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Answer. Much has been learned from basic and clinical research about cancer prevention over the last decade. The research and application program initiated by the NCI has focussed on nutrition as both a cause and means of preventing and controlling cancer, and the NCI Chemoprevention Program is addressing at å fundamental level the role of chemical elements, both natural and synthesized, in the prevention of cancer. Over this year Dr. Wayne K. Hong reported the first definitive chemoprevention study to show that a vitamin A derivative is able to prevent head and neck cancers in high risk persons. In addition, we heard several months ago, that a study of dietary fiber has shown that a low-fat, high-fiber. diet can reduce the incidence of rectal polyps in persons with a family history of such polyps. These are but the first of what I am sure will be a plethora of results from the chemoprevention and diet and nutrition studies.

Using Its Surveillance, Epidemiology and End Results (SEER) database, NCI's Surveillance Program tracks cancer incidence and survival rates throughout the country to identify regions where progress has been made as well as areas where problems remain. This tracking system provides the information necessary for program planning not only for the Institute but for the Nation as a whole.

Equally as important, SEER has proven to be an important tool for the collection and analysis of data specific to minority populations. NCI has significantly expanded its efforts and improved its ability to monitor cancer incidence, mortality, and survival among Black Americans, Hispanics, and rural populations. For example, the 1992 Cancer Control Supplement to the National Health Interview Survey (NHIS) is an additional sampling of Hispanics. These data will provide a more precise estimate of cancer screening knowledge and practices, dietary intake, smoking habits and attitudes, and medical care for approximately 5,000 Hispanic adults. Coupled with comparable data from the 1987 NHIS Cancer Control Supplement, the Nation will have information with which to measure change in the prevalence of cancer risk factors for this population subgroup.

In 1985, NCI established six cancer control objectives. Their purpose was to define those activities that--based on current knowledge--would lead to significant reductions in the morbidity and mortality from cancer. Recently these objectives have been incorporated into the Department of Health and Human Services prevention objectives known as 'Healthy People 2000."

NCI's objectives call for significant smoking reduction to less than half the level of 1985, a decrease in dietary fat to 30 percent of calories, an increase in dietary fiber to between 20 to 30 grams per day, a substantial increase in breast and cervical cancer screening, and an increase in the use of state-of-the-art treatment. We estimated in our report that, with full achievement of these objectives, mortality could be reduced by 25 percent and by 50 percent if we increase the rate of progress in our' development of new treatments.

In 1992, through the National Health Interview Survey conducted by the National Center for Health Statistics, under co-sponsorship of the National Cancer Institute, we will obtain national estimates of smoking rates, dietary patterns, and screening behavior. From these figures we will be able to gain our most precise assessment of progress toward the prevention goals. The most recent National Health Interview Survey that stressed cancer control was conducted in 1987.

In 1987 some 32 percent of males smoked as did 27 percent of females. These figures were down significantly from the 1965 figures of 52 percent for males, but down only 7 percent from the 1965 figure of 34 percent for females. State trends seem to indicate that the smoking figures are continuing to drop, and in 1992 we will be able to assess progress from a national sample. Turning to breast cancer screening, we believe there has been considerable progress since 1987. In 1987, only 36 percent of women over 40 had had a mammogram. From smaller surveys conducted in 1989 and 1990, we believe that figure to be at least 60 percent today. Although this is a considerable improvement, we need to determine whether breast cancer screening has become routine practice. It is only through periodic screening, rigorously adhered to, that we can hope to achieve the full potential of screening: a reduction in breast cancer mortality rate by 30 percent. Data from NCI's cancer database, the Surveillance, Epidemiology, and End Results Program, strongly suggests that screening for cervical cancer is continuing, and correspondingly, the cervical cancer mortality rates are continuing to decline. It is this same database that shows that lung cancer incidence rates for males appear to be on the decline.

Together with the Centers for Disease Control and the Food and Drug Administration, we have developed a National Plan for Breast and Cervical Cancer Screening aimed at achieving the breast and cervix cancer control objectives. Representatives from state and local government, academe, and a variety of public and private sector agencies participated in two national meetings held to assist in development of the plan.

Directing cancer prevention and control efforts at those who suffer most or disproportionately from cancer is a cornerstone of the program. The National Black Leadership Initiative on Cancer (NBLIC) was established by the National Cancer Advisory Board and NCI in late 1987 and is a continuing activity: The purpose of this health education initiative is to solicit the assistance of Black Americans who are leaders in the business, civic, religious, and lay communities to develop coalitions to promote NCI's cancer prevention and control goals and to stimulate the involvement of the Black American community in this effort.

Substantial reductions in cancer incidence and mortality can be achieved with preventive technologies currently available. Where we see the least improvement in cancer statistics is among poor and minority populations. The challenge now posed is to disseminate the available information to these populations by culturally relevant means. To meet the Healthy People/2000 objectives, it is essential that we transfer the results of research as fully and as expeditiously as possible. Our task is to forge partnerships with other Federal agencies, and with the public and private sectors. To fully effect this transfer, NCI has developed a number of approaches keyed to particular risk factors, behaviors, and population groups, and all involving the broad public and private sectors who, working together, will help to achieve these objectives.

These are but a few examples of NCI's initiatives aimed at the full application of our knowledge. If the Nation were to quit smoking tomorrow, fully adopt the breast and cervical cancer screening guidelines, reduce fat in the diet to 30 percent of calories, increase fiber as recommended, and fully apply all of our existing knowledge regarding treatment, we believe that we would see, by the end of this decade, a significant reduction in cancer mortality. Although we cannot achieve the needed public and health profession behavior

changes overnight (it has taken some 25 years to reduce the prevalence of smoking among males from 52 percent to 32 percent), we believe the Nation can reduce its cancer mortality.


Question. Dr. Mason, the Disadvantaged Minority Health Improvement Act of 1990 was passed by Congress and signed by the President last fall. Does the President's budget for FY 92 recommend funding the programs authorized under the Act?

Answer. The Disadvantaged Minority Health Improvement Act of 1990 established the office of Minority Health in statute and required that it carry out specific activities. The FY 1992 request for the OMH includes funding for these activities authorized by the law:

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Establishment of short and long-range goals and
objectives and coordination of all other activities
within the Department related to disease
prevention, health promotion, service delivery and
research concerning disadvantaged and minority
individuals ($400,000 for monitoring and
implementing the Minority Health Strategic Planning
and Coordination Process).
Interagency agreements with other agencies of the
PHS ($4,000,000 for interagency agreements).
Establishment of a national minority health
resource center ($750,000 for Office of Minority
Health Resource Center).

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Support of research, demonstrations and evaluations
($600,000 non-AIDS and $400,000 AIDS for research,
demonstrations, studies and analyses).
Coordination of efforts to promote minority health
programs and policies in the voluntary and
corporate sectors ($850,000 non-AIDS and $150,000
AIDS for assistance to private sector groups).
Development of health information and health
promotion materials, and assistance to providers of
primary health care and preventive health services
in obtaining the assistance of bilingual health
professionals and other bilingual individuals
($3,500,000 for community coalition grants and

$2,500,000 for AIDS education/prevention grants). The Act also authorized programs administered by the Health Resources and Services Administration (HRSA). The FY 1992 HRSA budget proposes to continue these programs at the current services level, with an expansion of the Health Professions Student Loan Program.



BUDGET REQUEST Senator HARKIN. Our next witness is Dr. J. Jarrett Clinton, Acting Administrator of the Agency for Health Care Policy and Research (AHCPR). This agency is charged with conducting research that will enable us to enhance the quality and effectiveness of health care services, enhance access to appropriate health services, and disseminate information to health care providers.

AHCPR conducts medical treatment effectiveness research, health services research, rural health research, and technology assessment.

The budgets for medical treatment effectiveness research have taken big leaps over the past 3 years, jumping from under $6 million in 1989 to almost $63 million in 1991. The budget request for 1992 breaks this pattern, requesting essentially level funding for this research. This is one area that I am very interested in, and I want to hear the agency's plans for this initiative in the area of medical treatment effectiveness research.

Dr. Clinton has been Acting Administrator since its creation. Again, Dr. Clinton, we welcome you to the subcommittee. Your full statement will be made a part of the record. Please proceed with your remarks.

Dr. CLINTON. Thank you, Mr. Chairman. Our written presentation outlines our request for $122 million for the coming fiscal year, about a 6-percent increase over the prior years, and provides considerable detail about the sources of financing and the various aspects of that program.

In my opening statement this morning I would like to focus on three things I think that we have particularly accomplished in the 16 months that the agency has been in existence.

ACCOMPLISHMENTS First of all, we have created a new agency within the family of agencies in the Public Health Service and become the eighth in that family. We have brought in staff from basically every component of the Public Health Service. We have staff transferred from the Health Care Financing Administration, from GAO, and from the Veterans Administration. We bring an extraordinary wealth of experience and expertise to bear on the issues of health services and health systems research.

We have developed procedures and accounting systems that will serve us well as we proceed as a more proactive agency in the fu

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