MedBuzz: After a trip to the Galapagos, Dr John Marshall reflects on evolution in nature, cancer, and medicine. From Darwin’s observations to the rise of AI and precision oncology, he explores how rapidly cancer adapts, how technology is reshaping care, and why the future of medicine must still preserve the human touch. Main Topic: In this episode of Oncology Unscripted, Dr John Marshall reflects on a practice-changing cholangiocarcinoma study from China and what it reveals about the rapid evolution of cancer research worldwide. As novel therapies transform care and China expands its investment in science while the US devests, he asks whether we can keep pace and the impacts of the global evolution of in oncology. Interview: Watch now as Dr John Marshall sits down with Dr Louis Weiner, director of Georgetown University’s Lombardi Cancer Center, for a candid conversation about leadership, scientific change, and the future of oncology. Reflecting on innovation, institutional transition, and the pressures reshaping cancer research, they explore what it means to evolve as a leader and honoring the work and the people.
MedBuzz:
After a trip to the Galapagos, Dr John Marshall reflects on evolution in nature, cancer, and medicine. From Darwin’s observations to the rise of AI and precision oncology, he explores how rapidly cancer adapts, how technology is reshaping care, and why the future of medicine must still preserve the human touch.
Main Topic:
In this episode of Oncology Unscripted, Dr John Marshall reflects on a practice-changing cholangiocarcinoma study from China and what it reveals about the rapid evolution of cancer research worldwide. As novel therapies transform care and China expands its investment in science while the US devests, he asks whether we can keep pace and the impacts of the global evolution of in oncology.
Interview:
Watch now as Dr John Marshall sits down with Dr Louis Weiner, director of Georgetown University’s Lombardi Cancer Center, for a candid conversation about leadership, scientific change, and the future of oncology. Reflecting on innovation, institutional transition, and the pressures reshaping cancer research, they explore what it means to evolve as a leader and honoring the work and the people.
MedBuzz: What Can the Galapagos Teach Us About Cancer, AI, and the Future of Medicine?
John Marshall, MD: Hey, everybody out there. John Marshall, Oncology Unscripted, having just come back from the trip of a lifetime. Went to the Galapagos with my wife and our friends. Talk about a boat full of science nerds. We did the National Geographic tour, and everybody was a science nerd there to see what was going on in the evolutionary world and to reflect on the past.
I did a little studying in my preparation to go. I’d, of course, read The Origin of Species a long time ago. We all should have read that. But I was also reading some other books about Darwin and his going there in 1835 and the impact of his science. And I was thinking a lot about the past and the science of the past and what they knew, and they basically were having to observe patterns. And the physician was incredibly important in trying to pull out the history from the patient because we didn’t have that much we could do for people except try and make diagnoses based on history. We didn’t have lab tests, and we didn’t do much surgery and certainly didn’t have much in the way of medicines, and we were dependent on our relationship to the earth.
And, by the way, I do want to give you a little shout-out to this book, if you’re looking for a book to read, called Braiding Sweetgrass by Robin Wall Kimmerer. My daughter gave me this book, said, “Dad, you need to read this.” But it’s all about our relationship to the earth and how we nurture one another and how we’ve sort of forgotten that relationship.
And, of course, that fed perfectly into the visit to the Galapagos. But what I was also thinking was on the other side of this coin, and that is the future of medicine. And now we have not only genetics and precision medicine and CAT scanners, we have AI, which is going to cause an evolution going forward, and the importance of needing to hold on to the past, remembering the past, not the made-up history that’s being recreated, but remembering our past in science and in healthcare so that we go forward using our new technologies to our advantage.
There’s been recent papers on this subject around AI, and are physicians just going to go away? Will we still be important, or will the computer modeling replace us completely? You know, radiologists are nervous they’re going to get replaced. Certainly oncologists feel less nervous because we’re so interpersonal. And how could a computer do that? Let’s be honest. A computer probably can do it, and probably do it maybe in some ways better than we do day in and day out.
So where will the physician role be as AI evolves moment by moment, where we’re all using it, right? We’re all logging in to answer a question or even take a test when it’s legal to use your computer to take a test. Many of us are using it. Certainly for patient care we’re using it. Our patients are using it to check on our recommendations. And so we clearly see this rapid evolution in how we are delivering cancer care.
Is evolution slow or fast? We were taught that it takes millions of years to develop a new species. But there was a family that was at the Galapagos. They went for 30 years, and they were able to show that even within 30 years they could see changes within species. You might want to take a look at this explorer in short pants, probably in a bad hat, talk about the speed of evolution and our current impact that it’s having on us.
How quickly could you evolve in this moonscape of a place called the Galapagos Island? We used to say that it took millions and millions of years to evolve, but a family came here and studied over 30 years. They could demonstrate in a very short period of time the actual world of evolution. And this is what we deal with in the world of cancer today.
Very rapid evolution, very rapid selective pressure under the treatments we are giving. The cells that emerge are then resistant and can survive. And so that’s what has happened here in the Galapagos Islands. We need to figure out how to crack that evolution in our clinics tomorrow.
Young people with colon cancer was not in existence 30 years ago, and now it is. So is that evolution? Is that natural selection? Is it unnatural selection that we’re forcing, and what the human role is on all of that?
We need to be reflective back to our relationship to our planet and those around us and our role as stewards, but also as participants in the evolutionary process. So I hope you, too, can reflect back on the past. Take those lessons learned to the future. Yes, use the new technology to its fullest, but don’t forget that human touch that’s going to be so important for us as we move forward in our own personal evolutionary journey.
John Marshall, Oncology Unscripted.
Galapagos videos
John Marshall, MD: John Marshall, Oncology Unscripted. Been thinking a lot about natural selection because guess where I am? I’m in the Galapagos Island. But natural selection is actually kind of a vicious thing. It is survival of the fittest, the ones that make it to the top.
Now, the reason they figured it all out here at the Galapagos is it’s a very challenging environment, and creatures from other places got here and had to evolve quickly, very quickly, in order to survive here in these waters and on this land. But now there is not much in the way of natural predators because the ones that made it, in fact, are the ones that can survive. There are very few predators out here. So they’re very trusting, and I think about what we do in the world of cancer care day in and day out.
And isn’t that also natural selection? Cells get mutations. Those mutations cause those cells to be able to survive better than the cells around them, actually spread from one place to another and grow over there and survive, ultimately killing the host if left unchecked. And our whole job is to try and kill just the right ones, leaving the other ones safe and sound to survive to another day.
And we’re influencing this by trying to influence natural selection. But that’s what they’re doing here. That island right there has the land iguana on it, that it actually died out because people had come here, but then some smart people figured out, some naturalists figured out, how to grow ’em, and then put ’em back on the isle.
And then we went and saw them this morning. They’re beautiful, golden, almost orange iguanas, land iguanas. Beautiful. Not beautiful. They’re really cool, though, that’s for sure. So we are influencing things. And so what’s natural selection, meaning that’s what the world’s supposed to do, and then what’s human-influenced natural selection, stuff we’re trying to change or alter natural selection?
Isn’t that what you and I try to do day in and day out when we’re treating our patients, is trying to undo something that was actually driving what may be natural selection? I realize this is a sticky subject.
What’s natural, what’s not? What are we trying to influence? What are we trying to alter? Certainly we don’t want our patients to die. Certainly we want to interfere with cancer as best we can. That’s our mission. That’s what we do. But there are times that I also think the naturalists here are doing very much the same thing that we’re trying to do, is reset, get it back the way it was before we messed it all up.
Somewhere along the way, more to come from the Galapagos and maybe some more on natural selection. John Marshall, Oncology Unscripted.
John Marshall, MD: John Marshall, Oncology Unscripted. What Darwin saw when he came here for the first time was that creatures could evolve from one to the next. There’s a beautiful little yellow warbler that was evolved. You see the giant tortoise there in front. That’s not the original version. That’s the version that evolved over time. And Darwin was the first one in 1835, was only here for five weeks, to see that this phenomenon of science was happening. He had no idea why. He had no idea about DNA. It took 150 years for anyone to figure out about DNA and the mechanics of evolution.
The principle of scientific evolution was controversial, right? Because you had creation on one side, and on the other side you had this new science of evolution, of natural selection for the reason that we were here. And even Darwin himself had to wait 20 to 30 years to publish his book in order to have the confidence to overcome the current belief that evolution did not exist. That creation was the only way forward. And we are in a similar place today in our world where we’re seeing new science, and yet the public is against science at the moment, and we have to be careful not to repeat ourselves the same way with Darwin. So more to come from Oncology Unscripted.
John Marshall, MD: Hey, everybody. John Marshall for Oncology Unscripted. I am right here on the Galapagos Island, and I want to interview yet one more famous scientist. This is a guy named Charles Darwin, and he came here and he observed something for the first time. It came to him. It was sort of an epiphany, and I want to ask him about it, but he’s feeling a little flat today.
John Marshall, MD: Hey, everybody out there in internet land. John Marshall for Oncology Unscripted. I’m here in the central island of the Galapagos, and if you can’t tell, there is one of the little beautiful creatures that lives here, a giant tortoise. Now the question is, how did it get here? One side of science for a long time believed that God put it here, these are very young islands, and that God placed it here. Another side of science said this beautiful creature was floating in the ocean for 500, 600 miles and landed on this island and evolved from that original trip through the water. And there was a contentious debate about how this creature got here.
So you know what? We do interviews on this program. So let’s ask it how it got here. Mr. Giant Tortoise, can you remember back how your people originally got here onto this beautiful island?
Mr. Tortoise: Well, yes.
John Marshall, MD: Well, can you tell us a little bit more? Was it God plunked you here, or did, in fact, you float up from somewhere else?
Mr. Tortoise: Well, some of it’s kind of a blur to me.
John Marshall, MD: Do you remember back when man first came here, when people first came here? What was that like?
Mr. Tortoise: Well, as a matter of fact, I knew Charles Darwin. Charles Darwin was a friend of mine, and you, doctor, you’re no Chuck Darwin.
John Marshall, MD: Well, that is no question. That is true, that I am no Charles Darwin. From the Galapagos, Oncology Unscripted.
Are We Watching a Global Evolution in Cancer Care Leadership?
John Marshall, MD: John Marshall, Oncology Unscripted. You know, I still get journals. I think I’ve mentioned that before. I still get the actual paper copy. And this one came into my inbox, into my mailbox, just yesterday, and I was scanning down and I found a paper that actually, in my field, it’s in cholangiocarcinoma, that was looking at perioperative, preoperative, neoadjuvant treatment for cholangio, and it’s in the New England Journal.
And you would’ve thought I would’ve already known the result, and maybe I’m just not paying attention. So I went to page 983, and I saw that neoadjuvant chemotherapy along with lenvatinib and, by the way, a PD-1 inhibitor preoperatively had a major positive impact on overall outcome in cholangio.
And I’m like, how did I not know about this? And I looked at the authors, and I looked at where this study was done, and I realized the paper was done in China. And we’ve talked on this program before about the impact of research that’s being done in China on all of us. First, we were skeptical of Chinese data. Now it’s in the New England Journal. It is an important article and probably practice-changing for us in bile duct cancers.
We talk about competition and new science and who’s discovering what and being somewhat envious of the Chinese product that’s coming out. But let’s also remember that the Chinese are doubling down on their investment. Their patient population is participating in this innovative science, whereas here in the United States, new budget numbers say we’re going to decrease the investment in science and science research, cancer, and everything else as well.
So how can we compete when they’re increasing their investment and we are devaluing the science and investment that we’re putting in there? So we’ve got to come to terms with this in order to move forward.
I think about our acceptance of this. We’ve been fighting it, but now we’re accepting it.Even our current administration is embracing the idea that we’re going to have to figure out energy. Maybe it’s solar energy to keep up with the Chinese, not just to beat the Chinese, if you will, but to keep up with the Chinese.
So I’ve been reflecting a lot not only on this paper and the rapid evolution that we are seeing in novel therapies as new drugs, targeted agents, and immunotherapies are moving into every corner of cancer care and other diseases as well, but also our sort of relationship with others around us on this planet and how we, instead of competing—healthy competition’s okay—but instead of competing economically and medically and scientifically, how we work more and more together as a group. And I don’t think the current environment is sustaining that or supporting that.
Hopefully it’ll evolve over time to where it improves. Fingers crossed. I would like to see it in my lifetime. Not holding my breath, however. But I do think it’s the way we should be going. John Marshall, Oncology Unscripted.
The Evolution of Leadership: A Candid Conversation With Dr Louis Weiner
John Marshall, MD: Hey, everybody. John Marshall, Oncology Unscripted, and as you know, I get to interview the smartest people in the world for this part of my day, and there is no smarter person than—also my very good friend and my boss and my colleague, Dr. Louis Weiner. And so let me introduce you guys to the guy I’ve been spending the last two decades with here at Lombardi.
Dr. Louis Weiner, our cancer center director. Lou, thank you for joining us today for Oncology Unscripted.
Louis Weiner, MD: Thank you, John. It’s a real pleasure to be here with you today. Although I’m confused. You said you were interviewing the smartest people in the world, so I don’t think I qualify.
John Marshall, MD: Oh, no.
Louis Weiner, MD: I’m really happy to be here.
John Marshall, MD: We are so glad you’re here and joining us. And you know what really spawned all of this is, you know, I just got back from a trip of a lifetime to go to the Galapagos and was thinking a lot about science of the past 200 years ago, what Darwin could know, what he could write about 200 years ago without the advantage of all the science we have today.
You are having a little—I had a change of life with stepping down as the chief—your decision to step down as the cancer center director, evolution going forward. So it really inspired me to say, well, let’s talk about this a little bit. But let me first sort of set this up. So you’ve been a cancer center director, what, 20 years? Right around there.
Louis Weiner, MD: Eighteen years, preceded by 13 years as chair of the Department of Oncology at Fox Chase Cancer Center.
John Marshall, MD: But who’s counting, right? Eighteen years. Yeah.
Louis Weiner, MD: Years of performance reviews and budget analysis.
John Marshall, MD: So let’s start there. What was the worst part of being a cancer center director?
Louis Weiner, MD: I just told you. No. You know, so here’s the thing. If you take the job seriously, which I certainly do, what you care about, other than the broader mission, of course, are the people you work with and the people who look to you for guidance, support, and for help in their career journeys. And having to make difficult decisions about who stays employed and who I support and who I don’t support as much, you know, in terms of the available resources, that’s been painful. And I’m glad it was painful because if you stop feeling that, then you shouldn’t be doing the job.
And I had the privilege of beginning my tenure as a cancer center director at the end of 2007, beginning of 2008, just as the world was catching fire financially with the dawn of the Great Recession and the necessary impact it had on our ability to do work. And I’ve lived through not only that and the painful recovery from that, COVID and all the challenges that that created, and now the challenges that are associated with a seeming lack of interest in progress in cancer research from the federal authorities as they exist now, which really continues a long-term gradual decline, or not a decline as much as a dissonance between the level of opportunity we have scientifically to make a difference and the amount of resource that’s available to actually pursue those ideas. And so that’s been the biggest challenge.
John Marshall, MD: You know, Sara and I talk a lot on this program about the impact of the government on oncology and on healthcare, et cetera, and we have made reference to the current funding cycle. You know, I know in our executive meetings we’ve been talking about that a little bit. Can you reflect a little bit about how much that increases the steepness of the climb or the rolling the rock up the hill when you have to also fight the fundamental funding source?
Louis Weiner, MD: Well, first of all, my nickname should be Sisyphus because that’s exactly what happens. Every time we feel like we’re moving forward and we can see a path toward really significant progress, something seems to happen. And I think that’s the nature of the job, and I think that’s the nature of life.
But what I find so challenging is that right now there are people at our cancer center who have had grants favorably reviewed. Ben Weinberg, my colleague, and I had one of them, actually, that get really spectacular scores and percentile rankings in the top 10%, in the top 10% of all grants that have been rated.
Okay, they don’t get funded anymore.
John Marshall, MD: Right.
Louis Weiner, MD: And so what happens is it’s very discouraging. And then for old guys like us, you know, we’ve been through the battles and we sort of have a built-in resilience because we sort of understand there are going to be cycles to this and there’ll be future opportunities or different opportunities. But I really worry about my earlier-career colleagues who are trying to establish a foothold, you know, to climb up, to push that rock up the hill, and they’re not able to get that foothold. And I just think that the long-term impact on American science is going to be really profound. So I worry about that all the time.
John Marshall, MD: Yeah, and these are the people, of course, that are going to take the science that you and I have helped contribute to and take to the next level. And if they don’t have, as you refer to it, a good foothold—
Louis Weiner, MD: Right.
John Marshall, MD: You know, it won’t make progress. But let me let you brag a bit about the impact that you’ve had on our science today.
I mean, when I think about one of the grants I put in 25 years ago, it was about immunotherapy and GI cancers, and people said, “That’s never going to work, so why are you going to bother to do that?” I know that’s been one of your key sciences. Do you think that’s been the most impactful thing over the last couple of decades, or has there been other stuff, precision medicine? What do you think has been the most impactful?
Louis Weiner, MD: So first of all, I wake up in the morning and I pinch myself thinking of how lucky I am because I’ve had the opportunity, for whatever reasons, to make important contributions, and I think I have to divide my pinches into two major realms. One of them is what I’ve accomplished in leadership because, at the end of the day, we are all servants for a larger cause, right? And that larger cause is much bigger than any one discovery.
To have been able to lay the groundwork and make it possible for two generations of young emerging scientists and clinicians and clinician leaders to do their work and do things that I would never have thought of doing, and to see them develop and to contribute to progress is enormously satisfying for me. So let’s get that out of the way right away.
On a personal note, I was a bit naive and stubborn, but I guess in some ways had a vision that turned out to be true. I believed early, when I was interviewing for a fellowship, that there was a capacity for the immune system to be used to treat human cancer. Everybody thought I was an idiot for feeling that way.
And then when I finished my fellowship and I started working back then in Philadelphia trying to develop these things called monoclonal antibodies to treat cancer, I had very talented and accomplished people, some of whom you and I know very well, say, “You know what? Are you wasting your time on that stuff for? You seem like a bright guy. Find yourself a disease and do your stuff.”
And I said, “No, no. This is going to work. I think so.” And you know what? Those people who told me that did just fine in their careers, and I’ve done just fine in my career. And so I think the thing that I’m most proud of is the idea that you could harness the power of the body’s immune system to attack cancer.
And initially that was done with monoclonal antibodies. I was involved in the earliest antibodies. I made some of the first bispecifics and actually tested one in the clinic. We did hardcore lab work that identified the properties of antibodies, their affinity, how tightly they attached to their targets, their size, other molecular properties, what was necessary for things to work in the clinic. And some of those principles became the foundational elements of modern antibody therapies of cancer.
How cool is that? How neat is it to have been able to play a role in the development of those things and to see the field now? As I was talking to somebody the other day who is taking Humira (adalimumab), a monoclonal antibody, for treatment of an ulcerative proctitis kind of problem, and he said, “You know, you don’t realize it, but I’m not pooping blood because of the work you did years ago to create these monoclonal antibodies. So thank you very much.”
John Marshall, MD: Yeah.
Louis Weiner, MD: It was kind of cool. It’s kind of cool. So I—and then, you know, even though that had happened, nobody really believed that immunotherapy could work.
And this is really even before checkpoint antibodies exploded and became such an important thing. And I was able to convince the American Association for Cancer Research to do two things. One was to found an immunology-focused journal, which is called Cancer Immunology Research, which I’m now finally, after God knows how many years, rotating off the editorial board of. And the other was to create the Cancer Immunology Working Group, started off with a couple hundred people in a 25,000-person organization and I think now is 35,000 members. And to have had a role in creating and enabling infrastructure like that, that has now allowed people with interest in immunotherapy to talk to each other, collaborate with each other, and make discoveries together has been fantastic.
John Marshall, MD: Yeah. I wanted to kind of wrap us up a little bit. You struck me at a meeting we were at last week together when you were talking about stepping down as cancer center director, that it was kind of time for a new voice. And having done this myself as the Chief here, I felt the same way, a time for a new voice.
And I think you even used the term evolution and that it just needs a fresh look. Could you reflect on that a little bit? Because one of our themes is remembering the past, but it is important as we move forward. And I find myself as a teacher down in clinic still coaching people how to give 5-FU and how it works and some of the fundamental studies that we did.
It’s important to remember history—
Louis Weiner, MD: Yeah.
John Marshall, MD: —that our government is, by the way, trying to rewrite, but it’s important to remember our medical history so that we can help guide the next generation. Reflect a bit on that.
Louis Weiner, MD: Well, first of all, I think that it’s not surprising to me that a man who just returned from the Galapagos would be asking me these questions. But I will say that I’ve been interested in the notion of evolutionary biology and its role in cancer. When you really think through how we give therapies, if we ignore the capacity of cell populations to evolve in response to what we do, we suffer the fate of fools, in my view. And I think we’re only now beginning to understand that.
But I think you can actually scale that not only from the cell and the organism, but all the way through into society. And I think that we are in an evolution. We are always evolving, and if we try not to evolve, we suffer the fate of dinosaurs.
John Marshall, MD: Hmm.
Louis Weiner, MD: So I grew up in a world where there was more money available to support science, where there was a kind of order to it. Right? There were rules and there were orders, there were hierarchies, and those of us who succeeded learned how to navigate those hierarchies and how to succeed within them using the tools available to us.
And, you know, basically that’s all been blown up in a lot of ways, not only by the current political climate, but by the accelerating pace of change, the advent of AI and the still unknown ways it’s going to work, right? The ways in which we have to become more creative in how we try to finance research, create public-private partnerships, things like that.
And, you know, I am a perfectly honed creation of the evolutionary selection pressures that were applied on me as I was growing up and developing as a scientist. And while I think I still have a lot to contribute and look forward to being able to do it, I think you want somebody with a longer runway than I might have, and also somebody who’s been forged in the crucible of the current level of evolutionary biology, evolutionary selection pressures, if you will, in order to move forward.
I think healthy organizations benefit from hybrid vigor. They benefit from dynamic new leadership that respects and honors the past, but also takes a fresh look at it and says, “How do we move forward in the future?” You and I have a boss in Norm Beauchamp, for example, our EVP, who represents a really good example of how hybrid vigor can energize an organization and move things forward.
And so, you know, I’m super excited about what’s next for me because I have all kinds of things I want to accomplish, both in helping the cancer center, advancing my own research, which is still moving forward really nicely, and maybe spending a little more time enjoying a grandchild or two from time to time as I go through it.
John Marshall, MD: We will leave it right there. I could not have said any of that any better. So Dr. Louis Weiner, partner, friend, boss, mentor to so many, not just me, I really am appreciative of our time that we have spent together as we’ve walked through our cancer journeys, cancer research journeys together. And thank you for spending the time with us today on Oncology Unscripted, Lou. Thank you.
Louis Weiner, MD: It’s been a ball.
This transcript has been generated by AI and edited for clarity.