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Translating epidemiologic research to improve population
health through global engagement
Graham A Colditz, MD DrPHNiess-Gain Professor
Chief, Division of Public Health Sciences
AEA 30th Anniversary, Sydney Uni, 30 September, 2017
Department of SurgeryDivision of Public Health Sciences
High School:Newington College,Stanmore
Department of SurgeryDivision of Public Health Sciences
BScMed
S&P
Department of SurgeryDivision of Public Health Sciences
Department of SurgeryDivision of Public Health Sciences
Department of SurgeryDivision of Public Health Sciences
Department of SurgeryDivision of Public Health Sciences
Economic costs of diabetes: JAMA 1989
JAMA 1989
Department of SurgeryDivision of Public Health Sciences
BMI and Relative Risk of incident diabetes over 8 years, NHS Colditz et al Am J Epidemiol 1990
Department of SurgeryDivision of Public Health Sciences
Department of SurgeryDivision of Public Health Sciences
June 26, 1995
Every Woman’s delemma
THE ESTROGEN DILEMMAAMERICA'S NO. 1 DRUG IS AN ELIXIER OF YOUTH, BUT WOMEN MUST DECIDE IF IT'S WORTH THE RISK OF CANCER
Department of SurgeryDivision of Public Health Sciences
Selected Causes of Death –1970–72 AND 2002–04, Australia
Department of SurgeryDivision of Public Health Sciences
Department of SurgeryDivision of Public Health Sciences
Department of SurgeryDivision of Public Health Sciences
Doll and Peto 1979
Now IARC 2016 many prospective cohorts for obesity as a cause of cancer
Department of SurgeryDivision of Public Health Sciences
Workgroup reviewed measures of adiposity; animal models; mechanisms; and epidemiologic evidence.Concluded lack of body fatness lowers risk, or obesity causes cancer.
NEJM August 25, 2016
Department of SurgeryDivision of Public Health Sciences
Department of SurgeryDivision of Public Health Sciences
Evidence, 2016
RiskIncreaseAssociatedwithObesity LevelofEvidence
Small(RR1.09-1.34)
Moderate(RR1.35-1.99)
Large(RR2.0-4.9)
VeryLarge(RR5.0+)
Convincing Ovary Colon Breast Esophagus Thyroid Gastriccardia
LiverKidney Uterus
Gallbladder Pancreas
MeningiomaMultiplemyeloma
Probable Malebreast
Fatalprost.DiffuseLargeB-celllymphoma
IARC Report NEJM 2016
Department of SurgeryDivision of Public Health Sciences
Current situationWe are not implementing proven chronic disease prevention and treatment interventions.
Instead we allow millions of people to develop and die from highly preventable diseases.
By not implementing these interventions in ways that reach populations with greatest need, we are permitting disparities to persist.38M deaths each year from NCDs, and 74% of them are in low & middle income countries.
Emmons and Colditz, NEJM 2017
Department of SurgeryDivision of Public Health Sciences
Global NCD burden as cause of death
Department of SurgeryDivision of Public Health Sciences
NCD burden and ageing population –costs of care outstrip budget
Allocation cannot keep up with cost of care, even in high income countries
Economist Sept 10, 2016
Department of SurgeryDivision of Public Health Sciences
Chan, et al…Hu JAMA 2009SEA – includes IndiaWestern Pacific – China, Australia etc.
Department of SurgeryDivision of Public Health Sciences
Over 80% CHD and Diabetes can be prevented through lifestyle!1.Healthy diet (high cereal fiber, low glycemic
load, high polyunsaturated fat), 2.Physical activity (>30 minutes per day), and 3.Not being overweight or obese (BMI<25)
• Hu, .. Colditz,… Willett NEJM 2001• Stampfer, et al NEJM 2000
Department of SurgeryDivision of Public Health Sciences
Estimated new cancer cases, World, 1975 to 2050: Region
Bray and Moller Nat Rev Cancer 2006
2012 – 14 M cases
1.7 M breast(1 in 4 cancersin women)
Department of SurgeryDivision of Public Health Sciences
Sept 14 2017
Department of SurgeryDivision of Public Health Sciences
Malik et al Nat Rev Endocrinol 2013
Excess energy è Obesity è NCDs
Department of SurgeryDivision of Public Health Sciences
WHO priorities:population-wide interventions – Prevention § Reducing tobacco use (a best buy)§ Promoting healthy diets§ Promoting physical activity§ Reducing harmful alcohol use§ Cancer specific strategies
§ Hepatitis B vaccine (a best buy)§ HPV vaccine§ Cervical cancer screening§ Not currently recommended in low income countries – colon
cancer screeningWHO: Global status report on non-communicable diseases, 2010
Department of SurgeryDivision of Public Health Sciences
Best buys for 4 risk factors§ Reduce tobacco use:
§ Protect from exposure§ Warning dangers§ Enforce bans on advertising§ Raise taxes
§ Promote healthy eating§ Reduce harmful alcohol§ Increase physical activity
Department of SurgeryDivision of Public Health Sciences
Kirby Lancet Oncol 2016
Department of SurgeryDivision of Public Health Sciences
Best buys for 4 risk factors§ Reduce tobacco use
§ Promote healthy diet:• Reduce salt/sodium in food• Replace trans-fat with unsaturated fatty acids• Reduce saturated fats• Reduce content of free sugars in food and drinks• Eat plants not animal products
§ Reduce harmful alcohol§ Increase physical activity
Department of SurgeryDivision of Public Health Sciences
WHO priorities:Individual-based interventions in primary care
• Cardiovascular disease and Diabetes• Multi-drug therapy (including glycaemic control for
diabetes mellitus) to individuals who have had a heart attack or stroke, and to persons with a high risk (> 30%) of a CVD event in the next 10 years;
• Providing aspirin to people having an acute heart attack• Cancer• Smoking cessation, aspirin, blood pressure
treatment, and lipid lowering agents
Department of SurgeryDivision of Public Health Sciences
What skills do we need?• Mentoring• Diversity• Global focus => work life balance
Department of SurgeryDivision of Public Health Sciences
1975 – Jake Najman, medical sociology
1977, Ken Donald B.Sc. (Med) - research
1978-9 Chris Bain “Go to HSPH”
1976-9 Mary Sheehan
medical student research
Mentors
Department of SurgeryDivision of Public Health Sciences
Translating research to practiceImplementation Science• Design • Frameworks• Analysis (what is the unit here)
Let’s also think about de-implementation
Department of SurgeryDivision of Public Health Sciences
Tomorrows leaders• They are here already – being trained• What skills do they need (not something
to think about for the future but we need these skills now!)
• Success is not just getting our trainees to their first jobs!
Department of SurgeryDivision of Public Health Sciences
Reporting•Stats methods•Measurement
Evidence synthesis•BCG team•Methods
Translation to practice•Risk prediction•Implementation science
Arrived Boston, Sept 1981
Core Issues in Moving from Research to Practice
Department of SurgeryDivision of Public Health Sciences
MeasurementExamples include: • Reproducibility of age at menopause• Diet• Physical activity • Biomarkers
Department of SurgeryDivision of Public Health Sciences
Evidence synthesis
IOM examples from Fred’s work: Vaccines“Adverse effects of Pertussis and Rubella vaccines” NAP 1991From mine: “Veterans and Agent Orange”, NAP 1994, 1996
Department of SurgeryDivision of Public Health Sciences
Citations: JAMA 1994 – 1116; Pediatrics 1995 – 428
Methods development: Berkey et al
Department of SurgeryDivision of Public Health Sciences
Aims of Response to CDC RFAProject objectives.As defined in the Request for Proposals released by the Centers for Disease Control and Prevention in the summer of 1992, the specific aims for the study were:
A To review the available literature and data bases for data on BCG efficacy and provide a written report on the data that are amenable to meta-analysis.
B To provide a written proposal for study design and methodology for meta-analysis of the available data. Specific attention will be placed on limitations of methods used for meta-analysis, and estimates of confidence to be placed in the estimates of efficacy.
C To perform the meta-analyses using an agreed upon methodology and report on the efficacy of BCG in subgroups. Specific attention will be placed on analyses to assess the efficacy of BCG in children and adults, and the relative efficacy of different vaccine strains.
Department of SurgeryDivision of Public Health Sciences
Aim so f response to RFA
Citations 377
Department of SurgeryDivision of Public Health Sciences
Translation to Practice: Prediction Models
Evolution from modeling breast cancer incidence to applications in breast, colorectal, ovarian, and other cancers
Move beyond disease etiology to stratify population for interventions
Department of SurgeryDivision of Public Health Sciences
Purposes of Risk Prediction Determine study eligibilityRisk stratification
E.g., to counsel or guide lifestyle modification – prevention
Intervention decisionRisk estimation and classification for eligibility for services, e.g. MRI
Understand disease etiologyModel incidence and temporal relations of risk factors (life-course
models)
Department of SurgeryDivision of Public Health Sciences
To Fulfill PurposesDevelop model
Validate
Implement
Adjust
Department of SurgeryDivision of Public Health Sciences
Cancer Prevention
Reviewed evidenceTranslate to practiceTest pencil and paperDevelop cancer tool on lineExpand to other diseases
ValidateCancer &Heart diseaseEmmons K, et al 1999
Kim D., et al J Clin Epi 2004De Vito L et al 2015
Department of SurgeryDivision of Public Health Sciences
Future: Implementation Sciences
How pragmatic is this trial? See PRECIS criteria?
Designs for interventions in health systems?
Thorpe et al CMAJ A pragmatic–explanatory continuum indicator summary(PRECIS): a tool to help trial designers
Department of SurgeryDivision of Public Health Sciences
Implementation Sciences Methods• Methods for policy research• Methods for large scale studies required for scale up• Methods appropriate for capturing multi-level influences,
given organizational complexities• Choosing the correct unit of analysis, given there are “so
many” at play• Real world random assignment• Rapid launch of natural experiments (investigators adopt,
they’re off and running)
Department of SurgeryDivision of Public Health Sciences
Implementation Sciences Methods (Con’t)• Simulation methods• Long-enough observation to capture de-
implementation• Methods to capture “diagnostic appropriate”
treatment, given the variations of under-use, over-use, and inappropriate use of guidelines/ interventions etc.
• Power estimation for studies when organizational change is the outcome
Department of SurgeryDivision of Public Health Sciences
Department of SurgeryDivision of Public Health Sciences
Wall-eCaptain
Will we all have access to driverless cars?
What will our cancer risk be?