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Oncology Unscripted With John Marshall

Oncology Unscripted With John Marshall

By: John Marshall
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 Oncology Unscripted with John Marshall, MD brings you a unique take on the latest oncology news including business news, gossip, science, and a special in-depth segment relevant to clinical practice. Language Learning
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  • Oncology Unscripted With John Marshall: Episode 20: Why Are More Healthy Young Adults Getting GI Cancer?

    Oncology Unscripted With John Marshall: Episode 20: Why Are More Healthy Young Adults Getting GI Cancer?
    Aug 20 2025
    Why Are More Healthy Young Adults Getting GI Cancer?[00:05]John Marshall, MD:John Marshall for Oncology Unscripted. Big paper coming out of _JAMA_—it's actually a review article. Really, really smart people and friends up in Boston looked at this. We all see it: this emerging trend of younger and younger people getting all kinds of cancer. This particular paper wasn’t about all kinds of cancer, but we’re clearly seeing it in GI cancers. We don’t really understand what’s going on, but we see it—it’s impacting our clinic. Maybe it was first recognized in the colon cancer clinic, but we’re seeing it in other clinics as well.We have two kinds of schools of thought on why this is happening. On one side, we’ve got this sort of traditional “here’s who gets cancer” list. So, you have a gene, you’ve inherited it, or you have some behavior that increases your risk, or you’re overweight or something, right? You have some known risk factor that we all learned in medical school that’s causing this cancer.Now, if that were true, then our normal 60/40 split of cancers—40% on the right side, 60% on the left side—would hold true in colon cancer. But in fact, most of these young people with colon cancer—up to like 90-something percent—all have rectosigmoid cancers. So, what the heck’s going on? And most of the patients that we see, at least that I see here in Washington, DC, don’t have any of those things on the list that we all memorized.They’re all very fit. They have no real reason to have this—no strong family history and certainly no gene. So, we are looking for novel explanations. The leading one right now has mostly to do with microbiome and understanding what that’s all about. We’re not going to drill down on that today, but we are looking for the explanation as to why.Now, the other piece that goes with this is: if you’re a young person, is your cancer better? Well, it actually doesn’t look that way. If anything, it looks like it might be worse. We know that we fail to diagnose it earlier because it’s not on our radar. If I’m in an urgent care clinic or in an ER or something—or even if I’m a patient with the symptoms—you don’t think to yourself, “Oh, I could have colon cancer,” because you’re 40 years old, and it’s too young to have colon cancer.So, it isn’t a better cancer. But on the flip side, because you’re younger as a patient, doctors tend to be more aggressive. They tend to push treatments harder because young people can take it well. On the flip side of that, they also have much longer to live if we give them some sort of permanent toxicity—say, neuropathy from oxaliplatin.So, it is clearly its own thing. It has its own impact on day-to-day living for these people, because they have to keep working, because they need health insurance here in the United States. They have to tell people about it. So, the impact on their lives is much bigger than, say, if you’re a retired 73-year-old with a good support system.So, that impact is a bit worse. The disease probably is worse. The failure to diagnose is worse. We don’t really know what the biology and the cause is, and more isn’t necessarily better. So, there’s a lot to talk about and think about. Take a look at this paper, see the emerging trends, and share it with your colleagues in other areas of healthcare so that they’re aware of it, too.John Marshall for Oncology Unscripted.[03:51]MedBuzz: Fellows, Funding, and Fewer Radiologists[00:05]John Marshall: John Marshall for Oncology Unscripted, with a little bit of buzz, a little bit of gossip, a little bit of stuff that's trending.You know, this is the end of July when we're filming this, and the squeaky-clean new fellows are here. Don't you love July? New residents and new fellows—you get to teach 'em how 5-FU works and where the bathroom is, and all of those things. But it is—I love this time of year with the new fellows because they're very eager and very interested in learning everything they can. They're not too tired. Everything is good and positive as they learn and go forward. And so, it's just been a great month for us here at Georgetown, and I hope if you work with new trainees—residents, fellows—that you too are having a positive time with them.I've also—the month of July—been struck by a certain late-night TV host who was fired, let go, because his message was to counter the sort of government message that is going on right now. So, I've been really anxious about having any sort of counter message that's out there, because you know what? You might get canceled if you are caught too often with this sort of counter message.How that's affecting us here at an NCI-designated cancer center—or wherever you are—is that I'm not sure what the NCI is gonna look like too long from now. We know there are gonna be cuts. We know the payline—there have been predictions that it'll drop as low as 4% for grants...
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    38 mins
  • Oncology Unscripted With John Marshall: Episode 19: Who Really Benefits From Cancer Innovation—and How Can We Do Better?

    Oncology Unscripted With John Marshall: Episode 19: Who Really Benefits From Cancer Innovation—and How Can We Do Better?
    Jul 15 2025
    ACCESS THROUGH INNOVATION: THE POWER OF SMARTER CANCER CARE STRATEGIES[00:00:05] John Marshall, MD: John Marshall for Oncology Unscripted. Really no script at all, but we are post-ASCO here in Washington, DC, trying to take all of those major innovations that we all get so excited about—curves with big deltas that we saw in all sorts of different cancers, including the humblest of them all: GI cancers.So, now the question is: how do you take those innovations and those changes—some of them are added to NCCN, some of them may be FDA-approved, some of them in The New England Journal of Medicine, some not—and apply them to our patients? Many of them are novel tests, maybe not covered by insurance.Many of them are new drugs that don't have a label and may not yet be approved by healthcare coverage. Many of them, as we will talk about, are not available to most of the world. In fact, they're only available to us here in the wealthy corners of our planet. And so, how do we go from that innovation to the patient to realize those benefits?I want to highlight two papers because, thematically, they go along with what we are talking about this cycle. So, you've probably seen this journal before—it's called The New England Journal of Medicine—but I want you to make sure and look at this paper by Andrea Cercek. You know about it. This is using IO therapy in MSI-high positive primary cancers, and of course the rectal cancer data. This bar plot right here: 100% of patients with rectal cancer, MSI-high, had a positive clinical response and didn't need surgery. It's not quite 100% in some of these other cancers, but it's dramatically positive, and we here in the United States have access to those therapies for patients with these dramatically positive benefits. But, as you will hear, not everybody has that access and, therefore, they don't even really want to know what their MSI-high status is, because they can't do anything about it.A second paper, also from a journal you've probably seen before—recent cover change; I kinda like the old cover better myself—Journal of Clinical Oncology. This is also a GI cancer paper. This is from a European consortium group, and there are also some US folks here. They took samples from adjuvant clinical trials in colon cancer and developed a sort of digital path–generated signal of risk, and were able to sort patients into their risk categories so that we could know who needs chemotherapy and who doesn't—who's going to benefit from chemotherapy and who doesn't. Similar to what we are seeing with the MRD ctDNA testing.This is pretty damn cool because everyone's getting surgery, or most of the world who has healthcare is getting surgery. The analysis that this requires is actually relatively inexpensive compared to some of the fancier tests that are out there. It enables a sorting of patients into risk factors—so much, importantly, for whom needs treatment. Because, right now, we're treating everybody. But more importantly, who doesn't need treatment? How much value can we find with these tests that actually identify the patient who's already cured or who will be upfront resistant to the treatment, therefore not needing it?This is really where AI is going. And both of these papers speak to this concept of access and value. When something's a 100% benefit rate, the whole world should have access to that—and that's where you can have MSI for rectal cancer with IO therapy. When, on the other hand, an inexpensive test—a series of tests—can show you who needs treatment and who doesn't, there's incredible value. The whole world saves money if we can apply that kind of metric to decision-making going forward.So, I think these two papers are really good examples of how the progress we are making improves the value and our efficiency going forward, so that as we approach the next generation of cancer care and cancer interventions, we can do it better, more effectively, less expensively—so that one day we can say, yeah, that was worth it.John Marshall for Oncology Unscripted.MEDBUZZ: WHAT IF THE BEST CANCER DRUG IS THE ONE YOU CAN’T GET?John Marshall, MD: We've been talking a lot and thinking a lot about access to cancer care. And let's start hometown—let's start here in the good old US of A—and talk about unequal access to cancer care. Here, we all know that what color you are, what your race is, what your gender is, who your parents were, what type of insurance you have, urban versus rural—we all know about those differences in access to cancer care. A new one that's emerging is specialization of the team that you're seeing. So, general oncology teams versus disease-specific oncology teams tend to produce different outcomes, simply because everything is moving so fast, the subtleties are something that the specialized team can keep up with, that a generalist would struggle with. And this is an important issue that we need to figure out, as a nation, how to ...
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    55 mins
  • Oncology Unscripted With John Marshall: Episode 18: “Badge-up” with Dr Marshall at ASCO 2025

    Oncology Unscripted With John Marshall: Episode 18: “Badge-up” with Dr Marshall at ASCO 2025
    Jun 10 2025
    “Badge-up” with Dr Marshall at ASCO 2025John Marshall, MD: John Marshall coming to you live Oncology Unscripted, not from my office back in Georgetown, but from beautiful downtown Chicago, Illinois at ASCO 2025. Look at this amazing place. 40,000 of our closest friends.To get in, you need to have one of these. So, I'm gonna go ahead and badge up. I got a fancy red collar thing here, boy, that makes me stand out even that much more.But what we're gonna talk about today first is the social aspect. You remember in anticipation of coming, we were a little worried about would people from outside the US come to the meeting, and, yep, they've come, but not to the same extent that they have in years past. So very clearly international travel being affected by the world today, and, therefore, our community, which is so important to get together on a regular basis, probably being a little bit affected by this. But it is an incredible time to get together, to share thoughts, to give a hug or two, to shake a hand or two, and connect with those of us in our community who are dedicated to trying to cure cancer to find positive outcome for our patients for Monday morning, for Tuesday morning, in the week ahead.So, let's start with some high-level reviews of the most important science. Later today, we will have the plenary session where five abstracts will be presented, each one of which has significant impact on our patients going forward. Let's start, in my world of GI cancer, where immuno-oncology, again, doubling down in the microsatellite unstable patient adjuvant IO in MSI patients with chemotherapy proving to be better than chemotherapy alone. Not tested against IO alone, which will clearly be the next question, but for now, starting next week, MSI-high, IO plus chemotherapy in the adjuvant setting in colon cancer.What about gastric cancer? Same thing, IO, and this is not an MSI-high, added to chemotherapy showing survival benefit for our patients with gastric cancer. So, as of today, new standards where IO will be added to adjuvant perioperative therapy for patients with gastric cancer.And the third area where IO has been shown to be a benefit in this plenary session is adding it to radiation and chemotherapy in head and neck cancer, something we've long been needing. Improved novel therapies for head and neck cancer. IO has just entered that field too in the curative intent combo chemo RT setting. So, three major places where IO is gonna have an impact starting today.Now I'm not even gonna try to talk about polycythemia vera. I'm not even sure I can spell it, so I'm gonna make you look that one up yourself.But I wanna finish from a plenary perspective on this breast cancer study. Of course, it's always breast cancer. They are the smartest, they have the most money, they have the highest survival of all of our solid tumors, and, yep, they did it again. They actually show that if you monitor patients who are getting therapy and you can use circulating tumor DNA, so a blood test that can demonstrate the emergence of resistance before there's a change in the clinical scenario. And if you add in, in this case, an androgen hormone degrader, that in fact you can intervene and actually extend survival and progression-free survival significantly. So, this is real time monitoring, using novel blood tests for resistance and changing your therapy in advance of any other clinical signal. Clearly, this is the way things are gonna be going more and more as we define therapies for our patients. Not so much using CT scans and waiting on progression, but blood tests that demonstrate resistance at a much earlier time point.Two other important GI papers. Not part of the plenary. There wasn't room for everything in the plenary, and this is, guess what? It's now good to be BRAF colon cancer. Do you remember when it used to be bad to be HER2-positive breast cancer? Do you remember when it used to be bad to be MSI-high? Well, it's not bad anymore for those two because the therapies work. It used to be bad to be BRAF V600E-mutated colon cancer. Just a bad prognostic sign. Nothing you can do about it. Study just presented showed that the addition of BRAF-targeted therapies and frontline metastatic colon patients with a 30-month median survival. So, that took a bad marker, we can now deal with it. What does that mean for your clinic? I'm gonna be strong here. It now means that it is malpractice, you are not practicing the standard of care, if you're not doing frontline molecular testing in colorectal cancer. You are obligated to find Ras mutations, BRAF mutations, MSI, and HER2 before you initiate treatment. So, this positive BRAF study affects standard of care in your practice today, so you have to do that going forward.There was a study looking at the novel, local therapy for pancreas cancer called tumor treating fields. That showed some positive data, finally, in pancreas cancer, so that's exciting. Tomorrow morning ...
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    11 mins
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