Stacking the odds against cancer

The importance of cancer prevention became clear to Professor Bob Steele, Director of the Scottish Colorectal Cancer Screening Programme and Chair of the UK National Screening Committee, through his work as a colorectal surgeon. As a senior registrar in Aberdeen many of the patients he operated on already had an advanced stage of the disease and there was little he could do to save them.

A move south to Nottingham where one of the first bowel screening trials was taking place in 1990 highlighted how well patients could do if their cancer was detected at an earlier stage. It became more curable and more survivable. It was, he says, “highly motivating for a surgeon to see a public health intervention having such an effect.”

Since then Professor Steele has coordinated the roll out of a national screening service for bowel cancer first in Scotland and then throughout the UK. It is estimated the screening programmes have saved around 2000 lives a year in the UK.

However, the fact that so many people being screened already had the disease raised another question.

“I was seeing an endless stream of people with bowel cancer,” he says. “And yes, screening meant that many of them had early disease which could be cured by surgery but it made me think. Wouldn’t it be better to prevent it in the first place?”

Professor Annie Anderson, a dietician who holds a chair in Public Health Nutrition within the School of Medicine, has devoted much of her career to understanding the factors that influence lifestyle change, and is a passionate advocate for cancer prevention.

Together she and Professor Steele pooled their expertise and established the Scottish Cancer Prevention Network, which is run from the University’s Centre for Research into Cancer Prevention and Screening, and is dedicated to disseminating information about cancer prevention to individuals, health professionals, policy makers and government.

They provide advice on how to stack the odds against developing cancer and encourage policy makers to build legislative and environmental structures to enable change rather than inhibit it.

“We wondered could we put prevention work and screening together,” explains Professor Anderson. “I’m a nutritionist and I could see that the evidence for lifestyle factors on cancer was very strong. Up to 50% of cancers could be prevented through lifestyle factors. The problem is how do we raise awareness of this and help people engage with that information

“We are always looking for that teachable moment when someone is more likely to take the information on board. We see lots of people coming for screening and it seemed to make sense to try to reach out to them there.”

Together they launched the BeWEL study where patients, discovered through bowel screening to have pre-cancerous lesions, were offered weight loss and physical activity support. The study demonstrated an increase in awareness of risk factors as a result of participation. The Scottish Government is now funding a feasibility study in Tayside and Clydeside to see if the programme can be rolled out.

Other programmes have followed. ActWELL provides life coaching sessions to women attending for breast cancer screening. Also funded by the Scottish Government, the study has enlisted the help of more than 500 women to date and seeks to reduce their risk of developing breast cancer by helping them make sustainable lifestyle changes.

“We’re looking for interventions that will appeal to people,” explains Professor Anderson. “It is about trying to tip the balance. Behaviour change takes time. If you look at smoking it took a generation to change minds and behaviours. And it has to come from people. When they start making little changes and demanding alternatives then politicians and local authorities take notice.

“What we are doing is highlighting the evidence and that is a huge motivator for me, to have that evidence from science and to think about the ways we can use it to make a difference to people’s lives. It is about linking it all up to bring about change.

“What we have here is a unique approach. It is very collaborative and very interdisciplinary. We are very much a part of a network. For example we work with Alcohol Forum Scotland and the Don’t Pink My Drink Campaign which is inspired by the way the alcohol industry deliberately targets women. We are bringing preventative public health measures and cancer screening together.”

Professor Steele believes the collaborative nature of their work has direct benefits for patients.

“We are feeding directly into public health interventions,” he believes. “Policy makers often don’t recognise the significance of the research being presented to them or there may be delays in bringing research to their attention.

“We have direct access to governance groups and we are able to feed research directly into these groups which means research results can be put into practice much more rapidly.”

He cites the recent introduction of a new Faecal Immunochemical Test (FIT) kit for bowel screening introduced in Scotland in 2017.

“We knew the original test, the gFOBT test, had limitations. It required three samples, it didn’t find all cancers and there was a false positive rate. It also didn’t have as high a take up rate as we would have liked so we used that information and set about introducing a new kit.”

As a result the new FIT kit, which requires only one sample from patients, was developed and introduced, sparking an increase in take-up by 10%. It also picks up more cancers and has fewer false positive results.

“The reason we can make changes like this so quickly is because the system is joined up,” he explains. “We have a very clear route to translation and putting things into practice.”