Catchment Area: An Opportunity for Collective Impact, Strategic Collaboration, and Complementary Focus

An important advance in enhancing the impact of the NCI Centers Program was to incorporate an expectation that each NCI-Designated Cancer Center (referred to herein as “center”) define and justify their catchment area. Guidelines for the catchment area were described in 2016 in a new section of the Cancer Center Support Grant (CCSG) Application entitled Community Outreach and Engagement (COE; ref. 1). Beyond guidance that catchment boundaries should cover the immediate area around and the majority of patients served by the center, the remaining rationale for its selection is largely left to each center's discretion. As highlighted by DelNero, Buller, and colleagues’ (2) article in this issue of CEBP, centers define their catchment area using geographic boundaries ranging from part of a county to multiple states. Once defined, centers are responsible for understanding and addressing needs of the catchment area population, cancer burden, and cancer risk factors. Ongoing bidirectional engagement ensures that community priorities inform strategic directions of the center to advance cancer care, research, clinical trials, and outreach with a strong emphasis on equity in cancer outcomes. This publication as well as another providing complementary information supported by the American Association of Cancer Institutes (3) coincides with the 50th Anniversary of the National Cancer Act that laid the foundation for the NCI Cancer Centers Program. The analyses by DelNero, Buller, and colleagues (2) show the great progress in achieving high geographic (77% of all counties) and population (88% of the total) coverage by the 63 centers. While based in 36 states, centers’ catchment areas span 43 states and the Asian Pacific Islands.

The authors also shed light on surprising coverage gaps. For example, three southern states (AR, LA, and MS) with the highest levels of environmental and behavioral cancer risk factors and the worst health indicators (4) are not covered. While simply having an NCI-Designated Cancer Center in the area is neither necessary nor sufficient to achieve high-quality cancer outcomes, prior studies suggest that patients treated at these centers have superior outcomes (5,6). Centers also provide access to novel clinical trials and engage in cancer control efforts, particularly for underserved populations. The information provided through the visualizations show key adjacent areas that would benefit from NCI-Designated Cancer Center attention. Plans to increase coverage by existing centers and those aspiring designation are underway and should be closely monitored. To extend coverage, existing center leaders should consider information from these recent analyses, plan strategic collaborations with local health systems, and identify novel funding sources to support these underserved communities.

In addition to coverage, the Figs. 3–5 in the DelNero, Buller, and colleagues's article (2) also highlight key patient- and population-level variables of the catchment areas such as population density, geographic size, and diversity of age, sex, and race/ethnicity. However, the current catchment area characterization was not designed to highlight subpopulations experiencing cancer health disparities (e.g., specific Asian ethnicities, transgender individuals) whose small size, dispersion, and accessibility may limit research and hamper outreach by cancer centers (7). Furthermore, the figures did not illustrate important factors operating at other levels such as availability of primary care and oncology providers. As such, visualizations of key subgroups and factors at other levels are an important next step. To fully mobilize COE teams to address cancer equity in their catchment, future visualizations should leverage national and state secondary data sources that are georeferenced or provide geography level data points, such as the American Community Survey Data via the U.S. Census and health care access data from the Health Resources and Services Administration. The mapping tool developed by the authors (https://gis.cancer.gov/ncicatchment/app/) provides an excellent foundation to add other relevant data related to subpopulations, cancer care delivery, and social determinants of health such as lack of health insurance, persistent poverty, and availability of safety-net providers for the underinsured/uninsured.

We have reached a critical inflection point to consider how the concept of catchment area can further enhance the impact of NCI-Designated Cancer Centers. CCSG applications from almost all NCI-Designated Cancer Centers have been or soon will be reviewed/renewed with the catchment area as a foundational part of the narrative. In addition to the COE section, other components must address how the catchment area influences center activities as a whole including, but not limited to, each research program and sections relevant to clinical trials. Generally speaking, positive ratings for COE improve to the center's overall score. Over the past 5 years, centers have learned from NCI leadership, professional forums such as the American Society for Preventive Oncology, and directly from each other, about optimal ways to define the catchment area. As the concept of catchment areas and the tools to understand them mature and evolve, future approaches should include strategic planning to foster novel research collaborations, enhancing cancer control efforts, and supporting coordination with state or other entities with reach in and beyond the catchment area.

To share in the responsibility of meeting the needs of U.S. communities, cancer center leaders should foster complementary research and outreach foci across centers. Understanding populations, cancer burden, and risk factors within each center establishes an excellent foundation for building mutually beneficial research partnerships among centers and their communities. For example, the leaders of the large academic cancer centers in Florida established the Florida Academic Cancer Center Alliance (8) to promote collaborative research by supporting information exchange, networking among researchers, and pilot funding across member institutions. This approach has resulted in the creation of novel partnerships to address statewide needs such as pancreatic cancer disparities (9). Similar efforts are underway in Texas with conscious documentation of opportunities for coordinated investment and sharing of metrics. As a result of COE requirements, most centers have a clear process to continually engage with community organizations and partners to understand local needs and priorities. This infrastructure provides a valuable resource for researchers across NCI-Designated Cancer Centers to foster collaborations based on similar populations, cancer burden, or risk factors. COE leaders are uniquely positioned to make these connections as they both engage with community advisors and partners and are knowledgeable about catchment area relevant research across the entire cancer continuum. From an outreach perspective, partnering with centers with similar geographies (e.g., rural) or populations (e.g., HIV+) can expedite innovative research and sharing of best practices for disseminating cancer control efforts to key segments of the U.S. population that are particularly vulnerable to cancer disparities due to multiple, intersecting social determinants of health.

The seemingly simple act of defining a geographic catchment also helps centers align with ongoing public health and policy efforts within and beyond the catchment area. For example, the Centers for Disease Control and Prevention's Comprehensive Cancer Control Program provides funding and technical assistance to establish state cancer plans and regional coalitions to prevent and control cancer (10). Similarly, the U.S. Office of Management and Budget defines core-based statistical areas around commuting patterns. These metropolitan areas “contain a large population nucleus and adjacent communities that have a high degree of economic and social integration with that nucleus.” Thus, cancer care delivery and health system planning are driven by commuting patterns around that nucleus. As policies at the federal, state, regional, and county/city levels may influence delivery of care across the cancer control continuum, cancer centers could partner in studying the positive and negative effects of policies that target distinct and overlapping parts of their catchment areas. Overlaying information on catchments, established public health infrastructures, and policies supporting safety-net health organizations and programs may help centers expand partnerships with other stakeholders to achieve a common goal.

One could interpret and respond to catchment area descriptions as a way of setting clear boundaries or territories. But, given the unmet needs for coverage highlighted in this publication and the continuing cancer prevention, screening, and care disparities that have been exacerbated by the COVID-19 pandemic (11–13), a greater focus on collaboration among centers and rewarding that collaboration is worthy of consideration. The publication by DelNero, Buller, and colleagues (2) serves as a baseline to track catchment area growth and change over time. Improving cancer care, enhancing outreach to underserved populations, and advancing research (including clinical trials) is tremendous challenge in the United States, and centers do not fulfill these responsibilities in isolation from each other. Sharing community priorities and perspectives on catchment area populations, risk factors, and cancer burden across centers would provide a platform to identify and plan substantive collaborations that are driven by both scientific expertise and meeting the needs of key subgroups that are disproportionately affected. Thus, we suggest that while defining the catchment area is an important first step, centers should now step forward in recognizing that optimizing our collective impact requires strategic, complementary collaboration to address research questions and outreach across catchment areas.

S.T. Vadaparampil reports grants from NCI during the conduct of the study. J.A. Tiro reports grants from NCI, NIH outside the submitted work.