THE POLITICS OF CANCER

THE POLITICS OF CANCER

With over 900,000 new cases and 450,000 deaths last year in the United States alone, cancer has now reached epidemic proportions. Cancer strikes one in three people and kills one in four. It is now the only major killing disease in the industrialized world whose rate are sharply rising.

Analysis of overall cancer rates standardized for age, sex and ethnicity, has demonstrated steady increases since the 1930s, with more recent sharp annual increases in incidence rates by some 2 percent and in mortality rates by some 1 percent. Striking confirmation of these recent increases comes from estimates of the lifetime probability of getting cancer for people born at different times. For white males born between 1975 to 1985 for instance, the probability of developing cancer has risen from 30 to 36 percent and from 19 to 23 percent for dying from cancer. Such overall increases in cancer rates are also reflected in increasing rates for cancers of organs including lung, breast, colon, prostate, testis, urinary bladder, kidneys and skin, malignant melanoma and lymphatic/hematopoetietic malignancies including non-Hodgkin's lymphoma. Lung cancer is responsible for about one-third of the overall recent increase in incidence rates. Some 75 percent of all cancer deaths occur in people over 75 years, and recent increases are largely restricted to these ages.

Static cure rates
The overall cancer "cure rate," as measured by survival for over five years following diagnosis, is currently 50 percent for whites but only 38 percent for blacks. There is no evidence of substantial improvements in treatment over the last few decades, during which five-year survival and age-adjusted mortality rates for the major cancer killers--lung, breast and colon--have remained essentially unchanged. The only improvements have been for cancer of the cervix, and for relatively rare cancers, such as testicular seminomas, Hodgkin's disease and childhood leukemia treated with radiation and/or chemotherapy. Apart from immediate toxicity, such treatment, while effective, can increase the subsequent risk of developing a second cancer by up to 100 times.

Increasing Carcinogenic Exposures
Cancer is an age-old and ubiquitous group of diseases. Its recognized causes and influences are multifactorial and include natural environmental carcinogens (such as aflatoxin and sunlight), lifestyle factors, genetic susceptibility, and more recently, industrial chemicals. Apart from modern lifestyle factors, particularly smoking, increasing cancer rates reflect exposure to industrial chemicals and run-away modern technologies whose explosive growth has clearly out paced the ability of society to control them. In addition to pervasive changes in patterns of living and diet, these poorly controlled technologies have induced profound environmental degradation, resulting in the contamination of air, water, food and workplaces with toxic and carcinogenic chemicals. This has led to involuntary exposures.

With the dawn of the petrochemical era in the early 1940s, technologies such as fractional distillation of petroleum, catalytic and thermal cracking and molecular splicing became commercially established. The annual U.S. production of synthetic organic chemicals at the time was about one billion pounds. By the 1950s, this had reached 30 billion pounds annually, and by the 1980s over 400 billion pounds annually. The overwhelming majority of these industrial chemicals has never been adequately, if at all, tested for chronic toxic, carcinogenic, mutagenic and teratogenic effects, let alone for ecological effects. And much of the available industrial data is at best suspect.

Occupational exposure to industrial carcinogens has clearly emerged as a major risk factor for cancer. The National Institute for Occupational Safety and Health (NIOSH) estimates that some 10 million workers are now exposed to 11 high-volume carcinogens. Five to 10-fold increases in cancer rates have been demonstrated in some occupations. Also persuasive are British data on cancer mortality by socio-economic class, largely defined by occupation, which show that the lowest class, particularly among males, has approximately twice the cancer mortality rate of the highest class.

Living near petrochemical and certain other industries in highly urbanized communities increases cancer risks, as evidenced by clustering of excess cancer rates; high levels of toxic and carcinogenic chemicals are deliberately discharged into the air of surrounding communities by a wide range of industries. Fall- out from such toxic air pollutants is an important source of contamination of surface waters, particularly the Great Lakes. While there still are no regulatory requirements for reporting and monitoring these emissions, unpublished government estimates indicate that they are in excess of 3 billion pounds annually.

Another result of run-away technologies is the hazardous waste crisis. The disposal of hazardous waste has increased from less than one million tons of hazardous waste in 1940 to well over 300 million tons annually in the 1980s--more than one ton per person per year. The industries involved--fossil fuel, metal mining and processing, nuclear, and petrochemical--have littered the entire land mass of the United States with some 50,000 toxic waste landfills, 20,000 of which are recognized as potentially hazardous, 170,000 industrial impoundments (ponds, pits, and lagoons), 7,000 under ground injection wells, not to mention some 2.5 million underground gasoline tanks, many of which are leaking. Not surprisingly, an increasing number of rural and urban communities have found themselves located on or near hazardous waste sites, or downstream, down-gradient, or downwind from one. Particularly alarming is growing evidence of contamination of ground water from such sites, contamination which poses grave and difficult to reverse hazards for centuries to come.

Environmental contamination with highly potent carcinogenic pesticides has reached alarming and pervasive proportions. Apart from the high level exposure of workers in manufacturing, formulating and applicating industries, contamination of ground and surface waters has become commonplace. While the exact numbers are uncertain, it is probable that tens of millions of homes nationwide are contaminated with varying levels of chlordane/heptachlor, pesticides still registered by EPA for termite treatment. Yet, in extensive hearings some 15 years ago the Agency concluded that exposure to such pesticides posed an "imminent hazard" because of carcinogenic as well as chronic toxic effects and they were subsequently banned for agricultural use.

Much cancer today reflects events and exposures in the 1950s and 60s. Production, uses and disposal of synthetic organic and other industrial carcinogens were then minuscule compared to current levels, which will determine future generations' cancer rates. There is every reason to anticipate that even today's high cancer rates will be exceeded in the coming decades.

While most concern has understandably focused on increasing cancer rates, these substantially underestimate the extent and scope of the public health effects of environmental pollutants. Only a small proportion of the tens of thousands of petrochemicals in commerce, well under 500, are carcinogenic. However, many of these, together with other non-carcinogenic petrochemicals, can induce other chronic toxic effects, including neurological, reproductive and probably immunological diseases, whose true causation is generally not suspected let alone investigated.

Who's to blame
Industry
Twentieth century industry has aggressively pursued short-term economic goals, uncaring or unmindful of harm to workers, local communities and the environment. So far, industry has shifted the responsibility for such costs and harm to society-at-large. Belated government efforts to control polluting industries have generally been neutralized by well-organized and well-financed opposition. Excepting special purpose legislation for drugs, food additives and pesticides, there were no regulatory requirements for pre-testing industrial chemicals until the 1976 Toxic Substance Control Act. This legislation, which industry had stalled for years, is now honored more in the breach than in observance.

Apart from the failure to pre-test most chemicals, key in industry's anti-regulatory strategy has been the generation of self-serving and misleading data on toxicology and epidemiology, regulatory costs and cost-benefit analyses. The track record of such unreliable and often fraudulent data is so extensive and well documented as to justify the presumption that much industry data must be treated as suspect until proven otherwise.

Attempts by the Carter administration to develop comprehensive, "generic," regulation of occupational carcinogens, later reversed by the Reagan administration, were attacked by the Manufacturing Chemists Association, which created the American Industrial Health Council to organize opposition. Such reactions generally reflect reflex ideology and short-sighted preoccupation with perceived self-interest rather than with efficiency and economy. The virtual uniformity of industry opposition to regulation is in marked contrast to the heterogeneity of size and interests of the industries involved. Regulation has, in fact, generally resulted in substantial improvements in industrial efficiency and economy, particularly in large industries, by forcing development of technologies for recovery and recycling of valuable resources. A deplorable result of regulation, however, has been and continues to be the export of the restricted product or process to less developed countries.

Apart from well-documented evidence on control and manipulation of health and environmental information, industry has used various strategies to con the public into complacency and divert attention from their own recklessness and responsibility for the cancer epidemic. Key among these is the "blame-the-victim" theory of cancer causation, developed by industry scientists and consultants and a group of conservative pro-industry academics, and tacitly supported by the "cancer establishment." This theory emphasizes the faulty lifestyle-smoking, a fatty diet, sun bathing, and genetic susceptibility, as the major causes of preventable cancer. And at the same time it trivializes the role of involuntary exposures to occupational and environmental carcinogens. Another misleading diversion is their claim that there is no evidence of recently increasing cancer rates other than lung cancer, for which smoking is given the exclusive credit. While the role of lifestyle is obviously important and cannot be ignored, the scientific and exclusionary basis of this theory is as unsound as it is self-serving. Certainly, smoking is a major, but not the only, cause of lung cancer. Evidence such as the following clearly incriminates the additional role of exposure to occupational carcinogens and carcinogenic community air pollutants: some 20 percent of lung cancers occur in non-smokers; there have been major recent increases in lung cancer rates in non-smokers; an increasing percentage of lung cancer is of a histological type (adenocarcinoma) not usually associated with smoking; high lung cancer rates are found with certain occupational exposures independent of smoking; and excess lung cancer rates are found in communities where certain major industries are located. The chemical industry clearly uses tobacco as a smoke screen to divert attention from the role of carcinogenic chemicals in inducing lung cancer as well as other cancers.

When it comes to diet, the much touted role of high fat consumption, while clearly linked to heart disease, is based on tenuous and contradictory evidence with regard to breast and colon cancers. The evidence certainly does not justify the wild claims by lifestyle theorists that some 30 to 40 percent of all cancers are due to faulty diet. For instance, a 1982 National Academy of Sciences report concluded that "in the only human studies in which the total fiber consumption was quantified, no association was found between total fiber consumption and colon cancer." Similarly, a large scale 1987 study, based on the eating habits of nearly 90,000 nurses, concluded that "there is no association between dietary fat and breast cancer." Another illustration of grossly misleading strategies relates to the identification of chemical carcinogens. When a particular chemical or product is threatened with regulation on the basis of animal carcinogenicity tests the industry invariably challenges the significance of these tests, while routinely using negative test results as proof of safety. At the same time industry insists on the need for long-term prospective epidemiological investigations to obtain definitive human evidence. To test this apparent reliance on direct human evidence, researchers at Mt. Sinai Hospital in New York compiled a list of some 100 chemicals accepted as carcinogenic on the basis of animal tests, but for which no epidemiological information is available, and sent this list to 80 major chemical industries. Respondents were asked whether any of the listed carcinogens were in use and, if so, whether epidemiological studies had been conducted, whether they were being conducted, or whether they intended to conduct them in the future, and if not, why not. The responses were revealing. The great majority of those industries using particular carcinogens replied that they had done no epidemiological studies, were not doing any, and didn't intend to do any for various reasons, including alleged difficulty, impracticality, expense, or because of their belief that these chemicals could not possibly be carcinogenic to humans. A perfect catch-22. Knock the animal tests and insist on human studies, but make sure that the human studies are never done.

Industry positions are vigorously advocated by trade associations, such as the Chemical Manufacturers Association, public relations firms, such as Hill and Knowlton, and front organizations, such as the American Council on Science and Health (the contributions of whose director Elizabeth Whelan, have been aptly characterized as "voodoo science"). Disturbingly, another major source of support for anti- regulatory strategies is a stable of academic consultants who advance the industry position in arenas including the scientific literature, federal advisory committees, and regulatory and congressional hearings.

Government
Presidents play a powerful role in setting national public health priorities, not unnaturally reflecting their own political agendas. Reagan, however, is unique in having run for office on an ideological anti-regulatory platform, and in having then systematically used his office to implement this ideology, often in contravention to the spirit and letter of the law. Reagan has thus neutralized legislative mandates on controls of toxic and carcinogenic exposure by frontal assaults on regulatory agencies. Strategies employed include: staffing senior positions with unqualified, ideologically selected staff hostile to their agency mandates; budget cutting; insisting on formal cost-benefit analyses which focus on industry costs with little or biased consideration of costs of failure to regulate and which effectively stall the regulatory process; illegal, behind closed doors meetings with industry; and making regulations dependent on the Office of Management and Budget with its subservience to the White House. An informative example is the White House decision to block the $1.3 million 1984 request by the National Institute for Occupational Safety and Health (NIOSH) to notify some 200,000 workers of risks from previously undisclosed exposure to workplace carcinogens, as identified in some 60 government studies, in order to enable medical follow-up and early diagnosis of cancer. The reason for this refusal of modest funding seems to have been a desire to shield corporations from possible legal claims. Such a track record justifies the conclusions of a 1984 Congressional Study Group report that "efforts to protect public health and the environment from the dangers of toxic pollution have ground to a standstill under the Reagan administration."

The U.S. Congress has become sensitized to public health and environmental concerns, as exemplified in a plethora of legislation in recent decades. Such legislation has evolved fragmentarily, reflecting particular interests and priorities. New laws have focused on air, water, food or the workplace, or on individual classes of products or contaminants, such as pesticides or air pollutants, with little or no consideration of the need for more comprehensive and integrated approaches. Furthermore, legislative language traditionally has been ambiguous thus giving maximal regulatory discretion to bureaucracies which in some instances have then become closely associated with or even "captured" by the regulated industries. A noteworthy exception is the 1958 Delaney Amendment to the Federal Food, Drug and Cosmetic Act, with its absolute prohibition against the deliberate introduction of any level of carcinogen into the food supply. Even so, the Reagan FDA is re- defining the Delaney Amendment to allow carcinogenic food additives at levels alleged to be devoid of significant risk.

Congress has also tended to abdicate decision-making to scientific authority--or perceived authority--rather then questioning its basis in the open political arena. Of particular importance was passage of the 1971 Cancer Act in response to orchestrated pressures from the "cancer establishment," the National Cancer Institute (NCI), American Cancer Society (ACS), and the clinicians aggressively pushing chemotherapy as a primary cancer treatment. The cancer-establishment misled Congress into the unfounded and simplistic view that the cure for cancer was just around the corner, provided that Congress made available massive funding for cancer treatment research. The Act did just this, while failing to emphasize the need for cancer prevention. It also gave the NCI virtual autonomy from the parent National Institutes of Health, establishing a direct chain of command between the NCI and the White House. Some 16 years and billions of dollars later, Congress still has not recognized that the poorly informed special interests of the cancer establishment have minimized the importance of and failed to adequately support critically needed cancer prevention efforts. Nor has Congress recognized the long overdue need for oversight of the NCI. Given the heterogeneity of congressional interests, the complexity of the problem involved, the heavy industry lobbying, the indifference of the general scientific community and the well-orchestrated pressures of the cancer establishment, it is not surprising that Congress has still to realize that we are losing the war against cancer.

Until recently, state governments have largely deferred to federal authority, exercising relatively minor roles in cancer prevention. Reagan's federal de-regulatory efforts have begun to reverse this relationship. Regulatory actions against carcinogens are now emerging at the state level, such as the banning of chlordane/heptachlor and aldrin/dieldrin for termite treatment by Massachusetts and New York, the banning of daminozide (Alar) for apple ripening and tough restrictions on ethylene dibromide food tolerances by Massachusetts, and informative occupational labelling laws by various states, such as the "right to know" workplace legislation of New Jersey. Some such state initiatives have evoked federal preemption by restricting regulations, such as the 1983 Hazard Communication Standard of the Occupational Safety and Health Administration. In striking paradox to Reagan's new federalism which claims to have popular support in its efforts to get big government off the backs of the people, in February 1987, a coalition of labor and citizen organizations asked the U.S. Court of Appeals to enforce its 18 month old order directing OSHA to expand coverage of its communication standard from manufacturing to all workers. In an apparent about face, the Chemical Manufacturers Association is supporting the expansion in conformity with regulations developed for various states.

The Cancer Establishment
The cancer establishment continues to mislead the public and Congress into believing that "we are winning the war against cancer," with "victory" possible only with more time and money. The NCI and ACS also insist that there have been major advances in treatment and in cures, and that there has been no increase in cancer rates (with the exception of lung cancer which is exclusively attributed to smoking). Yet, the facts show just the contrary.

The cancer establishment periodically beats the drum to announce the latest "cancer cure" and dramatic "breakthrough." These announcements reflect optimism and wishful thinking, rather than reality. The extravagant and counterproductive claims for interferon as the magic cancer bullet of the late 70s have been followed by the unpublicized recognition of its limited role in cancer treatment. The latest NCI "breakthrough" claims for interleukin-2 as a cancer cure are grossly inflated and rest on questionable data. These claims fail to reflect the devastating toxicity and lethality of this drug, and gloss over the high treatment costs, which can run into six figures. Equally questionable are claims by the NCI and ACS that overall cancer survival rates have improved dramatically in recent years. These claims, based on "rubber numbers" according to one prominent critic, ignore factors such as "lead-time bias," earlier diagnosis of cancer resulting in apparently prolonged survival even in the absence of any treatment, and the "over diagnosis" of essentially benign tumors, particularly of the prostate, breast, and thyroid, as malignant. Revealing is the recent finger-pointing by the director of the NCI, Vincent DeVita at community physicians for using inadequate doses of chemotherapy drugs as the "real" reason why cancer cure rates are no better than they are.

The NCI misrepresentations are well reflected in budgetary priorities which are largely and disproportionately directed to cancer treatment research, to the neglect of cancer prevention. Even the very modest funding of cancer prevention is largely directed to endorsing industry's "blame-the-victim" concept of cancer causation. Thus the NCI exaggerates the role of tobacco for a wide range of cancers besides lung, and treats as fact the slim and contradictory evidence relating diet to colon, breast, and other cancers. Apparently still oblivious to mounting criticism, the NCI continues to vigorously propagate these misrepresentations. A 1986 NCI document on cancer control objectives, the executive summary of which fails to even mention environmental and occupational exposures to carcinogens and focuses on diet and tobacco as the major causes of cancer, rashly promises that annual cancer mortality rates could be reduced by 50 percent by the year 2,000.

More disturbing than indifference to cancer prevention is evidence uncovered in September 1982 by Rep. Dave Obey, D-Wisc., that the NCI has pressured the International Agency for Research on Cancer (IARC) funded in part by the NCI, to downplay the carcinogenicity of benzene and also formaldehyde in IARC monographs which review and rank the carcinogenicity data on industrial and other chemicals. Such evidence is noteworthy since, contrary to the scientific literature and its own explicit guidelines, IARC has also downgraded the carcinogenicity of other carcinogenic industrial chemicals, such as the pesticides aldrin/dieldrin and chlordane/heptachlor, and the solvents trichloroethylene and perchloroethylene.

Following nearly a decade of fruitless discussions with the ACS, at a February 1987 press conference, a national coalition of major public interest and labor groups headed by the Center for Science in the Public Interest and supported by some 24 independent scientists, charged that the ACS "is doing virtually nothing to help reduce the public exposure to cancer causing chemicals. Despite its promises to the public to do everything to 'wipe out cancer in your lifetime,' the ACS fails to make its voice heard in Congress and the regulatory arena, where it could be a powerful influence to help reduce public exposure to carcinogens." More specific criticisms included the following:

ACS fails to support, and at times has been hostile to, critical legislation that seeks to reduce or eliminate exposure to environmental and occupational carcinogens. For example, ACS refused to join a coalition of major organizations, including the March of Dimes, American Heart Association, and American Lung Association, to support the Clean Air Act. ACS has rejected requests from congressional subcommittees, unions, and environmental organizations to support their efforts to ban or regulate a wide range of occupational and environmental carcinogens. Giant corporations, which profit handsomely while they pollute the air, water and food with cancer causing chemicals, must be greatly comforted by the ACS's silence.
ACS's approach to cancer prevention largely reflects a "blame the victim" philosophy, which emphasizes faulty lifestyles, rather than workplace or environmental carcinogens. For instance, ACS blames the higher incidence of cancer among blacks primarily on their diet and smoking habits, which diverts attention from the fact that blacks work in the dirtiest, most hazardous jobs, and live in the most polluted communities.
A few days after the press conference, ACS announced a "new set of policies," passing resolutions for improved regulation of such chemicals as asbestos and benzene, and for cleanup of toxic waste sites. However, there has been no evidence of any real change of heart in the ACS since then.

The Lifestyle Academics
The lifestyle academics are a group of conservative scientists including Richard Doll, warden and director of the industry financed Green College, Oxford, his protege R. Peto, a statistician also from Oxford, and more recently Bruce Ames, a California geneticist. The puristic pretentions of the lifestylers for critical objectivity are only exceeded by their apparent indifference to or rejection of a steadily accumulating body of information on permeation of the environment and workplace with industrial carcinogens, and the impact of such involuntary exposures on human cancer. Consciously or subconsciously, these academics have become the mouthpiece for industry interests, urging regulatory inaction and public complacency. Among the more noteworthy contributions of these academics is a series of publications claiming that smoking and fatty diet are each responsible for 30-40 percent of all cancers, that sunlight, drugs and personal susceptibility account for another 10 percent, leaving only a few percent unaccounted for which, just for want of any better reason, are then ascribed to occupation. According to the lifestylers, this then proves that occupation is an unimportant cause of cancer and does not warrant much regulatory concern. Apart from circularly referencing each other as authority for these wild guesses, the lifestylers have never attempted to develop any estimates of how many workers are exposed to defined levels of specific carcinogens. Without such estimates there is no way of attempting to determine just how much cancer is due to occupation.

The lifestyle theory was further advocated in a 1981 report dealing with the causes of cancer in the United States by Doll and Peto. In the report, they denied evidence off increasing cancer rates other than for lung cancer, which was largely ascribed to tobacco without adequate consideration of the importance of carcinogenic community and occupational exposures. To reach their misleading conclusions on static cancer rates, Doll and Peto excluded from analysis people over the age of 65 and blacks, the groups where cancer mortality rates are already the highest and are increasing. They claimed that occupation was only responsible for some 4 percent of all cancers, without apparent consideration of a wide range of recent studies dealing with the carcinogenic effects of such exposures. This wild 4 percent guess was matched by "guesstimates" that diet was determinant in some 35 percent of all cancers. To trivialize the significance of animal carcinogenicity data on industrial chemicals, Doll and Peto minimized the predictive value of these tests, while emphasizing the epidemiological data as the basis of regulation.

Doll is prompt to side with industry in downplaying evidence on carcinogenicity of industrial chemicals. He recently lent enthusiastic support to the Australian Agent Orange Royal Commission in their dismissal of the experimental and epidemiological carcinogenicity data on the herbicides 2,4-D and 2,4,5-T.

Ames is a geneticist who, in the 1970s, developed bacterial assays for mutagenicity which he advocated as short-term tests for carcinogens. He then published a series of articles warning of increasing cancer rates and of the need for tough regulation of industrial carcinogens, such as the fire retardant Tris and the fumigant ethylene dibromide. By the 1980s, however, Ames did an unexplained 180 degree switch, now claiming just the opposite, that overall cancer rates are not increasing, that industrial carcinogens are unimportant causes of cancer which do not need regulating, and that the real causes of cancer are natural dietary carcinogens, largely because mutagens can be found in a variety of foods.

What To Do About It
The cancer epidemic poses a grave and growing crisis of enormous cost to health, life and economy for the nation. The Politics of Cancer (Sierra Club Books, Samuel Epstein, M.D., 1978) concluded with the following specific recommendations designed to reduce the toll of preventable cancer:

Cancer must be regarded as an essentially preventable disease.
The hidden political and economic factors which have blocked and continue to block attempts to prevent cancer must be recognized.
The ineffective past track record of government in cancer prevention must be recognized.
The critical roles in cancer prevention that public interest groups and informed labor leadership have exercised must be recognized and their further efforts fully encouraged and supported.
Congress must resolve the major inconsistencies in a wide range of legislation on environmental and occupational carcinogens.
Substantially higher federal priorities for the prevention of cancer must be developed.
Policies of the various federal agencies with responsibilities in cancer prevention must be effectively integrated and coordinated.
Top business management must recognize the essential similarities between their long-term interests and goals and those of society. Prevention of occupational cancer and cancer in the community-at-large is of primary importance to both.
The American Cancer Society must be influenced to balance its preoccupation with treatment with activist programs designed to prevent cancer.
The medical and scientific community must accept a higher degree of responsibility and involvement in the prevention of cancer by actions on both the professional and political levels.
Medical schools and schools of public health must be persuaded to massively reorient their educational and training programs from the diagnosis and treatment of disease and cancer to prevention.
Chemicals in consumer products and in the workplace must be clearly and simply identified and labelled.
Additional new approaches must be developed for obtaining and for retaining honest and scientifically reliable data on the carcinogenicity and toxicity of new chemicals already in commerce; such data must be made accessible to public scrutiny. Maximum legal penalties should be directed against all those responsible, directly and indirectly, for distortion or manipulation of toxicological and epidemiological data on the basis of which decisions on human safety and risk are based.
Apart from actions on a political level, there are limited personal options. To some extent, it may be possible to reduce the chances of developing cancer by making informed changes in lifestyle, use of consumer products and work.
The major determinants of preventable cancer are political and economic, rather than scientific, and as such must be addressed in the open political arena. Cancer prevention must be made, at least, to rank with inflation on the next local, state and national political tickets.

A decade later, these goals still stand as valid, but none have been achieved while cancer rates have steadily risen. To prevent similar conclusions a decade from now, the cancer prevention rhetoric must be translated into reality.

To compete with the well-financed propaganda of industry that is tacitly supported by the cancer establishment and lifestyle academics, an educational offensive must be mounted to inform the public and develop grassroots pressures for a cancer prevention campaign. The cutting edge for such campaigns can be provided by the major public interest organizations, including the Natural Resources Defense Council, Sierra Club, Environmental Defense Fund, Public Citizen's Health Research Group, Environmental Action, Consumer Federation of America, National Campaign Against the Misuse of Pesticides, the National Campaign Against Toxic Hazards, Greenpeace, the Rachel Carson Council, and the Center for Science in the Public Interest. Equally critical will be involvement of the Industrial Union Department, AFL/ CIO, and key unions, such as the United Steel Workers of America, United Rubber Workers, Linoleum and Plastic Workers of America, International Association of Machinists, Oil Chemical and Atomic Workers, Amalgamated Clothing and Textile Workers, and the United Auto Workers. Many of these organizations have well informed professional staff, and some have played major roles in whatever limited legislative and regulatory successes have been achieved over the last two decades.

Active support at the local level is being provided by activist citizen and labor groups that have formed in response to community or regional concerns such as hazardous waste dumps, contaminated drinking water or lawn care chemicals; the motto of such groups is "Think globally, act locally." Further support can be provided by a small network of independent and government scientists, whose thinning ranks, however, have been recently boosted by the welcome involvement of professional organizations such as the American Public Health Association and the American Lung Association.

A potential source of cancer prevention funding is the multi- million dollar budget of the American Cancer Society (ACS) raised by voluntary public contributions. An economic boycott of the ACS is now well overdue. Funding inappropriately used by the Society should be diverted to public interest organizations and labor. Other potential funding sources include certification to participate by designation in the United Way and Combined Federal Campaign.

Public interest and labor organizations should develop coalitions with initially limited objectives, focused around specific areas of cancer prevention of local concern. These could be subsequently expanded into wider rainbow coalitions with more comprehensive goals. The Congress, revitalized by the defeat of the Reagan revolution and by a democratic renaissance, is now more likely to be receptive to such initiatives. This receptiveness should be directed into increasing governmental concern for cancer prevention and restoring the fragmented regulatory apparatus. Key congressional members should be galvanized into making cancer prevention a major political priority and presidential candidates should be brought into the debate.

Equally important are initiatives at the state level, which offer encouraging precedents. These include the banning of chlordane and heptachlor for termite treatment by Massachusetts in 1985 and New York in 1986, largely at the impetus of a citizen group, People Against Chlordane (PAC), passage of a $1.5 billion hazardous waste cleanup bond by New York, the Environmental Quality Bond Act of 1986, and passage of Proposition 65, the Safe Drinking Water and Toxic Enforcement Act of 1986, by California. Proposition 65, masterminded by the Sierra Club and Environmental Defense Fund and supported by a coalition of California public interest citizen and labor groups, is a sophisticated referendum which imposes tough financial penalties on industries knowingly discharging carcinogens into drinking water supplies. The Proposition mandates full public disclosure of such discharges by industry and state officials. However, Governor Deukmejian, responsive to special interest lobbying, has recently neutralized the scope of the new legislation by restricting it to only epidemiologically confirmed carcinogens. This restriction is now under legal challenge. Irrespective of the outcome of this challenge, Proposition 65 has excited national interest and is being used as a model for similar regional initiatives.

Among early congressional priorities should be the enactment of comprehensive white collar crime legislation. This would impose tough sanctions on individual executives, managers and professionals of industries found guilty of wilful "non- disclosure" of information on hazards to workers, local communities and the nation. White collar crime legislation should also be extended to U.S. and multinational corporations which export carcinogenic products or processes which have been banned or regulated in the United States to less developed countries, especially in the absence of full disclosure of hazards to the ultimate users and consumers. Attention should also be directed to developing comprehensive new "cradle-to-the- grave" legislative approaches to the regulation of toxic and carcinogenic chemicals. Such legislation can be designed to complement regulation by the judicious application of marketplace pressures, in the form of financial incentives and disincentives designed to wean industry from unsafe practices, and to ensure that responsible industry is not penalized and subject to unfair competition. At present, other than the prospect of toxic tort litigation, there are virtually no incentives for industry to develop safer new products and processes. Legislation is needed to develop federal R&D funding to promote such benign technologies and also to ensure that they are closely coordinated with environmental, energy and resource policies.

A critical legislative priority is amendment of the National Cancer Act to give the highest possible priority to cancer prevention, to redress the historic imbalance existing in the NCI between cancer prevention and research, diagnosis, treatment and the basic sciences, and also to insulate the NCI from direct presidential influence. In addition to replacing NCI's director DeVita who, in spite of his contrary protestations, has been indifferent if not hostile to cancer prevention efforts and has played a major role in perpetrating the myth that we are winning the war against cancer, senior NCI staff should be restructured and boosted by a critical mass of professionals competent in environmental and occupational cancer and committed to cancer prevention. The National Cancer Advisory Board should be reconstituted with a balanced mix of independent cancer prevention professionals, representatives of public interest and labor organizations and concerned citizens, and should be subject to close congressional oversight. Such oversight should insure that the institutional resources are largely directed to cancer prevention, that grants and contracts reflect this priority and that NCI staff play a key role in providing the supporting scientific basis for legislative and regulatory cancer prevention efforts at the national and state levels.

Cancer is essentially a preventable disease. Given high national priority, this goal will be achieved.

Samuel S. Epstein, M.D. is professor of Occupational and Environmental Medicine at the School of Public Health, University of Illinois Medical Center, Chicago. He is author of The Politics of Cancer and co-author of Hazardous Waste in America. (C) Samuel S. Epstein.