Hawaiians), Asian-Americans, under-served/low-income groups and blue-collar workers. Members of these groups have unique

circumstances which serve as barriers to receiving quality health care services.

Early Detection

The goal of early detection research is to increase the impact of early detection on cancer morbidity and mortality. Emphasis is also placed on efforts to achieve application of early cancer detection in medical practice and to evaluate the impact of such practices. Research initiatives on new methods and approaches in early detection are undertaken with the goal of extending this research to comparative trials in high-risk groups, and in other defined populations. New evaluation endpoints, the surveillance of trends in the use of early detection methods, and the development of strategies for clinical education are ongoing goals of the program.

Recent findings from genetic studies have opened up the possibility of identifying high-risk groups and developing surveillance strategies for the early detection of disease, most notably in the area of colo-rectal cancer. Genetic and biochemical markers, for example, the use of the marker CA125 to detect ovarian cancer, enhance the possibilities of early detection in cancers previously resistant to such efforts. Success in the standardization of nomenclature in the reporting of test results, as in the widely accepted Bethesda System of Pap Smear reporting, will result in more accurate early detection and treatment.

Community Clinical Oncology

The Community Clinical Oncology Program (CCOP) is a network of community cancer specialists, primary care physicians, and other health care professionals who conduct both clinical treatment research and cancer prevention and control research studies in the areas of early detection and screening, chemoprevention, smoking, patient management, continuing care, and rehabilitation.

In June 1990, 51 community programs in 29 states were funded through the CCOP with awards varying in length from three to five years. The current program involves over three hundred hospitals and 2,100 physicians. Approximately 5,000 patients per year are entered onto treatment clinical trials through the CCOP Program, which represents about one-third of the Phase III annual accrual to NCI-approved randomized clinical trials. In addition, the CCOP contributes substantially to the NCI's effort to increase accrual to high priority intervention trials. The development of cancer prevention and control research in the CCOP network has been increasing steadily since funding for this effort was begun in 1987, with approximately 7,000 patients/subjects enrolled annually in cancer prevention and control studies.

Minority-Based Community Clinical Oncology Program

Since the CCOP model is an effective mechanism for linking investigators and their institutions with the clinical trials network, a Minority-Based CCOP (MBCCOP) was initiated to provide minority cancer patients with access to state-of-the-art cancer treatment and control technology. Twelve programs with greater than 50 percent of new cancer patients from minority populations were funded for three years, beginning in 1990. Through this effort, NCI aims to meet a need of minority cancer patients and individuals at risk for cancer by establishing a system of oncology programs for participation in research trials through the NCI network.

The Surveillance Program

Using its Surveillance, Epidemiology and End Results (SEER) database, NCI's Surveillance Program tracks cancer incidence and survival rates throughout the country to identify regions where progress has been made as well as areas where problems remain. This tracking system provides the information necessary for program planning not only for the Institute but for the Nation as a whole.

Equally as important, SEER has proven to be an important tool for the collection and analysis of data specific to minority populations. NCI has significantly expanded its efforts and improved its ability to monitor cancer incidence, mortality, and survival among Black Americans, Hispanics, and rural populations. For example, the 1992 Cancer Control Supplement to the National Health Interview Survey (NHIS) is an additional sampling of Hispanics. These data will provide a more precise estimate of cancer screening knowledge and practices, dietary intake, smoking habits and attitudes, and medical care for approximately 5,000 Hispanic adults. Coupled with comparable data from the 1987 NHIS Cancer Control Supplement, the Nation will have information with which to measure change in the prevalence of cancer risk factors for this population subgroup.

CANCER AND DIET

Question. Past NCI Director Arthur Upton said in 1979 that up to 50 percent of human cancer may be associated with dietary factors. Does NCI still subscribe to the estimate? If not, what percentage of cancers are linked with diet? Does NCI's degree of support for nutrition related research match the current scientific estimate of the important role of nutrition and cancer?

Answer. Evidence began accumulating in the 60's and 70's strongly suggesting that diet was strongly implicated in certain cancers. Dr. Upton made his estimate in 1979, but in 1981 a now widely referenced study hypothesized that from 10 to 70 percent of cancer deaths could be attributed to diet, with a "best estimate" of 35 percent. Not all scientists accept this estimate, but a relationship of diet to cancer is well-established. If accurate, the effect of diet is roughly the same as the impact of cigarette smoking, and potentially an even larger effect.

Shortly after publication of the study, the National Research Council produced an NCI-sponsored report summarizing the growing evidence of a relationship between diet and cancer. During this period, NCI had increased its emphasis in cancer prevention with a particular focus on understanding the role of diet in cancer and identifying ways to reduce cancer incidence. It is worth stressing, however, that while many scientists believe that diet plays a role in cancer, there are uncertainties about the precise role of total calories, fiber, and other dietary factors. Not surprisingly, there also are divergent views among respected scientists about the best research approaches to address these uncertainties.

The accumulation of evidence regarding fat and cancer, and other evidence regarding the potentially protective effects of increased dietary fiber, led NCI to establish interim dietary guidelines suggesting that Americans consume no more than 30 percent of their calories from fat and that they increase their dietary fiber from approximately 10 grams per day to between 20 to 30 grams per day. These guidelines were prudent actions based on laboratory, animal, and epidemiologic studies. Recently the Department of Health and Human Services (DHHS) published nutritional guidelines carrying the same recommendations, and for the first time, the Department is now specifying the 30 percent figure for daily fat intake in its publications.

NCI's support of nutrition research and training is substantial, increasing from a total of $52.7 million in FY 1987 to $67.0 million in 1990 for all nutrition-related research. The figure may increase substantially if NCI, in cooperation with the National Heart, Lung, and Blood Institute, proceeds with a low-fat dietary intervention trial to reduce breast cancer, colorectal cancer and cardiovascular disease. The trial will last some ten years and cost over $100 million. The decision to move forward hinges on the results of an ongoing feasibility study to test the methods for dietary change among minority, less-educated, the poor, and the general populations. If the dietary change proves feasible, we would consider moving forward with a full-scale trial.

REDUCTION OF CANCER MORTALITY

Question. Do you still believe that NCI will attain its goal of a 50 percent reduction in cancer mortality by the year 2000? If so, please show in a detailed way how NCI intends to achieve that goal in less than nine years. If not, what reallocation of NCI resources do you purpose to attain this goal?

Answer. Our most recent mortality data is for 1988 and, for the period 1985-1988, we see little change in the overall mortality from cancer, but very significant changes in some cancers (recent data on lung cancer among males, colorectal cancer incidence and mortality, cancer mortality among those under age 65, and breast cancer mortality among those under age 50). However, there has been not been sufficient time to reflect the impact of changes since 1985 in smoking, nor the impact of increased screening for breast and cervical cancer, nor changes in diet. Therefore, in evaluating the progress toward achieving the

cancer control objectives, we must rely, at this point in time, on behavioral data.

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In 1985, NCI established six cancer control objectives. Our purpose was to define those activities that based on current knowledge would lead to significant reductions 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 report that, with full achievement of these objectives, mortality could be reduced by 25 percent and by 50 percent if we increase the rate of progress in our development of new treatments.

In 1992, through the National Health Interview Survey conducted by the National Center for Health Statistics, under cosponsorship of the National Cancer Institute, we will obtain national estimates of smoking rates, dietary patterns, and screening behavior. From these figures we will be able to gain our most precise assessment of progress toward the Year 2000 goals. The most recent National Health Interview Survey that stressed cancer control was conducted in 1987.

In 1987 some 32 percent of males smoked as did 27 percent of females. These figures were down significantly from the 1965 figures of 52 percent for males, but down only 7 percent from the 1965 figure of 34 percent for females. State trends seem to indicate that the smoking figures are continuing to drop, and in 1992 we will be able to assess progress from a national sample. Turning to breast cancer screening, we believe there has been considerable progress since 1987. In 1987, only 36 percent of women over 40 had had a mammogram. From smaller surveys conducted in 1989 and 1990, we believe that figure to be at least 60 percent today. Although this is a considerable improvement, we need to determine whether breast cancer screening has become routine practice. It is only through periodic screening, rigorously adhered to, that we can hope to achieve the full potential of screening: a reduction in breast cancer mortality rate by 30 percent. Data from NCI's cancer database, the Surveillance, Epidemiology, and End Results Program, strongly suggests that screening for cervical cancer is continuing, and correspondingly, the cervical cancer mortality rates are continuing to decline. It is this same database that shows that lung cancer incidence rates for males appear to be on the decline.

We see other hopeful signs in the rates of colorectal cancer. After decades of an increase in colorectal cancer incidence, the rate appears to have peaked, the last several years showing a significant decline. While this does not confirm a new trend in colorectal cancer incidence, it does correlate with what we believe to be recent dietary patterns associated with the increased intake of fiber and a reduction in fat. The long term

trends in colorectal cancer mortality show a continuing decline, correlating with improvements in detection and in treatment.

To meet the Healthy People/2000 objectives, it is essential that we transfer the results of research as fully and as expeditiously as possible. Our task is to forge partnerships with other Federal agencies, and with the public and private sectors. To fully effect this transfer, NCI has developed a number of approaches keyed to particular risk factors, behaviors, and population groups, and all involving the broad public and private sectors who, working together, will help to achieve these objectives.

For instance, NCI has launched the America Stop Smoking Intervention Trial (ASSIST), a nationwide study to apply the results of a decade of smoking research in some 20 communities across the country. The effort has the potential to reach 50 million Americans and accelerate the smoking quit rates. Perhaps even more important, the program may be a model for programs aimed at the other components of cancer control.

Together with the Centers for Disease Control and the Food and Drug Administration, we have developed a National Plan for Breast and Cervical Cancer Screening aimed at achieving the breast and cervix cancer control objectives. Representatives from state and local government, academe, and a variety of public and private sector agencies participated in two national meetings held to assist in development of the plan.

Directing cancer prevention and control efforts at those who suffer most or disproportionately from cancer is a cornerstone of the program. The National Black Leadership Initiative on Cancer (NBLIC) was established by the National Cancer Advisory Board and NCI in late 1987 and is a continuing activity. The purpose of this health education initiative is to solicit the assistance of Black Americans who are leaders in the business, civic, religious, and lay communities to develop coalitions to promote NCI's cancer prevention and control goals and to stimulate the involvement of the Black American community in this effort. Among the NBLIC's priorities are the promotion of smoking cessation, diet modification, and early detection, screening and treatment. Given the success of the NBLIC, NCI is using this established format to develop similar initiatives for both the Hispanic and Appalachian populations.

These are but a few examples of NCI's initiatives aimed at the full application of our knowledge. If the Nation were to quit smoking tomorrow, fully adopt the breast and cervical cancer screening guidelines, reduce fat in the diet to 30 percent of calories, increase fiber as recommended, and fully apply all of our existing knowledge regarding treatment, we believe that we would see, by the end of this decade, a significant reduction in cancer mortality. Although we cannot achieve the needed public and health profession behavior changes overnight (it has taken some 25 years to reduce the prevalence of smoking among males from 52 percent to 32 percent), we believe the Nation can reduce its cancer mortality.