Slovakia, Slovenia, and the Russian Federation. Some levelling of rates in some countries, such as Poland or the Czech Republic, was observed over more recent calendar years. Oral cancer was low, but moderately upwards in European women, mainly from central and eastern Europe. These trends should be essentially interpreted in terms of patterns and changes in exposure to alcohol and tobacco, and call for urgent control of these factors, as well as for improved diagnosis and management of oral cancer in central and eastern Europe.

Cancer mortality in Europe, 1995-1999, and an overview of trends since 1960

Mortality data, abstracted from the World Health Organization database, are presented in tabular form for 26 cancer sites or groups of sites, plus total cancer mortality, in 36 European countries during the period 1995-1999. Trends in mortality are also given in graphic form for 23 major countries plus the European Union as a whole over the period 1960-1999. In the European Union, total cancer mortality declined by 7% for both sexes over the last 5 years considered. The fall since the late 1980s was 10% in both sexes, corresponding to the avoidance of over 90000 deaths per year, as compared to the rates of the late 1980s. For the first time, over the last few years, some leveling of mortality was reported also in the Russian Federation, the Czech Republic, Poland, Hungary and other Eastern European countries, although cancer rates in those areas remain exceedingly high. The overall favorable pattern of cancer mortality over recent years is largely driven by the decline of tobacco-related cancer mortality in men. However, important components of the trends are also the persistence of substantial falls in gastric cancer, mainly in Russia and Eastern Europe, the recent decline in intestinal cancer in both sexes and of breast cancer in women, together with the long-term falls in uterine (cervical) cancer, leukemias, Hodgkin's disease and other neoplasms amenable to advancements in diagnosis and treatment. Female lung cancer mortality has been declining in the Russian Federation, but is still rising in other areas of the continent. Thus, urgent intervention is needed to bring under control the tobacco-related lung cancer epidemic in European women before it reaches the high level observed in North America. Supplementary material for this article can be found on the International Journal of Cancer website at http://www.interscience.wiley.com/jpages/0020-7136/suppmat/index.html

The role of type of tobacco and type of alcoholic beverage in oral carcinogenesis

Incidence rates of oral and oropharyngeal cancers (oral cancer) in Spain are among the highest in Europe. Spain has a population heavily exposed to various types of tobacco and alcoholic beverages but the role and impact of tobacco type and beverage type in oral carcinogenesis remain controversial. To estimate the independent and joint effects of tobacco smoking and alcohol drinking habits on the risk of developing oral cancer, we carried out a multicenter, hospital-based, case-control study in Spain. Data from 375 patients newly diagnosed with cancer of the oral cavity or oropharynx and 375 matched control subjects were analyzed using multivariate logistic regression procedures. All exposure characteristics of amount, duration and cessation of both tobacco smoking and alcohol drinking were strongly associated with cancer risk following a dose-dependent relationship. At equal intake or duration levels, black-tobacco smoking and drinking of spirits were both associated with a 2- to 4-fold increase in cancer risk compared to blond tobacco smoking or drinking of wine or beer, respectively. While ever exposure to smoking only or drinking only was associated with a moderate and nonsignificant increase in cancer risk, a history of simultaneous exposure to both habits was associated with a 13-fold increase that was compatible with a synergistic effect model (p-value for interaction: 0.008). Exposure to black tobacco smoking and/or drinking of spirits may account for up to 77% of oral cancer occurrence in Spain. Both black tobacco smoking and drinking of spirits place individuals at a very high risk of developing oral cancer. Simultaneous exposure to tobacco and alcohol consumption increases oral cancer risk in a synergistic fashion, even when consumption levels are moderate. These results underline the importance of type of tobacco and alcohol concentration in oral carcinogenesis.

Factors influencing the relation between alcohol and mortality--with focus on wine

The impact of alcohol intake on mortality has been described in a large number of prospective population studies from many countries. Most have shown a J-shaped relation between alcohol intake and subsequent mortality, indicating that there are both beneficial and harmful effects of ethanol on health. In exploring the French paradox, it has been suggested that wine may have beneficial effects additional to that of ethanol. Recently, several prospective population studies have supported this idea. However, it is also likely that the apparent additional beneficial effect of wine on health is confounding.

Risk factors for cancer of the oral cavity and oro-pharynx in Cuba

In terms of worldwide levels, Cuba has an intermediate incidence of cancer of the oral cavity and oro-pharynx. We studied 200 cases of cancer of the oral cavity and pharynx, of whom 57 women (median age = 64) and 200 hospital controls, frequency matched with cases by age and sex, in relation to smoking and drinking history, intake of 25 foods or food groups, indicators of oral hygiene and sexual activity, and history of sexually transmitted diseases. Odds ratios (OR) and 95% confidence intervals (CI) were obtained from unconditional multiple logistic regressions and adjusted for age, sex, area of residence, education, and smoking and drinking habits. In the multivariate model, high educational level and white-collar occupation, but not white race, were associated with halving of oral cancer risk. Smoking > or =30 cigarettes per day showed an OR of 20.8 (95% CI: 8.9-48.3), similar to smoking > or =4 cigars daily (OR = 20.5). Drinking > or = 70 alcoholic drinks per week showed an OR of 5.7 (95% CI: 1.8-18.5). Hard liquors were by far the largest source of alcohol. Increased risk was associated with the highest tertile of intake for maize (OR = 1.9), meat (OR = 2.2) and ham and salami (OR = 2.0), whereas high fruit intake was associated with significantly decreased risk (OR = 0.4). Among indicators of dental care, number of missing teeth and poor general oral condition at oral inspection showed ORs of 2.7 and 2.6, respectively. Number of sexual partners, marriages or contacts with prostitutes, practice of oral sex and history of various sexually transmitted diseases, including genital warts, were not associated with oral cancer risk. 82% of oral cancer cases in Cuba were attributable to tobacco smoking, 19% to smoking cigars or pipe only. The fractions attributable to alcohol drinking (7%) and low fruit intake (11%) were more modest. Thus, decreases in cigarette and cigar smoking are at present the key to oral cancer prevention in Cuba.

Smoking, type of alcoholic beverage and squamous-cell oesophageal cancer in northern Italy

Between 1992 and 1997, we conducted a case-control study of oesophageal cancer in 3 areas of northern Italy. Cases were 275 men, ages 39-77 years (median age 60), with a first incident squamous-cell carcinoma of the oesophagus. Controls were 593 men, ages 36-77 years (median age 60) admitted for acute illnesses, unrelated to tobacco and alcohol, to major hospitals of the areas under surveillance. Number of daily cigarettes was strongly associated with risk [odds ratio (OR) for > or =25 cigarettes/day = 7.0)]. Long-duration smoking showed particularly elevated ORs (OR = 6.4 for > or =35 years), and excess risk declined after smoking cessation (OR = 1.5 after > or = 10 years). Oesophageal cancer risk steeply rose with increasing level of alcohol consumption. ORs were 6.2 for 35-55 drinks and 24.5 for 84 drinks or more per week. No trend in risk emerged for duration of alcohol drinking or age at start of drinking. The risk in the highest joint level of alcohol drinking and current smoking was increased 130 folds (i.e., compatible with a multiplicative model). Excess risk in drinkers chiefly derived from wine. In conclusion, alcohol drinking and cigarette smoking were both important, but the roles of dose and duration of exposure differed. The association with alcohol was stronger than the one with smoking by exposure intensity, but apparently unaffected by duration or other temporal variables.