U. S. National Cancer Institute

• Misguided policies
• Funding lucrative drug treatments
• Caving in to corporate interests

The U. S. National Cancer Institute (NCI) has claimed to be committed to preventing cancer, but its budget and policy priorities deny it. Of an approximately $4.6 billion 2003 budget, the NCI allocates less than one percent to researching occupational cancers, even though they are the most preventable cancers. Over 10 percent of adult cancer deaths result from occupational exposures, which are also a recognized cause of cancer in children: parents exposed to carcinogens on the job often expose their unborn children to the same cancer-causing chemicals. And while the NCI says that diet accounts for roughly one-third of all cancers, it spends just $1 million on education, media, and public outreach to promote the consumption of fruits and vegetables for cancer prevention, while ignoring well-documented evidence that produce contaminated with carcinogenic pesticide residues increases risk. It also fails to educate the public about the cancer risks posed by a wide range of industrial by-products and contaminants, particularly dioxin.

The cancer establishment has a long history of trivializing or ignoring prevention initiatives while claiming major gains in the war on cancer. Both the National Cancer Institute and the American Cancer Society (ACS) are fixated on damage control—screening, diagnosis, and treatment—and genetic research, and are largely indifferent to cancer prevention. For the American Cancer Society, that indifference approaches outright hostility. What the cancer establishment calls prevention is more aptly described as a "blame-the-victim" approach, emphasizing poor lifestyle habits while downplaying the role of avoidable exposures.

The cancer establishment has been most negligent in its failure to provide Congress, regulatory agencies, and the public with well-documented scientific evidence of known cancer risks. This information is essential for Congress if it is to protect the public by legislating or banning the addition of recognized carcinogens, from food additives to pesticides. Regulatory agencies need it to create standards for a wide range of industrial carcinogens and, as citizens, we have a right to know about and to protect ourselves from dangerous chemicals that contaminate our food, air, water, and consumer goods. Where was the cancer establishment last May, when the Environmental Protection Agency, entrusted with keeping the nation's water supplies safe, approved arsenic levels that pose a greater cancer risk than any other tap-water standard (on the grounds that it could not justify the high costs of regulation since most resulting cancers would be "curable")?

This aversion to prevention is complicated by conflicts of interest springing from the cancer establishment's intimate connections with corporate America. The cancer drug industry regularly trolls the National Cancer Institute for executive hires, prompting former NCI Director Samuel Broder to charge that "the NCI has become what amounts to a governmental pharmaceutical company." Meanwhile, industrial interests are well represented on the American Cancer Society's twenty-two member board, which was created in 1990 to solicit corporate contributions over $100,000. The board includes members from companies that either profit handsomely from treating cancer, like Amgen, or contribute to the disease by polluting the environment with a wide range of carcinogens, like the major pesticide manufacturer, American Cyanamid. It is no great surprise that ACS policies more often reflect the interests of these companies than those of public health.

The U. S. National Cancer Institute grossly exaggerates its alleged allocations for research and advocacy on primary prevention, while trivializing the role of industrial carcinogens as avoidable causes of cancer. NCI claimed that $350 million (17 percent) of its approximately $2 billion 1992 budget was allocated to primary prevention. However, primary prevention expenditures (based on published independent estimates, unchallenged by the NCI) were less than $50 million (2.5 percent), of which $19 million (0.9 percent) was allocated to occupational cancer (24). Only $15 million (0.03 percent) of the
$4.2 billion 2002 budget is allocated to intramural occupational research. These trivial allocations strikingly illustrate the NCI's past and current reckless neglect of primary cancer prevention.

The NCI leadership has used manipulation and semantics to mislead and confuse Congress about its claimed allocations for primary cancer prevention. The institute massively exaggerates such allocations by including unrelated" secondary prevention" screening, diagnosis, and chemoprevention by the use of dietary "nutraceuticals" or drugs such as tamoxifen in questionable efforts to reduce susceptibility to prior carcinogenic exposures. Not surprising was the
reaction by Rep. David Obey (D-WI) at hearings before a House Subcommittee of the Committee on Appropriations on March 16, 1992: "A number of scientists have suggested that cancer prevention receives an even smaller percentage of the budget than what NCI considers primary prevention." This skepticism is further
detailed in later exchanges between Rep. Obey and Dr. Klausner. Rep. Obey's questions and Dr. Klausner's responses of May 1, 1998, are summarized below, followed by my comments on Klausner's responses (13).

Question: "Provide a breakdown of NCI's cancer prevention funding by
categories— where prevention is the primary purpose of the grant."
Answer: "Funding for primary prevention in 1997 was over $480 million, almost 50 percent [of which] was directed towards environmental exposures, 19 percent was directed towards nutrition research, 14 percent involved smoking, and 2 percent was related to occupational exposures. . . . Opportunities in cancer prevention are emerging and we anticipate fully to take advantage of these opportunities." Comment: The claimed $480 million primary prevention expenditures,
approximately 20 percent of the budget, are inconsistent with the NCI's February 1997 budget for "research dollars by various cancers," listing an allocation of $249 million for "cancer prevention and control." Furthermore, no information was provided on the alleged 50 percent expenditure on "environmental exposures." The 19 percent for nutrition research was allocated to chemoprevention, in attempts to protect against avoidable exposures to environmental carcinogens, and to the "protective effects" of low-fat, high fruit and vegetable diets, while
ignoring evidence on the role of dietary contamination with carcinogenic pesticides. As disturbing was the less than 2 percent allocated to occupation, the single most important cause of avoidable carcinogenic exposures. The balance of 15 percent of the alleged $480 million primary prevention expenditures was unaccounted for. In response to a later request for information from the House Committee on Government Reform and Oversight, Klausner responded by simply
doubling this figure to approximately $1 billion.

Question: "Other than tobacco and exposure to sunlight, do you think that the general public has been adequately informed about avoidable causes of cancer?"
Answer: "The NCI and other organizations including the ACS ... have worked for years to inform the public about lifestyle choices that could increase or decrease the risks of cancer— through NCI's Cancer Information Services— and through distribution of millions of publications. In addition, when testing shows that chemicals cause cancer, NCI and other agencies including the National Toxicology Program (NTP) and the International Agency for Research on Cancer
(IARC) publicize the test results."
Comment: This response illustrates the NCI's fixation on personal responsibility for cancer prevention. The NCI still takes no responsibility for public dissemination of scientific information on avoidable risks from involuntary and unknowing exposures to a wide range of carcinogenic chemicals, including those identified and systematized by the IARC and, on a more limited basis, by the NTP. And senior NCI scientists are on record as denigrating the human
relevance of carcinogenicity test data. Furthermore, the NCI has rarely, if ever, testified before Congress on the validity of published evidence on avoidable carcinogenic exposures, nor has it provided such information to regulatory agencies.

Question: "Should the NCI develop a registry of avoidable carcinogens and make this information widely available to the public?"
Answer: "Such information is already available from NCI's Cancer Information Service— and also from IARC and the NTP."
Comment: The IARC and the NTP have not developed such registries, nor is it their mission.

Question: "During the hearing, you stated that NCI could effectively spend $5 billion by 2003. Provide a budget mechanism table that shows how you would allocate this level of spending in 2003, compared to 1998."
Answer: "NCI envisions a three-pronged approach:
1. Sustain at full measure the proved research programs that have enabled us to come this far.
2. Seize 'extraordinary opportunities' to further progress brought about by our previous successes. Our goals in these areas are: Cancer genetics; pre-clinical models of cancer; and imaging technologies, defining the signatures of cancer cells.
3. Create and sustain mechanisms that will enable us to rapidly translate our findings from the laboratory into practical applications that will benefit everyone."
Comment: This response is as broad in generalization as it is sparse in detail. The most revealing evidence of the NCI's highly restricted policies on primary prevention is detailed in its Cancer Progress Report of 2001 (9). The report compares past "progress with the cancer-related targets set forth in the Department of Health and Human Services Objectives for the first decade of the 21st century."
The report states that "behavioral factors," detailed in nineteen pages, are responsible for as much as 75 percent of all cancer deaths in the United States, while recognizing that "certain chemicals in the environment are known to cause cancer." However, these carcinogenic chemicals, summarily dealt with in three pages, are restricted to secondhand smoke; benzene in the air, particularly from
smoking and occupational exposures; and radon in the home.

An even more limited comprehension (or greater neglect) of prevention is revealed in the "Highlights" of the NCI's Cancer Facts of May 2001, which begins "Cancer prevention is a major component and current priority— to reduce suffering and death from cancer. Research in the areas of diet and nutrition, tobacco cessation, chemo-prevention, and early detection and screening are the NCI's major cancer prevention programs" (25). No mention is made of environmental and occupational carcinogens.

When President Nixon launched the war on cancer in 1971, the cancer establishment seized the opportunity to pursue its own narrow self-interest. Its policies and strategies on cancer continue to ignore the essential steps required to wage an effective battle against the disease and remain based on two myths: First, that there has been dramatic progress in the treatment and cure of cancer. Second, that any increase in cancer incidence and mortality is due to an aging population and smoking—discounting evidence that occupational exposures and urban air pollution are also implicated in many cases of lung cancer—while denying any significant role for involuntary and avoidable exposures to industrial carcinogens.

Cancer is preventable. But we'll make little headway if public officials like Al Gore and Dianne Feinstein fail to recognize the importance of prevention and the critical need for drastic, immediate reform. It is time for the cancer establishment to deploy its considerable war chest toward implementing meaningful cancer prevention strategies and eliminating the toxic output of industry. We must put lives before profits. Only then will we begin to make real progress in the war on cancer.

REFERENCES
1. Ries, L. A. G., et al. SEER Cancer Statistics Review, 1973– 1999. National Cancer Institute, Bethesda, Md., 2002.

2. Dinse, G. E., et al. Unexplained increases in cancer incidence in the United States from 1975 to 1994: Possible sentinel health indicators? Annu. Rev. Public Health 20: 173– 209, 1999.

3. Edwards, B. K., et al. Annual report to the nation on the status of cancer, 1973– 1999, featuring implications of age and aging on the U. S. cancer burden. Cancer 94( 10): 2766– 2792, 2002.

4. Davis, D., and Hoel, D. (eds.). Trends in Cancer Mortality in Industrial Countries. New York Academy of Sciences, New York, 1990.

5. National Cancer Institute and American Cancer Society. Report Card. Bethesda, Md., March 12, 1998.

6. Stolberg, S. G. New cancer cases decreasing in U. S. as deaths do, too. New York Times, March 13, 1998.

7. Bailar, J., and Gornik, H. L. Cancer undefeated. N. Engl. J. Med. 336( 22): 1569– 1574, 1997.

8. Clapp, R. W. The decline in U. S. cancer mortality from 1991 to 1995: What's behind the numbers? Int. J. Health Serv. 28( 4): 747– 755, 1998.

9. National Cancer Institute. Cancer Progress Report. Bethesda, Md., 2001.

10. Greenberg, D. Science, Money, and Politics. University of Chicago Press, Chicago, 2001.

11. Kolata, G. Test proves fruitless, fueling new debate on cancer screening. New York Times, April 9, 2002.

12. Fellers, L. Taxol is one of the best cancer drugs ever discovered by the federal government: Why is it beyond some patients' reach? Washington Post Magazine, May 31, 1998.

13. Epstein, S. S. The Politics of Cancer, Revisited. East Ridge Press, Fremont Center, N. Y., 1998.

14. Doll, R., and Peto, R. The causes of cancer: Quantitative estimates of avoidable risks of cancer in the U. S. today. J. Natl. Cancer Inst. 66: 1191– 1308, 1981.

15. Stallones, R. A., and Downs, T. A. A Critical Review of Estimates of the Fraction of Cancer in the U. S. Related to Environmental Factors. Report to the American Indus-trial Health Council. University of Texas School of Public Health, Houston, 1979.

16. Landrigan, P. Commentary: Environmental disease: A preventable epidemic. Am. J. Public Health 82( 7): 941– 943, 1992.

17. Anderson, S. J., et al. Expanding the Public's Right-to-Know: Materials Accounting Data as a Tool for Promoting Environmental Justice and Pollution Prevention. Inform, New York, 2000 (www. informinc. org).

18. Doody, M. M., et al. Breast cancer mortality after diagnostic mammography: Findings from the U. S. scoliosis cohort study. Spine 25( 16): 2052– 2063, 2000.

19. Ford, L. Letter to J. W. Stratton, Interim Director, California Environmental Protection Agency, Sacramento, June 23, 1995.

20. Greaves, P., et al. Two-year carcinogenicity study of tamoxifen in Alderley Park Wistar-derived rats. Cancer Res. 53( 17): 3919– 3924, 1993.

21. Kliewer, E. V., and Smith, K. R. Breast cancer mortality among immigrants in Australia and Canada. J. Natl. Cancer Inst. 87( 15): 1154– 1161, 1995.

22. Lichtenstein, P., et al. Environmental and heritable factors in the causation of cancer: Analyses of cohorts of twins from Sweden, Denmark, and Finland. N. Engl. J. Med. 343( 2): 78– 85, 2000.

23. Willett, W. C. Balancing life-style and genomics research for disease prevention. Science 296: 695– 698, 2002.

24. Epstein, S. S. Evaluation of the National Cancer Program and proposed reforms. Am. J. Ind. Med. 24: 109– 133, 1993.

25. National Cancer Institute. Cancer Facts. Bethesda, Md., May 25, 2001.

Excerpted from “ The High Stakes of Cancer Prevention” by Samuel Epstein and Liza Gross, Tikkun Magazine, Nov/Dec 2000 www.tikkun.org; and THE CRISIS IN U. S. AND INTERNATIONAL
CANCER POLICY by Samuel S. Epstein, Nicholas A. Ashford, Barry Castleman, Edward Goldsmith, Anthony Mazzocchi, and Quentin D. Young. International Journal of Health Services Volume 32, 4:669-707, 2002.

CONTACT:
Samuel S. Epstein, M.D., Chairman
Cancer Prevention Coalition
2121 W. Taylor St., M/C 922
Chicago, IL 60612

epstein@uic.edu