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NCI Director's Meeting on Cancer Prevention February, 1978, Bethesda On Monday, February 13, 1978, a meeting was held to consider the present and future role of the National Cancer Institute (NCI) in cancer prevention. Eleven scientists, 6 from NCI and 5 from outside, were invited to this discussion by Dr. Arthur Upton, NCI Director. Both the Director and. Associate Director as well as Dr. Domanski (in charge of extramural grants) were present during the meeting. I. Purpose of the Meeting This meeting was cochaired by Dr. Bailar, Editor in Chief of the Journal of the National Cancer Institute, and Dr. Ernst Wynder, President of the American Health Foundation. In the opening remarks, the cochairmen stated that the goal of the meeting is to inform us of what is going on in cancer prevention, and what is not going on but should be, and to develop a national strategy. Dr. Wynder emphasized that there is more basic research than actual prevention at the present time. He called for more free exchange among intramural and extramural scientific communities in cancer prevention research, and that all segments should collaborate to set priorities and to do the doable. Dr. Mike McGinnis, Deputy Assistant Secretary for Health, Special Health Initiatives of HEW, revealed that a review is underway by a Departmental Task Force on cancer prevention, which is a major area of research in the Department. A group of experts are preparing working papers in this area. In addition there is also assessment of research activities of NIH in relation to environment, services and target areas. Dr. Upton, Director of the Cancer Institute, welcomed participants and stressed the responsibility and opportunity of DCCP. He emphasized that the Congress and general public always ask NCI to do more work on cancer prevention. Cancer prevention is on the top priority list of NCI, and he asked members attending the meeting, especially consultants, to help NCI to reshape the cancer preven- tion programs. ti II. Present Activities of the NCI Dr. Gregory O'Connor, Acting Director, Division of Cancer Cause and Prevention (DCCP), reported briefly on the activities of the Division. He defined cancer prevention as "any alteration of the host or environment which precludes the development of cancer". DCCP is organized as a research division. Their major activities include 1) smoking and health; 2) chemoprevention; 3) immunoprevention; 4) identification of high risk groups; 5) nutrition and diet; 6) bioassay program for identification of chemicals in the environment which may endanger humans. Additional work is mainly in the basic research area, involving genetics, gene transformation, DNA repair and promoting agents. - cr 0 .. ~ u7 N ... A

2 Dr. Gio Gori then reported on activities relating to smoking and nutrition within DCCP. He emphasized that smoking is the largest cause of cancer today. Major prevention activities are through education and risk reduction. The American Cancer Society and the National Clearinghouse on Smoking are mostly in the education area. He reviewed in detail the activities of the Tobacco Working Group (TWG) the cooperation with National Heart and Lung Institute (NHLI) and the USDA in conducting various studies during the past 8 years. As people continue to smoke it is important to reduce the risk. During the past decade the tar and nicotine content in cigarettes has drastically decreased and some of the cigarettes on the market now have only 8 or even 1 mg of tar. When smokers gradually get used to extremely low tar and nicotine cigarettes it will be much easier for them to stop smoking. The nutrition program was started in 1974. Diet appears to be important in developing certain types of cancer. Dr. Robert Hoover, Head of the Environmental Studies Section, DCCP, reported on studies on other hazards. He described their activities in the areas of environmental epidemiology; biostatistics; identification of hosts and using "map" method to characterize location, race, and life pattern; occupational studies; therapeutic drugs; antineoplastic agents and field studies such as lung cancer in the Georgia coast, colon cancer in Nebraska, nasal sinus problems in the N. C. furniture painting area. They are also working on many other miscellaneous subjects such as chloroform in water and air, radiation effect such as 1-131, and study of high risk families in searching for genetic markers. Questions were raised as to how they coordinate their programs with EPA, USDA,-and other areas of expertise, how well their program has been peer reviewed by outside experts, and their activities in the area of metabolic epidemiology. Dr. Fink, Director of the Division of Cancer Control and Rehabilitation (DCCR) reported on their ongoing program. DCCR is only four years old. The function is to transfer information from research to bedside. The major program areas include 1) occupational and interagencies work with OSHA, Stanford Research Institute with emphasis on specific carcinogens such as asbestos fibers, etc.; 2) radiotreatment; 3) life style (e.g. smoking); and 4) general environment. There are three major activities underway: 1) the identification and develop- ment of control technology; 2) information education; and 3) the community prevention strategy. At the present time their funding is approximately $6 million. III. Development of a National Strategy After the presentation of the current activities by NCI scientists, the invited consultants presented their views on the development of a national strategy on four major areas. (A) Dr. Tso discussed the national strategy on smoking and health. The objective is to reduce risk of disease in smokers. He outlined three major approaches , wh;ch TI;G originated and presented a six-point work plan. There was a general o~ r LA N V1 N r. J

3 concensus of high priority for tobacco health research in cancer prevention. Dr. Hoover commented on the lack of a unified national strategy. lie particularly pointed at the USDA tobacco price support program. Dr. Tso stated that tobacco price support is entirely a separate program. It has no bearing on the tobacco research program or on the smoking and health program. (B) Dr. Hegsted, Prof. of Harvard University, discussed national strategy on nutrition. He stated that this area of research has been neglected for many years, although there are frequent reports on possible presence of carcinogens and cocarcinogens in diet. The major strategy should be to provide adequate nutrition to prevent disease. He said there is data available from NHLI animal nutrition tests relating to diseases, not much in human, although the epidemiologic evidence is clear. The job is to convince those who are responsible to initiate action. Much more can be done in prevention than to answer why. Many chronic diseases can be prevented by changing the diet. Dr. Wynder commented that there is quite some animal evidence on nutrition and cancer. (C) Dr. Kuschner, Dean of Medicine, N. Y. State University at Stoneybrook, discussed national strategy on industry and product-related carcinogens. He did not address priorities, instead described ongoing research which he has been involved with such as ionizing radiation, alkylation agents, and many others. He strongly disagreed with the statement in an American Cancer Society publication some years ago and a similar statement recently by the National Resources Council that "80 to 90 percent of cancer is environmentally determined". He considered that the statement is extremely unfortunate and there is no data to support such a thesis. Dr. Kuschner questioned at what degree should NCI be involved in a routine testing program and in basic research. He emphasized the need of a national death registery and stated that multiple -etiology may be the result of high risk exposures such as smoking and uranium mining, air pollutants, etc. (D) Dr. Hochbaum of the University of North Carolina discussed education in cancer prevention. He is a behavior scientist and said that most people know the risk involved with cigarette smoking. The problem is how to teach them to stop and how to prevent exsmokers from going back. In other areas he placed emphasis on medical intervention and early detection for cancer prevention. There is a general fear in the public of cancer. Newspapers and research publications frequently report the health risk on almost everything, and as a result the general public has become almost immune to the problem. He believes that threatening people is not good. There is already a lack of credit- ibility of the medical profession including NCI. He used saccharine as one of the examples. There are many other ways to prevent cancer besides education, for example, if an insurance company establishes certain criteria as high risk factors, it certainly will reduce some of the high risks. (A 0 ~ ~ ut ~ N r CO

4 IV. Discussions Following the special reports there was a general discussion. Dr. Domanski who is in charge of the grant program in DCCP described areas of grant research. The areas involved are molecular structure of potentially hazardous chemicals; metabolites of carcinogens; development of carcinogenic screening program; metabolism and carcinogenicity; relationship between carcinogens and mutagens; DNA repair and epidemiological studies. Dr. Bailar emphasized_ the importance of setting up priorities in the area of cancer prevention. Particularly the need of a specific program to stimulate grant for cancer prevention, work with establishment to examine the current ongoing programs, and coordinate this research program toward prevention research, additional training for epidemiologists, and establish a specific focus charged with the development of epidemiology for cancer prevention and convene a meeting for the purpose of development of programs relating to cancer prevention. Dr. Wynder stressed the need of a better relatinnship for intra and extramural research and keep the public informed on major policy decisions, more emphasis on peer review system, and a balanced funding for different programs, and in cooperation with various disciplines. At this point Dr. Upton stated that he is actively considering appointing an associate director charged with the duties of coordinating intra and extramural research. Dr. Kuschner stated that cancer prevention is not only a national program but a global problem. Students lost interest in preventive medicine. School of public health, and especially the department of preventive medicine, are not well supported. For a medical student it is more glamorous and challanging to study surgery or internal medicine than preventive medicine. Training of a epidemiologist also has a low appeal to medical students. There is a definite need to change this attitude and stimulate more action for preventive medicine. V. Synopsis Dr. Bailar summarized the general discussions and suggested the following: 1) Stimulate more grant application for cancer prevention; 2) Press f or new study sections on environmental carcinogenesis; 3) Establish a focal point within NCI on cancer prevention; 4) Conduct national meeting of experts to set up priorities for cancer prevention research; 5) Training for and raise the image of epidemiologists; 6) Effective linkage and exchange between intra and extramural research; 7) Assessment to meet the needs of centers of cancer prevention; 8) Reorient NCI priorities; and 9) Standardize policy on regulatory agency especially involving EPA, OSHA and NCI. . In conclusion Dr. Upton thanked the participants and also announced that a board of ;;cientific counselors for NCI is to be established. There will be 15 scientists meeting approximately 3 times per year to consult, evaluate and advise the National Cancer Institute program. 0 0 .. vt ut ~ N .+ %0

5 The following materials are attached: t1 Letter from Dr. Upton on the meeting and list of attendance. #2 Meeting agenda. V3 Tso's Report on vCI National Strategy on Smoking and Health. #4 The Working Conference on cancer prevention as suggested by Dr. Bailar. #5 A questionnaire chart prepared by Drs. Bailar and Wynder on primary cause of cancer mortality. 176 Wynder: "Cancer prevention, a questionaire of priorities". T. C. Tso February 16, 1978