AGING WOMEN AND BREAST CANCER
Release Date: October 5, 1999
PA NUMBER: PA-00-001
National Institute on Aging
National Cancer Institute
National Institute of Nursing Research
THIS PA USES THE "MODULAR GRANT" AND "JUST-IN-TIME" CONCEPTS. IT INCLUDES
DETAILED MODIFICATIONS TO THE STANDARD APPLICATION INSTRUCTIONS THAT MUST BE
USED WHEN PREPARING APPLICATIONS IN RESPONSE TO THIS PA.
PURPOSE
This program announcement (PA) replaces PA-96-034, which was published in the
NIH Guide, Vol. 25, No. 12, April 19, 1996.
The National Institute on Aging (NIA), the National Cancer Institute (NCI),
and the National Institute of Nursing Research (NINR) invite research
applications to focus on the unique problems of older women with breast
cancer. Breast cancer affecting elderly women is a major health problem. The
purpose of this broad-based program announcement is to expand the knowledge
base on breast cancer in older women through studies in the fields of biology,
clinical medicine, epidemiology, and the behavioral and social sciences.
HEALTHY PEOPLE 2000
Each NIH PA addresses one or more of 22 Health Promotion and Disease
Prevention priority areas identified. These areas can be found via the WWW at
http://odphp.osophs.dhhs.gov/pubs/hp2000
ELIGIBILITY REQUIREMENTS
Applications may be submitted by foreign and domestic for-profit and non-
profit organizations, public and private, such as universities, colleges,
hospitals, laboratories, units of state and local governments, and eligible
agencies of the Federal government. Racial/ethnic minority individuals, women,
and persons with disabilities are encouraged to apply as principal
investigators.
MECHANISM OF SUPPORT
The mechanisms of support will be the individual research project grant (R01),
exploratory/developmental grant (R21), and the Small grant (R03).
Responsibility for planning, direction, and execution of the proposed project
will be solely that of the applicant.
For all competing individual research project grant (R01), small grant (R03)
and exploratory developmental grant (R21) applications requesting up to
$250,000 direct costs per year, specific application instructions have been
modified to reflect "MODULAR GRANT" and "JUST-IN-TIME" streamlining efforts
being examined by NIH. Complete and detailed instructions and information on
Modular Grant applications can be found at:
https://grants.nih.gov/grants/funding/modular/modular.htm. Applications that
request more than $250,000 in any year must use the standard PHS 398 (rev.
4/98) application instructions.
RESEARCH OBJECTIVES
Background
Of the 175,000 new breast cancer cases estimated for 1999, over 82,000 will be
in women 65 years or older (American Cancer Society, 1999). As national
incidence and mortality data show, aging is an important risk factor for
breast cancer. Age-adjusted rates reported by the National Cancer Institute
Surveillance, Epidemiology, and End Results (SEER) Program reveal that women
65 years or older have an incidence rate of 440.6 per 100,000 population as
compared to 74.5 per 100,000 for women under 65 years of age. The peak breast
cancer incidence rate of 483.3 per 100,000 is in the age group 75-79 years.
The breast cancer mortality rate for women under 65 years of age is 14.7 per
100,000 as compared to the rate for women 65 years and older which is 122.9
per 100,000. The peak mortality rate is 200.5 per 100,000 for women 85 years
and older (SEER, 1999).
This population-based epidemiologic evidence demonstrates the disproportionate
number of older-aged women afflicted with breast cancer. Yet, there is
insufficient information on biological mechanisms affecting the onset and
progression of cancer in older women, recommended treatment, response of older
women to cancer risks and symptoms, individual and family coping with breast
cancer, and survival outcome (including quality of life). The dearth of data
on these issues makes it difficult to provide answers to the many questions
that arise about breast cancer in older women.
The problems of breast cancer and its association with advanced age have not
been adequately addressed. Breast cancer prevention, early detection, and
management in older women may be complicated by the presence of other
diseases, age-associated problems, and risk factors. No comprehensive
guidelines for prevention, diagnosis, pretreatment evaluation, or treatment
have been formulated which take into account the multiple health problems and
recurrent medical, economic, and social needs of women age 65 and older who
survive breast cancer or are newly diagnosed with the disease. Although older
women are less likely to engage in cancer prevention practices such as
mammography screening, little research has promoted the development of
strategies to improve either patient or physician behavior to encourage
communication about cancer prevention. Sufficient data on the treatment of
elderly women with breast cancer are not available from clinical trials. With
the changing age and ethnic profiles in the United States which project an
expansion of the aged female population in coming decades, there is an even
greater need to address the problems of breast cancer control for older women.
The targeted areas of research relevant to this multidisciplinary solicitation
are identified below.
Biology --- Age-related factors in carcinogenesis. Applicants are encouraged
to focus on biological factors that contribute to the increased incidence of
breast cancer in older women and/or affect treatment outcome. The following
examples are illustrative, but not exclusive:
o The control of repair and cell death "programs," and how that relates to
cell senescence, aging and cancer (e.g., research on BPH, caloric restriction,
lymphocyte selection, cell loss),
o Any age-related biological factors that affect the initiation, promotion, or
treatment of cancer, including protein or gene therapy(e.g., research on
control of telomerase expression, oxidative damage, mitochondrial function),
o Age-related differences in invasion and metastases of breast cancer in older
women,
o Cell senescence in breast tissue, and age-related changes in gene expression
affecting predisposition to cell immortalization,
o Age-related differences in drug sensitivity and metabolism,
o Age-related changes in sensitivity to systemic and local hormones, growth
factors, and cytokines on breast cell proliferation and carcinogenesis,
o Age-related changes in secretion of hormones, growth factors, and cytokines
by breast tissue which act in a paracrine manner to alter the secretion of
growth-promoting factors from nearby adipose andstromal tissues.
o Age-related differences in stress, pain, and mood which contribute to the
functional impairment of neuroendocrine, neuroimmunology, and neurotransmitter
systems.
Clinical Medicine --- The full range of prevention and treatment issues that
involve screening, early detection, diagnosis, perioperative and/or
postoperative management, adverse physical influences on surgical outcome, and
influence of age on physician/surgeon treatment decisions for operative risk.
Research questions centering on these processes may be addressed individually
or combined. While related issues designated by the applicant will be
considered, the following topics are of major interest to the NIA, NCI, and
NINR:
o Testing new interventions or treatment strategies, in older women
especially, in the presence of patients" comorbid conditions to reduce age-
associated complications or lessen age-associated reduction in treatment
efficacy (as measured by treatment outcomes such as quality of life,
functional status, and/or survival experience),
o Age-associated and ethnicity-associated differences in breast cancer
treatment efficacy and effectiveness for such outcomes as survival rates,
treatment complications, side effects of treatment, and functional status,
o Factors responsible for differences in treatment received (e.g., stage at
diagnosis, presence of comorbid conditions, age selection bias by physicians)
and the effects of interactions among such factors,
o Special features of aging and/or symptoms of illness in old age that
influence the treatment and care of older-aged breast cancer patients and
relate to treatment differences or modifications made because of old age,
o Assessment of the effectiveness of different treatments relative to the
stage of disease and characteristics of old age (e.g., poor repair mechanisms,
functional loss, greater susceptibility to toxicity of treatment),
o Evaluation of tolerance and response to standard or experimental adjuvant
chemotherapy regimens or multimodality breast cancer treatment interventions,
controlling for physiologic parameters and other factors,
o Effects of age-associated, cultural, and life-style changes on sensitivity,
specificity, prognostic value, and predictive value for treatment
responsiveness, of breast cancer screening and diagnostic techniques (e.g.,
mammography, MRI, gross and histopathologic breast and lymph node biopsy
measures, receptor assays). Testing new methods and technologies to reduce
age-associated problems in diagnosis and prognosis,
o Barriers to recruitment of older women to breast cancer clinical trials
(e.g., comorbid conditions, physical frailty, lack of transportation).
o Studies designed to examine the impact of mental health interventions on the
treatment outcomes and treatment costs for comorbid breast cancer in older
women, with a focus on special populations (e.g., oldest-old, nursing home
populations, minorities, older women diagnosed with genetic markers),
o Exploration of the interaction of aging, the pharmacodynamics and
pharmacokinetics of medications (e.g., anti-estrogen therapeutics and other
types of chemotherapy) used to treat breast cancer, on mood and other measures
of mental status in older women.
Epidemiology --- Studies in the context of aging and/or old age that (1)
investigate risk factors in cancer etiology, (2) evaluate methods of
prevention, (3) elucidate the pattern of breast cancer as an illness for
patients, and (4) improve clinical effectiveness of the diagnostic and
management processes for older-aged women breast cancer patients. Studies may
focus on the etiology of breast cancer in combination with data from other
disciplines such as genetics and molecular epidemiology, or on issues in
epidemiology and clinical practice that represent pressing clinical problems.
o Relationships and interactions of aging and age to breast cancer risk (e.g.,
relative prominence of various physiologic and etiologic risk factors at
different ages, factors affecting risk and age of onset of breast cancer in
high-risk individuals),
o Improved methods to identify high risk older women through development of
new techniques to distinguish premalignant changes from nonmalignant age-
associated changes in breast tissue,
o Development of epidemiologic approaches addressing the possible role of
related changes such as hormonal status, both endogenous and exogenous
(exercise, education, nutrition, and immune function) as risk factors for
breast cancer in women,
o Prospective studies on the early detection, diagnosis, and treatment of aged
breast cancer patients,
o Analyses of existing databases applicable and relevant to addressing
treatment of older women breast cancer patients. Emphasis on older ethnic
populations is encouraged,
o Effects of previous and/or concurrent illnesses on breast cancer treatment
recommendations,
o Occurrence of second breast cancer primaries: synchronous (two or more
cancers present at the same time) and/or metachronous (first cancer followed
by a second tumor at a later date),
o Validation of new methodologies to identify high-risk older women,
o Molecular epidemiology and epidemiologic studies of age- related biological
factors that affect the onset, progression, metastatic behavior, and mortality
outcome of breast cancer in older women,
Behavioral and Social Sciences --- Special concerns include health behaviors
and beliefs about aging and breast cancer, interactions between health
professionals and older people, effects of breast cancer on psychosocial and
physical functioning, sociodemographic factors related to breast cancer
prevention in older women, long-term care for older women with breast cancer,
and the complex interactions among aging, breast cancer and psychosocial
disease, and gender influences.
Research is also needed on older people"s attitudes toward breast cancer and
aging, age differences in current cancer- related behaviors (e.g., willingness
to obtain or prescribe a mammogram), strategies for encouraging doctor-patient
interactions and treatment decisions, and the effects of living with cancer in
later life. Researchers are invited to make age comparisons and to look at
aging processes across the life course. Specific behavioral and social
research issues of interest are listed. Related issues will be considered.
o How age (e.g., aging processes or age-related attitudes or behaviors)
affects the diagnosis, treatment and care of persons with breast cancer,
o How age interacts with race, ethnicity, and socioeconomic status(SES) to
affect attitudes and behavior and consequent diagnosis, treatment, and care,
o Strategies for promoting behavioral change by older women and their health
care providers to increase preventive health behaviors, and how to implement
such changes on community-wide basis over long periods of time (e.g.,
institutional and financial incentives as in coverage for mammograms),
o Social and behavioral processes and interventions in symptom recognition of
breast cancer, as well as interpretation and action for cancer-related
symptoms in older women,
o Doctor/older patient interactions and their influence on breast cancer-
related behaviors. Strategies for improving cancer related communications,
adherence to medical and life-style recommendations, and encouraging
appropriate health utilization and functional outcomes,
o Behavioral and social factors affecting cancer treatment decisions (e.g.,
joint influence of age, SES, and race/ethnicity as well as patient
preferences, payer source, coverage),
o Self-management interventions for coping with breast cancer, such as
increasing self- efficacy regarding cancer treatment and employing pain
management strategies,
o Relationship of community and area level factors (e.g. location and
availability of preventive diagnosis and treatment services)independent of, or
in interaction with, sociodemographic and psychosocial characteristics of
older women that affect diagnosis, treatment, self-care, and family
caregiving,
o Consequences of cancer in older women for household arrangements and the
provision of resources by family and social network members,
o Strategies to reduce caregiver burden and how caregiving is influenced by
age, family and household structure and composition, and the economic and
social burdens caregiving imposes.
o Strategies that combine information sharing with psychosocial support to aid
patients/caregivers facing complex health related decisions.
o Clarification of the relationships and interactions of aging, biologic and
psychosocial factors which contribute to the comorbidity of breast cancer and
mental disorders in older women (e.g., late onset depression, early onset
depression with recurrent episodes, schizophrenia, etc.) and how these factors
contribute to the course, diagnosis and treatment of both illnesses.
Although not a formal sponsor of this PA, the National Institute on Mental
Health (NIMH) is interested in receiving applications if comorbid cancer and
mental disorders in women such as depression or anxiety are the focus of
study. Of particular interest are studies of risk, course, and outcome that
inform the development of new interventions aimed at mental disorders,
symptoms, or related disability. The interventions may be prevention,
treatment, or rehabilitation. For more information, see the NIMH program
announcement, PA-99-071, "Research on Co-Morbidity: Etiology and Prevention"
at http://www.nimh.nih.gov/grants/pamenu.htm. Please contact Peter Muehrer,
Ph.D., Health and Behavioral Sciences Research Branch, NIMH, at 301/443-4708,
Email: [email protected].
DEFINITION OF "OLD AGE" OR "ELDERLY" FOR THIS PROGRAM ANNOUNCEMENT
This PA focuses in particular on women aged 65 years and older because the
highest cancer incidence and mortality rates are found in this age group.
Also, women in their mid- seventies and older are generally those most
severely affected by breast cancer and are already quite likely to have
preexisting chronic conditions. However, the definition of "old age" or
"elderly" is flexible and dependent on investigator- defined parameters.
Applicants are expected to identify what is meant by "old" in the context of
their research. Age comparisons with younger women are appropriate and maybe
included.
INCLUSION OF WOMEN AND MINORITIES IN RESEARCH INVOLVING HUMAN SUBJECTS
It is the policy of the NIH that women and members of minority groups and
their sub-populations must be included in all NIH supported biomedical and
behavioral research projects involving human subjects, unless a clear and
compelling rationale and justification is provided that inclusion is
inappropriate with respect to the health of the subjects or the purpose of the
research. This policy results from the NIH Revitalization Act of 1993
(Section 492B of Public Law 103-43).
All investigators proposing research involving human subjects should read the
"NIH Guidelines For Inclusion of Women and Minorities as Subjects in Clinical
Research," which have been published in the Federal Register of March 28, 1994
(FR 59 14508-14513) and in the NIH Guide for Grants and Contracts, Volume 23,
Number 11, March 18, 1994,
https://grants.nih.gov/grants/guide/notice-files/not94-100.html
APPLICATION PROCEDURES
Applications are to be submitted on the grant application form PHS 398 (rev.
4/98). Application kits are available at most institutional offices of
sponsored research and may be obtained from the Division of Extramural
Outreach and Information Resources, National Institutes of Health, 6701
Rockledge Drive, MSC 7910, Bethesda, MD 20892-7910, Phone (301) 710-0267,
Email: [email protected]. Applications are also available on the internet
at https://grants.nih.gov/grants/funding/phs398/phs398.html
Submit a signed, typewritten, original of the application, including the
checklist and five signed photocopies in one package to:
CENTER FOR SCIENTIFIC REVIEW
NATIONAL INSTITUTES OF HEALTH
6701 ROCKLEDGE DRIVE, ROOM 1040, MSC 7710
BETHESDA, MD 20892-7710
BETHESDA, MD 20817 (for express/courier service)
SPECIFIC APPLICATION INSTRUCTIONS FOR MODULAR GRANTS
The modular grant concept establishes specific modules in which direct costs
may be requested as well as a maximum level for requested budgets. Only
limited budgetary information is required under this approach. The just-in-
time concept allows applicants to submit certain information only when there
is a possibility for an award. It is anticipated that these changes will
reduce the administrative burden for the applicants, reviewers and Institute
staff. The research grant application form PHS 398 (rev. 4/98) is to be used
in applying for these grants, with the modifications noted below.
BUDGET INSTRUCTIONS
Modular Grant applications will request direct costs in $25,000 modules, up to
a total direct cost request of $250,000 per year. (Applications that request
more than $250,000 direct costs in any year must follow the traditional PHS398
application instructions.) The total direct costs must be requested in
accordance with the program guidelines and the modifications made to the
standard PHS 398 application instructions described below:
PHS 398
o FACE PAGE: Items 7a and 7b should be completed, indicating Direct Costs
(in $25,000 increments up to a maximum of $250,000) and Total Costs [Modular
Total Direct plus Facilities and Administrative (F&A) costs] for the initial
budget period. Items 8a and 8b should be completed indicating the Direct and
Total Costs for the entire proposed period of support.
o DETAILED BUDGET FOR THE INITIAL BUDGET PERIOD - Do not complete Form Page 4
of the PHS 398. It is not required and will not be accepted with the
application.
o BUDGET FOR THE ENTIRE PROPOSED PERIOD OF SUPPORT - Do not complete the
categorical budget table on Form Page 5 of the PHS 398. It is not required
and will not be accepted with the application.
o NARRATIVE BUDGET JUSTIFICATION - Prepare a Modular Grant Budget Narrative
page. (See https://grants.nih.gov/grants/funding/modular/modular.htm for sample
pages.) At the top of the page, enter the total direct costs requested for
each year. This is not a Form page.
o Under Personnel, list key project personnel, including their names, percent
of effort, and roles on the project. No individual salary information should
be provided. However, the applicant should use the NIH appropriation language
salary cap and the NIH policy for graduate student compensation in developing
the budget request.
For Consortium/Contractual costs, provide an estimate of total costs (direct
plus facilities and administrative) for each year, each rounded to the nearest
$1,000. List the individuals/organizations with whom consortium or
contractual arrangements have been made, the percent effort of key personnel,
and the role on the project. Indicate whether the collaborating institution is
foreign or domestic. The total cost for a consortium/contractual arrangement
is included in the overall requested modular direct cost amount. Include the
Letter of Intent to establish a consortium.
Provide an additional narrative budget justification for any variation in the
number of modules requested.
o BIOGRAPHICAL SKETCH - The Biographical Sketch provides information used by
reviewers in the assessment of each individual"s qualifications for a specific
role in the proposed project, as well as to evaluate the overall
qualifications of the research team. A biographical sketch is required for
all key personnel, following the instructions below. No more than three pages
may be used for each person. A sample biographical sketch may be viewed at:
https://grants.nih.gov/grants/funding/modular/modular.htm.
- Complete the educational block at the top of the form page,
- List position(s) and any honors,
- Provide information, including overall goals and responsibilities, on
research projects ongoing or completed during the last three years,
- List selected peer-reviewed publications, with full citations.
o CHECKLIST - This page should be completed and submitted with the
application. If the F&A rate agreement has been established, indicate the
type of agreement and the date. All appropriate exclusions must be applied in
the calculation of the F&A costs for the initial budget period and all future
budget years.
o The applicant should provide the name and phone number of the individual to
contact concerning fiscal and administrative issues if additional information
is necessary following the initial review.
REVIEW CONSIDERATIONS
Applications will be assigned on the basis of established Public Health
Service referral guidelines. Applications that are complete will be evaluated
for scientific and technical merit by an appropriate peer review group
convened in accordance with NIH peer review procedures. As part of the initial
merit review, all applications will receive a written critique and undergo a
process in which only those applications deemed to have the highest scientific
merit, generally the top half of applications under review, will be discussed,
assigned a priority score, and receive a second level review by the
appropriate national advisory council or board.
Review Criteria
The goals of NIH-supported research are to advance our understanding of
biological systems, improve the control of disease, and enhance health. In
the written comments, reviewers will be asked to discuss the following aspects
of the application in order to judge the likelihood that the proposed research
will have a substantial impact on the pursuit of these goals. Each of these
criteria will be addressed and considered in assigning the overall score,
weighting them as appropriate for each application. Note that the application
does not need to be strong in all categories to be judged likely to have major
scientific impact and thus deserve a high priority score. For example, an
investigator may propose to carry out important work that by its nature is not
innovative but is essential to move a field forward.
o Significance: Does this study address an important problem? If the aims
of the application are achieved, how will scientific knowledge be advanced?
What will be the effect of these studies on the concepts or methods that drive
this field?
o Approach: Are the conceptual framework, design, methods, and analyses
adequately developed, well-integrated, and appropriate to the aims of the
project? Does the applicant acknowledge potential problem areas and consider
alternative tactics?
o Innovation: Does the project employ novel concepts, approaches or method?
Are the aims original and innovative? Does the project challenge existing
paradigms or develop new methodologies or technologies?
o Investigator: Is the investigator appropriately trained and well suited to
carry out this work? Is the work proposed appropriate to the experience level
of the principal investigator and other researchers (if any)?
o Environment: Does the scientific environment in which the work will be
done contribute to the probability of success? Do the proposed experiments
take advantage of unique features of the scientific environment or employ
useful collaborative arrangements? Is there evidence of institutional support?
In addition to the above criteria, in accordance with NIH policy, all
applications will also be reviewed with respect to the following:
o The adequacy of plans to include minorities and their subgroups as
appropriate for the scientific goals of the research. Plans for the
recruitment and retention of subjects will also be evaluated.
o The reasonableness of the proposed budget and duration in relation to the
proposed research.
o The adequacy of the proposed protection for humans, animals or the
environment, to the extent they may be adversely affected by the project
proposed in the application.
AWARD CRITERIA
Applications will compete for available funds with all other recommended
applications. The following will be considered in making funding decisions:
o Quality of the proposed project as determined by peer review
o Availability of funds
o Program priority
INQUIRIES
Inquiries are encouraged. The opportunity to clarify any issues or questions
from potential applicants is welcome.
Direct inquiries regarding programmatic issues to:
Rosemary Yancik, Ph.D.
Cancer Section, Geriatrics Program
National Institute on Aging
Gateway Building, Suite 3E327
7201 Wisconsin Avenue
Bethesda, MD 20892-9205
Telephone: (301) 496-5278
FAX: (301) 402-1784
Email: [email protected]
Claudette G. Varricchio, DSN, RN, OCN, FAAN
Division of Cancer Prevention and Control
National Cancer Institute
Executive Plaza North, Suite 300
Bethesda, MD 20892
Telephone: (301) 496-8541
FAX: (301) 496-8667
Email: [email protected]
Janice Phillips, Ph.D., R.N.
Program Director
National Institute of Nursing Research
Building 45, Room 3AN12
Bethesda, MD 20892-6300
Telephone: (301) 594-6152
FAX: (301) 480-8260
Email: Janice_Phillips@ nih.gov
Direct inquiries regarding fiscal matters to:
Mr. Joseph Ellis
Grants and Contracts Management Office
National Institute on Aging
Gateway Building, Suite 2N212
7201 Wisconsin Avenue, MSC 9205
Bethesda, MD 20892-9205
Telephone: (301) 496-1472
FAX: (301) 402-3672
Email: [email protected]
Mr. Robert E. Hawkins, Jr.
Grants Administration Branch
National Cancer Institute
Executive Plaza South, Room 243
Bethesda, MD 20892
Telephone: (301) 496-7800 Ext. 213
FAX: (301) 496-8601
Email: [email protected]
Mr. Jeff Carow
Grants Management Office
National Institute of Nursing Research
Building 45, Room 3AN-32
Bethesda, MD 20892-6301
Telephone: (301) 594-5974
FAX: (301) 480-8256
Email: [email protected]
AUTHORITY AND REGULATIONS
This program is described in the Catalog of Federal Domestic Assistance No.
93.866. Awards are made under authorization of the Public Health Service Act,
Title IV, Part A (Public Law 78-410), as amended by Public Law 99-158, 42 USC
241 and 285) and administered under PHS grants policies and Federal
Regulations 42 CFR 52 and 45 CFR Part 74. This program is not subject to the
intergovernmental review requirements of Executive Order 12372 or Health
Systems Agency review.
The PHS strongly encourages all grant and contract recipients to provide a
smoke-free workplace and promote the non-use of all tobacco products. In
addition, Public Law 103-227, the Pro-Children Act of 1994, prohibits smoking
in certain facilities (or in some cases, any portion of a facility) in which
regular or routine education, library, day care, health care or early
childhood development services are provided to children. This is consistent
with the PHS mission to protect and advance the physical and mental health of
the American people.