The mission of the NIH, an agency in the Department of Health and Human Services (DHHS), is to develop and apply fundamental knowledge about the nature and behavior of living systems to extend healthy lives and reduce the burden of illness and disability. The NIH, which began as a one-room Laboratory of Hygiene in 1887, today has over 27 institutes and centers and a 2002 budget of $23.3 billion (US). It stands as an unparalleled national (and international) resource and is the focal point for nearly all federally sponsored health research. It was within this context of improving the health of the nation, through research and application of knowledge, that the National Cancer Act was envisioned in the years between the establishment of the NCI in 1937 and the development of this unprecedented legislation in 1971.

As shown in Table 81-1, an Act of Congress in 1937 ⁶ made the conquest of cancer a national goal and set the stage for the formation of the NCI in 1939 from two existing laboratories. ⁷ The Office of Cancer Investigations at Harvard merged with a pharmacology division of NIH and the NCI was relocated to Bethesda, MD. This legislation also established the National Cancer Advisory Cancer Council, and directed the Surgeon General to “provide for, foster, and aid in coordinating research related to cancer within the NCI and among other agencies and organizations.” It would be 34 years before President Richard Nixon would sign bold legislation that would elevate the conquest of cancer to a national crusade.

Table 81-1

Legislative History of the National Cancer Program.

President Nixon signed the National Cancer Act on December 23, 1971, and declared a “war” on cancer. This unprecedented legislation ⁸ was the outgrowth of an equally unprecedented research advocacy effort led by philanthropist Mary Lasker that prompted the Senate to adopt a resolution in 1970 calling for a study of cancer in America. The subsequent report from the Yarborough Commission, headed by Texas Senator John Yarborough, provided the details for a legislative plan that would become the National Cancer Act. It is interesting that this legislation never fully defined the concept of a national cancer program, which remains a topic of individual interpretation to this day.

The major goals of the National Cancer Act were to create a national cancer program that significantly expanded the authorities and responsibilities of the NCI, while maintaining it as an institute within the NIH. The most unique aspect of the National Cancer Act was that it provided the NCI director with direct access to the president of the United States. The act specifically mandated that the NCI develop its programs with the advice of a new National Cancer Advisory Board (NCAB); and submit an annual budget, termed the “bypass budget,” directly to the president, bypassing the approval of the NIH director. In addition, the act established a threemember panel, the President's Cancer Panel (PCP), which was specifically required to submit an annual report to the President. The NCI Director and members of both the NCAB and PCP became presidential appointees. This sweeping legislation granted to the Director of the NCI broad authority to plan and develop an expanded, intensified and coordinated National Cancer Program that included the NCI and related programs, other research institutes and federal and nonfederal programs. The National Cancer Act also authorized the first 15 cancer centers and mandated cancer control programs. As shown in Table 81-1, the 1971 legislation was amended in 1974 (P.L. 93–352) to further broaden the authorities of the NCI to include award of construction grants and information collection, analysis and dissemination responsibilities.

Although the Mary Lasker-led advocacy movement of the 1970s led to the National Cancer Act, the broad scientific community voiced concerns about singling out one institute and granting it such sweeping authorities. There were also concerns that the NCI would subsume funding from other institutes and that the increased investment in cancer research would undermine the quality of research across the NIH. In fact the national focus on defeating cancer over the past 31 years has only served to attract additional funding for nearly all of the Institutes of the NIH. Moreover, the relatively small number of approved individual investigator-initiated grants funded in 2002, approximately 22%, indicates that far too many good ideas still go unfunded. Therefore, the concern expressed in the 1970s that increased support for cancer research would result in “blanket funding” of mediocre science has never emerged as a problem. In fact, the ever-increasing size, scope and complexity of the National Cancer Program serves to keep the relative level of funding for new ideas and new investigators significantly below where it was in 1971.

Legislation passed in 1978, P.L. 95-622, recodified the National Cancer Act and further consolidated and expanded the authorities of the NCI director (Table 81-1). Interestingly, the language describing the National Cancer Program dropped the phrase “including other federal and nonfederal programs.” This legislation significantly expanded the mission of cancer centers to include basic research and prevention and called for an overall expanded and intensified research program focused in cancer prevention. Perhaps the most important aspect of the changes mandated in this act was the significant emphasis on environmental carcinogenesis and prevention.

Although some additional laws were passed between 1978 and 1993 that further strengthened some aspect of the National Cancer Program, or mandated a specific emphasis area, it was not until 1993 that patient advocacy would once again have a profound effect on the National Cancer Program. In June of 1993, the NIH Revitalization Amendments ⁹ specifically required the NCI to intensify and expand research on breast and prostate cancer. Further, the legislation mandated a case control study of elevated breast cancer rates on Long Island and mandated a set-aside for cancer control activities at 7%, 9%, and 10% for 1994, 1995, and 1996, respectively. The period of “earmarking” for specific cancers had arrived.

The legislative history of the NCI and the National Cancer Program parallels the focus and effectiveness of cancer survivors and advocates over the years, beginning in 1971 with the group led by Mary Lasker. Today cancer has evolved beyond a health problem into a sociopolitical issue of enormous scope and impact. Interestingly, another concern expressed by the scientific community at the time of the enactment of the National Cancer Act was well founded—the unrealistic expectation of a quick cure for cancer. Many would argue that the lack of such a dramatic cure during the past 31 years has led to an increasing overall sense of apathy (and/or denial) among the public at large.