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Dr. FARBER. I am scientific director of the Children's Cancer Research Foundation in Boston, responsible there for the care of children with cancer and for a research program designed to find new methods of treatment for children with cancer. I am also professor of pathologoy at Harvard Medical School, stationed at the Children's Hospital; and am a member of the National Advisory Cancer Council.

Dr. HELLER. Dr. Ralph Meader.

Mr. MEADER. I am Chief of the Cancer Research Grants Branch of the National Cancer Institute; and as such under the general guidance of Dr. Heller carry out the administration of the research grants funds appropriated by the Congress. In this effort the National Cancer Institute, Public Health Service, is advised by the National Advisory Cancer Council, a group of appointed officials, nongovernmental employees, of which Dr. Farber is a member. Dr. HELLER. Dr. Paul Wermer.

Dr. WERMER. I am Paul L. Wermer, of Chicago. I am secretary of the committee on research of the council on pharmacy and chemistry of the American Medical Association. I am here as a representative of that association to outline our activities in the clinical research and education in cancer.

Dr. HELLER. Dr. Ira Nathanson.
Dr. NATHANSON. My name is Dr. Ira T. Nathanson. I am associate
clinical professor of surgery at Harvard Medical School; the director
of the Massachusetts division of the American Cancer Society; I am
a member of the staff of Huntington Laboratories; which are the
laboratories of the Harvard cancer committee; and I am chairman
of the National Research Council's Committee on Cancer Diagnosis
and Therapy.

Dr. HELLER. Dr. Gordon Granger.
Dr. GRANGER. Dr. G. A. Granger, Acting Medical Director of the
Food and Drug Administration. We are involved in enforcing the
Food, Drug, and Cosmetic Act.

Dr. HELLER. Have I overlooked any witnesses in the audience not known to me?

I believe, Mr. Chairman, that constitutes the group of witnesses.

The CHAIRMAN. Now that you have introduced your associates, will you introduce yourself and give your background.

Dr. HELLER. I am Dr. John R. Heller, Director of the National Cancer Institute, a Federal activity charged by the Congress with the responsibility for the study of the causes, diagnosis, treatment, and prevention of cancer; a very broad charge which the Congress established in 1937 and implemented with the appropriate funds. And since that time there has been a very marked expansion of activity in the Federal program. This has received the support of the people, as evidenced by the interest of the Congress.

The CHAIRMAN. With reference to your mentioning the fact that this was a Federal agency, it is always gratifying to members of this committee to realize that it was this committee which established the several national institutes that have performed so well; and our only regret is that probably there has not always been sufficient appropriations to have accomplished all you would have liked to have done. We are hopeful, however, that by hearings such as these and acquainting the general public with the situation that exists, both with

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respect to the number of people incapacitated by these diseases and also by the work that can be done in the way of research, there will be a more general support given to the efforts to make all of these institutes more effectual in carrying out the will of Congress by providing appropriations that will enable them to do so. Now you may proceed, Dr. Heller.

Dr. HELLER. Thank you, Mr. Chairman. Members of the panel, the chairman desires that we discuss the several broad aspects relating to causes, diagnosis, treatment, and prevention of cancer, with especial emphasis toward the magnitude of the problem, the economic impact upon our socity, the accomplishments of research, the accomplishments of the translation of research into those elements which lead to control of the disease in the population, and the most important element of research-to find and establish and develop those elements which can lead ultimately to the control of cancer.

I should like to establish in as broad terms as I can, Mr. Chairman, some of the facets which we see as residing in the framework of this very complex question of cancer control; cancer control being used in the broad sense, embracing research in all of its facets.

To begin with, cancer is not only an extraordinarily complex disease but it is one in which the cause is not established. There being no known definitive cause of cancer in the medical sense, the diagnosis of the disease has been hampered by this very fact of being unable to establish a cause or causes.

I should like to establish, also, the fact that cancer is not considered usually as one disease. It is considered as many diseases. It is likely, therefore, that there may be various causes involved rather than one

By the same token, there will probably be a number of treatments instead of one treatment for cancer.

We are confronted, then, with a situation in which research, while aimed at the general problem of cancer, nevertheless has to consider these several complicating variables.

Cancer, as most of you know, is a disease which has grown not only in importance—it has always been important to our society—but has grown because we are an aging population in the sense that each year more of us are entering the older age brackets, since medical science has been successful in eliminating those communicable diseases especially which previously were major causes of death. We find that since 1900, cancer has come from eighth place in cause of death to second place at this time. While it is primarily a disease of the older age groups it must be remembered that better than 15 percent of the deaths from cancer occur in individuals under the age of 45.

It is estimated that this year, 1953, there will be about 224,000 deaths from cancer. There are coming to medical attention each year about 530,000 cases of cancer. It is estimated that at the rate at which we are acquiring cancer 50 million of the present population of the United States probably will acquire cancer and about 25 million of them will die from that disease.

I would not like to leave in the minds of the committee a grim or gruesome picture because of the statistics which I have related. There is cause for optimism. This optimism will be developed by the several members of the panel. I think that the evidence which you will hear will indicate to you that advances have been made and

cause.

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.

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CURABILITY

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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

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