that such advances are susceptible of great improvement in the next few years; and certainly the dedication of the men of medicine in the research and the control fields of cancer is such that we can look forward confidently to what we, from the public-health viewpoint, call control of the disease, which is aimed ultimately at eradication. Falling short of eradication, the alleviation of pain, and the prolongation of the useful years of life which an individual can enjoy and live out for the most part his normal span, are at least secondary goals. But we are not content with that; we are aiming at the ultimate elimination of the disease.

We will speak of cancer as a disease because it is usually considered that, but I should like to reemphasize my point that cancer probably is many diseases, and some of the research which will be related I think will bear that out.

I should like to comment very briefly upon the economic impact of cancer on our society.

It is quite apparent that loss of productiveness particularly on the part of a breadwinner is a very disrupting and a very important element in our social economy.

It is estimated that about $12 billion each year is lost as a result of this loss of productivity.

Not included in that, however, is an element which to me is of almost equal importance, and that is the tremendous drain upon the finances of the family as a result particularly of the loss of the breadwinner and the consequent expense both of treatment and hospitalization, besides the crippling of this individual in the event of arrest or cure of the disease. That will be substantiated as this hearing progresses and I shall leave to other members of the panel the development of the advances in therapy and diagnosis; I shall leave also the elements of research in its broadest sense, and we shall attempt to relate research to the interest of this committee in the situation of the outlined accomplishments which we hope will be apparent to you and which have been inherent in the proposition that there is reason for optimism.

Similarly, the various members of the group testifying will also establish, I am sure, and it will become apparent to you, the difficulties confronting the worker in cancer.

I should like to leave with you the proposition that it is not a simple matter; cancer research is not simple and cancer control is not simple. We must overcome the lag between what we know and what we do, and we look to cancer research to furnish us surgical means and better tools with which to do this job.

I should like to indicate that we will embrace this agenda which the chairman has requested that we consider; we will not follow this agenda in a strict, rigid form, Mr. Chairman, but it will be encompassed in the discussion.

I should like to develop several important points which I believe will be pertinent to the committee and I should like to ask Dr. Charles Cameron, medical and scientific director of the American Cancer Society, to indicate and amplify the magnitude and scope of this cancer problem.

Dr. Cameron.

39087-53-pt. 1—10

STATEMENT OF DR. CHARLES CAMERON, MEDICAL AND SCIENTIFIC DIRECTOR, AMERICAN CANCER SOCIETY

Dr. CAMERON. Mr. Chairman and committee members, may I enter a prepared statement for the record?

The CHAIRMAN. Without objection, so ordered.

(The prepared statement referred to is as follows:)

CANCER IN THE UNITED STATES

A statement of the extent of the problem, the nature of the program to combat it, and accomplishments of the control effort, prepared by the American Cancer Society, Inc.

CANCER'S INCREASE

Fifty years ago the annual death rate from cancer in the United States was 64 per hundred thousand of population. The estimated death rate for the current year is in the order of 145 per hundred thousand. Much of cancer's increase is attributable to the unprecedented lengthening of the span of life brought about in two generations by sanitation, by immunization, by antibiotics, and by more extensive yet safer surgery (chart 1).

The life expectancy for men is today close to 60 years and that for women has already passed the scriptural 3 score years and 10. The aggregate result is that there are today more than 3 times as many persons in the United States over the age of 45 as there were at the turn of the century (chart 2). Since cancer is predominantly a disease of persons beyond the age of 45 (chart 3), it would perhaps not be unexpected that there should be 3 times as many cancer deaths recorded today as there were 50 years ago. However, this explanation does little to dispel the alarm with which one views the anticipated increase over the next 50 years if present rates of increase continue unchanged (chart 4). Whereas for the present year the number of deaths attributable to cancer is estimated at 220,000, by the year 2000 the annual number of cancer deaths is expected to reach 415,000. However, the fact should be noted here that a substantial number of present cancer deaths are avoidable and that this anticipated increase can be significantly reduced.

The late increase in cancer's recorded incidence and mortality is, to an indeterminate degree, due also to more accurate diagnosis now available generally. Improved standards of medical care, by reducing deaths from infectious and parasitic diseases, and by diagnosing cancer with greater precision, serve to increase the reported amount of cancer in a population. Thus, while the mortality from infectious and contagious diseases varies inversely with the number of doctors per unit of population (chart 5), the paradoxical fact is that the more doctors there are, the higher the cancer death rate appears to be (chart 6). This could lead the unwary-and it sometimes does-to conclude that if one has cancer a doctor is the last person he should see; what it actually means is that, in areas with adequate or high-standard medical services, more people escape early death and fewer patients with cancer die unattended, undiagnosed, and untreated. This fact is further borne out by comparing the nations of the world having death rates of less than 1,500 per 100,000 of population with those having death rates in excess of that figure, whereby it is noted that the countries having high general death rates tend to have low cancer rates, whereas countries having low general death rates tend to have high cancer rates (chart 7). High living standards, high literacy rates, good nutrition, high-quality and generally available medical care reduce deaths from infectious, parasitic (epidemic), and nutritional diseases, leaving little left to die from except cancer and heart disease.

While these two factors-lengthening life and wider recognition of canceraccount for the bulk of cancer's mounting incidence and mortality, they do not appear to do so for every kind of cancer. Indeed, at least one form of cancer, namely, cancer of the lung, is increasing at an alarming rate and one which suggests the operation of cancer-producing factors of relatively recent development.

THEN AND NOW

At the turn of the century, cancer in the United States was eighth in the list of causes of death preceded by heart disease, tuberculosis, pneumonia, Bright's disease, diarrhea and enteritis, and diseases of the vascular system. Seventyeight thousand people a year were dying from it. What research there was was more of alchemy than science. There was but one specially designated cancer hospital and there were no cancer clinics. There was no support from the Federal Government of programs of research or control, and only one State recognized its responsibility in this respect. No word of cancer appeared in the media of public information. Nowhere was cancer a reportable disease. The biopsy was still a subject of controversy among doctors. X-rays were being employed somewhat gingerly and radium cost five times its present price, thereby limiting its availability greatly. The operation for cancer of the rectum was an innovation, and tumors of the central nervous system, of the lung, of the pancreas, and of the esophagus were not yet surgical diseases. Anesthesia was limited to 2 or 3 agents of limited flexibility. Medical education was unstandardized and diplomas from "mills" afforded their purchasers the same rights and privileges as were open to the graduates of first-class schools.

Today, cancer is second among the causes of death, now striking 1 in every 5 of our population and being the cause of 1 in every 7 deaths. The countrywide budget for cancer research in the United States is in the order of $15 million annually. The American College of Surgeons approves 11 cancer hospitals, 539 cancer clinics, and 113 cancer diagnostic clinics. There are about 240 cancerdetection centers, the primary objective of which is to uncover unsuspected cancer in presumably well persons. This year's appropriation by the Federal Government for cancer research and cancer control is $20,237,000, and the voluntary health agency, the American Cancer Society, has this year received $19,500,000 in contributions from the public. Cancer information is given wide attention in newspapers, magazines, on the radio, and television. X-rays are being generated at higher and higher voltages and targeted with increasing precision, while radium or its new substitute, radioactive cobalt, are available widely throughout the country. Surgery has boldly extended its frontiers so that there is virtually no part of the body now sacred before the scalpel. Virtually everything we know today about cancer has been learned in a single generation, yet we are still in the green years of medical progress and there is no evidence to justify resignation nor apathy in respect of future progress in the control of this disease.

CURABILITY

Yet, while it is true that the curability of most forms of cancer is being slowly increased, the stark fact remains that successful treatment is still delimited by the extent of disease. Which is to say that, by and large, cancer is curable only when it is reasonably localized or confined to the organ in which it originates. However, the cardinal feature of this disease is to spread, sooner or later, from its site of origin to distant parts of the body-a phenomenon known as metastasis. Once such dissemination has occurred, even today's heroic surgery and high energy radiations are usually ineffective. To an important degree, whether cancer is localized or disseminated is a function of time—although equally important, and sometimes more so, the inherent biological behavior, or growth activity, of a tumor is also determining. Tumors vary greatly in their speed of growth and in their tendency to spread, characteristics not susceptible of influence today. Time is the only factor determining the outcome about which anything can be done, assuming, of course, the availability of adequate treatment. With the importance of time or delay in influencing the result in mind, consider the fact that cancer of the cervix, the most frequent cause of death from cancer among women, is curable in 70 to 80 percent of patients treated while it is confined to the neck of the womb, whereas not more than 20 percent of all patients with this disease are actually being cured; that cancer confined to the breast can be cured 8 times out of 10, whereas the overall cure rate of breast cancer is less than 35 percent; that small cancers of the mouth can be cured 65 percent of the time, whereas fewer than one-third of all oral cancers are actually being cured; that 80 percent of cancer of the larynx is curable when treated while the disease is confined to 1 vocal cord, although cures being accomplished do not amount to more than 15 percent of all patients (chart 8). This striking dichotomy between cures achievable under optimal conditions of localized disease and expert treatment

and the cures actually being accomplished is one of the unique features of cancer and one which forms the basis of the program for its control.

While, as has been said, "early diagnosis" is not synonymous with "curable," the principle, "the earlier, the better," remains a cardinal precept in medical practice and in cancer control.

In aggregate, it is probable that about one-fourth of patients with cancer today. receiving proper medical care, are being cured. With the methods of treatment presently at hand, it is estimated that twice this number could be cured, provided the aforementioned optimal conditions could be achieved. In terms of actual numbers, this means that approximately 73,000 lives are being saved yearly and that an equal number now dying are potentially salvageable. The remaining doomed half of those destined to develop cancer must look to the advances of future research for their salvation (chart 9).

PUBLIC EDUCATION

Recognizing the critical importance of time, or delay, in influencing the results of cancer treatment, a group of doctors in 1913 recommended the establishment of a voluntary organization whose objective it would be, among other things, to develop and carry on a broad program of public education. Specifically, the program would seek to inform the laity of the early warning signs of cancer and to make clear the importance of immediately heeding them. Today this program of public education continues and its basis is the Seven Danger Signals of Cancer (chart 10). Every medium of communication and public information is utilized in promulgating this information: Printed pamphlets, motion pictures, radio, television, exhibits, window displays, billboard posters, car and bus cards, bulletin-board handbills, special mailings, and talks by properly qualified persons to groups and assemblies of many kinds, such as women's clubs, parent-teacher associations, church guilds, industrial groups, and mass public meetings.

Recent studies offer evidence that this 40-year-old effort in health education of the public has borne fruit. Virtually every study of the trend of the factor of delay for which the patient is responsible has shown a consistent lowering in the element of delay. To put it another way, more patients are being seen with earlier cancer than ever before (charts 11, 12, and 13). These findings are substantiated by the experience of most practicing physicians who have commented on this facet of the problem.

PROFESSIONAL EDUCATION

The increasing consciousness of cancer on the part of the public has imposed added burdens on the medical profession, for it is a fact that the earlier the cancer, the more difficult it is of diagnosis. Therefore, in order to assist doctors to maintain a high index of suspicion paralleling that of the public, the American Cancer Society conducts its national office and affiliated divisions an intensive program of profession education (chart 14).

Through publications, library reference services, the monthly index of current cancer literature, through motion-picture films produced in cooperation with the National Cancer Institute, through refresher courses, and now through the medium of closed circuit color television, the society endeavors to bring to the practicing physician, already overburdened by an avalanche of new medical information, the facts about cancer which will facilitate his handling of the clinical problems which it presents in office practice.

Eighty-eight clinical fellowships awarded annually permit young physicians to obtain additional training in the diagnosis and treatment of cancer in its special forms; and 15 fellowships in exfoliative cytology or smear diagnosis permit qualified pathologists to spend varying periods up to a year in acquiring proficiency in this new and extremely useful diagnostic technique. In addition, fellowships are available to permit young physicians who have already obtained in the United States extensive training in radiation therapy to go abroad to study for a period of 1 year at selected radiation therapy centers in the Scandinavian countries, the United Kingdom, and France. Every 3 years, the American Cancer Society joins with the National Cancer Institute and the American Association for Cancer Research in conducting a National Cancer Conference, in which clinical and research aspects of cancer are reviewed and progress evaluated.

DETECTION OR CASE FINDING

But useful as the danger signals have been and will continue to be, experience demonstrated (1) that all too often the apperance of a danger signal was, in fact, a manifestation of moderately advanced disease, and (2) that it was frequently possible to discover cancer-"silent" cancer-in patients who had no signs nor symptoms of disease. This was, in effect, discovering cancer before it had given rise to gross expressions of its presence. The effort to find cancer in nonsymptomatic patients was begun on a formal scale in 1937 and initially it was confined to the search for cancer of the uterus. When it had been shown that truly early and curable cancers could be found in patients in advance of symptoms, the practice was taken up by others and extended to other body sites. There are today some 240 cancer detection centers in the United States (chart 15), which operate for the most part in the environment of a hospital clinic and which endeavor to confine their activity to the search for cancer and other diseases in presumably well persons. More recently, medical societies in a number of States have endeavored to have this practice of cancer detection adopted as a formal regime oriented to office practice and it can safely be said that these routine physical checkups, so important in the maintenance of health, particularly in older persons, are more widely sought than ever before. Nevertheless, only a small fraction of the population submits to such regular examination.

In an analysis of the effectiveness of this type of preventive medicine-preventive in the sense of preventing deaths-the American Cancer Society studied the cancer yield in some 52,000 examinations conducted in 90 detection centers. It was found that the rate of cancer for the entire group of examinees unselected as to age was eight per thousand. The rate of cancer discovered varied from 1.2 cases per thousand for the group under 30 years of age, to 34.3 per thousand in the group aged 60 and beyond, with, as was to be expected, a progressive rise in the cancer yield with advancing years. These facts suggest that, while it may be impractical and, indeed, impossible, to examine the entire population for evidence of cancer or other disease on a regular schedule, nevertheless an approach to effective chronic disease prophylaxis might be achieved through the establishment of such screening devices as selection according to age. Thus, it seems poor economy to attempt to find cancer under the age of 40. It appears distinctly worthwhile to do so in persons beyond the age of 50 (chart 16).

SERVICES OF THE AMERICAN CANCER SOCIETY

Approximately two-thirds of the cancer detection centers referred to above have been supported in some measure by field units of the American Cancer Society. Other services subsidized or provided by the society in an effort to improve the quality of cancer service in the United States include financial assistance to cancer clinics and cancer diagnostic clinics, previously referred to (chart 17). The society also maintains information services in most of the major cities and in many of the smaller communities. The society supports local visiting nurse associations in order to increase the quantity and quality of nursing care to patients confined to the home; in addition it is the society's policy to provide, where needed, practical nursing service and housekeeping assistance. Many units of the society, further, provide drugs to indigent patients for whom the purchase of vitamins, hormones, and narcotics is burdensome, if not impossible. The society's volunteer arm provides transportation for patients going to and from the hospital or doctor's office, unlimited dressings for those needing them, maintains loan closets where some 240 items of sickroom necessity or convenience are stocked and available without cost, recreational therapy programs for patients confined to home or hospital and a home visiting service (chart 18).

STATISTICAL RESEARCH

Evidence at hand indicates that, whereas there does not appear to be any significant difference in susceptibility to cancer in general in different parts of the world, there is noted a predeliction for certain kinds of cancer in certain areas or among certain ethnic groups. Study of the geographic distribution of cancer according to its type and site is now recognized as a respectable enterprise and the American Cancer Society and the National Cancer Institute are engaged in various studies in an effort to elucidate the pattern of incidence of cancer and