I’m a Royal Marsden doctor – the new rules for lowering your cancer risk under 60

Across the world, rates of cancer are on the rise. A World Cancer Research Fund (WCRF) analysis published last month found that cases of seven types of cancer in particular have risen sharply among young people in England. The number of people under 50 diagnosed with prostate cancer has quadrupled since 2001, while the incidence of early-onset bowel, kidney and uterine cancer has more than doubled. In addition, diagnoses of early-onset breast cancer, pancreatic and liver cancers have also increased significantly. “It’s really noticeable among all my colleagues across the world,” says Professor Naureen Starling, a consultant medical oncologist at The Royal Marsden, who specialises in treating gastrointestinal cancers. “It used to be rare, but over the last 10 to 15 years, we’ve all seen a real increase in the number of patients in their 20s, their 30s and their 40s coming to our clinics.” “We don’t fully understand what’s driving it,” admits Professor Starling, noting that the WCRF and other experts have proposed risk factors including processed diets, lack of exercise, obesity, and environmental pollutants such as chemicals in the food chain, microplastics, and air pollution. “These are some of the theories floating around, but unlike with smoking [and the subsequent decrease in lung cancer that we’ve seen since rates of smoking have decreased], it’s much more difficult to prove cause and effect,” she says. The blunt truth is that we don’t entirely know why cancer is on the increase and developing earlier. In the absence of a full understanding, lifestyle choices that may reduce risk factors are the only variables we have control over. Here, Professor Starling, who has seen thousands of patients over the years and directs the Royal Marsden’s clinical trials unit, shares how she and her family try to foster healthy habits to reduce their risk. Exercise is as effective as drugs – so make it a habit “One of the most convincing findings that links lifestyle and cancer occurrence comes from a really important study published last year, called the CHALLENGE study,” says Professor Starling. This study followed 889 colon cancer survivors over three years. Half of the patients were assigned a structured exercise programme guided by personal trainers, while the other half received health education materials advising them to increase their exercise levels. Five- and eight-year follow-ups showed that the group who followed the structured exercise programme had a 28 per cent lower risk of recurrence or new cancer, and a 37 per cent lower risk of death overall. When it was presented at the American Society of Clinical Oncology’s annual meeting, the session was titled “as good as a drug” – and “it got a standing ovation”, says Professor Starling. “I have always done some form of exercise, and when I was younger I ran half-marathons – but the thing about exercise is that you have to make it a habit, like brushing your teeth, as opposed to ‘well, if I get time I’ll go to the gym’. So about three years ago we all began planning it in the family schedule.” For Professor Starling, that means working out four days a week – twice during the working week, after she leaves clinic (“I try not to let myself get back inside the house first because the minute I’m through the door, I know that my resolve to go for a run will diminish”). On Saturdays and Sundays, she’ll head to the gym with her husband or one of her two teenage sons. “It helps to go with someone,” she says. “I do a mixture of strength training, which as I’ve got older I’ve come to recognise is really important for ageing well, alongside cardiovascular exercise,” says Professor Starling. “I was very intimidated by the gym, the free weights and weight machines at first, but my husband bought me a package with a personal trainer for my birthday a few years ago and he demystified it all.” This exercise habit feeds into how the family spend the rest of their leisure time – prioritising activity, staying off screens and being outdoors if at all possible – and led to Naureen, her husband and younger son Ollie climbing Mount Kilimanjaro last month to raise money for The Royal Marsden Cancer Charity, surpassing their original target of £20,000 to raise £62,000. Clear out your snack cupboard – avoid UPFs “At the end of a consultation, patients will typically ask me ‘What else can I do to help myself?’ and it’s part of the appointment I really rather enjoy: we talk about moving and eating well, and having a nutritious diet,” says Professor Starling. “We’re not living in the same world our grandparents did,” she notes. “One of the things that’s increased since the 1960s is intake of ultra-processed foods, for example.” Starling has made real changes to her family kitchen in recent years. “We used to have a snack cupboard where we’d have chocolate and crisps and this and that, and we don’t have that any more. Fizzy drinks are also an absolute no in our household: I used to enjoy a Diet Coke, but have now switched to kombucha, which is fermented and good for your gut microbiome. “I also really push the fibre agenda, which is so important for gut health – we do need 30 grams a day and very few of us actually meet that. We always serve a salad and vegetables with every meal, and cook from scratch largely – my husband’s a great cook.”Several major studies, including reports from the World Cancer Research Fund and Cancer Research UK, show that consuming an extra 10 grams of dietary fibre per day reduces bowel cancer risk by roughly 10 per cent. “The boys have always been pretty good at eating their vegetables [which are high in fibre], even when they were little, so I never had to sneak vegetables into their food or hide them in sauces – but if they’d been fussy, I would have. If you ask them now, they would roll their eyes because I’m always going on at them about their gut microbiome at dinner time!” Consider intermittent fasting “Personally, I don’t really drink. The government advice is for a minimal or very moderate alcohol intake – it’s helpful in terms of lowering cancer risk, but also important for health as a whole. “I don’t eat much red meat [high consumption is linked with an increased risk of colorectal cancer] and I only eat in a time-restricted window – it’s not for everybody, but it’s really worked for me,” she says. Some research has shown that eating in an eight-hour window – known as intermittent fasting, in this case a 16:8 fast (16 hours fasting, typically overnight) may have benefits for insulin sensitivity, weight management and gut health, although long-term benefits are not fully established and there are individual differences in how women’s physiology responds to this sort of diet. “Some of the microbiome experts advocate for it,” says Professor Starling – as some research has shown it can help ‘good’ gut bacteria to flourish. “And of course for eating a good, varied diet within that time frame. I’m never very hungry in the morning, so I’ll eat lunch around 12 or 1pm, make sure to organise my afternoon snacks around protein and fibre, and then eat with the family for dinner. So it’s still sociable, as that’s important for me. Meal times are family time.” What about vitamins? Cod liver oil, iron and vitamin D tablets are the only supplements you’ll find in Professor Starling’s medicine cabinet. Her approach to supplementation is a mixture of evidence-based – blood tests showed her to be low in vitamin D and iron – and family tradition: “My mum always pushed the cod liver oil, and some things from your childhood just stick! So I do take a little cod liver oil capsule. But a while ago, I was found to be profoundly deficient in vitamin D, as lots of people of my skin colour and ethnicity can be.” People with darker skin tones tend to produce vitamin D less readily, requiring greater light exposure to make the same amount as those with lighter skin. “But that’s quite useful for anyone living in Northern Europe, particularly in the winter – and iron is often something we women tend to be a little low in, so can be worth looking at, too.” Many observational studies show a link between high vitamin D levels in the blood and a lower risk of colorectal cancer, although no direct preventative effect has been proven. Avoid ‘new’ vices and keep things simple Among the relentless rise of many cancers are some outliers. Lung cancer, for example, is declining, thanks to far fewer people smoking. But don’t be fooled into replacing an old vice with a new threat to health, such as vaping. “I’m not a respiratory physician, but I’d be pretty cross if my boys took up vaping. It comes back to exposures – the lungs are not meant to be exposed to whatever is contained in vapes, and the health risks therefore must be there. It’s not a ‘safe’ alternative to smoking – the long-term consequences of these chemicals are unknown.” Avoid microplastics and forever chemicals The same goes for avoiding pollutants in our environments, she adds. Many things we are exposed to on a daily basis are carcinogenic – potentially cancer-causing – such as traffic fumes and air pollution. According to Cancer Research, air pollution causes roughly 10 per cent of cancer cases in the UK. “You can’t control the level of pollution outside your house,” she says. Instead, one way of limiting unnecessary exposure is to keep what you use on your skin, or what you clean your house with, as simple as possible. Professor Starling always tries to avoid unnecessary chemicals. “My mum’s very old-fashioned, so she would use white vinegar and bicarbonate of soda, for instance, to clean surfaces and to do the washing, and that’s something that’s passed down to me. Although if you speak to my family, they’ll say, ‘Really, Mum, when do you do the cleaning?’” Don’t subscribe to stigma As much as Professor Starling tries to live – and advocates for – a healthy lifestyle, she is keen to point out that no one should ever feel “to blame” for an early onset cancer diagnosis. “This comes up in focus groups – it’s really important that none of our young patients feels stigmatised. So many of them are super fit, slim, healthy, eat well. They’ve done nothing ‘wrong’. This is what it comes back to: we don’t really fully understand the causes, and [the rising rates of cancer are] complex, multifactorial. And that’s why we need such a massive focus on research now, so that we can get solid answers as to why young patients are developing these cancers in the first place.” For more information or support, visit The Royal Marsden Cancer Charity, royalmarsden.org