Implementation of Cancer Plans in the United States: A Review.

State cancer plans facilitate prioritization and stakeholder engagement in preventing and controlling cancer. Implementation plans further help stakeholders prioritize efforts, reduce redundancy, and find opportunities for work synergies. A review of cancer plan implementations plans was performed in the development of an implementation plan for the Florida Cancer Plan. This review sought to identify, characterize, and summarize the use of implementation plans that support comprehensive cancer control activities. Although 100% of states and territories published a cancer plan and 78% of states provided funding for implementing their state cancer plans, only 32% published an implementation plan. Commonalities and unique features of state cancer plan implementations are presented and discussed. An example implementation plan is provided for states without a plan to model.

1. Introduction

A crucial component of comprehensive cancer control (CCC) is a plan developed collaboratively by multiple and diverse stakeholders with aspirational goals, evidence-based strategies, and measurable objectives [1,2,3]. Historically, each state prioritizes their goals, strategies, and objectives based on several factors including specific cancer burdens affecting their communities, stakeholder capacity, feasibility, and political will [4]. A typical cancer plan can contain twelve to sixty objectives, but usually encompasses the continuum of cancer from prevention to early detection to treatment to survivorship. As limited resources preclude working on all objectives at once, cancer consortiums must adopt some method of selecting objectives [5]. This selection process and work to synergize efforts makes up a state’s cancer control implementation plan. In some cases, an implementation plan document is crafted and used as an operational supplement to the cancer plan document.

The history of CCC plans and supplemental implementation plans within the United States represents a gradual but concerted effort to streamline cancer burden reduction into coordinated action. Early initiatives in CCC focused on the use of plans, in conjunction with registries, to target specialized foci, such as screening initiatives, incidence reduction, and mortality improvements [6,7,8]. At the federal level, the Center for Disease Control and Prevention (CDC) established the National Breast and Cervical Cancer Early Detection Program in 1991 in partnership with states’ departments of health to provide low-cost screening and diagnostic services to vulnerable populations [9]. The CDC furthered its cancer control programming the following year through the establishment of the National Program of Cancer Registries, which sought to characterize the current cancer burden at the federal level [9]. In 1998, the CDC launched the National Comprehensive Cancer Control Program (NCCCP) at a limited scale within select states [10]. Defined by a primary mission goal of promoting health equity through cancer control, the NCCCP grants resources and funding to relevant organizations to reduce cancer burden. Over the next two decades, the program successfully expanded to include all fifty states and various jurisdictions, each with well-defined and ambitious CCC plans [11]. The creation of dedicated implementation plans to supplement the overall CCC plan and increase the actualization of objectives, however, has been much more limited in scale.

Recently, the Florida Cancer Control and Research Advisory Council (formerly known as Cancer Control and Research Advisory Board or CCRAB) led the State of Florida in establishing its 2020–2025 Florida Cancer Plan [12]. The Council also established an Implementation Plan for the State of Florida’s Cancer Plan. In preparation for implementing the Florida Cancer Plan, the Council closely reviewed cancer plan implementation in other states to determine best practices. This review of published literature sought to identify, characterize, and summarize the use of implementation plans as a means of comprehensive cancer control by 50 States and 9 territories. Included in this analysis is a review of the common and unique elements of each implementation plan, and how such efforts synergize with existing cancer burden reduction initiatives. This review is a summary of the Council’s background research and is provided with the hopes of assisting other states, territories, and the public when designing and actuating their plans to ultimately reduce cancer burden.

2. Methods

A review of published English articles was conducted using the guidelines established by the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) [13]. A comprehensive literature search was conducted from June 2020–August 2020 through the PubMed-NCBI database using the following search terms / phrases: state cancer plan, cancer implementation plan, cancer control plan, and comprehensive cancer control. Additional studies were also collected using the references discussed within the collected articles. This study is exempt from IRB approval because the data used are derived from previously published research. Additionally, the official Department of Health websites for each state and jurisdiction were reviewed from June 2020–August 2020 to identify and review published NCCCP plans and implementation plans. Search and article criteria included specific discussions or reviews of cancer burden reduction from publications from 1990 and onwards. Figure 1 summarizes the search yield and study selection process using the standardized PRISMA flowchart. A total of 221 articles were screened and 156 were fully assessed, with 54 articles excluded from qualitative synthesis due to the content discussed being predominantly unrelated to CCC within the United States or repeated data. Fifty-nine (59) articles were used directly from published CCC plans for the quantitative analysis presented in Table 1 and Table 2. Appendix B includes the PRISMA checklist.

Figure 1

Flow diagram of search and study selection.

Table 1

State Cancer Plans in the United States and Plans for Implementation, all access 31 August 2020.

State	Cancer Plan Website	Implementation Plan
Alabama	https://www.alabamapublichealth.gov/cancercontrol/ (accessed on 31 August 2020)
Alaska	http://dhss.alaska.gov/dph/Chronic/Pages/Cancer/partnership/default.aspx (accessed on 31 August 2020)
Arizona	https://www.azdhs.gov/prevention/tobacco-chronic-disease/cancer-prevention-control/az-cancer-coalition/index.php#az-cancer-control-prevent (accessed on 31 August 2020)
Arkansas	https://arcancercoalition.org/about-us/ (accessed on 31 August 2020)	X
California	https://www.cdph.ca.gov/Programs/CCDPHP/DCDIC/CDSRB/Pages/California-Dialogue-on-Cancer-(CDOC).aspx (accessed on 31 August 2020)
Colorado	https://www.coloradocancercoalition.org/colorado-cancer-fund/grant-application/ (accessed on 31 August 2020)	X
Connecticut	http://ctcancerpartnership.org/ (accessed on 31 August 2020)
Delaware	https://www.healthydelaware.org/Consortium#:~:text=The%20Delaware%20Cancer%20Consortium%20was,potential%20methods%20for%20reducing%20both (accessed on 31 August 2020)
Florida	http://www.ccrab.org/cancer-plan (accessed on 31 August 2020)	X
Georgia	https://dph.georgia.gov/cancer-prevention-and-control/comprehensive-cancer-control-program (accessed on 31 August 2020)
Hawaii	https://health.hawaii.gov/cancer/home/coalition/ (accessed on 31 August 2020)
Idaho	https://www.ccaidaho.org/about-ccai (accessed on 31 August 2020)
Illinois	https://www.ipha.com/news/illinois-cancer-partnership#gsc.tab=0 (accessed on 31 August 2020)
Indiana	https://www.in.gov/isdh/28395.html (accessed on 31 August 2020)	X
Iowa	https://canceriowa.org/grants/fy2021/ (accessed on 31 August 2020)	X
Kansas	http://cancerkansas.net/Workgroups (accessed on 31 August 2020)
Kentucky	https://www.kycancerc.org/ (accessed on 31 August 2020)
Louisiana	https://healthylouisiana.org/about (accessed on 31 August 2020)
Maine	https://mainecancer.org/apply-for-a-grant (accessed on 31 August 2020)
Maryland	https://phpa.health.maryland.gov/cancer/cancerplan/Pages/collaborative.aspx (accessed on 31 August 2020)
Massachusetts	https://www.mass.gov/service-details/massachusetts-comprehensive-cancer-prevention-and-control-network-mccpcn-work (accessed on 31 August 2020)
Michigan	https://www.michigancancer.org/CancerPlan/ComprehensiveCancerControlPlan-2016–2020.html (accessed on 31 August 2020)
Minnesota
Mississippi	https://www.umc.edu/cancerinstitute/Cancer-Research/Cancer-Registries/Mississippi%20Cancer%20Registry/Mississippi-Partnership-for-Comprehensive-Cancer-Control.html (accessed on 31 August 2020)
Missouri	https://www.cancernmo.org/about-the-consortium (accessed on 31 August 2020)	X
Montana	https://dphhs.mt.gov/publichealth/cancer/cancercoalition (accessed on 31 August 2020)	X
Nebraska	https://www.necancer.org/implementation (accessed on 31 August 2020)
Nevada	https://nevadacancercoalition.org/get-involved/task-force (accessed on 31 August 2020)	X
New Hampshire	https://www.nhcancerplan.org/index.php/workgroups/93-task-forces/221-goals-objectives-strategies (accessed on 31 August 2020)
New Jersey	https://www.nj.gov/health/ces/public/surveillance-unit/ (accessed on 31 August 2020)	X
New Mexico	http://www.nmcancercouncil.org/ (accessed on 31 August 2020)
New York	https://www.health.ny.gov/diseases/cancer/consortium/index.htm (accessed on 31 August 2020)
North Carolina	https://publichealth.nc.gov/chronicdiseaseandinjury/cancerpreventionandcontrol/index.htm (accessed on 31 August 2020)
North Dakota	http://www.ndhealth.gov/compcancer/cancer-programs-and-projects/nd-comprehensive-cancer-control-sub-contract-request-for-proposals/ (accessed on 31 August 2020)	X
Ohio	https://www.ohiocancerpartners.org/ (accessed on 31 August 2020)
Oklahoma	https://www.ok.gov/health/Disease,_Prevention,_Preparedness/Chronic_Disease_Service/Cancer_Prevention_Programs_/Comprehensive_Cancer_Control_Program/Oklahoma_Comprehensive_Cancer_Network_(OCCN)/index.html (accessed on 31 August 2020)
Oregon	https://www.oregon.gov/oha/PH/DiseasesConditions/ChronicDisease/Documents/hpcdp-strategic-plan.pdf (accessed on 31 August 2020)
Pennsylvania	http://www.pacancercoalition.org/workgroups (accessed on 31 August 2020)	X
Rhode Island	https://www.prcri.org/our-partners (accessed on 31 August 2020)
South Carolina	https://www.sccancer.org/the-alliance/ (accessed on 31 August 2020)	X
South Dakota	https://www.cancersd.com/resources/grant-opportunities/ (accessed on 31 August 2020)	X
Tennessee	https://www.tn.gov/health/health-program-areas/fhw/tccc/coalition-leadership.html (accessed on 31 August 2020)
Texas	https://www.cprit.state.tx.us/about-us (accessed on 31 August 2020)	X
Utah	http://www.ucan.cc/members/implementation/ (accessed on 31 August 2020)	X
Vermont	http://vtaac.org/our-partnerships/ (accessed on 31 August 2020)
Virginia	https://cancercoalitionofvirginia.org/pages/about-CACV.php (accessed on 31 August 2020)
Washington	https://www.doh.wa.gov/YouandYourFamily/IllnessandDisease/Cancer/ComprehensiveCancerControl#:~:text=The%20Washington%20State%20Comprehensive%20Cancer,broad%20spectrum%20of%20cancer%20issues (accessed on 31 August 2020)	X
West Virginia	https://moh.wv.gov/awards-mini-grants/Pages/default.aspx (accessed on 31 August 2020)	X
Wisconsin	https://wicancer.org/programs/action-areas/ (accessed on 31 August 2020)	X
Wyoming	https://health.wyo.gov/publichealth/prevention/cancer/wyoming-cancer-coalition/ (accessed on 31 August 2020)
Washington, D.C.	https://www.dccanceranswers.org/about/mission/ (accessed on 31 August 2020)	X
Pacific Region	http://www.pacificcancer.org/index.html (accessed on 31 August 2020)
America Samoa	http://www.pacificcancer.org/pacific-partners/american-samoa.html (accessed on 31 August 2020)
Commonwealth of Northern Mariana Islands	http://www.pacificcancer.org/pacific-partners/northern-mariana-islands.html (accessed on 31 August 2020)
Federated States of Micronesia	http://www.pacificcancer.org/pacific-partners/federated-states-of-micronesia.html (accessed on 31 August 2020)
Guam	http://www.pacificcancer.org/pacific-partners/guam.html (accessed on 31 August 2020)
Republic of the Marshall Islands	http://www.pacificcancer.org/pacific-partners/marshall-islands.html (accessed on 31 August 2020)	X
Republic of Palau	http://www.pacificcancer.org/pacific-partners/palau.html (accessed on 31 August 2020)
Puerto Rico	https://www.iccp-portal.org/puerto-rico-model-collaborative-and-parcipative-approach (accessed on 31 August 2020)

Table 2

Analysis of State Cancer Plans in the United States.

State or Territory	Is the Cancer Plan Current to 2020/2021?	Engagement: Existence of Task Forces and/or Workgroups	Existence of Regional Coalitions	Grant Applications on Website
Alabama	X	X
Alaska	X	X
Arizona
Arkansas	X			X
California
Colorado	X	X		X
Connecticut		X
Delaware	X	X
Florida	X		X
Georgia			X
Hawaii	X	X	X
Idaho	X	X
Illinois	X
Indiana	X	X	X	X
Iowa	X			X
Kansas	X	X	X
Kentucky	X		X
Louisiana	X	X	X	X
Maine	X	X		X
Maryland	X
Massachusetts	X	X
Michigan	X	X
Minnesota	X	X	X
Mississippi	X		X
Missouri	X
Montana	X	X		X
Nebraska	X	X
Nevada	X	X
New Hampshire	X	X
New Jersey			X
New Mexico		X
New York	X	X
North Carolina	X	X
North Dakota	X	X		X
Ohio	X	X
Oklahoma	X
Oregon
Pennsylvania	X	X		X
Rhode Island		X
South Carolina	X	X		X
South Dakota	X	X		X
Tennessee	X	X
Texas		X		X
Utah	X			X
Vermont	X	X
Virginia	X		X
Washington	X	X	X
West Virginia	X	X	X	X
Wisconsin	X	X		X
Wyoming	X	X
Pacific Region		X	X
America Samoa
Commonwealth of Northern Mariana Islands
Federated States of Micronesia	X
Guam	X	X
Republic of the Marshall Islands	X
Republic of Palau	X
Puerto Rico		X
Washington DC	X

Study eligibility was determined a priori and included all publications that discussed comprehensive cancer control and/or implementation plans. Our analysis was guided by PICO (population, intervention, comparison, and outcome) principles of systematic reviews when applicable. The scope (population) of this review was defined as the states, territories, and jurisdictions associated with the United States. The intervention was the existence of published cancer control implementation plans or organizations. As a core component of this study was to compare the commonalities and differences of implementation plans (and identify regions that lacked such a plan), the comparison group was reviewing cancer control strategies between States that used a formalized implementation plan. A secondary function was comparing differing strategies among States with a cancer implementation plan versus States that do not have a plan. The outcome of this review is to provide a qualitative review of the distribution and defining features of cancer implementation plans that are produced by States and related jurisdictions.

Data extraction was performed independently by the first author (MWB) under the direct supervision of the senior author (CRC). Any disagreements were discussed and revised by the authors. Information was extracted on the characteristics of comprehensive cancer control, the use and design of cancer plans, funding to support implementation, and the use and design of implementation plans. All the data supporting the statements of this manuscript are presented and appropriately referenced throughout this document. We acknowledge the risk of selection and publication bias when screening and including articles, and the inherent difficulty in limiting such biases when the information used to form this study involves qualitative assessment to characterize plan elements.

Percentages were calculated from this data in the context of 59 states and territories. All descriptive statistics were analyzed using Microsoft Excel. Characteristics of comprehensive cancer control and plans were summarized using simple descriptive statistics which serve as the primary summary measurement.

3. Results

Every U.S. state (N = 50) and U.S. territory (N = 9) had an online publication of their cancer plan, with 46 of 59 (78%) publishing a current plan and 13 of 59 (22%) publishing an out-of-date plan (Table 1). The organization of NCCCP plan objectives varied from state to state and included specific categories such as screening and vaccination goals, as well as specific improvements in cancer survivorship quality of life [14,15,16].

Of the 59 states and territories, 19 (32%) had a distinct implementation plan document that specifically addressed cancer plan evidence-based implementation strategies. State departments of health participated in funding 46 of 59 (78%) implementation efforts.

The implementation plans took many forms. Nineteen states and territories published documents that presented implementation on a website. As an example, the State of Florida’s cancer plan implementation plan is provided in Appendix A. Nevada published “action plans” to correspond with task force objectives.

Nineteen states had websites that presented implementation strategies and served as a hub to link cancer stakeholders and initiatives, such as on Florida’s Department of Health website. Other states, such as Colorado and 14 others, directly solicited for implementation grant applications aligning with their cancer plans.

Collectively, these implementation plans demonstrate a wide variety of efforts by states and territories to actualize their state cancer plans.

4. Discussion

4.1. Common Elements among the Implementation Plans

Task forces, subcommittees, and workgroups for implementing state cancer plans were used in 34 states. These organizational structures functioned to organize and mobilize stakeholders. The Pennsylvania Cancer Coalition, for example, had workgroups focused on specific types of cancer such as lung and colorectal cancer [17]. Comparably, organizations such as Delaware’s Cancer Consortium had action teams dedicated to overarching topics such as risk reduction, prevention, and cancer registry [18]. Thirteen states (19%) used workgroups and coalitions based on regional model. In this strategy, states were divided into smaller regions based on city or population distribution to facilitate more compartmentalized approaches. Both topical task forces and regional coalitions provided targeted approaches to delegate responsibility within the broader cancer control plan and, when used in conjunction with an implementation plan, served as a vehicle for evidence-based actionable change. These findings are summarized in Table 2.

4.2. Unique Examples of Implementation

There were several instances for state cancer councils to use tailored strategies in their implementation plans. For example, New Mexico and Montana both had workgroups dedicated to cancer control in their Native American populations [19,20]. With the third and fifth largest proportion of Native American populations, respectively, the existence of dedicated workgroups facilitated initiatives that targeted healthcare disparities specific to Native Americans [21].

Focus on pediatric cancer was found in Idaho, which published a childhood cancer strategic plan alongside their comprehensive control plan during the 2006–2010 period [22]. Florida’s state cancer plan 2020–2025 also contained a pediatric cancer section and plans for implementation to include survivorship issues such as transition from adolescent care clinics to adult care clinics [6].

The Cancer Council of the Pacific Islands has sought to unify cancer control initiatives within the Pacific region through the creation a regional plan with the participating members of American Samoa, Commonwealth of the Northern Mariana Islands, Federated States of Micronesia, Guam, Republic of the Marshall Islands, and Republic of Palau. The result was a comprehensive plan in 2012 of constituent jurisdictions that sought to unify individual approaches under a broader framework [22]. Each of the individual jurisdictions also produced their own cancer control plans, and the existence of the additional regional comprehensive plan served to supplement individual efforts [23]. The Pacific Region plan also presented a tailored approach to cancer control that appreciates the nuances of the constituent demographics.

Geographically, states with implementation plans were distributed sporadically throughout the mainland United States except for the Southern United States, where only Florida and South Carolina had implementation plans. The reason for the notable absence of implementation plans is not clear and may involve other health priorities competing for health policy work.

4.3. Measuring Progress of Implementation

The core function of an implementation plan is to stimulate and maximize the evidence-based efforts made by stakeholders to complete the varied cancer control plan goals. To fully appreciate the effectiveness of these interactions and better guide resource allocation, states must also have systems to review cancer control progress. Most directly, the progress made in reducing cancer burden can be examined within each newly published cancer plan. Cancer plans set goals for over the course of a designated period (often five years) and are subsequently followed by a new plan with revised objectives. Thus, the production and release of regularly updated cancer plans inform individuals on the progress that has been made in the reduction in cancer burden, as well as discuss newly identified areas of focus. Further, cancer consortiums and affiliated organizations have participated in the distribution of burden reduction data online, as seen in New York and the Comprehensive Cancer Control Plan Dashboard website [24]. The dashboard actively tracks and displays forty pertinent measurements of cancer burden including prevention, detection, and survivorship, and provides comparisons between the most recent state data with previous baselines and their upcoming 2023 objectives. Through the aggregation of cancer control data presented in an accessible and regularly updated format, such dashboards provide a transparent review of the progress being made towards cancer control. The dashboards also inform policymakers on areas of deficiencies that require more attention to improve progress.

4.4. Synergies in Implementation

Collectively, these implementation plans enable resource allocation and accountability. The ability to measure the exact impact of an implementation plan and its synergy with the control plan remains difficult to quantify. States’ cancer registries function as an effective way to examine population-adjusted rates in specific cancer incidence, morality, and survival. Further, prior reports present the utility of general state cancer plans in actualizing burden reduction goals through increased communication and coordination among stakeholders [25]. However, attempts to attribute the degree of change in these statistics in states with an implementation plan compared to states that do not have an implementation plan are inherently confounded, as every area has varying demographics, culture, and evolving goals. Further, the absence of a published implementation plan did not imply that the resources for implementation were not readily accessible to stakeholders; these resources may have been distributed privately by the various cancer consortiums.

In the absence of an adequate control group to quantify the benefit of implementation plan, there may be qualitative benefits in documenting an implementation plan. One of the benefits of producing an implementation plan document is that it requires stakeholders to agree on elements for prioritizing collaborative work and then identifies those priorities for action. The Implementation Plan for the State of Florida is provided in Appendix A as an example of a model that could be adapted in states that do not presently have an implementation plan. Florida’s cancer plan implementation plan may also be used to update implementation plans in other states. Another benefit of producing a physical document for cancer plan implementation is that it encourages stakeholders to sign up for participation and enables a steering council to see areas of redundancy and complementary areas of synergy.

5. Conclusions

The evolution and expansion of the NCCCP was critical in establishing coordinated and standardized approaches to cancer reduction within the United States. This was accomplished through the organization of resources, stakeholders, and seed funding. The multifaceted nature of comprehensive cancer control at the state and local level is very challenging because of limited resources. This challenge can be greatly reduced through the production of implementation plans; however, such plans, in any form, are still absent in many US states and jurisdictions.

The implementation of a cancer plan through published documents, informational websites, funding opportunities, and task forces represents many of the fundamental approaches taken to reduce cancer burden. Equally important are methods to record and assess the extent of progress being made in cancer control, with updated cancer plans and online dashboards serving as transparent tools to present measured data.

The 19 implementation plans listed in Table 1 and their components described in Table 2 exemplify varied and innovative approaches to address specific cancer burden objectives and function as valuable reference for those interested in CCC. The linked websites in Table 1 also serve as a useful and powerful directory for individuals and organizations interested in exploring, establishing, and adopting their own CCC implementation plans. The collective identification of current cancer implementation plans and recognition of their utility in cancer control is critical for increased adoption of such plans, especially in states and regions that do not presently have a formalized implementation strategy. The increased production and adoption of implementation plans serve to further reduce cancer burden and supplement the existing efforts accomplished by cancer control plans. Implementation plans provide for the actionable evidence-based strategies to effectively execute Cancer Plan objectives.

This report also shows evidence for the significant and impactful work by the CDC in supporting US states and jurisdictions in planning their cancer prevention, early detection, and control. Capitalizing on this success, the CDC should receive more support for its work in assisting US states and jurisdictions to boost financial resources for implementing their cancer plans.