Ep 32 Last Call: Alcohol, Breast Cancer and the Advice Gap

Heather (00:04)
Hi everyone, welcome to Dr. Patient. If you've been listening to my podcast for a while, you'll know that I rarely dive into actual health advice. But because it's Women's Health Month, I wanted to put something out there for all my girls, and I know it might make me a little unpopular, at least for a minute, and I'm okay with that. So with that preamble, I'm sorry to tell you that the fact is that having a few drinks a week increases your risk of getting breast cancer, among other cancers as well.

but I'm focusing today on chesticles as my daughter calls them because Women's Health Month. And with breast cancer globally being the most frequently diagnosed cancer in women, this deserves our attention. I'll be talking about what the medical research shows us about this association, what patients are told about it, and I'll guess at why more patients aren't told about it. With that, let's jump in.

Never. Once a week. Sometimes. This is the range of advice I've received from my various breast cancer doctors about how much I can consume alcohol since completing my surgery, chemotherapy, and radiation for breast cancer four years ago. An informal survey on my local Facebook breast cancer group confirms this variance in what advice is given. Dozens of members report being told that

It's okay to have anywhere from one to five drinks per week, to none ever, to none just during chemotherapy, to making sure that they, quote, exercise to negate the risk from the alcohol, end quote. And no, that is not a thing. Given that there's been a ton of solid research and data for decades now showing that consuming at least one drink a day and maybe even as little as three drinks per week for a woman increases the risk of developing breast cancer,

I expected that by now there would be a party line on this. As a physician, I'm shocked at the range of all of this conflicting advice. And it's tough to unravel just why the range exists at all. Let's dive more deeply into what research has been done on this because it's actually fascinating and a little alarming. If you've heard about the association between alcohol and breast cancer before, maybe this won't surprise you. But if you have not heard about this before,

You may be surprised to hear that the link between alcohol and cancers has been noted since the 19th century. The 19th century. At that time, the association was based on clinical observation alone. huh, cancers seem to happen often in the presence of lots of alcohol use. Epidemiology, which is the study of how diseases are distributed in populations and what factors influence them, didn't exist yet.

So all doctors had was observing and noting these potential links. It wasn't until the 1950s that researchers started doubling down on studies examining the association, at first with cancers of the upper GI tract, like mouth, throat, and esophagus only. About 30 years later, in 1987, alcohol was formally listed as a carcinogen. And 20 years later, both colorectal and breast cancers were added to the list of those cancers known to be associated with alcohol. And there have now been hundreds of studies on this topic, and the vast majority of them point to the same findings.

Before I get into the specifics of what the research shows, a quick sidebar on language, because I'm going to be using the word association a lot, and I want you to know what that actually means. In the medical and scientific community, saying that things are associated

is a deliberately cautious way of saying that they occur together more often than they would just by chance. But it doesn't necessarily mean that one causes the other. For example, ice cream sales are associated with drowning deaths. But ice cream doesn't cause drowning, that would be literally tragic. Hot weather increases both ice cream consumption and swimming, which can lead to drowning, so they all show up at the same time.

That's an association. I'm pointing this out because for a long time, the link between alcohol and breast cancer was described this way, associated. But I want to be clear about where the science stands now. For breast cancer, we are past that.

The relationship between alcohol and breast cancer has moved from associated to causal. This means it has been established that alcohol actually causes breast cancer directly. This is not a small distinction. It's a huge discovery that has massive health implications for a population that drinks a lot. One of the tools researchers use to make that leap from associated to causal, it's what's called a meta-analysis.

This is where data from many, sometimes hundreds of studies are all pooled and analyzed together to produce a much stronger, more reliable picture than any single study could. It matters because individual studies on alcohol are genuinely hard to do well. People aren't always honest about how much they drink and isolating alcohol from other lifestyle factors that can influence health like diet, exercise, sleep and smoking can be tricky.

But when you combine enough well-designed studies, the picture comes much more into focus. In 2015, a research group in Italy led by Dr. Bagnardi, a professor of medical statistics specializing in cancer research, published a major meta-analysis that helped confirm that causal link between alcohol and breast cancer. It pulled together data from over 500 studies.

What they found was that compared to the already known lifetime risk of developing breast cancer in the US, which is about 13 % or one in eight women that are non-drinkers or occasional drinkers, the Bagnardi group found that women who averaged just one drink per day had an approximately 7 % rise in that lifetime risk. Put differently, because math is complex.

Non-drinkers or occasional drinkers have that 13 % lifetime risk that I mentioned, while women who have one drink a day have more like a 20 % lifetime risk or one in five women. On top of that very annoying fact, they found that the risk was dose dependent, meaning that for each extra drink in a week, the risk goes up. It's a linear association, which implies that there is no safe minimum.

Researchers have also been able to clarify over time why alcohol does this to breast tissue specifically. So I'm going to delve into biochemistry for a minute. Don't panic. It will be okay.

Alcohol affects breast tissue in two distinct ways. First, when your body breaks down alcohol, it produces a chemical called acetaldehyde, which directly damages DNA in multiple ways, which is a problem because DNA is like the instruction manual that tells your cells how to grow and divide normally. When DNA gets damaged, cells can start growing out of control, which is how cancer begins. The second way that alcohol affects breast tissue

is that it increases circulating estrogen in your body, which is also a problem because most breast cancers eat estrogen as a food source to help it grow. So it's a double whammy effect. As my own brilliant breast surgeon, Dr. Nora Jaskowiak recently said to me, quote, it's all about biology. Alcohol is turned into acetaldehyde, which is a gene mutator.

And it can increase circulating estrogen levels, which cannot be good in the setting of estrogen receptor positive breast cancers, end quote. There it is in a nutshell. And I'll note that she is the only one of my breast cancer doctors that asks me about alcohol use every time I see her and recommends none at all for all of her patients. You go girl. And thank you for pushing on it.

Anyway, through all of this research, we've also discovered that alcohol's effect on breast tissue is probably greatest during the teenage and young adult years, when breast tissue is dividing rapidly and is especially vulnerable to damage. Think of it as wet cement. It's easier to leave a mark before it hardens. Once breast tissue fully matures, which typically happens after a full-term pregnancy, it becomes a bit more resistant to damage, though not immune by any standard.

To be clear, I am not saying that if you've had a kid, none of this matters anymore. It's more just that the alcohol use may have a bit more damaging effect when you're younger. I think about this factoid a lot, as I'll admit that I drank quite a bit during college and have wondered if it played a role in my own breast cancer. And I think about it a lot because I have a young adult daughter who I'm sure drinks sometimes. And no, you're not in trouble, but we will talk later. Okay, so we have decades of rigorous

replicated, well-designed research that has moved from observation to association to causation, and the mechanism of it is well understood. So why on earth aren't all of my doctors telling me this and advising me to lay off of it and give it up altogether? And not just me as a breast cancer survivor, but all women. Let's start with what awareness numbers actually look like.

As it stands now, only somewhere between a quarter and a half of US adults know that alcohol is even a risk factor for developing any kind of cancer. Among women, only somewhere between 11 and 40 % know that alcohol is a risk factor for breast cancer specifically. And only about half of general healthcare providers bring it up in a health visit, as self-reported by patients. So we have a situation where the science is solid, the risk is real,

and the information is simply not moving well from the research studies into the exam room. Why? I have some thoughts on why. The first is time. There are inherent time and workflow constraints on today's wellness visits. There's literally not enough time in an annual healthcare visit today to get to everything that should be covered. So most doctors start with the big things, illness, problems, medications, and they cover preventive health.

and topics like diet, fitness, and alcohol use at the end if they have time. I would guess that this is the single most common reason why it's not discussed. On the other hand, even when doctors do ask about alcohol intake, patients often lie about it because they do not want to be judged and do not want to hear how harmful drinking is to them. This is one reason why

Many doctors' offices will instead use a lifestyle questionnaire before the visit starts that includes questions on alcohol and drug use, smoking, sexual activities, and other stuff, because patients are more likely to give an honest answer on a questionnaire as opposed to being asked directly by their healthcare provider. If you get one of those questionnaires, please be as truthful as you can. I added a link in the show notes to a 2024 article called

Are we all lying to our doctors about how much we drink? Which, no judgment because statistically some of you are not, and it has some useful tips for how to actually have that conversation with your doctor, which I suggest you do.

In terms of counseling breast cancer patients, I've wondered if there's also a reluctance on the doctor's part to restrict the pleasures of people who are already struggling. I mean, for many people, alcohol is a coping mechanism. If someone has just been diagnosed with breast cancer and is facing surgery, chemo, and radiation, telling them to give up drinking on top of everything else can feel cruel, even when it's medically appropriate. Personally, though, I think honesty would serve the patient better.

Lastly, there's sort of a structural gap between primary care and cancer specialists, or any specialists really. Primary care providers may not be too deep into the breast cancer specific alcohol research. It's not their specialty. At the same time, cancer specialists may be assuming that that lifestyle counseling is happening in that primary care office. And so I bet this difference in practice style plays into why the conversation doesn't happen because it's literally just falling between the cracks.

On top of all of this, I have to acknowledge the decades of contradictory messaging from the medical community itself about alcohol. One example is the idea that a few glasses of red wine per week are protective to our cardiovascular system. That trend known as the French paradox, which sounds so cool, was popularized by a French researcher that noticed that there were pretty low rates of coronary artery disease in France despite their diet being rich in saturated fat.

I mean, think of all that delicious butter, cheese, and cream sauce, and fatty meats. And he postulated that perhaps the red wine that they drank were somehow protective of their cardiovascular system. Then the French paradox was covered in a 60 minutes episode in the US in 1991, which of course resulted in a massive spike in the US red wine sales as everyone jumped on that bandwagon.

I mean, what a fun idea. Yay, we should drink lots of red wine. Party time. The trouble is that soon after those original studies that suggested the benefit were largely debunked and found to be flawed. It's hard to turn the ship of healthcare advice when new data comes to light. And let's be honest, people hear what they want to. And who wants to hear that the red wine helping the heart thing is wrong? How annoying and disappointing, right? It's no longer party time.

Beyond the French paradox, the messaging regarding alcohol intake from healthcare organizations in the US has broadly changed over the last couple of decades. All major health groups have moved away from suggesting that alcohol intake is healthy or protective, so that's progress. Now, most of them have some form of a modified statement. For example, the American Heart Association stresses minimizing or avoiding alcohol.

The American Cancer Society says it's best not to drink alcohol, but if you're going to, no more than one drink a day for women, while the CDC says up to one drink a day is okay. And politics unfortunately makes an appearance on this topic. Organizations like the CDC and NIH, the National Institutes of Health,

really should operate independently from politics, but they don't because they're in actuality operating under the federal government, which is political. For example, in January of 2025, then Surgeon General Dr. Vivek Murthy, who was nominated for his second term by Joe Biden, And who is, in my opinion, the last really sensible Surgeon General.

issued a formal advisory calling for cancer warning labels on alcoholic beverages, essentially the cigarette style warning label treatment, and pointed out that alcohol is the third leading cause of preventable cancer in the US after tobacco and obesity. And I love that he squeezed that in just 17 days before he was dismissed by the Trump administration. Since then, none of the acting or Trump nominated surgeon generals, since none of them have been formally approved yet,

have said a word about the risk of cancers from alcohol. And while the US government has for decades recommended that women limit their alcohol to no more than one drink per day, these guidelines were quietly revised just a few months ago in January of 2026. The specific limit for women was replaced with a vague recommendation to just quote, limit alcoholic beverages, end quote. And,

the language warning that alcohol heightens cancer risk was removed entirely. Really not helpful. Further, Dr. Oz, the current administrator of the Centers for Medicare and Medicaid Services, said this year that, quote, in the best case scenario, I don't think you should drink alcohol, end quote. But then went on to say that alcohol is, quote, an excuse to bond and socialize.

And there's probably nothing healthier than having a good time with friends in a safe way."

Well, I guess I'd consider not getting cancer a more healthy choice than downing shots at a bar with friends, but what do I know? Remember that we have an administration and a secretary for health and human services that are generally anti-preventive medicine. So while it's really and truly disturbing, it's not surprising. Meanwhile, there's been no shortage of news coverage, often appearing in October to recognize Breast Cancer Awareness Month. Just to name a few, the Washington Post in 22 with

Doctors want alcohol warning labels to flag cancer risks. The World Health Organization saying straight up that there is no safe level of alcohol with regards to breast cancer risk. And the New York Times returning to this topic repeatedly in 2019 with even a little alcohol may raise cancer risk. And again in January 2025 with the battle over what to tell Americans about drinking.

These stories typically make a splash in the news cycle for about a week and then the news moves on as it does. And yet here we are with more than half of Americans still unaware that alcohol is linked to cancer at all. So clearly the news coverage isn't doing what it needs to.

If you look at social media, which unfortunately is where a lot of people get their health advice today, the picture is not great. A content analysis published in the Journal of Alcohol, Clinical and Experimental Research in 2026, looked at alcohol related posts on Instagram and TikTok and found that accurate information about cancer risk is nearly absent, while the vast majority of posts portray alcohol in a positive or comedic light.

nearly a quarter of TikTok posts specifically referenced intoxication or binge drinking. You've probably seen the whole mommy wine culture corner of the internet where a glass of wine is the universal symbol of self care and surviving parenthood. And look, I get it. I have felt that specific maternal exhaustion hundreds of times, if not thousands. But when that messaging drowns out the cancer risk messaging, we have a problem.

On the other side, there is a genuine and growing sober curious movement on social media that's pushing back. And there are excellent science communicators doing real work to get accurate health information out there. But for every one of those accounts, there are 10 more telling you that your evening rose is basically a vitamin. So if you're getting your health info from social media, at least check the credentials, look for sources, and maybe be a little suspicious of basically

all of it. To be sure, there's still so much that's unknown about all this. For example, we don't know clearly that alcohol increases the risk of recurrence of a previous breast cancer. A few studies suggest it does, and it may or may not. We don't know if seven drinks on one day is the same as one drink a day over a week, so don't ask me that. We don't know if wine is worse than beer or any other alcohol choice.

Though for now, it all seems to be the same because really alcohol is alcohol, regardless of what plant it comes from. So here's where I land on it all. As a physician who's had breast cancer, I have a vested interest in this from both sides of the bed. I have read all of this research. I've lived through the diagnosis and treatment. And

I've made the decision to avoid alcohol whenever possible because the evidence is too strong for me to ignore it. And this is not a simple task as I'm learning. Alcohol is deeply woven into social life, celebrations, travel, rituals, and more. It also makes things feel more fun and bearable, at least for the two hours until I start getting sleepy from it. Unfortunately, there is no known safe amount of alcohol when it comes to breast cancer risk.

the more you drink and the longer you drink over your lifetime, the higher the risk. So reducing or eliminating alcohol is one of the most actionable steps you can take to lower your risk of breast cancer. All this being said, this is a really personal decision. I had one friend tell me last year that a glass of wine per night actually helps her get through her breast cancer diagnosis and I totally get that.