Choosing the best options for every cancer patient

In Person: Dr. Brian Samuels

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Dr. Brian Samuels is director of the Northwest Oncology Program at Northwest Specialty Hospital in Post Falls. A board-certified oncologist and author of more than 60 articles and book chapters, Samuels was previously on the faculty of the University of Chicago and the University of Illinois. The following interview was conducted at Northwest Specialty Hospital.

How difficult is it to tell a patient they have cancer?

Cancer's still a very bad thing to be diagnosed with. We don't always have the ability to cure people. But I do think that a lot of the treatments are now able to help patients live longer with less dramatic impact on their quality of life. Today we can help patients with newer drugs that are not as hard to take. Our ability to help people with the side effects has also improved dramatically.

What makes you feel good about your job?

There's no doubt that we do cure a proportion of people we see and that's very gratifying for the physician. We have patients who have diseases that we know without our intervention would inevitably be fatal, but that after treatment, those patients go on to lead normal lives.

It's equally fulfilling to be able to help people with diseases you know you can't cure to live better lives.

I really think it's the feeling you made a difference.

What about the cost of cancer treatments?

In cancer care today, treatments are so expensive, you have to be a multi-millionaire to say "I'll just write a check."

In a perfect world, physicians would be able to choose the best treatments for their patients and apply it. It's clear, however, that that's not financially feasible.

How do you deal with bureaucratic interference?

Because the cost of care is so high, you have to justify the cost of the treatment. So it soon deteriorates into bureaucracy-for-the sake-of-bureaucracy.

I think a lot of medicine now is very circumscribed by the bureaucratic requirements that go with it. I spend at least as much time either filling out paperwork, requesting certain treatments, justifying those treatments and then making sure the medical records justify the treatments, as I do interfacing with the patients themselves.

What about the rising cost of drugs?

Yes, we have pills that cost $15,000 a month.

What's happening is there are a number of older drugs we use that are still very effective and they're relatively cheap because they're off-patent. Many of the newer drugs - which are often significantly less toxic - are the ones that tend to be so dramatically expensive.

How does that happen?

It's complex. It's becoming increasingly expensive to develop new drugs. The FDA (U.S. Food and Drug Administration) is on drug developers to prove their drugs work and this has become more expensive. At the same time, I think there's a huge profit motive in the development of cancer drugs that may be excessive.

The soapbox part of me says, "Look at the profit and loss sheets of major drugs companies and you can see that."

Will there ever be a "miracle drug" to wipe out cancer?

Advances in cancer drugs are incremental. It's like the development of new operating systems in computers.

The cancers that kill the vast majorities of people - cancers such as breast, colon and prostate - have very complex genetic abnormalities. For those, you're not going to develop one drug and advances will stay incremental.

There are new groups of drugs being developed all the time. But my experience has been, alas, that all those developments have been incremental rather than breakthroughs.

Part of the reason for this is that cancer is not one disease - in reality it's hundreds of different diseases.

I think what we're going to see is that we'll continue to chip away at cancer. I think it would be nice to think someone's going to invent a cure for cancer, but realistically that's not going to happen. We've made strides over the past 10 years, but, once again, the progress is incremental.

Are there exceptions?

There are a number of cancers that are usually relatively rare and well-identified. For example, in chronic myeloid leukemia - where there is a specific change in chromosome structure and a specific abnormal gene - drugs have now been developed to target the abnormal gene and turn it off.

But aren't we already curing cancer in lab animals?

You can reliably cure cancer in mice but not in humans. It's extremely frustrating.

In the first place, you can do tests on lab animals and inoculate mice with tumors and the tumors will grow. Sometimes they will even be cured. But not so with humans.

It's frustrating that the results of a given drug with lab mice are never as good as when you try to treat people with it.

What do you think of the "alternative" treatments celebrities are known for trying?

If you go on the Internet and look, you'll always find tens of thousands of cures for cancer, etc. It's quite certain three or four of them are valid, but which one should you pick? And none of them have been scientifically validated.

There are a number of medications used in modern medicine that are based on plant and natural products. Many chemo drugs come from plants, so it's not impossible that some mixture of herbs might have an anti-cancer effect. But how you can discern those from the majority of cancer ripoffs, I just don't know.

Do you worry about making mistakes?

Oh yes. You don't make arbitrary decisions, but sometimes you have to decide between treatments. I think I try to do as much as possible to involve patients in making choices. They have to be educated to make the decision, but we want them to be participants in that decision.

In the end, you often have to tell them what the best choice is.

Are there times you have to say "I don't know?"

Certainly there are times when equal paths have equal validity.

How do you handle the trust your patients put in you?

The trust issue is hard because I think every patient kind of comes into the experience trusting you to cure them and you know that's not always going to be the case. You then have to deal with balancing being honest with the patient, but not destroying any hope they have.

I think you're sustained by those people you cure. Even with those people you don't cure, you know you've made a difference.

How long is your typical workday?

I'm usually here at least 12 hours a day-that's counting the hospital. Then I spend a couple of hours at home catching up on paperwork and on new developments.

I try to spend as much time as I feel the patient needs. Often that's more time than I can afford, but I want to give it anyway.

Any regrets?

To say I haven't regretted anything wouldn't be true. I've regretted I haven't had as much time as I would have wanted with my children as they were growing up because I was always at the office or the hospital.

As a native of Africa, do you feel totally at home in North Idaho?

My wife and I were both born in Africa, but we have always loved the American Northwest and initially thought we'd retire in the Northwest. We wanted a different life experience from our previous one in Chicago.

I was raised in the city - in colonial Africa - and it was probably like most American cities. Suburbia there was like suburbia here.

We go back to Africa every few years to visit. I think part of you never leaves when you're born in Africa. I had to buy an American-English dictionary when I came here.

Do you see yourself as an American?

I think we feel American. When things happen around the world, we identify as being Americans.

SNAPSHOT

Dr. Brian Samuels

Family: Wife, Lesley, children David, Mark and Emma

Education: The Godfrey Huggins School of Medicine, University of Zimbabwe

Age: 59

Hobbies: Power boating, hiking, photography

Favorite music: American folk

Favorite sports team: Chicago Cubs

Quality you admire most in a friend: Integrity

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