For a decade or more, research has shown that alcohol increases the risk of several different cancers, yet most people are unaware of this link and the harms drinking can cause. A new ARG project, in collaboration with UCSF, seeks to change that by raising awareness among young women that alcohol use is a risk factor for breast cancer.
To learn more about this unique project, we sat down with Principal Investigator and Scientist Priscilla Martinez, to talk about the study, what it’s like to do research during a pandemic, and what’s coming up next.
Thanks so much for agreeing to chat with us, Priscilla. To get us started, can you provide us with an overview of the study?
Sure, but first I want to acknowledge the California Breast Cancer Research Program which funded the project and our research partners at the University of California, San Francisco who initiated our collaboration. Dr. Peggy Reynolds and Julie Von Behren are cancer epidemiologists who brought their expertise and joy of research to the study team. We couldn’t have done this work without them.
The primary aim of the project was to inform young Californian women that alcohol is a risk for breast cancer. We proposed developing a campaign that would directly reach women between the ages of 18 and 25 to let them know that if they drink, they’re at risk. We also aimed to support organizations that work with this population by providing them with what we learn so they can better inform their clients.
We just completed the first phase which included a literature review and message development.
Is that what spurred the study, that women aren’t aware of the link between alcohol and breast cancer?
Absolutely. It’s shocking that only about 25% of women know that alcohol increases the risk of breast cancer, which means that if they do drink, they are drinking without being fully informed of its consequences. Considering breast cancer is the second leading cause of cancer death among women, this is critical information that everyone should know. For this specific population of younger women, it’s even more critical that they understand how their drinking impacts their health since, for many, alcohol use is an integral part of their social behavior. This age group also frequently engages in binge drinking, that is consuming five or more drinks in one occasion, which again, increases their risk.
So why don’t women know? Is it a lack of research?
No, not at all. There is extensive research on alcohol use and breast cancer risk. What is difficult about doing this work is that you can’t do randomized controlled trials (RCT) where you expose one group of individuals to the risk factor and compare outcomes to a control group. But that doesn’t mean the research is lacking; it’s simply more difficult to quantify the causal effect without using an RCT design. However, there is no dispute: alcohol increases the risk of breast cancer in women. Full stop.
The other reason that women aren’t aware of this risk is that the alcohol industry has done a really good job of promoting their own narrative. Even when they acknowledge the risk, they frame it in a way that suggests doubt—the way they communicate risk makes it seem less credible. It’s really difficult for public health to compete when the alcohol industry collectively spends up to two billion dollars annually on advertising.
We also found that there hasn’t been a concerted effort to educate people about alcohol’s relationship to cancer. Sure, we have warning labels that state alcohol can increase the risk of cancer, but most of us ignore the fine print. However, if the information was more specific—listing all the cancers you’re at risk for, including breast cancer—people may start to pay attention.
I think it’s also the responsibility of our health care providers. Currently, it’s not part of their training except to ask about alcohol use in an effort to identify problem drinkers. With what we know about alcohol’s relationship to cancer, practitioners need to be telling their clients that any alcohol use is risky.
Any alcohol use, even a small amount?
Yes, there is no safe level. If you drink, you’re at risk. Risk starts at zero then increases with each drink—it’s a linear relationship and that applies to all associated cancers. A meta-analysis that used data from 53 studies found that for each drink consumed per day the risk of breast cancer increases by 7% compared to women who don’t drink.
That’s shocking. So is that what you hope to add to the conversation?
Definitely. That and the fact that any level of alcohol consumption is unhealthy. Most people think about drinking in terms of addiction or problem drinking and don’t think of regular, moderate use as having negative effects. We know even a little bit isn’t good—you’re putting your health at risk for breast cancer with each sip.
Knowing this message is critical information to communicate, can you tell us about the study design and why you chose that approach?
The goal was to educate young women so we thought, let’s go to young women and tell them directly which meant designing a public health campaign that could reach all of California. We could have done a legislation push, but that seemed a little circuitous and more of a long term approach. We didn’t want to waste time or resources—we needed to take the most direct and effective route.
Once we decided to develop a campaign, we used a three-prong approach. First, we needed input from young women, and because of the subject matter, we wanted to have an open conversation with them about breast cancer and their drinking, and to learn how best to communicate our message to them. We collected this data through focus groups and online surveys.
Second, we formed an advisory committee comprised of stakeholders that work in the areas of alcohol use and breast cancer to help inform our messaging and provide input on dissemination strategies.
Third, we conducted an extensive literature review of current research, including alcohol’s link to breast cancer, young women’s alcohol use, communication theory and models, and campaign approaches. This information was shared with our stakeholders.
So you used a mixed methods approach, is that right?
Exactly. We ended up with both quantitative and qualitative data. Really, it’s a very rich set of data that we’re working from.
What are some surprising discoveries you made that you can share?
What was interesting, was that drinkers wanted more direct, more startling messaging whereas non or light drinkers preferred a direct message but one that is positive—something more inspirational than scary. I was very surprised to find these differences based on type of drinker. I expected differences because of geography or background. I didn’t think drinking status would really matter.
From a methods perspective, I was surprised that in our recruitment strategy, which was a multiple-pronged approach, Craig’s List was the most effective tool, even for this younger population. That was definitely unexpected.
I also thought the young women might be angry when they learned that alcohol is a risk factor for breast cancer. Instead, their response was a more deflated acceptance of it. Some participants shrugged their shoulders, like they weren’t surprised. Yet, they didn’t want to blame anyone like the alcohol industry or their doctors.
We also didn’t expect to have so many people interested in participating. The response to our recruitment ads was very surprising.
That’s very interesting. Studies often struggle with recruitment. Why do you think you had such a positive response?
Our inclusion criteria was fairly broad while our recruitment was targeted, so that helped. We also used several different methods to reach young women. And we have to acknowledge that COVID-19 played a role.
So you conducted this study while we were in lockdown?
We did! The study began in January and we started recruiting for the focus groups in late February for in-person sessions in March. We were about to conduct our first in-person focus group when California started to talk about a possible lockdown. We were worried that we may have to cancel our focus groups at the last minute, so we quickly pivoted to an online format. No one on our team had ever conducted online focus groups before so we scrambled a bit, made some changes to our approach, signed up for a Zoom account, and boom—we were up and running!
Of course, the fact that COVID-19 is still a major threat and it’s not going away anytime soon, we also had to rethink our dissemination strategy. It didn’t make sense to consider bus ads or putting up posters on college campuses—we knew it had to be a completely online campaign.
That’s a pretty significant pivot. Do you think COVID-19 impacted the study at all?
It did for sure. At the beginning we were concerned about how the study would go but once we adapted and went with the flow, the changes we had to make resulted in, what I think is, a stronger study.
In what way is it stronger?
For one, we ended up with participants from across California. With in-person focus groups, we had to limit the number of groups and regions we could reach because of travel expenses and time considerations. When we switched to an online format, we could recruit from every county and our time was much more open.
As I mentioned before, we had a huge number of responses. Originally, we planned on recruiting 36 women. At the end, we had over 150 who were eligible. Conducting online focus groups also allowed for more flexibility—both for our team and the participants. We could run the groups when women were available and could quickly shift days and times as needed. Fortunately, our target audience is tech savvy and very comfortable sharing their stories via video conferencing so we didn’t run into any kind of resistance.
And because people were suddenly out of work or their college campuses had closed, young women had time to participate and were looking for other ways to make some much-needed money (women received a stipend for their participation).
I have to say, as a team, we adapted to this drastic profound change in our personal and work environment really effectively. We still carried out the project on schedule. We collected more data than we anticipated. We accomplished the goal of coming up with messaging and strategies and did it on budget. As a team, we worked really well together to make this study successful. I’m very proud of everyone.
What was your favorite aspect of the study? And how does it connect to the rest of your research?
I liked running the focus groups. They were fun and so inspiring to hear these women’s stories, to gain their perspective and experiences. I was really grateful for their willingness to share such personal information with us. It’s a scary topic and some women knew people with breast cancer, like their mom or aunt, so it is very emotional. Speaking with them also made me feel extremely hopeful about the future—these are smart, strong, and caring individuals—it was very encouraging.
Also, it felt good to connect to people in this time—to see each other and laugh and share—I treasured that.
I also appreciate that this study gives us the chance to do what we often don’t have a chance to do as researchers—communicate study results to the public. It’s not something we get to do very often and it’s an important piece of the work.
In terms of this project connecting to my other work, it does methodologically—I’m a proponent of using different types of methods to get at a problem. It also builds on ARG’s other cancer-focused research, which includes warning labels, alcohol use post cancer treatment, and more broadly, our studies on alcohol consumption and risk of chronic diseases, including cancer.
What are the next steps?
Now that we’ve developed the messaging, the next step is to refine and finalize the messaging and implement the dissemination plan which includes reaching out to California-based organizations that have a stake in this kind of work. Then in early 2021, we’ll be engaging directly with young women via a social media campaign. We’re also working on culturally-adapting our materials for Spanish-speaking women, and building an interactive, cool-looking website!
We also want to apply for further funding to continue this work to ensure all women are aware of their risk. We also hope to investigate the nuances of alcohol and breast cancer, including the effect of different drinking patterns and relationships to other risk factors.
And of course, we need to write papers, papers, and more papers.
There’s a lot of work to do!
Wow, this has been very educational and inspiring and we look forward to seeing the campaign when it’s launched. We’ll check back in then for an update. Thank you so much for sharing your experience with us, Priscilla. Such a pleasure.