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To the present day, 10 patients have been treated in this fashion. Initially, the first 5 patients were given only 1 treatment; however, later patients have been given as many as 4 treatments. We believe that the results of these investigations warrant further study, and changes in the nuclear reactor for more extended studies and application of this therapy in other types of cancer have been made.
A nuclear reactor designed especially for medical investigation would considerably augment such studies, since a more satisfactory facility might be constructed for proper positioning of patients and a more suitable quantity of neutrons might be obtained.
These comments will serve to give you an idea of some of our investigations in cancer. However, I hasten to add that this constitutes only one phase of our applied medical investigations.
We also have an extensive program in the employment of isotopes in the study of fluid accumulations in the body, such as in children with kidney disease known as nephrosis, a form of Bright's disease, and in the study of high-blood pressure, hyperthyroidism and sickle cell anemia.
In summary, at Brookhaven we are investigating the therapeutic application of nuclear energy in an attempt to find new isotopes or improved methods for the use of isotopes in an effort to improve irradiation therapy in cancer. In addition to the use of these short half-life isotopes, investigations have been undertaken in an effort to utilize directly the nuclear reactor in the treatment of cancer to the application of thermal neutron capture by boron.
I thank you.
Mr. DOLLIVER. I was interested in your recital of procedures used in the treatment of brain cancer by the use of boron.
What has been the clinical results of those treatments?
Dr. GODWIN. We think that there has been some clinical improvement in these cases. I might add that all these patients have died, and we are now pursuing a very intensive investigation of the possible pathological changes which have resulted from the slow neutron therapy
Mr. DOLLIVER. Of course, a brain cancer is generally about as hopeless a thing in medicine as can be imagined; is that not so?
Dr. GODWIN. Yes; it is. I think the average survival time for this high type of malignant tumor is about 180 days. Some of the patients live a little longer. There might be variations in the survival time of any one patient. One may live 2 years, possibly, but the average is about the 6 months' period.
Mr. ROBERTS. Doctor, is the information which has been obtained from work being done at your institution being made available to other institutions on an international basis? You are working in cooperation with other institutions, not only in this country, but in other countries of the world. Is that true?
Dr. GODWIN. Well, other countries have access to our publications. We publish this material in national medical journals which are open to inspection by physicians in general, and many of these journals go to other countries. Most of the information that I have mentioned here has been publicized in one way or another, either by talks or print. The germanium-titanium-phosphate needle is really a recent development and has just been presented at the American Medical Society.
Mr. ROBERTS. It has been mentioned that in practically all cases of brain tumor or cancer there are no cures or recoveries. As a usual thing, is that cancer of the bony structure of the head or the brain tissue ?
Dr. GODWIN. That is a disease of the brain tissue itself, the supporting tissue of the neuron. The thing that supports the neurons is the glia, and this is a tumor of that supporting structure.
Mr. ROBERTS. I suppose these treatments are very expensive; are they not?
Dr. GODWIN. They involve the use of many facilities, many individuals very highly trained, and I would say they would be considerably expensive.
Mr. ROBERTS. Take an average case. What would your estimate of the cost be?
Dr. GODWIN. I am sorry that I am not able to give you a figure on that. I would not know how to break it down.
Mr. ROBERTS. Most of the cases you get, I assume, are pretty far advanced.
Dr. GODWIN. Yes. Patients with this particular tumor, generally, are in fairly bad shape. As we have indicated, they have a poor prognosis.
Mr. ROBERTS. It is a rather hard thing to diagnose, and I think in many cases it is far advanced before doctors even know what it is.
Dr. GODWIN. Like so many other cancers, it may not manifest itself until it has become a rather large tumor, possibly this large [indicating] sometimes.
Dr. BUGHER. I think it is true that all these patients were considered completely hopeless, with no prospect whatever other than a fatal termination within a period of a few weeks if not so treated.
Mr. ROBERTS. Changing the subject a little bit, I keep hearing a lot about these atomic-cocktail treatments for heart diseases. Are you familiar with that situation?
Dr. GODWIN. Yes.
We have not done this type of work at Brookhaven. It is being done in various parts of the country, but I know of Dr. Blumgart's work, who is in Boston, and he has been killing off the thyroid through the use of radioactive iodine, iodine 131, in the hope of reducing the basal metabolic rate and improving the medical situation generally. Possibly Dr. Warren could elaborate on this a bit, since Dr. Blumgart is from Boston.
Dr. WARREN. If I may speak, I have been following with great interest Dr. Blumgart's work. He is a close neighbor of mine and is also a faculty member of the Harvard Medical School. I have treated some cases of this type myself. The rationale for treatment is this: It rests on the fact that certain types of heart disease are brought about by an overloading of the heart. The secretion of the thyroid gland is one of the substances which drives the heart. By removal of that secretion, or lowering it materially, it lessens the load and converts a patient who is a cardiac cripple into a fairly well individual.
For example, a number of Dr. Blumgart's patients who are young women have been able to go through childbirth successfully after treatment.
One uses iodone treatment for this purpose because the thyroid has the function of picking up iodine very avidly. It feeds it in the secretion it makes, so one feeds it radioactive iodine, which is then concentrated in the gland and giving off its radiation there serves to destroy the thyroid. Then a very carefully graded replacement of the thyroid hormones can be carried out artificially, if it is indicated, or if it is not needed, there is not a supply of the material. This is the way of making over an overpowering driving force on the heart.
Mr. ROBERTS. That is a relatively new approach to the treatment of heart disease; is it not?
Dr. WARREN. This type of treatment would have been impossible unless we had an atomic-energy program,
Mr. ROBERTS. We can say that the chances of success from this treatment are fairly good; is that right?
Dr. WARREN. There are a number of individuals who have been helped. One cannot treat every case of heart disease in this way, of course. It is only certain types that can be so treated.
Mr. DOLLIVER. You say if there is too much destruction of the thyroid by the radioactive iodine, then the thyroid material must be replenished ?
Dr. WARREN. In certain instances it is advisable to give small amounts of thyroid hormones because it is one of the normal hormones in the body, and it is very much like weighing out substances in a scale. You will put in the weight that you think balances in the opposite
pan of the scale and then you may have to add a little bit more to that weight to get the exact balance that you want.
Mr. DOLLIVER. Normally, the body itself functions to keep the thyroid balance; does it not?
Dr. WARREN. Normally it does, but in certain cases of heart disease this output of thyroid hormone drives the heart so hard that it cannot carry out its functions of keeping up the circulation, and the patient is a complete invalid.
Mr. DOLLIVER. After this treatment by means of irradiated iodine, do
you find that the body again resorts to its normal natural balance of thyroid production, or do you have to continue this treatment, as for instance they do in the injection of insulin for the relief of diabetes?
Dr. WARREN. If the balance is struck just right, there is nothing that has to be done. In a few cases small amounts of thyroid hormone have to be given more or less continuously, much as insulin has to be given.
Mr. DOLLIVER. Of course, the determination of what needs to be done must be made by a physician?
Dr. WARREN. That is true.
The CHAIRMAN. In order that I may understand more in detail the hospitals that have been referred to, I would like to ask a question. Already hospitals have been mentioned at Oak Ridge, Argonne, and Brookhaven for cancer study. I would like someone to inform me just what is the nature of those hospitals. Are they research institutions entirely? Are they limited to a small number, or are they on a large scale? Are they open for general cancer treatment? Just what is the nature of these hospitals that you have referred to at Oak Ridge, Argonne, and Brookhaven?
Dr. BUGHER. They are entirely research hospitals. They have beds only for specially selected cancer patients who are a part of the research. The largest number of beds is at the hospital in Chicago, which is 58, so that there is no intent to open these hospitals for general admission of cancer patients. Each hospital is affiliated with other medical centers which act as the screening mechanisms to assist in the selection of the particular patients that should be received under these special conditions.
The object is to develop new methods. Once a new method is evolved, then it is something that can be used generally. I think Dr. Godwin made clear that at Brookhaven there are certain outstanding developments, one of which is the application of the slow neutron, the thermal neutron with boron inside the tumor cells to produce radiation being created or liberated within the cell itself. A background of his remarks is also the suggestion that they are thinking of a reactor designed, not for just physical experiments, or production of weapon materials, but for medical purposes exclusively that will come in tíme. We do not quite know what the reactor should be at the present time. It is very clear that the line they are working on is one of remarkable promise in the treatment of certain classes of tumors.
He also mentioned the recent development of this disappearing radiation source which is put in place, does its radiation locally, and is gradually absorbed and vanishes from the scene without any toxicity as far as the patient is concerned. It is a very stimulating development.
The CHAIRMAN. What is the number of patients in the several hospitals ?
Dr. GODWIN. We have about 35 at Brookhaven.
Dr. BUGHER. Fifty-eight at Chicago. At San Francisco the laboratory does not have beds, but it is attached to a hospital that does provide the beds. These research beds cannot be compared to the bed capacity and requirements of a hospital giving treatments to a large number of patients as a routine thing.
If I may turn to the program of the Oak Ridge Cancer Research Hospital, directed by Dr. Brucer, this hospital is operated by the Oak Ridge Institute of Nuclear Studies and in the same way as the Associated Universities, Inc., bring the northeastern universities into the Brookhaven orbit, so does the organization at Oak Ridge bring the southeastern medical schools into a very close working relationship is connection with this hospital.
STATEMENT OF DR. MARSHALL BRUCER, DIRECTOR, MEDICAL
DIVISION, OAK RIDGE INSTITUTE OF NUCLEAR STUDIES, OAK RIDGE, TENN.
Dr. BRUCER. Mr. Chairman and members of the committee, when in late 1947 Dr. Warren, with considerable encouragement from the Congress, suggested that we start up a cancer-research program, he did not make a unilateral decision as to the work which we would undertake; instead, he consulted a group of university medical schools on the type and scope of cancer research which the AEC might properly undertake.
The situation in cancer is exceedingly complex, and we knew we had to limit our studies within very definite bounds. We decided that what we should be doing in Oak Ridge are things for which Oak Ridge is particularly adaptable, that we should adapt our program to the tremendous facilities of Oak Ridge, and since Oak Ridge is the headquarters of the production of isotopes we limited ourselves to the study of isotopes. Since this was to be a cancer program we felt that we should limit ourselves also to the use of isotopes in the therapy and diagnosis of cancer in humans. Since we were a group of medical schools conducting a program using Federal funds, we felt that we should try to limit ourselves to the very, very practical studies. However, we wanted to define the word "practical" with the realization that what is impractical today might be practical tomorrow. This, we felt, was our main objective, to make some of the facilities of Oak Ridge in the use of isotopes which are practical today very practical for medical practice tomorrow.
The program also had one other phase. We would be a research hospitaì dealing with approximately 20 patients at one time. We did not have a service function. We did not have to accept a large volume of patients. We could take our patients from all the medical schools in the entire southern area. We could collect which patients we wanted, and since we did not have a service function and the immediate treatment of a particular patient, since this was not a necessity in our program, we felt that we could do certain studies which many hospitals could not do.
Most medical-school hospitals have to accept a large number of patients, and they have to do something for the patient immediately. They have to have a rather rapid turnover of patients. When patients are kept in hospitals for a long period of time it is exceedingly expensive. We did not have this limitation. We had only to deal with a very few patients so we divided our program into two phases, a phase involving the internal use of isotopes, where the isotopes were given by mouth, or injected into the vein, or injected into the abdominal cavity, or into the bladder, and another phase which was the external use of isotopes where you take a large dose of radiation and let it shine into the body.
On the internal isotope program there is one part of this program which is very important and which could not be done, or was impractical to do in many medical schools, and that is the one dealing with problems where the patient has to be watched over many, many weeks.
Since we can keep our patients as long as we think it is necessarv, we decided to take a certain portion of our patient load from people who were in a hopeless condition, patients who we recognized would die in the hospital and who had hopeless cases of cancer. This would allow us also to experiment. It give us the moral background for doing new things, using new isotopes which might or might not be very dangerous and to use them in human beings.
There is a certain amount of work that can be done in animals, but certain things must be done in the human patient. Certain cancers appear only in human patients, not in animals, and they cannot be studied in animals; they have to be studied in humans. We thought that the proper place to start the studies would be on patients where, even if we made a mistake, we could not make much of a mistake, and so this is one phase of our program.