is essential to note, as well, the role of the NCI's program in reducing the toll of cancer. It is only the joint pursuit of basic and applied research, along ology and epidemiology, prevention and treatment research, earch training that we will conquer this disease. The of this program have been startling in our new knowledge ost fundamental processes of the cancer cell, and in their ion into new cancer treatments, new detection methods, and revention research. Cancer prevention, which once seemed le, is now a realistic goal of our research program. remains committed to our cancer control objectives and is t both of their achievement and the concomitant reduction r mortality. CANCER PREVENTION stion. Please provide a line item budget with full s for current and proposed NCI funding in the following wer. 3. Lifestyle Reducing environmental carcinogens in air, NCI supports primary prevention activities which s a variety of research areas. Activities in the areas of nutrition, lifestyle and environmental carcinogenesis are :ed below. Funding for primary prevention efforts is as lence continues to accumulate from epidemiologic and tal studies that nutritional factors contribute to a nt portion of cancers in humans. Animal studies, which to investigate mechanisms of action, consistently that diet and nutrition have significant impact on tumor he promotion and progression of carcinogenesis. Human for the role of dietary and nutritional factors comes e international variations of cancer incidence, from f migrants, and from case-control and cohort studies. s diet and nutrition program conducts research in al and molecular regulation, prevention-related ogy, clinical trials and nutrition studies. The program s and validates cancer-preventive dietary patterns; and, he information dissemination channels of the NCI, s changes to the dietary patterns of the American public. arch in diet and nutrition comprise four distinct areas: and epidemiologic studies; clinical nutrition studies; clinical trials; and expansion of the knowledge base on diet and cancer. These four areas of study are interrelated and together provide for a comprehensive research program on diet, nutrition and cancer. Examples of diet and nutrition studies are described below: Breast cancer mortality rates among women in China and Japan are about one-fifth those of white American women. When Asian women migrate to the United States, however, their rates of breast cancer rise over several generations to those prevailing among Caucasian women. The rising trend is suspected to be related to the gradual adoption of a Western diet, which is high in fat, calories, meat, and dairy products. This hypothesis is being tested in a population-based case-control study of breast cancer among Asian-American women living in the United States. Extensive information on diet, physical activity, growth, and body size will be evaluated to assess the role of nutrition in childhood, adolescence, and adult life. Breast cancer incidence rates in the United States have been increasing at a rate of 1-2 percent per year for the past 20 years, mainly among postmenopausal women. However, in the past few years, the increase has been 3-4 percent and predominantly among premenopausal women. Several possible explanations for this increase are being investigated in a case-control study of premenopausal breast cancer initiated this year. Information is being collected on diet, alcohol consumption patterns and body size at various times in life. Anthropometry and biochemical measurements are being used in both breast cancer studies to complement the dietary information. Endometrial and ovarian cancer, like breast cancer, are highly correlated with dietary fat in international comparisons. However, few careful studies of these cancers have been conducted to disentangle the effects of obesity, total calories, fat, saturated fat, and low fruit and vegetable consumption. Obesity, patterns of weight gain as an adult, body fat distribution, dietary patterns and fat cell biochemistry will be correlated with hormone levels and endometrial cancer risk in another NCI study. In an ovarian cancer study, the interaction of diet, genetics, reproductive factors and hormone use will be investigated. These studies will be important in understanding the origins of breast and genital cancers, and therefore the means to prevent them. Efforts are underway to study the role of nutrition for tumors that occur in excess among Black Americans. Specifically, prostate, pancreatic, and esophageal cancers and multiple myeloma are being investigated in a large multicenter case-control study. Emphasis is being placed on whether dietary factors can explain, at least partially, the higher rates of these cancers among Black American. While tobacco smoking remains the major cause of lung cancer, evidence is accumulating that other environmental and host factors influence the risk. Several studies of lung cancer have demonstrated a protective effect associated with the intake of fresh fruits and vegetables. Whatever the mechanism, the current evidence is sufficiently strong and well-documented to warrant public health recommendations regarding the cancer-inhibiting potential of fresh fruits and vegetables. Studies continue to assess the relation of these foods, and their specific constituents, to the risk of a variety of cancers. An NCI study, in an area of China whose population is at high risk for stomach cancer, noted protective effects for vegetables of the allium class, including garlic and onions. This year, a case-control study of stomach cancer in high- and low-risk areas of Italy also revealed protective effects related to the intake of garlic and other fresh vegetables, with both types of the major histologic types of stomach cancer being affected. A follow-up study is assessing the role of diet on precancerous lesions of the stomach (i.e., chronic atrophic gastritis, intestinal metaplasia, and dysplasia) in the high-risk area of China. Esophageal cancer also 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 underway 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. Results of many epidemiologic and animal studies suggest that diet is an important risk factor in colon cancer. Since a randomized controlled trial with colon cancer as an endpoint could require a sample size greater than 100,000, an alternative approach is to study the recurrence rate of adenomatous colonic polyps. These polyps are suspected as precursor lesions of colon cancer and are easy to detect. Initiatives are underway to examine the effect of a low-fat, high-fiber diet on the recurrence rate of adenomatous polyps. This randomized controlled trial will require an estimated sample size of less than 2,000. The National Cancer Advisory Board recommended that the NCI conduct a feasibility study to develop the methods for achieving dietary change among minority and less educated women, along with further consideration of intervention methods for non-minority participants. This phase is scheduled to be completed in three years. Should the study prove to be successful, NCI will initiate the Women's health Trial, with the overall long range objective of determining 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 total mortality including coronary heart disease. The important relationship of diet and nutrition in the development of cancer has become well known through various research efforts. Laboratory studies have shown a cancer inhibitory function for various natural and synthetic nutrients in various models. These studies have been corroborated by human epidemiologic studies of nutrient intake, tissue levels, and cancer incidence. The objectives of these etiologic studies are to: (a) assess the role of fats, selenium, and vitamins A, E, and C in breast cancer development; and (b) evaluate the relation of intake of various nutrients to subsequent cancer, particularly breast, colon, and lung. LIFESTYLE Dietary changes--particularly toward lower fat and higher fiber diets--are believed to have considerable potential to reduce cancer; but the most effective means to effect these recommended changes needs research. One example of current research is the NCI/Giant Food Project designed to test how consumer information about the relationship between diet, cancer and other chronic diseases, such as informational brochures, in-store displays, shelf labeling and mass media campaigns, affects food purchasing habits. The results from this project are anticipated by the end of 1991. The current NCI/Giant Foods project on the effectiveness of point-of-purchase dietary information is planned for expansion and dissemination to more food and diet-related channels. This project will involve work with private agencies, including food, drug and health-related firms and trade associations, to improve cancer prevention and control outcomes through product modifications and marketing practices designed to encourage consumer behavior consistent with cancer prevention. Working with produce growers, The California Department of Health has launched a statewide community and media promotion, "5-A-Day-For Better Health", to increase consumption of fruits and vegetables. Print and electronic advertising, bag stuffers, food demonstration and recipes are among the wide range of project activities. NCI is considering expanding this to a national campaign. NCI continues to study the health risks and benefits associated with hormonal replacement therapy (HRT). In a study of breast and endometrial cancers in Sweden, positive trends with increasing total duration of estrogen treatment were found for both cancers. The risk for breast cancer was not changed with the addition of cyclic progestins to the treatment regime. However, no significant risk for endometrial cancer occurred when estrogen was opposed by progestins. Studies will continue to evaluate the risk and benefits (e.g., prevention of osteoporosis and cardiovascular disease) of HRT, providing baseline data for policy-making in this important area of public health. Analyses of data from the Surveillance, Epidemiology and End Results (SEER) program, which covers cancer registration for about 10 percent of the U.S. population, revealed rising trends in the incidence of adenocarcinomas of the esophagus and gastric cardia. The increases averaged 4-10 percent per year from 1976 to 1987, exceeding those of any other cancer. The cancers disproportionately affected white males, and rarely occurred in women. By the mid-1980's, adenocarcinomas accounted for about one-third of all esophageal cancers, while cardia cancers accounted for about one-half of all stomach cancers with specified subsites among white males. A new initiative will investigate the rising incidence and unusual demographic patterns of these poorly understood cancers, including the role of lifestyle. 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. NCI is also involved in designing and identifying the most effective strategies for bringing cancer methods and information to the public and to the nation's health care professionals. The research identifies and develops strategies to surmount the barriers limiting the full transfer of new scientific results to practice. Objectives are also designed to foster cancer control research across the country utilizing state and local health authorities in developing cancer control plans for their regions and making maximal use of existing data on cancer. Staff working in public health agencies or in offices and clinics who serve public health populations need the benefit of training, tested intervention materials and office systems to properly use such materials. The ethnic and low literacy initiative involves the development of nutrition materials by Hispanic, Black, Asian, Native American, Hawaiian professionals for use in physician offices and clinics serving these populations. Initial materials are expected in 1991. A primary care nutrition guide is completed and ready for assessment. A program entitled Prescribe for Health is designed to increase the adoption and continued use of screening tests by primary care providers. This program will work through intermediary organizations organizations with influence over the routine practice of primary care medicine -- such as Health Maintenance Organizations, professional societies, and medical insurance companies. The two screening activities required for initial implementation will be breast and cervical screening. additional screening practices will be added as the program develops. The target population for the products of the study will be persons who visit primary care physicians, covering over 70 percent of the United States population each year. It is anticipated that a successful demonstration during this effort will become a wider application activity. Two Studies by NCI and other groups have shown a relation between exposure to environmental tobacco smoke (ETS) and lung cancer, particularly among nonsmoking women married to smokers. These findings have increased public awareness of the hazards associated |