Advancing Implementation Science in Global Cancer Control: Lessons Learned from a PAHO Cervical Cancer Meeting

I was offered the opportunity to contribute to global cancer control work when I spent much of 2019 working on a detail at the Pan American Health Organization (PAHO), one of six regional offices of the World Health Organization (WHO). PAHO provides technical assistance to Member States (countries) in the Americas: North America, Central America, South America, and the Caribbean, to set health priorities and mobilize 52 countries and territories to combat diseases. The United States is one of the Member States and decision-making bodies of PAHO. Designated as a Regional Advisor and Consultant within the Non-Communicable Diseases Unit of PAHO, I directed and assisted with projects relating to cervical cancer, prostate cancer, palliative care, and the preparation of technical documents. Most salient was my work in cervical cancer prevention and control in response to the 2018 WHO Call for Action to eliminate cervical cancer.

The National Cancer Institute (NCI) serves as a WHO collaborating center on cancer control, with the NCI Center for Global Health at the helm. NCI has a long-standing relationship with PAHO, continuing to promote international collaboration and providing guidance, scientific knowledge, evidence-based resources, and other technical assistance to PAHO. I was able to leverage my expertise from NCI’s Division of Cancer Control and Population Sciences to benefit PAHO, which did not have as much staff experience in cancer control research or implementation science.

Early in my role with PAHO, I contributed to the successful planning and execution of the cervical cancer elimination meeting convened at the PAHO Headquarters in Washington, DC. This meeting supported the PAHO Plan of Action 2018-2030, a guide and framework approved by all Member States in the Americas Region, to implement organized cervical cancer control intervention programs.  In addition, the meeting allowed for improvements of the WHO draft Global Strategy towards cervical cancer elimination, developed for all six WHO Regions. There were representatives from WHO, Ministries of Health in 27 Member States, 12 partner organizations (e.g., United Nation agencies, non-government organizations, civil society), as well as US Government entities: HHS, CDC, and NCI. The meeting aim was to support and guide countries in the Americas in planning activities to accelerate and improve HPV vaccination coverage, cervical cancer screening, and follow-up and treatment, to move towards the elimination of cervical cancer.

As I participated in follow-up meetings and conferences to the cervical cancer consultation, I discovered the importance of improving research in implementation science in the Americas, especially in Latin America and the Caribbean, as the difference between what we know and what was delivered in those countries for cervical cancer control was significant. It was evident that countries had limited knowledge on how essential it is to determine and use appropriate implementation strategies to integrate cancer control evidence into their various populations and to understand and address population context. Further discussions reinforced the challenge with nomenclature, terms, and definitions that were used differently in understanding the field of implementation science. I also observed that there was limited training and expertise in dissemination and implementation research within the region, yet immense desire to remedy this. There was a demand for an increased number of cancer control international researchers and practitioners and a critical need for capacity building in IS.

Even though the PAHO-led cervical cancer meetings were well attended, high-level, and productive, my additional interactions with the PAHO point of contact and cancer control leads within various countries greatly enhanced my global perspective on cancer control. As the cancer-focused expert at PAHO Headquarters, I convened cancer workgroups, engaged external cancer partners, medical directors and researchers, and developed technical documents for country use. I oversaw the development of cancer screening projects, technical guidance documents and online courses, reviewed country-specific cancer control plans, as well as guided independent consultant volunteers as they enthusiastically and tirelessly worked remotely to show their support for global cancer control. These volunteers from various academic institutions were ready and willing to lend their expertise to PAHO on top of their other responsibilities. The collaborations among countries, research partnerships, and volunteers showed the influence of PAHO and the strong support to improve cancer control in the Americas.

Despite my active role in global cancer control, multiple challenges abounded throughout my months working at PAHO. Some of the work being done involved translation of materials to Spanish, which created some difficulties for volunteers, including me. There were language barriers in email communications with countries and the translation of meeting materials and virtual course video recordings, even with volunteers who spoke both English and Spanish. Delays in country project assignments became common place due to reasons such as the training of new country staff, country readiness, scheduling conflicts, email response time, staff turnover, and funding issues. Working in global health has its challenges and, on some occasions, cancer takes a back seat. Competing priorities such as infectious diseases, infant mortality, opioids, crime, and transportation, can create delays when trying to implement cancer programs. In addition, implementing programs globally requires understanding not only the needs of the country or population, but all the challenges that may delay or hinder progress and strategies to target those barriers. However, I learned that preparing for those challenges and learning from other countries with similar infrastructure, needs, interest, and success stories, are critical to achieving success in program implementation.

While I am no longer on detail at PAHO, I am encouraged that my efforts at PAHO benefited countries and I was able to share and increase scientific knowledge in implementation science and cancer control in the Americas, while building my capacity in global cancer control. I was also able to apply my knowledge to the virtual NCI 2020 Implementation Science Consortium in Cancer, which convened a Global Health Action Group that brought together researchers and practitioners, domestically and globally, to discuss priorities in global health. Donna Shelley (NYU), Anne Rositch (JHU), and I facilitated the action group discussion that primarily focused on IS capacity building in low- and middle- income (LMI) countries, along with context and equity, technology, and stakeholder engagement priorities.  This meeting revealed the need for future IS research and action planning in global regions.

The significance of increasing implementation research studies globally is noteworthy, to better inform national efforts here in the US aimed at supporting lower-resource communities. PAHO is a practice-focused organization and relies on research findings and guidance to implement interventions. Accelerating research and practice and leveraging existing research at NCI, especially research focused on LMI areas, will benefit global cancer control work. Nations are increasingly interconnected through travel, collaborations, and engagement. It is beneficial to all populations if we continue to build the science of implementation, build cancer research capacity, and improve understanding on how to support the most vulnerable populations in cancer prevention and control.