The genesis and evolution of the National Cancer Program was the focus of the President's Cancer Panel on July 19. This meeting, hosted by the Massachusetts General Hospital, represented the first of four meetings to be held this year exploring the current state of the Program and future directions. Speakers representing academia, industry, and government provided historical perspectives on the Program's evolution, and raised issues about future goals for research and medicine, communication and education, and a public health agenda that must also address concerns about access to care, in the context of a national cancer program.

The need for a coordinated cancer research effort was recognized by legislators as early as 1937, with the establishment of National Cancer Institute (NCI) within the Public Health Service and direction to the Surgeon General to promote coordination of research conducted by the NCI and other agencies, organizations, and individuals. In 1971, the National Cancer Act was signed into law to expand and intensify a "coordinated cancer research program encompassing the programs of the NCI, related programs of other research institutes, and other Federal and non-Federal programs." Proponents of the Act advocated increased emphasis on the application of research results to improve methods of cancer detection, treatment, prevention, and control for the general public. Like the rapid success demonstrated by the marshalling of Federal resources for the Manhattan Project (the atomic bomb) or the Apollo Project (the manned moon landing), it was anticipated this Federal "war on cancer" would find quick success. The NCI Director was charged with its overall coordination responsibility of what has come to be called the National Cancer Program. The President's Cancer Panel was created to monitor its implementation and report any delays or barriers to its progress directly to the President.

It is clear now, 28 years after the National Cancer Act, that no magic bullet existed or exists for halting cancer. Unlike most other diseases, cancer comprises perhaps 100 different disorders. In 1971, very little was known about its complex mechanisms-how a normal cell becomes a tumor cell or how a tumor cell multiplies and spreads. It was believed that cancer could be conquered through information dissemination and cancer control programs designed to bring the benefits of knowledge to all Americans, but in 1971, knowledge about cancer and treatment options was far too limited to achieve the goal. The National Cancer Program has since evolved to place the greatest emphasis on the conduct of basic research, with far less emphasis on the application of findings to reduce the burden of disease in the general public. However, neither in 1971 nor today has the issue of access to all phases of cancer care for all Americans been addressed adequately.

In 1993, the NCI, through a subcommittee of the National Cancer Advisory Board chaired by current Panel member Paul Calabresi, began an evaluation of the National Cancer Program, in part to respond to a Congressional request to assess its achievements, reinvigorate the Program, and put forth a new plan to carry the Program into the next century. In requesting the evaluation, Congress praised breakthroughs in molecular biology and other basic cancer research areas, but expressed concern over the continuing rise in cancer rates and the fact that not all populations were benefiting from advances. A final report, Cancer at a Crossroads, presented to Congress in 1994, prioritized 37 recommendations for proceeding into the 21st century. Although this report generated considerable interest and much progress has been made in addressing its recommendations, it is now time to reassess both the meaning and status of the National Cancer Program. As noted, by Panel Chair, Dr. Harold Freeman, Cancer at a Crossroads provides an excellent starting point for continuing discussions on the evolution and future of the Program.

The issue of coordination of a national cancer effort continues to be daunting, and is made more difficult by the unclear definition of the entity referred to as the "National Cancer Program." With little legislative history on the meaning of the term, an open question remains of how broadly to define the National Cancer Program and realistically coordinate its implementation. As one speaker suggested, "The National Cancer Act should be rewritten to clearly define the full scope of cancer activities addressed by the National Cancer Program-from basic research to application and public's health-as well as
clarify the scope of Government and non-Government participants involved."

Collaboration was repeatedly hailed as the essence of any successful, coordinated effort. Limitations exist, however, on what can be legislated in terms of non-Governmental action. A clear message to the Panel was the need for more translation and application of research. If the 20th century is remembered for its breakthroughs in basic cancer research and improvements in treatment through specialized academic health and cancer centers, then the 21st century should be remembered for its progress in translating discoveries and applying them to all populations, in both community and specialized settings, with increased emphasis on prevention, cancer control, and the public's health. In looking toward the future, societal trends will affect application of discoveries. The aging and diversification of the population, for example, has clear public health and cancer control implications. Advances in information technology and mapping the human genome will have significant effects on how cancer care is delivered in the next century. Creativity is needed in applying new knowledge to the benefit of all Americans.

In excess of 40 million people remain uninsured and without meaningful access to care. Even among the insured, application of advances in cancer care and the quality of care delivered vary dramatically. Public health models that distribute benefits to a larger number of people need to be explored in the context of cancer. Great opportunity exists in expanding prevention strategies within public health models. Dr. Howard Koh, Massachusetts Commissioner of Public Health, cited tobacco and lung cancer as one of the greatest public health disasters of our time, and expressed hope that we will also remember the 20th century as the end of the "tobacco and cancer" century. In addition, the National Cancer Program of the future must incorporate new communication and education strategies to reduce the cancer burden. Science can provide information about cancer risks and probability of outcomes. It cannot make individual value judgments regarding behavioral or health care decisions based on that information. In moving forward, all of these issues are important. The Panel will build on this meeting's discussions in public meetings scheduled for September 22, November 19, and December 6, 1999.