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Columnists .. . SUNDAY. NTAY 1, 1977 , Editorials I ~ =< How the Arnerk~n Cancer Society ~ Focuses on SLa~~h ~ror Ca~~es, ~3an ~aer ~'haa~ on the En~,~aa-onmentea9 Causes SL9E 6ZOOS

By Daniel S. Greenberg ' A J . and Judith E. Randal t W HILE EVIDENCE accumulates that the vast ma• jority of cancers are environmental in origin, the government's $F31Smillion-a•year "War on Cancer" is dominated by an outdated strategy aimed at cures rather than prevention. " The origins of this inisemphasis lie in a little-known and complex relationship between the government's Na- tional Cancer Institute (NCI) - the "Pentagon" of the . tiYar on Cancer - and the private but powerful Ameri- can Cancer Society (ACS), which, among other things. serves as NC('s ministry of information for educating the public about cancer. One effect of their collabora• tlon is the domipance of the curative strategy, which is ' akin to dealing with aviation disas-ters mainly by seeking to reconstruct wrecks rather than to prevent them: Under scientific and public pressure. NCI has been shifting additional resources to research into the origins .nd prevention of cancer, but the movement has been ` clow and the sums involved are relatively small. Though NCI officials have publicly stated that environmental tources account for as much as 90 per cent of all cancers - other estimates vary from 50 per cent upward -- lbout 15 per cent of NCI's funds are in the environmen- ;a1 category. -' . Privately, many NCI staff members express doubt that -he actual sum is that high. Last year, 1)r. Umberto Saf- tiotti~ who was then the associate director for carcinoge- oiesis, wrote a long memorandum to Dr. Frank J. Raus- tber, then director of NC1, complaining that he was jamstrung by insufficient staff and resources. Saffiotti hen quit the post for another at the agency. While there is no question about the humane intent of ;l1 Involved, questions do arise about the domination of ,CS by a particular school of thought on what the Iriorities should be in the quest to control cancer. The WS, many of whose directors have ties with major in- i Justries, places the emphasis on diagnosis and cures, L other than prevention. )ts strong campaign against ci- -arettes is a major exception, and there are a few others, bough'of a significantly smaller scale. But in the main, tCS has sltown little Interest In the environmental , rigins of cancer, many of which are in Industrial pro- ; esses and products. ~/ Asked about this specifically, lrving J. Rimer,-ACS 9ce president for public information, said that the so- iety has "a very grave concern about looking for the en- Sronmcntal causes of cancer" and has long supported oth the population studics of its own epidemiologist, , r. Cuyler )lamrnond. ancf the occupational cancer in- cstikations o,f !)r. Irving .1. Srllikc,ff of New 1'ork's htt. inai Ilospital, uith ahom Ilamnlond often collaborates. I, check confirmed Itaminond's long association with Greenbern is editor of u lt'ashiatltmt-bus('d new.c(ef_, tr. Si'ienc•e & Cot'crrlnrrrtt lteporl, and wr•ite•s (I )in,rrn Oil /rculth core Irulitics for flre ,Nclrr /;,Illinrut onrnol of Alr,firine. Hrnlcin! i,^r lt'nsl+irl(ltorn scienc•r' (•or• • -~Wurlenl for the j\'eto York Dni/U Newc nrr(( scieuce ol11';/ e,iltorof (.7/f(ln(!1' M(1tlQ;l1le. Sellikoff. But only 10 to 15 per cent of what Sellikoff and his colleagues have been spending in recent years has been contributed by the Cancer Society. The rest has come from several federal agencies, although not NCf. ACS Influence over NCI's strategy ancd spending has been effected through the society's representation on the major advisory bodies that guide the institute's programs. The influence is extensive and is typified by a vast program that some cancer specialists consider one of the major medical scandals of all time: the joint NCI- ACS breast cancer screening project. Against the advice of many of its own staff and advisory experts, NCI was persuaded by ACS to pay for more than four-fifths of this $54 million undertaking, the X-ray portion nf v.-hic•h has since been deemed possibly worthless as well as dan• ' gerous to many of the 280,000 women who were drawn in for examinations. 'Since X-rays are a two-edged tool - they can trigP.er as well as find cancer - NCl has repeatedly been ad- vised to scale down and even terminate indi~criminate screening. John C. Bailar 111, the physician-statistician who is editor-in-chief of the presticious Journal of the National Cancer Institute, has warned that the program "contains the seeds of a major disaster." Irwin D. J. Bross, Ph.D., director of biostatistics at Buffalo's Roswell Park Memorial Institute, one of the nation's leading cancer research centers, has charped that: "This expo- sure to diagnostic X-ray will probably result in the worst iatrogenic [disease caused by medical treatmentl epi- demic of breast cancer in historv." - Nevertheless, the screening continues, only partially abated. spurred on by an ACS publicity campaign desig- ned to counter doubts as to its safety and utility. Methods used by the ACS to promote X-ray screening employ oversimplifications on a suhject already bur• dcned by fear and poor public understanding. For example, in an interview in the March fteader's Dit;est, Dr. Benjamin F. Byrd Jr., inlmediate pa.t presi- ctent of the ACS, notes that mammography (breast X-ray examination) can save a woman's life anil. "even if there is a slightly Increased risk of her getting the disease In the distant future las a result of X•ray exposurel, there's also an excellent chance that by that time science will have learned to control the disease." The Digest failed to note that X-rays actually have a mixed record for detecting cancer, that unintrusive and harmless techniques, such as physical examination, will often suffice and that any foreseeable "control" of breast cancer is likely to involve disfiguring surgery and harsh drugs. Nor was it mentioned that the author•inter- viewer of the article, lt'alter S. Ross, is a part-time em ployce of the ACS, which initiated and oversees the X- ray screening progra m.

. A Sclf-l,inlilt•d ljule rh 0 ITS CRI•:DIT, the ACti has Iod the campaign against cigarettes and recently has alerted the pub- lic and health officials to the carcinogenic dangers of as- bestos and vinyl chloride gas. although most of the as- bestos and vinyl chloride research has been financed by the National Institute of Lnvironmental Health Sci- ences, a sister agency of NCI in the National Institutes of Health complex. But apart from these and several minor, ventures Into the environmental control of cancer. ACS has had the effect of diverting attention from industry. For example, when a government-produced "cancer atlas" showed that the disease tends to be most preva-" lent in heavily industrialized areas - with New Jersey cited as the most cancer-ridden - La.+rence Garfinkel,' the ACS assistant vice president for epidemiology and statistics, was quoted in Medical World News as saying. ~ that "The people in the (New Jersey) State Health De- partment partment are promulgating an aura of cancer phobia to ' get money for studies." Questioned about the accuracy of the quotatlon, Gar- finkel said: "I was misquoted. What I did say was that if I uas in the health department and wanted to get some- thing started, I might even do the same thing." He added: "I believe we can save more lives in 1977 by get- ting people to stop smoking than by a stepped-up anti-in- dustrial campaign." ACS's widely publicized "Seven Warning Signs of Cancer" are not supplemented by warnings about in- ~ dustrial smokestacks or cautions about products other than cigarettes. In the long and bitter struggle for passage of the Toxic Substances Control Act, a landmark law aimed at elimi- nating hazardous chemicals, particularly carcinogens, from the environment, the ACS was a late and perfunc- tory supporter. ACS did not testify on the legislation, and its letter urging President Ford to approve the bill arrived so close to the scheduled signing ceremony that it may have gone unnoted. According to a top labor official, "It took a gigantic ef fort" to get ACS to send the letter. The society played no role in the decision by the Con- sumer Product Safety Commission to ban the flame re- tardant Tris from children's sleepwear because it has been shown to be a carcinogen in animals, accnrding to officials at the commission and crirntists at the Environ- mental Defense Fund, µhich f;uaded the curnmission into orderinQ tht• han. In its public education campaigns and choice of the , scientific research for which it provides financial sup- port, the ACS has shown scant interest in the carcinoge-. nic effects of air and water pollution, drugs and food ad-, ditives. Its look-the-other-way attitude closely resembles that of the drug and chemical industries, with which many of its dirertors - all unpaid volunteers - are di- rectly or indirectly associated. I3litrttittg the 1'ictiitt , A CS LITERATt'RE; intended for the public is vir- tually devoid of advice or information concerning the causation and prevention of cancer, apart from stric- tures against smoking and excessive sun exposure. Though vast antounts of information have been accu- mulated about environmental orit;ins of cancer, the AC.'S continues to entphasize the mysteries and to play on a blame-the-victim theme. Thus, in a widely distributed pamphlet, "Answering Your Questions About Cancer," i I k the questlon is asked, "«'hy does cancer start'." The an- swer: "No one knows. In fact, the basic causes for rnost cancers are unknown. llowrver, the causes of certain cancers have been identified: overexposure to ultra- violent rays of the sun, excessive radiation, smoking ci- garettes and contact with certain chemicals." Nowhere is it mentioned that the National Institute of Occupational Safety and Health (a part of the Depart- ment of Health, Education and Welfare) estimates that 6 million Americans are exposed to known carcinogens in their work places. Among them are hospital operating• room personnel, dye workers, coke oven -vorkers, cer- tain wood workers and others who have been shown to be at increased risk of the disease. Nor is it stated by ACS that several substances, such as saccharin and several widely prescribed drugs and food colors, have been identifigd as suspect in this regard. A request to the District of Columbia chapter of the ACS for literature on origins and prevention of cancer brought the reply, "I wish we had something like that." An ACS compilation of its own research spending In fiscal 1975 shows that it provided scientists with S9,14a; • 000 for new research projects that year. Of that sum. $92,000 was for environmental studies and $145,300 for research on chemical carcinogens. In fiscal 1976, the total awarded for new research projects rose to 513,281.- 000. There were no new awards in the environmental category: the sum for chemical carcinogenesis came out to $394,000. Research does not lend itself to simple definitional classifications, and it is quite likely that ACS projects under other labels have value for environmental studies. But measured in any terms, the causation and preven- tion of cancer - the main exception being cigarettes - bas never figured large in ACS planning. Efforts by congressional investigators to enlist ACS support against chemical carcinogens have almost in- variably drawn no response. Rep. L. H. Fountain lD-N.C.I, chairman of the subcommittee on intercovernntental re- lations of the Ilouse Government Operations Committee, recalls with sonte bitterness trying to obtain ACS assis- tance in connection with a series of hearings lie held to prod the Food and Drug Administration to ban the syn- thetic estrogen diethylstilbestrol (DES) as an animal feed additive. DES had been shown to have caused vaginal cancer in the teenage daughters of women who had taken the hor- mone to prevent miscarriages; it has since been shown to have caused sexual abnormalities in their sons as w•ell. "We approached a representative of the ACS to help us," Fountain said. "We could never get anything but silence out of the society." • In June, 1972• sonie six months after the hearings. Fo>intain also sought support from NCI's top advisory group, the National Cancer Advisory E3oard, many of whose members have close links to ACS. It was his hope that the board would take a position that would put pres- sure on FDA to ban the substance. Again, he was disap- pointed. Board inentbers Mary Lasker and Elmer Itobst - both long influential in ACS affairs - joined other membcrs of the board in thanking Fountain and expressing inter- est in the background niaterial he sent thent• but the DES issue was not added to the board's agenda.

1)cf cnrliti" Sac.charitt HliN Tllk: Food and Drug Administration re- cently announced its intention to ban saccharin as a carcinogen, the move was denounced by the presi- dent of the ACS, Dr. R. Lee Clark, who until recently was a member of the President's Cancer Panel, a three-mem- ..ber statutory body that serves as a direct link between the National Cancer Institute and the 1Vhite liouse. , Opening the society's annual science writers'seminar, which was held this year in Sarasota, Fla., Clark said that ."there is no evidence that [saccharin] causes human .cancer" - despite the fact that FDA's scientists, like .their Canadian counterparts. found the evidence of Ca- .nadian animal tests so compelling that they recom• mended the ban. Clark's argument in behalf of the arti- ficial sweetener was that its value for obesity control outweighs its alleged carcinogenicity - a curious con- clusion for the head of an organization dedicated to the .eradication of cancer and one that is controversial' among diabetologists and experts on weight control. And Frank Rauscher (director of NCI from 1972 to 1976, now director of research for ACS), while "confess- ing," as he put it, that he was the principal author of the official ACS statement from which Clark drew his ..remarks, admitted that he had drafted the statement without having read the Canadian study that caused the FDA to act. - ` Meanwhile, Alan C. Davis, the ACS vice president for governmental relations, acknowledged that ACS na- tional headquarters in New York had received many re- ports from local chapters that they had been flooded with calls from people who mistakenly thought the so- ciety had instigated the proposed ban. Davis deaied firmly that the society was pressured Into taking its pro-saccharin stand. But he was frank to say that many of these callers had threatened to with- hold gifts during the society's April fund-raising drive unless the ACS made its position satisfactorily clear. Meanwhile, the ACS position on saccharin is giving some of its. staunchest scientific supporters serious con- ccrn. Among these is Nobel prizewinner David Baltimore, whose chair in microbiology at the Massachusetts lnsti- tute of Technology is financed by the ACS. At the sci- ence writers' seminar. Baltimore said that "by under- mining the implication of the Delaney amendment .(which prohibits the intentional addition of carcinoge- nic compounds to commercial foodstuffs(. . . the American Cancer Society has done the American people a dangerous disservice" and set "a dangerous preced- ent." Speaking of the Caloric Control Council, whose diet- drink industry membership uses more than 75,per cent of the saccharin consumed in this country and which has been running a nationwide pro-saccharin and anti- Delaney newspaper advertising campaign, he added: "I really believe that the Cancer Society his been playing into their hands." ACS does in f:.,r acknowledge a relatinnship with the Coca-Cola Company, a pillar of the Calorie Control Coun- cil and manufacturer of the artificially sweetened soft drink, Tab. In its latest annual report, the society notes that "a generous grant from the Coca-Cola Company supported transportation" for an ACS delegation of "volunteers and staff officers" that visited the Soviet Union last June. ' Uneqttal Relaliuttsltip T 0 UNDERSTAND the politics of cancer research, it is necessary to examine the relationship between the National Cancer Institute and the American Cancer Society, the richest, by far, of American disease-related philanthropies -'with a current budget of $114 million - and the highest-paying «•hcn it contes to salaries for its national headquarters bureaucracy. IIn ACS' latest available tax-exempt filing with the Internal Revenue Service, covering fiscal year 1975, the top staff salary re- ported was SCrt,750, and the five highest salaries aver- aged out to $51,602. In that same year, its nearest finan- cial competitor in health-related charities, the American Heart Association, reported ;50,751 as its top staff salary, and the five highest averaged 5-11•413. Since then, the top ACS salary has risen to at least $75•00U; this is the fig• ure that was announced as Rauscher's salary when he quit government service last year to join ACS.) Founded In 1937 as tlte first component of what even- tually became the multi-billion-dollar National Institutes of Health, NCI evolved into a scientifically competent or- ganization that performs research in its own laborato- ries and provides funds for research in universities, ho- spitals and other non-government institutions. Spending by Its own administrative and research staff takes up only 13 per cent of the current $815 million budget. The rest goes outside - which means that NCI is a bankroll of formidable proportions for the support of cancer re- search In non-government facilities. . NCI's scientific and fiscal prowess, however, has al- ways been accompanied by political timidity and cau- tion, even after the National Cancer Act of 1971 more than tripled its budget in six years. The ACS, on the other hand, is a bustling, nation.vide organization whose stated "objective is to eliminate cancer entirely as a human disease." Toward this goal, it has become extraordinarily adept at influencing public attitudes and hopes - and pocketbooks. For years, ACS fund raisers routinely told the public that the organization was unable to finance promising research "due to insufficient funds." Last year, the Na- tional Information Bureau, a charity-inonitoriiig service, challenged ACS on the ground that it «as making this claim at a time when it had over $31 million in unconi- mitted reserves. The ACS board responded that in its ap- peals ACS "will now place research in perspective as part of the overall program needs." ]leadquartered in New York, mhere it %kas incorpo- rated as a non-profit organization in 1922, ACS is thr hest organized of disea.e-related charities, v.•ith f,tl chartered divisions within which are nearly 2.1100 luc•al units: all in all, it has nearly 2.1NK1 paid staff inenibers anil cmne 2.5 million volunteers, ranging from coin-collectint; door.

(,J bell ringers to recovered cancer patients who counsel the newly affticted. Though research, the objective that ACS emphasizes in its fund-raising appeals, is the largest single activity, it actually is only a minor part of the society's overall ac- tivities. occupying only 26.3 per cent of last year's budg- et. Not far behind, with a combined total of 20 per cent, were the categories of "fund raising" and "management & general." "Professional education," "patient services," "community services" and several other activities re- ceived the balance. These proportions are more or less common in the health-charity field; the American fleart Association, for example, closely matches ACS' research allocations, with 28 per cent going into that category. But as the largest organization of its type. ACS is the plumpest target for Friticism of what appears to some as relatively low apportionments for research and service programs and high apportionments for fund-raising and salaries. In its latest annual report, for example, ACS Executive Vice President Lane W. Adams states, "We expect to have criticism, and we would be surprised if there were none. Since we don't equivocate about cancer, it is un- derstandable that promoters of unproven methods of cancer treatment would seek to discredit the society. The only sure way to turn off strident critics is.to stop working responsibly in the cancer field." Tlte Power Elite T HE POWER of the ACS doesn't come from its money or programs, which are relatively small in comparison to the burgeoning budgets of the National Cancer Institute. Rather, ACS' power comes from its ability to influence the spending strategy of the politi- cally passive NCL ACS actually receives only a small slice of NCI's money, but it wields great influence over where the bulk of the money goes. ACS accomplishes this through an intricate network of influential people who have been enlisted in the crusade. While NCI has traditionally been administered by ob- scure civil servants - more timid than most, since full- time scientific careers provide poor grooming for the rough-and-tumble of Washington politics - ACS, nation- ally and in thousands of community chapters, has evol- ved into a socially attractive gathering place for the phil- anthropic elite (the annual Cancer Ba11 is a stellar social event in many communities), where good intentions and good connections are firmly cemented by the universal dread of cancer. With the leadership of the ACS more or less evenly di- vided between 1ay Individuals and researchers and phy- sicians, the former category reads like a«'ho's Who of. the American establishment. In the category of life menibers - "persons of emi- nence who have rendered outstanding service in the cause of cancer control" - are a select 32, among whom the lay personc include such past and present ACS lead- ers as: Elmer Bobst, a longtinit• executive and now hon- or2ry director of the 1Varner-Lambert pharmaceutical company; Emerson Foote. co fuunder of the Foote, Cone L. Itrlding advrrtising agcnry;.l. I.runard Itrinsch, board chairnian, ('os ('ahle ('onimu1iit'ations; Matthew B. Rosenhaus, board chairman, the J. B. 1%'illiams Co.; George E. StrinQfellow, past senior vice president. Thomas A. Edison Industries, and Travis T. Wallace, founder and chairman emeritus, Great American Re- serve Insurance Co. The l94member ACS House of Delegates, from which the 1llimember National Board of Directors is drawn. Includes similar eminences, among them Mary Lasker, the best-known woman in national medical politics, who has been honorary chairman of the board since 1957. There is no black or labor union representative among the 32 life members, though this year, for the first time in ACS history, the president-elect is a black, Dr. I,aSalle D. Leffall Jr. of Howard University. There is only one black and one labor representative among the 19-1 mem- bers of the House of Delegates. Ninety-four of the dele- gates are lay members; of these, 18 are senior officers or dlrectors of banks, seven are members of investment firms and 13 are business or industrial execUtives. Whatever it Is that leads to the policies that the board sets for the ACS, certain aspects of the policies are trou- bling to some scientists. Dr. Robert L. llandschumacher. chairman of the Yale Medical School department of pharmacology, reports that he once tried to interest Lane Adams, the ACS executive vice president, in a more aggressive approach toward the rapidly rising cancer incidence and low survival rate in blacks. ltand- schumacher says that Adams rejected the suggestion on the, ground that "blacks don't give much to the society anyway." (Adams denies ever having said this but adds, "All minority groups are very difficult to reach, both 1 with programs as well as our (fund-raisingj crusade:" 0verwheLmittg the NCI W ITII ALL T1iIS social and business power at its command, the ACS has usually been able to over- whelm the civil servants of the NCI. In the opinion of Rep. David Obey (D-«'is.), who has been urging NCI to put additional resources into identifying environm(,ntal carcinogens. ACS wants to keep the Cancer Institute strong in bankroll and weak in staff so that it can direct its spending without too much interference. The contrast in styles of the two organizations was il- lustrated by the relative positions they took in 1971, when President Nixon and Sen. Edward Kennedy ID- Mass.), then a presumed presidential aspirant, entered Into a bizarre competition to become the nation's cham- pion against cancer. The ACS, with honorary board chairman Mary Lasker making use of her political con- nections, pushed hard to sever the Cancer Institute from the National Institutes of Health complex and give it an autonomous status, the object being greater visibility and an end to cancer having to compete with other dis- eases for government research funds. Established as an independent agency, along the lines of NASA, the prop- osed Conquest of Cancer Agency would have an unob- structed pipeline to the Treasury. ln those days, confidence was high that virus causa- tion played a major role in human cancer and both newspaper reports of the period and congressional testi- mony were replete with accounts of research findings implying that, given enough muncy, it unuld,be only a matter of time before antidotes or preventive vaccines became available. ------

The ACS now concedes that this hope is somewhat remote and has said nothing on the subject recently. But ' since viruses, in contrast to industrially spawned chemi- rais, have never had a lobby, the beauty of the virus em- phasis was that ne establishment oxen need be gored - apart from tobacco, which had long before demon- strated an ability to survive government designation as a proven killer. Meanwhile, more than $717 million has been spent since 19F5 on a so far futile effort to identify a virus that unequivocably causes cancer in man. With Nixon and Kennedy sprinting to win favor with the cancer lobby, NCI researchers suggested that, scien- tifically, it might not he a sound idea to detach cancer research from the overall biomedical research effort. However, with the Nixon administration glaring them down, they suggested it very timidly indeed. Non-government scientists, appalled at the prospect of a separate cancer research empire,. felt no such re- straint, however. After an eruption of dissent in the biomedical research community, the issue was resolved with a compromise that gave NCI semi-autonomous sta- tus, plus a direct, and unique, link to the White House through a newly established three-member President's Cancer Panel. Appointed to chair the panel was Benno Schmidt, managing partner of the J. Ii. 1Vhitney invest- ment firm and an old ally of Mrs. Lasker. As chairman of the panel for the past six years, Schmidt has been industrious beyond anyone's expecta- tion. Well-informed, imperious and well-connected with the political figures who determine NCI's budgetary fate, he has also been a consistent damper on efforts to steer NCI into a greater commitment on environmental carcinogenesis. Schmidt's approach, which is the same that is used by the ACS, is that the top priority should be given to lung cancer and its principal cause, cigarettes, plus continued emphasis on basic research. That lung cancer and its causation merit a high priority is beyond dispute. The , disease tops the list, with 23 per cent of all cancer deaths; the cure rate remains low and the incidence is Nevertheless, as other causes of cancer have been identified. Schniidt, in his powerful position as chair- man of the President's Panel, has generally discouraged an expansion of the environmental strategy beyond ci- garettes. Thus, in January, 1976, at a meeting where NCI staff members presented their case for further environmen- tal studies and public education on chemical carcinofie- nesis, Schmidt responded that "one of the things that • has been concerning me in recent months is that we are diluting the public urge to get rid of cigarette smoking .:. by including, considerably more conjecturabk in my opinion than is the case with cigarettes, a lot of other things in the publicity ... It goes without saying that if we knew what causes cancer and if we could remove- it without removing the whole environment, we would remove those things forthwith." In a telephone interview last week, Schmidt said that he was not opposed to environmental research, and noted that NCI funds in this category had risen from $97.5 million in fiscal 1976 to a projected S127.5 million for next year. "I was objecting," he said in regard to his 1976 remarks, "to causing the public to put cigarettes in the same category as things on which the evidence isn't as strong." Three years after Congress and the President declared the war on cancer, the neglect of environmental studies caused NCI's top science advisory body to appoint a sub- committee to examine the issue. Reporting back on its deliberations, the subcommittee stated: "There was an obvious sense of general astonish- inent throughout the meetings that the National Canc•er Program does not appear to have accorded an adequate priority nor sense of urgency to the field of environtnon• tal carcinogenesis, particularly where this concerns chemical carcinogens." As part of its response to this indictment, tiC) trans- ferred nearly q million to the National Institute for Oc- cupational Safety and Health to support environmental carcinogenesis research. , rising. ......

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