Alcohol and Breast Cancer

Alcohol & Breast Cancer
Alcohol consumption may influence the risk of breast cancer, researchers note

By RenÃ?Â© Jackson, BSN, RN

According to the American Cancer Society’s Cancer Facts & Figures 2002, this year among women in the United States, an estimated 203,500 new invasive cases of breast cancer are expected to occur. In addition, 54,300 new cases of in situ breast cancer are expected to occur, and an estimated 39,600 deaths are anticipated from breast cancer this year.

The risk of breast cancer increases with age. Risk is higher in women who have: a personal or family history of breast cancer; biopsy-confirmed atypical hyperplasia; increased breast density; a long menstrual history; obesity after menopause; recent use of oral contraceptives or post-menopausal estrogens and progestins; never had children or had their first child after age 30; or consume alcoholic beverages.

“Alcohol consumption is a potentially modifiable behavior that may influence the risk of breast cancer, a leading cause of morbidity and mortality in women,” according to a study analysis published in the Journal of American Medical Association.1 Alcohol consumption was positively associated with the risk of invasive breast cancer. Women who consumed 2-5 drinks per day increased their risk of developing breast cancer compared with nondrinkers.

Studies also show that all types of alcohol (e.g., beer, wine, liquor) were each positively associated with breast cancer risk. Nor does it make any difference whether a woman is pre- or postmenopausal. Experimental results in recent epidemiologic studies indicate that ethanol is a tumor promoter and chronic ethanol exposure enhances metastasis and breast cancer growth. The association between alcohol consumption and increased risk for breast cancer has been a consistent major finding in studies done in the past 20 years.

Alcohol & Estrogen Levels
Some studies have found that women with alcoholism have higher estrogen levels than moderate alcohol consumers and nondrinkers. According to Maurice J. Cairoli, MD, a board-certified medical oncologist at Fox Chase Cancer Center at Virtua Memorial Hospital, Burlington County, NJ, “the presumed mechanism of action is that alcohol increases circulating levels of total and bioavailable estrogen.”

However, Dr. Cairoli stated that there is no data on how, if at all, preexisting endogenous levels of estrogen modify the risk of breast cancer associated with alcohol consumption. Dr. Cairoli said that women with higher levels of endogenous circulating estrogen levels, irrespective of history of alcohol use, are at greater risk for developing breast cancer.

In premenopausal women, alcohol intake has been associated with higher concentrations of estrogen. Compared with nondrinkers, moderate alcohol intake by premenopausal women may decrease menstrual cycle variability and frequency of long cycles. This increases cumulative exposure to endogenous estrogens.

In postmenopausal women not using hormone replacement therapy (HRT), moderate alcohol intake can lead to increased blood estrogen levels. A study done at the Fox Chase Cancer Center in Philadelphia suggests a possible mechanism by which consumption of one or two alcoholic drinks per day by post-menopausal women could increase a woman’s risk of breast cancer.

In postmenopausal women using HRT, there is a pronounced effect of alcohol consumption on blood estradiol levels. In another study, it was observed that postmenopausal women taking oral estradiol daily (1 mg) and who consumed 15.6 g of alcohol per week showed a 3.3-fold increase of estradiol. Therefore, women who drink alcohol and use oral estradiol for replacement therapy may actually have much higher circulating estradiol levels from use of HRT alone.

Increased estrogen levels in women consuming alcohol appear to be important mechanisms underlying the association of alcohol and breast cancer.

Alcohol & Folate
A study done at the Department of Medical Epidemiology, Karolinska Institute, Stockholm, Sweden, looked at major dietary patterns and their association with breast cancer risk. The study used data from a prospective study of 61,463 women with an average follow-up of 9.6 years and 1,328 incident cases of breast cancer. No association was found between the “Western” dietary pattern (red and processed meats, refined grains, fat, sweets) and the “healthy” dietary pattern (fruit, vegetables, fish, poultry, low-fat, whole grains), and breast cancer risk. The exception was that women who were in the “drinker” dietary pattern had a moderately increased breast cancer risk.

The risk of breast cancer is also increased in women who consume more than average amounts of alcohol and have low dietary intake of folate. In a 1986 cohort study by a group of researchers at the University of Minnesota, a 59 percent increased risk of breast cancer was found in a group of women who consumed more than 4 g alcohol a day (about half of a drink) and had less than 172 mcg/day of folate intake. In women who drank the same amount of alcohol but had a greater than 172 mcg/day intake of folate, no increase of breast cancer was detected. It should be noted, however, that this study was evaluated with food sources of folate, rather than supplements.2

Consumed alcohol also interferes with folate metabolism, which reduces the bioavailability of dietary folate even further. Since a function of folate is as a cofactor in the synthesis and repair of DNA, it is thought that high consumption of alcohol in promoting folate deficiency may predispose individuals toward development of cancer.

Relative Risk
If a woman has a close relative (mother, sister) with breast cancer, drinking alcohol may more than double her risk of developing the disease. A study done at the Mayo Clinic Cancer Center in Rochester, MN, specified that women who drank daily and had a close relative with breast cancer increased their risk more than those with distant relatives with breast cancer.

The study included 426 families with a history of breast cancer, including 9,032 women who were either blood relatives of patients or who had married into their families. The women reported how much alcohol they had consumed throughout their lifetime, and about risk factors such as HRT, smoking and exercise. Women who were first-degree relatives of women with breast cancer, and were daily drinkers, had twice the increased risk of breast cancer compared to first-degree relatives who never drank.

In comparison, women who had married into the family but were not blood relatives had no higher risk of breast cancer if they were daily drinkers than if they never drank.

Dr. Cairoli stated that it does not appear alcohol consumption acts synergistically with other known risk factors for breast cancer, but rather in an additive fashion. Also, the type of alcohol consumed has not been shown to be important, but rather the quantity consumed.

Nursing Perspective
Colleen Carey, BSN, RN, OCN, breast health coordinator at Virtua Health, said that Fox Chase Cancer Center at Virtua Memorial Hospital in Burlington County takes an approach similar to that of any other patient with a co-occurring disease: assessment, intervention and support. Carey said that as part of any nursing and physician assessment and patient history interview, patients are asked about their social history: alcohol intake, drug use, smoking, etc. This provides a baseline as well as an opportunity to discuss substance issues, counseling, prevention, and to assess desire of the patient to modify or quit. She added that a diagnosis of cancer and the stress/anxiety related to a health crisis may increase drinking and substance abuse.

Interventions at Virtua Health require a multidisciplinary approach that includes physicians, nurses and social workers. Virtua’s substance abuse program, Alcove, includes one-on-one therapy, counseling, education, family support and teaching-coping skills.

The relationship between alcohol and the risk of developing breast cancer will continue to be the focus of research. Alcohol consumption is a modifiable behavior, and as such offers women a way of decreasing their risk of developing the disease.

References
1. Smith-Warner, S.A., Spiegelman, D., Yaun, S.S., et al. (1998). Alcohol and breast cancer in women: A pooled analysis of cohort studies. Journal of the American Medical Association, 279, 535-540.

2. Babbitt, J. (2002, January). Breast cancer risk is increased for women who drink more than average amounts of alcohol if their dietary folate intake is low. Retrieved April 3, 2002 from the World Wide Web: http://www.breast.link.com/blink/plsql/HomePageNav?h_article_id=376

Resources
American Cancer Society. (2002). Cancer facts & figures 2002. Atlanta: Author.

Ballagh, S. (1999). Alcohol: The link between hormone replacement and breast cancer risk. Women’s Health Issues, 9(6), 338-342.

Naieralski, J., & Devine, C. (1998). Alcohol and the risk of breast cancer (fact sheet No. 13). New York: Cornell University, Program on Breast Cancer and Environmental Risk Factors in New York State.

National Cancer Institute. (1996). Racial/ethnic patterns of cancer in the United States 1988-1992 (NIH Pub. No. 96-4101). Bethesda, MD: Author.

Rohan, T., Jain, M., Howe, G., & Miller, A. (2000). Dietary folate consumption and breast cancer risk. Journal of the National Cancer Institute, 92(3), 266-269.

Schorr, M. (2001, July 30). Family risk of breast cancer raised by alcohol. Retrieved April 2, 2002 from the World Wide Web: http://www.owcdemo.wellsource.com/dh/content.asp?ID=323

Singletary, K., & Gapstur, S. (2001). Alcohol and breast cancer: Review of epidemiologic and experimental evidence and potential mechanisms. Journal of the American Medical Association, 286, 2143-2151.

Terry, P., Suzuki, R., Hu, F., & Wolk, A. (2001). A prospective study of major dietary patterns and the risk of breast cancer. Cancer Epidemiological Biomarkers, 10(12), 1281-1285.

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