B&B INFORm^,iriom ImAj3F- M^m^ommE@ 300 @em=r. M=ot=L"n SouLcvAno Ulapblept M,%RLBono, Maptv"@4o Z077Z 11 USA 0 C301) 24WCI 10 DEPART@,IENT OF I-IEAL-Ti-i, EDUCATION, AND WELFARE PUE3L[C li!--ALTH SERVICE I-IEALTI-I 6-EIRVICES AND I,iEfqTAL HEALTF-I AD,'@INISTRATIOT\l -Date: September 29, 1970 PI efi.@, I 0 li[tt2 ADOL, @D?S Stibj,-ct: @l@iterial for Noverilt@er 9 Council l,'COL,ipg To: Members of @%JP National Advisory Council Enclosed is a copy of the most recent paper -Drei-)ared by the Inter- Society Commission for Heart Disease ]-Resources entitled "The Prii-oary Prevention of the Atherosclerotic Di-se,--ses." Your comments @.7ill be We have asked Drs. I,,richt, Staiiiler,.Lilienfeld, and Fredrickson to attend the i,iondEy afternoon session of your Council, meeting on November 9, 1970, in order to provide the 7rei-obers @.7itli an opportunity to question them regarding the report and to discuss its recoT,,rienda- tions. Publication of this paper is scheduled for the December issue of Circulation. lqe shall look fon-7ard to seeing you at that meeting. Margaret H.6'Sloan, M.D. Associate Director for Organizational Liaison Enclosure 'y@ C" f IC LI-@C l' 17- 1 DEPARTMENT OF HEALTI-1, EE)UCATIOt,4, AND WEL-f:-AIRE dif-f-(-i-ont o-r li,-,,irt d-I ti-n to L]IC E3!lbjCct 0-@ -it- io- diagnosis ard Lrcatrcnt 'to re'lipl,)ilit, - i aiic', co-ritinuit)- crrl- Ti,@cse liivc 1)@,c-.,A Coi-incil for tlic--ir aTiO ap, tlicv liavc, bec.@ii coirplc@L-ed. Th!.ay t-.Iic--@ J-JL-ty irouc and i-7il-I.prob@bly b@, co,--.,nletcd ncxt surj7@i(,,r. Tf,.Cy t'lic-@l be updated, published i,,L inonograpli forr-, and gi\,cr. i,7',-dc die-tribu,L--i-on. I am ciacloo-'Lp,- copies of the docu7@ciitp, N.,hic'ti ',,iave bccn rc-,,,ic\.7-ad by the Counc@Ll n:-)d oloo a copy oj' t@i@ r,-@cept contr,@'- ciill--Iticd "The ilrii--,li--v of tile- At'tierosclcrotic I on Vehicle t-7c woulcl apprcc'L-@tc your conir..2nt. l@Te leave a@,kc-.d Drs. St-ninlLr, Lilio-nfc-ti.cl, and Predricic@;on to attend tli,,- lion,,:,-ly Fcaso@iorL of your Cou.-icil 0-1 Nov-c,-4ber 9 in 6@@Q@cr to tlic,, to question Llicm. recording the atherocci.crosic r(,-poi-t to dicc:uss itr, PL@blicac-ic-,i of this paper is ccli,-@6u.Lcd for ttie DeccT.@)c-r iosuc- olL lle rshall lool, @ar-,@7ard to fe@ing-yott at tl-,,it raec--tiiig,. qincere-ly, Y@arF@arc-t 11. Sloan, M.D. Associai'-e Director for Orgaiiizational Liaison Enclosur:@s' Letter for ne@.., Coui)c,-.ili c-, r,@ S ci@ t e n-.'r) c r51970 C. rost) r r i ii ci, r c c and Sniti@, !,,.ic, D.C. 2@U036- De,-tr i'2'r. Crcsby 'er TI)e -vice cont-ract the q tic of the latcs'L- ac,)It of !.ICctrt decease. This is to nrov4l-llcl- for of criteria of I-iith Election @07 0-@- our "Tlii% O@urE,,co,@l Cener,-.1 c-;hall -and t-:Iiintaiii on i cur,,-ert a li.st or 141.sts o@, facilities ill tile equiT,,,,-)e(.,' rnd c;t@if-fed to I)-roviOa the yeost advanced Once techniques in tr,.c, treatment o'ic c@ariccr, or tof-ctl%er xyit,i sucili rc-t-atod tlic@ eV,--il- ability oi@ -iclvaiic@--cl speci,-at-, traiiiir@@ in Gu--'I '-'acilities ag 11 @! el i-@ u s e E-uc.,l or related to I.icenped ,)rnc- tit'Loii(@rs ot,ier perso-is recuirin@I sl-)c'l-). In'Loriiitioii. To the on(i o' list or li,-@ts ctiier -L information ir@ost Useful the Our,:!@2on Ge-oel-a.1 chall froui time to ccnrult %;ith interested national profes- sion.al organizations. Siitilar cortract:s lii-,7e ij(-cii T-P-d,-- iii the field of cancer @qi:h the A.@-ricc.-Li College oL' and- in the ficlei of ,-,troke i.7'.th t!ie. AT.,.erican l@earolo@icil. tessellation. Both the C,)Iie,-e of- Surgaons an,-! the t@@sociitio-,i ',,ave -2lected to wait until the end ol t@,,c!ir ict-Il.vitv bc!fore zelc@isi.,i57 a report. )lo%.,over, tii-- 1',Ieprt Cui(leliro:,s Groun (t;ie Inter-Socicty on 'f"teart ti-,(@ of has dc@'10ed to release their coqtributio-.7L-" as cor@pleted, in a ser4-es of pairs beEIntiinc, @,it% the prevention of Reprinted from Thi- -I)iteric(iii Journal of Rot,ntgeiiolog@-, Radiuni Therap@, (itid Nzicl(,(ii, JIt,dicint- X'ol. CN'III, No. 1, januar,,., IQ70 THE ROLE OF THE REGIONAL MEDICAL PROGRAMS IN THE CARE OF CANCER PATIENTS* By MARGARET H. SLOAN, M.D.t BETHESDA, MARYLAND T IS a great honor to be requested to the diagnosis and treatment of these address the members' of the American diseases." Radium Society, and I sliall try my best to Each region would organize itself, de- fulfill the responsibility such an invitation termine its own boundaries, identify its entails. own needs, and, with Federal support, de- Three years ago the Department of velop a program to meet those needs. Each He.dtli, Education, and Welfare began the region would have a Regional Advisori- implementation of new legislation-PL Group composed of representatives of ail 89-239-whicii former HEW Secretary the major health interests of the region, John Gardner called an experimei-it in including the consumer. Each program "creative Federalism." This legislation was would build on the resources of manpower, based on some, but by no means all, of the facilities, and relationships alreadv in exis- recommendations of the President's Com- tence. Initiative would come from the re- mission on Heart Disease, Cancer, and gions and decision-makin@ would be left Stroke which made its report in December at the local level to the maximum extent of i964- possible consistent with responsible admin- Most of you are already aware of the his- istration of the taxpayers' funds. Since no tory of PL 89-239 and the nature of the pro- two regions in the United States are alike, gram finally passed bv the Congress and each regional program was expected to be signed into law on October 6, i965, as the unique and responsive to the specific needs Heart Disease, Cancer, and Stroke Amend- and opportunities of that region. meiits of that year. You know that, during The kinds of activities which could be the len@thy legislative process, the pro- supported under regional medical programs posed bill was si,nificantlv transformed would include: continuing medical educa- from the concept of a network of Federally tion of physicians, nurses, allied health supported and constructed centers to that personnel and of the public; research, dem- of a series of Federally supported programs onstration and training; and the improve- based on voluntary cooperitive arrange- ment of facilities and services. They would ments between the major health interests not include patient care costs unless the of a region. These programs were to help patient was involved in research, demon- narrow the gap between the level of medical stration or training for the purposes of a care we know how to deliver, based in lar@e regional medical pro-ram (RMP). The)- part on the knowledge gained through the would not interfere with the essentially tremendous investment in biomedical re- voluntary system of American medicine, search since World War 11, and the ex- with physician-patient relationships nor tremely variable quality of medical services with the methods of payment for medical actually available to patients across the services. country. The goal of the legislation is quite A Division of Regional Medical Pro- 'fic: "To afford to the medical profes- grams was established within the National speci sion and the medical institutions of the Institutes of Health in February of i966, Nation... the opportunity of making avail- guidelines and regulations were published, able to their patients the latest advances in and the first grants were awarded as of *PresentedattheFifty-firstAnnualMeetingoftheAmerican RadiumSocicty,Philadelphia, Pennsylvania,April27-30, ig6g. t Associate Director for Organizational Liaison, Division of Regional Medical Programs. 9 Io Margaret H. Sloail JANUARY, 1970 Jul), i of that year. These were planning We have seen medical schools working grants awarded to give support to a reg' n- together and medical schools working with 'o al medical program staff while it was en- medical societies, hospital associations and gaged in planning an operational program. practicing physicians as the@, have never (In the HEW reorganization of last sum- done before. mer, the Division was relocated in the Each of you has the opportunity to par- Health Services and Mental Health Ad- t'cipate in your local program, to make sure ministration., and the National Center for that the needs in the field of radiotherapy Chronic Disease Control was joined with it in your region are adequately considered. in what is now called the Regional Medical You mav try to help and find the field Programs Service.) dominated by surgeons, internists, or We now have 55 regional medical pro- those preoccupied with continuing medical grams which cover the entire population of edu ca tion, bu t a t leas t we hope you will try. the United States, the Commonwealth of I should point out that PL 89-239 is not a Puerto Rico, Guam., American Samoa, and bricks and mortar program; that is, it has the Trust Territories. Thirty-seven of these no construction funds. However, it can have been converted to operational status provide rental of space, the purchase of and 43 are expqcted to be operational by equipment, and up to go per cent of the the end of this fiscal year. These regional cost of renovation. I think the prohibition medical programs vary greatly in size and of construction funds was a wise limitation, population, all the way from a single for if all the organizers of Regional Medi- metropolitan area, as in New York or cal Programs had been turning to the Di- Washington, D. C., to an area encompass- vision for help in building a new addition ing the four mountain states of Idaho, to the hospital or a new wing for the medi- Nevada, Montana, and Wyoming. In popu- cal school, they would never have concen- lation they vary from 6oo,ooo people in trated on the development of cooperative Vermont to the inhabitants of the entire arrangements among the health interests state of California, which are approaching of the region and on identifying the needs 20 million. of small hospitals and practicing physi- How are they really doing-these 55 dif- cians to deliver better care to patients. ferent programs? Some are going very well. ffhat potential do Regional Medical Pro- Some are not yet off the ground. And in grams have to aid in achieving the goals of some, town and gown problems, interschool the Ymerican Radium Society? After all, rivalries, reluctance of some medical schools our goals and yours are in part the same. to broaden their horizons from research and We all want to help improve the quality of the teaching of medical students to include medical care actually reaching the patient. service to the community, and the pre- And in the field of radiotherapy, it means 0ccupation of some physicians with busi- that every patient requiring the use of ra- ness-as-usual, or as they have known it for dium, radioisotopes, or radiation from many years, have prevented the develop-- whatever source for the treatment of can- ment of the cooperative arrangements on cer should be able to obtain it within his which these programs are based. Neverthe-: region, delivered by a well-trained radio- less, in each of these regions some coopera- therapist. In the field of radiodiagnosis, it tive arrangements have been developed means that the most complicated diagnos- within which doctors, nurses, hospital ad- tic tests requiring x rays or radioisotopes ministrators, allied health personnel, com- can be performed as close to home as feas- munity leaders and consumers who are in- ible, but certainly somewhere within his terested in improving prevention, diag- region of the country. Eventually, we nosis, treatment, and rehabilitation of would like to see that each of our 55 regions patients with heart disease, cancer, stroke, has at least one radiation center where the and related diseases can work together. most complicated diagnostic and treatment VOL. zog, No. i IZe@lotial ',\IeLlical Proizrani@ for Cizicer procedures can be performed. I am de- therapy training programs largely sup- lighted that Dr. del Regato described so ported by the National Cancer Institute graphically this morning the potential role but Dr. Juan del Regato has suggested that of a community hospital in the treatment additional members might be added to of cancer because this is the level at which their ranks if some radiologists could be Regional Medical Programs seem likely persuaded to take additional training in to have their greatest impact. Eventually, radiotherapy and the care of patients un- we would hope to see trained manpower dergoing this form of treatment. Perhaps and sophisticated equipment located also the Regional Medical Programs will soon in the smaller community hospitals and be able to support such specialized training. larger clinics, as close to the patient's Similar problems exist in the field of family as possible, but the great shortage Nuclear Medicine. Capability in this field of radiotherapists in the United States will also should be available on a regional basis make it extremely difficult to achieve this and eventually in all major hospitals. in the foreseeable future. And in this day of Now what have the Regions actually sharp competing demands for every dollar, supported to date in the field of cancer and it is extremely difficult to justify the loca- of radiation therapy in particular? As of tion of radiotherapy equipment on any mid-April, ig6g, 52 cancer projects have basis other than patient load. Finally, it is been funded in 37 operational regions, rep- recognized that a radiotherapist, like a car- resenting a level Of $3.2 M per year. This diac surgeon, requires a certain volume of constitutes about 7 per cent of the total work to keep his talents sharp and to sup- project budget for these regions. In con- port a program of clinical and basic re- trast to this figure, 8 per cent has been de- search and training. For these reasons, then, voted to the field of stroke and 28 per cent the Committee on Radiation Therapy Stud- to heart disease. ies of the National Cancer Institute has Of the 52 funded cancer projects, i2 are proposed, and the American College of concerned with radiotherapy, including ac- Radiology and the Committee on Guidelines tivities directed toward continuing educa- for Cancer Care Facilities supported by the tion of physicians as to the potential bene- Division of Regional Medical Programs fits of radiotherapy for certain types of have agreed, that no hospital should con- cancer and the indications for referral, con- sider establishing a supervoltage radiother- sultation on treatment planning, dosimetry, apy facility unless it will receive at least and the management of irradiated patients; equi 'ng radio- instruction for physicians in radiophysics 3oo new cancer patients r n therapy each year. and in nuclear medicine; and the training It is doubtful that the number of trained of radiolo@ic technicians. In three cases m radiotherapists in the country today will we have provided partial funding for a co- permit the establishment of as many radio- balt 6o unit when all other funding sources therapy facilities as the country really had been exhausted. needs, if every patient who ought to have Applications now approved but unfunded such therapy should receive it. On the other include 4 additional projects: 2 radioiso- hand, there are supervoltage units available tope training programs for physicians and/ in the country today which are not fully or technicians; a mammography training used or are not staffed by well-trained ra- program; and the augmentation of radi- diotherapists. A goal of Regional Medical ation therapy departments to serve regional Programs, therefore, is to aid in the develop- needs. Radiotherapists appear to be in- ment of radiotherapy departments on a re- creasing their participation in Regional gional basis in relation to patient need and Medical Programs, for of the iS cancer the availability of trained radiotherapists. projects in the present review cycle, no less The supply of qualified radiotherapists is than i i are in the field of radiotherapy and being increased slowly through the radio- nuclear medicine. Margaret H. Sloan JAI,,UARY, I970 You might be interested to know more apply for continued support through their about one of the three regions in which we locaf Regional Medical Programs, and we aided in the purchase of supervoltage x-ray have already funded a few which were con- equipment in order to assure the avail- sidered of high quality and essential for ability of optimum therapy within a rea- continuation. Unfortunately, Regional sonable geographic distance. Please don't Medical Programs Service is also partici- ask me to define what a "reasonable dis- pating in the current budgetary restriction, tance" would be, but I think you will agree and we cannot be very encouraging at this that if you lived in Alaska and a member time, but as soon as some easing of tile of your fam'lN -let us say, your son-de- budgetary crunch will be possible, such veloped Hodgkin's disease or some other training programs would be appropriate for form of cancer for which radiotherapy was RNIP support. indicated, it would be unreasonable to have One other area has been brought to our to send him 2,ooo miles to Seattle for a attention recently by Dr. Robert Loevenger long series of treatments. Early in the de- of the National Bureau of Standards. I velopment of the Washington-Alaska Re- know that this audience is well aware of the gional Medical Pro@ram, a supervoltage difficulties encountered in the calibration radiotherapy facility was identified as one of radiation equipment and the checking of the highest priority needs in the Alaska of the calibration equipment itself. A pro- half Of the two-state region. Application for posal has been made to the Division to de- assistance was made to the Washington- velop a network of calibration services in Alaska RMP, approved at the local level, the United States based on geographically and forwarded to Washington for review, distributed radiology centers, where calibra- which also resulted in approval. The com- tion instruments which have been checked munity responded in an amazingly coopera- against the standards at the National Bu- tive way. A fund-raising drive was initiated reau of Standards would be located. Any- among the citizens of Alaska, and funds one wishing to check his own calibration were obtained to build the building for the equipment against one of these secondary therapy department. Then the construction standards would then not have to travel p trade unions of Anchorage held a meeting very far to do so, and the chances of error and voted to contribute their labor free of would be decreased. Radiophysicists could charge to the cause, and the RMP came be based at such centers and render cali- along with the cobalt 6o unit. The whole bration and dosimetry services to the radi- facility was officially opened for business in ologists in that region, as is being done now a great celebration about a month ago. in the Washington-Alaska Regional Medi- What else could Regional Medical Pro- cal Program and in Texas through the grams do which would be of special interest M. D. Anderson Hospital and Tumor to this audience? Another area certainly Institute. could be the training of radiation technol- Perhaps the activity of greatest interest ogists to become radiotherapy technicians, to you would be the Division's response to for that seems to be a shortage category Section 907 of our legislation. This reads in the United States today. The entire area as follows: of radiotechnician training, presently Su p- "T@e Surgeon General shall establish, and ported by the Cancer Control Program, is maintain on a current basis, a list or lists of in serious jeopardy, as you are well aware, facilities in the United States equipped and and, with present budgetary restrictions, it staffed to provide the most advanced methods is doubtful that any relief will be forthcom- and techniques in the diagnosis and treatment ing in fiscal year I970- It would be per- of heart disease, cancer, or stroke, together fectly feasible for all grantees with training with such related information, including the programs for radiotherapy technicians to availability of advanced specialty training in N OL. ios, No. i IteLzional Nledical Progriiiiis ior CAticer I such facilities, as he deems useful.... To the which should be available in anv major end of making such list or lists and other medical center. When completed, these information most useful, the Surgeon General guidelines will be distributed to all hospi- shall from time to time consult with interested tals, interested professional organizations, national professional organizations." and physicians. There will be nothing com- The Surgeon General and the Division pulsory about these guidelines, and -,,et we were quick to turn to the appropriate na- believe their very existence will serve as an tional professional organizations for help in important stimulus toward improvement carrying out this requirement of the legis- in quality of services delivered. It is pos- lation. Although many people feared that sible that accreditation utilizing these a Surgeon General's list would mean the guidelines ma), be carried out eventually on imposition of Federal "standards" on lios- a voluntarn- basis bN- the American Coflege pi tals throughout the countr),, our Advisory of Surgeons or the joint Commission on Council considered that our response to Accreditation of Hospitals. Section 907 would be satisfactory, if we de- veloped Guidelines for Medical Facilities SUMMARY capable of providing the latest advances in Regional Medical Programs represent a the diagnosis and thcrap@- of Heart Dis- new channel for the improvement of medi- ease, Cancer, and Stroke. These -Uidelines cal care in the United States. Their empha- would be prepared by the most outstanding sis is on cooperative arrangements which leaders in the treatment of these diseases will provide for: we could find. The guidelines, when com- I. The optimal utilization of existing re- pleted, would be used just as the word implies, to serve as guides to the further sources of manpower and facilities; 2. the identification of gaps in informa- development of medical facilities so that tion, manpower, or facilities, which physicians would be aided in delivering the need to be filled; highest quality of medical care we know how to provide. 3- the initiation of research, demonstra- tion, and training activities with a The Division has therefore entered into major emphasis on continuing educa- three contracts with appropriate national tion of physicians, nurses, allied health professional organizations which could co- ordinate the participation of all other in- personnel, and the public; and terested professional organizations in these 4- the development of facilities and ser- three fields. In the area of cancer, we have vices on a regional basis. contracted with the American College of In all of these efforts, we seek for new and Surgeons, which, through its Cancer Com- innovative approaches, local initiative, the mission, already had a nucleus of the major greatest possible support from the health national professional and voluntary health interests of a region, and cooperative ar- organizations, specialt), groups., and Gov- rangements leading to regionalization. If ernment agencies deeply concerned over any of you have ideas which you believe the need to improve the care of cancer would contribute to these'goals, please con- patients. An expert committee was orga-, tact your own Regional Medical Program nized under the Chairmanship of Dr. War- or the Division in Bethesda. We welcome t7 ren H. Cole, and I am sure many of you your suggestions and advice. After all, these have heard something about the "Cole areyourprograms. Committee" on Guidelines for Cancer Care Facilities. Dr. Justin Stein, Dr. Milford Division of Regional Medical Programs Schulz, and Dr. Antolin Raventos have Wiscon 13uilding, Room 3i6 Public Health Service participated in drafting for that Committee gooo Rockville Pike a statement on radiotherapy requirements Bethesda, Maryland 20OI4