Senator KENNEDY. At the end of my statement, I will insert into the hearing record an appendix which further amplifies the nature of the cancer problem and the progress of the cancer program.

Finally, I want to just make a brief reference to the remarks the President of the United States made when we in the Congress were considering this legislation in 1971. The President stated:

This, however, will differ from other programs in a very important respect. This program I have asked be the one program within the National Institutes of Health and within the whole health establishment of the United States that is independently budgeted and that is directly responsible to the President of the United States.

Truly, this has been a unique feature of this cancer program. And I am most interested to have a detailed progress report from the witnesses today on how this has worked and whether this mechanism, if it has been successful, might possibly be utilized for other health programs.

[The appendix referred to follows:]

APPENDIX TO ACCOMPANY THE OPENING STATEMENT OF SENATOR EDWARD M. KENNEDY

"Cancer" is a term applied to more than 100 clinically distinct diseases which kill someone in the United States every 112 minutes. In 1973, it was estimated that 642,000 Americans will become new cancer cases, 1,310,000 Americans will be cancer patients and 350,000 Americans will die of cancer. The annual cost of cancer is about $18 billion, which cannot measure the incalculable suffering of victims, their friends and families.

Cancer is a widespread biological phenomenon with different incidences, appearances and functioning. It is induced by widely different chemical, physical and biological agents, most of which are unknown. Cancers have many similarities to the host tissues from which they originate. This makes early diagnosis more difficult than with infectious diseases caused by organisms which the body recognizes as foreign to the host tissues. A major effort of the national cancer program is to develop tests which can identify the presence of small numbers of cancer cells with a reliability similar to that of well-known erologic tests for bacterial diseases.

In the early stages of cancer there may be relatively few cancer cells among billions of normal cells. The best chances for curative treatment are at this stage because the balance of forces is in favor of the patient and a skilled therapist. Unfortunately, however, most patients do not seek medical attention until their initial cancer has progressed by abnormal growth and destructive invasiveness to establish new cancerous growths (metastases). If untreated, cancers usually are fatal. However research supported by the National Cancer Institute has developed effective therapies for curing or controlling 10 forms of advanced cancer that were invariably fatal a decade ago. Cancer causation involves many interrelated factors: heredity, exposure to a variety of agents, singly or in combination and at various doses and routes of administration; host factors that produce different resistences to different agents and different means of handling

the many agents (host metabolism, hormonal patterns, immunological responses of the host). Epidemiological data, particularly in occupational settings, have clearly implicated approximately 22 chemical agents in human cancer causation; about a thousand chemicals are now known to induce cancer in animals.

In the early 1900's few cancer patients had any hope of cure. The 5-year survival rate in the late 1930's was about 1 in 5. Ten years later it was 1 in 4 and today the figure is about 1 in 3. This means that roughly 55,000 patients are being saved each year. The immediate goal of cancer control in this country is to save 321,000 lives a year, or half of those who develop cancer. On the basis of 5-year survival, about 224,000 Americans will be saved from cancer this year. About 1,500,000 Americans are alive and free of cancer 5 years after treatment. An additional 1,000,000 cancer patients diagnosed and treated within the last 5 years will live to join these ranks.

Although these improvements in cure rates are impressive and gratifying, the vastly complex nature of cancer requires a coordinated biomedical research effort of unprecedented dimensions. Many methodologies and approaches must be used to solve problems and gain significant new knowledge. Cancer is a chronic disease process, with causation and development extending over several years in most patients. In fact, with several occupational cancers, the period of exposure to the causative agent occurs about a decade prior to the diagnosis. This long time span makes it difficult to evaluate research findings and new methods of prevention, diagnosis, and treatment.

Since its creation in 1937, the National Cancer Institute has been the primary agency through which the Federal Government has sought to marshal biomedical research toward the goal of controlling cancer. The activities of the Institute have been directed toward providing, through research, improved means for the prevention and diagnosis of cancers in man, and the cure and rehabilitation of those cancers that have not been prevented.

The National Cancer Act of 1971 rested on the conviction that medical and scientific understanding of cancer had reached a level where sustained pursuit of new scientific leads could advance national capacities to prevent, diagnose, and treat cancer. The act stipulated that an intensified and coordinated national program would be needed to quicken the pace for developing the means to bring cancer under control.

The National Cancer Act gives the National Cancer Institute the responsibility for organizing this complex undertaking and for channeling the resources needed for this program. The act specifically directs the director of the Institute to "plan and develop an expanded, intensified, and coordinated cancer research program encompassing the programs of the National Cancer Institute, related programs of the research institutes, and other Federal and non-Federal programs." This mandate includes support for cancer research in industry and in other countries outside the United States.

To speed the translation of research results into widespread applications, the act directs the establishment of a cancer control program to demonstrate to both the medical community and general public the applications of the latest advances in cancer prevention and control.

The act further directed the Institute to provide supporting resources for the national cancer program. These include:

Collection, analysis and dissemination of all data useful in the prevention, diagnosis and treatment of cancer, including establishment of an international cancer research data bank.

Continuing support of appropriate manpower training programs in fundamental sciences and clinical disciplines.

Support of the large-scale production and distribution of specialized biological materials and other chemicals and drugs for research. An overall strategy for the national cancer program has been developed, based on a consensus among Federal and non-Federal clinicians and laboratory scientists about the direction, content and pace of the research program. The strategy and plan for the national program will be revised regularly as new information and concepts flow from the laboratory and clinic. The overall strategy involves the systematic sharing of cancer information by public and private agencies throughout this country and abroad. It requires continued assessment of resource needs and logistical planning to meet those needs. In some cases, it necessitates the redeployment of existing facilities, the rapid evolution of new kinds and combinations of research support, the reassignment of science management responsibilities, and the development of new mechanisms of technological transfer and information retrieval and application.

The national cancer program plan includes a strategic plan and an operational plan. The strategic plan, developed with a broad spectrum of advice from the scientific and medical communities, presents the major national goal, objectives, program strategy, implementation strategy, and estimated resources necessary to achieve the objectives. The operational plan, which is nearing completion, will include more detailed information concerning plans for specific research programs to implement the strategic plan.

A preliminary outline of the national cancer program plan and the research strategy was developed by the National Cancer Institute. with the advice of the National Advisory Cancer Council. Then, in a unique event in the history of biology and medicine in this country, 250 laboratory and clinical scientists met in a series of 40 planning sessions between October 1971 and March 1972 to develop a scientific and operational foundation for the national cancer program. The resulting strategic plan was reviewed by the President's Cancer Panel, the National Cancer Advisory Board, the director and staff of the National Institutes of Health, National Cancer Institute staff, the Association of American Cancer Institutes, the American Association for Cancer Research and the Institute of Medicine of the National Academy of Sciences.

The goal of the national cancer program is to develop means to significantly reduce the incidence of cancer in man and the suffering and death from cancer. The general strategy of the program is to provide for a balanced effort covering the entire spectrum of basic applied and developmental research. The strategy will be implemented through laboratory, field and clinical programs that are judged most likely to produce the information and technology that can be transferred rapidly to medical practice. The program will be

"balanced" in the sense that all promising options will be pursued, taking into account the current state of research knowledge, the probability of success of the option, and the impact of the successful completion of the option.

The national cancer program has a mandate that goes beyond the traditional NIH research mission. Simply stated, the program must build effective bridges from laboratory and clinical research to those who can benefit from the results of research-to physicians, their cancer patients, and all at risk to cancer.

CENTERS

The most visible manifestation of bridge building during the past year has been the establishment of a national network of cancer centers demonstrating optimum cancer care at locations selected to provide maximum public and professional access.

In 1971, when the National Cancer Act granted NCI authority to establish clinical cancer research and demonstration centers, there were three preexisting comprehensive cancer centers: The M. D. Anderson Hospital and Tumor Institute, Houston; Memorial SloanKettering Cancer Center, New York; and Roswell Park Memorial Institute, Buffalo.

Some 20.6 million people were within 60 miles of these three centers and 33.7 million people were within 120 miles.

Within the past year, nine additional medical institutions have established comprehensive cancer centers with assistance from the National Cancer Institute. These institutions are:

University of Alabama School of Medicine, Birmingham.
Children's Cancer Research Foundation, Boston.

Duke University Medical Center, Durham, N. C.

Fred Hutchinson Cancer Research Center affiliated with the University of Washington, Seattle.

The Johns Hopkins Medical Institutions, Baltimore.
University of Miami School of Medicine, Miami.

Mayo Foundation, Rochester, Minnesota.

University of Southern California (with the Los Angeles County Department of Hospitals), Los Angeles.

University of Wisconsin Medical Center, Madison.

As a result, today, 53 million Americans are within 60 miles of a comprehensive cancer center and 92 million are within 120 miles.

The distances 60 miles and 120 miles are not arbitrary. Studies show that 60 miles is generally the greatest distance a patient can reasonably drive for daily therapy, and 120 miles is the greatest distance a patient might be expected to travel for consultation without requiring an overnight stay.

By July 1974, at least six additional comprehensive centers will be underway. At that time, well over one-half the population should be close enough for a patient to visit a comprehensive cancer center for a consultation and return home the same day by surface transportation. The country will need 30 to 35 comprehensive cancer centers to serve adequately the entire U.S. population.

Now, I want to describe the particular aspects of my bill. First of all, it is a 3-year extension of the act through June 30, 1977. The bill

proposes substantial increases in the two sets of authorization levels for the program. For the basic research and training program, the bill authorizes $750 million, $830 million, and $985 million for the fiscal years 1975, 1976, and 1977, respectively. For the prevention and control program, the bill authorizes $50 million, $65 million, and $85 million for those same fiscal years. The bill also removes the limitation in the act which prohibits the creation of not more than 15 comprehensive cancer centers. I believe the Nation requires 30 to 35 such centers in order to bring high quality comprehensive cancer care within the reach of everyone. I can see no reason why any family should be denied the best possible cancer diagnosis and treatment simply because of where they live. Finally, the bill makes a number of minor though important technical amendments to the Cancer Act.

Senator KENNEDY. This morning, the subcommittee is privileged to receive the testimony of a host of distinguished persons. I certainly hope that, based upon today's testimony, the committee can promptly report legislation to the Senate. Clearly, there must be no hiatus in the continued operation of the national cancer program.

Let me say at the outset that we are delighted to have the distinguished Secretary of HEW here to present the administration's program. He has appeared before this committee on many different. occasions, and we want to welcome him back with his associates.

We want to mention, Mr. Secretary, that we applaud the efforts of the administration. The funding of this program has not quite reached the levels that we expected, but I think that the administration deserves credit for giving a sense of priority to this program.

I am also mindful that one of the features that troubled the administration was the prevention and control program, and I think the administration has demonstrated good faith with the Congress in developing active programs in this area.

I think that the work that they have done in combining the Federal Government's participation with that of private organizations, such as the American Cancer Society, is an excellent example of the type of cooperation that can exist between the Federal Government and private associations, and I think you are to be commended for that.

We are delighted that Dr. Rauscher is here, as well, and we want to commend him for the leadership that he has provided.

We will be interested in any comments he would like to make, particularly in the manpower area;

We have just had a chance to review your testimony. There are a few points which we would like to develop with you, and we look forward to your responses.

I want to recognize the Senator from Colorado, Senator Dominick, who has been so interested in the development of this program and the effect of our legislatio: in this area. He has been enormously interested in this subject matter as he has in so many other health areas. We have benefited tremendously from his participation in all our deliberations.