Alcohol and Alcoholism Advance Access originally published online on November 24, 2005
Alcohol and Alcoholism 2006 41(2):140-142; doi:10.1093/alcalc/agh245
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
CLINICAL IMPLICATIONS OF CONTINUED ALCOHOL CONSUMPTION AFTER DIAGNOSIS OF UPPER AERODIGESTIVE TRACT CANCER
Center for Drug and Alcohol Programs, Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC 29425, USA, 1 Department of Otolaryngology—Head and Neck Surgery, Medical University of South Carolina, Charleston, SC 29425, USA and 2 Department of Stomatology, College of Dental Medicine, Medical University of South Carolina, Charleston, SC 29425, USA
* Author to whom correspondence should be addressed at: Center for Drug and Alcohol Programs, Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, 67 President Street, P.O. Box 250861, Charleston, SC 29425, USA. Tel.: +1 843 792 5547; Fax: +1 843 792 7353; E-mail: millerpm{at}musc.edu
(Received 20 June 2005; first review notified 30 August 2005; in final revised form 20 October 2005; accepted 31 October 2005)
 |
ABSTRACT |
|---|
 TOP ABSTRACT INTRODUCTIONCONTINUED ALCOHOL USE AFTER...CLINICAL IMPLICATIONSREFERENCES |
|---|
Aims: To examine clinical implications of findings on the relationship between continued alcohol consumption in patients after diagnosis and treatment of upper aerodigestive tract cancer. Methods: Clinical research literature on the prevalence and effects of alcohol consumption after oral cancer diagnosis was reviewed. Since limited research is currently available on this important clinical topic, all published studies were considered regardless of size and methodology. Results: Between 34 and 57% of oral cancer patients continue to drink alcohol after cancer diagnosis. Continued drinking increases complications from surgery, increases the likelihood of recurrent cancer, and reduces disease-specific survival. Older patients and those with a longer and heavier drinking pattern prior to diagnosis are more likely to continue drinking after diagnosis. Conclusions: Findings indicate that routine alcohol screening of newly diagnosed oral cancer patients as well as brief intervention and/or treatment referral is warranted. Monitoring of alcohol consumption for the first year after diagnosis and treatment is recommended.
|
INTRODUCTION |
|---|
|
TOPABSTRACTINTRODUCTIONCONTINUED ALCOHOL USE AFTER...CLINICAL IMPLICATIONSREFERENCES |
|---|
While the frequency of cancer of the upper aerodigestive tract (UADT) varies among different countries, it is a worldwide medical problem affecting nearly 400 000 individuals yearly. Approximately 30 000 Americans are diagnosed with UADT cancer annually, with 8000 dying from the disease each year (Silverman, 2001
). In Italy, this cancer represents 
4% of all malignancies in men and 1% in women (Nocotera et al., 2004). Almost half of UADT cancer patients will not survive 5 years (Ries et al., 2001) and, in Europe and the United Kingdom, both incidence and mortality have risen over the last 30 years (Binnie 1991; LaVecchia et al., 1992).
It has been estimated that 75% of UADT cancer is associated with heavy alcohol consumption, smoking, and, in many cases, a combination of the two (Blot et al., 1988). There is strong and consistent epidemiological evidence that alcohol consumption increases the risk of cancer of the oral cavity and pharynx (Elwood et al., 1984; Brugere et al., 1986; Franceschi et al., 1990; Doll et al., 1995). While the combined use of alcohol and tobacco dramatically increases risk, the major risk factor for never-smokers is alcohol consumption, with an odds ratio (OR) 3-fold higher in drinkers than non-drinkers (Bagnardi et al., 2001).
In a meta-analysis of >200 studies investigating the effects of alcohol on the risk of developing cancer, Bagnardi et al. (2001) concluded that alcohol consumption of 50 g (i.e. four standard drinks) or more per day significantly increased the risk of developing UADT cancer. However, significant increases in risk existed even at 25 g (or two standard drinks) per day. Research has yet to identify a threshold level of alcohol consumption below which no increased risk is evident.
The most recent national report on oral health by The National Institute of Dental and Craniofacial Research, ‘Oral Health US, 2002’ (Dental, Oral and Craniofacial Data Resource Center, 2002), indicated that there has been little improvement in the survival rates for patients with UADT cancer in the past 30 years. While survival is highly correlated with stage of cancer at diagnosis, size and location of tumour, and patient age, evidence suggests that heavy alcohol consumption (as well as continued smoking) may also be implicated (Allison, 2001). Since heavy alcohol use is a major risk factor for UADT cancer, tertiary prevention targeting drinking behaviour may help to prevent recurrent cancers and prolong survival in these patients.
|
CONTINUED ALCOHOL USE AFTER CANCER DIAGNOSIS |
|---|
|
TOPABSTRACTINTRODUCTIONCONTINUED ALCOHOL USE AFTER...CLINICAL IMPLICATIONSREFERENCES |
|---|
Although research on drinking patterns of patients diagnosed with UADT cancer is somewhat limited, available studies indicate that
34–57% of patients continue to consume alcohol following cancer diagnosis (Vander Ark et al., 1997; Christensen et al., 1999; Do et al., 2003). These percentages may well be an underestimation since data are based solely on self-reports, with no corroboration by collaterals or the use of alcohol biomarkers for verification. Indeed, with smoking patterns, Hald et al. (2003) found that up to 50% of self-reported non-smoking UADT cancer patients were, in fact, actively smoking as evidenced by serum cotinine and end-expired carbon monoxide measures. Thus, the precise prevalence of continued alcohol use by UADT cancer patients has not been well documented. Previous studies have used simple quantity/frequency questions rather than validated and more detailed screening questionnaires [e.g. alcohol use disorders identification test (AUDIT), CAGE, Fagerstrom tolerance scale] and timeline follow-back (TLFB) procedures. Studies using a combination of screening instruments with these patients are rare.
In this regard, Martin et al. (2002) found that by adding the CAGE questionnaire to the normal clinical routine of asking simple quantity/frequency questions, detection of chronic alcoholics among UADT cancer patients was increased from 16 to 64%. The further addition of gamma-glutamyltransferase (GGT) or carbohydrate-deficient transferrin (CDT) biomarkers led to an 80–85% detection rate, respectively. Use of all tests in combination improved detection rates to 91%.
Effects of continued drinking after diagnosis
Heavy drinking appears to have a detrimental effect on cancer treatment outcome. During and after surgery and/or radiation treatment, continued heavy drinking has been found to be associated with treatment complications, cancer recurrence, and a markedly lower survival rate (Falk et al., 1989; Deleyiannis et al., 1996). Alcoholism prior to the initial cancer diagnosis is associated with increased risk of death within 5 years after diagnosis (Deleyiannis et al., 1996).
UADT cancer patients who are alcohol abusers or alcohol dependent have a 2- to 4-fold increased risk of developing complications during and after cancer surgery (Spies and Rommelspacher 1999). Spies et al. (1996) showed that, after oropharyngeal tumour resection, intensive care stays were significantly prolonged in alcoholics owing to an increased incidence of sepsis and pneumonia. Post-operative mortality in these patients was increased 3-fold (Tonnesen et al., 1992).
Recurrence of UADT cancer after treatment via second primary tumours (SPTs) is related to the duration and severity of the patient's drinking history prior to diagnosis (Wynder et al., 1977; Day et al., 1994). In addition, Do et al. (2003) found that the risk of SPTs was 50% higher in patients who continued to drink >14 drinks per week after treatment, even after adjusting for smoking status. After adjusting for age at diagnosis and stage and site of cancer, alcohol intake emerged as an independent predictor of SPTs. In a recent multicenter European investigation of 876 male patients with laryngeal and hypopharyngeal carcinoma, continued consumption of alcohol was associated with more than a 3-fold increase in risk of development of SPT (Dikshit et al., 2005).
Factors associated with continued drinking after diagnosis
Little is known about the pattern and course of alcohol consumption during and after treatment for UADT cancer. What little evidence is available suggests that male gender, older age, less severe disease, less education, and heavier and longer drinking histories are factors associated with continued drinking (Gritz et al., 1999; Allison, 2001). While Christensen et al. (1999) found that patients who believed (i) that something other than smoking caused their cancer, and (ii) that they had little control over their future cancer-related health were more likely to continue smoking; these beliefs were unrelated to continued drinking.
In studying 191 UADT cancer patients whose median time since cancer treatment was 14 months, Allison (2001) found that frequency of drinking increased significantly with time since surgery. Some evidence suggests that alcohol use may initially decline from diagnosis to 1 month after diagnosis, and then increase significantly after that time (Gritz et al., 1999). Initial reduction in drinking after diagnosis may be related to the patient's perceived health risk, although this perception may dissipate gradually over time.
Other than these two studies, little is known about specific changes in alcohol consumption over time, from initial diagnosis, through treatment, to short- and long-term follow-up. Indeed, there may be critical time frames when clients are either more responsive to intervention or, however, more vulnerable to relapse.
Even less research is available on the interdependence of alcohol and tobacco use in UADT cancer patients. Preliminary evidence suggests that the patterns of these behaviours after diagnosis may be quite different. Significantly, Allison (2001) found trends for increasing odds for alcohol drinking with increased time since treatment and decreasing odds for smoking with increased disease state. Further research along these lines may suggest that post-cancer interventions aimed at smoking and alcohol use require a significantly different emphasis as well as different strategies.
Along these lines, many other questions about the drinking/smoking connection with these patients remain to be answered. For example, does continued alcohol use make it more difficult for patients to quit smoking or vice versa? Although not specifically involving cancer patients, studies from the smoking literature suggest that abstinence from alcohol facilitates smoking cessation (Sobell et al., 1996; McClure et al., 2002). Indeed, heavy drinkers are more likely to continue smoking after cancer diagnosis than light or moderate drinkers (Vander Ark et al., 1997).
|
CLINICAL IMPLICATIONS |
|---|
|
TOPABSTRACTINTRODUCTIONCONTINUED ALCOHOL USE AFTER...CLINICAL IMPLICATIONSREFERENCES |
|---|
Strong evidence suggests that continued alcohol use can increase UADT cancer treatment complications, increase chances of second primary tumours, and increase mortality. In spite of this evidence, little research on factors associated with continued alcohol consumption has been reported. Much information is lacking. For example, are binge drinkers or daily drinkers at greater risk or does type of alcoholic beverage consumed matter in continued drinking after diagnosis? What factors contribute to the initial decrease in drinking immediately after initial cancer diagnosis, with the likelihood of heavier drinking increasing over time? What is the pattern and relationship between continued alcohol consumption and smoking after diagnosis? What are the specific characteristics of those who continue drinking after diagnosis?
Routine alcohol screening at the time of diagnosis as well as periodic monitoring of alcohol consumption patterns after diagnosis and treatment are indicated. Since many patients quit drinking immediately after diagnosis only to resume former drinking patterns after a few weeks, monitoring of drinking habits at each post-treatment follow-up visit for at least 6 months to a year is warranted. The use of alcohol biomarkers such as GGT and CDT in addition to self-report screening questionnaires (e.g. AUDIT) has been shown to provide more accurate detection of alcohol use patterns and alcohol use disorders in these patients.
Following positive screens, education and brief intervention is recommended. This is particularly important since newly diagnosed UADT cancer patients have little knowledge of the relationship between alcohol use and their disease (Irish et al., 1996). In addition, since the prevalence of alcohol dependence in patients with UADT cancer can exceed 50% (Seitz and Simanowski 1986), referral to an alcohol treatment specialist would be indicated for many patients. This is particularly important since those with a longer and more severe history of alcohol use disorders are the ones most likely to continue drinking after diagnosis and treatment (Gritz et al., 1999).
It is readily apparent that more extensive research on patterns of continued alcohol consumption in UADT cancer patients is warranted. Findings could lead to a better understanding of this phenomenon, which, in turn, could result in the development of effective screening and intervention strategies.
|
REFERENCES |
|---|
|
TOPABSTRACTINTRODUCTIONCONTINUED ALCOHOL USE AFTER...CLINICAL IMPLICATIONSREFERENCES |
|---|
Allison, P. J. (2001) Factors associated with smoking and alcohol consumption following treatment for head and neck cancer. Oral Oncology 37, 513–520.[CrossRef][ISI][Medline]
Bagnardi, V., Blangiardo, M., La Vecchia, C. et al. (2001) Alcohol consumption and the risk of cancer. Alcohol Research and Health 25, 263–270.[ISI][Medline]
Binnie, W. H. (1991) Risk factors and risk markers for oral cancer in low incidence areas of the world. In: Oral Cancer: Detection of Patients and Lesions at Risk. Johnson NW ed., pp 64–87. Cambridge University Press, Cambridge.
Blot, W. J., McLaughlin, J. K., Winn, D. M. et al. (1988) Smoking and drinking in relation to oral and pharyngeal cancer. Cancer Research 48, 3282–3287.
Brugere, J., Guenel, P., LeClerc, A. et al. (1986) Differential effects of tobacco and alcohol in cancer of the larynx, pharynx, and mouth. Cancer 57, 391–395.[CrossRef][ISI][Medline]
Christensen, A. J., Moran, P. J., Ehlers, S. L. et al. (1999) Smoking and drinking behavior in patients with head and neck cancer: effects of behavioral self-blame and perceived control. Journal of Behavioral Medicine 22, 407–418.[CrossRef][ISI][Medline]
Day, G. L., Blot, W. J. and Shore, R. E. (1994) Second cancers following oral and pharyngeal cancers: role of tobacco and alcohol. Journal of the National Cancer Institute 86, 131–137.
Deleyiannis, F. W. B., Thomas, D. B., Vaughan, T. L. et al. (1996) Alcoholism: Independent predictor of survival in patients with head and neck cancer. Journal of the National Cancer Institute 88, 542–549.
Dental, Oral and Craniofacial Data Resource Center (2002) Oral Health U.S., 2002. Bethesda, MD.
Dikshit, R. P., Boffetta, P., Bouchardy, C. et al.(2005) Risk factors for the development of second primary tumors among men after laryngeal and hypopharyngeal carcinoma. Cancer 103, 2326–2333.[CrossRef][ISI][Medline]
Do, K., Johnson, M. M., Doherty, D. A. et al. (2003) Second primary tumors in patients with upper aerodigestive tract cancers: joint effects of smoking and alcohol (United States). Cancer Causes and Control 14, 131–138.[CrossRef][ISI][Medline]
Doll, R., Forman, D., La Vecchia, C. and Woutersen, R. (1995) Alcoholic beverages and cancers of the digestive tract and larynx. In: Health Issues Related to Alcohol Consumption. Macdonald, I. ed., pp 351–393. Blackwell, Oxford.
Elwood, J. M., Pearson, J. C. G., Skippen, D. H. et al. (1984) Alcohol, smoking, social and occupational factors in the aetiology of cancer of the oral cavity, pharynx and larynx. International Journal of Cancer 34, 603–612.
Falk, R., Pickle, L., Brown, L., et al. (1989) Effects of smoking and alcohol consumption on laryngeal cancer risk in coastal Texas. Cancer Research 49, 4024–4029.
Franceschi, S., Talamini, R., Bara, S., et al. (1990) Smoking and drinking in relation to cancers of the oral cavity, pharynx, larynx, and esophagus in Northern Italy. Cancer 50, 6502–6507.
Gritz, E. R., Carmack, C. L., deMoor, C. et al. (1999) First year after head and neck cancer: quality of life. Journal of Clinical Oncology 17, 352–360.
Hald, J., Overgaard, J. and Grau, C. (2003) Evaluation of objective measures of smoking status. Acta Oncologica 42, 154–159.[CrossRef][ISI][Medline]
Irish, J. C., Brown, D. H., Liu, T. C. et al. (1996) Tobacco, alcohol, and oral cancer: The patient's perspective. The Journal of Otolaryngology 25, 88–93.[ISI][Medline]
LaVecchia, C., Lucchini, F., Negri, F. et al. (1992) Trends in cancer mortality in Europe: 1955-1989. European Journal of Cancer, 232–235.
Martin, M. J., Heymann, C., Neumann, T. et al. CD (2002) Preoperative evaluation of chronic alcoholics assessed for surgery of the upper digestive tract. Alcoholism: Clinical and Experimental Research 26, 836–840.[CrossRef][ISI][Medline]
McClure, J, B., Wetter, D. W., deMoor, C. et al. (2002) The relation between alcohol consumption and smoking abstinence: results from the Working Well Trial. Addictive Behaviors 27, 367–379.[CrossRef][ISI][Medline]
Nocotera, G., Gnisci, F., Bianco, A. et al. (2004) Dental hygienists and oral cancer prevention: Knowledge, attitudes and behaviors in Italy. Oral Oncology 40, 638–644.[CrossRef][ISI][Medline]
Ries, L. A., Eisner, M. P. and Kosary, C. L. (eds) (2001) SEER cancer statistics review: 1973-1998. National Cancer Institute, Bethesda, MD.
Seitz, H. K. and Simanowski, U. A. (1986) Ethanol and carcinogenesis of the alimentary tract. Alcohol: Clinical and Experimental Research 10, 33S–40S.[Medline]
Silverman, S. (2001) Demographics and occurence of oral and pharyngeal cancers. The outcomes, the trends, the challenge. Journal of the American Dental Association 132, 7S–11S.
Sobell, L. C., Cunningham, J. A. and Sobell, M. B. (1996) Recovery from alcohol problems with and without treatment: prevalence in two population surveys. American Journal of Public Health 86, 966–972.
Spies, C. D. and Rommelspacher, H. (1999) Alcohol withdrawal in the surgical patient: Prevention and treatment. Anesthesia and Analgesia 88, 946–954.
Spies, C. D., Neuner, B., Neumann, T. et al. (1996) Intercurrent complications in chronic alcoholics admitted to the intensive care unit following trauma. Intensive Care Medicine 22, 286–293.[ISI][Medline]
Tonnesen, H., Petersen, K., Hojgaard, L. et al. (1992) Postoperative morbidity among symptom-free alcohol misusers. Lancet 340, 334–340.[CrossRef][ISI][Medline]
Vander Ark, W., DiNardo, L. J. and Oliver, D. S. (1997) Factors affecting smoking cessation in patients with head and neck cancer. Laryngoscope 107, 888–892.[CrossRef][ISI][Medline]
Wynder, E. L., Mushinski, M. H. and Spivak, J. C. (1977) Tobacco and alcohol consumption in relation to the development of multiple primary cancers. Cancer 40, 1872–1878.[CrossRef][ISI][Medline]
CiteULike 
Connotea 
Del.icio.us What's this?
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||