NCP

Pdt. R. M. Nixon National Cancer Program (1971)

Legislative History of the National Cancer Program
Source : http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=cmed6.section.19481

The mission of the NIH, an agency in the Department of Health and Human Services (DHHS), is to develop and apply fundamental knowledge about the nature and behavior of living systems to extend healthy lives and reduce the burden of illness and disability. The NIH, which began as a one-room Laboratory of Hygiene in 1887, today has over 27 institutes and centers and a 2002 budget of $23.3 billion (US). It stands as an unparalleled national (and international) resource and is the focal point for nearly all federally sponsored health research. It was within this context of improving the health of the nation, through research and application of knowledge, that the National Cancer Act was envisioned in the years between the establishment of the NCI in 1937 and the development of this unprecedented legislation in 1971.

An Act of Congress in 19376 made the conquest of cancer a national goal and set the stage for the formation of the NCI in 1939 from two existing laboratories.7 The Office of Cancer Investigations at Harvard merged with a pharmacology division of NIH and the NCI was relocated to Bethesda, MD. This legislation also established the National Cancer Advisory Cancer Council, and directed the Surgeon General to “provide for, foster, and aid in coordinating research related to cancer within the NCI and among other agencies and organizations.” It would be 34 years before President Richard Nixon would sign bold legislation that would elevate the conquest of cancer to a national crusade.

President Nixon signed the National Cancer Act on December 23, 1971, and declared a “war” on cancer. This unprecedented legislation8 was the outgrowth of an equally unprecedented research advocacy effort led by philanthropist Mary Lasker that prompted the Senate to adopt a resolution in 1970 calling for a study of cancer in America. The subsequent report from the Yarborough Commission, headed by Texas Senator John Yarborough, provided the details for a legislative plan that would become the National Cancer Act. It is interesting that this legislation never fully defined the concept of a national cancer program, which remains a topic of individual interpretation to this day.

The major goals of the National Cancer Act were to create a national cancer program that significantly expanded the authorities and responsibilities of the NCI, while maintaining it as an institute within the NIH. The most unique aspect of the National Cancer Act was that it provided the NCI director with direct access to the president of the United States. The act specifically mandated that the NCI develop its programs with the advice of a new National Cancer Advisory Board (NCAB); and submit an annual budget, termed the “bypass budget,” directly to the president, bypassing the approval of the NIH director. In addition, the act established a threemember panel, the President's Cancer Panel (PCP), which was specifically required to submit an annual report to the President. The NCI Director and members of both the NCAB and PCP became presidential appointees. This sweeping legislation granted to the Director of the NCI broad authority to plan and develop an expanded, intensified and coordinated National Cancer Program that included the NCI and related programs, other research institutes and federal and nonfederal programs. The National Cancer Act also authorized the first 15 cancer centers and mandated cancer control programs. As shown in Table 81-1, the 1971 legislation was amended in 1974 (P.L. 93–352) to further broaden the authorities of the NCI to include award of construction grants and information collection, analysis and dissemination responsibilities.

Although the Mary Lasker-led advocacy movement of the 1970s led to the National Cancer Act, the broad scientific community voiced concerns about singling out one institute and granting it such sweeping authorities. There were also concerns that the NCI would subsume funding from other institutes and that the increased investment in cancer research would undermine the quality of research across the NIH. In fact the national focus on defeating cancer over the past 31 years has only served to attract additional funding for nearly all of the Institutes of the NIH. Moreover, the relatively small number of approved individual investigator-initiated grants funded in 2002, approximately 22%, indicates that far too many good ideas still go unfunded. Therefore, the concern expressed in the 1970s that increased support for cancer research would result in “blanket funding” of mediocre science has never emerged as a problem. In fact, the ever-increasing size, scope and complexity of the National Cancer Program serves to keep the relative level of funding for new ideas and new investigators significantly below where it was in 1971.

Legislation passed in 1978, P.L. 95-622, recodified the National Cancer Act and further consolidated and expanded the authorities of the NCI director (Table 81-1). Interestingly, the language describing the National Cancer Program dropped the phrase “including other federal and nonfederal programs.” This legislation significantly expanded the mission of cancer centers to include basic research and prevention and called for an overall expanded and intensified research program focused in cancer prevention. Perhaps the most important aspect of the changes mandated in this act was the significant emphasis on environmental carcinogenesis and prevention.

Although some additional laws were passed between 1978 and 1993 that further strengthened some aspect of the National Cancer Program, or mandated a specific emphasis area, it was not until 1993 that patient advocacy would once again have a profound effect on the National Cancer Program. In June of 1993, the NIH Revitalization Amendments9 specifically required the NCI to intensify and expand research on breast and prostate cancer. Further, the legislation mandated a case control study of elevated breast cancer rates on Long Island and mandated a set-aside for cancer control activities at 7%, 9%, and 10% for 1994, 1995, and 1996, respectively. The period of “earmarking” for specific cancers had arrived.

The legislative history of the NCI and the National Cancer Program parallels the focus and effectiveness of cancer survivors and advocates over the years, beginning in 1971 with the group led by Mary Lasker. Today cancer has evolved beyond a health problem into a sociopolitical issue of enormous scope and impact. Interestingly, another concern expressed by the scientific community at the time of the enactment of the National Cancer Act was well founded—the unrealistic expectation of a quick cure for cancer. Many would argue that the lack of such a dramatic cure during the past 31 years has led to an increasing overall sense of apathy (and/or denial) among the public at large.

VIRUSES AND CANCER

source : http://www.smokershistory.com/NCA1971.htm

The Congress took special recognition of the increasing pace of research on cancer viruses with the initiation of the special virus leukemia program in 1964. The previous decade had seen the revival of cancer virus research and, with several findings becoming available in late 1963 and early 1964, the state-of-the-art reached the stage where a special program appeared warranted. By that time it had been clearly demonstrated that several cancers in animals were caused by viruses and some could be prevented by vaccination. A number of preliminary findings in man indicated similarities to the animal situation. The way to produce certain key reagents had been developed and ways to scale up to sizable required quantities could be visualized. Needed animal systems were available and the means for developing others-- for example, monkeys--were foreseen. Crucial laboratory tests were well along--though many others later proved to be necessary.

Good progress has been made since the special virus leukemia program was initiated, and the name has been changed to the special virus cancer program to indicate results and opportunities enlarging beyond leukemia.

We have made continual evaluations of the program and continually modify the program to take this into account. More than 80 viruses are now known to produce cancers in many different animal species, including subhuman primates, man's closest relatives--about 20 viruses discovered in the past 3 years. With some types of virus, we have attained pilot plant scale production, a critical step for the early stages of vaccine development and safety testing. Production of animals, including monkeys, and animal and human tissue culture systems is now scaled up to meet program needs. We can now produce requisite quantities of key reagents, have management capability to handle necessary logistics, and have required laboratory tests to determine within populations whether particular viruses may be related to particular cancers. Preliminary findings indicate strong association between Burkitt's lymphoma patients and a herpes type virus known as the EB-type virus. Similar association exists for nasopharyngeal cancers--that is, cancers in the back part of the mouth and the back part of the nasal area, and also in the upper throat. Also this association exists with infectious mononucleosis. Other studies are underway. Now, as you know, finding something in association with a disease does not in itself mean that that something necessarily causes the disease. We must determine quantitative relations on the association and systematically collect additional information. If it all hangs together, circumstantial evidence mounts, and causation may look more and more likely; but the causative significance is demonstrated after the disease is reduced or eliminated upon removal, reduction, or blocking action of the causative agent. We have completed this sequence in several animal cancers, but we are in the midst of the process with human cancers and have not yet established the virus causation of any cancers in man.

The circumstantial evidence continues to point to viral causation of several kinds of cancers, however. One important negative finding was attained last year: there appears to be no relationship between human cancers and the 31 adenoviruses, several of which can cause disease in man; that is, diseases of the respiratory tract or GI tract. There appears to be no association between any of these 31 adenoviruses and cancers in man, though many of these adenoviruses are known to produce cancers in hamsters. The capability of the special program allowed us to pin down this critical answer in only 9 months' time, during which we actually examined 300 cancer patients in terms of their serum specimens. We ran laboratory tests against all 31 adenoviruses and found no correlation between any of the types of adenoviruses and the types of human cancers.

We have checked this out with more critical and sensitive techniques and the same findings hold; so this has led to a marked shift of priorities in this area of adenoviruses and cancer. We put it pretty much on the back burner now.

The stages of development varies with different kinds of tumors. In some, such as Burkitt's lymphoma, we appear to be well along in determining the relationship between the disease and the EB virus and may be close to starting vaccine development. In others, such as lung cancer, only very preliminary findings are available. From the knowledge gained in the special program, however, we can now determine critical relations more rapidly.

TUMORS ASSOCIATED WITH VIRUSES

It is important to group different kinds of tumors together in relation to certain kinds of viruses; so I will discuss three groups of tumors.

TUMORS ASSOCIATED WITH HERPES-TYPE VIRUSES

The first group are the tumors associated with the herpes-type viruses. Several important tumors are associated with these herpes-type viruses. These are DNA viruses related to those causing fever blisters and shingles. Yet they are not the same viruses that cause those diseases. Tumors associated with these viruses each year causes in the United States about 30,000 deaths and 70,000 new cases. These are the Burkitt and other ]ymphomas, nasopharyngeal cancers, cancers of the penis and uterine cervix, chronic myeloid leukemia, and suggestively certain other tumors, and certainly in some animal species, including the economically important disease in chickens known as Marek's disease. We are requesting $7.2 million for work with these tumors.

The state of the art varies with the different kinds of tumors. We are probably furthest along with Burkitt's lymphoma and nasopharyngeal cancers in our attempts to pin down virus causation of human cancers. The EB herpes-type virus, now available in quantity from tissue culture, has permitted us to gain important information on patients with lymphoma or nasopharyngeal cancers; such patients have antibodies in their serum against EB virus. I might add that quantitatively patients with these lymphomas have very much higher levels of antibody and antibodies are found in 100 percent of the patients.

In corresponding nondiseased control groups of the same age we can find EB virus in some of the subjects or we can find the antibodies against the EB virus but the levels are much lower and the percentages run much lower than in the case of the patients where it is 100 percent. These findings, coupled with the extensive animal and tissue culture data, are strongly indicative that the EB virus is the causative agent in producing these tumors. We must conduct much more extensive fieldwork with human populations, however, to prove causation, ultimately by the actual demonstration of a reduction in incidence of these tumors by corrective measures developed from the research. The data are suggestive that vaccination will be successful in preventing these types of tumor. In the coming year we will gather the additional information in population groups exhibiting high incidence of Burkitt's lymphomas and nasopharyngeal cancers, those types where the association is strongest and we have the most data available. The highest incidence is found in populations in Africa and in Southeast Asia, and we are working with the International Agency for Research on Cancer to ensure the international cooperation necessary to move ahead. We need more data to be sure of the validity of the early findings, to assess important time and space relationships of what the EB virus is doing in these populations, and how its distribution relates to cancer induction. We expect, to improve further the yield and purity of EB virus aml to conduct critical work necessary in a preliminary way for vaccine development. We still have need for an improved animal model for safety testing and fundamental studies.

Here I might interpose that we just this year produced three new animal cancers caused by herpes-type viruses in three different species of animals. These are in primates, including chimpanzees, and in rab- bits and guinea pigs, so we have hopes that the monkeys here again will serve as a suitable animal model system not unlike the polio story for needed tests for safety and effectiveness.

All these efforts are expensive since they involve large numbers of animals, costly materials, complicated logistics, complex equipment, and highly skilled workers in various locations.

In the case of cervical and penile cancers and chronic myeloid leukemia, data available to date are not so extensive. Here we will employ the methods developed for the lymphomas and nasopharyngeal cancers to try to obtain the required information as rapidly as possible. Here also we will conduct additional field investigations and extensive laboratory studies; they will involve the same type of complex and expensive resources.

TUMORS ASSOCIATED WITH THE TYPE C VIRUS

The second group of tumors and viruses I want to discuss are the tumors associated with the type C virus. This is a virus that was discovered in animals years ago, known to be strongly associated with causation in animal leukemias. We have established clearly that we can transmit the virus and produce the disease as early as 2 weeks in mice with this type of virus.

These other tumors are associated with the cancer-causing virus known as type C, an RNA virus so designated from electron microscopy when seen in human and animal tumors and known to produce certain animal cancers. Several different species are involved and transmission of the virus has been clearly demonstrated in mice, cats, and chickens. The tumors associated with this virus are the leukemias--particularly childhood leukemia--sarcomas of bone, muscle, cartilage, and connective tissue, and other tumors, including Wilms' tumors in kidneys in children. Mortality from the leukemias--other than chronic myeloid leukemia which seems to be more associated with the herpes-type virus--totals 13,500; new cases of leukemias will total 17,000. Deaths from sarcomas this year in the United States are expected to be around 3,000, and 4,000 new cases can be expected. We are requesting $7.5 million for work on these tumors.

Evidence is mounting that tumors associated with type C virus may be produced in a manner different from the production of tumors associated with the herpes-type virus which I just discussed a moment ago. Although we have successfully prevented leukemias by vaccination in animals, there is some question whether this procedure will be effective in man. Evidence suggests that the genetic information of the type C virus is transmitted from one generation to the next in a covert and incomplete form. Several recently discovered techniques can reveal its presence. Sometimes a full virus can be detected, infect normal cells, and can induce cancers. Radiation, which under some conditions produces cancers, and cancer-causing chemicals are effective means for bringing forth the expression of this genetic information of the virus. Its presence can also be detected by immunological means. Sometimes special tissue culture cell lines or a helper virus, that is, a second virus, is required to bring forth these viruses.

A top priority question then is whether these findings in animals are directly applicable in man. Are cancers produced by the expression of this type C virus genetic information in all cases, including induction of cancers by chemicals? Only part of the time and with only some kinds of cancers? Or is a different mechanism entirely involved? Answers are especially critical since the approach to control of these cancers may be dependent upon the manner in which these interactions take place. Considerable investment of funds must be made to develop materials, animals, laboratory studies, and complex field investigations to determine the extent of cancer causation, with primary emphasis on the ]eukemias and sarcomas. Because of the causative role of chemicals in association with viruses, complex field studies in populated areas will be conducted to monitor populations for cancer incidence, virus exposure, patterns of antibodies against viruses, and exposure to chemical agents. Again, these efforts are costly because of the complicated logistics, expensive reagents and equipment, and the participation of highly skilled investigators. These studies have importance far beyond the cancer field since the laboratory developments here open up new approaches to gaining understanding of the manner in which cells function, and, in the case of development of embryos and repair of damaged tissues, the manner in which cells differentiate into new tissues.

In other words, learning about how this virus becomes expressed, or "switched on," as some people say, is a very similar problem to understanding how the cell controls its work through DNA and the RNA controlling the protein synthesis. We do have a handle, though, to get hold of this process in this case because we can bring out these viruses by special techniques and procedures which will allow us to follow the genetic information in relation to whether the expression is turned on or turned off. Sometimes we get tumors formed the way it is turned off, but with other conditions we get other findings. For example, these kinds of tumors all produce special proteins which are called antigens which we detect by looking for antibodies against these antigens. This is another way to tell whether that virus is there and whether it is being expressed or not. This provides us, then, a tool for finding out whether hereditary or genetic information is "switched on" or "switched off," not unlike the kind of hereditary information we have in the cell's own contents in the chromosomes. But this is somewhat simpler because the genetic information instead of being in the cell's own chromosome is actually a piece of virus that is transmitted from cell to cell and under special conditions we can get a handle on that by converting it into the full-blown virus or converting it so we can see expressions in other ways. This has ramifications in many fields besides cancer research.

OTHER VIRUS-ASSOCIATED TUMORS

Available research leads indicate that cancers of breast, lung, and large bowel and neuroblastomas are associated with viruses. Type C is the kind we were just talking about. Type B is the different kind. We see both of these kinds of virus particles in breast cancer cases. We see virus particles recently reported in lung tumors. Here this is such recent information that we do not yet have a category desiganation in terms of the name of this type of virus particle. We also have common antigens--as I mentioned a moment ago, special proteins detectable by immunological means like those produced by the sarcomas I was talking about--with neuroblastomas and cancers of the large bowel. This suggests virus association, but by no means establishes it. Mortality from these cancers next year will be 135,000, and new cases will number 212,000. We believe that the research leads are not as fully developed in this area as in the other two groups of tumors; therefore, we are requesting $4 million to develop programs along the line successful in the other areas, despite the larger magnitude of this part of the cancer problem.

CAUSATION BY CHEMICALS AND VIRUSES

Several lines of research (in sarcomas, leukemias, lung cancer, and other cancers) indicate increased incidence of cancer causation when chemicals and viruses act simultaneously. Recent public interest in environmental chemicals adds urgency to the need for further research in this area. An example of this is the Secretary's Commission on Pesticides under the chairmanship of Dr. Mrak.

We are requesting $2 million for the viruses-chemicals studies, that is, study of the interaction between viruses and chemicals, in this budget. We would propose to use such money for bioassay and screening; data generation and improvement of the assay systems involved; mechanisms of action of these interactions: and pathogenesis (that is, the better delineation of the course of the cancer in its initiation and development). Related studies, for which $800,000 is requested, will be conducted in population groups in conjunction with the third national cancer survey and migrant and other population groups, particularly cancers of uterine cervix, penis, and large bowel.

Background Paper. The National Cancer Program: Enduring Issues, by Michael McGeary
Source : http://www.iom.edu/?id=13984

The National Cancer Program: Enduring Issues Michael McGeary The following background paper was prepared by a consultant for the National Cancer Policy Board. It was intended as background for discussion, and does not necessarily reflect the views of the National Cancer Policy Board, the Institute of Medicine, the National Research Council, or the National Academy of Sciences. It is posted as public background information only. The National Cancer Policy Board was established by the Director of the National Cancer Institute in part to advise him on his statutory responsibilities as head of the National Cancer Program. The Board has begun by focusing on several key pieces of a national programcancer care, prevention, and research (NCPB, 1997).

The National Cancer Program formally dates from 1971, when it was created by P.L. 92-218, the "War on Cancer" Act. According to Section 407 of the Act, titled "National Cancer Program":

(a) The Director of the National Cancer Institute shall coordinate all of the activities of the National Institutes of Health relating to cancer with the National Cancer Program.

(b) In carrying out the National Cancer Program, the Director of the National Cancer Institute shall: (1) with the advice of the National Cancer Advisory Board, plan and develop an expanded, intensified, and coordinated cancer research program encompassing the programs of the National Cancer Institute, related programs of the other research institutes, and other Federal and non-Federal programs.

The purpose of this paper is to review the current status of the National Cancer Program, the issues involved in implementing it, and the prospects for reinvigorating it. The approach is historical, because the fundamental issues concerning a "national" cancer program were highlighted in the debate on the National Cancer Act of 1971 and during its initial implementation, and because it is important to ask why the original conception of the program was not realized and gradually lapsed before thinking about whether and how to mount a more active program today.

The first part of the paper will explore what the National Panel of Consultants on the Conquest of Cancer, the original proposers of a National Cancer Program, had in mind in 1970. As we shall see, they touched on some of the most basic and enduring issues in biomedical research policy generally (how much to invest in basic research vs. how much in applied research and development, top-down vs. bottom-up planning and direction, how far a federal agency can and should go in coordinating related activities in other federal and/or state agencies or the private sector, and how much effort a research agency should put into technology development and transfer). The Panel tried to shift the pendulum toward more applied research and development, more active dissemination of state-of-the-art practices, more centralized planning and program direction, and stronger federal leadership of national activities.

The second part of the paper will look at the early implementation history of the National Cancer Program. The concept gradually fell into desuetude.

The third part reviews the status of the program today, beginning with the 1994 report of the Subcommittee to Evaluate the National Cancer Program of the National Cancer Advisory Board, which recommended a revival of the national coordination feature of the National Cancer Program as well as more emphasis on translational and applications research.

The final part reviews key points from the history of the National Cancer Program and summarizes some enduring central issues that will have to be addressed in strengthening and expanding the current Program.

1. Origins of the National Cancer Program

In its 1970 report, the National Panel of Consultants reviewed the impact of cancer and the major advances in fundamental understanding of cancer made during the previous decade, and concluded: "A national program for the conquest of cancer is now essential if we are to exploit effectively the great opportunities which are presented as a result of recent advances in our knowledge. (1) The Panel identified three "major ingredients" in an effective national program: a new independent agency (the National Cancer Authority), a comprehensive national plan "for a coherent and systematic attack on the vastly complex problems of cancer," and expanded financial resources (U.S. Senate, 1970:3-4).

At the present time there is no coordinated national program or program plan. The National Cancer Institute has done excellent work itself and has supported grants and contracts in the scientific community which have resulted in much outstanding work, but the overall research effort is fragmented and, for the most part, uncoordinated. The effort in cancer should now be expanded and intensified under an effective administration charged with developing and executing a comprehensive national plan for the conquest of cancer at the earliest possible time.

Most of the debate leading to passage of the National Cancer Act a year later centered on the advisability of creating an independent National Cancer Authority subsuming the National Cancer Institute and reporting directly to the president, but the debate reflected an underlying difference of opinion about the proper scope of the federal effort against cancer that goes to the heart of what a national cancer program should be. The medical research lobby led by Mary Lasker, which conceived of the War on Cancer, had a strong view about what the program should encompass as well as how it should be carried out, but other groups had conflicting views.

The Lasker forces were one part of the trifold coalition that accounted for the spectacular growth in NIH's budget from the mid- 1950s to the late 1960s (the other parts were supportive congressmen in key legislative positions and strong NIH leadership). (2) Lasker also had access to Democratic presidents. (3) But after 1968, the key congressmen (Senator Lister Hill and Congressman John Fogarty) and NIH director James Shannon were gone. A Republican, Richard Nixon, was president, and federal budget cutting and the New Federalism were in vogue. Growth in the NIH budget, including NCI, halted after 1968. Concerned, Lasker and her associates arranged for a Senate resolution creating the Panel of Consultants and directing it to recommend the measures needed to achieve cures of the major kinds of cancer at the earliest possible moment, (4) and they played a key role in choosing panel members and staff with sympathetic views, including prominent Republicans with close ties to President Nixon.

Although Mary Lasker was widely appreciated for her help in greatly increasing the NIH budget, her views about how that money ought to be used did not coincide completely with those of the biomedical research community or NIH leadership (Strickland, 1972:187,207). Lasker believed there was too much emphasis on research relative to efforts to turn the results of research into practical therapies for patients, and she was impatient with the reluctance of scientists and federal research managers to engage in directed research. Lasker believed that federal health efforts should be much more aggressive in trying to make an immediate difference and boldly marshal the full range of national resources against categorical diseases such as cancer. In other words, compared with what NCI then did, the National Cancer Program should be engaged in a broader and more balanced range of activities ranging from basic research to dissemination of state-of-the-art practices at the community level, and more actively coordinate all cancer-related activities within NIH (not just NCI) with those of other federal agencies, state and local governments, foundations, voluntary, and other nonprofit organizations, and industry.

In addition to calling for an independent National Cancer Authority, a comprehensive national plan, and more funding, the Panel report called for increased support of existing comprehensive cancer centers and establishment of new ones around the country as the best organizational means of carrying out an expanded attack on cancer. Such centers would allow multidisciplinary interaction in both clinical and nonclinical research, teaching, diagnosis, preventive programs, and the development and demonstration of improved methods in the delivery of patient care. They also could work with medical centers and clinics in their areas "to assure the widespread use of the best available methods for early detection and treatment of cancer," and collect data and disseminate useful information to professionals and the public (U.S. Congress, 1970:6).

The original draft of the Panel's report had language about using large-scale planning and management techniques similar to those developed by NASA, reflecting the view of the Panel's staff that medical research was "lacking the organization and discipline necessary to achieve spectacular results in a reasonable time." The scientist members of the panel objected, and words like 'centralized control' were deleted; 'administration' was used in place of management, and the panel's emphasis on the importance of freedom in basic research was explicitly spelled out (Rettig, 1977:100). For example, the recommendation that a comprehensive national plan for a coherent and systematic attack on cancer be developed was modified by the sentence: Such a plan would include not only programmatic research where that is appropriate, but also major segments of much more loosely coordinated research where plans cannot be definitively laid out nor long-range objective clearly specified (U.S. Congress, 1970:3). The report ended up calling for the generous use of grants in order to stimulate continued independent exploration, particularly in those areas where knowledge is not sufficiently mature for a coordinated program aimed at reaching defined objectives, and for reliance in the planning process on the participation of the scientists who will be doing the work rather than hierarchical imposition of a research plan from above. However, the effective use of collective planning does not mean that centralized administration or management of resources should be sacrificed (U.S. Congress, 1970:7).

Opposition to the legislation based on the Panel of Consultants report focused mostly on the provision transforming NCI into an independent agency and came from NIH leadership and the biomedical research community, but there were also serious reservations about the program planning aspects of the bill. For example, Harold Ginsberg, professor of microbiology at the University of Pennsylvania School of Medicine, and Salvador Luria, Nobel laureate and professor of biology at MIT, testified (among others) that the basic knowledge about the nature of cancer was not well enough understood for a large-scale program-planning effort leading to a cure for cancer within a short of fixed time period, no matter how much money was spent (Rettig, 1977:238-239).

The organizational status of the National Cancer Program ended up being a compromise. Instead of a new independent agency, NCI was elevated to a bureau, and the NCI director was made a presidential appointee and given the authority to submit a budget request directly to the president. Another vestige of the original provision for an independent National Cancer Authority was the establishment of the National Cancer Program under which the NCI director was given planning and coordination authority beyond NCI. As quoted above, Section 407 gave the NCI director general authority to coordinate all cancer-related activities within NIH and also with all other governmental and nongovernmental organizations, and went on to give the NCI director a number of specific national program responsibilities, including to:

use the research facilities and personnel of NIH for accelerated exploration of opportunities in areas of special promise.
encourage and coordinate cancer research by industrial concerns.
collect, analyze, and disseminate all data useful in the prevention, diagnosis, and treatment of cancer, including establishment of an international data bank on the results of cancer research wherever conducted.
establish or support the large-scale production or distribution of specialized biological materials and other therapeutic substances needed to further cancer research.
support training programs.
call special meetings of the NCAB if needed to avoid delay in acting on a new scientific or technical finding.

Section 407 also created the President's Cancer Panel to monitor the development and execution of the National Cancer Program. In addition to mandating an annual report on the status of the National Cancer Program, Section 407 said any delays or blockages in rapid execution of the Program shall immediately be brought to the attention of the President by the Panel.

The 1971 act included several additional sections creating new programs aimed at extending research into practice. Section 408 provided for the creation of new national cancer research and demonstration centers for clinical research, training, and demonstration of advanced diagnostic and treatment methods. Section 409 reestablished the cancer control program with a separate appropriation.

2. Implementation of the National Cancer Program

Even before the legislation was signed into law in December 1971, NCI director Carl G. Baker, M.D., began an elaborate program planning effort that culminated in a strategic plan sent to Congress in October 1973 and a five-year operational plan in August 1974. The strategic plan was updated once, in 1974, and rolling five-year plans were issued annually until the mid-1980s (5).

In the first few years, there was extensive input from the scientific community into scientific program contained in the strategic plan for the National Cancer Program. The plan was organized as a multi-level hierarchy of goals, objectives, approaches, approach elements, and project areas. Baker and staff posed the fundamental goal (develop the means to reduce the incidence, morbidity, and mortality of cancer in humans) and developed seven objectives for working purposes. A series of 40 panels involving more than 250 scientists met at Airlie House between October 1971 and March 1972 to identify several approaches to each of the seven objectives, several approach elements under each approach, and multiple project areas under each approach element.(6) The result was summarized in the wheel, a circular graphic that was used to illustrate the conceptual basis for the National Cancer Program (Figure 1).

There were several more rounds of planning involving large numbers of researchers, including cancer control planning sessions held in September 1973 and a major revision of the strategic plan in January 1974 that fed into the first five-year operational plan (NCI, 1974). After that, however, the plan was revised each year by staff. The text began to be repeated from year to year, with just the numbers updated.

The plans explained that the NCI director was also director of the National Cancer Program and responsible for its development and management. That is, the NCI director had two hats. He was head of NCI, the lead federal cancer research agency. He was simultaneously charged with developing [with the advice of the National Cancer Advisory Board] a coordinated program in cancer research and control that includes activities conducted in and out of the Federal Government, to assure the Nation of a well-balanced cooperative program that recognizes the relevant contributions and achievements of the biomedical community (NCI, 1974:1-2).

Most of the reaction to NCI's planning of the National Cancer Program had to do with the dangers of overplanning NCI's own research program. An IOM committee chaired by Lewis Thomas reviewed the National Cancer Program plan and strongly urged that a distinction be made between the majority of cancers, about which basic knowledge was weak and undirected investigator-initiated research projects were the most appropriate strategy, and cancers in which enough was known to benefit from a planned and directed program, such as childhood lymphatic leukemia, Hodgkin's Disease, and Wilms' tumor (7). The plan responded to this issue by explicitly stating that a major part of the program would be continuing full support of research projects generated spontaneously by independent scientists, aimed at broadening the knowledge base with respect to cancer (NCI, 1974:VI-6).

The National Cancer Program concept in the 1971 act went well beyond the traditional directed vs. undirected research issue. First, it called for a greater and sustained effort to identify areas of research in which knowledge has reached a stage where a focused effort might have a significant payoff for control of cancer in man (NCI, 1974:VI-6). This would imply an effort not only to do research but to monitor the results, have criteria to decide when research results are ready to be developed for practical use, and devote significant resources to applied research and development.

Second, the National Cancer Program concept saw NCI, although primarily a research agency, becoming involved not only in the development of research results into practical applications but working with the full range of national institutions involved in cancer in bringing those applications to bear in prevention, diagnosis, treatment, and rehabilitation efforts as part of a national attack on cancer. The National Cancer Program was not supposed to become the national cancer care system but it was supposed to interact enough with the system to improve the delivery of patient care by promoting the use of state-of-the-art treatments by front-line health care providers (8).

The War on Cancer started off with great fanfare. President Nixon signed the act into law just before Christmas 1971, saying there would be progress against cancer because of recent scientific advances and because the law permitted the President to take personal command of the federal effort to conquer cancer so that its activities need not be stymied by the familiar dangers of bureaucracy and red tape (quoted in Strickland, 1972:289). Nixon had already increased NCI's budget by a third ($100 million) in FY 1972. In May 1972, Nixon appointed a new director, Frank J. Rauscher, Jr., recommended by the President's Cancer Panel.

At his first press conference, Rauscher emphasized the new cancer control program, which was to be the main vehicle for translational research and applications work. He said, My philosophy is, let's do what we can do now with existing data. He defined cancer control as demonstrating to the medical community that existing knowledge can be put to immediate use in care of patients with certain rapidly-growing cancers and talked about sending scientists out from cancer centers to community medical institutions to show them state-of-the-art chemotherapy for acute lymphatic leukemia, Hodgkin's' disease, and non-Hodgkin's' lymphoma (NIH, 1972).

In the first year and a half, NCI began a flurry of initiatives, including the designation of the first dozen comprehensive cancer research and demonstration centers and the establishment of 21 grant-supported cooperative cancer research groups, 20 breast cancer screening centers jointly funded by NCI and the American Cancer Society, 10 cancer rehabilitation demonstration-action programs in cancer centers and community hospitals, and a program in which 7 leading cancer centers would develop prototype chemotherapy programs and train physicians in about 120 community hospitals (NCI, 1973b).

The cancer research program expanded greatly in the first few years as funding jumped at nonincremental rates. The rest of the National Cancer Program did not grow at that rate. What happened? First, as Ginsberg, Luria, and other researchers warned in the hearings on the War on Cancer Act, there was still an enormous lack of basic knowledge on which to act. In the first annual report of the President's Cancer Panel, chairman Benno Schmidt (who had chaired the Panel of Consultants), said Of course, we are still far away from being able to put either a date or a price tag on the ultimate conquest of cancer. Schmidt explained there will be no quick breakthrough and work on the cancer problem will take years. He noted concern of researcher that national cancer program planners would not realize vast areas of ignorance (Schmidt, 1973:7):

In the opinion of the Panel, there is no need for this concern. The plan and the program provide for a very large element of unplanned, untargeted, undirected, investigator-initiated science....No one in authority has the nature of this program confused with that of the Manhattan project or the space program.

Secondly, the cancer control program did not become a, let alone the, major thrust of NCI. It turned out that there was also a great amount of ignorance about how to effect change, either in the practices of community physicians or in behavior putting individuals at risk, such as smoking. The demonstration projects often turned out not to be replicable.

Third, the demands of running a greatly expanded NCI demanded much attention, and there were severe limits to the voluntary coordination that the NCI director and his division directors could effect beyond NCI. National Cancer Program gradually shrank to be largely NCI's activities alone. This trend was probably hastened by the natural tendency of NCI leaders to focus their time and energies on sustaining the Institute's budget generally and the number of new and competing NCI research grants in particular and by a realistic appraisal of the limits of voluntary coordination. To put it another way, running NCI is itself a full-time job.

The national planning and coordination effort was not sustained for long. First, as already noted, the extensive use of external scientists in the planning process did not continue after the first revision of the strategic plan in 1974. No mechanism for involving affected organizations as organizations (rather than individual scientists as experts on program advisory and proposal review panels) was ever set up, although NCI has always made efforts to ensure diversity of institutional backgrounds in appointments to the NCAB.

Second, the 1971 act was recodified in 1978. In the process, the language regarding the scope of the National Cancer Program as including other federal and nonfederal programs was dropped (Tisevich, 1996:2621).

Third, there was little national (or even federal) planning and coordination in any case. Although the opening overview of the scope of the National Cancer Program in the five-year plans had a figure showing the various groups included, both NCI-funded and non-NCI-funded (Figure 2), the subsequent chapter describing National Cancer Program coordination did not contain much. They typically listed the cancer-related programs of other federal agencies, then described the NIH, DHEW, and federal interagency committees that NCI officials served on, and had a small section on coordination with nonfederal organizations (the last was dropped after 1982). In 1975, an Interagency Coordinating Committee for the National Cancer Program was set up, chaired by the NCI director, to provide a forum for the exchange of information on the cancer-related activities and policies of Federal agencies (e.g., DOD, USDA, NSF, FDA, NIOSH, CDC) and to promote joint or cross-funded projects (NCI, 1975:VI-15). But the committee was not mentioned in any succeeding plans! Interagency committees with more focus lasted longer (Interagency Collaborative Group on Environmental Carcinogenesis; Interagency Coordinating Committee for Cancer Control and Rehabilitation chaired by the director of the NCI Division of Cancer Control and Rehabilitation), but they did not add up to a comprehensive program. NCI funding of the comprehensive cancer centers was offered as the main form of coordination with nonfederal organizations, although there were some joint projects with state health departments and the American Cancer Society. As time went on, the activities described in the text supported less and less the standard final paragraph in the coordination chapter: The National Cancer Program, by coordinating information exchange and research planning between the Federal and non-Federal participants in the program, helps facilitate a concerted and cooperative effort against cancer.

3. Current Status of the National Cancer Program

In FY 1993, the House and Senate appropriations subcommittees with jurisdiction over the NCI budget called for an evaluation of the National Cancer Program after more than 20 years. The language of the House subcommittee was reminiscent of the views of the instigators of the National Consultant Panel on the Conquest of Cancer:

The Committee notes that since the initiation of the expanded war on cancer in 1971, more than $23 billion has been appropriated for cancer research at the NCI. While the Institute is to be congratulated on many breakthroughs in molecular biology and other basic cancer research areas, the Committee must express its impatience with the lack of overall progress (excerpted in NCAB, 1994:A-1).

The Senate subcommittee was more positive about the achievements of the Program, listing several recent research advances, but it too showed an interest in improved patient care and outcomes. It noted that overall survival rates had improved from 38 percent in 1971 to more than 52 percent, and asked for a plan for future research across the broad spectrum from basic biology to applications and for evaluation of cancer control efforts including the distribution and quality of preventive services, screening, diagnosis and treatment, aftercare, and rehabilitation; and the barriers to state-of-the-art cancer treatments which are detrimental to our ability to adequately address cancer in some populations, particularly minority and older Americans (excerpted in NCAB, 1994:A-2).

The NCAB conducted the evaluation in three phases. In the first phase, six panels of experts met to identify advances over the previous decade and evaluate the potential of that new scientific knowledge in preventing cancer, reducing morbidity and mortality, and improving survival and quality of life (NCI, 1994). In Phase II, the President's Cancer Panel collected information and heard testimony about progress and problems in the Program. In the final phase, a subcommittee of the NCAB reviewed the materials from Phases I and II, and from the Special Commission on Breast Cancer, and reported recommendations for the future directions of the National Cancer Program (NCAB, 1994) (9).

In the executive summary of its report, the NCAB Subcommittee identified six problems hindering progress against cancer, most of which are outside the purview of NCI and research per se (NCAB, 1994:5). One was the lack of national coordination in cancer-fighting efforts in the public, private, and voluntary sectors (10). An absence of coordination of the National Cancer Program (NCP) results in research and service gaps and costly duplication of effort. (11)

The Subcommittee quoted the mandate in the original 1971 National Cancer Act that the NCI director plan and develop an expanded, intensified, and coordinated cancer research program encompassing NCI programs, related programs of the other institutes, and other federal and nonfederal programs, and noted that several years later, the responsibility for other federal and nonfederal programs was removed from the authorities of the NCI director and put in the general authorities of all the NIH institutes.

This Subcommittee believes strongly that the original legislation characterized correctly the broad scope of NCP research-related activities. It is the Subcommittee's view that the NCP extends beyond research to its application to the people and includes all nonresearch, nongovernmental, and community constituents whose actions impact the cancer problem. Better coordination and collaboration among all public, private, and voluntary agencies with cancer related activities are critical if we are to reduce the burden of cancer.

In the body of the report, the Subcommittee took a more positive approach to the coordination issue. It argued that the success of the National Cancer Program is dependent on the entire community, and illustrated the point with its own concept of the National Cancer Program wheel. All the actors involvedindividuals, organizations, and agenciesare arrayed around the wheel (which in a way underlines the complexity as well as the necessity of coordination in impacting cancer at the individual level) (Figure 3compare with Figure 1).

The Subcommittee gave a clearer presentation than the program plans of the early 1970s of the interrelated but different stages involved in the National Cancer Program, and it emphasized that the set of actors is different in each stage (NCAB, 1994:10):

Basic research, the foundation and engine. The key participants are the basic scientists and sponsors who fund their work and the basic research infrastructure.
Translational research, the bridge connecting basic research to its application. This is the stage at which basic science discoveries are first tested in humans and fundamental research becomes a product or service, and the key participants are researchers and their funders, individuals who enroll in clinical trials, and firms, regulatory agencies, and third-party payers who determine whether promising technologies reach the application stage.
Application of research. In this stage, findings that have advanced beyond basic and translational investigation undergo final study in a defined population, and if warranted, dissemination to the general public. The key participants in this phase are not researchers or research funding agencies but pharmaceutical and biotechnology firms, medical providers and third-party payers, legislative, legal, and regulatory institutions, and each individual.

The report also repeated a basic premise of the report of the Panel of Consultants that the NCI-designated cancer centers are a primary vehicle for carrying out the National Cancer Program, along with the community clinical oncology programs and clinical trials cooperative groups. Not only are the centers and related programs a mechanism for relating basic and translational research and research training, they are involved in efforts to apply the results of research through public information and education programs, community outreach activities, and training programs for community physicians in state-of-the-art treatments (NCAB, 1994:13).

The Subcommittee's first recommendation was:

Establish a Presidentially led plan for overall coordination of the National Cancer Program that includes appropriate Cabinet-level representation, criteria for broad participation in Program planning and activities, and re-establishment of the 1971 legislative authority for national coordination of NCP cancer-related research activities of government, industry, and voluntary sectors.

The report contains 36 more recommendations (e.g., for strengthening basic research, translational research, and the application of research), but they do not address the lack-of-coordination problem or clarify further how the broad range of actors that must pull together in a successful National Cancer Program can be better coordinated. That task is apparently left for an NCI director strengthened by restoration of the 1971 coordination authority and energized by a presidentially mandated planning exercise. To date, the legislative authority to coordinate federal and nonfederal programs has not been reinstated.

4. Conclusion

After a brief recap of the main points from the history of the National Cancer Program, this section discusses three perennial tensions that affect the National Cancer Program.

Historical Points

Origins
The impetus behind what became the National Cancer Program was the view among members of the medical research lobby that great advances in the understanding of cancer had been made over the previous 15 years, but NCI was too focused on basic research and not active enough in developing practical applications of research findings of benefit to people or in getting the word out about those applications. The purpose of the Program was to do more than support good basic research but to have an immediate impact on cancer incidence, morbidity, and mortality by building up applied research and development (called translational research and applications today) and actively promoting their transfer into widespread use.
The group assumed there would be strong and sustained public, and therefore political, support for a crash program to conquer cancer on the scale of the Manhattan Project or the Apollo Project.
Although the expansive language about the National Cancer Program remained in the National Cancer Act of 1971, opposition to a crash program and the super agency proposed to carry it out from researchers concerned about feasibility and executive branch leaders concerned about costs and the impact on other research programs led to a compromise on organizational arrangements that left the head of the National Cancer Program in an anomalous position.

Implementation
Over the years the broad conception of the National Cancer Program as the basis for coordinated national action on a broad range of activities faded, and NCI leadership came to focus on NCI's research programs and on efforts to increase funding for undirected basic research. The broad attack on cancer led by the NCI director along the lines envisaged by the Panel of Consultants and its supporters did not eventuate for some very practical reasons.
The NCI director's formal authority to plan and coordinate a national program among other federal and nonfederal organizations withered away.
The rest of the NCI director's special status and authorities (presidential appointment, direct and immediate access to the President through the President's Cancer Panel, the bypass budget, and authority to coordinate cancer-related activities within all of NIH) have not been used much, and NCI generally functions like the other NIH institutes in terms of planning and budgeting.

Current Status
A recent broad-based subcommittee appointed by the National Cancer Advisory Board called for the resurrection of the National Cancer Program to accelerate the transfer of new knowledge to practical use.
The NCAB subcommittee made a number of specific recommendations for improving and increasing basic research, translational research, and work on research applications (and for an increasing budget to pay for it), but although it said there was a serious lack of coordination, it was not very specific about the problems or solutions beyond recommending that there be a new Presidentially led plan for overall coordination and restoration of the NCI director's lost coordination authority.
The current director is undertaking a major reorganization of the NCI (including the Division of Cancer Prevention and Control) and is open to new ideas about strengthening the cancer program and improving quality of cancer care provided to the poor, minorities, and the elderly.
The practical limits to a nationally coordinated program against cancer remain, including lack of knowledge about what works (witness disagreements among organizations about mammography for women under 50), distrust of central direction by voluntary organizations and state and local governments, fragmentation within the executive branch, the taxing demands of managing the NCI itself, and the sheer costs in time and money of continuous comprehensive planning and coordination.

Enduring Issues
How best to distribute types of research at NCI (or anywhere)?
This issue involves the trade-off between investing in basic research versus investing in other types of research, not to mention activities aimed at getting research results into practical use. Although, NCI is one of the largest federal research agencies and has done comparatively well over the years, its budget is always limited in terms of the problems it is trying to solve. What is the appropriate balance between investment in:
basic research (which is aimed at gaining a fundamental understanding of the mechanisms of cancer better to prevent or treat it),
translational research (which is aimed at turning existing knowledge into better prevention and education programs, diagnostics, clinical techniques, etc.), and
applications (which involves transferring research results into practical use)?
The allocation of funds among these categories tends to look different depending on whether one sees the NCI as a research institution or as the nation's lead agency in the fight against cancer. There are always those who think the best way to proceed is to put a greater share of NCI's budget into basic research projects, preferably individual investigator-initiated grants, because that is where significant breakthroughs are likely to happen resulting eventually in fundamental prevention and cures, and there are always those who think that past progress in research is not being used quickly or broadly enough and want to allocate more resources to applied research, development and testing of applications, and dissemination and outreach activities to make more of a difference now.
The appropriate balance among research categories within NCI is also affected by what and how well other organizations and agencies are addressing in the National Cancer Program agenda (see coordination issue below).

How to translate research into clinical care?
As broadly as the National Cancer Program was defined in the initial planning stages, and it was conceived to be much bigger than the NCI mission, no one ever thought it could or should become the delivery system for cancer care. No matter how much investment NCI or other institutes and agencies make in translational research or in education and demonstration programs on better applications, a number of other organizations affect what is actually done in day-to-day cancer carepurchasers and insurers, providers, other federal agencies (Health Care Financing Administration, Food and Drug Administration, Centers for Disease Control and Prevention, Agency for Health Care Policy and Research, etc.), state and local governments, and so on. This problem is not disappearing. With the advent of managed care, in fact, other organizations are not just regulating cancer care provision but, in their coverage decisions, affecting the amount and kinds of clinical research that can be done and the incorporation of state-of-the-art technologies and techniques into widespread practice. Although NCI might be able to concentrate on its research mission, a National Cancer Program has to actively look for ways to improve technology transfer, that is, disseminating state-of-the-art knowledge and practice into everyday use.

How to achieve coordination?
Increased national coordination was the least successful outcome of the 1971 National Cancer Act and the National Cancer Program it created. Why is coordination so hard? Part of the answer, graphically illustrated by the National Cancer Program wheel of the NCAB Subcommittee (Fig. 3), is the fragmented and decentralized nature of the system. In addition to NCI and the advisory groups it works under (NCAB and President's Cancer Panel), other NIH institutes and a number of other federal agencies are involved in cancer-related activities one way or anotherAHCPR, HCFA, FDA, CDC, DOD, VA, USDA, DOE, et al. There are, of course, numerous nonfederal organizations and agencies involved at various levels and pointsstate and local governments, ACS and many other voluntary cancer groups, pharmaceutical and biotechnology industries, hospitals and clinicians, employers and insurers.

A second part of the answer is the voluntary nature of the coordination authority granted in the National Cancer Program. The 1971 National Cancer Act did not give the NCI director authority to command anyone else to do anything, and in any case, despite certain expanded formal authorities (bypass budget, President's Cancer Panel access to the President), the NCI director is layered under the NIH director and DHHS. The idea was that sharing information would lead to opportunities for voluntary joint action. It did in many cases, but it was always (and still is) limited by the third part of the answer, the sheer complexity of the problem, lack of knowledge about what is effective to do, and resulting differences of opinion among independent organizations about desirable policies.

A fourth reason for the difficulty of coordination is its high cost, especially in time demands on organizational leaders, versus the expected payoff (given the many constraints already discussed). Informal (and therefore uncounted) coordination occurs through a natural division of labor among organizations who generally know what each other is doing and do not need regular formal coordination meetings. Even as director of the National Cancer Program, the NCI director only has the power to persuade, and a large number of others to persuade. And the director cannot get around potential role conflicts between being director of NCI, with all the vested programmatic interests (and rivalries with other federal programs for budget) that implies, and being director of the National Cancer Program, of which NCI is just one piece.

Although the kind of comprehensive coordination implied by the 1971 National Cancer Act is probably unworkable, the director of the National Cancer Program might be able to coordinate activities in carefully chosen areas by exhortation and education, that is, using the position as a bully pulpit. Could the NCI director exercise leadership in any issues similar to the way a series of Surgeons-General attacked smoking or C. Everett Koop led in AIDS policy, or is the position too layered and too occupied by running NCI itself? This vocal and public role, to be effective, must be careful to focus only on issues for which change is possible, that are clearly important and likely to remain so, and where moral suasion is sufficient for the task (as opposed to bureaucratic or budget authority).

The dilemmas posed by aspirations for a National Cancer Program directly impinge on the role of the National Cancer Policy Board as well, a topic best left to the Board for discussion.

References
IOM (Institute of Medicine)
1973 The National Cancer Program Plan: A Review. Washington, DC: National Academy of Sciences, April 6.
NCAB (National Cancer Advisory Board)
1994 Cancer at a Crossroads: A Report to Congress for the Nation, from the NCAB Subcommittee to Evaluate the National Cancer Program. September.
NCI (National Cancer Institute)
1972 National Cancer Program, Summary of Project Areas Proposed for the National Cancer Plan. September.
1973a National Cancer Program, The Strategic Plan. January.
1973b National Cancer Program, Progress and Achievements. November 9.
1974 National Cancer Program, Operational Plan: FY 1976-1980. August.
1975 National Cancer Program, 1975 Annual Plan for FY 1977-1981. October.
1994 Measures of Progress Against Cancer: Consolidated Report.
NIH (National Institutes of Health)
1972 The NIH Record, XXIV (June 7):1,7.
Rettig, Richard A.1977 Cancer Crusade: The Story of the National Cancer Act of 1971. Princeton U Press.
Schmidt, Benno1973 Annual Report of the President's Cancer Panel for 1973.
Strickland, Stephen P.1972 Politics, Science, and Dread Disease: A Short History of United States Medical Research Policy. Cambridge, Mass.: Harvard University Press.
Tisevich, Dorothy A.1996 Legislative history of the National Cancer Institute and the National Cancer Program, Cancer, 78(Dec. 15):2620-2621.
U.S. Congress1970 Senate Committee on Labor and Public Welfare, National Program for the Conquest of Cancer, Report of the National Panel of Consultants on the Conquest of Cancer, parts I and II, 91st Cong., 2nd sess., November.

EndNotes:

(1)The story of the National Panel of Consultants and subsequent legislative history of is well told by Richard A. Rettig (1977). Stephen P. Strickland has a good short account in the last chapter of his post-war history of NIH (1972:Ch.XII).
(2)Strickland (1972) provides the fullest account of how the coalition came into being and operated.
(3)For example, in 1966, she got President Johnson to invite the Secretary of HEW, the Surgeon-General, and the NIH institute directors to the White House. Johnson surprised them by asking whether too much energy was being spent on basic research and not enough on translating laboratory findings into tangible benefits for the American people (quoted in Strickland, 1972:207).
(4)Senator Ralph Yarborough, the resolution's sponsor, told his colleagues on the Senate floor that the goal was to defeat cancer by the nation's bicentennial in 1976 (Rettig, 1977:81). Yarborough and Congressman Claude Pepper, who introduced a similar resolution in the House, also mentioned the Moon-shot analogy.
(5)Before becoming director in July 1970, Baker was associate director for program, responsible for planning and analysis. With Louis Carrese, he developed the convergence technique, an adaptation of program planning techniques from systems analysis to the management of research, which was used in NCI's major directed research programs (e.g., special virus leukemia program in 1964, chemotherapy program in 1965, and carcinogenesis program) (Rettig, 1977:70-71).
(6)There were 7 objectives, 35 approaches, 146 approach elements, and 764 project areas (NCI, 1972).
(7)The Thomas committee mentioned the development of leukemia chemotherapy as a possible example of a problem that might benefit from a centrally managed scientific plan (IOM, 1973:12).
(8)The Program did become the health care delivery system for most children with cancer, however, because there are relatively few of them and they can be accommodated in a reasonably sized clinical trials program and a few specialized medical centers.
(9)The NCAB subcommittee had 15 members from a variety of backgrounds. Five were members of the NCAB (including the chairman), and one was chairman of the President's Cancer Panel. Others were from industry, academia, and the National Coalition for Cancer Survivorship. The results of Phases I and II and the report of Special Commission on Breast Cancer are summarized in appendixes to the NCAB Subcommittee's report.
(10)Other problems included problems with health care insurance; inadequate cancer care, especially for the poor, elderly, and uninsured; and unhelpful or limiting laws, policies, and regulations (the Subcommittee also cited inadequate support of translational and basic research).
(11)In another place, the report said Federal and state cancer research and care programs are not well coordinated and at times work at cross-purposes. Realigning and streamlining these programs and processes must be among the highest priorities in the effort to re-engineer government and private sector cancer activities (NCAB, 1994:9).