Advancing the science of integrating multiple interventions by blending and bundling

Abstract

Cancer prevention and control research has produced a variety of effective interventions over the years, though most are single disease focused. To meet the Cancer Moonshot goal to reduce the cancer death rate by 50% by 2047, it may be necessary to overcome the limitations of siloed interventions that do not meet people’s multiple needs and limitations in system capacity to deliver the increasing number of interventions in parallel. In this article, we propose integrating multiple evidence-based interventions as a potential solution. We define 2 types of integrated interventions, blended and bundled, and provide examples to illustrate each. We then offer a schematic and outline considerations for how to assemble blended or bundled interventions including looking at the intervention need or opportunity along the cancer continuum as well as co-occurring behaviors or motivations. We also discuss delivery workflow integration considerations including social-ecological level(s), context or setting, implementer, and intended beneficiary. Finally, in assembling integrated interventions, we encourage consideration of practice-based expertise and community and/or patient input. After assembly, we share thoughts related to implementation and evaluation of blended or bundled interventions. To conclude the article, we present multiple research opportunities in this space. With swift progress on these research directions, cancer prevention and control interventionists and implementation scientists can contribute to achieving the promise of the reignited Cancer Moonshot.

Since the passing of the National Cancer Act in 1971, funding for cancer prevention and control research has greatly expanded. In these past 50 years, numerous innovations have been developed and tested, resulting in clinical practice and public health guidelines across the cancer continuum, from prevention to survivorship. Since 2016, the Cancer Moonshot has renewed and accelerated the research community’s focus on scientific discovery and, in 2022, set a new goal to reduce the cancer death rate by half within 25 years and improve the lives of people with a history of cancer diagnosis (1). In our assessment of recently funded cancer prevention and control implementation research, the overwhelming majority is single disease, single intervention focused (2). In this article, we outline why the current approach may not be sufficient to achieve the Moonshot goal and propose integration of multiple evidence-based interventions as a potential solution.

Current limitations on implementation of cancer prevention and control interventions

Siloed interventions don’t meet multiple needs

One limitation on the potential positive impact of cancer prevention and control evidence-based interventions is the scientific enterprise responsible for developing and studying how best to implement evidence-based interventions. Structures and policies at the federal level lead to research and public health funding that is often siloed by risk factor or disease, particularly across the National Institutes of Health and Centers for Disease Control and Prevention (CDC), often resulting in single-focus research and public health programs. Yet, this research funding and program delivery model does not reflect the realities and needs of communities.

Our traditional development of interventions targeting one condition or behavior for one population at one time hinders our ability to achieve intended benefits. People are multifaceted and have multiple needs; they are more than the single behavior or health issue that a given evidence-based intervention targets. The movement toward whole-person care calls for “looking at the whole person—not just separate organs or body systems—and considering multiple factors that promote either health or disease. It means helping and empowering individuals, families, communities, and populations to improve their health in multiple interconnected biological, behavioral, social, and environmental areas” (3). Further, from a scientific perspective, studying things in combination could increase external generalizability because it would better mirror how public health services and complex clinical care is delivered in the real world.

Limited systems capacity for delivering increasing number of evidence-based interventions in parallel

Another limitation is that we have limited health care and public health systems capacity to implement and sustain the growing number of evidence-based interventions in parallel given the complexity of cancer prevention and control. This is particularly acute in primary care and safety net clinical settings as well as in public health departments in communities with limited resources (4-6). The individual siloed evidence-based intervention approach may have limited positive impacts for communities experiencing disparities in cancer incidence or mortality as well as comorbid chronic disease if multiple health concerns are not considered together. One lesson from the COVID-19 pandemic is that community-engaged, whole-person, and family-oriented approaches to outreach and delivery of multiple clinical evidence-based interventions were efficient and effective (7,8).

The limited system capacity for cancer prevention and control is urgent to address given the aging US population, persistent health disparities, and increasing cancer incidence globally, particularly in low- and middle-income countries. Limited capacity has been defined in terms of workforce shortages, staff burnout, and technology shortcomings and manifests in brief clinical encounters, limited clinician awareness and familiarity with new guidelines or innovations (9,10), and limited sustained funding for public health programming in community settings (11). Individual programs developed in the context of a clinical trial are often not feasible to implement with fidelity in routine practice. Implementing the growing number of evidence-based interventions then, in a parallel or siloed approach, might be impossible. For example, a limited workforce means fewer opportunities to train a limited number of implementers on each new evidence-based intervention because they are busy delivering other services. Notably, as part of their Global Strategy to Accelerate the Elimination of Cervical Cancer as a Public Health Problem, the World Health Organization promotes integrating HIV and cervical cancer prevention, screening, and treatment to “increase efficiencies and maximize impact” (12). This builds on the Political Declaration on HIV and AIDS, adopted by the United Nations General Assembly in 2016, that emphasized the need for integration of services to address co-infections and comorbidities, including substance use, mental health, viral hepatitis, and human papillomavirus (13).

Considering integration of evidence-based interventions to optimize cancer prevention and control

Integration of evidence-based interventions may address the limitations presented by siloed interventions and limited system capacity. Integrating evidence-based interventions breaks down disease silos, getting closer to a whole-person care approach and increasing relevance to real-world contexts, possibly resulting in increased adoption and sustainability. Evidence-based interventions could be integrated such that they are an efficient and cost-effective use of time and resources, addressing the limited system capacity to deliver evidence-based interventions in parallel. Next, we define what we mean by evidence-based interventions and then propose a typology of integrated interventions with initial definitions and examples to spur discussion and debate and hopefully help the field coalesce around research and practice opportunities.

Defining evidence-based interventions and their integration

The National Cancer Institute defines implementation science as “the study of methods to promote the adoption and integration of evidence-based practices, interventions, and policies into routine health care and public health settings to improve our impact on population health” (14). Despite having related goals, the fields of implementation science and public health have evolved terminology that warrants distinction and clarification.

In public health, the terms intervention and program are widely used and often interchangeable. For the purposes of this article, we will use the term evidence-based intervention to refer to “the thing being implemented” (15), whether it be a clinical practice guideline, general or specific intervention, program, or policy (16). Evidence-based interventions are evidence based when efficacy or effectiveness research has shown that they produce intended behavior or health outcomes. Implementation research is the study of how implementation strategies (17,18) can help people or places using an evidence-based intervention.

Many evidence-based interventions are multicomponent, meaning they combine 2 or more programmatic elements or strategies that may increase demand, increase access, and/or increase health-promoting behaviors or delivery of a clinical or public health service (19). Typically, the multiple components differ on how they are delivered (eg, child or school and parent or home components) but focus on a single behavior or health topic (eg, childhood obesity). Multilevel evidence-based interventions often focus on improving a single health topic or behavior by employing programmatic elements or strategies that intervene at 2 or more levels of a social-ecological model (eg, biological, psychological, behavioral, interpersonal, organizational, community, or environmental) (20). Not all multicomponent evidence-based interventions are multilevel, but multilevel evidence-based interventions are typically multicomponent.

Increasingly, we are seeing examples of integration of multiple evidence-based interventions to address multiple health or disease outcomes. That is the focus of this article—how public health professionals and researchers, particularly interventionists and implementation scientists, can generate evidence to support decision making about how to best integrate and deliver multiple evidence-based interventions. We approach this question first from a cancer lens, given the numerous evidence-based interventions available, but we recognize that there are evidence-based interventions that are not cancer specific that may make sense to combine with cancer-focused evidence-based interventions in a way that is mutually beneficial.

Characterizing a typology of integrated interventions

Below we present 2 primary pathways toward evidence-based intervention integration: blending and bundling. Each path may have different benefits, challenges, and decision points. Conceptual distinction among the different approaches for combining multiple evidence-based interventions is important because consistency in language helps the field advance in studying related processes and outcomes. Table 1 provides a summary.

Table 1.

Definitions and examples of blended and bundled interventions^a

Integrated intervention type	Definition	Examples (outcomes)
Blended intervention	Components from 2 or more evidence-based interventions focused on at least 2 behaviors or health topics that have been harmonized into a holistic intervention and are no longer distinguishable as separate. The blended intervention aims to have enhanced implementation, client, service, behavioral, or health outcomes compared with delivery of the original evidence-based interventions separately. Components of a blended intervention are delivered in the same manner.	Tobacco cessation counseling plus lung cancer screening shared decision making (smoking behavior, lung cancer screening uptake, lung cancer mortality) (25)
		Smoke Free SafeCare (secondhand smoke exposure plus child maltreatment prevention) (28)
		Collaborative care for management of multiple cancer symptoms (sleep disturbance, pain, anxiety, depression, and energy deficit or fatigue) (29)
Bundled intervention	An approach to deliver multiple distinct behavior change and/or clinical evidence-based interventions, simultaneously or intentionally sequenced over time, to address multiple health or disease outcomes. Evidence-based interventions are bundled with the aim of improving implementation, client, or service outcomes and/or enhancing positive behavioral or health outcomes for multiple cancer types or other health concerns compared with delivery of the original evidence-based interventions separately.	Wellness care bundles: Welcome to Medicare initial preventive physical examination; Medicare’s Annual Well Visit coverage (30, 55); Kaiser Permanente annual adult well-care visit (31)
		Multiple cancer screening bundles (cancer screening uptake and early detection of multiple cancer types) (34-40, 52)
		Take CARE (Clinical Avenues to Reach Health Equity) cervical cancer prevention bundle (tobacco cessation, HPV vaccination, Pap test or HPV self-test) (41)
		Survivorship shared care models (health-related quality of life; patient experience; dietary, physical activity, and sedentary behaviors; financial toxicity; adherence to cancer therapies, future cancer screenings; and adverse events) (45, 46)

^aHPV = human papillomavirus; Pap = Papanicolaou smear test.

Blended intervention

We propose that a blended intervention comprises components from 2 or more evidence-based interventions focused on at least 2 behaviors or health topics that have been harmonized into a holistic intervention and are no longer distinguishable as separate. The blended intervention aims to have enhanced implementation, client, service, behavioral, or health outcomes (21) compared with delivery of the original evidence-based interventions separately. Unlike multicomponent interventions, components of a blended intervention are delivered in the same way (eg, by a community health worker in churches). Some have used the term blended intervention to refer to delivery through multiple modes (eg, in-clinic or in-person plus online or virtual or e-health) (22,23), though we refer to such interventions as hybrid or multimodal.

An example of a blended intervention is the provision of tobacco cessation counseling or other support (evidence-based intervention 1) during a lung cancer screening shared decision-making visit (evidence-based intervention 2) with the goal of reducing smoking behavior and associated lung cancer risk and improving adherence to lung cancer screening guidelines (3 behavioral or health outcomes). The blending is in the delivery of both evidence-based interventions within a single episode of care, and from the perspective of the patient, disentangling the evidence-based interventions would be challenging given both evidence-based interventions are related to the long-term outcome of reducing lung cancer mortality. Indeed, evidence suggests that sustained tobacco cessation makes lung cancer screening more effective in terms of reduced mortality (24). Although this integration is required by the Centers for Medicare and Medicaid Services for reimbursement (25), one study looked at whether imaging facilities were using evidence-based interventions in their delivery and found that the least effective evidence-based interventions (eg, educational pamphlet) were the most commonly implemented compared with the most effective (eg, comprehensive behavioral therapy with tobacco treatment specialists and pharmacotherapy), which were least commonly offered (26). Work is underway to identify effective tailoring of smoking cessation to the context of lung cancer screening to support enhanced effectiveness and implementation (27).

In another example, researchers at Georgia State University are conducting a clinical trial of a blended intervention for the prevention of secondhand smoke exposure and child maltreatment (28). They are blending components of 2 evidence-based interventions: Some Things are Better Outside, which is effective in promoting adoption of smoke free home rules; and SafeCare, which is effective in promoting positive parenting, home safety, and child health. The resulting blended intervention, Smoke Free SafeCare, is being evaluated in an effectiveness-implementation hybrid trial.

The term blended has been used by some in health services to mean addressing physical and mental or emotional needs simultaneously. Another example of a blended intervention is assessing, triaging, and treating multiple common cancer symptoms, which are often interrelated, through multimodal evidence-based interventions including psychosocial or behavioral, pharmacological, and rehabilitative. Investigators at the Mayo Clinic have designed a pragmatic clinical trial to evaluate the effectiveness and implementation of an electronic health record–supported collaborative care symptom monitoring and treatment approach that holistically addresses sleep disturbance, pain, anxiety, depression, and energy deficit or fatigue (29).

Bundled intervention

We propose that a bundled intervention constitutes an approach to deliver multiple distinct behavior change and/or clinical evidence-based interventions, simultaneously or intentionally sequenced over time, to address multiple health or disease outcomes. Evidence-based interventions are bundled with the aim of improving implementation, client, or service outcomes (eg, reducing clinic and patient burden and loss to follow-up) and/or enhancing positive behavioral or health outcomes for multiple cancer types or other health concerns compared with delivery of the original evidence-based interventions separately.

Related to the whole-person approach to health care, there are several good examples of bundled preventive care interventions. For example, the Welcome to Medicare and Annual Wellness visits focus on health promotion and preventive care and include review of an extensive health risk assessment of medical and social health history, eligibility, and counseling about multiple services including vaccinations for influenza and pneumonia, blood pressure and body mass index measurements, vision testing, mental health screening, and potentially some screenings during that visit as well as a written plan outlining additional screenings, shots, and preventive services needed (30). Similarly, the integrated health system, Kaiser Permanente, offers an annual adult well-care visit to members, with a reminder timed to their birthday, to provide similar health promotion and preventive care services aligned with clinical practice and national guidelines by age and sex (31).

Specific to cancer prevention and control, some have proposed the concept of one-stop-shop, cross-cancer, and integrated approaches to multiple cancer prevention and screenings (32-34). For example, a community-wide bundled evidence-based intervention designed to promote cancer screening among African American adults, the Targeting Cancer in Blacks intervention, increased mammography screenings, fecal occult blood tests, proctoscopy exams, digital rectal exams, and Pap tests (35-37). On a national level, participants in the CDC-funded Colorectal Cancer Control Program (CRCCP) Learning Collaborative implemented multilevel bundled interventions for colorectal, breast, and cervical screenings (38). Recent results from a clinical trial of an individualized 3-in-1 approach to cancer screening found that tailored messaging or tailored messaging plus a patient navigator increased the percentage of rural women who were up to date with breast, cervical, and colorectal cancer screenings (39,40). Researchers at the Ohio State University Comprehensive Cancer Center are currently conducting community-based participatory research in 10 health systems across 4 states to study a cervical cancer prevention bundle called Take CARE (Clinical Avenues to Reach Health Equity) with an equity focus on reducing cervical cancer disparities in rural Appalachia (41). This multilevel bundled intervention includes 3 complementary evidence-based interventions: Break Free (tobacco cessation), I Vaccinate (human papillomavirus [HPV] vaccination), and Papanicolaou or HPV self-testing through the “HOME Initiative” (42-44).

Another cancer-specific example of a bundled intervention is the delivery of survivorship services through shared care models. Researchers in the Netherlands (45) and Australia (46) have developed and are evaluating shared care models where cancer specialists and general practitioners have distinct responsibilities to deliver coordinated care services at various intervals, as well as to interact with each other in support of addressing patients’ needs and self-management. Guided by a comprehensive survivor care plan, evidence-based interventions delivered include clinical services and counseling to address multiple outcomes, tailored for each patient’s needs: adherence to cancer therapies and future cancer screenings; management of long-term and late effects of cancer and its treatment; health-related quality of life; patient experience; dietary, physical activity, and sedentary behaviors; and financial toxicity.

Advancing equitable dissemination and implementation of integrated cancer prevention and control evidence-based interventions

Although there are some examples of blended and bundled cancer prevention and control interventions, opportunities remain to advance how we think about developing optimal integrated interventions and ensuring their equitable dissemination and implementation.

Assembling blended or bundled interventions

Given the distinctions proposed between blended and bundled interventions, and the growing number of available evidence-based interventions across the cancer continuum, researchers and implementers must consider how to select evidence-based interventions for integration. In a bundled intervention, the full evidence-based interventions for different disease categories would be delivered together, and a blended intervention would take components of different evidence-based interventions and combine them into a new intervention. Figure 1 illustrates one way of thinking about this. The funnel represents the universe of available evidence-based interventions, including evidence-based interventions across the cancer continuum as well as evidence-based interventions for the prevention and management of other common chronic and infectious conditions of relevance to public health. Admittedly, it is not possible to be comprehensive in including all possible evidence-based interventions, but the general idea is that there is a universe of evidence-based interventions from which to select. To choose which evidence-based interventions to use and whether to blend or bundle, it may be helpful to think through related intervention needs and opportunities as well as delivery workflow integration and gather input from community members and partners.

Figure 1.

Schematic for designing blended or bundled interventions. CT = computed tomography scan; EBI = evidence-based intervention; FIT or FOBT = fecal immunochemical test or fecal occult blood test; Hep B, Hep C = viral hepatitis B, C; HPV = human papillomavirus; Pap = Papanicolaou smear test; STI = sexually transmitted infection.

Intervention need or opportunity

Consider position on the cancer continuum. Integrating multiple prevention and/or early detection evidence-based interventions likely makes sense. Further, it might make sense to combine prevention and health promotion–focused interventions targeting other conditions with cancer prevention–focused interventions. However, it could also make sense to integrate a health promotion intervention (eg, nutrition or physical activity) with a cancer treatment or survivorship evidence-based intervention if the integration of said interventions is expected to cause improved behavioral or health outcomes.

Consider patterns of co-occurring behaviors or motivations. For example, integrating nutrition with physical activity evidence-based interventions, or alcohol with tobacco prevention or cessation evidence-based interventions, is common in public health because those health risk behaviors or positive health-promoting motivations and behaviors often correlate and reinforce each other. Similarly, if a patient is motivated or open to receive a specific vaccination or screening, it could make sense to offer multiple vaccinations or screenings. However, this may not always be acceptable to patients and should be further explored as to when it is best applied. For example, bundling multiple vaccinations has mixed evidence in pediatrics where some evidence shows increased uptake when the meningococcal conjugate, tetanus diphtheria and acellular pertussis, and HPV vaccines are announced together (47,48), and others report parental and patient resistance when multiple shots are offered (49). The CRCCP Learning Collaborative also found that not all patients are open to discussing screening for multiple cancers at once, therefore it should not be an expectation even if a patient may be due for multiple tests (38).

Delivery workflow integration

Consider which social-ecological level(s), context or setting, and implementer the evidence-based intervention was developed for. Selecting evidence-based interventions that are intended to be delivered in the same setting (eg, clinic, school, home), by the same implementer (eg, community health worker, primary care provider, online health coach), and at the same social-ecological level (eg, policy, community, organizational, interpersonal, individual) would likely make integration easier. Evidence-based interventions addressing or influenced by shared social or structural determinants might also make sense to integrate to advance equity. Of note, it is possible to design multilevel integrated interventions with evidence-based interventions and/or implementation strategies targeted at more than one social-ecological level.

Consider the intended beneficiary of an evidence-based intervention. Blending or bundling evidence-based interventions designed for a particular population based on age or risk profile would make sense. Alternatively, a bundled intervention might leverage an evidence-based intervention delivered for one beneficiary in one setting (eg, infant at pediatrician for well child visit) to reach another intended beneficiary (eg, maternal postpartum depression screening). Another example is the effective bundling of parental tobacco cessation within the context of pediatric health care, especially when the parent may find enhanced motivation to reduce the medically at-risk child’s secondhand smoke exposure (eg, primary care pediatrics or oncology treatment) (50,51). Related to whole-person care, bundled interventions could be designed as a whole family or generational approach, ensuring that all members receive appropriate preventive care and health promotion services.

Community and/or patient and partner engagement

Consider practice-based expertise and community and/or patient input to inform intervention needs/opportunities and delivery workflow integration and determine what is best blended or bundled. Some evidence-based interventions may fit together more naturally than others. For example, evidence-based interventions that incorporate similar components (eg, counseling or peer mentoring) and their delivery are supported through common implementation strategies (eg, increasing demand or using incentives) may make sense to blend into a holistic intervention. Mammography, Pap smear, and colonoscopy cannot be delivered simultaneously because they are provided by different clinical specialists and require different equipment, but bundling stool-based colorectal cancer tests with mammography appears feasible and effective (52). Bundled dissemination of age- and risk-appropriate screening recommendations across cancer types through patient reminder–recall or navigation to appointment scheduling could also be acceptable. Therefore, community and partner engagement with intended evidence-based intervention implementers and beneficiaries is critical in designing integrated interventions and implementation plans to ensure relevance, acceptability, feasibility, and adoption.

Implementing blended or bundled interventions

Once an integrated intervention is assembled, several questions about implications for dissemination and implementation emerge. As with any implementation effort, commitment from leaders and middle managers and a climate supportive of integration will likely be important. Resources, including funding, staffing, and technology to facilitate implementation, will also likely be critical.

There are administrative and cost considerations unique to integration. Attention to pacing and sequencing of the integrated evidence-based interventions will inform when components or services are best delivered, in what order, and at what time points. If evidence-based interventions designed for different implementers are integrated, the new intervention may have workflow and workforce implications like renegotiating who delivers what, when, and where. With bundled interventions, there may be questions around who is responsible for billing and coordination of services and ongoing management if multiple providers are involved in implementation. A blended or bundled intervention may require rethinking of strategies to support implementation. Some strategies may be beneficial to retain if they can support implementation of the newly integrated intervention, whereas other strategies may be superfluous or overly burdensome or costly.

Theoretically, there may be cost efficiencies for health systems and/or providers and patients if technology systems, time, and staffing can be leveraged for multiple service delivery. Cost savings might also be realized through a generational approach that includes multiple family members in integrated cancer prevention and control evidence-based interventions. However, cost savings have not been consistently found in integrated delivery systems (53) so research is needed on economic implications of integrating evidence-based interventions. Several of CDC’s CRCCP grantees found that although integrated approaches “can be efficient, there were challenges caused by differing eligibility for screenings by age, [sex], frequency, and location of services” (38). Among their lessons learned was that integration of multilevel, multicomponent interventions to promote multiple cancer screenings had benefits but that higher intervention complexity and cost were negatively related to implementation success (54).

Evaluating blended or bundled interventions

Once assembled, integrated evidence-based interventions should plan to evaluate integrated outcomes rather than measuring or reporting only in isolation. Assessments associated with the individual evidence-based interventions may vary in mode of data collection, timing, length, and so forth so thought must be given to integration and alignment of assessments, both for service eligibility and for outcomes. The CRCCP Learning Collaborative’s conceptual model for integrated delivery of colorectal, breast, and cervical cancer screenings highlights that evaluation should jointly assess the facilitators and barriers to integrated implementation, implementation outcomes, screening outcomes, and economic outcomes to fully understand the independent and combined effects of the evidence-based interventions (54). Subramanian et al. (54) highlight challenges related to assessing processes and outcomes, specifically related to estimating resource use and assigning costs separately to each evidence-based intervention and outcome, which may make joint estimates of impact most feasible.

In one example evaluation, Champion et al. (52) found that bundling mammography and colorectal screenings improved adherence rates compared with usual (siloed) care; women who were adherent to mammography had a 4.5 times greater odds of being adherent to colonoscopy. In contrast, Ng, Jensen, and Fritz (55) found that the addition of the initial preventive physical examination coverage benefit in 2005 was insufficient to increase use of preventive services among new Medicaid beneficiaries, suggesting a need for implementation research to determine effective strategies for increasing uptake of bundled interventions by providers and patients.

Research opportunities

Research on integrated interventions to date has been limited, particularly in implementation science where the focus has largely been on studying implementation barriers and facilitators and testing implementation strategies for individual evidence-based interventions (2). Subramaniam et al. (54) also noted limited research in this space and outlined 8 specific research priorities related to integrated cancer screening interventions. Adding to their recommendations, we propose additional opportunities that could advance implementation of integrated cancer prevention and control interventions. Table 2, which is mapped to the areas specified in the prior section, lists some research directions specific to blended or bundled interventions. Table 2 also lists various opportunities related to implementation and evaluation of outcomes that are common to blended or bundled interventions. Generally, research is needed to explore the benefits and drawbacks of blended or bundled approaches. Pragmatic clinical trials and practice-based public health research that include community or partner engagement may be helpful for rigorously studying integrated interventions in real-world contexts.

Table 2.

Potential research directions related to integrated interventions

Research area	Research opportunity
Assembling blended interventions	Hybrid type 1 or 2 (56) effectiveness-implementation studies of blended interventions
	Stepped wedge or factorial studies [eg, Multiphase Optimization Strategy plus Sequential Multiple Assignment Randomized Trial design (57-59)] to optimize which components to blend and assess how and whether components remain active after integration
Assembling bundled interventions	Hybrid type 3 (56) effectiveness-implementation studies of bundled interventions
	Stepped wedge or factorial trials to optimize pacing and sequencing of evidence-based interventions and determine which implementation strategies best support bundled delivery
Implementing blended or bundled interventions	Studies that assess contextual factors and determinants that enable or limit readiness for and successful implementation of integrated interventions (54,60)
	Studies that explore preferences and attitudes about integrated interventions from implementer and evidence-based intervention beneficiary perspectives
	Experimental or quasi-experimental studies that test strategies tailored for implementation of blended or bundled evidence-based intervention delivery
	Studies that assess blended or bundled evidence-based interventions as a strategy to advance equitable implementation and health equity
	Studies that assess blended or bundled evidence-based interventions as a strategy for scale-up and sustainability
Assessing integrated outcomes	Studies on the economic impacts of blended or bundled evidence-based interventions for patients, providers, and systems
	Studies that evaluate how blending or bundling may improve implementation, service, and client outcomes (21) compared with nonintegrated evidence-based intervention delivery
	Studies that evaluate behavior and health outcomes with an integrated approach, including exploring interaction effects across evidence-based interventions
	Measure development studies and studies that apply mixed methods to innovate techniques for data capture and tracking to assess combined and disentangle individual effects from the integrated evidence-based interventions

In this article, we posit that siloed, single-focus interventions and limited system capacity to deliver the increasing number of evidence-based interventions are major limitations to advancing cancer prevention and control. To address these limitations, we propose integrating multiple evidence-based interventions through blending or bundling, providing distinct definitions and examples. We offer a schematic to support thinking about how to craft integrated interventions and provide considerations related to implementation and evaluation of integrated evidence-based interventions. With swift progress on the research directions we outline, cancer prevention and control interventionists and implementation scientists can contribute to achieving the promise of the reignited Cancer Moonshot.

Data availability

No data were generated or analyzed for this commentary.

Author contributions

Aubrey Villalobos, DrPH, MPH, MEd (Conceptualization; Visualization; Writing—original draft; Writing—review & editing) and David Chambers, DPhil (Conceptualization; Supervision; Writing—review & editing).

Funding

Not applicable.

Conflicts of interest

The authors have no conflicts of interest to report.