Join Dr. John Marshall in the third episode of Oncology Unscripted as he explores the challenges oncologists face in staying current with rapidly evolving data and increasingly complex therapies. Tune in for practical advice around sourcing trusted medical evidence in the era of artificial intelligence (AI) and navigating the American Board of Internal Medicine (ABIM) Maintenance of Certification (MOC) program featuring an enlightening discussion with ABIM Medical Oncology Board Chair, Suresh G. Nair, MD.
Oncology Update: Introduction [00:00:00]
John Marshall, MD: Welcome back to Oncology Update. My name is John Marshall here from Georgetown University, Washington, D. C., the land of freedom. I don't know what it is the land of anymore, but welcome back to Episode 3 of Oncology Update.
Our theme for this session is going to be, how do you stay up to date? How do your patients stay up to date with all that's going on in the world of oncology? And are you, in fact, delivering state-of-the-art treatment? Or are you, in fact, maybe delivering something, some recommendation that maybe AI created? So, we do want to, you know, Be careful about that.
Oncology Update: New and Noteworthy [00:00:40]
But before we do, let's kind of start with some of the news of the week. You know, everyone knows who Dennis Slamon is, an amazing scientist and clinician who, really, his group really defines the whole HER2 targeted pathway, defined the use for trastuzumab in more than one disease and turned HER2 into something that you didn't want, to, now, something it is you want, in certainly in breast cancer. And he, of course, rightfully receives another, major award from the National Foundation for Cancer Research, so a big shout out to Dennis Slamon for the incredible progress that he has made and the impact he's had on so many people. You think about how many lives that man and that science has saved just through that research that he's done. It really is impactful.
On the other side. I want to give acknowledgement to Dr. Harpreet Singh, who worked at the FDA in drug approvals, right? So, the whole idea of giving back to the government, working for not very much money to try and establish the metrics, et cetera, for FDA approval for medicines. But just recently, Dr. Singh took a job as the CMO for Precision for Medicine, which is a, basically a research CRO. And that's very much similar to what we see here in Washington of that kind of revolving door between working for the government and then working for industry. Taking the skills and the inner inside knowledge and the like that's important out to the rest of the world to try and improve the process there. So that's a little bit of what's going on in the world of drug development.
But, maybe most importantly, this is Juneteenth. Actually, we are recording session 3 here, episode 3 here. And it's also part of Pride Month. And so, we have a lot of folks who are out there, who really are underrepresented in our research, underrepresented for access to the treatments we have, for a variety of reasons. Not just here in the United States, but everywhere around the world. And I know many of us are working to try and level that playing field. I always think about this as a really difficult subject, is health care a right or is it a privilege? And we try to dance both of those here in the United States with the private health insurance and other government health insurances underneath that are clearly not providing the same level of care. And these kinds of months that we think about those who are less fortunate or those who have struggled with their own personal world in a world that's not necessarily built to—ready to receive them. And so, I do think we have to make sure we're taking care of everyone and acknowledging all of that that goes on. So, it's an important month, the month of June for us all to stop and reflect a bit on all of this, particularly in health care.
Oncology Update: Vetting Medical Information [00:03:47]
But let's look at the science of the week. Now, you're going to think, this is, you're waiting for a Nature paper or some major JCO paper. I'm actually going to show you a minor JCO paper. It was written by a very good friend and a person who I really go to for my sort of ethics checks. And this is Dr. Paul Helft out in Indiana, and his team put forward a survey paper that was published in JCO looking at what patients are doing on the Internet, what they're going to see on the Internet, and then what they're bringing into us as information they have found on the Internet. Again, sometimes it's supportive care things, but often it's therapies that someone has posted somewhere on the internet that might be helpful for their cancer. They're looking for a better answer than the ones we are giving them. And it comes to mind is how many times a week does somebody come in with, you know, I've heard that ivermectin can really help cure my cancer. Or, you know, if we just allowed more medical marijuana. This would solve the whole problem. People wouldn't have cancer. Maybe they wouldn't care about having cancer, but they wouldn't have cancer is what they think. Or turmeric is my favorite one. You would think that whole, you know, populations would never get cancer because of the turmeric that is in the diet in certain populations. But no, that seems to be a popular one. Acupuncture and other sorts of mind-body approaches are of course very popular. But many times, you know, we in the healthcare industry aren't really qualified to comment on the things that are being brought in, or they irritate us, or they just take time, and we spent time then waving off the things that patients have found on the Internet. And there's an entire, you know, burgeoning literature around this, and we clearly see that social media and the Internet are actually promoting this sort of alternative oncology all the way to what we would call quackery. And the publishers want this. You know, in my position in academia, it's very common that I'll get emails from some new journal that's just coming out that they need new reviewers, and they want an editorial board or something. And I see that mostly as spam email myself. But, you know, somebody’s saying yes to that. And somebody then is publishing stuff that may not be up to the same scientific rigor that we're used to. And we might come across some of those things on the Internet searches and not really be able to judge what it is we're seeing. And this has created these so-called predatory journals that are out there to just make a living having medical information, no matter what quality of medical information is out there. And a nice recent paper did summarize a lot of this that's out there to be careful. Because when we're going online ourselves, we really need to figure this out.
Now, where do you go for your information to stay most up to date? Well, I bet you go to UpToDate sometimes. And that's obviously a much fuller annotated version of things. It requires you to do some reading and thinking in order to apply the knowledge there. But most of us are going to NCCN. It used to be that around here, at least, that we would not allow our fellows to cite NCCN as the reason to do a treatment. That was not the source document. The source document was the study on which the NCCN guidelines were based. So, you had to know where the NCCN guidelines came from so that you could interpret that. But somewhere along the way, we sort of slipped off of that. Don't you think that if it's on there, then it's legit. And the payer on the other side is like, well, if it's on there at the right level of evidence, we'll cover it. So, it's almost more important to be on NCCN than it is on FDA. Once you're on the market, NCCN will get you covered. So, it creates a sort of new target that's separate from the FDA, different levels of evidence.
Did you look down in six-point at the very bottom of the NCCN guidelines on every one, it has the disclaimer and I'm going to read it just so you guys can read, hear this out. NCCN explicitly disclaims the appropriateness or applicability Of the NCCN content, the guidelines and any derivative resources or the use of or application of the NCCN content, the guidelines or any such derivative resources to any specific patients care or treatment.
That's exactly how we use it. Right. We look up a patient who. You know, we're not quite sure what the rules are. We're not quite sure if that drug's got approval or you covered. We're not quite sure what to do next. So, we open up NCCN and make an individual patient decision based on what's on that, even though they in fact, say that that's not what we built it for in the baseline. So, I just want us to remember that that's where that sits.
Now, in the old days. I used to be able to know pretty much everything I needed to know to be a practicing oncologist. I could study it; I could remember it. Nowadays, I can't. And there's so many new drugs, they have so many new names and funky names that I can't remember, that in fact, I'm constantly, even in my own space in GI cancer, needing to reconfirm or look back up in the internet of some place—NCCN, UpToDate, or even just Google, to figure out where the answer in fact is.
Oncology Update: Tracking FDA Decisions [00:09:45]
And so, I just did a little looking myself about, new drugs that were approved, but now have been withdrawn. It came through my inbox that a, a drug infigratinib (Truseltiq), which you may know as an FGFR fusion molecule for cholangiocarcinoma, was withdrawn. The approval was withdrawn. Originally approved in '21, just in May 2024 was withdrawn. And so, if I had one of those FGFR fusions, even though this drugs on the market, I can't use it for cholangiocarcinoma. But if I looked that up, and I didn't see that it was withdrawn, I might not. I may only see the FDA, the positive FDA approval, but there are a bunch of them here. And in fact, there were 29 drugs withdrawn that had initial approvals within cancer medicine.
Some of the others that we noticed was belantamab mafodotin-blmf (Blenrep). Okay, so Blenrep is a drug for multiple myeloma. It's been withdrawn. It was withdrawn back in 23, but new data, we think it may be coming back on. So, it depends on when you looked up what your reference pops up in your search of whether that drugs in or whether that drug is out. In my world, pembrolizumab (Keytruda) was originally approved for gastric/GE junction cancers. Now that's been withdrawn, depending on what your PD-L1 status is, etc. And then also a really interesting one that maybe, you know, you younger people don't even know the arc of, but gemtuzumab ozogamicin (Mylotarg), was originally approved in 2000, withdrawn in 2011, but then back on the market in 2017. So, you get my idea of what really is out there, what really is FDA approved, and these accelerated approvals give us access to medicines, importantly, but then sometimes they are pulled back.
Now, just in June. There were a bunch of approvals. There are six new approvals. I want to read you a couple of them because they're pretty pedantic, if you will. One of them is a drug called blinatumomab (Blincyto). You've probably heard of that one. But the approval is for adult and pediatric patients one month and older, CD19 positive, Philadelphia chromosome negative, B cell precursor, ALL. How about this one? repotrectinib (Augtyro)? This is for 12 years and older for patients who have NTRK gene fusions. Now, I've only found one of those in my entire career, but you need to know that there are drugs that that just got added to the list of other drugs that are out there. Another one is a drug called lisocabtagene maraleucel (Breyanzi), I believe it's how you pronounce that. And this one is for adult patients with relapsed and refractory mantle cell lymphoma, who have received at least 2 prior lines of systemic therapy, including a BTKi drug.
So, you have got to really know what's going on. If you're a general oncologist, how would you know what's going on? So, you're dependent on looking stuff up. You're dependent on our education resources and other online resources to keep up.
So how about this one? This is real or not real? This is a paper that a search found and it's for entrectinib (Rozlytrek), you remember I talked about repotrectinib, this is for entrectinib, for NTRK fusion positive solid tumors after a larotrectinib (Vitrakvi) or repotrectinib, so as third line, if you will, for entrectinib. Now, this paper is from the Journal of Clinical Oncology, says it was published in 2021. And in fact, one of the authors is one of my partners here at Georgetown, named Mike Atkins, and Rick Pazdur is listed as an author on this paper, Michael Slayman, Jeff Weber, a lot of prominent people are authors on this paper. And you would think if this came up in your inbox that this is real, right? And so, you might even take this paper and send it to the insurance company, to the guy at Aetna, and say, look, I got a JCO paper here that says I got a response rate that's very high in this patient population. It's already an approved drug. Let me give it to my patient in front of me. Except, it's not real. This paper was created. By an AI search engine, and it says it's a JCO paper. It was completely the right format, the right color scheme, the right font, the right references. But what made us all suspicious was the author list. Why would Rick Pazdur, from the FDA, be on a paper such as this? Mike Atkins doesn't do this kind of research, technically. And then we went one further step. And in fact, showed that the page numbers from this JCO paper didn't line up correctly with the journal. And so, this really suggested that we were getting a bum paper. This was a made up what they call hallucinated paper. So, we also have to be careful at that level.
Oncology Update: Maintaining Certification in Today’s World [00:15:03]
All right, so how do you keep up? And I want to kind of shift gears a little bit to our maintenance of certification, or MOC. Now, I'm in internal medicine. It's originally boarded in medicine, then oncology, and I've only maintained my oncology after a while, my 4th go-around, and this 4th go-around, because I do it every 10 years, this go-around, I decided not to sit for the exam and to take the maintenance of certification, questions. Those of you who are doing this out there know what this is all about. But maybe most some of you do. Some of you don't. So, every quarter I get 30 questions in a portal. And these questions are heme/onc questions, onc questions, med onc questions. And the way I do it is that I put 2 hours on my calendar each quarter. 1 hour I do 15 questions. Next hour. I do another 15 questions just so I make sure and get it done. But you also know that when you go on to this, you have 4 minutes to answer the question. And there's a clock running up in the corner there. And you can use any online resource that you want, but you can't talk to somebody. So, when I originally started this, I thought, Division Chief, we've got a big fellowship program here, maybe I should do this in front of the fellows. And they're like, nope, you can't do that because this has to be just you and whatever internet resources you have. So, they're giving us the internet. to do this. So, what I do is I have two screens. I put the question over here, my little clock running over there, and open here, I've got, what do I have open? I have NCCN Guidelines, and I have UpToDate open on my computer screen, and I read the question. It's always a leukemia question or one more breast question and the like, and I don't know a lot about that, so I really need to understand what my answers are. So, I look it up, and I'm doing pretty well. Every 30 questions, I might miss three or four. But that's with all of these resources, and I get nervous about the clock running down, and I am pressed for time. And so, in the end, I just hit one and say, I hope I'm right. And most of the time so far, I'm right. Except the GI questions. I'm getting killed on the GI questions because I really know the medical literature in GI cancers. And one of them recently was a case where a patient had liver mets that was resected, had not had adjuvant therapy a couple years before, and there's no literature on what to do with that patient. None at all. And so, I put, you know, you observe the patient, which is to me, what would be a standard of care. If you had an isolated liver met, it was removed, you don't know what to do. But then I missed the question. Missed it because it said I should give chemotherapy. There's no data for this. In fact, the data does suggest maybe progression free, but no overall survival benefit, no true adjuvant effect. So, I go on to their reference, which was the NCCN guidelines and down in the small print, some branch point way down here. It basically said, look, if you've never given adjuvant, consider giving adjuvant. That was the correct answer by the ABIM version of the process, which, in my opinion, is a very controversial answer. And, yeah, I could see the argument for, but there's no literature to support that. And so, you know, this is why I'm kind of frustrated. Now I'm getting nervous every time there's a GI question that comes up because, you know, do I know too much? Do I not know enough? What's going on here? Why am I missing the GI question?
So, it is clear that we can't know everything anymore. There's too much coming at us. There's too many funky words. There's too many subtleties to genetics and the drugs, etc. So, we need to get better. I need to get better at online access. I need to have trusted sources. Sure, UpToDate and NCCN are very good sources. I don't hear anything different than that, but we also need to have that sort of inside baseball knowledge about what the right way to do it is. What's the right way to dose things? This sort of thing. Right? So, we need good, over our shoulder help that the Internet can provide to make sure that we're providing state of the art care for the patient in front of us with all of its complexities and all of this changing that's going on so that we're dependent on it just as much as everybody else is. So, we need to get better at it.
And so, with this, I just challenge all of us to think a second time when you're going on a search, and you find a paper that supports what you want to do for a patient. Do some cross referencing. Think a second. Was it created? Real? Is it on guidelines? Is it cross referenced with other sources before you then go forward? If it's a therapy you've never given before, try and find somebody who has, and talk to them about what is the right dose, what is the right way to monitor for side effects, et cetera. Because those kinds of subtleties are awfully hard to get off of the internet and find, phone a friend and figure it out. Because I think with that, we'll all be better doctors and using this great tool, this great knowledge base that's in front of us, using it wiser for the patient.
So, to really try and dig down deeper on this issue of the ABIM and MOCs, there's a lot of confusion about that. We are lucky enough to have a guest visit us for a brief interview. From the inside, one of the leaders at the ABIM
MOC Ins and Outs: Interview with ABIM Chair Suresh Nair, MD [00:20:53]
So as promised, I have a world's expert on how we get board certified in oncology, and we're lucky enough that Dr. Suresh Nair has agreed to spend a little bit of time with us. Now, if you don't know who he is, you should. He's an important guy. He was the physician in chief at the Lehigh Valley Health Network and Pennsylvania, just north of where I'm sitting. When I look through his resume, the guy likes Pennsylvania for sure. He's been from the east side to the west side with all of his training, and he's trained in some of the best places in the world, and he has dedicated himself to building just an incredible practice there. Part of his busy life as well has been to be involved in the ABIM. The process and certifying us all for our licensure. He's an oncologist, and in 2022, if my numbers are right, he actually took on the leadership role in the ABIM structure over medical oncology and having somebody like that to give us a few minutes is really special.
So, Suresh, let me first say thank you and welcome.
Suresh G. Nair, MD: John, I feel honored. Thank you so much. And to be, as I said, being with a legendary oncologist who I respect highly. Thank you.
John Marshall, MD: Well, I get in trouble a lot, as you know, so hopefully we'll keep each other out of trouble on this one. Because for the first time, this was number 4 for me on going around on, on a, on a getting recertified and I thought I had been doing it right. But it was December 15th of 2023 that I realized that I wasn't doing it right. My CMEs weren't MOCs, for example. And so, I had to very quickly figure out how I was going to do everything by the deadline so that I maintain my board certification. So, I had a panic moment here as a senior doc.
I wanted to talk a little bit about my choice, for example, to take the test. Sitting down formally number two pencils, no longer, versus the orderly tests as a way to maintain and just to get your high level that those of us in oncology are doing this. Who's doing what? Everybody, or is it a gemish all over the place?
Suresh G. Nair, MD: I've been on the ABIM med onc board for the last five years, and as you said, the last two years as the chair. So, I was there as the board responded to diplomats that sometimes the 10-year exam took time out of practice to go to courses, and it was very stressful. And especially I feel like in oncology where things are changing, you know, by the week, by the day for some of the questions. I know you probably had the same experience, the areas that I spent a lot of time in like melanoma, kidney, I was getting some of the questions wrong because the test questions were written five years ago. And they have to go through verification and standardization and all of that. So, the longitudinal knowledge assessment (LKA) was launched. We have about 14,000 board certified oncologists, 85 percent of them are engaged in the LKA, once they become eligible for it, and about 15 percent are choosing to do the 10-year. I also did the 10-year exam about two years ago. I've decided to do the 10-year in oncology and I'm doing the LKA in hematology and in internal medicine. I don't practice much hematology anymore, but I was originally boarded in that at the University of Pittsburgh, and I thought I would try it out, and it's been a bit humbling, but I'm gradually—I have a barely passing score and continue to improve in that. We are finding that, we're continuing to listen to the diplomats and we're looking at making some changes because, I too, the week of Christmas and the new year was reading a lot of up to date to get my MOC credits because I too had a deficit and, you know, I didn't have the hundred that was needed and So at the board level, we're looking at giving—there is credit for the LKA. You do get MOC credits for that, which I think more and more a lot of diplomats are going to, but we're working with ASCO, working with thought leaders in all facets of CME and maintenance of certification credits.
John Marshall, MD: Yeah, no, I think that's really great. And it's, it's, you're having to live it yourself. You know what it feels like when all of us are out there, because you and I are pretty specialized. A lot of generalists might do better on some things, but still need the props you know, resources and source things to help with the questions. When I first started, I did really badly on the first 30.
I have to share with you that the four minutes was stressful to me. I kept watching. I wasn't. very good actually at looking things up. And as I've done this now for a year or more, I actually realized that I've gotten better at looking things up. Now what I'm not sure of is, is that making me a better doctor or not? I mean, I can find the answer what's being asked, but I don't necessarily have any familiarity with What I'm talking about so I can match the words up to get the right answer But how much feedback have you had in that way that people because I do feel smarter I actually used to dread the time when I was doing The questions to now sort of looking forward to it because I do leave knowing more than I did before. What's been the feedback so far to you at your end?
Suresh G. Nair, MD: The feedback's been very similar to you John in that the four minutes is stressful. There is a time bank that you can click on for extra time for certain questions. I, I too, on, on the hematology, which I don't practice as much and I'm doing it for pure learning I didn't do that well in the first two, and now I've been engaged in about two years and keep getting better.
One of the things it's made me do is areas that I feel weak, and I do when I have some time read up on that area a little bit. And I'm noticing my scores going up and getting expertise. We are, you know, kind of wrestling with certification versus education. So, it's not a pure education tool. When we go to ASCO and we sit at the education sessions, that's a pure education tool. This is also a summative assessment, and there's a lot of science at ABIM. I've been very impressed with the test gurus there. There's a lot of science that basically about 96 percent of us end up being certified, but it is stressful to some degree. But I think all of us believe in lifelong learning. And there is, there is some science that when, when the test has some stakes. We actually learn at a higher pace.
John Marshall, MD: No question. My juices go up on when I'm doing those questions. No, no, I totally they do. And, and I believe I take away things that I wouldn't normally have ever learned if I hadn't come across the question.
Let me come back to the, you know, you miss questions, I miss questions, but in our own field, right? So, I'm getting the leukemia questions right, but I missed, there was a question the other day, where it was a resection of a colon met in the liver, and the question was, do you give chemo afterwards? Well, I happen to know there is zero literature to tell you what to do one way or the other. And when I got the answer wrong because I said to observe the patient and done in the subtext was the reference was NCCN guidelines. So, I went to the NCCN guidelines and saw that said, well, consider this. And so of course, you know, you know too much, right? And so, it's a frustrating moment. How do I miss that question? When I know the literature there and you and I talked a little bit before about How does the ABIM keep up to date? Where are the sources of the questions and that sort of thing?
Suresh G. Nair, MD: So, so we have a test writing committee and a test approval committee, and our board has given feedback for instance in the LKA, okay, there's 30 questions. There's usually at least one or two that the standard of care has changed, even if the question was written, you know, two years ago. I think a clear case would be in melanoma at the plenary, the neoadjuvant change from pembro to, you know, ipi/nivo now the two doses and our, our, we have a, you know, there, there's been test questions that, that If you do what we heard at ASCO, what's in the New England Journal, you probably could get it wrong. So, so one of the, one of the suggestions at our last board meeting was to have a group of experts. Literally, the, the, the week of go live of LKA go through with it with the fine-tooth comb, because it is very frustrating to diplomats.
John Marshall, MD: But I was thinking to us in my head was like, could you put the date up there? Because I remember we were talking about. You know, if I go on a Google search for something, and if I find an answer I like, but it's an older answer, it might not still be correct, but it's what I was looking for. And so, I don't keep looking. I'm done. I validated what I thought I knew, and then I move on. And, and so, as you say, we're, this is assessing a moving target. So, there is a time, but I think your strategy is perfect. It's just making sure that folks, Have a good look.
That still wouldn't have solved my problem.
Suresh G. Nair, MD: No, and we acknowledge that there's just some bad questions. That that question you were you were right, you know, based on the literature based on studies. And NCCN sometimes it's just more opinion rather than studies. And so, unfortunately, there are on the board, you know, so they are looking continuing to look for more test writers. We are starting to get a good number of applicants. And then what one other important direction that the board is going and based on listening to the ASCO survey of the diplomats is to tailor the exam so that 70 percent of the exam will be general content, 30%. We can't hit every narrow specialty, but the major specialties that we have that physicians in the future could say, I specialize in GI, or I specialize in lung, and so, so it can be more tailored to them. Because this is a summative assessment and the science has to be intact, right now we're working on what's called practice profiles and kind of focused assessment and we'll be having the fall meeting where our committee will present a lot of stuff to us.
We have Furman McDonald is the new CEO and president of ABIM. You know, had a distinguished career at Mayo Clinic was at Penn and really is, is a strong listener and I heard his vision at the ABIM Council last week. There was always this feeling the board was a bit tone-deaf to the diplomats and I, I see that changing. I'm a practicing community oncologist who has been lucky enough to have partnerships and stay involved in NCI trials. I'm supposed to be 40 percent clinical, but I ended up being 80 percent clinical in my 40 percent time. So, so I hope I bring the practicing physician perspective to the board. The board has been receptive and sometimes it does seem like it’s turning a plane around. Because they have to keep the science and the validity that the board certification means, you know, that that it means something to the public. One of the things we want to do is to celebrate maintenance of certification but continue to evolve.
And one of the areas we're grappling with now is the, you know, quick adoption of AI. Now Siri soon going to have AI on our phones you know, pretty much any, any Google search, you know, there's an AI running in the background. We know we can't run away from societal innovation. So, we just need to continue to see, you know, what's the most important thing to try to test. And more and more we're actually finding, it goes back to John, how you started, I think trust and being able to trust your physician because patients are going to be confused, there's going to be misinformation, there's going to be a lot of things. So how do, how do we test for, you know you know, trust and, and, and the things that makes a human physician different from a, from a robot.
John Marshall, MD: Totally right. I'll be quick, but the AI thing you mentioned, there was some complicated gene in one of the questions and I, instead of typing it, I tried to swipe and copy it and this alarm went off and it basically says, if you do that one more time, we're going to do something bad to you. So, I haven't done it again. Okay. But anyway, you have put some checks and balances on the ability to just cut and paste that question over and put it in AI and see what the answer is. But listen, I know you've had a busy day already. And you're giving us extra time on short notice to talk about a really important question about how do we keep up to speed and you are the sort of overseer of truth in many ways. And, like you. I am proud of my certification, and I am proud to be part of that club. We were all worked very hard to get the 1st one, and so we should continue to maintain that. And I think it's great to hear how both receptive you are, but at the same time, holding our feet to the fire to make sure that we're providing the public with a trusted human on the other side who knows what they're talking about and knows when they don't know what they're talking about. Maybe more importantly and knows how to figure it out for the patient in front of us.
So, Suresh, thank you so much for this. And good luck as you continue in your leadership role.
Suresh G. Nair, MD: John, I really appreciate it thank you so much. All right. Thank you.
John Marshall, MD: Thank you all for joining us for episode three of Oncology Update, where we focused on the whole concept of how do we stay up to date. I'll see you in a couple of weeks for episode four.
Oncology Update With John Marshall: Episode 3—How Do You Stay Up To Date?
Oncology Update: Introduction [00:00:00]
John Marshall, MD: Welcome back to Oncology Update. My name is John Marshall here from Georgetown University, Washington, D. C., the land of freedom. I don't know what it is the land of anymore, but welcome back to Episode 3 of Oncology Update.
Our theme for this session is going to be, how do you stay up to date? How do your patients stay up to date with all that's going on in the world of oncology? And are you, in fact, delivering state-of-the-art treatment? Or are you, in fact, maybe delivering something, some recommendation that maybe AI created? So, we do want to, you know, Be careful about that.
Oncology Update: New and Noteworthy [00:00:40]
But before we do, let's kind of start with some of the news of the week. You know, everyone knows who Dennis Slamon is, an amazing scientist and clinician who, really, his group really defines the whole HER2 targeted pathway, defined the use for trastuzumab in more than one disease and turned HER2 into something that you didn't want, to, now, something it is you want, in certainly in breast cancer. And he, of course, rightfully receives another, major award from the National Foundation for Cancer Research, so a big shout out to Dennis Slamon for the incredible progress that he has made and the impact he's had on so many people. You think about how many lives that man and that science has saved just through that research that he's done. It really is impactful.
On the other side. I want to give acknowledgement to Dr. Harpreet Singh, who worked at the FDA in drug approvals, right? So, the whole idea of giving back to the government, working for not very much money to try and establish the metrics, et cetera, for FDA approval for medicines. But just recently, Dr. Singh took a job as the CMO for Precision for Medicine, which is a, basically a research CRO. And that's very much similar to what we see here in Washington of that kind of revolving door between working for the government and then working for industry. Taking the skills and the inner inside knowledge and the like that's important out to the rest of the world to try and improve the process there. So that's a little bit of what's going on in the world of drug development.
But, maybe most importantly, this is Juneteenth. Actually, we are recording session 3 here, episode 3 here. And it's also part of Pride Month. And so, we have a lot of folks who are out there, who really are underrepresented in our research, underrepresented for access to the treatments we have, for a variety of reasons. Not just here in the United States, but everywhere around the world. And I know many of us are working to try and level that playing field. I always think about this as a really difficult subject, is health care a right or is it a privilege? And we try to dance both of those here in the United States with the private health insurance and other government health insurances underneath that are clearly not providing the same level of care. And these kinds of months that we think about those who are less fortunate or those who have struggled with their own personal world in a world that's not necessarily built to—ready to receive them. And so, I do think we have to make sure we're taking care of everyone and acknowledging all of that that goes on. So, it's an important month, the month of June for us all to stop and reflect a bit on all of this, particularly in health care.
Oncology Update: Vetting Medical Information [00:03:47]
But let's look at the science of the week. Now, you're going to think, this is, you're waiting for a Nature paper or some major JCO paper. I'm actually going to show you a minor JCO paper. It was written by a very good friend and a person who I really go to for my sort of ethics checks. And this is Dr. Paul Helft out in Indiana, and his team put forward a survey paper that was published in JCO looking at what patients are doing on the Internet, what they're going to see on the Internet, and then what they're bringing into us as information they have found on the Internet. Again, sometimes it's supportive care things, but often it's therapies that someone has posted somewhere on the internet that might be helpful for their cancer. They're looking for a better answer than the ones we are giving them. And it comes to mind is how many times a week does somebody come in with, you know, I've heard that ivermectin can really help cure my cancer. Or, you know, if we just allowed more medical marijuana. This would solve the whole problem. People wouldn't have cancer. Maybe they wouldn't care about having cancer, but they wouldn't have cancer is what they think. Or turmeric is my favorite one. You would think that whole, you know, populations would never get cancer because of the turmeric that is in the diet in certain populations. But no, that seems to be a popular one. Acupuncture and other sorts of mind-body approaches are of course very popular. But many times, you know, we in the healthcare industry aren't really qualified to comment on the things that are being brought in, or they irritate us, or they just take time, and we spent time then waving off the things that patients have found on the Internet. And there's an entire, you know, burgeoning literature around this, and we clearly see that social media and the Internet are actually promoting this sort of alternative oncology all the way to what we would call quackery. And the publishers want this. You know, in my position in academia, it's very common that I'll get emails from some new journal that's just coming out that they need new reviewers, and they want an editorial board or something. And I see that mostly as spam email myself. But, you know, somebody’s saying yes to that. And somebody then is publishing stuff that may not be up to the same scientific rigor that we're used to. And we might come across some of those things on the Internet searches and not really be able to judge what it is we're seeing. And this has created these so-called predatory journals that are out there to just make a living having medical information, no matter what quality of medical information is out there. And a nice recent paper did summarize a lot of this that's out there to be careful. Because when we're going online ourselves, we really need to figure this out.
Now, where do you go for your information to stay most up to date? Well, I bet you go to UpToDate sometimes. And that's obviously a much fuller annotated version of things. It requires you to do some reading and thinking in order to apply the knowledge there. But most of us are going to NCCN. It used to be that around here, at least, that we would not allow our fellows to cite NCCN as the reason to do a treatment. That was not the source document. The source document was the study on which the NCCN guidelines were based. So, you had to know where the NCCN guidelines came from so that you could interpret that. But somewhere along the way, we sort of slipped off of that. Don't you think that if it's on there, then it's legit. And the payer on the other side is like, well, if it's on there at the right level of evidence, we'll cover it. So, it's almost more important to be on NCCN than it is on FDA. Once you're on the market, NCCN will get you covered. So, it creates a sort of new target that's separate from the FDA, different levels of evidence.
Did you look down in six-point at the very bottom of the NCCN guidelines on every one, it has the disclaimer and I'm going to read it just so you guys can read, hear this out. NCCN explicitly disclaims the appropriateness or applicability Of the NCCN content, the guidelines and any derivative resources or the use of or application of the NCCN content, the guidelines or any such derivative resources to any specific patients care or treatment.
That's exactly how we use it. Right. We look up a patient who. You know, we're not quite sure what the rules are. We're not quite sure if that drug's got approval or you covered. We're not quite sure what to do next. So, we open up NCCN and make an individual patient decision based on what's on that, even though they in fact, say that that's not what we built it for in the baseline. So, I just want us to remember that that's where that sits.
Now, in the old days. I used to be able to know pretty much everything I needed to know to be a practicing oncologist. I could study it; I could remember it. Nowadays, I can't. And there's so many new drugs, they have so many new names and funky names that I can't remember, that in fact, I'm constantly, even in my own space in GI cancer, needing to reconfirm or look back up in the internet of some place—NCCN, UpToDate, or even just Google, to figure out where the answer in fact is.
Oncology Update: Tracking FDA Decisions [00:09:45]
And so, I just did a little looking myself about, new drugs that were approved, but now have been withdrawn. It came through my inbox that a, a drug infigratinib (Truseltiq), which you may know as an FGFR fusion molecule for cholangiocarcinoma, was withdrawn. The approval was withdrawn. Originally approved in '21, just in May 2024 was withdrawn. And so, if I had one of those FGFR fusions, even though this drugs on the market, I can't use it for cholangiocarcinoma. But if I looked that up, and I didn't see that it was withdrawn, I might not. I may only see the FDA, the positive FDA approval, but there are a bunch of them here. And in fact, there were 29 drugs withdrawn that had initial approvals within cancer medicine.
Some of the others that we noticed was belantamab mafodotin-blmf (Blenrep). Okay, so Blenrep is a drug for multiple myeloma. It's been withdrawn. It was withdrawn back in 23, but new data, we think it may be coming back on. So, it depends on when you looked up what your reference pops up in your search of whether that drugs in or whether that drug is out. In my world, pembrolizumab (Keytruda) was originally approved for gastric/GE junction cancers. Now that's been withdrawn, depending on what your PD-L1 status is, etc. And then also a really interesting one that maybe, you know, you younger people don't even know the arc of, but gemtuzumab ozogamicin (Mylotarg), was originally approved in 2000, withdrawn in 2011, but then back on the market in 2017. So, you get my idea of what really is out there, what really is FDA approved, and these accelerated approvals give us access to medicines, importantly, but then sometimes they are pulled back.
Now, just in June. There were a bunch of approvals. There are six new approvals. I want to read you a couple of them because they're pretty pedantic, if you will. One of them is a drug called blinatumomab (Blincyto). You've probably heard of that one. But the approval is for adult and pediatric patients one month and older, CD19 positive, Philadelphia chromosome negative, B cell precursor, ALL. How about this one? repotrectinib (Augtyro)? This is for 12 years and older for patients who have NTRK gene fusions. Now, I've only found one of those in my entire career, but you need to know that there are drugs that that just got added to the list of other drugs that are out there. Another one is a drug called lisocabtagene maraleucel (Breyanzi), I believe it's how you pronounce that. And this one is for adult patients with relapsed and refractory mantle cell lymphoma, who have received at least 2 prior lines of systemic therapy, including a BTKi drug.
So, you have got to really know what's going on. If you're a general oncologist, how would you know what's going on? So, you're dependent on looking stuff up. You're dependent on our education resources and other online resources to keep up.
So how about this one? This is real or not real? This is a paper that a search found and it's for entrectinib (Rozlytrek), you remember I talked about repotrectinib, this is for entrectinib, for NTRK fusion positive solid tumors after a larotrectinib (Vitrakvi) or repotrectinib, so as third line, if you will, for entrectinib. Now, this paper is from the Journal of Clinical Oncology, says it was published in 2021. And in fact, one of the authors is one of my partners here at Georgetown, named Mike Atkins, and Rick Pazdur is listed as an author on this paper, Michael Slayman, Jeff Weber, a lot of prominent people are authors on this paper. And you would think if this came up in your inbox that this is real, right? And so, you might even take this paper and send it to the insurance company, to the guy at Aetna, and say, look, I got a JCO paper here that says I got a response rate that's very high in this patient population. It's already an approved drug. Let me give it to my patient in front of me. Except, it's not real. This paper was created. By an AI search engine, and it says it's a JCO paper. It was completely the right format, the right color scheme, the right font, the right references. But what made us all suspicious was the author list. Why would Rick Pazdur, from the FDA, be on a paper such as this? Mike Atkins doesn't do this kind of research, technically. And then we went one further step. And in fact, showed that the page numbers from this JCO paper didn't line up correctly with the journal. And so, this really suggested that we were getting a bum paper. This was a made up what they call hallucinated paper. So, we also have to be careful at that level.
Oncology Update: Maintaining Certification in Today’s World [00:15:03]
All right, so how do you keep up? And I want to kind of shift gears a little bit to our maintenance of certification, or MOC. Now, I'm in internal medicine. It's originally boarded in medicine, then oncology, and I've only maintained my oncology after a while, my 4th go-around, and this 4th go-around, because I do it every 10 years, this go-around, I decided not to sit for the exam and to take the maintenance of certification, questions. Those of you who are doing this out there know what this is all about. But maybe most some of you do. Some of you don't. So, every quarter I get 30 questions in a portal. And these questions are heme/onc questions, onc questions, med onc questions. And the way I do it is that I put 2 hours on my calendar each quarter. 1 hour I do 15 questions. Next hour. I do another 15 questions just so I make sure and get it done. But you also know that when you go on to this, you have 4 minutes to answer the question. And there's a clock running up in the corner there. And you can use any online resource that you want, but you can't talk to somebody. So, when I originally started this, I thought, Division Chief, we've got a big fellowship program here, maybe I should do this in front of the fellows. And they're like, nope, you can't do that because this has to be just you and whatever internet resources you have. So, they're giving us the internet. to do this. So, what I do is I have two screens. I put the question over here, my little clock running over there, and open here, I've got, what do I have open? I have NCCN Guidelines, and I have UpToDate open on my computer screen, and I read the question. It's always a leukemia question or one more breast question and the like, and I don't know a lot about that, so I really need to understand what my answers are. So, I look it up, and I'm doing pretty well. Every 30 questions, I might miss three or four. But that's with all of these resources, and I get nervous about the clock running down, and I am pressed for time. And so, in the end, I just hit one and say, I hope I'm right. And most of the time so far, I'm right. Except the GI questions. I'm getting killed on the GI questions because I really know the medical literature in GI cancers. And one of them recently was a case where a patient had liver mets that was resected, had not had adjuvant therapy a couple years before, and there's no literature on what to do with that patient. None at all. And so, I put, you know, you observe the patient, which is to me, what would be a standard of care. If you had an isolated liver met, it was removed, you don't know what to do. But then I missed the question. Missed it because it said I should give chemotherapy. There's no data for this. In fact, the data does suggest maybe progression free, but no overall survival benefit, no true adjuvant effect. So, I go on to their reference, which was the NCCN guidelines and down in the small print, some branch point way down here. It basically said, look, if you've never given adjuvant, consider giving adjuvant. That was the correct answer by the ABIM version of the process, which, in my opinion, is a very controversial answer. And, yeah, I could see the argument for, but there's no literature to support that. And so, you know, this is why I'm kind of frustrated. Now I'm getting nervous every time there's a GI question that comes up because, you know, do I know too much? Do I not know enough? What's going on here? Why am I missing the GI question?
So, it is clear that we can't know everything anymore. There's too much coming at us. There's too many funky words. There's too many subtleties to genetics and the drugs, etc. So, we need to get better. I need to get better at online access. I need to have trusted sources. Sure, UpToDate and NCCN are very good sources. I don't hear anything different than that, but we also need to have that sort of inside baseball knowledge about what the right way to do it is. What's the right way to dose things? This sort of thing. Right? So, we need good, over our shoulder help that the Internet can provide to make sure that we're providing state of the art care for the patient in front of us with all of its complexities and all of this changing that's going on so that we're dependent on it just as much as everybody else is. So, we need to get better at it.
And so, with this, I just challenge all of us to think a second time when you're going on a search, and you find a paper that supports what you want to do for a patient. Do some cross referencing. Think a second. Was it created? Real? Is it on guidelines? Is it cross referenced with other sources before you then go forward? If it's a therapy you've never given before, try and find somebody who has, and talk to them about what is the right dose, what is the right way to monitor for side effects, et cetera. Because those kinds of subtleties are awfully hard to get off of the internet and find, phone a friend and figure it out. Because I think with that, we'll all be better doctors and using this great tool, this great knowledge base that's in front of us, using it wiser for the patient.
So, to really try and dig down deeper on this issue of the ABIM and MOCs, there's a lot of confusion about that. We are lucky enough to have a guest visit us for a brief interview. From the inside, one of the leaders at the ABIM
MOC Ins and Outs: Interview with ABIM Chair Suresh Nair, MD [00:20:53]
So as promised, I have a world's expert on how we get board certified in oncology, and we're lucky enough that Dr. Suresh Nair has agreed to spend a little bit of time with us. Now, if you don't know who he is, you should. He's an important guy. He was the physician in chief at the Lehigh Valley Health Network and Pennsylvania, just north of where I'm sitting. When I look through his resume, the guy likes Pennsylvania for sure. He's been from the east side to the west side with all of his training, and he's trained in some of the best places in the world, and he has dedicated himself to building just an incredible practice there. Part of his busy life as well has been to be involved in the ABIM. The process and certifying us all for our licensure. He's an oncologist, and in 2022, if my numbers are right, he actually took on the leadership role in the ABIM structure over medical oncology and having somebody like that to give us a few minutes is really special.
So, Suresh, let me first say thank you and welcome.
Suresh G. Nair, MD: John, I feel honored. Thank you so much. And to be, as I said, being with a legendary oncologist who I respect highly. Thank you.
John Marshall, MD: Well, I get in trouble a lot, as you know, so hopefully we'll keep each other out of trouble on this one. Because for the first time, this was number 4 for me on going around on, on a, on a getting recertified and I thought I had been doing it right. But it was December 15th of 2023 that I realized that I wasn't doing it right. My CMEs weren't MOCs, for example. And so, I had to very quickly figure out how I was going to do everything by the deadline so that I maintain my board certification. So, I had a panic moment here as a senior doc.
I wanted to talk a little bit about my choice, for example, to take the test. Sitting down formally number two pencils, no longer, versus the orderly tests as a way to maintain and just to get your high level that those of us in oncology are doing this. Who's doing what? Everybody, or is it a gemish all over the place?
Suresh G. Nair, MD: I've been on the ABIM med onc board for the last five years, and as you said, the last two years as the chair. So, I was there as the board responded to diplomats that sometimes the 10-year exam took time out of practice to go to courses, and it was very stressful. And especially I feel like in oncology where things are changing, you know, by the week, by the day for some of the questions. I know you probably had the same experience, the areas that I spent a lot of time in like melanoma, kidney, I was getting some of the questions wrong because the test questions were written five years ago. And they have to go through verification and standardization and all of that. So, the longitudinal knowledge assessment (LKA) was launched. We have about 14,000 board certified oncologists, 85 percent of them are engaged in the LKA, once they become eligible for it, and about 15 percent are choosing to do the 10-year. I also did the 10-year exam about two years ago. I've decided to do the 10-year in oncology and I'm doing the LKA in hematology and in internal medicine. I don't practice much hematology anymore, but I was originally boarded in that at the University of Pittsburgh, and I thought I would try it out, and it's been a bit humbling, but I'm gradually—I have a barely passing score and continue to improve in that. We are finding that, we're continuing to listen to the diplomats and we're looking at making some changes because, I too, the week of Christmas and the new year was reading a lot of up to date to get my MOC credits because I too had a deficit and, you know, I didn't have the hundred that was needed and So at the board level, we're looking at giving—there is credit for the LKA. You do get MOC credits for that, which I think more and more a lot of diplomats are going to, but we're working with ASCO, working with thought leaders in all facets of CME and maintenance of certification credits.
John Marshall, MD: Yeah, no, I think that's really great. And it's, it's, you're having to live it yourself. You know what it feels like when all of us are out there, because you and I are pretty specialized. A lot of generalists might do better on some things, but still need the props you know, resources and source things to help with the questions. When I first started, I did really badly on the first 30.
I have to share with you that the four minutes was stressful to me. I kept watching. I wasn't. very good actually at looking things up. And as I've done this now for a year or more, I actually realized that I've gotten better at looking things up. Now what I'm not sure of is, is that making me a better doctor or not? I mean, I can find the answer what's being asked, but I don't necessarily have any familiarity with What I'm talking about so I can match the words up to get the right answer But how much feedback have you had in that way that people because I do feel smarter I actually used to dread the time when I was doing The questions to now sort of looking forward to it because I do leave knowing more than I did before. What's been the feedback so far to you at your end?
Suresh G. Nair, MD: The feedback's been very similar to you John in that the four minutes is stressful. There is a time bank that you can click on for extra time for certain questions. I, I too, on, on the hematology, which I don't practice as much and I'm doing it for pure learning I didn't do that well in the first two, and now I've been engaged in about two years and keep getting better.
One of the things it's made me do is areas that I feel weak, and I do when I have some time read up on that area a little bit. And I'm noticing my scores going up and getting expertise. We are, you know, kind of wrestling with certification versus education. So, it's not a pure education tool. When we go to ASCO and we sit at the education sessions, that's a pure education tool. This is also a summative assessment, and there's a lot of science at ABIM. I've been very impressed with the test gurus there. There's a lot of science that basically about 96 percent of us end up being certified, but it is stressful to some degree. But I think all of us believe in lifelong learning. And there is, there is some science that when, when the test has some stakes. We actually learn at a higher pace.
John Marshall, MD: No question. My juices go up on when I'm doing those questions. No, no, I totally they do. And, and I believe I take away things that I wouldn't normally have ever learned if I hadn't come across the question.
Let me come back to the, you know, you miss questions, I miss questions, but in our own field, right? So, I'm getting the leukemia questions right, but I missed, there was a question the other day, where it was a resection of a colon met in the liver, and the question was, do you give chemo afterwards? Well, I happen to know there is zero literature to tell you what to do one way or the other. And when I got the answer wrong because I said to observe the patient and done in the subtext was the reference was NCCN guidelines. So, I went to the NCCN guidelines and saw that said, well, consider this. And so of course, you know, you know too much, right? And so, it's a frustrating moment. How do I miss that question? When I know the literature there and you and I talked a little bit before about How does the ABIM keep up to date? Where are the sources of the questions and that sort of thing?
Suresh G. Nair, MD: So, so we have a test writing committee and a test approval committee, and our board has given feedback for instance in the LKA, okay, there's 30 questions. There's usually at least one or two that the standard of care has changed, even if the question was written, you know, two years ago. I think a clear case would be in melanoma at the plenary, the neoadjuvant change from pembro to, you know, ipi/nivo now the two doses and our, our, we have a, you know, there, there's been test questions that, that If you do what we heard at ASCO, what's in the New England Journal, you probably could get it wrong. So, so one of the, one of the suggestions at our last board meeting was to have a group of experts. Literally, the, the, the week of go live of LKA go through with it with the fine-tooth comb, because it is very frustrating to diplomats.
John Marshall, MD: But I was thinking to us in my head was like, could you put the date up there? Because I remember we were talking about. You know, if I go on a Google search for something, and if I find an answer I like, but it's an older answer, it might not still be correct, but it's what I was looking for. And so, I don't keep looking. I'm done. I validated what I thought I knew, and then I move on. And, and so, as you say, we're, this is assessing a moving target. So, there is a time, but I think your strategy is perfect. It's just making sure that folks, Have a good look.
That still wouldn't have solved my problem.
Suresh G. Nair, MD: No, and we acknowledge that there's just some bad questions. That that question you were you were right, you know, based on the literature based on studies. And NCCN sometimes it's just more opinion rather than studies. And so, unfortunately, there are on the board, you know, so they are looking continuing to look for more test writers. We are starting to get a good number of applicants. And then what one other important direction that the board is going and based on listening to the ASCO survey of the diplomats is to tailor the exam so that 70 percent of the exam will be general content, 30%. We can't hit every narrow specialty, but the major specialties that we have that physicians in the future could say, I specialize in GI, or I specialize in lung, and so, so it can be more tailored to them. Because this is a summative assessment and the science has to be intact, right now we're working on what's called practice profiles and kind of focused assessment and we'll be having the fall meeting where our committee will present a lot of stuff to us.
We have Furman McDonald is the new CEO and president of ABIM. You know, had a distinguished career at Mayo Clinic was at Penn and really is, is a strong listener and I heard his vision at the ABIM Council last week. There was always this feeling the board was a bit tone-deaf to the diplomats and I, I see that changing. I'm a practicing community oncologist who has been lucky enough to have partnerships and stay involved in NCI trials. I'm supposed to be 40 percent clinical, but I ended up being 80 percent clinical in my 40 percent time. So, so I hope I bring the practicing physician perspective to the board. The board has been receptive and sometimes it does seem like it’s turning a plane around. Because they have to keep the science and the validity that the board certification means, you know, that that it means something to the public. One of the things we want to do is to celebrate maintenance of certification but continue to evolve.
And one of the areas we're grappling with now is the, you know, quick adoption of AI. Now Siri soon going to have AI on our phones you know, pretty much any, any Google search, you know, there's an AI running in the background. We know we can't run away from societal innovation. So, we just need to continue to see, you know, what's the most important thing to try to test. And more and more we're actually finding, it goes back to John, how you started, I think trust and being able to trust your physician because patients are going to be confused, there's going to be misinformation, there's going to be a lot of things. So how do, how do we test for, you know you know, trust and, and, and the things that makes a human physician different from a, from a robot.
John Marshall, MD: Totally right. I'll be quick, but the AI thing you mentioned, there was some complicated gene in one of the questions and I, instead of typing it, I tried to swipe and copy it and this alarm went off and it basically says, if you do that one more time, we're going to do something bad to you. So, I haven't done it again. Okay. But anyway, you have put some checks and balances on the ability to just cut and paste that question over and put it in AI and see what the answer is. But listen, I know you've had a busy day already. And you're giving us extra time on short notice to talk about a really important question about how do we keep up to speed and you are the sort of overseer of truth in many ways. And, like you. I am proud of my certification, and I am proud to be part of that club. We were all worked very hard to get the 1st one, and so we should continue to maintain that. And I think it's great to hear how both receptive you are, but at the same time, holding our feet to the fire to make sure that we're providing the public with a trusted human on the other side who knows what they're talking about and knows when they don't know what they're talking about. Maybe more importantly and knows how to figure it out for the patient in front of us.
So, Suresh, thank you so much for this. And good luck as you continue in your leadership role.
Suresh G. Nair, MD: John, I really appreciate it thank you so much. All right. Thank you.
John Marshall, MD: Thank you all for joining us for episode three of Oncology Update, where we focused on the whole concept of how do we stay up to date. I'll see you in a couple of weeks for episode four.