# Presentation: 493333

## Mark Clanton, M.D. M.P.H.

- Deputy Director
***Cancer Care Delivery Systems***
**Moving Discovery Through to Delivery:**
**A Critical Opportunity for Leadership and Partnership**
**January 25, 2005**

## Importance of Disseminating the Evidence

-   Scientific knowledge achieves its highest value and best purpose when that knowledge is used to advance the human condition.

## 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

## Burden of Cancer in U.S.

**    ****Cancer is the leading cause of death for American’s under 85 years of age.**

## Burden of Cancer in U.S.

**1,368,030** **New Cancer Cases Projected in 2004**
**563,700** **Cancer Deaths Projected in 2004**

## Cost of CancerTreatment

**$1.2 billion**

**1963               1972**            **1985                2002**

**$3.8 billion **

**$60.9 billion**

**$18.1 billion**

## Cancer: A Disease Process

**Natural Death**

**Birth**

**Susceptibility**

**Pre-initiation**

**Malignant Transformation**

**Evolution/**
**Progression**

**Lethal Phenotype**

**Cancer: ****A Disease Process**

**Life Span**

**Death Due to Cancer**

**Cancer Burden**

**Prediction/Prevention**

**Treatment**

**Modulation**

**Narrowing**** ****Gap**

## Publication

**Publication**

**Bibliographic databases**

**Submission**

**Reviews, guidelines, textbook**

**Negative        results**

**variable**

**0.3 year**

**6. 0 - 13.0 years**

**50%**

**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**

**Expert**
**opinion**

**Inconsistent**
**indexing**

**Original research**

**Acceptance**

**Implementation**

**E.A. Balas, 2000**

**Notes:**
This is a very busy slide, developed by Andy Balas.

The point is to illustrate how it takes so long for a published finding to actually get into practice:  17 years to turn 14% of original research to the benefit of patient care.

AHRQ’s TRIP and QI programs are intended to shorten this timeframe.

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

- There is a critical disconnect between research discovery and program delivery and this disconnect is 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.***

**Notes:**
An our commitment to reducing cancer health disparities also recognizes the important role that our historical failure to ensure equal access to new technologies plays in contributing to cancer health disparities.  (mention Black/white differences in mortality)

## THE DISCOVERY-DELIVERY CONTINUUM

**Discovery**

**Development**

**Delivery**

**Community**
** ****Health**
** *****Practice***

**Primary**** ****Care**
***Practice***

**Oncology**
** *****Practice***

**Basic Science**

**Translational**
**Science**

## Discovery to Development

- Discovery to Delivery

## Research-Practice Partnerships?

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

## Partnership Models 

**State Cancer Plans (ACS, CDC, C-Change, ACoS, ICC, NAACCR, LAF) **
**Collaborate with partners to support and expand the Cancer Control PLANET for Community Health Practice**

## http://cancercontrolplanet.cancer.gov

_**http://cancercontrolplanet.cancer.gov**_

## Slide 15

## Development of Clinical PLANET

## Screening implementation is complicated

**Process of Care**

**OUTCOMES**

**Risk Assessment**
- Age
- Family Hx
- Exposure Hx
- Genetics
- Lifestyle

**Detection**
- Screening
- CBE/Mammography
- Pelvic/Pap
- FOBT/sigmoidoscopy
- Symptomatic

**Diagnosis**
- Mammography
- Ultrasound
- Colposcopy
- Biopsy
- Repeat Exams

**Treatment**
- Surgery
- Radiation
- Adjuvant
-    Chemo
- Palliative Care

- Morbidity
- Mortality
- Quality of Life
- Satisfaction
- Quality of
-    Death

**Intermediate Outcome**
**Invasive cervical cancer**
**Late-stage breast cancer**

**Notes:**
This figure describes the continuum of cancer care. It shows two important points: 1) that there are specific stages of care (I.e. detection, diagnosis, treatment) and, 2) transitions between these stages. 

The quality of care is affected by both.  Mandelblatt and colleagues have provided a comprehensive review of factors that influence access to care. I consider these the transitions.  Her review focuses on both patient and physicians factors.  It is one of several models that make one major point. Physicians and patients do not operate in isolation. They interact with each other and each operates in the context of a surrounding environment of culture, and a healtcare system.  

At each point of transition these surrounding factors influence care.  We know for example that outreach reminders can facilitate recruitment to screening. We know that follow-up after an abnormal screening examination are facilitated by mailed reminders. 

There are many ways things can go wrong.  People may never know that screening could help them. They may never receive a recommendation. Even if they receive a recommendation they may not be notified about the result.  IF they are notified about the abnormal result do they get to the appropriate people for the next step in evaluation.  Finally, do they understand the treatment could help them, that finding a cancer is not a death sentence, it is reason for hope.

Good quality care is about the entire process of care, the transitions, and the specific types of care that occur.  We’re relatively good at mammography, sigmoidoscopy, and PAP smears. At least relative to managing the process of care. 

## Systems change is critical

- Systematic implementation of evidence based medicine
- Guidelines are necessary but not sufficient
- IOM report
- Systemic change is needed
- The chronic care model
- An implementation guide for teams

## Organizing the chaos of change

- Conceptual organization
- The chronic care model

## Moving Science into Oncology Practice

- Food and Drug Administration (FDA) Collaboration
- Centers for Medicare and Medicaid Services (CMS) Collaboration

## WE HAVE BEEN TALKING ABOUT DISSEMINATION FOR QUITE A LONG TIME 

- When the NCI was first authorized in 1937, Congress mandated that "NCI promote the useful application of research results."
- "The Cancer Control section of the National Cancer Act of 1971 is designed to ensure more rapid and effective communication of research results to medical practitioners and, as appropriate, to the general public..."

- Dialogue to Action!

## Slide 22