Episodes

  • Oncology Unscripted With John Marshall: Episode 25: New Hope in GI Cancer Care

    Oncology Unscripted With John Marshall: Episode 25: New Hope in GI Cancer Care
    Dec 18 2025
    MedBuzzTariffs, Taxes, and Trade-Offs: Can Raising Taxes in the UK Get You Cheaper Drugs in the US?John Marshall, MD: John Marshall for Oncology Unscripted. There's been all sorts of stuff going on out there in healthcare—in the business of healthcare—and a recent article that was just published in The New York Times told us something about the relationship between the National Health Service, how patients get access to drugs there in Great Britain, and our relationship with them and the tariffs. You're like, how could the tariffs have anything to do with the National Health Service?Well, let me give you a very short little background, if you don't know already, on the National Health Service—Britain’s public health system. The Brits love it. It's tax-based. It's not fancy, it's not frilly. But if we're going to bring in some new medicine or some new expensive therapy—whatever it is—the budget has to be balanced.So, either they have to remove something from what the patients have access to, or they have to raise taxes. And there is a committee known as the NICE committee, the National Institute of Clinical Excellence—staffed by physicians that, in fact, governs that. You're thinking, where is Marshall going with this?Well, where he is going—and The New York Times presented this—is that because of the tariffs, right? Britain makes some drugs, and we import them here and use them. Well, if the tariffs are in place, those drugs will be more expensive to import. And the whole idea behind the tariffs is to make it so that more Americans are doing the manufacturing.Well, the Trump administration and the National Health Service just made a new deal where the Brits will get access to more drugs—so they'll raise their expenses, if you will. And it's going to hit the bottom line over there...because they're going to have access to medicines that they don’t currently have access to. In exchange, the U.S. is going to say, “Well, we'll waive those tariffs on drugs you import.” So, it is access over here for an economic change—an international economic change—around the tariffs.I have no idea how this is going to work out. I didn’t really understand all the math—were taxes going to go up in Great Britain? Were they going to call it a wash because the tariffs were not going to be in place? I don’t know.The good thing for patients in the UK is that they're going to have more access to more medicines. What I worry about is that it'll come on the backs of either going into debt—if the National Health Service goes into more debt, sort of like our healthcare system—or, in fact, they raise taxes, or somehow they magically make the budgets balance.So, we need to look ahead to 2026 and see just what happens with this UK National Health Service–Trump tariff deal that was just reported in The New York Times.Stay tuned here for more updates on Oncology Unscripted.[03:04]Editorial/Main TopicWhat I Tell Every New Patient With CancerJohn Marshall, MD: John Marshall for Oncology Unscripted.I start almost every new patient appointment by talking with the patient and saying that I—I don't really know why people get cancer. We memorize lists of what we're supposed to do and what we're not supposed to do, but, bluntly, almost everybody sitting across the room from me didn't do anything on the bad list, and yet here they are, sitting there with cancer.It seems to me—and I think this is popular science thinking as well—that we probably all get cancer all the time. But our bodies actually have outstanding spell checkers and an outstanding functional immune system that can see early cancers and fix them before they cause any trouble. So, what that actually means, then, is that those cancers that make it—those cancers that survive through the spell checker or through the immune system—must have figured out a way to get around the spell checker, or have broken the spell checker, or maybe are hiding from the immune system.And so, almost all of our new research going on right now in cancer medicine is either trying to fix the spell checker—and by this, I mean targeted therapies, signaling pathways, et cetera—or it's trying to turn back on, wake back up, or uncover the tumor from the immune system so the immune system can go in and do its job.And so, I think what you see at almost any conference nowadays focuses on those two approaches. It's not some new chemotherapy, although chemo continues to be very important and has cured a whole lot of people, so don't get me wrong about that. But what we're seeing in terms of innovation has a lot to do with improving the immune system, measuring the immune system, having better immunotherapy or immunotherapy combinations, and, at the same time, uncovering the molecular abnormalities of our cancers and having targets to those—and, in some cases, combining those with novel therapies as well.So, be on the lookout for the next innovation: either ...
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    22 mins
  • Oncology Unscripted With John Marshall: Episode 24: How Do We Translate MRD Innovation Into Everyday Oncology Practice?

    Oncology Unscripted With John Marshall: Episode 24: How Do We Translate MRD Innovation Into Everyday Oncology Practice?
    Dec 15 2025
    MedBuzz: From Hormones to Heroines: Couric, Cancer, and the Case for ChangeJohn Marshall, MDHello, everybody. John Marshall for Oncology Unscripted, coming to you from my now almost empty office. I've been in this office for, gosh, 20-plus years. It's the big office. You may or may not know I stepped down as the division chief here at Georgetown. We planned it—I wanted to do it a while ago. They said no. So, I finally got to step down because I wanted to do some other things. I get a lot of time back from meetings I really didn’t want to go to in the first place, so I’m happy about that. And it’s enabled me to get back to the world of clinical cancer research and to try and innovate in our space and do a lot less administrative things. So, I am glad for the clean-out, moving down to a smaller office in a fresh region. Probably one of the last times—maybe the last time—I film from this spot. But I wanted to take some time to review some high-level things that have changed in a big way just in the last week or two. The one that struck me the most is that there's been a change in black box warnings around hormones for postmenopausal women. I lived this too, where we went from hormones being a good thing—and all postmenopausal women were more or less taking them—to then it was unopposed estrogens were evil. And then the cancer lobby—and the breast cancer lobby—really was responsible for making it so women stopped taking hormones. We made it so terrifying that hormones were going to cause breast cancer that, you know, certainly oncologists weren’t prescribing it. GYNs stopped doing it. Primary care docs stopped doing it because no one was really willing to take the risk. And I think about the suffering, quite honestly, that postmenopausal women have endured since this time. It is really, really remarkable. And only now—only now—that people have gone back to actually look at the clinical trials and look at the studies, they actually pretty clearly show that hormone replacement is not bad for these people. In fact, if you look at the colon cancer literature, surprisingly, there was evidence that it decreased the risk of getting colon cancer. And even despite that, they didn’t want to change it around. So, I am excited about that black box warning change. If you’re a postmenopausal woman or you know some that are around you, make sure that if they’re interested, there are new options for those patients.But there’s a second warning that has been installed, and this is around 5-FU and DPD testing—dihydropyrimidine dehydrogenase testing—for 5-FU clearance. Why I think it's a big deal is not only is it an updated Black Box, but NCCN has embraced it. I think it’s a big enough deal that I hope you will click in and watch my interview with Howard McLeod, who is really the world’s expert in this space, about what we should be doing, how to do it, and some of the practical aspects of that.So, make sure and click on that interview and watch it. It’ll be worth your time. All you clinicians out there should do it. Now, whether or not it will become routine, whether or not it will become standard of care, whether or not you’ll get sued if you don’t do it—those things will evolve. But I do think it will be part of your everyday life. So, good to keep up to speed on that.And then lastly, sort of an emotional note to make—and that is, this is the actual 25th anniversary of something I bet you remember. That’s when Katie Couric had a colonoscopy on television, and it was on a morning TV program, The Today Show. She did that because, of course, her husband had had colon cancer, and she became quite a strong advocate.Her sister Emily later developed pancreas cancer and died of that, and she’s been very involved in Stand Up to Cancer and so many things. But I think back about that moment when Katie Couric said, “You’ve got to be getting your colonoscopy.”And the reason it comes up is that, one, we’re giving her a 25th anniversary award here at Georgetown—one of our Luminary Awards. So, we’re very excited about that. I’m going to get to see her later this week and thank her in person. But I was also thinking about the impact that I believe she has had on the number of people who get colon cancer.If you really do the math, the interventions that have changed with colonoscopy, etc., in the United States have probably reduced the number of people who get colon cancer every year by about 20,000. Now, 150,000 people get colon cancer every year. It would be much higher than that if we didn’t have effective screening. So, screening works—fewer people in our clinics—and we need to applaud her for all that she has done.So, that’s all the gossip that’s fit to print for this session of Oncology Unscripted. I hope it gives you a little something to think about, look up, or consider as you move forward in your day tomorrow.John Marshall. See you later.Editorial: ...
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    24 mins
  • Oncology Unscripted With John Marshall: Episode 23: The Molecular Space Race: Will It Bring Earlier Detection and Better Treatment?

    Oncology Unscripted With John Marshall: Episode 23: The Molecular Space Race: Will It Bring Earlier Detection and Better Treatment?
    Nov 18 2025
    MEDBUZZ [0:00:05]When the Sources of Trusted Information Change—Who Do We Believe?John Marshall, MD:Happy whatever day it is today when you're watching this. John Marshall for Oncology Unscripted. A little bit of a rainy day here in Washington, DC. It's been a little bit of a weird time here in Washington, DC—even weirder than it normally has been.Let's start with a little of the business of our world today—the business of oncology. You may have seen that we have a new National Cancer Institute director: Dr Anthony. Professor of medicine, he's kind of a basic science guy, but he's also a medical oncologist from Dana-Farber. Would you take that job if it was offered to you? I knew some of the candidates who were in line for it—or the finalists—and you'd really have to want that job to take it right now, because of all the unsettledness at the NIH in general, et cetera. So, I'm grateful that this very smart person has said yes to the job. Now, what he does—one of his areas of expertise—is programmed cell death, which is sort of a subtle way of getting a cancer cell to kill itself, right? So maybe, just maybe, he'll use some of that expertise to help in the shifting of government. A little programmed cell death around here might go a long way. So, fingers crossed that he succeeds in maintaining and growing the research that we are doing in cancer, much of which is sponsored through the National Cancer Institute. So, fingers crossed.But as soon as he gets the job, what happens? Well, we shut down the government.We've done this before. It is weird in Washington when the government shuts down. Whether it's patients who now don't have a job for the moment and who risk not having health insurance to receive their ongoing cancer care—in my case—or care in general out there.We're clearly seeing an impact on patients. We're clearly seeing an impact on government operations. I'm supposed to fly to Florida to get measles, maybe, this coming weekend, and I'm not sure we will do it because—who knows if there'll be air traffic controllers available? Would you go to work if you weren't getting paid?I had a recent call with an NCI colleague who is going to work, who is seeing patients, and is trying to manage things—but is uncertain about whether they will be paid.I also happened to come across recently somebody in the medical center who works up in McLean. If you know what offices are in McLean, I'll let you figure that out—sort of secret spy stuff. Normally, they're incredibly busy, but because there aren't any other government activities going on, they're kind of sitting there saying, "Well, we can't do what we normally do because we're dependent on the rest of the government to do what we do." So even those who are going to work are kind of stalled.So, there's a whole lot going on. The one positive—and it's not really a positive to make up for the negatives—is that the traffic's a lot lighter here in Washington. But still, not enough to make up for it.Now, I do want to talk a bit about another big topic that’s come forward. You know that RFK Jr. fired 17 members of the Advisory Committee on Immunization Practices. This is the group that gathers to make recommendations around vaccines and immunizations in general. He fired a lot of them. He put some replacements in—many of whom have been featured in other articles—I won’t drill down into the weeds on some of this, but many of them are more than just anti-vaxxers. They’re suggesting that we’ve mismanaged this as a medical community, and that we’ve not been telling the true scientific story.The new people who’ve been put in place haven’t made any formal recommendations yet. But the most recent one that came out is that there’s even some debate about whether newborns should be given hepatitis vaccines. And that data is very, very tight about how many lives are saved because of vaccines—as they all have been shown. But we’ve forgotten data, and we’re going to have to relearn the lesson going forward.Do you read the front page of the paper or don’t you? In my family, it’s split. My wife only reads the sports section. I read the front section—or at least read the headlines.In the Washington Post editorial page was an article written by the last six Surgeon Generals—right and left—appointed by different presidents over time. And this was a very thoughtful piece that basically summarized that RFK Jr.—he’s perfectly entitled to have his own opinions about things—but he’s not entitled (this was their conclusion) to put other people’s health at risk.And they collaboratively, collectively, emphatically said that that is what is going on with this new ACIP committee—with RFK Jr. at the helm. That we are putting a lot of people at risk, and it’s what’s making us all very, very anxious in the medical community today.Now, I want to talk in closing on this about a book that I am reading. Don’t worry, it...
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    33 mins
  • Oncology Unscripted With John Marshall: Episode 22: ESMO, Efficiency, and Evidence: A Look Ahead at New Data and Important Updates

    Oncology Unscripted With John Marshall: Episode 22: ESMO, Efficiency, and Evidence: A Look Ahead at New Data and Important Updates
    Oct 14 2025
    [00:00:05] Main Topic ESMO, Efficiency, and Evidence: New Data, China’s Science Leap, and Leucovorin and Autism John Marshall, MD: Hey everybody, John Marshall from Oncology Unscripted. There is so much going on right now that we're gonna need a full hour-long show, but we're not gonna do that to you. We still promise short bites here and there of the stuff that's going on, just to make sure you're in the loop. I'm sure you are.But let's start with a little science. And the science we wanna focus on is the upcoming ESMO meeting. We've looked at the leading abstracts that are gonna be presented there, and there's not gonna be a lot of surprises about the content. There's a lot of innovation in precision medicine and immunotherapy and different diseases, and positive randomized trials, and some exciting early-phase clinical trials. But what I think is worth noting is that a pretty high percentage of the science that's being presented at ESMO actually comes from China—Chinese pharmaceutical companies sponsoring it, China's institutions running the clinical trials. And there's been a lot of discussion about the quality of Chinese data.Just recently, on September 23rd, Scott Gottlieb—who used to be, of course, the head of the FDA—did a very nice opinion piece in The Washington Post about the impact of Chinese drug development. The quality wasn't actually that bad—it was just less expensive. They were able to do clinical research much less expensively than we can here in Western society, if you will.So, it's not so much intellectual innovation—it's efficiency in getting answers out. His whole editorial is about: how do we reshape and reprioritize our own clinical research infrastructure? How does the opportunity of a, I don't know, a world turned upside down in terms of regulatory oversight, et cetera, give us a chance to maybe improve the process, to lower the cost of drug development, so that our innovation—which we really still remain the hub for—can actually be brought forward and not create some sort of global intellectual property war, which he refers to, but more: how do we keep up with the pricing structure and the innovations that are out there?So, I encourage you to not only look through the abstracts from ESMO—because there are some very important positive results from that—but also think a little bit about how we, in different parts of the world, even the playing field around the cost of new drug development. I encourage you to read that Scott Gottlieb Washington Post editorial.One of the big abstracts that will be presented is around MRD ctDNA testing and using that technology as a way to define who should receive adjuvant therapy and who should not. Of course, we are interviewing the lead author on that paper, so stick around for that interview. But we clearly can see that genetic testing may, in fact, have a major impact on making us more efficient on who should get adjuvant therapy and who should not.So, I do clearly think that's the evolution that's going forward. You wanna make sure to keep your finger on the pulse of MRD ctDNA testing in the decision-making process for adjuvant therapy and subsequent treatment.I'm lucky enough to be running a protocol here in the United States looking at MRD positivity in patients with colorectal cancer, and others are doing it in other diseases.One of the ways that could, in fact, make that much less expensive is digital pathology. Because it turns out that a digital image of an H&E slide—and there's some fascinating data around this—can actually predict risk almost as well as genetic testing. So, that's very inexpensive. It takes 20 minutes to scan it in, send it off to the computer, AI reads it back, and gives you a risk factor.So, I do want you to also keep a nose out for digital pathology as an impact.But maybe the most unsettled science that I saw in the last week actually was also in The Washington Post. Now, The Washington Post, in one issue, reported on vaccines killing children, our administration down the street is going to be talking about how evil vaccines are—continuing that discussion that their rising costs are gonna break us in the U.S. Our economy is so built around healthcare that the rising costs are eventually gonna break it. And the risk is that what I'm saying right now might land me in the same boat as Jimmy Kimmel—of getting fired. But you know, last night he was back on again. So maybe that will only be temporary. But the science I wanna talk about is this whole connection between, say, Tylenol—acetaminophen—and autism. And the only reason it says “Tylenol” is that Donald Trump can't say the word “acetaminophen.” And so many people out there are affected with autism over many, many decades—even well before Tylenol/acetaminophen was invented. But what really caught my eye is these smaller studies that have suggested that leucovorin—which is folinic acid, okay? It’s reduced folic ...
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    33 mins
  • Oncology Unscripted With John Marshall: Episode 21: Watching Vaccine Access Collapse in Real Time

    Oncology Unscripted With John Marshall: Episode 21: Watching Vaccine Access Collapse in Real Time
    Sep 16 2025
    [00:00:05] MedBuzz: Back to Being ‘Just a Doctor’John Marshall, MD: John Marshall for Oncology Unscripted, coming to you live from this big office. This is the biggest office because, you know, I've been the Chief of the Division here at Georgetown for 20 years. I didn't want the job when I was first offered it a long time ago. I ended up saying yes. Of course, that's a dramatic change in one's academic career—taking on administrative roles like this. You do get the big office, which is nice, but you also get a lot of other stuff. You know too much. You know who's mad at whom, you know who you need to recruit, and who you need to un-recruit—all of those things. You have the business side of a cancer business going on, and you're a doctor, and you're doing clinical research, and you're trying to educate everybody around you.About a year or so ago, I decided in my own head that 20 years is enough. And so, as of this summer, I have officially stepped down as the Chief of the Division here at Georgetown. My colleague and much smarter friend, Dr. Steven Liu—lung cancer expert, world expert—is stepping in to be the Chief of our Division, and he's already hit the ground running. The fresh voice is honestly already a positive. You can just hear the freshness of his voice and his attitude and his energy. You know, the Mayo Clinic actually has a structure where you can only be in a leadership position for so many years, and it has to turn over. And I really like that. It's sort of like what we hope our presidential terms will be. But who knows—that may change. But there's a limit: you do the job for a certain period of time, and then someone else steps in and gives you that fresh voice and fresh perspective. But that's not the traditional way of doing it. Most of the time, people hold on to their position as long as they can hold on to it, until they can't do it anymore or they decide to go to some other institution.But the reason I'm sharing this is that I'm now in this sort of weird new place. I'm an ordinary staff physician. All of a sudden—yep. I have my patients, I'm doing my thing, I'm putting people on clinical trials, I'm educating the brand-new fellows who just showed up here about a month ago. Great fun having brand-new fellows 'cause they don't even know how to spell 5-FU, much less how well it works, how it works, and the side effects, etc. So, I love the first few months 'cause you're teaching people a lot of new things that they need to know. But anyway, that part's very exciting. So, I'm still doing all of that.But what I'm gonna have to get used to is not knowing everything—also not feeling responsible for everything. And that's gonna be a change for me. So, any of you out there who've either been through that transition or who maybe wanna offer me some therapy—I'm in line for some therapy as I transition, as I begin to slow down my academic career, withdrawing as the Chief of the Division, but still doing my day-to-day job and still trying to cure cancer.Take care of each other out there. Take care of your bosses and those leaders. It's not a great, fun job. But also, remember: those of us who are now back in the trenches—we need to take care of each other as well. John Marshall for Oncology Unscripted.[00:03:35] Editorial: Watching Vaccine Access Collapse In Real TimeJohn Marshall, MD: John Marshall Oncology Unscripted. First piece of advice: don’t read the newspaper. Second piece of advice: don’t watch C-SPAN, for sure. Just yesterday on C-SPAN was the big congressional hearings. I did read the summary of it in The Washington Post, where RFK Jr. was interviewed—cross-examined for three hours by both sides of the aisle—about what he has been doing with the CDC. And I think we all, as medical professionals, need to take a big step back and a pause and sort of ask: what the hell is going on?You know, the specifics first. He fired everybody at the CDC. He has hired new people at the CDC. They have not come forward with any formal vaccine recommendations. This is all about vaccines and the like.Yesterday in clinic, a patient of mine—who would be a candidate for both flu and COVID vaccines, who could have, a month ago, walked into CVS and gotten both of those injections—now, in the state of Virginia (and I think there are about 14 other states where this is true), has to have a prescription. This came out from CVS and Walgreens—that you have to write a prescription. Physicians have to write a prescription so that patients can take it to the CVS and Walgreens to get their vaccines. Some states are not providing them at all. Some states have gone the other way, where they’ve formed collaborations—and this is those cool West Coast states: Washington, Oregon, Hawaii, California. They’ve formed a consortium to say, “We are gonna set our own policy,” because the government’s policy right now is up in the air about whether you can get access to them, whether...
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    20 mins
  • 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