Fifty years after Richard Nixon launched the “war on cancer,” President Biden is undertaking his own effort to “end cancer as we know it.” Reflecting on the centerpiece of Nixon’s effort — the National Cancer Act of 1971 — is key to maximizing the potential of Biden’s push. This act was undoubtedly transformational: it dramatically increased funding for research, created a network of cancer centers and expanded the authority of the National Cancer Institute (NCI) over all aspects of national cancer planning.
Yet, as critical as it was in charting the path for the extraordinary scientific progress that followed, the act was both unrealistically ambitious and not ambitious enough. Its aim was to eradicate a disease about which relatively little was known, an effort that was, in the words of Sol Spiegelman, then-director of Columbia University’s Institute of Cancer Research, like “trying to land a man on the moon without knowing Newton’s laws of gravity.” At the same time, the act’s laserlike focus on the science left other elements of the fight — including equitable access to care, coherent reimbursement systems and public health strategies — largely ignored.
In the half century since the act’s passage, cancer care in the United States has undergone profound change. Mortality rates declined 32 percent between 1991 and 2019 (the last year of complete data), and new therapeutic advances, focused on individualized cancer treatments, have transformed something once thought to be a death sentence into a disease that can often be cured or managed in the long term. At the same time, inequitable access and soaring prices keep effective care out of reach for many. Public health interventions remain chronically underfunded, despite their well-established effectiveness. And the complex network of research entities that drive innovation are often unproductively siloed.
The Biden administration is now looking ahead. But to optimize the path forward, we need to understand the history of the 1971 effort, as well as the broader vision it declined to embrace.
“Mr. Nixon: You can cure cancer.” So began a full-page advertisement that ran in The Washington Post on Dec. 9, 1969. Appearing mere months after the moon landing, the ad quoted groundbreaking cancer researcher Sidney Farber to tell readers that the cure for cancer was within reach: “We lack only the will and the kind of money and comprehensive planning that went into putting a man on the moon.”
It was a bold statement at a time when cancer was the nation’s No. 2 leading cause of death. Cancer survival rates beyond five years were relatively low, and there remained a strong stigma around even publicly discussing the illness. But the 1969 ad heralded a legislative campaign to combat this crisis, and it culminated in the National Cancer Act.
The act proved to be a bicameral compromise. Driven by a lobbying campaign marshaled by patient advocate Mary Lasker, the Senate overwhelmingly passed the first iteration of a bill written by Sens. Ted Kennedy (D-Mass.) and Jacob Javits (R-N.Y.) on July 7, 1971. That bill would have created an independent National Cancer Authority — a new government agency that advocates framed as NASA for cancer.
This original vision, however, found few allies in the House of Representatives. Experts argued against creating a separate agency, stressing the potential for wasteful spending and the risk of creating a silo around cancer as well as undermining the National Institutes of Health (NIH). Others pointed out that even this aggressive proposal included scant support for preventive approaches. Cancer’s NASA lacked any ambitious vision of public health.
Rep. Paul Rogers (D-Fla.) broke the impasse and crafted a compromise. Instead of an independent agency, the NCI would remain in the NIH. Meanwhile, funding for cancer research would increase by $1.5 billion over three years and the NCI director would report directly to the president. The compromise bill established 15 NCI-designated cancer centers (today, there are 71) to be major hubs of research, training and treatment. The bill also set up an international cancer research databank and created the Surveillance, Epidemiology, and End Results (SEER) program at NCI, which has proven essential to understanding cancer incidence and outcomes across populations.
At the signing ceremony on Dec. 23, 1971, Nixon told the assembled guests that those with cancer would know “that everything that can be done by government, everything that can be done by voluntary agencies in this great, powerful, rich country, now will be done.”
But much was left on the sidelines. For one thing, the act made no explicit reference to cancer disparities. In May 1972, less than six months after the measure became law, scientists at Howard University reported that cancer mortality rates for Black Americans had grown by 32 percent since 1954 compared with 3 percent among White people, proving that race would be a critical issue in cancer research.
Public health, long a stepchild of major health initiatives, was also largely ignored despite widely known evidence about its connection to cancer. The link between smoking and lung cancer, for example, was definitively laid out by Surgeon General Luther Terry in 1964. By the late 1960s and early 1970s, similar public-health-minded efforts targeted carcinogens in the environment and reconsidered risk factors such as poor nutrition. But only a minor section of the act was dedicated to “cancer control programs.” In 1975, NCI proposed dedicating just 7.4 percent of its funding to cancer control efforts.
To some extent, this narrow approach was understandable in 1971. After all, the modern health-care landscape was only in its infancy — Medicare and Medicaid were six years old, and the Clean Air Act just a year old. Yet, these omissions also stemmed from the National Cancer Act’s view of science alone as the answer. Over the long term, this lack of a broader vision of the context in which cancer exists has hampered efforts to end the disease.
And a successful vision today needs to be broader still because new issues that lawmakers and advocates in 1971 did not foresee have become increasingly salient over time, including private sector engagement, pricing and survivorship.
In the 1970s and 1980s, roughly 60 percent of pharmaceutical development was funded by the U.S. government. The role of the private sector has subsequently grown far more than anyone could have expected. Today, private industry funds a significant percentage of new research and a whopping 90 percent of clinical trials. And public-private partnerships, with government incentivizing research, offer great promise for future breakthroughs — as they did in the case of coronavirus vaccines.
Questions about pricing and payment mechanisms also weren’t central policy questions in 1971. But even today, when pricing is a dominant health-policy issue, little attention is paid to rationalizing cancer reimbursement; the business of cancer care has long relied heavily on the bloated prices of some treatments — such as chemotherapy — to subsidize inadequate funding for other essential work at the same institutions, such as research and development.
And Black Americans still suffer from the highest cancer death rates of any racial or ethnic group — disparities that could largely be addressed by ensuring equitable access to screening, treatment and health insurance.
A broader focus on public health and prevention would help ensure this equitable access. One third of all cancer cases are preventable. Yet, public health funding continues to languish: The entire Centers for Disease Control and Prevention budget was only $7.9 billion for 2020 — for everything from pandemic preparedness to cancer — whereas the NCI budget, which just focuses on cancer, was $6.3 billion. And while the 2010 Patient Protection and Affordable Care Act (ACA) significantly expanded access to health care, a dozen states still refuse to expand Medicaid under the ACA, leaving millions of Americans uncovered even as lack of insurance is a predictor of poor cancer outcomes.
Finally, survivorship has emerged as a key issue thanks to the scientific advances of the past 50 years. There were just 3 million cancer survivors in 1970, with a five-year survival rate of 49 percent. By 2030, it is estimated that there will be approximately 22 million survivors with a five-year survival rate exceeding 70 percent. Strengthening the types of support cancer survivors need — including access to care and insurance — is essential.
For all the new challenges, two principles remain as relevant as they were half a century ago. First, we would not have the luxury of engaging these broader questions without the groundbreaking science the National Cancer Act supported. Second, covid has amply demonstrated what Biden calls the value of a “whole-of-government” response — one that harnesses the power of government to advance science and collaboration, while also tackling the broader structural context in which disease exists. For cancer, this means continuing to accelerate scientific progress while addressing equity, prevention, access and affordability for all kinds of patients who will confront this disease in their lives.