An orientation to the US National Cancer plan for the research community

Abstract

The US National Cancer Act of 1971 designated the director of the National Cancer Institute as responsible for coordinating federal agencies and nonfederal organizations to make progress against cancer. As part of her role, the immediate past director of the National Cancer Institute (MMB) led the development of a National Cancer Plan that was formally released on April 3, 2023. The plan includes 8 aspirational goals “to achieve a society where every person with cancer lives a full and active life and to prevent most cancers so that few people need to face this diagnosis.” Research findings provide a foundation for each goal, and research gaps are included in the strategies for meeting each goal. The President’s Cancer Panel, also created by the National Cancer Act, conducted an initial assessment of progress toward the plan goals by hearing from 12 organizations at a virtual public meeting on September 7, 2023. The purpose of this commentary is to orient the scientific community to the plan and call attention to related knowledge gaps that could benefit from research.

The National Cancer Act of 1971 (1), colloquially known as the war on cancer, established the National Cancer Program, with the goal of making progress against cancer through the coordinated effort of federal agencies and nonfederal institutions and organizations. The Act designated the National Cancer Institute (NCI) director as responsible for coordinating program activities. To bring focus to the National Cancer Program, Dr Monica Bertagnolli, director of NCI at the time, led the creation of a National Cancer Plan (2) (hereafter, Plan). Representatives from National Institutes of Health, Department of Health and Human Services, and elsewhere contributed to the Plan. It was released by the Department of Health and Human Services on April 3, 2023. The current director of NCI, Dr Kimryn Rathmell, has expressed her support for the Plan, as evidenced by her inclusion as a co-author of this commentary.

Ultimately, the Plan seeks “to achieve a society where every person with cancer lives a full and active life and to prevent most cancers so that few people need to face this diagnosis” (2). It establishes 8 aspirational goals and accompanying strategies to achieve this goal. Defined as the backbone of the Plan, research findings provided a foundation for each goal, and the accompanying strategies include research gaps. The Plan provides an opportunity for the scientific community to revisit how research fits within a larger context, consider future directions, and pursue new collaborations.

The President’s Cancer Panel (3) (hereafter, Panel) was asked to conduct an initial assessment of progress toward Plan goals and thus hosted a virtual public meeting on September 7, 2023 (4). The Panel invited representatives from 12 stakeholder organizations to present their activities and discuss opportunities to accelerate progress. Organizations were selected such that the discussion would reflect an array of stakeholder perspectives, including those of clinicians, care delivery organizations, employers, and advocacy groups. The representatives and the organizations, including mission statements and web pages, are shown in Table 1.

Table 1.

Characteristics and activities of organizations participating in the President’s Cancer Panel’s National Cancer Plan stakeholder meeting on September 7, 2023^a

Organization name (Abbreviation)	Presenter (Title)	Mission statement	Web page
American Association for Cancer Research (AACR)	Philip D. Greenberg, MD (President) – University of Washington Margaret Foti, PhD, MD (honoris causa) (CEO)	To prevent and cure cancer through research, education, communication, collaboration, science policy and advocacy, and funding for cancer research.	aacr.org
American Cancer Society (ACS)	Karen E. Knudsen, MBA, PhD (CEO)	To improve the lives of people with cancer and their families through advocacy, research, and patient support to ensure everyone has an opportunity to prevent, detect, treat, and survive cancer.	cancer.org
American Society for Radiation Oncology (ASTRO)	Jeff M. Michalski, MD, MBA, FASTRO (President) – Washington University School of Medicine in St. Louis	To advance the specialty of radiation oncology through promotion of equitable, high-quality care for people with cancer; cultivating and educating a diverse workforce; fostering research and innovation; and leading policy development and advocacy.	astro.org
American Society of Clinical Oncology (ASCO)	Clifford A. Hudis, MD, FASCO, FACP (CEO) Lynn M. Schuchter, MD, FASCO (President) – University of Pennsylvania	To conquer cancer through research, education, and promotion of the highest quality, equitable patient care.	asco.org
American Society of Preventive Oncology (ASPO)	Anita Kinney, PhD, RN, FAAN, FABMR (President) – Rutgers University	To foster the continuing development of investigators and other professionals involved in cancer prevention and control and the exchange and translation of scientific information to reduce the cancer burden.	aspo.org
Association of Community Cancer Centers (ACCC)	Olalekan Ajayi, PharmD, MBA (President) – Highlands Oncology Group	To be the leading education and advocacy organization for the cancer care community.	accc-cancer.org
CEO Roundtable on Cancer (CEO RoC)	William C. Louv, PhD (CEO) David M. Reese, MD (Chair, Board of Directors)	To develop and implement initiatives that reduce the risk of cancer, enable early diagnosis, facilitate access to the best available treatments, and hasten the discovery of novel and more effective anticancer therapies to help eliminate cancer as a personal disease and public health problem.	ceoroundtableoncancer.org
Healthcare Information and Management Systems Society (HIMSS)	Anne Snowdon, PhD (Chief Scientific Research Officer) – University of Windsor	To reform the global health ecosystem through the power of information and technology.	himss.org
National Comprehensive Cancer Network (NCCN)	Robert W. Carlson, MD (CEO) Wui-Jin Koh, MD (Senior Vice President and Chief Marketing Officer)	To improve and facilitate quality, effective, equitable, and accessible cancer care so all patients can live better lives.	nccn.org
National Hispanic Medical Association (NHMA)	Elena V. Rios, MD, MSPH, MACP (President and CEO)	To empower Hispanic physicians to lead efforts to improve the health of Hispanic and other underserved populations in collaboration with Hispanic state medical societies, residents, medical students, and other public and private sector partners.	nhmamd.org
National Medical Association (NMA)	Yolanda Lawson, MD, FACOG (President) – Baylor Scott & White Health Edith P. Mitchell, MD, MACP, FCCP, FRCP (past President) – Thomas Jefferson University	To advance the art and science of medicine for people of African descent through education, advocacy, and health policy to promote health and wellness, eliminate health disparities, and sustain physician viability.	nmanet.org
Oncology Nursing Society (ONS)	Danya T. Garner, PhD, RN, NPD-BC, OCN, CCRN-K (President) – University of Texas MD Anderson Cancer Center Brenda M. Nevidjon, MSN, RN, FAAN (CEO)	To advance excellence in oncology nursing and quality cancer care.	ons.org

a

CEO = chief executive officer.

The meeting reflected a breadth of activities that are encompassed within the Plan and will be incorporated into the Panel’s report to the President about the meeting. Research topics were woven throughout the meeting, as evidence that informs ongoing efforts and knowledge gaps impeding progress. This commentary focuses on that aspect of the meeting, to orient the scientific community to the Plan and call attention to related knowledge gaps that could benefit from research.

Goal 1: Prevent cancer

This goal states that “all people and society adopt proven strategies that reduce the risk of cancer” (5). The Plan notes that broad research strategies in this area include fundamental discoveries that extend our understanding of cancer causes and precancer development; epidemiological research investigating the interplay of genetics, behavior, and environment; individual- and community-based behavioral interventions; elimination or prevention of infections that lead to cancer; and approaches to limit exposure to toxins.

Several organizations described activities that build on research evidence and would benefit from additional research. A need for more effective behavioral interventions to reduce cancer risk is a priority for the American Society of Preventive Oncology (ASPO). Such interventions could include personalized behavioral alerts, which are also of interest of the Healthcare Information and Management Systems Society (HIMSS). Promoting healthy lifestyle choices in the workplace lies at the core of activities undertaken by the CEO Roundtable on Cancer (CEO RoC). In addition to encouraging healthy behaviors through community and corporate partnerships, the American Cancer Society (ACS) called attention to the importance of promoting human papillomavirus vaccination, developing chemopreventive agents, and conducting epidemiological studies aimed at better understanding cancer risk factors. The National Hispanic Medical Association (NHMA) reminded attendees of the need for non-English language, culturally competent educational interventions. Discussion throughout the meeting highlighted the need to address clearly recognized research gaps in behavioral interventions and chemoprevention, including how to implement successful strategies into standard models of care delivery.

Goal 2: Detect cancers early

This goal states that “cancers are detected and treated at early stages, enabling more effective treatment and reducing morbidity and mortality” (6). Development of novel detection strategies and related harm-benefit assessments, as well as practices to improve uptake of existing screening modalities, is central to the research strategies articulated in the Plan.

ACS, ASPO, CEO RoC, and HIMSS described early detection efforts that are very similar to their prevention activities, therefore, those are not repeated here. In terms of early detection specifically, ACS invests substantial effort in maintaining up-to-date screening guidelines tailored to the public, clinicians, and policy makers. Those guidelines require evidence, with ASPO noting that substantial gaps remain in understanding effectiveness of existing screening modalities, including how timing and frequency impact diagnosis, treatment, and survival. ASPO and ACS indicated a critical need for better understanding emerging early detection approaches, such as at-home human papillomavirus self-sampling as a cervical cancer screening modality and blood-based multicancer early detection technology. ACS expressed a need to better understand the processes by which patients receive follow-up care for positive results. The National Medical Association (NMA) called attention to the need to address myths and misconceptions about early detection that may be common in some communities and populations. Although not discussed at the meeting, the 2022 Panel report “Closing Gaps in Cancer Screening: Connecting People, Communities, and Systems to Improve Equity and Access” identified a need for research on implementing cancer risk assessment, screening guidelines, and clinical decision support into electronic health records (7). The presentations and discussion highlight the need for research on screening benefit and harms to keep pace with emerging strategies and technical advances.

Goal 3: Develop effective treatments

This goal states that “effective treatment, with minimal side effects, is accessible to all people with all cancers, including those with rare cancers, metastatic cancer, and treatment-resistant disease” (8). The Plan discusses research strategies that run the gamut from basic science, preclinical work, clinical trials, and population-based research. Specific needs include better understanding how cancer develops and spreads; identifying molecules that could be targeted for treatment; approaches to developing new drugs; moving promising treatments forward more quickly; minimizing toxicities; and predicting treatment response and long-term outcomes.

The organizations participating in the meeting focus less on treatment than other activities, so topics such as cancer biology and identification of therapeutic targets received limited attention. Most of the discussion of treatment trials focused on the need to enroll more diverse populations, which has been included in the next section. Researchers with an interest in treatment development may wish to consult the Panel 2018 report “Promoting Value, Affordability, and Innovation in Cancer Drug Treatment” to review recommendations that remain relevant (9). Developing treatments has always been a core focus at NCI and will continue in the context of exciting opportunities to develop new approaches based on emerging knowledge in areas such as imaging, immune regulation, and tumor genetics. The Plan goal of developing effective treatments remains a priority and will receive more focused attention in future activities.

Goal 4: Eliminate inequities

This goal states that “disparities in cancer risk factors, incidence, treatment side effects, and mortality are eliminated through equitable access to prevention, screening, treatment, and survivorship care” (10). The Plan strategies include research to understand the cause of and intervene on inequities within each of the other goals. Addressing structural barriers and ensuring equitable benefits from research are also noted to be important.

Reducing inequities is a goal of every participating organization and was by far the most discussed topic at the meeting, as reflected in the length of this section. Organizations’ activities often simultaneously addressed other parts of the Plan, most commonly overlapping with the goal of optimizing the workforce. For clarity, activities pertaining directly to the breadth and depth of cancer-related challenges faced by individuals and populations will be discussed in this section, with workforce considerations addressed in a subsequent section.

Educating scientists and others about the impact of inequities, as well as articulating priorities, was a nearly universal activity. For example, the American Association for Cancer Research (AACR) and NMA sponsor annual disparities symposia. AACR and the National Comprehensive Cancer Network (NCCN) publish annual progress reports relevant to disparities. The latter report includes a focus on addressing bias in care settings, with contributions from ACS and the National Minority Quality Forum. The Association of Community Cancer Centers (ACCC) incorporates relevant material into its clinical education programs, with a particular focus on variation in supportive care needs, which has historically received less attention than disparities in treatment.

Identifying and addressing inequities was another broad area of focus. ASPO members conduct research aimed at understanding and intervening on causes of inequity across the cancer continuum. ACS is launching a new epidemiological cohort of Black women to better understand the impact of their lived experience on cancer risk. ACCC, the American Society of Clinical Oncology (ASCO), and the American Society for Radiation Oncology (ASTRO) include disparities-relevant assessments in their clinical performance metrics, which may trigger quality improvement initiatives. ASCO and ASTRO are conducting demonstration projects of models of care designed to meet the needs of residents in rural communities. AAAC, ASCO, and NMA have developed toolkits and taken other steps to increase diversity among clinical trial participants.

Although not exhaustive, the Plan includes examples of groups particularly susceptible to inequities: “racial or ethnic groups, those who live in rural or underserved areas, people with disabilities, and sexual and gender minority individuals” (2). Several organizations noted that there is substantial heterogeneity within those groups. NCCN has recognized this by changing guideline language to be more inclusive of gender-diverse members of the sexual and gender community. NHMA described the importance of recognizing that a group perceived as having a single ethnicity can include individuals from different countries and cultures. The experience of immigrants varies by legal status and generation, with the possibility that younger and older cohorts may not share traditions and thus may respond differently to cancer topics.

Health disparities present a challenge in meeting all the Plan goals. In addition to research focused on this topic, relevant secondary aims and endpoints should be prioritized for inclusion in studies when there is an opportunity to identify factors contributing to disparities that could be addressed by interventions, including policy change.

Goal 5: Deliver optimal care

This goal states that “the health care system delivers to all people evidence-based, patient-centered care that prioritizes prevention, reduces cancer morbidity and mortality, and improves the lives of cancer survivors, including people living with cancer” (11). The Plan notes that uptake of advances in prevention, detection, and treatment may be limited by factors such as care complexity, access issues, individual social determinants of health, and societal costs. Adoption of new approaches will require robust evidence of meaningful benefit and implementation strategies that are realistic within the context of challenges faced by clinical professionals and health-care delivery organizations.

Approximately half of the participating organizations have a substantial focus on clinical care. The Oncology Nursing Society (ONS), ACCC, ASCO, ASTRO, and NCCN offer some combination of educational opportunities, resource materials, and clinical guidelines. Several organizations sponsor efforts intended to directly impact the care delivery environment. ACCC has an initiative focused on overcoming insufficient reimbursement and lack of relevant specialists to address disparities in supportive care. ASCO has recently introduced a patient-centered care certification program for delivery systems, based on standards developed from a prior initiative aimed at establishing a medical home model in oncology settings. In addition, ASCO is conducting a demonstration project involving a hub and spoke delivery model that would facilitate rural patients receiving care locally rather than traveling great distances. ASTRO sponsors a program that recognizes facilities with high-quality and safe care, as well as another that facilitates shared learning based on care incidents occurring across the United States. These activities reflect the types of collaborations among government agencies, health systems, insurers, and other groups that will be necessary to move discoveries responsive to other Plan goals into everyday cancer care.

Goal 6: Engage every person

This goal states that “every person with cancer or at risk for cancer has an opportunity to participate in research or otherwise contribute to the collective knowledge base, and barriers to their participation are limited” (12). Suggested strategies include making it easier for patients to share their data and tissue specimens, streamlining access to trials and observational studies, and incorporating research into standard clinical practice. Bringing research to communities, including expanded opportunities for researchers to engage more directly with the public, is essential to bridging gaps in knowledge and health care, as well as building trust in medical science.

Expanding research participation requires new ways of engaging with the community, examples of which suffused the activities of presenting organizations. AACR has a long-standing program aimed at promoting interactions between scientists and leaders of patient advocacy groups. ACCC works closely with state oncology societies and local advocacy organizations, as well as partners with legal experts to address cancer patients’ financial hardship challenges. ACS described leveraging volunteer knowledge across their activities. ASCO touched on their efforts to enhance local medical care by collaborating with community-based organizations. CEO RoC has a program to engage with historically Black colleges and universities and Hispanic-serving institutions. HIMSS noted that improving access to and use of clinical data requires collaboration with clinicians and patients. NHMA described a program in which high school students are trained as interpreters to assist with cancer care and hopefully increase student interest in medical careers. Although these partnerships often have a broader focus, they provide a foundation for expanding access to and participation in research.

Goal 7: Maximize data Utility

This goal states, “secure sharing of privacy-protected health data is standard practice throughout research, and researchers share and use available data to achieve rapid progress against cancer” (13). Examples of needed improvements touch on data capture, quality, and availability, while emphasizing the importance of respecting individuals’ privacy.

Data challenges came up frequently during the presentations and discussion. HIMSS was the most explicit, echoing the Plan’s stated need for a “data ecosystem,” suggesting that success likely depends on the extent to which using data to improve patient outcomes is a priority. Additionally, HIMSS noted that the expertise and technology to build such a data ecosystem exists, but the necessary partnerships and infrastructure are lacking. ASCO and ASTRO are pursuing implementation of standard clinical data elements and data exchange to improve patient care and outcomes, with an additional goal of supporting research. AACR has, for almost a decade, supported a registry of genomic data associated with clinical outcomes across cancer types, with 14 public data releases for research purposes. Also, approximately a decade ago, CEO RoC created a platform where academicians or industry could make patient-level data from phase III cancer treatment trials available to authorized researchers. Several organizations mentioned nascent activities to assess and implement machine learning and artificial intelligence in clinical and research settings. As frequent data generators and users, researchers have an obligation to consider how their studies can contribute to building a data ecosystem, including sharing data willingly and adopting clinical data standards for their studies.

Goal 8: Optimize the workforce

This goal states that “the cancer care and research workforce is diverse, reflects the communities served, and meets the needs of all people with cancer and those at risk for cancer, ensuring they live longer and healthier lives” (14). The Plan includes multiple strategies to improve the workforce, many of them focused on addressing barriers to career advancement. This includes completing training, securing permanent employment, and identifying research opportunities with the potential to expand career opportunities.

Participating organizations universally expressed concern about the impact of workforce issues on patient outcomes, with nearly all of them taking steps to address overall personnel shortages, a lack of diversity, and uneven geographic distribution. In terms of the pipeline of clinicians, ASCO, ASTRO, and ONS are pursuing opportunities to increase trainee interest in oncology care, including mentoring programs, summer internships, and specific rotations for nurse, advanced practice provider, and physician trainees. AACR, ACS, and ASPO focus more on developing researchers, which they pursue through activities such as funding opportunities for early career individuals and scholarships to attend scientific meetings and workshops. Many of these programs include a focus on increasing participation from members of underrepresented populations. NHMA, NMA, and ONS reminded meeting attendees of the need to improve the awareness of cancer care and research as career options among high school and college students, as well as to help interested students overcome challenges to pursuing such careers. Although the scientific community has embraced opportunities of this type for many years, the Plan challenges researchers and research institutions to consider how to balance the need for individual recognition to support career advancement with the reality that conducting research requires functioning within a team environment.

Discussion

Research and researchers play an essential role in meeting the National Cancer Plan’s overarching goal “to achieve a society where every person with cancer lives a full and active life and to prevent most cancers so that few people need to face this diagnosis.” This commentary from the initial Panel meeting to learn about relevant activities from 12 organizations provides insight into how initiatives are building on research evidence and where there are opportunities to assess the impact of ongoing activities and identify new directions. Researchers are encouraged to seek opportunities to support the Plan goals by collaborating with organizations such as those presenting at the meeting.

The Plan recognizes that achieving the stated goals will require NCI and other federal agencies to support “a comprehensive research portfolio to achieve each goal” (2). Existing investments in intramural research and extramural grant funding address every goal. Examples include the development of trials to understand multicancer detection assays; several national networks focused on conducting all phases of treatment trials; and multiple cooperative agreements addressing care delivery topics such as telehealth and symptom management. The original Cancer Moonshot funded initiatives to identify new targets for cancer prevention therapies; develop additional infrastructure to expand participation in clinical trials; and a scholarship program to support the growth of junior scientists from diverse backgrounds. NCI holds an extensive portfolio of research intended to understand and address disparities in cancer outcomes, including providing subject matter expertise and funding for National Institutes of Health–wide initiatives such as the Community Partnerships to Advance Science for Society. NCI and the Centers for Medicare and Medicaid Services have long collaborated on improving data availability for research by linking claims data with data from the Surveillance, Epidemiology, and End Results Program. Emerging collaborations with the Advanced Research Projects Agency for Health and the Food and Drug Administration will build on those linkages. Maintaining and expanding these initiatives will require sustained Presidential and Congressional support.

This initial meeting offered direction for the scientific community, as well as highlighted research gaps for stakeholders outside the research community. The presentations and discussions were driven by the focus of participating organizations and available time, leaving open future opportunities to discuss research gaps in more detail, particularly as related to the basic science of cancer, efforts to develop treatments, and considerations outside the context of the United States. Realizing the ambitious goals of the Plan will require a shared focus and integration of efforts across community; health-care delivery; and basic, translational, clinical, and population research contexts. The Panel will continue to play a key role in facilitating engagement across these contexts and identifying opportunities for the President to support the National Cancer Plan.

Data availability

Not applicable.

Author contributions

Ann M. Geiger, MPH, PhD (Writing—original draft; Writing—review & editing), Elizabeth M. Jaffee, MD (Conceptualization; Writing—review & editing), Mitchel S. Berger, MD (Conceptualization; Writing—review & editing), Carol L Brown, MD (Conceptualization; Writing—review & editing), W. Kimryn Rathmell, MD, PhD (Writing—review & editing), and Monica M Bertagnolli, MD (Conceptualization; Writing—review & editing).

Funding

Not applicable.

Conflicts of interest

None of the authors report any financial conflicts of interest.

Acknowledgements

The authors thank Maureen Johnson, Ph.D. and Samantha Finstad, PhD for their support in developing and hosting the President’s Cancer Panel meeting described herein, as well as coordinating preparation of this commentary.