Critique 134: Comments on “Section 2.3, Alcohol Consumption,” from the “World Cancer Report 2014” issued by the World Health Organization – 11 February 2014
The following is a critique by Members of the International Scientific Forum on Alcohol Research of the section on alcohol consumption (Section 2.3) included in the “World Cancer Report 2014,”(1) released on 3 February 2014 by the World Health Organization.
From reading this report, it is clear that the conclusion of the authors is that all alcohol consumption is harmful, regardless of the amount consumed, the type of beverage, or the pattern of drinking. Indeed, epidemiological data clearly show that heavy alcohol consumption and “binge” drinking are associated with many adverse effects (and would never be advised by responsible agencies). However, the WHO seriously undermines its credibility by publishing a report that seems to deliberately ignore overwhelming scientific evidence showing that light-to-moderate consumption of alcohol not only reduces overall mortality but is usually not associated with an increased risk of cancer. The casual reader of this report would assume that “alcohol” (not just heavy drinking) is the leading cause of death throughout the world, although the authors do state that malignant neoplasms attributable to alcohol represent less than 1% of all deaths (0.4% of all deaths of women and 0.8% of all deaths of men).
Research cited in the WHO report: It appears that the authors have been very selective in choosing the data upon which they base their conclusions, often citing their own work and ignoring thousands of scientific articles relating alcohol consumption to cancer rates and mortality. For example, while the authors of the WHO report cite alcohol as a factor for colorectal cancer, a recent analysis from the very large Women’s Health Study/Health Professional’s Study on alcohol and colorectal cancer(2) showed that after 1998, when dietary folate was increased in the USA, there has been no significant relation between alcohol and colorectal cancer. While the authors of the WHO report state that “Alcohol consumption is related to more than 200 ICD 10 code diseases . . . including diabetes and cardiovascular diseases,” they do not indicate that essentially all epidemiologic studies show a decrease in the incidence of Type 2 diabetes and essentially every type of vascular disease among moderate drinkers.
When references are given in the WHO report related to cancers for which the risk is decreased by alcohol (e.g., renal, lymphoid malignancies), the authors state: “These apparently protective observed effects should be interpreted with caution since the biological mechanisms are not understood and confounding and/or misclassification of abstainers may be responsible for the observations that have been made.” They do not indicate that similar caution may be warranted for epidemiologic studies showing adverse effects of alcohol.
No mention is made in the WHO report of beverage-specific differences, although epidemiologic studies for many decades [e.g., Klatsky et al(3); Grønbæk et al(4)] have shown that cardiovascular disease risk is lower among consumers of wine than of other beverages. Further, Grønbæk et al(5) and others have shown lower cancer mortality for wine consumers than for other drinkers. Hundreds of experimental studies[e.g., (6,7)] have demonstrated anti-cancer activity of the polyphenols in wine, adding plausibility to the epidemiologic results.
Effects of alcohol on mortality: The authors of the WHO report present little discussion of the relation of alcohol to mortality, either cancer related or all-cause mortality. In addition to the study by Grønbæk et al,(5) a recent report on more than 50,000 cancer deaths(8) showed no increase in the risk of cancer death for “moderate” drinkers (those reporting 1-3 drinks/day) when compared with non-drinkers, and significantly decreased risk of all-cause mortality. Indeed, almost all prospective studies have shown that non-drinkers, even lifetime abstainers, die at an earlier age than do moderate drinkers.
It is also surprising that the authors fail to mention another recent paper, co-authored by Rehm (the first author of the new WHO report), that presented data showing that the lowest total mortality risk over 12 years in the very large European Prospective Investigation into Cancer and Nutrition (EPIC) study was found among men and women who consumed moderate amounts of alcohol.(9) Further, in a recent study of women with invasive breast cancer, those who consumed alcohol after developing their cancer had no increased risk of dying of breast cancer, and a significantly lower risk of all-cause mortality;(10) the editorial accompanying this paper concluded: “Based on the best available evidence, including [the present report(10)], it appears that modest alcohol consumption after breast cancer diagnosis, up to approximately one drink per day on average, may be associated with optimal overall survival, without compromising breast cancer-specific survival.”(11)
Need for a balanced message on alcohol and health: Excessive and binge drinking in young people is a growing scourge in many parts of the world, and alcohol consumption (especially in conjunction with smoking) clearly increases the risk of upper aero-digestive cancers; further, even moderate consumption is associated with a slight increase in the risk of breast cancer in women. However, the scare tactics condemning all alcohol consumption in the WHO report tend to obscure those important messages. A more scientific and balanced opinion on the topic was recently published by Banks:(12); instead of focusing so completely on warning about the adverse health effects of abusive drinking, Banks presented a scientifically valid and balanced view that concluded: “The evidence . . . indicates that, in later life, on average and bearing in mind the priorities and risks of specific individuals, drinking at least some alcohol, but not too much, is likely to minimize the overall risk of death.(12)”
It is the opinion of our Forum that WHO, in the alcohol section of its new publication World Cancer Report 2014, has not provided an objective and balanced report on alcohol and cancer based on scientific data. Instead, it has issued paternalistic blanket condemnations against alcohol, and recommends approaches for reducing availability of alcohol to the general population rather than those that focus on binge drinkers and others who misuse alcohol. By doing so, WHO has lost credibility and, more importantly, has missed a key opportunity to convey important messages about alcohol and cancer that could lead to appropriate recommendations to help improve the health of the public.
References for these comments
- Nan H, Lee JE, Rimm EB, Fuchs CS, et al. Prospective study of alcohol consumption and the risk of colorectal cancer before and after folic acid fortification in the United States. Annals of Epidemiology 2013;23:558-563.
- Klatsky AL, Armsttrong MA. Alcohol beverage choice and risk of coronary artery disease mortality: do red wine drinkers fare best? Am J Cardiol 1993;71:467-469.
- Grønbæk M, Deis A, Sørensen TL, et al. Mortality associated with moderate intake of wine, beer, or spirits. BMJ 1995;l310:1165-1169.
- Grønbæk M, Becker U, Johansen D, et al. Type of alcohol consumed and mortality from all causes, coronary heart disease, and cancer. Ann Intern Med 2000;133:411-419.
- Clifford AJ, S.E. Ebeler SE. EbelerJD, et al. 1996. Delayed tumor onset in transgenic mice fed an amino-acid diet supplemented with red wine solids. Am J Clin Nutr 1996;64:748-756.
- Barron CC, Moore J, Tsakiridis T, et al, Inhibition of human lung cancer cell proliferation and survival by wine, Cancer Cell International 2014;14:6; doi:10.1186/1475-2867-14-6.
- Jin M, Cai S, Guo J, Zhu Y, et al. Alcohol drinking and all cancer mortality: a meta-analysis. Ann Oncol 2013;24:807-816. doi: 10.1093/annonc/mds508.
- Bergmann MM, Rehm J, Klipstein-Grobusch K, et al (38 authors). The association of pattern of lifetime alcohol use and cause of death in the European Prospective Investigation into Cancer and Nutrition (EPIC) study. Int J Epidemiol 2013;42:1772-1790.
- Newcomb PA, Kampman E, Trentham-Dietz A, et al. Alcohol consumption before and after breast cancer diagnosis: Associations with survival from breast cancer, cardiovascular disease, and other causes. J Clin Oncol 2013; jco.ascopubs.org/cgi/doi/10.1200/JCO.2012.46.5765.
- Demark-Wahnefried W. To your health: How does the latest research on alcohol and breast cancer inform clinical practice? J Clin Oncol 2013; jco.ascopubs.org/cgi/doi/10.1200/JCO.2013.490466.
- Banks E. Commentary: Lifetime alcohol consumption and mortality: have some, but not too much. Int J Epidemiol 2013;42:1790–1792; doi:10.1093/ije/dyt218.
A recently released report by IARC (International Agency for Research on Cancer) of the World Health Organization, entitled “World Cancer Report 2014,” includes a section on alcohol consumption as a factor in the etiology of cancer. From reading this report, it is clear that the conclusion of the authors is that all alcohol consumption is harmful, regardless of the amount consumed, the type of beverage, or the pattern of drinking. The members of the International Scientific Forum on Alcohol Research (the Forum) have real concerns about the WHO report.
It appears that the authors have been very selective in choosing the data upon which they base their conclusions, often citing their own work and ignoring thousands of scientific articles relating alcohol consumption to cancer rates and mortality. The report fails to discuss potential lower risks of cancer associated with polyphenols in wine and some other beverages. It ignores the consistent finding in almost all prospective epidemiologic studies over many decades that total mortality rates are lower among light-to-moderate alcohol consumers (and recent evidence suggests that this may even be true among people with cancer).
Members of the Forum strongly agree that heavy alcohol consumption and “binge” drinking are associated with many adverse effects (and would never be advised by responsible agencies). However, the WHO report seriously undermines its credibility by publishing a report that seems to deliberately ignore overwhelming scientific evidence showing that light-to-moderate consumption of alcohol not only reduces overall mortality but is usually not associated with an increased risk of cancer.
Excessive and binge drinking in young people is a growing scourge in many parts of the world, and alcohol consumption (especially in conjunction with smoking) clearly increases the risk of upper aero-digestive cancers; further, even moderate consumption is associated with a slight increase in the risk of breast cancer in women. However, the scare tactics condemning all alcohol consumption in the WHO report tend to obscure those important messages.
It is the opinion of our Forum that WHO, in the alcohol section of its new publication World Cancer Report 2014, has not provided an objective statement on alcohol and cancer based on current scientific data. By doing so, WHO has lost credibility and, more importantly, has missed a key opportunity to convey important focused messages about alcohol and cancer that would be more likely to improve the health of the public.
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Comments on this critique have been provided by the following members of the International Scientific Forum on Alcohol Research:
Dee Blackhurst, PhD, Lipid Laboratory, University of Cape Town Health Sciences Faculty, Cape Town, South Africa
Mladen Boban, MD, PhD, Professor and Head of the Department of Pharmacology, University of Split School of Medicine, Croatia
Giovanni de Gaetano, MD, PhD, Department of Epidemiology and Prevention, IRCCS Istituto Neurologico Mediterraneo NEUROMED, Pozzilli, Italy
Luc Djoussé, MD, DSc, Dept. of Medicine, Division of Aging, Brigham & Women’s Hospital and Harvard Medical School, Boston, MA, USA
R. Curtis Ellison, MD, Section of Preventive Medicine & Epidemiology, Boston University School of Medicine, Boston, MA, USA
Harvey Finkel, MD, Hematology/Oncology, Boston University Medical Center, Boston, MA, USA
Oliver James, MD, Emeritus Professor of Hepatology, University of Newcastle, UK; former Head of Medicine, University of Newcastle, UK
Ulrich Keil, MD, PhD, Professor Emeritus, Institute of Epidemiology and Social Medicine, University of Münster, Münster, Germany; Adjunct Professor, Department of Epidemiology, University of North Carolina, Chapel Hill, NC, USA
Dominique Lanzmann-Petithory,MD, PhD, Nutrition/Cardiology, Praticien Hospitalier Hôpital Emile Roux, Paris, France
Arduino A. Mangoni, PhD, Strategic Professor of Clinical Pharmacology and Senior Consultant in Clinical Pharmacology and Internal Medicine, Department of Clinical Pharmacology, Flinders University, Bedford Park, SA; Australia
Fulvio Mattivi, PhD, Head of the Department Good Quality and Nutrition, Research and Innovation Centre, Foundazione Edmund Mach, San Michele all’Adige, Italy
Ross McCormick PhD, MSC, MBChB, Associate Dean, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
Jean-Marc Orgogozo, MD, Professor of Neurology and Head of the Neurology Divisions, the University Hospital of Bordeaux, Pessac, France.
Erik Skovenborg, MD, Scandinavian Medical Alcohol Board, Practitioner, Aarhus, Denmark
Creina Stockley, PhD, MBA, Clinical Pharmacology, Health and Regulatory Information Manager, Australian Wine Research Institute, Glen Osmond, South Australia, Australia
Arne Svilaas, MD, PhD, general practice and lipidology, Oslo University Hospital, Oslo, Norway
Pierre-Louis Teissedre, PhD, Faculty of Oenology – ISVV, University Victor Segalen Bordeaux 2, Bordeaux, France
Dag S. Thelle, MD, PhD, Senior Professor of Cardiovascular Epidemiology and Prevention, University of Gothenburg, Sweden; Senior Professor of Quantitative Medicine at the University of Oslo, Norway
Fulvio Ursini, MD, Dept. of Biological Chemistry, University of Padova, Padova, Italy
David Van Velden, MD, Dept. of Pathology, Stellenbosch University, Stellenbosch, South Africa
Andrew L. Waterhouse, PhD, Marvin Sands Professor, Department of Viticulture and Enology, University of California, Davis; Davis, CA, USA
The International Scientific Forum on Alcohol Research consists of scientists of many disciplines who have research interests in the health risks and benefits of alcohol consumption. Their common goal is to provide unbiased, scientifically accurate, up-to-date, and balanced critiques of emerging research reports and other publications related to alcohol consumption. Members receive no remuneration for their contributions to the Forum. Of the current 41 members, three are from institutes that are partly supported by the wine industry.
The preparation of critiques of published papers is coordinated by the Institute on Lifestyle & Health at Boston University School of Medicine in Boston, MA, USA, with funds provided by various organizations, including several in the alcoholic beverage industry. Such funds are provided as unrestricted donations to Boston University, and the donors have no knowledge of which scientific publications the Forum will review or what their comments will be on these papers; they only learn of the results of these deliberations upon publication of critiques on the Forum’s web-site, www.bu.edu/alcohol-forum, when the reports are made available to the public.