Implementation Science - Opportunities in Cancer Research
The enormous gap between what we know can optimize health and what gets implemented in everyday practice is a critical impediment to improving the health of cancer patients and survivors. Implementation science, a growing research field, uses a scientific approach to find the best ways to integrate proven, effective interventions into routine health care.
The field of implementation science bridges the divide between research and practice to improve patient and population health outcomes. It enables maximum impact for NCI’s investments in cancer research, with a focus on equity, so that even the most disadvantaged and underserved communities gain the benefits of the latest scientific advances.
NCI supports implementation science through a multifaceted approach: developing research initiatives, providing tools and resources to cancer researchers, disseminating knowledge on evidence-based cancer control interventions, and training investigators.
The Cancer Moonshot℠ Blue Ribbon Panel recognized important opportunities in implementation science and identified several specific areas for focused support:
- Accelerating the delivery of colorectal cancer screening, follow-up, and referrals to care in regions of the United States where screening rates are below national standards
- Enhancing the delivery of tobacco cessation treatments
- Developing approaches to identify and care for individuals with inherited cancer syndromes
The goal of NCI’s efforts is to ensure that health care practitioners and public health systems deliver evidence-based cancer care to patients and families that will improve outcomes for all populations. Effective implementation of evidence-based care in diverse settings, including low-resource environments, will help reduce the cancer disparities that exist today.
Meeting Patients and Providers Where They Are
For the last two decades, NCI has supported research to develop implementation strategies for interventions that improve cancer outcomes in health care and community settings. In addition, the NCI Community Oncology Research Program (NCORP) serves as a laboratory for conducting implementation science studies in cancer care delivery research. NCI-funded implementation science research has addressed post-treatment survivorship care, the use of cancer screening tests, and more. Examples of NCI-funded research projects include the following:
Increasing Cancer Screening in Underserved Communities
In Chicago’s Chinatown, Chinese immigrant women face language, cultural, and access barriers in obtaining breast and cervical cancer screenings and follow-up care. Because of these barriers, the screening rates for this population are only half of those of white women, resulting in poorer outcomes among this population. To address this issue, NCI funded a research partnership between Northwestern University, Rush University Medical Center, Mercy Hospital & Medical Center, and the Chinese American Service League to adapt and implement a community-based patient navigation program for breast and cervical cancer screening. Existing patient navigation services were adapted to be culturally relevant and were aligned with community structure, clinic processes, and policy contexts. From 2014 to 2017, navigation services were provided to 678 women. Although evaluation of this program is ongoing, it illustrates a promising approach for adapting patient navigation programs to underserved populations.
Improving the Care of Cancer Survivors
Much of the complex post-treatment care for survivors, who number 16.9 million and counting in the United States, has become the responsibility of primary care physicians, many of whom do not have the means, knowledge, or skills to provide comprehensive survivorship care. This care includes surveillance for disease recurrence (or new primary cancers) and interventions to mitigate the late and long-term adverse effects of cancer and its treatment.
To study the capacity for and barriers to the delivery of comprehensive survivorship services in primary care settings, NCI-funded researchers at Rutgers University evaluated the survivorship care provided by a diverse group of family medicine and internal medicine practices in multiple states. Their research revealed that major barriers to integrating comprehensive survivorship services into routine primary care included the lack of a recognized clinical category for cancer survivorship (i.e., describing a distinct patient population with unique needs), limited information or guidance from oncologists to inform actionable care plans, and inadequate information systems to support survivorship care.
These findings point to the need for evidence-based implementation strategies to improve the care of cancer survivors, a priority NCI continues to pursue, including through a recent request for applications aligned with the Childhood Cancer Survivorship, Treatment, Access, and Research (STAR) Act. Included in this funding opportunity are implementation studies to develop and evaluate interventions to improve survivorship for these populations.
Promoting Wellness in Low-Wage Worksites
Small businesses (workplaces with fewer than 200 employees) in low-wage industries (e.g., food services, entertainment and recreation, retail trade) are often unable to implement health promotion interventions. NCI-funded researchers at the University of Washington evaluated the effectiveness of HealthLinks, a program developed in partnership with the American Cancer Society to support healthy eating, physical activity, tobacco cessation, and breast, cervical, and colon cancer screening for employees of small businesses in low-wage industries in Washington State.
The researchers measured employers’ commitment to change, as it is usually assumed that this commitment is a prerequisite for implementing and sustaining a systemic change. However, the researchers showed that planning and technical support, more than commitment or motivation, were the keys to effective implementation. Thus, implementation strategies can improve the delivery of care even when leadership lacks commitment.
Setting the Foundation
To build the field of implementation science in oncology, NCI provides resources, training, and collaborative opportunities. For example, the institute is:
Building the Implementation Science Knowledge Base
NCI created databases that provide researchers and practitioners access to resources that can help with the design, implementation, and evaluation of evidence-based cancer control programs. Since 2003, NCI has reviewed and posted more than 200 peer-reviewed cancer control intervention and program materials on the Research-Tested Intervention Programs (RTIPs) website. The website requires program developers to include materials needed for their programs to be implemented in a range of community and health care settings and rates the programs on the strength of evidence and readiness for implementation.
Strengthening the Implementation Science Workforce
NCI is investing in education and training programs to develop a workforce of implementation researchers to move the field forward. As one example, in 2018, NCI began hosting an annual training institute, the Training Institute for Dissemination and Implementation Research in Cancer (TIDIRC), that has provided more than 100 researchers with a thorough grounding in implementation science across the cancer control spectrum. NCI also supports an additional training program with the National Institutes of Health and Department of Veterans Affairs to build the workforce throughout the health research community. Nearly 350 investigators have participated in this training since 2011.
The Future: Precision Implementation
The field of implementation science holds promise for reducing the burden of cancer and improving the health of all Americans. Priority areas for NCI include improving health equity and access to evidence-based cancer care, ensuring sustainability of evidence-based practices, and discontinuing ineffective or harmful practices. Read more about this area of research in Ross’s story.
In the near term, to further build on NCI’s prior investments, the institute has issued funding opportunity announcements under the Cancer Moonshot to support new research centers to advance implementation science. The funding will enable the rapid development, testing, and refinement of innovative approaches to implement a range of evidence-based cancer control interventions. Each center will establish implementation laboratories from existing clinical and community sites that will facilitate implementation in real-world settings.
In the long term, NCI aims to support a rapid-learning health care system by building and disseminating the implementation science knowledge base. A rapid-learning health care system harnesses ongoing data collected on patients, providers, and systems to drive real-time, continuous improvements in the delivery of care.
Pooling information across thousands of clinical and community practices, where interventions are adopted and sustained, will teach stakeholders how to develop effective implementation strategies in varied settings. A data ecosystem for implementation science will enable researchers and other stakeholders to identify successes, limitations, and targeted goals for future implementation science projects.
NCI’s investments in this area of research will move us toward a future of “precision implementation,” where interventions are adopted, accepted, and sustained at an optimal level within the range of contexts and populations in which they are used.