The way I look at the consumption of alcoholic beverages is that I had plenty in my pre-OC life, and now that I never want to go through THAT again, it is Gary's "no brainer" to abstain. It is one of the few things I am sure are connected to OC over which I have control, the other being smoke and smoking. That said, a former OC patient friend and I have decided that if and when we are definitely terminal, there will be much partying with banned substances (grin). I can wait.

Here is my treatise on why this study is annoying to me.

The known statistical information about SCC recurrence is that overall 65% of patients with locally advanced cancer will experience recurrence. These numbers are average across all ages and socio-economic factors.

Recurrence is an awful word because it is not absolute as to how a

Hear! Hear! Mark, stay on the soapbox

Cheers!

Tizz

"Life is a sexually transmitted disease which invariably results in death"

I agree with Mark on this one. As a matter of statistics (God are we really going here again!!) 75% of OC's are tobacco related, and that is well documented. However the number that were exclusively alcohol related is unknown. The vast majority of the time alcohol is a co-factor and not the mutanogenic agent. The method of action has been discussed here before and is also discussed in the main body of the site. High alcohol consumption has the ability to thin the cell wall membrane, in this case the oral mucosal tissues. In smokers, this makes the transference of tobacco combustion carcinogens readily able to access the cell. The relationship of HPV to oral cancer is a far more prevalent CAUSATIVE agent as well as a facilitator and co factor in many cancers (not only oral but even uterine and breast) than alcohol is according to new data. The issues of lifestyle in relationship to disease in general are a touchy subject - but it has been clearly defined that individuals that have poor lifestyle habits, which include poor eating habits (high fat, few vegetables), obesity as a result of those habits to excess, smoking, excessive drinking, little exercise and more, all contribute to higher disease of all types in that population of people in general - not just in cancer. It is also well known in the dental community that people that have two or more of the poor lifestyle choices also don't take care of other parts of their body like their teeth and gums.

The secret to all this is everything in moderation in my opinion. Just as exercise is vital to good health, obsessive, excessive exercise is destructive. Balance in all things......

As an aside, no one here has mentioned the medically reported health benefits (cardiac) related to a small regular consumption of alcohol.

Abstinence from alcohol for those that are unable to drink in moderation is, as many who have let it take over their lives to the point of destruction, self evident that that person needs to find a mechanism to bring things in line. Addictive behaviors are a separate issue from what we define as precipitating factors in recurrence, which regular readers here know I think is a misnomer in too many cases. Surgical only solutions to oral cancers leaving micro-mets which blossom 18 months later are too frequently named recurrences rather that incomplete treatment as they should be. There are legal ramifications to this which often end up in court. The bottom line is that we cannot with certainty TODAY state how many are actual recurrences, how many are incomplete treatment results, and how many are secondary primaries, and lastly how many are the consequence of continued cancerization via patients who continue down a bad path, or field cancerization from original causes. I brought this study to several of the OCF science advisors, and the common statement was that from a methodology perspective the study has flaws.

Lastly, one of the authors is a personal friend, Terry Day. The authors acknowledge that ALL studies (that includes those with small populations or from small institutions etc.) were included in this overview of the literature format paper. We all know that small population studies are not worth the paper they are written on. Remember the 19 person study on dental tooth whiteners causing oral cancer (19 people in total)? Please note that if you did (before June of 05) a retrospective literature search and published a paper on whether oral cancer screening works or not in reducing the death rate, (something that we all know works because disease found in early stages has better long-term outcomes), would have found that there was no scientific evidence that opportunistic oral screenings would produce any positive benefits. A POINT WHICH UNTIL JUST RECENTLY THE CDC HAS USED TO AVOID PUTTING ANY MONEY OR EFFORT INTO ORAL CANCER SCREENINGS IN THE US. There just are not a lot of studies on alcohol consumption by post treatment oral cancer patients to draw from. Personally I think drawing conclusions from an area in which there is little published peer reviewed data is a problem. Also this study offers no concrete recommenedations...like what is acceptable (in these doctors opinions), or what is moderate, excessive, etc. It leaves way too much to be desired, and with all due respect to my friend, I believe that the drive to publish in the medical community often leads to preliminary and often contradictory publications. Also please note that this was not published in Lancet , NEJM, or JAMA, it was published in a small alcohol specific journal. It is unlikely that it would have met the requirements to be published in one of the major journals. When you evaluate the many, many articles that are published, there is much to consider in the weight that you place on the statements and conclusions made in them.

Just a statistician's comment on research using small samples.

Small sample studies are not always suspect just because the sample size is small. For example, if the sample can be said to represent the population in all regards and if they find a statistically significant difference between two groups (e.g. drinkers and nondrinkers), that isn't necessarily suspect, in fact it's more impressive that they found the difference with a small sample--the difference must be a more sizable one to be detected (although NO finding should be taken too seriously until there is some form of replication--repitition-- of the results in another study).

Where small sample studies really fall down is when they find there is NO effect of something (eg. oral cancer screening) because with a small sample size, there can actually be an effect that doesn't come out to be statistically significant because of a lack of power (power grows as sample size grows) to detect the difference. One should always be suspicious of concluding that there is defniutely NO effect of somehting and basing policy on that unless the sample sizes are quite large.

There is a statistical method called meta-analysis which statistically combines results of small sample studies to increase power to detect an effect overall, and it's often used when there is controversy about whether an effect exists or not (such as there seems to be with the effect alcohol on OC). Was this study a meta-analysis? Because, if so, that is a little more convincing than a simple review of the literature, which really can't tell you much.

But even metaanalyses are only as good as the data that goes into them. If some of the studies they used were flawed, for other reasons than small sample size, then even if it is a meta-analysis there can't be any strong conclusions. Then of course there is the fact that none of these variables can be randomly assigned. It is indisputable that people who drink more than a small amount are also less likely to take care of themselves in other ways, as Brian said. Although these things can be statistically covaried out if they are measured.

But I'm not 100% convinced that alcohol only acts directly on oral cell memebranes in being a co-factor for oral cancer. It seems like the truth is we just don't know enough to know all the ways it could affect things. I just read an article that found that alcohol consumption was also related to recurrences of breast cancer, at least for post-menopausal women. So maybe there's something else at work there too.

Brian, do you happen to know a citation for the relation of HPV to breast cancer that you mentioned? I'd be interested in reading more about this.

Nelie

Those are very good points, and certainly elucidate us on one of the various issues with conducting studies. I guess my personal prejudice against small studies is apparent. Lack of elimination of other factors is a bias that flaws many studies, but certainly there are many great examples of meta studies that were of extreme value. But I still believe that those studies are only as good as the FACTS and conclusions drawn in the included studies, and can be flawed by poor prior scientific methodology. Meta analysis must take care not to introduce its own bias in the author's selection of those prior studies that support the conclusions that they would like to come to. Case in point are many of the studies done by the tobacco industry which reviewed only those prior papers (many funded by them) that reached a conclusion that they had a preconceived notion that they wished to reach. Bottom line is no single study is worthy until the conclusions can be repeated by other independent investigators, and all bias removed from the study itself. Since Nellie is someone who understands this more deeply than I, would you please post a reply that explains bias and some of the forms that it takes? I think it would help everyone, especially those that routinely review the studies that we publish in the news section so that that can make intelligent decisions about what they are reading.

The evidence was only recently found at Johns Hopkins and the information surprised everyone since it was completely unexpected and was a by-product of them looking for something else. The article is to be published in the next few months, and I will put it in the news section of the site when it comes out. I had a chance to review a preliminary copy from Dr. Gilllison one of the co-authors.

In my opinion (which isn't always worth that much) I have seen so many small studies, that were poorly funded, and following that, poorly populated, and following that, had poor elimination of other factors which may have induced the same outcome that were not measured or even considered, I find many of them suspect. The bleaching study that I mentioned above, didn't even ask the two people who had developed oral cancers (with the only apparent commonality between them that they used tooth whiteners) if they had been tested for HPV, an already established causative agent that they would have no way of knowing they were positive for as people in their 20's who never smoked or drank to excess. This was by one of the most prominent otolaryngology professors in the US publishing!! The conclusion that whitening agents were the causative factor when one of the KNOWN causes was not even explored, was a mistake of huge proportion. But now the myth of whiteners and oral cancers is fully embedded in the public's mind and I get an email about it every week.....

The inability to eliminate other causative factors makes it easy to publish a paper which reaches a conclusion that something "needs further investigation", but by the time that last sentence is read, the masses have been exposed to the faulty studies sensational claim. That was exactly the case with the study - every major paper in the US picked up the story and ran with it...but guess how many looked at it carefully and thought about the lack of looking for alternative conclusions (HPV) or used the sentence that it was a preliminary finding and needed further looking into...none. Meta-analytical techniques are of great value when the need to establish repeatability is considered. A review of 12 different hospitals experience might be proof that even with different surgeons, different facilities, but the same population characteristics of patients would all have a similar outcome, validating the procedure, even when used in different environments by different doctors of varying skills.

I like this technique when you look at something historically over a protracted period. A retrospective look at cervical cancer death rates from a period of 1948 to 1958 would show a dramatic almost 70% reduction in death rates. That data would be partly assembled from a variety of sources since the SEER system was not fully implemented at the time. The FACT that the death rate dropped would be established from numerous sources, but the causative agent was left for another publication and study

Brian, I'd be happy to post an explanation of bias and the forms it can take but you'll have to give me a couple of days. Between family coming for Thanksgiving and sleeping a lot during the end of my breast cancer rad the past couple of weeks, I'm way behind on grading for my online class. Writing something about bias sounds like a lot more fun, quite honestly, but also something I'd want to spend some time on wording well, and duty calls first.

Thank you for you willingness to do this. When done I would like to not only have it here, but to find a place for it in the main web site where we can talk about the conflicting data, preliminary data, and understanding publications in general, so that patients and their families will have some sound basis for navigating the huge amount of enformation that is out there, and being added to every single day. I am not qualified to write it and your willingness considering the load that you are already carrying, is greatly appreciated. Clearly you must deal with first things first, and that is your own health.

Statistics aside, for quality of life reasons I would like to enjoy a social glass of wine or beer but cannot because it all tastes like vinegar to me.

Love from an abstemious Helen

What a great thread! One of the subjects I teach is social research. We have a wonderful saying about research numbers: "Statisticians use statistics the way a drunk uses lamposts - for support, not illumination." Try as we might, we cannot make numbers tell us only what we want to hear. Those who drink will always cite the numbers that support that. Tom