Is a Few Too Many? Alcohol Consumption and Prostate Cancer Upgrading during Active Surveillance

Is a Few Too Many? 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Alcohol Consumption and Prostate Cancer Upgrading during Active Surveillance Jack Campbell, Michelle I. Higgins, Zhuo Tony Su, Yuezhou Jing, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8371269/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Men with favorable-risk prostate cancer (PCa) undergoing active surveillance (AS) often seek lifestyle modifications that may reduce their risk of disease progression. We assessed the association between alcohol intake and biopsy upgrading during AS. In this prospective observational study, we included 1,505 men (median follow-up 3.5 years) who were diagnosed with grade group (GG) 1 PCa during 2005–2023 and upon AS enrollment completed a questionnaire estimating alcohol consumption during the preceding 5 years, which we categorized as <1, 1-6, and ≥7 drinks per week. Multivariable competing risk proportional hazards regression was utilized to evaluate self-reported alcohol intake for association with upgrading to ≥GG2 and extreme upgrading to ≥GG3 on a surveillance biopsy, adjusting for baseline clinicopathological prognostic factors, smoking history, and body mass index. Increased alcohol consumption was positively associated with upgrading to ≥GG2 (p¬ for linear trend = 0.008). Compared to <1 drink per week, consumption of ≥7 drinks per week was associated with a 47% increase in the risk of upgrading (subdistribution hazard ratio 1.47, 95% confidence interval 1.16–1.85). No significant association was found between alcohol consumption and extreme upgrading. Our findings identify alcohol consumption as a potentially modifiable lifestyle factor associated with upgrading during AS. active surveillance prostate cancer alcohol consumption Full Text Men pursuing active surveillance (AS) for favorable-risk prostate cancer (PCa) often seek evidence-based lifestyle interventions to mitigate the risk of disease progression and avoid treatment and associated morbidity. Alcohol is associated with increased risk for several malignancies and is the third leading preventable cause of cancer in the U.S. 1 Although the current U.S. dietary guidelines recommend limiting intake to ≤2 drinks per day for men, a recent Surgeon General’s advisory suggested these limits may still confer cancer risk. 2,3 The relationship between alcohol consumption and PCa remains uncertain, as epidemiologic studies show conflicting results. 4,5 Data in the early-stage PCa AS population are particularly limited. Using one of the largest and longest-running prospective AS cohorts, we examined the association between baseline, self-reported alcohol consumption and PCa grade progression during AS. Our institutional AS Program has monitored men with favorable-risk PCa since 1995. 6 The current study included men in the program who were diagnosed with grade group (GG) 1 PCa between 2005 and 2023, underwent a confirmatory biopsy (typically within 18 months of the diagnostic biopsy) verifying ≤GG1 disease, and upon AS enrollment prospectively completed a questionnaire estimating their alcohol consumption during the 5 years preceding their PCa diagnosis. Institutional Review Board approval and informed consent were obtained from all participants (IRB number NA_00045103). Self-reported alcohol consumption was categorized as: <1 drink per week, 1-6 drinks per week, and ≥7 drinks per week. We evaluated two outcomes: any upgrading (i.e. to ≥GG2) and extreme upgrading (i.e. to ≥GG3) on a surveillance biopsy. Multivariable competing risk proportional hazards regression was used to assess the association between alcohol consumption and each upgrading outcome. Competing events for upgrading during AS included volume reclassification only on a surveillance biopsy triggering treatment, elective treatment, and non-PCa mortality; competing events for extreme upgrading additionally included upgrading to GG2. The regression models adjusted for smoking (current or former smoker versus never smoker), body mass index (BMI), and established AS prognostic factors at baseline including year of diagnosis, age, prostate-specific antigen (PSA) density, number of positive biopsy cores, and maximum percent involvement of a core at diagnosis. 6 A linear contrast was used to assess the linear trend across the alcohol consumption categories by using the median alcohol consumption value for each category. We performed statistical analyses using STATA version 18.0 (StataCorp LLC, College Station, TX). All tests were two sided, with statistical significance set at p <0.05. We included 1,505 men. Self-reported alcohol consumption during the preceding five years is summarized in Table 1 , along with other baseline characteristics. After a median follow-up of 3.5 years (quartiles 1.6–6.2), 515 men experienced upgrading to ≥GG2, including 161 with extreme upgrading to ≥GG3. The cumulative incidence of upgrading was 19% (95% confidence interval [CI] 17%–21%) at 3 years from cancer diagnosis, and 29% (26%–31%) at 5 years; that of extreme upgrading was 6% (5%–7%) at 3 years and 9% (7%–10%) at 5 years. After adjusting for baseline covariates, increased alcohol consumption was significantly associated with an increased risk of upgrading ( p =0.008 for linear trend). Compared with <1 drink per week, consumption of ≥7 drinks per week was associated with a 47% increase in the risk of upgrading (subdistribution hazard ratio 1.47, 95% CI 1.16–1.85). Alcohol consumption was not significantly associated with extreme upgrading ( Table 2 ). In a prospective cohort of over 1,500 men, after adjusting for baseline prognostic factors, smoking history, and BMI, we found that increased self-reported alcohol consumption was positively associated with PCa grade progression during AS. To our knowledge, this is the first prospective study to identify alcohol consumption as a potential risk factor for P­Ca grade progression during AS. The only prior AS study examining alcohol consumption as part of a broader lifestyle analysis found no association with progression, although its small sample size likely limited statistical power 7 . Alcohol consumption was significantly associated with upgrading to ≥GG2, whereas no association was observed with extreme upgrading to ≥GG3. It is likely that true dedifferentiation from GG1 to > GG3 takes longer than to GG2. We have previously shown that extreme upgrading increases significantly with age. 8 Thus, our relatively limited follow-up, and the low number of extreme upgrading events—only 49 men consuming ≥7 drinks/week experienced extreme upgrading—may have reduced our ability to detect an association for this endpoint. Alcohol may exert long-term cumulative effects through pathways such as acetaldehyde mediated DNA damage, oxidative stress, and chronic inflammation, which could plausibly influence progression risk over time among men on AS. 3 Our observation that ≥7 drinks/week was associated with a nearly 50% increased risk of grade progression falls below the U.S. Dietary Guidelines’ recommended limit of ≤14 drinks per week 2 . Instead, our results are consistent with recommendations of the World Health Organization, which emphasize that no level of alcohol consumption is completely risk-free, as even low intake may increase cancer risk. 9 Intake patterns in our cohort are consistent with the general U.S. population, with 4% reporting excessive intake (≥16 drinks/week) and 40% classified as light drinkers (<4 drinks/week), comparable to the Centers for Disease Control and Prevention estimates for older American adults. 10 Strengths of our study include the large sample size, prospective data collection, and rigorous follow-up. Limitations include reliance on self-reported intake, lack of lifetime or post-diagnosis alcohol data, and inability to assess binge drinking patterns. Although we adjusted for smoking, BMI, and established clinical prognostic variables, there may be unmeasured confounding factors inherent to an observational study design. Specifically, lifestyle factors such as diet and exercise may contribute to the observed association between alcohol consumption and biopsy upgrading, but we did not have detailed information on these factors for the entire cohort. In conclusion, in a large prospective cohort, increased self-reported alcohol consumption at baseline was positively associated with PCa grade progression during AS. In particular, consumption of ≥7 alcoholic drinks per week was associated with a significant, nearly 50% increase in the risk of PCa grade progression during AS. No association was observed between alcohol consumption and extreme progression to GG3 or worse disease. Our findings may help inform clinical counseling for men pursuing AS regarding how alcohol consumption relates to their risk of progression. Declarations Funding Sources: None. Conflicts of Interest: None. References Islami F, Marlow EC, Thomson B et al (2024) Proportion and number of cancer cases and deaths attributable to potentially modifiable risk factors in the United States, 2019. CA Cancer J Clin 74(5):405–432. 10.3322/caac.21858 U.S. Department of Agriculture; U.S. Department of Health and Human Services. Guidance on Alcoholic Beverages. In: Dietary Guidelines for Americans, 2020–2025. 9th ed. U.S. Department of Agriculture and U.S. Department of Health and Human Services (2020) :48–49. Accessed October 5, 2025. https://www.dietaryguidelines.gov/resources/2020-2025-dietary-guidelines-online-materials U.S. Department of Health and Human Services. Alcohol and Cancer Risk: The U.S. Surgeon General’s Advisory. Washington, DC, Office of the Surgeon General (2025) : Accessed October 5, 2025. https://www.hhs.gov/surgeongeneral/reports-and-publications/alcohol-cancer/index.html Macke AJ, Petrosyan A (2022) Alcohol and Prostate Cancer: Time to Draw Conclusions. Biomolecules 12(3):375 Published 2022 Feb 28. 10.3390/biom12030375 Zhao J, Stockwell T, Roemer A, Chikritzhs T (2016) Is alcohol consumption a risk factor for prostate cancer? A systematic review and meta-analysis. BMC Cancer 16(1):845 Published 2016 Nov 15. 10.1186/s12885-016-2891-z Tosoian JJ, Mamawala M, Epstein JI et al (2020) Active Surveillance of Grade Group 1 Prostate Cancer: Long-term Outcomes from a Large Prospective Cohort. Eur Urol 77(6):675–682. 10.1016/j.eururo.2019.12.017 Vandersluis AD, Guy DE, Klotz LH et al (2016) The role of lifestyle characteristics on prostate cancer progression in two active surveillance cohorts. Prostate Cancer Prostatic Dis 19(3):305–310. 10.1038/pcan.2016.22 Druskin SC, Mamawala M, Tosoian JJ et al (2019) Older age predicts biopsy and radical prostatectomy grade reclassification to aggressive prostate cancer in men on active surveillance. J Urol 201:98–105. 10.1016/juro.2018.08.023 World Health Organization. No level of alcohol consumption is safe for our health. WHO Regional Office for Europe. Published January 4 (2023) Accessed October 5, 2025. ehttps://www.who.int/europe/news/item/04-01-2023-no-level-of-alcohol-consumption-is-safe-for-our-health Boersma P, Villarroel M, Vahratian A (2020) Heavy Drinking Among U.S. Adults, 2018. NCHS Data Brief No. 374. National Center for Health Statistics Tables Table 1, Baseline characteristics of men with grade group 1 prostate cancer undergoing active surveillance (N=1505) Clinical Characteristics Participants Age at diagnosis, median (quartiles), years 65.5 (61.0-69.2) Race, No. (%): White 1307 (86.8%) Black 128 (8.5%) Other/Unknown a 70 (4.7%) Body mass index, median (quartiles), kg/m 2 26.6 (24.5-29.4) Total PSA level at diagnosis, median (quartiles), ng/mL 4.9 (3.9-6.4) PSA density at diagnosis, median (quartiles), ng/mL 2 0.10 (0.08-0.14) Number of positive cores at diagnosis, median (quartiles) 1 (1-2) Maximum core involvement at diagnosis, median (quartiles), % 10 (1-20) Year at diagnosis, median (quartile) 2013 (2009-2016) Smoking history, No. (%): Never 894 (59.4%) Former 551 (36.6%) Current 60 (4%) Alcohol use in 5 years before diagnosis, No. (%): None 218 (14.5%) less than 1 per week 227 (15.1%) 1 per week 109 (7.3%) 2 to 3 per week 262 (17.4%) 4 to 6 per week 249 (16.5%) 7 to 10 per week 214 (14.2%) 11 to 15 per week 160 (10.6%) 16 or more per week 66 (4.4%) Abbreviations: IQR: interquartile range, BMI: body mass index, PSA: prostate specific antigen, GG: grade group. a The “Other” category includes men who identify as “Asian/Pacific Islander,” “Hispanic,” or “Other,” as well as men of unknown race. Table 2. Association between alcohol intake at baseline and prostate cancer upgrading to grade group (GG) ≥2 and extreme upgrading to ≥GG3 on surveillance biopsy in men diagnosed with GG1 disease managed with active surveillance Upgrade ≥GG2) Upgrade (≥GG3) Alcohol use No. of men No. of events SHR (95% CI) p-value No. of events SHR (95% CI) p-value Zero or <1 drink per week 445 147 1 0.0076 49 1 0.5589 1-6 drinks per week 620 190 1.10 (0.87, 1.39) 63 1.15 (0.77, 1.71) ≥ 7 drinks per week 440 178 1.47 (1.16, 1.85) 49 1.10 (0.72, 1.70) Competing events: volume reclassification only on surveillance biopsy, any elective treatment, death not due to prostate cancer. Upgrading to GG2 was also a competing event for the analysis of extreme upgrading. Adjusted for baseline risk factors of age, year of diagnosis, PSA density, number of cores with cancer and max percent of core involvement, smoking history, and body mass index. p-values for linear trend. Abbreviations: GG: grade group, SHR = subdistribution hazard ratio, CI = confidence interval. Additional Declarations The authors declare no competing interests. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8371269","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Short Report","associatedPublications":[],"authors":[{"id":560911428,"identity":"6528ee71-6eac-4ee7-bf9d-ea0b3e7017b7","order_by":0,"name":"Jack Campbell","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAzklEQVRIiWNgGAWjYBACxgYwYSPHz3CGgSEBKkCMljRjyQZitUD1HUrccIAHYQZewNx++Onmwh0HjI0Pnj264QGDjeyGA4Qs6Ekzuz3zzB05swPn0m4kMKQZE9Yyg8HsNm/bM2OzA2fMgFoOJxKhhf0bUMvhxM0NYC3/idHCYwbWsoEBrOUAEVp6csqAfkkzlgA7zCDZeCYhLYbtx7fdLtwBjMoZZ8xu/qiwk+0jqKUBGNBglgRIqQEB5SAgzwDTwt9AhPJRMApGwSgYkQAASMVRxNAOZcsAAAAASUVORK5CYII=","orcid":"","institution":"Johns Hopkins University School of Medicine","correspondingAuthor":true,"prefix":"","firstName":"Jack","middleName":"","lastName":"Campbell","suffix":""},{"id":560911444,"identity":"2809c566-725d-494d-b7dd-7a8c6c949990","order_by":1,"name":"Michelle I. 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Alcohol Consumption and Prostate Cancer Upgrading during Active Surveillance\u003c/strong\u003e\u003c/p\u003e","fulltext":[{"header":"Full Text","content":"\u003cp\u003eMen pursuing active surveillance (AS) for favorable-risk prostate cancer (PCa) often seek evidence-based lifestyle interventions to mitigate the risk of disease progression and avoid treatment and associated morbidity. Alcohol is associated with increased risk for several malignancies and is the third leading preventable cause of cancer in the U.S.\u003csup\u003e1\u003c/sup\u003e Although the current U.S. dietary guidelines recommend limiting intake to ≤2 drinks per day for men, a recent Surgeon General’s advisory suggested these limits may still confer cancer risk.\u003csup\u003e2,3\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eThe relationship between alcohol consumption and PCa remains uncertain, as epidemiologic studies show conflicting results.\u003csup\u003e4,5\u003c/sup\u003e Data in the early-stage PCa AS population are particularly limited. Using one of the largest and longest-running prospective AS cohorts, we examined the association between baseline, self-reported alcohol consumption and PCa grade progression during AS. Our institutional AS Program has monitored men with favorable-risk PCa since 1995.\u003csup\u003e6\u0026nbsp;\u003c/sup\u003eThe current study included men in the program who were diagnosed with grade group (GG) 1 PCa between 2005 and\u0026nbsp;2023, underwent a confirmatory biopsy (typically within 18 months of the diagnostic biopsy) verifying ≤GG1 disease, and upon AS enrollment prospectively completed a questionnaire estimating their alcohol consumption during the 5 years preceding their PCa diagnosis. Institutional Review Board approval and informed consent were obtained from all participants (IRB number NA_00045103).\u003c/p\u003e\n\u003cp\u003eSelf-reported alcohol consumption was categorized as: \u0026lt;1 drink per week, 1-6 drinks per week, and ≥7 drinks per week. We evaluated two outcomes: any\u0026nbsp;upgrading (i.e. to ≥GG2) and extreme upgrading (i.e. to ≥GG3) on a surveillance biopsy. Multivariable competing risk proportional hazards regression was used to assess the association between alcohol consumption and each upgrading outcome. Competing events for upgrading during AS included volume reclassification only on a surveillance biopsy triggering treatment, elective treatment, and non-PCa mortality; competing events for extreme upgrading additionally included upgrading to GG2. The regression models adjusted for smoking (current or former smoker versus never smoker), body mass index (BMI), and established AS prognostic factors at baseline including year of diagnosis, age, prostate-specific antigen (PSA) density, number of positive biopsy cores, and maximum percent involvement of a core at diagnosis.\u003csup\u003e6\u003c/sup\u003e A linear contrast was used to assess the linear trend across the alcohol consumption categories by using the median alcohol consumption value for each category. We performed statistical analyses using STATA version 18.0 (StataCorp LLC, College Station, TX). All tests were two sided, with statistical significance set at \u003cem\u003ep\u003c/em\u003e \u0026lt;0.05.\u003c/p\u003e\n\u003cp\u003eWe included 1,505 men. Self-reported alcohol consumption during the preceding five years is summarized in \u003cstrong\u003eTable 1\u003c/strong\u003e, along with other baseline characteristics. After a median follow-up of 3.5 years (quartiles 1.6–6.2), 515 men experienced upgrading to ≥GG2, including 161 with extreme upgrading to ≥GG3. The cumulative incidence of upgrading was 19% (95% confidence interval [CI] 17%–21%) at 3 years from cancer diagnosis, and 29% (26%–31%) at 5 years; that of extreme upgrading was 6% (5%–7%) at 3 years and 9% (7%–10%) at 5 years. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAfter adjusting for baseline covariates, increased alcohol consumption was significantly associated with an increased risk of upgrading (\u003cem\u003ep\u003c/em\u003e=0.008 for linear trend). Compared with \u0026lt;1 drink per week, consumption of ≥7 drinks per week was associated with a 47% increase in the risk of upgrading (subdistribution hazard ratio 1.47, 95% CI 1.16–1.85). Alcohol consumption was not significantly associated with extreme upgrading (\u003cstrong\u003eTable 2\u003c/strong\u003e). \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn a prospective cohort of over 1,500 men, after adjusting for baseline prognostic factors, smoking history, and BMI, we found that increased self-reported alcohol consumption was positively associated with PCa grade progression during AS. To our knowledge, this is the first prospective study to identify alcohol consumption as a potential risk factor for P­Ca grade progression during AS. The only prior AS study examining alcohol consumption as part of a broader lifestyle analysis found no association with progression, although its small sample size likely limited statistical power\u003csup\u003e7\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eAlcohol consumption was significantly associated with upgrading to ≥GG2, whereas no association was observed with extreme upgrading to ≥GG3. \u0026nbsp;It is likely that true dedifferentiation from GG1 to \u003cu\u003e\u0026gt;\u003c/u\u003eGG3 takes longer than to GG2. We have previously shown that extreme upgrading increases significantly with age.\u003csup\u003e8\u003c/sup\u003e\u0026nbsp; Thus, our relatively limited follow-up, and the low number of extreme upgrading events—only 49 men consuming ≥7 drinks/week experienced extreme upgrading—may have reduced our ability to detect an association for this endpoint. \u0026nbsp;Alcohol may exert long-term cumulative effects through pathways such as acetaldehyde mediated DNA damage, oxidative stress, and chronic inflammation, which could plausibly influence progression risk over time among men on AS.\u003csup\u003e3\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eOur observation that ≥7 drinks/week was associated with a nearly 50% increased risk of grade progression falls below the U.S. Dietary Guidelines’ recommended limit of ≤14 drinks per week\u003csup\u003e2\u003c/sup\u003e. Instead, our results are consistent with recommendations of the World Health Organization, which emphasize that no level of alcohol consumption is completely risk-free, as even low intake may increase cancer risk.\u003csup\u003e9\u003c/sup\u003e Intake patterns in our cohort are consistent with the general U.S. population, with 4% reporting excessive intake \u0026nbsp;(≥16 drinks/week) and 40% classified as light drinkers (\u0026lt;4 drinks/week), comparable to the Centers for Disease Control and Prevention estimates for older American adults.\u003csup\u003e10\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eStrengths of our study include the large sample size, prospective data collection, and rigorous follow-up. Limitations include reliance on self-reported intake, lack of lifetime or post-diagnosis alcohol data, and inability to assess binge drinking patterns. Although we adjusted for smoking, BMI, and established clinical prognostic variables, there may be unmeasured confounding factors inherent to an observational study design. Specifically, lifestyle factors such as diet and exercise may contribute to the observed association between alcohol consumption and biopsy upgrading, but we did not have detailed information on these factors for the entire cohort.\u003c/p\u003e\n\u003cp\u003eIn conclusion, in a large prospective cohort, increased self-reported alcohol consumption at baseline was positively associated with PCa grade progression during AS. In particular, consumption of ≥7 alcoholic drinks per week was associated with a significant, nearly 50% increase in the risk of PCa grade progression during AS. No association was observed between alcohol consumption and extreme progression to GG3 or worse disease. Our findings may help inform clinical counseling for men pursuing AS regarding how alcohol consumption relates to their risk of progression. \u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding Sources:\u0026nbsp;\u003c/strong\u003eNone.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of Interest:\u0026nbsp;\u003c/strong\u003eNone.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eIslami F, Marlow EC, Thomson B et al (2024) Proportion and number of cancer cases and deaths attributable to potentially modifiable risk factors in the United States, 2019. CA Cancer J Clin 74(5):405\u0026ndash;432. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3322/caac.21858\u003c/span\u003e\u003cspan address=\"10.3322/caac.21858\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eU.S. Department of Agriculture; U.S. Department of Health and Human Services. Guidance on Alcoholic Beverages. In: Dietary Guidelines for Americans, 2020\u0026ndash;2025. 9th ed. U.S. Department of Agriculture and U.S. Department of Health and Human Services (2020) :48\u0026ndash;49. Accessed October 5, 2025. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.dietaryguidelines.gov/resources/2020-2025-dietary-guidelines-online-materials\u003c/span\u003e\u003cspan address=\"https://www.dietaryguidelines.gov/resources/2020-2025-dietary-guidelines-online-materials\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eU.S. Department of Health and Human Services. Alcohol and Cancer Risk: The U.S. Surgeon General\u0026rsquo;s Advisory. Washington, DC, Office of the Surgeon General (2025) : Accessed October 5, 2025. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.hhs.gov/surgeongeneral/reports-and-publications/alcohol-cancer/index.html\u003c/span\u003e\u003cspan address=\"https://www.hhs.gov/surgeongeneral/reports-and-publications/alcohol-cancer/index.html\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMacke AJ, Petrosyan A (2022) Alcohol and Prostate Cancer: Time to Draw Conclusions. Biomolecules 12(3):375 Published 2022 Feb 28. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3390/biom12030375\u003c/span\u003e\u003cspan address=\"10.3390/biom12030375\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhao J, Stockwell T, Roemer A, Chikritzhs T (2016) Is alcohol consumption a risk factor for prostate cancer? A systematic review and meta-analysis. BMC Cancer 16(1):845 Published 2016 Nov 15. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12885-016-2891-z\u003c/span\u003e\u003cspan address=\"10.1186/s12885-016-2891-z\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTosoian JJ, Mamawala M, Epstein JI et al (2020) Active Surveillance of Grade Group 1 Prostate Cancer: Long-term Outcomes from a Large Prospective Cohort. Eur Urol 77(6):675\u0026ndash;682. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.eururo.2019.12.017\u003c/span\u003e\u003cspan address=\"10.1016/j.eururo.2019.12.017\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVandersluis AD, Guy DE, Klotz LH et al (2016) The role of lifestyle characteristics on prostate cancer progression in two active surveillance cohorts. Prostate Cancer Prostatic Dis 19(3):305\u0026ndash;310. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1038/pcan.2016.22\u003c/span\u003e\u003cspan address=\"10.1038/pcan.2016.22\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDruskin SC, Mamawala M, Tosoian JJ et al (2019) Older age predicts biopsy and radical prostatectomy grade reclassification to aggressive prostate cancer in men on active surveillance. J Urol 201:98\u0026ndash;105. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/juro.2018.08.023\u003c/span\u003e\u003cspan address=\"10.1016/juro.2018.08.023\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization. No level of alcohol consumption is safe for our health. WHO Regional Office for Europe. Published January 4 (2023) Accessed October 5, 2025. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003eehttps://www.who.int/europe/news/item/04-01-2023-no-level-of-alcohol-consumption-is-safe-for-our-health\u003c/span\u003e\u003cspan address=\"http://ehttps://www.who.int/europe/news/item/04-01-2023-no-level-of-alcohol-consumption-is-safe-for-our-health\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBoersma P, Villarroel M, Vahratian A (2020) \u003cem\u003eHeavy Drinking Among U.S. Adults, 2018.\u003c/em\u003e NCHS Data Brief No. 374. National Center for Health Statistics\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1, Baseline characteristics of men with grade group 1 prostate cancer undergoing active surveillance (N=1505)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 77.7567%;\"\u003e\n \u003cp\u003eClinical Characteristics\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 22.2433%;\"\u003e\n \u003cp\u003eParticipants\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 77.7567%;\"\u003e\n \u003cp\u003eAge at diagnosis, median (quartiles), years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22.2433%;\"\u003e\n \u003cp\u003e65.5 (61.0-69.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 77.7567%;\"\u003e\n \u003cp\u003eRace, No. (%): White\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22.2433%;\"\u003e\n \u003cp\u003e1307 (86.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 77.7567%;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Black\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22.2433%;\"\u003e\n \u003cp\u003e128 (8.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 77.7567%;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Other/Unknown\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22.2433%;\"\u003e\n \u003cp\u003e70 (4.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 77.7567%;\"\u003e\n \u003cp\u003eBody mass index, median (quartiles), kg/m\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22.2433%;\"\u003e\n \u003cp\u003e26.6 (24.5-29.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 77.7567%;\"\u003e\n \u003cp\u003eTotal PSA level at diagnosis, median (quartiles), ng/mL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22.2433%;\"\u003e\n \u003cp\u003e4.9 (3.9-6.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 77.7567%;\"\u003e\n \u003cp\u003ePSA density at diagnosis, median (quartiles), ng/mL\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22.2433%;\"\u003e\n \u003cp\u003e0.10 (0.08-0.14)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 77.7567%;\"\u003e\n \u003cp\u003eNumber of positive cores at diagnosis, median (quartiles)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22.2433%;\"\u003e\n \u003cp\u003e1 (1-2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 77.7567%;\"\u003e\n \u003cp\u003eMaximum core involvement at diagnosis, median (quartiles), %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22.2433%;\"\u003e\n \u003cp\u003e10 (1-20)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 77.7567%;\"\u003e\n \u003cp\u003eYear at diagnosis, median (quartile)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22.2433%;\"\u003e\n \u003cp\u003e2013 (2009-2016)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 77.7567%;\"\u003e\n \u003cp\u003eSmoking history, No. (%): Never\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22.2433%;\"\u003e\n \u003cp\u003e894 (59.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 77.7567%;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Former\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22.2433%;\"\u003e\n \u003cp\u003e551 (36.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 77.7567%;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Current\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22.2433%;\"\u003e\n \u003cp\u003e60 (4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 77.7567%;\"\u003e\n \u003cp\u003eAlcohol use in 5 years before diagnosis, No. (%): None\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22.2433%;\"\u003e\n \u003cp\u003e218 (14.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 77.7567%;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;less than 1 per week\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22.2433%;\"\u003e\n \u003cp\u003e227 (15.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 77.7567%;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;1 per week\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22.2433%;\"\u003e\n \u003cp\u003e109 (7.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 77.7567%;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;2 to 3 per week\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22.2433%;\"\u003e\n \u003cp\u003e262 (17.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 77.7567%;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;4 to 6 per week\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22.2433%;\"\u003e\n \u003cp\u003e249 (16.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 77.7567%;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;7 to 10 per week\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22.2433%;\"\u003e\n \u003cp\u003e214 (14.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 77.7567%;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;11 to 15 per week\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22.2433%;\"\u003e\n \u003cp\u003e160 (10.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 77.7567%;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;16 or more per week\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22.2433%;\"\u003e\n \u003cp\u003e66 (4.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAbbreviations: IQR: interquartile range, BMI: body mass index, PSA: prostate specific antigen, GG: grade group.\u003c/p\u003e\n\u003cp\u003e\u003csup\u003ea\u003c/sup\u003e The \u0026ldquo;Other\u0026rdquo; category includes men who identify as \u0026ldquo;Asian/Pacific Islander,\u0026rdquo; \u0026ldquo;Hispanic,\u0026rdquo; or \u0026ldquo;Other,\u0026rdquo; as well as men of unknown race.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2.\u003c/strong\u003e Association between alcohol intake at baseline and prostate cancer upgrading to grade group (GG) \u0026ge;2 and extreme upgrading to \u0026ge;GG3 on surveillance biopsy in men diagnosed with GG1 disease managed with active surveillance\u003c/p\u003e\n\u003ctable cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 34px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"bottom\" style=\"width: 32px;\"\u003e\n \u003cp\u003e\u0026nbsp;Upgrade \u0026ge;GG2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 0px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"bottom\" style=\"width: 32px;\"\u003e\n \u003cp\u003e\u0026nbsp;Upgrade (\u0026ge;GG3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 27px;\"\u003e\n \u003cp\u003eAlcohol use\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 7px;\"\u003e\n \u003cp\u003eNo. of\u003cbr\u003e\u0026nbsp;men\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 7px;\"\u003e\n \u003cp\u003eNo. of\u003cbr\u003e\u0026nbsp;events\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 17px;\"\u003e\n \u003cp\u003eSHR\u003cbr\u003e\u0026nbsp;(95% CI)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8px;\"\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 0px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 7px;\"\u003e\n \u003cp\u003eNo. of\u003cbr\u003e\u0026nbsp;events\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 17px;\"\u003e\n \u003cp\u003eSHR\u003cbr\u003e\u0026nbsp;(95% CI)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 8px;\"\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27px;\"\u003e\n \u003cp\u003eZero or \u0026lt;1 drink per week\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e445\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e147\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003e0.0076\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 0px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003e0.5589\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27px;\"\u003e\n \u003cp\u003e1-6 drinks per week\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e620\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e190\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e1.10 (0.87, 1.39)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 8px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 0px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e1.15 (0.77, 1.71)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 8px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27px;\"\u003e\n \u003cp\u003e\u0026ge; 7 drinks per week\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e440\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e178\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e1.47 (1.16, 1.85)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 0px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 7px;\"\u003e\n \u003cp\u003e49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17px;\"\u003e\n \u003cp\u003e1.10 (0.72, 1.70)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eCompeting events: volume reclassification only on surveillance biopsy, any elective treatment, death not due to prostate cancer. Upgrading to GG2 was also a competing event for the analysis of extreme upgrading. Adjusted for baseline risk factors of age, year of diagnosis, PSA density, number of cores with cancer and max percent of core involvement, smoking history, and body mass index. p-values for linear trend.\u003c/p\u003e\n\u003cp\u003eAbbreviations: GG: grade group, SHR = subdistribution hazard ratio, CI = confidence interval.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Johns Hopkins University School of Medicine","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"active surveillance, prostate cancer, alcohol consumption","lastPublishedDoi":"10.21203/rs.3.rs-8371269/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8371269/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eMen with favorable-risk prostate cancer (PCa) undergoing active surveillance (AS) often seek lifestyle modifications that may reduce their risk of disease progression. We assessed the association between alcohol intake and biopsy upgrading during AS. In this prospective observational study, we included 1,505 men (median follow-up 3.5 years) who were diagnosed with grade group (GG) 1 PCa during 2005–2023 and upon AS enrollment completed a questionnaire estimating alcohol consumption during the preceding 5 years, which we categorized as \u0026lt;1, 1-6, and ≥7 drinks per week. Multivariable competing risk proportional hazards regression was utilized to evaluate self-reported alcohol intake for association with upgrading to ≥GG2 and extreme upgrading to ≥GG3 on a surveillance biopsy, adjusting for baseline clinicopathological prognostic factors, smoking history, and body mass index. Increased alcohol consumption was positively associated with upgrading to ≥GG2 (p¬ for linear trend = 0.008). Compared to \u0026lt;1 drink per week, consumption of ≥7 drinks per week was associated with a 47% increase in the risk of upgrading (subdistribution hazard ratio 1.47, 95% confidence interval 1.16–1.85). No significant association was found between alcohol consumption and extreme upgrading. Our findings identify alcohol consumption as a potentially modifiable lifestyle factor associated with upgrading during AS.\u003c/p\u003e","manuscriptTitle":"Is a Few Too Many? Alcohol Consumption and Prostate Cancer Upgrading during Active Surveillance","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-17 06:53:55","doi":"10.21203/rs.3.rs-8371269/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"289e1155-33d1-4a5f-a4f8-b519e6ec2d38","owner":[],"postedDate":"December 17th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-12-17T06:53:55+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-17 06:53:55","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8371269","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8371269","identity":"rs-8371269","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}