First published in 1977, Cancer Crusade: The Story of the National Cancer Act of 1971, is a dispassionate legislative history—a book you can trust.
To put it simply, anyone who wishes to understand the events that half a century ago created the modern cancer program should turn to this authoritative book. With permission of the author, Richard A. Rettig, Cancer Crusade can be downloaded on the Cancer History Project’s website.
Two other books published on CHP are:
- Stairway of Surprise, a previously unpublished memoir by Charles Gordon Zubrod
- Simone’s Maxims, by Joseph V. Simone
It’s hard to miss the fact that echoes of the debates that rocked the medical establishment during the buildup to a the National Cancer Act continue can be heard to this day:
- Rettig tells us about tensions between NIH and NCI, stemming from assertions of independence of the cancer program. (You can see this theme play out in the first issue of The Cancer Letter and, with clock-like regularity, thereafter.)
- Rettig recounts debates about direction of funds and relative merits of grants vs. contracts. (You will find discussion of the subject in Otis Brawley’s conversation with directors of Roswell Park Cancer Center, Memorial Sloan Kettering Cancer Center, and MD Anderson Cancer Center. The conversation is posted here.)
- Rettig tells us about strident political rhetoric comparing the “conquest of cancer” with the triumphs of American engineering—the Manhattan Project and, of course, the moonshot. (The argument about the relative roles of science and engineering now involves the Biden Administration’s proposal to create Advanced Research Projects Agency for Health, or ARPA-H.)
Rettig is not a journalist, not a biographer, not a historian. He is a political scientist writing a smart legislative history. And yet, the characters in his story are so formidable and his narrative so rich that Cancer Crusade acquires the characteristics of a work of journalism, biography, history—and, of course, political science.
“When I was a graduate student at MIT, in political science, I encountered NIH and its role in the American healthcare system. The encounter was in analysis of [NIH] in political terms,” Rettig said to us recently. He was particularly intrigued by the NIH Director James Shannon, his deputies, and their relationships to the key members of Congress, especially on appropriations.
Shannon, a gigantic presence in this book, is a physician who had done work in malaria and kidney function, who served as NIH director from 1955 to 1968, presiding over a rapid expansion of biomedical research. That period is known interchangeably as “the Shannon years” and “the Golden Age.”
The pressure on Congress to dramatically increase appropriations for NIH came largely from outside the medical establishment, from a group of wealthy socialites who were galvanized into action by the philanthropist Mary Lasker. The group also included the cancer pioneer Sidney Farber and the heart surgeon Michael DeBakey.
Mary was the widow of Albert Lasker, the founder of modern American public relations and creator of a variety of national brands of consumer products, including—problematically—Lucky Strike cigarettes.
Lasker et al. sought to inspire the academic establishment to set its sights higher, to go for the cures.
“I am opposed to heart attacks and cancer and strokes the way I am opposed to sin,” Lasker has famously said. A masterful manipulator with a special talent for arranging mirrors to create desired illusions, Lasker had access to Democratic presidents and legislators, including, notably, the Kennedys. Thanks to YouTube, you can hear her conversation with Lyndon and Lady Bird Johnson.
The Laskerites felt the cure for cancer could be easily accomplished if there was money to fuel research. Research required money.
In the 1950s what cancer research that existed was funded by philanthropy and clinical revenues. The idea of government funding medical research was rare, and government-funded medical research was often done through government contracts and governed by the same rules and regulations that the government used to buy bombers and warships.
Someone in government specified what was needed and negotiated getting it done. The idea of an investigator-initiated grant, a scientist in a university having an idea for research and getting it funded was not widely used and not accepted in many parts of the NIH. The National Cancer Act would change that.
It has been said, albeit with scant documentation, that the Lasker’s American Cancer Society funded more research grants than the government in the 1950’s. Lasker used the talents learned from her husband, Albert, to build a field army of advocates in communities across the U.S. Theirs was a movement to get the government into funding cancer research. The feeling was that the government had deep pockets and only the government could launch a sustained research effort.
Rettig became interested in the Shannon-Lasker concerto while he was still at MIT, he said.
“The hook got set early, independent of cancer, and early recognition of the role of Mary Lasker and her allies. Those were the antecedents to this,” Rettig said. With the buildup to the National Cancer Act, “cancer became the dominant motivating enemy to be vanquished,” Rettig said. The memory of this landmark law was still fresh, and the story was Rettig’s to tell.
About half of Cancer Crusade chronicles the legislative history of the National Cancer Act and the interplay between two archenemies—Kennedy and Richard M. Nixon. Rettig doesn’t gauge whether there was indeed a groundswell of grassroots support that led politicians to be interested in a cancer effort. Anecdotally, we know that in the hustings, comparisons were heard of how much money was spent on cancer, compared to other government programs.
Kennedy’s career had suffered a catastrophic setback in July 1969, when a car he was driving went off a bridge on Chappaquiddick Island, killing Mary Jo Kopoechne, a young woman who had been working on Robert Kennedy’s campaign. Ted Kennedy won reelection to his Senate seat, but lost his position as the Majority Whip.
Kennedy needed an issue that could propel him to presidency in 1972. There was, clearly, an opportunity.
Initially, the Laskerites had been relying on Sen. Ralph Yarborough to develop their cancer bill. Yarborough had convened a “panel of consultants,” which issued a report calling for bold action on cancer.
Alas, Yarborough lost his Senate seat, and under normal circumstances, the effort to develop a bill would have been stalled at the end of 1970. For Kennedy, this was an opportunity to jump in and lead.
“Nixon got deeply involved because of Kennedy,” Rettig said to us, recapping his book’s key argument. “He didn’t want yet another Kennedy to mar his political career. Nixon feared Kennedy, from his experience with late Jack Kennedy, and was not about to let another Kennedy influence and wreck his own political career. And so, that was a very important precipitating factor in the president’s involvement in this.”
The Kennedy bill, optimistically called the Conquest of Cancer Act, proposed giving the cancer program unprecedented autonomy, including pulling NCI out of NIH.
Shannon, by then a former NIH director, was strongly opposed to this idea. The Laskerites have gone too far, Shannon wrote at the time:
The creation of an independent Cancer Authority, removing the NCI from the ambit of the NIH, would, in my opinion, not accomplish anything that could not be done within present NIH processes, or trivial and easily realized modifications thereof. On the other hand, it would unleash forces of a divisive character which would quickly destroy the integrity of the NIH. I predict that in a very short time, orderly governance would be replaced by anarchy, and that instead of a judiciously balanced program of biomedical research, program emphasis would be entirely determined by uncritical zealots, by experts in advertising and public relations, and by rapacious “empire builders.” These latter forces are not to be disdained and they have played an invaluable role in the past quarter century in making the lay public aware that, through research, there was a real possibility of realizing inchoate public hopes and aspirations to control disease. As forces modulating the scientific judgment process, their contributions have been positive and important. As determinants, however, I would expect them to create chaos.
Ultimately, through compromise, the National Cancer Act was softened, leaving NCI within NIH, but giving it unique authorities that include the Bypass Budget and presidential appointment of NCI directors. (No other NIH institute or center is run by a presidential appointee). Unique authorities also include the President’s Cancer Panel, which is designed to have direct access to the president.
At the signing of the NCA, on Dec. 23, 1971, a sense of optimism could be felt in the room. Some congressmen seriously discussed cancer being cured by America’s bicentennial—by July 4, 1976.Indeed, if the U.S. could build an atomic bomb, if the U.S. could put a man on the moon, the U.S. could cure cancer.
The NCA, as signed by President Nixon, created a “National Cancer Program” led by the presidentially appointed director of the National Cancer Institute. The act also created:
- The National Cancer Advisory Board. The NCAB members are appointed to four year terms by the president. The board does secondary review of grants to be funded by the National Cancer Institute. To this day, representatives of other government agencies involved in cancer have non-voting seats on the NCAB examples include the FDA, CDC, Veterans Administration, Environmental Protection Agency.
- The concept of NCI-designated cancer centers. Previously, there were self-designated cancer centers, some were recognized by NCI but there was no “NCI designation.” The Association of American Cancer Institutes, started in 1959, was a major supporter of the movement for a National Program.
- A formal NCI drug development program.
- A mandate for a cancer control program. This was manifest through:
- A directive for the NCI to provide cancer information and education. This led to the Cancer Information Service, and is seen today in such things as Physician Data Querry and PDQ.
- A requirement for maintenance of population data. This led to the Surveillance Epidemiology and End Results Program.
- Creation of the Division of Cancer Prevention and Control.
The act reemphasized and expanded support for the clinical trials groups, which were, for the most part, formed in the 1950s and early 1960s.
At its core, the law provided increased support for cancer research around the country and made the NCI Director pivotal to the country’s cancer effort. In terms of appropriations, the law was a huge success.
At the time of the signing of the NCA, the NCI budget was just $149 million. By 1979, it had grown to $940 million.
The growth can be seen below:
- 1971: $149 million
- 1979: $940 million
- 1992: $1.8 billion
- 1998: $2.6 billion
- 2002: $4.2 billion
- 2010: $5.1 billion
- 2015: $4.95 billion
- 2017: $5.64 billion
- 2021: $6.56 billion
The growth resulted in dramatic increases in the grant funding, primarily to universities, in the extramural community. Today, 73% of the NCI budget is for grants. The request for application (RFA) is a grant mechanism that allows ACS to request investigator-initiated proposals in areas the Institute sees a need. It is currently 18% of the NCI budget.
Whether they realized it or not, the politicians and advocates who clashed over the legislative sausage-making Rettig describes in Cancer Crusade had, in fact, built the launching pad for the National Cancer Program’s ultimate takeoff.
Cancer Crusade is available on the Cancer History Project as a free download, as a PDF or e-book. A print version is available here.
