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~ A C ~~~~_ P~sl Ne~ Editorial: Preventive Oncology and the Nx*~ National Cancer Program'•2 PREVENTIVE MEDICINE 9l823-825 (t980)/vQ& lIY CHAIRMEN xCHARLES LEMAISTRE , ERNST L. WYNDER President President University of Texas System Cancer Center American Health Foundation PARTICIPANTS 1~( NATHAN BERLIN Director Cancer Center Northwestern University ~( IRVING SELIKOFF Professor of Medicine and Community Medicine and Director Environmental Science Lab Mt. Sinai School of Medicine }( LESTER BRESLOW Dean School of Public Health University of California at Los Angele"s STEPHEN CARTER Noxhern California Center Program ~r Guy NEWELL /` Director Office of Cancer Prevention University of Texas System Cancer Center x ARTHUR UPTON Professor and Chairman Department of Environmental Medicine New York University BERNARD WEINSTEIN ~irector of Environmental Sciences Columbia University )<- JOHN WEISBURGER Vice President for Research Naylor Dana Institute American Health Foundation , DEFINING CANCER PREVENTION Cancer prevention is the reduction of the occurrence of cancer by identifying causes and developing measures to remove or counteract them. STATE OF THE ART Epidemiological study has disclosed identifiable causes for a significant propor- tion of human cancers, and there has long been a serious financial and professional commitment to uncovering the causes and mechanisms of carcinogenesis. Some ' In Apri11980, a group of scientists met with the American Health Foundation Staff and Dr. Vincent DeVita, the Acting Director of the National Cancer Institute, to define preventive oncology and how preventive oncology could best evolve with the National Cancer Program. An additional participant in the afternoon session of the conference was Dr. Joshua Lederberg, President of Rockefeller Univer- sity. As part of this conference, Dr. DeVita outlined the role of preventive oncology within the program of NCL The present communication has had the input of the above participants as well as Lester Breslow, who could not personally be with us. g Sponsored by the American Health Foundation, 320 East 43rd Street, New York, N.Y. 10017, April 14, 1980. ' To whom requests for reprints should be addressed. 823 TIMN 0114788 0091-7435/80/060823-03502.00/0 Copytigl# Q 1980 by Academic Press. Ieo. All rishts of mpmductioa in any form reserved. T-1 , :C

may argue that any investigation of the mechanism of any disease is ultimately preventive in nature. History, however, has repeatedly shown that the prevention of certain diseases, including certain cancers, is not necessarily contingent on deciphering the precise mechanism by which a given agent initiates cancer or a cell defends itself. While there has been much verbal emphasis on the ultimate potential of cancer prevention, a relatively small proportion of the total National Cancer Program budget is devoted to, and consequently relatively few inves- tigators are involved with, the exploitation of existing knowledge for cancer pre- vention. PROBLEMS OF CANCER PREVENTION Several factors underlie our failure to advance preventive oncology adequately. Preventive medicine of any kind plays a limited role in medical school training, and it receives little more than lip service from the medical care providers, espe- cially hospitals. It would appear that in medicine, as in politics, we tend to be crisis oriented. This general neglect for preventive medicine by the medical estab- lishment and society is reflected in the priorities within the National Institutes of Health. This state of affairs is not, however, irreversible. If the leadership of the Na- tional Cancer Program would place greater emphasis on cancer prevention, and if its disciplines could be ihterrelated and enhanced within a given institution, the pace and success rate of cancer prevention could be accelerated. SMOKING AND CANCER AS EXAMPLES ^ Tobacco-related cancers may serve as an example. It is universally agreed that tobacco-related cancers are, in principle, among the most preventable types of cancers. Although a yearly Surgeon General's Report on Smoking and Health is issued, few organized programs implement the knowledge already available. There is presently no working group on Smoking and Health at NCI. There are no study sections intended for proposals specifically in this area or that suggest new fields of research. Yet, we can coordinate major national efforts for a class- room health education project to prevent children from beginning to smoke; we can promote smoking cessation programs at the workplace and in the community; we can accelerate efforts to pinpoint the harmful agents in tobacco smoke so that they can be removed; and we can interrelate epidemiologic capabilities to monitor the effect of the so-called "less harmful cigarettes" on the risk of cancer and other tobacco-related diseases. Decisive implementation of such programs would have a major impact on tobacco-related cancers in the future. Similar coordinated programs, in occupational and in nutritional car- cinogenesis, could significantly advance our knowledge of the origin and potential prevention of several types of neoplastic diseases. Estimates of the percentages of cancers related to environmental causes have ranged from 50 to 90%. Whatever the specific percentage, it is large. We know through studies of the distribution of cancer throughout the world that cancer is not an inevitable consequence of aging. Since most investigators in oncology seem TV4N 0114789 T~.~.~ t 3fv to sup, detern It is tion, l: nity a nature syster tently cally i ventic deterr maxir cance multic The effort I. epide strent resea pertis 2. ter st enabl tion. in ca cial s 3. lishec revie Ca incid tality goals succe orgar progr

r EDITORIAL 825 ftimately evention igent on icer or a ultimate National w inves- ncer pre- to support this concept, the question remains: why do we not act upon it and, if we determine to.,act, how can we best undertake such action? ~ ' FUTURE DIRECTIONS It is evident that the current small and piecemeal approach to cancer preven- tion, both within the National Cancer Institute and scientific and medical commu- nity at large, has had very limited success. Much has been learned about the nature of the carcinogenic process at the molecular level. This has, in turn, yielded systems for the detection of'carcinogens. But this new knowledge is not consis- tently and deliberately applied to the mechanisms of cancer causation for numeri- cally important cancers, thus leading to their possible prevention. If cancer pre- equately. vention is to play an important part in our total national cancer effort, we must training, determine how best to design and put in place a unified program to bring about the zrs, espe- maximum possible benefit. Accordingly, we recommend that the framework of -nd to be cancer prevention be materially strengthened by the establishment of several cal estab- multidisciplinary cancer prevention programs in appropriate institutional settings. stitutes of The following general guidelines are recommended for coordinating preventive efforts in research and education with the goal of the elimination of cancer: ~f the Na- 1. A multidisciplinary cancer prevention program should include activities in on, and if epidemiology, metabolic epidemiology, and health education. It would be ution, the strengthened (although this is not essential) by the additional ability to conduct research in experimental carcinogenesis. Several institutions could pool their ex- pertise into a multidisciplinary cancer prevention program. 2. Such a multidisciplinary cancer prevention program at an institution or cen- .greed that ter should be in the position to apply for a cancer prevention CORE grant, thus e types of enabling the center to attract candidates of the highest calibre into cancer preven- I Health is tion. It is particularly important that some sense of long-term financial continuity ilable. in cancer prevention be provided, since prevention centers cannot rely on finan- There are cial support from patients, as can clinical centers. iat suggest 3. An appropriate organizational division for such programs should be estab- 7or a class- lished within the NCI, along with appropriate extramural advisory and peer- smoke: we review groups. ammunity; Cancer prevention has two readily measured end points, the reduction of the )ke so that incidence of cancer and, through early detection of cancer, the reduction in mor- to monitor ~ tality. All of our activities must be directed toward the swift achievement of these r and other goals. Those involved in cancer prevention are optimistic about our opportunity to )uld have a 1 succeed but we recognize that to realize these opportunities we should ideally organize our efforts within the framework of multidisciplinary cancer prevention ional car- I programs. .d potential ERNST L. WYNDER auses have We know it cancer is ology seem '1'IIVIIV 0114790