Abstract
Background
Previous epidemiologic studies of overall alcohol intake and basal cell carcinoma (BCC) are inconsistent, with some evidence for differences by type of alcoholic beverage. While alcohol may enhance the carcinogenicity of ultraviolet (UV) light, this has not been evaluated in existing epidemiologic studies.
Objective
To evaluate alcohol intake in relation to early-onset BCC, and explore potential interactions with UV exposure.
Methods
BCC cases (n=380) and controls with benign skin conditions (n=390) under age 40 were identified through Yale Dermatopathology. Participants provided information on lifetime alcohol intake, including type of beverage during an in-person interview. Self-report data on indoor tanning and outdoor sunbathing were used to categorize UV exposure. We calculated odds ratios (OR) and 95% confidence intervals (CI) using unconditional multivariate logistic regression in the full sample and in women only.
Results
There was no statistically significant association between lifetime alcohol intake and early-onset BCC overall (above median intake vs. no regular alcohol intake OR 1.10, 95% CI 0.69-1.73) or in women only (OR 1.21, 95% CI 0.73-2.01). Similarly, intake of red wine, white wine, beer or hard liquor and mixed drinks was not associated with early-onset BCC. In exploratory analyses, we saw limited evidence for an interaction (pinteraction=0.003), with highest risk for high alcohol and high UV exposures, especially in women, but subgroup risk estimates had wide and overlapping confidence intervals.
Conclusions
Overall, we did not observe any clear association between lifetime alcohol intake and early-onset BCC.
Introduction
Basal cell carcinoma (BCC), a type of non-melanoma skin cancer (NMSC), is the most common cancer.1 Though rarely fatal, this malignancy causes considerable morbidity and places a high burden on health care systems.2 BCC has been rising in incidence during the past several decades, with notable increases among young people, particularly females.3 The rapidly changing incidence pattern suggests a role for lifestyle factors in BCC risk.
While evidence from epidemiologic studies and laboratory research indicates ultraviolet (UV) radiation is the primary environmental risk factor for melanoma and NMSC,4 other behavioral and lifestyle factors are also of interest in relation to skin cancer. One such exposure, alcohol, has been investigated in relation to skin cancer in several epidemiologic studies. Alcohol intake has been linked to an increased risk of malignant melanoma in some research,5-9 though other studies have not found an association.10-12 A recent meta-analysis on alcohol drinking and melanoma has found a positive association.13 Regarding NMSC, three prospective studies have reported an increased risk of BCC associated with alcohol,14-16 and one cohort study found an increased risk of NMSC associated with alcohol,17 while one other cohort study and several case-control studies found no association.18-21 In addition to the inconclusive evidence of an association between BCC and total alcohol, there is also mixed evidence indicating risk may differ by type of alcoholic beverage consumed.15-17,21
There are several hypothesized mechanisms by which alcohol may impact skin carcinogenesis, including a potential role in enhancing the carcinogenicity of UV exposure. Research suggests this could be due to alcohol altering the antioxidant nutrient defense system in skin,22 as well as interfering with immune function.23 Compromised immune function is an established risk factor for BCC.1 Although there are plausible pathways for UV exposure to interact with alcohol to impact skin cancer risk, thus far, epidemiologic studies on alcohol intake and skin cancer have not evaluated this potential interaction.
Previous research on alcohol and skin cancer has focused on skin cancer among older individuals, who also may have different alcohol exposures than young adults. In addition, there is limited epidemiologic data on different types of alcoholic beverages in relation to BCC risk. Therefore, we evaluated lifetime alcohol intake (overall and by beverage type) in relation to early-onset BCC in the Yale Study of Skin Health in Young People and explored potential interactions with UV exposure.
Methods
Yale Study of Skin Health in Young People
The Yale Study of Skin Health in Young People was a case-control study focusing on early-onset BCC and related lifestyle factors, conducted in Connecticut between July 2007 and December 2010. The study is described in detail elsewhere.24 Sample size calculations were based on having at least 80% power to detect effect sizes ranging from 1.2 to 2.0 for hypothesized risk factors ranging in prevalence from 5% to 50% in controls. BCC cases were identified through Yale University's Dermatopathology database. Control subjects were individuals with non-UV related minor benign skin conditions randomly sampled from the same database and frequency matched to BCC cases on age at biopsy, gender, and biopsy site. The three most common diagnoses among the controls were cyst (16.4%), seborrheic keratosis (16.2%), and wart (11.4%). All other conditions were present in <10% of controls. Skin cancers and precancers (e.g., actinic keratoses) were ineligible for control sampling.
A total of 389 cases (participation rate=72.8%) and 458 controls (participation rate=60.7%) enrolled in the study. Participants completed an in-person interview using a structured questionnaire, and several mailed self-administered questionnaires. Interviewers also collected a saliva sample for buccal cell DNA from 98.9% of participants. Yale University's Institutional Review Board approved the study and participants (or guardians) provided written informed consent.
Data collection
The structured interview contained questions on self-reported phenotype characteristics (eye, skin and hair color; skin reaction to strong sunlight for the first time in summer for one hour without sunscreen; skin reaction after repeated and prolonged exposure to sunlight), outdoor UV exposure (general exposure, intentional sunbathing, outdoor activities), indoor tanning (ever/never, number of sessions), history of sunburns, sunscreen use, smoking, family history of skin cancer, oral contraceptive use, oral or injected immunosuppressive medications, as well as sociodemographic information. Interviewers were blinded to case-control status until the end of the interview, when participants were asked about their personal history of cancer.
Participants over 21 years of age (the legal drinking age in this location at the time of interview) were asked whether they consumed alcoholic drinks regularly, defined as at least once per week for 6 months or longer. Those who responded affirmatively to regular drinking were then asked about consumption of four types of alcoholic beverages, namely red wine, white wine, beer, and hard liquor or mixed drinks. Participants were asked to estimate the average number of drinks of each beverage type over a period of time of their choosing (per day, week, month or year), as well as the duration of the drinking behavior for two different age periods (before age 25 and age 25 to one year prior to interview). Cumulative numbers of drinks of each type of alcoholic beverage across the two time periods (before age 25 and age 25 to one year prior to interview) were calculated by multiplying average number of drinks by duration. Total lifetime number of alcoholic drinks was then calculated by summing across the four beverage types across the two age periods. Individuals without regular alcohol consumption were assigned a zero value for lifetime drinks.
Statistical Analysis
Our analytic sample was limited to non-Hispanic whites: 380 (97.7%) cases and 390 (85.2%) controls. We further excluded three cases with Gorlin Syndrome, which predisposes individuals to multiple BCCs early in life, 25 six cases and five controls less than 21 years of age at the time of interview, and six cases and three controls missing data on frequency of alcohol intake. This left 747 individuals (365 cases and 382 controls) for analysis.
We used descriptive statistics (Chi-square test, Wilcoxon rank sum test, and t-test) to evaluate differences between cases and controls. Then using multivariate unconditional logistic regression, we calculated odds ratios (ORs) and 95% confidence intervals (CIs) for the association between lifetime alcohol intake and early-onset BCC in the whole sample, as well as in females only. Due to the limited sample of males in our population, we did not evaluate effects in that group alone. We categorized lifetime number of alcoholic drinks into three categories: no regular drinking, below or equal to median number of lifetime drinks, and above the median. Similar variables were created for the lifetime drinks of the individual beverage types. Median intake was based on consumption among regular drinking control subjects and individuals who did not regularly drink alcohol served as the reference group for these analyses.
All models were adjusted for study frequency matching variables (gender, age at diagnosis, and body site of biopsy), factors significantly associated with alcohol drinking in the analytic population (level of education, smoking status, hours spent outdoors in warm months, number of sunburns, and family history of skin cancer), as well as variables related to skin cancer risk in our population (indoor tanning, skin color, and long-term skin reaction to sun exposure). We also evaluated immunosuppressive medication use (ever/never taken) in the model for the overall sample, and oral contraceptive use (ever/never taken 3 months or longer) in the model for women only. Neither impacted our risk estimates and so was not included in final models. The multivariate models for the individual alcoholic beverage types were also mutually adjusted for all other types of alcoholic beverages. We evaluated the linear trends using an ordinal categorical variable for each measure of alcohol intake.
We also conducted exploratory analyses on the interaction between total alcohol intake and UV exposure in relation to risk by including cross-product terms in the multivariate models. We first explored the interaction with continuous measures of exposure (lifetime alcoholic drinks and lifetime indoor tanning sessions; lifetime alcoholic drinks and lifetime sunbathing sessions). We then evaluated the interaction between categories of alcohol and UV, with the former as a three-level categorical variable (no regular drinking, below or equal to median number of lifetime drinks, and above the median) and the later categorized in two ways: ever versus never indoor tanning, and a combined three-level categorical variable that incorporated UV exposure from both indoor tanning and outdoor sunbathing. For the three-level UV variable, participants were classified into “below or equal to median for both indoor tanning and outdoor sunbathing,” “mixed - above the median for either indoor tanning or outdoor sunbathing,” and “above the median for both indoor tanning and outdoor sunbathing;” median cut-points were derived from the distribution of these exposures in exposed controls. Stratified analyses were conducted for any p-value for interaction less than 0.10. Subgroup analyses were not adjusted for multiple comparisons considering the exploratory nature of these analyses. All analyses were conducted using SAS software (SAS, Version 9.3, SAS Institute Inc., Cary, NC) and reported p-values are two-sided.
Results
69.6% of the study participants were female (reflecting the gender distribution in all early-onset BCC cases we identified) and the median age at skin biopsy was approximately 36 years. Compared to controls, BCC cases were more likely to have a higher level of education, lower BMI, fairer complexion, burn rather than tan with sun exposure and a family history of skin cancer (Table 1). The majority of study participants regularly consumed alcoholic drinks (76.3% of cases and 72.0% of controls). The median number of lifetime drinks was 3064 for cases, and 2270 for controls. Number of lifetime drinks differed by gender, with a median of 5086 drinks for male participants and 2064 for female participants (p<0.001, data not shown).
Table 1. Selected characteristics of BCC cases and controls in Yale Study of Skin Health in Young People.
Characteristics | Cases, N= 365 N1 (%) | Controls, N=382 N1 (%) | P value2 |
---|---|---|---|
Age (y), Median (IQR) | 36.4 (33.6-38.5) | 36.8 (32.9-38.5) | 0.966 |
Female | 253 (69.3%) | 270 (70.7%) | 0.684 |
Body site of skin biopsy | <0.001 | ||
Head | 195 (53.4%) | 160 (41.9%) | |
Extremity | 71 (19.5%) | 123 (32.2%) | |
Trunk | 99 (27.1%) | 99 (25.9%) | |
Lifetime alcoholic drinks, median (IQR) | 3064 (104-6736) | 2270 (0-5824) | 0.096 |
Education | 0.009 | ||
≤ Some college | 98 (26.9%) | 139 (36.4%) | |
College graduate | 112 (30.7%) | 115 (30.1%) | |
≥ Some graduate school | 155 (42.5%) | 128 (33.5%) | |
Hair color | <0.001 | ||
Black/dark brown | 100 (27.5%) | 157 (41.1%) | |
Light brown | 127 (34.9%) | 153 (40.1%) | |
Blonde/fair | 98 (26.9%) | 62 (16.2%) | |
Red | 39 (10.7%) | 10 (2.6%) | |
Skin color (inner upper arm) | <0.001 | ||
Olive | 15 (4.1%) | 74 (19.4%) | |
Fair | 203 (55.6%) | 232 (60.7%) | |
Very fair | 147 (40.3%) | 76 (19.9%) | |
Skin reaction with first summer sun exposure | <0.001 | ||
Turn brown, no burn/ mild burn then tan | 138 (37.8%) | 226 (59.3%) | |
Painful burn/ Severe burn | 227 (62.2%) | 155 (40.7%) | |
Skin reaction with prolonged sun exposure | <0.001 | ||
Deeply tanned/ moderately tanned | 201 (55.1%) | 289 (75.7%) | |
Mildly tanned / freckled without tan | 164 (44.9%) | 93 (24.3%) | |
Family history of skin cancer | 240 (65.8%) | 148 (38.7%) | <0.001 |
Body mass index, kg/m2 | <0.001 | ||
≤ 25.0 | 238 (65.2%) | 202 (52.9%) | |
25-29.9 | 87 (23.8%) | 106 (27.8%) | |
≥30.0 | 40 (11.0%) | 74 (19.4%) | |
Smoking status | <0.001 | ||
Never | 226 (61.9%) | 197 (51.6%) | |
Former | 109 (29.9%) | 121 (31.7%) | |
Current | 30 (8.2%) | 64 (16.8%) | |
Outdoor sun exposure in warm months (h), mean ± SD | 9017 ± 3392 | 8365 ± 3177 | 0.007 3 |
Sunburns (n), median (IQR) | 7 (1- 17) | 3 (1- 9) | <0.001 |
Abbreviation: BCC, basal cell carcinoma; IQR, Interquartile range
May not sum to total due to missing data.
Chi-square test for categorical variables, Wilcoxon rank sum test for continuous variables.
T-test.
Multivariate risk estimates were calculated for BCC in relation to lifetime total alcohol intake and the individual alcoholic beverage types in the overall population and in women only (Table 2). No statistically significant association was found between lifetime alcohol intake and early-onset BCC (OR for above median intake vs. not regular drinker=1.10, 95% CI=0.69-1.73). There also was no evidence of an association in women only (OR=1.21, 95% CI=0.73-2.01). Similarly, intake of red wine, white wine, beer or hard liquor and mixed drinks were not associated with early-onset BCC in the full sample or women alone.
Table 2. Adjusted ORs for early-onset BCC among all subjects (n=736) and women (n=515) according to cumulative lifetime alcoholic drinks.
Total alcohol | Red wine | White wine | Beer | Liquor | |
---|---|---|---|---|---|
Overall | |||||
Median among controls | 4314 | 520 | 487 | 2248 | 816 |
No regular alcohol consumption | |||||
cases/controls | 88/106 | 163/179 | 186/206 | 110/134 | 141/156 |
OR (95% CI)1 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 |
Below median | |||||
cases/controls | 131/135 | 104/96 | 97/85 | 119/121 | 117/109 |
OR (95% CI)1 | 1.04(0.67-1.59) | 1.07 (0.66-1.75) | 1.08 (0.48-1.34) | 1.04 (0.62-1.76) | 0.90 (0.59-1.59) |
Above median | |||||
cases/controls | 140/136 | 92/102 | 76/86 | 130/122 | 101/112 |
OR (95% CI)1 | 1.10 (0.69-1.73) | 1.07 (0.65-1.76) | 0.80 (0.48-1.34) | 1.18 (0.68-2.04) | 0.90 (0.55-1.46) |
P-trend | 0.434 | 0.341 | 0.348 | 0.849 | 0.203 |
Women | |||||
Median among controls | 3234 | 520 | 520 | 1560 | 780 |
No regular alcohol consumption | |||||
cases/controls | 69/82 | 115/133 | 117/137 | 88/109 | 104/117 |
OR (95% CI)1 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 |
Below median | |||||
cases/controls | 100/112 | 66/63 | 71/60 | 95/100 | 82/77 |
OR (95% CI)1 | 0.93 (0.57-1.51) | 1.10 (0.61-1.99) | 1.19 (0.66-2.15) | 0.91 (0.49-1.69) | 1.02 (0.56-1.85) |
Above median | |||||
cases/controls | 80/72 | 68/70 | 61/69 | 66/57 | 63/72 |
OR (95% CI)1 | 1.21 (0.73-2.01) | 1.24 (0.70-2.21) | 0.86 (0.47-1.57) | 1.18 (0.64-2.19) | 0.86 (0.49-1.50) |
P-trend | 0.635 | 0.295 | 0.501 | 0.748 | 0.683 |
Adjusted for age, gender (for overall sample model), body site of biopsy (head, extremity, trunk), indoor tanning (never, ever), skin color (olive, fair, very fair), education (some college or less, college graduate, some graduate school), smoking status (never, former, current), hours spent outdoors in warm months (continuous), sunburns (continuous), and family history of skin cancer (yes, no) in all models; and mutually adjusted for the other subtypes of alcohol in models for beverage subtype.
We conducted exploratory analyses to assess whether alcohol and UV exposures interacted to affect risk of BCC (Table 3). Among females, we observed statistically significant effect modification of the association of alcohol with BCC by never/ever indoor tanning. Although there was suggestion of a positive association with higher alcohol intake for female indoor tanners, and an inverse association with higher alcohol intake among females who never indoor tanned, the stratified risk estimates had broad and overlapping confidence intervals. Similarly, there was evidence of an interaction between alcohol and the three-level combined indoor tanning and outdoor sunbathing UV exposure variable for males and females combined pinteraction= 0.023) and females alone (pinteraction= 0.008); but again the risk estimates had broad and overlapping confidence intervals. When both UV exposure and alcohol were examined as continuous variables, we did not observe any statistically significant effect modification by indoor tanning or sunbathing (data not shown).
Table 3. Stratified analyses for cumulative lifetime total alcohol and early-onset BCC by indoor tanning status, and indoor tanning and outdoor sunbathing.
Indoor tanning status | Indoor tanning and outdoor sunbathing | ||||
---|---|---|---|---|---|
|
|
||||
Never | Ever | Low | Mixed | High | |
Overall | (n=736) | (n=731) | |||
No regular alcohol consumption | |||||
cases/controls | 32/29 | 56/77 | 33/32 | 28/34 | 26/40 |
OR (95% CI)1 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 |
Below median | |||||
cases/controls | 44/45 | 87/90 | 46/47 | 39/38 | 44/47 |
OR (95% CI)1 | 0.68 (0.30-1.53) | 1.13 (0.67-1.89) | 0.69 (0.29-1.63) | 0.90 (0.40-1.99) | 1.54 (0.74-3.21) |
Above median | |||||
cases/controls | 43/57 | 97/79 | 37/53 | 41/35 | 63/48 |
OR (95% CI)1 | 0.45 (0.18-1.11) | 1.42 (0.82-2.47) | 0.36 (0.14-0.92) | 1.03 (0.42-2.55) | 1.92 (0.91-4.03) |
P interaction | 0.100 | 0.023 | |||
Women | (n=515) | (n=510) | |||
No regular alcohol consumption | |||||
cases/controls | 21/18 | 48/64 | 20/15 | 24/27 | 24/40 |
OR (95% CI)1 | 1.00 | 1.00 | 1.00 | 1.00 | 1.00 |
Below median | |||||
cases/controls | 18/23 | 59/69 | 17/24 | 26/30 | 33/36 |
OR (95% CI)1 | 0.63 (0.22-1.86) | 1.06 (0.60-1.88) | 0.60 (0.24-1.48) | 0.78 (0.31-2.01) | 2.01 (0.80-5.08) |
Above median | |||||
cases/controls | 7/24 | 96/68 | 10/18 | 25/23 | 68/50 |
OR (95% CI)1 | 0.30 (0.09-1.04) | 1.68 (0.94-3.00) | 0.36 (0.12-1.08) | 1.28 (0.50-3.26) | 3.09 (1.26-7.59) |
P interaction | 0.003 | 0.008 |
Adjusted for age, gender (for overall sample model), body site of biopsy (head, extremity, trunk), indoor tanning (never, ever), skin color (olive, fair, very fair), education (some college or less, college graduate, some graduate school), smoking status (never, former, current), hours spent outdoors in warm months (continuous), sunburns (continuous), and family history of skin cancer (yes, no).
Discussion
In this study of BCC among young people, we did not observe an association between lifetime alcohol intake and risk of early-onset BCC. There was also no clear evidence of an association between early-onset BCC and individual alcoholic beverage types.
While we did not observe an association between alcohol and early-onset BCC, several cohort studies have found a moderately increased risk of BCC associated with greater alcohol consumption. In a cohort of Danish females, a 10 gram increase in daily alcohol intake was associated with a statistically significant relative risk of 1.05 for BCC.16 Similarly, in a cohort study among US radiological technologists, there were 30 and 40% increased risks of BCC for individuals who consumed 3-6 drinks per week and 7-14 drinks per week, respectively, compared to nondrinkers.14 Another US cohort study observed a 29% increased risk of BCC for people who drank 15-29.9 g alcohol per day.15 However, the data are not entirely consistent, as one other cohort study and several case-control studies found no statistically significant associations between overall alcohol intake and BCC.18-21,26 It is important to consider that because our outcome is early-onset BCC only, the alcohol association could be different for this specific BCC outcome as opposed to the existing cohort studies in which most BCC cases are older. In addition, because alcohol may be related to risk through its interaction with the carcinogenic and immunosuppressive actions of UV, it is possible that in our young sample the total exposure to UV is lower than that of older cohorts, thus these younger individuals are less susceptible to any co-carcinogenic effects of alcohol.
Our exploratory analyses on the interaction between alcohol and UV exposures showed some intriguing patterns that suggest that alcohol may be a risk factor only among those with the highest UV exposure. However, these results should be interpreted with caution, as we did not observe a significant main effect of alcohol nor did we observe a significant interaction when alcohol and UV exposure were evaluated as continuous variables. While the interaction may be real, it is also possible that the group of people who consumed greater alcohol and engaged in indoor tanning/outdoor sunbathing may have differed in other unmeasured factors potentially related to skin cancer risk as compared with those who did not drink, never tanned indoors and sunbathed infrequently. Additional larger studies, ideally with prospectively collected alcohol and UV data, or consortial efforts are required to further investigate this possible interaction, especially as there is some evidence from mechanistic research supporting the hypothesis that alcohol may enhance the carcinogenicity of UV exposure.22,23
Evidence from studies that examined beverage type-specific effects of alcohol on BCC has also been mixed. Red wine was inversely associated with BCC among women, but not men, in a US cohort study, while white wine was associated with an increased risk of BCC risk in the overall population and women only.15 In the same study, liquor was associated with an increased risk of BCC in the overall population and in men only.15 In a Danish population, intake of wine and spirits was related to marginal increases in BCC in both men and women, while intake of beer was associated with a decreased risk.16 In our investigation, no statistically significant relationship was found for different types of alcoholic drinks with BCC; however, our power to examine these associations was more limited than for our measure of total alcohol.
To our knowledge, the present study is the first to evaluate alcohol and early-onset BCC and to explore the potential modifying effect of UV exposure on the association between alcohol consumption and BCC. With detailed assessment of alcohol consumption, we were also able to explore the association by different types of alcoholic beverages. In addition, with extensive information on major skin cancer risk factors and UV related activities, we evaluated and adjusted for numerous potential confounders. Finally, since there has not been an established association between alcohol intake and skin cancer covered in the popular media, reporting of alcohol intake was unlikely to differ by case-control status (recall bias), although both cases and controls may have reported inaccurately due to social desirability biases.
Despite some strengths, the present study had several limitations. Firstly, the retrospective nature inherent in case-control studies limits the accuracy of self-reported information and UV exposure reporting could suffer from both social desirability and recall biases. Although alcohol intake was by self-report, as expected it was correlated with pack-years of smoking in our study population (p-value < 0.001), providing some internal validation of the self-report measure. Secondly, based on the wording of our questionnaire, we could only assess number of lifetime alcoholic drinks and were not able to calculate a measure of average alcohol consumption (per week/per day); the measure used by many studies that had food frequency questionnaires. Thus far, only one cohort study has assessed lifetime alcohol consumption, and in that study, as in ours, there was no overall association between alcohol and BCC.16 Consequently, the ability to compare our results with previous studies of alcohol and BCC is somewhat limited. Third, we did not have sufficient power to fully examine risk by alcoholic beverage type and our interaction analyses were exploratory in nature given our sample size. Fourth, the majority of our study population was female, reflecting the incidence pattern of BCC in young people,27 but thus limiting our ability to comprehensively evaluate the relationship between alcohol and early-onset BCC in men. In addition, our controls were drawn from a central dermatopathology facility serving Connecticut dermatologists; we chose this method to identify controls most likely to represent our source population (young people who saw a dermatologist). To our knowledge, the control skin conditions have not been related to alcohol intake but this remains a consideration. Finally, our study population was limited to one state, Connecticut, and our sample was reasonably well-educated which could limit the generalizability of our results to a broader population.
In conclusion, we did not observe a clear or consistent effect of lifetime total alcohol intake or intake of specific types of alcoholic beverages and risk of early-onset BCC, although larger and better powered studies are needed to examine the association of alcohol with risk in populations exposed to high levels of UV or with greater cumulative exposure to both alcohol and UV.
What's already known about this topic?
Existing evidence on an association between alcohol intake and basal cell carcinoma (BCC) is mixed, with several cohort studies finding an increased risk, but one cohort and several case-control studies observing no association.
Some evidence indicates the association may differ by type of alcoholic beverage.
What does this study add?
This is the first investigation of alcohol intake in relation to early-onset BCC among people under age 40.
We conducted an exploratory evaluation of effect modification by ultraviolet (UV) light exposure, as alcohol may enhance UV light's carcinogenicity.
There was no overall association between alcohol and BCC. Our exploratory interaction analyses provide intriguing data for future studies evaluating alcohol, UV, and skin cancer.
Acknowledgments
Funding: This study was supported by the Yale SPORE in Skin Cancer funded by the National Cancer Institute of the National Institutes of Health (P50 CA121974; R. Halaban, PI). Additional support from the Nancy Hildreth Memorial Fellowship in Chronic Disease Epidemiology, the National Cancer Institute of the National Institutes of Health (F32 CA144335), and a CTSA Grant from the National Center for Research Resources of the National Institutes of Health (UL1 RR024139).
Footnotes
Conflict of Interest: None declared.
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