Cancer programs in the DACP

The cancer research program at the Department of Ambulatory Care and Prevention spans the spectrum of cancer, from cancer prevention, diagnosis, and treatment to cancer survivorship. The Department of Ambulatory Care and Prevention is a unique multi-disciplinary department, sponsored by Harvard Medical School and Harvard Pilgrim Health Care, with a broad portfolio of cancer research spanning a variety of defined populations and a range of clinical, health services, and policy research areas. In addition to strong relationships with the two outstanding sponsoring institutions, the Department has active collaborations with both local and national research networks positioned at the forefront of epidemiological and health services cancer research. The populations and collaborations available to researchers in cancer, examples of cancer projects and the faculty involved in cancer research are described below:

Cancer Research Network (CRN)

The Cancer Research Network (CRN) is funded by the National Cancer Institute and consists of research programs, enrolled populations, and data systems of 13 health maintenance organizations nationwide. Harvard Pilgrim Health Care is a founding and active member of the network. The CRN provides investigators an opportunity to access a population of over 10 million enrollees and to collaborate with investigators based at the health plans. The investigators have expertise in epidemiology, health services, behavioral medicine and biostatistics. Collaborations with the CRN provides an ideal population for studies involving basic, clinical and population sciences, addressing diverse communities, requiring large samples of patients and/or providers, examining preventive strategies, involving rare cancers, and investigating the dissemination of proven technologies and/or interventions. The availability of data includes: claims, tumor registry, full text medical records, and pharmacy. Data from the established CRN Cancer Counter and the developing Virtual Data Warehouse are available to the Department of Ambulatory Care and Prevention investigators.

Dana-Farber/Harvard Cancer Center (DF/HCC)

The Department of Ambulatory Care and Prevention leads the Community Practice Core of the Dana-Farber/Harvard Cancer Center (DF/HCC). DF/HCC is a National Cancer Institute-designated Comprehensive Cancer Center consisting of a consortium of seven Harvard institutions (Beth Israel Deaconess Medical Center, Brigham and Women's Hospital, Children's Hospital, Dana-Farber Cancer Institute, Harvard Medical School, Harvard School of Public Health, and the Massachusetts General Hospital.) The goal of the DF/HCC is to facilitate the development of new and improved models for the prevention and treatment of cancer. The DF/HCC is made up of research programs in the disciplines of basic, clinical, and population sciences that promote collaborations at the participating institutions. Various research-related services are provided through DF/HCC Cores, including expertise in survey design and administration, biostatistics, tissue sampling, among others. Members of the Department of Ambulatory Care and Prevention engaged in cancer-related research are eligible for membership in the DF/HCC and can take advantage of the services provided by the Center, including those of the Community Practice Core.

The DF/HCC Community Practice Core facilitates the conduct of cancer-related research by DF/HCC investigators within the community practice settings of Harvard Vanguard Medical Associates, Harvard Pilgrim Health Care, and the Cancer Research Network. The CPC has led to the initiation of numerous cancer-related studies within these settings.

Harvard Vanguard Medical Associates (HVMA) and HealthOne Care System

Harvard Vanguard Medical Associates is a multi-specialty medical group practice that delivers comprehensive health care to a community of over 300,000 patients at 14 offices in and around the Metropolitan Boston area. Through the merger of Harvard Vanguard Medical Associates with other provider groups, the resulting HealthOne network will serve a population of approximately 600,000 members. The long-standing collaboration between the Department of Ambulatory Care and Prevention and HVMA provides an ideal setting for investigators doing population and/or clinical-based research. Investigators have access to HVMA computerized medical data including automated medical records, claims, pharmacy, and membership data. Via the DF/HCC Community Practice Core (described above), we have expanded the types of electronic data in the HVMA Tumor Registry that are available for cancer research in this population. HVMA is currently implementing a patient-centered program, aimed at enhancing patient care through a multidisciplinary team approach. This initiative will expand the research opportunities within the HVMA settings.

Harvard Pilgrim Health Care (HPHC)

Harvard Pilgrim Health Care (HPHC) provides health care coverage to 900,000 individuals in Massachusetts, Maine and New Hampshire. The HPHC provider network includes physicians who practice in a variety of settings, including individual practices, small medical groups and large multi-specialty groups. The Department of Ambulatory Care and Prevention has long-standing research collaborations with the health plan. Harvard Pilgrim Health Care is ideal for investigators of all levels wishing to execute research projects with a larger population of patients and providers. Outpatient and hospitalization claims and pharmacy data are available. In addition, we have recently linked the HPHC data to the Massachusetts Cancer Registry and are testing the data for future use in funded studies. The leadership teams of the Department of Ambulatory Care and Prevention and Harvard Pilgrim Health Care's Medical Management team has recently established improving cancer care as a priority area for cooperative activities.

Major Areas of Cancer Research by DACP Investigators

Screening

DACP faculty members have led several projects examining the efficacy and consequences of mammography and other breast cancer prevention strategies in female populations. Harvard Pilgrim Health Care's extensive computerized health records make it an ideal setting for studies of this nature. An example of a recent study is a randomized trial in eight health centers to reduce patient anxiety after false-positive mammography readings Ref 1. This work flows from an earlier study showing a previously unappreciated high cumulative incidence of false-positives among women receiving annual mammograms for ten years. Ref 2. Other studies demonstrated a relatively low cost of immediate reading of screening mammography, Ref 3, a strong interest in continuing mammography screening among elderly female patients, the efficacy of mammography among women at an increased risk of developing breast cancer, Ref 4., and the information that women desired prior to initiating mammography screening. Ref 5.

Patients' decision making

Several studies examining the role of informed decision making on younger women's choices to initiate screening mammography, older women's decision's to continue screening, and women's decisions to undergo contralateral prophylactic mastectomy after breast cancer have been conducted. Ref 6.

Prevention

Breast cancer prevention, both primary and secondary, is another area of interest. A current study examines the risk factors for recurrence of ductal carcinoma in situ of the breast. A CRN study recently evaluated the effectiveness of bilateral prophylactic mastectomy among women at an increased risk of breast cancer and contralateral prophylactic mastectomy among women with breast cancer. Ref 7, Ref 8.

Quality of life

Quality of life studies have focused on women diagnosed with ductal carcinoma in situ of the breast, Ref 9., women with breast cancer who had a contralateral prophylactic mastectomy Ref 10., and women at an increased risk of breast cancer who had bilateral prophylactic mastectomy.

Treatment

Several researchers at the Department are collaborating on a study examining the adherence to aromatase inhibitors by women with early stage breast cancer.

Smoking Cessation

A number of smoking cessation studies have been conducted, including two CRN smoking cessation projects aiming to improve methods for monitoring quality of care using electronic medical records, help improve programs designed to increase adherence to national tobacco treatment guidelines, and provide useful information for developers of electronic medical records. The current study is developing methods for coding tobacco cessation activities in the medical records using a natural language processing, a method which can drastically reduce the costs and time needed to review medical records by hand. Ref 11, Ref 12.

Colorectal and lung cancer

An ongoing study funded by the National Cancer Institute is examining the care and outcomes of lung and colorectal cancer, Cancer Care Outcomes Research and Surveillance Consortium (CanCORS). Ref 13. Another study is based at HVMA and aims to improve screening of patients at increased risk for colorectal cancer because of family history.

Ovarian cancer

An ongoing study funded by the Centers for Disease Control and Prevention aims to determine the patient, provider and hospital characteristics in the diagnosis of ovarian cancer in Harvard Pilgrim Health Care.

Prevention

A recently completed randomized controlled study, "Cancer Prevention through Health Centers - Healthy Directions," included ten Harvard Vanguard health centers. The researchers tailored the intervention designed to target cancer prevention among multiethnic, low-income populations, by incorporating elements of the social context in which people live into the design and delivery of the intervention. The demonstrated success of the implementation and effectiveness of the intervention encouraged the researchers to submit a follow-up grant application to NCI to further this work. Ref 14. Ref 15.

Faculty Members Involved in Cancer Research and Areas of Focus

Larissa Nekhlyudov, MD, MPH, Assistant Professor (Acting Director of Cancer Research, Associate Site Director for the CRN)
Suzanne Fletcher, MD, MSc, Professor Emerita (CRN Site Principal Investigator)
Robert Fletcher, MD, MSc, Professor Emeritus (Colorectal Cancer)
Muriel Gillick, MD, Clinical Professor (Aging and Palliative Care)
Martin Kulldorff, Associate Professor (Biostatistics)
Lingling Li, PhD, Instructor (Biostatistics) Dennis Ross-Degnan, ScD, Associate Professor (Drug Policy)
Nancy Rigotti, MD, Associate Professor (Smoking Cessation)
Steven Simon, MD, MPH, Assistant Professor (Colorectal Cancer Screening)
Natasha Stout, PhD, Instructor (Breast cancer screening, Modeling) Anita Wagner, PhD, Assistant Professor (Drug Policy)

Selected References:

1. Barton MB, Morley, Moore S, Allen JD, et al. Decreasing womens' anxieties after abnormal mammograms: a controlled trial. J Natl Cancer Inst. 2004;96:529-538.
2. Elmore JG, Barton MB, Moceri VM, et al. Ten-year risk of false positive screening mammograms and clinical breast examination. N Engl J Med. 1998;338:1089-1096.
3. Same as Ref 1.
4. Elmore JG, Reisch LM, Barton MB, et al. Efficacy of breast cancer screening in the community according to risk level. N Jatl Cancer Inst. 2005;97:1035-1043.
5. Nekhlyudov L, Li Rong, Fletcher SW. Information and involvement preferences of women in their 40s before their first screening mammogram. Arch Intern Med. 2005;165:1370-1374.
6. Nekhlyudov L, Bower M, Geiger AM, et al. Womens' decision-making roles regarding prophylactic mastectomy. J Natl Cancer Inst Monographs. 2005;35:55-60.
7. Herrinton LJ, Barlow WE, Yu O. Efficacy of prophylactic mastectomy in women with ulilateral breast cancer: a Cancer Research Network project. J Clin Oncol. 2005;23:19:4275-4286.
8. Geiger AM, Yu O, Herrinton LJ. A population-based study of bilateral prophylactic mastectomy efficacy in women at elevated risk for breast cancer in community practice. Arch Intern Med. 2005;165;5:516-520.
9. Nekhlyudov L, Kroenke CH, Jung I, et al. Prospective changes in quality of life after ductal carcinoma in situ: results from the Nurses' Health Study. J Clin Oncol. 2006;24:2822-2827.
10. Geiger AM, West CN, Nekhlyudov, et al. Contentment with quality of life among breast cancer survivors with and without contralateral prophylactic mastectomy. J Clin Oncol. 2006;24:1350-56.
11. Hazelhurst B, Sittig DF, Stevens VJ, et al. Natural language processing in the electronic medical record: assessing clinician adherence to tobacco treatment guidelines. Am J Prev Med. 2005;29:434-439.
12. Stevens VJ, Solberg LI, Quinn VP, et al. Relationship between tobacco control policies and the delivery of smoking cessation services in nonprofit HMOs. J Natl Cancer Inst Monogr. 2005;35:75-80.
13. Ayanian JZ. Chrischilles EA, Wallace RB, et al. Understanding cancer treatment and outcomes: the Cancer Care Outcomes Research and Surveillance Consortium. J Clin Oncol. 2004;22;15:2992-2996.
14. Emmons K, Stoddard A, Gutheil C, et al. Cancer prevention for working class, multi-ethnic populations through health centers: The Health Directions Study. Cancer Causes and Control. 2003;14:729-737.
15. Lobb R, Gonzalez Suarez E, Fay ME, et al. Implementation of a cancer prevention program for working class, multiethnic populations. Prev Med. 2004;38;6:766-776.