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Mr. DOLLIVER. Dr. Brucer, I want to inquire about a matter that Mr. Teeter called to my attention and that is this: The development of the technique of rotational radiation-is that a proper term ?

Dr. BRUCER. Yes, sir, that is a good term.
Mr. DOLLIVER. Would you explain that to us and tell us its advan-

Dr. BRUCER. One of the first men to use radiation in therapy was an Englishman named Dr. Knox in London, England, at the Royal Cancer Hospital. This was in 1906. The first way he tried to use his machine was by rotating the machine over the patient. But he had trouble in doing that because in 1906 the energy X-ray that he was using was very low, and therefore he could not get sufficient penetration into the body. Also, in order to get the low energy which he was getting, he had to have tremendous electrical cables coming to the machine and therefore he could not rotate the machine. So there was a mechanical difficulty, which was an energy difficulty, in 1906.

During the history of the development of X-ray therapy throughout the next some fifty-odd years there has been an increase in the energy every year or so and there has been such an increase in the amount of energy until we finally came to 1940 and the advent of that area where we now have 1-million-volt energy, and so forth. But with the development of the X-ray machine, as the energy went up, the machine became larger and larger and became impossible to move around with, with complete freedom.

With the development of isotopes, within a period of a few years, we have truly high-energy radiation, but at the same time we have it self-contained in a source which is no larger than the end of this pen. Now, we do not have the large cables, so that we do now have a complete freedom of rotating the machine. It is not the large, bulky thing that used to be in the 3-story, 2-million-volt X-ray machine, because I think for the first time we can start to study what is no longer termed rotation therapy. We have changed that; we do not want to just rotate the machine; now we want to have what we call moving-field therapy because we are going to make the machine, or move the machine over the patient in any direction so we can develop what Robert Knox was trying to do in 1906—to develop an area of concentrated radiation inside the body, no matter where it may be inside the body.

Mr. DOLLIVER. Is there not also a technique that might be called a crossfire therapy-where you direct two beams at a certain spot in the body?

Dr. BRUCER. This is the technique that is now used, and of course it is much the same type of technique to develop a concentration of radiation inside the body. If you use 2-beam crossfire, the crossfire area will have a much greater absorption of energy than with 1 beam; if you use 4 beams that is even better; if you integrate this over an infinite number of beams on a rotating system, then you have got as good as it is possible to get-then you have approached the 1-million area, or as far as radiation can go.

Mr. DOLLIVER. You get the maximum benefit?
Dr. BRUCER. Yes, sir, you are getting the maximum benefit then.

Mr. DOLLIVER. Well, is that rotational or crossfire technique generally used at the present time, or is it still in the experimental stage?

Dr. BRUCER. To a large extent it is still in the experimental stage, but there are a number of people in the country who have started to approach it. Within the last 10 or 15 years it has been slowly growing.

Mr. DOLLIVER. Is that being worked upon by you and the Oak Ridge Institute to any extent?

Dr. BRUCER. On the smaller machine this is impossible, but on the large machine we have done some work. The new machine is being made so it has a complete fredom of rotation.

Mr. DOLLIVER. Do you anticipate that there will be further development in this technique ?

Dr. BRUCER. There is a very rapid development going on throughout the world right now in these techniques.

Mr. DOLLIVER. Thank you.

Dr. BUGHER. Mr. Chairman, may I introduce a little change in our program at this moment with your permission, because Dr. Warren has to catch a plane back to Boston at 1:20, in order to make an address in Boston, and I would like to have him address his remarks at this time, to follow later with the discussion of the Chicago Cancer Research Hospital and then further questions.

The CHAIRMAN. Very well. I think Mr. Carlyle had one question which he desired to ask of the witness who has just spoken.

Mr. CARLYLE. It might require some time, though, to answer that question and I shall be glad to delay it.

The CHAIRMAN. I have in mind as we are approaching the end, I presume, of the testimony to be offered, that it would probably be more convenient for everyone concerned if we continued until we finished, rather than adjourn at this time, as we usually do.

Very well, you mav proceed.

Dr. BUGHER. Dr. Warren as you know has been one of the greatest contributors to the advancement of knowledge in the field of cancer in the United States. He has been the initiator of many of the developments in the atomic-energy field and is, more than any other single individual, responsible for the program which we are discussing today.

I have requested that he give us his opinions and advice relative to: the directions which our research should follow and the trends which exist, as he can see them, based on what we know today.

Dr. Warren.

STATEMENT OF DR. SHIELDS WARREN, DIRECTOR, CANCER

RESEARCH INSTITUTE, NEW ENGLAND DEACONESS HOSPITAL, BOSTON, MASS.—Resumed

Dr. WARREN. The advent of atomic energy offered to cancer research workers an almost boundless horizon, both as regards sources of radiation for treatment, and tools for research and the understanding of some of the fundamental aspects of the cancer problem, which is very closely linked with the problem of life itself.

Cancer is an abnormal growth in cells, as you heard yesterday. We had been able prior to the availability of radioisotopes to estimate what cells were doing by seeing some of the raw materials that went into the cells-seeing something of their form and shape under the microscope—and learning some of the end products that came from the activity of these cells.

With the availability of the radioisotopes--which means that every atom-every molecule can be followed in its course through the cell, it became possible to learn a great deal of basic information in the field of how cells grow, how they are put together and the nutritional material that is brought to them into the cells, into tissue and into organs, and under abnormal circumstances into the cancers of those organs.

The problem of growth and the problem of cancer, as you heard yesterday, is very intimately related one with the other, and the most potent tool that has ever been found for the understanding of growth and production, both normal and cancerous, is this group of radioisotopes—the tagged atoms—which enable us to follow all of the processes that take place.

Now, radiation is like fire. Fire is absolutely essential to us; without it, we would be cold, our food would be raw, but, like fire also, it is a potentially dangerous thing, and uncontrolled radiation, either in the course of the operation of an atomic pile or in the explosion of an atomic bomb, can be even more destructive than a fire. So that a great portion of the effort of the Division of Biology and Medicine has been concerned with keeping the atomic energy business safe, as well as making available the numerous tools that it provides for research in the life sciences.

Just as an example of the safety that has been brought about, I myself have had the unfortunate task of diagnosing and recommending treatment for all but one of the pioneer workers with X-ray in the New England area who, because they did not realize the danger of radiation, had cancers develop on the exposed portions of their bodies, more particularly their hands.

That sort of thing cannot happen now because of the greater understanding of radiation that has been brought about and because we have learned to control it much more effectively than in the past.

Up until the time of the development of atomic energy—the existence of the Manhattan project and the Atomic Energy Commissionapproximately 1 out of every 10 people who worked with radium was damaged by that radium. As you know, we have had a startlingly fine accident rate in the Atomic Energy Commission and in the Manhattan District. There have been only two deaths among the thousands of people involved; there have been only a handful of slight injuries, this in spite of the fact that, instead of handling roughly a pound of radium which was the case up to about 1940, the equivalent of literally hundreds or even thousands of tons of radioactive material have been handled by the workers in the Atomic Energy Commission.

I think it is worthwhile showing that industrial safety can be achieved if one knows how to go after it and one does go after it.

The Atomic Energy Commission today is one of the safest businesses, instead of being one of the ones that might have carried an enormous risk.

Now, cancer is a group of diseases and not any one disease. It behaves differently according to the cells from which it arises; it behaves differently with the different sites in the body in which it occurs. I doubt very much that there is ever or there will ever be found one single cause for cancer. In fact, we know already that there are a number of causes and some causes we do not know. I doubt very much that there will ever be one cure for cancer, and I feel certain

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that in the applications of atomic energy to the problem, we will find ways of curing certain types of cancer but not all. But, the fact that we can at the present time ameliorate, that we can at the present time actually cure certain types of cancer, makes the picture very hopeful for the future and makes it very worthwhile to keep working in this field.

Now, we have a variety of tools, as Dr. Bugher told you earlier, We have these four different types of radiation which can be applied, each having particular characteristics and each particular ways in which it can be utilized.

The ultimate effect on the cell of all these types of ionizing radiation is essentially the same and the variations we have is in the ways that it can be applied, whether externally or internally—whether certain tissue will pick up one isotope or another isotope, and the essence of the problem of radiation therapy is how to get the maximum damage into the cancerous tissue with the minimum damage to the normal tissue. One cannot radiate without some damage to the adjacent normal tissue, just as a surgeon when he operates has to leave a scar, so the radiologist, when he works, has to leave a scar showing where the cancer has been destroyed and where some of the normal tissue immediately adjacent to the cancer has been also destroyed by radiation.

One of the great problems in the treatment of cancer is that its outlines cannot be sharply defined, and one always has to assume that it extends further than the obvious portions of it. It is somewhat comparable to the problem of the iceberg, the great bulk of which may be submerged.

In the use of radiation treatment, we always need to apply the treatment to a larger field than the obvious field that is shown. For that reason, some degree of selectivity between the sensitiveness of normal tissue and the tumor tissue is of great importance. Fortunately, rapidly growing cells such as we have in many types of cancer are much more susceptible to radiation injury than are normal cells, and this is what gives radiation its advantage—that one can selectively hit certain types of malignant cells without doing too great an amount of damage to the adjacent normal cells.

It is very important in a research program such as that of the Atomic Energy Commission to see that there is a prompt dissemination of the knowledge so that other groups of physicians can make use of it for the benefit of cancer sufferers widely. It is all important that training should continually go on so that there are ample skilled people who know how to do this work in the event that it suddenly becomes of large-scale importance. The training both in the national laboratories and in the universities and research institutions where radiation work is going on is an integral part of the total program in this field.

Also, atomic energy is not a monopoly of the Atomic Energy Commission. We do not feel that only those people who wear the AEC label should work with these materials, and we are very happy to train people in other agencies of the Government and in the various professions throughout the country in the utilization of these materials.

You probably know that at the great new National Institutes of Health, that is being built at Bethesda, there is a special wing for iso

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11 fini tope therapy so that patients there will have the benefit of new adit that

vances that have been made.

We keep in careful touch with the cancer program, both of the t time opeful

United States Public Health Service and those of the various private ng in

agencies; that of the the American Cancer Society, of the Damon

Runyon Fund and others, as well as the work that is going on at the rlier

various universities, and we hope that we are carrying out the instruclied, tions given us initially by Congress and to concern ourselves with those

aspects of the atomic-energy problem that will be of benefit to the

cancer sufferer, without any inefficient wastage or duplication of effort ition

that is being carried on by institutions. that

We feel that we can initiate certain things and tell whether they are tain

good and whether they are not good. If it is good, show others how to e of

do it and make it possible for them to apply such finds on a laboratory scale and we can then continue on with the unsolved portions of the

problem with the special facilities that are available at the Atomic mal

Energy Commission laboratories. cent

Thank you, sir.

The CHAIRMAN. We certainly thank you, Doctor. I was beginning to be a bit nervous over the fact that it is now a quarter of 1 and your

plane leaves at 1:20. by

Dr. WARREN. If I may be excused, then, sir, I would appreciate it.

The CHAIRMAN. We certainly are indebted to you for your presence its

here today. We probably would have asked some questions - either Mr. Dolliver or someone else--but recognizing the necessity of your

going and going fast we will forego that and try to study your testinay

mony and see whether that will inform us without further questioning he

Þr. WARREN. Thank you, sir. "or

The CHAIRMAN. You have such a reservoir of information and of

knowledge that we hate to see anybody get away from us who could

give so much to us. of

Dr. WARREN. I, myself, am very sorry, sir. This is an overriding al

thing that I could not very well change.

The CHAIRMAN. Surely. Will some member of the staff go with the doctor to make sure he gets quick transportation ?

Dr. BUGHER. May we proceed, sir?
The CHAIRMAN. Yes.

Mr. CARLYLE. I would like to ask any member of the panel just one question.

The CHAIRMAN. Go ahead.

Mr. CARLYLE. As I recall, this committee was told yesterday that there were more different kinds of cancer known to the human body than all other diseases of the body combined. Now, the question that I have in mind is this: How many diseases of the human body other than cancer are being studied and considered at this time in the hope that this new radiation would be useful in treating those diseases !

Dr. BUGHER. Well, the list is very formidable. Offhand, I would not be able to give you numbers. But in the general medical program which is being carried on by the general support of the Commission there are explorations into nearly all of the types of disease, if not into every disease. As a good example of the thing that we mean here, some of our disturbances may be related to things that invade the body

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39087-53—-pt. 1----27

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