Long-Term Faculty Development Program Two new programs for oncology faculty development will be initiated during FY 1991. Both are long term development programs for young, but established, Latin American and Caribbean or Central and East European scientists at cancer institutes. The institutes nominate a limited number of their scientists to the respective selection committees. Two-to-four collaborative candidates per year will then be accepted in each one of the programs for three-to-four year collaborative research at NCIsupported laboratories. The East European Oncology Faculty Development program will focus initially on the pharmacological sciences and/or biotechnology. The NCI will continue its efforts to enhance scientific cooperation and to promote information exchange with other countries. Cooperation will include studies basic to all common cancer sites and will focus on epidemiology research, technical workshops, short and long-term scientist exchanges, and clinical trials. PREVENTION Question. In 1985, NCI stated that its strategic goal was to reduce cancer mortality by 50 percent by the year 2000. Please detail exactly what NCI supported research is underway in the prevention of cancer and how that is making an impact on the problem. Answer. NCI's cancer control objectives identify activities that if undertaken by the broadest applicable segments of the population will lead to reductions of major proportion in the morbidity and mortality from cancer. Recently these objectives have been incorporated into the Department of Health and Human Services prevention objectives known as "Healthy People/2000." NCI's objectives call for significant smoking reduction to less than half the level of 1985, a decrease in dietary fat to 30 percent of calories, an increase in dietary fiber to between 20 to 30 grams per day, a substantial increase in breast and cervical cancer screening, and an increase in the use of state-of-the-art treatment. We estimated in our 1985 report outlining the objectives that with full achievement mortality could be reduced by 25 percent and by as much as 50 percent if we increase the rate of progress in our development of new treatments. The National Cancer Institute translates the results of its basic and clinical research into the means to prevent cancer, to find efficient and effective ways to detect the disease early when it is most treatable, and to assure that the public and professionals alike have access to the knowledge and tools that can reduce the burden of cancer. The following areas of research and application are projected to lead to significant reductions in cancer mortality. Risk Assessment Descriptive studies by NCI staff continue to examine the characteristics of cancer in the United States, with emphasis on geographic patterns, time trends, and sexual and racial disparities. For example, the elevated rates of oral cancer among women in the southeastern United States stimulated studies that identified snuff dipping, a longstanding practice in the rural south, as a major cause of this cancer. This finding prompted legislative action affecting the advertisement and labeling of smokeless tobacco, as well as educational initiatives about its health hazard. A number of investigations have been undertaken due to concerns about cancer risks associated with indoor and outdoor air pollution. Studies by NCI and other groups have shown a relationship between passive smoking and lung cancer, particularly among nonsmoking women married to smokers. These studies indicate an overall risk of about 30 percent, rising to 70 percent among those most heavily exposed to environmental tobacco smoke (ETS). These findings have increased public awareness of the hazards associated with the inhalation of ETS, and have influenced public policy regarding the regulation of smoking in public places. This Among whites the incidence of malignant melanoma has increased at a rate 4.4 percent each year over the period 1973-87, giving an overall increase of 79 percent. This increase has been faster than for any other major cancer in whites. Dysplastic nevi have been identified as a precursor lesion in 90 percent of familial melanomas and serves as a marker of predisposition. finding indicates that physicians should examine all available family members for the presence of nevi and melanoma, and institute periodic medical surveillance and preventive measures to reduce sunlight exposure and sunburns. Studies will continue to be pursued to isolate the susceptibility gene, which will aid in genetic screening for predisposition to melanoma, and to clarify the array of environmental and host factors contributing to melanoma. Esophageal cancer occurs more often among Chinese-Americans than Caucasian Americans. Dietary factors will be evaluated in Linxian, China, which has the world's highest rates of this cancer. In collaboration with scientists in China, a large-scale, five-year randomized intervention trial is in its final stage to evaluate whether certain groups of vitamins and minerals can inhibit late-stage progression to cancer in a high-risk population with multiple micronutrient deficiencies. Chemoprevention The goal of chemoprevention is the inhibition of carcinogenesis. A growing body of epidemiologic, basic science and clinical trial data support the efficacy and merit of chemoprevention research. Currently, there are 22 agents undergoing clinical testing, 250 agents in preclinical investigations and 1,000 agents under study. The program also includes preclinical studies to evaluate the toxicity and safety of chemopreventive agents where necessary. The program's human Study efficacy trials are designed to determine the potential for chemoprevention methods and regimens to reduce cancer incidence in the aggregate as well as influence the incidence of specific cancers, the rate of regression and/or progression of preneoplastic changes, and changes in cellular or biochemical parameters associated with tumor regression or progression. participants are varied and include volunteers from the general population; populations at high risk for cancer because of occupation, lifestyle, or place of residence; persons with preneoplastic lesions, and/or persons with previously treated cancer. A number of these trials are intermediate endpoint studies and are testing biological and biochemical parameters which may serve as surrogate markers for cancer endpoints in chemoprevention trials. Several ongoing trials focus upon those at high risk for lung cancer. One such trial has been initiated to determine whether markers of early lung carcinoma can be identified and whether beta-carotene can modify either their frequency and/or progression. In another trial, participants will receive the vitamin A derivative 13-cis retinoic acid or a placebo and be evaluated for decreases in bronchial squamous metaplasia/dysplasia, a possible precursor lesion of lung cancer. Nutrition and Cancer Studies Because as much as 25 to 35 percent of cancer mortality could be related to diet, nutrition studies seek to establish an association between dietary intake of fiber, micro- and macronutrients, vitamins, minerals or other food stuffs and the prevention or development of cancer. The diet and cancer component of the Cancer Prevention Research Program combines the results of the chemoprevention studies along with epidemiological research to test the role of the diet and nutrition interventions in the prevention of cancer. A number of intervention studies have been initiated in three broad areas, including etiologic studies, clinical nutrition studies, and prevention trials. These projects represent collaborative efforts in investigating dietary, nutritional, and constitutional factors relating to cancer prevention and involve NCI researchers in the United States and abroad. Furthermore, nutrition intervention studies testing the efficacy of multiple vitamins and minerals in the prevention of esophageal cancer mortality are continuing in an NCI-sponsored study of 34,000 subjects in China. In Finland beta-carotene and vitamin E are being tested as lung cancer chemopreventive agents among 29,000 male smokers. In the United States a synthetic derivative of vitamin A, 13-cis retinoic acid, is being used in a clinical trial in this country to prevent recurrence of basal cell skin cancers among approximately 1,000 persons with previous tumors. Dietary Intervention to Prevent Cancer Among Women The NCI has designed a dietary intervention trial to test whether a low-fat diet can reduce the incidence of breast and other cancers as well as mortality from all causes. Prior to launching this trial, the NCI will conduct a feasibility study to test the methods for dietary change among a broad cross-section of the American population including minority populations, as well as those less-educated, and the poor. The feasibility phase is scheduled to be completed in three years, and if the trial is proved feasible, NCI expects to proceed with the large-scale intervention trial. The long-range objective of the full trial, termed the Women's Health Trial, is to determine whether a low-fat dietary pattern, designed to reduce total fat and saturated fat, and to increase the intake of fruits, vegetables, and grain products, can decrease the incidence of cancer in postmenopausal women. Primary objectives are to determine whether adoption of a low-fat dietary pattern will reduce breast cancer incidence, reduce combined breast cancer and colo-rectal cancer incidence, and reduce mortality from all causes including coronary heart disease. State and Local Health Departments State and local health departments form a national infrastructure through which cancer prevention and control efforts may be addressed. They have the statutory responsibility for the health of the community, provide direct health service to a significant part of the population, have a particular orientation to the health needs of underserved populations who may have a higher than average cancer risk and poorer experience, and are experienced in working with a broad range of community groups and agencies. Since 1987, NCI has funded 21 states plus Los Angeles County and the District of Columbia to build their cancer control capacity or utilize existing data resources to develop a state cancer plan and to initiate interventions based on that plan. In addition, NCI staff have provided technical assistance in such areas as planning, program development, and data and registry improvement. Monthly mailings of materials related to cancer prevention and control are sent to each of the 50 state health departments and the District of Columbia. In addition, NCI staff collaborate with representatives from states across the country to produce reports for guiding public health agency activities, and for developing state tobacco prevention and control plans, and for promoting screening mammography. The resulting reports have been disseminated to key cancer control individuals in every state. Community Intervention Trial for Smoking Cessation (COMMIT) Results from intervention research trials have suggested that community-based and sustained programs produce larger, more costeffective treatment results. Therefore, in 1988, the Community Intervention Trial for Smoking Cessation (COMMIT) began the evaluation of a four-year community-based intervention protocol integrating all previous trial results. The trial design includes 11 pairs of communities located in western Washington, western Oregon, northern California, New Mexico, Iowa, North Carolina, upstate New York, metropolitan New York, New Jersey, and Massachusetts in the United States and in western Ontario in Canada. Following the baseline survey in early 1988, one community from each pair was selected randomly as the intervention site. Across the eleven intervention communities, COMMIT involves more than two million people with particular emphasis on the heavy smokers (25 or more cigarettes a day) due to their greater cancer risk and their difficulty in quitting. The four-year intervention effort has involved more than 1,000 doctors, 700 dentists, 1,400 worksites, 1,000 community organizations, 250 media outlets, 400 schools, 60 cessation service providers, and almost 200,000 smokers. While significant progress was made in the 1980's in tobacco control, the major reduction in tobacco use targeted by both NCI and the Public Health Service will not be reached without an accelerated effort. Recognizing this need, NCI has initiated the American Stop Smoking Intervention Study for Cancer Prevention (ASSIST). ASSIST is a large-scale demonstration project conducted through and in collaboration with health departments serving states or large metropolitan areas, and with the American Cancer Society (ACS). In each of the selected states or large metropolitan areas, comprehensive smoking prevention and control programs are planned for implementation in 1992 to disseminate the best available tobacco control technologies currently available. The potential impact of ASSIST will depend upon the size and number of award sites. The upper estimates for the program are that up to 97 million Americans, including 27 million smokers, could be reached by ASSIST. Up to 20 sites will be funded for a 24 month planning period beginning in July of 1991. Cancer and Minorities The reduction of disproportionately high cancer death rates found in minority and medically underserved groups continues to be a major focus of the NCI. These populations include Black Americans, Hispanics, and Native Americans (American Indians, Alaska Natives and Native Hawaiians) as well as low-income groups. I have personally re-emphasized NCI's support in addressing this issue in various forums, including testimony before both the House and the Senate Subcommittees on Appropriations. - Lifestyle factors have been hypothesized by experts as contributing heavily to the disproportionate rate of deaths from cancer in minority and medically underserved populations. Some of the factors implicated are tobacco use both smoking and smokeless forms of tobacco, alcohol, diets high in fat and low in fiber, occupational risks, and patterns of care related to early detection, diagnosis, and treatment. It is important to stress that many of the issues discussed here are linked to poverty and the special circumstances posed by poverty-driven lifestyles. For example, young people from diverse minority and underserved groups may be more prone to begin smoking and to continue to do so for a lifetime. NCI supports programs targeting special high-risk populations which experience excessive cancer rates and are under-served in terms of cancer prevention and control programs. These special high-risk population groups include Black Americans, Hispanics, Native Americans (American Indians, Alaskan Natives, Native |