Methodological Biases in Estimating the Relationship Between Alcohol Consumption and Breast Cancer: The Role of Drinker Misclassification Errors in Meta‐Analytic Results
Open accessAbstract
Background: While alcohol consumption has been linked to breast cancer in women, few studies have controlled for possible biases created by including former or occasional drinkers in the abstainer reference group. We explored the potential for such misclassification errors as sources of bias in estimates of the alcohol–breast cancer relationship. Methods: Meta‐analyses of population case–control, hospital case–control, and cohort studies to examine relationships between level of alcohol use and breast cancer morbidity and/or mortality in groups of studies with and without different misclassification errors. Results: Of 60 studies identified, only 6 were free of all misclassification errors. The abstainer reference group was biased by the inclusion of former drinkers in 49 studies, occasional drinkers (<10 g ethanol [EtOH] per week) in 22 and by both these groups in 18. Occasional drinkers were also mixed with light or hazardous‐level drinkers in 22 studies. Unbiased estimates of the odds ratio (OR) for breast cancer were 1.011 (95% confidence interval [CI]: 0.891 to 1.148) among former drinkers (n = 11) and 1.034 (95% CI: 1.003 to 1.064) among occasional drinkers (n = 17). Hazardous‐level drinking (>20 g < 41 g EtOH/d) was not significantly associated with breast cancer in studies with occasional drinker bias. However, in studies free from occasional drinker bias, the OR for breast cancer was 1.085 (95% CI: 1.015 to 1.160) for low‐level (<21 g/d) drinkers (n = 17), 1.374 (95% CI: 1.319 to 1.431) for hazardous‐level drinkers (n = 26), and 1.336 (95% CI: 1.228 to 1.454) for harmful‐level (>40 g/d) drinkers (n = 9). Conclusions: While the great majority of studies of the alcohol–breast cancer link include misclassification errors, only misclassification of occasional drinkers was found to bias risk estimates significantly. Estimates based on error‐free studies confirmed that low, hazardous and harmful levels of alcohol use each significantly increase the risk of breast cancer.
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Relative risks for cancer are dependent on the systematic search strategy, inclusion and exclusion criteria, reference group (including former drinkers), use of case-control and/or cohort studies, and use of categorical or continuous estimates for alcohol consumption.
“Furthermore, as with other diseases related causally to alcohol consumption, the relative risks for cancer are dependent upon the systematic search strategy, inclusion and exclusion criteria, reference group (and if this includes former drinkers) of the underlying studies 172, 173, 174, use of case–control and/or cohort studies 175 and use of categorical or continuous estimates for alcohol”
From The relationship between different dimensions of alcohol use and the burden of disease—an update (2017) · cites this paper as [174]
Beneficial effects of non-heavy drinking on ischaemic diseases have been put into question for different reasons.
“While these beneficial effects have been put into question for different reasons (e.g. 174, 258, 259), and while they may be overestimated using standard epidemiological methodology because of biased comparison groups 260, biological pathways corroborate some protective effect.”
From The relationship between different dimensions of alcohol use and the burden of disease—an update (2017) · cites this paper as [174]
The comparison group still is a problem in alcohol epidemiology.
“Finally, the comparison group still is a problem 174”
From The relationship between different dimensions of alcohol use and the burden of disease—an update (2017) · cites this paper as [174]
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- Authors
- Zeisser, C., Stockwell, T. R., & Chikritzhs, T.
- Affiliations
- University of Victoria (CA)
- Curtin University (AU)
- Corresponding author
- Stockwell, Tim R.
- Venue
- Alcoholism: Clinical and Experimental Research
- Publisher
- Wiley
- Published
- 2014-08
- Volume
- 38
- Issue
- 8
- Pages
- 2297-2306
- ISSN
- 0145-6008 (ISSN-L)
- 1530-0277
- PMC
- PMC4149760
- OpenAlex
- W1974587619
- Cited by
- 33
- References
- 42
- Citations by year
- 2026: 3 · 2025: 1 · 2023: 1 · 2022: 2 · 2021: 3 · 2020: 2 · 2019: 3 · 2018: 3 · 2017: 7 · 2016: 6 · 2015: 2
- FWCI
- 3.71
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- Alcoholism Clinical and Experimental Research (publishedVersion)
- PubMed (publishedVersion)
- PubMed Central (acceptedVersion)
- eSpace (Curtin University) (submittedVersion)
- Funders
- US National Institutes of Health (1RO1AAO19939-02)
- Topics
- Health Sciences › Medicine › Pathology and Forensic Medicine › Alcohol Consumption and Health Effects
- Physical Sciences › Mathematics › Statistics and Probability › Statistical Methods in Epidemiology
- Health Sciences › Medicine › Oncology › Global Cancer Incidence and Screening
- Keywords
- alcohol consumption, breast cancer, misclassification bias, former drinkers, hazardous drinking, alcohol and cancer risk
- MeSH terms
- Alcohol Drinking, Breast Neoplasms, Female, Humans, Meta-Analysis as Topic, Comorbidity, Bias, Alcohol Abstinence
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