The 17 Samurai

Hiroto Inaba, MD, PhD, is an oncologist at St. Jude Children’s Research Hospital and the principal investigator for the Total Therapy 17 clinical trial. Dr. Inaba is also a 17th generation samurai. He will explain everything ...

I was not actually supposed to leave Japan. My family expected me, as its first son, to follow tradition, stay home and someday replace my father as head of the household. I originally planned to spend only a couple of years at St. Jude before returning to my home in the Kii Mountains, but this place has been really hard to leave.

My most famous samurai ancestor, Yoshimichi Inaba (also known as Ittestu Inaba), was born in 1515 during the Sengoku period, the “age of warring states” in which the famous movie Seven Samurai is set. Yoshimichi died in 1589, but he still works with his daimyō (samurai lord) today, as a character in a series of samurai video games.

I represent the 17^th generation of my branch of the Inaba lineage after Yoshimichi, and I also lead the 17^th iteration of the influential St. Jude Total Therapy protocol investigating treatments for acute lymphoblastic leukemia (ALL) and lymphoma. The two “17s” are a coincidence, and my heritage and my work also have a few things in common.

Since Yoshimichi’s day, the descendants of samurai have found new vocations, but the philosophy behind that way of life, known as bushido, is still very meaningful in Japan. In fact, I sometimes refer to my mission at St. Jude as “fighting leukemia with the samurai spirit.”

At first glance, bushido might seem too traditional or inflexible for guiding scientific research or caring for gravely ill children. I like to point out that my name, Hiroto, means flexible, contrasting with my 16th century ancestor’s nickname, Ittetsu, which actually became a Japanese word meaning stubborn or resolute, due to his character. Here in the 21st century, I must be flexible enough to incorporate new scientific findings and better methods for fighting cancer.

Flexibility had its place in bushido philosophy and in the history of samurai. In The Book of Five Rings, 17th century sword-master Musashi Miyamoto advised his readers to shift effortlessly between disciplines and options when presented with new information. Yoshimishi’s daimyō, Nobunaga Oda, was proud of his archers’ accuracy, but he did not hesitate to adopt a strange new technology called teppo (matchlock guns), imported by the Portuguese, and arm his soldiers with them.

The Virtues of Bushido

Bushido is not only about fighting. Several of the virtues historically admired by samurai have survived in modern Japanese culture. As a pediatric oncologist, I have found that three specific virtues are helpful guides in my clinical practice.

• Courage
  The true warriors in our struggle with cancer are the patients and their families. They are the leaders while we, on the treatment side, are their helpers. My patients have displayed courage that would have made Yoshimichi very proud—or very cautious, if he were confronted by an opponent displaying such courage. The Survivors Day observance at St. Jude is a great experience, and I care about how my patients do after they complete their therapy. And, the Day of Remembrance is especially important to me, for the memory of my bravest fighters.
• Honesty
  The relationship between a patient and a physician is based on trust. In a difficult case, I want to be honest. Before going to patients and family members to explain a difficult situation, I always try to propose a positive course. I never approach a patient without doing this. Everybody reacts to this kind of difficult situation in different ways. Still, there are miracles. I don't know if that's related to bushido, but you never give up.
• Benevolence
  The bushido concept of benevolence was about showing mercy to people under a ruler or commander’s control and sympathy for anyone who is suffering or less fortunate. In the United States, benevolence in health care usually means helping patients to pay for treatment and related expenses. As a St. Jude physician, I know my patients and their families do not worry about the cost of care that we provide, or even the cost of lodgings and local transportation. This frees me to focus on caring for patients and helping to safeguard their future quality of life. I pay a lot of attention to how the family is doing, socially and mentally, and how we can help there.
• The Good Fight
  Honesty and benevolence, as well as politeness and rectitude, are praised in modern Japan as core bushido virtues. In medieval Japan, however, samurai did not win battles and protect their communities with good manners or beautiful calligraphy. They had to fight. Similarly, I must protect my patients by finding better ways to defeat ALL and lymphoma. As a child, I was told to respect the memory of Yoshimichi, and I show that respect by aggressively attacking cancer while protecting my patients from the adverse effects of its treatment. If Yoshimichi had faced a samurai enemy as dangerous as leukemia, he would have tried to surround such an opponent before the battle began or trick him into making mistakes. And I think he would recognize the environment in which I fight leukemia today. The decisive battles of the 16th century were not fought in wide fields, but in valleys and mountain passes. These were narrow, hidden places, comparable to the interiors of bones, blood vessels and the central nervous system, where leukemia develops. Canadian biochemist and cancer researcher Richard Béliveau, PhD, has also taken inspiration from samurai culture. “Cancer is the enemy to beat,” Dr. Béliveau explained, “and to win, it takes imagination, skill and perseverance, values inextricably linked to the samurai spirit. He describes the same spirit in cancer patients as they "live every day with great intensity, as did the samurai.”

Total Therapy 17

Today we are fighting ALL and lymphoma with a new “order of battle” known as Total Therapy 17 (TOT17). It is the 17th iteration of the St. Jude Total Therapy clinical trial, which began in 1962, when Dr. Donald Pinkel introduced simultaneous, multi-drug therapy for ALL.

Through the previous 16 Total Therapy trials, we have learned how individual children respond to leukemia medications in very different ways. To reduce toxicity and the risk of adverse effects, we select doses and medications tailored for each individual child.

The objective of Total 17 is to further refine this selection process with precision medicine. Every child in the trial undergoes genomic testing of both normal tissue and leukemia cells to target the therapy. The leukemia-cell data can identify abnormal mutations that may be targetable by new drugs. If the patient does not respond well to treatment, we can add those agents to a therapy to improve the responses.

That's why my fight will not only be treating patients. My fight will include working with our researchers, my fellow clinicians and the companies with new tools we can bring to the fight, to increase survival.

We are seeing a 94% survival rate with ALL, but we still want to go to 100%. There is a way to get there. We have many things to do.