Oncology Unscripted With John Marshall: Episode 13: From Science to Survival: Dr Marshall Sounds the Alarm on the Dangerous Freeze on Cancer Research

[00:00:05] John Marshall, MD

Hello, everybody. John Marshall from Oncology Unscripted. Do you know where I was this past weekend? I was in San Francisco. It's actually pretty nice weather there in San Francisco. I go pretty much every year. In fact, I have gone to every GI ASCO. 

Skipping This Test in Frontline Metastatic Colon Cancer? That’s Malpractice.

[00:00:24] It's really usually my first business trip of the year. Usually, the weather out in San Francisco is kind of rainy and gloomy in the fifties, but it was pretty sunny compared to here out east where it was cold and snowy. So it was kind of good to get away, but that's not really why I go. It's also not a meeting you go to learn a lot of new science. That's usually ASCO and ESMO and other places. Occasionally there's some data, and I'll talk about some of that in just a minute. The reason most of us go to GI ASCO, and I with my perfect attendance at GI ASCO, is to see the people. The GI cancer community is very, very close. Some of us argue that that may be why we haven't made more success, but we are a very, very close community. And this gives us an opportunity to get together, share meals, share ideas, compare notes, and become better at what we do through our camaraderie and our collaboration. 

But I do want to make sure and give you the highlights of what happened at GI ASCO. Now the first, and this has really been true for many, many years there is I've been very discouraged, as you know, in the progress that we're making in GI cancers. For example, colon cancer, I have been giving essentially the same adjuvant therapy for colon cancer for 20 years. There is no other cancer where we have failed to make some advances in adjuvant therapy over the last two decades. Essentially, until a paper that was presented in San Francisco, I had been giving the same frontline treatment for metastatic colon cancer until now. Yes, we had MSI, but that's kind of its own different disease. But now what we have is a 9 percent wedge of colon cancer that has BRAF V600E mutations. I remember, because I'm this old, when it used to be bad to be HER2-positive for breast cancer. Now, you want to be HER2-positive for breast cancer because we know how to control that pathway, right? It's a good thing when you're HER2-positive. 

BRAF, for a long, long time, was just bad news. We had nothing we could do for it, and it was just a bad prognostic marker. So why would you care about knowing? Now you have to know because now we have frontline therapy, proven combination BRAF, EGFR therapy with chemo, big increase in response rate, big increase in Overall survival, new FDA approval that you have to know about for BRAF patients. So no longer can you wait till later to do your RAS and BRAF testing in colon. You have to, or it is malpractice if you don't- yes, sir, yes, ma'am. You need to do it frontline so you can incorporate your frontline treatment of your patients because now that BRAF has some drugs to target to it, we can, in fact, improve the outcome for those patients. So, for me, that was the biggest data set that was out there. 

Let me share two other high-level observations. And that is one that we were part of, but others have also shown a similar data set, is that does specialized care is only seeing GI and not knowing anything about breast cancer and lung cancer, et cetera. Does that make me a better doctor? Does it make our team have a better product than if you're a general practitioner who's having to see all of the new treatments and understand all of the nuances all at once? And there's a couple of different beliefs in this. One is that as long as you're practicing the guidelines, as long as you're following the rule book, you in fact do just as well as those who are writing the guidelines and writing the rule book. But some new data we presented and others also presented there suggested that if you are a specialist, things like proper molecular profiling, time to treatment, those kinds of things, can overcome even social determinants of health, which, by the way, with our new administration, there are no imbalances in social determinants of health. That's all gone. it's just wiped away. But those of us who know they still exist; specialization might allow you to prioritize that. So then the question becomes, how do we connect our specialists, those who live one disease day in and day out, to our community docs who are doing most of the work of treating most of our patients in this country and doing a fabulous job. How do we help them? How do we help them to do even better out there with making sure our patients get the best care? And that's our next step of going forward. And that was a theme that came out of the ASCO GI meeting. 

But the last piece I want to really emphasize, and this is again back to that frustration of