2. It has provided increased funds for clinical and laboratory research as well as for cancer control.

3. It has attempted to avoid bureaucratic interference with cancer programs by providing a direct budget link from the National Cancer Institute to the Office of Management and Budget, and by creating a cancer panel to monitor progress monthly and report delays and obstructions directly to the President.

4. It has recognized the need for a critical mass of physicians and scientists to achieve optimal clinical care and has required the establishment of a network of comprehensive cancer centers. These centers not only should provide a nationwide network for cancer diagnosis and treatment, but should become regional centers for cancer control and also should become centers of excellence in cancer research.

B. WEAKNESSES

1. The Directors of the National Cancer Institute and the National Institutes of Health have become political appointees rather than career scientists.

2. The number of comprehensive cancer centers to be named is too few to provide the type of care the Congress visualized as being within a day's driving distance for most citizens of the United States.

3. The act does not provide a specific budget, either in relative or absolute terms, for the training of biomedical scientists.

4. The act does not provide personnel within the National Cancer Institute in any way commensurate with the added resources in dollars. Not only intramural programs but extramural programs as well require scientific, managerial, and supporting personnel to operate them effectively. As an example, two National Cancer Institute wards at the Clinical Center are not in operation today because nursing personnel slots or ceilings are not available.

5. The act does not require adequate outside peer review of both contract and grant programs. This is important when the executive branch of Government decides for other purposes to eliminate large numbers of advisory committees, as has occurred this past year.

6. The act does not provide guidance as to what programs should be funded by which mechanism: grant or contract. Such guidance could insure a specific or percentage amount of grant-funded basic research.

7. Finally, the act proposes a truly national cancer program and plan, yet the National Cancer Institute functions administratively much as before, despite the great increase in its budget and responsibilities.

Mr. Chairman, these recommendations are made within the context that research can be carried out through a number of different administrative mechanisms.

First, the National Cancer Institute was functioning effectively within the NIH prior to the enactment of the plan of 1971; second, it could function well if the original act creating a separate agency for cancer research had been passed by the Congress.

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However, the following recommendations are made within the context of the act as it was finally passed. Parenthetically, I would say a word here about the budget.

of

I certainly agree with Dr. Stone, Dr. Rauscher, and Mr. Schmidt that the cancer program should not be mounted at the expense other Institutes at NIH.

I was very pleased to hear Secretary Weinberger indicate that the extra $100 million for cancer research the President proposed today would not be at the expense of other Institutes, and particularly pleased to hear Mr. Schmidt defend the need for additional resources within the other Institutes.

I should point out, if we add up the numbers, the President is proposing $100 million in addition to his original fiscal 1974 budget proposal of $500 million, whereas the Congress passed $540 million for cancer research in fiscal 1974. Moreover, there are some additional funds released from impoundment (approximately $50 million) so the latest increase should be viewed in this light.

I submit those numbers so the record will be clear.
Now, as to the actual recommendations regarding the act.

IV. RECOMMENDATIONS

1. The Director of the National Cancer Institute and of the National Institutes of Health should be career appointees. Politicization of National Cancer Institute and NIH should cease.

Senator KENNEDY. You would be opposed to a Presidential appointment?

Dr. STEINFELD. I think if the Director of NIH and of National Cancer Institute were within the career system and were to make a decision which did not appeal to his political superiors, those scientists would still have the protection of either the Civil Service Commission or the Commission Corps system, and I think in many instances this would be extremely valuable. The people who do not have this career protection are not quite as free to do what their scientific judgment directs. So I think career appointments would be an advantage.

2. The number of cancer centers to be designated in the next 3 years should be increased to 30. A definite number is desirable and can be reviewed again in 3 years.

3. A portion of the National Cancer Institute budget should be reserved for training the research scientists and clinicians of tomor

row.

Senator KENNEDY. You are satisfied there is scientific expertise and manpower to provide the kind of support that Mr. Schmidt mentioned earlier to 30 centers of some excellence?

Dr. STEINFELD. I think they could be developed and I believe within the next 3 years, this should be our goal.

I think 15 does not blanket the country the way the Congress indicated, and I do think naming centers is an excellent idea because it leads to the form of cooperation that both Dr. Frei and Dr. Durant described.

I think naming them is a good idea, and having the number 30 would probably reach the goal Congress had in mind for the Nation. Senator KENNEDY. We do not set it precisely, but we have indicated that this figure is approximately 30 to 35.

Obviously, I think we would be guided by how those resources could best be utilized.

I think the thrust of our amendment on this is to achieve what you have outlined here, and I am glad you support it.

Dr. STEINFELD. I certainly support that amendment, and think it is an excellent one.

We need not only research scientists but clinicians expert in the diagnosis and treatment of cancer as well as in cancer control. Funds should be provided to institutions rather than individuals, so as to stabilize institutional funding in a period of rapidly changing academic and governmental responsibilities.

I think a very real problem has developed over the past few years in which training funds go to the individual rather than to the institution.

4. The act should provide a specific number of personnel-scientific, medical, managerial, and supportive-to carry out the purposes of the act. If the cancer program is a national priority research and medical program, the Office of Management and Budget should provide personnel as well as fiscal resources to carry out the Congress' and the President's decisions.

5. Both grants and contracts should be reviewed by outside peer groups. The mechanism for choosing peer review groups should be changed to provide a mechanism for input from the Congress, the American Association for Cancer Research, the American Society for Clinical Oncology, and the National Academy of Sciences.

6. The contract mechanism should be restricted to use for the purchase of products or services. It should be used to purchase research only after such resarch programs are recommended by senior outside scientific review bodies.

7. The Congress should take some responsibility for implementation, or at least continuing oversight of the cancer program; and for review of the choice of Cancer Panel, Board, and scientific review body membership within the National Cancer Institute.

This last may be the most controversial, but also the most significant of the recommendations. It is common knowledge among the scientific communities that the Directors of the various Institutes at the National Institutes of Health seldom have their choices for National Advisory Council members approved.

I believe recommendations for the Cancer Board should come from a group composed of the Director and Deputy Director of the National Cancer Insttute and a representative from each of the American Association for Cancer Research, the American Society of Clinical Oncology, and the National Academy of Sciences.

The nominations should be nonpolitical, and should be submitted for informational purposes to the chairman and minority leader of both the Senate and House committees responsible for oversight of the cancer program at the same time that they are submitted to the President of the United States.

The same elected Members of Congress should receive the Cancer Panel's monthly report and should meet at least quarterly with the Cancer Panel and the Director of the National Cancer Institute to review programs and problems.

While in the past many of the scientific groups have been chosen entirely intramurally by NIH staff, the magnitude and the scope of the national cancer program require that the members of all senior scientific committees be selected in such a way as to insure scientific objectivity and immunity from political surveillance.

Having greater participation of the scientific community in the choice of advisory groups and having bipartisan congressional overview of the program, should make the program more truly an initiative of both the legislative and executive branches of Government.

In conclusion, the Cancer Act of 1971, endorsed overwhelmingly by both the legislative and executive branches of Government, was not only a reflection of our Nation's desire to conquer cancer but an expression of our dissatisfaction with the current priority for cancer research and dissatisfaction with the current administrative and management mechanisms available to do the job.

Work, both scientific and administrative, by Dr. Rauscher and his senior staff at the National Cancer Institute has started the program successfully on the route charted by the Congress.

My purpose today is to suggest mechanisms, exclusive of dollars, which can help the National Cancer Institute, by providing for greater involvement of the Congress and the biomedical community, in achieving our goal of conquering cancer.

Senator KENNEDY. Very good, very helpful suggestions and recommendations.

We would like to stay in touch with you on a number of these proposals.

I gather that you gentlemen agree without qualification about the provision of our legislation that permits the expansion in the number of cancer centers, and feel that is a desirable feature and one that ought to be supported.

Do I understand the thrust of your testimony to include that general support?

Dr. FREI. Yes.

Senator KENNEDY. This statement will be useful both to me and to the other members of the subcommittee in the course of our deliberations.

Dr. FREI. I think the answer is emphatically yes, with the emphasis on the fact that the 15 or 18 Cancer Centers, comprehensive Cancer Centers, that now have been designated are in varying stages of development.

Some are very mature and some relatively new. I think the additional Cancer Centers, I guess it is the proposal to be added as they are over the next 3 years could take advantage of the experience not only of the old Cancer Institutes, as Dr. Clark pointed out, but also of some of the problems and opportunities of the relatively recent

ones.

Senator KENNEDY. Because you have Federal funds, have you felt the cold hand of Federal takeover in any of the centers you have been associated with? Has this caused you undue concern?

Dr. STEINFELD. I certainly have not. We are the newest center, but it would seem to me in working with the National Cancer Institute staff that they are looking for help, looking for advice, and we certainly have had considerable help from National Cancer Institute staff, and nothing that would be inimical to the development of the Cancer Center.

Dr. FREI. As Mr. Schmidt emphasized, none of the comprehensive centers are totally dependent financially on the Federal Government. All of them have a varying base of private or State support, which assures some degree of independence.

I think the comments that Dr. Steinfeld made with respect to increasing scientific input, and decreasing political input into the selection of scientific advisors for the national cancer center program, and key administrators of the national cancer center program is also important in that context.

Dr. DURANT. I would like to reiterate the testimony of the other witnesses.

I think the number of Centers needs to increase, otherwise we are likely to have two classes of citizens, those with ready access to the availability of the Centers, and those who do not.

I believe the importance of review in reviewing the programs of the Centers is essential in order to keep them scientifically excellent. I do not consider that political interference, but scientific guid

ance.

We have not felt the cold hand of the Feds on our programs.

I feel that we have been tremendously helped by the National Cancer Act, and by the community of scientists around the nation who have supported this legislation.

Senator KENNEDY. I want to thank you for your testimony.

One of the goals of the legislation is to obtain firsthand information from those who have been out in the field. I think I share with all of those who support the changes in the legislation, a very strong belief that this flexibility will be used by the Institute to support excellence and availability of information to the greatest number of American citizens.

I think we are completely aligned in that understanding, and I think the clarifications that Mr. Schmidt made about ongoing commitments and limitations in this area are important and should be established in the record as well.

I want to thank you gentlemen very much. We may be submitting some additional questions to you in the course of the legislative process that lies ahead.

Thank you again.

At this time I would like to welcome Dr. John Cooper, president of the Association of American Medical Colleges, Washington, D.C. We are delighted to have you here.

STATEMENT OF DR. JOHN COOPER, PRESIDENT, ASSOCIATION OF
AMERICAN MEDICAL COLLEGES, WASHINGTON, D.C.

Dr. COOPER. Thank you very much, Senator Kennedy.

Senator KENNEDY. I apologize for our time problem. We have two votes back to back by 2:30, and the full committee goes into executive