Public health professionals and providers have a role to play in increasing awareness of alcohol’s cancer risk, the U.S. surgeon general said last week.
In an advisory, Surgeon General Vivek Murthy, M.D., highlighted the link between alcohol consumption and increased cancer risk. The risk may rise around one or fewer drinks per day and is well-established for at least seven types of cancer. Alcohol consumption is the third leading preventable cause of cancer in the U.S., behind tobacco and obesity.
The advisory called on public health messaging that highlights alcohol consumption as a leading modifiable cancer risk factor and for expanded efforts to increase general awareness. Providers should inform patients in clinical settings about this connection, promote alcohol screening and offer treatment referrals. Murthy also called for an update on health warning labels on alcohol-containing beverages and for a reassessment of the guideline limits for alcohol consumption to account for cancer risk.
“This new advisory deepens our understanding of the direct link between alcohol and cancer risk,” Suzette Glasner, Ph.D., chief scientific officer at Pelago, a digital substance use management clinic, told Fierce Healthcare in an email. “With this new knowledge, Americans can be empowered to make healthier choices that preserve their well-being.”
Excessive alcohol use is often unrecognized and underreported by patients. To that end, the U.S. Preventive Services Task Force recommends screening adults for unhealthy alcohol use in primary care settings and offering those engaged in risky drinking with brief behavioral counseling interventions. Brief counseling interventions can range from feedback on the patient’s screener to a conversation about the impacts of excessive alcohol use on health to a plan to reduce alcohol use, with a referral as needed.
The American Medical Association (AMA), too, makes clear that physicians should establish routine alcohol screenings. Despite this, not all doctors regularly screen—and even those who do may not intervene with patients who need it. One study found that between 2014 and 2016, screening with a validated questionnaire occurred in less than 3% of primary care visits.
A separate analysis of data from 2015-16 found less than 40% of office-based primary care physicians who screened for alcohol misuse always intervened with patients who flagged positive.
A number of factors stand in the way of universal screening adoption and streamlined referrals to care, according to Joseph Lee, M.D., president and CEO of the Hazelden Betty Ford Foundation. The nonprofit offers addiction and mental health treatment across more than half a dozen states.
A key consideration: how socially acceptable drinking is. “If this were cigarette use or some other well-known carcinogen, I don't think they’d think twice about talking to their patients about it,” Lee told Fierce Healthcare. Ad campaigns targeting consumers encourage higher levels of drinking and normalize alcohol consumption, he added, which can also affect physicians’ judgment.
Additionally, providers may feel they lack the time to screen for alcohol use. But given alcohol use disorder can be an underlying driver of many health conditions, Lee said, screening as a first step in care is crucial to get a more holistic understanding of a patient. Doctors should also communicate to patients that despite guidelines on moderate alcohol use, Lee added, no amount of alcohol consumption is safe for health.
Seemingly contradictory science or misinformation can affect what patients believe about drinking. An example is the often cited but inconclusive data that red wine is good for heart health.
“It’s really hard to wrap your arms around this,” Christoph Dankert, chief network officer at value-based healthcare platform Carrum Health, told Fierce Healthcare. “How do you walk that nuance, how do you take somebody through that trade-off?”
Carrum has established value-based Centers of Excellence for employers and unveiled a new treatment model for substance and alcohol use disorders last fall. The latest advisory “is a wake-up call for the medical community to engage more in it,” Dankert said. Like wearing sunscreen, the advisory makes clear that to reduce cancer risk, “there’s maybe something you can do.”
Physicians should learn how to do intervention counseling and motivational interviewing, the AMA recommends, the training for which should be taught at medical schools. Primary care clinics should establish close working relationships with alcohol treatment specialists, counselors and self-help groups in their communities and, where possible, integrate specialized alcohol and drug treatment programs into the routine clinical practice of medicine. Doctors are also encouraged to get education on the pharmacological treatment of alcohol use disorders and co-morbid mental health conditions. The AMA did not offer up an interview in response to Fierce Healthcare’s request.
For physicians looking to start routine screenings, several tools are available, including the AUDIT-C and the NIAAA Single Alcohol Screening Question. Hazelden offers its own free screening tool, after which it takes on a fuller assessment to determine the right care pathway for a person in need.
After a screen, referrals for additional assessments and triage should be made to a specialist who is familiar with substance use disorders, like a licensed substance use counselor or mental health professional, according to Lee of Hazelden. Many health systems today do screen and refer effectively, he acknowledged. “The general gradient, though, is it’s still challenging,” Lee said. “Continuing to make that workflow easier is something that we all need to make a priority.”
Evidence shows that such interventions are effective. Through a multiyear project, the American Academy of Family Physicians (AAFP) aimed to train family physicians on best practices and worked with a dozen family medicine practices to implement alcohol screening and brief interventions. These practices ultimately saw both their screening and intervention rates increase for men and women. They also led to more screenings being performed by physicians, nurse practitioners and PAs, as any clinician with proper training can perform them. The AAFP did not immediately respond to a request for comment.
Besides training clinicians, working with employers is another powerful way to reach patients, Dankert of Carrum argues. Treating substance use disorders costs employer-sponsored insurance $35.3 billion annually, per a Centers for Disease Control and Prevention study. Because of this, employers take the issue of alcohol misuse seriously and jump at the opportunity for a streamlined solution. “You have a real stake in this. You have a responsibility, legally and morally,” Dankert said of employers.
It can be hard for patients to find and get into good treatment. There are many treatment centers that look high-end, per Dankert, but consumers have little way of knowing whether their outcomes are good or how much they cost. Clinics in fee-for-service also have a perverse incentive to keep patients coming back. This leads to the “rinse-and-repeat” cycle of rehab, Dankert noted. The meaningful way to deliver quality care is a team-based approach, measuring outcomes and being held accountable to them. Carrum uses bundled payments to incentivize providers to keep patients healthy.
“We’re big believers in value-based care in alcohol use disorder treatment to weed out all the predatory treatment centers, to focus providers…on delivering the treatment that gets patients better,” Dankert said.