Abstract
We aimed to explore positive and negative associations of consuming alcohol with psychosocial outcomes among colorectal cancer (CRC) survivors. We used data of an observational prospective cohort study, consisting of 2625 Dutch CRC survivors enrolled 1-11 years post-diagnosis that were followed-up in 4 yearly surveys. Generalized estimated equation models were used to examine longitudinal associations between alcohol consumption and anxiety, depression, and health-related quality of life (HRQoL), while correcting for sociodemographic, lifestyle and clinical characteristics. Compared to lifetime abstainers, former alcohol consumption was associated with more depressive symptoms, and worse global quality of life and social functioning, while current drinking was associated with less anxiety, depression and better HRQoL. More drinks per week was associated with less nausea/vomiting. Compared to abstainers, moderate (≤7 drinks/week) and heavy alcohol consumption (>7 drinks/week) were associated with less anxiety and depression and better HRQoL, mostly attributable to wine consumption. Whereas current alcohol consumption was longitudinally associated with less anxiety and depression and better HRQoL, former drinking was associated with worse psychosocial outcomes, although based on a small sample size. It is important to consider that besides the potential negative effects of alcohol on patients’ health, alcohol consumption may be positively related with psychosocial outcomes.
Supplemental data for this article is available online at https://doi.org/10.1080/01635581.2022.2044063
Introduction
Colorectal cancer (CRC) is the second most common cancer and cause of cancer death in Europe (Citation1), and the number of CRC survivors is increasing (Citation2). Consuming alcohol is not only a risk factor to develop CRC (Citation3), but CRC survivors are also advised not to consume any alcohol, including specific alcoholic beverage types, or to reduce its use (Citation4). Although alcohol seems to promote CRC carcinogenesis (Citation5), its relation to (quality of) survival after CRC diagnosis is not clear from the literature (Citation6). Some studies even find that consuming light amounts of alcohol is better for CRC survival (Citation7), especially wine consumption (Citation8).
In cancer survivors, roughly one third of the population has psychosocial problems, such as anxiety, depression and fatigue, often persisting years after treatment (Citation9). Psychosocial problems are not only associated with various late effects of cancer, but they have also been shown to have a negative impact on morbidity and mortality (Citation10), and might be a barrier for behavioral changes (Citation11). Generally, consuming any alcohol is believed to reduce negative and enhance positive emotions, to emphasize feelings of relaxation and to increase social bonding (Citation12). Yet, inconsistent associations have been observed between alcohol consumption and depression, anxiety, or health-related quality of life (HRQoL). Whereas some studies found that alcohol consumption was associated to more psychosocial problems (Citation13–15), others did not find any association (Citation16, Citation17) or even found a reverse association (ie., better psychosocial outcomes when patients consumed more alcohol) (Citation18).
Perhaps it is important to know how well CRC survivors are dealing with their disease, both physically and mentally, and this may alter their drinking behavior. They may drink to cope with the stress of having CRC, but on the other hand, they may also drink during social activities or regular daily habits, while recovering from their disease. There may also be a difference in survivors who stopped consuming alcohol, perhaps due to experienced problems or treatment side effects, or the ones who never drank. Previous research hardly investigated whether persons were lifetime abstainers or former drinkers. Moreover, most research in this area was cross-sectional or investigated other cancer types like head and neck or cervical cancer (Citation13–18). It is not clear at present if alcohol is associated with worse or better psychosocial outcomes in CRC survivors, and whether this for instance differs over the survivorship trajectory.
Therefore, we first aimed to assess longitudinal associations between alcohol consumption and psychosocial outcomes (anxiety, depression, and HRQoL) in a large CRC survivor cohort with study enrollment 1-11 years post-diagnosis, examining associations for lifetime abstainers vs. former or current drinkers, number of drinks, and different beverage types (beer, wine, and liquor). In addition, we investigated the influence of time since diagnosis on the association between alcohol and psychosocial outcomes.
Materials and Methods
Setting and Participants
Data was used of 2625 stage I–IV CRC survivors participating in an observational prospective cohort study within the Patient Reported Outcomes Following Initial Treatment and Long-Term Evaluation of Survivorship (PROFILES) registry (Citation19). PROFILES is linked to the Netherlands Cancer Registry that routinely collects information from all newly diagnosed cancer patients in The Netherlands. The study was conducted according to the Declaration of Helsinki guidelines and approved by the medical ethics committee of the Maxima Medical Center in Veldhoven (the Netherlands, protocol number 0822). Written informed consent was obtained from all subjects before participation. Details of the data collection have previously been reported (Citation20). In short, CRC survivors participating in the prospective cohort study were asked to complete surveys, either online or on paper, in yearly waves from 2010 onwards. Supplemental Figure 1 shows the flowchart of this cohort. We did not take wave four into account, as this was an additional time point halfway between waves 3 and 5, and had different variables measured. The same participants were asked throughout all waves and there was a good response rate between waves (81-83%). For the present analyses, we used data from four yearly waves conducted between 2010 (between 1-11 years post-diagnosis) and 2013 (between 5-14 years post-diagnosis). We used the maximum amount of data of alcohol consumption and did not select survivors with all other data completed.
Psychosocial Outcomes
Anxiety and depressive symptom scores were calculated from the validated Hospital Anxiety and Depression Scale (HADS), which consists of seven items for anxiety and seven for depression (range 0-21 points), with higher scores indicating more symptoms (Citation21). A cutoff value of eight points for each subscale is used to identify clinically relevant levels of anxiety or depressive symptoms (Citation22).
Next, HRQoL was assessed with the validated European Organization for Research and Treatment of Cancer Quality of life Questionnaire - Core 30 (EORTC QLQ-C30, version 3.0) (Citation23). HRQoL domains were global quality of life and cognitive, emotional, physical, role, and social functioning. Symptom scales included fatigue, pain, and nausea/vomiting. According to the EORTC guidelines, a sum score was calculated for every domain and symptom scale (0-100 points). Higher scores on domains represent better quality of life or functioning, whereas higher scores on symptom scales mean more complaints (Citation23). For this manuscript, we did not take the EORTC single items into account.
Alcohol Consumption
Alcohol consumption was recorded at every measurement with questions like the average frequency of alcohol consumption per week in the past year, and the number of glasses of beer, wine, and liquor. For each alcoholic drink, we assumed that all types of alcoholic beverages, ie., beer (5% alcohol in 250 mL), wine (12% alcohol in 100 mL) or liquor (35% alcohol in 35 mL), contain 10 grams ethanol per unit of consumption (Citation24). Alcohol consumption was defined at each time point as A) lifetime abstainers, former or current drinker; B) the number of drinks/week; C) the categories of nondrinkers, moderate drinkers (≤7 drinks/week) and heavy drinkers (>7 drinks/week), according to the most recent Dutch guidelines (Citation24). We additionally checked whether lifetime abstainers responded consistently at each time point.
Covariates
Information was collected about age and sex, as well as education level, which was categorized as low (lower vocational and primary education), medium (intermediate vocational and secondary education) and high level of education (higher vocational and university). Participants also filled out questionnaires about their lifestyle. Physical activity was measured as the number of hours per week of moderate-to-vigorous physical activity (MVPA) by the Short QUestionnaire to ASsess Health-enhancing physical activity (SQUASH) (Citation25). Smoking was recorded as nonsmoker, former and current smoker. Body mass index (in kg/m2) was determined based on self-reported body height and weight. The Self-Administered Comorbidity Questionnaire (SCQ) was used for the number of comorbidities (none, 1 or ≥2) (Citation26). Clinical characteristics like tumor localization (colon or rectum), tumor stage (I-IV), treatments received besides surgery (chemotherapy and radiotherapy), and the placing of a (permanent) stoma (yes/no) were retrieved.
Statistical Analyses
All variables were described as percentages or means and standard deviations or as medians and interquartile ranges for non-normally distributed factors. We compared sample characteristics of survivors across the lifetime abstainers, former and current drinkers using chi-square tests for categorical variables, independent sample t-tests for normally distributed continuous variables and Mann-Whitney U tests for non-normally distributed continuous variables. Then we also showed all sample characteristics at the four time points.
Next, to determine associations of alcohol consumption with psychosocial outcomes over time, we used generalized estimating equations (GEE) with an exchangeable correlation structure. GEE analyses take into account within-person correlations when examining multiple observations per subject over time and it can handle missing subjects (Citation27). First, we analyzed associations between alcohol status (ie., lifetime abstainers vs. former or current drinkers) and psychosocial outcomes with linear GEE, and with logistic GEE for dichotomous anxiety or depressive symptoms above their cutoff values. As sensitivity analyses, we ran these analyses while excluding the former drinkers, determining current drinkers vs. the lifetime abstainers. Next, we used the number of drinks of alcohol as a determinant, and psychosocial factors as the outcomes. Subsequently, we analyzed the categories of drinking (ie., nondrinkers vs. moderate or heavy drinkers) as determinant to see if the relation between alcohol and psychosocial outcomes depends on how much they drink. We corrected all analyses for a priori defined confounders, including age, sex, education, physical activity, smoking status, BMI, months since diagnosis, cancer localization, chemotherapy, radiotherapy, and stoma placement. Then, we ran the analyses for each of the beverage types, mutually corrected for the other beverage types, to examine whether they were independently associated with psychosocial outcomes.
Next, we analyzed potential effect modifications of time since diagnosis, sex, and age in the analyses of drinks/week and psychosocial outcomes, by adding the interaction term alcohol*time since diagnosis, alcohol*sex or alcohol*age group into the models, respectively. When the interaction terms were statistically significant, we stratified for groups: for persons being either below or above the median baseline time since diagnosis, for sex, or for age groups below or above the retirement age (65 years in the Netherlands at that time). All analyses were conducted using SPSS version 24.0 (IBM Corp., Armonk, NY, USA). Significance level was set at p ≤ 0.01, two-tailed.
Results
Sample Characteristics
shows the sample characteristics for the entire sample, and for the lifetime abstainers, former and current drinkers. At baseline, survivors were on average 69 years old and 45% was female. Supplemental Table 1 shows the sample characteristics of the baseline and three follow-up time-points of this cohort. shows the characteristics of the sample at each wave, regarding alcohol consumption and depression, anxiety and HRQoL. While 24% was lifetime abstainer, 8% was former drinker, and 69% was current drinker at baseline. Of the current drinkers, 48% drank moderate amounts (<7 drinks/week) and 20% drank heavy amounts of alcohol (≥7 drinks/week) at baseline. Of the survivors, 21% had clinically relevant anxiety symptoms and 19% had clinically relevant depressive symptoms.
Table 1. Sample characteristics according to alcohol use.
Table 2. Alcohol consumption and psychosocial factors and HRQoL at each wave.
Alcohol Consumption and Psychosocial Outcomes
Compared to lifetime abstainers, former alcohol consumption was associated with more depressive symptoms, and worse global quality of life and social functioning, whereas current drinking was associated with less anxiety, depression and better scores on almost all HRQoL domains and symptom scales (). In sensitivity analyses, we excluded the former drinkers, and saw that current drinkers showed very consistent results compared to lifetime abstainers (data not shown). The number of drinks/week was only associated with less nausea and vomiting (). When we examined categories of alcohol consumption, we saw that both moderate and heavy alcohol consumption, relative to no consumption, were associated with all psychosocial outcomes: less anxiety and depression and better HRQoL (). When we analyzed beverage types separately in relation with the psychosocial outcomes, we saw that both beer and liquor were not related with any outcome, while consuming more wine per week was associated with better physical and role functioning, and with less complaints of fatigue and pain (Supplemental Table 2). We found no effect modification for time since diagnosis, age, or sex.
Table 3. Longitudinal associations between alcohol consumption (predictor), psychological and HRQoL domains and symptom scales (outcomes).
Discussion
We assessed longitudinal associations between alcohol consumption and psychosocial outcomes (ie., anxiety, depression and HRQoL) in a large CRC survivor cohort with study enrollment 1-11 years post-diagnosis, followed-up for 4 consecutive years. Over the years of follow-up, we found that current alcohol consumption was associated with better psychosocial outcomes, both for moderate and heavy drinking patterns, while former drinking was potentially associated with worse outcomes. Of the separate alcoholic beverage types, only wine consumption was associated with better psychosocial outcomes, while beer and liquor were not. There were no effect modifications for time since diagnosis, nor on age or sex.
We found that both moderate and heavy alcohol consumption were related to less anxiety and depression and better HRQoL, as compared to nondrinkers. One study also found that moderate drinkers had a higher health status, compared to former drinkers or lifetime abstainers, even though they controlled for important chronic health conditions, demographic and lifestyle factors associated with health (Citation28). Also in the Stockholm Public Health cohort, former alcohol consumption was associated with higher odds of poor self-rated health and psychological distress, compared with moderate drinking (Citation29). One study reported that current drinking in the year of diagnosis of oral cancer or oral epithelial dysplasia, whether it was moderate or heavy consumption, was associated with less depression post-diagnosis (Citation30). We might conclude that alcohol consumption is associated with better psychosocial health, or that former drinkers may have stopped due to health reasons, such as a CRC diagnosis.
Considering the first explanation, one study considering alcohol patterns and biomarkers reported that alcohol use was associated cross-sectionally with better allostatic load score (based on biomarkers from the cardiovascular, inflammation, glucose metabolism, lipid metabolism, sympathetic and parasympathetic nervous systems, and the hypothalamic-pituitary-adrenal axis), which are associated with better long-term health outcomes (Citation31). However, they did not see any differences between lifetime abstainers and former drinkers in allostatic load score (Citation31). Most probably, both (moderate) alcohol consumption, and most particularly wine consumption, may be associated with a healthy lifestyle and better health. Other studies suggested that moderate alcohol consumption may often occur in combination with other behaviors that reduce the effects of stress on depression, or enhance relaxation and social bonding (Citation12, Citation32). Gibson-Smith et al. also found that a high Mediterranean diet score, including moderate consumption of wine, was associated with less depression and anxiety, and nondrinkers had higher symptom scores of depression and anxiety (Citation33). Dietary patterns, such as the Mediterranean diet, reduce inflammation and may reduce cancer-related fatigue (Citation34).
Even though the number of former drinkers was relatively small at baseline (N = 200, 8%), we found that former alcohol consumers had more depressive symptoms and lower HRQoL. Considering the second explanation, it is found that alcohol abstainers may dislike the acute effects of alcohol, while former drinkers reported to have health reasons to quit (Citation35, Citation36). This might have occurred in our study, since former drinkers more often have a slightly higher tumor stage, a stoma placement, or other chronic diseases. Also in rheumatoid arthritis patients, former drinkers had more psychological distress or fatigue than current drinkers (Citation37). There were hardly studies investigating these alcohol patterns in cancer patients. In a qualitative study after a trial of smoking and alcohol cessation, which was performed before bladder cancer surgery, patients reported that they experienced the trial as an integral part of the surgery, and nausea and medication side-effects kept them from smoking or drinking (Citation38). However, after surgery, when feeling better, they had social events or stressful situations, and they started again with these old habits (Citation38). Generally, in the Netherlands we have a culture in which drinking alcohol is normative (Citation39). A qualitative study among quitters and drinkers in Australia (with a strong drinking culture) found that persons who decline an offered drink, may not only reject the drink, but also symbolic meanings attached to that drink, such as celebrating positive occasions (eg., weddings) or showing solidarity (eg., funeral) (Citation40). Future research is needed to replicate these findings in a larger sample, and to examine why persons are consuming alcohol (ie., for coping or for social activities) and why they quit drinking.
We did not find any effect modification by time since diagnosis. To our knowledge, only one earlier study has looked at these factors in CRC survivors in a longitudinal cohort before, and they looked at a reverse association. Anxiety and depression pre-diagnosis were associated with drinking more alcohol up until 4 and 8 years post-diagnosis, respectively, but after that they were not related anymore (Citation18). For other lifestyle factors, they did find an opposite association, namely higher BMI, worse diet and less physical activity were associated with anxiety or depression, although they did not correct for any confounders (Citation18). These findings possibly argue for the earlier made comment about the associations between alcohol consumption and an overall healthy lifestyle and better health status. Of course, it remains largely unknown how the causality is, whether alcohol consumption causes better psychosocial outcomes, or vice versa. Overall, our findings could reflect survivors slowly regaining their lifestyle habits when things get back to normal after CRC, including increased participation in social life that may be accompanied by more casual alcohol use (social drinking). Above all, it remains essential to state that alcohol consumption is harmful and can promote CRC carcinogenesis and various other illnesses, both in healthy individuals as in CRC survivors. Before changing any alcohol-related guidelines for CRC survivors, more knowledge should be gained about the reasons for consuming alcohol, for example, whether survivors drink as a coping mechanism or as a social activity.
There are some limitations of our study. As the number of former drinkers is low, we could not stratify this group for other variables, such as sex, age, tumor staging or time since diagnosis. Nor did we know when survivors stopped drinking alcohol before the first wave or whether the cancer diagnosis influenced this. Neither did we have access to pre-diagnosis alcohol consumption or psychosocial factors. Furthermore, it remains unknown whether nonrespondents at the follow-up declined to participate because of poor physical or mental health. In addition, most participants had a medium level of education in the current study. Higher education levels are associated with more alcohol consumption (Citation41), mostly wine (Citation42), and with less depression (Citation43). Therefore, we took education level into account as a potential confounder. The study also had important strengths. It was a population-based longitudinal cohort study with a large sample size and good response rates, thereby making it a representative study population. Furthermore, a wide variety of confounders were considered in the longitudinal analyses.
To conclude, this may be the first longitudinal cohort study that examined the associations between alcohol consumption, both former and current drinkers, with psychosocial outcomes in CRC survivors. Over time, we found that, compared to never drinkers, former drinkers reported slightly worse psychosocial outcomes, while current drinkers reported less anxiety and depression and better HRQoL. This was the case for moderate and heavy drinkers, and mostly for wine consumption. It is important to consider that besides the adverse effects of alcohol on patients’ health and on CRC carcinogenesis and various other illnesses, alcohol consumption, in particular wine, may be positively related to psychosocial outcomes. Not only the number of consumptions per person, but also health reasons for quitting drinking should be considered in CRC survivors, as well as the reasons for current drinking.
Authorship
Formulating the research questions: DR, MJLB, MPW, FM; Designing the study: DR, MJLB, MPW, FM; Analyzing the data: DR, FM; Interpreting the findings: DR, MJLB, MPW, FM; Writing the article: DR, MJLB, MPW, FM.
Supplemental Material
Download Zip (280.5 KB)Acknowledgments
We thank all patients and their physicians for their participation in the study. In addition, we want to thank the following hospitals for their cooperation: Amphia Hospital, Breda; Bernhoven Hospital, Veghel and Oss; Catharina hospital, Eindhoven; Elkerliek Hospital, Helmond; Jeroen Bosch hospital, ‘s Hertogenbosch; Maxima Medical Centre, Eindhoven and Veldhoven; Sint Anna hospital, Geldrop; Elisabeth-Tweesteden hospital, Tilburg and Waalwijk; VieCury hospital, Venlo and Venray.
Disclosure Statement
No potential conflict of interest was reported by the authors.
Additional information
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References
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