Scaling up Areas of Research: Leveraging NCI-Designated Cancer Centers
DCCPS supports NCI-Designated P30 Cancer Centers in developing new ways to prevent, diagnose, and treat cancer. Through several recent initiatives focused on cancer control, the cancer centers have expanded their capacity to conduct research, plan strategy, facilitate professional collaborations, and implement efforts to improve healthcare. These initiatives exemplify how DCCPS is able to leverage the cancer centers to scale up an area of science through targeted administrative supplements and incentivize implementation into the cancer patient community.
Population Health Assessment in Cancer Center Catchment Areas
o create programs that best prevent, diagnose, treat, and provide care for survivors, cancer centers must thoroughly understand the populations they serve. DCCPS supported supplemental funding to conduct research to better characterize the populations and communities within the NCI-Designated Cancer Center catchment areas. The initiative sought to enhance cancer centers’ capacity to acquire, aggregate, and integrate data from multiple sources, as well as plan, coordinate, and enhance catchment area outreach activities. Surveys conducted at each of the 29 funded cancer centers included common demographic and behavioral measures to facilitate cross-site and local-versus-national comparisons on constructs relevant to cancer control. The short-term goal of the supplemental funding was to support local research to better define and describe the cancer center catchment area using a multilevel population health framework. The long-term goal was to facilitate collaborations in which local area providers, public health practitioners, policymakers, and nonprofit organizations utilize data to develop or expand applied cancer control research, planning, intervention, and implementation efforts, with particular attention to local-level health disparities and communication inequalities. The 29 centers funded in FYs 2016 and 2018 have published 33 peer-reviewed publications to date, with two special journal issues published in 2019: A Focus Issue of Cancer Epidemiology, Biomarkers & Prevention and Special Section in the Journal of Rural Health. Pooled analyses and subsequent publications are under review to examine cancer screening uptake and cancer beliefs in rural catchment populations, and social determinants of health in catchment populations. Four grantee meetings were held from 2016–2020, with the culminating grantee meeting held virtually in March 2020. This initiative has led to catchment area data collection efforts now incorporated into the P30 Cancer Center Support Grants (CCSGs) funding opportunity announcement (FOA).
Human Papillomavirus (HPV) Vaccine Uptake
In September 2020, DCCPS awarded a third round of supplements to 11 NCI-Designated Cancer Centers to support investigation of vaccine hesitancy related to uptake of the HPV vaccine in regions with low adolescent HPV vaccination rates. The short-term goals for this one-year supplement are to understand characteristics of vaccine-hesitant communities within the cancer center catchment areas, identify promising and innovative approaches to reducing hesitancy and other barriers to HPV vaccination, and gather pilot data to guide future interventions to reduce vaccine hesitancy and increase HPV vaccination. This supplement is part of a larger effort to bring together NCI-Designated Cancer Centers, CDC programs, and state/local health departments and their immunization programs. These administrative supplements are being offered in response to the Cancer Moonshot Blue Ribbon Panel Report’s recommendation “to expand the use of proven prevention and early detection strategies” and the World Health Organization’s (WHO) report, which cited vaccine hesitancy as one of the “ten threats to global health in 2019.” Two previous rounds of supplements were issued to cancer centers that focused on increasing HPV vaccination rates in regions with low HPV vaccination uptake: NCI funded 18 supplements in 2014 and 12 supplements in 2017.
Tobacco Cessation in Cancer Patients
Continued smoking after a cancer diagnosis can interfere with treatment and worsen a patient’s prognosis. Fortunately, quitting can help improve a patient’s prognosis and reduce cancer treatment toxicity. The Cancer Center Cessation Initiative (C3I) was launched by NCI using Cancer Moonshot funds to help cancer centers build and implement sustainable tobacco cessation treatment programs to routinely address tobacco use among their patients. The C3I provided resources from FY 2017 through FY 2020 to 52 NCI-Designated Cancer Centers to create sustainable systems to identify and treat tobacco use among patients who smoke. Centers are working to modify electronic health records (EHRs) and clinical workflows, identify and surmount patient, clinician, clinic, and health system barriers, and achieve institutional buy-in for providing tobacco treatment as part of routine oncology care. Ultimately, the goal is to improve cancer patient outcomes by ensuring that treating tobacco use is a standard of care for cancer patients. Many C3I sites have made considerable progress. Examples include 50% patient engagement (May et al) and an increase in tobacco treatment referrals from 10 to 24 per month (Meyer et al). With assistance from the C3I Coordinating Center, a number of centers have successfully modified EHRs to allow for automatic identification and referral. In just the first year of funding, EHR referrals increased from 32% to 68% of centers (D’Angelo et al).
Rural Cancer Control
Rural communities face numerous challenges compared to urban areas along the entire cancer control continuum, reflected in higher average death rates from cancer for all cancer sites combined. This long-standing public health challenge calls for sustained support for research, with interdisciplinary cross-sectional collaborations. In FYs 2018 and 2019, DCCPS awarded 21 and 20 administrative supplements, respectively, to P30 CCSGs to develop rural cancer control research capacity. These supplements provided resources to support the time and effort of teams at NCI-Designated Cancer Centers, in collaboration with rural communities and clinics, to develop comprehensive rural cancer control research programs that serve low-income and underserved populations. Over one-third of these awarded supplements focused on improving cancer control efforts among American Indian (AI) populations. Awardees of the rural supplements established working groups that continue to meet regularly to discuss issues pertaining to rural cancer control. Over the past year, a consortium of cancer centers, many being former rural supplement recipients, formed IC-4 (Impact of COVID-19 on the Cancer Continuum Consortium), a consortium of centers working to understand the impact of the pandemic on the continuum of cancer care, from prevention to survivorship. This supplement opportunity was the first of numerous rural cancer control-focused funding efforts, including two RFAs that followed (RFA-CA-19-064, RFA-CA-20-051), and investigators have been able to utilize their work and the connections established with the rural supplement to be successful in subsequent applications.
Cancer and Aging
The NCI Annual Plan & Budget Proposal (PDF, 18.3 MB) for FY 2020 highlighted the need to increase understanding of the role of aging in cancer. DCCPS is making strategic investments in aging research that will contribute to population health by preserving or promoting health span and ensuring equitable access to and benefit from advances in cancer prevention, control, and population science. A lifespan approach to the elimination or reduction of cancer risk associated with obesity, tobacco use, and physical inactivity is critical for the primary prevention of cancers and other chronic conditions that contribute a substantial public health burden during midlife and older adulthood. Surveillance methods are needed to track aging-relevant factors associated with cancer burden (e.g., multiple chronic conditions, polypharmacy, short- and long-term adverse effects, financial toxicity, residential stability and institutional care transitions [nursing homes, hospice], and behavioral and social exposures). As pediatric and adolescent and young adult (AYA) cancer survivors age chronologically and biologically and experience adverse physical, psychosocial, and behavioral outcomes, interventions to prevent, ameliorate, or rehabilitate aging-related consequences of cancer and its treatments are a priority. In FY 2020, DCCPS funded eight cancer centers, with the goal of addressing these critical research questions.
Community Outreach and Engagement
Community outreach and engagement (COE) has been a fundamental activity of the NCI-Designated Cancer Centers since the initiation of the cancer centers program in 1971. Historically, COE has been commonly considered an extension of centers’ population science/cancer prevention and control research programs. However, since the 2016 and 2019 reissuances of the P30 CCSG guidelines, COE is expected to now span all aspects of centers’ programs, including basic, clinical, translational, and population research. Cancer centers—working with community stakeholders—should identify community needs, communicate those needs across the center’s leadership and research programs (i.e., “in-reach”), and catalyze activities of special relevance to the cancer center’s self-defined geographic catchment area population. In 2020, DCCPS provided supplemental funding to 23 cancer centers to generate examples of research projects where outreach to and engagement of communities resulted in high-impact science. In addition, centers are expected to work with communities to disseminate and implement evidence-based interventions and guidelines, public education, and public health policy recommendations. This bidirectional relationship between communities and cancer centers promotes an understanding of cancer that is more holistic (bench-to-bedside-to-community), transdisciplinary, encompassing of different views and experiences, culturally sensitive, and reflective of mutual goals. In 2021, additional supplements may be issued to encourage greater engagement of NCI-Designated Cancer Centers in comprehensive cancer control planning efforts in their catchment areas.
Financial Hardship During Cancer Treatment
DCCPS is supporting research at NCI-Designated Cancer Centers via a supplement initiative to find new ways to address the difficult financial challenges that cancer survivors often face throughout treatment and follow-up care. The causes of cancer-related financial hardship are multifaceted, stemming from high out-of-pocket costs, inadequate insurance coverage, missed days from work or job loss, and other related challenges. Thus, a program of services is needed to address this complex problem. A 2019 survey sponsored by DCCPS suggested that most NCI-Designated Cancer Centers offer a range of financial navigation services. However, 40% of centers reported a lack of staff awareness about available financial navigation services, and 46% reported that the pathways or workflows to connect cancer patients with existing financial services were unclear. Additionally, over 50% of centers reported that patients were reluctant to ask for financial help when they needed it, and 37% of centers could not estimate the percentage of their patients who experience cancer-related financial hardship. Collectively, these findings suggest a need to both enhance the systematic identification of patients experiencing financial hardship and improve the coordination and delivery of financial navigation services. This supplement initiative is intended to help cancer centers develop or expand their capacity and infrastructure to deliver financial navigation services and to collect the preliminary data necessary to more broadly implement and evaluate financial navigation programs. To date, DCCPS has funded 11 centers under this initiative. Each project is in the first year of funding, and data collection is underway. DCCPS leads a quarterly investigator meeting to share information and updates among the funded teams. At the end of the funding period, findings from each project will be shared with other NCI-Designated Cancer Centers, as well as with other institutions that provide cancer care, to inform future research and service delivery in these settings.
National Childhood Cancer Registry
To enable better understanding of the needs of childhood cancer patients, DCCPS provides administrative supplement support to a subset of NCI-Designated Cancer Centers to encourage the centers to submit critical existing data that is available at the cancer centers but not routinely reported to cancer registries. The Childhood Cancer Data Initiative (CCDI) symposium hosted by NCI in July 2019 identified a critical need to collect, analyze, and share data to address the burden of cancer in children and AYAs. Currently, cancer registries in the US hold structured information on every cancer case, including childhood cancers, within their respective catchment area. Using registry data as a base, an infrastructure is being constructed that brings together key information on every childhood cancer patient and will be maintained to support research on childhood cancer survivors throughout treatment and follow-up care. The National Childhood Cancer Registry (NCCR) is envisioned as a connected data infrastructure to enable sharing of childhood cancer data from multiple and heterogeneous data sources. Incorporating available data on genomic and tumor characterization, residential history, social determinants of health, measures of financial toxicity, longitudinal treatments including oral agents, and longitudinal outcomes data including recurrence and subsequent cancers can enhance the core infrastructure of registry data on pediatric patients. To date, DCCPS has provided supplement finding for this effort to 10 cancer center sites.
Patterns of Cannabis Use Among Cancer Patients
In FY 2020, DCCPS funded 12 NCI-Designated Cancer Centers to study patterns of cannabis use among cancer patients. Common conditions for which cannabis has been used among cancer patients include anorexia, nausea, and pain; however, the extent of use, modes of use, perceived risks and benefits of use, and provider interactions about use are uncertain, as well as the degree of accessibility by patients given the variation in state laws concerning legalization of marijuana. As a first step, NCI is supporting research at these centers to survey patients about their use of cannabis during cancer treatment across regions with varying state regulations. All centers will administer a core set of questions in addition to their center-specific research questions. Approximately 12,000 cancer patients will be surveyed across the sites in 2021, with some sites including provider surveys. The survey results will inform future research activities as well as clinical care. The NCI Cannabis, Cannabinoids, and Cancer Research Symposium, in December 2020, highlighted many additional research gaps concerning cannabis use, including potential drug-drug interactions, side effects, impact on comorbid conditions, beneficial effects, modes of use, and dosages.
Persistent Poverty
Advances in cancer prevention, diagnosis, treatment, and survival have unfortunately not benefited everyone equally, and disparities in cancer outcomes persist, as discussed regarding the CPHHD program. Populations living in persistent poverty, in particular, face higher rates of cancer morbidity and mortality. DCCPS announced an administrative supplement opportunity in FY 2021 for NCI-Designated Cancer Centers to enhance research capacity in persistent poverty areas. The purpose of this opportunity is to provide resources to support multidisciplinary research teams at these centers, in collaboration with clinics that serve underserved populations living in persistent poverty areas, to plan, implement, and sustain a cancer control research program that focuses on low-income and/or underserved populations. As such, awardees will be expected to address challenges and opportunities related to working in partnership with these clinics, and enhance delivery of cancer control and prevention strategies to improve overall health and lessen the burden of cancer in these areas. The long-term goal of this supplement is to build the capacity for healthcare clinics and/or safety net providers to implement evidence-based cancer prevention and control programs and practices focused on underserved populations in persistent poverty areas. These supplements align with the White House’s Executive Order On Advancing Racial Equity and Support for Underserved Communities Through the Federal Government and are part of a larger NCI research initiative to inform, test, and strengthen cancer control programs that are sustainable in these communities of persistent poverty across the US. NCI envisions this effort will lead to new partnerships within communities and among local and state agencies and organizations, and increase the centers catchment area to focus on previously excluded underserved populations.
Cancer Survivorship
In FY 2021, DCCPS released a funding announcement for administrative supplements to NCI-Designated Cancer Centers to support research aimed at better understanding and addressing organizational factors that contribute to disparities in outcomes among childhood cancer survivors. Over the past several decades, advances in cancer treatment and supportive care have resulted in a growing US population of childhood cancer survivors. At the same time, research in childhood cancer survivorship is also expanding, due in part to the Childhood Cancer Survivorship, Treatment, Access, and Research (STAR) Act. Yet, these achievements have not benefited all children equally. Community, health system, organizational, process-of-care, or policy-related barriers may contribute to disparities in survivorship outcomes for childhood cancer survivors. Studies of disparities in treatment and survivorship outcomes among children with cancer are sparse, and even fewer interventions targeting disparities have been tested. Evaluating the root causes of inequities in survivorship outcomes will require understanding barriers that exist in the cancer center care environment. This supplement initiative is a part of a larger NCI research initiative to engage cancer centers and communities in collaborative, translational research focused on decreasing the cancer burden for children diagnosed with cancer across the US, including among minority and underrepresented populations. The long-term goal of this administrative supplement opportunity is to generate research that will work to eliminate organizational or structural inequalities for children diagnosed with cancer.
Footnotes
May JR, et al. Leveraging patient reported outcomes measurement via the electronic health record to connect patients with cancer to smoking cessation treatment. Int J Environ Res Public Health. 2020 Jul 13;17(14):5034.
Meyer C, et al. A lean quality improvement initiative to enhance tobacco use treatment in a cancer hospital. Int J Environ Res Public Health. 2020 Mar 24;17(6):2165.
D’Angelo H, et al. Tobacco Treatment Program Implementation at NCI Cancer Centers: progress of the NCI Cancer Moonshot-funded Cancer Center Cessation Initiative. Cancer Prev Res. 2019 Nov; 12 (11):735–740.
