I have referred to the increase in cancer, and there is, as you pointed out, an increase in heart disease, but this is at the expense of decreases in most other diseases-diseases which were at the turn of the century the leading causes of death.

In 1900 tuberculosis was called the great white plague and it was a leading cause of death. Today it is eighth in the list of causes of death.

So recently as my own medical school days, pneumonia was called captain of the men of death, and it took the life of 1 in every 3 which it struck. Today as a result of the sulfa drugs and antibiotics, pneumonia has a mortality rate of less than 8 percent.

Typhoid fever, which swept across the country and decimated whole populations in rural areas, is now a disgrace to any community and a single case of typhoid fever-a single case of smallpox-is enough to send an entire city's population to be vaccinated within a space of 10 days.

The life expectancy for men as a result of these accomplishments of medicine in the control of infectious, contagious, nutritional diseases, is close to 68 years, and that for women has already passed the scriptural threescore and 10.

The aggregate result is, as you will see on chart 2, that there are about 3 times as many people in the United States over the age of 45 as there were at the turn of the century.

The next chart indicates that cancer is a disease of those 45 and beyond, and since there is this unprecedented increase in the older segment of our population, it is perhaps not too unreasonable that we should have as many as 3 times the number of deaths from cancer as we had 50 years ago. Whereas, for the present year the estimated deaths attributable to cancer will come to well over 200,000—about 224,000-the deaths which may be anticipated at the present rate of increase according to chart 4, will reach a figure of 415,000 in a short space of 47 years.

Now the late increase in cancer-recorded incidence and mortalityis due, to a degree which we cannot determine, to more accurate diagnosis which is more generally available today than ever before. Improved standards of medical care, by reducing death from infectious diseases and by diagnosing cancer with greater precision, serve to increase the reported amount of cancer in the population.

I will call your attention to chart 5 which indicates that mortality from infectious and parasitic diseases appears to vary based on the number of doctors in a population. The more doctors there are, the fewer the deaths from infectious diseases, but with respect to cancer we are faced with the unhappy paradox as shown in chart 6 that the more doctors there are in the community, the higher the cancer death rate is, which could lead and sometimes does to the theory that if you have cancer the doctor is the last person whom you should see. What we are sure of, though, is that it means in communities with high standards of medical care one's chances of dying from cancer are substantially less than they are in other areas. High living standards, high literacy rates, good nutrition, high quality, and generally available medical care, reduce these deaths from infectious, contagious, and nutritional diseases and that leaves little to die from except cancer and heart disease.

While these two factors-lengthening of life and wider recognition of cancer-account for the bulk of cancer's mounting incidence and mortality and for the recorded increase in cancer, 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 it has been called by some observers an epidemic of cancer and suggests the operation of cancer-producing factors of relatively recent development.

Now, at the turn of the century, cancer, as has been pointed out, was eighth in the list of causes of death. It was preceded by Bright's disease, tuberculosis, pneumonia, diarrhea, enteritis, and diseases of the muscular system; 78,000 people a year were dying from it. What research was being carried on was in terms more of alchemy than science.

There was but one specifically designated cancer hospital in this country and there were no cancer clinics at all. 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—that is, the taking of a piece of tissue to study it under the microscope to be sure it was cancer, was still a matter of medical controversy. X-rays were being employed somewhat gingerly and radium cost five times its present price, thereby limiting its availability sharply.

The operation for cancer of the rectum, now performed in every crossroads hospital, 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.

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 cancer detection 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 from the scalpel.

This recital, I hope, serves to underscore the point that virtually everything we know today about cancer-virtually everything we know that is utile in treating it and diagnosing it-we have learned in a single generation. And, yet, we must all agree that we are still in the green years of medical discovery, and nothing certainly will be adduced here today or no evidence presented which would justify a position of apathy or resignation, with respect to future progress in this disease.

I want to close my remarks concerning the extent of this problem, by referring to the curability of cancer today since Dr. Heller has, I think, so effectively discussed the economic aspect of it. There is no other disease which presents such a disparity of curability under varying conditions of early diagnosis and expert treatment.

I want to say a word about localized disease. One of the features of cancer is that sooner or later it spreads from its point of origin and goes to other parts of the body. This is partly due to the biological features of the tumor, but is also partly due to the factor of time. Therefore, the interval between the onset of the signs and symptoms and the time treatment is given, is of utmost importance in the control of this disease today, assuming, of course, the availability of expert treatment.

Chart 8 shows what this disparity is. Cancer of the breast, treated under the best circumstances today while the disease is confined to the breast, can be cured 7 or 8 times out of 10. Of all cases with breast cancer in the United States, we are not curing more than one-third. Cancer of the neck of the womb-the leading cause of death from cancer among women-is now curable 7 times out of 10 when it is treated while the disease is confined to the cervix; we are not curing more than 20 percent of cancer of the cervix in this country. Cancer of the mouth is curable in two-thirds of the cases when it is treated while the tumors are no bigger than my little fingernail. Countrywide, we are not curing more than one-third of our oral cancer. Now, this disparity is identifiable for almost every form of cancer and it is the basis for the program of education and control, which I trust will be elucidated in more detail as the days go on.

In aggregate, what I have said means according to chart 9 that it is possible today to cure one-half of all cancer. We are actually curing only one-half of that half. The remaining one-half of patients who develop cancer must look to the advances yet to come from research enterprises now under way.

One final word-it is information supplied to me actually by Dr. Heller and his staff-and it concerns the economic impact of this disease. The officers of the National Cancer Institute have calculated that on the basis of the number of patients destined to get cancer this year, there will be admitted to hospitals in the United States in the course of this single year 114,530 patients who will stay in the hospital an average of 27 days. According to my multiplication this means 11,921,310 patient-days in the United States in a single year attributable to cancer. If the cost in a hospital can be average at $15 a day-and that is conservative-I am sure some of my esteemed friends here will say, this means that we are paying $178,819,000 a year for treating cancer, and we are losing at the rate of 3 to 1. Thank

you.

Dr. HELLER. Mr. Chairman, it is no accident that the men around this table know each other, because they work together and have learned to work as a team.

We have, I hope, established the point that cancer is an extraordinarily complicated, complex disease, well recognizing that there has been an understanding, in fact an urgency in our minds that it is necessary that all the resources available in this great Nation be mobilized on as integrated a basis as possible, compatible with our democratic way of doing things in medicine and in other endeavors.

I should like to establish with the committee the point that there is a liaison of understanding in knowledge and exchange of information-intelligence if you please-in this cancer control and cancer research effort.

I have requested Mr. Runyon of the American Cancer Society to speak on that point. Mr. Runyon is executive vice president of that society.

The CHAIRMAN. Before we proceed, would it be possible and would you be willing, Doctor, for members of the committee who desire to be given the opportunity to ask such questions as they may desire? Dr. HELLER. Definitely, Mr. Chairman.

The CHAIRMAN. In that connection, I would like it also to be recognized by those who are present about the table, who have been introduced to us, that you may ask each other questions if you wish, in order to make more plain or to emphasize any point that you wish. In other words, this is a symposium that is being held with you people who are here as recognized representatives of these organizations and the committee is privileged to take part in it. Are there any questions which the members of the committee desire to ask at this time?

Doctor, I would like to ask the question as to what is the situation with respect to the number of beds available to care for cancer victims?

Dr. CAMERON. I think the answer to that is a difficult one to arrive at, if the question is predicated on the basis that cancer beds are specifically designated as such. If you were to hold to that basis for the question, I should estimate that we could probably count not more than 1,800 beds in this country. But, every bed in every hospital designated as a general hospital is available to patients with cancer. They are received just as are patients with heart disease or with acute appendicitis.

So, the number of beds available for cancer patients is not a specific problem disassociated from the major problem of the availability of hospital beds and facilities.

The CHAIRMAN. You used the figure 1,800. I presume you have in mind particular hospitals that are so designated?

Dr. CAMERON. Precisely.

The CHAIRMAN. Those are beds solely and entirely for cancer treatment?

Dr. CAMERON. Yes, sir.

The CHAIRMAN. I notice on chart 7 some very interesting figures relating to death rates and causes of cancer by countries-selected countries. There seems to be a very pronounced difference in the cancer rate in different countries. What is that due to, in your opinion?

Dr. CAMERON. It is due not to any difference in susceptibility to cancer, we believe, but to two factors: One, the standard of medical care, by which I mean the accuracy of reporting cancer; and No. 2, the age of the population.

Not very long ago someone got excited over the fact that there was very little cancer on the island of Ceylon. The death rate from cancer on Ceylon-which I think is not in this list-is 11 per 100,000, the lowest in the world. But there are very few people in Ceylon who live beyond the age of 35; they die from the diseases we have been talking about today as having been controlled in this country,

or from similar ones. So they do not live long enough to get cancer. The operation of those two factors accounts for most of the disparity in the incidence or mortality from cancer.

Let me say one more word; this chart which you have referred to divides the countries of the world according to their general death rates. The countries with a general death rate from all causes greater than 1,500 per 100,000 of population are in the right-hand column, and those with general death rates of less than 1,500 per 100,000 are in the left-hand column. You will note in the column where the death rates are high, there are relatively low rates from cancer, whereas in the countries where people grow old-where the total death rates are lower-there are the highest recorded death rates from cancer.

The CHAIRMAN. Well, having in mind the explanation that you have just made, how would you account for the difference between El Salvador and Costa Rica?

I am asking you the question more from the standpoint of trying to ascertain what is the underlying cause. Those two countries are very close to one another and have the same general characteristics. I have been in both of those countries, but it would be hard to express my opinion as to wherein they differ, and yet I notice that the rate for El Salvador is 1,747.4, and the cancer rate is 12.9, while in Costa Rica the cancer rate is 62.8. In other words, five times as much almost as its neighbor, El Salvador. Yet the total rate of death is approximately the same, 1,708.7 against 1,747.4 in El Salvador.

Dr. CAMERON. These death rates from cancer are notoriously unreliable, and all this chart does is to express a trend. I could not explain it perhaps as well as you can since I have not been to either country. Actually the difference between the two would be of doubtful statistical significance. When we get a range from 43 and 146, then we have something that we can talk about with reasonable

assurance.

Actually I have only one possible explanation, sir, and it is a very limp one. Is not Costa Rica closer to the United States?

The CHAIRMAN. If it is I would not know it personally based on the time it takes to fly from El Salvador to Costa Rica.

Dr. CAMERON. No, sir.

Mr. WILLIAMS. El Salvador is north of there.

The CHAIRMAN. That is what I thought. El Salvador is north of Costa Rica. Costa Rica is immediately next to Panama.

Dr. CAMERON. Well, my explanation is limper than ever.

The CHAIRMAN. Sir?

Dr. CAMERON. My explanation is limper than ever.

Mr. DOLLIVER. Might it be explainable on the basis of the accuracy of diagnosis or the post mortem examination as to the cause of death? Dr. CAMERON. That well could be. As I pointed out, that is one of the factors which appear to explain these differences. I am not sufficiently familiar with the difference in diagnostic facilities in the countries we are talking about to be able to assign it to that specifically. The CHAIRMAN. Well, there was that difference which was so striking that I thought there might be some significance there.

I am inclined to think that there may be a lot to what you say with reference to the accuracy of the figures, because when you go into one of those countries you are impressed that that could be very readily