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The CHAIRMAN. I was wondering whether that condition arises naturally.
Dr. MIDER. To the best of my knowledge, sir, it does through socalled spontaneous tumors.
Dr. HELLER. Mr. Chairman, many studies have been made of great interest relating to the natural occurrence of cancer in fish or on trees. The so-called knars or galls on trees are considered to be the equivalent of cancers and there are also cancers in certain animals.
There is a very serious livestock problem in the southwestern part of the United States which has been occupying the attention of veterinarians and cancer experts as well, so that there is a natural occurrence of cancer in practically all animals and in many plants. There is sometimes almost a predictable incidence if you use enough of them. Taking 100,000 trees we would find the next 100,000 would have perhaps a similar incidence. It varies in different climates and under different conditions.
The CHAIRMAN. That is very interesting. All of this indicates to me the extreme necessity of having as comprehensive a research program as it is possible to carry on.
Now, may I ask one further question. Having in mind the question that was introduced by Mr. Dolliver, using cancer of the breast as an illustration, would that affect a child who was breast fed?
Dr. HELLER. Dr. Mider, can you answer that?
Dr. MIDER. That is a very difficult question, Mr. Chairman. Do you want me to restrict my answer to the human population? The CHAIRMAN. To what?
Dr. MIDER. To the human population?
The CHAIRMAN. I will not restrict you in any sense. If you can give us an answer I would appreciate it. I did not intentionally try to find a hard one. It just came to my mind, that is all.
Dr. MIDER. There appears to be a substance that occurs in mice which can be transmitted in the milk of mothers to their suckling infants which strongly influences the likelihood of the development of cancer of the breast. It would now appear that, while this material is very important, mice can develop cancer of the breast in the absence of the so-called milk factor which was originally described by Dr. Bittner.
We have no conclusive evidence to suggest that comparable material can be demonstrated in human mothers. The rabbit, which also develops considerable frequency of breast cancer, has so far failed to reveal any evidence of a comparable influence.
The CHAIRMAN. Mr. Dolliver.
Mr. DOLLIVER. I do not know whether these terms that I am about to use are recognized medical terms or not. If they are not, please correct them.
I have heard the terms used, "benign" and "malignant," which is a growth which is not benign, but is violent, so to speak. I would be glad if we could have the relationship between those two kinds of growth explained by some of the panel, if there is any connection between them or if they are two separate kinds of growths and difficulties.
Dr. HELLER. Mr. Dolliver, tumors are not, necessarily cancers. What you refer to is the so-called benign tumor as contrasted or opposed to a malignant tumor.
Mr. DOLIVER. That is right.
Dr. HELLER. Tumors do occur which are benign as contrasted with malignant, and why there should be that difference is not known.
In many instances they are similar in some of their characteristics. The so-called benign tumor does not expand by simple mechanical pressure or disease the organs or interfere with the functions of the body, nor does it metastasize, that is, spread through the body which, as Dr. Cameron has pointed out, is one of the characteristics of the socalled malignant tumors. There are other pathological differences, of course, but that is an explanation which is as simple as I can make it. Mr. DOLLIVER. Are there clinical, scientific means of distinguishing between benign and malignant tumors?
Dr. HELLER. Yes, sir.
Mr. DOLLIVER. They are certain and without any doubt as to the nature of the tumors?
Dr. HELLER. Well, I would not say it as unequivocally as that, Mr. Dolliver. The best way for the determination as to whether it is benign or malignant is by a procedure called biopsy-taking a slice of tissue and looking at it under the microscope and detecting the presence of certain cells which are characteristic or changes in cells which are characteristic of cancer which are discernible to the trained pathologist and indicate whether cancer is present or not. I can say that there are a certain number of tumors on which there is a difference of opinion on the part of experts in the field. It may be 5 10, or 15 percent or even one-half who say that it is malignant and others that it is not, and there, of course, is one of the fields in medicine in which the sense of the majority usually rules as to whether it is malignant or not.
I wonder if some of my pathologist friends on the panel like Dr. Farber would care to carry that explanation further.
Dr. FARBER. Mr. Dolliver, in answer to your question, a malignant tumor is one that has the capacity for causing death or that will cause death unless removed early enough and completely enough before it has spread to the other parts of the body. Of course, a tumor may cause death if it is so situated as to put pressure upon a very vital area. For example, a very slowly growing tumor which does not have the capacity to spread to other parts of the body, situated on the brain may, nevertheless, cause death if not removed.
So, the term "benign" must be defined in terms of the whole picture and finally in terms of what it does to the human body as well. The differentiation between the two, as Dr. Heller pointed out, is very well defined. There is a group of people in the country in the medical profession known as pathologists who are highly skilled in differentiating the nature of a tumor from the study of a small piece of tissue which is removed by the surgeon at the operation, usually before the entire operation is performed. For example, when there is a malignant tumor present we have a diagnosis made by a pathologist while the patient is still under the anesthetic before very much of the operative procedure has been carried out. In a case of cancer of the breast the diagnosis is made by the pathologist from a piece of tissue which is given to him by the surgeon before the breast is removed, and the condition of the tissue is then determined and is the basis of the report of the pathologist.
The CHAIRMAN. Along the line that you have just answered Mr. Dolliver, how many men in the United States are capable of making an accurate biopsy?
Dr. FARBER. Mr. Chairman, I would say that here are hundreds or probably a few thousand men who are trained in this country in such a way as to permit them to make a perfectly accurate diagnosis from biopsy of a tumor.
The CHAIRMAN. I notice in this chart No. 4 entitled, "Forecast of Cancer Deaths" that at the present we have an annual rate of 211,000. I notice that by the year 2000 it is going to reach 415,000 deaths per
Is that estimate projected on the basis of increased population or is it based upon that factor together with the number that have already died in the past?
Dr. CAMERON. It is based on both, Mr. Wolverton.
It is based on the esitmated increase in total population, and it is based on the estimated lengthening of the life span. You will note that the curve begins to level off at about the year 2000, and that is because at that time it is anticipated that the age of our population will begin to stabilize.
The CHAIRMAN. Well, of course, I do not see how, in view of what is known at the moment, it could be estimated that there will be no improvement between the present, 1953, and the year 2000 in the detection of the disease and the treatment of it.
Dr. CAMERON. No, that is why we say, "If present rates continue." The CHAIRMAN. Óh, I notice that. I did not notice that before. That is a very significant thing, "If present rates continue." We are trying to get that "if" out of our system by our hearings here today and by what we hope will develop as a result of them.
Could you give any figures as to the cost of cancer illness to the Nation or to communities or to families? I am personally aware of the great cost that can come to a family where this disease strikes an individual.
Is there any estimate of what the average cost is of caring for a patient? There may be different classifications of patients, but is there any information that you can give us along the line of cost? We are intensely interested in this question of cost because it is so apparent that at the present cost of medical attention and hospitalization is a real difficult situation that is faced by the average family. When I say "the average family," I mean a family that is not poor and a family that is not rich-the average family.
Dr. CAMERON. First, Mr. Chairman, let me say before passing that to the Director of the Institute, that I think there are some figures on that, at least I know that they have addressed attention to this paricular matter. It is difficult to arrive at a meaningful figure for the reason that cancer of the lip, for instance, requires no hospitalization and can be treated virtually in one sitting successfully, resulting in no loss of earning power. It is very different from cancer of the rectum, which is removed, and which requires from 6 to 8 weeks convalescence, after which there may be a return to a modified type of employment and then followed in a year or two by further evidence of it and a gradual increase of invalidism and death. That is one of the complexities that grows out of the inherent complexity of cancer. I do
not see how an average figure would be meaningful, but if there is one I am sure that Dr. Heller has it.
Dr. HELLER. Mr. Chairman, I do not have a figure which I believe would be meaningful to the committee. With your permission I should like to have the privilege of inserting it in the record. (The matter referred to follows:)
COST OF MEDICAL CARE TO CANCER PATIENTS
(Prepared by National Cancer Institute, October 4, 1953)
Only a few attempts have been made to study the costs of medical care to individual cancer patients. Agencies interested in this subject have found it difficult to locate suitable areas for such studies and to enlist the full support and cooperation of hospital associations and medical societies concerned, an essential requirement for the successful collection of data. One of the obstacles is that hospitals do not routinely tabulate or maintain information on admissions, discharges, or hospital stay according to diagnosis. The only recent study on hospital costs for cancer patients, which can be located, is the one conducted by the American Cancer Society for the Vermont State Cancer Commission in 1947.1 Good data are available on length of hospital stay for cancer patients, which, when coupled with the results of the Vermont survey, can yield acceptable approximations for hospital costs. The recent morbidity surveys of the National Cancer Institute in 10 urban areas 2 indicated that 3 out of every 4 diagnosed cases of cancer receive hospital care. Further, the average total length of hospital stay (first admission and readmissions) for hospitalized cancer patients can be expected to amount to 32 days. While hospital per diem costs have risen rapidly in recent years and vary considerably in different regions of the country and by size of hospital, a typical cost figure for room and board would be close to $10 a day. According to the Vermont study, the per diem charges accounted for three-fifths of the total amount billed by hospitals.
Assuming that this relationship still holds, a per diem rate of $10 means an average cost per hospital day of $16 to $17 to the cancer patient. Using these results, the estimated average total cost of hospitalization to the patient hospitalized turns out to be $535. On the basis of the schedule of fees for surgery and supporting services contained in typical Blue Shield plans, an individual from a family of low or moderate income can be expected to pay at least an additional $350 for physicians' services (diagnosis, surgery, radiation, and followup care). Individuals normally earning higher incomes would pay considerably more. Thus, the average cancer patient hospitalized (3 out of every 4 cases diagnosed) can expect to pay at least $885 for diagnosis and treatment. These estimates are minimal because they do not take account of the cost of care subsequent to hospital discharge (stay in nursing and convalescent homes and medical care in the patient's home).
The cost of medical care to cancer patients not requiring hospitalization or discovered too late to warrant treatment (1 out of every 4 cases diagnosed), can be fixed at $100, at least. Again, this figure does not include the cost of nursing or convalescent home care. For all cancer patients, whether hospitalized or not, the cost of diagnosis and treatment would average at least $700 per patient.
Many families are confronted with higher-than-average hospital bills. this connection certain other data from the Vermont study are of interest. They suggest that the top 10 percent of the hospital bills would be for amounts in excess of twice the average hospital bill. One of 10 cancer patients hospitalized at present can be expected to run up hospital bills of more than $1,070. Patients and their families are confronted with these bills at a time when income is drastically reduced, either through loss of income by the wage earner or through the necessity of hiring housekeeping help. It is not surprising that according to the Vermont experience, slightly more than one-fifth of the patients were unable to make any payment from their own resources toward their hospital bill. More than one-fourth of the patients required some charitable aid
1 Daniel F. Horn, Report of Cancer Survey. Vermont State Cancer Commission, Biennial Report, 1946-48.
2 Cancer Illness in Ten Urban Areas in the United States, National Cancer Institute, Cancer Morbidity Series, 1950-52.
in the payment of their bills. Two-thirds were able to pay their bills in full from their own resources.
VOLUNTARY INSURANCE PROTECTION IN CANCER CASES
At the end of 1952, about 91 million persons in the United States were insured against the costs of all or part of their hospital care, 73 million against all or part of their surgical bills, and 36 million against other medical bills, principally for cases cared for in the hospital. With the exception of approximately 5 million persons enrolled in several other types of programs, the entire coverage was under Blue Cross, medical society, and insurance company contracts. Most of the voluntary health-insurance programs existing in the United States today, however, were developed to provide protection mainly against short-term hospitalized illnesses. They were not intended to cover chronic or long-term cases, and many of their provisions make them of limited value in cancer cases. Provisions of insurance company group contracts for hospitalization.—The usual payments for hospital care range from $4 to $7 per day for 31 days for any one hospitalization period, with usually no limit to the number of days that benefits are payable during the year if each hospitalization is for a different illness. Payments also are made for additional hospital charges usually based upon the daily benefit and ranging from 5 to 31 times the daily amount. There is no restriction as to the type of additional service except that coverage is not granted for doctors' fees or nurses' room or board.
The plans exclude hospitalization for industrial injuries or diseases for which the employee is entitled to benefits under workmen's compensation laws, hospitalization for military service-connected disabilities, and for plastic operations for cosmetic or beautifying purposes.
Provisions of group insurance contracts for medical and surgical expense.— Almost all group contracts for medical and surgical expense provide reimbursement for surgical expense only. The insured employee is reimbursed for the surgical fee up to the amount listed in the Schedule of Operations for the operation performed, but not more than the actual fee charged by the doctor. Typical schedules are the $150 maximum plan and the $250 maximum plan. The policies also specify a maximum amount that will be paid during any one continuous period of disability, should more than one operation be required. This amount ranges from $150 to $300.
Among the few contracts offering reimbursement for medical nonsurgical expense, the majority are limited to reimbursement of costs of physicians' visits while the employee is in the hospital or to in-hospital benefits. Payments to employees are usually up to $3 for a hospital or home visit and $2 for an office visit, but not exceeding 50 visits per year. The first 2 or 3 visits in an illness are generally excluded, but the first treatment in an accident case is included. Medical expense insurance written by insurance companies generally excludes occupational injuries or illnesses that entitle the insured to benefits under workmen's compensation or occupational disease laws. It also excludes plastic surgical operations for cosmetic or beautifying purposes, if the condition existed at the time the policy was written. The coverage in the policies written by the large insurance companies is otherwise usually all-inclusive, even covering chronic conditions, alcoholism, a heart condition, and nervous breakdowns.
Blue Cross and Blue Shield plans.-The benefit provisions of Blue Cross and Blue Shield plans vary widely from plan to plan. Some plans specify the number of days of hospital service or indemnity, usually varying from 21 to 150 days for each condition requiring hospitalization. Other plans provide benefits usually 21 or 30 days plus 50 percent or a specified dollar amount per day for an additional 30, 60, or as high as 180 days in a few plans. Some plans pay a maximum of 21 days the first year and increase it to 30 or 31 days in the second or third year of membership with the number of days of care remaining the same thereafter.
Some Blue Cross plans limit the number of days for the year but the current trend is to allow a maximum number of days for each illness instead of each year. Originally, almost all plans excluded care for preexisting conditions,
3 Editorial staff of Prentice Hall, Inc.: Successful Employee Benefit Plans. New York, Prentice Hall, Inc., 1952, pp. 49-53; 60–63.
Editorial staff of Prentice Hall, Inc.: Successful Employee Benefit Plans. New York, Prentice Hall, Inc., 1952, pp. 54-59; 66-69; Voluntary Prepayment Medical Care Plans, 1953, Council on Medicine Service, American Medical Association; Blue Cross Guide, 1953, Blue Cross Commission.