Professor Rebecca Fitzgerald, professor of cancer prevention at the University of Cambridge and co-chair of the SAPEA working group supporting the EU’s Scientific Advice Mechanism, discusses the evidence for and benefits of better cancer screening.
Why was there a need to review cancer screening in Europe?
We wanted to see if we could improve the cancer screening programmes we have got – which are for breast, cervix, and colorectal.
New evidence suggests, for example, that we should reduce the age at which we start screening for breast cancer, from about age 45, because data shows that aggressive breast cancer is increasing in younger women.
We’re also finding that one type of screening does not fit all. For instance, some women have denser breast tissue than others, and you probably need to do an MRI for those women as well as a mammography.
We also asked whether the evidence supports new screening programmes that aren’t currently being done.
Which entirely new screening programmes has the Scientific Advice Mechanism recommended?
Lung cancer was especially interesting here. We’ve got good evidence from two large-scale trials that you can use low-dose CT (computer tomography) to screen for lung cancer, because there are now scanners with low doses of radiation that do not harm people. We recommend this approach for people who are smokers or ex-smokers. We also supported prostate cancer and – in countries with high incidence - gastric cancer.
'Technology and evidence is moving fast so the (cancer-screening) situation requires rethinking.' Prof Rebecca Fitzgerald
Can you tell us about interesting technologies emerging for testing cancers in new ways?
There’s been a lot of excitement about blood and exhaled breath tests to detect cancer, perhaps for detecting multiple cancers at the same time. The technology is moving fast, and the evidence is still being generated, so their suitability for screening requires reappraisal on a regular basis.
There is great hope that we will be able to detect DNA shed into the blood by early-stage cancers by taking a single blood sample from patients who might not even have symptoms. But the experts agreed that these methods are not ready for a [general] roll-out, even though they show great potential for the future.
What are the benefits to detecting cancer earlier?
Overwhelming evidence shows that if you find cancers earlier, the treatments are much more straightforward. Often you then don’t need to give toxic chemotherapy, but instead can just remove the lesion (cancerous tissue) with a small operation or endoscopy. It therefore follows that your quality of life is dramatically better when you are fighting cancer earlier than when the cancer has advanced. If you detect something early, the chance of curing it is also much higher.
Which cancers would benefit from new cancer screening methods?
The review looked at the evidence for screening for pancreatic, ovarian, oesophagus and gastric cancers. Some of these cancers are not common, but they can also be hard to detect. So patients diagnosed with pancreatic cancer, for instance, have really poor outcomes. We would like new screening methods for such cancers, but the evidence to support such screens is not there yet.
Will the recommended changes pose challenging costs issues for member states?
Some of the changes, such as improving the standards of screening for colorectal screening, are relatively straightforward to do and should be cost effective.
There’s good evidence especially that lung cancer screening will have a big impact and reduce the cost of treatment by detecting the disease earlier. Though, such new screening programmes, as well as the expansion of breast cancer screening, will require more scanners and health infrastructure, which some countries may find easier to introduce than others. Still, the new screening should be beneficial and cost effective.
'Some of the changes, such as improving the standards of screening for colorectal screening, are relatively straightforward to do and should be cost effective.' Prof Rebecca Fitzgerald
Prostate cancer screening is more controversial, since the study results are not consistent around their use of prostate surface antigen (PSA). This is a protein that is often elevated in men with prostate cancer and it is easy to test for. The recommendation is to test for PSA levels in the blood of men up to the age of 70.
What research and innovation gaps could be filled by the EU Mission on Cancer to assist with cancer screening?
We need to bring more early-detection technologies and biomarkers through from research into clinical trial and implementation. This requires testing in the at-risk population in large studies. Those poor-outcome cancers where no screening exists are especially in need of new approaches for high-risk groups.
Can you tell me about your own research interests?
I’m a professor of cancer prevention at the University of Cambridge and I’m particularly interested in using innovative technologies to detect cancer earlier. I was involved right from the beginning of this review of cancer screening, where we didn’t just rely on a paper-based exercise, but convened three workshops of experts to address very specific questions.
My own expertise is in cancer of the oesophagus, which is not one of the most common cancers, but nor is it rare, and it has been increasing dramatically over the last 30 years. The outcomes are really poor, unless you can detect it early, when it can be easy to remove with endoscopy based treatment in an outpatient setting.
Along with my team I’ve developed something called the Cytosponge test, which is really a simple pill on a string that you swallow and then pops out as a sponge that is pulled back along the oesophagus to collect cells that can then be tested with a lab test called TFF3 (for signs of precancer).
We have shown that this test can detect 10 times more cases of pre-cancer (called Barrett’s oesophagus) than current practice and as a follow-on we are about to launch a screening trial in the UK that will recruit more than 120,000 patients to see if we can reduce mortality from cancer of the oesophagus by offering this test.
Beating cancer plan
One of the first activities in the Europe’s Beating Cancer Plan and the EU Mission on Cancer is to improve cancer detection through better cancer screening for some of the most common cancer types.
On September 20, 2022, the commission presented a new EU approach to cancer screening, based on the latest available scientific developments and evidence. It will support member states ensuring that 90% of the EU population who qualify for breast, cervical and colorectal cancer screenings are offered such screening by 2025.
Recommendations of the Scientific Advice Mechanism (SAM) to the European Commission have informed this policy initiative. The role of SAM is to give valuable science advice for policy. The SAPEA consortium which is composed of European academies surveyed the state of cancer screening knowledge in their evidence review report.
Leading cancer experts from across the world discussed the latest scientific progress and integrated extensive reviews of scientific literature and clinical trials in their conclusions.
Informed by science, the Group of Chief Scientific Advisors published its recommendations for EU policy makers in their scientific opinion, as a response to the question on how to improve cancer screening in Europe.
In 2020, more than 1.3 million Europeans died with cancer. One-in-two EU citizens will develop cancer in their lifetimes, according to estimates. If nothing changes, cancer will become the leading cause of death in the EU by 2035.
The EU Mission on Cancer sets out to bring concrete solutions to the challenges of cancer through research and innovation.
Follow the link to the factsheet A New EU approach to cancer screening.