ISC3: Penn Implementation Science Center in Cancer Control

The Penn Implementation Science Center in Cancer Control (ISC3) is a $4.9 million, five-year grant from the National Cancer Institute that is part of the national network of ISC3s. Our goal is to apply insights from behavioral economics to rapidly accelerate the pace at which evidence-based practices for cancer care are deployed and the extent to which they are delivered equitably, thereby increasing their reach and impact on the health and health equity of individuals with cancer.

Penn ISC3 implements projects across an Implementation Laboratory that spans Penn Medicine’s geographic footprint. This includes 6 hospitals, 12 outpatient oncology clinics, and 18 radiation centers with over 400 physicians and advanced practice providers serving patients from Pennsylvania, New Jersey, and Delaware. Penn Medicine currently sees over 300,000 outpatient visits and more than 10,000 discharges, and more than 9,000 patients participate in nearly 600 clinical trials each year. As of 2021, Penn Medicine serves over 19,000 new cancer patients a year.

Penn ISC3 is composed of Signature Projects focused on increasing the uptake of evidence-based practices, as well as Methods Projects focused on refining implementation strategy design; conducting mixed methods analysis of potential implementation mechanisms; and centering our projects on equitable implementation.

Signature Projects

• Tobacco cessation: Tobacco use limits the effectiveness of cancer treatment, so our first signature project focuses on helping people stop using tobacco. This project tests behavioral economics-informed multilevel implementation strategies to increase Tobacco Use Treatment Service (TUTS) referral and engagement. It aims to conduct a 4-arm pragmatic cluster randomized clinical trial (RCT) to test the effectiveness of nudges to clinicians, nudges to patients, or nudges to both to increase TUTS referral and to conduct a quantitative evaluation to identify moderators of implementation effects on TUTS referral.
• Serious Illness Conversations: Serious illness conversations (SICs) are an evidence-based approach to eliciting patients’ values, goals, and care preferences that improve patient outcomes, but they are not widely used. The SIC project tests behavioral economics-informed multilevel implementation strategies to increase SIC frequency and timeliness. It aims to conduct a 4-arm pragmatic cluster RCT to test the effectiveness of nudges to clinicians, nudges to patients, or nudges to both in increasing the frequency and timeliness of SIC documentation and to conduct a quantitative evaluation using secondary data to identify moderators of implementation effects on SIC rates.
• Patient-Reported Outcomes: Routine monitoring of patient-reported outcomes (PROs) for patients with advanced solid malignancies is an evidence-based practice that improves symptoms and quality of life, reduces unplanned acute care, and extends overall survival. Still, there is variation in adoption of and adherence to routine PRO monitoring, owing to multilevel barriers to implementation and concerns among clinicians regarding the utility of PROs in actual practice. This study will identify the extent to which clinician- and patient-directed implementation strategies affect patient adherence to PRO monitoring. These outcomes will inform future health system strategies to promote PRO adherence and thereby improve outcomes equitably for patients with cancer.
• Breast MRI Screening: Women with dense breasts have 3-5-fold increased risk for breast cancer as women without dense breasts. Dense breast tissue can “mask” small tumors, leading to reduced mammography sensitivity. Recent randomized controlled trials demonstrate that supplemental breast MRI screening improves detection of small, invasive cancers that are not detected by mammography. This project proposes a multilevel randomized 2×2 factorial pilot trial to determine whether electronic health record (EHR) nudges increase utilization of supplemental breast MRI screening among eligible women with extremely dense breasts.
• Increasing Genetic Testing for Breast and Ovarian Cancer Predisposition: Germline genetic testing is recommended by the National Cancer Center Network (NCCN) in individuals with a personal history of ovarian cancer, young-onset (<45 years) breast cancer, and a family history of ovarian cancer or male breast cancer, among others. Recent publications demonstrate that the uptake of genetic testing is under-utilized, and rates consistently lower, in minority populations. This project seeks to use cutting-edge EHR-based algorithms to identify patients for whom genetic testing is recommended based on NCCN guidelines, particularly those without a family history. In addition, it will utilize a sequential design to encourage patients and providers to engage in these screening tests.

Methods Projects

• Rapid-cycle approaches: The rapid-cycle approaches project supports the signature projects in applying insights from innovation methods drawn from industries outside of healthcare to accelerate the pace of learning. It aims to apply rapid-cycle approaches within the signature projects to optimize implementation strategy design and feasibility.
• Contextual mixed methods analysis: This project uses mixed methods approaches to develop an empirical basis for understanding and overcoming barriers and facilitators to implementation across projects. It aims to apply the Consolidated Framework for Implementation Research (CFIR) to capture and describe multilevel factors across and within signature projects and conduct Qualitative Comparative Analysis (QCA) to identify necessary and sufficient conditions for implementation. It also aims to and collect data on baseline inner setting via quantitative surveys and post-implementation mixed-methods data via surveys and semi-structured interviews.
• Health equity: This project ensures that all signature projects have a focus on identifying and documenting cancer-related health disparities and uses implementation science measures, methods, strategies, and frameworks to more explicitly center health equity. It aims to identify and understand existing health disparities prior to initiating each signature project. It also aims to engage in contextual inquiry, using mixed-methods research and purposeful sampling of populations experiencing inequities to understand how the implementation strategies are received by individuals who experience health disparities as well as a more in-depth understanding of factors that shape these inequities. Building on the wider health equity methods project, the National Cancer Institute awarded Penn ISC3 with an additional health equity-focused supplemental grant. This supplement will focus on how social determinants of health (SDOH), social needs, and social risks impact the implementation of evidence-based cancer care and health equity.

To learn more about Penn ISC3, please visit pennisc3.com.

Penn ISC3 uniquely harnesses cutting-edge research at the intersection of implementation science, behavioral economics, and cancer care innovation to address the strategic priorities emphasized in the National Cancer Institute’s Moonshot Blue Ribbon Panel. Penn ISC3 will produce new knowledge with the potential to reduce the research-to-practice gap in cancer care and improve outcomes equitably for millions of Americans with cancer.

National Institutes of Health, National Cancer Institute

Affiliated ISC3 Centers: Implementation Science Center for Cancer Control Equity (ISCCCE), Harvard T.H. Chan School of Public Health; Building Research in Implementation and Dissemination to close Gaps and achieve Equity in Cancer Control (BRIDGE-C2), Oregon Health & Science University; Colorado ISC3, University of Colorado School of Medicine; Optimizing Implementation in Cancer Control (OPTICC), University of Washington; Implementation and Informatics – Developing Adaptable Processes and Technologies (iDAPT), Wake Forest School of Medicine/University of Massachusetts Medical School; Washington University Implementation Science Center for Cancer Control (WU-ISCCC), Washington University in St. Louis

Penn Partners: Abramson Cancer Center, Penn Center for Health Care Transformation & Innovation, University of Pennsylvania Health System, Penn Implementation Science Center, Center for Health Incentives and Behavioral Economics, Penn Medicine Nudge Unit, Penn WayToHealth; Mixed Methods Research Lab