In this installment of Oncology Worldwide, internationally regarded lymphoma expert and cancer survivor, Kensei Tobinai, MD, Chief, National Cancer Center Hospital, Tokyo, sheds light on the Japanese oncology experience.
What was the medical school experience in Japan like?
When I received my medical education at Tohoku University School of Medicine, in Sendai, Japan, the educational system comprised a 6-year course consisting of an initial 2 years for general education, followed by 2 years dedicated to basic research in medicine, and the last 2 years studying clinical medicine. At the 6th grade level in medical school, I decided to proceed to internal medicine, but at that time I was still wondering what field of internal medicine I should specialize in.
When I graduated from medical school, the most interesting field for me was endocrinology, probably because I felt it to be a more logical and scientific discipline compared with the remaining fields I had to choose from at that time.
What influenced your decision to pursue a career in oncology?
After graduating from medical school in 1976, I worked as a clinical trainee initially, and subsequent to my trainee period I served as a staff physician for 4 years in Iwaki Kyoritsu General Hospital, Iwaki, Fukushima, which is only about 50 km (~31 mi) from the Fukushima Daiichi Nuclear Power Plant (the site of the March 2011 nuclear disaster).
I attended an initial 2-year rotating education program in various fields of internal medicine, including respiratory medicine, gastroenterology, hematology, cardiology, nephrology, and endocrinology/diabetes mellitus in this general hospital. At that time, I realized that most hospitalized patients in the first three areas listed above were those with cancer.
In the late 1970s, in the wards of internal medicine in Japanese hospitals, most patients with advanced-stage cancer had very unsuccessful clinical courses, even though they received the best chemotherapy regimens available. So I felt that the most significant unmet need in medicine was cancer, and I pursued a career in oncology.
What drew your clinical and research interests to lymphomas?
Among patients with cancer, those with hematologic malignancies were the most difficult ones to manage in the late 1970s. I encountered many patients with acute leukemia, lymphoma, and myeloma who showed miserable treatment outcomes. At that time, I experienced one rapidly deteriorating patient with skin exanthema, hepatosplenomegaly, generalized lymphadenopathy, high fever, marked polyclonal hypergammaglobulinemia, and autoimmune hemolytic anemia. The pathologist who examined the biopsy specimen suspected “immunoblastic lymphadenopathy,” which had been proposed as a new disease entity of lymphoproliferative disorders by Drs. Robert Lukes and Barbara Tindle in The New England Journal of Medicine in 1975. However, immunoblastic lymphadenopathy was later found to be a distinct entity of peripheral T-cell lymphoma and was renamed as angioimmunoblastic T-cell lymphoma.
In addition, I had one young male patient with acute lymphoblastic leukemia, bulky mediastinal mass, and bone marrow involvement. The tumor cells in his bone marrow had an “e-rosette” formation with sheep erythrocytes, one of the representative analytic methods for immunophenotyping at the time, indicating a T‑cell derived tumor. My experiences with these two characteristic patients with T-cell malignancy in Iwaki Kyoritsu General Hospital greatly influenced my decision to specialize in hematologic malignancies, especially lymphoma.
At medical school, I learned lymphoma classification as a simple three-disease structure, consisting of Hodgkin disease, lymphosarcoma, and reticulum cell sarcoma. However, the actual patients with lymphoid malignancies were very heterogeneous with regard to cellular origin and clinical behavior. I felt that there remained many important unsolved issues in lymphoma research.
After the initial 4-year training in Iwaki Kyoritsu General Hospital, I moved to Tokyo and became a resident in hematology/oncology at National Cancer Center Hospital, where I began to deeply involve myself in lymphoma research. During the resident course at the National Cancer Center between 1980 and 1983, an epoch-making discovery was made in oncology research—namely, that human T-cell lymphotropic virus type I, an RNA retrovirus, was found to be a causative agent of adult T-cell leukemia-lymphoma.
Was there a mentor along the way who helped shape your career?
When I received training in hematology/oncology as a resident in the National Cancer Center Hospital, Dr. Masanori Shimoyama, who was a Chief of the Hematology/Oncology Division at that time, taught me the importance of reporting the results of laboratory and clinical research with scientific manuscripts. Since then, I have made continuous efforts to scrupulously report the findings of our own research.
Nowadays, to conduct a qualified research trial on lymphoma, cooperation with other investigators is essential in view of the need for cooperation between basic and clinical researchers—both intramural and extramural cooperation—including national and international multicenter trials. The National Cancer Center, where I have worked for 28 years, is one of the most suitable institutions to conduct such cooperative investigations in oncology in Japan.
Access to Care
What’s the situation in Japan concerning patient access to cancer care?
Although I am not a specialist in this field, I feel that the National Health Insurance System, which covers all people who live in Japan, is still working adequately. Of course, there are many significant problems in the current Japanese health-care system for patients with cancer, including financial deficit, paucity of medical oncologists and radiation oncologists, “drug lag” (delay in the approval of new oncologic agents compared with North America and Europe), and inadequate (but developing) status of end-of-life care for patients with cancer.
In Japan, patients can visit the clinic of the doctor of their choice to receive consultation or disease management. This may be a preferable system for patients, but it is somewhat problematic in terms of efficiency. For instance, more than half of the patients who visit my clinic are those who want second opinions. Medical costs for cancer care, especially the high costs of new agents, are becoming a significant issue in Japan.
Nevertheless, basically all patients who are registered in the National Health Insurance System in Japan can receive expensive oncologic agents such as rituximab (Rituxan), imatinib mesylate, ibritumomab tiuxetan (Zevalin), and allogeneic hematopoietic stem cell transplantation.
Obstacle to Care
What is the greatest challenge to the Japanese cancer care system?
Considering the tremendous deficiency issues in the financial affairs of the Japanese national and local governments, and the increasing demands of Japanese patients with cancer and their families requesting more expensive, high-quality care, including end-of-life care, financial issues are the greatest challenge for the future of the Japanese cancer care delivery system.
Any last thoughts about the future of cancer care and survivorship in Japan?
Although problems in cancer care will continue to occur, based on my own experience of more than 30 years as a clinical oncologist, future cancer care will be further refined and become more sophisticated mainly due to advances in oncology research, including the incorporation of more effective new agents and less invasive surgical interventions.
As a matter of fact, I am a cancer survivor who has enjoyed successful cancer management. In 2006, I received a partial gastrectomy in the National Cancer Center Hospital because an annual checkup revealed the presence of early gastric cancer. My body weight decreased approximately 10% after gastrectomy, but my marginally abnormal findings in blood sugar and blood pressure were normalized, and my current health condition is very good. So I am a healthy 5-year cancer survivor.
Finally, I would like to thank people all over the world, including those in the field of oncology, for all the kind and generous support we received after the disaster caused by the earthquake and tsunami on March 11, 2011, and subsequent nuclear accidents on the Pacific coast of east Japan. Although a long time will be needed for a full recovery, I believe the situation in the affected areas is gradually improving, and most areas of Japan, including Tokyo, are functioning as normally as prior to the earthquake. ■
Disclosure: Dr. Tobinai reported no potential conflicts of interest.