Love Affair With Alcohol Is Driving GI Cancers

Kristin Jenkins

July 05, 2017

UPDATED July 6, 2017 // Europe could be headed for sharp increases in rates of alcohol-related digestive cancers unless strategic political and clinical efforts reshape the cultural status quo in a region where the per capita daily drinking rates are the highest in the world, a new report issued by United European Gastroenterology (UEG) suggests.

With an average alcohol consumption of two drinks per day, adults in all 28 member states of the European Union (EU) face a 21% increased risk for colorectal and esophageal cancer, say the authors of the new report, Alcohol and Digestive Cancers Across Europe: Time for Change, published online July 4.

More than one fifth of the European population aged 15 years and older are drinking heavily at least once a week, and not one state within the EU has "light" per capita alcohol consumption, defined as an average of one or fewer alcoholic drinks per day.

Moderate alcohol consumption was defined at one to four drinks per day.

"Heavy" drinking, defined as consuming five or more drinks each day, is associated with a significantly increased risk for pancreatic, liver, and gastric cancer. This is particularly true for those living in Eastern Europe, where the risk of dying from an alcohol-related cancer is seven times higher than in the Mediterranean region of the EU.

According to the World Health Organization, in 2016, annual per capita consumption of pure alcohol in the EU was estimated to be 27 liters, compared to 22 liters in the United States. This translates into a per capita alcohol consumption in the United States that is approximately one third that of Europe.

Common GI Cancers

The five most common digestive cancers in the world — colorectal, esophageal, pancreatic, liver, and gastric — are responsible for more than three million deaths annually and more than a third of cancer deaths globally, the authors point out.

By 2030, the number of new cases of cancer is expected to rise by eight million, and by 2050, the number of cancer deaths is predicted to increase by five million.

"Europe is the region with the highest level of alcohol consumption in the world and, as a result, Europe bears the highest burden of ill health and premature death linked directly to alcohol," says Marris Jesse, MD, deputy secretary for health and a representative of the Estonian EU presidency, in the report's introduction. "To address this endemic matter, tackling the harmful use of alcohol should be a key priority for the European Union. Appropriate response has to be comprehensive, encompassing policies and interventions from alcohol taxation, availability and marketing regulations to good access to counselling and treatment."

Tragically, 9 out of 10 Europeans are not aware of the link between drinking and digestive cancer risk, even though 30% of deaths from gastrointestinal diseases can be directly attributed to alcohol, the report authors note. Lack of awareness appears to be a common phenomenon, even among healthcare professionals, they add.

There needs to be a seismic shift in attitudes towards social drinking.

"There needs to be a seismic shift in attitudes towards social drinking to address the complacency concerning the negative effects of alcohol, as well as dramatically changing the general lack of awareness about the impact of even moderate regular drinking on digestive cancers," the authors write. "We welcome and support involvement and contributions from medical and research communities in the alcohol policy debate."

The UEG report, which was produced from the latest scientific literature with support from the European Association for the Study of the Liver, the Association of European Cancer Leagues, the European Liver Patients Association, Pancreatic Cancer Europe, EuropaColon, and Eurocare (the Alcohol Policy Alliance), also highlights the profoundly worse impact of alcohol on the health of women compared to men.

Results from the European Prospective Investigation Into Cancer Study show that a single daily drink of alcohol is linked to 80% of cases of cancer of the upper digestive tract, colon, and liver in women. In men, two drinks a day is attributed to 57% of cases of digestive cancer.

"We urgently require a focused multidimensional approach from policy and decision makers at both European and national levels to dramatically increase public and healthcare professional awareness of the dangers of alcohol, as well as to implement further strategies across the region to reduce alcohol intake and the resulting incidence of digestive cancers," says Michael P. Manns, director of the Department of Gastroenterology, Hepatology and Endocrinology at the Medical School of Hannover in Germany and UEG president from 2015 to 2017.

The UEG supports the recently recommended target for a minimum 10% reduction of total alcohol consumption by 2025, the report authors say, adding that a number of issues must first be addressed.

"One of the main challenges in addressing high drinking levels is how deeply embedded alcohol consumption is within the European society, both socially and culturally," notes Markus Peck, MD, associate professor of medicine and vice-chairman of the Department of Gastroenterology and Hepatology at the Medizinische Universität Wien, Austria.

"Contrary to many other diseases, tackling alcohol consumption is one of the most difficult political endeavors," Dr Peck told Medscape Medical News. "Here, industry interests are directly competing against health benefits. Unfortunately, EU market interests and massive lobbying by the drinks industry have so far prevented effective policy measures on an EU level, despite the fact that direct and indirect cost to society incurred by alcohol consumption is much higher than tax income from it. Only a continuing effort of civil society, media, and professional medical associations might be able to have an impact in the long run."

More investment in public and primary care education campaigns is needed to increase awareness and give consumers a chance to make informed choices. More data about the impact on disease risk of different types of alcohol, different patterns of drinking, other lifestyle factors, such as smoking, and genetics are also needed.

There is currently no known or established level of safe alcohol consumption when relating to cancer risk. Dr Stephan Haas

To redress ongoing confusion about appropriate levels of consumption, mixed messaging about the health risks of alcohol consumption needs to be replaced with clear and consistent information about the health risks of drinking alcohol. "There is currently no known or established level of safe alcohol consumption when relating to cancer risk," points out Stephan L. Haas, MD, PhD, of the Karolinska University Hospital in Stockholm.

A unified approach to national screening programs is the only way to increase uptake rates to more than 60%, the report authors say, noting that policy makers play a critical role in promoting cancer prevention, early diagnosis, and improved cancer treatments.

"Access to diagnostic services and specialists needs to improve across Europe, as there is still considerable disparity between countries," says Bohumil Seifert, MD, PhD, head of the Department of General Practice at the Charles University in Prague, Czech Republic. "There needs to be European recommendations to help improve primary care awareness of the dangers of alcohol and its link to digestive cancers and the importance of early diagnosis."

Education campaigns are vital for mobilizing patients and for helping primary care practitioners identify at-risk patients early, Dr Seifert notes. In the Czech Republic, where the incidence of colorectal cancer used to be one of the highest in Europe, high-risk drinkers are now identified more effectively with a detailed questionnaire that asks patients how often they drink rather than how much.

Once identified, a high-risk patient would then be channeled into "a 'brief intervention' pathway where the risks of drinking and the link to digestive cancers are explained in detail," Dr Siefert explains. Primary care practitioners, who are well positioned to reduce a patient's risk for digestive cancers, can tell a heavy drinker that cutting back from four drinks a day to one can potentially lower risk for colorectal cancer by more than 20%, he points out.

Improved educational efforts and better screening programs have also been successful in reducing the colorectal cancer incidence rates in the Czech Republic, which lowers mortality rates. Primary care physicians are referring patients earlier, "ensuring quicker diagnosis and improved patient outcomes," Dr Siefert says.

More evidence that screening works comes from a study of the UK screening program. Interventions such as a general practitioner endorsement letter, telephone advice, and an enhanced patient leaflet can increase the number of patients who undergo bowel cancer screening, it shows. Importantly, these interventions can successfully engage alcohol-dependent patients at highest risk.

Reducing the alcohol burden by "cracking down on advertising for alcohol" is also highly advisable, starting with a complete ban on all TV alcohol advertising and any advertising aimed at under-age consumers, said Dr Peck.

Policy-related actions should include decreasing access to alcohol, which has proven to be one of the most effective measures to curb alcohol consumption, he pointed out. Alcohol should only be available for purchase in dedicated liquor stores, and minimum pricing that caters to the most vulnerable — including "junior drinkers" and the unemployed — should be eliminated.

Patterns of drinking behavior embedded in European culture must also be changed. Early evidence shows that when stricter regulation of alcohol sales, marketing, and access is combined with new behavioral norms, even societies with centuries-old drinking traditions can reduce overall alcohol-related health risks.

"In France, changes to regulations and cultural eating habits, with people no longer permitted to drink wine at work, as well as enforcing stricter alcohol advertising regulations, has reduced alcohol consumption, with digestive cancer incidence declining as a result," notes Rebecca Fitzgerald, MD, an honorary consultant in gastroenterology and general medicine at Addenbrooke's Hospital, Cambridge, in London.

It is time for Europe to change its approach and attitude towards alcohol consumption. Dr Paul Fockens

"It is time for Europe to change its approach and attitude towards alcohol consumption," says Paul Fockens, UEG president (2017-2019) and professor of gastrointestinal endoscopy in the Faculty of Medicine of the Universiteit van Amsterdam.

"UEG calls upon EU policy makers and citizens to recognize the evidence of the digestive cancer risks associated with alcohol consumption," Dr Fockens comments. "The societal costs and healthcare implications of increased alcohol consumption are huge. Now is the time to take positive and proactive action for the benefit of current and future generations."


The authors report no funding or relevant financial relationships.

UEG. Alcohol and Digestive Cancers Across Europe: Time for Change. Published online July 4, 2017. Full text


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