Episodes

  • 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
  • Oncology Unscripted With John Marshall: Episode 17: Badges, Booths, and Buses: Welcome to ASCO 2025

    Oncology Unscripted With John Marshall: Episode 17: Badges, Booths, and Buses: Welcome to ASCO 2025
    May 28 2025
    Badges, Booths, and Buses: Welcome to ASCO 2025John Marshall, MD: John Marshall Oncology Unscripted. You know what this is? Yeah. You know what this is. This is my ASCO badge. It is that time of year again where I. I don't know, 40, 50, 60,000 of us and our closest friends all fly up to Chicago, stay in hotels that are overpriced, get bused around downtown Chicago, even on Saturday and Sunday. We get in nice clothes. We go to the convention center. We probably share a virus or two, but we mostly share important new information around the world of cancer. Maybe the most important cancer meeting there is on an annual basis, both from a social but also professional level do we gather to really exchange ideas and hear what's happening out there in the world Now. I also in my badge, got this, a 30-year member, God. know what that means? I got one also called ASCO Ambassador. I'm not even really sure what that means. Maybe I owe 'em money. I don't, I don't know what that's all about. I got my thing that I'm gonna submit to win whatever it is they're giving out, this year at ASCO. So, I've got all my equipment, I'm ready to go.Titles of the abstracts have been released, and there's a lot of really cool information. I know we've been kind of having a sub-theme around pancreatic cancer, last few episodes and during the oral presentations, there are three very important, probably practice changing abstracts around pancreatic cancer, around perioperative treatment for resectable pancreas, cancers, novel therapies that are being brought to the table for pancreas cancer. So, whether you're going or not, you need to know what happened at ASCO. And so, stay tuned because we're also going to be broadcasting from the meeting, and we'll of course follow up with some of the key data post ASCO. Now, most of us, when we think about ASCO, we start with what are the plenary papers this year? And there are five. Two of the five happen to be GI. That's, that's a record. I think for us. Normally it's all breast and then maybe something else. But two of these five are in fact, GI cancers. One is around immunotherapy in the perioperative setting of gastric cancer. Gotta be positive. It's why it's in the plenary session. The other is not news in some way, but, God, if it had been negative, we would really need to rethink things. It's using IO therapy in the adjuvant setting for MSI, high mismatch repair deficient colon cancer. Important study around head and neck and immunotherapy. So, big, continued theme around immunotherapy, incorporation, some targeted therapy in breast cancer. Again, positive. Yet another positive breast cancer study, and the last is around polycythemia vera. Have to kind of throw something to the heme team there. So, it looks like a very interesting year for new data and new research.But if you are thinking about ASCO, I mean. Will people be going? The United States is not the favorite place to be, particularly if you're from another country right now, a huge number of people usually come from around the world. I'll be interested to see do they decide to come, or do they decide to stay home because they're concerned about being in the US and feeling vulnerable at a time when nobody wants to feel vulnerable.Have you ever been to ASCO? It's a zoo. It's a huge convention center, like I say, 40, 50,000 people that are there. But you keep crossing people that like, you know, we did fellowship together, or I know you, you're a friend of mine. Let's stop and talk for a second. Or let's just wave at each other and remember that each other still exists. It's a wonderful experience and if you've never been. You should absolutely go. If you've been every year for the last 30 years like me, then you're eager to go back and see all of your friends and show off your new comfortable shoes and your new tie.ASCO has become more commercial. If you've ever been in the big area, the booth area where all the displays are, they're just remarkable and they have to be divided by US and EX-US because of the different rules. Although still, I've never seen one as quite as good as one I saw early on in my career where they actually had a flowing fountain of water through the entire exhibit. because it was a medicine to help dry mouth and so this water was going to improve your overall feeling, this water in the desert, if you will. I don't even think that drug actually ever really stuck around. But, anyway, they had the best booth, the most remarkable booth that I have ever seen, but it's still pretty commercial, pretty crowded. A lot of people crosstalk on the academic side as well as on the corporate side.I was talking to a company the other day and they were saying that a very high percentage of their business actually gets transacted while in Chicago. Not just ideas exchanged in a follow up email or a call later, but they actually do the discussion and sign on the dotted line while they're in Chicago. So, a lot more closure at ...
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    32 mins
  • Oncology Unscripted With John Marshall: Episode 16: No Evidence of Disease—No Need for the Knife?

    Oncology Unscripted With John Marshall: Episode 16: No Evidence of Disease—No Need for the Knife?
    May 12 2025
    No Evidence of Disease—No Need for the Knife?John Marshall, MD: John Marshall for Oncology Unscripted. Let's talk a little science and cancer medicine. I’m gonna come at you from a little bit of a different angle. Yep. A GI cancer angle, but a little bit different.We have long felt in order to cure GI cancers, we had to do surgery, that it was the only way to ultimately cure people. But we all know that when we do neoadjuvant something could be chemo chemoradiation. we operate. A certain sub portion of the patients have no evidence of disease in their pathology specimen, and we sort of say, we just put somebody through a big operation gastrectomy, esophagectomy, could be a Whipple, could be a rectal surgery that they actually didn't probably need or benefit from, but we had no way of determining that until we did surgery. And so, as you know as well, there's increasingly neoadjuvant therapies for a bunch of different cancers. People are having good clinical responses where after the neoadjuvant treatment, by scope or by scan, and now by new blood testing, we can't find evidence of disease. We're torn about whether we can simply watch and wait that patient and see their cancer comes back, or do we have to operate anyway.And there's a new paper that just came out, that I used actually in last week's tumor board here at Georgetown about watchful waiting in esophageal cancer versus surgery. So basic story, neoadjuvant treatment, everybody got it. If you had a complete clinical response, you were randomized, so not done in the United States. We'd never pull it off here, were observed for clinical recurrence and not operated on unless they had a recurrence. The other half were operated on, and then they looked for survival. And believe it or not, there was no difference survival outcome. So, some of those people avoided a surgery that they didn't need in the end and no impact on the survival. Now we still need to do better because it's still pretty crummy survival in this group of patients whether you had surgery or not, but still no difference.In rectal cancers, we are increasingly not doing surgery. I've got a 35-year-old woman who had a very good initial response, a very good response to chemoradiation, no clinical evidence of disease. Doesn't want a colon surgery and a permanent ostomy, as you might imagine, at 35 years of age. And we've been doing watchful waiting, including doing MRD testing, and so far, nine months with no evidence of disease. And I'm sure all of you have patients like that. We are also, of course, doing this in pancreatic cancer. And the reason for obvious reasons is that it's a difficult operation. A lot of people don't want the operation. More often, it's because of where the tumor is. It might be grabbing onto a blood vessel that the surgeon doesn't really think they can get around. Or it might be that the risk of the surgery is just too great for that individual patient. So, we are doing neoadjuvant treatment. We are doing radiation, sometimes maintenance after, sometimes not, and observing. And you, like me, have had over your career some patients whose tumors never regrew and maybe just maybe got out of the need for surgery. So, this then brings up. What are the right treatments? How do you pick which patients should have surgery, which you're not. The current neoadjuvant study that's in the cooperative groups here in the United States is surgery first versus chemoradiation first, followed by surgery. Should we begin thinking about a no surgical arm in this group of patients? As our drugs are getting better, as we are learning more about targeting RAS and BRCA and the other molecular targets that we have. Will we get to a place where we can actually increasingly avoid what is fairly morbid surgery? Let's particularly think about pancreas cancer, in this regard, because remember. It's very good at sowing early seeds. It's very good at metastasizing early, and in fact, only one out of 10 is found with resectable pancreatic cancer at initial diagnosis most have already spread. So, the value of that resection, don't get me wrong, it is the way we cure people, but the relative value of that resection in the global scope of pancreatic cancer is increasingly in question. So, as we pick therapies, highest response rate, three drug combinations, 5-FU, irinotecan, liposomal irinotecan, and oxaliplatin. Highest response rate, highest survival in the books for metastatic disease. As we use regimens like that in the neoadjuvant setting, as we add to those regimens with new targeted therapies, I do think what we will see is more and more opportunities for observation in that patient population.We held a think tank here at Georgetown back in the fall where we invited people from all over the country who were experts in this field to think about this issue and the consensus among, what I think are some of the smartest people in the world around this subject was, that yes, indeed, the ...
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    35 mins
  • Oncology Unscripted With John Marshall: Episode 15: We Funded the Cure—Now We're Pulling the Plug?

    Oncology Unscripted With John Marshall: Episode 15: We Funded the Cure—Now We're Pulling the Plug?
    Apr 16 2025
    We Funded the Cure—Now We're Pulling the Plug?John Marshall: Welcome to Washington DC. My name is John Marshall. This is Oncology Unscripted. There is a whole lot of stuff going on out there, seemingly unscripted, seemingly without much in the way of a sense of motivation, really a plan. It's just blow it up. Let's see what'll happen after the fact. But let's stop for just a second and think about what science, federally funded science, has accomplished over the last many decades here. Because a lot of us, including a lot of the population as well as the government, feels like, it was really business that did everything, not the government. So, we should shift all of this money over to business and take it away from the government. So, they're firing all sorts of people here in Washington and around the country with the science community.But let's start by acknowledging what science has done for our health. So first, we know that cancer mortality has fallen dramatically. If you think about when I first started as a fellow a thousand years ago, really the only investment in clinical translational research was through the National Cancer Institute, occasional company here and there, and all of this improvement that we're seeing today comes really from that beginning, and so we've had a clear, positive influence. But let's look at some of the details here. The concept of, I don't know, rituximab, immunotherapy, and multi chemotherapy treatments, and the cures for lymphomas comes out of government invested research, bone marrow transplant comes out of government investment research.How about understanding HPV and using vaccines? I know. Vaccines are crazy things that we shouldn't be giving because they're terrible things, right? According to the current government. But let's talk about the discovery of HPV and vaccines, which is going to get rid of HPV-mediated tumors. What about imatinib? Remember that drug that was really out of the beginnings, of government research? But you know what? One of the ones that's my favorite is actually HER2. HER2 was discovered with government funded research, the therapies for treating HER2-targeting, transforming it from just a bad target, prognostically bad target, to something that actually is good news nowadays because we know how to treat it well. That was all done with government research, right? And so then here comes swooping in a pharmaceutical company under the name of Genentech that took it and made it into a billion-dollar profit that helped to fund other research.And so, we have failed to value the innovation that comes from the government world, and there's just so much of it out there. And over the last month or so, there's been this dramatic downsizing of grants, grant applications, payment for grants that are funded, downsizing the number of people who are at the National Cancer Institute and other places around the world where there is federal funding for these with the, with the idea being that that's just wasteful, I guess that's the thought. We know that the NIH investment has fueled a great deal of economy in all of the places that it's ongoing. So, not only is it producing science and our understanding of the biology of cancer and other diseases, it is also helping the local economy. Then what really got me going on, this was an ad. I'm pretty sure you're probably seeing them too, at your home for our new president and our new, folks that have taken over, ruling our country in a completely different way. And in fact, this team had the boldness to put out an advertisement that in four years they will cure cancer. You should watch it. It's just unbelievable. If they're going to fire all of these people who are the brains and the brain trust and the innovators and they're not going to fund the science that's teaching us what we need to know in order to actually cure cancer. We're going to get rid of all of those people and somehow through some other mechanism, they are going to have cured cancer in four years. So, what have we got to worry about? Right? This is going to be all fine because don't you worry our boss is going to cure cancer.Speaking of cancer that we need to cure. We've been talking a lot lately about pancreatic cancer and what a difficult disease it is, and despite great deal of investment and positive input around it, we've made some strides, but not the kind of strides we need to make. But I do want to reinforce the progress that we have made. I've been thinking a lot about pancreas cancer comparing to colon cancer. I'm still giving the same adjuvant therapy I've been giving in colon cancer for 21 years. That's an embarrassing statement. On pancreas cancer, we have made progress. We know the drugs that are working there better. We are curing more people with pancreas cancer. One of those innovations is liposomal irinotecan, and the idea that you could take existing drugs and improve their performance by modifying their delivery and...
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    26 mins
  • Oncology Unscripted With John Marshall: Episode 14: The Gender Gap in Genius: Why Credit Still Isn’t Equal

    Oncology Unscripted With John Marshall: Episode 14: The Gender Gap in Genius: Why Credit Still Isn’t Equal
    Mar 26 2025
    Published, Performed, Passed Over—Because Science Still Has a Gender Problem[00:00:05]John Marshall, MD: John Marshall, Oncology Unscripted. It's unscripted because you can't make this stuff up. I don't know if your week or the last two has been anything like mine, but our country and our science and healthcare, and all of that stuff, is really undergoing an incredible number of changes so quickly that we can't even catch up with what the impact will be. And maybe It's only because we're in health care, but I gotta believe that the impact that all of these changes these edicts that are coming out on Friday afternoons are going to have are going to have on science on the future of discovery on curing cancer we're really feeling that threat. And so, what I wanted to do is talk a little bit about that uh, today in our current episode. Now, our main theme today is about the imbalance of credit in the scientific community. And we've really drilled down on the topic around women in science. And how they, over the decades, century, has not really been able to get the same credit as men. But we have to talk about all that's been going on just in the last one to two weeks. You know, we went from the freeze that we've already talked about to now this cutting of people, just firing a bunch of people. A bunch of people at the FDA. A bunch of people at the NIH. A bunch of people at the National Cancer Institute. And these are essentially all levels. Some of them leadership levels, some of them mid, some of them are the earliest hires, those within their first couple of years were fired on a dime, no matter what role they were playing. One person that I know, I used to coach her in basketball when she was a young woman. Now she's a grown woman and she's an epidemiologist working at the FDA. And because she's only a year and a half into her career, she was fired on Friday afternoon. And what she was doing was reviewing medical devices to make people better able to get around. Accessibility was what she was all about, and now no one's doing that job. So, I don't know, will there be no improvements in accessibility because those people are not there?We then had the cap on indirects applied. All the cancer center directors got an email around that. All the medical center leaders and academic center leaders got the email. And so, we're all scurrying around to see what can we still do moving forward. What do we have to stop on a dime in order to keep the books open and to keep everything going the best we can. What will be the future of research and science in the current world without all of this infrastructure?Diversity, equity, inclusion, and accessibility. Gone. Right? So, if we can't have that, how will we acknowledge and credit those folks whose role it is to make sure that we are hiring the best person, not the person who looks like the last person, right? So, quality and qualifications are what DEIA was all about. Not about what others seem to think it's all about. So how are we going to maintain that and will the quality of those folks that are in these positions therefore fall because we're not hiring the best people.MedBuzz: Welcome to the Healthcare Hunger GamesJohn Marshall, MD: In our world here in Washington, we've been on this wild swing back and forth where, one Friday, we think that our fellows are no longer going to be hired, that they're going to all be fired. All trainees within the NIH are going to be fired. That was the word. Then it was like, no, we think they can stay, but then, later on this week, it's back on the table. So, we're being called to immediate meetings to say, well, are we going to have fellows from the NIH or not going forward? And if you think about what that would do, not only to them as individuals, but how about all the people that they are taking care of, all the people that are on clinical trials that are getting lifesaving care for cancers and other illnesses that those fellows are critical in providing their care and learning as for the next generation, and so I don't really know. where we are. I've been in cancer center meetings all week long about what we can keep, what we're not going to be able to keep. What sorts of progress can we make? Is it worth writing grants anymore? Should we just give up on this for the moment, tread water and wait, and see? My wife went down to one of the protests, and I know they happened all across the country and there were a lot of people there, who came out all across the country to say, none of this makes sense. This is not good for each other. This is not good for us. And most of us are sitting around thinking, well, who is it good for? Why is this being done? Is there a methodology? Is it just random? Is it just random rich people who are playing with us? Is it random rich people who are reducing government so that they can reduce taxes so they can have even more money? We don't know. We don't know if there's a strategy here ...
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    43 mins
  • Oncology Unscripted With John Marshall: Episode 6: The Weight of The White Coat: Battling Burnout

    Oncology Unscripted With John Marshall: Episode 6: The Weight of The White Coat: Battling Burnout
    Feb 20 2025
    THE WEIGHT OF THE WHITE COAT: BATTLING BURNOUTHow Do Middlemen Impact Our Practices? [00:00:00]John Marshall, MD: Welcome back everybody to Oncology Unscripted. It is August and if you're lucky like I am, August is vacation time for me. I am at this beautiful place somewhere in the south, somewhere near a golf course and an ocean; a little river flowing right over there, some egrets and an occasional pelican flying by. There are fruity rum drinks, most evenings, which makes for a very pleasant time away from work. So, I'm on vacation, and I hope you guys have gotten some time away.We're going to focus on in the second part of our series of three programs on the middlemen in our lives. The last episode, which many of you have commented on and have watched, is around pharmacy benefits managers; their role in our healthcare system and how they've inserted themselves and made a bunch of money and not necessarily adding value. Today, we're going to riff a little bit along the electronic medical records, certainly a middle thing in our lives that many of us are sort of frustrated by. And then our next episode will focus on clinical research organizations that I know many of you can be frustrated about, as well. Silent Crisis: Can You Admit You're Burned Out? [00:01:27]But, to set up this EMR vacation setting. I think we ought to talk a little bit about the concept of burnout. Now I'm on record as having officially burned out. It was in, really, 2018, 2019. I didn't really know it. I just thought I was grumpy because I had good reason to be grumpy. But it was actually my wife and my daughter who noticed that I just wasn't my same old self. I had lost my sparkle. And I thought a lot at that time about my own personal burnout: therapy, I ended up taking a sabbatical, my wife and I wrote a book. We had to get away for a while in order to deal with that. 30 years of being an oncologist is a big deal. And then I started to look into this issue of burnout and realized that lots of us in our space have a lot of burnout. There's some studies that have been done and basically looks at, sort of, not only our burnout, but how are we dealing with burnout. And given that I'm on vacation, I thought it would be kind of useful to look at some of the data for us around vacation. And we don't take very much vacation. And when we do, we actually work. Like this morning, I actually have already seen four patients in tele visits. God help us. So even though I'm on vacation, I'm still working. And I bet many of you do that the same way. So, in this survey. 60 percent of us as physicians, we're only taking 15 days or fewer per year. That's terrible. With 20 percent of us, one in five, taking only five vacation days a year. And most of us, when we're on vacation, like me right now, 70 percent of us work every day of a typical vacation. We do something. We check email; we do something while we are on vacation. And a third of us will spend more than 30 minutes a day on work while on vacation. Now, looking at subspecialties, oncologists are a little bit better because 60 percent of us were taking about three to four weeks of vacation. But you get more vacation than that!Is Relaxation Worth Sacrificing RVUs? [00:03:46]I know as well as you know that we're disincentivized to take vacation, right? Because we are RVU-driven, and every week I'm not getting RVU's, I'm actually getting less money. So, if I take vacation, I'm actually making less money.Now, the other thing that sort of started happening more recently is this concept of paid time off PTO, right? Didn't used to be called that. It used to be called vacation. If you're in a business where when you're on vacation, you're paid, you're supposed to call it PTO. For those of us who don't have that sort of tracking system, we call it vacation. but it still makes me feel guilty, I guess.Are Your Patients and Staff Mad When You Go on Vacation? [00:04:32]Now, one other perspective that I learned the hard way when I took my sabbatical is just how angry patients get when we're on vacation. Our staff also is angry at us when we're on vacation because we're not immediately available and they depend on us in order to, you know, do the day-to-day stuff we have to make decisions here and there. And our patients, particularly when we take a longer vacation, do get kind of fussy at us. Well, you know, as soon as you get back, let me get in to see you, or I need to see you right away. So right before and right after vacation, we clearly pay the price, by, you know, all the catching up that we have to do when we are away.PROMISES UNFULFILLED: THE EMR PARADOXDo You Love or Hate Your EMR? [00:05:17]Now, the new one that I think is the most kind of creepy of all is that of course our patients have access to their electronic medical record, right? Our topic for today. And so, they can look up their results or they can wait on, you know, they can find what their CT scan showed or their CEA level or ...
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    15 mins