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We are parents, we do not want to practice medicine.

However, at this point, many times the parent has to practice medicine because there is no data available and disseminated to the treatment centers that there are certain forms of diet that are going to be most beneficial in a certain type of drug treatment.

We thank you, Mr. Chairman, for your past efforts on our behalf, and we certainly are interested in answering any questions that you might have that our expertise might touch on.

Senator KENNEDY. That was very powerful testimony and very helpful to the committee.

I understand, you support the legislation and the amendments incorporated in the bill. Mr. SULLIVAN. Yes, we do.

Senator KENNEDY. You refer to it in the course of your statement and I think you elaborate on it, but these points are very worthwhile.

We will ask Dr. O'Conor and Dr. Rauscher, who was in charge of the data bank, for some responses to your points on nutrition. We will also explore what they are doing with regard to your points about the anesthetic for lumbar punctures, in addition to some of the other points you have raised here.

Let us see if we cannot begin to develop an open line of communication.

Mr. SULLIVAN. We would appreciate that.
We started 4 years ago, and it has expanded all across the country.

Mrs. MONACO. As Mr. Sullivan pointed out before, we have been concerned about the personnel problems and the job slot problems, and we stress this again, that for 2 years we have been talking about this and, suddenly, because of a public outcry and the work of this committee, the positions have been released.

Further, as Mr. Schmidt pointed out, this position release and authorization has not gotten down to the level of the NCI clinical treatment center re the level of the nursing and supportive personnel. They have many programs up there, and with the current status of drug treatment could prolong the comfortable lives of many children who have gotten to a low point and who need to have their own immune systems built up to continue their fight.

It is a shame to see the facilities that can save lives stand empty because the personnel are not available to make sure these facilities are properly utilized.

Senator KENNEDY. Well, I hope you will keep the heat on. I think it is terribly important that we do.

I think the reason we have seen as much progress in this area as we have is the very deep and legitimate concern of citizens like yourselves. I hope you will keep knocking on the doors and hollering from the belfries. I am sure you

will. Let me again thank you.

Our next panel consists of Dr. Emil Frei III, director, Children's Cancer Research Foundation of Boston, Mass.; accompanied by Dr. John Durant, director, Comprehensive Cancer Center, University of Alabama, Birmingham, Ala; and Dr. Jesse L. Steinfeld, chairman, Department of Oncology, Mayo Clinic, Rochester, Minn.

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Gentlemen, we are glad to welcome you. You testified before the committee as the former Surgeon General, Dr. Steinfeld.

For the witnesses who are here we will just keep on with our hearing and not break. We will have to recess around 2:00 to vote but we will continue on.

Dr. Frei is a distinguished researcher at a marvellous center, as all the centers are.

I appreciate your presence and look forward to your comments.



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Dr. Frer. Thank you, Senator Kennedy.

It is my privilege and honor to have been chosen as successor to Dr. Sidney Farber, founder and previous director of the Children's Cancer Research Foundation in Boston. This organization was started 26 years ago, and, until the past several years, has been devoted primarily to patient care and research in cancer and leukemia in children.

In view of the increasing progress in the treatment of childhood cancer and with the increasing number of basic and clinical research leads with respect to cancer, Dr. Farber initiated a program approximately 5 years ago to substantially enlarge our cancer center. This has led to the construction of the Dana Center, a 17-story building which will open this year and essentially triple our resources for clinical care and research. The Dana Center will be devoted primarily to clinical care and clinical research for adults with cancer. Thus in a sense, our center which was recently named a comprehensive cancer center by the National Cancer Institute is both old and new.

While we have autonomy with respect to programing and the utilization of resources, we are part of Harvard University and the Harvard Medical School and our appointments are made through the Harvard academic system. Through a formal Memorandum of Understanding developed by the university, the medical school, the Harvard hospitals and our cancer center, the relationship between the hospitals and the center has been carefully defined.

This, I believe, is a prototype organization for a strong autonomous cancer program integrated and interacting with a medical school and university that has extensive expertise and resources in the basic and clinical sciences generally. Let me illustrate how such an organization may work to the advantage of the patient, clinician, and scientist.

Immunology is an extremely promising area for clinical and basic research in cancer. Harvard Medical School has an extraordinarily comprehensive and strong program in immunology. We have recently recruited an outstanding young man to head our program at the Cancer Center in tumor immunology. In addition to his basic

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and clinical work in tumor immunology, he interacts and works very
closely with clinical and basic scientists at the medical school work-
ing in other aras of immunology.
This interaction has proven

highly effective. Developing basic concepts and techniques in immunology are immediately communicated and, where appropriate, applied to tumor immunology programs at the center.

When, and if appropriate, such observations are applied in the clinic. Thus, we both have our cake and can eat it in the sense that we have a strong autonomous highly focused cancer program and at the same time, we have the help, good will, and interaction with and personnel and material resources of the Harvard general hospitals and medical school.

Parenthetically of course, we are available to them when our clinical and research developments are appropriate to their interests and needs. This pattern of development applies to other clinical and scientific disciplines relating to cancer such as chemotherapy, pharmacology, virology, etc. This development has been very substantially facilitated by the National Cancer Act.

I would like to turn from the general to the specific and illustrate two areas of clinical research. Prior to 20 months ago osteogenic sarcoma, as indicated in this illustration, was associated with spread to the lungs, starting within a few months and by 12 to 18 months, some 80 percent of the patients had Jung metastases. Starting 26 months ago, we employed combination treatment involving vincristine, methotrexate and citrovorum factor.

I won't go into the details of this treatment except to say that of the 14 patients treated starting 20 months ago, only one has developed lung metastases. When this is presented in terms of survival, you will note that prior to July 1972, only 40 percent of patients remained alive at 20 months whereas 100 percent of the patients whose treatment was started during the past 20 months remain alive.

Thus, there is preliminary evidence that major progress has been achieved in the treatment of an otherwise highly fatal tumor. This progress has been achieved in the past 2 years, as a result of the application of laboratory and clinical research in cancer.

The next illustration shows results in the treatment of acute lymphocytic leukemia achieved during the past 18 months at the Children's Cancer Research Foundation. Of 60 patients 96 percent entered complete remission and of these, 92 percent remain in complete remission at 18 months. If one plots the survival from time of diagnosis, 92 percent of all patients remain alive at 18 months. If one extrapolates this data out to 5 years, based on assumptions derived from previous studies and other diseases, more than 50 percent of patients will remain in complete remission, that is, free of clinical and laboratory evidence of disease. Of patients who remain in complete remission for 5 years, over 50 percent should remain disease free indefinitely. As you know, there has been steady progress in the treatment of acute leukemia.

I want to emphasize that this progress has been so substantial that experience in recent years is entirely consistent with the realistic hope that definitive control of at least some patients with this disease has been achieved and will increasingly be achieved.

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These two examples of progress that I have presented to you can be most readily accomplished when the medical, paramedical and research expertise, material resources and patients are concentrated in a cancer center. This is essential since the delivery of cancer services, clinical cancer research and basic research in cancer is becoming increasingly multidisciplinary; that is, it takes a team effort.

It is extremely important, and it has indeed been a charge of the National Cancer Act to the comprehensive cancers centers to play a leadership role in what is known as cancer control or the outreach program. Briefly defined this means that the very best of patient services in cancer ranging from prevention, detection, diagnosis, treatment, followup and rehabilitation be made available to every American. In addition, progress in clinical services and treatment such as I demonstrated should be extended to the community as rapidly as possible. Accordingly, we have recruited a top-flight leader for our cancer control program and are working in collaboration with the other major cancer programs in the Boston area in developing a cancer control or outreach program.

Ultimately, patient care services must and should be delivered in the community and the emphasis of our cancer control program is, wherever possible, to assist communities and community physicians in developing clinical cancer programs.

Such programs will have continuing relationships to the regional comprehensive cancer center in areas of postgraduate education, patient referral, emergency and elective telephone consultations and other interactions.

The enlargement of our cancer center, the increased resources for patient care, clinical and basic research and our community outreach program has been made possible through the National Cancer Act.

I would emphasize that while considerable progress has been made in cancer, and while we have come a considerable way, we have still a longer way to go. Thus, the Children's Cancer Research Foundation, in addition to increasing its resources through private support will be calling on the national cancer program for continuing and increasing support for our enlarging program.

We are by no means fully funded for maximal activity. It should be emphasized that we work very closely with the national cancer program and many of our clinicians and scientists interact with the clinical and scientific activities of the National Cancer Institute and serve in major advisory capacities.

In summary, the original basic justification for the National Cancer Act was that cancer represents a major health problem for Americans and that there were many research developments and leads both at the basic and clinical level, which indicated that expanded support for cancer activities, whether in cancer centers or elsewhere, was a good health investment.

The National Cancer Institute was initiated only 3 years ago, and while it has had growing pains, I believe these pains represent exactly what they are, signs of growth and health. It is not surprising that scientists disagree on the relative emphasis that should be given to, for example, immunology as compared to chemotherapy

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research. The fact is that both of the above disciplines have, and will
continue to contribute to progress in the control of cancer and must
be supported. It is also not surprising that clinicians and scientists
disagree on the relative merits of a mission-oriented program such as
a cancer center as compared to cancer-related research in the tradi-
tional university system. Both are essential since certain types of
progress in the control of cancer can best be achieved in mission
oriented cancer centers while others are best achieved employing
more traditional approaches.

Scientists and clinicians may take extreme positions and such
positions are often most vocal and newsworthy. I would hope that
you would not be deterred by the controversies and flack that attend
the enlarging cancer program but rather that you would recognize
them as the pains that occur and are essential to rapid growth and

I wish to thank the committee on behalf of our center and of cancer workers all over the world and most particularly on behalf of patients whose health will be benefited by the National Cancer Act and its continuation.

Senator KENNEDY. Dr. Durant?

Dr. DURANT. Senator Kennedy, I want to thank you for the opportunity to talk to you and to tell you today about the development and progress of the Comprehensive Cancer Center in Birmingham.

I am speaking to you today, not only as director of the center but also as the president of the Alabama Division of the American Cancer Society, representing 43,000 volunteers. The subject of cancer research and control has been particularly important to me since I became philosophically committed to the importance of cancer centers in 1962 to 1963, the year when I was a fellow supported by the National Cancer Institute Training Grant at Memorial Hospital in New York City.

The first thing which made the center in Birmingham, Ala. possible was the combination of outstanding enthusiasm and support of the people of Alabama and the existence of the National Cancer Act of 1971. However, more importantly the real impetus to the development of our center began in 1968, with a human tragedy, the death of a young person in the prime of life, namely our former Governor, Mrs. Lurleen Wallace. Concerned about the distance she had to travel to the M.D. Anderson Hospital and inspired by her personal courage, the people of our State responded to a private fund-raising effort of the Governor, Mr. Albert Brewer. Over 40,000 people contributed a total of nearly $5 million, virtually all of which has been collected. The purpose of this money was to provide matching funds for the development of a cancer center in Alabama. Alabamians were used to supporting important health care measures, having seen a major academic medical school grow up in a quarter of a century, watched the development and contributions to cancer of the Southern Research Institute, and repeatedly returning to the Senate the Honorable Lister Hill. Fortunately, 'for us, the National Cancer Institute had a program with funds to support a planning grant for the development of a center in Alabama. From 1970 to 1972 we

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