difficult. This expectation has certainly proven accurate perhap even conservative. Nevertheless, progress had been made and the out look for ultimate success seems brighter now.

VITAL STATISTICS

In 1937, 144,774 Americans died of cancer, a crude death rate of 112.4 per 100,000. That year approximately 48,000 cases were cureda cure rate of 25 percent. In 1967, 305,000 Americans will die of can cer, a crude death rate of 153 per 100,000. The 5-year cure rate is now better than 35 percent. Physicians will cure 165,000 cancer cases in 1967, and it is safe to predict that the salvage rate will continue to ris as we achieve wider application of our present knowledge through pro grams such as the Regional Medical Program for Heart Disease, Can cer, and Stroke, and as we gain additional knowledge through research now in progress.

Even so, we seem to be losing ground. The cancer rate is increasing more rapidly than the cure rate. What does this mean? Part of the answer lies in population growth and longer lifespan. More peopl live long enough to get cancer. But this cannot explain the total in crease. New cancer causes must be at work.

CANCER CAUSES AND PREVENTION

I am firmly convinced that the unexplained increase in cancer mus be attributed largely to an increase in man's exposure to cancer-causing agents in his daily environment.

This is most easily documented when the exposure is peculiar to particular occupation where exposure is intense and long continued You are all familiar with the old stories of skin cancer and the petro leum industry, bladder cancer and the aniline dye industry, lung can cer and the chromate industry, et cetera. New examples crop up every year. One of the most spectacular recent examples being the discovery of the 50-fold increase in incidence of lung cancer in Japanese worker in a nitrogen mustard gas factory over a comparable group in the gen eral population. We have developed working relationships with in dustry to detect new occupational cancer and identify and eliminat the cause as quickly as possible.

In the population at large, cause-and-effect relationships are much more obscure. The only clear-cut example is the relationship between cigarette smoking and lung cancer. If one eliminates this examplesmoking and lung cancer-in the general population, he is left with number of changes most difficult to explain. One is the rapid decreas of stomach cancer in the United States, while it remains high in Japan Chile, Finland, and Russia. Studies now in progress implicate dietar factors, but the problem is still unsolved. Cervical cancer is also de creasing as a cause of death, but this seems to be due to early detection through Pap smears. Unfortunately, the general trend of cancer inci dence is upward and for no apparent reason in terms of specifi carcinogens.

Certainly, new carcinogens are entering our environment despit active testing programs which have identified hundreds of chemical as potentially cancer-causing or carcinogenic. The more we learn, the more complex the problem becomes. Weak carcinogens become

strong carcinogens in the presence of certain chemicals which by themselves are not carcinogenic at all. The same applies to the interaction of chemicals and viruses. Our special virus program, authorized by the Congress 2 years ago, is now moving forward with increasing momentum. At last, human cancer cells growing in the test tubes are producing virus particles in quantities which in the next few months will permit the preparation of reagents with which we can measure the serologic status of substantial human populations, and it is only a matter of time, I believe, until viruses join the list of causes of cancer in man. At this time, we can only speculate as to the role they may play in the growing number of cancer deaths, or whether practical control measures will evolve.

Among the experts a new concept of carcinogenic burden is emerging, which takes into account the possible cumulative effect of repeated exposure to a variety of carcinogens and co-carcinogens, which ultimately results in the appearance of cancer, the nature of which depends not only on the type of exposure, but also on individual suscep tibility.

To explore the inter-relationships of various cancer causing influences, we have established a new center for carcinogenesis research in collaboration with the Atomic Energy Commission at the Oak Ridge National Laboratory, which will come into full operation next year and where we hope to develop not only specific inter-relationships, but ultimately general principles which will permit us to predict the interaction of various agents and to establish safe levels. During the past several years as knowledge accumulated on the chemistry and biology of DNA and RNA, major progress has been made in understanding in some detail how a carcinogenic chemical or virus converts a normal cell to a malignant one. Herein lies the greatest hope for the future. If we can discover a physio-chemical phenomenon common to all the thousands of carcinogenic agents, we may ultimately devise a chemical or biological manipulation to prevent or reverse the malignant change.

MANAGEMENT OF THE ADVANCED CANCER PATIENT

Thirty years ago, the advanced cancer patient was generally considered a hopeless problem, treated largely with narcotics to dull the pain and sent home to die. Today the outlook is different. Many of the symptoms which characterize advanced cancer can be managed effectively by skillful use of modern medical science, if the physician is willing to try and society is willing to pay the cost. There is little excuse these days to tell the patient nothing can be done.

More important than control of symptoms, is control of the cancer itself, and major strides have been made here. In part, this has been accomplished by developments in radiation therapy, which make it possible to control life-threatening metastases and in favorable circumstances, to cure previously incurable disease. During the past year it has become evident that Hodgkin's disease, if discovered when it is reasonably localized and treated aggressively with X-ray, can be completely controlled in about 40 percent of the cases for periods exceeding 15 years, which must be regarded as cures. Heretofore, this disease has been regarded as incurable.

The entire history of practical drug therapy of cancer is encom passed within the 30-year period and in the past several years, I hav reported to you evidence which would indicate we are actually curing advanced choriocarcinoma in women with drugs. Last year I reported that more than 100 children with acute leukemia have survived years or more without evidence of the disease. Acute leukemia, chor iocarcinoma, and Hodgkin's disease are relatively rare forms o malignancy and taken together account for only 3.2 percent of cance deaths. From a practical standpoint, complete control of these form of cancer would make small impact on the total problem, but to m they are extremely important as a demonstration that what is incur able today may be curable next year, and the direction in which it wil lead us in searching for a cure of other cancers.

Perhaps the greatest accomplishment in recent years is the devel opment of drugs which produce spectacular remissions for periods months or years and which restore the patient to comfortable, norma activity, even though his life may not be substantially lengthened Cancer of the breast, one of the commonest cancers in women, respond frequently to the use of steroid hormones or anticancer drugs. Can cer of the prostate in man similarly responds to endocrine manipula tion. Cancer of the large bowel, another common cancer, respond in a substantial percentage of cases to treatment with 5-fluorouracil

THE CHANGING PROBLEM, STRATEGY, AND ORGANIZATION

In 1937, there were almost no leads for a direct attack on the cance problem, which dictated the strategy of investing broadly in funda mental biology in order to understand normal processes, cell growth multiplication, and differentiation. The National Cancer Institut stood virtually alone as a source of support for biomedical researc and training in non-Federal institutions. After World War II, th National Institutes of Health began to evolve both general and cat egorical programs for the support of biomedical research and train ing, but for the first years, the National Cancer Institute continue to be the chief Federal source for the support of fundamental biology Beginning about 10 years ago, Federal funds for the support o fundamental biology through general sources such as the Nationa Science Foundation and a variety of programs of the National In stitutes of Health, gradually shifted to these emerging organization the role of supporting the type of biomedical research which is fur damental to the solution of almost any disease problem. Reorga ization of the Public Health Service resulted in the transfer of th cancer control function to the Bureau of State Services. With th strong support of basic research, reinforcing its own efforts, the NO began focusing more directly on human cancer. An interinstitu tional network for evaluating cancer tests was established and mad a real contribution by demonstrating the inadequacy of a number tests for which extravagant claims were being made. In 1955, major drug development program was launched with enthusiast support from the Congress. In 1958, intensive efforts were launche on the viral etiology of cancer. In 1961, a buildup in carcinogenes research began. Next came the creation of the leukemia task for and then the special program on leukemia and viruses. There a now many leads to be pursued and many resources with which

pursue them. Our strategy is to pursue these leads with all the resources available, without regard to the organizational location. To this end, we have established a number of joint programs such as the one with the Atomic Energy Commission at Oak Ridge, with the Department of Agriculture at the University of Kentucky, and with several of the other Institutes. The most recent example is a broad, long-term study of birth control, which was initiated by the National Cancer Institute because of its interest in the possible carcinogenic effect of the substances and devices recently introduced. After the planning stage, the program was transferred to Child Health and Human Development, since the cancer aspect is a relatively minor part of the total study, and I am sure the cancer aspects will be thoroughly explored by Dr. Roy Hertz, who has left the Cancer Institute to become their scientific director.

To fulfill our changing role, we have carried out a sweeping internal reorganization designed to consolidate the various fragments of our programs concerned with specific problem areas under a single

manager.

NEW PROGRAMS

During the current year, we have launched several new programs. One is the task force on breast cancer, which will pull together the entire effort on this major disease, which has so stubbornly resisted control.

Another is a new approach to clinical training on an institutional and interinstitutional basis, aimed at increasing and improving cancer training of all medical and paramedical personnel at the undergraduate, graduate, and postgraduate levels. The initial response is most encouraging.

Much attention has been devoted to the role of the National Cancer Institute in the new regional medical program, which we believe will increase greatly the national capability to solve the cancer problem.

APPROPRIATION REQUEST

Mr. Chairman, the request for the National Cancer Institute for 1967 is $163,957,000, compared to the 1966 operating level of $163,706,000. The 1967 budget request contains increases of $2,907,000, including: $428,000 for research fellowships; $168,000 for training grants: $981,000 for direct research; $942,000 for collaborative studies: $124,000 for review and approval of grants; and $264,000 for program direction. These increases are partially offset by decreases of $1.156,000 for research grants and $1,500,000 for chemotherapy

contracts.

APPRAISAL OF THE CANCER BUDGET BY THE SUBCOMMITTEE CHAIRMAN

Mr. FOGARTY. Thank you, Doctor. The adjusted appropriation for 1966 is $163,706,000. The request for 1967 is $163,957,000, a mathematical increase of $251,000, but for all practical purposes a cutback in most of your programs, is that right?

Dr. ENDICOTT. There are cutbacks in some of them, yes, sir.
Mr. FOGARTY. Most of them.

Dr. ENDICOTT. The direct research program has actually increased The carcinogenesis program has an increase. The fellowship pro gram has an increase. But most of the rest are reduced to som extent.

Mr. FOGARTY. You have these three increases and everything els will be cut back.

Mr. CARDWELL. In total there is an increase of $2.9 million whic provides $428,000 increase for research fellowships, $168,000 increas in training grants, $981,000 increase for direct research, $942,00 increase for collaborative studies, $124,000 increase for review and approval of grants and $264,000 for increases for program direction Mr. FOGARTY. Is my $163 million figure right?

Mr. CARDWELL. Yes, sir. There are offsetting decreases of a mil lion and a half in cancer chemotherapy and a decrease of $1,156,00 in research grants.

Mr. FOGARTY. Many of these that you call increases won't be suf ficient to cover increased costs.

Mr. CARDWELL. The information that we have indicated that in sofar as the cost of continuing projects into 1967 and beyond, the National Cancer Institute estimates that cost will actually decrease Is that not correct, Doctor Endicott?

Mr. FOGARTY. You are cutting back in most of your programs Take the fellowship program as an example. You mentioned ther is an increase. But on new awards you are cutting back 72.

Mr. CARDWELL. That would still leave an increase of 31.

Mr. FOGARTY. You are cutting back 72. You will have to cut back and make 72 fewer new awards in 1967 under this budget than you are making this year. Are these justifications correct?

Mr. CARDWELL. Yes, sir.

Mr. FOGARTY. On page 105 you show minus 72 new awards in 1967 On page 107, under new training grant programs, you are cutting back 18 and $2 million. This is another example of the type of thing you find when you analyze these so-called increases you spoke of.

In the field of cancer, the whole program is going to be cut back under this budget because this $251,000 won't come anywhere near meeting your increased costs. We are going backward instead of ahead.

You did not fare very well, Dr. Endicott. You asked for $188 million and the Department and Bureau of the Budget cut your request $24,177,000.

Dr. ENDICOTT. Yes, sir; there was a reduction.

Mr. FOGARTY. I thought we were supposed to be expanding this program of research in cancer. This is the biggest cut in the Institute's request I have seen since the Cancer Institute was formed in 1937.

Mr. CARDWELL. Insofar as the reduction shown in the record between what was requested of the Bureau of the Budget and what was actually identified in the President's final budget is concerned, the Bureau of the Budget and the Secretary did leave to the Surgeon General and the Director of National Institutes of Health the job of selecting priorities. I admit he had a very tough series of choices to make. There are substantial increases in many of the other Institutes. He did make choices, I gather, between the Institutes.

Mr. FOGARTY. No; there are no substantial increases at all. The increases don't even total up to as much as the increased costs.