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received approximately $225,000 to work out the plans of our pro-
gram. In addition, the Alabama regional medical program, through
its local regional advisory group provided additional planning funds
of $161,493 to plan a regional program in radiation therapy. These
funds not only provided help in getting started, they also provided
tremendous impetus for interest in cancer among both patients and
physicians. This has increased our influence on the delivery of medi-
cal care tremendously.

I believe that there are two fundamental problems facing human-
ity in relationship to cancer. The first is the gap in our knowledge
concerning certain fundamental information about the cause and
biology of cancer. The second is concerned with the gap in delivering
to all of the people the best of what we already know. There tends to
be some kind of artificial division in the minds of many people who
insist on making one or the other of these of primary importance.
This should not be. Both can and should go on together as there will
be no sudden breakthroughs which will suddenly abolish the problem
but rather the gradual development of knowledge and techniques,
and the application of these to clinical situations. Centers must and
can stimulate progress in both of these areas. I believe the early
results from our own efforts will confirm this.

In 1968 when I first came to Birmingham from Philadelphia, the number of new cancer patients seen at the University of Alabama Hospital and the Birmingham Veterans Administration Hospital were approximately 1,200 per year, or about 12 percent of the expected new cases for the entire State.

In 1973, only 5 years after the planning began and not quite 2 years after the award of our first center grant, approximately 2,300 patients were seen, or 23 percent of the expected new patients from the entire State.

We believe that our experience with the outcome in patients seen at our center supports the importance of the center concept. In review of all of our patients from 1958-72 our cumulative 5-year survival was 42 percent, a considerable difference from 33 percent, the widely publicized figure put out by the American Cancer Society.

In the period from 1968-72, our cumulative 5-year survival was 47 percent with a standard error of 3.5 percent, meaning that there was only a 5-percent chance that a survival rate above 40 percent was a statistical accident.

Furthermore, the epidemiologists and the statisticians in our cancer center assure me that these results are not due to special selection or distribution of cases.

In other words, the data seem to support the notion that referral to a major cancer center, such as ours and others like it can and does result in improved survival and that the creation of a center will result in an increasing number of patients having access to the diverse and complicated expertise of the facilities available at that center.

Our own efforts have been directed in two major ways. We have worked hard at developing basic, laboratory research programs directed at and answering some of the fundamental questions regarding the nature of cancer. We have been given the support to recruit

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and begin a program in the area of medical genetics which may
ultimately answer fundamental questions about the ordinary control
of cellular growth and division which is lost when cancer develops
within a cel]. We have supported research that has indicated some of
the ways in which chemicals ordinarily not carcinogenic in them-
selves may act with other chemicals to increase greatly the potential
to produce a cancer.

We have supported research which offers promise of understanding
the development of the immune system and how alterations in this
system can result in malignancy within the system itself or in the
rest of the body. These are but a few of the programs whose growth
and contributions have been aided by the development of the center
in Birmingham. Each of them is, incidentally, improved and made
more efficient by the fact that they have had to withstand peer
review, the most single important factor in maintaining scientific
excellence.

Not only have we supported basic, fundamental research, we have also worked very hard at developing a regional program which can respond to the direction of the original legislation which directed centers to develop programs which would involve practicing physicians of the region. In Alabama this is a necessity. We are one of the most indigent of the 50 States. We have one of the poorest physicianpopulation ratios in the Nation. In order to address ourselves to meeting these sorts of problems it has been necessary to develop plans to utilize to the fullest scarce resources, personnel, facilitiesparticularly radiation therapy-and knowledge. We have developed a model telephonic consultation service which, although available to any physician with any kind of a patient problem, has seen calls about cancer become the most frequent category of request.

We have been enthusiastically received by physicians practicing radiation therapy in Birmingham, Anniston, and Huntsville, the areas in which the demonstration project is now working.

We have begun plans for a network for the treatment of patients with diseases of the blood and blood forming organs and have a specially trained nurse visiting regularly, a practicing oncologist in Mobile and Montgomery, and we are working out plans for extensive programs in the rehabilitation of patients with cancer.

We are working with the American Cancer Society in its "Let No Woman Be Overlooked" program to get a Pap smear on every woman in the State. The chief of our gynecological cancer service is active in that program which proposes to begin the collection of Pap smears on special populations of high-risk patients in eight of the highest risk counties spread throughout the State.

We have also worked at the development of facilities and personnel. We now have 58 physicians and investigators supported by 41 technical personnel in our program. This represents considerable growth since 1968. Through the generosity of the National Cancer Institute Center's program, we have been awarded $3.5 million in renovation and construction grants in the past 2 years. Almost all of this money is currently either being spent for facilities under construction or about to be let for bid.

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The ability to respond so quickly to the needs of the people and the direction of programs has stimulated the Governor to designate $2 million in revenue sharing monies to construct 80 beds at such time as these become necessary and feasible.

In summary, I believe that we have made a small but significant
beginning. Since planning began in 1968, we have doubled our
patient load, improved somewhat our survival rates, built programs
for and trust with community physicians, and begun construction of
over 60,000 net square feet of facilities.

I trust that you will believe that this is sufficient evidence to
continue support of legislation which will make it possible to deliver
to those 40,000 people who originally donated money to the program
and also to all of the people of the State of Alabama, the progress in
both fundamental research and health care delivery which they were
promised and are expecting. The next 3 years will not see sudden
breakthroughs in Alabama, but I trust it will see the development of
additional data and progress which will result in increasing cure
rates and improved quality of survival for as many of the people of
our region as possible.
Senator KENNEDY. Thank

you.
Dr. Steinfeld ?

Dr. STEINFELD. Thank you, Senator Kennedy. It is a pleasure to be
here today to testify on the 1974 amendments to the Cancer Act.

I would like to divide my testimony into the following sections: I.
The Problem: Clinical and Laboratory; II. Recent Accomplish-
ments: Clinical and Laboratory; III. The Cancer Act; A. Strengths;
B. Weaknesses: and IV. Recommendations.

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1. THE PROBLEM: CLINICAL AND LABORATORY

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Cancer will strike over 50 million Americans now alive-one of four of us in this room. One of six will die as a result of that cancer. This means that today one of three American victims of cancer is cured of his tumor using surgery and/or radiotherapy and/or chemotherapy. Obviously there is hope.

In the above figures lies the dilemma facing both biomedical research scientists and the Congress. We do not know the final or ultimate cause or causes of cancer, We do not know that final event by which a virus, chemical, or radiation changes a normal into a neoplastic cell.

And we are not certain who, where, or when such a discovery will be made; or how it will be translated into a preventive or curative measure for human cancer.

Because this is unknown-many members of the scientific community urge you to support “basic science"_biochemists, molecular biologists, geneticists, immunologists--because we are so far from understanding the nature of the neoplastic cell. And, of course, they are correct.

We need more fundamental information in oncology as well as all of biology. We need to train and nurture the brilliant, inquisitive young student, so that we can learn more about man and his diseases. Our bright and research-oriented youngsters are one of our most

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precious natural resources and we must train them, and provide the
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science. This is important.

Cancer funds should be used to support both training in and the
conduct of basic biomedical investigations.

But that is not all of the story. Six hundred and fifty thousand
Americans will develop cancer this year and 350,000 will die of the
disease. Many could be saved even though we do not know the
ultimate cause of cancer, through what we do know about preven-
tion, early detection and adequate treatment.

Currently we are, without any question, saving patients' lives, even
though, I repeat, there is much about cancer that we do not know.
Moreover, it is quite possible that in the final analysis cancer will
turn out, like infectious diseases, to be many diseases.
Indeed, I have estimated that there are over 200 different human

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Several centuries ago, physicians might have talked about curing
or finding the cause of fever or infection at a time when they did not
have instruments sufficiently fine to see bacteria or viruses. Even
then, however, it was possible through sanitation, good nutrition,
good hygiene, and vaccines to combat successfully many of the infec-
tious diseases.

Similarly, with cancers. We can prevent many cancers, if, for
example, our citizens would stop smoking cigarettes. We can also
prevent other cancers by prohibiting the release of carcinogenic
agents into our home or work environments.
We can identify high-risk groups with certain cancers, do diagnos-
tic tests at regular intervals to pick up tumors at a stage when they
are curable.

And, finally, we can use our tools more intelligently and in combi-
nation in the treatment of cancer: combining surgery, radiotherapy
and chemotherapy and possibly immunotherapy in order to improve
results. And all of this can be done now.

Mr. Chairman, it is obvious that we must both improve our present diagnostic and therapeutic armamentarium, and we must do more research on fundamental biological processes.

I would interpret the arguments you have heard about basic science versus the national cancer program as coming from the uninformed. This is not an either-or proposition.

I have interpreted the Cancer Act the Congress passed several years ago as recognizing the need to work simultaneously on both problems; and that was a wise decision.

I believe that in the renewal of the legislation, you can help bring the scientists together by making more explicit the dual nature of the thrust the Congress has proposed, and by earmarking to a certain degree funds for both programs. I will return to this in the recommendations later,

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II. RECENT ACCOMPLISHMENTS: CLINICAL AND LABORATORY

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It is the nature both of science and medicine that advances cannot be predicted, so that some of the progress in clinical oncology, as

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well as in basic oncology, has been made by scientists not wholly affiliated with the national cancer program. But most of the advances can be traced directly or indirectly to the support of the National Cancer Institute or the American Cancer Society.

In the past few years we have identified a group of young women at risk to development of vaginal cancer because their mothers were given the chemical, diethylstilbestrol, to prevent miscarriage during the first trimester of pregnancy.

More data has been obtained linking the body's immune system to cancer development since patients treated with immunosuppressive agents to permit renal transplantation have been found to have 35 times the expected rate of lymphomas.

Recent National Cancer Institute studies have shown that advanced non-Hodgkin's lymphoma patients can survive with control of the disease for long periods by combination chemotherapy.

In a large repetitive screening program-every 4 months—at the Mayo Clinic for heavy smokers at high risk to lung cancer, previousiy unsuspected lung cancer has been detected and localized during a subsequent screening, after the first tests were negative. In all but one of these patients it has been possible to remove the tumor surgically. This program, if successful, may represent a way to improve the otherwise dismal prognosis of the lung cancer patient.

Additional results are accumulating, showing higher survival in patients receiving chemotherapy after presumed curative surgery in tumor types with a very poor prognosis.

This may be the most significant clinical advance of all; in that it will stimulate well-controlled prospective combination treatment studies in the common cancers, which kill so many in the United States.

In the laboratory, great strides have been made in our understanding of animal tumor viruses, their transmission and multiplication.

In man, Herpes viruses have been implicated by immunologic techniques in carcinomas of the oropharynx and genitourinary tract. The carcinoembryonic antigen, CEA, and alpha-fetoprotein have been further studied as guides to the successful treatment of cancer and/or the extent of tumor within an individual patient.

At the cellular level, a component of the cell membrane, a glycoprotein, has been found to disappear when normal cells are transformed into cancer cells. This seems to be associated with appearance of an enzyme called a protease; and when the protease is inhibited, the cancer cells stop growing.

Of course, the number of advances in both clinical and laboratory science are enormous.

I want only to emphasize that the Cancer Act of 1971 has not slowed but, in fact, has speeded up progress at all levels.

III. THE CANCER ACT

A. STRENGTHS

1. The Cancer Act has focused the attention of the scientific and medical community, all of our citizens, the Congress and the executive branch of government on the cancer problem.

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