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Jill Clark

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.

Who holds responsibility for public health?

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CancerWatch campaigns for better public health in order to reduce the incidence of cancer, and thereby reduce the misery of the 146,000 cases of cancer (40% of the total) that are believed to be avoidable each year. As any campaigner for better public health knows, an important aspect of a health campaign lies in discerning who holds responsibility for it in order that those entrusted with responsibility can be made to accept it and be made accountable for it.

Let us trace the responsibility for public health in the UK over the last twenty years. Seminal to the battle for improving public health were the Wanless Reports of 2002 “Securing our future health” and in 2004 “Securing good health for the whole population”. These reports were commissioned by H.M. Treasury and were carried out in order to determine the long term resource requirements of the National Health Service. They acknowledged that poor public health was likely to put significant pressure on NHS budgets and was thus considered a financial and economic problem. The reports emphasised the long term financial benefits of improving public health. These reports formed a catalyst for a number of House of Commons select committees and other bodies to report on public health.

In the case of obesity, for example, a number of reports ensued, followed by a government White Paper which clearly identified obesity as a public health priority and enabled comprehensive and wide ranging recommendations to be made. At this point obesity was identified not just a financial problem but clearly as a health problem as well.

As such, responsibility for obesity could be shared between the state and the population. Policy was thus directed to help people choose better lifestyles, and various “shared responsibility” papers followed to exhort the population to live healthier lifestyles.

But then Tony Blair, the then Prime Minister, spoke of the obesity epidemic as the result of millions of individual decisions. Other politicians followed suite, and thus the obesity epidemic finally became a personal problem and the responsibility of individuals, not of the state. Obesity finally became the individual’s fault and therefore, only the individual could correct it. So, like magic, the politicians absolved themselves of responsibility. And that, with the important exception of childhood obesity, has been the situation ever since.

Identifying where responsibility lies is important, as it informs us about the tools that can be used to remedy the problem. For example, if obesity is a public problem then legislation can authorise public health interventions into private life in the same way that legislation is used to enable interventions for the control of communicable disease.

In government policy papers there has been little reference to legislation as a public health tool. Policy predicated on individual responsibility and choice does not leave much room for regulation and compulsion in its armoury. They forget that much is dependent on the regulatory and legislative environment — labelling, social media, and advertising to mention just a few.

Legislation is not a magic wand, but well constructed regulations can:

  • Impose enforceable duties on bodies which are in a position to improve the health environment;
  • Provide powers (such as licensing, taxation, inspection) which give some leverage in ensuring that stakeholders recognise responsibilities
  • Set norms to influence public opinion

The only institution that can pass laws in this country is Parliament, (although local government can play a subsidiary role), so if the government refuses to take responsibility, legislation, a major tool to control improve public health, is lost from the public health armoury.

In 2012 the Government’s refusal to take responsibility for public health was made explicit when it passed responsibility for public health to local government under the 2012 Health and Social Security Act. It is very difficult to see what tools local government has at its disposal to deliver meaningful improvements in public health. Local authorities can build cycle lanes, but it has been pointed out that the real solution to obesity is about consuming fewer calories, and taking more exercise has only a limited effect. Local authorities can and do run the smoking cessation services, but again, these have limited effect. They control licencing for alcohol premises but that has never reduced alcohol consumption, and is more about law and order issues.

This is not to say that national government has completely absolved itself of responsibility for public health. For example, its excellent Child Obesity Programme is well respected; unfortunately the average age of a child is nine, the average age at which an individual is diagnosed with bowel cancer (for which obesity is a major risk factor) is age about 70, so we have some 60 years to wait to see if the programme is genuinely effective.

CancerWatch believes central government should take more responsibility for public health. Currently the government spends almost £150bn on the NHS (fundamentally a sickness service) each year, but delivers only £3bn a year to local government as the public health grant to deliver public health for the nation. CancerWatch respectfully suggests that refusal to take responsibility for public health by central government may account for why an advanced industrial nation like the UK seems to be getting sicker and sicker and is increasingly overburdening the NHS, when a greater acceptance of responsibility by central government might make us healthier and healthier.