1. Eastman, Peggy

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A new committee of the National Academies of Sciences, Engineering, and Medicine held its first meeting in Washington, D.C., to study national cancer control efforts and formulate an updated strategy to reduce the U.S. burden of cancer and improve the quality of life for cancer survivors. The ambitious study is supported by the NCI, American Cancer Society, and CDC.

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The multidisciplinary committee plans to hold a second meeting in October in California and release the report containing its recommendations in Spring 2019, said Committee Chair Michael Johns, MD, Chancellor Emeritus, Professor of Medicine and Public Health at Emory University and Former President and CEO of Emory Healthcare. Johns told Oncology Times the report will go through an extensive review process by outside reviewers before its release.


Johns, whose medical/surgical background is in head and neck cancer, noted the committee's challenge will be to determine what new strategic recommendations should be made, given previous reports and advances in science. A number of reports on the U.S. cancer system infrastructure system have been published by the National Academies, including A National Cancer Clinical Trials System for the 21st Century (2010), and Delivering High-Quality Cancer Care (2013).


The 2013 report stated that the cancer care delivery system is in crisis because of an aging population and the projected increase in cancer cases; workforce shortages; the rising costs of cancer care; information overload of clinicians due to advances in scientific knowledge; and limitations of the tools used to improve the quality of care. That report found that cancer care delivery is often "not as patient-centered, accessible, coordinated, or evidence-based as it could be, detrimentally impacting patients."


Asked if the new committee intends to plan an event to present its findings to Congress next spring, since Congressional appropriations fund cancer research, Johns said the committee should probably start thinking now about how its recommendations can have the most impact on Capitol Hill.


The first meeting was an information-gathering one designed to examine the "essential ingredients that are needed to transform cancer control," said Johns. "Cancer is a growing public health challenge globally," he noted, and while U.S. deaths have dropped annually since the 1990s, it still represents millions of U.S. diagnoses (1.7 million projected for 2018) and claims thousands of patients (600,000 U.S. deaths projected for 2018). Johns posed these questions: How can we do better? What needs to be done differently? How can the concept of "control," which has been defined and applied narrowly in practice, be expanded?


Under its broad charge, the new committee will consider potential actions:


* establish comprehensive national goals for cancer control; identify potential mechanisms to evaluate and advance progress toward these goals;


* identify challenges to achieving these goals and highlight knowledge gaps that impede progress in cancer control;


* foster collaboration and coordination among key stakeholders, clarifying roles in cancer control efforts, building on existing efforts, and developing and implementing plans of action to overcome challenges; and


* prioritize cancer control interventions that have the potential to achieve significant progress in improving population health and reducing health disparities.



Invited speakers at the meeting addressed some of these issues.


Coordinated Efforts

Leslie Given, MPA, Vice President of Strategic Health Concepts, urged the new committee to stress the need for coordination across silos and the need to build on the work of coalitions in cancer control. Fragmentation and silos make progress at all levels more difficult, said Given, who helped develop the National Comprehensive Cancer Control Program of the CDC. "Coalitions are engines of change." Coalitions among academia, business, government, professional medical societies, and advocacy groups are the cornerstone of comprehensive cancer control, she stressed. She cited the network of cancer coalitions around the U.S., including data-driven state cancer control plans, which she called "blueprints for action." These are "waiting for a unified vision," Given told the committee. "We need to attach funding to the vision."


Asked by Oncology Times what effect precision medicine is likely to have on a national cancer control strategy, Given said, "I would suggest that we take a more precautionary approach to precision medicine. Let's not jump into this feet first." She said care needs to be taken before expanding precision medicine to the entire population.


The committee should take a new look at cancer screening with an eye to cost-effective analysis, said Louise B. Russell, PhD, Distinguished Professor Emerita at Rutgers University and an Adjunct Professor of Medical Ethics and Health Policy at the University of Pennsylvania. "By itself, screening doesn't make people healthier; only successful treatment does," said Russell, who co-chaired the U.S. Public Health Service panel on cost-effectiveness in health and medicine. "We've been very slow to move away from annual screening in the U.S."


She suggested that the committee study targeted screening, lengthening the intervals between screenings when appropriate, improving the accuracy of screenings, improving follow-up of abnormal screen results, and reducing adverse effects from screening.


Communication Strategies

Clear communication to the public is essential in any national cancer control strategy, emphasized Elizabeth A. Platz, ScD, Professor and Deputy Chair of the Department of Epidemiology at the Johns Hopkins Bloomberg School of Public Health and Co-Leader of the Cancer Prevention and Control Program at Hopkins' Sidney Kimmel Comprehensive Cancer Center. She stressed that an effective communication plan is especially important when there are changes in a national cancer control strategy; otherwise the public becomes confused and the strategy is undermined.


Platz cited the massive decline in the U.S. smoking rate, which she attributed in part to successful cancer control efforts. She urged the committee to build on these efforts for the segment of the population that still smokes, by supporting tobacco-free campuses and universities; tobacco cessation for cancer patients who smoke at the time of diagnosis; and smoking quit lines, with texts as well as telephone messages.


Platz also said the committee should consider better uptake of current cancer control strategies, such as HPV vaccination, labeling of foods for calorie content, and restrictions on tanning bed use. Like Russell, she urged the committee to consider cost-effectiveness in its deliberations. "We need to incorporate cost-effectiveness into our cancer control strategies," which is done routinely in other countries, she noted.


Simulation Modeling

Simulation modeling can evaluate the impact of cancer control interventions and evaluate their contribution to different populations, said Eric J. Feuer, PhD, Chief of the Statistical Research and Applications Branch of the Division of Cancer Control and Population Sciences at the NCI. He is also NCI Project Scientist for the Cancer Intervention and Surveillance Modeling Network (CISNET), a collaborative group of investigators who use simulation modeling to guide public health research and priorities.


Feuer noted that CISNET's work has had a major effect on helping the U.S. Preventive Services Task Force set cancer screening guidelines-on mammography, for example. Feuer cited breast cancer as an example of an area where simulation modeling can help to predict subtype mortality. He urged the committee to consider modeling as part of an overall cancer control strategy.


Asked by Oncology Times if modeling can be used for risk-stratified screening, Feuer said yes. But he noted that it is important to consider a person's values in cancer screening as well as risk. For example, he said, one person may be thrilled to hear that he doesn't need another colonoscopy because he is at low-risk, whereas a second person given the same information might think she was being denied medical care. Feuer said that, while there has been a lot of interest in risk-stratified screening, there is a concern that such a strategy could be too complex to implement practically in the general population.


Agreeing on the need for modeling in designing a national cancer control strategy was Anna D. Barker, PhD, Professor and Director of Transformative Healthcare Networks and Co-Director of Arizona State University's Complex Adaptive Systems Initiative. "If we can't model this disease, we can't control it," said Barker, who-while working at the NCI-developed and led or co-led trans-disciplinary programs, including the Nanotechnology Alliance for Cancer, Cancer Genome Atlas, and Clinical Proteomics Technologies Initiative. Barker stressed the need for predictive disease models which foster the management of cancer as an emergent complex adaptive system.


As the committee designs its U.S. cancer control strategy, "Quality cancer data are essential," said Christopher Cogle, MD, Professor of Medicine at the University of Florida and Chair of the Florida Cancer Control and Research Advisory Council. He noted that in studying the Florida cancer registry, for example, he and his colleagues found troubling gaps in data. He said they had to convince legislators that they needed to put more money into their state cancer registry.


"It would have been helpful to have had a national cancer plan that would have buttressed our efforts," said Cogle. He noted that with the coming of the "silver tsunami," the aging of the population, there will be an opportunity to better understand aging-acquired cancers, making quality cancer data even more important.


Focus on Patient Care

Several speakers urged the committee to place adequate focus on palliative care in its deliberations on a national cancer control strategy. "Aggressive end-of-life cancer care is worse care," said Holly G. Prigerson, PhD, the Irving Sherwood Wright Professor of Geriatrics at Weill Cornell Medical College; Professor of Sociology in Medicine; and Director of the Cornell University Center for Research on End-of-Life Care. Not only is the quality of life worse when the patient is subjected to multiple interventions unlikely to do much good, but "it's also hugely expensive," she said. Noting that an inordinate amount of Medicare money is spent on the last week of life, Prigerson said, "You can't buy a better death."


She said it is important for advanced cancer patients to "get the gist" of how long they have to live, understanding that they have months, not years. She added that oncologists need to discuss end-of-life issues with their patients, honestly addressing issues of values and the quality of the patient's life.


"We need to incorporate patients with advanced cancer into our state cancer control plans," agreed Lee Schwartzberg, MD, Executive Director of the West Cancer Center; Professor of Medicine; and Chief of the Division of Hematology/Oncology at the University of Tennessee Health Science Center. He noted that this incorporation of advanced cancer patients is already being done with breast cancer.


Schwartzberg, founding Editor-in-Chief of the journal Community Oncology, also urged the committee to consider workforce issues in its deliberations-especially in community oncology, since some 80 percent of cancer patients are treated in the community. He noted that mergers and acquisitions are the norm today in community cancer care practices, and the implications of consolidation have to be considered when it comes to a national cancer control strategy.


Also, "Cancer centers today are being asked to do more and more," emphasized Schwartzberg, and many of these services are non-reimbursable, unfunded mandates. He noted that his center has embraced patient-centered care, providing extended care and weekend hours, offering shared decision-making, and routinely collecting patient-centered outcomes of care.


"Once patients are diagnosed they have a strong attachment to their oncologist," said Schwartzberg. But, he noted, the oncology workforce is shrinking at a time when there is increased demand for cancer care, and that has to be considered in any comprehensive U.S. cancer control strategy. As previously reported in Oncology Times, according to a 2017 survey from the Association of Community Cancer Centers, 47 percent of survey respondents reported full-time equivalent (FTE) vacancies for oncologists, 60 percent reported FTE vacancies for oncology nurses, and 35 percent had openings for advanced practitioners.


Peggy Eastman is a contributing writer.


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