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The National Cancer Act at 30: Looking Back, Planning Ahead

Eastman, Peggy

doi: 10.1097/01.COT.0000315320.08160.63

WASHINGTON, DC—Just over 30 years ago the nation declared war on cancer when President Richard Nixon signed the National Cancer Act of 1971 on December 23 of that year. Although measurable progress has been made on many fronts, the war is far from won and requires a new assault, said speakers at a meeting here in November presented by the American Association for the Advancement of Science (AAAS) and Americans for Medical Progress (AMP). The meeting was called “30 Years of Fighting Cancer: Reflections on the Past, Challenges for the Future.”

During the next 30 years, the number of Americans over age 65 will double, and cancer—if not eradicated—will soon supplant heart disease as the nation's number one disease killer, warned Anna D. Barker, PhD, President and Chief Executive Officer of BIO-NOVA, Inc., and a member of the National Cancer Legislation Advisory Committee (NCLAC).

In 15 to 20 years an aging US population will cause new cases of cancer to escalate by as much as 30 percent, she said. “Somebody had better think about this. Maybe this meeting can be a wake-up call. We need a national, full-scale commitment at all levels to cancer.”

Dr. Barker, who has lost many family members to cancer, said that while cancer is probably the most feared disease ever, people in the general population do not realize how high their risk of cancer really is (one out of two men and one out of three women will develop cancer in their lifetimes, according to data presented at the meeting).

Dr. Barker also warned about a shortage of biomedical researchers to work on the science of cancer. “We should be flush with biomedical researchers, and we're not,” she said.

She said an area that is particularly in need of highly trained scientists is that of the interaction between genes and the environment. A recent report from NCLAC stated, “The number of health professionals choosing careers in cancer research is critically low, and is fast approaching the crisis level.”

This report recommended that the National Cancer Institute implement a medical school debt-forgiveness program and expand support for training and mentoring new MDs and PhDs who pursue careers in cancer research.

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Jettison War Metaphor?

In recent years, there has been criticism of the use of the war metaphor in relation to the nation's attack on cancer. Dr. Barker said she continues to be in favor of that. “I like the war metaphor—it's more appropriate now than ever,” she said.

In contrast, however, former NCI Director Samuel E. Broder, MD, who is now Executive Vice President for Medical Affairs of Celera Genomics, urged the country to drop the war metaphor. He also warned against hyped press conferences and overblown statements about research advances in the effort to find cures for cancer in the 21st century. “Cancer cells are not impressed by hype,” he said.

Dr. Broder said military metaphors in science are not helpful now and do a disservice to US servicemen and women in uniform. He noted that even in 1971, many scientists objected to the use of war metaphors to describe the goals of the National Cancer Act.

He decried “triumphalism” in announcing new discoveries, which he said interferes with “the scholarly agenda” of solid science. Instead, he said, scientists need humility. “One cannot rush creativity” or make it respond to a particular political mandate or a particular timeline, he warned.

Dr. Broder cited recent declines in mortality rates for many cancers—including cervical, colorectal, Hodgkin's disease, stomach, and testicular—as an example of real progress based on years of solid science that needs no hype. “The death rate is a clear and unmistakable endpoint,” he noted.

While decrying war metaphors, Dr. Broder praised the National Cancer Act of 1971 as a courageous milestone event. He noted that there was criticism of the act's daring in 1971, stemming largely from “the very audaciousness of the original purpose of the act.” But, he said, “Can we really believe that we would have made more progress without the audacity or the naïveté?”

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Policy, Funding, Reimbursement

Another speaker, the Honorary Paul G. Rogers, a former Congressman from Florida who was a cosponsor of the National Cancer Act of 1971 and is now Chair of Research!America, a nonprofit public education and advocacy organization, said, “Our nation is looking to science more now than ever for answers. The American people know that without research there is no hope for diagnosis, for treatment, or for cure of diseases. We've got to show that curing diseases is a benefit not only to people, but also a cost benefit.”

He noted that while it is impossible to put a monetary value on a human life, policy decision-makers relate to dollars saved and are more willing to allocate resources for cost-effective policies.

The NCLAC report cited a study from the Mary Woodward Lasker Charitable Trust in which nine leading US economists found that eliminating just one cancer death per 1,000 people would yield $46 million in savings to the American people. Reducing cancer deaths by 20 percent, the study noted, would save $10 trillion (twice the national debt).

Policy decisions on reimbursement, especially Medicare, drive oncology practices, sometimes put physicians at odds with policy makers, and could affect treatment advances in the war on cancer, speakers noted.

“What you get paid to do tends to drive what you do,” said Ellen Stovall, President and Chief Executive Officer of the National Coalition for Cancer Survivorship.

Ms. Stovall, who began treatment for Hodgkin's disease as a new mother on the very day President Nixon signed the National Cancer Act into law, cited the fact that there is no Medicare reimbursement for oral cancer drugs—unless they have first existed in an intravenous form—as a potential barrier to advances in cancer care. “Gleevec is not covered by Medicare,” she noted.

Ms. Stovall, a member of OT's Editorial Board, also said that any changes in Medicare reimbursement to oncologists could have a major, adverse effect on cancer patients' access to quality care. A recent General Accounting Office (GAO) study concluded that oncologists are being reimbursed at too high a level by Medicare for chemotherapy drugs administered in their offices, because they can obtain the drugs at well under what Medicare pays.

Medicare currently reimburses physicians 95 percent of the average wholesale price (AWP) for chemotherapy drugs. Oncologists have consistently maintained that the 95% rate is needed to subsidize the related costs of administering the drugs in an office setting (such as nutritional and psychological support services). One solution: Reduce Medicare reimbursement for chemotherapy drugs but increase Medicare payment for oncologists' practice expenses.

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Disparities in Mortality Rates

The nation will be hampered in the war on cancer in the 21st century if it cannot narrow the gap that exists in mortality rates between minority and non-minority cancer patients, said Otis W. Brawley, MD, Professor of Medicine, Hematology, and Oncology at Emory University School of Medicine and Professor of Epidemiology at Emory's Rollins School of Public Health.

Dr. Brawley, a former NCI researcher, noted that there is no overall difference in biology between minorities and non-minorities, and that therefore “race is a sociopolitical construct.” He said his gut feeling is that most of the disparity in cancer mortality between minorities and nonminorities revolves around socioeconomic status and not race.

Poverty itself can be viewed as a carcinogen, said Dr. Brawley, noting that when minority cancer patients receive equal medical treatment, their outcomes are more similar to those of non-minorities. For example, he said five-year mortality statistics from the Department of Defense—where all men and women in uniform are provided health care—are more nearly like those of five-year mortality statistics on the population at large from NCI's Surveillance, Epidemiology, and End Results (SEER) program.

The NCLAC report recommended expanded funding to intensify biomedical research directed at reducing cancer-related population health disparities.

Will the promises of the 1971 National Cancer Act be kept? Brian J. Druker, MD, Director of the Leukemia Center at Oregon Health & Science University, said he is hopeful. Dr. Druker, whose work was instrumental in the development of Gleevec (STI571—imatinib mesylate), said, “All in all, I'm an optimist. If we can do this with one cancer, we can do it with all cancers. If we can keep research strong, we can do with cancer in the 21st century what we did with infectious diseases in the 20th century.”

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Cancer Research Milestones

This list of milestones in cancer research was distributed at the meeting, compiled by the NCI, National Foundation for Cancer Research, and the American Cancer Society.

▪ 1971: National Cancer Act (P 92–218) signed by President Nixon, establishing a national program to search for a cancer cure.

▪ 1972: E. Donnall Thomas, MD, pioneered the technique of bone marrow transplantation to treat cancer (an achievement for which he went on to receive the Nobel prize in 1990).

▪ 1973: Hurbert Boyer, PhD, and Stanley M. Cohen, PhD, successfully recombined DNA; Paul Berg, PhD, cloned the first gene (received the Nobel Prize in 1980).

▪ 1974: V. Craig Jordan, PhD, DSc, showed that tamoxifen prevented breast cancer in rats by binding to the estrogen receptor. In 1978, the FDA approved tamoxifen for treating estrogen receptor-positive breast cancer.

▪ 1975: Cesar Milstein, PhD, and Georges Kohler, PhD, developed hybridoma technology, which produced a monoclonal antibody that can manipulate and enhance the immune system (Received Nobel Prize in 1984).

▪ 1976: J. Michael Bishop, MD, and Harold Varmus, MD, discover proto-ocogenes I normal DAN, showing that a normal cell could have latent cancer genes (received the Nobel Prize in 1980).

▪ 1978: Walter Gilbert, MD, and Frederick Sanger, PhD, developed procedures to sequence DNA, which enabled the study of the actions of specific genes (Received Nobel Prize in 1980).

▪ 1979: Robert Weinberg, PhD, demonstrated the first biologically active oncogene in human bladder cancer—more than 50 oncogenes are known today; Arnold Levine, PhD, discovered the p53 protein, later found to be the most frequently mutated gene in human cancer.

▪ 1980: Robert Gallo, MD, and colleagues discovered the first virus that causes cancer—HTLV-1, which causes T-cell leukemia in humans.

▪ 1981: Thomas Cech, PhD, showed that RNA could cut and splice itself and act like an enzyme not just as a “genetic messenger” as previously believed (Received Nobel Prize in 1989); T. Ming Chu, PhD, and Gerald P. Murphy, MD, developed the prostate-specific antigen (PSA) test for screening and possible early detection of prostate cancer.

▪ 1982: Richard Palmiter, PhD, developed the first “transgenetic mouse,” a mouse with a gene for rat growth hormone, opening up new ways to research how cancers are caused and can be treated.

▪ 1986: Robert A. Weinberg, PhD, cloned the first of some 20 now-known tumor-suppressor genes, the retinoblastoma gene.

▪ 1989: R. Michael Blaese, MD, French Anderson, MD, and Steven Rosenberg, MD, PhD, carried out the first gene transfer experiment in humans.

▪ 1991: Carcinogens in the environment—such as radiation from the sun and chemicals from cigarette smoke—became more closely linked to specific gene damage that can cause cancers.

▪ 1992: Chemoprevention trials were expanded to test the power of assorted vitamins, minerals, and drugs to intervene before invasive disease begins.

▪ 1993: Gary Nabel, MD, PhD, demonstrated the possibility of treating cancer through direct gene transfer when he injected specially coded genes into the tumors of melanoma patients.

▪ 1997: Judah Folkman, MD, and Timothy Browder, MD, cured cancer in mice by blocking the blood supply to tumors with angiostatin and endostatin.

▪ 1998: Dennis Slamon, MD, PhD, showed the effectiveness of the genetically engineered monoclonal antibody Herceptin to treat advanced breast cancer.

▪ 1999: Robert Weinberg, PhD, turned a normal human cell into a cancer cell with three defined elements: an oncogene, inactivation of two suppressor genes, and the gene for telomerase.

▪ 2000: The draft sequence of the human genome was announced.

▪ 2001: STI571 (Gleevec) was shown to target receptor cells of chronic myelogenous leukemia and was approved by the FDA; Leland Hartwell, PhD, Paul M. Nurse, PhD, and R. Timothy Hunt, PhD, received the Nobel Prize for research into cell division revealing information about mutant cell division.

© 2002 Lippincott Williams & Wilkins, Inc.
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