Implementation science in cancer prevention and control: a framework for research and programs in low- and middle-income countries

Cancer in People with HIV

We review the intersection of human immunodeficiency virus (HIV) and cancer globally, including the complex interplay of oncogenic infections, chronic inflammation, and behavioral and other factors in increasing cancer risk among people with HIV (PWH). We discuss current cancer screening, prevention, and treatment recommendations for PWH. Specific interventions include vaccination, behavioral risk reduction, timely HIV diagnosis and treatment, screening for specific cancer sites, and multifaceted treatment considerations unique to PWH including supportive care and drug interactions. Finally, the potential of novel therapies and the need for inclusive cancer clinical trials are highlighted. Collaborative multidisciplinary efforts are critical for continued progress against cancer among PWH.

The Past and Future of Inflammation as a Target to Cancer Prevention

Inflammation is an essential defense mechanism in which innate immune cells are coordinately activated on encounter of harmful stimuli, including pathogens, tissue injury, and toxic compounds and metabolites to neutralize and eliminate the instigator and initiate healing and regeneration. Properly terminated inflammation is vital to health, but uncontrolled runaway inflammation that becomes chronic begets a variety of inflammatory and metabolic diseases and increases cancer risk. Making damaged tissues behave as "wounds that do not heal" and sustaining the production of growth factors whose physiologic function is tissue healing, chronic inflammation accelerates cancer emergence from premalignant lesions. In 1863, Rudolf Virchow, a leading German pathologist, suggested a possible association between inflammation and tumor formation, but it took another 140 years to fully elucidate and appreciate the tumorigenic role of inflammation. Key findings outlined molecular events in the inflammatory cascade that promote cancer onset and progression and enabled a better appreciation of when and where inflammation should be inhibited. These efforts triggered ongoing research work to discover and develop inflammation-reducing chemopreventive strategies for decreasing cancer risk and incidence.

Global Cancer Drug Development-A Report From the 2022 Accelerating Anticancer Agent Development and Validation Meeting

Rapidly expanding systemic treatment options, combined with improved screening, diagnostic, surgical, and radiotherapy techniques, have led to improved survival outcomes for many cancers over time. However, these overall survival gains have disproportionately benefited patients in high-income countries, whereas patients in low- and middle-income countries (LMICs) continue to experience challenges in accessing timely and guideline concordant care. In September 2022, the Accelerating Anticancer Agent Development and Validation workshop was held, focusing on global cancer drug development. Panelists discussed key barriers such as the lack of diagnostic services and human resources, drug accessibility and affordability, lack of research infrastructure, and regulatory and authorization challenges, with a particular focus on Africa and Latin America. Potential opportunities to improve access and affordability were reviewed, such as the importance of prioritizing investments in diagnostics, investing health infrastructure and work force planning, coordinated drug procurement efforts and streamlined regulatory processing, incentivized pricing through regulatory change, and the importance of developing and promoting clinical trials that can answer relevant clinical questions for patients in LMICs. As a cancer community, we must continue to advocate for and work toward equitable access to high-quality interventions for patients, regardless of their geographical location.

Downregulation of miR-599 predicts poor outcome in cervical cancer patients and promotes the progression of cervical cancer

OBJECTIVE

Cervical cancer remains a leading cause of gynecological cancer-related death. In this study, we aimed to investigate the expression pattern of miR-599 and its prognostic significance in cervical cancer.

MATERIALS AND METHODS

The RT-qPCR analysis was used to detect the expression levels of miR-599 in cervical cancer tissues and cell lines. The association between miR-599 expression and clinical characteristics of cervical cancer patients was analyzed using the χ² test. The Kaplan-Meier analysis and multivariate Cox proportional hazards model were used to explore the prognostic significance of miR-599. Then, CCK-8 assays, transwell migration, and invasion assays were used to assess the effects of miR-599 on tumor cell proliferation, migration, and invasion of cervical cancer cells, respectively.

RESULTS

miR-599 expression was significantly downregulated in cervical cancer tissues and cells compared with non-cancerous tissues and HaCaT cells, respectively. Statistical analysis revealed that miR-599 expression was associated with lymph node metastasis and FIGO stage. The miR-599 expression was an independent prognostic factor for overall survival. Functionally, overexpression of miR-599 suppressed cell proliferation, migration, and invasion of cervical cancer cells, while downregulation of miR-599 had opposite effects.

CONCLUSION

miR-599 acts as a tumor suppressor in cervical cancer that inhibiting cell proliferation, migration, and invasion of cervical cancer cells, suggesting that miR-599 may be a potential prognostic biomarker and novel targeted strategy for cervical cancer.

C/Can City Engagement Process: An Implementation Framework for Strengthening Cancer Care in Cities in Low- and Middle-Income Countries

The effective implementation of locally adapted cancer care solutions in low- and middle-income countries continues to be a challenge in the face of fragmented and inadequately resourced health systems. Consequently, the translation of global cancer care targets to local action for patients has been severely constrained. City Cancer Challenge (C/Can) is leveraging the unique value of cities as enablers in a health systems response to cancer that prioritizes the needs of end users (patients, their caregivers and families, and health care providers). C/Can’s City Engagement Process is an implementation framework whereby local stakeholders lead a staged city-wide process over a 2- to 3-year period to assess, plan, and execute locally adapted cancer care solutions. Herein, the development and implementation of the City Engagement Process Framework (CEPF) is presented, specifying the activities, outputs, processes, and indicators across the process life cycle. Lessons learned on the application of the framework in the first so-called Key Learning cities are shared, focusing on the early outputs from Cali, Colombia, the first city to join C/Can in 2017. Creating lasting change requires the creation of a high-trust environment to engage the right stakeholders as well as adapting to local context, leveraging local expertise, and fostering a sustainability mindset from the outset. In the short term, these early learnings inform the refinement of the approach in new cities. Over time, the implementation of this framework is expected to validate the proof-of-concept and contribute to a global evidence base for effective complex interventions to improve cancer care in low- and middle-income countries.

The role of dissemination and implementation science in global breast cancer control programs: Frameworks, methods, and examples

Global disparities in breast cancer outcomes are attributable to a sizable gap between evidence and practice in breast cancer control and management. Dissemination and implementation science (D&IS) seeks to understand how to promote the systematic uptake of evidence-based interventions and/or practices into real-world contexts. D&IS methods are useful for selecting strategies to implement evidence-based interventions, adapting their implementation to new settings, and evaluating the implementation process as well as its outcomes to determine success and failure, and adjust accordingly. Process models, explanatory theories, and evaluation frameworks are used in D&IS to develop implementation strategies, identify implementation outcomes, and design studies to evaluate these outcomes. In breast cancer control and management, research has been translated into evidence-based, resource-stratified guidelines by the Breast Health Global Initiative and others. D&IS should be leveraged to optimize the implementation of these guidelines, and other evidence-based interventions, into practice across the breast cancer care continuum, from optimizing public education to promoting early detection, increasing guideline-concordant clinical practice among providers, and analyzing and addressing barriers and facilitators in health care systems. Stakeholder engagement through processes such as co-creation is critical. In this article, the authors have provided a primer on the contribution of D&IS to phased implementation of global breast cancer control programs, provided 2 case examples of ongoing D&IS research projects in Tanzania, and concluded with recommendations for best practices for researchers undertaking this work.

Strengthening breast surgery workforce capacity: implementation of competency-based training programme

BACKGROUND AND RATIONALE

Quality education is a prerequisite for building a sustainable health system. To address this requirement, it is necessary to strengthen capacity and expand the training opportunities to ensure equitable and efficient development of core professional competencies for specific contexts and educational needs.

METHODS AND RESULTS

A competency-based training programme for Breast Surgeons was built and was applied based on the Consolidated Framework for Implementation Research (CFIR). This framework provides a pragmatic structure for approaching complex interactions, multi-level and transient constructs in the real world. CFIR guided the implementation process and verified what works, where and why across each step. CFIR guided implementation was through an adaptable approach of the domains and creating relevant constructs that set up an ideal roadmap to analyse and improve learning needs, the curriculum design and the learning environment.

CONCLUSION

The outcomes described in this manuscript demonstrate that evidence-based principles can be implemented in health professionals' training and clinical practice even in resource-constrained settings. Building strong and sustainable healthcare workforce capacity is an urgent need for improved health service delivery and addresses real-life workplace needs in low-middle income countries. This programme integrates training with service to solve problems and develop initiatives to address existing local health priorities. While the article focuses on a training programme development, findings are shared to promote dissemination into other settings.

Conceptual Framework to Guide Early Diagnosis Programs for Symptomatic Cancer as Part of Global Cancer Control

Diagnosing cancer earlier can enable timely treatment and optimize outcomes. Worldwide, national cancer control plans increasingly encompass early diagnosis programs for symptomatic patients, commonly comprising awareness campaigns to encourage prompt help-seeking for possible cancer symptoms and health system policies to support prompt diagnostic assessment and access to treatment. By their nature, early diagnosis programs involve complex public health interventions aiming to address unmet health needs by acting on patient, clinical, and system factors. However, there is uncertainty regarding how to optimize the design and evaluation of such interventions. We propose that decisions about early diagnosis programs should consider four interrelated components: first, the conduct of a needs assessment (based on cancer-site-specific statistics) to identify the cancers that may benefit most from early diagnosis in the target population; second, the consideration of symptom epidemiology to inform prioritization within an intervention; third, the identification of factors influencing prompt help-seeking at individual and system level to support the design and evaluation of interventions; and finally, the evaluation of factors influencing the health systems' capacity to promptly assess patients. This conceptual framework can be used by public health researchers and policy makers to identify the greatest evidence gaps and guide the design and evaluation of local early diagnosis programs as part of broader cancer control strategies.

Resource-Stratified Guideline-Based Cancer Care Should Be a Priority: Historical Context and Examples of Success

Low- and middle-income countries (LMICs) are shouldering most of the burden of the rapidly increasing cancer incidence and mortality worldwide, and this situation is projected to worsen in coming decades. Studies estimate that more than one million deaths could be prevented annually if all patients received high-quality care, but most LMICs lack the resources and infrastructure to adopt U.S. or European clinical oncology practice guidelines. Several organizations have developed resource-stratified guidelines (RSGs) to provide graduated and/or region-specific strategies for cancer diagnosis and treatment. The birth of these efforts traces to 2002, when the World Health Organization (WHO) called for tailoring cancer treatments to the level of available resources by country; the Breast Health Global Initiative (BHGI) formalized the first stratified guidelines for breast cancer shortly thereafter. Since then, multiple organizations including ASCO and the National Comprehensive Cancer Network (NCCN) have created guidelines customized for various cancer subtypes and regions. These RSGs offer roadmaps for policy makers, clinicians, and health care administrators in LMICs to design projects in implementation science that can gradually and strategically raise the quality of cancer care in their nation or region. Although the same resource limitations that complicate cancer care in these areas also pose barriers to data gathering and research, some countries have met the challenge and are improving cancer care using RSGs as a metric for success.

Natural Language Processing for Surveillance of Cervical and Anal Cancer and Precancer: Algorithm Development and Split-Validation Study

Background

Accurate identification of new diagnoses of human papillomavirus–associated cancers and precancers is an important step toward the development of strategies that optimize the use of human papillomavirus vaccines. The diagnosis of human papillomavirus cancers hinges on a histopathologic report, which is typically stored in electronic medical records as free-form, or unstructured, narrative text. Previous efforts to perform surveillance for human papillomavirus cancers have relied on the manual review of pathology reports to extract diagnostic information, a process that is both labor- and resource-intensive. Natural language processing can be used to automate the structuring and extraction of clinical data from unstructured narrative text in medical records and may provide a practical and effective method for identifying patients with vaccine-preventable human papillomavirus disease for surveillance and research.

Objective

This study's objective was to develop and assess the accuracy of a natural language processing algorithm for the identification of individuals with cancer or precancer of the cervix and anus.

Methods

A pipeline-based natural language processing algorithm was developed, which incorporated machine learning and rule-based methods to extract diagnostic elements from the narrative pathology reports. To test the algorithm’s classification accuracy, we used a split-validation study design. Full-length cervical and anal pathology reports were randomly selected from 4 clinical pathology laboratories. Two study team members, blinded to the classifications produced by the natural language processing algorithm, manually and independently reviewed all reports and classified them at the document level according to 2 domains (diagnosis and human papillomavirus testing results). Using the manual review as the gold standard, the algorithm’s performance was evaluated using standard measurements of accuracy, recall, precision, and F-measure.

Results

The natural language processing algorithm’s performance was validated on 949 pathology reports. The algorithm demonstrated accurate identification of abnormal cytology, histology, and positive human papillomavirus tests with accuracies greater than 0.91. Precision was lowest for anal histology reports (0.87, 95% CI 0.59-0.98) and highest for cervical cytology (0.98, 95% CI 0.95-0.99). The natural language processing algorithm missed 2 out of the 15 abnormal anal histology reports, which led to a relatively low recall (0.68, 95% CI 0.43-0.87).

Conclusions

This study outlines the development and validation of a freely available and easily implementable natural language processing algorithm that can automate the extraction and classification of clinical data from cervical and anal cytology and histology.

Underutilisation of nuclear medicine scans at a regional hospital in Nigeria: need for implementation research

Background

Nuclear medicine needs better integration into the Nigerian health system. To understand the relevant public health initiatives that will be required, this study assessed the pattern of nuclear medicine imaging services at the first nuclear medicine centre in Nigeria from January 2010 to December 2018.

Methods

The data of consecutive nuclear medicine (NM) scans performed between 1st January 2010 and 31st December 2018 at the NM department in a tertiary hospital in Nigeria were extracted from patient records and analysed using SAS version 9.4 (SAS Institute, Cary, NC). The National Cancer Institute’s Joinpoint software and QCIS (QGIS project) were used to estimate imaging trends and geographical spread of patients.

Results

An average of 486 scans per year was performed during the study period. Patients travelled from 32 of Nigeria’s 36 states, and the majority (65%) travelled more than 100 km to obtain NM scans. Bone scans accounted for 88.1% of the studies. The remainder were renal scintigraphy (7.3%), thyroid scans (2.5%), whole-body iodine scans (1.7%) and others (0.4%).

Conclusions

NM in Nigeria appears underutilised. Furthermore, the studies to characterise the access gaps and implementation needs will contribute to the design of practical strategies to strengthen NM services in Nigeria.

Developing a conceptual framework for implementation science to evaluate a nutrition intervention scaled-up in a real-world setting

Objective:

The aim of this paper is to identify and develop a comprehensive conceptual framework using implementation science that can be applied to assess a nutrition intervention in a real-world setting.

Design:

We conducted a narrative review using electronic databases and a manual search to identify implementation science frameworks, models and theories published in peer-reviewed journals. We performed a qualitative thematic analysis of these publications to generate a framework that could be applied to nutrition implementation science.

Results:

Based on this review, we developed a comprehensive framework which we have conceptualised as an implementation science process that describes the transition from the use of scientific evidence through to scaling-up with the aim of making an intervention sustainable. The framework consisted of three domains: Domain i – efficacy to effectiveness trials, Domain ii – scaling-up and Domain iii – sustainability. These three domains encompass five components: identifying an ‘effective’ intervention; scaling-up and implementation fidelity; course corrections during implementation; promoting sustainability of interventions and consideration of a comprehensive methodological paradigm to identify ‘effective’ interventions and to assess the process and outcome indicators of implementation. The framework was successfully applied to a nutrition implementation program in Bangladesh.

Conclusions:

Our conceptual framework built from an implantation science perspective offers a comprehensive approach supported by a foundational and holistic understanding of its key components. This framework provides guidance for implementation researchers, policy-makers and programme managers to identify and review an effective intervention, to scale it up and to sustain it over time.

Mortality from oral and oropharyngeal cancer in Brazil: impact of the National Oral Health Policy

The objective was to investigate if there is an association between the mortality rates due to oral and oropharyngeal cancer in Brazil and the expansion of access to public primary and specialized dental care services that resulted from the implementation of the National Oral Health Policy, between 2000 and 2013. The mortality data were obtained from the records of the Mortality Information System and the exposure variables were obtained from databases of the Brazilian Ministry of Health and the Brazilian Institute of Geography and Statistics. The main exposures investigated were "coverage of primary dental care" and "number of specialized dental care centers". Additional covariates included "Gini index of household income", "average number of years of study", "proportion of unemployed people" and "proportion of smokers". For the statistical analysis, a random coefficient model was used. There was a statistically significant association between the mortality rates by oral and oropharyngeal cancer with coverage by primary dental care and the number of specialized dental care centers with males. This study found that the expansion of the coverage of primary dental care and the number of specialized dental care centers are associated with the reduction of mortality rates due to oral and oropharyngeal cancer in Brazil. There is plausibility for the association found, which needs to be confirmed by implementation studies.

A synthesis of implementation science frameworks and application to global health gaps

Background

Implementation science has been growing as discipline in the past decades, producing an increasing number of models in the area. On the other hand, most frameworks are intended to guide the implementation of programs, focusing on identifying elements and stages that increase their success. This article aims to structure this discussion, proposing a simplified tool that synthesizes common elements of other frameworks, and highlight the usefulness to use implementation science not only in identifying successful implementation strategies but as a tool to assess gaps in global health initiatives.

Methods

The study was carried out through a combined methodology that included an initial search of implementation science frameworks, experts’ opinions, and the use of references in frameworks to elaborate a list of articles to be reviewed. A total of 52 articles were analyzed, identifying their definitions of implementation science and the elements of different frameworks.

Results

The analysis of articles allowed identifying the main goals and definitions of implementation science. In a second stage, frameworks were classified into “time-based”, “component-based” and “mixed”, and common elements of each type of model were used to propose a synthetic framework with six elements: Diagnosis, Intervention provider/ system, Intervention, Recipient, Environment, and Evaluation. Finally, this simplified framework was used to identify gaps in global health was using The Lancet Global Health Series. Potential areas of intervention arise for five different global health issues: malaria, non-communicable diseases, maternal and child health, HIV/AIDS, and tuberculosis. Prioritization strategies differ for the different health issues, and the proposed framework can help identify and classify all these different proposals.

Conclusions

There is a huge variety of definitions and models in implementation science. The analysis showed the usefulness of applying an implementation science approach to identify and prioritize gaps in implementation strategies in global health.

Electronic supplementary material

The online version of this article (10.1186/s41256-019-0115-1) contains supplementary material, which is available to authorized users.

Positive cancer care in Peru: Patient and provider perspectives

Peruvian women experience high mortality from reproductive cancers, partially due to suboptimal cancer care utilization and experiences. In this qualitative study, we examined factors contributing to positive cancer care experiences. Our sample included 11 cancer patients and 27 cancer providers who attended the First International Cancer Symposium survivorship conference in Lima, Peru in 2015. We conducted thematic analysis. Emergent themes revealed that, for patients, individualized empathic care by providers was an important facilitator to positive cancer care experiences. For providers, the ability to provide such care depended on provider norms and facility infrastructure to support such patient-centered practices.

Research Needs for Implementing Cancer Prevention and Early Detection in Developing Countries: From Scientists' to Implementers' Perspectives

Implementation of evidence-based cancer prevention and early detection in low- and middle-income countries (LMIC) is challenging. Limited and inappropriate introduction of novel alternatives results in an equity gap whereby low-income populations receive a lower benefit. Implementation research represents an opportunity to foster the adoption and expansion of evidence-based cancer control strategies; however, scientific development in high-income countries does not necessarily fulfill the particular needs of LMIC in the field. A review on the link between implementation research and practice, the tension between theory and pragmatism, the conflict around implementation research methods, and determinants of research priority definition was carried out by considering the perspective of cancer prevention and early detection implementers in LMIC. Basic principles and alternatives to overcome implementation research challenges in these settings are discussed.

Using a cross-contextual reciprocal learning approach in a multisite implementation research project to improve self-management for type 2 diabetes

This paper reports on the use of reciprocal learning for identifying, adopting and adapting a type 2 diabetes self-management support intervention in a multisite implementation trial conducted in a rural setting in a low-income country (Uganda), a periurban township in a middle-income country (South Africa) and socioeconomically disadvantaged suburbs in a high-income country (Sweden). The learning process was guided by a framework for knowledge translation and structured into three learning cycles, allowing for a balance between evidence, stakeholder interaction and contextual adaptation. Key factors included commitment, common goals, leadership and partnerships. Synergistic outcomes were the cocreation of knowledge, interventions and implementation methods, including reverse innovations such as adaption of community-linked models of care. Contextualisation was achieved by cross-site exchanges and local stakeholder interaction to balance intervention fidelity with local adaptation. Interdisciplinary and cross-site collaboration resulted in the establishment of learning networks. Limitations of reciprocal learning relate to the complexity of the process with unpredictable outcomes and the limited generalisability of results.

The 'Be Cancer Alert Campaign': protocol to evaluate a mass media campaign to raise awareness about breast and colorectal cancer in Malaysia

Background

Breast and colorectal cancer are the two most common cancers in Malaysia. Low awareness coupled with stigma and erroneous beliefs delay help-seeking behaviours, lead to late presentation and contribute to poor detection rates. Promoting cancer awareness through mass media may be effective in improving cancer-related knowledge and uptake in screening tests. However, research is sparse regarding the cultural translation and implementation of mass media campaigns in Malaysia (and Asia) in terms of raising awareness about colorectal and breast cancer.

Methods

A collaborative partnership comprising researchers from Malaysia and the UK as well as policy makers, public health experts and non-government organisations from Malaysia was formed to design, deliver and evaluate the Be Cancer Alert Campaign. Each awareness-raising campaign will run for five weeks (Colorectal Cancer in April 2018, followed by Breast Cancer in October 2018). Evaluation of the campaigns will take place in Gombak district (Colorectal Cancer) and Petaling district (Breast Cancer) respectively, in the form of a pre-post randomly selected household survey and collection of service utilisation data. Occupants who are aged 40-years and above and are able to answer questions independently will be selected from each household. A sample of 730 with 80% power will detect a change of 6.09% in knowledge that unexplained lump or swelling is a symptom of breast cancer or changes in bowel habits is a symptom of colorectal cancer.

Discussion

Malaysia and most South-East Asian countries have a low middle-income economy, with limited resources for cancer control. Late-staged cancers impose a significant economic burden on patients, households, communities, employers, health systems and governments. Our proposed strategy for the implementation of the culturally sensitive mass media cancer awareness-raising campaign will serve as a blueprint for cancer prevention and control policy in South-East Asian countries where the burden of cancer is increasing and there are high cancer death rates.

Research Priorities and Resource Allocation in the Investigation of New Drugs for Cancer in Least Developed Countries

Cancer incidence has increased significantly in low- and middle-income countries. The priorities of international health research are not always aligned with the global burden of cancer. This study aims to analyze global tendencies in clinical trials in oncology and discuss research priorities and resource allocation in the investigation of new drugs for cancers that significantly affect the least developed countries. This was a retrospective and analytical study that included data collected from the World Health Organization's International Clinical Trials Registry Platform (ICTRP) in 2014. According to our results, there was a tendency for clinical trials involving breast and lung cancer to be conducted in countries with a lower level of economic development. On the other hand, cervical, stomach, and liver cancer, despite the significant burden that these place on middle- and low-income countries, were studied little among the countries selected. In conclusion, the organizations that most fund research to develop new drugs for cancer treatment continue to show little interest in prioritizing resources to fund research for certain types of cancer such as those of the cervix, stomach, and liver, which have a significant impact in low- and middle-income countries.

Global Health Pathology Research: Purpose and Funding

Like in all areas of science, it is important for funders and investigators of pathology to work together to develop a well-designed, well-executed clinical research agenda. In the first section of this article, the authors discuss how the National Institutes of Health (NIH) peer-review process applies to global health pathology research projects. Then, the authors present an illustrative sampling of NIH-funded projects with performance sites in low- and middle-income countries with 2 examples focused on cancer and anatomic pathology. Finally, the authors relate the research agenda to overarching strategic recommendations for enhancing global pathology.

Population-based cancer screening programmes in low-income and middle-income countries: regional consultation of the International Cancer Screening Network in India

The reductions in cancer morbidity and mortality afforded by population-based cancer screening programmes have led many low-income and middle-income countries to consider the implementation of national screening programmes in the public sector. Screening at the population level, when planned and organised, can greatly benefit the population, whilst disorganised screening can increase costs and reduce benefits. The International Cancer Screening Network (ICSN) was created to share lessons, experience, and evidence regarding cancer screening in countries with organised screening programmes. Organised screening programmes provide screening to an identifiable target population and use multidisciplinary delivery teams, coordinated clinical oversight committees, and regular review by a multidisciplinary evaluation board to maximise benefit to the target population. In this Series paper, we report outcomes of the first regional consultation of the ICSN held in Agartala, India (Sept 5-7, 2016), which included discussions from cancer screening programmes from Denmark, the Netherlands, USA, and Bangladesh. We outline six essential elements of population-based cancer screening programmes, and share recommendations from the meeting that policy makers might want to consider before implementation.

Transforming Cancer Prevention through Precision Medicine and Immune-oncology

We have entered a transformative period in cancer prevention (including early detection). Remarkable progress in precision medicine and immune-oncology, driven by extraordinary recent advances in genome-wide sequencing, big-data analytics, blood-based technologies, and deep understanding of the tumor immune microenvironment (TME), has provided unprecedented possibilities to study the biology of premalignancy. The pace of research and discovery in precision medicine and immunoprevention has been astonishing and includes the following clinical firsts reported in 2015: driver mutations detected in circulating cell-free DNA in patients with premalignant lesions (lung); clonal hematopoiesis shown to be a premalignant state; molecular selection in chemoprevention randomized controlled trial (RCT; oral); striking efficacy in RCT of combination chemoprevention targeting signaling pathway alterations mechanistically linked to germline mutation (duodenum); molecular markers for early detection validated for lung cancer and showing promise for pancreatic, liver, and ovarian cancer. Identification of HPV as the essential cause of a major global cancer burden, including HPV16 as the single driver of an epidemic of oropharyngeal cancer in men, provides unique opportunities for the dissemination and implementation of public health interventions. Important to immunoprevention beyond viral vaccines, genetic drivers of premalignant progression were associated with increasing immunosuppressive TME; and Kras vaccine efficacy in pancreas genetically engineered mouse (GEM) model required an inhibitory adjuvant (Treg depletion). In addition to developing new (e.g., epigenetic) TME regulators, recent mechanistic studies of repurposed drugs (aspirin, metformin, and tamoxifen) have identified potent immune activity. Just as precision medicine and immune-oncology are revolutionizing cancer therapy, these approaches are transforming cancer prevention. Here, we set out a brief agenda for the immediate future of cancer prevention research (including a "Pre-Cancer Genome Atlas" or "PCGA"), which will involve the inter-related fields of precision medicine and immunoprevention - pivotal elements of a broader domain of personalized public health.

Government Service as a Public and Personal Good

The concerted, strategic efforts of government leaders can create rapid accelerations in knowledge and the application of that knowledge for the public good. Government service can represent part or all of one's career. Working at the National Institutes of Health (NIH) early in my career helped me develop a macro-level understanding of how the NIH operates, what forces propel change, how priorities are set, and how programs are developed. While leading a large division at the National Cancer Institute later in my career, after many years in a research institution and academia, we created new models for collaboration, including transdisciplinary centers, the first NIH unit focused on dissemination (now implementation science), and tools that enabled citizens, scientists, and others to access and use effective interventions, new data sets, and ways to aggregate data to show local cancer profiles. In this article, I provide my own career as an example of the opportunities afforded by federal service-for both individuals in government service and the public good.

Global health from a cancer care perspective

Cancer is now recognized as one of the four leading causes of morbidity and mortality worldwide, and incidence is expected to rise significantly in the next two decades. Unfortunately, low- and middle-income countries (LMIC) suffer disproportionately from the world's cancer cases. The growing burden of cancer and maldistribution of cancer care resources in LMIC warrant a massive re-evaluation of the structural inequalities that produce global oncological disparities and a worldwide commitment to improve both prevention and treatment strategies. Efforts to improve cancer care capacity should focus on horizontal strengthening of healthcare systems that provide safe, affordable, effective and sustainable care. In response to current deficiencies, many international organizations have started to partner with LMIC to create solutions. Telemedicine and international collaboration are also promising ways to effect change and improve global oncological care.

Using implementation science to advance cancer prevention in India

Oral, cervical and breast cancers, which are either preventable and/or amenable to early detection and treatment, are the leading causes of cancer-related morbidity and mortality in India. In this paper, we describe implementation science research priorities to catalyze the prevention and control of these cancers in India. Research priorities were organized using a framework based on the implementation science literature and the World Health Organization's definition of health systems. They addressed both community-level as well as health systems-level issues. Community-level or "pull" priorities included the need to identify effective strategies to raise public awareness and understanding of cancer prevention, monitor knowledge levels, and address fear and stigma. Health systems-level or "push" and "infrastructure" priorities included dissemination of evidence- based practices, testing of point-of-care technologies for screening and diagnosis, identification of appropriate service delivery and financing models, and assessment of strategies to enhance the health workforce. Given the extent of available evidence, it is critical that cancer prevention and treatment efforts in India are accelerated. Implementation science research can generate critical insights and evidence to inform this acceleration.

Implementation Science for Global Oncology: The Imperative to Evaluate the Safety and Efficacy of Cancer Care Delivery

PURPOSE

The development of cancer care treatment facilities in resource-constrained settings represents a challenge for many reasons. Implementation science-the assessment of how services are set up and delivered; contextual factors that affect delivery, treatment safety, toxicity, and efficacy; and where adaptations are needed-is essential if we are to understand the performance of a treatment program, know where the gaps in care exist, and design interventions in care delivery models to improve outcomes for patients.

METHODS

The field of implementation science in relation to cancer care delivery is reviewed, and the experiences of the integrated implementation science program at the Butaro Cancer Center of Excellence in Rwanda are described as a practical application. Implementation science of HIV and tuberculosis care delivery in similar challenging settings offers some relevant lessons.

RESULTS

Integrating effective implementation science into cancer care in resource-constrained settings presents many challenges, which are discussed. However, with carefully designed programs, it is possible to perform this type of research, on regular and ongoing bases, and to use the results to develop interventions to improve quality of care and patient outcomes and provide evidence for effective replication and scale-up.

CONCLUSION

Implementation science is both critical and feasible in evaluating, improving, and supporting effective expansion of cancer care in resource-limited settings. In ideal circumstances, it should be a prospective program, established early in the lifecycle of a new cancer treatment program and should be an integrated and continual process.