Mark Clanton, M.D. M.P.H.Mark Clanton, M.D. M.P.H.Deputy DirectorDeputy Director

Cancer Care Delivery SystemsCancer Care Delivery Systems

Moving Discovery Through to Delivery:Moving Discovery Through to Delivery:A Critical Opportunity for Leadership and PartnershipA Critical Opportunity for Leadership and Partnership

January 25, 2005January 25, 2005

Importance of Disseminating the EvidenceImportance of Disseminating the Evidence

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

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*The Central Goals of Healthy People 2010*

• Increase quality and years of healthy life

• Eliminate health disparitiesEliminate health disparities

• Increase quality and years of healthy life

• Eliminate health disparitiesEliminate health disparities

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

Burden of Cancer in U.S.Burden of Cancer in U.S.

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

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

Burden of Cancer in U.S.Burden of Cancer in U.S.

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

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

Cost of CancerCost of CancerTreatmentTreatmentCost of CancerCost of CancerTreatmentTreatment

$1.2 billion$1.2 billion

1963 19721963 1972 1985 20021985 2002

$3.8 billion $3.8 billion $60.9 billion$60.9 billion

$18.1 billion$18.1 billion

Natural Death

Birth

SusceptibilitySusceptibilityPre-initiationPre-initiation

Malignant Malignant TransformationTransformation

Evolution/Evolution/ProgressionProgression

Lethal Lethal PhenotypePhenotype

Cancer: A Disease ProcessA Disease Process

Life SpanLife Span

Death Due to CancerC

an

cer

Bu

rde

nC

an

cer

Bu

rde

n

Prediction/Prevention TreatmentModulation

NarrowingNarrowing GapGap

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 It takes 1717 yearsyears to turn to turn 14 per cent14 per cent of original research of original research to the benefit of patient careto the benefit of patient care

17:14

Original research

Acceptance

Implementation

E.A. Balas, 2000

NCI’s Challenge: Close the Gap Between Discovery and DeliveryNCI’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.

• 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.

THE DISCOVERY-DELIVERY CONTINUUMTHE DISCOVERY-DELIVERY CONTINUUM

Discovery Development Delivery

Community Health

PracticePractice Primary CarePracticePractice

Oncology PracticePracticeBasic Basic

ScienceScience TranslationalTranslationalScienceScience

Translational Research vs. Research Translation

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

Academic Cancer& Medical Centers

CCOPs & ACoSApproved CancerPrograms

Municipal & RuralHospitals & Clinics

Research-Practice Partnerships?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 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

• 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

Development of Clinical PLANETDevelopment of Clinical PLANET

Screening implementation is complicatedScreening implementation is complicated

Limits of Epidemiologic Evidence

Failure to Screen/ Failure to act on symptoms

Failure to Detect

Sensitivity/specificity of testTechnology resourcesQuality of readingBiologic Characteristics

Failure in follow-up

System- failurePatient non-compliance

Failure in Dx

Sensitivity/ specificityTechnology resourcesQuality of reading

Failure in Follow-up

SystemPatient

Treatment Failure

Treatment efficacyPatient complianceProvider error

POTENTIAL FAILURES

Process of Care OUTCOMES

Risk Assessment

AgeFamily HxExposure HxGeneticsLifestyle

DetectionScreening•CBE/Mammography•Pelvic/Pap•FOBT/sigmoidoscopy

Symptomatic

Diagnosis

MammographyUltrasoundColposcopyBiopsyRepeat Exams

Treatment

SurgeryRadiationAdjuvant ChemoPalliative Care

MorbidityMortalityQuality of LifeSatisfactionQuality of Death

Intermediate Outcome

Invasive cervical cancer

Late-stage breast cancer

Systems change is criticalSystems change is critical

Systematic implementation of evidence based medicineGuidelines are necessary but not sufficient

IOM report

Systemic change is needed

The chronic care modelAn implementation guide for teams

Systematic implementation of evidence based medicineGuidelines are necessary but not sufficient

IOM report

Systemic change is needed

The chronic care modelAn implementation guide for teams

Organizing the chaos of changeOrganizing the chaos of change

Conceptual organizationThe chronic care model

Conceptual organizationThe chronic care model

Improved Outcomes

Informed,Activated

Patient

ProductiveInteractions

Prepared,Proactive

Practice Team

Resources and Policies

Community

DeliverySystemDesign

DecisionSupport

ClinicalInformation

Systems

Self-Management

Support

Health System

Health Care Organization

Chronic Care Model

Moving Science into Oncology PracticeMoving Science into Oncology Practice

Food and Drug Administration (FDA) Collaboration

Centers for Medicare and Medicaid Services (CMS) Collaboration

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

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..."

• 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..."