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1 Subject: BMJ - Decision on Manuscript ID BMJ Body: 01-Jun-2015 Dear Dr. Cao Manuscript ID BMJ entitled "Light-to-Moderate Alcohol Intake, Drinking Patterns and Risk of Cancer: Results from Two Prospective US Cohort Studies" Thank you for sending us this paper and giving us the chance to consider your work, which we enjoyed reading. Decision: We are pleased to say that we would like to publish it in the BMJ as long you are willing and able to revise it as we suggest in the report below from the manuscript meeting: we are provisionally offering acceptance but will make the final decision when we see the revised version. Deadline: Because we are trying to facilitate timely publication of manuscripts submitted to BMJ, your revised manuscript should be submitted by one month from todays date. If it is not possible for you to submit your revision by this date, we may have to consider your paper as a new submission. Yours sincerely Anita Jain Editor The BMJ ajain@bmj.com ** THE REPORT FROM THE MANUSCRIPT COMMITTEE MEETING, REVIEWERS REPORTS, AND THE BMJ S GENERAL REQUIREMENTS FOR RESEARCH PAPERS ARE AVAILABLE AT THE END OF THIS LETTER.** First, however, please read these four important points about sending your revised paper back to us: 1. Deadline: Your revised manuscript should be returned within one month. 2. Online and print publication: All original research in The BMJ is published with open access. The full text online version of your article, if accepted after revision, will be the indexed citable version (full details are athttp://resources.bmj.com/bmj/about-bmj/the-bmjs-publishing-model), while the print and ipad BMJ will carry an abridged version of your article, usually a few weeks afterwards. This abridged version of the article is essentially an evidence abstract called BMJ pico, which we would like you to write using a template and then it to papersadmin@bmj.com (there are more details below on how to write this using a template). Publication of research on bmj.com is definitive and is not simply interim "epublication ahead of print", so if you do not wish to abridge your article using BMJ pico, you will be able to opt for online only publication. Please let us know if you would prefer this option. If/when your article is accepted we will invite you to submit a video abstract, lasting no longer than 4 minutes, and based on the information in your paper s BMJ pico evidence abstract. The content and focus of the video must relate directly to the study that has been accepted for publication by The BMJ, and should not stray beyond the data. 3. Open access publication fee: The BMJ is committed to keeping research articles Open Access (with Creative Commons licences and deposit of the full text content in PubMedCentral as well as fully Open Access on bmj.com). To support this we are now asking all authors to pay an Open Access fee of 3000 on acceptance of their paper. If we accept your article we will ask you to pay the Open Access publication fee; we do have a waiver policy for authors who cannot pay. Consideration of your paper is not related to whether you can or cannot pay the fee (the editors will be unaware of this), and you need do nothing now. 4. How to submit your revised article: Log into and enter your Author Center, where you will find your manuscript title listed under "Manuscripts with Decisions." Under "Actions," click on "Create a Revision." Your manuscript number has been appended to denote a revision. You may also click the below link to start the revision process (or continue the process if you have already started your revision) for your manuscript. If you use the below link you will not be required to login to ScholarOne Manuscripts. (Document Task not available) You will be unable to make your revisions on the originally submitted version of the manuscript. Instead, revise your manuscript using a word processing program and save it on your computer.

2 Once the revised manuscript is prepared, you can upload it and submit it through your Author Center. When submitting your revised manuscript, you will be able to respond to the comments made by the reviewer(s) and Committee in the space provided. You can use this space to document any changes you make to the original manuscript and to explain your responses. In order to expedite the processing of the revised manuscript, please be as specific as possible in your response to the reviewer(s). As well as submitting your revised manuscript, we also require a copy of the manuscript with changes highlighted. Please upload this as a supplemental file with file designation Revised Manuscript Marked copy. IMPORTANT: Your original files are available to you when you upload your revised manuscript. Please delete any redundant files before completing the submission. INFORMATION ON REVISING THE CONTENT AND FORMAT OF YOUR ARTICLE **Report from The BMJ s manuscript committee meeting** These comments are an attempt to summarise the discussions at the manuscript meeting. They are not an exact transcript. Members of the committee were: xxx (chair), yyy (statistician), [and list other eds who took part] Decision: provisional acceptance Detailed comments from the meeting: The committee was overall interested in the topic. We feel it is a timely and relevant piece of work. First and foremost, please revise your paper to respond to all of the comments by the reviewers. Their reports are available at the end of this letter, below. Please also respond to these additional comments by the committee: 1. Was death treated as censored in the survival models? Why did these models condition on followup cycle? 2. The Cox models yield Hazard Ratios not Relative Risks. The paper needs some clarity as to how alcohol consumption was incorporated into the models, - as a time-varying covariate? 3. Multivariate has been used where the actual meaning might be multivariable. IMPORTANT When you revise and return your manuscript, please take note of all the following points about revising your article. Even if an item, such as a competing interests statement, was present and correct in the original draft of your paper, please check that it has not slipped out during revision. a. In your response to the reviewers and committee please provide, point by point, your replies to the comments made by the reviewers and the editors, and please explain how you have dealt with them in the paper. It may not be possible to respond in detail to all these points in the paper itself, so please do so in the box provided b. If your article is accepted it will then be edited, proofed, and - after your approval - published on bmj.com with open access. This open access Online First article will not be a pre-print. It will represent the full, citable, publication of that article. The citation will be year, volume, elocator (a unique identifier for that article): eg BMJ 2008;337:a145 and this is what will appear immediately in Medline, PubMed, and other bibliographical indexes. We will give this citation in print and online, and you will need to use it when you cite your article. c. Please write an abridged version of the article for the print and ipad BMJ using the appropriate BMJ pico template for your study's design. Please be reassured that it doesn't take long to complete this. When your BMJ pico is ready please it to papersadmin@bmjgroup.com.the templates for you to download are at d. Please include these items in the revised manuscript to comply with BMJ style: Title: this should include the study design eg "systematic review and meta-analysis Abstract structured abstract including key summary statistics, as explained below (also see for every clinical trial - and for any other registered study - the study registration number and name of register in the last line of the structured abstract. Introduction

3 this should cover no more than three paragraphs, focusing on the research question and your reasons for asking it now Methods: for an intervention study the manuscript should include enough information about the intervention(s) and comparator(s) (even if this was usual care) for reviewers and readers to understand fully what happened in the study. To enable readers to replicate your work or implement the interventions in their own practice please also provide (uploaded as one or more supplemental files, including video and audio files where appropriate) any relevant detailed descriptions and materials. Alternatively, please provide in the manuscript urls to openly accessible websites where these materials can be found Results please report statistical aspects of the study in line with the Statistical Analyses and Methods in the Published Literature (SAMPL) guidelines summary statistics to clarify your message. Please include in the results section of your structured abstract (and, of course, in the article's results section) the following terms, as appropriate: For a cohort study: Absolute event rates over time (eg 10 years) among exposed and non-exposed groups RRR (relative risk reduction) one or more references for the statistical package(s) used to analyse the data, eg RevMan for a systematic review. There is no need to provide a formal reference for a very widely used package that will be very familiar to general readers eg STATA, but please say in the text which version you used for articles that include explicit statements of the quality of evidence and strength of recommendations, we prefer reporting using the GRADE system Discussion please write the discussion section of your paper in a structured way, to minimise the risk of careful explanation giving way to polemic.please follow this structure: statement of principal findings of the study strengths and weaknesses of the study strengths and weaknesses in relation to other studies, discussing important differences in results and what your study adds. Whenever possible please discuss your study in the light of relevant systematic reviews and meta-analyses (eg Cochrane reviews) meaning of the study: possible explanations and implications for clinicians and policymakers and other researchers; how your study could promote better decisions unanswered questions and future research Footnotes and statements What this paper adds/what is already known box (as described at ID of ethics committee approval and name of the ethics committee/irb; or a statement that approval was not required (see and a statement that participants gave informed consent before taking part a statement that any identifiable patients have provided their signed consent to publication. Please submit, as a supplemental file, the signed BMJ patient consent form giving consent to publication in The BMJ of any information about identifiable individual patients. Publication of any personal information about a patient in The BMJ, for example in a case report or clinical photograph, will normally require the signed consent of the patient. competing interests statement (see contributorship statement+ guarantor (see transparency statement: a statement that the lead author (the manuscript s guarantor) affirms that the manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies are disclosed. copyright statement/ licence for publication (see signed patient consent form(s), if the article gives enough personal information about any patient(s): this sometimes occurs even in research papers - for example in a table giving demographic and clinical information about a small subgroup in a trial or observational study, or in quotes/tables in a qualitative study - (see a data sharing statement declaring what further information and data you are willing to make available, over and above the results reported in the paper. Suggested wording: "Data sharing:

4 technical appendix, statistical code, and dataset [state whether any patient level data have been anonymised] are available at this repository or website OR from the corresponding author at ". If there are no such further data available, please use this wording: "Data sharing: no additional data available". For papers reporting the main results of trials of drugs or devices we require that the authors state, at a minimum, that the relevant anonymised patient level data are available on reasonable request from the authors The BMJ has partnered with the Dryad Digital Repository datadryad.org to make open deposition easy and to allow direct linkage by doi from the dataset to The BMJ article and back - we encourage authors to use this option funding statement (see statement of the independence of researchers from funders (see for studies funded or sponsored by industry (see a statement describing the role of the study sponsor(s), if any, in study design; in the collection, analysis, and interpretation of data; in the writing of the report; and in the decision to submit the article for publication assurance, in the cover letter, that a clinical trial funded by a pharmaceutical or other commercial company follows the guidelines on good publication practice (see inclusion in the list of contributors the name(s) any professional medical writer(s), specifying in the formal funding statement for the article who paid the writer. Writers and authors must have access to relevant data while writing articles. Patient centred research for studies that are relevant to patients we expect authors to report in their articles the extent of their study s patient-centredness, as highlighted by these questions: did you involve patients/service users/carers/lay people in the design of this study? Please state whether you did, and give details (Methods section) was the development and/or selection of outcome measures informed by patients priorities and experiences? Please give details (Methods section) were patients/service users/carers/lay people involved in developing plans for participant recruitment and study conduct? If so, please specify how (Methods section) have you planned to disseminate the results of the study to participants? If so how will this be done? (Describe in brief footnote) are patients thanked in the contributorship statement or acknowledgements? for articles reporting randomised controlled trials: did you assess the burden of the intervention on patients quality of life and health? If so, what evaluation method did you use, and what did you find? (Methods and Results sections) REFEREE COMMENTS Reviewer: 1 Recommendation: Comments: The theme is very important, missing often in the field of alcohol i.e. the oncogenicity of alcohol. Alcohol is clearly oncogenic. The study deals with the two most oncogenic substances in our world. The sample is huge and the duration of the study a decade. The relative risk is to small, anyway. in particular 30 g/d, was more strongly associated with risk of cancer among ever than among never smokers How much? It is already known the risk of breast cancer in women drinking alcohol. The introduction is balanced and states the problem. How can we balance the fact that same patients usually have been submitted to screening (breast, cervix, colon) and others not. It depends on oneself will. It is important to include vitamins? Both regularity of drinking and heavy episodic drinking were weakly associated with increased risk of total cancer, however, once cumulative alcohol consumption was added to the models, the associations were not significant The authors must avoid this kind of affirmations. Regarding discussion of breast cancer the authors must consider obesity. The graphics are very illustrative, giving a clear message on the relationship of alcohol and tobacco. The paper must be accepted. Additional Questions: Please enter your name: Rui Marinho Job Title: Prof. Institution: Hospital Santa Maria

5 Reimbursement for attending a symposium?: No A fee for speaking?: No A fee for organising education?: Funds for research?: No Funds for a member of staff?: No Fees for consulting?: No Have you in the past five years been employed by an organisation that may in any way gain or lose financially from the publication of this paper?: No Do you hold any stocks or shares in an organisation that may in any way gain or lose financially from the publication of this paper?: No If you have any competing interests (please see BMJ policy) please declare them here: Reviewer: 2 Recommendation: Comments: In this study of two large prospective cohorts, the investigators report that light-to-moderate alcohol consumption was associated with minimally increased risk of total cancer in women and men. When restricting to alcohol-related cancers, light-to-moderate alcohol consumption was associated with increased risk in women, particularly for breast cancer, but risk for alcohol-related cancers in men was limited to ever-smokers. This manuscript provides important and useful information that estimates the risk of total cancer associated with light-to-moderate drinking. As discussed by the authors, alcohol is an established risk factor for many cancers, but the evidence at lower levels of consumption is less clear and warrants additional research. Light-to-moderate alcohol consumption is common in the United States, making it an important area of research for clinicians and public health researchers. Additionally, as smoking and alcohol consumption are correlated, decreases in the prevalence of cigarette smoking provide further rationale for updated risk estimates for alcohol. The research question is clearly defined, the study population and methods are clearly described, and the results are well-presented and coherent. I also strongly support the use of non-drinkers as the referent group. The current study also has a number of advantages, including repeated assessment of alcohol and assessment of drinking patterns and binge drinking. The authors were also careful not to overinterpret their findings. Major Comments: 1. The Methods section notes that data on beverage types (beer, wine, liquor) were collected in the FFQ (Page 6, Lines 43-45). Although previous evidence for beverage types has been inconsistent, it would be useful for the authors to briefly mention whether associations for specific beverages were consistent with their overall findings. 2. The authors include current and former smokers together in their stratified analyses. As the cancer risks of former and current smokers are substantially different, as are health behaviors in these two groups, the authors should present the results for former and current smokers separately. There are also many former smokers in the population, such that it is important to provide risk estimates for alcohol in this group. 3. Total cancer, the main endpoint in this analysis, reflects the distribution of specific cancer-sites in the underlying population. In order for readers to compare the current findings with past studies, and those in other populations, it would seem useful for the authors to provide some information on the associations of alcohol and individual cancer types. In order to keep this request from getting out of hand, yet still provide valuable information, the authors could restrict their presentation to each of their specified alcohol associated cancers (colorectum, female breast, oral cavity, pharynx, larynx, liver, esophagus), and place these data in the supplement. Minor Comments 1. Repeated assessments of alcohol use are a key advantage of the study. As there have been concerns in the literature with regards to possible contamination of the non-drinking referent group by former heavy drinkers, it would be useful for the authors to briefly mention whether many participants in the study stopped drinking alcohol during follow-up, as well as the consistency of alcohol use in participants over time. 2. Were data on smoking use and other covariates also updated over time in the analysis, or was

6 baseline information used? Please clarify. 3. The manuscript would benefit from a more detailed summary of prior studies of alcohol drinking and cancer, for example, the 2015 British Journal of Cancer article by Bagnardi et al., Alcohol consumption and site-specific cancer risk: a comprehensive dose-response meta-analysis, could be included. 4. In the Introduction and what is already known box, the authors state that the association between light-to-moderate drinking and overall cancer risk has not been evaluated in the US (Page 5, Line 35). Although I agree that light-to-moderate drinking is understudied, the current description seems a little strong. Neal Freedman, NCI Additional Questions: Please enter your name: Neal Freedman Job Title: Investigator Institution: National Cancer Institute Reimbursement for attending a symposium?: No A fee for speaking?: No A fee for organising education?: No Funds for research?: No Funds for a member of staff?: No Fees for consulting?: No Have you in the past five years been employed by an organisation that may in any way gain or lose financially from the publication of this paper?: No Do you hold any stocks or shares in an organisation that may in any way gain or lose financially from the publication of this paper?: No If you have any competing interests (please see BMJ policy) please declare them here: Reviewer: 3 Recommendation: Comments: Comment to BMJ article from Cao et al on Light-to-Moderate Alcohol Intake, Drinking Patterns and Risk of Cancer: Results from Two Prospective US Cohort Studies : Alcohol drinking is an important and growing health problem in many countries. For general reader this paper adds additional information on light-to-moderate alcohol intake, drinking patterns and general cancer risk from two large and well conducted U.S. cohort studies, in particular among never smokers. The paper is well written and the analyses well conducted. The main study limitations are the small number of observations among never smoking men with alcohol-related cancers (up to 10 times less than for women), which in consequence widen for men the confidence limits around the very small point estimates. However as clearly shown in Table S4, statistically point estimates are not different for total cancer and alcohol-related cancer among never smoking men and women (e.g g/d total cancer: never smoker, women 1.12(1.01, 1.25) men 1.04(0.90, 1.20); g/d alcohol-related cancer: women 1.21(1.05, 1.40) men 1.36(1.02, 1.81)). Moreover, risk of alcohol-related cancer become even larger for men than for women among smokers drinking 5 gram per day and more. In contrast, the authors of this analysis conclude at the end that even in never smoking women risk of alcohol-related cancers increases within the range up to one drink a day, whereas among men the cancer risk is not appreciably increased up to two drinks per day. Since the point estimates between men and women are not different or even higher for men, I would like to suggest that they modify their conclusion more in the direction that they observed a small increased risk of alcohol-related cancer within the range up to one drink a day even in never smoking women and that among never smoking men, the point estimates appear to be fairly similar, but that they were not significant under 15 gram per day may be due to limit power. In contrast among smokers, risks of alcohol-related cancer were even higher among men than among women for dinking 5 gram per day or more. Table S4 (Joint association of alcohol consumption and smoking on risk of cancer and alcohol-related Cancer) show very important results and should go from the supplements in the main paper. In Table S3 and S5 a lot of hypotheses are tested exploratively. Except for smoking in Table S4 and in contrast to the authors, I could not observe in these tables much difference after stratification by age, family history of colorectal cancer, family history of breast cancer, BMI, multivitamin use, aspirin use and AHEI Among women, risk of total cancer (Table S3) was only sporadically different for aspirin use ( g/d: 1.00(0.93, 1.07) 1.08(1.01, 1.14); g/d: 1.21(1.11,

7 1.32) 1.06(0.98, 1.15)), and among men for BMI (0-4.9 g/d: 1.11(1.01, 1.22) 0.94(0.85, 1.05); g/d: 1.15(1.03, 1.29) 0.95(0.83, 1.07)) and AHEI-2010 (0-4.9 g/d: 1.09(0.99, 1.21) 0.97(0.87, 1.07)). Risk of alcohol-related cancer (Table S5) was only different among women for family history of breast cancer (0-4.9 g/d: 0.90(0.79, 1.04) 1.07(1.01, 1.14)), multivitamin use ( g/d: 1.35(1.21, 1.52) 1.14(1.01, 1.29)) and aspirin use ( g/d: 1.01(0.91, 1.11) 1.21(1.11, 1.32)), and among men for AHEI-2010 (0-4.9 g/d: 1.15(0.91, 1.45) 0.81(0.65, 1.02); g/d: 1.25(0.99, 1.58) 0.90(0.72, 1.13); g/d: 1.46(1.13, 1.90) 1.09(0.85, 1.39)). However, these sporadic differences may be due to chance, because many hypotheses were tested. I would suggest deleting smoking history in Table S3 and S5, because smoking is much better modeled in Table S4. I also would like to suggest adding some discussion on power limitations with very small increased risk and on multiples testing. The authors should be consistent with digits after the point for Ptrend. To illustrate the dose-response relationship, the authors could add the three following references in the introduction: a) WCRF/AICR report (2007) for dose-response meta-analyses on results of cohort and case-control studies published until 2006, b) the IARC monograph N 96 (2010) for review of dose-response estimates reported by observational studies published until 2007, c) Latino-Martel P et al (CMAJ, 2011) for review of doses-response-relationships reported by cohort studies published between 2007 and Additional Questions: Please enter your name: Manuela Marron Job Title: Epidemiologist and Biologist Institution: University Medicine of the Ernst-Moritz-Arndt University Greifswald, Institute for Community Medicine Reimbursement for attending a symposium?: No A fee for speaking?: No A fee for organising education?: No Funds for research?: No Funds for a member of staff?: No Fees for consulting?: No Have you in the past five years been employed by an organisation that may in any way gain or lose financially from the publication of this paper?: No Do you hold any stocks or shares in an organisation that may in any way gain or lose financially from the publication of this paper?: No If you have any competing interests (please see BMJ policy) please declare them here: No. Reviewer: 4 Recommendation: Comments: These analyses address and important issue with a large and in some ways highly detailed data source on alcohol intake, alternative risk factors and cancer incidence. Findings are generally supportive of previous understandings of cancer risks. Separating smokers and non-smokers is an important addition considering the high degree of confounding between alcohol and tobacco behaviors. However, there are some limitations and concerns regarding the conceptualization of risk factor measurement and categorization and methods utilized to estimate risk relative to drinking patterns. 1) A major limitation is the lack of information on prior alcohol intake given that the samples are middle-aged at baseline and that cancer risks are related to accumulated intake and patterns of intake. Importantly, lifetime abstainer status is not assessed so that the reference group includes both lifetime abstainers and former drinkers who may have been heavy drinkers in the past. As compared to a clean no alcohol group, a bias toward lower or non-significant effects of drinking would be expected and this reduces confidence in the findings of non-significant risks among lighter drinkers. 2) The assessment of alcohol use patterns is also fairly basic at each measurement time but is considerably strengthened by the multiple assessments. While the serving sizes used to calculate intake from drinks were those presented to respondents, I assume, they are unusual and do not seem to be based on typical American drink choices. 3) The operationalization of alcohol intake appears to take the average of all assessments over the period of the study. This is problematic as only alcohol intake in or prior to the year in which risks are compared in the survival models, as they move through years or ages, is theoretically relevant.

8 This seems to be a situation in which updated accumulated alcohol measures would be used as timevarying risk factors. 4) In regards to the survival models, it is not clear why age-as-timescale models are not used as these seem more appropriate for health risks of this type. Further, no results from tests of the key assumption of the proportionality of hazards are reported. 5) Finally, the discussion seems overly focused on the null results in specific groups although many harmful associations are found. Given the limitations of the data and methods there is not a high level of confidence in these null results that would support his focus. Additional Questions: Please enter your name: William Kerr Job Title: Senior Scientist Institution: Public Health Institute Reimbursement for attending a symposium?: No A fee for speaking?: No A fee for organising education?: No Funds for research?: No Funds for a member of staff?: No Fees for consulting?: No Have you in the past five years been employed by an organisation that may in any way gain or lose financially from the publication of this paper?: No Do you hold any stocks or shares in an organisation that may in any way gain or lose financially from the publication of this paper?: No If you have any competing interests (please see BMJ policy) please declare them here: END Date Sent: 01-Jun-2015