Women, alcohol, and breast cancer: opportunities for promoting better health and reducing risk

Older women have been relatively neglected in discussions of reducing alcohol‐related harm

Alcohol use and the associated risks and potential harms for those who use it and others are among the most challenging and controversial issues in health care. An increasing array of harms associated with the consumption of alcohol, even at lower levels of use, have been identified by researchers.1 This is not a welcome message for many.

However, one area that has received relatively little attention in health promotion and clinical settings is the causal or contributory role of alcohol in cancer. In this issue of the MJA, Grigg and colleagues report their investigation of a novel brief animation‐based intervention for improving awareness of the alcohol–breast cancer risk connection in a double‐blinded, randomised controlled trial that included 557 women over 40 years of age who attended routine breast screening in Melbourne.2 At baseline, awareness of the link between alcohol use and breast cancer was low (20% of participants in each group), and the women had generally low levels of alcohol literacy. Awareness of the link had increased in both arms at week 4 of the study (to 65% in the active intervention group, and to 38% for those who received only nutritional advice), but the change over time was significantly greater in the active arm.2 This was a laudable study for many reasons, notwithstanding its focus on a health care setting where women may be especially motivated to engage in health‐promoting activities.

Breast cancer is the cancer most frequently diagnosed in Australian women; about one in seven will be diagnosed with it in their lifetimes.3 Prevention messages to date have focused on family history and age, as well as modifiable risk factors such as overweight, obesity, and physical activity.4 However, there is now a strong body of evidence that alcohol consumption increases breast cancer risk.5

The importance of the role of alcohol in breast cancer and preventive interventions is increasing with the rise in alcohol consumption among older women, in contrast to declining consumption in other population groups.6 Why women over 40 are drinking more alcohol is a complex and multifaceted question. Factors include more liberal attitudes to drinking by women, previously frowned upon or deemed the domain of less than respectable women. This perception has changed dramatically in recent years, facilitated by skilful, well funded promotional activities by alcohol marketers,7 and parallels significant changes in women's roles in society and their growing independence, agency, and autonomy. Women also have opportunities to drink alcohol where it was not previously available (eg, hairdressing salons, shopping centres, “happy hours” in retirement villages). Further, negative drivers of alcohol use are probably also involved, including the use of alcohol to help manage stress, anxiety, and depression.8

During the COVID‐19 pandemic, various changes in drinking patterns were identified in certain groups, including increased daily and heavy drinking by women in midlife.9 For many, alcohol was a mechanism to help reduce stress and pressure. Women were reported to carry additional burdens associated with working from home, providing home schooling for their children, and caring for isolated and homebound relatives, in addition to broader pandemic‐induced stress. Concomitantly, opportunities for socialising were very restricted, further encouraging drinking at home, whether alone or in company.9

In the context of these major changes to drinking patterns for women, awareness of the harms associated with alcohol use that are largely (but not exclusively) specific to women, including breast cancer risk, should be promoted. Increased clinical attention in novel settings where advice can be provided will allow more women to make informed choices. More than 1.8 million Australian women were screened by BreastScreen during 2018–2019,10 and the breast screening service intervention described by Grigg and colleagues2 could be readily implemented on a larger scale. While advice to reduce alcohol consumption is not always be palatable and may be met with resistance, even disbelief, it is increasingly important that we find ways to effectively inform women about the breast cancer risk associated with alcohol consumption and to find effective and supportive behaviour change mechanisms. Health‐related behavioural change is complex and consequently needs the engagement of multiple players as well as supportive environments (macro‐level factors).

Risky drinking by older women is a relatively new concern; preventive strategies have largely been centred on alcohol use by young people and middle‐aged men. However, research provides increasing evidence for the elevated risks incurred by women who drink alcohol, even at relatively low levels. It is time to turn our attention to those who have not been the traditional focus of attention of alcohol‐related harm mitigation discussions — women over 40 — certainly not in relation to the increased risks associated with cancers, most notably breast cancer.