Fiftieth Anniversary of the National Cancer Act of December 1971
President Nixon signing the National Cancer Act
First published Jan. 15, 2022
Although a few centers devoted to cancer research and care developed in industrialized countries, including the United States, in the late 19th century, these had little effect on those with the disease. They were largely devoted to surgical and radiotherapeutic approaches to cancer treatment until the mid-20th century. Until that time most adult cancer patients were cared for by general surgeons or internal medicine specialists and children by pediatricians. Medicine was traditionally organized around organ systems. For example, nephrologists saw patients with renal cancer and gastroenterologists cared for patients with gastrointestinal cancers. Hematologists cared for patients with leukemia, lymphoma or myeloma. In most hospitals or clinics there was no such thing as a medical or pediatric oncologist who cared for patients with cancer. Surgeons excised cancers and a few took it upon themselves to administer the very limited chemotherapy available for non-hematological cancers in the 1960’s. Specialized (radiation) therapists treated those cancers that were amenable to irradiation. The diagnostic techniques were limited to biopsy of an obvious mass and standard radiographs. The latter required relatively large masses to be identified by which time many cancers had metastasized to distant tissue sites. There was a pessimism among physicians that if the cancer was not found early and excised surgically, the diagnosis of cancer left the medical profession with little to do for the patient. Some physicians would telegraph this pessimism by responding to colleagues when asked, “What did the patient you just examined have?” and the answer was “He or she had the Big C!” The implication being that the disease was more powerful than one’s ability to do anything about it.
The ability to make oncology a functional and effective discipline, a discipline that involves all organ systems and is devoted to the prevention and cure of cancer of any organ system was provided by the United States Congress with the encouragement of Richard Milhous Nixon (1913–1994), the 37th President of the United States. In 1970, in his State of the Union address, he committed the United States government to decreasing and eventually eliminating the threat of cancer. This consequential legislation was the result of a farsighted and unrelenting advocacy effort, led by the philanthropist Mary Lasker that resulted in the Senate adopting a resolution in 1970 calling for the study of cancer in the United States. As part of this national effort, in October 1971, the Army’s Fort Detrick biological warfare facility in Maryland was converted in part to a cancer research center, the Frederick Cancer Research and Development Center. It became an internationally recognized center for cancer research.
On December 23, 1971, President Nixon signed into law the National Cancer Act of 1971, stating, “I hope in the years ahead we will look back on this action today as the most significant action taken during my Administration.”
The National Cancer Act (Public Law 92–218), dubbed “The War on Cancer,” gave the National Cancer Institute autonomy at the National Institutes of Health with special budgetary authority to be determined by Congress. The Cancer Chemotherapy National Service Center increased its efforts to acquire new anti-cancer compounds for testing with the awarding of an acquisition and inventory contract responsible for the collection and documentation of test agents. In 1973, the Surveillance Epidemiology and End Results Program of the National Cancer Institute was initiated as an authoritative source of information on cancer incidence and survival in the United States. The Program, known by the acronym SEER, began to collect and publish cancer incidence and survival data from population-based cancer registries. Since cancer is not a reportable disease in the United States, this initiative was vital to measure the incidence, prevalence, and mortality of cancer of each specific tissue (e.g. lung, colon, pancreas and so forth) by age, ethnicity and gender and to track changes in incidence, survival and mortality and, thus, measure the extent of the problem and progress in its control.
In 1972, the National Cancer Institute was reconstituted into the office of the director and four divisions: (i) cancer biology and diagnosis, (ii) cancer cause and prevention, (iii) cancer treatment, and (iv) cancer research grants (later named the division of extramural activities). The extramural program vastly expanded cancer research funded by the federal government to include university centers, research institutes and other related institutions, expanding considerably the trained medical and scientific minds working on the problem. Moreover, this program incentivized physicians and scientists to enter oncology as a discipline as a result of the vastly increased resources available.
The increased focus on and fiscal support for cancer research resulted in the Cancer Centers Program of the National Cancer Institute. In 1973, the director of the National Cancer Institute, Frank J. Raucsher, Jr., named three academic institutions the first comprehensive cancer centers: Roswell Park Memorial Institution (later Roswell Park Comprehensive Cancer Center) in Buffalo, NY, Fox Chase Cancer Center in Philadelphia, PA and M.D. Anderson Cancer Center in Houston, TX. Additional centers were funded, thereafter, aiming initially for 18 centers spread geographically, so as to have an impact in all regions of the country. These centers were of three types: comprehensive cancer centers, clinical cancer centers, and cancer research laboratories. At last count, there were 71 NCI-designated cancer centers in 36 states and the District of Columbia.
There, also, was expansion of Institute-funded, cooperative, and multicenter cancer therapeutic trial groups. One of the most influential leaders at the National Cancer Institute from the mid-1950s through the mid-1970s was Charles Gordon Zubrod (1914–1999), who modeled the new attack on the leukemias, especially the acute leukemias, after the highly successful malarial treatment and prophylaxis program he was involved with during the Second World War. He likened the attack on malaria, vital to the allies’ success in the Asian and African theaters of war, to the Manhattan Project in its organization. The medical scientific community did not favor targeted research, preferring investigator-initiated approaches, but Zubrod thought both approaches were useful and necessary. He set up the Acute Leukemia Task Force at the National Cancer Institute, which initiative led to the first effective therapy for this group of diseases and ultimately to curative therapy, especially in children and younger patients. Their application of multiple drugs with different targets was innovative and, initially, thought cavalier by the medical establishment who were traditionalists for whom drug combinations were considered inadvisable in most cases; except for bacterial endocarditis (two drugs) and tuberculosis (three drugs). He started the concept of regional multicenter groups, such as the Eastern Cooperative Oncology Group and the Southwestern Oncology Group to cooperate to study the effects of newly introduced drugs and drug combinations on cancer treatment. This expanded the patient numbers that could be studied simultaneously and in a rigorous and uniform manner and, thus, acquired answers much more quickly than could individual institutions.
The infusion of money and concepts led to attractive opportunities for scientists and physicians to focus on the management of patients with cancer, as well as its causation and pathogenesis. These initiatives fostered (i) the development of the specialties within oncology (e.g., medical, pediatric, gynecologic, surgical, and radiation oncology), (ii) the development of departments of neoplastic diseases, (iii) the development of cancer centers in university medical centers, (iv) the expansion of basic research relevant to cancer genetics, cytogenetics and (v) the study of the pathobiology of cancer cell growth and survival.
The results have been dramatic with many cancer centers developing throughout the country and the world providing a environment for the training of healthcare professionals and scientists who devote themselves to improvement in cancer care. There has been the development of new diagnostic approaches, including the ability to interrogate the human genome for cancer causing mutations and to facilitate diagnosis and uncover new targets for treatment. Improved radiographic diagnostic approaches, notably, magnetic resonance imaging (MRI) and positron emission tomography (PET) have provided sensitive measures of the extent of the disease. The development of innumerable pharmacological agents, many with specific biochemical targets, new immunological approaches to attack cancer cells, improved radiation approaches, more strategic surgical approaches and a better understanding of and provision of the psychosocial support needed by patients and their families.
If one compares the advances in life expectancy of patients who have cancers of various organ systems, the progress in the 50 years since the war on cancer began has been profound. It has been propelled by advances in risk assessment, identification of predisposing behavioral and genetic factors, early diagnosis and a wide variety of improved treatments: surgical, radiotherapeutic, chemotherapeutic, plus other pharmacotherapy, immunotherapy and blood cell transplantation. A decrease in the incidence of cancer, that is prevention, has been achieved by the identification of the cancer-causing effects of high-risk behavior, especially tobacco smoking, alcohol beverage consumption, exaggerated sun exposure, red meat ingestion and exposure to asbestos and mitigation of these and other environmental risk factors. The epidemic of obesity is a challenging problem as obesity has been shown to increase the incidence of at least 13 types of cancer. Effort to increase awareness of those risks has been spearheaded by the U.S. Public Health Service and many non-governmental agencies.
Cancer is a disease of evolution in that some frequency of mutations in cells, especially as a function of aging, will invariably result in cancers of various tissues. That is, there is a basal incidence of cancer that is unrelated to exogenous factors. Nevertheless, a marked decrease in the incidence of cancers related to human behavior, such as smoking, has been achieved and treatment of those cancers that are inevitable can be life-prolonging or life-saving. Perhaps, biomedical science can find a way to minimize the effects of naturally occurring mutations by preventing the evolution of small stable clones of cancer cells into progressive neoplasms.
The comment by President Nixon that he hoped his administration would be remembered, principally, for spearheading the National Cancer Act of 1971 would have been true had the Watergate Scandal not intervened. The Act’s effects have had an astounding benefit on human welfare.
Written November 2021