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Leveraging Systems Thinking and Simulation to Guide Selection and Implementation of Evidence-Based Colorectal Cancer Screening Interventions

Wheeler, Stephanie B. PhD, MPH*†‡§; Leeman, Jennifer DrPH, MDiv†§∥; Hassmiller Lich, Kristen PhD, MHSA*; Tangka, Florence K.L. PhD; Davis, Melinda M. PhD, MA#; Richardson, Lisa C. MD, MPH

doi: 10.1097/PPO.0000000000000317
Review Articles

A robust evidence base supports the effectiveness of timely colorectal cancer (CRC) screening, follow-up of abnormal results, and referral to care in reducing CRC morbidity and mortality. However, only two-thirds of the US population is current with recommended screening, and rates are much lower for those who are vulnerable because of their race/ethnicity, insurance status, or rural location. Multiple, multilevel factors contribute to observed disparities, and these factors vary across different populations and contexts. As highlighted by the Cancer Moonshot Blue Ribbon Panel working groups focused on Prevention and Early Detection and Implementation Science inadequate CRC screening and follow-up represent an enormous missed opportunity in cancer prevention and control. To measurably reduce CRC morbidity and mortality, the evidence base must be strengthened to guide the identification of (1) multilevel factors that influence screening across different populations and contexts, (2) multilevel interventions and implementation strategies that will be most effective at targeting those factors, and (3) combinations of strategies that interact synergistically to improve outcomes. Systems thinking and simulation modeling (systems science) provide a set of approaches and techniques to aid decision makers in using the best available data and research evidence to guide implementation planning in the context of such complexity. This commentary summarizes current challenges in CRC prevention and control, discusses the status of the evidence base to guide the selection and implementation of multilevel CRC screening interventions, and describes a multi-institution project to showcase how systems science can be leveraged to optimize selection and implementation of CRC screening interventions in diverse populations and contexts.

From the *Department of Health Policy and Management,

Lineberger Comprehensive Cancer Center,

Cecil G. Sheps Center for Health Services Research,

§Center for Health Promotion and Disease Prevention, and

School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill, NC;

Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA; and

#Oregon Rural Practice-Based Research Network, Department of Family Medicine, and OHSU-PSU School of Public Health, Oregon Health and Sciences University, Portland, OR.

This research was funded, in part, by the Centers for Disease Control and Prevention and National Cancer Institute Special Interest Project entitled “The Cancer Prevention and Control Research Network” (3 U48 DP005017-01S8, principal investigators: S.B.W. and J.L.; and 3 U48 DP005006-01S3, principal investigators: Shannon and Winters-Stone). M.M.D. was supported by a Cancer Prevention, Control, Behavioral Sciences, and Populations Sciences Career Development Award from the NCI (K07CA211971). Support for this work also came from The American Cancer Society and the NCI-funded Mentored Training for Dissemination and Implementation Research in Cancer Program (MT-DIRC) (5R25CA171994), in which S.B.W. and M.M.D. are fellows.

The authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article.

The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

Reprints: Stephanie B. Wheeler, PhD, MPH, Health Policy and Management, University of North Carolina at Chapel Hill, 135 Dauer Dr, CB#7411, Chapel Hill, NC 27516. E-mail:

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