Photo: British Academy
Professor Jane Wardle was a pioneering psychologist who died last year, leaving an incredible legacy of research. Here we look at one of her many achievements, her work on bowel cancer screening.
In 2010, a landmark paper was published that transformed the outlook for bowel cancer prevention and survival. The culmination of over 15 years of research, it was a true breakthrough. Directly leading from this research, a one-off test, called bowel scope screening, is now being rolled out on the NHS in England. The programme has the potential to cut bowel cancer mortality by a staggering 40%.
The story of how that research came to be reveals how one remarkable researcher, Professor Jane Wardle, brought an insight and approach to cancer research that has changed the field forever.
A bold hypothesis
Sometimes in science it can take one simple but bold hypothesis to forge a new path. Back in the early 1990s, Professor Wendy Atkin, an epidemiologist at Imperial College, had such a hypothesis. At the time, the UK had no screening programme for bowel cancer, despite the disease killing more people each year than breast and cervical cancer. As a cancer that is typically silent until an advanced stage, early diagnosis is key to improving survival. Wendy proposed that a one-off sigmoidoscopy, using a flexible endoscope to look inside the large bowel, could not only detect bowel cancer earlier, but also offer significant protection against the cancer for the rest of a person’s life. Wendy had noted that most colorectal cancers develop from benign polyps, in a slow transition that can take decades. So a screening programme that removed these just once, at the right age, could prevent bowel cancer developing. She estimated that such a programme could prevent 5,500 bowel cancer cases and 3,500 deaths in the UK each year. As Wendy recalls, “I was suggesting that having a one-off intervention could halve your risk of getting bowel cancer for the next 10 years. It was a dramatic thing to say.” She urged that a large randomised controlled trial, to demonstrate the benefits of one-off sigmoidoscopy, be started without delay.
An unlikely collaboration
Around the same time, Wendy became aware of the work of a clinical psychologist who had recently joined a small team called the Health Behaviour Unit, funded by the Imperial Cancer Research Fund (a predecessor charity to CRUK). Professor Jane Wardle had produced some influential work on obesity, and had started to look at how behavioural science could support cancer prevention. At the time, this was a marginal area, and the unit was only a handful of researchers. Yet Wendy was impressed with Jane’s research and invited her to be part of the first expert meeting to discuss plans for a bowel scope trial.
As Dr Christian von Wagner of today’s Health Behaviour Research Centre at UCL puts it, “Wendy realised she had the science for a test that could be extremely effective clinically. But one that was going to be a hard sell to patients, so behavioural input was going to be critical.” This was the start of a close collaboration that would last decades, and was key to the success of the trial. The solid scientific approach of Jane’s behavioural work was to underpin every aspect of the bowel scope studies, and set a new paradigm of embedding behavioural science in cancer research.
Wendy cannot overstate Jane’s contribution. “I have no doubt that Jane being part of that first meeting, and where that then took us, was pivotal to the whole trial. Even though she was initially sceptical that a one-off test could have such a big effect, she embraced the concept and came up with brilliant ideas from the very start.”
The scale of the project was vast, with 375,000 people contacted initially, and as Wendy remembers, “Even in establishing how to phrase the invitations to get people enrolled, Jane knew just how to approach it to achieve a high response.”
Behaviour as key
Jane produced hard evidence to understand people’s motivations for attending screening or not, to understand people’s fears and how to overcome them, and above all how to achieve high uptake. It was a huge operation, galvanising such a large number of people to have an invasive test of their colon, but thanks to Jane, Wendy never felt overwhelmed. “Working with Jane you just felt you could do anything. She was involved in all of it. Not only was she brilliant at dealing with the public, but also with the clinical set up, the management, the Department of Health, funders, the whole lot.”
The trial took place in 14 hospitals around the country, with a host of doctors, nurses and administrators involved all involved in delivering the new clinical service. The team achieved over 40,000 sigmoidoscopy examinations in just two years. An amazing feat and a testament to Jane’s driving force behind the work. It was then a waiting game to see if the ambitious hypothesis would be played out in the results, which would be assessed over a decade later.
During this time, Jane’s team conducted many studies on the cohort group, including influential work into socioeconomic inequality in screening programmes. She went on to direct a team of world-renowned experts to establish how public health trials could overcome this.
Beyond bowel cancer
As the bowel scope studies progressed, Jane’s research was also expanding in many other areas. Under her direction, behavioural research was becoming key to projects as diverse as skin cancer, diet and obesity, cervical cancer screening, and public awareness of cancer. Despite this, the research group was still in a precarious position. Professor Martin Jarvis was part of the Health Behaviour Unit at UCL from its inception, and a colleague of Jane’s for over 40 years. He remembers the unit’s funding review in 2000, when budgets were tightening. “Word was that the review panel might be coming to discontinue the unit’s funding. There was a feeling that compared to cell and molecular science, they might think behavioural science unimportant. I remember a real sense that we were singing for our survival.”
The panel included two eminent molecular biologists who would go onto win Nobel Prizes. Jane, now as Director of the unit, had to present to them. “She absolutely wowed them,” recalls Martin. “She blew them away with the scientific rigour of the research. I see that review as a real turning point. From then on, it felt that the importance of behavioural work was understood and supported.” Jane had not only saved the behavioural research group, but catapulted the work firmly into the mainstream. Major advances, such as the introduction of the human papilloma virus (HPV) vaccine in 2008, were made possible by Jane’s work. Health behaviour was becoming of central importance to cancer research.
In 2010, the results of the 40,000 people who had undergone flexible sigmoidoscopy were compared with the control group. The results were dramatic. After 11 years of follow-up, incidence of bowel cancer was reduced by a third, and the risk of dying from bowel cancer reduced by over 40%, in those who underwent screening. In fact for someone who did not have bowel cancer diagnosed at screening, future risk of developing bowel cancer was reduced by over 50%, just by having the test.
Dr Christian von Wagner remembers the palpable excitement of the time. “Jane was very excited about the findings, and the wide media coverage. It was a true breakthrough.” By October 2010, David Cameron had announced £60 million funding to introduce one-off flexible sigmoidoscopy screening on the NHS, offered to people at the age of 55. Jane and Wendy’s collaboration had brought a change in health policy that would directly save lives.
By the end of this year, screening centres across England should offer bowel scope screening. But to realise the huge potential of the programme, the NHS urgently needs to unlock endoscopy capacity, to allow a dramatic increase in the numbers of people screened. More specialist nurses need to be trained to deliver the programme fully, so that the benefit of decades of research can be realised, and the true impact on bowel cancer mortality achieved.
Jane’s work on bowel scope shows how behavioural science can be the key that translates research from the lab into policy and practice. Under Jane’s direction, the original Health Behaviour Unit had grown from a handful of researchers to a thriving team of over 70. She published an incredible 600 papers in her lifetime, and supervised over 40 PhD students. Her mentorship was remarkable. Katriina Whitaker, who joined Jane’s team as a post-doctoral researcher remembers, “Jane was incredible, she seemed to operate in some sort of time vacuum, the group kept expanding yet she always had time for everyone. She created an environment where we all knew what everyone was working on, which is significant in the cross collaborations and success of the group.”
Jane trained this huge army of researchers. A whole future generation, which is an extraordinary legacy in itself.
A true pioneer of health psychology, and a force of intelligence and character that touched everyone she met. Jane Wardle put behavioural research firmly at the heart of CRUK, transforming not only the outlook for bowel cancer, but the whole field.
Jane Wardle’s research
The breadth of Jane’s research and collaborations was staggering. In addition to bowel cancer screening, two other major areas of her work included:
Obesity and weight management
Pioneered work on how genes influence eating behaviour, including landmark studies to show how the FTO gene affects appetite
Established Gemini, the largest study of twins ever set up to study genetic and environmental influences on weight from birth
One of the first behavioural scientists to explore how habit formation can influence healthy lifestyle habits
Developed Top Ten Tips leaflet, assessed in a large randomised control trial, and established the charity Weight Concern
Influential in developing the first validated measure of public recall and recognition of signs and symptoms of cancer, the Cancer Awareness Measure
Pivotal to the thinking about early diagnosis research and establishing the National Awareness and Early Diagnosis Initiative (NAEDI)
In this article
Professor of Gastrointestinal Epidemiology, Cancer Screening and Prevention Research Group, Imperial College London
Professor of Health Psychology, Health Behaviour Research Centre, UCL
Senior Lecturer in Behavioural Research in Early Diagnosis of Cancer, Health Behaviour Research Centre, UCL
Senior Lecturer, University of Surrey
CRUK Science Blog: A tribute to Professor Jane Wardle
CRUK Science Blog: New study marks major advance in bowel cancer screening
UCL Health Behaviour Research Centre
CRUK: About bowel cancer screening
The Jane Wardle Prevention and Early Diagnosis Prize
Following Jane’s death, we announced a prize set up in her memory, for an individual at any career stage who has produced world-leading research in the field of prevention and early detection of cancer.
This story is part of Pioneering Research: our annual research publication for 2015/16.