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two, and what difference those advances have or will make in people's lives.
Answer. In addition to the advances described in the field of gene therapy which opens up the possibility direct alterations in the body to replace defective or missing genes and which allow for specific, highly targeted use of natural disease fighting entities to attack tumors, there are many other areas of progress which are directly relevant to patients. Once cancer patients were treated primarily with surgery and/or radiation. Then chemotherapy was gradually added and followed by combinations of drugs. Now drugs are being used at different points in the therapy adjuvant to surgery or radiation. NCI - supported research has developed a number of adjuvant treatments for some common tumors. Some therapies are specific to a certain stage of a cancer, but directly or indirectly they affect the outlook for patients. These recent therapeutic improvements offer new hope for the 150,000 patients with breast cancer, particularly the 60,000 who have node negative disease, and the 157,000 with colon and rectum cancer. The latest research advance improves survival and reduces relapse for patients with rectal cancer and promises to save an additional 3,000 lives a year.
A new neoadjuvant treatment involving chemotherapy and radiation before surgery, suggests that patients with advanced esophageal cancer, some 11,000 new cases annually, substantially increase their disease-free survival under this treatment regimen compared to standard treatments.
Another achievement is the accelerated development of a promising new drug which has shown promising results in ovarian, breast, and other cancers. This drug, taxol, is isolated from the bark of the western yew. Major efforts are being made to solve the problems of supply. Since this drug operates at the level of the cell cycle, it provides a new approach for patients whose disease has proven resistent to other forms of treatment.
A potentially important breakthrough has occurred due to basic cancer research. Various studies supported by NCI have shown the importance of a suppressor gene, p53, in a number of types of cancer. An NCI-supported researcher at Johns Hopkin's University has recently replaced a missing gene in the laboratory and reversed colon cancer in the test tube. This gene appears to be important in lung cancer as well. Recently, NCI-scientists found that it was instrumental in the inherited Li-Fraumeni syndrome which is characterized by numerous kinds of tumors. Finding a critical gene like this and beginning to learn how to replace or repair holds the possibility that rather than relying on treatment as we know it now, we will be able to replace suppressor genes to allow the body's own mechanisms to stop the cancer in its tracks.
NCI has recently reported on important studies further supporting the link between diet and health. For instance, the Nurses Health Study followed 90,000 women for six years and showed that a low fiber and high fat diet increases risk of colon cancer. A number of studies support the hypothesis that high fat diets play a role in breast cancer. NCI is beginning a feasibility study in minority groups which will eventually help to establish
solid data on this important subject. All of this information on the role of diet and that of specific dietary components, such as fat, will help provide the public with choices to improve health.
On January 23, 1991, NCI and the Susan G. Komen Foundation, with considerable support from the Congress, sponsored a second Women's Leadership Summit entitled "Women in the Workplace: The Challenge of Breast Cancer." Marilyn Quayle gave the keynote address and Barbara Bush held a reception at the White House for those who attended the Summit which, like last year's Summit, took place on Capitol Hill. Over 200 corporate leaders attended to hear scientists talk about breast cancer research. Presentations on worksite programs were also made. This Summit helped to focus attention on the subject of breast cancer and to help carry the message and stimulate programs in order to reach many more women.
IMPACT OF BUDGET LEVELS
Question. Dr. Broder, you are aware of this Committee's commitment to the medical research programs at the NIH, particularly those at the NCI. I have recently been told that the NCI budget has actually decreased by 6 percent when corrected for inflation while the other programs have increased by 27 percent. Can you describe for me how that has translated to many of the programs which are unique to your Institute--such as the Community Clinical Oncology Program, Cancer Prevention and Control Program and Cancer Centers?
Answer. The NCI budget has decreased in constant dollars since 1980. The NCI budget has decreased approximately six percent in 1980 dollars, while the overall NIH budget has increased by about 27 percent. These percentage figures were obtained using the 1980 deflator for 1991 (1.9088) from the Biomedical Research and Development Price Index (BRDPI). Overall, in current dollars the NCI budget has increased by $852 million or 89 percent between FY 1980 and the request for FY 1992 and the NIH budget has increased by 156 percent. of the major mechanisms used by NCI, two have kept pace with the growth of NIH in 1980 constant dollars. Research Project Grants have grown by about 29 percent, which is quite similar to the growth for this mechanism across the NIH. This is a result of the stabilization objectives set by NIH in recent years. Efforts funded through the Intramural Research mechanism have also grown in 1980 constant dollars, by approximately 22 percent. Although the addition of monies for AIDS-specific new initiatives is not factored out for this figure, for cancer-specific activities, the intramural program has fallen by about five percent in 1980 constant dollars.
Other NCI mechanisms have experienced a decline in constant dollars, although they have continued to produce significant. results. These mechanisms are either unique to NCI or are used predominantly by NCI. One major example is the NCI Cancer Prevention and Control Program. A vital component of the Institute's research effort against cancer, the Cancer Prevention and Control Program has experienced a 33 percent decline in 1980 constant dollars. The Community Clinical Oncology Programs (CCOPs), which are a part of the Cancer Prevention and Control Program, have in turn lost about 8 percent.
Other NCI mechanisms have also experienced a loss in purchasing power. The Clinical Cooperative Groups program has declined by about 32 percent in 1980 constant dollars. This is the mechanism that NCI uses for major clinical trials. The budget for NCI research and development contracts has declined by nearly
half during he same period. These contracts are the most effective means for accomplishing certain very important NCI operations, including the Surveillance Epidemiology End Result (SEER) program, the Cancer Information System (CIS) and the development of monoclonal antibodies for use in cancer treatment (under the Biological Response Modifier Program). Cancer Centers have fared somewhat better, losing about 14. percent of their purchasing power since 1980. This loss in purchasing power has slowed our capability to expand the Institute's nationwide cancer information dissemination and community outreach network as well as the geographic dispersion of basic and clinical cancer research.
NCI PROFESSIONAL JUDGMENT
Question. In your professional judgment, how much money above the President's Budget does the NCI need to continue to stabilize its grants and begin to address these program cuts which have occurred over the past decade?
Answer. In my professional judgment, the primary consideration for funding within the Cancer Program is a requirement to develop a balanced program, one that will take full advantage of all research findings with the goal of a rapid translation of basic research successes into clinical applications. Our highest priority has always been the support of basic research and it will always remain an extremely high priority for NCI. Given today's biotechnology revolution, we need to adapt findings to the immediate benefit of the cancer patient as well as to develop interventions that are effective in the prevention of cancer. One measure to initiate such a capability would be stable support for the entire Program, especially research grants, cancer centers, clinical trials, intramural research, and prevention and control. To support approximately 35 percent of competing grants, the same percentage as was funded in 1980, as well as to restore those mechanisms that have not kept pace with inflationary requirements during the past decade, would require approximately $320 million over the 1992 President's Budget.
1980 SPENDING LEVEL
Question. Dr. Broder, how much would it take to get the NCI back to its 1980 spending level?
Answer. For the National Cancer Institute to reach its 1980 real spending level, those NCI mechanisms that have experienced a loss in purchasing power since 1980 would require an increase of close to 20 percent over current budget for Cancer Centers, approximately 50 percent for both Clinical Cooperative Groups and Cancer Prevention and Control, and approximately 90 percent for Research and Development Contracts. This would result in a request of approximately $320 million beyond the 1992 President's Budget.
PROGRESS BY TYPE OF CANCER
Question. Dr. Broder, for what types of cancer have we made the most progress?
Answer. Cancer mortality for all sites minus lung has declined three percent during the 16-year interval 1973-88. Annual cancer mortality rates (deaths per 100,000 persons, ageadjusted to the 1970 U.S. standard population) for the period 1973-1988 show that improvement is evident in the large reductions in the annual cancer mortality rates among persons under age 65. Between 1973 and 1988 the mortality rate for all cancers combined for persons under 65 decreased 4.3 percent. Annual cancer mortality rates, age-adjusted to the 1970 U.S. standard, for all cancers combined among persons 65 years and older increased 13 percent during the 15 year-period 1973 through 1987.
Mortality from cancers of the uterine corpus and cervix, urinary bladder, thyroid, and stomach has declined between 20 and 40 percent; reductions of 10 to 20 percent have occurred for oral cavity, colon and rectum, and breast cancer among women less than 50 years of age. Reductions of five to 10 percent have occurred in cancers of the ovary and larynx and in leukemia. Cancer in young adults has decreased greatly, for example testicular cancer and Hodgkin's disease have declined by more than 50 percent. However, other cancers have shown increases: lung cancer and melanoma are up over 30 percent, and increases of 10 to 20 percent occurred for multiple myeloma, non-Hodgkin's lymphoma, prostate, kidney and renal pelvis, esophagus, brain and nervous system, and liver and intrahepatic cancers. Breast cancer mortality for females 50 years and older increased five percent during the interval 1973 and 1988. Thus, there is good news and bad news in our progress against cancer, and we need to make sure we accelerate the pace of progress against the cancer suffered by the American people.
The following tables present data by site regarding progress in various types of cancers from 1973 to 1988.