# Application of MODIFI to the adaptation of a complex, multilevel intervention to enhance access to high-quality cancer services in rural cancer hospitals

## TL;DR

Researchers adapted a cancer care intervention from Kentucky to Iowa using the MODIFI approach to improve access to cancer services in rural areas.

## Contribution

Application of the MODIFI framework to adapt a complex, multilevel cancer intervention across different contexts.

## Key findings

- MCCAN was adapted to Iowa as I-CAN, requiring changes to 11 core functions due to contextual differences.
- Contextual differences included referral patterns, resources, and unfamiliarity with the intervention process.
- Adapted forms evolved as affiliates gained experience and faced organizational changes.

## Abstract

The University of Kentucky Markey Cancer Center Affiliate Network (MCCAN) is a complex, multilevel evidence-based intervention (EBI) aimed at enhancing access to high-quality cancer services for under-served patients. MCCAN is promising but has not been scaled beyond its original context. We aimed to adapt MCCAN, originally developed in Kentucky, to address systematic differences that threatened its implementation and effectiveness in a new context, Iowa, yielding the Iowa Cancer Affiliate Network (I-CAN).

We report our adaptation of MCCAN using the Making Optimal Decisions for Intervention Flexibility during Implementation (MODIFI) approach: (1) identify key information about MCCAN, learning about Kentucky and Iowa contexts and users; (2) adapt MCCAN’s forms while leaving its core functions intact to produce I-CAN; and (3) evaluate I-CAN. Specifically, we conducted studies to identify MCCAN’s forms and core functions, gathered extensive knowledge of the original and new contexts, and identified systematic differences between the two. We created a matrix to map MCCAN’s core functions to its original forms, contextual differences between Kentucky and Iowa, and proposed adapted forms to produce I-CAN. We interviewed I-CAN affiliates to assess perceptions of acceptability, feasibility, and efficacy.

MCCAN forms were mapped to eight intervention and 10 implementation core functions. Adaptation was required for 11 core functions, as contextual differences impacted the ability of the original forms of those core functions to be carried out in the new context. Contextual differences reflected existing relationships and referral patterns, as well as available resources (e.g., personnel and infrastructure). Lack of familiarity with the intervention process and outcomes limited the ability of I-CAN affiliates to evaluate potential adapted forms. Forms evolved as I-CAN affiliates gained practical experience in applying them and/or experienced changes in organizational structure, personnel, etc.

We successfully adapted MCCAN, a complex, multilevel EBI designed to support community hospitals and enhance access to high-quality cancer services and programs in Kentucky to improve care for patients in Iowa affected by cancer—nearly half of whom reside in rural areas. Our application of MODIFI suggests several opportunities for refinement to advance successful EBI adaptation.

ClinicalTrials.gov, NCT05645328. Registered 01 December 2022, https://clinicaltrials.gov/study/NCT05645328

The online version contains supplementary material available at 10.1186/s43058-025-00805-x.