Originally published as JCO Early Release 10.1200/JCO.2009.21.4395 on February 23 2009

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In Reply

University of Cambridge, Department of Oncology, Strangeways Research Laboratories, Cambridge, United Kingdom

We wish to clarify that current alcohol intake is alcohol intake at the time that the questionnaire was completed, and as we make clear, the timing of questionnaire completion in relation to diagnosis varies. However, the effect of alcohol on all-cause mortality was not dependent on the time of questionnaire completion in relation to diagnosis (data not shown). Alcohol intake at age 30 years was also recorded as a measure of past alcohol intake, but this was not shown to influence overall survival.

We accept that use of all-cause mortality may result in some misclassification. However, the majority of deaths in women of this age group will be due to breast cancer, and if this effect were only driven by a reduction in other causes of mortality, the effect would need to be large.

Broadly speaking, whatever we adjusted for, the effect of alcohol intake remained the same. The risk reduction in the univariate analysis was only slightly attenuated in the multivariate model, but the latter was based on only half the number of cases, and therefore was not significant. There was no difference in the effect according to whether or not the patients had been treated with chemotherapy (data not shown).

We did not adjust for physical activity, as this was not measured in our study. However, if anything, high levels of physical activity are likely to be associated with lower alcohol intake. Therefore, adjusting for physical activity would be likely to increase the effect of alcohol.

We agree that there is limited evidence for the effects of alcohol consumption on breast cancer survival,^1,2 although the effects of alcohol on breast cancer incidence are established.^3,4 While, the study of 125 patients by McDonald et al⁵ found an increased risk of death with consumption of at least one alcoholic drink per week, other studies have found no effect on survival.^1,6 Indeed, this is the reason for our caution in the interpretation of our results. We have also described potential causes of bias in our study.⁷ However, this was a large population-based breast cancer case series; our results add to the evidence available and do not show evidence of reduced survival with increased alcohol consumption. In summary, we stand by our conclusion that moderate alcohol consumption is unlikely to cause harm.

AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

The author(s) indicated no potential conflicts of interest.

ACKNOWLEDGMENT

G.B. is funded by a fellowship from Cancer Research UK and The Royal College of Radiologists. P.D.P.P. is a Cancer Research UK Senior Clinical Research Fellow.

REFERENCES

1. Rock CL, Demark-Wahnefried W: Nutrition and survival after the diagnosis of breast cancer: A review of the evidence. J Clin Oncol 20:3302–3316, 2002.[Abstract/Free Full Text]

2. Doyle C, Kushi LH, Byers T, et al: Nutrition and physical activity during and after cancer treatment: An American Cancer Society guide for informed choices. CA Cancer J Clin 56:323–353, 2006.[Abstract/Free Full Text]

3. Smith-Warner SA, Spiegelman D, Yaun SS, et al: Alcohol and breast cancer in women: A pooled analysis of cohort studies. JAMA 279:535–540, 1998.[Abstract/Free Full Text]

4. Hamajima N, Hirose K, Tajima K, et al: Alcohol, tobacco and breast cancer: Collaborative reanalysis of individual data from 53 epidemiological studies, including 58,515 women with breast cancer and 95,067 women without the disease. Br J Cancer 87:1234–1245, 2002.[CrossRef][Medline]

5. McDonald PA, Williams R, Dawkins F, et al: Breast cancer survival in African American women: Is alcohol consumption a prognostic indicator? Cancer Causes Control 13:543–549, 2002.[CrossRef][Medline]

6. Dal Maso L, Zucchetto A, Talamini R, et al: Effect of obesity and other lifestyle factors on mortality in women with breast cancer. Int J Cancer 123:2188–2194, 2008.[CrossRef][Medline]

7. Barnett GC, Shah M, Redman K, et al: Risk factors for the incidence of breast cancer: Do they affect survival from the disease? J Clin Oncol 26:3310–3316, 2008.[Abstract/Free Full Text]

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