GUEST EDITORIAL

Triad Clinical Cancer Control Program:A Partnership for Data-Based

Community Intervention

GERALD L. WOOLAM, MD*President-Elect, American Cancer Society, Atlanta, Georgia; Joe Arrington Cancer Center

and Texas Tech University School of Medicine, Lubbock, Texas

Surgeons are privileged to participate directly in thecare of individual cancer patients, but, in addition, manysurgeons choose to expand their influence through par-ticipation in cancer control activities of organizations andinstitutions. Two such organizations that surgeons widelysupport are the American Cancer Society (ACS) and theAmerican College of Surgeons (ACoS) Commission onCancer (COC). The ACS and the COC have enjoyed along-standing and mutually supportive relationship sincethe establishment of their predecessor entities in 1913.Despite somewhat different target audiences for theirmessages, the two organizations have a largely commonvolunteer physician base and similar goals.

The Commission on Cancer was established by theAmerican College of Surgeons in 1965 but is now amultidisciplinary organization with membership repre-senting 36 organizations. Its primary goal is to reduce themorbidity and mortality caused by cancer through pre-vention, standard-setting, monitoring and reporting onquality of care, collection of statistics regarding cancertreatment, and education. Important components in ac-complishing these goals are the institutional ApprovalsProgram, ensuring standards in the 1,500 approved pro-grams that treat >80% of the cancers in the United States;the grassroots network of 1,800 Cancer Liaison Physi-cians, who volunteer their time to support local approvedcancer programs; and the use of cancer registry data toimprove outcomes.

The ACS is a not-for-profit organization with a highlyprofessional staff and some 2,000,000 volunteers locatedin virtually every community in the country. The ACS iscompleting a decade-long reorganization designed to po-sition the Society to more effectively impact cancer in-cidence, mortality, and quality of life for survivorsthrough science-based and measurable cancer control ini-tiatives, collaborations, advocacy, information services,and support of research.

The shared intent of the COC and the ACS, to reducethe morbidity and mortality caused by cancer, has led toa number of important collaborative initiatives, includingclinical programs directed toward early detection ofbreast and colorectal cancer, implementation of Ameri-can Joint Committee on Cancer (AJCC) TNM staging,promotion of clinical trial participation, and support oftobacco control in youth and young adults. The two or-ganizations have cosponsored the AJCC and closely col-laborate on the Cancer Liaison Program.

The National Cancer Data Base (NCDB) was estab-lished by the ACoS in 1988 with financial support by theACS and compiles data on stage of diagnosis, treatment,and outcomes through voluntary submissions by hospi-tals and other institutions. The NCDB was designed toserve as a resource for evaluating national and regionalcancer care patterns and trends and to provide data forcomparative assessments of local hospital programs.Since 1995, the NCDB has been jointly governed andmanaged by the ACS and the ACoS, partly in an attemptto widen the audience for use of the data beyond hospitalphysicians to include community cancer control plan-ners.

Although the ACoS COC, ACS, and tumor registrarshave long worked together, a more formal relationshipwas established among these three groups in 1994 whenthe Triad Clinical Cancer Control Program was estab-lished, bringing together representatives from the CancerLiaison Program, the ACS, state cancer registrar associa-tion presidents, and other interested parties, includingstate health department or state cancer registry represen-tatives. The purpose of the program was to maximize the

*Correspondence to: Gerald L. Woolam, MD, 3702 21st Street, Suite203, Lubbock, TX 79410. E-mail: gerwoolam@aol.comAccepted 9 June 1999

Journal of Surgical Oncology 1999;72:57–58

© 1999 Wiley-Liss, Inc.

efforts of state and regional cancer-related organizationsby identifying issues, developing strategies, and imple-menting programs to enhance cancer control at the stateand local levels.

The initial project of the Triad in 1996 was directedtoward evaluation of the ACS’s Resources, Information,and Guidance (RIG) service programs and identificationof unmet needs of newly diagnosed cancer patients. Upuntil that time, the ACS had no detailed information onthe nationwide utilization of its patient services pro-grams. Analysis of Triad data supported the need forreliable, unbiased, and easily accessible information oncancer, treatment options, and community resources toaid in decision-making by patients. Partly on the basis ofthis survey, the ACS embarked on the development of itsnew national cancer information system, using call cen-ters (1-800-ACS-2345) and an enhanced web site (http://www.cancer.org). Plans are underway for hospitals tovoluntarily report information about cancer treatment fa-cilities to the public through the ACS information sys-tem.

More than a dozen states have now conducted Triadprojects that have led to specific cooperative plans. Forexample, the RIG studies have formed the basis for tar-geted interventions for needed services in Indiana and todistribution of educational materials in Nebraska. To-bacco control and education activities for youth andadults have been planned in Colorado, Utah, and otherstates. Breast screening for under-served populations hasbeen carried out by the Triad in Alabama, and breastcancer treatment evaluations, including adherence totreatment standards for early breast cancer, have beeninitiated in several states including Virginia, California,and North Carolina. In Ohio, the Triad has brought to-gether additional partner organizations to develop a statecancer plan. Other Triad projects have included studiesof screening and stage of diagnosis for breast, prostate,colorectal, and cervical cancers; identification of high-risk groups; and evaluation of quality of treatment datacollection.

More recently, multistate Triad conferences have beenheld in ACS’s Mid-Atlantic (DE, MD, VA, WV, andDC), and Mid-South (AL, AR, KY, LA, MS, and TN)divisions. The focus of these meetings has been on iden-tifying information needs and ways to cooperate in re-gional cancer control planning. At the Mid-South Triadmeeting, for example, data from the NCDB were pre-sented, which showed significant regional differences in

treatment for prostate cancer and geographic and racialdifferences in stage of diagnosis for cervical and breastcancers. As the ACS develops its new nationwide cancercontrol program, these kinds of analyses will be useful inplanning for the most effective distribution of resourcesand evidence-based interventions.

It is clear that there is a need for data-based targetingof cancer control activities. Despite recent success inreduction of cancer incidence and mortality, there remainsignificant problems in the ethnic, socioeconomic, re-gional, and age-specific distribution of cancer risk factorsand treatment. Examples of these disparities abound. Thehigher risk for death from breast cancer among African-American women and the doubled risk of dying of pros-tate cancer among African-American men comparedwith white men suggest a need and opportunity to de-velop meaningful and tailored plans to address these dif-ferences. Similarly, youth smoking rates are increasingalarmingly nationwide, but the problem is much moreacute in some regions than in others. Regional and localplanning for comprehensive cancer control activities isessential if those inequities are to be specifically definedand addressed and if limited cancer control resources areto be efficiently allocated.

The potential for utilizing NCDB; state tumor regis-tries; the Center for Disease Control and Prevention’sNational Center for Health Statistics; the National Can-cer Institute’s Surveillance, Epidemiology, and End Re-sults program and Behavioral Risk Factor SurveillanceSystem; the Youth Risk Behavior Survey; and other datasources for targeted cancer control intervention planningis obvious. Unfortunately, these resources have not beenadequately integrated and coordinated despite ongoingefforts to move toward a single comprehensive nationalcancer surveillance system in the United States. TheTriad program is an effort that offers some promise ofmoving toward the goal of data-based planning to furtherreduce cancer incidence and mortality and to improve thequality of life for cancer survivors.

Rapid advances in science and technology are leadingto impressive opportunities to improve the early diagno-sis and treatment for cancer, but ensuring access to andapplication of state-of-the-art care as well as encouragingthe behavioral changes that can prevent cancers is adaunting task that is truly society-wide in scope. Sur-geons should consider contributing to this effort by par-ticipating in organizations such as the ACS and the COC.

58 Woolam