Comprehensive Cancer Control: Can We Practice What We Preach?

Jon F. Kerner, Ph.D.

Division of Cancer Control and Populations Sciences

The Central Goals of Healthy People 2010*

Increase quality and years of healthy life

Eliminate health disparities

* USDHHS Healthy People 2010. Washington D.C. January 2000. Volume #1: page 2

NCI’s Challenge: Health Disparities Present Scientific, Moral and Ethical Dilemmas

Profound advances in biomedical science have occurred over the last several decades, which for many Americans, have contributed to increased longevity and improved quality of life.

Despite this progress, a heavier burden of disease is borne by some population groups in the United States, particularly the poor and underserved.

The unequal burden of disease in our society is a challenge to science as well as a moral and ethical dilemma for our nation.

Target for Change: By 2008, develop a system to monitor and document cancer disparities in Maryland.

Objective 1: Increase public and community awareness about cancer health disparities and cancer prevention, screening, and treatment in Maryland.

Chapter 3: Cancer Disparities Goal: Reduce cancer health disparities in Maryland.

Objective 2: Develop and implement health care programs designed to reduce cancer disparities among targeted populations in Maryland.

Objective 3: Increase cancer disparities documentation and intervention on a systematic basis in Maryland.Objective 4: Increase provider education and reimbursement aimed at reducing cancer disparities

Executive Summary

Objective 5: Improve access to, and utilization of, cancer screening and treatment options for underserved populations.

Objective 6: Improve the quality of cancer care received by racial/ethnic minorities.

NCI Map of Grants by State – FY 2002Division # of

Grants in MD

% Of Grants

Total NCI Dollars in MD

% of Total NCI Dollars

DCCPS 21 8.8% $8,100,446 9.2%DCB 81 34.0% $20,644,935 23.4%DCP 21 8.8% $7,363,333 8.3%DCTD 73 30.7% $26,432,837 30.0%DDES 42 17.6% $25,712,575 29.1%Total 238 100.0% $88,254,126 100.0%

THE CANCER CONTROL CONTINUUM

Cancer Continuum

Prevention

Focus

• Tobacco Control• Diet• Physical Activity• Sun Exposure• Virus Exposure• Alcohol Use• Chemoprevention

Detection• Pap Test• Mammography• FOBT• Sigmoidoscopy• PSA

Treatment• Health Services

and Outcomes Research

Survivorship• Coping• Health Promotion

Cross Cutting Issues

• Communications• Surveillance• Social Determinants and Health Disparities• Genetic Testing• Decision Making• Dissemination of Evidence-based Interventions• Quality of Cancer Care• Epidemiology• Measurement

Diagnosis• Informed

Decision Making

Distribution of DCCPS Grants in Institutions in the State of Maryland by the Cancer Control Continuum (FY 02)

(n= 21, Total Dollars= $8.1 million)

Epidemiology5 Grants (24%)

$2.5 million

Survivorship1 Grant (5%)

$406 K

Treatment3 Grants (14%)

$633 K

Diagnosis0 Grants

Detection5 Grants (24%)

$1.8 million

Prevention7 Grants (33%)

$2.8 million

6/21 (28.6%) grants and 26.6% of grant funds focus on health disparities research

Chapter 5: Tobacco-Use Prevention and Cessation & Lung Cancer  Goal: Substantially reduce tobacco use by Maryland adults and youth.

Executive Summary

Targets for Change:

By 2008, reduce lung cancer mortality to a rate of no more than 57.3 per 100,000 persons in Maryland. Maryland Baseline: 59.5 per 100,000 in 2000 (age-adjusted to the 2000 U.S. standard population). Source: Maryland Division of Health Statistics

By 2008, reduce the proportion of Maryland middle school youth that currently smoke cigarettes to no more than 6.2%. Maryland Baseline: 7.3%. Source: Maryland Youth Tobacco Survey (2000)

By 2008, reduce the proportion of Maryland high school youth that currently smoke cigarettes to no more than 20.3%. Maryland Baseline: 23.7%. Source: Maryland Youth Tobacco Survey (2000)

By 2008, reduce the proportion of Maryland adults that currently smoke cigarettes to no more than 15 %. Maryland Baseline: 17.5%. Source: Maryland Adult Tobacco Survey (2000)

By 2008, increase the proportion of Maryland adults that would support a proposal to make all restaurants in their community smokefree to 72.1%. Maryland Baseline: 63.0%. Source: Maryland Adult Tobacco Survey (2000)

MD Target: 57.3

Maryland Baseline: 59.5 per 100,000 in 2000 (age-adjusted to the 2000 U.S. standard population).

US Target: 44.9U.S. Baseline: 56.1 per 100,000 in 2000 (age-adjusted to the 2000 U.S. standard population).

CDC Office of Smoking Health State Highlights 2002 report Maryland

NCI’s Challenge: Close the Gap Between Discovery and Delivery

There is also a critical disconnect between research discovery and program delivery and this disconnect is, in and of itself, a key determinant of the unequal burden of cancer in our society.

Barriers that prevent the benefits of research from reaching all populations, particularly those who bear the greatest disease burden, must be identified and removed.

THE DISCOVERY-DELIVERY CONTINUUM

DiscoveryDiscovery DevelopmentDevelopment DeliveryDelivery PolicyPolicy

How do we model Interagency partnership across the continuum?

How do we increase investment in the development process?

Translational Research vs. Research Translation

"Cutting-Edge" "State-Of-The-Art" "Resource-Limited"

Academic Cancer& Medical Centers

CCOPs & ACoSApproved CancerPrograms

Municipal & RuralHospitals & Clinics

1 NCI-designated Cancer Center 0 CCOPs; 35 ACoS

Reducing the cancer burden

Fundamental Research

Surveillance Research

Intervention Research

KnowledgeSynthesis

Application and Program Delivery

Dynamic Model of Cancer Research & Diffusion and Dissemination

Adapted from the Advisory Committee on Cancer Control, National Cancer Institute of Canada, 1994.

DisseminationDissemination

Publication

Bibliographic databases

Submission

Reviews, guidelines, textbook

Negative results

variable

0.3 year

6. 0 - 13.0 years50%

46%

18%

35%

0.6 year

0.5 year

9.3 years

Dickersin, 1987

Koren, 1989

Balas, 1995

Poynard, 1985

Kumar, 1992

Kumar, 1992

Poyer, 1982

Antman, 1992

Negative results

Lack of numbers

Expertopinion

Inconsistentindexing

It takes 17 years to turn 14 per cent of original researchIt takes 17 years to turn 14 per cent of original research to the benefit of patient careto the benefit of patient care

17:14

Original research

Acceptance

Implementation

E.A. Balas, 2000

TTranslating RResearch into IImproved OOutcomes (TRIOTRIO)

Use and communicate cancer and behavioral surveillance data to identify needs, track progress and motivate action.

Collaboratively develop tools for accessing, and promoting adoption of, evidence-based cancer control interventions.

Support regional and local partnerships to develop models for identifying infrastructure barriers, expanding capacity and integrating science into comprehensive cancer control planning and implementation.

http://cancercontrol.cancer.gov/d4d/

Working Together To Make the WholeGreater Than the Sum of Its Parts

National Partnership Model in Comprehensive Cancer Control

ACSNCI

CDC

R&D

Synt

hesi

s

Dire

ct S

ervi

ceR

& D

Dissem

.&

Diffusion

R & D

Synthesis

Synthesis

Dissem. & Diffusion

Direct Service

ervice

Dis

sem

. & D

iffusion

Research-Practice Partnerships?

“Getting a new idea adopted, even when it has obvious advantages, is often very difficult.” -- Everett Rogers, Diffusion of Innovations

Maryland Grantee Institutions

No. of Grants

Total Dollars

% of Dollars

Comp.

Cancer

Center

141 $68,906,165

78.1%

30 Other Institutions

97 $19,347,961

21.9%

Total 238 $88,254,126

100%

P30/P50 Review Committee Report Recommendation #2

2. Make better use of centers as entrepreneurial resources for planning, innovation and dissemination

2.6 Provide support via P30 to centers making links with state agencies, health departments, CDC, etc.

2.7 Modify the P30 award to encourage novel methods and infrastructure for disseminating new knowledge in early detection, prevention, cancer control and clinical research

2.2 Use existing resources of centers as cost-effective sites for piloting new research and dissemination programs

Observations about Centers’ Interest in Dissemination and Diffusion

Few cancer centers articulate a specific interest in dissemination based on information from Web sites.

There are few population sciences shared resources and none are specifically focused on D and D.

There are few people already within cancer centers with the skill set needed to develop the D and D area.

If it is an “unfunded mandate,” D and D will not occur on the appropriate scale.

Potential Partners for All Cancer Centers and Academic Medical Centers in Comprehensive Cancer Control

Schools of public healthSchools of allied health professionalsSchools of communicationBusiness schoolsHealth departmentsVoluntary health organizationsPrivate sector, e.g. advertising agencies

Application of D&D Models in Cancer Centers

Create Knowledge Transfer Teams—Provide support for people whose role is to assess the appropriateness of discoveries in different areas for dissemination (perhaps as part of a Dissemination Core).

New Associate Director position?

Knowledge Synthesis Model—Encourage cancer centers to seek training opportunities for people in knowledge synthesis (KS), actively encourage more KS prior to grant funding as part of grant evaluation, more aggressively promote existing knowledge syntheses to cancer centers.

Discourage cancer center PR departments to promote the study finding “du jour?”

Application of D&D Models in Cancer Centers

“To him who devotes his life to science, nothing can give

more happiness than increasing the

number of discoveries, but his cup of joy is full when the results of his studies

immediately find practical applications.”

~Louis Pasteur

Our goal is to turn knowledge into applications that benefit people.