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Jill Clark

Sector Review – Punching Below Our Weight – Cancer Prevention

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To commemorate World Cancer Day 4th February 2024, we are publishing our latest report “Punching Below Our Weight: A Review of the Cancer Charity Sector’s Attitudes to Cancer Prevention”, in which we review almost 50 organisations in the cancer charity sector for their attitudes to cancer prevention.

Although a widespread commitment to prevention exists among cancer charities, prevention is often outcompeted by other priorities, particularly by care and treatment issues that can be more immediately relevant to the beneficiaries. When charities do campaign on prevention, their work tends to focus on secondary prevention, by campaigning for improved detection of cancer, or primary prevention in the form of information and awareness-raising work to shape individual choices. Primordial prevention, which requires structural change at a societal level, rarely features.

From the perspective of individual charities, these choices are entirely understandable. However, our report sets out how we could develop a stronger approach to prevention in the sector. Based on the input we received from the sector, we propose three core elements for the sector’s policy approach on prevention:

a. Stronger emphasis on primordial prevention emphasising social and environmental conditions including regulatory and other legal changes

b. Continued emphasis on the need for improved public health and prevention services

c. Stronger focus on solutions that will modify commercial behaviours.

For more information on the results from this wide-ranging review, the links to the review itself and its executive summary are given below:

https://cancerwatchuk.org/wp-content/uploads/2024/01/PunchingBelowOurWeight_review.pdf

https://cancerwatchuk.org/wp-content/uploads/2024/01/ExecSummary_PunchingBelowOurWeightReview.pdf

What do cancer charities think about prevention?

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CancerWatch exists to campaign for improved cancer prevention, and we will take a major step forward when we achieve registration as a charity this year. From there, we will aim to build up our campaigning activity.

But what should that new activity look like? What work can we do that will not replicate what other charities are doing? What should be the top priorities that we campaign for? We have initial ideas about what the answers to those questions might be, but we don’t presume that we automatically know best. We want to have the best understanding we can of the policy challenges ahead, and the work of the wider sector, as we develop our work.

We are therefore reaching out to established cancer charities, public health campaigners and others, to ask for their input. How do they feel the UK is currently doing on cancer prevention? What’s the outlook for the future, and what are the priorities for improving it? We are approaching over 100 organisations and individuals, and asking them to complete our call for evidence.

To provide some context on the questions we’re asking, and why we have formed the views we have (so far), we have published this discussion paper. It expands on the themes we explored on our blog during Cancer Prevention Action Week, and outlines the need for improved cancer prevention. It suggests that a major policy shift is needed to create structural change, rather than encouraging healthier individual choices that not everyone can easily make. It also explores the role of the voluntary sector in securing previous changes such as the smoking ban, and asks what more it might be able to achieve in the future.

We will compile a full report of our findings, and publish it this autumn. Sign up to receive updates if you would like to be notified when it comes out.

State of play: screening

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Throughout this Cancer Prevention Action Week, we are reviewing the current state of public policy for the major risk factors in causing preventable cancers.

CancerWatch’s mission is to secure a reduction and ultimately the elimination of preventable cancers. Very technically, screening might seem to sit outside the scope of this work: if a screening programme identifies that someone has developed cancer, surely it’s too late to prevent it? In that case yes, but some screening is for pre-cancerous conditions rather than cancer itself.

What’s more, the screening programmes we already have are only part of the likely future picture. As the genetic causes of all sorts of diseases, including cancers, are increasingly understood, and with the cost of genetic testing now greatly reduced, it will become increasingly common for people to have the option to get their genome checked for potentially harmful mutations. The mutation of the BRCA1 and BRCA2 gene that greatly increases the likelihood of someone developing breast cancer, as perhaps made most famous by Angelina Jolie, is the highest profile example, but more genetic risk factors are regularly being discovered. More people will inevitably get themselves tested for more cancer risks in the future, and it is important that genetic counselling is available for anyone using these services.

However, concentrating on the here and now, there are currently screening programmes for cervical, breast and bowel cancer, all overseen by the UK-wide National Screening Committee. There may be scope for improving these programmes, although their effectiveness is surprisingly hard to identify, with figures on numbers of lives saved difficult to pin down with certainty.

That said, there certainly seems to be scope for expanding the scope of some of the programmes: according to Breast Cancer Now, a quarter of breast cancer cases occur in women aged 75 and over , but the screening programme only covers women aged 50 to 71. Similarly, the bowel screening programme covers people aged 60 to 74, but Bowel Cancer UK reports 59% of cases occurring over the age of 70, implying a significant number of cases occurring in people outside the scope of the programme.

There may also be scope for making greater use of the processes and infrastructure of the screening programmes, for instance by sending information on lifestyle choices to help reduce cancer risk alongside the communication to invite people in for tests. While our view is that the greatest gains are to be made from structural changes to reduce cancer risks, improved information to equip individuals to make healthy decisions has its place, and currently this feels like an obvious opportunity being missed.

Undoubtedly screening will become a larger part of the cancer treatment landscape over coming years, as new and better ways of identifying more types of cancer are developed. Screening for lung cancer is being rolled out, for example, alongside the new NHS lung health checks. It is important that these programmes are well devised, fully resourced, and regularly evaluated, to ensure that they are as effective as possible.

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State of play: alcohol

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Throughout this Cancer Prevention Action Week, we are reviewing the current state of public policy for the major risk factors in causing preventable cancers.

Like poor diet and smoking, alcohol can cause many illnesses. The most widely recognised are probably liver disease and the life-disrupting effects of alcohol addiction, but the causal link to cancer is also clear. Cancer is a known factor in causing seven cancers, and the alcohol itself is the problem: whether you consume it in wine, beer or spirits doesn’t matter. There is a further, secondary effect: alcoholic drinks can often be surprisingly calorific, and consuming excess calories raises the risk of obesity, which is itself a cause of cancer.

Among the main causes of preventable cancers, alcohol is the one where policy has diverged most sharply between the nations of the United Kingdom – or, perhaps more accurately, where English policy is lagging behind the rest of the country. Scotland and Wales have introduced minimum unit pricing (Northern Ireland consulted on it in 2022, with next steps still awaited), which has proved successful in restricting the availability of cheap high-strength alcohol.

More generally, English policy tends not to approach alcohol use as a population health issue in the way that the devolved nations tend to. There has been no new strategy on alcohol harm since 2012, when a bold strategy was published that promised minimum unit pricing, banning multi-buy alcohol promotions in shops, obliging local authorities to consider public health when making alcohol licensing decisions, and other population-level interventions. For the most part, these commitments were simply not implemented, often without any formal announcement or explanation. No further significant action on alcohol has been announced since then.

What action would be useful? As with the other main causes, change needs to be structural in nature. There will be a place for measures to equip individuals to make their own decisions, such as through better labelling of alcoholic drinks, but the interventions that will make the biggest difference will be those that shape our environments to make the healthy choice the easy one. Restrictions on the display of alcohol in shops would be one avenue to explore, as would many of the 2012 proposals, not least tightening the framework for local decision-making about licensing alcohol sales and, of course, minimum unit pricing.

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State of play: diet and food

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Throughout this Cancer Prevention Action Week, we are reviewing the current state of public policy for the major risk factors in causing preventable cancers.

There is a clear link between obesity and numerous cancers – 13, according to Cancer Research UK. This link is both statistically clear, and increasingly well understood in biomedical terms: fat cells do not simply sit in the body, but interact with its processes, particularly influencing growth and sex hormones and causing inflammation, all of which increases rates of cell division and therefore the risk of a cancer developing.

However, tackling obesity is a complex and sensitive topic. As we discussed in a previous article, the temptation to blame individuals for making poor choices is strong, but wrong-headed. The rise in obesity levels over recent decades has been overwhelmingly caused by changes in diet. The prevalence of obesity doubled from 1990 to 2020, following major structural changes to the food we buy and how we buy it. From the 1970s onwards, ready-made, “ultra-processed” foods high in salt, fat and sugar became more common in our diets: the UK has the highest consumption of these foods in Europe.

At the same time, supermarkets came to dominate food retail, spurred on by changes to planning laws that made large out-of-town shops feasible. Supermarkets achieved a dominance that enabled them to drive down prices for consumers, but also exert enormous influence over what is available for us to buy, and how attractive different products can seem.

Takeaway food options have also expanded enormously over recent decades, most commonly offer tasty but unhealthy meals, and are more common in economically deprived neighbourhoods.

The need for changes to diet and food supply

It is CancerWatch’s view that major structural changes are needed in order to reduce levels of preventable cancer. This must mean making changes to our food chain and distribution: while changing individual behaviours has its place in the mix, this sort of change is always easiest for people who are already relatively well-off and relatively advantaged. But that is not where change is most needed: the problems with our food supply are a key factor in health inequalities. Sir Michael Marmot’s second review of health inequalities identified the characteristics of an unhealthy high street: they include higher density of payday loan, alcohol, gambling and fast food outlets. And over a million people in the UK live in “food deserts”, meaning they lack access to cheap and nutritious food (in practice, this usually means access to a supermarket).

We therefore argue that this issue should be approached and framed in terms of food and diet, rather than obesity. There are several advantages to taking this approach. One is that it encompasses other food-related factors in causing cancer, such as processed and red meat, which are clearly established factors in causing bowel cancer, and heavily implicated in stomach and pancreatic cancer as well.

Even more importantly, discussion of healthy eating is more acceptable to public opinion. Obesity is still widely understood (or misunderstood) as a personal failing arising from individual choices, and many people are inclined to reject messaging suggesting that individual choice is not the main problem. However, people are generally more receptive to messages about healthy eating, or diet as a factor in improving their overall health, rather than focusing just on wider causes of obesity. Messages pointing out the role of health inequalities also tend to be better received when they relate to access to food, rather than to levels of obesity. This is therefore the route to achieving public buy-in for structural change (although entirely discounting the role of personal responsibility is understandably greeted with scepticism: people expect to continue to see it as part of the policy mix).

Cancer Research UK’s much-publicised advertising campaign in 2019, drawing attention to the link between obesity and cancer, therefore somewhat fell into the obvious trap. CRUK’s policy positioning on what is needed to reduce the incidence of preventable cancers by reducing obesity is entirely right, and it is true that the link between obesity and cancer is not as widely known as it needs to be. But their posters might have done better to call for a specific policy change to improve diets: without that, their messages were directed at an audience of individuals, which carried the implication (whether intentional or not) that it was for those individuals to do something about it, and nobody else.

Policy options, and action to date

So, what action could be taken, and how much is already on course to happen? The good news is that action can be taken on many fronts: there is no shortage of possibilities. Planning reforms could be deployed to address unhealthy high streets, for example, and food deserts could be targeted through a collaborative approach between supermarkets and government both locally and centrally. The power of supermarkets more broadly could be leveraged to good effect: they are being prohibited from heavily promoting unhealthy foods from October this year (albeit this measure is much delayed), but could potentially use their dominant market position to promote healthy choices more heavily.

Measures to prompt the reformulation of food and drink to be more healthy could also be developed. The Soft Drinks Industry Levy (better known as the sugar tax) led many manufacturers to reformulate their products, and has enjoyed widespread public support. More measures of this sort are surely viable.

Public Health England undertook much valuable policy development work in this area, prior to its abolition (for example this paper on calorie reduction and this on a whole system approach to obesity). Unfortunately the Government Food Strategy published last year falls well short of taking the bold structural action needed, including failing to adopt many of the recommendations of the independent National Food Strategy that it had previously commissioned. Until much stronger action is taken, the costs of our current food supply and dietary problems will continue to be passed on to the NHS, and many people will continue to develop preventable cancers.

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State of play: smoking

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Throughout this Cancer Prevention Action Week, we are reviewing the current state of public policy for the major risk factors in causing preventable cancers.

Tobacco use is the area where historically there has been the strongest policy action to prevent harm. Much of the progress in extending life expectancy over the later part of the twentieth century and early part of the twenty-first can be attributed directly to success in reducing levels of smoking, and the UK has been a world leader in this. It is also the lifestyle factor whose link to cancer is most widely known and accepted.

Why do people smoke?

Why people start smoking and why they continue to smoke are subtly different questions, but the answers to both lie in wider determinants of health: socio-economic background and personal circumstances are major drivers of smoking behaviour.

Analysis by the Office for National Statistics and Public Health England shows that the likelihood of someone smoking increases in line with the level of deprivation in their neighbourhood. Smoking also correlates very clearly with a person’s housing tenure (renters are more likely to smoke than owner-occupiers) and occupational group (workers in routine and manual occupations are more likely to smoke).

Smoking uptake flows through generations: young people who are exposed to smoking behaviour, for instance via their parents, are more likely to see smoking as normal, more likely to have ready access to tobacco, and more likely to try it. Once they are addicted, they also find it harder to quit: in communities where smoking is still very visible, quit rates are lower (although attempts at quitting are no less common), and these trends reinforce each other. The reverse is seen in communities where smoking is less common: each generation is less likely to see it as normal, less likely to take it up, and more likely to find it easy to quit when they try.

As this implies, changing patterns of smoking behaviour is hard and takes time. Growing awareness of the harms caused by smoking brought rates down in the later decades of the last century, but more so among better off and more educated people. The ban on smoking in indoor spaces in 2007 built on many years of shops, restaurants and other facilities first having no-smoking areas, and then often banning smoking entirely. These changes made smoking more and more inconvenient, and marginal in society, an effect amplified by a ban on tobacco advertising, and requirements to sell cigarettes in plain packaging, and hide them from view in shops.

Smoking cigarettes has also been made more expensive. From November 1993, there was a commitment to increase tobacco duty by at least 3% per year, and by at least 5% from 1997; and it had been on a rising trajectory even before that. A slightly more complex set of rules was introduced in 2017, which has maintained the effect of annual rises.

Current policy

However, despite a history of strong action in the past, tobacco policy in the UK appears to be faltering. The Government set a strong ambition in 2019, for England to be smoke-free (defined as only 5% of the population smoking) by 2030. Wales has also set a target of 2030, and Scotland 2034. However, the independent Khan Review, which published its findings last year, reported that the English target will be missed by seven years without further policy action, and by 14 years in the least well-off parts of the country. Cancer Research UK has separately estimated that the England target is due to be missed by nine years.

The Government has yet to respond to the Khan Report: it has committed to doing so as part of a health disparities white paper, which has been subject to delay and was even reported to have been cancelled by the Truss administration (although health ministers later confirmed that it would be published). A new Tobacco Control Plan should then follow, but is similarly overdue. The bold interventions recommended in the report would, if implemented, be a striking but welcome departure from recent policy approaches. The recommendations include:

  • Increasing tobacco duty markedly more steeply than recent rises
  • Significant investment in smoking cessation services across the NHS
  • Progressively increasing the age at which tobacco may be bought, effectively prohibiting its purchase by people born after a certain date
  • Licensing for tobacco sales, to reduce the number of outlets where it can be bought
  • A “polluter pays” approach, in which the costs of these measures would be met at least partly by a levy on tobacco manufacturers.

Scotland, Wales and Northern Ireland all have tobacco control plans of their own, although some of the tougher actions proposed in the Khan Report would require UK-wide legislation by Parliament.

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Cancer prevention needs structural change: individual responsibility isn’t enough

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It’s a remarkable statistic that around 40% of cancers in the UK are preventable. It offers great hope for improvements in the future, but at the same time makes depressingly clear how many people are becoming ill and dying who would otherwise have enjoyed years of good health.

Overwhelmingly, the things that make these cases preventable are to do with lifestyle: the major factors in causing cancer that can be changed, and therefore bring that figure down, are smoking, diet (mostly by causing obesity) and drinking alcohol. Yet this immediately creates the temptation to argue that individuals simply need to make better choices for themselves. Unfortunately, “simply” is the most important and most misleading word in that sentence: in truth, there is nothing simple about altering people’s lifestyles to reduce cancer. If it were simple, we would have cracked it by now, and that 40% figure would have been reduced to almost nothing.

Our central aim as CancerWatch is therefore to push for the structural changes that are necessary to reduce and eventually eliminate avoidable cancers. This article explores what that means: why the tempting narrative of personal responsibility has led to policy failure, and what sorts of changes are actually necessary. Over the rest of Cancer Prevention Action Week, we will be publishing articles looking at the state of play in each relevant policy area: smoking, diet, alcohol, and screening.

What drives people’s choices?

Advocates of an approach that focuses solely on personal responsibility often argue that people can be relied upon to make rational choices. They are of course correct – indeed, more correct than they realise.

For someone leaving work late and tired after a long day, picking up food from one of the many takeaway outlets on their way home, rather than cooking a healthy meal from scratch, will be a rational choice. For someone who has to feed a family on a tight budget and who doesn’t have the use of a car, buying cheap processed food from the nearby convenience store, rather than finding a way to travel to a large supermarket to buy fresh food, will be a rational choice. For someone who has grown up around people smoking and drinking regularly, joining in with the behaviour of their peers will be a rational choice. Satisfying a craving, or even a passing fancy, whether for a cigarette, a drink or a slice of cake, will often be a rational choice, compared to expending the effort and enduring the distraction needed to resist it – provided, of course, that the cigarette, drink or cake are easily at hand.

It will be clear from these examples that a person’s circumstances have a huge bearing on the choices they make. This includes people’s social and economic circumstances, which determine what they can afford to do, what they have time to do, and what other people around them encourage them to do. The basic geography of where they live will matter a great deal: most commonly in the United Kingdom, cheap and healthy food can only readily be obtained at a supermarket, so if you live a long way from one of those but nearer to numerous takeaways and convenience stores, location is likely to shape your choices. Equally, if you are under ongoing financial pressure, or live in a poor quality home, or have to deal with a difficult family life, things like quitting smoking or cooking healthy meals will very naturally not seem like high priorities.

From this, it will be obvious not only how circumstances shape people’s health, but also how this drives inequalities across our society, with the people who consistently make healthy choices generally being those who have the money and time to do so.

The argument is not won

Set out in this way, it all seems like common sense to suggest that wider factors need to be addressed, and that unhealthy choices are not simply the product of individual failings. Unfortunately, recognition of this idea, let alone support for it, is lacking.

Research by Nesta and the Behavioural Insights Team in 2021, which looked specifically at food and diet choices, found that the public overall tends towards the “personal responsibility” view. There is a correlation between the level of support enjoyed by a public health measure and the extent to which people believe it will be effective: the more likely people feel it is to work, the more likely they are to support it. Unfortunately, there is widespread belief that the best way to improve health is to enable individuals to make healthier decisions, mostly by providing information and encouragement. Other interventions to change the food choices available to people, or the incentives for different choices, clearly enjoy less public support.

Where stronger interventions have been applied, such as with the ban on smoking in enclosed public places or the sugar tax that prompted many manufacturers to reformulate their products to reduce sugar levels, they have enjoyed public support and there is no significant public pressure to repeal them. It may be that stronger measures can be expected to attract support after their implementation, but certainly many potential interventions appear unlikely to enjoy much support at the moment.

However, those earlier successful measures show the path we need to be taking. Crucially, this does not simply involve regulation to curtail personal freedom. That may be part of the mix, such as tougher restrictions on smoking in public places, whether enclosed or not. But often regulatory solutions will address business behaviours: it might mean restricting advertising of unhealthy products further, using planning rules to reduce proliferations of takeaways, or incentivising more reformulation of unhealthy products. None of those measures would strictly prevent people from consuming unhealthy substances, but it would need to be a deliberate and active choice, rather than the natural or obvious one.

For Cancer Prevention Action Week, therefore, we need to be clear about what sort of action is needed. By all means, people should be given information and encouragement to make healthy choices, but the action that is required above all else is bold, structural change. Healthy choices should be made the easiest, most convenient and most affordable choices for everyone. Substantial reform of how tobacco, food and alcohol are consumed and regarded in our society is the only way to achieve this.

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Image by Howard Lake on Flickr, reproduced under Creative Commons licence BY-SA 2.0

Obesity and Planning Permission

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The obesogenic nature of our inner cities has long been a cause of concern for activists campaigning against poor health, and the key instrument for control of inner city environments is planning permission. In the post war years such permission has become fiercely complex and very much the realm of lawyers, yet normal inhabitants of any town have to interact with it if they want to complain about commercial and retail development in their urban environment.

Planning permission determines the character of the built environment, and nowhere is this more true than in the case of restaurants and retail food outlets. For those of us who are concerned about obesity, the fast food and hot food takeaway sector is an area of significant focus. We are not talking about lunchtime takeaway shops, whose staple is sandwiches and salads, many of which are quite healthy We are talking about the evening purveyors of kebabs, chips, fried chicken wings, oversized pizzas, king sized burgers and such like, where the calorific content is significant but the nutritional contents in minimal.

The poor quality of inner city environments also has the effect of discriminating against the poorer and less advantaged members of society, due to the high level of social housing and poor quality of rented accommodation that often exists in the inner city. The middle class leafy suburbs have traditionally been more insistent at keeping low quality fast food restaurants and take-aways out of their areas; they have a better understanding of the damage these retail units do to the environment in which they live.

Public health is not normally considered an adequate reason for refusing planning permission, but increasingly local councils with poor health metrics in their areas are taking action. Within the planning system, local government can control development by using Planning Directives, and these are increasingly being used. Other such tools include Supplementary Planning Documents, and a number of local councils, such as Dagenham and Coventry City council have used these as tools to reduce the prevalence of fast food takeaways in their areas.

It is unfortunate that local authorities often use child (as opposed to adult) obesity as a diversionary tactic, emphasising how they prohibit hot fast food take-aways from operating close to schools, and other no doubt worthy child health policies, but they fail to address the key issue of adult obesity caused by the overall poor quality of the inner city environment. Making the matter especially difficult, of course, is that at a time of hollowing out of town centres, councils try to attract retail outlets to their inner city areas, encouraged by the need for councils to attract business rates to their locality at a time of budgetary cuts from central government.

Unfortunately, there is no quick fix for obesity. In practice to make policies effective they have to be used with other anti-obesity tactics. But anti-obesity campaigners should increasingly ask why these poor quality hot fast food retails outlets exist in their cities at all.

The Problem with Children’s Obesity

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During the lockdown, my front door has been the recipient of countless leaflets promoting take-away food of a distinctly dubious nutritional quality. This caused me to write to my local council complaining about high fat, fast food take-aways and the effect they had on obesity. I received a fulsome letter back from the local councillor in charge of health, but it talked only about childhood obesity.

Good cause to worry? UK children are the fattest in Europe and have become fatter since the lockdown according to figures released in autumn 2020 by the National Child Measurement programme.

When children start school more than a fifth of four year olds are classed as overweight and a tenth as obese, meaning they have a BMI of 30 or above. By the time they go to secondary school more than a third of children are overweight and a fifth are obese. Across England, childhood obesity has risen while the gap between the rich and the poor has widened.

The Conservatives pledged to “tackle childhood obesity” in the party’s 2019 manifesto. In 2018 the Tories had committed to halving the problem by 2030.

The campaign is very worthy and well meaning, but there is a more subtle aspect to it. Obesity is a major risk factor for many lifestyle (ie preventable) cancers, so it is important that obesity should be controlled and eliminated.

A number of cancers are caused by obesity: bowel cancer, uterine cancer, oesophageal cancer, breast cancer and others. Indeed, some campaigners are now saying that obesity causes more cancer than smoking. Other lifestyle diseases, such as diabetes or cardiovascular disease are also diseases of the overweight.

However, a characteristic of lifestyle cancers is that they tend to affect the elderly, not the young. For example the average person who gets cancer of the oesophagus is aged 70. The average age of a child is half 18, thus aged 9. So there is a 60 year gap between the cancer itself and the precautionary action being taken. In a sense, you could argue that in the case of cancer of the oesophagus, for example, you have to wait 60 years to know if the child obesity campaign has really been successful. Similar figures would apply to other lifestyle diseases.

No government department works to a 60 year time horizon so why did the Department of Health and Social Care (DHSC) embark on this? The answer is that it is an easy option for them. It is “doable” (Amsterdam has already succeeded), it is measurable, and because children are involved, everybody sees it as a “good thing” rather than part of a so-called nanny state.

Unfortunately, worthy as it is, in my opinion, the campaign against child obesity is also acting as a decoy, a diversionary tactic for what really needs to be tackled, which is adult obesity. It is adult obesity that needs to be tackled now, not in 60 years time. It may be easier and more convenient for the DHSC to turn a battle against “obesity” into a battle against “child obesity” but the two are very different, and the battle against the latter risks sidelining the battle against the former.

After all, the battle against adult obesity would lead you into concepts such as “fat taxes”, finger wagging and concepts alien to a “free society”, whatever that is. It is easier to advocate policies that have already been shown not to work, but apply them to children, where you have more control, and therefore make weak policies seem more successful.

Of course, the assumption is that if you can fix child obesity you will fix adult obesity. I would argue that the logic is the other way around, not to mention that the time horizons are just too long to carry any meaning. Perhaps you can hope that putting emphasis on preventing obesity generally through the child obesity drive will leach through to adult obesity. But I say fix adult obesity first, then you will find child obesity will fix itself.

JMC March 2021

Briefing Note – Bowel Cancer

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Briefing Note on Bowel Cancer in the UK

Bowel cancer is one of the most common cancer types. Sometimes it is referred to as colorectal cancer, which is another name for the disease. Bowel cancer in general has been rising in the past few decades and there are many theories for this rise. Please read below for the latest developments in bowel cancer and also tips on how to prevent it.

Background

Bowel cancer accounts for 11% of all new cancer cases in the UK. Every year, about 42,300 people are diagnosed with bowel cancer in the UK. 1 in 15 men and 1 in 18 women will get bowel cancer during their lifetime. Many risk factors influence your bowel cancer risk: age, obesity, and diet are the main risks. 

However, shorter term, the overall trend for bowel cancer in the UK is decreasing. Although bowel cancer cases were rising between 1971 and 1998, there was then a period of no new increases until 2012. Since 2012, we seem to be getting on top of the disease. The rate of new cases decreased by 4% in the last decade.  However, still around 70 in 100,000 people are diagnosed with bowel cancer in the UK every year.

What are the risk factors?

The main risk factor is age: your risk of getting bowel cancer increases dramatically with your age. The majority of people with bowel cancer are typically above 80 years old and the rest above 50. The rate of new cases in people aged below 50 years old is extremely low (Cancer Research UK, 2015-2017). The average age at the time of diagnosis is between 63-72 for colon and rectal cancers. 

This may be due to your lifestyle that affects your risk during your lifetime. There are many risk factors that are well-known to increase risk of bowel cancer:

  • Diet especially lack of dietary fibre and over consumption of red meat
  • Obesity and being overweight
  • Smoking
  • Alcohol
  • Previous cancer history
  • Medical conditions (IBS, colitis, chronic inflammation)
  • Radiation
  • Infections
  • Hereditary conditions

Some reports in the media may also mislead you into thinking that mobile phones, artificial sweeteners, genetically modified foods or plastic bottles are risks. However, not all these ‘facts’ are true. Many of them are not backed up by scientific studies. You can read more about the biggest myths around bowel cancer here:

https://www.cancerresearchuk.org/about-cancer/causes-of-cancer/cancer-myths

The key fact is that eating fibre reduces your risk of bowel cancer by at least 20%. 9 out of 10 people in the UK are not eating the recommended amount of fibre every day. Many scientific studies have linked the reduction in bowel cancer cases with dietary fibre. Interestingly, increased refrigerator use was linked to reduced gastric cancer risk in Asia –possibly also in Western countries. Similarly, antibiotics were linked to some types of bowel cancer, but were found to prevent others. Aspiring use, calcium and vitamin D are thought to prevent your risk of bowel cancer. Chronic inflammation and changes in your gut microbiome may also contribute to your bowel cancer risk. However, care is needed when interpreting bowel cancer risk factors from isolated studies. Scientific studies need to be repeated across continents to establish a relationship between a risk factor and cancer. 

Bowel cancer in young adults

Worryingly, since 2010, the number of new cases among people aged 20-39 years old increased sharply by 5-19%. Since bowel cancer is significantly associated with lifestyle and diet, the main explanation would be the rising levels of obesity and diabetes in younger population. Moreover, young people nowadays tend to be less physically active and may have a higher consumption of red meat, increasing their bowel cancer risk.

Source: Cancer Research UK, https://www.cancerresearchuk.org/health-professional/cancer-statistics/statistics-by-cancer-type/bowel-cancer/incidence#heading-Two, Accessed 05/2020

Bowel cancer and sex

Bowel cancer is more common among men than women. Men form almost 56% of all cases, whereas women only 44%. This may be due to different lifestyle habits: women tend to be more interested in healthy diet, exercise and general healthy lifestyle than men, reducing their bowel cancer risk. Perhaps interestingly, women also tend to have a better prognosis than males. This was in past linked to differences in hormonal levels.

Source: Cancer Research UK, https://www.cancerresearchuk.org/health-professional/cancer-statistics/statistics-by-cancer-type/bowel-cancer/incidence#ref-2, Accessed 05/2020

Bowel cancer prevention

The main factor contributing to decreasing levels of bowel cancer is screening. The UK has a national screening programme for bowel cancer,  that helps to reduce bowel cancer incidences and severity thanks to early diagnosis. In 2011, a ‘Be Clear on Bowel Cancer’ campaign was launched to promote bowel cancer awareness. This helped to improve the bowel cancer statistics drastically, possibly by removing the stigma around diagnostic procedures. If people feel that going for colonoscopy can be part of a yearly check-up and there is no shame associated with it – more people seek early diagnosis and treatment for bowel conditions, in turn helping to prevent bowel cancer. Probably thanks to improved screening and awareness, the survival for bowel cancer patients has been steadily improving by almost 60% since 1971.

Source: Cancer Research UK, https://www.cancerresearchuk.org/health-professional/cancer-statistics/statistics-by-cancer-type/bowel-cancer/survival#heading-Two,accessed 05/2020

Bowel Cancer in the UK

Despite the awareness campaign the age standardised incidence rate of bowel cancer in the UK is amongst the highest in the world. Many Western countries have high rates of bowel cancer among their population, including Germany, Spain, Canada and Australia. This may be due to low levels of dietary fibre, poor lifestyle, consumption of red meat, alcohol and smoking.

Lifestyle factors are likely to contribute to a poorer survival rate in the UK than in other countries. France, Canada and United States have higher survival rates for colorectal cancer than the UK. Although the UK has been improving its survival rate over the last decade with the screening programmes playing a significant role in catching bowel cancer in its earliest stages and improving patients’ prognosis. Awareness around bowel cancer and its risk factors is still low in the UK, in contrast to the US.

A main difference between the UK and US is also in clinical recommendations. UK NICE guidelines do not recommend endoscopy or imaging for people with irritable bowel syndrome (IBS). However, almost half of IBS patients in the US receive endoscopy, possibly detecting early-stage tumours more often. Colonoscopy is the primary screening method for early-stage colorectal cancers. Getting people at risk of bowel cancer to the doctor in the UK earlier will improve the risk and prognosis.

Source: The colorectal epidemic: challenges and opportunities for primary, secondary and tertiary prevention. (Brenner and Chan 2018)

The future and prevention of bowel cancer

Prevention and early detection play significant roles in reducing your risk of bowel cancer, and your prognosis if you are diagnosed. Eating a high fibre diet, avoiding tobacco and alcohol consumption, eating less red meat and improving your exercise habits will all help in reducing your risk of bowel cancer.

But the good news is that there are several trials underway to further reduce your risk, for example scientists are trialling low dose aspirin for preventing bowel cancer, as well as improvements to bowel cancer screening.  We encourage you to join our campaigns against the incidence of bowel cancer as well as other life threatening cancers.

Taking care of your body and gut will not only improve your bowel cancer risk, but also lifestyle and quality of life. 

Produced by the CancerWatch team, Summer 2020 

References

Bowel cancer statistics [WWW Document], 2015. . Cancer Research UK. URL https://www.cancerresearchuk.org/health-professional/cancer-statistics/statistics-by-cancer-type/bowel-cancer (accessed 5.22.20).

Brenner, H., Chen, C., 2018. The colorectal cancer epidemic: challenges and opportunities for primary, secondary and tertiary prevention. British Journal of Cancer 119, 785–792. https://doi.org/10.1038/s41416-018-0264-x

Center, M.M., Jemal, A., Smith, R.A., Ward, E., 2009. Worldwide Variations in Colorectal Cancer. CA: A Cancer Journal for Clinicians 59, 366–378. https://doi.org/10.3322/caac.20038

Exarchakou, A., Donaldson, L.J., Girardi, F., Coleman, M.P., 2019. Colorectal cancer incidence among young adults in England: Trends by anatomical sub-site and deprivation. PLOS ONE 14, e0225547. https://doi.org/10.1371/journal.pone.0225547

Keum, N., Giovannucci, E., 2019. Global burden of colorectal cancer: emerging trends, risk factors and prevention strategies. Nature Reviews Gastroenterology & Hepatology 16, 713–732. https://doi.org/10.1038/s41575-019-0189-8

Kunzmann, A.T., Coleman, H.G., Huang, W.-Y., Kitahara, C.M., Cantwell, M.M., Berndt, S.I., 2015. Dietary fiber intake and risk of colorectal cancer and incident and recurrent adenoma in the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial12. Am J Clin Nutr 102, 881–890. https://doi.org/10.3945/ajcn.115.113282

Loomans-Kropp, H.A., Umar, A., 2019. Cancer prevention and screening: the next step in the era of precision medicine. npj Precision Oncology 3, 1–8. https://doi.org/10.1038/s41698-018-0075-9

Mármol, I., Sánchez-de-Diego, C., Pradilla Dieste, A., Cerrada, E., Rodriguez Yoldi, M.J., 2017. Colorectal Carcinoma: A General Overview and Future Perspectives in Colorectal Cancer. Int J Mol Sci 18. https://doi.org/10.3390/ijms18010197

Murphy, N., Norat, T., Ferrari, P., Jenab, M., Bueno-de-Mesquita, B., Skeie, G., Dahm, C.C., Overvad, K., Olsen, A., Tjønneland, A., Clavel-Chapelon, F., Boutron-Ruault, M.C., Racine, A., Kaaks, R., Teucher, B., Boeing, H., Bergmann, M.M., Trichopoulou, A., Trichopoulos, D., Lagiou, P., Palli, D., Pala, V., Panico, S., Tumino, R., Vineis, P., Siersema, P., van Duijnhoven, F., Peeters, P.H.M., Hjartaker, A., Engeset, D., González, C.A., Sánchez, M.-J., Dorronsoro, M., Navarro, C., Ardanaz, E., Quirós, J.R., Sonestedt, E., Ericson, U., Nilsson, L., Palmqvist, R., Khaw, K.-T., Wareham, N., Key, T.J., Crowe, F.L., Fedirko, V., Wark, P.A., Chuang, S.-C., Riboli, E., 2012. Dietary Fibre Intake and Risks of Cancers of the Colon and Rectum in the European Prospective Investigation into Cancer and Nutrition (EPIC). PLoS One 7. https://doi.org/10.1371/journal.pone.0039361

Soriano, L.C., Soriano-Gabarró, M., García Rodríguez, L.A., 2018. Trends in the contemporary incidence of colorectal cancer and patient characteristics in the United Kingdom: a population-based cohort study using The Health Improvement Network. BMC Cancer 18, 402. https://doi.org/10.1186/s12885-018-4265-1

Yan, S., Gan, Y., Song, X., Chen, Y., Liao, N., Chen, S., Lv, C., 2018. Association between refrigerator use and the risk of gastric cancer: A systematic review and meta-analysis of observational studies. PLoS One 13. https://doi.org/10.1371/journal.pone.0203120

Yang, Y., Wang, G., He, J., Ren, S., Wu, F., Zhang, J., Wang, F., 2017. Gender differences in colorectal cancer survival: A meta-analysis. International Journal of Cancer 141, 1942–1949. https://doi.org/10.1002/ijc.30827

Why is Smoking Becoming a Working Class Tragedy?

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The Background

About 8m (2016) people, some 15% of the population still smoke. This contrasts with the situation after the Second World War when over 80% of the population smoked.  During the 1970s and 80s in particular there were considerable declines in smoking as the medical science behind the dangers of smoking became better known in the population.

But this obscures a key unpalatable truth, that most of the reduction in smoking has been as a result of the middle classes giving up smoking, rather than an across-the-board reduction which policy makers assume.  Among people in lower socio-economic groups the decline has been much smaller.

Key Statistics for Smoking and Inequality

Indeed, there is a close link between cigarette smoking and social class.  In 2017 studies by Action on Smoking and Health (ASH) showed that about 26% of adults in manual occupations smoked compared with 11% in managerial and professional occupations.

Additionally the working classes are more likely to be heavy smokers (defined as adults who smoke more than 20 cigarettes a day).   A YouGov survey commissioned by ASH in 2019 found that 30% of current smokers in higher social groups AB smoked less than 6 cigarettes a day compared to 17% in lower social group E.  

Additionally, 18% of smokers reported smoking 20-30 cigarettes a day in the lower socio-economic groups with only 5% smoking that number of cigarettes a day in the higher socio-economic groups.  In other words, the higher the social class, the fewer the cigarettes smoked by smokers.

Higher smoking prevalence is associated with almost every indicator of deprivation or marginalisation in society compared to the population as a whole.  For example, smoking is more common among the unemployed; people with mental health problems; people who live in social housing; people without qualifications, and people in contact with the social justice system.

How much health inequality is caused by smoking?

There have been various studies to try and identify this.  Using the incidence of mortality in large datasets probably give the best results.  For example, in a long term study of over 10,000 civil servants in London, smoking was found to account for around a third of the difference in death rates between the lowest and the highest socio economic groups over a period of 25 years. (1)

In an international study of deaths among men aged 35-70 which included data on 600,000 men, smoking was found to account for about half the difference in mortality between the top and bottom socio economic groups in England. (2)

In general, long term studies have found that around a third to a half of health inequalities are caused by smoking.  For reference, of the other causes, about 30%  of health inequalities are considered to come from obesity, with the final 20% or so being the result of alcohol and a variety of other causes relating to poverty.

Why does nobody seem to care?

Nearly all British government health institutions, such as the Dept. of Health and Social Care, the NHS, and quasi-government institutions such as Public Health England, and Health and Wellbeing boards run by local government, claim to put health inequalities at the heart of their work, and in many cases are legally obliged to do so.  In practice, the phrase “health inequalities” is a euphemism for good intentions, but where little action is taken. Indeed, smoking cessation services (which have been delegated to local authorities) have been severely reduced in recent years due to constant budget cuts. 

It is the case with many public health matters, that there is still a reliance by policy makers on “individual responsibility”, in other words, smoking among lower socio economic groups is the responsibility of those specific groups; as far as the health authorities are concerned it is a case of tut, tut, hands up, – nothing to do with me, mate!  Or better still, blaming it on the cigarette companies.

But perhaps the really reason that officials are indifferent to the health inequalities of smoking is that cigarettes bring in some £12.5bn a year of taxation (incl. VAT) for central government, not an insignificant amount and roughly equivalent to the amount raised from stamp duty taxes.

Why should we care?

We should care because cigarettes cause some of the deadliest of all cancers and diseases, and it is an abomination that people suffer from these diseases and have shorter lifespans just because they were born into lower socio-economic groups.  Smoking causes harm to every organ of the body, but as far as cancer is concerned the most relevant cancer is lung cancer, one of the most deadly of cancers.  But it also causes some twelve other cancers, among them bowel, bladder, kidney, oesophageal and pancreatic cancer.

Who should take action?

Everybody should take action to lobby against these types of health inequalities, not just cancer campaigners like CancerWatch, but also groups campaigning for greater social justice such as the Child Poverty Action Group, food banks, trades unions representing lower paid workers, providers of social housing, politicians who campaign of behalf of lower income groups, not to mention other health charities.  These groups and associations all have their part to play and CancerWatch will be encouraging them to play it.

The CancerWatch Team

Summer 2020

Notes:

  1. Stringhini S, Sabia S, Shipley M et al. Association of socioeconomic position with health behaviors and mortality. JAMA 2010; 303(12):1159-1166 
  2. Jha P, Peto R, Zatonski W, et al. Social inequalities in male mortality, and in male mortality from smoking: indirect estimation from national death rates in England and Wales, Poland, and North America. The Lancet 2006; 36: 367–370. 

Labelling: what’s in a bottle of wine?

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In front of me I have a bottle of Australia McGuigan Estate Merlot. Like most people I enjoy a glass of wine and I often glance at the label to read a bit of background information about the wine. But since becoming a campaigner against cancer I increasingly look more closely at the health information given on the label.

Let’s decipher the label. The first piece of information of note is “13% vol”. I think many people might know that this relates to the alcohol content, but how many know its relevance? Is 13% a high content or a low content of alcohol? With some further investigation I suspect it will show that this wine is of medium strength — 5.5% would be a wine with low alcohol, 17% would be high — but for the many who don’t have a specialist interest in wine labels, how would they know?

Reading on, in capital letters we are told that it is a wine of Australia and a smaller comment that it contains sulphites. Sulphites, or sulphur dioxide are a legal preservative to stop wine oxidising or being contaminated. They can have unpleasant side effects so they are mentioned on the label. As we shall see, this is one of the few pieces of health information that are added by law. There is also another piece of mandatory information, the quantity of wine that the bottle contains, in this case expressed as 75cle.

Then in a little box that measures 2.5cm by 1.5cm on the back of the bottle is some crucial health information pertaining to this bottle. It shows the bottle of wine has 9.8 units (of alcohol) and an image of a 125ml glass showing 1.6 units. There is also a comment “UK Chief Medical Officers recommend adults do not regularly exceed 3-4 units (men) and 2-3units a day (women)”. The Australians obvious think there are several Chief Medical Officers in the UK. Finally, there is what I think is a tiny ‘prohibited’ sign with a pregnant women on it. It is all in very, very small font and frankly, pretty well illegible.

Bizarrely, because the labelling on non-alcoholic drinks are more closely regulated, generally, alcohol free wines and beers have considerably more health information on their labels than alcoholic beverages. Additionally, alcohol has considerably lower levels of health information than most foodstuffs, in spite of the fact that alcohol in its purist form is basically a form of poison. How did we reach this point?

Back in 2007, the UK Department of Health reached a wide voluntary agreement with the alcohol industry to include specified unit and health information on alcohol labels. This expectation was then absorbed into the Public Health Responsibility Deal which was designed to ensure that alcoholic products on the shelf would have responsible health information. In practice, that has never happened – the alcohol companies did as little as possible, and then in a font so small that much of the information is illegible. Very little further action has been taken since then, resulting in a situation where most bottles of alcohol will contain less health information than a piece of cheese or a packet of biscuits.

Any form of food labelling is highly complex and is based on legislation that was put in place by the European Union from 2014. It key purpose was to allow consumers to make informed choices and make safe use of food and free movement of food. Typically it includes information on allergens, use by dates, nutritional declarations, ingredients, storage, country of origin, energy (calories) and reference intakes. Font size is also specified.

However, the labelling of alcohol is entirely another matter. The relevant regulations are the European Union regulations 1308/2013, 1169/2011 and 607/2009. They stipulate the information to be put on alcoholic labels: the mandatory information is Alcohol by Volume (ABV, alcoholic strength), provenance, bottler, nominal volume expression eg 75cl, and lot number. Additionally, common allergens, mainly sulphites, are mandatory in specific wine products. There is also provision for minor optional items. The rest of any information remains self regulated mainly by the Portman Group, also known as Drinkaware, an industry funded organisation. Increasingly health information is delivered away from the alcohol by way of a website.

Typically alcoholic strength will not be set in a reference indicator. However, under the voluntary agreement with the drinks industry there will often be information on unit content per product/per serve and, occasionally the Chief Medical Officer’s stipulation not to drink more than 14 units a week. Occasionally there may be calorie content, but only because the supermarkets demanded this information.

Other information that should and could be shown includes information on the dangers of binge drinking; specific health information such as the damage that drinking can do to your liver; nutritional information and mandatory energy ie calorie content; ingredients; drink driving warnings; age restrictions; and use by dates.

This may seem a lot, but it is little more than the information that can be found on most foodstuffs which are considerably less harmful than alcohol. Most foodstuffs have to include traffic light diagrams and background information including, in some cases copious ingredients, which take up a large percentage of the packaging, yet space is found.

Improved labelling will not automatically reduce the damage that alcohol causes. But it is a start on the long haul to reduce the incidence of liver, bowel, and breast cancers that are caused by misuse of alcohol. The start of any public health campaign is education and awareness, a hopeless task if information is not available.