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in particular are in process of accepting greatly increased reeponsibility for pro. grsm~ cDrnbalt Jng the~ tllseaset. At the same time~ society as a whole has a heavy stake in the success of this endeavor. It is appropriate a~d neoessary that the Federal government encourage, stimulate and support the upward thrust of national health, Events of the past two decades have proved beyond quesllon thkt such encouragement and support~ fur from iltterferlng '~ith personal end seienlific freedom, has in fact created the conditicns in which such freedom can realize full fruition, The solatlo, to the problems ~ heart dise~s~ cancer and stroke. can be built only on the foundation of . profound a~d truly national com- mitment to this end. by both pubilc and private resources. The nation's strength clerives from the strength of its people, A national inveslment in the prolonging of' productive lifo for its people pays r[c[~ dividends in national productivity. Good h~alth is good business for the nation. But in a democratic soeiely~ there are other rnotive~ ~r actfon~ more corn- palling still. Henri disease, cancer and strake cut life short; they cattail the enjoyment of liberty; they make futile the pursuit of happiness. One true tneasure of a nation's greatness is its success in making ava~lakle to i~s people the me~ns for pTotectlng end enriching their individual li~es. The President's Commission on Heart Disease, Cancer and Stroke bases its Report on the conviction that the Unlted States will measure up to greamess~ that it will choose to continue and accelerate the forward thrust of medical Tesearc|l 8cross new thresholdg of d~covery; and that il w[f] resolve to make rally available the he.eftts of scientific know[edge to all those whose life and opportunlty for i~di~idual ~lfiJlmenl depend upon them. We do not promise that our program will save a million live~ next year. We do not guarantee to all the millions of victims of heart disease, ~ancer an~l stroke a new lifo free from pain and fear. But we believe that ma~y thousands of men and w~.~en wh~ might live will die, needtessly~ year by year~ until the nation m~kes ~is .ew commitment. We believe that m~ny thousanlls of men and women will suffer and stand idle, ncedlessl~ yeer b~' )'ear, until ~he ~ati~n pledges its full ~"soure¢~ to tke~r ca.se. To these men and women we dedicate this Report. XV HEAR'[ DISEASE, CANCER AHD STROKE

PART i///~hapler O,e PROBLZ E I EZOURCZ . AHD THE DIMENSIONS OF THE PROBLEM The first of the three objectives set for the Conamlss~on was to measure the magnitude of the impact of heart dlsease, cancer and stroke o1/the Anlerl- can people. Such measurements have been made by many people, in various ways. The usual product of these assessments is a set of stalislieal tables. The numbers run into millions, sometimcs billions. The columns drift into abstraction--age- adjusted death rates, nmndloura, productivity. These tabulations are valuable and necessary. They are especially valuable when they furffish clues for a more efficient attack on specific aspects of the prob- lem. But they do not measure the true impact of the three great killing dlseases on the American people. They do not quantitate grief for more than one million American families every year. They do not express tbe personal economic hardship that comes in the wake of a father's sudden, falal heart altack. Nowhere in the tables will you find the heartbreak and the long emotional stress Ihat follow a mother's death from cancer. They may count the number of hours of idleness enforced by chronic dlsabillty, but they do not measure the length of each hour. Tbese represent the true impeel of heart disease, cancer and stroke. They should be read inlo every statistical paragraph, table and chart in the mate. rim that follows. The Changing l'atte~n o/Sickness and Health lleart disease, cancer and stroke are overwbehnlngly the leading causes of dealh in the United States today, l)iseases of the hear t and elreulatory system-- a broad category that includes strokes--now claim nearly a million lives each year. Cancer takes over a quarter million more. In 1963, these diseases accounted for 71 percent of all deaths in the nation. Compared with them~ all the olher enemies of man--the great range of infectious diseases, accidents, congenital and nutritional disorders~fede into relative in. signilleance. It has not Mways been thus. The ascendancy of the three great killers is a recent deveffipment. It is, in fact, a byproduct of brilhant progress in biolnglcal selenee and medical service. A few short ileeades ago, tuberculosis was the greatea single menace to American health, Pneumonia and influenza took a heavy tell each year. Infectious diseases of infancy cut off many lives that had barely begun, For the overworked physician of horse-and-buggy days, heart disease and eaneer were far down on his llst of preoccupations. ! HERRT DISEASE, CANCER AND STROKE ~56-4~90-64~2

We are the beneficiaries of a great medical revolution. The first half cen- tury cf scientific medicine has resulted in a swlflly growing population~ a greatly lengthened tifespan, a leve~ of well.belng tar above the highest expectations of our grandfatbers' generation. DEATHS FROM HEART DISEASE, CANCER AND STROKE iN 1963 2 HEART DISEASE, CANCER AND STROKE ]t has also resulted in a helghtenltlg of our own asldrations, Death Dora heart disease or cancer, at a relatively advanced ag¢~ was once personalty tragic but phi]osophicully aceoptefile. Todag we are no longer willing to tolerate what was once "tbo illevita hie." Our new intolerance is based on knowledge--that heart disease~ cancer aefi ~tr~k~ I~e~d not k~ so n~l~y i~eople t~day, ~d that t~m~rr~',~ ~l~ll r~ pye- mature deaths wlil be w~tbin onr power to prevent. From this intolerance comes deter~ninatiot~. The n~gtlitude of the problem, as discussed in this chapter, is nol a slatu5 qvo to be lam~ntefi azld accepted~ btlt a cha/lenge to he met. HEART DISEASE Deserlf~tlon The te~nl bear~ dlsco.~e, as commonly used. includes a large number of condi. lions affecting the heart and circulator!" system. It is not a slng]e disea~, bLIt ;nany. Tile cardiovascular-rentTI diseases--to use the broadly inclusive technical terms--can be divided into three major categories: I } SIrr~k~s--damage to the blood ~ es.~els af[ecling the eenir al nexvo~s system: q2l Diseases of the heart itself and the blood vessels serving tbe fled), inelud. ing rheumatic fever and rheumatic heart disease, arteriosclerosis and de- generati~'e heart disease, functional diseases of the heart, high blood pres. sure and hypertensive heart disease, and numerous other slraeifie disease entities;

STROKES 201,166 HEART DISEASE 707,830 HYPERTENSIVE HEART DISEASE AND HYPERTENSION 73,791 (3) Kidney diseases, including chronic nephrilis and renal sclerosis, which are relaled Io the circulatory system and are therefore included in lhe broad category. Deaths/rom Heart Disease In 1963, 994.74? people in Ihe United States died of the cardiovascular-renal diseases. Of these deaths, about one-fiftt~ 1201.1661 ~ere caused hy s~rohes. B) far Ihe largest share i707.g301~ over 70 percent, were caused by heart disease, predominangy arteriosclerotic heart disease including c<~onary disease t 546,813 I. Hyper/ezlsive heart disease and hypertension aceoun/cd for ahout 7 percent i73,- 791), with Ihe renlaining deaths distrlhuted among other dlsordets of tl~e heart and circu)atory system. Heart diseases land strokes) accounted for more than half Ig0.1 percent) of all deaths in the United States i~ 1963. In 1900. these diseases accounted for only about one death in seven. Heart disease is predominantly, hut by no means exclusively, a cause of death among older people. Ahnu/ 72 percent of the 707,830 heart disease deaths in 1963 occurred in persons aged 65 and over. There are striking differences in the heart disease rates by sex. Men oummn- her women as victims by a tactor of nlor¢ than one-lhird.-4H,989 to 295,841. This is a relatively new and sill1 ineomplately understood phenomenon; until about 1930, the heart disease death rates for men and women were of about the same magnitude. ( 1963~994,747 DIED) I PERCENT 10 20 30 40 50 60 70 80 90 100 3 HEART DISEASE, RANCER AND STROKE

~resti~g ~d, ~nex~la~ned ~ariati~s ~xi~ in the g¢ogr~ph~ d~tr~b~ti~ cardiovascular disease deaths h~ the United StaWs. There is higher mortality- /or both men and women in the Eastern and far Western Slates, with lower ~ort~lity ~n tt~e C~sxlral and Mo~tai~ regi~s, Death rates appear I~ b~ higher in large cities than in smaller towns and rural districts, htzI lbese diffor- enees do not fully account for the State-by.State and regional variations. More- ~¢t~ it is helleved that twrson~ horl~ in "hlg~ mortality'~ States carry ,~itb. them a high mortality tendency even though they ma~ die in a "low mortality" State, DEATHS FROM HEART DISEASE 4 HEART DISEASE, gANCER AgD STROKE Illness and Disahilily The |te~rt disea~s, i~x addit~o~x to their dominance al a cause of death, arc the cause of extremely widespread illness and disability in the United Slates. Studies ¢~nducled by the National Health Survey of the U.S. Public Health Service in 196~62 ~dicate that an estimated 14.6 million adults ~uffered ~rom definite heart disease, and nearly as many had suspected heart disease. Of every 100 persons in Ihe population between the t~gcs of ]8 and 79, 13 had definite hearl d~sease a~d 12 more had suspected heart disease. Thus nct~rly one-fourth of the aduh population studied lives in ~ettainty t~r in jeopardy ~f hear~ disease.

Tile most common condillon discovered hy the Survey +++as hyperlensfve heart disease~ witll 10.5 million "definite" aud 4.7 million "suspect" cases. For coro- nary heart disease, the estimates were 3.1 million "definite" and 2.4 million "suspect," In sharp contrast with rnortallty figures, "definite" heart disease was found to be more frequent in women than in men. Women were mote likely to be suffering from hypertensk,e heart disease, while men were more likely tQ have coronary heart disease or heart disease of congenilal or syphilitic origin. The frequency o1 heart disease increases sharply with a~e. Fewer than 2 percent at tfio~c a~ed 11~-24 had definite heart disease, while at I}le other extreme 39 percent of the nlen and 46 percent of rite women aged 75-79 had definite beart disease. Economic Impact The economic cost Io the nation of any disease may be measured in terms of its direct co~t~ in dlagno,ls, trealment, and tehabilltation of patients suffer. lug from the disease and the indirect costs u~soeiated with loss of earnings due to disability and premature death. Heart disease, with its enormous death t¢)ll and still ~reater prevalence as a chronic disabling condition, imposes a muitlbillion dollar hurden on the economy each year, Direct expenditures for hospital and nursing home care, physicians' serv. ices, drugs and ether ~nedieal servlces for persons with heart di~ase anlounted to $2.6 billlem in 1962. Ab~t 15 percent .~f ~he J~taJ dap~ ~f c~r~ h~ !]~e r~a!i~'s short-tprm hospitals are for care of heart disease patients, as are 28 percent of the patient days in skilled nursing homes. One out of lea visits to physicians in private practice are in connection with heart disease. Likewise, the drug b~ll for cardiovascular patients is estimated at 10 percent of all expenditures far proscriptions. The direct costs are only the beginnl.g. Those who are dlsa~ded hi" heart disease add another burden to the economy, owing to loss of oulput. Taking into account members of the labor force, housewives, and others who were unaMe to attend to their u~ual actkitie~, a total of 132 million work clays were lost bl 1962. The~e are equivaIent to 540,000 mall years, ~hich amount to $2.5 billion in terms 011962 dollars. Other losses result from premalure death. As we have seen. approximately a querier of a nlillion people in Ihe mo~t productive years (25-641 died of heart disease in 1963. shghtly more than in Ihe preceding year. Assuming that Ihe deaths occurred evenly over the year. more than $1 hillion worth of output was lost in 1962. Had all those who died in 1962 lived iust one more year. rite economy would have gained $2 billion worth of output. The nation is still payin~ in lost output for the people who died prematurely of h~a~t disease in the recent p~st. Of 26 million deaths due to cardiovascular diseases in the period 19¢sq-1961, 6 million persor~ would have survived to 1962 and worked or kept house if this 5 HEART DISEASE, CANCER AND STROKE

6 HEAR'/ DISEASE, CANCER AND STROKE major cause of death bad been eliminated. The assumption is that the eardlo- vasoalar Iindudlng in this instance stroke) death rate became zero while the rates for all other causes remaln~ unchanged, In money terms the loss in output amounted to $24.5 billion. It may he belpfd to ¢~mpare lhese Ioss, e~ dt~e to heart tllsea¢,¢ to the gro~ aatlonal product ~fite raarket value of all goods and services produced hy the economy). For this purpose the value of output imputed to housewives must be excluded. The sum of dlreet coals, plus losses of output by members of the labor force due to heart disease, amounted to $22.4 billion, or d percent of GNP in 1962. Progress and Prospect The prospects are excdhr~t for reducing the toll of heart disease in the years imraediatdy ~bead. Great strid~ h~e been r~ade tat the past 15 years on the research frontier, Today's challenge is two.leiden bring these advances not just to the fortunate few but to the many wha'ean benefit from them, and to continue to acquire new life-savlng knowledge. .~Iedieal research in the heart disease field has already paid rich dividends on the growing pubiie and private investment in biomedical science. This progrees has been docu moated in depth in the Report of the Second National Conference on Cardiovascular Diseases, based on an intensive review by hundred~ of physicians and scientlsts. The following are a few of many examples: Advances in surgery in the past ten years have already saved thousands of lives and promise to save many more. Patients suffering from aneurysm--a ballooning out and dfinnlng of the walls of an artery--were until recently almost cerlaln to die within a year. Now the damaged section of the blood vessel can be removes and replaced with a sub- stitute vessel made of a plastic material. A recent analysis of 1,000 such eases showed more than 90 percent success, even with extensive aneurysrns of the aorta near the heart. Similar procedures, with similar prospects of suCCess, can also he employed for replacing s~gments ~f blood vessel~ damaged hy ar~rlosderods in the many instances in wMch such damages are localized. Surgery of a MgMy complex nature is now possible on the heart itself, thanks to the developr~ent of artificial machines which can temporariIy substitute for the vital functions of the heart and lungs, Valves of the beart whleh are defe¢. tlve because of congenital henri disease can sometimes be repaired, and valves with acquired damage are also being treated successfully. Research on high Mood pressure has brought into being a number of ex- cellent drugs that effectively lower elevated blood pressure levels. This advance hel already helped to produce, in the hit decade, a significant reduction in the death rates for hypertensive heart dlseasa. The~ drugs also make it possibh for many people who suffer from high blond pressure to return to work and a normal lifo. The~e is no queglon that tbls gain would not have ecourre~ -~i~hout effeetlve research and its application.

We have not yet achieved a similar decline in the death rate from atherosdero. sis, especially of the coronary arteries. Coronary heart disease remains the number one cause of death in the nation. But exciting beginnings have been made in this area also, and the prognosis for coronary patients is substantially better than it was a decade ago, Electrical devices known as cardiac pacemakers have been developed that can restore a normal rate in a diseased and slowed-down heart. Some of these pacemakers, implanted inside the chest, can maintain a normal heart rate for years; over 3,000 people who might otherwise he dead are now living with ira. planted pacemakers. Arterial embo]lsm--a dreaded complication of acute heart attacks--is now greatly reduced in frequency thanks to anticoagulant drugs, Proralsing work is now underway with dot.di~oiving drugs for the treatment of thrombosis. In still another promising area, hard-won progress is being made in the extremely complex area of transplanting organs--lncludlng kidneys, lungs, iicers, and recently hvarts--into man. Perhaps most dramatic of all, research efforts are now being directed toward the devdopment of an artili¢ial heart to replace a diseased heart. Experimental models have already been tried in man. and an effective model is within the range of possibility by 1970 or even earlier. This challenge--as exciting as any a~rosa the entire range of science--is enormously complex. It requires the combined excellence of physicians, engineers, experts in the devdopment el syn- thetic materials, and many others. But physicians and engineers alike agree that this is not a dream. The goal is feasible; the problems are not insuperable. Concerted effort on a large seah may well produce one of the most dramatic breakthroughs in scientific history. Progress in understanding and controlling heart disease has far exceeded the fondest hopes of medical men a generation ago. But the challenges are many and formidable. Genuine control awaits further research discovery. Meanwhile, substantial reduction of the toll of heart disease awaits a major nationwide effort to apply what is already known, CANCER Description Cancers are uncontrolled new growths which invade and destroy living tissue. They are made up largely of cancerous cells which differ from normal cells in many ways, Cancerous growth of the cells in various tissues occurs throughout the biological world. Birds and many species of animals are amieted with various types of the disease. Its causes are not fully underslood--ahhough knowledge of factors relating to its development is growing rapidly. It is now clear that physical, chemical, genetic, viral, environmental, and perhaps other factors are involved. In man, cancer occurs in a variety of forms in many different organs of the body. The frequency el cancers in different sites varies relative to race, sex, 7 HEAI~i" DISEASE, CAgCER AND STROKE

occupation, geography, and other factors. It also varies dramatically wltb the passage of time. Within a single general, ion in the UnJtfd Stttteg one form of cancer---car~itaoma of the lung in raen--hat |nereascd strikingly while enother--- gtomach cancer in men'as declined sharply. Cancer Deaths Cancer is the cause of 16 percent of all deaths in the United States. It is by a wide margin our second greatest killer. In 1962, 278,562 Americans died of cancer; in I963, the number was 285,362; in 1964, the n umber will exceed 300,000. These figures stand in sharp conlrast to the tituation in 1900, when only 3.7 percent of all deaths were attrlhutcd to cancer and when the dlsea~ stood far down on the llst of causes of mortelity. DEATHS FROM CANCER DEATHS PER REGION 8,175 1~;,470 18,t~45 :23,743 25,470 32,412 31~,e§f~ 59,336 f*4 ,¢45 The rise of cancer as a health ~enace can be charged in large part to the changing age ¢oraposition of our population. Many more people are surviving the infectious diseases of youth and middle age only to t~uccmnb to the dlseaees r~ the more ad~aneet~ years. Yet cancer, like heart disease, is by no means r~served for the aged. In 1963, :qUilT IRSE&SE, CAtlCE¢ ASO srfloKE 45 geroent of cancer deaths were in the age groups under 65. About 9 per- I

eent--representing 25,629 people--were under 45. And cancer is either the first or the second cause of death in children hetween 1 and 14 years, Acute leukemia isthe single most common form of cancer in children. When cancer death rates are adjusted for the changing age composition of the population, it is still evident that cancer is an increasing threat. In 1900, the adjusted death rate was 79.6 per 100,000 people; in 1963, the comparable rate was 126.6, Since 1933 there have been substantial changes in the cancer death ratos for men and women, For men, from 1933 to 1963, the cancer death rule has risen from 104.6 to 147.1 per 100,000. For women, it has declined during the same period from 125.9 to 109.8. Tlltts cancer, wbieb 30 years ago was more of a menace to women titan men. has now reversed itself. Cancer of the lung now accounts for 24 percent of all cancer deaths in males, with s total of 36,895 deaths in 1963. Other leading cancer sites in males are tire prostate (15,446 deaths), colon 113,932), slomach (11,896) and pancreas (8,9~L For women, the leading sites are breast (25,139 deaths/, colon (16,684), uterus (14,147), ovary (8,404) and stomach (7,404). Thirty years ago, in males, stomach cancer accounted for 27 percent of all cancer deaths and lung cancer for only about 4 percent. In females, cancer of the uterus and ot the slomaeh were the two leading sltes--- in terms of death rates 30 years ago, accounting for 22 and 16 percent of all cancer deaths respectively, Illness and Disability It is estimated Ihat about 830.000 people in the United States will he under treatment for cancer in i964. This figure includes an estimated 540,000 new cases diagnosed for tile first time. On the basis of current trends, about one out of every four people alive in the United States today can be expected to develop cancer at some time during his or her lifetime. Thus, unless cancer illness rates are cut, about 48,000,000 people now living WlU h~2ollle cancer su~erers. Moreover, about 32 million Americans now alive will die from cancer unless new preventive measures, treatments or curative procedures are developed and widely used, Economic Impact The economic toll a~ociated with cancer also costs billions of dallars annually. Direct costs for diagnosis, trealmcnl, and care of cancer patients amounted to $1.2 billion in 1962, More than half of the direct costs is for hospital care. Approximately 950,000 patients with a primary diagnosis of cancer spent more than 14 million days in short.terra hospitals, a~zountiag for 8 percent of the total days of care in the nation'~ short-term hospitals. The cost of the services ot physicians in private practice for cancer patients is $172 million. As in heart disease, these direct costs are only a part of the total economic impact of the disease. 9 NEAgT DISEASE, CANCER AND STROKE