Background
Recognizing the persistent gap between the availability and use of evidence-based treatments to prevent and control cancer,1 a critical component of then Vice President Biden’s Cancer Moonshot initiative was support for the NCI’s commitment to implementation science, defined as the systematic study of methods to optimize the utilization of evidence-based treatments to improve health. Emerging from this commitment, the Cancer Center Cessation Initiative (C3I) was established to guide national efforts to increase the use of evidence-based tobacco cessation treatments within NCI-designated Cancer Centers.2 Despite the Surgeon General’s Report establishing the causal link between tobacco use and poor clinical outcomes among patients with cancer and widespread availability of safe and effective tobacco treatments,3 only one-third of oncologists provide tobacco treatments to patients4 and only 15% of patients with cancer who continue to smoke report the use of cessation treatments.5 Support from NCI’s C3I has expanded the use of evidence-based treatments for tobacco use across cancer centers, but challenges remain for ensuring acceptable reach, utilization, and sustainability.6
To address remaining challenges, members of the C3I community, including staff and investigators at US cancer centers and the C3I Coordinating Center, formed the C3I Implementation Science Working Group. This working group’s mission is to bring together clinicians, scientists, and policymakers who share a common interest in implementation science and treating tobacco use in the oncologic context. Leveraging national expertise in implementation science and tobacco research and NCI investments, including the NCI-funded Implementation Science Centers in Cancer Control (ISC3; https://cancercontrol.cancer.gov/is/initiatives/isc3), the working group will identify effective implementation strategies to reduce the tobacco treatment practice gap within cancer care delivery (the specific working group agenda is described later), broadening the impact and sustainability (ie, the continuation of tobacco use treatment programs at sites after funding ends) of C3I. Here, we describe case studies of implementation science research within C3I and discuss the working group mission and goals.
Case Studies of C3I Implementation Science Research
C3I has supported 3 cohorts, totaling 52 NCI-designated Cancer Centers. Early implementation outcomes across sites, such as reach (ie, the proportion of patients assessed for tobacco use and engaged in evidence-based treatment) and effectiveness (ie, the proportion of patients who quit smoking), have been reported6–8 and learnings from initial cohorts were passed on to later cohorts via webinars and site-to-site mentoring. Following are examples of implementation work from the 3 cohorts.
Cohort 1: Washington University in St. Louis
After an assessment of barriers and facilitators, consistent with the use of evaluative and iterative strategies as an implementation method,9 we developed and implemented the Electronic Health Record (EHR)-enabled Evidence-based Smoking Cessation Treatment (ELEVATE) program10,11 that enacted a paradigm shift to a point-of-care tobacco treatment model. The ELEVATE program is a bundled implementation strategy that includes (1) an EHR-enabled team care workflow that provides scripted advice and an opt-out offer of counseling via phone, text, or app by closed-loop referrals to national quit-lines and smokefree.gov (reflecting a change to the infrastructure to facilitate implementation9), and (2) a learning health system approach (eg, a cycle of data-to-knowledge, knowledge-to-practice, and practice-to-data, including feedback). ELEVATE increased reach, defined as the proportion of current smokers who received evidence-based tobacco treatment (from 3.2% among 815 patients who smoke to 32.8% among 2,511 patients who smoke) (see Figure 1), and yielded a smoking cessation rate of 29.5% at 6 months.12 The program cost at $70/patient was much lower than most tobacco treatment programs.8 Consequently, ELEVATE has been scaled up from 21 to more than 900 clinics at Washington University/BJC HealthCare, and serves as a model for a sustainable C3I program.
Illustrative example of impact from C3I-supported efforts on reach from Washington University in St. Louis.
Note: Relative risk (adjusted for age, sex, race), 10.06 (95% CI, 6.89–14.68); P<.0001 in generalized estimating equation models.
Citation: Journal of the National Comprehensive Cancer Network 19, Suppl_1; 10.6004/jnccn.2021.7094
Illustrative example of impact from C3I-supported efforts on reach from Washington University in St. Louis.
Note: Relative risk (adjusted for age, sex, race), 10.06 (95% CI, 6.89–14.68); P<.0001 in generalized estimating equation models.
Citation: Journal of the National Comprehensive Cancer Network 19, Suppl_1; 10.6004/jnccn.2021.7094
Illustrative example of impact from C3I-supported efforts on reach from Washington University in St. Louis.
Note: Relative risk (adjusted for age, sex, race), 10.06 (95% CI, 6.89–14.68); P<.0001 in generalized estimating equation models.
Citation: Journal of the National Comprehensive Cancer Network 19, Suppl_1; 10.6004/jnccn.2021.7094
Cohort 2: Mayo Clinic Cancer Center
The Mayo Clinic Cancer Center (MCCC) used a change to its infrastructure9 to facilitate implementation by using an “opt-out” clinical workflow that systematically screened and referred all tobacco-using patients to a Nicotine Dependence Center (NDC).13 Through a phased implementation process spanning across Minnesota, Wisconsin, Arizona, and Florida, the workflow was implemented across ambulatory practices. From July 2019 to May 2021, 3,727 NDC referrals were received. As of April 2021, 681 (18%) of those referred had completed ≥1 NDC appointment, of which 173 (27%) were relisted as former smokers in the EHR. C3I support also catalyzed the implementation of changes to infrastructure at the health system level by including structured documentation in the EHR to record e-cigarette use,14 the establishment of a tobacco and e-cigarette registry, an EHR alert for scheduling staff to update tobacco use history, a patient engagement video delivered via an appointment portal, and use of the NCI’s Cancer Patient Tobacco Use Questionnaire. Changing the health system infrastructure as an implementation strategy using an “opt-out” referral workflow that does not require clinician involvement demonstrated effectiveness and sustainability in oncology practices.
Cohort 3: City of Hope Cancer Center – Beckman Research Institute
The City of Hope Cancer Center – Beckman Research Institute (COH) conducted a needs assessment and surveyed cancer center staff attitudes regarding tobacco treatment, consistent with using evaluative and iterative implementation strategies.15 The tobacco use rate (97.9% of patients assessed) was 4.0% to 9.7% of oncology patients across 36 academic and community sites.15 COH increased resource commitment to the COH cessation program, and senior leaders initiated monthly “Moonshot Shoutout” communications to staff to promote the establishment of a tobacco treatment program, consistent with training and educating stakeholders as an implementation strategy.15 The multidisciplinary cessation program developed and distributed culturally sensitive and multilingual educational materials to patients. Training modules were built for smoking cessation champions and clinical staff to develop stakeholder interrelationships.15 To support efficient and effective access to tobacco treatments, a clinical informatics team modified the EHR to include Best Practice Advisories, initially with an “opt-in” approach but transitioning to an automated “opt-out” referral to cessation treatment (changed infrastructure) and the use of “SmartPhrases” (abbreviations or a few words to pull long phrases or sentences into patient’s EHR). An in-person cessation clinic was supplemented by telehealth, online, and quit-line counseling. To overcome multidepartmental “silos” and geographic barriers, COH leadership designated multilevel cessation champions (physicians, advance practice providers, and oncology nurses) at each academic and community site. For evaluation and monitoring, COH is tracking referrals, cessation clinic engagement, and smoking abstinence, as well as staff attitudes, as a form of audit and feedback as an implementation strategy.9 Because COH is in the third cohort of the C3I initiative, data collection to assess impact is currently ongoing.
Implementation Science Working Group Agenda
The C3I Implementation Science Working Group, co-led by Drs. Chen, Ramsey, and Schnoll (each with roles in C3I and ISC3), began in December 2020 to bring together clinicians, scientists, and policymakers across C3I sites who share the common interest in implementation science and treating tobacco use in the oncologic context. Through monthly meetings, smaller interest groups, and activities, this working group will help strengthen the national community committed to implementation science and tobacco use in the cancer context, and engage in manuscripts, cross-institutional research and mentoring consultation, and toolkit development to enhance the state of the science in this area, including the cataloguing of effective implementation strategies that promote treatment engagement, lead to reduced tobacco use rates, and facilitate sustainability, similar to past efforts.9
The working group began with a member survey of interests in implementation science domains (eg, reach, sustainability), priorities, and perceptions of barriers and facilitators to program sustainability. Among 13 respondents representing 12 cancer centers, program effectiveness (85%), implementation strategies (70%), and context (70%) were the top 3 interests. Collaborating on papers and developing a toolkit of effective implementation strategies for other groups interested in implementing tobacco cessation treatment services within the oncologic context were considered top priorities. Funding availability was cited as the most frequent barrier to sustaining programs (58%), and modifications to the EHR was cited as the most feasible method to sustaining programs (36%). These data helped form the mission and goals of the working group.
Based on initial meetings and data collection, the working group members established a set of immediate and long-term goals (Table 1). In the near term, the working group hopes to stimulate interest in implementation science and tobacco treatment, broaden the community of people interested in implementation science and tobacco treatment, and explore avenues for bridging across C3I working groups. In the long-term, the working group hopes to facilitate multiple papers focused on implementation science and tobacco treatment, develop a cross-institutional consulting service for implementation science and tobacco treatment (including with cancer treatment facilities not supported previously by the C3I initiative), devise a toolkit of implementation strategies for other cancer centers (within and beyond C3I) to use to establish a sustainable tobacco cessation program, and increase the number of multi-institutional grants and publications focused on this area. To date, we have established writing teams (supported by the co- chairs) who are working on 3 papers: (1) the present paper describing the working group, (2) a state-of- the-science paper describing the current literature and gaps and priorities for the field, and (3) a data-based paper characterizing implementation strategies used by C3I programs and evaluating their effects on program reach and effectiveness. The working group has also facilitated new consultations between C3I sites on program implementation and supported efforts to develop novel ideas for future implementation science and tobacco control research.
Immediate and Long-Term Goals of the C3I Implementation Science Working Group
Conclusions
The C3I Implementation Science Working Group facilitates and promotes the overall goals of the C3I Moonshot program, including the provision of direct support to initiative members on the implementation of sustainable efforts to ensure that patients with cancer are screened for tobacco use and provided with evidence-based tobacco treatments. The case studies presented here illustrate the use of implementation strategies (eg, changed infrastructure) to achieve these goals, which can be adopted by other C3I sites or other cancer treatment facilities across the nation not formally involved in C3I. By building an implementation science community dedicated to addressing the gap in tobacco treatment utilization across NCI-designated Cancer Centers, we aim to advance C3I’s mission to mitigate the adverse impacts of tobacco use on cancer risk and outcomes.
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