Innovation In Cancer Care Research Articles

Solar Lentigines are Associated with Better Outcome in Cutaneous Melanoma.

The rising incidence of cutaneous melanoma and its stable high mortality rates despite innovative cancer care, require better prediction of the clinical outcome. In a large cutaneous melanoma population we explored whether the known clinical risk factors for melanoma susceptibility (nevus phenotype, phototype, family and personal history of melanoma and sun damage) affect melanoma outcomes. A total of 1,530 melanoma patients were included. Multivariable analysis adjusted for age, gender, melanoma stage, localization and subtype showed that familial melanoma, solar lentigines on head and neck, the back of hands, arms and shoulders were associated with a better relapse free survival. The presence of atypical naevi was associated with an increased risk of relapse. After Bonferroni correction, the correlation between presence of solar lentigines on the back of the hands and arms remained the most robust and significant prognostic factor for the relapse free survival in cutaneous melanoma patients.

Factors influencing middle managers’ commitment to the implementation of innovations in cancer care

To identify and illuminate influences on middle managers' commitment to innovation implementation. A qualitative study was conducted, employing the methods of grounded theory. Semi-structured interviews were used to collect data from middle managers (n = 15) in Nova Scotia and New Brunswick, Canada. Data were collected and analysed concurrently, using an inductive constant comparative approach. Data collection and analysis continued until theoretical saturation was reached. The data revealed middle managers contemplate two central issues in terms of their commitment to implementation, that is whether or not they fully engage in and support the implementation of a particular innovation. These issues are (1) ease of implementation and (2) potential benefit for patients. Middle managers' views and expectations related to ease of implementation are influenced by available resources, fit with setting, and stakeholder buy-in. Their views on patient benefit are influenced by external evidence of benefit and local gaps in care. These findings provide further insight into the factors that influence middle managers' commitment to innovation implementation, and how middle managers consider these factors in the context of their work settings.

Art and Challenges of Precision Medicine: Interpreting and Integrating Genomic Data Into Clinical Practice.

Precision medicine is at the forefront of innovation in cancer care. With the development of technologies to rapidly sequence DNA from tumors, cell-free DNA, proteins, and even metabolites coupled with the rapid decline in the cost of genomic sequencing, there has been an exponential increase in the amount of data generated for each patient diagnosed with cancer. The ability to harness this explosion of data will be critical to improving treatments for patients. Precision medicine lends itself to big data or "informatics" approaches and is focused on storing, accessing, sharing, and studying these data while taking necessary precautions to protect patients' privacy. Major cancer care stakeholders have developed a variety of systems to incorporate precision medicine technologies into patient care as soon as possible and also to provide the ability to store and analyze the omics and clinical data aggregately in the future. Scaling these precision medicine programs within the confines of health care system silos is challenging, and research consortiums are being formed to overcome these limitations. Incorporating and interpreting the results of precision medicine sequencing is complex and rapidly changing, necessitating reliance on a group of experts. This is often performed at molecular tumor boards at large academic and research institutions with available in-house expertise, but alternative models clinical decision support software or of virtual tumor boards potentially expand these advances to almost any patient, regardless of site of care. The promises of precision medicine will be more quickly realized by expanding collaborations to rapidly process and interpret the growing volumes of omics data.

Understanding Utilization Management Policy: How to Manage This Increasingly Complex Environment in Collaboration and With Better Data.

As innovation in cancer care continues and newer costly therapies receive approval, utilization management will continue to grow as an important way that payers can attempt to control costs and value while providing service to their patients. Although utilization management may be necessary, it takes many forms and is optimized when it ensures appropriate patient access to services and minimizes administrative burdens of physicians and staff. These opportunities are best explored in collaboration with payers. Information systems today provide an excellent platform for data sharing to facilitate collaborative efforts between care delivery organizations and payers to optimize these efforts. As state and national policies differ regarding utilization management, it is important for clinicians to be both aware and involved.

Cancer Patients' Recommendations for Nature-Based Design and Engagement in Oncology Contexts: Qualitative Research.

To explore cancer patients' recommendations for nature engagement based on their subjective nature experiences and observations in the cancer setting. The rationale was to gain practical insight for delineating relevant and translatable nature-based care and design opportunities in oncology contexts. Innovative cancer care services are needed to respond to growing demand and shifting healthcare needs. Engagement with nature has shown multiple health benefits and presents a promising opportunity for application in healthcare to improve outcomes. Qualitative research design using content analysis was used. Eligible adults with any cancer diagnosis participated in semistructured and audio-recorded interviews. Transcribed textual data included responses to two open-ended questions querying about participants' recommendations related to nature-based opportunities in the cancer setting. Deductive analysis used three predetermined categories: "recommendation: features," "recommendation: functions," and "cautions." Twenty patients with cancer (nine female) participated. Broad recommendations incorporated (1) using nature for vital sensory stimulation and engagement, (2) using nature for personal space and freedom to enable private and social exploration, (3) using views to nature for distraction and comfort, and (4) accessing nature for physical activity and movement. Three critical factors were determined for avoiding adverse experiences: determining appropriate expenditure and resourcing, selection of appropriate nature-based design materials, and exercising caution around demanding nature engagement and harsh weather conditions. Cancer patients' recommendations reveal the importance of engaging with nature in their experiences of health and recovery. The findings can inform planning appropriate and safe integration of beneficial nature engagement in cancer settings and support services.

Two Innovative Cancer Care Programs Have Potential to Reduce Utilization and Spending.

Cancer patients often present to the emergency department (ED) and hospital for symptom management, but many of these visits are avoidable and costly. We assessed the impact of 2 Health Care Innovation Awards that used an oncology medical home model [Community Oncology Medical Home (COME HOME)] or patient navigation model [Patient Care Connect Program (PCCP)] on utilization and spending. Participants in COME HOME and PCCP models were matched to similar comparators using propensity scores. We analyzed utilization and spending outcomes using Medicare fee-for-service claims with unadjusted and adjusted difference-in-differences models. In the adjusted models, both COME HOME and PCCP were associated with fewer ED visits than a comparison group (15 and 22 per 1000 patients/quarter, respectively; P<0.01). In addition, COME HOME had lower spending ($675 per patient/quarter; P<0.01), and PCCP had fewer hospitalizations (11 per 1000 patients/quarter; P<0.05), relative to the comparison group. Among patients undergoing chemotherapy, fewer COME HOME and PCCP patients had ED visits (18 and 28 per 1000 patients/quarter, respectively; P<0.01) and fewer PCCP patients had hospitalizations (13 per 1000 patients/quarter; P<0.05), than comparison patients. The oncology medical home and patient navigator programs both showed reductions in spending or utilization. Adoption of such programs holds promise for improving cancer care.

Identifying critical steps towards improved access to innovation in cancer care: a European CanCer Organisation position paper

In recent decades cancer care has seen improvements in the speed and accuracy of diagnostic procedures; the effectiveness of surgery, radiation therapy and medical treatments; the power of information technology; and the development of multidisciplinary, specialist-led approaches to care. Such innovations are essential if we are to continue improving the lives of cancer patients across Europe despite financial pressures on our healthcare systems. Investment in innovation must be balanced with the need to ensure the sustainability of healthcare budgets, and all health professionals have a responsibility to help achieve this balance. It requires scrutiny of the way care is delivered; we must be ready to discontinue practices or interventions that are inefficient, and prioritise innovations that may deliver the best outcomes possible for patients within the limits of available resources. Decisions on innovations should take into account their long-term impact on patient outcomes and costs, not just their immediate costs. Adopting a culture of innovation requires a multidisciplinary team approach, with the patient at the centre and an integral part of the team. It must take a whole-system and whole-patient perspective on cancer care and be guided by high-quality real-world data, including outcomes relevant to the patient and actual costs of care; this accurately reflects the impact of any innovation in clinical practice. The European CanCer Organisation is committed to working with its member societies, patient organisations and the cancer community at large to find sustainable ways to identify and integrate the most meaningful innovations into all aspects of cancer care.

Developments in Molecular Testing and Biosimilars.

Molecular testing and biosimilars offer the potential for increased access to targeted treatment options and reduction in healthcare costs, but come with significant challenges in ensuring patient access to innovation in cancer care while maintaining safe, effective, ethical, and affordable treatment options. As providers, payers, patients, and the larger healthcare systems become inundated with a wide variety of molecular diagnostics and an increased number of biosimilars coming to market, it will be important to understand regulatory guidance and policy implications relating to the appropriateness of molecular testing and the clinical use of biosimilars in cancer care. In September 2016, NCCN hosted the Molecular Testing and Biosimilars Policy Summit to address the challenges, issues, and opportunities in both the molecular testing and biosimilar landscapes. Keynote presentations and panelists further discussed the status and future of molecular testing and biosimilars within the oncology space, as well as patient access and education needs moving forward.

Racial and Ethnic Disparities in Oncotype DX Test Receipt in a Statewide Population-Based Study.

Background: Racial disparities have been reported in breast cancer care, yet little is known about disparities in access to gene expression profiling (GEP) tests. Given the impact of GEP test results, such as those of Oncotype DX (ODx), on treatment decision-making for hormone receptor-positive (HR+) breast cancer, it is particularly important to assess disparities in its use. Methods: We conducted a retrospective population-based study of 8,784 patients diagnosed with breast cancer in Connecticut during 2011 through 2013. We assessed the association between race, ethnicity, and ODx receipt among women with HR+ breast cancer for whom NCCN does and does not recommend ODx testing, using bivariate and multivariate logistic analyses. Results: We identified 5,294 women who met study inclusion criteria: 83.8% were white, 6.3% black, and 7.4% Hispanic. Overall, 50.9% (n=4,131) of women in the guideline-recommended group received ODx testing compared with 18.5% (n=1,163) in the nonrecommended group. More white women received the ODx test compared with black and Hispanic women in the recommended and nonrecommended groups (51.4% vs 44.6% and 47.7%; and 21.2% vs 9.0% and 9.7%, respectively). After adjusting for tumor and clinical characteristics, we observed significantly lower ODx use among black (odds ratio [OR], 0.64; 95% CI, 0.47-0.88) and Hispanic women (OR, 0.59; 95% CI, 0.45-0.77) compared with white women in the recommended group and in the guideline-discordant group (blacks: OR, 0.39; 95% CI, 0.20-0.78, and Hispanics: OR, 0.44; 95% CI, 0.23-0.85). Conclusions: In this population-based study, we identified racial disparities in ODx testing. Disparities in access to innovative cancer care technologies may further exacerbate existing disparities in breast cancer outcomes.

Next-generation Sequencing-based genomic profiling: Fostering innovation in cancer care?

OBJECTIVES:With the development of next-generation sequencing (NGS) technologies, DNA sequencing has been increasingly utilized in clinical practice. Our goal was to investigate the impact of genomic evaluation on treatment decisions for heavily pretreated patients with metastatic cancer.METHODS:We analyzed metastatic cancer patients from a single institution whose cancers had progressed after all available standard-of-care therapies and whose tumors underwent next-generation sequencing analysis. We determined the percentage of patients who received any therapy directed by the test, and its efficacy.RESULTS:From July 2013 to December 2015, 185 consecutive patients were tested using a commercially available next-generation sequencing-based test, and 157 patients were eligible. Sixty-six patients (42.0%) were female, and 91 (58.0%) were male. The mean age at diagnosis was 52.2 years, and the mean number of pre-test lines of systemic treatment was 2.7. One hundred and seventy-seven patients (95.6%) had at least one identified gene alteration. Twenty-four patients (15.2%) underwent systemic treatment directed by the test result. Of these, one patient had a complete response, four (16.7%) had partial responses, two (8.3%) had stable disease, and 17 (70.8%) had disease progression as the best result. The median progression-free survival time with matched therapy was 1.6 months, and the median overall survival was 10 months.CONCLUSION:We identified a high prevalence of gene alterations using an next-generation sequencing test. Although some benefit was associated with the matched therapy, most of the patients had disease progression as the best response, indicating the limited biological potential and unclear clinical relevance of this practice.

The promise of virtual navigation in cancer care: Insights from patients and health care providers.

Virtual navigation (VN) in health care is a proactive process by which patients obtain information and support via Internet resources to manage their illness demands. The objective of this analysis was to explore converging and diverging perspectives of key stakeholders: patients with cancer and Health Care Providers (HCPs), about a cancer-related VN tool called the Oncology Interactive Navigator (OIN™). A qualitative secondary analysis was performed combining data sets from two prior studies exploring perspectives of VN among patients (study 1, n=20) and HCPs (study 2, n=13). An inductive approach was used to explore converging and diverging views across groups. Findings explore how patients' and HCPs' views converge and diverge and the processes necessary to ensure optimal uptake of VN innovations in cancer care.

PCN270 - Cost Per Qaly as a Potential Hurdle in Accessibility to Innovative Cancer Care in Selected Cee Countries

PCN270 - Cost Per Qaly as a Potential Hurdle in Accessibility to Innovative Cancer Care in Selected Cee Countries

Increasing Minority Enrollment Onto Clinical Trials: Practical Strategies and Challenges Emerge From the NRG Oncology Accrual Workshop.

Racial and ethnic diversity has historically been difficult to achieve in National Cancer Institute-sponsored clinical trials, even while as many as 80% of those trials have faced difficulty in meeting overall recruitment targets. In an attempt to address these issues, NRG Oncology recently convened a comprehensive workshop titled "Clinical Trials Enrollment: Challenges and Opportunities." Discussants at the workshop included representatives of the three legacy groups of the NRG (ie, Gynecologic Oncology Group, National Surgical Adjuvant Breast and Bowel Program, and Radiation Therapy Oncology Group), a minority-based community clinical oncology program, a large integrated health care system, the leadership of the National Cancer Institute, and a large patient advocacy group. This article summarizes the concepts discussed at the workshop, which included: needs assessments, infrastructural support, training of investigators and research staff, specific clinical trial recruitment strategies (both system and community based), and development and mentoring of young investigators. Many new, more specific tactics, including use of diverse cancer care settings, direct-to-consumer communication, and the need for centralized information technology such as the use of software to match trials to special populations, are presented. It was concluded that new, innovative trial designs and the realities of limited funding would require the adoption of effective and efficient recruiting strategies, specialized training, and stakeholder engagement. US clinical research programs must generate and embrace new ideas and pilot test novel recruitment strategies if they are to maintain their historic role as world leaders in cancer care innovation and delivery.

Medical innovation does not require a new law.

In the last months of the UK coalition government, the Liberal Democrats (www.libdems.org.uk) vetoed Lord Saatchi's proposed law after it had successfully had a third reading in the House of Lords and was set to go to the Commons. The Liberal Democrat Health Minister Norman Lamb said that in preventing the proposed legislation he wanted to avoid the threat that the new law might pose to patient safety. Lord Saatchi's Bill now reappears in this new parliament as the Access to Medical Treatments (Innovation) Bill, and is sponsored by a Conservative Member of Parliament. Supported by No. 10 Downing Street (www.gov.uk/government/organisations/prime-ministers-office-10-downing-street), the Bill may well become law. Many lawyers oppose the Bill in its current form. The Medical Defence Union, Action against Medical Accidents, and Association of Personal Injury Lawyers have come out against the Bill. The most crucial reason for this opposition is the erroneous idea (promulgated in ‘Are rigid management protocols stifling innovation in cancer treatment?’) that fear of litigation is preventing innovation in cancer care, by promoting ‘defensive medicine’. This idea, that scientific progress has, as Lord Saatchi claims, been ‘stopped by the law’ is wrong and illustrates a misunderstanding of the basic elements of clinical negligence law. Doctors are already given protection by the law when they innovate, as long as the treatment proposed is agreed by colleagues, is as safe as possible, and the newness of the treatment (and for example lack of knowledge of complications or follow-up data) is fully understood by the patient. Those who promote the Bill appear to be unaware that the Bolam test is satisfied even if only a very small body of reasonable medical opinion supports the treatment given and the management of the patient stands up to logical scrutiny as being rational and justifiable (the ‘Bolitho test’). The recent UK Supreme Court case of Montgomery (which deals with informed consent) is a good illustration of how the law is able to react flexibly and pragmatically to changes in the doctor–patient relationship that have occurred in recent years. The Bolam test would not prevent doctors from departing from standard practice in appropriate and justifiable circumstances. There are other legitimate concerns about the Bill, for example that it does not give patients the right to new treatment and that it may promote irresponsible innovation on vulnerable patients where their right to redress in the civil courts is expressly removed by the legislation. Experimentation without professional accountability does not empower or give a patient ‘clarity and certainty’. In his condemnation of the Bill, Sir Robert Francis QC stated that the barrier to innovative treatment is not the law of negligence but ‘overzealous bureaucracy, scarcity of resources, ethical reservations and decision making processes’ (Response of Robert Francis QC to Legislation to encourage medical innovation – A consultation). Research charities have become successful in raising money and patient awareness. Advances could easily be made by a better utilisation of knowledge, by freeing clinicians from strict management protocols, or by looking at the option of prescribing novel drug treatments outside clinical trials by different licensing arrangements. None of these depend on the Medical Innovation Bill becoming law. None declared. Completed disclosure of interests form available to view online as supporting information. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

Physician's peer exposure and the adoption of a new cancer treatment modality.

New technologies, often with limited evidence to support their effectiveness, frequently diffuse into clinical practice and increase the costs of cancer care. The authors studied whether physician peer exposure was associated with the subsequent adoption of a new approach to adjuvant radiotherapy (brachytherapy) for the treatment of women with early-stage breast cancer. A retrospective cohort study was performed using Surveillance, Epidemiology, and End Results (SEER)-Medicare data. Data from 2003 through 2004 were used to classify surgeons as early brachytherapy adopters and, among non-early adopters, whether they shared patients with early adopters (peer exposure). Data from 2005 through 2006 were used to examine whether women were more likely to receive brachytherapy if their surgeons were exposed to early adopters. Overall, the percentage of women receiving brachytherapy increased from 3.2% in 2003 through 2004 to 4.7% in 2005 through 2006. In this latter period, a total of 2087 patients were assigned to 328 non-early adopting surgeons. In unadjusted analyses, patients whose surgeons were connected to early adopters during 2003 through 2004 were found to be significantly more likely to receive brachytherapy in 2005 through 2006 compared with those whose surgeons were not connected to early adopters (8.0% vs 4.1%; P = .003). In adjusted analyses, the predicted probability of receiving brachytherapy among patients whose surgeon did have an early-adopting peer was 3.9% versus 1.0% among those whose surgeons did not have an early-adopting peer (P = .03). Exposure to peers who were early adopters of brachytherapy was found to be associated with a surgeon's subsequent uptake of brachytherapy. The results of the current study provide an example of a novel approach to examining the diffusion of innovation in cancer care.

Multi-level factors influence the implementation and use of complex innovations in cancer care: a multiple case study of synoptic reporting.

BackgroundThe implementation of innovations (i.e., new tools and practices) in healthcare organizations remains a significant challenge. The objective of this study was to examine the key interpersonal, organizational, and system level factors that influenced the implementation and use of synoptic reporting tools in three specific areas of cancer care.MethodsUsing case study methodology, we studied three cases in Nova Scotia, Canada, wherein synoptic reporting tools were implemented within clinical departments/programs. Synoptic reporting tools capture and present information about a medical or surgical procedure in a structured, checklist-like format and typically report only items critical for understanding the disease and subsequent impacts on patient care. Data were collected through semi-structured interviews with key informants, document analysis, nonparticipant observation, and tool use/examination. Analysis involved production of case histories, in-depth analysis of each case, and a cross-case analysis. Numerous techniques were used during the research design, data collection, and data analysis stages to increase the rigour of this study.ResultsThe analysis revealed five common factors that were particularly influential to implementation and use of synoptic reporting tools across the three cases: stakeholder involvement, managing the change process (e.g., building demand, communication, training and support), champions and respected colleagues, administrative and managerial support, and innovation attributes (e.g., complexity, compatibility with interests and values). The direction of influence (facilitating or impeding) of each of these factors differed across and within cases.ConclusionsThe findings demonstrate the importance of a multi-level contextual analysis to gaining both breadth and depth to our understanding of innovation implementation and use in health care. They also provide new insights into several important issues under-reported in the literature on moving innovations into healthcare practice, including the role of middle managers in implementation efforts and the importance of attending to the interpersonal aspects of implementation.Electronic supplementary materialThe online version of this article (doi:10.1186/s13012-014-0121-0) contains supplementary material, which is available to authorized users.

82IN - Personalised Medicine in National Cancer Plans: How Can Innovation Be Translated Into Policy?

ABSTRACT Stratified, precision or personalised medicine (PM) is emerging as one of the most important areas of clinical innovation in cancer care. Yet, implementing policies to translate these innovations to practice entails deep changes, including in how patient information is treated, how funding is allocated, how diagnostic tests are validated and carried out, how care is organised, how clinical trials are conducted and how new drugs are approved. National Cancer Control Programmes (NCCPs), for their part, have emerged as the primary instrument to coordinate the range of cancer control policies within individual countries, and virtually all European countries have adopted one. This means that for PM to be integrated into cancer care at a national scale, they should ideally be contemplated first within the broad framework of an NCCP. Before deciding how to integrate PM concepts within an NCCP, it is important to understand two facts about PM in cancer. First, although currently PM is in a relatively early stage of development, it is clearly an active area of interest for researchers and clinicians, so— sooner or later—PM will objectively and widely be considered an integral part of cancer control. In other words, it is in the best interests of health systems to start preparing now for the future. Secondly, PM will not be limited to the spheres of diagnosis and care. From regulatory structures, data exchange and technological infrastructures, to professional training, clinical trials, health services research and patient education and engagement, PM concepts must eventually be integrated into all areas of cancer control, and indeed of healthcare. While it is still somewhat premature to implement definitive, large-scale changes to cancer care policy, it is not too early to develop strategic PM approaches to professional training, biobanks, clinical trials and patient education. These actions, properly set within the solid foundation of an evidence-based NCCP, will set the groundwork for the organised and coherent uptake of future innovations in PM, ensuring that a personalised approach is implemented—equitably, rationally and with sufficient evidence—at a population level. Disclosure: The author has declared no conflicts of interest.

Fighting a smarter war against cancer

Molecular Profiling in Cancer: Research or Practice, Georgetown University Hotel and Conference Center, Washington, DC, USA, 6–7 December 2013 On the 6th and 7th of December 2013, the Ruesch Center for the Cure of Gastrointestinal Cancers (DC, USA) hosted its fourth annual symposium entitled Molecular Profiling in Cancer: Research or Practice. This topic was selected for the 2013 symposium because of the explosion of molecular profiling assays that are available to us as practicing oncologists, which are believed, by most, to be a significant advancement in cancer care innovation. The Ruesch Center has been hosting topical symposia for the last 4 years. We have focused on: biomarker use in cancer medicine (2010); defining value in cancer care (2011); how to engage the ‘other 97%’ of patients in clinical trial enrollment, when currently we capture only 3% of patients on average (2012); and, of course, molecular profiling in cancer care (2013).

Improving the quality of cancer care in America.

Thomas Feeley is the Helen Shafer Fly Distinguished Professor of Anesthesiology, and the Head of the Institute for Cancer Care Innovation at the University of Texas MD Anderson Cancer Center (TX, USA), which he has led since its formation in 2008. He received his undergraduate degree and M.D. from Boston University (MA, USA) and trained in anesthesiology and critical care medicine at Harvard’s Beth Israel Hospital in Boston. He was a faculty member at Stanford University (CA, USA) for 19 years prior to moving to The University of Texas MD Anderson Cancer Center in 1997 to lead the then newly created Division of Anesthesiology and Critical Care. Dr Feeley served on the Institute of Medicine’s Committee on Improving the Quality of Cancer Care: Addressing the Challenges of an Aging Population that published its report in September of 2013. He was recently appointed by Texas Governor Rick Perry to the board of directors of the Texas Institute for Health Care Quality and Efficiency. In addition to his research and administrative roles, Dr Feeley provides patient care services in the delivery of anesthesia.

Dissemination, implementation, and quality improvement research within the HMO Cancer Research Network.

215 Background: The HMO Cancer Research Network, funded by the National Cancer Institute, provides infrastructure support to facilitate cancer research in non-profit integrated healthcare delivery systems. A key CRN goal to improve quality and outcomes through research and research-based methods for accelerating implementation of innovations in cancer care. Methods: The CRN is led by a Steering Committee and an Executive Committee. CRN Scientific Working Groups support activity within distinct areas; the CRN Communication and Dissemination Scientific Working Group (C&amp;D SWG) supports the design, conduct and reporting of research on (1) communication and decision makin in cancer care and (2) dissemination and implementation of cancer research findings and best practices. C&amp;D SWG activities include monthly calls presenting C&amp;D research resources, project ideas and funding opportunities; individual consultation and technical assistance to support CRN researchers developing funding applications and conducting research in relevant areas; and mentorship for CRN Scholars. General CRN resources to facilitate research to improve cancer care quality include a multi-institution Virtual Data Warehouse with accompanying query tools to facilitate preparatory-to-research and collaborative research studies and specific cancer-related data items; funding for Developmental and Pilot Studies; and an Outreach and External Collaborations Core to facilitate research collaborations among (a) CRN institution-based scientists, (b) scientists at other institutions, and (c) clinical and operations partners. Results: The CRN C&amp;D SWG continues to stimulate increased awareness and interest in conducting dissemination and implementation studies and quality improvement research in cancer care, and to support the development of new project ideas and funding applications and the successful completion and publication of such studies. Conclusions: CRN activities facilitate innovative multi-site, multi-disciplinary cancer studies in the integrated delivery system setting, and motivate continued evolution of CRN institutions as the nation's premier learning health care systems. Supported by U24 CA171524.