Impacts of the CIHR Institute of Cancer Research 2001-2009

Making an impact by building a national research community

We stressed earlier the challenge that the Institute has faced in making an impact, given its meagre funding resources. Here we discuss the most important way in which the Institute met that challenge, by becoming a community-builder.

Collaborating and partnering

The potential for this new Institute to be viewed as a competitor and interloper was high, but instead, respondents repeatedly lauded the way the Institute always worked collaboratively, willing to share leadership and credit, and contribute towards and build on what others were doing. Many NCIC-connected respondents particularly commented on the extremely effective and collegial relationship quickly established and maintained between these two key funders.

The Institute in fact made it possible for the community to come together and achieve much greater things than were possible before: "The Institute's role has been instigating, catalytic, getting alignment to do big things. It was always about: where could we collaboratively have the biggest impact and work together to make that happen?"

The Institute had as its clear priority to improve cancer control in Canada, and received clear payoff for its willingness to eschew glory and instead be a team player: "The thing that impresses me is how, with that relatively modest budget, the Institute has been able to get partners, and be influential outside, as well as within, CIHR. Its accomplishments are way larger than the budget allowed for."

Catalyzing the Canadian Cancer Research Alliance (CCRA)

"The Institute has played a leadership role in catalyzing relationships, getting people to think more as a unified community."

The Institute, however, developed a much more ambitious goal than simply working well with the other funders. The charities and foundations that fund-raised to survive saw each other as competitors, not collaborators. Nonetheless inspired by the recently created (2001) National Cancer Research Institute, a consortium of 21 cancer research funding organization in the UK, the Institute promulgated the somewhat heretical idea that to get real impact, "there has to be a coordinated national approach to cancer and cancer research strategy." In making this happen, another respondent notes that the Institute "has been both a leader and a significant and willing partner."

"The biggest impact by far was the creation of CCRA. Without the Institute's leadership, it wouldn't have happened. It's really an incredible achievement to have brought 26 funding agencies to the table."

The Institute first brought funders and stakeholders together to form the Research Action Group (RAG) of the Canadian Strategy for Cancer Control (CSCC), to make the case that research was an important and effective component of Canada's cancer care plan. The Institute also brought together all the major funders of cancer research to discuss funding of large transformative cancer research projects or platforms, which no single organization could fund alone with the money they had at the time, and this group evolved into the Canadian Cancer Research Alliance (CCRA). Since it was widely recognised that the RAG and the CCRA had similar aims and overlapping membership, the groups merged. When out of the CSCC activities came the federal government's decision to fund the independent Canadian Partnership Against Cancer (CPAC), the emerging funders' Alliance became part of that Partnership. Much credit is given to the Institute's founding Scientific Director for bringing all these funders together and enabling them to focus their collective efforts on identifying how research could further Canada's cancer control agenda. A major outcome of that collective and coherent voice was the decision by CPAC to incorporate a significant research component, with about $12.5M of its average annual $50M in federal funding to be invested in research.²¹

The Alliance (CCRA), under the joint leadership²² of the Institute and the NCIC, became the Partnership's (CPAC) advisory body to identify the most effective approaches to investing its new research funds. Supported by the Alliance's recommendation, the Partnership determined that its major research commitment, totalling $42M of its $50M five-year research investment, would be to the Canadian Partnership for Tomorrow Project (otherwise known as the cancer cohort), with the remainder allocated to a partnership with the Terry Fox Foundation focused on translational research, starting with a project on early detection of lung cancer in smokers. The Alliance is also developing a Canadian cancer research strategy, which should be published in early 2010. As the Institute is a leading member of the Alliance, this resulting national strategy will play a key role in guiding the Institute's own research strategy, and identifying the specific role that the Institute can play in the complex research landscape.

Many respondents emphasized that bringing together the research community is a much greater achievement than might be apparent: "I never believed it would work! But it's been a very important realization of where we are, where we should be, and what we need to do to get there."

Connecting the research community

The Institute chose to concentrate its financial resources in supporting a few key underfunded areas of high need, and its human resources in coordinating research funders to further the larger goal of improving cancer control in Canada. With every strategic choice comes an opportunity cost, and with ICR a drop in a funding ocean, the Institute has had limited activity in, and low impact on, the basic biomedical community who comprise the majority of Institute-affiliated investigators. This lack of visibility is an unfortunate, but unavoidable consequence of the Institute's wise decision to concentrate its resources where its small contributions could make a big difference. The Institute has recognized, however, that it would be timely to expand its communications with the research community, and this is a priority in its emerging strategic plan.

Delivering ICR's Initiatives and activities

Priority-setting and budgeting

Priority-setting process

Respondents found the Institute's priority-setting process to be appropriate and fair. While the Delphi exercise was considered unsuccessful, it was compensated for by other consultation activities, and the overall process and its resulting priorities were viewed as good and reasonable.

"I think the Institute hit way above its weight. Despite its small budget, the Institute was able to use its funds quite strategically to get things going."

The Institute undertook its consultations in collaboration with the other major cancer organizations, including the Canadian Strategy for Cancer Control (CSCC), the National Cancer Institute of Canada (NCIC), the Canadian Alliance of Provincial Cancer Agencies (CAPCA) and Health Canada. When it came time to order and shorten the preliminary list of priorities, the Institute's Board was expanded with key stakeholders and potential partners to make the final selection of six priorities (later expanded to eight, adding "Training" and "Access to Care").

The broadly composed Institute Advisory Board (IAB) was seen as unique and a great benefit to strategic planning: "one strength of such a diverse portfolio is that there are people at the table interested in all things." Respondents further noted that "the Board is well-chosen, consisting of high quality, impactful people, because that's how you get vision and strategic direction." The Institute drew effectively on its Board to expand its reach and capacity, and build relations with other stakeholders: "it has cross-representation on a whole lot of other organizations, which makes us well-connected." The Institute is more challenged now, however, to define the new role of a mature IAB (as opposed to a start-up IAB), which maintains this level of engagement and leadership, without the excitement of all that early unallocated funding to spend on new opportunities.

The Strategic Plan

Many respondents expressed their admiration for the Institute's choice of palliative and end-of-life care as its first initiative: by identifying such a non-traditional area as its top priority, the Institute clearly signalled that it was "business not as usual." In fact, several respondents identified the Institute's best achievement as "broadening the focus of cancer research out from the laboratory bench and into the rest of the pillars."

However, respondents generally agreed that the Institute – like almost all the CIHR Institutes in their inaugural strategic plans – had far too many priorities: "It seems to me we are doing an awful lot of little things. Each person around the table had a wish list, and we were trying to please all of them." Another concurs that "the IAB has so many responsibilities across so many pillars, it's all about giving a small piece to everyone, rather than a real strategy. The result is too small to have an impact." Furthermore, there is a high administrative cost associated with each Request for Applications but for most, "extremely low grant gain. It would make sense, if there were more grants funded as a result."

Another respondent warns that, with so many small, low-impact initiatives, "what gets funded looks like operating grants rather than strategic initiatives, and it adds fuel to the argument – especially for biomedical researchers – who see it as a waste of money." With such a large research community unaffected by the Institute's small investments, a number of respondents believed this Institute has a particular need to show its investments have real impact, and "prove that the money wasn't better spent on open competition operating grants."

Ultimately, the Institute must find its niche and focus its resources: "$8M for a national cancer agency isn't much. What is the Institute uniquely positioned to do, that no one else can?"

Budget-setting process

While supportive of the priority-setting process, a number of IAB members did express reservations about the subsequent processes to allocate the Institute's budget against those priorities: "The mechanism for getting things on the agenda for funding is primarily advocacy; I'm not entirely confident in this process." Another IAB member concurs, though noting: "What always happens is that there are a few strong voices that influence the decisions – but then these are the strong leaders in those areas who can get things done. This was more like a political thing: palliative care got something, so what can we give the clinical community, the lab scientists? It was not about strategic needs for cancer care, but more about the research communities. It's probably very difficult to avoid that kind of thing – I don't even know if it's good to avoid it."

The frequency with which this issue arose suggests, however, that the process of priority-setting for the Institute could be improved. As another IAB member noted "It would have been helpful if the Institute was given some guidance on this process. We're clinicians and scientists, not skilled managers. A framework, a how-to, would have been useful. I think unless CIHR does this, we're going to continue to see Institute strategic plans being highly sensitive to the interests of the people who are most vocal on the Boards." It would be timely for CIHR to collect experiences and best practices in Institute strategic planning, and share these across the Institutes. Undoubtedly all Institutes could benefit from learning from each other, and translating the experiences of those Institutes which seem to have found a more comfortable balance of structured process versus individual championing, leading to a greater sense of consensus and confidence in the results. An example would be the considerable guidance and advice that the NCE Secretariat provides to fledgling Networks of Centres of Excellence, which have annual budgets smaller than the CIHR Institutes.

Focusing the investment strategy

Despite concerns about spreading the Institute's resources too widely, what in the end distinguishes this Institute from many others is its decision to invest the bulk of its early resources into a single, high-impact initiative (Palliative and End-of-Life Care), rather than spreading it equally across all the priorities. While many are concerned that the Institute has not made itself well-known to its broader research community as a result, there is virtually unanimous agreement that with this approach, the Institute was able to have major impact, making an important and unique contribution to research in a critical area of health care.

As a result of this single large commitment, the Institute found that the funds remaining were insufficient to make a major impact on several of its other priorities, and some of these were ultimately not pursued in any substantial way beyond their first years. While this decision might be viewed as a failure by the Institute to achieve all its objectives, we would argue that the Institute was actually learning "on the job" to make more effective decisions about how to invest its funds in a concentrated fashion, where it could make a difference.

Unplanned changes to the investment strategy

There seems to be a tension between the IAB's strategic planning processes and ongoing responsiveness to the public agenda. Unlike other situations when a CIHR Institute has proactively embraced the opportunity to respond to a public need – such as the Institute of Infection and Immunity at the time of the SARS outbreak – there is a some unease at the IAB that its careful and considered planning can be put aside to make room for priorities imposed externally, such as wait times or biomarkers for imaging: "'Access to Care' just magically appeared on our list of priorities from one day to the next." There is concern about how these decisions are made, and how budget is allocated to these activities. There are important differences between SARS and these cancer-related issues, not the least being that SARS was a clear and present health emergency, while access to care may have been more of a political crisis.

Strategic initiatives and their achievements

This section contains summaries of the analyses of each of the Institute's research priorities. The full reviews are included in Annex A.

1. Palliative and End of Life Care

"Palliative and end-of-life care was one of the Institute's crowning achievements; to me, it's an indication of what can be done when you have passionate champions, collective will, and good people forging something larger – the collective, getting the bigger bang for the buck. I've held that example up here to show that you don't have to have a $40M project to make a real difference. You just need to show leadership, pick your areas."

With a discretionary budget for strategic initiatives equivalent to less than 2% of the total invested in cancer research in Canada, the Institute was challenged to find investments that could make a real difference for Canadians. However, much to the surprise of the research community, the Institute chose palliative and end-of-life care as its top priority and major area to fund. This area was seriously underfunded and under-capacity, and the funds brought together by the Institute and its many partners had an enormous effect on building capacity and spurring a major expansion of Canada's palliative and end-of-life care research efforts.

The Palliative and End-of-Life Care initiative has been reviewed in detail separately,²³ and was considered extremely successful by respondents interviewed during that analysis, a conclusion supported by database and bibliometric analysis. This current assessment of the Institute as a whole has confirmed, with a broader group of stakeholders, that the Palliative and End-of-Life Care initiative was not merely a success within itself, but is seen as the major achievement of the Institute since its inception. The Palliative and End-of-Life Care initiative is considered, in fact, to be a model for translational research investments for CIHR and other funders.

The Palliative and End-of-Life Care initiative demonstrates well what successful integrated KT can look like in action. However, as this initiative came to a close, it became clear that it had created a new community of researchers which CIHR is ill-equipped to support through its traditional approaches and programs. There is as yet, no comfortable home in CIHR to support either integrated teams or highly applied research whose goals are health improvement rather than academic achievement. As a result, the successes of this initiative are high, but so is the risk of losing the lasting benefits of this investment, as few mechanisms to support this kind of research exist outside the initiative which created it.

2. Molecular Profiling of Tumours

The Institute's Advisory Board recognized the necessity of establishing a national tumour bank network as an essential first step in supporting any initiative under this priority. In consequence, all its funding under this priority has gone to the Canadian Tumour Research Network (CTRNet), which has now been funded for five years and is currently under review for renewal.

Researchers involved with CTRNet believe it has been highly successful in creating standardized protocols, policies, quality control measures and an accreditation process, all now being used across Canada. They believe the quality of tumour banks is improving as a result of CTRNet. Other respondents, while agreeing that the Standard Operating Procedures (SOPs) developed by CTRNet are useful, seem to view these as a fairly limited return on a rather large investment, and feel that the "single window access" they anticipated is still missing. Some suggested that CTRNet, had it been more visionary, could have used the CIHR's starting investment as leverage to do much more.

The main challenge, however, seems to be that whether or not CTRNet achieves its goals, many stakeholders remain concerned that Canada has much larger needs. With the advent of the national cancer cohort, and hundreds of individual investigator's collections being created, the need for a national repository is growing, and is not being addressed. We note that the Institute has not advanced its involvement in this research priority beyond the establishment of CTRNet, which was intended at the time to be just a first step.

3. Clinical Trials

The "Non-Cytotoxic Cancer Clinical Trial Priority Announcement" seems little known and of limited impact according to respondents, or within the scientific literature.²⁴ While some respondents felt that some important trials were funded that wouldn't have been otherwise, others believed that these trials would have better been in the CIHR open competition.

On the other hand, respondents were very supportive of the one-time transfer of funds made to the NCIC Clinical Trials Group (CTG): while a single contribution could only have small overall impact, respondents believed that the investment helped the CTG successfully make an important transition. Many respondents strongly supported the view that the Institute should be making ongoing investments in building clinical trials infrastructure in general, and the CTG in particular.

4. Early Detection of Cancer

The few respondents aware of this initiative generally thought it was a well-intentioned idea but ultimately had limited impact. The timing did not seem to be right for the Institute to identify a niche area in early detection where it could have made a real difference: the initiative focused on colorectal screening, but three successive RFAs attracted less response than had been hoped. Nonetheless, the initiative likely contributed to Canada's small but growing capacity in colorectal screening research.

5. Risk Behaviour and Prevention

The Institute addressed this priority by investing through the Canadian Tobacco Control Research Initiative (CTCRI), a partnership which included several CIHR Institutes, Health Canada, the Canadian Cancer Society (CCS), and NCIC, who managed the CTCRI programs. Because the Institute invested through an external organization, this initiative has remained low-key, and is mostly unknown outside of the tobacco control research community. However, both partners and related research communities saw the Institute's contribution to, and championship of, this initiative as critical to its success.

The CTCRI has had significant impact: both respondents and the publication data support the view that Canada has become a world leader in the field of tobacco control research, and that the CTCRI was a critical component of that success. With the conclusion that CTCRI has successfully achieved its goals, the initiative has now been closed. While stakeholders believe the research capacity is now internationally competitive and well able to access other kinds of funding, some are nonetheless concerned that CIHR's funding mechanisms are not well able to review or support this kind of highly-applied and policy-oriented research, with its strong social science component.

6. Molecular and Functional Imaging

This initiative has been addressed through RFAs in 2003 and 2009, with a new approach being considered following a late 2009 workshop. The two RFAs provided limited funding for a short term, and their impact was commensurate. However, the Institute nonetheless found three of the originally-funded teams had commercialization achievements. A respondent noted that the new approach involves strategic planning with a broad community of stakeholders and researchers, and with adequate funding would be well-positioned to have the larger impacts its predecessor was unable to achieve.

7. Access to Quality Cancer Care

With the 2007 launch of seven New Emerging Teams (NETs), Access to Care became the Institute's second major investment, after palliative care. Many respondents pointed to the two initiatives collectively as models of how to run a good initiative, noting important components such as: identifying an area of high need where additional funds can make a real difference, working with well-coordinated partners, and taking a broad approach with a preliminary planning workshop to identify directions and needs.

We were able to attend an Institute-sponsored workshop for the funded teams in October 2009 at the mid-point of their funding, and have in-depth discussions with their members and leaders. Like investigators involved in NETs we have interviewed elsewhere, Access team members particularly value the novel insight that comes from the cross-pollination of ideas within NETs, and have found NETs fertile grounds for training and mentoring.

There is hope among respondents that the Access to Care teams will prove to be as pivotal to that research community as the Palliative and End-of-Life Care teams have been in theirs. However, while it is far too early to judge the ultimate success of the Access to Care teams, respondents have reservations about the likelihood that this initiative will achieve its full potential. There seem to be two major concerns: 1) having been told that there is no potential for renewal funding for a team, in open competition or otherwise, the teams seem to have emphasized short-term activities such as pilot projects, over long-term investments in building relationships, research capacity and infrastructure. 2) So far, there is limited involvement of decision-makers in the teams; the NETs are unsure how to address CIHR's KT expectations, and lack the support to do so.

CIHR has an opportunity to increase the impacts of its considerable investment in teams by bringing together its grantees' best practices and lessons learned in making teams work. Through training and mentoring, it could support developing teams and help them build effective relationships among the researchers and research users.

8. Research Training

In 2001 and 2002, CIHR and partners launched the Strategic Training Initiative in Health Research, to fund transdisciplinary, integrative health sciences research training programs known as STIHRs. The Institute's response to this opportunity is an excellent example of how it has gone about achieving its objectives. Having identified training as a priority, and the new STIHRs as an effective vehicle for capacity development, the Institute sought to maximize the impact of this program for cancer research by engaging a wide range of partners to collectively increase the funding for cancer STIHRs. CIHR was going to fund six cancer STIHRs; with the additional $13.3 million raised by the Institute, it funded 22 cancer STIHRs instead.

In other studies, we have consistently received positive feedback from a wide range of STIHR trainees, who compare their experience favourably with that of peers enrolled in more traditional programs. The cancer STIHRs are no exception. Trainees, investigators, and partners find they offer unique opportunities for hands-on training experience, coupled with focused courses addressing key curriculum gaps. STIHRs enhance collaboration and translational research among both trainees and their mentors.

Each STIHR provides a unique environment and opportunities: it would be worthwhile for CIHR to collate and make available the best practices and experiences of the many STIHRs, and clarify some of the expectations and ideals for effective performance. It would also be timely to perform a thorough analysis of the benefits and challenges of the various CIHR mechanisms for supporting trainees, to better understand the roles each play in meeting student and national training needs, and in contributing to the achievement of CIHR's training objectives.

Breast and prostate cancer initiatives

While not, strictly speaking, a priority of the Institute, ICR has managed CIHR contributions to two external partnered initiatives in support of breast and prostate cancer. The total investment in the Canadian Breast Cancer Research Alliance (CBCRA) by all funding partners was $178M between 1993 and 2007-08. The far more modest Canadian Prostate Cancer Research Initiative (CPCRI) ran for ten years, with total funding of around $10M from all partners.

As we have found with other initiatives, substantial long-term support in basic research consistently results in high-impact research output, and these two initiatives are no exception. CBCRA funding has resulted in the production of world-leading publications, stability in research output, and maintenance of Canada's strong competitive position in this field. CPCRI has had a much smaller but still marked impact, leading to significant increases in both number and quality of Canadian publications.

Canadian Partnership for Tomorrow Project (aka the CPAC cancer cohort)

Several respondents pointed to CPAC's newly-developed cancer cohort as a major Institute accomplishment. Although the cohort is not an Institute activity, respondents believed it would probably not exist – certainly not so soon or so large – without the active championship and backing of the founding Scientific Director of CIHR's Institute of Cancer Research.

The cohort itself elicited strong and contradictory views from respondents about its merits and impacts. A major common theme, however, was concern about the cohort's sustainability, and the impact this lack of a long-term funding plan is likely to have on CIHR. Another major issue is the lack of capacity – both in terms of enough skilled people, and also of adequate funds to support this kind of research – to use the data generated, and the need for funding opportunities linked to making use of the cohort findings.

Building partnerships

The Institute's strengths as partner and collaborator

Respondents reported excellent experiences working with the Institute, whether as a formal partner, or more generally as a collaborator in the cancer community. Its major assets are intangible, but no less critical for all that: the trust of its partners, and the strength of its people.

"The Institute recognized, and demonstrated, that collaborative funding can be synergistic and not just additive."

A key foundation for the Institute's relationships is trust: other organizations were confident that the Institute's motivation was to do what was best for cancer care and control. It was seen as "an honest-broker between those with fund-raising needs or a specific disease focus." As a result, the Institute was perceived as open to new ideas, and willing put its money into someone else's good idea if that seemed the most effective way of achieving collective goals. It never insisted on having the leadership or the limelight, and from the outset, the Institute invested significant resources in ensuring it had a strong and mutually beneficial relationship with NCIC and the Canadian Cancer Society. In consequence, though it built a lower profile for itself, the Institute was highly effective in supporting Canada's cancer control strategy: it gained respect and trust, and thus had the ability to bring people to the table, and keep them there, moving the agenda forward.

The Institute attracted and made good use of high quality human resources. Its IABs were strong and well-regarded, and effectively used to expand the Institute's expertise and capacity to interact well with other organizations. Its staff demonstrated a determination to make the Institute a good partner: respondents found them focused on identifying partners' needs and finding ways to address them, "coming to the table in solution-oriented mode"; "always looking for ways to do thing better by doing them together." Other adjectives used to describe Institute staff included: competent, collegial, cooperative, committed, credible, enthusiastic, flexible, knowledgeable, passionate, and responsive.

The Institute's challenges as partner and collaborator

Even the best partnership has its challenges, and respondents noted several key areas where collaboration with the Institute could be improved. With respect to the Institute's own functioning, partners spoke strongly for the need to be engaged earlier, when ideas are incubating and not when programs need funding: "We don't want to be asked at the last minute to pony up, instead of helping to create the initiative. That's not really a partnership, but basically just passing around a tin cup." Another partner concurs, noting: "Many times, we felt like we had been presented with something after the fact. We would have liked to have had some input into it at an earlier stage. Why present us with a fait accompli? Why didn't we hear about this sooner?"

Many stakeholders identified the Institute's small budget as its major weakness as a partner.

Another considerable concern for many partners, consistent with the experience of those associated with other Institutes, is that while the Institute itself was bending over backwards to be flexible and accommodating, "CIHR is a very large bureaucracy, with rules and regulations that definitely got in the way of making a good partnership." Furthermore, in the community that led the idea of national funding partnerships, the new Treasury Board rules that do not allow CIHR to transfer its funds to another organization seem like a return to the former MRC approach to partnering: "give me your money and don't bother me." Several partners are concerned that true value-added isn't always being achieved: "a lot of partnerships are really brokerages – the Institute is just funding what it was going to do anyways. There is little incremental, little real added-value – they've just slapped a partnership label on it."

Translating knowledge into health improvements

Major achievements

While the Institute has not launched any dedicated "KT programs," it has made several contributions to translating knowledge into health improvements, as noted throughout this document. The most significant of these has been the Palliative and End-of-Life Care initiative, which stands out as a model to all CIHR of what integrated KT can look like and achieve. The major KT achievements of that initiative are described in detail in a separate report.²³ If there is a KT lesson to be drawn from the Palliative and End-of-Life Care initiative, it's that effective KT comes from an integrated approach, not from one-off, separate, KT efforts. The Palliative and End-of-Life Care initiative was not created to be a "KT activity;" rather, it was an initiative whose goals could only be achieved through an integrated KT approach. Without deliberately trying to do so, the initiative attracted mixed teams of decision-makers and researchers who were working together to test and apply health care improvements in real time, thus spurring the beginnings of significant improvements in palliative and end-of-life care. The Access to Care teams also have considerable potential for effective KT, but may need some assistance to realize that opportunity.

As noted above, the teams funded in 2003 under the imaging initiative had some initial successes with knowledge transfer into the commercial sphere, including three resulting patent applications and two start-up companies.

The Institute's funding of the NCIC Clinical Trials Group also has important KT consequences, since the results from trials in which this Group is involved lead to the development and refinement of clinical guidelines, approval of new drugs, and systematic reviews.

The need for KT infrastructure

Both researchers and funders noted that there is a growing realization that "we need to do KT, but we don't know how, we don't have the infrastructure, and we don't know how to fund it well. We're still really focused on discovery research and recognizing individual heroes and stars." As the Access to Care and Palliative and End-of-Life Care initiatives make very clear, KT is about building long-term relationships, something not well-supported through standard operating grants. CIHR needs to provide both the funding mechanisms, and the training and support, which will allow funded researchers and knowledge users to contribute to CIHR's KT mandate.

A number of decision-makers also discussed the need to create "research pull" in the health care system: "Instead of believing we'll be rewarded for improvements and innovation, we are afraid to make any changes because they might affect our budget." There needs to be "cultural change so that people are rewarded for making things cost less – not losing their budget as a result. CIHR can't push the idea of innovation on a system that is not interested. There needs to be pull from the system. If the health care system decides it wants to reward improvements, and efficiencies, the need for CIHR would go up 100-fold." One route for the Institute to consider might be a dialogue with the Canadian Health Services Research Foundation, whose major objective is to increase the use of research evidence in decision-making in the health care system.

Conclusions and building blocks for the future

Key achievements: has the Institute made a difference?

The Institute's primary challenge was to identify how, in this well-established and well-funded research area, it could find itself an appropriate role. It needed to deal with two major issues: first, how could it add value to the already-busy cancer research scene without replicating capacity or activities that existed elsewhere? Second, how could it improve research outcomes with a discretionary budget so small relative to the overall scale of cancer research funding?

We asked key respondents to identify what, in their view, were the Institute's most successful or effective activities. Overwhelmingly, two key achievements were identified, which as it turns out, align nicely with the two aspects of the challenge it faced at its inception:

The creation of a coherent and coordinated funding community, ultimately resulting in the Canadian Cancer Research Alliance (CCRA) and its associated activities, including the Canadian Partnership for Tomorrow Project.
The strategic initiative in Palliative and End-of-Life Care.

These achievements were described in detail in the sections "Catalyzing the Canadian Cancer Research Alliance", and "Strategic initiatives and their achievements".

With just these two activities, it is certain that the CIHR Institute of Cancer Research has had a major impact on improving Canada's ability to fund the research it needs, and on enhancing the care of cancer patients. Also highly-rated, in terms of actual and potential impact, are the Institute investments in the Training Programs, the NCIC Clinical Trials group, the Canadian Tobacco Control Initiative, and Access to Care.

Best practices and lessons learned

Throughout this report, there are a number of recurring themes and issues raised by respondents and/or highlighted by the qualitative analysis, which suggest best practices and lessons which could be learned from the Institute's experiences.

Priority-setting

The most important thing about priorities, which are relatively easy to select in a boardroom, is to have no more of them than you can actually implement: human, financial, and partnership resources need to be focused to ensure the greatest possible impact. Initiatives which are too small, too short, or lack a responsive research community have limited viability and impact. ICR's greatest success came from concentrating major resources into a single key area, palliative and end-of-life care.

The IAB identified the need for more systematic and transparent structures to identify and allocate resources to priorities; we believe all the Institutes could benefit greatly from CIHR-wide guidance and sharing of best practices in priority-setting processes.

Partnering and collaborating

The Institute is lauded as a great partner, largely because of the attitudes and approaches of its staff, and its determination to use its "non-partisan" status effectively to focus collaborative efforts on the greater good. This approach allowed the Institute to have an impact way beyond what its limited funding power would predict.

Partners would, however, like to be engaged at the earliest possible stage of conceiving new strategies, and not be approached after-the-fact for funding contributions.

Delivering on priorities

The Access to Care and Palliative and End-of-Life Care initiatives are viewed as models for establishing effective initiatives which engage and nurture the key communities involved. Palliative and End-of-Life Care further provides CIHR with one of its best examples of effective integrated knowledge translation in action; the success factors and challenges of this initiative and others across CIHR need to be translated among Institutes to share the lessons learned, and apply them to future initiatives.

The Palliative and End-of-Life Care initiative also demonstrates that the biggest KT impact may come from integrated approaches to problem-solving rather than isolated "KT activities", an important consideration for future RFAs and team building. There is a great need for CIHR-wide guidance, training and best practices in building and maintenance of teams, as well as STIHRs.

Funding strategic research

The Institute has been challenged to fund new kinds of investments with old mechanisms. CIHR should evaluate the goals of many kinds of strategic investments, and identify the kinds of different funding approaches it may need. Many large investments would benefit from clearly-defined deliverables, with on-going interactions, monitoring and support to the funded teams. Other investments need different kinds of review mechanisms, commensurate with goals rooted in health system outcomes rather than academic achievements. Perhaps the forthcoming second international review of CIHR will provide this opportunity for reflection.