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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2021. Advancing Progress in the Development and Implementation of Effective, High-Quality Cancer Screening: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26019.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2021. Advancing Progress in the Development and Implementation of Effective, High-Quality Cancer Screening: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26019.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2021. Advancing Progress in the Development and Implementation of Effective, High-Quality Cancer Screening: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26019.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2021. Advancing Progress in the Development and Implementation of Effective, High-Quality Cancer Screening: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26019.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2021. Advancing Progress in the Development and Implementation of Effective, High-Quality Cancer Screening: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26019.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2021. Advancing Progress in the Development and Implementation of Effective, High-Quality Cancer Screening: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26019.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2021. Advancing Progress in the Development and Implementation of Effective, High-Quality Cancer Screening: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26019.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2021. Advancing Progress in the Development and Implementation of Effective, High-Quality Cancer Screening: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26019.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2021. Advancing Progress in the Development and Implementation of Effective, High-Quality Cancer Screening: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26019.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2021. Advancing Progress in the Development and Implementation of Effective, High-Quality Cancer Screening: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26019.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2021. Advancing Progress in the Development and Implementation of Effective, High-Quality Cancer Screening: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26019.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2021. Advancing Progress in the Development and Implementation of Effective, High-Quality Cancer Screening: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26019.
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Advancing Progress in the Development and Implementation of Effective, High-Quality Cancer Screening PROCEEDINGS OF A WORKSHOP Erin Balogh, Sarah Domnitz, Margie Patlak, and Sharyl J. Nass, Rapporteurs National Cancer Policy Forum Board on Health Care Services Health and Medicine Division PREPUBLICATION COPY—Uncorrected Proofs

THE NATIONAL ACADEMIES PRESS  500 Fifth Street, NW  Washington, DC 20001 This activity was supported by Contract No. 200-2011-38807 (Task Order No. 75D30119F00080) and Contract No. HHSN263201800029I (Task Order No. HHSN26300008) with the Centers for Disease Control and Prevention and the National Cancer Institute/National Institutes of Health, respectively, and by the American Association for Cancer Research, American Cancer Society, American ­ C ­ ollege of Radiology, American Society of Clinical Oncology, Association of Ameri- can Cancer Institutes, Association of Community Cancer Centers, Bristol-Myers Squibb, Cancer Support Community, CEO Roundtable on Cancer, Flatiron Health, Merck, National Comprehensive Cancer Network, National Patient Advocate Foundation, Novartis Oncology, Oncology Nursing Society, Pfizer Inc., Sanofi, and ­ ociety for Immunotherapy of Cancer. Any opinions, findings, conclusions, or S recommendations expressed in this publication do not necessarily reflect the views of any organization or agency that provided support for the project. International Standard Book Number-13: 978-0-309-XXXXX-X International Standard Book Number-10: 0-309-XXXXX-X Digital Object Identifier: https://doi.org/10.17226/26019 Additional copies of this publication are available from the National Academies Press, 500 Fifth Street, NW, Keck 360, Washington, DC 20001; (800) 624-6242 or (202) 334-3313; http://www.nap.edu. Copyright 2021 by the National Academy of Sciences. All rights reserved. Printed in the United States of America Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2021. Advancing progress in the development and implementation of effective, high-quality cancer screening: Proceedings of a workshop. Washington, DC: The National Academies Press. https://doi.org/10.17226/26019. PREPUBLICATION COPY—Uncorrected Proofs

The National Academy of Sciences was established in 1863 by an Act of Congress, signed by President Lincoln, as a private, nongovernmental institution to advise the nation on issues related to science and technol- ogy. Members are elected by their peers for outstanding contributions to research. Dr. Marcia McNutt is president. The National Academy of Engineering was established in 1964 under the charter of the National Academy of Sciences to bring the practices of engineering to advising the nation. Members are elected by their peers for extraordinary contributions to engineering. Dr. John L. Anderson is president. The National Academy of Medicine (formerly the Institute of Medicine) was established in 1970 under the charter of the National Academy of Sciences to advise the nation on medical and health issues. Members are elected by their peers for distinguished contributions to medicine and health. Dr. Victor J. Dzau is president. The three Academies work together as the National Academies of Sci- ences, Engineering, and Medicine to provide independent, objective anal- ysis and advice to the nation and conduct other activities to solve complex problems and inform public policy decisions. The National Academies also encourage education and research, recognize outstanding contributions to knowledge, and increase public understanding in matters of science, engineering, and medicine. Learn more about the National Academies of Sciences, Engineering, and Medicine at www.nationalacademies.org. PREPUBLICATION COPY—Uncorrected Proofs

Consensus Study Reports published by the National Academies of Sciences, Engineering, and Medicine document the evidence-based consensus on the study’s statement of task by an authoring committee of experts. Reports typically include findings, conclusions, and recommendations based on information gathered by the committee and the committee’s deliberations. Each report has been subjected to a rigorous and independent peer-review process and it represents the position of the National Academies on the statement of task. Proceedings published by the National Academies of Sciences, Engineering, and Medicine chronicle the presentations and discussions at a workshop, symposium, or other event convened by the National Academies. The state- ments and opinions contained in proceedings are those of the participants and are not endorsed by other participants, the planning committee, or the National Academies. For information about other products and activities of the National A ­ cademies, please visit www.nationalacademies.org/about/whatwedo. PREPUBLICATION COPY—Uncorrected Proofs

WORKSHOP PLANNING COMMITTEE1 NICOLE F. DOWLING (Co-Chair), Associate Director for Science, Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention STANTON L. GERSON (Co-Chair), Interim Dean and Senior Vice President, Medical Affairs, School of Medicine; Director, Case Comprehensive Cancer Center; Professor of Hematological Oncology; and Director, National Center for Regenerative Medicine, Case Western Reserve University GARNET ANDERSON, Senior Vice President and Director, Public Health Sciences Division, Fred Hutchinson Cancer Research Center; Principal Investigator, Clinical Coordinating Center, Women’s Health Initiative; and Affiliate Professor, Department of Biostatistics, University of Washington KENNETH ANDERSON, Kraft Family Professor of Medicine; American Cancer Society Research Professor; and Clinical Research Director, Jerome Lipper Multiple Myeloma Center and LeBow Institute for Myeloma Therapeutics, Harvard Medical School and Dana-Farber Cancer Institute EDWARD J. BENZ, JR., President and Chief Executive Officer, Emeritus, Dana-Farber Cancer Institute; and Richard and Susan Smith Distinguished Professor of Medicine, Genetics and Pediatrics, Harvard Medical School OTIS W. BRAWLEY, Bloomberg Distinguished Professor of Epidemiology and Oncology, Bloomberg School of Public Health, Sidney Kimmel Comprehensive Cancer Center, and School of Medicine, Johns Hopkins University SUSAN CURRY, Dean Emerita, College of Public Health; and Distinguished Professor, Health Management and Policy, The University of Iowa NANCY E. DAVIDSON, President and Executive Director, Seattle Cancer Care Alliance; Raisebeck Endowed Chair for Collaborative Research, Senior Vice President, Director, and Professor, Clinical Research Division, Fred Hutchinson Cancer Research Center; and Head, Department of Medicine, Division of Medical Oncology, University of Washington 1 The National Academies of Sciences, Engineering, and Medicine’s planning commit- tees are solely responsible for organizing the workshop, identifying topics, and choosing s ­ peakers. The responsibility for the published Proceedings of a Workshop rests with the workshop ­ apporteurs and the institution. r v PREPUBLICATION COPY—Uncorrected Proofs

CONSTANTINE GATSONIS, Henry Ledyard Goddard University Professor of Biostatistics; Founding Director, Center for Statistical Sciences; and Founding Chair, Department of Biostatistics, Brown University LORI HOFFMAN HŌGG, Veterans Health Administration National Program Manager for Prevention Policy, National Center for Health Promotion and Disease Prevention; and National Oncology Clinical Advisor, Office of Nursing Services, Department of Veterans Affairs HEDVIG HRICAK, Chair, Department of Radiology, Memorial Sloan Kettering Cancer Center ALEX KRIST, Professor, Family Medicine & Population Health; Co-Director, Virginia Ambulatory Care Outcomes Research Network; and Director, Community Engaged Research, Center for Clinical and Translational Research, Virginia Commonwealth University; and Chair, United States Preventive Services Task Force MICHELLE M. LE BEAU, Arthur and Marian Edelstein Professor of Medicine, Section of Hematology/Oncology; Director, Cancer Cytogenetics Laboratory; and Director, Comprehensive Cancer Center, University of Chicago LISA RICHARDSON, Director, Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention SUDHIR SRIVASTAVA, Chief, Cancer Biomarkers Research Group, Division of Cancer Prevention, National Cancer Institute ROBERT A. WINN, Director, Massey Cancer Center, and Professor of Internal Medicine, School of Medicine, Virginia Commonwealth University Project Staff RACHEL AUSTIN, Senior Program Assistant (from November 2020) ERIN BALOGH, Co-Director, National Cancer Policy Forum LORI BENJAMIN BRENIG, Research Associate ANNALEE GONZALES, Administrative Assistant KATHERINE HAWTHORNE, Senior Program Assistant (until September 2020) SHARYL NASS, Co-Director, National Cancer Policy Forum, and Senior Director, Board on Health Care Services MICAH WINOGRAD, Senior Finance Business Partner EMILY ZEVON, Program Officer vi PREPUBLICATION COPY—Uncorrected Proofs

NATIONAL CANCER POLICY FORUM1 EDWARD J. BENZ, JR. (Chair), President and Chief Executive Officer, Emeritus, Dana-Farber Cancer Institute; and Richard and Susan Smith Distinguished Professor of Medicine, Genetics and Pediatrics, Harvard Medical School PETER C. ADAMSON, Global Head, Oncology Development & Pediatric Innovation, Sanofi GARNET L. ANDERSON, Senior Vice President and Director, Public Health Sciences Division, Fred Hutchinson Cancer Research Center; Principal Investigator, Clinical Coordinating Center, Women’s Health Initiative; and Affiliate Professor, Department of Biostatistics, University of Washington KAREN BASEN-ENGQUIST, Annie Laurie Howard Research Distinguished Professor; Professor of Behavioral Science; and Director, Center for Energy Balance in Cancer Prevention and Survivorship, University of Texas MD Anderson Cancer Center SMITA BHATIA, Professor and Vice Chair of Outcomes for Pediatrics; Gay and Bew White Endowed Chair in Pediatric Oncology; Director, Institute for Cancer Outcomes and Survivorship; and Associate Director for Outcomes Research, Comprehensive Cancer Center, University of Alabama at Birmingham LINDA BOHANNON, President, Cancer Support Community CHRIS BOSHOFF, Chief Development Officer, Oncology, Pfizer Inc. CATHY J. BRADLEY, Grohne Chair for Cancer Prevention and Control Research; Professor and Associate Dean for Research, Colorado School of Public Health; and Deputy Director, University of Colorado Cancer Center OTIS W. BRAWLEY, Bloomberg Distinguished Professor of Epidemiology and Oncology, Bloomberg School of Public Health, Sidney Kimmel Comprehensive Cancer Center, and School of Medicine, Johns Hopkins University CYNTHIA BROGDON, Head, U.S. Oncology Portfolio Strategy, Bristol Myers Squibb WILLIAM G. CANCE, Chief Medical and Scientific Officer, American Cancer Society 1 The National Academies of Sciences, Engineering, and Medicine’s forums and roundtables do not issue, review, or approve individual documents. The responsibility for the published Proceedings of a Workshop rests with the workshop rapporteurs and the institution. vii PREPUBLICATION COPY—Uncorrected Proofs

ROBERT W. CARLSON, Chief Executive Officer, National Comprehensive Cancer Network CHRISTINA CHAPMAN, Assistant Professor of Radiation Oncology, University of Michigan K. ANDREW CRIGHTON, Chief Executive Officer, CEO Roundtable on Cancer GWEN DARIEN, Executive Vice President, Patient Advocacy and Engagement, National Patient Advocate Foundation NANCY E. DAVIDSON, President and Executive Director, Seattle Cancer Care Alliance; Raisebeck Endowed Chair for Collaborative Research, Senior Vice President, Director, and Professor, Clinical Research Division, Fred Hutchinson Cancer Research Center; and Head, Department of Medicine, Division of Medical Oncology, University of Washington GEORGE D. DEMETRI, Professor of Medicine and Director, Ludwig Center, Harvard Medical School; Senior Vice President for Experimental Therapeutics; Director, Center for Sarcoma and Bone Oncology; Quick Family Chair for Medical Oncology, Dana-Farber Cancer Institute; and Associate Director for Clinical Sciences, Dana-Farber/Harvard Cancer Center JAMES H. DOROSHOW, Director, Division of Cancer Treatment and Diagnosis; Deputy Director for Clinical and Translational Research; and Head, Oxidative Signaling and Molecular Therapeutics Group, National Cancer Institute NICOLE F. DOWLING, Associate Director for Science, Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention SCOT W. EBBINGHAUS, Vice President and Therapeutic Area Head, Oncology Clinical Research, Merck Research Laboratories KOJO S. J. ELENITOBA-JOHNSON, Professor, Perelman School of Medicine; and Director, Center for Personalized Diagnostics and Division of Precision and Computational Diagnostics, University of Pennsylvania STANTON L. GERSON, Interim Dean and Senior Vice President, Medical Affairs, School of Medicine; Director, Case Comprehensive Cancer Center; Professor of Hematological Oncology; and Director, National Center for Regenerative Medicine, Case Western Reserve University HEDVIG HRICAK, Chair, Department of Radiology, Memorial Sloan Kettering Cancer Center viii PREPUBLICATION COPY—Uncorrected Proofs

CHANITA HUGHES-HALBERT, Associate Dean for Assessment, Evaluation, and Quality Improvement, College of Medicine; Professor, Department of Psychiatry and Behavioral Sciences; Distinguished AT&T Endowed Chair for Cancer Equity, Hollings Cancer Center, Medical University of South Carolina MIMI HUIZINGA, Vice President and Head, U.S. Oncology Medical, Novartis Oncology ROY A. JENSEN, President, Association of American Cancer Institutes; Professor of Pathology and Laboratory Medicine, Anatomy and Cell Biology, and Cancer; Director, The University of Kansas Cancer Center; William R. Jewell, M.D., Distinguished Masonic Professor; and Director, Kansas Masonic Cancer Research Institute, University of Kansas RANDY A. JONES, Professor of Nursing, University of Virginia School of Nursing; and Assistant Director for Community Outreach Engagement, University of Virginia Emily Couric Cancer Center BETH Y. KARLAN, Vice Chair, Women’s Health Research; Professor, Department of Obstetrics and Gynecology, David Geffen School of Medicine; and Director, Cancer Population Genetics, Jonsson Comprehensive Cancer Center, University of California, Los Angeles LISA KENNEDY SHELDON, Clinical and Scientific Affairs Liaison, Oncology Nursing Society; and Oncology Nurse Practitioner, St. Joseph Hospital SAMIR N. KHLEIF, Director, Jeannie and Tony Loop Immuno-Oncology Lab; Biomedical Scholar and Professor of Oncology, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center; and Member, Society for Immunotherapy of Cancer KAREN E. KNUDSEN, Executive Vice President, Oncology Services; and Enterprise Director, Sidney Kimmel Cancer Center, Jefferson Health MIA LEVY, Sheba Foundation Director, Rush University Cancer Center; Associate Professor of Medicine, Division of Hematology and Oncology; and System Vice President, Cancer Services, Rush System for Health SCOTT M. LIPPMAN, Professor of Medicine, Senior Associate Dean, and Associate Vice Chancellor for Cancer Research and Care; Chugai Pharmaceutical Chair in Cancer, University of California, San Diego NEAL MEROPOL, Vice President and Head of Medical and Scientific Affairs, Flatiron Health; and Adjunct Professor, Case Comprehensive Cancer Center LARISSA NEKHYLYUDOV, Medical Director of Brigham & Women’s Primary Care Associates at Longwood; Associate Professor of Internal Medicine, Harvard Medical School ix PREPUBLICATION COPY—Uncorrected Proofs

RANDALL A. OYER, Medical Director, Oncology, Ann B. Barshinger Cancer Institute; and Medical Director, Cancer Risk Evaluation Program, Penn Medicine Lancaster General Health CLEO A. SAMUEL-RYALS, Associate Professor, Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill RICHARD L. SCHILSKY, Senior Vice President, Executive Vice President, and Chief Medical Officer, American Society of Clinical Oncology JULIE SCHNEIDER, Associate Director, Research Strategy and Partnership, Oncology Center of Excellence, Food and Drug Administration LAWRENCE N. SHULMAN, Professor of Medicine and Deputy Director for Clinical Services and Director, Center for Global Cancer Medicine, Abramson Cancer Center, University of Pennsylvania LARA STRAWBRIDGE, Director, Division of Ambulatory Payment Models, Patient Models Group, Center for Medicare & Medicaid Innovation, Centers for Medicare & Medicaid Services GEORGE J. WEINER, C. E. Block Chair of Cancer Research; Professor of Internal Medicine; Professor of Pharmaceutical Science Experimental Therapeutics; and Director, Holden Comprehensive Cancer Center, The University of Iowa ROBERT A. WINN, Director, Massey Cancer Center; and Professor of Internal Medicine, School of Medicine, Virginia Commonwealth University Forum Staff RACHEL AUSTIN, Senior Program Assistant ERIN BALOGH, Co-Director, National Cancer Policy Forum LORI BENJAMIN BRENIG, Research Associate ANNALEE GONZALES, Administrative Assistant SHARYL NASS, Co-Director, National Cancer Policy Forum, and Senior Director, Board on Health Care Services MICAH WINOGRAD, Senior Finance Business Partner x PREPUBLICATION COPY—Uncorrected Proofs

Reviewers This Proceedings of a Workshop was reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise. The purpose of this independent review is to provide candid and critical comments that will assist the National Academies of Sciences, Engineering, and Medicine in mak- ing each published proceedings as sound as possible and to ensure that it meets the institutional standards for quality, objectivity, evidence, and responsiveness to the charge. The review comments and draft manuscript remain confidential to protect the integrity of the process. We thank the following individuals for their review of this proceedings: CHYKE A. DOUBENI, Mayo Clinic DAVID F. RANSOHOFF, University of North Carolina at Chapel Hill CAROLYN M. RUTTER, RAND Corporation MELISSA A. SIMON, Northwestern University Although the reviewers listed above provided many constructive com- ments and suggestions, they were not asked to endorse the content of the proceedings nor did they see the final draft before its release. The review of this proceedings was overseen by DANIEL R. MASYS, University of ­Washington. He was responsible for making certain that an independent examination of this proceedings was carried out in accordance with standards of the National Academies and that all review comments were carefully considered. Responsi- bility for the final content rests entirely with the rapporteurs and the National Academies. xi PREPUBLICATION COPY—Uncorrected Proofs

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Acknowledgments Support from the many annual sponsors of the National Academies of Sciences, Engineering, and Medicine’s National Cancer Policy Forum is crucial to the work of the forum. Federal sponsors include the Centers for Disease Control and Prevention and the National Cancer Institute/National Institutes of Health. Nonfederal sponsors include the American Association for Cancer Research, American Cancer Society, American College of Radiology, American Society of Clinical Oncology, Association of American Cancer Institutes, Asso- ciation of Community Cancer Centers, Bristol-Myers Squibb, Cancer Support Community, CEO Roundtable on Cancer, Flatiron Health, Merck, National Comprehensive Cancer Network, National Patient Advocate Foundation, Novartis Oncology, Oncology Nursing Society, Pfizer Inc., Sanofi, and Society for Immunotherapy of Cancer. The forum wishes to express its gratitude to the expert speakers whose presentations helped further the dialogue on opportunities to improve the evidence base for and delivery of high-quality cancer screening. The forum also wishes to thank the members of the planning committee for their work in developing an excellent workshop agenda. xiii PREPUBLICATION COPY—Uncorrected Proofs

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Contents ACRONYMS AND ABBREVIATIONS xix PROCEEDINGS OF A WORKSHOP 1 WORKSHOP OVERVIEW 1 CANCER SCREENING: PAST AND PRESENT 3 Breast Cancer, 9 Colorectal Cancer, 10 Cervical Cancer, 11 Lung Cancer, 12 Prostate Cancer, 13 Ovarian Cancer, 14 Overdiagnosis, 15 NEW SCREENING TECHNOLOGIES AND STRATEGIES 17 Multicancer Screening, 17 Personalized Screening, 19 CHALLENGES AND OPPORTUNITIES IN SCREENING TEST DEVELOPMENT AND VALIDATION 25 Preclinical Development, 26 Demonstrating the Clinical Value of Screening, 30 USING MODELING TO COMPLEMENT CLINICAL EVALUATION OF SCREENING 32 Modeling Outcomes, 32 Modeling Cost-Effectiveness, 33 xv PREPUBLICATION COPY—Uncorrected Proofs

xvi CONTENTS GUIDING PRINCIPLES FOR DEVELOPING SCREENING RECOMMENDATIONS 36 PATIENT DECISION MAKING 41 Shared Decision Making, 41 Patient Decision Aids, 47 PATIENT ACCESS TO SCREENING AND FOLLOW-UP CARE 48 Screening, 48 Follow-Up Care, 49 POLICY SUGGESTIONS TO IMPROVE CANCER SCREENING 53 Research, Development, and Clinical Testing of Screening Technology, 53 Guidelines Development, 58 Health Care Organization and Delivery to Facilitate Screening, 59 Education and Communication, 63 Insurance Coverage, 64 WRAP-UP 65 REFERENCES 66 APPENDIX A: STATEMENT OF TASK 79 APPENDIX B: WORKSHOP AGENDA 81 PREPUBLICATION COPY—Uncorrected Proofs

Boxes, Figures, and Table BOXES 1 Suggestions from Individual Workshop Participants to Improve Cancer Screening, 4 2 WISDOM Risk-Based Breast Cancer Screening Trial, 20 3 Early Detection Research Network, 28 4 Recommendation Development Process of the United States Preventive Services Task Force (USPSTF), 37 5 Ethical Principles That May Apply to the Evaluation of Cancer Screening, 40 6 Cervical Cancer Screening and Follow-Up Program at the MD Anderson Cancer Center, 51 FIGURES 1 Breast cancer is not a single disease, 19 2 Strategy for multimodal ovarian cancer screening process in the UK Collaborative Trial of Ovarian Screening, 24 3 Modeling the efficiency of mammography, 34 4 Age of screening cessation by comorbidity life expectancy, 35 5 Proportion of patients with breast cancer indicating which factors were “very important” in their surgical treatment decision making, by race/ ethnicity, 45 xvii PREPUBLICATION COPY—Uncorrected Proofs

xviii BOXES, FIGURES, AND TABLE 6 Variation in follow-up after an abnormal screening result, for breast, colorectal, or cervical cancer, 50 TABLE 1 Phases of Shared Decision Making, 42 PREPUBLICATION COPY—Uncorrected Proofs

Acronyms and Abbreviations AHRQ Agency for Healthcare Research and Quality AI artificial intelligence CA125 cancer antigen 125 CDC Centers for Disease Control and Prevention CDRH Center for Devices and Radiological Health CLIA Clinical Laboratory Improvement Amendment CMS Centers for Medicare & Medicaid Services CRCCP Colorectal Cancer Control Program CT computed tomography EDRN Early Detection Research Network ERSPC European Randomized Study of Screening for Prostate Cancer FDA Food and Drug Administration FQHC Federally Qualified Health Center HMO health maintenance organization HPV herpes papilloma virus LEEP loop electrosurgical excision procedure MPS MyProstateScore xix PREPUBLICATION COPY—Uncorrected Proofs

xx ACRONYMS AND ABBREVIATIONS MRI magnetic resonance imaging MyPeBS My Personal Breast Screening NCCN National Comprehensive Cancer Network NCI National Cancer Institute NICE National Institute for Health and Care Excellence NIH National Institutes of Health PET positron emission tomography PLCO Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial PSA prostate-specific antigen RCT randomized controlled trial ROC risk of ovarian cancer SNP single nucleotide polymorphism TMIST Tomosynthesis Mammographic Imaging Screening Trial TVS transvaginal ultrasonography UKCTOCS United Kingdom Collaborative Trial of Ovarian Cancer Screening USPSTF United States Preventive Services Task Force VHA Veterans Health Administration WHO World Health Organization WISDOM Women Informed to Screen Depending on Measures of Risk PREPUBLICATION COPY—Uncorrected Proofs

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New technologies and improved understanding of the genesis and progression of various cancers have added to the enthusiasm for potential new strategies to improve screening and early detection of cancer. Research is also under way to evaluate refinements in current screening approaches, including determining optimal screening intervals, the ages at which screening should begin and end, as well as more specific estimates of the potential risks and benefits of screening for certain populations, such as racial and ethnic minority populations and people who have elevated risk for specific cancers. However, there remain significant challenges to developing, validating, and effectively implementing new cancer screening approaches. Guidelines for screening issued by different organizations vary considerably with no clear way of deciding which guidelines are most trustworthy. There is also a need to improve access to high-quality cancer screening and follow-up care, particularly in low-resource communities and among populations who are underserved or have numerous barriers to receiving care.

To examine the challenges and opportunities related to improving current approaches to cancer screening, as well as the evidence base for novel cancer screening methods, the National Cancer Policy Forum held a workshop, Advancing Progress in the Development and Implementation of Effective, High-Quality Cancer Screening, on March 2-3, 2020, in Washington, DC. This workshop convened a broad range of experts, including clinicians, researchers, statisticians, and patient advocates, as well as representatives of health care organizations, academic medical centers, insurers, and federal agencies. This publication summarizes the presentations and discussions of the workshop and highlights suggestions from individual participants regarding how to improve cancer screening.

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