In breast cancer it has long been felt that if a mass in the breast were small in size it probably had not spread to other parts of the body, particularly the nodes in the armpit, and was “early” cancer. It is now recognized that the size of the primary mass does not necessarily bear a direct relationship to the stage of development of the cancerous process and that the stage of truly “early” breast cancer lies further back, in its development, toward a microscopic lesion. In lung cancer it is now recognized that cough, chest pain, expectoration, and loss of weight are manifestations of a late cancer. An early lung cancer produces no symptoms and reveals itself as a silent shadow on the X-ray film or through cancer cells in bronchial secretions which can be examined under the microscope.

Case finding

There is now no one screening procedure or test which will discover early cancer of all types. There are, however, tests for cancer of specific sites which are valuable case-finding tools. Other techniques and procedures are being developed and applied in this area.

It would be highly desirable to determine the kinds and types of people most apt to develop cancer. If this could be done case-finding efforts could be more specifically directed toward groups in which cancer of particular sites is most likely to occur. There are, in fact, geographic, climatic, racial, socioeconomic and environmental differences in the occurrence of cancer, whose significance to case finding has been appreciated only recently. There are, for example, racial differences in the incidence of cancer of specific locations. The incidence of cancer of the uterine cervix, to take one specific finding, is higher in Caucasians than in Negroes, while the reverse is true of cancer of the body of the uterus.

Facts of this type are not only guides to case finding, but suggest theories as to cancer causation which must be explored extensively.

Much has been written concerning the so-called cancer age the idea that cancer occurs rarely among people under 40. Sizable numbers of cancer patients are under 35 years of age. In fact, among children 5 to 19, cancer is the third leading cause of death.

Recent studies suggest that heredity may play an important part in the predisposition to some types of human cancer. Certain family groups appear to have a higher concentration of breast and gastric cancer. In cancer of other sites hereditary susceptibility has not been demonstrated, and it may be that heredity has little or no influence in some types.

The habits of people may have a relationship to cancer. For example, excessive cigarette smoking appears to have a relationship to the development of lung cancer, although the evidence is still inconclusive on this point. Numerous studies are being conducted to determine if such an actual relationship is primarily causative. Exposure of workers to a number of materials in their environment may be the basis for development of the majority of occupational cancers.

Case-finding programs have taken principles, devices, and procedures utilized by other disease-control programs and attempted to adapt them to the cancer problem. For example, the small X-ray film used in photofluorographic screening of the population for tuberculosis has a degree of usefulness in the discovery of early lung cancer.

Cancer clinics

A cancer clinic is a facility, usually located in a general hospital, and organized so that representatives of the various specialities, including surgery, pathology, radiology and internal medicine, can work with the patient's private physician on diagnosis and treatment.

The number of cancer clinics throughout the Nation has increased markedly in recent years, but there are still far fewer than are required to meet the need. The establishment of additional clinics is being promoted and encouraged. Diagnostic tests

A variety of general diagnostic tests for cancer have been developed, most of which have been extensively evaluated but none of which is sufficiently sensitive or specific for clinical use. However, the fact that some of them work to some extent is an indication that something tangible occurs in the body of a cancer patient which may be susceptible to measurement in a diagnostic procedure. Further intensive work is needed in this area and may result in a reasonably satisfactory general diagnostic test for cancer.

Such a test, if available, would be of considerable value in determining those individuals who would require further diagnostic study. Although it would be a considerable step forward in cancer control, a general diagnostic test would not eliminate the necessity for carrying on further diagnostic procedures to determine the organ or area of the body involved by the cancerous process. Lacking a general diagnostic test, there are certain techniques by which cancer of specific sites can be indicated in an early stage when opportunity for control is greatest. One of these is the cell-examination technique called exfoliative cytology-developed by Papanicolaou and Traut, which has proved its effectiveness as a diagnostic aid in cancer of the uterus, bladder, and stomach. This technique is based on the facts that: (1) Cancer cells do not adhere closely and consequently are shed readily; (2) these cells have characteristics by which they can be identified microscopically as cancer cells. The test is applicable to a number of body secretions or excretions, such as vaginal fluid, sputum, gastric washings, and urine.

It has been demonstrated that this technique can indicate the probable existence of uterine cancer, particularly where the cervix is involved, even in the absence of significant signs or symptoms and without suggestive gross findings. The technique has proved its effectiveness as a diagnostic aid also in cancer of the lung, bladder, and stomach.

Professional education

In recent years considerable effort has been devoted to the improvement of cancer teaching to undergraduate students in medical and dental, and, to a lesser degree, in nursing schools. These efforts have assured that graduates of these professional schools have a better understanding of cancer and are better equipped to handle the disease problem.

These educational efforts have been extended beyond the undergraduate years to graduate physicians who are qualified and interested in obtaining special training in the diagnosis and treatment of cancer. Both voluntary and governmental groups support such specialized training for physicians. The need for this training is increasing.

In addition, the level of competence of practicing physicians, public health workers, nurses, and other professional groups concerned with the control of cancer has been increased through educational media such as refresher courses, national conferences, teaching films, manuals or guidebooks, and professional bulletins.

Lay education

As the physician's index of suspicion of cancer is raised, it is also necessary to show the lay public the importance of cooperating with the medical profession for more effective cancer control. A well-planned, widespread, and continuous public educational program can reduce deaths from many types of cancer. It can do so by stimulating the individual's awareness of cancer and by teaching him to seek medical attention at the earliest moment in the development of his disease.

Carefully designed educational materials and devices have been produced and widely distributed by both voluntary and Government groups. Some of these have been most effective in showing people precisely what signs they should suspect as indicative of cancer.

In general, the public is better informed about cancer today than at any time in history. But the task of educating the entire adult population on a subject until recently taboo, in a way which will be accepted and understood, is complex and stupendous. With progress in research and therapy, the educational problem will increase. There will be more to tell, and the dividends from early detection will be higher.

CONCLUSION

Certain information has been furnished in this document concerning the problem of cancer, the resources with which to combat the challenge, and the current status of research and control. It is quite possible that more successful treatment than now exists may precede thorough understanding of the problems of normal and abnormal growth. To accomplish this, better diagnostic tests are imperatively required, so that early treatment can be applied and thereby achieve the best results.

It is impossible, of course, in a short summary report, to set forth satisfactorily an exposition which is definitive of the problem and at the same time sufficiently interpretative of the investigations in cancer being undertaken

throughout the country. Medical research is not static or predictable, but progress is being reported steadily as the facts assert themselves at the bedside or at the laboratory bench. The advances in cancer control have been made through continuity of effort and maintenance of progress in all aspects of the problems. Much more needs to be accomplished to effect total control of cancer, and there is much to encourage us that substantial gains toward that end can be expected in the near as well as the distant future.

Dr. MIDER. Dr. Heller, Mr. Chairman, gentlemen of the committee, and colleagues, I find it rather difficult to particularize on the excellent presentations that have preceded mine.

The National Cancer Institute historically has taken the attitude that it is one of the groups working in cancer research, that it is doing its best to contribute to the total effort, and that it has earned a position of leadership by virtue of the correctness of the work it has done and its prompt dissemination to all those interested in the field of cancer. Until very recently the facilities available to the staff had been limited to those appropriate to the study of cancer in laboratory animals. A large amount of the work falls in the area of basic research, but there has been a considerable effort directed toward the study of certain aspects of cancer in man.

It is well known that cancer is not equally distributed throughout the world, as part of the testimony this morning indicated. Neither is it equally distributed throughout the United States. And a part of the Cancer Institute's effort has been to attempt to define those groups in various areas and occupations or which for some other peculiar reason have a particularly high or a particularly low risk to specific anatomical types of cancer. Information of this type has been most helpful in guiding work in the laboratory on the causation of cancer and the principles that have been learned at the National Cancer Institute and at the Memorial Center and many other areas are summarized in full on page 12 of the document submitted by the National Cancer Institute this morning.

So that we have arrived at certain general principles relating to the extrinsic and intrinsic factors which together apparently are responsible for the causation of cancer. By establishment of these general principles, together with further study of life groups of the populace, we hope that we may hasten the practical prevention of cancer in man. Now, we have heard that cancer is a variety of diseases, and all of us agree to that; yet it has been standard procedure today to speak of cancer as one disease, and there is much merit in this, because various biochemical studies conducted at various institutions have shown that there is commonality in some of the chemical characteristics of malignant neoplasm. It has been shown that the enzymes, those proteins responsible for most of the functions of the cell, are more closely alike in this wide variety of cancer than in the normal tissue from which the cancer cells necessarily arise.

The chemical dissection of the cell that Dr. Cannan alluded to has proceeded rapidly at the National Cancer Institute and it would appear today that we need to discover and define even smaller quantities of biologically active substances than seems possible at this time. The leukemia studies that Dr. Farber has spoken of have profited considerably by the comparable studies on leukemia in experimental animals; its induction and its treatment by various types of ionizing rays and by chemotherapeutic agents. It is a source of much pride that probably the first effort directed toward the development of a

drug by any group in cancer research was pioneered by Dr. Murray Shear of our staff.

We hope to improve the efficacy of treatment with various types of X-rays and other types of ionizing radiations which are now becoming available. One factor that has limited the usefulness of X-rays is the undesirable side reaction which makes the patient ill. Dr. Jacobson at the University of Chicago was able to prevent some of these symptoms by a comparatively simple method of shielding the spleen; and more recently Dr. Lorenz of our staff has been able to prevent death from X-rays by the transfusion of very tiny amounts of bone marrow. It would appear that there may be some chemical substance provided by the bone marrow which may influence the person's reaction.

The intramural program of the National Cancer Institute has been in operation for almost 14 years. The record is a proud one, much too involved for me to give to you in detail, but if you wish I would be glad to prepare such a document to be inserted in the record at a future date.

It is becoming ever more clear we probably are not going to learn all the information that we need to control cancer efficiently and effectively from the study of cancer alone.

Dr. HELLER. Thank you, Dr. Mider.

Mr. Chairman, have you any questions of Dr. Mider?

The CHAIRMAN. Any questions, gentlemen?

Mr. CHARLES TOBEY, JR. Mr. Chairman, my name is Charles Tobey, Jr.

The CHAIRMAN. Now, Mr. Tobey, for what purpose are you asking recognition?

Mr. TOBEY. Because I possess information, sir.

The CHAIRMAN. I am not asking that. Is it for the purpose of making a statement, or asking a question; or for what purpose is it? Mr. TOBEY. It is for the purpose of giving the committee information it should have before the day is over.

The CHAIRMAN. Very well. If you will see the chairman when the committee has adjourned I would be glad to talk to you, as I have previously talked to you, and I will be glad to have any information you wish to give.

Dr. HELLER. Mr. Chairman, we have had a discussion of research, both basic and clinical. We have had some examples of advances that have been made. We have had an illustration of the translation of the laboratory findings to the patient.

I should like to complete the cycle of approach by requesting one or two of the panel members to give us some information which would enable the committee to understand the methodology and have information as to the plans and the attacks in what we call control; that is, translating to the private physician, translating to the patient, as it were, in a general sense, those things which are found at the bedside as well as at the laboratory bench.

I should like to call upon Dr. Ralph Meader, who is Chief of the Research Grants Branch, to give us briefly the way in which research grants are administered, and something of that mechanism, in order that the committee may have that transitional step by which the method of training research workers and of taking to the worker at

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the bench in the universities and others throughout the country the sort of support which the Congress recognized in its wisdom that we must have in order to carry on cancer research, is accomplished. With your permission, sir, I should like to call upon Dr. Ralph Meader to give us a brief explanation of that.

The CHAIRMAN. We would be pleased to hear Dr. Meader.

May I inquire, Dr. Heller, how many more witnesses you have? My only purpose in asking is realizing that the hour is becoming late and we have a desire to finish, so that no one will have to come back tomorrow.

Tomorrow, as you may know, I assume it will be a most interesting hearing, because representatives of the Atomic Energy Commission are supposed to be present to give us some information as to the studies they have been conducting. We have heard many statements made. I do not think anything has been said publicly as yet, so that much that will be said tomorrow will be of the first instance, so far as public information is concerned; and I am looking forward to that with a great deal of anticipation.

For that reason, and also the fact that I assume these witnesses are anxious to get back to their activities, I am trying to finish this this afternoon.

Dr. HELLER. Mr. Chairman, we have two more short presentations. The CHAIRMAN. I do not mean to cut you short. I want you to go ahead. This committee is willing to continue long enough to get the story before us as you folks wish to place it.

Dr. HELLER. Thank you, sir. Dr. Meader.

STATEMENT OF DR. RALPH G. MEADER, CHIEF, RESEARCH GRANTS BRANCH, NATIONAL CANCER INSTITUTE

Dr. MEADER. Mr. Chairman, Dr. Heller, and colleagues, and this committee, in the brief time that remains for me to present this material I shall try to hit only the highlights and to present to you some of the information on the manner in which the will of Congress or the will of the American people or philanthropic donors of funds for cancer research is able to be transmitted and carried into the activities of the individual research worker.

This fundamental problem is common to all organizations which have the problem of dispensing funds for support of cancer research and cancer control. There are many different sources from which these come, and there are many different places to which the funds could be distributed. Of course, the major problem is, Where can they be most effectively laid or placed; and, On what basis or what criteria are they distributed?

I think it is perhaps the simplest thing to say that it is on the basis of the best advice available to the Representatives of the Congress, the Surgeon General of the Public Health Service, or on the basis of the best advice given to the American Cancer Society or the various private organizations that the awards for cancer research are made, with the aid of individual scientists of the same type and caliber as those who have here addressed you and told you of the problems which are basic to the cancer process.

I might illustrate it first and perhaps most easily by telling you that a person who has an idea for research on the problem of cancer