Employers cannot afford to be in denial about cancer. Screening for the disease in the workplace could help benefit employees and employers, suggests Professor Gordon Wishart.
We are living in an epidemic of cancer. As startling as that claim sounds, the risk of cancer is currently one in three, and is predicted to rise to one in two by 2020, according to cancer charity Macmillan, a level of risk that certainly fits the criteria for calling it an epidemic. In the UK there are about 325,000 new cases of cancer every year, with 160,000 deaths.
The impact of this cancer burden is no longer just a matter for those personally affected. More than 100,000 of those diagnosed each year are of working age, and estimates suggest that more than 750,000 people of working age are living with a cancer diagnosis, according to Macmillan. While there are many different types of cancer, just six account for about 85% of the total: breast, bowel, lung, skin, prostate and cervical – which is why these are the six cancers targeted by HealthScreen UK, which offers educational and screening services for businesses and organisations.
Unorthodox though it may at first sound, screening in the workplace is an efficient and effective method of tackling cancer, with the potential to catch a significant number of cases at an early stage, while they are still treatable. In short, it saves lives. But why should employers take on such a responsibility?
Employers have a duty of care, of course. The Department of Health has also called for the support of employers in the early detection of all cancers in its national plan entitled Improving Outcomes (2012) and, as we will see, work puts many of us at increased risk. But whether companies do anything or not, cancer will affect their employees or the partners of their employees – and therefore their business. Increasing cancer incidence means more downtime from those employees, and if picked up at a late stage it is going to require more treatment and recovery, more time off work, and result in a significant reduction in productivity. This is not only from that employee, but perhaps family, friends and colleagues too. Any business that fails to build this into their five-year plan will suffer the consequences as surely as if they had ignored a looming recession.
Increase in cancer rates
Breast cancer, which has, by far, the most researched evidence, is a good example to use when examining the reasons for these increases, but it also demonstrates very clearly that investment in fighting cancer really can have a significant effect.
Like other types of cancer, breast cancer is increasing, with around 50,000 new cases in the UK per annum, according to statistics in 2010 from Cancer Research UK. That means a lifetime risk of one in eight, which is predicted to rise to one in seven by 2024. Worldwide, there were 1.5 million cases diagnosed in 2010, predicted to rise to two million by 2030 – a huge health burden (Slack R et al, 2012). Little wonder, then, that we have become so aware of this form of cancer.
While incidences of breast cancer have increased, however, the mortality rate has actually been falling since the 1980s. Figures from 2011 show the number of deaths to be 11,762, with a fall of 45% for women aged 50-64 since 1989. So, we are doing well in terms of breast cancer treatment, not just because of screening and having proper breast units, but also because of better education and people being more breast aware, factors that empower individuals to better manage their own breast health. As with all forms of cancer, being able to recognise it and catch it early is key to survival.
Work and associated cancer risk
So why, then, is breast cancer increasing at all? There are lifestyle factors directly affecting risk, some of which are probably familiar to us, such as obesity and alcohol intake. Obesity in post-menopausal women increases risk because the body makes more oestrogen. There is also plenty of evidence that shows the risk of breast cancer is directly proportional to alcohol intake. Drinking patterns in women are very different in this generation from previous generations, and it seems likely that we have not even begun to see the impact of binge drinking in young girls.
Some factors, however, are less widely known. Shift work, for example, or working as part of a flight crew, are factors known to increase risk. One-third of women in the UK work shift patterns that include an element of night-shift work, and we now know that over a prolonged period of time this increases breast cancer risk by 50% (Slack R et al, 2012) (in men, shift work carries a similar increased risk of prostate cancer). The average risk at the moment is one in eight, or 12%. If you have performed prolonged shift work, that goes up to 18%. But if you start with a higher risk, say 30%, as a result of having family members who have had breast cancer, that goes up to 45%. Members of flight crews – male and female – have the same increased risk of breast cancer as shift workers – almost 50%. We believe that may be partly due to exposure to cosmic radiation, in addition to the associated shift-work patterns.
With more than 10,000 cancers in the UK being thought to be work related (Rushton L et al, 2012), companies have a huge task ahead to provide awareness, early detection services and try to limit the liability in other ways. Legal cases have not yet been tested in the British courts, but in Scandinavia, nurses and female air crews have already successfully claimed compensation for their breast cancer diagnoses.
Some risk factors are linked to the world of work in more subtle ways. Factors now known to increase risk of breast cancer include having no children or having them late in life (ie after 25), not breast feeding, starting periods early and a late menopause. With pressure on women to have both a career and a family, many put off having children or decide not to have them at all because of a desire or need to work. The downside of this social shift is increased breast cancer risk.
There are other work-related factors that further increase general cancer risks. Stress is a known factor, and studies in the US have shown that simply sitting for long periods increases risk of colon endometrial, and lung cancer – which has prompted some to claim “sitting is the new smoking”. Even those working nine to five in comfortable offices are not immune.
Room for improvement
We are pretty good at dealing with breast cancer. There is high awareness and a national NHS screening programme. Even so, screening could be done in a much better way, with more assessment of individual risk factors for a more targeted screening process, so-called risk-stratified screening. There is an opportunity for the private and corporate sectors to lead the way, using the more advanced workplace screening and education programmes available to them.
After the heartening example of breast cancer, let us turn to lung cancer, for which survival rates are very poor. Ninety per cent of lung cancers come to light as a result of symptoms such as weight loss, or a cough – perhaps coughing up blood. By the time that happens, however, it is already too late for surgery or other curative treatments. Twenty-five per cent of all cancers, in fact, present in A&E departments, according to the National Cancer Intelligence Service, a sign that some early symptoms are still being ignored or going unrecognised.
Lung cancer is the most common malignancy among men in most countries, but is also rapidly increasing in women, largely as a result of smoking. It accounts for 23.4% of male and 17.9% of female cancer deaths (Quinn et al, 2005). Ninety per cent of cases are linked to smoking in developed countries. Because of the time it takes for the disease to develop, it will also be a while before we see the beneficial effects of actions we are taking now; many lung cancers currently being diagnosed are the legacy of lifestyles from 10, 20, 30 or more years ago.
Some 41,428 new cases were diagnosed in the UK in 2009 according to Cancer Research UK – a slightly lower incidence than breast cancer – but, by comparison, the number of deaths is huge: 34,859 in the UK in 2010. There is no national screening programme. Professional bodies have been debating the best method for many years now, such as chest x-ray or computerised tomography (CT) scans, and now there is some data on low-dose CT scans – but actually, there is a much better way.
New testing methods
There is now a blood test called Early CDT-Lung that detects seven antibodies made by the body in response to lung cancer, and which start rising very early in the natural history of the illness. This test was developed at the University of Nottingham, and is being made available through a company called Oncimmune, and the results are so compelling that NHS Scotland is running a randomised trial.
The trial is monitoring 10,000 men at high risk, 5,000 of whom are given the blood test. The numbers of lung cancers that present in both groups are then compared. This is a very exciting study that demonstrates there is a cheap, easy and reliable method for detecting lung cancers at a stage where they are still curable. Hopefully, this will be expanded into a European study and will indicate a way forward for the health services in England. But, again, the private and corporate sectors are ahead of the curve, with the test already being made available through screening bodies, such as HealthScreen UK.
Many are familiar with cervical cancer screening, which starts in England from age 25 (slightly younger in Scotland), in which women have a smear test every three years. This involves scraping some cells off the cervix, which are then sent for analysis. While this remains standard NHS procedure, there is a better way. Almost 100% of cases of cervical cancer are caused by HPV (human papilloma virus). Many countries have moved away from smear tests to screening just by testing for HPV, which can be detected and treated long before cancer even develops. It is hoped the UK will go the same way.
Currently, the UK has a two-tier strategy to tackle cervical cancer. First, girls are being vaccinated at the age of 12 or 13 and then cervical screening is carried when they are older. Like all cancer screening, however, there is never 100% uptake, and there is a good deal of research that is looking at ways to increase it.
One possible solution is a new, simple self-administered test for HPV. It looks like a pregnancy testing kit, and releases a small amount of fluid into the vagina, then takes it back in and is sent for testing of HPV. It can be done at home without the need to attend a clinic, and is highly effective at detecting the virus. This could be a good way to increase the number of people having cervical cancer screening. The test is available exclusively from GynaeHealth UK in the private sector and HealthScreen UK in the corporate sector, and is an example of a development aimed at encouraging early detection.
Opportunity for businesses
As we have seen, early detection greatly increases the chances of survival, and with an overburdened NHS unable to contemplate across-the-board screening programmes for many of the most common cancers, the role that business has to play in this process cannot be overestimated. There is an opportunity here for businesses to be proactive in saving lives – and protect their investment.
Hewlett Packard (HP) commissioned HealthScreen UK to run four workplace-based early detection programmes. These comprised educational initiatives and screenings for cancers of the breast, prostate, skin and lung among the workforce, and resulted in more than 10,000 appointments in the UK, Scandinavia and the US. Of these, 1,000 were referred for further tests, and these tests have so far detected about 50 cancers, although it is likely there are at least 50 more. What this means for individuals can be summed up in the words of one HP employee who was diagnosed: “Could you pass on my thanks to the breast nurse who examined me? If it wasn’t for her, it may not have been detected for a very long time.”
What is really significant about these figures is that they put the detection rate for all these cancers on the same level as the NHS breast screening programme. If these success rates were replicated nationally, it could considerably reduce the number of deaths from lung and other cancers.
It takes only a small shift in our thinking to bring about change. If the private and corporate sectors can summon the will to implement such initiatives across the business community, it would not only be life changing for those whose lives were saved but it would also have a significant and positive impact on the productivity of UK business.
Managing cancer in the workplace: An employer’s guide to supporting staff affected by cancer. Macmillan Cancer Support.
Occupational cancer – a workplace guide. TUC, February 2012.
Department of Health (2011). Improving outcomes – a cancer strategy.
Early Cancer Detection Test. Lung Cancer Scotland
Office for National Statistics: London. Quinn M, Wood H, Cooper N, Rowan S (eds) (2005). “Cancer atlas of the United Kingdom and Ireland 1991–2000”. In “Series on medical and population subjects no.68”.
Rushton L, Hutchings SJ, Fortunato L et al. “Occupational cancer burden in Britain”; BJC 2012, 107: S3-7.
Slack R, Young C, Rushton L. “Occupational cancer in Britain-female cancers: breast, cervix and ovary”; BJC 2012, 107: S27-32.