The Transition From the Committee on Cancer to the Commission on Cancer (1960–1965)

The five-year period from 1960 to 1965 was an epochal time in the 100-year history of the Commission on Cancer (CoC). Just prior to 1960, some critics wanted the American College of Surgeons (ACS) to abandon the Committee on Cancer.¹ However, the leadership of the Committee on Cancer chose a proactive route, reorganizing and repositioning it so dramatically that it emerged five years later as the CoC, which flourished and expanded its impact on the cancer community over the ensuing decades. This article relates the story of this pivotal transition and the leaders whose vision set the stage for this inflection point in the CoC’s history.

A strategic plan is developed

Prior to 1960, the primary function of the Committee on Cancer was conducting three-year surveys of the facilities, organization, and administration of the cancer clinics by field representatives of the Committee on Cancer, with an annual review and approval from the Accreditation Subcommittee. However, the system of accreditation did not necessarily ensure that all approved cancer services would provide the best care of the cancer patient. Moreover, not all cancer facilities were willing to be accredited, and the cost of maintaining a tumor registry was a barrier for some hospitals.

Lee Clark, Jr., MD, FACS, Chair, and members of the committee (see Table 1) proposed in 1960 that the goals of the committee be redirected, with a new emphasis on “an actual evaluation of the professional care of the individual patients and the results thereof at the community level.”² They created a bold and ambitious strategic plan, “Program for the Sixties,” with the theme of improving the care of the cancer patient at the community level. The nine-page document outlined major revisions and new criteria in four areas: accreditation procedures, education, regional program, and administration and operations (see Table 2).³

The Committee on Cancer’s Program for the Sixties reaffirmed the following basic standards for accreditation of a cancer facility:³

• Approval of the hospital by the Joint Commission on Accreditation of Hospitals
• A Cancer Committee composed of medical staff treating cancer patients
• An effectively operating cancer registry that would report survival results on an annual basis

New standards put in place

To achieve this objective, the committee redirected the primary program of the ACS by adding more robust conditions for accreditation, including the documentation of cancer-oriented medical staff, adequate facilities, an organizational plan, and an active tumor registry. A cancer registry had become requisite to accreditation in 1956, but the criteria for reporting registry results were inconsistent. In 1961, the reporting of three- and five-year survival rates became a new requirement for accreditation.⁴ This new expectation was a step forward, as it meant greater emphasis on the actual evaluation of the professional care of the patient with cancer, rather than on the administration of cancer programs. Thus, the committee effectively shifted the focus of accreditation to the treatment of the individual cancer patient and reporting end results obtained through a proper follow-up over five years.⁵

The committee then published a Manual for Cancer Programs in 1961, with a revision of the minimum standards requisite for approval of a cancer service. The new manual contained revised terminology of cancer programs (cancer hospitals, cancer clinical programs, and cancer registries) and a new standard requiring the reporting of end results, effective January 1, 1962, with a chapter on the “Preparation of End Results Reporting.” To establish an acceptable clinical cancer program, approved cancer clinics were required to appoint appropriate medical specialists to the staff of the cancer clinical activities group headed by a director, accept referral of private patients for diagnosis and recommendation, refer all nonprivate patients to the clinical activities group for management, and schedule regular clinical sessions to which medical staff and local physicians would be invited. In addition, the clinical staff was expected to actively pursue educational objectives, support their local committees on cancer, and encourage clinical research in cancer.²

The manual recommended a multidisciplinary approach to cancer management and, wherever appropriate, a cancer consultative service, complete reporting of survival rates from a well-organized registry, and educational programs. Each program facet for the Committee on Cancer was designed to improve medical management of the patient and focused on the care at the community level. A year later, the committee published A Handbook for Cancer Registry Secretaries.

The basic standards for approval of cancer programs also required accreditation by the Joint Commission on Accreditation of Hospitals (now The Joint Commission) or the local medical society for those facilities other than hospitals, a well-organized and functioning tumor registry, a local cancer committee composed of the medical staff of the cancer service, an evaluation of the survival and end results, and an annual report to the Committee on Cancer from their local tumor registry.

In addition, to establish an acceptable clinical cancer program, the clinics were required to appoint appropriate medical specialties to the staff of the clinical activities group, headed by a director, accept referral of private patients for diagnosis and recommendation, refer all nonprivate patients to the clinical activities group for management, and schedule regular clinical sessions to which the medical staff and local physicians are invited. In addition, the clinical staff should actively pursue educational objectives, support the local committees on cancer, and encourage clinical research on cancer.²

The committee realized that when the new system became operative, some of the then-approved programs might not qualify. It was planned that the new policy would be a permissive one, success depending upon the understanding and active support of the other national bodies concerned with cancer control, hospitals that conduct the cancer programs, and professional members of each local cancer service. The four full-time physician surveyors conducted new surveys of previously approved programs beginning in June 1961; within two years, a prodigious 657 surveys had been completed, and by 1963, 961 programs had been surveyed. Today, the CoC’s Accreditation Committee and its Program Review and Field Staff subcommittees survey more than 1,500 accredited cancer programs.

Expanded, multidisciplinary membership

The committee leadership also broadened its membership, especially as it related to the accreditation process. They understood the multidisciplinary need for adequate cancer care. In 1953, the committee added Liaison members from the American College of Physicians, American College of Radiology, and College of American Pathologists to serve on the Accreditation Subcommittee. In the 1960s, Liaison members were added from the U.S. Veterans Administration, National Cancer Institute, American Cancer Society, and Cancer Control Program of the U.S. Public Health Program. As the program progressed, Liaison members were added from the American Hospital Association, American Medical Association, American College of Obstetrics and Gynecology, American Academy of General Practice, and American Academy of Pediatrics.³ This strategy was integral to achieving credibility within the cancer community beyond the surgical discipline and set the stage for justifying the larger organization of a commission designation. Most of these organizations later became full members of the CoC. This was a critical and persistent feature of the commission that now comprises the Member Organization Committee of 60 organizations representing medical specialty societies, government agencies, patient advocacy and support groups, and others involved in the care of the cancer patient.

The establishment of a Regionalization Subcommittee was another important addition to the committee’s reorganization in 1961, which was essential to the expansion of the approved clinical cancer services.⁶ The committee created 12 new regional bodies throughout the nation and appointed Liaison physicians (mainly ACS members) in each of the states. The committee initiated a 10-point training program for Liaison Fellows and published a Manual for Liaison Fellows, with the goal of promoting cooperation with local organizations concerned with cancer, such as divisions of the American Cancer Society, state boards of health, and state chapters of the ACS. To enhance existing cancer services in the community, these Fellows were also to act as advisors to tumor clinic directors and registry personnel, and assist the ACS Field Surveyors. During this time, the number of Liaison Fellows reached 150.

The Committee on Cancer held its first Regionalization Program November 4–5, 1964, at the The University of Texas MD Anderson Hospital, Houston, with Liaison Fellows from 43 states, 17 members of the Committee on Cancer, and five College staff.⁷ The meeting was a success and led to continued expansion of the program, which today comprises more than 1,500 volunteer cancer liaison physicians who provide local support for the commission’s programs and activities as coordinated through the Committee on Cancer Liaison.

Educational programming

The ACS Board of Regents also directed the Committee on Cancer to be responsible for the College’s education programs relating to cancer at its annual Clinical Congress and sectional or state chapter meetings. The committee was charged with the responsibility of organizing an annual program for the Clinical Congress and for sectional/state chapter meetings, including exhibits, postgraduate courses, ciné clinics, exhibits, and the Surgical Forum (now the Scientific Forum). They also were encouraged to publish ACS Bulletin articles to describe the College’s cancer program, as well as to write editorials for surgical journals.

The first Postgraduate Course in Cancer, Basic Concepts in Chemotherapy, took place at the 1961 Clinical Congress. The College recorded its first motion picture of a Clinical Congress session—a General Session on Cancer of the Ovary. This pilot filming tested the feasibility of extending the educational impact of the Congress to physicians who were unable to attend the annual meeting. Cancer education information presented at the Clinical Congress was published in Postgraduate Medicine and selected papers from the Postgraduate Course were published in Cancer.⁸ Today, the CoC Committee on Education is responsible for the Cancer Education Program at the annual Clinical Congress, and the keynote speaker at the commission’s annual meeting, as well as educational workshops and contributions to the College’s online education center.

Establishment of the CoC

Within a few years of implementing the Program for the Sixties, the Committee on Cancer programs and activities were flourishing. The strategies described herein culminated October 3, 1964, when the Committee on Cancer Executive Committee unanimously approved a motion that stated the following precepts:^9,10

That the Committee on Cancer become the Cancer Commission, inasmuch as its functions have become so complex and far-reaching that its many subcommittees have already assumed duties of committee stature. This activity now calls for the assumption of continuing responsibility, and hence a permanent, rather than interim, structure.

Under this Commission, a Committee on Accreditation be set up to include as full members representatives of each specialty College. These representatives would propose minimum requirements for their own specialties.

In response, an ad hoc committee of the Board of Regents, chaired by William P. Longmire, Jr., MD, FACS, met on March 26, 1965, at the College headquarters. After a thorough review, the committee recommended approval to the full Board of Regents at its next meeting.¹¹

In June 1965, the Board of Regents approved the restructuring of the Committee on Cancer as a commission and giving full committee status to the subcommittees, the scope and responsibilities of which had greatly increased. There were two main programs—the Field Program, with Committees on Approvals and Regionalization, and the Scientific Program composed of the Committees on Education, Research, and Diagnosis and Treatment. The Research Committee was later changed to the Committee on Research and Patient Care.¹²

Ongoing growth

In the 55 years since the CoC was formally approved, the programs initiated by the leadership of the Committee on Cancer during that pivotal period from 1960 to 1965 have thrived. Some examples are:

• Expanded Liaison regional programs, which now number 1,600, and the addition of new Member Organizations, which now number 60
• Expanded tumor registries, leading to the National Cancer Database, and published five-year survival results
• The Subcommittee on Accreditation of Cancer Facilities, now the Accreditation Committee of the CoC, which has approved approximately 1,500 facilities
• The major revision of the Cancer Manual in 1961, which led to what is now Optimal Resources for Cancer Care
• The Survey Committee of Cancer Programs in Hospitals, which is now the Field Staff Subcommittee of the Accreditation Committee
• The Regionalization Program initiated in 1961, which is now the Cancer Liaison Committee of the American Joint Committee on Cancer
• The annual cancer programs for the ACS Clinical Congress initiated in 1961, which is now the responsibility of the Education Committee of the CoC

Over the years since 1965, CoC activities have had an impact on the practice of cancer care in all 50 states. Dr. Clark received the ACS Distinguished Service Award in October 1969 “for notable service to this College, particularly as Chairman of the Cancer Commission from 1960 to 1964. His vision outlined in the Commission’s Program for the Sixties is being realized in extending the benefits of our cancer program to every community in the land.”¹ Indeed, all leaders of the Executive Committee and College staff during that critical time in the 1960s deserve credit for setting the stage for a renewed organization, fulfilling their vision that ultimately “every cancer patient will have access to quality cancer care in an area near their home.”²

Acknowledgment

Special thanks to Meghan Kennedy, ACS Archivist; Melissa Leeb, Communications and External Relations Manager, ACS Cancer Programs; and Sandra Yates, head, McGovern Historical Center, Texas Medical Center Library, for providing documents from the R. Lee Clark, MD, FACS, papers.

References

1. Balch CM. The Surgical Legacy of Randolph Lee Clark, Jr., MD: First director and surgeon-in-chief of University of Texas MD Anderson Cancer Center II. Surgical Practice and leadership at University of Texas MD Anderson Cancer Center (1946–1978). Ann Surg Oncol. 2021;28(9):4794-4804.
2. Dr. R. Lee Clark’s lecture about the history of the Committee on Cancer when he received the American College of Surgeons Distinguished Service Award, October 5, 1969 (R. Lee Clark papers; MS 070; McGovern Historical Center, Texas Medical Center Library, Series VI, box 18, File 5).
3. Clark RL (Chair). The Committee on Cancer finalizes the cancer control program of the American College of Surgeons (known as the Program of the Sixties) in a nine-page document. Approved on October 9, 1960.
4. American College of Surgeons. Cancer Registries to Evaluate End Results. Clinical Congress News. October 14, 1960.
5. Clark RL, Mason JB. Goal of the cancer control program. Bull Am Coll Surg. 1962;47(6):361.
6. Clark RL, Williams AC. Regionalization: A program for mobilization of cancer teams. Bull Am Coll Surg. 1963;48(1):29-30.
7. American College of Surgeons. Committee on Cancer. 1965 Committee on Cancer Annual Report to the Board of Regents, Exhibit IV: First Annual Conference for Liaison Fellows Regionalization Program. November 4–5, 1964.
8. American College of Surgeons. Committee on Cancer. 1963 Annual Report of the Committee on Cancer.
9. American College of Surgeons. Committee on Cancer. Minutes Committee on Cancer, Annual Meeting, October 4, 1964, Chicago, IL.
10. American College of Surgeons. Committee on Cancer. 1964 Committee on Cancer Annual Report to the Board of Regents. March 21, 1965.
11. American College of Surgeons. Minutes of meeting of ad hoc committee appointed by the chairman of the Board of Regents to study proposals made by the Cancer Committee of the College. March 21, 1965.
12. Copeland MM, Cline JW. Commission on Cancer of the American College of Surgeons. Objectives and program. Cancer. 1967;20(4)596-600.