and Alaska Natives ages 18 years and older decreased to 26, 18, and 25 percent, respectively, but the smoking rate among African-American adolescents had begun to rise. Among Vietnamese males the smoking rate had decreased sharply from the 1984 to 1988 baseline of 55 percent to 35 percent in 1990. The average daily intake of vegetables, fruits, and grain products was moving toward the year 2000 target, with the daily intake of grain products exceeding the target of 6.0 servings. The proportion of primary care providers who routinely counsel patients about tobacco use cessation had exceeded the year 2000 target of 75 percent. In 1994, 56 percent of all females ages 50 years and older had received a clinical breast examination and mammogram. For African-American females the rate was 56 percent, whereas for Hispanics and low-income females the rates were 50 and 38 percent, respectively. The year 2000 target is 60 percent for all groups. In 1994, 94 percent of females reported having received a Pap smear. The proportion of Hispanic females ages 18 years and over who had ever received a Pap smear had increased from 75 percent in 1987 to 91 percent in 1994. The year 2000 target is 95 percent. Death rates from oral cancer were decreasing, but the rate among African Americans was still about twice as high as that among the general population.

More Good News

There was more good news in 1998, especially relating to the prevention and treatment of breast cancer. In April of 1998, NCI announced results of the Breast Cancer Prevention Trial, which demonstrated that tamoxifen was effective in preventing breast cancer (National Cancer Institute, 1998a). The data showed a 45 percent reduction in breast cancer incidence among the high-risk participants who took tamoxifen. In addition, herceptin was shown to be effective in targeting the abnormal gene HER-2/neu. This gene occurs in 30 percent of patients with breast cancer. As in other cases, these announcements reflect the fact that there is a substantial investment in research over many years before success is finally achieved.

The Fundamental Questions

The fundamental questions being asked by members of the public and their elected representatives can be expressed in simple terms: Is there a strategic plan for reducing the numbers of deaths from cancer, and when can measurable results be expected? Progress Report 1 did not provide satisfactory answers to these questions because the strategic plan, if it existed, appeared to place a high priority on understanding the mechanisms of



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