Deborah James departed this world on 28 June 2022, surrounded by her loved ones. Her life, as a 35-year-old deputy head teacher and mother of two children, was irretrievably transformed during Christmas 2016, after she was found to have a 6.5 cm-diameter tumour in her large bowel at colonoscopy. She was an unlikely victim, being young, healthy, physically active, and a vegetarian for 25 years. During the years that followed her diagnosis with advanced (Stage Four) bowel cancer, she shared her experiences of coping with cancer on her ‘@bowelbabe’ Instagram account, in a newspaper column (Things Cancer Made Me Say) for The Sun, the You, Me and the Big C podcast on BBC Radio 5 Live, numerous appearances on television and at charity events, and in a couple of bestselling books: F*** You Cancer: How to Face the Big C, Live Your Life and Still Be Yourself (2018) and How to Live When You Could Be Dead (2022). Shortly before her untimely death, in May 2022, she launched her Bowelbabe Fund for Cancer Research UK and was invested Dame Commander of the Order of the British Empire by Prince William at her parents’ home in Woking, Surrey.
Much is already known about bowel cancer, which is the fourth commonest type of cancer in the UK, with nearly 43,000 people diagnosed with the illness each year. The disease accounts for more than 16,500 deaths per year, making it the country’s second-biggest cancer killer. Early diagnosis increases the chances of successful treatment and long-lasting cure. Screening for early bowel cancer is available to everyone aged 60 to 74 years, registered with a GP and resident in England, and from April 2021 onwards is being expanded to make it available to everyone aged 50 to 59 years. Home test kits are dispatched by post, and a sample of stool is collected on a plastic stick. A faecal immunochemical test (FIT) for occult blood is performed upon return of the sample to a designated lab. For those above age of 75 years, tests may be requested every two years.
Some groups of people with pre-existing illnesses are at increased risk of bowel cancer and are hence subjected to surveillance programmes which allow early detection of cancer. The list includes those with certain types of bowel polyps (including some inherited “polyposis syndromes” running in families), which are often described as bumps or mushroom-like benign growths, and people with chronic inflammatory bowel disease (ulcerative colitis, Crohn’s disease).
Bowel cancer may be rarer in the young, but more than 2,600 people under the age of 50 are still diagnosed with the condition each year. Some authorities believe that bowel cancers in younger people grow and spread more aggressively than in older adults. The incidence of bowel cancer in the young has risen steadily in recent years, especially among those aged between 20 and 29 years. This increase is possibly linked to a rising incidence of obesity and the adoption of adverse lifestyles (physical inactivity, lack of fibre in the diet, alcohol consumption, and smoking), but more needs to be learnt. The “Never Too Young” campaign of Bowel Cancer UK (Deborah James was a patron) was launched in 2013, but a 2020 survey by the same organisation found that half of over a thousand young people living with bowel cancer had been unaware they could develop the disease before actually being diagnosed. This unawareness extended to their primary healthcare providers, with four in ten having to visit their GP three or more times before being referred for tests.
The symptoms of bowel cancer, which predominantly affects the large bowel (colon and rectum) are well-known, but may overlap with other, less serious, conditions. The BOWEL acronym is useful as an aide memoire, standing for: Blood in your Poo, Obvious change in bowel habits, Weight loss you can’t explain, Extreme tiredness for no reason, and Lump or pain in your tummy. Cancers in the right side of the colon are less likely to cause bowel symptoms, often presenting with unexplained anaemia, from hidden blood loss, or with undiagnosed tiredness and unexpected weight loss. Cancers in the left side of the colon are more likely to cause bowel symptoms, including visible blood in the stools and changes to one’s usual bowel habits, and can lead to obstruction of the bowel that requires urgent surgical attention.
The diagnosis of bowel cancer may be missed in the community, especially in older people, women, and the socially disadvantaged, and unwitting victims may be fobbed off with less concerning diagnoses which may require little in the way of investigation, such as irritable bowel syndrome, haemorrhoids, or diverticular disease. This propensity to delayed diagnosis and misdiagnosis, despite ‘alarm symptoms’, means that as much as a quarter of people with bowel cancer may be only diagnosed at an advanced stage of their illness, sometimes in hospital emergency departments, with accordingly worse outcomes. Ideally, in the UK, the diagnosis will be considered early where indicated by GPs and then followed up by an urgent suspected cancer referral pathway for further investigation. The diagnosis is usually confirmed by endoscopic examination of the interior of the bowel (sigmoidoscopy, colonoscopy) or by specialised imaging (CT scan, CT colonography).
Dame Deborah James will be remembered for her considerable, good-humoured, efforts, despite her own dismal prognosis, to help increase awareness of a condition that may be overlooked, due to either ignorance or embarrassment, but is eminently curable under the right circumstances.
Ashis Banerjee