A History of the National Cancer Institute’s Support for Implementation Science Across the Cancer Control

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A History of the National Cancer Institute’s Support for Implementation Science Across the Cancer Control

Introduction

This chapter reviews the historical development of the National Cancer Institute’s (NCI) Implementation Science Program. It discusses the history of implementation science at the NCI and the co-author’s personal and professional contributions to the development of NCI’s Division of Cancer Control and Population Science (DCCPS). All three authors played key roles (and CV continues to play a key role) in the evolution of the NCI’s DCCPS Implementation Science Program, and each brought a different background and perspective to the factors that contributed to the development of implementation science at NCI.

The Roots of Implementation Science in Cancer Control Research: From Discovery to Delivery

The history of cancer control in the United States is documented in multiple places on the NCI’s website.1 This history has directly impacted the growth of the field of implementation science in cancer. Figure 1B.1 provides an overview of the key events in the development of cancer control and implementation science at NCI.

Figure 1B.1 Overview of the key events in the development of cancer control and implementation science at NCI.|232x300px

Figure 1B.1Overview of the key events in the development of cancer control and implementation science at NCI.

In 1971, President Richard M. Nixon signed the National Cancer Act, which for the first time specified a role for the NCI that included a focus on cancer control. At the time of the passage of the Act, “the scientific community and the Congress thought . . . that many research advances existed which could affect cancer, but these advances were not being disseminated and used. The cancer control program was intended to bridge this gap.”2 From 1972 to 1982, the cancer control program budget was largely allocated to contract programs in professional education whereby NCI-designated cancer centers were provided cancer control program funds to conduct professional education with hospitals and clinical centers in each center’s self-designated catchment area. The transition of the cancer control program from a “diffusion of innovations”3 professional education model to a cancer prevention and control intervention research model took place in 1983 when the Division of Cancer Prevention and Control was established and a new definition and framework for cancer control research were developed that included a linear series of phases from hypothesis generation to demonstration and implementation projects.4

This research framework represented the first reference to eventual, long-term implementation science within the context of the NCI’s cancer research programs. During the 15-year lifespan of the Division of Cancer Prevention and Control, there was considerable growth in the number and diversity of NCI-funded intervention testing research grants (Phase 3) and defined population intervention studies (Phase 4) across the cancer control continuum. Based in part on this growth, in 1986, Dr. Vincent Devita, then director of the NCI, stated that a reduction in the cancer mortality rate by as much as 50% was possible “if current recommendations regarding smoking reduction, diet changes, screening, and state-of-the-art treatment are effectively applied.”5

Partially in response to this optimistic objective of reducing overall cancer mortality by 50% in 14 years, some in the research, practice, and policy communities remained concerned that the war on cancer was not making sufficient progress.6 In addition, the gap between what was known from these research investments and what was being done in practice and policy to reduce the burden of cancer for all Americans was continuing to grow.7 In response to these concerns and to important trends (e.g., an aging population, exponential expansion of electronic communications, health care management, and molecular biology), the Cancer Control Program Review Group was convened by NCI in 1996.8 The review group recommended that NCI make a long-term commitment to develop a more balanced partnership between the biomedical and behavioral/public health paradigms to reverse the upward trend in cancer mortality. It was also recommended that research should aim to reduce the burden and improve the quality of life of those who will get cancer despite our best efforts at prevention and the early detection and removal of precursor lesions. The review group recommended several organizational changes in NCI’s areas of research opportunity that required focused attention, including the creation or enhancement of four major research initiatives in basic behavioral science, primary prevention, screening, and rehabilitation and survivorship.

NCI’s Division of Cancer Control and Population Science

In 1997, DCCPS was established to enhance NCI’s ability to alleviate the burden of cancer through research in epidemiology, behavioral sciences, health services, surveillance, and cancer survivorship. First under the leadership of Dr. Barbara Rimer and then Dr. Robert Croyle, the division grew and evolved. The division aimed to generate basic knowledge about how to monitor and change individual and collective behavior and also to ensure that knowledge is translated into practice and policy rapidly, effectively, and efficiently. It was this latter mission that led to the recruitment of the first author (JK) in the 2000 to serve as deputy director for research dissemination and diffusion and implementation science and the second author (RG) in 2010 to serve as the deputy director for implementation science, respectively. The third author (CV) has played key leadership roles with the program throughout its duration.

Two factors influenced the growth of research dissemination and diffusion and implementation science within NCI. First was the growing accumulation of intervention studies that were being published in the peer-reviewed literature with little or no evidence that the lessons learned from this science were being translated into evidence-based practice or policy. The unequal burden of cancer incidence and mortality among many low-income and racially diverse populations strongly suggested that the gap between what was known and what was done to prevent and control cancer among medically underserved populations was not being closed by the passive diffusion of new research knowledge.9 Second, the methods used to integrate the lessons learned from cancer prevention and control intervention science with the lessons learned from practice and policy were not based on rigorous scientific methods nor in many cases even on careful evaluations.

Reflecting on these two different but related factors, the NCI, in partnership with the Center for the Advancement of Health and the Robert Wood Johnson Foundation, held a 2-day think tank meeting of researchers, practitioners, and intermediary research, practice, and policy funding agencies in September 2002 titled “Designing for Dissemination.”10 A key framework for understanding the challenges of integrating the lessons learned from science with the lessons learned from practice and policy was presented by Dr. Tracy Orleans from the Robert Wood Johnson Foundation (Figure 1B.2). As noted by Dr. Orleans, the continued emphasis on “pushing” scientific findings out through publication and presentation, although necessary, was not sufficient to increase uptake of evidence-based interventions (EBIs). Research would need to address both what practitioners and policymakers want (pull) and the infrastructure resources and contexts that exist to deliver these EBIs (delivery capacity).10 This was, at the time, referred to as dissemination research.

Figure 1B.2 Bridging the gap: A synergistic model.|300x167px

Figure 1B.2Bridging the gap: A synergistic model.

Source: Adapted from presentation given by Tracey Orleans, PhD (Robert Wood Johnson Foundation), at NCI-sponsored Designing for Dissemination meeting, 2002.

The meeting was also informed by an evidence review.11 At the meeting, a brief presentation was made of the systematic review of the literature specific to the dissemination of EBIs in five areas of cancer control:

  • • Tobacco control
  • • Dietary change
  • • Mammography screening for breast cancer
  • • Pap smear testing for cervical cancer
  • • Cancer pain management

The evidence review identified the following recommendations for future dissemination research:

    1. Increase the amount of research.
    1. Focus the research on the dissemination of effective cancer control interventions.
    1. Examine the best research designs and the best measures of outcome effectiveness.
    1. Define what constitutes a reasonable decline of effectiveness after an intervention is extended to more diverse populations and settings beyond a controlled clinical trial.
    1. Explore how qualitative research methods may help capture contextual factors that can serve as barriers to or facilitators for the adoption of EBIs.
    1. Explore establishing criteria for reporting dissemination research.

In addition, think tank participants were invited to participate in an online concept mapping exercise.12 The concept mapping data showed that each group of think tank participants (i.e., researchers, practitioners, and funding/policy agency intermediaries) held very different ideas about its own role and the roles of the other groups in disseminating and implementing EBIs. Researchers were the least likely to believe that translation and dissemination of research findings were their responsibility; because they were not trained in the science of dissemination and communication, their research grants generally did not pay for this type of work, and their interests and strengths lay elsewhere. Practitioners, whether clinicians or public health professionals, generally assigned responsibility for the synthesis and dissemination of research elsewhere. They viewed their job as acting on findings that are readily available and formatted for easy use. Intermediaries, whether public or private funders or of non-profit policy organizations, were most likely to describe translation and dissemination as activities for which they could provide leadership, but they were adamant that researchers and practitioners must play important partnership roles.

With respect to action steps that NCI should specifically take, the theme most commonly suggested for NCI was to join with other research and service funding agency intermediaries and take responsibility for supporting a nationwide permanent, community-based infrastructure for supporting the implementation of research findings (see, as an example, the US Department of Agriculture’s cooperative extension service).13 Other recommendations included the following:

  • • Increase funding for dissemination components in grants.
  • • Build dissemination requirements into requests for research grant applications.
  • • Require and fund the dissemination of effective interventions in existing intervention studies.
  • • Require research dissemination and diffusion in all applicable requests for proposals, and allocate resources for this component.
  • • Issue requests for applications on dissemination research, but also provide funds for the actual dissemination of research findings.
  • • NCI-funded comprehensive cancer centers should build in dissemination cores as a shared resource in future cancer center support grant applications.*
  • • Ensure that study review groups will better understand and appreciate this much-needed field of study.
  • • Train/educate NCI/National Institutes of Health (NIH) study sections regarding how to evaluate dissemination research using criteria other than those used for randomized controlled trials.
  • • Training and support should be provided to researchers and practitioners regarding how to disseminate and evaluate the impact of their research.
  • • NCI should provide more opportunities to develop a broader group of practitioners, researchers, and intermediaries exposed to this dissemination research and practice information.
  • • Involve practitioners and community partners in the research design stage, and promote research/practice partnerships.
  • • Develop systems for the dissemination of effective ideas, programs, and interventions by acting as a clearinghouse for state-of-the art dissemination methods and best practices.
  • • Promote online dissemination of knowledge and process assistance by developing a dissemination.gov website.

NCI was also urged to provide a clear vision and a specific action plan for necessary stakeholder collaboration.

Many of the aforementioned recommendations became the foundation for NCI’s commitment to the emerging concepts of dissemination and implementation (D&I) research and research dissemination and diffusion. To engage the large cancer prevention and control intervention research community in D&I research, NCI initially supported D&I research through the Dissemination and Diffusion Supplements program. This administrative supplement program provided small, short-term awards to existing NCI intervention research grantees (and, later, surveillance research grantees) engaged in cancer control research. A total of 20 supplements were issued between 2001 and 2008 (12 focused on cancer risk or prevention and 8 focused on surveillance).14 NCI’s sponsorship of these supplements paved the way for its participation in future more robust research initiatives.15

In parallel with the effort to seed the field of D&I research, and in response to the 2002 think tank meeting recommendation that NCI act as a clearinghouse for state-of-the-art dissemination methods and best practices and develop a dissemination.gov website, in 2003 NCI launched Cancer Control P.L.A.N.E.T. ( P lan, L ink, A ct, N etwork with E vidence-Based T ools). The P.L.A.N.E.T. web portal was designed to provide access to data and resources to help planners, program staff, and researchers design, implement, and evaluate evidence-based cancer control programs.16 It was developed in partnership with the Centers for Disease Control and Prevention (CDC), the American Cancer Society (ACS), the Substance Abuse and Mental Health Services Administration (SAMHSA), the American College of Surgeons Commission on Cancer, and the Agency for Healthcare Research Quality (AHRQ). Later, under Dr. Glasgow’s leadership, the Research-Tested Intervention Programs (RTIPs) section of the Cancer Control P.L.A.N.E.T. was expanded in 2012 to include reviews of the reach, adoption, implementation, and maintenance findings of the relevant research on RTIPs programs into data summaries and implementation guides.16

A key recommendation from the 2002 think tank meeting included that NCI should provide a clear vision and a specific action plan for necessary stakeholder collaboration, providing more opportunities to develop a broader group of practitioners, researchers, and intermediaries; involve practitioners and community partners in the research design stage; and promote researcher–practitioner partnerships. In response, the Cancer Prevention and Control Research Network (CPCRN) was initiated in October 2002, with funding from the CDC and NCI as part of their joint effort to more effectively translate research into practice. As a federally funded, national network of academic, public health, and community partnerships, CPCRN provided resources for these partners to work together to reduce the burden of cancer, especially among those disproportionately affected. The initial five CPCRN sites were selected through a competition among the CDC-funded Prevention Research Centers.

Since 2002, the network has focused on conducting community-based research to accelerate the adoption and implementation of evidence-based cancer prevention and control and advance the implementation science and practice.17 Members of the network have successfully collaborated on multiple implementation science grants. They have developed community-based grants designed to increase the adoption of EBIs and have tested and delivered training on how to identify, adapt, and implement evidence in public health practice (see http://cpcrn.org/pub/evidence-in-action). In 2007, the network piloted a research partnership with the Missouri 2-1-1 service that provides information and linkages to social services via a telephone exchange similar to 9-1-1. The network built on initial pilot work to study adaptation of evidence-based health programs and scale-up of the program with other state 2-1-1 systems.18,19 The CPCRN is currently focusing efforts on two signature projects: (1) strengthening colorectal cancer screening rates in populations served by Federally Qualified Health Centers and (2) contributing to the science and evidence base supporting community–clinical linkages to increase human papillomavirus vaccination initiation and completion.

As noted previously, NCI issued supplements to existing NCI funded R01, P01, P50, U01, and U19 grants to study the implementation of efficacious interventions and surveillance research. Based on success with the supplement program, NCI collaborated with other institutes and centers (ICs) in the development and launch of the first trans-NIH Program Announcements on Dissemination and Implementation Research in Health (PAR-06-039, PAR-06-071, and PAR-06-072) in 2005. These program announcements were designed to encourage transdisciplinary research on models for implementation science that would be applicable across diverse practice settings and studies that would assess the outcomes of implementation science efforts.

The PARs have been reissued four times since the original announcements were released in 2005. Participation from ICs at NIH has increased from 8 ICs in 2005 to 17 ICs, and the Office of Behavioral and Social Sciences and the Office of Disease Prevention also participate. This funding mechanism has been the single largest funder of major implementation science projects since its inception in 2005. Key themes emphasized in the 2013 revision of the PARs included calls for the study of adaptations during the implementation of evidence-based programs; health equity, health policy, and global health research; investigation of sustainability; and “de-implementation” (reduction in wasteful, harmful, and ineffective practices). To date, NCI has awarded 51 R01’s, 13 R03’s, and 48 R21’s under these program announcements. Because implementation science was a relatively new area of research, grants under the initial PARs were reviewed by Special Emphasis Panels (SEPs). Leaders from NCI and the National Institute of Mental Health (NIMH) had the opportunity to orient SEP peer reviewers on the focus of the program announcements. In 2010, the Dissemination and Implementation Research in Health standing study section was established at NIH, and all grants submitted under the PARs along with other implementation science-associated grants are now reviewed by this group.

NCI has spearheaded work to expand technical assistance by developing and co-sponsoring the annual D&I Science Conference and also by leading various D&I training courses for investigators. In 2005 and 2006, NCI and NIMH hosted joint technical assistance workshops for investigators interested in D&I research. The goal of these workshops was to provide an opportunity for researchers to learn more about the field of implementation science and also share the work that they were doing in this area. These workshops evolved from having invited speakers presenting on key topics in the field combined with technical assistance feedback sessions provided to investigators in 2005 to a moderately sized conference held on the NIH campus in 2007 attended by approximately 100 people. The annual NIH and Veterans Administration (VA) D&I science meeting grew to more than 1,200 by 2011. Themes at this meeting addressed key evolving issues within the implementation science field, including multilevel interventions, innovative implementation science designs, de-implementation, and global health. In 2013 (for that year only), the annual meeting changed format to a small invited working group meeting of implementation science experts that focused on consolidating research findings to date and identifying key areas for future research. Figure 1B.3 presents the conclusions of this meeting as summarized in Neta et al.20 In brief, key issues included measures and understanding of multilevel interventions, partnership research, fidelity to key intervention components, and external validity. Participants also identified priorities for future research, including the need for better understanding of contextual factors; economic issues; evolution, sustainability, and adaptation of programs; and pragmatic research designs.20

Figure 1B.3 Framework for enhancing the value of research for dissemination and implementation.|300x150px

Figure 1B.3Framework for enhancing the value of research for dissemination and implementation.

Source: Adapted from Neta G, Glasgow RE, Carpenter CR, et al. A framework for enhancing the value of research for dissemination and implementation. Am J Public Health . 2015; 105(1): 49–57.

This annual conference has grown in size and scope throughout the years. A record 702 abstracts were submitted for consideration for the 2017 annual conference. More than 1,000 people continue to participate each year, and the conference is now co-sponsored by NIH, Academy Health, AHRQ, the Patient Centered Outcomes Research Institute (PCORI), the Robert Wood Johnson Foundation, and the US Department of Veterans Affairs.

Dr. Glasgow’s appointment as Deputy Director for Implementation Science at DCCPS in 2010 coincided with an increased focus on implementation science. During Dr. Glasgow’s tenure at NCI (2010–2013), there were several implementation science activities within DCCPS as well as many new “external” collaborations and advances in the field to which the NCI group made substantial contributions; these are summarized in a 2012 trans-NIH publication.21 Examples of interagency activities during 2010–2013 include a key interagency conference co-sponsored by the NCI Implementation Science (IS) team with then new PCORI on key contextual factors and challenges faced by patients with multiple chronic conditions.22

Several activities revolved around expanding the implementation science focus of existing DCCPS programs and activities. Several papers were published that reviewed, presented models for, and discussed cancer-related future directions for implementation science within the context of areas such as genomics and public health,23 comparative effectiveness research,24,25 cancer survivorship,26 cancer surveillance,27,28 advances in and the need for practical patient-report measures,29 and global health,30 as well as the general field of implementation science.31 Implementation science approaches across these areas emphasized cancer research that was pragmatic, rapid, and contextual and that produced results that were generalizable, equitable, and sustainable.

The NCI IS team played an important and often seminal role in terms of both scientific and programmatic leadership and also in funding of several trans-NIH and cross-agency initiatives. An important goal during this time was to extend the cancer-specific focus of DCCPS to a broader view of cancer as a chronic illness that related to and shared many of the same behavioral and biological determinants as other chronic illnesses. These included common psychosocial issues (e.g., disease distress and depression); the importance of physical activity and disease self-management;32 interactions with the health care system; health inequities;33 and the impact of health policy issues, especially family stress and financial hardships, on chronic illness development and management.

Possibly the most important cross-agency project during this period was the My Own Health Report (MOHR) project.34,35 This project culminated in an NCI DCCPS- and AHRQ-funded cluster randomized pragmatic trial in 18 diverse, primary care clinics throughout the country that collaborated to assess the feasibility, cost, and impact of efforts to systematically collect and act upon brief patient report questions assessing health behaviors (eating patterns, smoking, physical activity, and drug use), mental health issues (distress, depression, anxiety, and alcohol use), quality of life, and patient preferences. Although led by NCI, MOHR included active involvement from AHRQ, NIMH, the Office of Behavioral and Social Sciences Research (OBSSR), CDC, and the Society of Behavioral Medicine, among other partners. Approximately half of the clinic sites were associated with the CPCRN.

The goal of MOHR was to evaluate the consistency with which such patient-report measures could be collected, used to set patient-driven goals, and provide feedback to patients, primary care providers, and staff among a wide variety of patient populations and clinical settings. These settings included community health centers, rural offices, and inner-city clinics as well as academic-affiliated clinics serving underserved populations. MOHR utilized rapid research practices36 to accomplish its goals within a very short period of time and with very limited funding.37

Key findings from MOHR included that it was feasible to collect and provide feedback on these patient-centered issues in diverse settings.38 This was only possible by allowing local clinics to tailor the timing (a few days before a visit, at the beginning of a visit, or in the exam room), modality (e.g., web based, computer tablet, phone call, or read to low-literacy patients), and language (English and Spanish). Initial reports on the patterns and interrelationship of different health behaviors,37 time and costs required, and initial results have been published,39 and papers on other implementation issues are forthcoming.

Training in D&I Research

In 2011, NCI, NIMH, OBSSR, and VA led efforts to develop the week-long Training Institute on Dissemination and Implementation Research in Health (TIDIRH).40 The goal of the training was to provide participants with a thorough grounding in implementation science across all areas of health and health care. Faculty and guest lecturers consisted of leading experts (researchers, practitioners, and educators) in implementation and evaluation approaches to implementation science; creation of partnerships and multilevel transdisciplinary research teams; research design, methods, and analyses appropriate for implementation science investigations; and conducting research at multiple levels of intervention (e.g., clinical, community, and policy). Participants were expected to return to their home institutions and share what they had learned to grow the field of implementation science (e.g., giving scientific presentations, forming new collaborations, mentoring, and submitting grant proposals).

Since 2011, more than 1,250 investigators have applied to TIDIRH, and approximately 200 investigators have participated in training. Since 2014, based on the success of the TIDIRH program, less centralized and more focused training programs, such as the Mentored Training in Dissemination and Implementation Research in Cancer at Washington University in St. Louis41,42and the Implementation Research Training Program in Cancer Prevention and Control at the University of Massachusetts Medical School, have been funded by NCI to further expand the pool of implementation scientists.

In 2014, NCI began developing a number of important international collaborations to help foster the growth and understanding of implementation science methodological challenges and research methods. International collaboration has primarily focused on training investigators. NCI collaborated with Argentina’s Ministry of Health on a implementation science workshop. The aim was to build a critical mass of cancer control researchers, program managers, and decision-makers with a knowledge of implementation science to promote the systematic uptake of EBIs to reduce the cancer. Sixty-three trainees participated in the 3-day training in Buenos Aires in November 2014. At least one of the trainees was awarded a competitive grant from the Argentina Ministry of Health for the proposal developed at this training.

Also in 2014, NCI began collaborating with the Union for International Cancer Control (UICC) to deliver master’s courses on implementation science. The first master’s course was designed to deliver a condensed version of the annual TIDIRH training to researchers who attended the 2014 UICC World Cancer Congress in Melbourne, Australia. A second master’s course was delivered in 2016 as part of the UICC World Cancer Congress in Paris. These master’s courses consisted of six webinars delivered between 3 and 6 months with an online interactive course component managed on a wiki site where participants could engage with faculty and other trainees on the development of research proposals. The course concluded with a 1-day in-person training session the day before the World Cancer Congress convened.

Based on evaluation and feedback from the initial UICC master’s course, NCI modified the online/in-person training and developed a different master’s course in implementation science for a new partnership with the US Agency for International Development (USAID) Partnerships for Enhanced Engagement in Research (PEER) program. A modified version of the course was open to eligible investigators from low- and middle-income countries in Southeast Asia (2015) and the Middle East (2016). The course was redesigned so that six webinars were delivered over 3 months. The webinars were prerecorded, and participants were able to complete assigned coursework over the 3-month period. All coursework had to be submitted via an online wiki platform in order for in-person training to be supported. The in-person training was extended to a 3-day in-person training with ample time spent in small groups working on individual implementation science grant proposals. Fifty investigators have participated in these trainings. To date, one of the investigators has received funding for her research project by the Ministry of Health in her country, and a second has received funding from the Conquer Cancer Foundation for her research.

In 2016, based on the experience from the international trainings with UICC and USAID, a new TIDIRH training model was piloted that delivered key trainings via webinars over a 3-month period and required trainees to engage in online coursework prior to participating in a 2-day in-person training. The goal of this pilot was to increase reach, reduce costs, and enhance sustainability to meet the growing demand for this training. Results from this pilot will be reported once the program has been completed.

Summary and Future Directions

The NCI has played a leadership role in the development of cancer prevention and control intervention and surveillance research, and implementation science more generally. Within NCI, the growth of its cancer prevention and control intervention research portfolio from 1982 through 1996 led to the recognition that absent a new focus on implementation science and a new infrastructure to integrate the lessons learned from research with the lessons learned from practice and policy, the limited diffusion of research evidence through publications and scientific presentations alone would not be sufficient to reduce the burden of cancer for all Americans.

With respect to more action-oriented research dissemination, NCI has also played a leadership role in developing and nurturing research, practice, and policy partnerships both within government (e.g., AHRQ, CDC, Health Resources and Services Administration, SAMHSA, and the VA) and with outside organizations and agencies (e.g., ACS, Robert Wood Johnson Foundation, PCORI, and the National Commission on Aging) sharing a concern for how the lessons learned from science can better influence cancer and chronic disease prevention and control practices and policies. Examples of these collaborations include the Cancer Control P.LA.N.E.T. web portal, including the RTIPs component;16 the CPCRN;17 and a series of scientific and think tank meetings to engage the research, practice, and policy communities in helping identify new and innovative approaches to integrating the lessons learned from science with those from practice and policy.

Although this chapter has focused on the development of research dissemination and diffusion tools and resources, and the growth and development of implementation science coordinated and led by NCI domestically and internationally (see Figure 1B.1), the research funding framework for implementation science and its translation into practice and policy also bear some commentary.

Soon after his arrival in 2001 as the director of NCI, Dr. Andrew von Eschenbach articulated a new vision of how NCI-funded science could lead to the elimination of death and suffering from cancer by 2015.43 Although 2015 has passed without having achieved this laudable goal, Dr. von Eschenbach’s editorial laid out an ambitious plan to seamlessly link discovery, development, and delivery of cancer research findings to reduce the time between “bench and bedside.” Discovery was described as the process that generates new knowledge about fundamental cancer-related processes at the genetic, molecular, cellular, organ, person, and population levels. Development was the process of creating and evaluating tools and interventions to reduce cancer burden, including the prevention, detection, diagnosis, and treatment of cancer and its sequelae. Delivery was the process of disseminating, facilitating, and promoting evidence-based prevention, early detection, diagnosis, and treatment practices and policies to reduce the burden of cancer in all segments of the population. To reach all segments of the population, NCI must especially focus its efforts on those populations who bear the greatest burden of disease.

In the first author’s work in Canada for the Canadian Partnership Against Cancer, Dr. Kerner employed this three D model and led a transdisciplinary Canadian research working group to adapt it into a framework for collaborative action in cancer prevention research funding for the Canadian Cancer Research Alliance.44

Figure 1B.4 provides a further adaptation of this three D framework to fit what we view as the challenge for NCI of finding the right balance between investments in fundamental discovery, translational, and intervention development research in relation to delivery and implementation science. As reflected in Figure 1B.4, much of discovery, translational, and intervention research is investigator initiated and obtains its funding through open competition pools of available research dollars. Conversely, much of delivery and implementation science is driven by focused requests for application funding announcements and by necessity requires greater cooperation and collaboration between researchers, practitioners, and policymakers to ensure that the science being proposed is well aligned with the contextual factors and local community conditions so as to translate delivery and implementation science findings into practical programs and policies.

Figure 1B.4 Conceptual model: Dissemination and implementation research funding context.|300x155px

Figure 1B.4Conceptual model: Dissemination and implementation research funding context.

Source: Adapted from Canadian Cancer Research Alliance. Canadian Cancer Research Alliance (2012). Cancer Prevention Research in Canada: A Strategic Framework for Collaborative Action . Toronto: CCRA.

Currently, the balance of research investment is heavily weighted in the area of discovery, translational, and intervention development research. As the research investment in applied (e.g., delivery and implementation) science has grown, some concerns have been voiced among basic scientists and clinical investigators that resources for their important foundational and translational research priorities are being reduced because of this growth.45 Although it is difficult to discern the trends in the exact funding proportions for basic, translational, intervention development, delivery, and implementation science at NCI, two overall trends are clear. First, whereas overall NIH funding for basic discovery research has declined from approximately $18 billion in 2003 to approximately $15 billion in 2016, applied research funding has plateaued to approximately $13 billion in 2016.46 Second, within NCI, although there has been considerable growth in implementation science funding from 2001 to 2016, largely from the grants funded through the NIH D&I PAR, it remains an extremely small proportion of the overall research funding envelope of NCI (2016 congressionally enacted budget of $5,213,509M) and will probably remain so for the foreseeable future.

Thus, NCI must work together even more assiduously with other research, practice, and policy intermediary organizations to ensure that the emerging implementation science findings do not simply “gather dust” in libraries or in online publication repositories. In particular, health policy issues have received very modest funding. NCI-funded implementation science must be translated into evidence-based implementation practices and policies that accelerate the adoption, adaptation, and implementation of evidence-based interventions to more rapidly and more equitably reduce the burden of cancer for all Americans. Future implementation science efforts in cancer research should build on and enhance the activities summarized in this chapter, including a focus on multisector partnerships; pragmatic research models, methods, and measures; and integration of research, practice, and policy activities that are culturally and contextually appropriate, sustainable, and reduce health inequities.