Istanbul, Turkey - July 2004
AN INTERVIEW WITH
PHILIP A. SALEM, M.D.
Director, Cancer Research Program
St. Luke's Episcopal Hospital
Clinical Professor of Medicine
University of Texas, Houston
What are the latest developments, the latest research as far as cancer is concerned, and what are the latest treatment methods?
While progress is steadily being made, it is certainly not fast enough. I wish we could have a drug tomorrow that would cure all cancers. However, I do not believe this will happen in the foreseeable future. Progress so far has been gradual, but is definitely going in the right direction. It is important to emphasize that right now, we are able to cure 40%-50% of all cancer patients if these patients are given the proper treatment. The tragedy is that more than 90% of cancer patients all over the world do not receive appropriate treatment, and this is why the results of the treatment of cancer have not been very impressive. The key to the proper treatment of cancer is to provide patients with access to cancer experts who work in institutions or programs where group consultations and teamwork are feasible. Cancer cannot be treated by one single doctor; it needs a team of doctors who work together as one single entity, in harmony, to provide the best care. Also, you need the supportive measures. This means that you have to have a very high-level pathology service to provide the right diagnosis. You also need to have a very sophisticated diagnostic radiology facility where patients can undergo the most modern imaging technology. This simply means that it is not enough to have a great doctor; you have to have a great system, a great network of cancer experts and network of supportive systems for diagnosis and treatment. This scientific climate is available only in a few centers in the world.
How close is the link between cancer and infection, and which infections can cause cancer? Which types of cancer are caused by infections?
By now, there is little doubt that some chronic infections may cause cancer. H.Pylori in the stomach is associated with higher incidence of stomach cancer, including lymphomas and adenocarcinoma. There is little doubt that schistosomiasis infection in the bladder causes bladder cancer. This is why bladder cancer is the most common cancer in Egypt. Also, there is a strong suspicion that Hepatitis (infection of the liver) would eventually cause cancer of the liver.
What about cancer vaccines. When will the first cancer vaccine be on the market according to you? Can you give a date, like in 10-20 years?
I cannot give a specific date, but vaccine therapy remains in the experimental phase. At this point in time, there is no vaccine which is used in the actual treatment for cancer. There are different experimental protocols evaluating vaccines, but at this point in time, they do not have vaccines available for the treatment of cancer. I would expect that vaccines would be more important in the prevention of cancer rather than its treatment.
Gene therapy and stem cell transplantation seem to be very promising. Do you think that treating cancer will be much more easier in the future, when these methods are developed?
I have no doubt that treating cancer in the future will be much easier and the results will continue to improve. Stem cell transplantation has a very promising role in the treatment of cancer, so does gene therapy. At this point in time, bone marrow transplantation has been shown to be very effective in the treatment of leukemias and some lymphomas. Gene therapy, however, remains in the experimental phase.
Why is there an increase in cancer cases? What are the major reasons for cancer?
The most important cause for cancer is tobacco smoking. Smoking kills four million people every year all over the world. There is no war in the history of man that has killed as many people. There are of course, many other reasons like exposure to asbestos, extensive exposure to sunlight and exposure to radiation.
How do you see the future as far as cancer is concerned?
I believe the future is very promising, but progress in cancer will continue to be step-wise. The speed of progress is going to be log rhythmic, and research is going extremely fast. Within ten years, I am almost certain that most cancer diseases will be treatable and many of them will be like any other chronic illness like diabetes and hypertension.
What are the most important factors that determine the cure of a patient?
Cure depends on three major factors:
- The nature of the cancer
- How advanced is the cancer in the body
- Whether the treatment of the cancer was appropriate or not
In your opinion, what is the cornerstone of excellence in cancer care?
The basic cornerstone is scientific knowledge. Without updated state of the art scientific knowledge, you cannot build a treatment program. However, because of the recent explosion in scientific knowledge relating to the treatment of cancer, it has become of utmost importance that doctors who treat cancer seek group consultations because there is not one single expert in cancer who knows everything about the disease. Therefore, treatment has to be designed by a group of cancer experts rather than by one single expert. Although I graduated from the two most prestigious cancer centers in America (Sloan-Kettering Cancer Center and M.D. Anderson Cancer Center), and I was on the faculty of M.D. Anderson as a professor of cancer treatment and research until 1991, and I have been in academic medicine and research for 36 years, I still feel that I cannot make the final treatment plan on a patient without a group consultation. Group consultation provides the cornerstone for guaranteeing the fact that the patient is receiving state of the art treatment.
In spite of this progress in cancer research and cancer treatment, I have heard you say many times that cancer medicine in America is in a crisis. Why is that?
I have told you that scientific knowledge is the cornerstone of treatment in cancer and in any disease. However, scientific knowledge, though necessary by itself is not sufficient. In cancer, the patient needs far more than scientific knowledge concerning the treatment of the disease. I believe that when we treat cancer, we need to remember that we are not treating the disease in vacuum; we are treating a human being who has the disease. These two philosophies are very different and demand different strategies. I believe in the latter. However, the latter demands a lot of time, a lot of care, and a lot of giving from oneself. In addition to scientific knowledge, what the cancer patients mostly need is love and care. They need to be treated by a doctor and medical staff who love them and come to know them very well as an individual, and who want to give them the best care in the world. It is not enough to give the scientific knowledge; because without love and care, the patient will not receive the absolute appropriate care.
People at large do not appreciate the big difference between giving a good treatment and good care. Good care means far more than giving good treatment. It means that you attend to the patient as a person; you attend to his fears, his concerns, to his images of death, dying and pain. You attend to the most divine and sacred essence of the person. This is why I have always believed that the relationship between the cancer doctor and his patient should almost be divine. There is no relationship among human beings which is more divine than the relationship between two persons, one threatened by death and the doctor struggling to salvage him from death. Love is a very important component of the patient's care.
Is there anything else that good care entails?
Of course, a lot of other things:
- The patient needs to be monitored almost daily. These patients are fragile and they need to be examined and seen almost daily, to make sure they do not develop fatal complications like bleeding and/or a very low blood count that predisposes them to infection and possible death. Also, chemotherapy may produce major side effects. If these side effects are not addressed in a preventive and prophylactic manner on a daily basis, major health problems and complications may occur You simply cannot put a patient on chemotherapy and ask him/her to come and see you once a week. Good care demands more than that.
- Good care also demands continuity of care. Therefore, patients need to be seen on Saturdays, Sundays and holidays. Disease does not take a vacation and you cannot be in charge of patients if you do not provide them with daily care. At Salem Oncology Centre, we are open every day and we have staff that is on-call 24 hours a day, 7 days a week, 52 weeks a year. Any discontinuation of care could be disastrous. Diseases do not take weekends off and do not celebrate holidays.
- Also, one of the important issues in cancer care is that the patient receives therapy at the hands of the same doctors, nurses, and the paramedical staff every day. Cancer patients cannot afford to have different doctors every few weeks because this will certainly cause a lot of turbulence in the continuity and quality of care. It is also important that the patient receives therapy at the hands of the same nurses and staff, so if any complication occurs at night and he calls, the voice that he hears on the other side of the phone is a familiar voice who knows the patient extremely well and can immediately diagnose the problem and recommend the exact and precise treatment for it.
- The emergency outreach program. One of the major issues in cancer therapy is the fact that if the patient develops a major problem at 2:00 o'clock in the morning and somehow could not come to the emergency room at the hospital, there are very few programs which are available in America and the rest of the world where the facility would send a nurse or a doctor to the hotel or apartment where the patient is staying. I am proud to say that at our facility, should the patient call at 2:00 o'clock in the morning and there is an emergency problem, one of my staff will immediately be dispatched to where the patient is staying and will deliver the treatment at that specific location. I know of several patients who died because they were too sick to come to the emergency room at night, and the hospital had no outreach program to dispatch medical professionals to see them at their hotels or apartments.
All the above emphasize the importance of having a dedicated team of medical professionals who take care of the patient daily, without interruption and the delivery of care 24 hours a day. This component of therapy is of utmost importance. I know of patients who receive the best treatment in the world, but who eventually died because the care component of therapy was not good enough. Therefore, I reemphasize again that excellent care is far more than excellent treatment. This is where, in my opinion, in big academic American institutions, these institutions may fail to provide what I consider the best care because they do not have enough medical and health professionals to attend to the overall needs of the cancer patients.
Why, in your opinion, this kind of care not delivered?
The answer is simply because this kind of care is very time-consuming and demands a lot of medical staff, and both of these issues are very expensive.
One of the challenges to American medicine is to allocate adequate time for patients. This is a problem because insurance reimbursement policies do not consider time in their equation. In a consultation, whether you see a patient for 5 minutes or 5 hours makes little difference. Therefore, with the reimbursement climate in America, doctors are forced to see a large number of patients to make ends meet. This leaves very little time for the doctor to allocate to every single patient. Also, because of cost containment strategies in America, physicians, hospitals and medical facilities are trying to cut down on costs, and this eventually leads to inadequate staff to attend to all the needs of the patient.
An additional important factor is that doctors in America are not trained in attending to the psychological and emotional issues associated with disease. It has not been clearly understood yet, that treating a human being takes far more than treating the disease that he has. The doctor has to be very sophisticated in the art of communication with the patient and should allocate a lot of time to lift the patient's spirits and educate him about his disease. We always have to tell the patient and family the truth, but there is delicate balance between telling the truth and maintaining good morals and spirits in the patient. In my opinion, at no point in time should the patient be stripped of hope. I believe there is always hope. I have treated many patients where I felt that the cure rate was zero percent and I have seen these patients ten years later. We should never forget that when we talk about the future, we are building our arguments and assertions on research done in the past, and sometimes we forget that new drugs may emerge as the patient lives on. I can easily say that in my lifetime, I have seen more than 100 patients where, when I started therapy, the chance for cure was zero and eventually new drugs emerged and the patient was lucky to live long enough to receive these agents and achieve cure. This is why I emphasize that the patient should never be stripped of hope.
Dr. Salem, I know you are of Lebanese origin. How do you feel being of Lebanese origin and being a very important doctor in America? You are in the last three editions of the America's Top Doctors.
I believe being of Lebanese origin has been a great advantage for me. Being from the Mediterranean world, I brought with me several weapons that I used daily. I brought with me the human warmth, the compassion, the ability to embrace the patient as a family member and the ability to give him of myself and of my time. Although I believe these traits are present all over the world, they are of special importance in the Mediterranean culture where I come from. Also, being of Mediterranean origin, I understand the world outside America much better. I know Europe extremely well and I understand the European mind. Also, I understand the Latin mind. Coming from the Mediterranean world has been a great advantage in practicing medicine in America because when you practice medicine, you have also to understand the culture of the patient you are treating. Dealing with the sick takes far more than science and knowledge. You have to understand his mind, his philosophy, his mythology, and his culture.
Also, as you well know, diseases and patterns of diseases change from one geographical area to the other. Being, of course, from the Mediterranean world, I understand more Mediterranean diseases. Take, for example, one cancer like lymphoma. This cancer has a very different pattern in the Mediterranean than the pattern in America. I devoted a good part of my life to researching a specific kind of lymphoma that afflicts the small intestine and exists only in the Middle East and the Mediterranean shores. Also, for example, lymphoma in bone is common in the Mediterranean world, but is extremely uncommon in the West. So being of Mediterranean origin is a great advantage for me to treat, here in America, people who come from the Mediterranean countries.
Dr. Salem, can you single out one achievement you have made at Salem Oncology Centre?
Probably, the most single achievement I have made here at Salem Oncology Centre is the fact that we have succeeded (my staff and I), in providing a facility which is the closest possible to home for the patient. Patients love to come to our facility daily because they love the nurses who take care of them and they feel very much at home here. Above all, they feel they are loved and cared for. We not only care for their medical needs, but we also care for other needs, including the family's needs. Patients from all over the world, Christians, Muslims, Jews, Buddhists, and Atheists come to this facility and get bonded by love. I am a great believer in the universality of man because I have seen patients who come from Argentina who are not any different, in essence, from those who come from Turkey and those who come from Turkey are not different from those who come from Mexico. All humans want to be loved, want to feel secure and they do not want to die.
On the first Sunday of every June, people around the world pause to honor all those who are living with cancer, and acknowledge the contributions of families, friends, health care providers, and scientist who support cancer victims and survivors in their fight for life.
To celebrate those who have survived and to inspire those who have recently been diagnosed with cancer, NOW talks to Dr. Philip Salem, one of the world’s leading cancer specialists who is of Lebanese origin and whose latest work and research have contributed to best practices for both treating and preventing cancer.
On National Cancer Survivor Day, Salem encourages survivors to be more proactive in the battle against cancer and assures that the strides researchers are making toward developing a cure for the disease is no myth. He shares new findings of how cancer can be prevented and how a national health policy in Lebanon could prevent up to 80 percent of cancer cases.
Salem has also spoken openly on Lebanese public life and politics. He describes himself as a great believer in Lebanon’s future but would like to see the country remain neutral in the conflicts of the Middle East. With its 18 different sects, Lebanon should strive to become an oasis of cultural pluralism and freedom.
Two books have recently been published on Salem: Philip Salem: The Rebel, The Scientist, and the Humanist (Dar al-Nahar/Saqi Books), and Cancer, Love, and the Politics of Hope: The life and Vision of Philip A. Salem, published by Quartet Books Limited and co-authored by Boutros Indari and Frances Mourani.
NOW: What is your message to Lebanese cancer survivors on National Cancer Survivors’ Day?
Dr. Philip Salem: First, I’d like to congratulate them for surviving cancer which is a major achievement, and second I’d like to advise them not to sit idle in the fight against cancer. Cancer survivors should be on the frontlines of the battle; they need to contribute by talking about their experience and by also volunteering to help other cancer patients. Most of those cured from cancer in the Middle East are very silent. This is why there’s an impression that cancer is inevitably a deadly disease. They can make a difference and this is why this is a responsibility that they should not shy away from.
NOW: Many argue that the cure for cancer is a myth, are you saying otherwise?
Salem: The cure for cancer is a reality. Today we can cure up to 60 percent of all cancer patients. The reason people don’t believe this figure is because those who have been cured, as I said before, do not speak out. I will tell you another shocking fact: Right now if we put the knowledge that has been generated from cancer research in the service of the people via a good national health policy we can eradicate the bulk of cancer diseases. I am talking at least 75 to 80 percent. But these policies are not only not available in Lebanon, they are also unavailable in many of the so-called developed countries. It is a fact that many of the cancer diseases are preventable but we actually do very little to prevent them.
NOW: So, can cancer be prevented? And if so, what needs to be done to avoid it?
Salem: Absolutely! So, yes, cancer is a preventable disease to a large extent. The first example is cervical (uterine) cancer, a common type of cancer among women. We have a vaccine by which if girls between the age of 13 and 30 are vaccinated, we can eradicate up to 75 percent of cervical cancer. If we prevent tobacco smoking, we can eradicate up to 80 percent of all lung cancer. Today, a bilateral mastectomy as the one Angelina Jolie recently [underwent], up to 90 percent of women carrying genetic predispositions can avoid breast cancer.
Many cancers are preventable especially those which are the product of chronic infection, so once the infection is cured, the cancer is avoided. Cervical cancer is one of those. The vaccine prevents the infection and consequently the cancer. The H-pylori infection in the stomach can produce cancer, and so if we treat the infection we can avoid the cancer. Same goes for liver cancer.
NOW: What are the most important factors that guarantee the cure of a patient?
Salem: This is an extremely important point. The factors are the following:
To make the right diagnosis. Shockingly more than 30 to 40 percent of initial diagnoses are wrong. To be able to cure the patient you have to pinpoint the exact nature of the cancer. This is the biggest problem cancer [patients] face because unfortunately the pathology laboratories – the venue where the diagnosis takes place – are not equipped with the most sophisticated technologies and with the experts to make the correct diagnosis.
The quality of treatment. In the developing nations we do not have any surveillance system to determine the quality of treatment. In the treatment of cancer we need a team of doctors; cancer is a result of many diseases and so cannot be treated by one single doctor. It requires the skills and talent of a team.
Courage and perseverance, not only on the patient’s part but also on the part of the doctor. Many patients give up early and so do many doctors. The treatment of cancer is a long and brutal journey; a special relationship needs to be built between the doctor and the patient. Cancer patients unfortunately all over the world are treated in an automated mechanical inhumane way. The doctor that does not love his patient cannot cure him.
NOW: As a Lebanese what is your opinion about the situation in Lebanon today?
Salem: The major problem of Lebanon is that it has always been a hostage to the conflicts in the Middle East. As it was a hostage to the Arab-Israeli conflict, today it has become a hostage to the conflict between the West and Iran.
I’m a great believer in the future of Lebanon, but Lebanon has a future only if we adopt a policy of neutrality. Not only as far as the conflicts in the Middle East are concerned but worldwide. Lebanon should be an oasis of culture, an oasis of freedom and of cultural pluralism.
The major challenge to the world now is the development of radicalism, and here I don’t only mean Islam. Any radical approach is an assault on civilization. Lebanon is a manifestation of the world and can be the best example of pluralism. Only in Lebanon you have 18 different sects that could live, survive, and interact, only in Lebanon can Arabs and Westerners live together, only in Lebanon can Islam and Christianity embrace each other.
NOW: Tell me more about the book Cancer, Love, and the Politics of Hope?
Salem: I am not the author of the book. It was written by Mr. Boutros Indari, an Australian journalist of Lebanese origin, and Mrs. Frances Mourani, a journalist from New Zealand. The book speaks briefly about my life story and about my upbringing, but it basically focuses on my ideology and philosophy, and on my views concerning Lebanon and the Arab world. It contains many of my writings, about both medicine and politics.
NOW: How best would you describe this ideology or philosophy?
Salem: My ideology is twofold: the first is that the right to health – that is, the right to medical care – is the most important right for a human being. The Declaration of Human Rights was published by the United Nations in 1947 and back then people had no idea about the significance of health. You have to be alive to be able to practice the rights to freedom and to free expression. If you don’t survive, the other human rights are irrelevant. It is important that we adopt a new charter at the United Nations whereby the right to live and the right to health and medical care are recognized as the most important of human rights, and we are working toward it. It is important that we raise awareness of governments toward this responsibility. It is a shame in the US that the government says it has no money to treat its citizens, yet still has trillions of dollars to launch wars.
Second, we need to re-humanize medicine all over the world. Medical care has become more automated and the patient is looked up on as merely a number or an object. The problem in most developed countries, the US being one of them, is that there are so many rules and regulations that have destroyed the divine human relation between the doctor and the patient. We need to restore this relationship between the doctor and the patient. This may sound [strange], but people who are treating patients know what this means, and know how it makes a difference between life and death.
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