Background
Alcohol is a carcinogen, and excessive alcohol use, which may indicate alcohol use disorder (AUD), has been linked to several cancers, including those of the head and neck, female breast, liver, and colorectum.1,2 Among cancer survivors, alcohol use and AUD can lead to several outcomes, including symptoms of depression and anxiety, lower overall quality of life, higher hospital readmission rates, and increased readmission-related costs.3–7 Additionally, survivors of certain cancers who consume alcohol may be at higher risk of cancer recurrence, new malignancies, and mortality.1
Studies suggest that AUD is common among cancer survivors. An analysis of the 2015–2020 National Survey on Drug Use and Health (NSDUH) found that 2.78% of respondents with a history of cancer (n=6,101) met the criteria for AUD.8 Additionally, cancer survivors report high rates of alcohol misuse. An analysis of National Health Interview Survey (2000–2017) data found that 34.9% of 34,080 cancer survivors exceeded moderate drinking thresholds, and 21.0% engaged in binge drinking.9 With the increasing burden of AUD in the general US population,10,11 AUD among cancer survivors may also be rising; however, trends in this population remain poorly understood.
In this study, we estimated the prevalence of AUD diagnoses among cancer survivors from 2012 to 2021 using health care claims data from individuals with employer-sponsored health insurance. Unlike previous research, which has relied on self-reported alcohol use to estimate AUD prevalence, our analysis focuses on clinical diagnoses of AUD. Because AUD and other substance use disorders (SUDs) are often underdiagnosed and undertreated in the United States,12 our estimates may not capture the full prevalence of AUD. However, they may reflect underlying trends in the burden of AUD among cancer survivors, which have not been previously explored. Examining AUD diagnoses can also shed light on AUD care in this population. Because receiving an AUD diagnosis is a necessary step for patients to receive appropriate treatment through their insurance, this study contributes to our understanding of the continuum of AUD care among cancer survivors.13 Additionally, we identified sociodemographic and clinical characteristics associated with an AUD diagnosis in this population, which may highlight potential risk and protective factors for AUD to be explored in future research.
Methods
Design and Data Source
This serial cross-sectional study used Merative MarketScan Commercial Claims and Medicare Supplement Insurance data from 2011 to 2021. MarketScan provides deidentified data from a convenience sample of >25 million US employees, their dependents, and retirement-age adults covered by employer-sponsored private health insurance. The dataset includes patient demographics, diagnosis codes, and claims for inpatient and outpatient services and prescriptions across years. Analyses were conducted using SAS 9.4 (SAS Institute Inc.) and Stata MP, version 18 (StataCorp LLC) from August 28, 2023, to May 10, 2024. This study was exempted from full ethical review by the Institutional Review Board of The University of Texas at Austin (STUDY00004975).
Study Population
For each year of the study period (2012–2021), we identified cancer survivors or individuals with a documented cancer diagnosis using ICD-9 and ICD-10 codes for malignant neoplasm in inpatient and outpatient claims (Supplementary Table S1, available in the supplementary materials). Eligible cancer survivors were aged ≥18 years, had no missing values for key variables (eg, patient identification, age, sex, and region), and maintained at least 6 months of continuous health insurance coverage prior to the earliest recorded cancer diagnosis in that study year.
Measures and Outcomes
Prevalence of AUD
In each year of the analysis, we identified cancer survivors with AUD based on at least 1 primary or secondary diagnosis of alcohol dependence, abuse, or related conditions (Supplementary Table S1) in their inpatient or outpatient claims. Although this approach captures recent AUD diagnoses, it does not necessarily identify incident cases or episodes. AUD diagnoses may appear in claims data after a patient is initially diagnosed with the condition, such as when an AUD-related health care claim is submitted months after the index AUD diagnosis.
We calculated the annual prevalence of AUD diagnoses for each year as the proportion of cancer survivors in that year who also had a recent AUD diagnosis. Additionally, we assessed AUD prevalence among selected subgroups, including survivors of alcohol-related cancers (ie, oral cavity, pharynx, larynx, esophagus, stomach, liver, colorectum, and female breast),1,14 those who received antineoplastic treatments during the analysis year, and those who received care in inpatient and outpatient settings. Finally, we calculated the period prevalence of AUD by taking the proportion of all unique cancer survivors across the study period who were identified to have a recent AUD disorder during at least 1 year of the study.
Covariates
Using data from 2021 only, we identified and analyzed patient-level sociodemographic and clinical characteristics potentially associated with an AUD diagnosis. Sociodemographic variables included age, sex, region of residence, metropolitan statistical area (MSA), type of health insurance, type of health care plan, and employment status. For cancer survivors residing in MSAs, we determined their area-level median family income (in 2023 US$) using data from the American Community Survey of the US Census Bureau.15 Data on race and ethnicity are not available in MarketScan.
For clinical characteristics, we estimated health care utilization in 2021, including the number of inpatient, emergency department, and outpatient visits, as well as outpatient prescriptions. We also noted whether the survivors had been diagnosed with alcohol-related cancer and were receiving antineoplastic therapies (Supplementary Table S1). Additionally, we identified patients who received selected medications using therapeutic class variables in outpatient pharmacy claims (Supplementary Table S2).
We evaluated cancer survivors’ history and level of physical and mental health comorbidities using major diagnosis codes (Supplementary Table S2) and ICD-9/ICD-10 codes (Supplemen tary Table S1). Finally, we calculated the Charlson comorbidity index (CCI) score to assess the severity of comorbidities.16
Statistical Analysis
We performed a time-trend analysis on the annual prevalence of AUD diagnoses using the Cochran-Mantel-Haenszel test and simple logistic regression.
Using data from 2021 alone, we employed independent t tests and chi-square tests to assess differences in clinical and demographic characteristics between cancer survivors with and without AUD. We also conducted multivariable logistic regression to explore the association between sociodemographic and clinical factors and AUD diagnoses. To examine the presence of multicollinearity among variables, we calculated the variance inflation factor, setting a threshold of >5 to indicate potential collinearity.17 We constructed multivariable regression models in a stepwise, iterative process to identify statistically significant variables associated with AUD diagnoses.18 We also performed multivariable analysis using Lasso logit models to automatically select a subset of variables that produced the best-fitting model.19
Results
Overall and Annual Prevalence of AUD Diagnoses
Among 5,956,137 eligible cancer survivors in 2012–2021, 105,778 received at least 1 AUD diagnosis and 5,850,359 had no AUD diagnosis. The period prevalence of AUD diagnoses was approximately 1.78%.
Between 2012 and 2021, the annual prevalence of AUD diagnoses among cancer survivors significantly increased from 0.78% to 1.43% (P<.0001; Figure 1, Supplementary Table S4). This increase was also observed among cancer survivors receiving antineoplastic agents, those with alcohol-related cancer, and those receiving care in inpatient or outpatient settings (Figure 1, Supplementary Tables S3–S5).
Trends in prevalence of AUD diagnoses among cancer survivors, 2012–2021.
Abbreviation: AUD, alcohol use disorder.
Citation: Journal of the National Comprehensive Cancer Network 23, 5; 10.6004/jnccn.2025.7007
Among the 8 alcohol-related cancers, the prevalence of AUD diagnoses in 2021 was highest among liver (11.37%), laryngeal (6.36%), esophageal (5.59%), and pharyngeal (4.36%) cancer survivors (Figure 2, Supplementary Table S5). The proportion of liver cancer survivors with AUD diagnoses increased from 6.43% in 2012 to 11.37% in 2021. In contrast, breast cancer survivors had a relatively lower prevalence, ranging from 0.42% in 2012 to 0.85% in 2021.
Trends in the prevalence of AUD diagnoses among survivors of alcohol-related cancers, 2012–2021.
Abbreviation: AUD, alcohol use disorder.
Citation: Journal of the National Comprehensive Cancer Network 23, 5; 10.6004/jnccn.2025.7007
Characteristics of Cancer Survivors With and Without AUD
In 2021, cancer survivors with AUD diagnoses were more likely to be male (66.0% vs 43.9%; P<.0001) and have higher health care utilization compared with those without AUD diagnoses. This included more frequent inpatient (≥2 visits: 17.4% vs 3.9%; P<.0001), emergency department (≥2 visits: 33.9% vs 12.2%; P<.0001), and outpatient visits (mean visits: 33.4 vs 23.1; P<.0001) (Table 1). Additionally, cancer survivors with AUD were more likely to be receiving any antineoplastic therapy, especially radiotherapy (8.5% vs 4.8%; P<.0001; Table 1).
Sociodemographic and Clinical Characteristics of Cancer Survivors in 2021
| Characteristic | Cancer Survivors | With AUD Diagnosis | Without AUD Diagnosis |
|---|---|---|---|
| Total, n | 791,233 | 11,320 | 779,913 |
| Age, mean [SD], y | 61.3 [13.7] | 61.0 [12.2] | 61.3 [13.7] |
| Sex | |||
| Male | 44.3% | 66.0% | 43.9% |
| Female | 55.7% | 34.0% | 56.1% |
| Region | |||
| Northeast | 15.7% | 16.6% | 15.7% |
| North Central | 30.3% | 33.7% | 30.2% |
| South | 40.7% | 36.7% | 40.7% |
| West | 13.1% | 13.0% | 13.1% |
| Unknowna | 0.2% | 0.1% | 0.2% |
| Metropolitan statistical area | |||
| MSA | 63.0% | 61.2% | 63.0% |
| Non-MSAb | 13.0% | 11.7% | 13.0% |
| Missinga | 24.0% | 27.1% | 24.0% |
| Area-level median family income (2023 US$)b | |||
| <$60,000 | 1.7% | 1.6% | 1.7% |
| $60,000–$80,000 | 24.7% | 25.5% | 24.7% |
| >$80,000 | 36.5% | 34.2% | 36.6% |
| Non-MSA | 13.0% | 11.7% | 13.0% |
| Missinga | 24.0% | 27.1% | 24.0% |
| Type of health insurance | |||
| Commercial | 66.6% | 67.8% | 66.6% |
| Commercial and Medicare Supplement | 33.4% | 32.2% | 33.4% |
| Type of health plan | |||
| Comprehensive/POS | 13.8% | 13.2% | 13.8% |
| EPO/PPO | 51.3% | 53.7% | 51.3% |
| HMO | 14.2% | 15.7% | 14.2% |
| CDHP/HDHP | 17.2% | 15.4% | 17.2% |
| Missinga | 3.5% | 2.0% | 3.6% |
| Employment status | |||
| Employed (full- or part-time) | 50.7% | 48.5% | 50.7% |
| Retired | 32.1% | 32.2% | 32.1% |
| Disability | 0.3% | 0.6% | 0.3% |
| Not employed | 3.8% | 2.6% | 3.8% |
| Others/Unknowna | 13.2% | 16.1% | 13.1% |
| Diagnosis of alcohol-related cancersc | 21.9% | 24.7% | 21.8% |
| Oral cavity | 1.0% | 2.8% | 1.0% |
| Pharynx | 0.8% | 2.3% | 0.7% |
| Larynx | 0.3% | 1.4% | 0.3% |
| Esophagus | 0.4% | 1.6% | 0.4% |
| Stomach | 0.4% | 1.0% | 0.4% |
| Colorectum | 4.2% | 6.2% | 4.2% |
| Liverd | 0.4% | 3.1% | 0.4% |
| Breast | 15.1% | 9.0% | 15.2% |
| Antineoplastic therapiese | 20.9% | 23.3% | 20.8% |
| Chemotherapy | 11.6% | 15.4% | 11.5% |
| Radiotherapy | 4.9% | 8.5% | 4.8% |
| Immunotherapy | 2.1% | 2.9% | 2.1% |
| CCI score, mean [SD] | 2.8 [3] | 4.1 [3.6] | 2.8 [3] |
| Physical comorbidities | |||
| Nervous system diseases | 23.1% | 35.4% | 22.9% |
| Respiratory diseases | 29.8% | 43.2% | 29.6% |
| Circulatory system diseases | 49.2% | 64.7% | 49.0% |
| Digestive diseases | 32.6% | 46.8% | 32.4% |
| Liver and pancreatic diseases | 8.0% | 21.8% | 7.8% |
| Metabolic diseases | 50.4% | 52.6% | 50.3% |
| Kidney diseases | 26.9% | 29.7% | 26.8% |
| Infectious diseases | 5.8% | 11.2% | 5.7% |
| Mental disorders | 14.9% | 35.9% | 14.5% |
| Number of inpatient visits | |||
| 0 | 86.2% | 58.5% | 86.6% |
| 1 | 9.8% | 24.1% | 9.6% |
| ≥2 | 4.1% | 17.4% | 3.9% |
| Number of ED visits | |||
| 0 | 74.3% | 44.5% | 74.7% |
| 1 | 13.2% | 21.6% | 13.1% |
| ≥2 | 12.5% | 33.9% | 12.2% |
| Number of outpatient visits, mean [SD] | 23.3 [22.3] | 33.4 [26.9] | 23.1 [22.2] |
Unless otherwise noted, values in this table represent the percentage (%) of the population within each column. Percentages for mutually exclusive and collectively exhaustive categories may not total 100% due to rounding. All characteristics of cancer survivors with and without AUD diagnoses were statistically significantly different at P<.0001.
Abbreviations: AUD, alcohol use disorder; CCI, Charlson comorbidity index; CDHP, consumer-driven health plan; ED, emergency department; EPO, exclusive provider organization; HDHP, high-deductible health plan; HMO, health maintenance organization; MSA, metropolitan statistical area; NA, not applicable; NSAID, nonsteroidal anti-inflammatory drug; POS, point-of-service; PPO, preferred provider organization.
“Unknown,” “Missing,” and “Others” are labels used in MarketScan and cannot be further disaggregated.
Data on area-level median family incomes were from the US Census Bureau and were only available for individuals residing in MSAs.
Some individuals were diagnosed with multiple alcohol-related cancers.
Alcohol-related liver cancer was limited to hepatocellular carcinoma and primary malignant neoplasm of the liver.
Antineoplastic treatments were identified using ICD, procedure, and therapeutic class or group codes in MarketScan, which are detailed in Supplementary Table S1.
Cancer survivors with AUD diagnoses were more likely to be diagnosed with alcohol-related cancer (24.7% vs 21.8%; P<.0001) and have physical and mental health comorbidities compared with those without AUD diagnoses (Table 1). For example, they had significantly higher mean CCI scores (4.1 vs 2.8; P<.0001). Additionally, the prevalence of depression and anxiety was >2 times as high among individuals with AUD diagnoses. Related to this, significantly more cancer survivors with AUD had pharmacy claims for antidepressants (46.0% vs 25.0%; P<.0001) and tranquilizers/antipsychotics (9.8% vs 2.6%; P<.0001) than those without AUD diagnoses (Supplementary Table S6).
In addition to mood disorders, comorbid SUDs were significantly more common among cancer survivors with AUD (Table 2). For example, nicotine dependence was far more prevalent among those with AUD compared with those without (25.5% vs 5.0%; P<.0001). Similarly, cannabis-related (4.6% vs 0.3%; P<.0001) and cocaine-related disorders (1.7% vs 0.03%; P<.0001) were also more frequent among cancer survivors with AUD.
AUD and Co-Occurring Mental and Behavioral Health Conditions in Cancer Survivors in 2021
| Mental and Behavioral Health Conditions | Cancer Survivors (n=791,233) |
With AUD Diagnosis (n=11,320) |
Without AUD Diagnosis (n=779,913) |
|---|---|---|---|
| Mood, anxiety, and psychotic disorders | |||
| Depression | 12.1% | 34.4% | 11.8% |
| Anxiety | 16.3% | 37.1% | 16.0% |
| Schizophrenia | 0.1% | 0.8% | 0.1% |
| Bipolar disorder | 0.9% | 5.1% | 0.8% |
| Substance use disorders | |||
| Opioid use order | 0.7% | 4.3% | 0.7% |
| Nicotine dependence | 5.3% | 25.5% | 5.0% |
| Cannabis-related disorders | 0.3% | 4.6% | 0.3% |
| Hallucinogen-related disorders | <0.01% | 0.1% | <0.01% |
| Cocaine-related disorders | 0.1% | 1.7% | 0.03% |
| Sedative-, hypnotic-, or anxiolytic-related disorders | 0.2% | 1.7% | 0.2% |
| Stimulant-related disorders | 0.1% | 1.0% | 0.04% |
| Other drug use disorders | 0.2% | 2.9% | 0.2% |
Abbreviation: AUD, alcohol use disorder.
Multivariable Analysis
Across all multivariable models, male cancer survivors had 2 to 3 times the odds of receiving an AUD diagnosis compared with female cancer survivors (Figure 3, Supplementary Table S7). Model 1 revealed that alcohol-related cancer survivors had higher odds of an AUD diagnosis compared with those with other cancers (adjusted odds ratio [aOR], 1.69; 95% CI, 1.61–1.77; P<.0001). Although this association was attenuated in subsequent models, it remained statistically significant. In Models 3 and 4, several physical and mental comorbidities—including liver and pancreatic diseases, circulatory diseases, depression, and anxiety—were significantly associated with AUD diagnoses (P<.0001). Additionally, several SUD diagnoses were strongly associated with AUD diagnosis. For example, cancer survivors diagnosed with nicotine dependence or cannabis use disorder had >3 times the odds of also being diagnosed with AUD (P<.0001). Those with a cocaine use disorder had 7.79 greater odds of an AUD diagnosis (95% CI, 6.07–10.00; P<.0001).
Adjusted odds ratios of AUD diagnoses among cancer survivors in 2021. Model 1 adjusts for sociodemographic variables (age, sex, calendar year, region, area-level median family income, type of health insurance, type of health care plan, and employment status) and diagnosis of alcohol-related cancers. Model 2 adds 3 types of antineoplastic therapies and CCI score. Model 3 further includes physical and mental health comorbidities and other SUDs. Model 4, based on Lasso logit models, adjusts for all covariates. Opioid antagonists were excluded from outpatient medications, because naltrexone—the primary treatment for both OUD and AUD—would highly correlate with AUD diagnosis.
Abbreviations: aOR, adjusted odds ratio; AUD, alcohol use disorder; CCI, Charlson comorbidity index; CDHP, consumer-driven health plan; EPO, exclusive provider organization; HMO, health maintenance organization; HDHP, high-deductible health plan; MFI, median family income; MSA, metropolitan statistical areas; NSAID, nonsteroidal anti-inflammatory drug; OR, odds ratio; OUD, opioid use disorder; POS, point-of-service; PPO, preferred provider organization; SUD, substance use disorder.
Citation: Journal of the National Comprehensive Cancer Network 23, 5; 10.6004/jnccn.2025.7007
Discussion
Prevalence of AUD Diagnoses
This serial cross-sectional study of 5.9 million cancer survivors with employer-sponsored health insurance found a 1.78% overall prevalence of AUD diagnoses. This analysis also found that AUD diagnoses among cancer survivors increased from 0.78% in 2012 to 1.43% in 2021—an 83% increase within a decade. Cancer survivors with AUD were more likely to be male, have higher health care utilization, be diagnosed with alcohol-related cancer, and have physical and mental health comorbidities, including SUDs.
Although research on AUD diagnoses among cancer survivors is limited,20 the prevalence found in this study aligns with previous estimates. An analysis of US veterans’ health care data reported a 5.1% prevalence of AUD diagnoses among predominantly male patients with cancer.21 Another study of a nationally representative sample of hospitalized cancer survivors in 2017 to 2018 found a 2.9% prevalence of AUD diagnoses,7 slightly lower than the 3.03% to 3.54% prevalence we observed among cancer survivors who received inpatient services during the same years. Our study expands on this literature by estimating the prevalence of AUD diagnoses in a large sample of cancer survivors with commercial insurance and characterizing recent time trends. Additionally, we included data on both inpatient and outpatient claims among cancer survivors, whereas previous studies have focused on a single source of care.7
The trends we observed may reflect an increase in AUD diagnoses rather than an actual rise in AUD prevalence among cancer survivors. In line with US prevention22 and survivorship care guidelines,23,24 which have emphasized the importance of behavioral health, adult cancer survivors may now undergo more frequent AUD screening, leading to a higher number of diagnoses. However, 2 trends suggest that our findings likely reflect a real increase in AUD among cancer survivors.
First, the prevalence of AUD has been increasing in the general US population. Studies have found that the adult prevalence of AUD has doubled between 2017 and 2022,10,11 with increases before and during the height of the COVID-19 pandemic.25–27 These trends have been attributed to wider access to alcohol, changes in the acceptability of alcohol use, the waning effect of population-level interventions (eg, taxes), and high rates of mental distress.28,29 Additionally, as cancer survivorship improves,30 the number of cancer survivors using or misusing alcohol and other substances may also increase. The use of substances, particularly opioids, among cancer survivors can be a form of “chemical coping,” which refers to the inappropriate use of substances to manage psychological distress related to their condition.31,32 The factors driving AUD among cancer survivors may be similar, though cancer survivors may also face unique or heightened risks that require further investigation.
Second, studies report that a larger proportion of cancer survivors today are using and misusing alcohol. Survey data show that up to one-third of cancer survivors drink beyond the recommended limits, and one-fifth engage in alcohol misuse.9,33,34 A study of cancer survivors in the All of Us Research Program reported a similar hazardous drinking rate (38.3%).35 Even among patients with advanced or high-risk cancers, hazardous alcohol use remains prevalent and often goes undetected.36–38 Given the stigma surrounding alcohol misuse, these numbers are likely underestimates.39 Using data on self-reported alcohol use and AUD symptoms, a study analyzing pooled NSDUH data (2015–2020) estimated the prevalence of AUD among cancer survivors to be 2.78%.8 Collectively, these findings suggest that AUD is not only increasing among cancer survivors but also underreported and underdiagnosed. Given the health risks associated with AUD and postdiagnosis alcohol use in this population, increased efforts are needed to ensure that cancer survivors are routinely screened and treated for AUD as part of their primary or cancer-related care.
Covariates of AUD Diagnoses
This study identified several factors associated with AUD diagnoses among cancer survivors. Male cancer survivors had significantly higher odds of AUD diagnoses, which is consistent with prior research on alcohol use and misuse.7,9,20,35 Additionally, we found that certain medical conditions were associated with AUD diagnoses in this population. A history of alcohol-related cancer was associated with an AUD diagnosis, which has been documented in population-based studies.35 For example, one study found that head and neck cancer survivors were more likely to be heavy drinkers compared with matched survivors of other cancers,40 and the NSDUH analysis similarly reported that head and neck cancer survivors were more likely to be diagnosed with any SUD, including AUD.8 In our study, liver cancer survivors had the highest prevalence of AUD diagnoses, consistent with many, though not all, prior studies.8,41–43 Given that alcohol consumption is a known risk factor for head, neck, and liver cancers,44,45 the AUD diagnoses captured in this study may have developed before cancer diagnosis and persisted throughout survivorship.
Consistent with our findings, tobacco, cannabis, and other drug use have also been associated with AUD diagnoses among cancer survivors.9,35,46,47 The most significant association observed was between AUD and cocaine use disorder, a relationship documented in prior studies and likely due to the heightened stimulant effects of cocaine when used concurrently with alcohol.48,49 Although our findings advance our understanding of potential risk factors for AUD among cancer survivors, additional research is needed to ascertain the direction of the association.
Limitations
This study has some limitations. First, the generalizability of our findings is limited, because individuals with other types of health insurance (eg, Medicaid) and the uninsured were not represented in the data. MarketScan data also primarily include working-age adults and their dependents, with limited representation of adults aged ≥65 years who qualify for Medicare. Second, the dataset did not include other important variables, such as laboratory test results, alcohol consumption, and race and ethnicity, which might be relevant to understanding the relationship between cancer survivorship and AUD. Furthermore, the study’s cross-sectional design did not allow us to establish a causal relationship between sociodemographic and clinical characteristics and AUD diagnoses. AUD may result from the mental and physical comorbidities explored in this study, and vice versa. For example, alcohol use has been shown to have a bidirectional relationship with depression.50 Additionally, identifying significant predictors across different models that include many coefficients presents challenges related to multiple testing.51 To address this, we highlighted only associations that had P<.0001 and would remain statistically significant after applying a correction for multiple testing (eg, Bonferroni). Finally, our reliance on diagnosis codes to identify cancer, AUD, and other clinical conditions may have led to misclassification or underreporting. Prior studies that used self-reported alcohol use data may be more sensitive to identifying AUD cases; however, these data are still subject to social desirability bias related to alcohol misuse.52
Conclusions
AUD diagnoses among US cancer survivors with private health insurance have increased over time, reflecting trends in the general population. To address the unique risks associated with alcohol use and misuse in this population, cancer care should integrate routine AUD screening and treatment.
Acknowledgments
The authors thank the Texas Center for Health Outcomes Research & Education (TxCORE) for providing and maintaining the data used in this study and in assisting in the completion of the research.
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