Bridging Behavioral Science with Cancer Prevention and Control: Contributions of an NCI Working Group (2009–2019)

The successful application of many seminal discoveries in cancer research depends critically on patient behaviors such as human papillomavirus (HPV) vaccination, compliance with screening and medication protocols, and the effective use of genetic information. Other behaviors such as tobacco use, reliance on cancer misinformation, and rejection of palliative care influence many disparate outcomes across the cancer control continuum. When considering the wide range of behaviors related to cancer morbidity and mortality, a key lesson from the behavioral sciences worth heeding is that most human behavior is regulated by a core set of basic biological, cognitive, emotional, motivational, and interpersonal processes. Consider that all of the above behaviors can be shaped at least, in part, by visceral responses, orientations toward risk and uncertainty, concerns about negative evaluations from others, and the desire to achieve personally relevant goals.

Abstracting lessons from the basic behavioral sciences for cancer prevention and control on a domain-by-domain basis would be inefficient without a higher level consideration of how behavioral processes apply throughout the entire cancer control continuum. Indeed, adopting an integrative, systematic, and interdisciplinary approach to cancer prevention and control, including attention to the broad importance of the behavioral sciences, was central to the early development of the National Cancer Institute (NCI's) Division of Cancer Control and Population Sciences (1). Nevertheless, achieving the promise of integrating core behavioral science principles with cancer prevention and control efforts requires navigating disciplinary barriers. Although behavioral scientists have explored how behavioral processes can be investigated in visible and well-known cancer domains such as smoking cessation (2), the nature of their training could make them less comfortable with other domains such as genomic panel testing and palliative care decision making (3). Concomitantly, cancer prevention and control scientists and practitioners might not be familiar with innovations in behavioral science that are published largely in discipline-specific journals. Several grant funding–driven working groups sponsored by the NIH have been instrumental in promoting the application of behavioral science concepts to health outcomes more broadly, including the Basic Behavioral and Social Sciences Opportunity Network, the Science of Behavior Change Common Fund initiative, and the Obesity-Related Behavioral Intervention Trials initiative (4). These efforts have relied on coordinated leadership by NIH behavioral and social scientists paired with strong grantee engagement. None of them, however, has had an explicit focus on cancer.

A working group supported by the NCI has been engaged in a long-term, multipronged effort to optimize the application of behavioral science to cancer prevention and control. Rather than conducting primary research following a grant funding model, the Cognitive, Affective, and Social Processes in Health Research (CASPHR) working group has coordinated efforts over a 10-year period to highlight key areas in need of attention from behavioral scientists, conducted reviews of mission-relevant areas and published key syntheses, built capacity for engaging with these issues (e.g., training for junior scholars), and offered counsel on NCI projects that provide resources to the extramural community such as nationally representative data on access to health information. In this article, we review the breadth of these activities and offer observations about future needs that can be addressed by CASPHR and like-minded investigators in the extramural community.

The NCI's Behavioral Research Program initiated the CASPHR working group in 2009 to ensure adequate attention to basic social and behavioral processes as part of its strategic planning and its overall mission of addressing behavioral risk factors for cancer. The starting point was to identify scholars with expertise in foundational cancer-relevant areas such as decision making, risk perception, emotion, motivation, discrimination, self-regulation, health behavior, and health communication, who could be complemented by NCI staff possessing similar and related expertise (see list of members in Acknowledgments). A major aim of the group has been to develop projects that engage with and are of value to the extramural research community. Doing so has involved connections with a diverse array of disciplines and professional communities, with some activities focused on promoting more cancer research in the behavioral sciences and others focused on incorporating more behavioral research into cancer research and practice. Although biological processes such as addiction and stress are also important predictors of behavior and interact with the types of processes featured here, other efforts supported by the NCI Behavioral Research Program have devoted more attention to those processes. This includes work by the NCI Network on Biobehavioral Pathways in Cancer (https://cancercontrol.cancer.gov/brp/bbpsb/ncintwk-biopthwys.html).

A significant effort of the CASPHR group has been to hold “state-of-the-science” meetings on topics that the group thought might benefit from establishing or accentuating the integration of behavioral sciences with cancer prevention and control (see Table 1). The meetings have included both CASPHR members and additional experts in the targeted areas of interest. Topics are selected on the basis of the feasibility of applying behavioral concepts, overall potential impact on cancer targets, significant gaps in the cancer prevention and control literature, and the extent to which the topics lend themselves to highly interdisciplinary, intensive discussions. The CASPHR working group selects these topics about a year in advance, working organically rather than being directed by NCI leadership, and typically builds author teams to develop manuscripts summarizing key lessons learned from these meetings.

All meetings have introduced novel perspectives and research questions, as well as follow-up activities. A meeting devoted to the effects of chemotherapy on cognition and brain function inspired a discussion about how some cognitive deficits may be attributable to diminished abilities to exert mental control over behavior and negative expectations regarding effects of chemotherapy—leading to a key publication on this topic in Psycho-Oncology (5). Another meeting highlighted the role that social connection can play in promoting resilience among underrepresented minorities, who are often at higher risk for cancer and other diseases. Still another considered how mobile health (mHealth) technologies can be used to capture intensive longitudinal data on health behaviors and their predictors, and to scale-up both individual- and social network–based behavioral interventions. A meeting on palliative care considered how psychological factors influence palliative care decisions and outcomes. We know, for example, that people tend to exaggerate the expected magnitude of their emotional experiences in the future (6), which can influence decisions such as the choice to accept palliative care. The latter meeting spawned an NCI-sponsored network on palliative care decision making, which concluded that much can be learned about both palliative care and emotion by conducting research at the junction of the two areas. These ideas were elucidated and elaborated upon in two articles—one published in a behavioral science journal and the other in a medical journal devoted to pain and symptom management (7, 8).

CASPHR has also recognized the importance of building capacity to advance the integration of basic behavioral science with cancer prevention and control through workshops, symposia, and training activities (see Table 2). Symposia at an assortment of professional meetings have been conducted on topics such as the benefits and limitations of shared decision making, the effects of discrimination on health outcomes, and the varied roles of cognitive processes in health behavior initiation and maintenance. The working group has hosted panel discussions designed to facilitate efforts by the investigators to incorporate behavioral research into specific domains such as genetic testing. Other panels have addressed the value of team science by highlighting the strategies interdisciplinary teams have used to successfully bridge behavioral science and applied health research. Training sessions have included a workshop for junior behavioral scientists on linkages between behavioral science and cancer research and another on methodological tools one can use when conducting research in health contexts. More broadly, CASPHR helped initiate and nurture the Social Personality and Health Network (http://sphnetwork.org/), a thriving research community that has provided an intellectual home for social and personality psychologists conducting research on health outcomes.

Complementing these activities is a series of intellectual products that highlight opportunities to integrate the behavioral sciences with cancer prevention and control, in addition to articles linked to the yearly state-of-the-science meetings (see Table 3). A key meta-analysis found that when interventions are successful at modifying health beliefs such as attitudes, norms, and self-efficacy, the interventions in turn elicit medium-sized effects on people's intentions to change their health behaviors linked to cancer and other diseases, and small-to-medium effects on actual behavior change (9). Importantly, the effects were more substantial for interventions designed to increase rather than decrease the performance of behaviors. This finding potentially highlights the value of focusing on promoting risk-decreasing behaviors such as physical activity in clinical settings. Conceptual articles led or coauthored by CASPHR members have considered how social and decision science can be applied to genetic risk communication and decision making (10), how social psychological constructs and the experimental medicine framework might be applied to health behavior interventions (3, 11), and the extent to which research on different health behaviors can be integrated more systematically (12). CASPHR members have also edited special issues of journals that feature exemplary integrative projects at the interface of behavioral science and health (13, 14). The success of these and similar activities by other NCI working groups sponsored by the Behavioral Research Program are assessed by several metrics including publication impact and grant portfolio analyses (15).

Finally, CASPHR has contributed behavioral content for several national surveys that have yielded public use datasets, which in turn have generated a substantial number of publications and other products. These include NCI's Health Information National Trends Survey, which measures attitudes, risk perceptions, engagement with and trust in health information, and health self-efficacy, among other constructs, and provides important insights into how much the U.S. public trusts and engages with health information (see https://hints.cancer.gov/). CASPHR members have also contributed to NCI's Family Life, Activity, Sun, Health, and Eating (FLASHE) study, which collected data on cognitive, affective, and motivational predictors of health behaviors in parent–adolescent dyads. This unique data resource has been used to demonstrate how adopting a dyadic perspective can enrich our understanding of critical cancer-related behaviors such as diet and physical activity (see https://cancercontrol.cancer.gov/flashe). For example, FLASHE data have been used to show that adolescents who tend to suppress their emotions have parents who are more likely to eat more low-nutrient, energy-dense foods, and fewer fruits and vegetables (16).

The CASPHR group's sustained level of activity has required not only a substantial investment of time and effort but also a high level of engagement, consistent leadership, and an NCI commitment to the provision of resources. Over the past 10 years, the group has benefited from frequent meetings, the extensive involvement of NCI staff and fellows, and a leadership model including one extramural co-chair and one NCI co-chair. Activities such as the yearly conferences have been led by both extramural CASPHR members and NCI staff, working collaboratively. The yearly meetings have also tended to include additional speakers with a track record of collaborative and interdisciplinary work, thereby maximizing the quality, discussion, and impact of the meetings. These efforts represent only one possible strategy for addressing the gap between behavioral science and cancer prevention and control, but they nevertheless have facilitated other efforts by raising awareness in both research communities about the possible synergies.

The behavioral science and the cancer prevention and control landscapes continue to evolve rapidly, presenting new opportunities for effective integration and application that might be considered by CASPHR and the larger extramural community over the next several years. For example, medical and popular opinion regarding the value of cancer screening has changed greatly over the past 10 years, necessitating the design of clear, impactful messages about screening, as well as the study of reactions to complex screening recommendations. Findings from behavioral science research are already informing how one might address the rampant uptake of electronic cigarettes in middle and high school students (17) and strategies to increase HPV vaccination rates (18). As evidence continues to accumulate regarding the cancer risks of consuming alcohol (19), behavioral science can help determine the most effective methods by which to communicate effectively about those risks. Furthermore, in the face of rapidly changing policy and public opinion regarding the legalization of cannabis, an increasingly used substance in cancer pain management (20), much still needs to be learned about its role in cancer prevention, control, and treatment. Behavioral science processes are certain to be important in that context, in part to be able to identify unintended consequences. Accordingly, CASPHR's 2019 annual meeting focused on how cognitive processes at the level of the provider can influence pain management of patients.

The field of behavioral science is itself changing in ways that have the potential to increase its relevance to cancer prevention and control. Behavioral scientists are increasingly capitalizing on innovations in research designs, measurement, and analytic tools that allow them to pursue research questions in more complex and problem-focused environments. In turn, such work generates an evidence base that is more applicable to cancer prevention and control needs. For example, researchers in behavioral science disciplines are increasingly adopting innovative research designs such as Sequential Multiple Assignment Randomized Trials and fractional factorial designs (21), as well as analytic tools such as agent-based models and other computational models (22).

Sensors, wearables, eye trackers, and other tools introduce new data sources that complement traditional measures. The evidence that emerges from the use of these methods could enrich our understanding of key cancer-related behaviors such as smoking, physical activity, medical compliance, and the seeking and use of medical information. Lessons learned from some of these domains may be translatable to other domains, and behavioral scientists are in a particularly unique position to facilitate such translation (12). Moreover, mHealth technologies are continually facilitating the implementation of interventions and accomplishing greater reach than has been feasible in the past. Finally, given that many behaviors such as substance abuse are driven by a complex combination of behavioral and biological factors, it is prudent to take an integrated approach to tackling these behaviors. The value of doing so continues to expand as we learn more, for example, about genetic predispositions that may determine and interact with behavioral factors to drive health risk. A nascent NCI-supported group has been addressing how genetic factors moderate the effects of weight loss interventions (23), and a related NIH effort has addressed the myriad biological and behavioral measures that can be used to address the impact of obesity interventions in general (24).

A sustained and systematic integration of behavioral science and cancer prevention and control will not only help address the burden of cancer-related morbidity and mortality but also enhance the generalizability and reach of behavioral science findings and theories, thereby providing a reciprocal benefit. Nevertheless, such an integration is not without impediment. Interdisciplinary team science can be a challenging endeavor, despite increasing relief from the somewhat artificial barriers that divide disciplines and fields (25). One lesson learned from CASPHR's activities over the past 10 years is that it is essential to design meetings with a mix of expertise in a conversational, task-focused format and to provide adequate infrastructure and professional incentives to collaborate on potentially impactful intellectual products of interest. Another lesson is that new and largely unanticipated areas of interest emerge regularly (e.g., survival value of palliative care, cognitive effects of chemotherapy, and uptick in use of electronic cigarettes), necessitating a nimble ethos when identifying areas of interest.

Continued membership in the CASPHR group over this extended period has also greatly facilitated a consistent approach to disparate research topics, revealing the unique value of a standing working group addressing multiple health targets from a common behavioral perspective. Of course, it is important to acknowledge that other working group models and other subdisciplines of the behavioral and social sciences can and do play a significant role in addressing key problems along the cancer control continuum. Whatever approach is taken, when behavioral research is maximally leveraged, the notable achievements of contemporary medicine are more likely to have their intended impact.

A.J. Rothman reports personal fees from Westat, Inc during the conduct of the study. No potential conflicts of interest were disclosed by the other authors.

The content of this article does not necessarily represent the opinion or formal position of the NCI or the NIH. Extramural CASPHR members do not serve in a formal advisory role to the NCI and are not in any way involved in the development of funding concepts and funding initiatives.

Conception and design: W.M.P. Klein, A.J. Rothman, J. Suls

Development of methodology: W.M.P. Klein

Acquisition of data (provided animals, acquired and managed patients, provided facilities, etc.): W.M.P. Klein

Analysis and interpretation of data (e.g., statistical analysis, biostatistics, computational analysis): W.M.P. Klein

Writing, review, and/or revision of the manuscript: W.M.P. Klein, A.J. Rothman, J. Suls

Administrative, technical, or material support (i.e., reporting or organizing data, constructing databases): W.M.P. Klein

Study supervision: W.M.P. Klein

CASPHR activities (including preparation of this article) are supported by internal funding at the NCI. Extramural CASPHR members from 2009–2019 include Jamie Arndt, Irene Blair, Angela Bryan, Linda Cameron, Ellen Peters, Alexander Rothman (co-chair), and Paschal Sheeran. NCI members have included Susan Czajkowski, Laura Dwyer, Rebecca Ferrer, Kara Hall, Annette Kaufman, William Klein (co-chair), Heather Patrick, and Jerry Suls. We are grateful to Laura Dwyer for her assistance with the curation and organization of CASPHR materials and products reviewed in this article, to Margaux Henquinet for her assistance with article preparation, to numerous NCI fellows for many contributions to CASPHR meetings and activities, and to Meg Gerrard and Rick Gibbons for leading an earlier interest group that helped provide the foundation for CASPHR. More information about CASPHR is available at https://cancercontrol.cancer.gov/brp/casphr/index.html.