How Does Alcohol Affect Breast Cancer Risk?

Welcome to The Breastcancer.org Podcast, the podcast that brings you the latest information on breast cancer research, treatments, side effects, and survivorship issues through expert interviews, as well as personal stories from people affected by breast cancer. Here’s your host, Breastcancer.org Senior Editor, Jamie DePolo.

Jamie DePolo: Hello, thanks for listening. In January, the U.S. Surgeon General put out an advisory on alcohol and cancer risk, calling for cancer risk-warning labels on alcoholic beverages. The advisory said alcohol contributes to nearly 100,000 cases of cancer each year, and about 20,000 deaths each year.

The advisory also cited a 2019 study showing that alcohol is more closely linked to breast cancer than any other cancer. More than 44,000 breast cancer cases in 2019 were related to drinking alcohol, which was about 16% of the total number of breast cancer cases that year. These are sobering numbers, if everybody forgives my terrible pun for a very serious topic. 

I’m joined by Dr. Tracy Crane, who is associate professor of medical oncology, co-leader of the Cancer Control Research Program, and director of Lifestyle Medicine, Prevention, and Digital Health, all at the Sylvester Comprehensive Cancer Center at the University of Miami. She joins us to discuss the latest information on alcohol and breast cancer risk.

Dr. Crane, welcome to the podcast.

Dr. Tracy Crane: Thank you so much for having me, it’s great to reconnect.

Jamie DePolo: Yes. So, there have been so many mixed messages about alcohol over the years. Red wine is good for your heart, other things: It helps you relax, keeps stress down. Knowing what we know today, right now, is there an amount of alcohol that’s safe, or I guess, healthy is perhaps a better word, that people can drink?

Dr. Tracy Crane: Well, I think that’s a great place to start because I think there has been a lot of mixed messaging, particularly around when we think about red wine, and the Mediterranean diet, and how this is a component of a Mediterranean diet. I think it’s important for people to be aware of what the risks are and then weigh those risks individually. I think that for what we know is that, you know, alcohol does not provide anything really nutritious for us, right? They are largely calorically dense, no real nutritive properties.

The association between heart health and red wine really comes from the polyphenols that is found in red wine, and I think, you know, lower amounts, you know, one glass maybe, for heart health overall. I think that’s a very different story than cancer risk. And I think that’s what consumers have to weigh is, what is my long-term health goal and you know, do I want to consume this alcohol for, you know, different reasons? So, I think you hit the nail on the head that those studies wee very specific to red wine.

Jamie DePolo: Okay, and not others. Now, based on what you said, I think the answer to this is no, but I’m going to ask you anyway. Are there any benefits at all to drinking alcohol?

Dr. Tracy Crane: No. I don’t think that there are any benefits. I mean, the same polyphenols you can get in that red wine you can find in other foods. So, the grapes have those polyphenols, the blueberries have those polyphenols. You know, you can get those really bioactive plants’ vital chemicals in a variety of other places. There’s nothing special really about the alcohol in the red wine that is doing that. It’s really based upon those polyphenols.

And I think it’s also important to think about where that data comes from and that literature, which is in Mediterranean cultures, where we really also know that community and environment is important, and you have to kind of also understand that part of the meal and the red wine is about that community and social engagement. So, how do we recreate that with something other than alcohol? 

Jamie DePolo: Right. So, I have questions about that, but later. But I want to ask you, too, in the surgeon general’s advisory, it seemed to me that alcohol increased cancer risk more in women than in men. And women are always advised – I think for men it’s like three to four drinks a week as far as possibly the best ratio, I don’t know, or you know, less, whereas women it’s always two. Do we know why that is? Is it just because women tend to be smaller, or what’s going on there?

Dr. Tracy Crane: Yeah. So, women do metabolize alcohol differently than men, so that is part of it. You know, and they also are generally smaller, right? So, there’s a body surface area for you to metabolize things. But I do think it’s interesting that the rates in breast cancer were particularly striking, and I think it’s important, you know, as breast cancer being, you know, one of those common cancers for women to experience over their lifetime, this is really important to get out there. And so, I’m happy that this is finally coming to the surface, and people forget that there’s been a warning label on alcohol for quite some time, but it’s not specific to cancer. 

Jamie DePolo: Right. Now, do we know how, like, what’s going on in the body? How does alcohol increase cancer risk, I guess in general, and then if we know anything about breast cancer specifically?

Dr. Tracy Crane: You know, we know that alcohol and acetaldehyde, right, is really the culprit here, that’s the carcinogen. And so, we know it causes DNA damage, right? And DNA damage certainly increases this risk for cancer. 

I think you also…there’s an association between other habits and behaviors that tend to go hand-in-hand with alcohol. So, we know people are more likely to smoke, they’re more likely to choose other kinds of food, inhibitions tend to go down so, I think even if you go into a social situation where you think okay, we;; I’m not going to do X, Y, Z, and suddenly you’ve had one glass of wine and you’re like oh well…

So, I think that’s part of it. It’s also the caloric density as I mentioned earlier. You know, we metabolize alcohol like fat, right? So, it’s more closely metabolized in the body to fat versus any other macronutrient.

So, we have carbohydrates, proteins, and fat, and protein and carbohydrates are about four calories per gram, fat is about nine calories per gram, alcohol is seven calories per gram. And it’s processed through the liver very similar to fat, and so, I think that’s likely one of the hypothesized places where it could be related to particularly post-menopausal breast cancer, right? Where we know it’s more of an obesity-related cancer, fat metabolizes similarly, you know, so, I think that that’s probably part of the scientific storyline, the undercurrent, right, with this breast cancer risk.

Jamie DePolo: Okay, and does it have anything to do…you mentioned post-menopausal risk, and I believe, if I’m remembering correctly, estrogen receptor-positive breast cancer is more likely…

Dr. Tracy Crane: Yes.

Jamie DePolo:…to be diagnosed in post-menopausal women. So, does alcohol somehow increase estrogen in the body or does it mess around with estrogen at all?

Dr. Tracy Crane: You know, I do know that when women drink alcohol, in particular hot flashes tend to be worse, we tend to experience more disrupted sleep so, it certainly is playing into some of those, you know, estrogen-sensitive symptoms that we see anyway, right? So, you know, you may fall asleep quite quickly with alcohol but you tend to wake up during the night, like I mentioned, hot flashes tend to get much worse. So, this tells us that likely, yes, you’re probably playing closer together. 

And if you think about what estrogen looks like, right? Estrogen is a ringed figure, right? When you think about the biochemical nature of estrogen, and it is also, you know, closely related to lipids and so forth, right? Stored in adipose tissue.

Jamie DePolo: Okay. Now, the advisory focused really specifically on the risk of a first-time cancer, and I looked around, I couldn’t find a lot of research on alcohol and the risk of recurrence. Do we know anything about that? 

Dr. Tracy Crane: You know, that’s a great question. I think that there are some larger, you know, and you have to remember how we get these data is through cohort trials. And that’s where we follow people for a very long amount, you know, over a period of time, and we watch for things to happen. And there are some large trials where I think we can begin to look at these data such as Women’s Health Initiative, The Women’s Healthy Eating and Living Study, trials where we collected all this data and looked over time.

I would have to look to see, I do think that it does play a role, certainly potentially increasing risk for recurrence after a diagnosis of breast cancer. So, I think women need to be particularly careful if they’ve had a diagnosis of breast cancer, and are looking for ways that they can reduce the risk of cancer coming back. One of those ways they should be considering is limiting their alcohol consumption. 

But it is important for people to remember that these are association trials, right? So, we can’t run a definitive trial where we give people alcohol and some people not alcohol and wait for cancer to happen. 

So, you know, keeping all that in mind, I think that that’s probably my best message that I can give to people is make yourself aware, know what a serving size is, a lot of times people don’t know, and then make these decisions. You know, maybe the glass of wine every night to unwind isn’t as important. Is there another way you could unwind? And saving maybe. If you want to have a celebratory glass of champagne at a wedding and saving it for those moments.

Jamie DePolo: Yeah, and you mentioned serving size. If I remember right, it’s basically a shot of hard alcohol…

Dr. Tracy Crane: That’s 1.5 ounces, yeah.

Jamie DePolo: …and then I can’t remember, what is beer and wine? It’s like a can of beer…

Dr. Tracy Crane: Twelve ounces, yeah. Beer is 12 ounces, or like a seltzer water or a wine cooler right, that’s about 12 ounces which is like a bottle, and wine is five ounces.

So, I always tell my patients, go home and measure how much five ounces is in your favorite wine glass. Again, awareness is key. I think that if nothing else, this is a moment that we can all kind of take stock on what we’re doing and then make decisions for ourselves about what we want to do. 

Jamie DePolo: Right. The advisory also said that only about 45% of people in the United States know that alcohol increases cancer risk. And this is I think sometimes the crux of the matter. Like, alcohol, it’s just, people get very emotional about it. It’s like, they feel like, I had a very hard day, I need a glass of wine to unwind. I’m going out with friends, I don’t want to be that person that doesn’t drink when everybody else is.

You know, I go to conferences. I was just in San Antonio at the San Antonio Breast Cancer Conference. There were a lot of receptions with alcohol, and you know, so, how do we change…I guess it’s almost like a reward mentality. Like, I had a hard day, I deserve this. How do we get out of that? Because that’s so…like, you can be very aware of the facts and still that emotional pull is difficult sometimes.

Dr. Tracy Crane: Yeah. I think that a really important point, is there’s a culture around alcohol and you know, changing the narrative is not an easy thing to do, but that’s really, and I’m hopeful that having these conversations is going to help us to change the narrative so that there isn’t stigma associated. If you say to somebody, you know, I’m choosing to, you know, be watching my alcohol, I’m not going to be drinking tonight, and then be fine with it, people not give you a hard time.

And it’s interesting that we’re seeing in our younger generations, actually, less alcohol uptake. I don’t know if you notice when you go out to restaurants and things now, you do have mocktails, right? There’s a very specific call-out to mocktails which I think is great, and this has been happening probably the last three to five years I’ve noticed this kind of uptick, which I think is…with this is the kind of stuff that has to happen to change the narrative and change the dialogue. 

But you’re right, it’s untangling, why is it that we think to alcohol first when we’ve had a hard day? And what are other things we could do instead? And just like changing any behavior, understanding why you’re doing it and then having a list of other things you can do at the ready is a great first step, because when you’re in the moment it’s hard.

So, when you’re out of the moment, take time to think about okay, if I come home and I’ve had a really bad day, what is something else I could do that would help me feel like I’m not alone, I’m not stressed out about something? And maybe it’s go for a walk, call a friend. You know, I actually really love the idea, and we actually, at Sylvester teach mocktail classes, right? 

Jamie DePolo: Oh, nice.

Dr. Tracy Crane: You still have the experience of coming home, having a nice mixed drink in terms of you put like, maybe pomegranate juice and lime juice and club soda, put it in your favorite glass. You know, I get a lot of enjoyment, I love my wine glasses. I like how they look and how they feel. Doesn’t have to always have alcohol in it, right? You can still enjoy that glass and make it special at the end of the day.

So, is it really the alcohol that you’re looking for, or is it the behavior and the reward of having, you know, just a moment to yourself to wind down? A lot of people need the wind down. Doesn’t mean you have to get rid of it, you just do it with something else.

Jamie DePolo: Right. So, now that leads me to my next question. So, I’ve seen ads for a product, this one in particular is called BRĒZ with the German line over the E, and it bills itself as, this is a quote, “A euphoric, calming, and inspiring next-gen social tonic with an unparalleled effect.” And it contains microdoses of cannabis and mushrooms. So, is this any better? Is this any healthier? I mean, I feel like, and I get, you know, I see ads for gummies. Like, oh, if you don’t want to drink, wind down with a gummy, you know. I’m sick of being hung over, try these gummies when you go out with friends.

And I’m just like, well, are we just swapping kind of one bad thing for another bad thing?

Dr. Tracy Crane: Yeah, you know, I think that, I think it goes back to the why. Why are you looking for something, and getting to the root of the craving, right? Or the root of the reason why you think you may want alcohol or this other, you know, microdosing of cannabis or adaptogens or whatever. Getting to the why is probably the most crucial part, and I don’t think we really know enough about all those other things.

And as I mentioned earlier in the podcast, that understanding why you’re drinking these different things and what your health outcomes, your goals are, is equally as important because if there’s extra calories, if there’s, you know, other things in these drinks, they may not be serving your overall purpose. Yeah, the alcohol may be gone, but if you’re adding another hundred calories and high-fructose corn syrup or artificial sweeteners or food dyes or whatever, right? You know, are you really making any benefit there?

Jamie DePolo: Right. What about…I think, and I’m just generalizing here, this may not be true, but I think a lot of people think well, I’m a little shy, I’m going out in a big group, alcohol helps me relax and maybe be less anxious in a social situation. Do you have any tips for somebody who feels like that?

Dr. Tracy Crane: So, I think that talking to somebody like, if you have somebody…you don’t always have somebody that you can meet up with at an event, but I think if you do, verbalizing ahead of time to that person and saying hey, I’m going to look for you, I’m a little bit shy in these situations, and being honest can be really helpful. I think, too, that there’s a ton of different podcasts and self-help, how to have a conversation with somebody, is a great, you know, maybe you want to look up a book or a few top tips. Right? There’s TED talks, there’s trying to help yourself feel more comfortable in those social situations.

And I think, you know, sometimes in our heads we kind of over-amplify what we think might happen, versus in the actual moment it may not really be quite what you’re perceiving it to be to the other person. Most times other people are maybe equally as shy or equally as reserved, but they’re not passing judgment, usually. And so, keeping that in mind and remembering what your own individual goals and desires are for what you’re trying to get out of the situation. 

But I think if you have somebody there you can talk to ahead of time and let them know maybe it’s uncomfortable for you is a great first step. And then thinking about things to have conversations with people with. Again, when you’re in the moment it’s way harder then you’re out of the moment, and you’ve kind of, you know, we do this in behavior teams a lot where we ask people to visualize what they’re going to do in a situation. It’s always easier to do it in role play before you have to get into the situation. I think that’s really good advice in these situations.

Jamie DePolo: That makes sense. So, finally, if there are folks out there, they’ve listened to this, they want to drink less, could you talk about…we’ve talked about mocktails and what we can do, but could you talk about some of the other benefits of drinking less besides decreasing cancer risk? And I know you talked about the caloric density, I’m sure perhaps if people have weight loss on their minds that might help with that, but are there other things as well?

Dr. Tracy Crane: Yes, and we know weight loss is one, for sure. A lot of times alcohol is mixed with other things, you have a lot of calories, and keeping that in mind is important when you’re thinking about one of your goals is to manage your weight. Also, hypertension. You know, alcohol is definitely a key player there. Type 2 diabetes. Again, a lot of these alcoholic beverages, not only does it mess with your metabolism, which is, you know, key in type 2 diabetes management, but it also is, you know, full of, sometimes, high-fructose corn syrup and added sugars, and so, again, keeping that in mind. So, for your type two diabetes, hypertension, these are really important.

And again, we talked earlier about red wine maybe and cardiovascular disease risk, but other types of alcohol are certainly not protective for heart disease. So, our big, main chronic diseases in the United States are only going to be benefitted if you are drinking less.

Jamie DePolo: Okay, and also, I believe, correct me if I’m wrong, alcohol can affect like, GERD or acid reflux?

Dr. Tracy Crane: Oh, yes. That’s a great point. That’s a great point, yeah, and certainly…and your sleep, right? Your sleep is definitely impacted by alcohol intake, and while sleep is not a chronic disease, it certainly is a key pillar in chronic diseases, right? And so, you know, this overall lifestyle, I think about it as, you know, pillars, you know, diet, exercise, sleep, stress management, and alcohol is going to impact all of those things individually. 

Jamie DePolo: Yeah. I’m assuming, too, if you’ve had a few drinks at night you’re going to be less likely to work out the next day because maybe you don’t feel so good. 

Dr. Tracy Crane: Yeah, less likely to work out, you’re going to have disrupted sleep. We know that alcohol definitely impacts your sleep rhythms. And we mentioned earlier, it certainly amplifies hot flashes if you’re a woman going through menopause, or perhaps had been on an aromatase inhibitor or something it certainly is going to cause problems more often.

Jamie DePolo: All right. Dr. Crane, thank you so much, this has been very helpful. I hope if people are thinking about drinking less, this has given them some good information. 

Dr. Tracy Crane: Yeah, I hope so, too, and thank you so much for having me, it’s a really important topic.

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