American Journal of Epidemiology

Copyright 2001 by the Johns Hopkins University Bloomberg School of Public Health
All rights reserved

Vol. 154, No. 8

Printed in U.S.A.

Alcohol and Risk of Breast Cancer Ellison et al.

Exploring the Relation of Alcohol Consumption to Risk of Breast Cancer

R. Curtis Ellison, Yuqing Zhang, Christine E. McLennan, and Kenneth J. Rothman

alcohol drinking; breast neoplasms; meta-analysis

Most studies that have examined the relation between

alcohol consumption and breast cancer risk have shown
some increase in risk with heavier drinking (14), and many
have suggested that there may be some increase in risk with
only light drinking (e.g., at an average intake of one drink
per day) (517). A 1994 meta-analysis by Longnecker (18)
showed a linear increase in risk, with an estimate of an
approximate 10 percent increase for each 10-g/day increment in alcohol consumption. Since 1994, however, there
have been more than 20 studies on the subject, with some
showing no increased risk associated with light to moderate
drinking. Among these are the EURAMIC Study from
Europe (19) and new results from the Framingham Study
(20). Furthermore, among studies reporting beveragespecific effects, some have shown an inverse relation
between wine drinking and breast cancer risk (2123). This
finding would be consistent with several new laboratory
studies indicating that resveratrol and other substances in
red wine may reduce the risk of breast cancer (2428).
Here we present results of a meta-analysis of the epidemiologic studies conducted through 1999. This new metaanalysis was prompted by the following questions: 1) Is
there a monotonic increase in the risk of breast cancer asso-

ciated with alcohol consumption? 2) Specifically, what is

the effect on risk of breast cancer associated with consuming alcohol at a level of one drink per day (considered moderate by US Department of Agriculture guidelines (29))?
3) Do results differ between case-control studies and cohort
studies? 4) Are there differences between more recent studies and studies conducted earlier? 5) Do results differ
between studies carried out in the United States and those
carried out in other countries (where women may consume
larger amounts of alcohol and drink more frequently)?
6) How does the duration of follow-up in cohort studies
affect results? 7) Does alcohol consumption relate differently to the risks for premenopausal and postmenopausal
breast cancer? 8) Are there differences according to the type
of alcoholic beverage consumed?
MATERIALS AND METHODS
Selection of studies

By searching MEDLINE (US National Library of

Medicine), we identified studies published between January
1966 and October 1999. We supplemented these with additional studies cited as references in previous meta-analyses,
pooled analyses, and reviews. To be included in our metaanalysis, a published study had to 1) be an original article or
other report on a cohort or case-control study, 2) report alcohol intake data that could be quantified as grams of alcohol
per day, 3) present data on incident cases of breast cancer
(rather than prevalent cases) or mortality from breast cancer,
and 4) report point estimates and an estimate of variability
for the primary outcome. We excluded studies if they

Received for publication January 19, 2001, and accepted for publication April 30, 2001.
Abbreviation: CI, confidence interval.
From the Section of Preventive Medicine and Epidemiology,
Evans Department of Medicine, Boston University School of
Medicine, Boston, MA.
Correspondence to Dr. R. Curtis Ellison, Boston University School
of Medicine, 715 Albany Street, Room B-612, Boston, MA 02118 (email: ellison@bu.edu).

740

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There are lingering questions regarding the relation between alcohol consumption and breast cancer risk in
women. The authors performed a meta-analysis of epidemiologic studies carried out through 1999 to examine
the dose-response relation and to assess whether effect estimates differed according to various study
characteristics. Overall, there was a monotonic increase in the relative risk of breast cancer with alcohol
consumption, but the magnitude of the effect was small; in comparison with nondrinkers, women averaging 12
g/day of alcohol consumption (approximately one typical drink) had a relative risk of 1.10 (95% confidence
interval (CI): 1.06, 1.14). Estimates of relative risk were 7% greater in hospital-based case-control studies than
in cohort studies or community-based case-control studies, 3% greater in studies published before 1990 than in
studies published later, and 5% greater in studies conducted outside of the United States than in US studies.
The findings of five US cohort studies published since 1990 yielded a relative risk of 1.06 (95% CI: 1.00, 1.11)
for consumers of 12 g/day, as compared with nondrinkers. Cohort studies with less than 10 years of follow-up
gave estimates 11% higher than cohort studies with longer follow-up periods. No meaningful difference was
seen by menopausal status or type of beverage consumed. Am J Epidemiol 2001;154:7407.

Alcohol and Risk of Breast Cancer 741

1) reported only prevalent cases, 2) included only nonquantifiable alcohol intake data, 3) were based on data from
another publication that was included in the meta-analysis,
4) were from reports published only as letters to the editor
or abstracts, or 5) had implausible outcomes (a criterion
used for only one study (30) that was similarly excluded by
Longnecker (18) as having implausible outcomes).
Of a total of 74 publications considered, we excluded 30.
The present meta-analysis of breast cancer incidence was
based on 42 reports providing data on 41,477 incident cases
of breast cancer. These reports consisted of all of the studies
listed in table 1 except for two studies on breast cancer mortality (49, 50), which provided data on 3,283 cases for a separate analysis. Table 2 shows characteristics of reports that
we considered but excluded and indicates the reasons for

exclusion. Studies that did not provide quantifiable alcohol

consumption data are listed as having insufficient data.
For several studies in which the data included in the metaanalysis were obtained from another publication, exclusions
are noted as data included in separate report.
Data extraction and unification

The quality of exposure information varied greatly among

the reports. In most of the cohort studies and some of the
case-control studies, investigators used self-reported food
frequency questionnaires for estimation of alcohol consumption, while in other studies they used specific questionnaires
or interviews. Fifteen studies reported some beveragespecific alcohol data; 13 of these had data on all three types

Study and year

(ref. no.)
Adami et al., 1988 (21)
Bowlin et al., 1997 (15)
Chu et al., 1989 (46)
Ewertz, 1991 (47)
Ferraroni et al., 1991 (8)
Ferraroni et al., 1998 (16)
Freudenheim et al., 1995 (23)
Friedenreich et al., 1993 (48)*
Fuchs et al., 1995 (49)
Gapstur et al., 1992 (3)*
Garfinkel et al., 1988 (50)
Graham et al., 1992 (4)*
Harris et al., 1992 (51)
Harvey et al., 1987 (5)
Hiatt and Bawol, 1984 (52)
Hiatt et al., 1988 (53)
Holmberg et al., 1995 (54)*
Howe et al., 1991 (2)
Hoyer and Engholm, 1992 (55)
Katsouyanni et al., 1994 (10)
La Vecchia et al., 1989 (9)
Levi et al., 1996 (56)
Longnecker et al., 1995 (13)
Longnecker et al., 1995 (12)
Martin-Moreno et al., 1993 (57)
Meara et al., 1989 (58)
Mezzetti et al., 1998 (17)
Nasca et al., 1990 (59)
Ranstam et al., 1995 (60)
Richardson et al., 1989 (61)
Rosenberg et al., 1990 (22)
Royo-Bordonada et al., 1997 (19)
Schatzkin et al., 1987 (62)
Simon et al., 1991 (63)
Smith et al., 1994 (64)
Sneyd et al., 1991 (1)
Swanson et al., 1997 (14)
Van den Brandt et al., 1995 (11)*
Van t Veer et al., 1989 (65)
Viladiu et al., 1996 (66)
Willett et al., 1987 (6)*
Willett et al., 1998 (67)*,
Young, 1989 (68)#
Zhang et al., 1999 (20)
Smith-Warner et al., 1998 (67)

Study
design
Case-control, community controls
Case-control, community controls
Case-control, community controls
Case-control, community controls
Case-control, hospital controls
Case-control, hospital controls
Case-control, community controls
Cohort study
Cohort study
Cohort study
Cohort study
Cohort study
Case-control, hospital controls
Case-control, community controls
Cohort study
Cohort study
Cohort study
Case-control, community controls
Cohort study
Case-control, hospital controls
Case-control, hospital controls
Case-control, hospital controls
Case-control, community controls
Case-control, community controls
Case-control, community controls
Case-control, hospital controls
Case-control, hospital controls
Case-control, community controls
Case-control, community controls
Case-control, hospital controls
Case-control, community controls
Case-control, hospital controls
Cohort study
Cohort study
Case-control, community controls
Case-control, community controls
Case-control, community controls
Cohort study
Case-control, community controls
Case-control, community controls
Cohort study
Cohort study
Case-control, community controls
Cohort study
Pooled analyses

Country
Sweden/Norway
United States
United States
Denmark
Italy
Italy
United States
Canada
United States
United States
United States
United States
United States
United States
United States
United States
Sweden
International
Denmark
Greece
Italy
Switzerland
United States
United States
Spain
United Kingdom
Italy
United States
Sweden
France
Canada
Multiple European countries
United States
United States
United Kingdom
New Zealand
United States
Netherlands
Netherlands
Spain
United States
United States
United States
United States
International

No. of
cases
422
1,013
3,217
544
2,569
210
740
419
350
643
2,933
367
604
1,524
838
303
672
1,573
51
798
2,402
230
1,431
6,662
762
1,116
2,566
1,608
393
349
133
315
121
87
753
840
1,645
405
200
330
1,023
806
506
287

* Some results from these papers were derived from the pooled analysis by Smith-Warner et al. (67).
Data were reported separately for premenopausal and postmenopausal status; entered as two studies.
Pooled data from studies from Argentina (97), Greece (98), Italy (99), Canada (100), Australia (87), and Italy (91).
Entered as three independent studies, because data were reported for three control groups.
Previously unpublished results from the Nurses Health Study that were included in the paper by Smith-Warner et al. (67).
# Entered as two independent studies, because data were reported for two control groups.

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TABLE 1. Studies included in a meta-analysis of alcohol consumption and breast cancer incidence or
mortality

742

Ellison et al.
TABLE 2. Studies excluded from a meta-analysis of alcohol consumption and breast cancer incidence
or mortality and reasons for exclusion
Study and year
(ref. no.)
Case-control,
Case-control,
Case-control,
Case-control,
Cohort study
Cohort study
Case-control,
Case-control,
Case-control,
Cohort study
Case-control,
Case-control,
Case-control,
Case-control,
Case-control,
Case-control,
Case-control,
Case-control,
Case-control,
Case-control,
Case-control,
Cohort study
Case-control,
Case-control,
Cohort study
Case-control,
Case-control,
Case-control,
Case-control,
Case-control,

Reason study
was excluded

hospital controls
community controls
hospital controls
hospital controls

community controls
hospital controls
hospital controls
hospital controls
hospital controls
hospital controls
community controls
community controls
community controls
community controls
community controls
community controls
community controls
hospital controls
hospital controls
community controls
hospital controls
community controls
community controls
community controls
hospital controls

of alcoholic beverages (beer, wine, and spirits). In the

remaining studies, only total alcohol consumption was
reported. Information on established risk factors for breast
cancer varied among the studies. Of the 13 cohort studies
included in the meta-analysis on incidence, nine were from
the United States and four were from other countries. Ten of
the case-control studies were from the United States, while
the remaining 19 were from other countries.
Statistical analysis

For all studies, the level of alcohol consumption used in

the meta-analysis was based on the categories reported in
the original paper. Most studies used the reported consumption of the women over a prolonged period of time prior to
the diagnosis of breast cancer. For each study, we took the
age range of the population and the ranges of all categories
of alcohol consumption reported and then calculated a
median consumption value for each category. To do this, we
obtained data from the 1988 alcohol supplement of the
National Health Interview Survey (31) for women of the
same age, created similar consumption categories for
women reporting current alcohol consumption, and took the
median value.
In the analyses, we first examined the shape of the doseresponse relation between alcohol consumption and risk of
breast cancer. The dose-specific confounder-adjusted logarithms of the relative risks from all studies were pooled, and
we fitted a curve using weighted quadratic spline regression
(32), with no intercept term. The weights were the inverse of
the covariance-adjusted variance of the logarithms of the

Prevalent cases
Data included in separate report
Letter to editor
Insufficient data
Insufficient data
Data included in separate report
Prevalent cases
Insufficient data
Insufficient data
Abstract
Data included in separate report
Insufficient data
Insufficient data
Abstract
Insufficient data
Prevalent cases
Insufficient data
Beverage-specific data only
Abstract
Data included in separate report
Insufficient data
Data included in separate report
Insufficient data
Data included in separate report
Insufficient data
Insufficient data
Data included in separate report
Data included in separate report
Data included in separate report
Implausible outcomes

relative risks. Since the results from the spline regression

analysis showed that there was a monotonic increase in relative risk of breast cancer with increasing alcohol consumption, in the later analyses, we applied the linear regression
model to assess the heterogeneity of estimates of alcohol
effect according to various characteristics of the studies.
These characteristics included type of study (cohort study,
community-based case-control study, hospital-based casecontrol study), number of years of follow-up for cohort studies (<10 years, 10 years), date of publication (before 1990,
1990 or later), location of the study (United States, outside
the United States), and menopausal status of the subjects
when their breast cancer was diagnosed (premenopausal,
postmenopausal). In the linear regression model, we created
an interaction term (an indicator term for the study characteristic dose of alcohol) to assess quantitatively whether
these characteristics modified the estimated alcohol effect
(33). The beta coefficient for each interaction term represents the ratio of log relative risks, i.e., the magnitude of difference in estimated alcohol effects according to characteristics of the study. We also applied the same approaches to
examine the effects of different types of alcoholic beverages
on the risk of breast cancer. In these analyses, consumers of
each specific beverage were compared with nondrinkers of
that specific beverage, adjusting for other alcoholic beverages consumed and study characteristics.
When we examined the association between total alcohol
consumption and breast cancer risk, we obtained adjusted
relative risks and the ratio of relative risks in increments of
12 grams of alcohol (ethanol) per day. For beverage-specific
analyses, we used an increment of one drink per day,
Am J Epidemiol Vol. 154, No. 8, 2001

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Begg et al., 1983 (69)

Brinton et al., 1997 (70)
Byers and Funch, 1982 (71)
Cusimano et al., 1989 (72)
Dupont et al., 1989 (73)
Gapstur et al., 1995 (74)
Haile et al., 1996 (75)
Harris and Wynder, 1988 (76)
Kato et al., 1989 (77)
Klatsky et al., 1987 (78)
La Vecchia et al., 1985 (79)
Le et al., 1984 (80)
Le et al., 1986 (81)
Metzger et al., 1990 (82)
OConnell et al., 1987 (83)
Paganini-Hill and Ross, 1983 (84)
Pawlega, 1992 (85)
Ranstam and Olsson, 1995 (60)
Reynolds et al., 1988 (86)
Rohan and McMichael, 1988 (87)
Rosenberg et al., 1982 (88)
Schatzkin et al., 1989 (89)
Talamini et al., 1984 (90)
Toniolo et al., 1989 (91)
Vaeth and Satariano, 1998 (92)
Viel et al., 1997 (93)
Webster et al., 1983 (94)
Weiss et al., 1996 (95)
Williams and Horm, 1977 (96)
Zaridze et al., 1991 (30)

Study
design

Alcohol and Risk of Breast Cancer 743

rather than 12 grams of alcohol per day, since any differences would presumably be due to substances other than
alcohol in the different beverages. For breast cancer mortality, results suggested a J-shaped relation between alcohol
consumption and breast cancer deaths, so we did not evaluate the association as a linear relation.
RESULTS

FIGURE 1. Relative risk of breast cancer by alcohol consumption. Based on all studies of incidence listed in table 1, with no adjustments. The
dose-response curve line represents estimates from a smoothed spline regression, with the lower line representing no effect. The y-axis presents relative risks on a log scale.

Am J Epidemiol Vol. 154, No. 8, 2001

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The dose-response relation between total alcohol consumption and risk of breast cancer, assessed using a spline
regression model, is shown in figure 1. There appeared to be
a monotonic increase in breast cancer relative risk with
increasing alcohol consumption. In comparison with nondrinkers, subjects consuming an average of 6 g of alcohol
per day (approximately one half of a typical drink) had a
4.9 percent increased risk (95 percent confidence interval
(CI): 1.03, 1.07), and those consuming 12 g/day (approximately one drink) and 24 g/day (approximately two drinks)
had 10 percent (95 percent CI: 1.06, 1.14) and 21 percent
(95 percent CI: 1.13, 1.30) increased risks, respectively.
Table 3 presents associations between alcohol consumption and breast cancer risk according to different study
characteristics. Estimates of alcohol effect obtained from
hospital-based case-control studies were slightly higher, on
average, than those from cohort studies (overall relative
risk ratio  1.07, 95 percent CI: 1.00, 1.14). The alcoholbreast cancer relation assessed from community-based
case-control studies was similar to that from cohort studies.
Our analysis also indicated that, overall, studies published
before 1990 showed slightly larger relative risks than studies published later (overall relative risk ratio  1.03, 95

percent CI: 0.99, 1.08), and studies published outside of the

United States yielded slightly higher estimates than US
studies (overall relative risk ratio  1.05, 95 percent CI:
0.99, 1.12).
In analyses limited to recent cohort studies conducted in
the United States, there was still a slight increase in risk of
breast cancer with alcohol consumption. For the five US
cohort studies on breast cancer incidence carried out since
1990 (3, 4, 20, 63, 67), with a total of 2,190 cases, the relative risk for consumers of 12 g of alcohol per day (versus
nondrinkers) was 1.06 (95 percent CI: 1.00, 1.11).
Also shown in table 3 is the relation of duration of followup in cohort studies to reported risk of breast cancer. In
cohort studies with 10 or more years of follow-up, the
relative risk of breast cancer for women consuming 12 g of
alcohol per day was only 4 percent higher than it was for
nondrinkers. When we compared cohort studies according
to duration of follow-up, the risk from the eight studies with
less than 10 years of follow-up was 11 percent higher (95
percent CI: 1.06, 1.16) than that from the five studies with
10 or more years of follow-up.
In 10 studies, data were available on both the premenopausal and postmenopausal occurrence of breast cancer. As table 3 indicates, the results suggested that the relative risks of breast cancer associated with alcohol
consumption were similar for premenopausal and postmenopausal women, with the adjusted estimate for premenopausal women being only 2 percent higher than that
for postmenopausal women.
Table 4 shows the relation of alcohol consumption to
breast cancer risk according to the type of alcoholic beverage consumed. These results are based on 13 studies that

744

Ellison et al.

TABLE 3. Relation of alcohol consumption to breast cancer in a meta-analysis of studies conducted through 1999, according to
study characteristics
Ratio of
relative
risks

95%
confidence
interval

1.10
1.17

1.0
1.07

1.00, 1.14

1.09

1.00

0.95, 1.04

1.08
1.12

1.0
1.03

0.99, 1.08

1.07

1.0

1.13

1.05

20, 52, 55, 62, 63

1.04

1.0

3, 4, 6, 11, 48, 53, 54, 67

1.15

1.11

1.06, 1.16

1, 13, 1517, 48, 51, 57, 65, 87

1, 13, 1517, 48, 51, 57, 65, 87

1.17
1.19

1.0
1.02

0.95, 1.09

Reference numbers
of studies included

Type of study*
Cohort study
Hospital-based case-control study
Community-based case-control study

Year of publication
Published during or after 1990

3, 4, 6, 11, 20, 48, 5255, 62, 63, 67

810, 16, 17, 19, 51, 56, 58, 61
1, 2, 5, 1215, 2123, 46, 47, 57, 59, 60,
6466, 68

14, 8, 1017, 19, 20, 22, 23, 47, 48, 51,

5457, 59, 60, 63, 64, 66, 67
5, 6, 9, 21, 46, 52, 53, 58, 61, 62, 65, 68

Published before 1990

Location of study
United States

36, 1215, 20, 23, 46, 5153, 59, 62, 63,

67, 68
1, 2, 811, 16, 17, 19, 21, 22, 47, 48,
5458, 60, 61, 65, 66

Outside of United States

Length of follow-up (cohort studies)

Cohort study with 10 years of
follow-up
Cohort study with <10 years of
follow-up
Menopausal status of cases#
Postmenopausal breast cancer
Premenopausal breast cancer

0.99, 1.12

* Data were adjusted for year of publication (<1990 vs. 1990) and location of study (United States vs. other countries).
Reference category.
Data were adjusted for type of study and location of study.
Data were adjusted for type of study and year of publication.
Data were adjusted for year of publication and location of study.
# Data were adjusted for type of study, year of publication, and location of study.

reported relative risks separately for each of the three types

of alcoholic beverages: beer, wine, and spirits. Results are
given as the relative risk for women averaging one drink per
TABLE 4. Relation of alcohol consumption to breast cancer
in a meta-analysis, according to type of alcoholic beverage
consumed*
Type
of
beverage
Wine
Beer
Spirits

Reference numbers
of
studies included
2, 6, 8, 14, 2023, 4648,
57, 60
2, 6, 8, 14, 2023, 4648,
57, 60
2, 6, 8, 14, 2023, 4648,
57, 60

Relative
risk
for one
drink
per day

Ratio of
relative
risks

1.14

1.0

1.10

0.96

0.91, 1.02

1.14

1.01

0.93, 1.09

95%
confidence
interval

* Data were adjusted for type of study, year of publication, and location of
study. Relative risk estimates presented are for women who consumed one
drink per day (the equivalent of 12 g of ethanol per day) or seven drinks per
week in comparison with nondrinkers of that type of beverage, adjusting for
intake of the other beverages. For consumption of three drinks per week, the
ratio of relative risks for beer versus wine and spirits versus wine would be
0.98 (95% confidence interval: 0.96, 1.01) and 1.00 (95% confidence interval:
0.97, 1.04), respectively.
Reference category.

day (equivalent to 12 g of alcohol) in comparison with subjects consuming none of that beverage; for the ratio of relative risks, we used wine consumers as the referent group.
Because of limited data on higher consumption levels, the
estimates of effect could only be compared for 14 or fewer
drinks per week of each beverage.
As table 4 shows, there were few differences between
intake and breast cancer risk for the different beverages. In
comparison with wine, the relative risk for beer was 0.96
(95 percent CI: 0.91, 1.02); the relative risk associated with
spirits, in comparison with wine, was 1.01 (95 percent CI:
0.93, 1.09). Thus, these analyses did not support the hypothesis that nonalcoholic components of wine modify the
alcohol-breast cancer relation.
Data on breast cancer mortality related to alcohol consumption were available from two cohort studies (49, 50)
with a total of 3,283 deaths from breast cancer. A separate
meta-analysis using a spline regression model suggested a Jshaped relation between alcohol consumption and breast
cancer mortality. The estimated relative risk of breast cancer
mortality was slightly below 1.0 for up to 6 g/day, and it
increased above 1.0 thereafter. Relative risks at 6, 12, and 24
g/day were 0.98, 1.15, and 1.16, respectively.
Am J Epidemiol Vol. 154, No. 8, 2001

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Relative risk
for consumption
of 12 g of
alcohol per day
(vs. nondrinking)

Study
characteristic

Alcohol and Risk of Breast Cancer 745

DISCUSSION

Am J Epidemiol Vol. 154, No. 8, 2001

ACKNOWLEDGMENTS

This research was supported by funds from the Institute

on Lifestyle and Health, Boston University School of
Medicine (Boston, Massachusetts).

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Our analyses confirmed that, overall, most studies

demonstrate a monotonic increase in the risk of breast cancer with increasing consumption of alcoholic beverages.
Our estimate that an average of one drink per day is associated with a 10 percent increase in breast cancer risk is very
similar to that reported by Longnecker (18). However, we
found that the relation of alcohol to breast cancer risk varies
by type of study. Hospital-based case-control studies, on
average, show stronger associations than cohort studies,
while community-based case-control studies suggest relative risks similar to those of cohort studies. One explanation
for these findings is that moderate alcohol consumers may
be less likely to be hospitalized, because of a protective
effect of moderate alcohol consumption against cardiovascular diseases (3437), diabetes (38, 39), osteoporosis (40),
gallbladder disease (41), and other conditions. Such an
effect would not play a role when controls were chosen from
the community, which is consistent with our finding of little
difference between results obtained from community-based
case-control studies and cohort studies.
Our analyses also suggested that effect estimates for
breast cancer risk according to alcohol consumption are
slightly greater for results of studies published before 1990
than for those published since then. This trend could be due
to publication bias, in that more strongly positive study
findings may have been more likely to be accepted for publication in the earlier years. With increasing interest in the
topic in recent years, other well-done studies showing less
of an effect may have been accepted.
We found that studies conducted outside of the United
States showed slightly higher relative risks associated with
alcohol consumption than studies conducted in the United
States. There are many factors that could relate to such a difference. For example, if the overall risk of breast cancer is
lower in another country than in the United States, the lower
baseline risk might lead to an increased relative risk associated with alcohol. Other differences, such as diet, early
growth factors, differences in age at menarche or first birth,
etc., may also result in differences in relative risk of breast
cancer for similar intakes of alcohol.
While most of the differences described above are of
small magnitude, a somewhat larger difference was seen
between estimated relative risks in cohort studies according
to the duration of follow-up for ascertainment of disease.
Cohort studies with less than 10 years of follow-up gave 11
percent higher relative risks of breast cancer than studies
with longer follow-up periods. This effect may be due to
aging of the population in the studies, since older women are
at higher baseline risk of breast cancer, which could lead to
a smaller relative risk from alcohol consumption (42). If that
is true, this possibility implies that studies which examine
rate differences, rather than rate ratios, may be more informative about the effect of alcohol consumption.
Our analyses did not demonstrate differences in the relation
between alcohol and breast cancer occurring before and after
menopause. On the basis of an increase in baseline risk associated with aging, one might expect to observe higher relative
risks for premenopausal women, but this result was not seen.

A number of studies have shown that resveratrol and

other nonalcoholic components of wine suppress the growth
of animal and human cancer cells (2428, 43, 44). This finding has led to the speculation that moderate wine drinkers
would have a lower risk of breast cancer than consumers of
other beverages. Our analyses did not support this contention, as we found little difference in relative risks of
breast cancer according to whether the beverage was beer,
wine, or spirits.
In summary, our study confirmed the results of an earlier
meta-analysis (18) showing a modest relation of alcohol
consumption to risk of breast cancer, with a 10 percent
higher risk being seen among women reporting approximately one alcoholic drink per day as compared with nondrinkers. Furthermore, our study also suggests that the magnitude of the association between alcohol consumption and
breast cancer risk appears to be even lower with longer-term
follow-up in cohort studies. The question of causality
remains unclear. As Longnecker stated in a recent commentary, A relation of this size is likely to remain controversial
because, in this instance, it is beyond the resolution of epidemiologic methods, as the possibility of confounding or
other bias seems difficult to exclude (45, p. 102).

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