OPENING REMARKS Dr. BRODER. Sir, with your permission, I would read a very brief statement. I would like to thank the distinguished chairman and distinguished members of the committee for the opportunity of being here. Our best response to the challenge of cancer, a disease which causes suffering and death beyond metaphor, must lie in an intense effort to generate knowledge and to apply it quickly. In doing so, we rely on the three foundation stones of the National Cancer Institute, which are, one, basic research; two, clinical trials in prevention and therapy; and three, the cancer centers. The NCI is committed to extend the results of its research to all Americans regardless of their race, age, income, social status, or place of residence. Again, this year, NCI cancer statistics show good news and bad news. The bad news is that minority groups, the poor, the underserved and those over 65 have disproportionately high rates of cancer, and consequently, these groups are targeted for our priority attention. The good news is that for white Americans under age 65, death rates have clearly declined in certain common cancers. Thus, while we have made progress, more progress is needed. Science underlies every aspect of the NCI program, and this year, among other scientific achievements, two NCI scientists, together with a colleague from the National Heart, Lung, and Blood Institute, made medical history by inserting new genetic material into human cells, and putting said cells back into a patient's body. These experiments presage future therapies, and are the legacy of prior NCI basic research on natural body mechanisms for fighting cancer. Recently, NCI-supported scientists have made a number of important genetic discoveries, including the location of molecular abnormalities, which contribute to the development of lung cancer, colon cancer, breast cancer, and prostate cancer. In addition, NCI-sponsored research has developed the location of the gene for familial malignant melanoma, and has identified specific genes implicated in the metastatic process, the process by which cancer cells spread widely. There is major progress in practical cancer treatment. Clinical trials have shown that in some cancers, what are called adjuvant treatments, that is, chemotherapy after surgery, can eliminate remaining microscopic tumors. Last year, an adjuvant treatment for one stage of colon cancer was shown to make an improvement of approximately one-third in the death rate of that particular disease. Prevention trials are also a very high priority. For example, NCI is studying interventions for individuals already at high risk of cancer. And one study is testing the effect of beta-carotene and retinol, substances which might be used for the treatment of asbestos workers who are at high risk for lung cancer. A recent NCI prevention study showed that a high wheat fiber supplement decreased the number of large bowel polyps, which are precursors to cancer of the large bowel. And of course, we are continuing programs to reduce smoking. The NCI cannot do its job from an ivory tower, and thus NCI reaches out to the public to provide information about reducing death and suffering from cancer. Last year about 19 million cancer information publications were mailed to the general public. And about 500,000 people called our cancer information CIS telephone service, which has a toll free number for personal answers to their questions. The Cancer Information Service [CIS] uses the NCI's most recent electronic databases to describe state-of-the-art cancer treatment and clinical trials. Screening and early detection are also very important. Thus, breast and cervical cancer are diseases where deaths could be reduced by more widespread screening for early detection. More than 6,000 women die each year of cervical cancer; most could have been saved with early PAP tests. There will also be approximately 150,000 new cases of breast cancer, and we believe that there will be approximately 44,000 deaths. The death rate could perhaps be reduced by 30 percent or more if physical exam and mammography guidelines were followed. Last fall, a women's leadership summit on mammography was held on Capitol Hill to launch the NCI National Breast Cancer Screening Awareness Campaign. This was an important initiative, with Mrs. Bush as the keynote speaker. Finally, future therapies will depend on a program of new drug development. The NCI is a national resource for such new drug development. A number of experimental drugs last year were introduced and were made available to the public at large. In some cases, the only available treatment for a cancer represents these experimental drugs. New drug approval status was given to drugs for advanced stages of testicular, prostatic, and ovarian cancer, and also for chronic lymphocytic leukemia. We expect to continue this momentum for the future. Mr. Chairman, the 1991 budget request for the National Cancer Institute totals $1.694 billion. I would be pleased to answer any questions. QUESTIONS SUBMITTED BY THE SUBCOMMITTEE Senator HARKIN. Dr. Broder, thank you very much. That was a succinct, yet enlightening statement. I appreciate that very much. There will be some additional questions from various Senators which we will submit to you for your response. [The following questions were not asked at the hearing, but were submitted to the Institute for response subsequent to the hearing:] QUESTIONS SUBMITTED BY THE SUBCOMMITTEE CANCER DEATH RATES Question. Since 1971 when President Nixon declared war on cancer we have spent approximately $16 billion on cancer research. In the 1990s I expect we will spend at least that amount on cancer research. In spite of this level of spending the overall deaths from cancer increase each year, while the rates from other major causes of death decline. In 1950, cancer caused 15 percent of all U.S. deaths; in 1985, 24 percent. Although some of the increase is due to an aging population, even the age-adjusted cancer mortality continues to climb. Incidence and death rates for those under and over 65 are on the rise. Dr. Broder, what are the cancer death rates for those both under and over 65? Answer. The age-adjusted (1970 U.S. standard) cancer mortality rates for 1983 to 1987 are: - 75.7 per 100,000 persons less than 65 years of age - 1,040.5 per 100,000 persons 65 years and older. The corresponding age-adjusted (1970 U.S. standard) cancer incidence rates for 1983 to 1987 are: - 189.8 per 100,000 persons less than 65 years of age - 1,983.3 per 100,000 persons 65 years and older. Question. Are we making progress? Answer. National mortality trends demonstrate significant improvements in certain age groups and cancers, although for others, there remains an increasing cancer burden. It is estimated that over one million Americans will be diagnosed with cancer in 1990, and approximately 500,000 people will die of cancer during this year. These projected estimates reflect the increasing number of older Americans in our population. Statistics show that these older Americans have a higher risk of developing the disease, as one-half of all cancer cases occur in persons age 67 and over. While overall the number of deaths and the cancer mortality rate have increased between 1973 and 1987, a closer look reveals that mortality rates have shown substantial declines for persons under age 65. This is especially true for children, for whom cancer mortality has dropped 36 percent. These significant improvements in cancer mortality occurred despite a persistent increase in the rate at which individuals develop cancer. The cancer incidence rate for all cancers combined increased by 14.6 percent between 1973 and 1987, while the overall cancer mortality rate rose by only 5.4 percent over the same time period. Some highlights of the progress are detailed below: Under Age 65 The mortality rate for all cancer sites combined has declined for both males and females under the age of 65 between 1973 and 1987. Cancer mortality in children has declined 36 percent in the 15 years between 1973 and 1987. This progress is attributable to treatment advances, particularly those developed through the Nation's network of clinical trials and cancer centers. - With the exception of children under age five, the annual decline in the overall cancer mortality rate for each age group under age 55 was greater from 1975 to 1987 than during the previous 25 years, 1950 to 1975. When lung cancer is excluded, the mortality rate for all other cancer sites combined has declined for both males and females under the age of 65 throughout the 15-year period of 1973 to 1987. Significant reductions can also be seen in the annual cancer mortality rates for various cancers among persons under age 65. For example, bladder cancer mortality has decreased 32 percent; ovary, 25 percent; colo-rectal cancer, 15 percent; oral cancer, 20 percent; cervical cancer, 39 percent, and corpus uteri, 37 percent. These are not rare cancers. Nevertheless, other cancers have shown increases: lung and bronchus, 15 percent; melanoma, 16 percent; multiple myeloma, seven percent; and esophageal cancer, five percent. Between 1973 and 1987, the overall mortality rate for all cancers combined for persons under age 65 decreased 4.5 percent. Over Age 65 - For persons ages 65 and older, the overall cancer rate has increased. Nevertheless, many prevalent cancers have shown significant declines. These include colo-rectal cancer, seven percent; bladder cancer, 20 percent: and cervical cancer, 40 percent. For other sites there has been an increase in mortality, including: all sites combined, 13 percent; lung cancer, up 53 percent; melanoma, 55 percent; brain cancer, 58 percent; nonHodgkin's lymphoma, 40 percent; multiple myeloma, 33 percent; breast cancer, 12 percent; and prostate cancer, eight percent. Minority Populations Black Americans continue to experience a disproportionate cancer burden. Black males have an overall mortality rate that is approximately 40 percent higher than that of their white counterparts. This is especially true for esophageal cancer where the mortality rate for Black Americans is three times the mortality rate for whites. The overall mortality rate for Black women, while not as high as that for Black men, is nevertheless about 20 percent higher than that experienced by white women. In 1987, the mortality rates were 213.4 per 100,000 for white males and 138.1 per 100,000 for white females. In contrast to these figures, the mortality rate for Black males was 299.8 per 100,000 and for Black females, 162.7. Similar race-sex differences were also noted for cancer incidence rates. In some instances, Black rates have been shown to be increasing for the same cancers for which mortality rates are falling among whites. For example, whites have experienced an 11 percent decrease in mortality from colo-rectal cancer. In contrast to this, the Black mortality rate has actually increased 10 percent for this same cancer between 1973 and 1987. The differences between five-year relative survival rates among Black and white Americans is particularly striking: 57 percent for white females as opposed to 44 percent for Black women, and 47 percent for white males as against 33 percent for Blacks. In summary, the data show a profile of both progress achieved and the challenges that remain. Mortality rates are decreasing for persons under age 65 for all cancer sites combined as well as for a large number of common specific cancers. Yet, for other cancers in this age group, mortality rates are on the rise, and the same decline seen in cancer mortality rates for those under age 65 cannot be demonstrated in persons over age 65. Decreases in diseases like colo-rectal cancer, bladder cancer, children's cancers, and a number of other cancers, all demonstrate that prevention and early detection combined with treatment can effectively reduce cancer mortality. On the other hand, experts have watched with considerable dismay as death from lung cancer continues to climb among women, despite all that is known about preventing this disease. For women, lung cancer mortality has finally overtaken breast cancer as the leading cancer killer. From 1973 to 1987, the death rate for female lung cancer rose by more than 100 percent. It is clear that we must continue to focus our efforts on the prevention of cancers such as lung and melanoma which have shown a rapid increase, and those cancers such as breast for which early detection (e.g., routine breast physical exam and low dose mammography) has been shown to significantly reduce cancer mortality. Through a variety of efforts in both prevention and treatment research, NCI is confident that the progress that has been achieved to date against cancer mortality will continue and that new inroads can be made to reduce the disproportionately high rate of cancer mortality rates experienced by Black and older Americans. Question. For the first time more women are dying of lung cancer than breast cancer. Does this suggest the need for a greater stop smoking campaign focused on women? Answer. Our most recent mortality figures come from the Surveillance, Epidemiology and End Results (SEER) data base in 1987. More women died from lung cancer in 1987 (42,700) than any other single cancer site, including breast cancer (40,900); and according to the American Cancer Society projections for 1990, lung cancer in women will account for 50,000 deaths or about 6,000 more than from breast cancer. Lung cancer has been the single |