Expanding Cancer Prevention Education to National and International Audiences: The National Cancer Institute's Principles and Practice of Cancer Prevention and Control Annual Summer Course
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- Faupel-Badger, J.M., van Bemmel, D.M., Wiest, J.S. et al. J Canc Educ (2011) 26: 619. doi:10.1007/s13187-011-0257-4
The Summer Curriculum in Cancer Prevention has been sponsored by the National Cancer Institute's Cancer Prevention Fellowship Program for over two decades. This curriculum includes a 4-week course entitled “Principles and Practice of Cancer Prevention and Control.” The ultimate goal of this course is to present the most current cancer prevention research to a diverse workforce of researchers and practitioners eager to address the current challenges in this field. The course covers the current status of cancer prevention research and practice, ranging from epidemiology and clinical practice, and from basic to behavioral science research. It is comprised of lectures grouped into nine modules representing broad and specific topics relevant to cancer prevention. Course participants come from a broad cross-section of career stages, professions, and research interests, and are from across the USA and other countries. Over time and in response to feedback from participants, the course has developed to meet the needs and expectations of this diverse audience, and may serve as a model for those interested in cancer prevention education and training in other countries.
In the USA, there are more than 1.5 million new cases and nearly 600,000 deaths, from cancer each year . Globally, there were 12.7 million persons diagnosed with cancer and 7.6 million cancer deaths in 2008, placing cancer as the leading cause of death worldwide . Approximately 56% of the cases and 64% of the deaths were in developing countries . The number of new cases is expected to reach 16 million by 2020, with 70% occurring in the developing world . Given cancer rates increase with age, and the increasing life expectancy in many countries, there is a growing urgency and need to escalate efforts to prevent cancer.
Despite the enormity of the cancer problem, and research evidence on how to prevent many types of cancer, it is surprising that formal cancer prevention education and training efforts are minimal. In the USA, efforts have been made to increase cancer prevention education in medical schools [4, 5]; however, most efforts are related to screening and offered primarily to medical students. There is limited information on cancer prevention education programs for researchers and other health professionals.
The state of cancer prevention education in most other countries is an especially serious problem. Even if cancer prevention educational efforts in professional and research institutions increased substantially, there is a need to educate the existing global workforce about such topics as screening, health behaviors, and chemoprevention to reduce cancer incidence and mortality. A recent article outlined six key elements for cancer control in Africa , although the general framework could be applied more broadly to low- and middle-income countries. Among the six elements were early diagnosis/prevention and education/training. The education and training priorities included a need to reduce the lack of cancer awareness and to increase knowledge and capacity through effective partnerships . An important aim of this element is to create cancer control plans that are evidence-based and sustainable , as research shows that lack of cancer prevention education is delaying the development of evidence-based national cancer control plans .
The National Cancer Institute's (NCI) Summer Curriculum in Cancer Prevention is trying to help fill this huge gap in cancer prevention education. The course entitled “The Principles and Practice of Cancer Prevention and Control” is an example of a short-term cancer prevention education effort. This broad-based, post-graduate level summer course in cancer prevention research, originally designed for NCI Cancer Prevention Fellows, has expanded to train a larger community. Attendees of the course now include participants from academic, medical, public health, and research institutions across the USA and the world, in addition to NCI Cancer Prevention Fellows. In this paper, we review information about course design for this diverse audience, selection of participants, evaluation, and suggestions for potential future directions in cancer prevention courses.
The NCI's Cancer Prevention Fellowship Program (CPFP), launched in 1986, is a postdoctoral training program bringing individuals from a broad array of health-related disciplines together to focus their talents on cancer prevention research from a public health perspective. The number of fellows who enter the program varies by year, but has ranged anywhere from 5 to 20 persons. An important educational component of the fellowship is the summer curriculum in cancer prevention. Originally, the curriculum was taught by CPFP leadership over 3 months, focusing heavily on epidemiology and biostatistics. In 1992, the CPFP began providing fellows the opportunity to attend an accredited university to attain a Master of Public Health (MPH) degree.
Number of participants in NCI Summer Coursea 1986–2011
Design of the Principles and Practice of Cancer Prevention and Control Course
The central focus of the course is cancer prevention, which sets this particular training apart from short courses elsewhere that emphasize cancer epidemiology or cancer registry training. The Principles and Practice of Cancer Prevention and Control (hereafter referred to as the “Principles”) course is largely taught in a lecture format with three lectures given daily over four consecutive weeks. The lectures are structured to be approximately 60 min in length followed by a 30-min discussion. Two thirds of the approximately 50 faculty members for the course each year are scientists from the NCI and one third are from other US-based research institutions.
The Principles course is organized into nine thematic modules and two special presentations. The first module is designed to provide an introduction to epidemiology methods, including considerations when interpreting results from a given study and the level of evidence needed to make inferences about causation. This module is strategically placed so all course participants begin with a shared understanding of epidemiology research as most subsequent presentations refer back to the methods and core principles necessary to conduct these studies.
At the end of the first week, “International Day” occurs. Participants from outside the USA present an overview of cancer and cancer prevention efforts in their home country. Approximately 30 different countries are represented among the Principles course participants each year (Table 1). Cancer control and prevention activities are as varied as the countries the participants represent. This day is truly unique, as it allows for a first-hand discussion highlighting the differing society and cultural beliefs, resources available, and general approaches to cancer prevention. The exchange of information and design of the day also presents an opportunity for participants to network with each other early in the 4-week curriculum.
Week 2 focuses on lifestyle factors related to cancer incidence and screening. This week usually begins with a day focused on occupational and environmental exposures related to cancer incidence. Physical activity, tobacco use, diet, and nutrition research are then featured prominently and have common themes (e.g., assessment, recommendations) which are discussed over the course of these lectures. The week concludes with the “Applications of Cancer Prevention” module which has largely focused on cancer screening, including recommendations and controversies in this area.
Annual Advances in Cancer Prevention Lecturer (2000–2011)
Title of Lecture
Bernard Levin, MD
University of Texas M.D. Anderson Cancer Center Houston, TX
Cancer Prevention: What is the Future?
Frederick P. Li, MD
Dana-Farber Cancer Center Boston, MA
The Identification and Care of Those at Highest Risk of Cancer
Leslie Bernstein, PhD
University of Southern California, Los Angeles, CA
Cancer Prevention Opportunities for Action
Elio Riboli, MD, ScM, MPH
International Agency for Research on Cancer Lyon, France
Cancer Prevention: A European Perspective
Waun Ki Hong, MD
University of Texas M.D. Anderson Cancer Center Houston, TX
Convergence of Molecular Targets for Cancer Prevention and Therapy
John Potter, MBBS, PhD
Fred Hutchinson Cancer Research Center, Seattle WA
What We Know and Don't Know about Colorectal Neoplasia
Frank L. Meyskens, Jr, MD
University of California Irvine, CA
The Promise and Perils of Clinical Chemoprevention 1980–2030
Barnett S. Kramer, MD, MPH
National Institutes of Health Bethesda, MD
Cancer Prevention: Distinguishing Strength of Evidence from Strength of Opinion
Patricia Ganz, MD
University of California Los Angeles, CA
Cancer Survivors: Charting an Agenda for Research, Treatment, and Quality of Care
Olufunmilayo F. Olopade, MD
University of Chicago Chicago, IL
Clinical Cancer Genetics and Prevention
Andrea De Censi, MD
E.O. Ospedali Galliera Genova, Italy
Cancer Prevention Therapy Accomplishments and Challenges
Judith MacKay, MBChB, FRCP (Edin), FRCP (Lon)
World Lung Foundation and Asian Consultancy on Tobacco Control, Hong Kong, China
Cancer Control – A Look at the Future
Additional international lecturers:
Fenton Howell, MBBCh, MPH, FRCPI
Health Service Executive Dublin, Ireland
Ireland Smoking Ban
David Forman, PhD
International Agency for Research on Cancer Lyon, France
The last week of the course finishes with exploring current topics in behavioral and social research, including an emphasis on health disparities. It also includes presentations on ethical and policy implications for cancer prevention research and disseminating information from research studies, given the practical importance of these topics. These lectures are usually among the most highly rated of all course presentations.
Principles and Practice of Cancer Prevention and Control 2010 Course Modules
No. of speakers
No. of evaluations returned a
2010 Overall score b
Introduction to the Cancer Problem
Cancer Prevention: An International Perspective
Occupational and Environmental Exposures in Cancer
Diet, Physical Activity, and Cancer Prevention
Applications of Cancer Prevention
Epidemiology, Prevention, and Control of Site-Specific Tumors
Annual Advances in Cancer Prevention
Behavioral Science and Community Interventions
Health Disparities and Cancer Prevention in Diverse Populations
Ethics, Law, and Policy in Cancer Prevention and Control
Disseminating Scientific Knowledge
Although selected talks in the Principles course address some current advances in laboratory research, beginning in 2000 an additional 1-week course was added to the curriculum (Molecular Prevention) to focus solely on the molecular underpinnings of cancer biology and prevention. More information on this course can be found at the course website (https://cpfp.cancer.gov/summer/summer.php).
With the combined attendance of NCI Cancer Prevention Fellows, domestic, and international participants, the course has grown to approximately 90 participants each year. The course is limited to this size as a maximum due to available meeting space for a 4-week course and funding. In most recent years, approximately 50% of the attendees have been international participants, mostly from low- and middle-income countries who receive financial support from the NCI to cover some of their travel-related expenses (Table 1). Applications from individuals in high-income countries are encouraged with the understanding that no financial support will be provided by the NCI. The remaining 50% of the class is divided between US participants (35% of total) and the NCI Cancer Prevention Fellows (15% of total).
Selection of Participants
Applicants for the course must submit a curriculum vitae and letter of nomination from a supervisor. International applicants must also include a statement of English proficiency. Each year, there are more applicants than can be accommodated in the course. Acceptance is determined by CPFP leadership, and selection is based on who is in the best position to put the course information received into practice. Preference is given to individuals with MD, PhD, and/or MPH level training. The prerequisites of having education or experience in epidemiology, biostatistics, and/or cancer biology also are recommended.
Participants in the course are most often PhD recipients. MD recipients are approximately 30% of the attendees. A greater proportion of the international participants are MDs or have an equivalent degree (average 59%), whereas the majority of US participants have PhD degrees (average 61%).
CPFP Fellows and Domestic Participants
From 1986 to 1991, the attendees of the summer course were only the NCI Cancer Prevention Fellows and a limited number of NCI/NIH Staff (Table 1). Cancer Prevention Fellows are required to attend the summer curriculum in cancer prevention during the first year of their training at NCI. Beginning in 1992, attendance at the course increased as participants from across the USA were selected to attend (Table 1). US participants include scientists from diverse backgrounds and career stages ranging from those who are beginning careers in cancer prevention research to more established scientists looking to incorporate cancer prevention into their research portfolios. Recent recipients of NCI career development “K” awards who have included this curriculum as part of the training plan in their applications also attend the course.
The CPFP, in partnership with the NCI Office of International Affairs (OIA), formally began accepting applications from international participants in 1998 (Table 1). These efforts were further expanded in 2007, when the NCI partnered with the International Atomic Energy Association's (IAEA) Programme of Action for Cancer Therapy (PACT) to expand cancer treatment and prevention efforts in low- and middle-income countries. As part of this partnership, the NCI Summer Curriculum in Cancer Prevention was opened to applicants from low- and middle-income countries nominated via IAEA-PACT. IAEA-PACT participants are nominated from across all IAEA member states (151 as of November 2010 - http://www.iaea.org/About/Policy/MemberStates/index.html).
NCI's OIA has placed an emphasis on recruiting individuals from low- and middle-income countries to attend the course and has provided financial support to offset living expenses and accommodations for the duration of the course. The overall emphasis on international participants from low- and middle-income countries centers on the growing cancer burden and relatively few individuals in these areas who have training in cancer prevention and control efforts. OIA also strives to maintain geographic balance across the international participants in the course, with Eastern Europe, the Middle East, Africa, Asia, and Latin America represented equally among OIA's portfolio from 1998 to 2011.
A limited number of scholars from the Republic of Ireland and Northern Ireland also attend the NCI Summer Curriculum in Cancer Prevention, including both the Principles and Molecular Prevention courses. This arrangement is part of the memorandum of understanding NCI signed in 1999 with representatives from health and research agencies in Ireland and Northern Ireland to form the Ireland-Northern Ireland-National Cancer Institute (NCI) Cancer Consortium. The mission of the consortium is to, “lessen the burden due to cancer across the island of Ireland through cross-border collaborations in cancer research and education .” Between 2002 and 2009, 115 participants from the island of Ireland attended the Principles course . More information on the consortium can be found at their website (http://www.allirelandnci.com/index.asp).
Evaluation efforts include participant assessment of each individual speaker conducted the same day as the presentation. The evaluation instrument contains structured (rated using a Likert scale from 1 [lowest] to 5 [highest]) and open-ended questions. Key elements for rating the individual speakers include: (1) appropriateness of topic to cancer prevention and control; (2) comprehensiveness of the lecture content; and (3) the speaker's ability to convey information. Summary evaluations are shared with presenters. They are encouraged to incorporate feedback from the evaluations, if necessary, and to update their lectures for the next year to ensure their information reflects the current state of knowledge in their field. In addition, evaluations are used by NCI CPFP staff to make adjustments to the syllabus for the following year. Table 3 presents the overall scores for each module in 2010. These scores were calculated by averaging the summary score for each individual speaker in that module. The number of speakers and the average number of evaluations returned across all speakers in each module are reported in Table 3. All modules were rated very highly, with Behavioral Science and Community Interventions, Application of Cancer Prevention Methods, Disseminating Scientific Knowledge, and Epidemiology, Prevention, and Control of Site-Specific Tumors being rated slightly more favorably.
Prior changes made in response to the evaluations include shortening the length of the Principles course and adding the previously mentioned Molecular Prevention Course. Recent modules on “Ethics, Law, and Policy in Cancer Prevention and Control” and “Health Disparities and Special Populations” were added based on feedback from participants and because of growing recognition that these areas had become more prominent in cancer prevention and control.
In 2010, the first overall evaluation/end-of-course survey was conducted. All course participants were provided the survey, of whom 34 completed it. The responses were anonymous; thus, we were unable to assess if bias was introduced by who returned the survey. Respondents gave the course an overall highly positive rating of 4.5 out of 5 (standard deviation ± 0.56), using a Likert scale from 1 (lowest) to 5 (highest). One hundred percent of the respondents would recommend the course to their colleagues and 92% indicated the course met or exceeded their expectations.
Recently, NCI's OIA conducted follow-up evaluations of participants from low- and middle-income countries supported by this office to attend the course from 1998 to 2009 and course participants from the Ireland-Northern Ireland-National Cancer Institute Cancer Consortium from 2002 to 2009. Manuscripts detailing these evaluations are currently in preparation. Overall, there was high satisfaction in the course and many international participants reported subsequent career outcomes that included a focus on cancer prevention (e.g., publications, grants, presentations, collaborations; personal communication, Joe Harford, PhD).
Two decades after the start of this broad-based, post-graduate course in cancer prevention research, the Principles course continues to be timely and fill a need. For NCI's Cancer Prevention Fellows who are beginning their careers toward becoming independent researchers and leaders (the original target audience for the course), it provides foundational knowledge and information. For domestic and international participants, the course provides a review of the state of the science in cancer prevention research across multiple areas and disciplines. Of note is that many international participants hold positions in the policy or government realm and have recently been given the responsibility to develop a cancer control plan for their home country, whereas others have recently had cancer control activities added to their portfolios (historically, their work has long focused on infectious disease).
In addition to the comprehensive didactic coursework in cancer prevention research, participants have the opportunity to benefit from a number of different networking opportunities. Participants may chose to use the time at NCI to meet with NCI staff regarding mutual research interests, establishing long-distance collaborations. In a few instances, attendees have returned to the NCI in visiting fellow positions to work with research groups on-site or applied to the NCI to become Cancer Prevention Fellows. Many participants maintain contact with each other, developing an international network of colleagues interested in cancer prevention.
Future directions for the course include incorporating more interaction among the participants into the syllabus. In 2011, we will foster more active learning in the course by piloting small group discussion sessions throughout the 4 weeks. These discussions will focus on key developments and challenges in the fields of cancer prevention and control. Additional topics under consideration are diversifying the site-specific cancers module to include cancers that are more prevalent in low- and middle-income countries, health economics as it relates to cancer prevention efforts, and community-based participatory research.
We also are considering how to make the lectures more accessible remotely, such as posting selected lectures and other materials on NIH websites. CPFP staff members also have been approached about considering whether a version of the Principles course could be delivered in international settings, perhaps on a regional basis. It may be worthwhile to have a regional group receive this training together. Further consideration also could be given to distance learning adaption of this course, including web-based tutorials. Although the logistics of offering this course in-person and off-site are daunting, CPFP staff members are available to discuss the technical aspects of implementing a similar cancer prevention education effort with others considering this either in the USA or internationally.
In conclusion, a recent compilation looking back at the progress of cancer prevention efforts from 1727 to the present demonstrated successful advances in the field resulted from collaborative, multidisciplinary efforts . Furthermore, papers focusing on the future of the cancer prevention workforce highlighted the need for cancer prevention curricula to train a broad group of individuals to build on these historic advances and to bring new disciplines into the fields of cancer prevention and control [10, 11]. The “Principles and Practice of Cancer Prevention and Control” course is helping to meet this charge by contributing to the training of a network of individuals both nationally and worldwide who represent a diverse workforce eager to address the current challenges of cancer prevention research.
We would like to thank past CPFP staff members, Ms. Barbara Redding and Dr. Douglas L. Weed, for their insightful discussions about the summer course and for maintaining detailed records on course format and attendance since its inception, and Ms. Studly Auguste, a current CPFP staff member, for her efforts to make the summer course a success. We also thank members of NCI's Office of International Affairs (OIA), Drs. Joe Harford and Makeda Williams and Ms. Isabel Otero, who discussed the history of OIA's involvement with the course and their follow-up efforts of international course participants with us. Lastly, we thank the NCI leadership for their continued support of the Summer Curriculum in Cancer Prevention.