Facial flushing response to alcohol and the risk of esophageal squamous cell carcinoma: A comprehensive systematic review and meta-analysis

Association between alcohol flushing syndrome and cancer: A systematic review and meta-analysis

Introduction

Alcohol flushing syndrome (AFS) is experienced by up to 46% of East Asians. This study aimed to review the risk of cancers in AFS patients, elucidate an exposure-response relationship, and understand risk associated with alcohol intake and cancer.

Method

An electronic database search of PubMed, Embase, Scopus and Cochrane Library was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines. Observational studies on AFS' effects and all cancers risk were included. Studies including patients with existing malignancy were excluded. Dichotomous variables were pooled using the Mantel-Haenszel method with a random effects model. Sensitivity and subgroup analyses were performed. PROSPERO (CRD42023392916) protocol was followed.

Results

A total of 18 articles were included in the final analysis with a total of 387,521 participants. AFS was associated with an increased risk of all cancers (odds ratio [OR] 1.19, 95% confidence interval [CI] 1.06-1.34), esophageal squamous cell carcinoma (OR 1.47, 95% CI 1.05-2.05) and gastric adenocarci-noma (OR 1.40, 95% CI 1.14-1.72). Men with AFS exhibited an increased risk of all cancers (OR 1.34, 95% CI 1.13-1.59). However, this was not observed in women. All cancers risk was associated with AFS in those who consumed drink (i.e. consumed alcohol) more than 200 g of pure ethanol/week (OR 1.68, 95% CI 1.20-2.37) but not those who consumed less than 200 g of pure ethanol/week (OR 1.27, 95% CI 0.90-1.79) or non-drinkers (OR 0.99, 95% CI 0.67-1.47).

Conclusion

AFS is associated with an increased risk of all cancers, particularly esophageal squamous cell carcinoma and gastric adenocarcinoma.

The alcohol flushing syndrome: A risk factor for cancer

Globally, alcohol consumption is responsible for an estimated 3 million deaths annually and contributes to over 740,000 new cancer cases each year.1 Acetaldehyde, a byproduct of alcohol metabolism, has been designated as first-class carcinogens by the International Agency for Research on Cancer.2 In East Asian countries such as China, Japan and Korea, approximately 36% of the population cannot effectively metabolise alcohol due to an inherited deficiency in the enzyme aldehyde dehydrogenase 2 (ALDH2).3 This deficiency leads to the accumulation of acetaldehyde in the blood, causing alcohol flushing syndrome (AFS), characterised by facial flushing, palpitations and nausea.4 AFS is a predictor of inactive ALDH2 and is associated with a higher risk of cancer development.

Epidemiologic relationship between alcohol flushing and smoking in the Korean population: the Korea National Health and Nutrition Examination Survey

Although facial flushing after drinking alcohol (alcohol flushing response) is common in Asian populations, the epidemiological features in a large sample have been investigated in only a few studies. This study assessed the epidemiologic characteristics and associated factors for alcohol flushing in a Korean population. This study was based on data collected during the 2019 Korea National Health and Nutrition Examination Survey (KNHANES). A total of 5572 Korean adults was included in the general population group, and the alcohol flushing group consisted of 2257 participants. Smoking and physical activity were evaluated as possible associated factors for alcohol flushing. The overall prevalence of alcohol flushing was estimated at 40.56% of the general population (43.74% in males and 37.4% in females), and the prevalence was highest at 60-69 years of age and lowest in individuals older than 80 years. Occasional, frequent, and persistent alcohol flushing was reported by 11.9%, 3.7% and 15.0% of current flushers, among whom persistent flushers consumed the least amount of alcohol. Subjects who currently smoke had a higher propensity of alcohol flushing (adjusted OR 1.525, 95% CI 1.2-1.938), and subjects with smoking history of 20-29 pack-years (PYs) showed the highest association (adjusted OR 1.725, 95% CI 1.266-2.349) with alcohol flushing after adjustment for confounders. In contrast, significant association was not found between physical activity and alcohol flushing. The results demonstrated that current smoking status is shown to be significantly associated with alcohol flushing, and that current smokers with a history of smoking ≥ 20 PYs had a higher likelihood of alcohol flushing than non-smokers or ex-smokers.

The alcohol flushing response is associated with the risk of depression

The alcohol flushing response is experienced by 36–45% of East Asians after they consume a small amount of alcohol. Because individuals with this response are unable to metabolize the toxic acetaldehyde derived from alcohol effectively, the response offers a potential indicator of the health risks associated with alcohol intake. Depression is a major health problem linked to alcohol consumption; it might also be associated with the alcohol flushing response. Therefore, we examined the association between the alcohol flushing response and the risk of depression in the general population of South Korea. Our analysis included 139,380 participants and used data from the 2019 Korean Community Health Survey. Only current drinkers were considered in the analysis. The relationship between the alcohol flushing response and depression was evaluated by logistic regression analysis using SAS 9.4. Of the participants, more than one-third were current flushers; compared to never flushers, current flushers had a significantly greater risk of depression (adjusted odds ratio [AOR] 1.23, 95% confidence interval [CI] 1.12–1.34, P < 0.001). Former flushers did not exhibit a risk of depression. The risk of depression was significantly greater among alcohol flushers who drank < 15 g alcohol/day (< 5 g alcohol/day: AOR 1.20, 95% CI 1.07–1.35, P = 0.002; 5–14.9 g alcohol/day: AOR 1.39, 95% CI 1.13–1.70, P = 0.002). In conclusion, a large number of South Koreans experience the alcohol flushing response; compared with never flushers, current flushers are more likely to develop depression with a small dose of alcohol (< 15 g alcohol/day).

Clinical Characteristics and Proposed Wheat-Cofactor Challenge Protocol with a High Diagnostic Yield in Adult-Onset IgE-Mediated Wheat Allergy

Background

IgE-mediated wheat allergy in adults can be childhood or adulthood onset. Adult-onset wheat allergy has been reported, but data on clinical characteristics and practical food challenge protocols are scarce.

Objective

We aimed to describe the clinical characteristics of adult-onset wheat allergy, laboratory results, and outcomes of a modified 3-day challenge protocol using a combination of aspirin, wheat, and exercise.

Patients and Methods

Patients with histories compatible with adult-onset wheat allergy were recruited from Siriraj Hospital, Thailand. Clinical history, skin prick tests (SPTs), and specific IgE (sIgE) levels were ascertained. Patients with no food challenge contraindications were asked to volunteer for wheat challenge. A modified 3-day protocol using 300 mg of acetylsalicylic acid, 60-75 g of wheat flour, and exercise was used for confirmatory diagnosis of conventional wheat allergy (WA) and wheat-dependent exercise-induced anaphylaxis (WDEIA).

Results

Thirty-three patients were recruited. The mean age of onset was 29.7 years (SD 10.5). SPTs yielded positivity rates of 9.1%, 84.8%, and 81.8% in commercial wheat, in-house gliadin, and in-house glutenin extracts, respectively. sIgE yielded a positivity rate of 61% and 88% in wheat and ω5-gliadin, respectively. Eighteen patients underwent oral wheat challenges. Of these, 17 patients (94.4%) had positive challenges leading to definite diagnoses of WA (35%), and WDEIA (65%). One WDEIA patient developed hypotensive anaphylaxis in the protocol.

Conclusion

WDEIA was the most common phenotype. Our modified 3-day protocol could differentiate WA and WDEIA and yielded a high positivity rate (94.4%). It should be used cautiously as severe reactions can occur.

Impact of alcohol drinking on cancer risk with consideration of flushing response: The Japan Public Health Center-based Prospective Study Cohort (JPHC study)

Alcohol drinking is a risk factor for cancer. The degree of risk is increased in subjects showing the flushing response, which is due to aldehyde dehydrogenase 2 (ALDH2) polymorphism. The attributable risk of alcohol drinking for cancer in Japan has not been sufficiently investigated with consideration of flushing response. We followed 78,825 Japanese in JPHC study cohort II. The association between alcohol consumption and cancer incidence was assessed according to self-reported flushing response using Cox proportional hazards regression models. The population-attributable fraction (PAF) of cancer incidence was also estimated. During 1993-2013 (average follow-up, 16.8 years), 8486 incident cancers (included 4386 alcohol-related cancers) were reported. Half of men and 36% of women had flushing response. In men with flushing response, moderate or higher alcohol drinking increased the risk of alcohol-related cancers compared with non-drinkers (150-299 g/week, HR 1.63, 95% CI, 1.43-1.99; 300-449 g/week, HR 2.02 95% CI, 1.67-2.44; ≥450 g/week, HR 1.75, 95% CI, 1.39-2.21). When flushing response was considered in comparisons between non-drinkers and non-flushers, non-flushing heavy drinkers had a slightly higher PAF than flushers (all cancers: flushers, 2.0% and non-flushers, 2.2%; alcohol-related cancers: flushers, 3.8% and non-flushers, 5.8%). Although the risk of alcohol-related cancer in men with flushing response increased with increasing alcohol consumption, heavy drinkers were also at high risk regardless of flushing response. Considering the PAF of alcohol consumption on cancer, efforts to discourage heavy alcohol consumption to reduce the incidence of alcohol-related cancers appear warranted regardless of flushing response.

Effect of Topical Brimonidine on Alcohol-Induced Flushing in Asian Individuals: A Randomized Clinical Trial

Importance

Alcohol flushing syndrome (AFS, also known as Asian glow and Asian flush) affects 20% to 47% of East Asians and causes significant psychosocial distress. There are no approved treatments for this condition.

Objective

To determine whether brimonidine gel, 0.33%, decreases facial erythema in patients with AFS after consumption of alcohol.

Design, Setting, and Participants

In this randomized clinical trial, 20 healthy volunteers of East Asian descent with a self-reported history of AFS were recruited between April 2018 and March 2019.

Interventions

Participants were randomized to application of brimonidine gel to either the left or right half of their face. Placebo control was applied to the opposite side. After 30 minutes, participants ingested alcohol.

Main Outcomes and Measures

Outcomes were specified before data collection. The difference in erythema between the treated and placebo side of each participant's face was measured 60 minutes after drug application (primary outcome) and at 90 and 120 minutes after drug application (secondary outcomes). Participants were asked to rate their likelihood of using the medication again and their likelihood of recommending the medication to a friend on a scale of 0 to 10.

Results

The mean (SD) age of the 20 individuals enrolled in the study was 30.5 (8.4) years, and there were 10 women (50%). There was a significant difference in erythema at 60 minutes after drug application as measured by the difference in Clinician Erythema Assessment score (2.1; 95% CI, 1.5-2.71; P < .001) and by the difference in Subject Self-Assessment score (1.7; 95% CI, 1.1- 2.3; P < .001). This effect persisted at 90 and 120 minutes. Individuals were likely to use the medication again (7.2; 95% CI, 6.0-8.3) and would also recommend it to a friend (7.6; 95% CI, 6.5-8.6).

Conclusions and Relevance

This study demonstrates that brimonidine gel is effective in reducing the facial erythema of AFS. Patients with psychosocial distress due to AFS may benefit from treatment with brimonidine.

Trial Registration

ClinicalTrials.gov identifier: NCT03497442.

Schwann cells expressing nociceptive channel TRPA1 orchestrate ethanol-evoked neuropathic pain in mice

Excessive alcohol consumption is associated with spontaneous burning pain, hyperalgesia, and allodynia. Although acetaldehyde has been implicated in the painful alcoholic neuropathy, the mechanism by which the ethanol metabolite causes pain symptoms is unknown. Acute ethanol ingestion caused delayed mechanical allodynia in mice. Inhibition of alcohol dehydrogenase (ADH) or deletion of transient receptor potential ankyrin 1 (TRPA1), a sensor for oxidative and carbonyl stress, prevented allodynia. Acetaldehyde generated by ADH in both liver and Schwann cells surrounding nociceptors was required for TRPA1-induced mechanical allodynia. Plp1-Cre Trpa1fl/fl mice with a tamoxifen-inducible specific deletion of TRPA1 in Schwann cells revealed that channel activation by acetaldehyde in these cells initiates a NADPH oxidase-1-dependent (NOX1-dependent) production of hydrogen peroxide (H2O2) and 4-hydroxynonenal (4-HNE), which sustains allodynia by paracrine targeting of nociceptor TRPA1. Chronic ethanol ingestion caused prolonged mechanical allodynia and loss of intraepidermal small nerve fibers in WT mice. While Trpa1-/- or Plp1-Cre Trpa1fl/fl mice did not develop mechanical allodynia, they did not show any protection from the small-fiber neuropathy. Human Schwann cells express ADH/TRPA1/NOX1 and recapitulate the proalgesic functions of mouse Schwann cells. TRPA1 antagonists might attenuate some symptoms of alcohol-related pain.

Psychosocial Motivators for Moderate Drinking among Young Asian Flushers in Singapore

Asians are more susceptible to alcohol flush syndrome and its associated health risks because they are genetically predisposed towards it. Guided by the theory of planned behaviour, this research examined the psychosocial factors associated with moderate alcohol consumption, in order to inform the development of a health campaign targeting young Asian "flushers" in Singapore. We employed a mixed-method design comprising an online survey and focus group discussions. The survey results identified perceived behavioural control as the most salient belief associated with moderate drinking intentions, particularly for Asian flushers. Although Asian flushers had more positive attitudes towards, and perceived behavioural control about drinking in moderation, they were more likely to consider that their peers disapprove of such a practice, compared to non-flushers. Additionally, Asian flushers did not consider themselves as having a higher risk of long-term health effects from alcohol consumption than non-Flushers despite their actual high-risk status. Focus group findings suggest that young Asian flushers have poor knowledge of, and skills associated with moderate drinking, in addition to feeling self-imposed social pressure. The study findings provide practical insights into bridging the information gap on Asian flush and promoting Asian flushers' drinking in moderation.

Risks of substance uses, alcohol flush response, Helicobacter pylori infection and upper digestive tract diseases-An endoscopy cross-sectional study

This study examines the effects of environmental hazards, including tobacco, alcohol/alcohol flush response, areca nut, and Helicobacter pylori (H pylori) infection on upper digestive diseases. This is a multi-hospital-based endoscopy-survey cross-sectional study. Subjects were received upper endoscopies in outpatient clinics at four hospitals in Taiwan between 2008 and 2013. Biopsy-based methods or urea breath test were used confirm the status of H pylori infection. In total, 8135 subjects were analyzed. Higher cumulative amounts of alcohol consumption were at higher risk of Barrett's esophagus and esophageal squamous cell carcinoma (ESCC), higher cumulative amounts of tobacco consumption were at higher risk of peptic ulcer, and higher cumulative amounts of areca nut consumption were at higher risk of duodenitis. Alcohol flush response was significant risk for reflux esophagitis and Barrett's esophagus (adjusted odds ratio [aOR] = 1.18 and 1.32, 95% confidence interval [CI] = 1.07-1.31 and 1.06-1.65, respectively). H pylori infection was inversely associated with ESCC risk (aOR = 0.20, 95% CI = 0.10-0.40). In addition, H pylori infection was consistently and significantly risk factors for gastrointestinal diseases, including peptic ulcer, gastric adenocarcinoma, and duodenitis (aOR = 5.51, 1.84, and 2.10, 95% CI = 4.85-6.26, 1.03-3.26, and 1.71-2.56, respectively). Besides the cumulative risk of alcohol, tobacco, and areca nut for Barrett's esophagus, ESCC, and peptic ulcer, respectively, presence of facial flushing was the significant risk for reflux esophagitis and Barrett's esophagus. H pylori infection was positively associated with peptic ulcer, gastric adenocarcinoma, and duodenitis, but inversely associated with ESCC.

Systematic review: the etiology of esophageal squamous cell carcinoma in low-income settings

Esophageal carcinoma causes over 380 000 deaths per year, ranking sixth worldwide in mortality amongst all malignancies. Globally, the squamous cell subtype is most common and accounts for 80% of esophageal cancers. Nonetheless, esophageal squamous cell carcinoma is much more poorly understood than esophageal adenocarcinoma, including what is driving such high prevalences, why it often presents in young patients, and shows such marked geographical delineations Areas covered: The current literature was searched for articles focusing on aetiopathogenesis of squamous cell esophageal carcinoma via a systematic review, particularly in low-resource settings. This was supplemented by papers of interest known to the authors. Expert commentary: Current putative mechanisms include polycyclic aromatic hydrocarbons, nitrosamines, acetaldehyde, cyclo-oxygenase-2 pathways, androgen and their receptor levels, as well as smoking & alcohol, micronutrient deficiencies and diet, mycotoxins, thermal damage, oral hygiene and microbiotal factors, inhaled smoke, viral infections such as HPV, and chronic irritative states. Etiology is likely multifactorial and varies geographically. Though smoking and alcohol play a predominant role in high-income settings, there is strong evidence that mycotoxins, diet and temperature effects may play an under-recognized role in low and middle-income settings.

Association of low-activity ALDH2 and alcohol consumption with risk of esophageal cancer in Chinese adults: A population-based cohort study

Existing evidence remains inconclusive as to how the association between inactive ALDH2 and esophageal cancer (EC) depends on alcohol consumption. The study is based on the China Kadoorie Biobank cohort, with 10 years follow‐up of 0.5 million adults aged 30–79 years. ALDH2 activity was assessed by both self‐reported flushing response and Glu504Lys (rs671 G > A) polymorphism. Among both male and female participants who consumed alcohol less than weekly (n = 69,519; 211 EC cases), low active or inactive ALDH2 was not associated with increased EC risk [HRs (95% CIs): GA vs. GG 0.75 (0.54, 1.04); AA vs. GG 1.01 (0.46, 2.20)]. Among male weekly alcohol consumers, both flushing response [n = 59,380; 501 EC cases; HRs (95% CIs): “soon after drinking” vs. “no” flushing response 1.45 (1.05, 2.01)] and rs671 [n = 10,692; 94 EC cases; GA vs. GG 3.31 (1.94, 5.67)] were associated with EC risk. The increased EC risk associated with “soon” response or rs671 GA was apparent in men consuming alcohol ≥30g/d. Among male daily consumers, the HRs (95% CIs) for EC associated with 15g/d of alcohol were 1.28 (1.15, 1.44) for “soon” response [vs. other responses: 1.12 (1.09, 1.15); p_interaction = 0.047; n = 36,401, 425 EC cases] and 1.41 (1.08, 1.82) for rs671 GA [vs. GG: 1.16 (1.06, 1.27); p_interaction = 0.493; n = 6,607, 80 EC cases]. Self‐reported flushing response had low sensitivity (56.8%) and high specificity (88.4%) in identifying rs671 A allele among male weekly alcohol consumers. In conclusion, low‐activity ALDH2 was associated with increased EC risk among male heavy alcohol consumers. More accurate measurement of alcohol‐related EC risk allows better achievement of precision prevention.

What's new?

Acetaldehyde is a toxic metabolite considered a major cause of alcohol‐induced carcinogenesis. The key enzyme for acetaldehyde elimination is acetaldehyde dehydrogenase 2 (ALDH2), and an association between ALDH2 genotype and EC risk that is dependent on alcohol consumption has been suggested. The evidence remains inconclusive, however. In this large prospective cohort of Chinese adults, the ALDH2 rs671 A allele was not associated with increased EC risk in the absence of alcohol consumption. The increased EC risk associated with low‐activity ALDH2, characterized as self‐reported flushing response or rs671 GA, was apparent in men consuming alcohol ≥30g/day, but not among light‐to‐moderate consumers.

Intakes of citrus fruit and risk of esophageal cancer: A meta-analysis

Esophageal cancer (EC) is the eighth most common cancer and the sixth most frequent cause of cancer death in the whole world. Many studies have investigated the association between citrus fruit intake and the risk of EC, but the results are inconsistent and not analyzed by category. We aimed to perform a meta-analysis of studies to evaluate the incidence between citrus fruit consumption and subtypes of esophageal cancer and derive a more precise estimation.Through searches of PubMed, OVID, and Web of Science we updated 1988 systematic review up to April 2016. Based on an inclusion and exclusion criteria, conventional meta-analysis according to DerSimonian and Laird method was used for the pooling of the results. Random-effect models were used to calculate subgroups.Twenty-five English articles (20 case-control studies and 5 cohort studies) comprising totally 5730 patients of esophageal cancer would be suitable for use in this study. The result indicated the inverse associations between intakes of citrus fruit and EC (relative risk [RR] = 0.65, 95% confidence interval [CI] 0.56-0.75, I  = 51.1%, P = .001), Esophageal squamous cell carcinoma (ESCC) (RR = 0.59, 95% CI 0.47-0.76, I  = 60.7%, P = .002), no significant relationship between citrus fruit and esophageal adenocarcinoma (EAC) (RR = 0.86, 95% CI 0.74-1.01, I  = 0.0%, P = .598).This meta-analysis indicates that intakes of citrus fruit significantly reduce the risk of ESCC and is no obvious relationship with EAC. Further studies about constituents in citrus fruit and its mechanism are warranted.

Endoscopic screening for synchronous esophageal neoplasia among patients with incident head and neck cancer: Prevalence, risk factors, and outcomes

Esophageal squamous-cell neoplasia (ESCN) is a common second primary neoplasia found in patients with head-and-neck squamous-cell carcinoma (HNSCC). This study sought to identify the risk factors for synchronous ESCN and how they influence survival in HNSCC patient. Eight hundred and fifteen incident HNSCC patients were prospectively recruited for endoscopy screening for ESCN using white-light imaging, narrow-band imaging, Lugol chromoendoscopy, and pathological confirmation. Associated lifestyle and clinicopathological data were collected. The interquartile follow-up period cutoffs were 11.3, 20.5 and 34.9 months. 124 patients (15.2%) were diagnosed as having synchronous ESCN (66 low-grade dysplasia, 29 high-grade dysplasia, and 29 esophageal squamous-cell carcinoma). Consumption of alcohol, but not betel nut or cigarette, was significantly associated with the presence of synchronous ESCN (adjusted odds ratio [aOR] = 7.1 and 10.9 for former and current drinkers, respectively). There was an interaction between cumulative dose of alcohol consumption and alcohol flushing response on the development of ESCN. High-dose drinkers with flush response were 16.9 times more likely to have esophageal high-grade dysplasia/SCC than non-drinkers. Compared with oral cavity cancer patients, those with hypopharyngeal, laryngeal and oropharyngeal cancer were 6.8, 4.6 and 2.8 times more likely to have esophageal high-grade dysplasia/SCC. HNSCC patients with synchronous ESCN had lower overall survival than those without (p < 0.0001). In conclusion, surveillance of ESCN is strongly recommended for the high-risk subpopulation of HNSCC patients, especially drinkers who have a flush response to alcohol, and those with distant metastasis of index cancer and cancers in hypopharynx, oropharynx and larynx.

Facial flushing after alcohol consumption and the risk of cancer: A meta-analysis

BACKGROUND

The association between facial flushing after alcohol consumption and the risk of cancer remains controversial. The aim of this study was to evaluate the relation between facial flushing and cancer risk.

METHODS

PubMed, EMBASE, and Cochrane Library were searched for relevant literature. The patients' baseline characteristics and estimated risks were extracted. Odds ratios (ORs) with 95% confidence intervals (CIs) were pooled to estimate the risk of facial flushing in cancer, and subgroup analysis was performed.

RESULTS

Ten studies with 89,376 participants from East Asia were included. The pooled OR of facial flushing in all cancers was 1.43 (95% CI, 1.08-1.91), with the pooled ORs of 1.94 (95% CI, 1.33-2.83) and 0.95 (95% CI, 0.80-1.12) in men and women, respectively. The pooled ORs were also estimated in different cancer types.

CONCLUSION

Our results showed that facial flushing response to alcohol was associated with higher cancer risk in men in East Asia, especially in esophageal squamous cell carcinoma, yet facial flushing was not significantly associated with cancer risk among women.