“The health care system is a federation of millions of entrepreneurs with no one in charge. No single entity can command change.”
The National Academies of Sciences, Engineering, and Medicine, recently released a consensus report that outlines several key strategies to implement a comprehensive national cancer control plan. This ambitious program aims to set a precedent that could help inform the control of other diseases. The study was undertaken by the Committee on a National Strategy for Cancer Control in the United States with support from the National Institutes of Health, the Centers for Disease Control and Prevention, and the American Cancer Society. Alliance Co-Principal Investigator Electra Paskett, PhD, served as a member of the cancer control committee.
During the report release event, report committee members characterized the current state of cancer control in America as a Complex Adaptive System (CAS), with initiatives ranging from basic risk awareness through end of life. The CAS is far more complex than the interaction between patients and clinicians; it actually encompasses a multi-layered system of “agents, operations, and organizations,” who are working individually on “piecemeal” programs. These stakeholders are failing to embrace all layers of the CAS, and operate primarily in response to societal outlooks around cancer control initiatives, rather than best practices.
The entities behind these efforts are in competition with each other, as the committee members explained: “there is an inherent conflict in a system that is based on different stakeholder perceptions, values, and priorities, which are seldom aligned.” This lack of alignment is the symptom of a system that “was never designed, it just emerged,” and it can sometimes spell disastrous consequences for public health. Members went on to cite the ongoing opioid epidemic as an example of an approach to disease control that lacked multi-layered coordination, with efforts to curb opioid abuse in Indiana and Kentucky leading to a dramatic increase in opioid overdoses and deaths. While the committee members acknowledged that the thousands of participants behind similarly fragmented cancer control programs might be operating with the best of intentions, they stressed that any effort lacking coordination and information sharing could eventually share a similar fate.
The committee members remarked that there is a certain similarity between the system of cancer control in America and the nature of cancer itself: “[Cancer] adapts to interventions we try to thwart it, it convinces the immune system to help it, it’s a complex adaptive system in itself.” Disrupting the complex adaptive system of cancer requires a comprehensive strategic vision, outlined in the Consensus Study Report Guiding Cancer Control: A Path to Transformation. The report includes several recommendations designed to improve coordination in a complex cancer control system that is inextricably linked “from cells to congress.” The main recommendations include:
- Improve availability of preventive, screening, diagnostic, therapeutic, and palliative interventions, as well as survivorship care, hospice care and social services according to patient and family preferences and values;
- Leverage scientific advances to improve therapies and better understand their scientific, clinical, and economic impacts;
- Integrate a broad range of data sources by integrating the use of social, behavioral, and other information made possible by the convergence of communication, social media, cognitive, financial, and other technologies;
- Use and evaluate advanced technologies for continuous analytics, rapid reporting of trends and patterns, and improved forecasting and performance reviews;
- Apply the tools of complex systems analyses for assessing the “value” of cancer control interventions, guiding the development of products and services, developing new payment mechanisms, and helping patients make informed decisions;
- Minimize waste and harm stemming from disparate clinical practices, interventions lacking evidence of effectiveness, and conflicting clinical practice guidelines;
- Track and monitor financial links, incentives, and disincentives throughout the processes and systems of cancer control and rigorously require conflict of interest disclosures across cancer care, research, and patient advocacy activities;
- Expand and support reproducibility strategies for developing reliable evidence from research;
- Discourage direct-to-consumer marketing of clinical products and services and tighten and enforce rules to curb promotion of non-evidence-based products and services;
- Launch and expand public engagement and outreach to broaden the understanding of cancer prevention as an integral component of a healthy life course.