Translating epidemiologic research to improve population health through global engagement

Translating epidemiologic
research to improve population
health through global
engagement
Graham A Colditz, MD DrPH
Niess-Gain Professor
Chief, Division of Public Health Sciences
AEA 30th Anniversary, Sydney Uni, 30 September, 2017

Department of Surgery
Division of Public Health Sciences
High School:
Newington College,
Stanmore

BScMed
S&P

Economic costs of diabetes: JAMA
1989
JAMA 1989

BMI and Relative Risk of incident
diabetes over 8 years, NHS
Colditz et al Am J Epidemiol 1990

June 26, 1995
Every Woman’s delemma
THE ESTROGEN DILEMMA
AMERICA'S NO. 1 DRUG IS AN ELIXIER
OF YOUTH, BUT WOMEN MUST DECIDE
IF IT'S WORTH THE RISK OF CANCER

Selected Causes of Death –
1970–72 AND 2002–04, Australia

Doll and Peto 1979
Now IARC 2016 many prospective
cohorts for obesity
as a cause of cancer

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

Evidence, 2016

Risk Increase Associated with Obesity

Level of
Evidence
Small
(RR 1.09-1.34)
Moderate
(RR 1.35 - 1.99)
Large
(RR 2.0 - 4.9)
Very Large
(RR 5.0+)

Convincing
Ovary Colon Breast Esophagus
Thyroid Gastric cardia
Liver
Kidney Uterus
Gall bladder
Pancreas
Meningioma
Multiple
myeloma

Probable
Male breast
Fatal prost.
Diffuse Large B-
cell lymphoma

IARC Report NEJM 2016

Current situation
We 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

Global NCD burden as cause of death

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

Chan, et al…Hu JAMA 2009
SEA – includes India
Western Pacific – China, Australia etc.

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

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 cancers
in women)

Sept 14
2017

Malik et al Nat Rev
Endocrinol 2013
Excess energy è Obesity è NCDs

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 screening
WHO: Global status report on non-communicable diseases, 2010

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

Kirby Lancet
Oncol 2016

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

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

What skills do we need?
• Mentoring
• Diversity
• Global focus => work life balance

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

Translating research to practice
Implementation Science
• Design
• Frameworks
• Analysis (what is the unit here)
Let’s also think about de-implementation

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!

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

Measurement
Examples include:
• Reproducibility of age at menopause
• Diet
• Physical activity
• Biomarkers

Evidence synthesis
IOM examples from Fred’s work:
Vaccines
“Adverse effects of Pertussis and
Rubella vaccines” NAP 1991
From mine: “Veterans and Agent
Orange”, NAP 1994, 1996

Citations: JAMA 1994 – 1116; Pediatrics 1995 – 428
Methods development: Berkey et al

Aims of Response to CDC RFA
Project 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.

Aim so f response to RFA
Citations 377

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

Purposes of Risk Prediction
Determine study eligibility
Risk stratification
E.g., to counsel or guide lifestyle modification – prevention
Intervention decision
Risk estimation and classification for eligibility for services, e.g. MRI
Understand disease etiology
Model incidence and temporal relations of risk factors (life-course
models)

To Fulfill Purposes
Develop
model
Validate
Implement
Adjust

Cancer
Prevention
Reviewed evidence
Translate to practice
Test pencil and paper
Develop cancer tool
on line
Expand to other
diseases
Validate
Cancer &Heart diseaseEmmons K, et al 1999
Kim D., et al J Clin Epi 2004
De Vito L et al 2015

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

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)

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

Wall-e
Captain
Will we all have
access to
driverless cars?
What will our
cancer risk be?

Translating epidemiologic research to improve population health through global engagement

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