[00:00:05] MedBuzz: Back to Being ‘Just a Doctor’
John Marshall, MD: John Marshall for Oncology Unscripted, coming to you live from this big office. This is the biggest office because, you know, I've been the Chief of the Division here at Georgetown for 20 years. I didn't want the job when I was first offered it a long time ago. I ended up saying yes. Of course, that's a dramatic change in one's academic career—taking on administrative roles like this. You do get the big office, which is nice, but you also get a lot of other stuff. You know too much. You know who's mad at whom, you know who you need to recruit, and who you need to un-recruit—all of those things. You have the business side of a cancer business going on, and you're a doctor, and you're doing clinical research, and you're trying to educate everybody around you.
About a year or so ago, I decided in my own head that 20 years is enough. And so, as of this summer, I have officially stepped down as the Chief of the Division here at Georgetown. My colleague and much smarter friend, Dr. Steven Liu—lung cancer expert, world expert—is stepping in to be the Chief of our Division, and he's already hit the ground running. The fresh voice is honestly already a positive. You can just hear the freshness of his voice and his attitude and his energy.
You know, the Mayo Clinic actually has a structure where you can only be in a leadership position for so many years, and it has to turn over. And I really like that. It's sort of like what we hope our presidential terms will be. But who knows—that may change. But there's a limit: you do the job for a certain period of time, and then someone else steps in and gives you that fresh voice and fresh perspective. But that's not the traditional way of doing it. Most of the time, people hold on to their position as long as they can hold on to it, until they can't do it anymore or they decide to go to some other institution.
But the reason I'm sharing this is that I'm now in this sort of weird new place. I'm an ordinary staff physician. All of a sudden—yep. I have my patients, I'm doing my thing, I'm putting people on clinical trials, I'm educating the brand-new fellows who just showed up here about a month ago. Great fun having brand-new fellows 'cause they don't even know how to spell 5-FU, much less how well it works, how it works, and the side effects, etc. So, I love the first few months 'cause you're teaching people a lot of new things that they need to know. But anyway, that part's very exciting. So, I'm still doing all of that.
But what I'm gonna have to get used to is not knowing everything—also not feeling responsible for everything. And that's gonna be a change for me. So, any of you out there who've either been through that transition or who maybe wanna offer me some therapy—I'm in line for some therapy as I transition, as I begin to slow down my academic career, withdrawing as the Chief of the Division, but still doing my day-to-day job and still trying to cure cancer.
Take care of each other out there. Take care of your bosses and those leaders. It's not a great, fun job. But also, remember: those of us who are now back in the trenches—we need to take care of each other as well. John Marshall for Oncology Unscripted.
[00:03:35] Editorial: Watching Vaccine Access Collapse In Real Time
John Marshall, MD: John Marshall Oncology Unscripted. First piece of advice: don’t read the newspaper. Second piece of advice: don’t watch C-SPAN, for sure. Just yesterday on C-SPAN was the big congressional hearings. I did read the summary of it in The Washington Post, where RFK Jr. was interviewed—cross-examined for three hours by both sides of the aisle—about what he has been doing with the CDC. And I think we all, as medical professionals, need to take a big step back and a pause and sort of ask: what the hell is going on?
You know, the specifics first. He fired everybody at the CDC. He has hired new people at the CDC. They have not come forward with any formal vaccine recommendations. This is all about vaccines and the like.
Yesterday in clinic, a patient of mine—who would be a candidate for both flu and COVID vaccines, who could have, a month ago, walked into CVS and gotten both of those injections—now, in the state of Virginia (and I think there are about 14 other states where this is true), has to have a prescription. This came out from CVS and Walgreens—that you have to write a prescription. Physicians have to write a prescription so that patients can take it to the CVS and Walgreens to get their vaccines. Some states are not providing them at all. Some states have gone the other way, where they’ve formed collaborations—and this is those cool West Coast states: Washington, Oregon, Hawaii, California. They’ve formed a consortium to say, “We are gonna set our own policy,” because the government’s policy right now is up in the air about whether you can get access to them, whether we should be providing them. How do you get access to them? And so we’re all up in the air about what's going to happen.
And then, of course, our brilliant RFK Jr.—who, by the way, doesn’t live very far from where I’m sitting right now. There was one day I was walking through Georgetown and crossed paths with him. I was like, “Ugh.” But anyway, he doesn’t live very far from here. But he’s saying that we should kind of get rid of vaccines in general—not just COVID vaccines, but vaccines in general.
And so there is, coming out from the ACIP, a set of recommendations. And a lot of states—and I live in one, Virginia, which is over that direction—had agreed from the beginning (and I think there are seven—I don’t know, a bunch of states) that they will follow whatever the law is, they will follow whatever the ACIP says. But that was before we got this new group of people who’ve stepped in to oversee this. And so it may be that it undoes things, and we’re gonna need to put new laws in place.
We just can’t have this discussion about CDC and vaccines without saying the word “Florida.” So, Florida has a Surgeon General named Joseph Ladapo. And Joseph Ladapo is a physician—MD, PhD, incredibly well-trained. He is a professor at the University of Florida. He trained at Harvard and other really good places, and he is all about public health. That’s his thing—more on the cardiovascular side of things. But during the pandemic, he was an anti-vaxxer then. And now, of course, you all know that Florida is trying to put forward where children no longer have a vaccine requirement to go to school, etc.—that they can undo that. And these are recommendations and laws that have been in place for over 100 years. And he says, “Nope, we’re not gonna do it anymore.”
You know, my mother had polio, for goodness’ sakes. Do we want to go back to that sort of world where children are going to be getting these infections that we had solved—pretty much solved—in the past? And so, you know, we’re joking about, you know, who’s gonna want to go to Disney World. Take your children to Disney World if everybody there is unvaccinated. Maybe it’s the alternative. Maybe that’s the place to go get exposed—like you remember when we were kids? We used to be told to go over and play with the kid who has chickenpox so that we would all get chickenpox. Well, maybe we’ll all just go to Florida so we all get measles, mumps, rubella, and polio—and other things like that.
So, who knows how this well-trained person has got it in his mind that this RFK Jr. sort of “vaccines are evil” is part of his mantra, and he’s applying this across the state of Florida.
So, I am so anxious about this because I think the next step is access to medical care in general. Right? We know that there are major cuts to Medicaid about to happen—influencing the shutting down of hospitals. Even in the state of Virginia, if we apply the current Medicaid cut recommendations that the new big bill signed, seven rural hospitals will have to close. Those people will not have access to hospitals in their area. Right? Also talking about reducing Medicare support. So, okay, fine—we're gonna reduce the amount of healthcare that’s available to people out there.
But what about medicines? What’s lifesaving, and what is a hoax that causes autism? Right now, the CDC and RFK think that vaccines are a hoax that cause autism. Okay, what about immunotherapy for MSI-high patients, right? Is that a hoax, or is that amazing, life-saving therapy? And so we’re splicing and dicing all of these things to the point where we’re not gonna have access to things that we know help broad populations avoid bad infections and death.
When is that gonna start to trickle down to other healthcare access, and who’s going to be making those decisions?
I think about the HPV vaccine. Right? This is available to both boys and girls. We think—we’re pretty sure—that if everybody were to get this, cervical cancer, head and neck cancers, and others would diminish dramatically because so many of them are caused by HPV infections. Are we gonna do away with those? That’s, in essence, a cancer vaccine—a prevention-of-cancer vaccine. Is that next on the chopping block? So that now our incredible discoveries of the linkage between HPV and cancer are undone—because we can’t prevent it anymore?
So, I am very unsettled. The people around us in healthcare are very unsettled. Pharmaceutical industry is very unsettled. Healthcare providers—small hospitals, rural hospitals—are very unsettled. Yet we are being led by people who do not represent the population, who do not represent the 80–90% majority of parents that want their children to have vaccines. What these people are representing are the 5–10% of people who are convinced that vaccines don’t do anything and are crazy to give.
And so we need to figure out how to push back, how to represent the majority against these people—to stand up against these people. Both sides of the aisle are uncomfortable about this. And my fingers are crossed that if enough of us get out and scream, if enough of us go up and hold a sign over a bridge or out on a walk somewhere, that enough people will hear—and we will rise up and take back our healthcare, take back our successes so that we can at least not step backwards. More people dying. More people suffering—when we’d already figured out how to prevent it.
I am hopeful, hopeful, hopeful that the months ahead will be better than the last eight months.
John Marshall for Oncology Unscripted.
[00:13:02] Main Topic: Running Into Risk: Colon Cancer and Marathon Runners
[00:00:05] MedBuzz: Back to Being ‘Just a Doctor’
John Marshall, MD: John Marshall for Oncology Unscripted, coming to you live from this big office. This is the biggest office because, you know, I've been the Chief of the Division here at Georgetown for 20 years. I didn't want the job when I was first offered it a long time ago. I ended up saying yes. Of course, that's a dramatic change in one's academic career—taking on administrative roles like this. You do get the big office, which is nice, but you also get a lot of other stuff. You know too much. You know who's mad at whom, you know who you need to recruit, and who you need to un-recruit—all of those things. You have the business side of a cancer business going on, and you're a doctor, and you're doing clinical research, and you're trying to educate everybody around you.
About a year or so ago, I decided in my own head that 20 years is enough. And so, as of this summer, I have officially stepped down as the Chief of the Division here at Georgetown. My colleague and much smarter friend, Dr. Steven Liu—lung cancer expert, world expert—is stepping in to be the Chief of our Division, and he's already hit the ground running. The fresh voice is honestly already a positive. You can just hear the freshness of his voice and his attitude and his energy.
You know, the Mayo Clinic actually has a structure where you can only be in a leadership position for so many years, and it has to turn over. And I really like that. It's sort of like what we hope our presidential terms will be. But who knows—that may change. But there's a limit: you do the job for a certain period of time, and then someone else steps in and gives you that fresh voice and fresh perspective. But that's not the traditional way of doing it. Most of the time, people hold on to their position as long as they can hold on to it, until they can't do it anymore or they decide to go to some other institution.
But the reason I'm sharing this is that I'm now in this sort of weird new place. I'm an ordinary staff physician. All of a sudden—yep. I have my patients, I'm doing my thing, I'm putting people on clinical trials, I'm educating the brand-new fellows who just showed up here about a month ago. Great fun having brand-new fellows 'cause they don't even know how to spell 5-FU, much less how well it works, how it works, and the side effects, etc. So, I love the first few months 'cause you're teaching people a lot of new things that they need to know. But anyway, that part's very exciting. So, I'm still doing all of that.
But what I'm gonna have to get used to is not knowing everything—also not feeling responsible for everything. And that's gonna be a change for me. So, any of you out there who've either been through that transition or who maybe wanna offer me some therapy—I'm in line for some therapy as I transition, as I begin to slow down my academic career, withdrawing as the Chief of the Division, but still doing my day-to-day job and still trying to cure cancer.
Take care of each other out there. Take care of your bosses and those leaders. It's not a great, fun job. But also, remember: those of us who are now back in the trenches—we need to take care of each other as well. John Marshall for Oncology Unscripted.
[00:03:35] Editorial: Watching Vaccine Access Collapse In Real Time
John Marshall, MD: John Marshall Oncology Unscripted. First piece of advice: don’t read the newspaper. Second piece of advice: don’t watch C-SPAN, for sure. Just yesterday on C-SPAN was the big congressional hearings. I did read the summary of it in The Washington Post, where RFK Jr. was interviewed—cross-examined for three hours by both sides of the aisle—about what he has been doing with the CDC. And I think we all, as medical professionals, need to take a big step back and a pause and sort of ask: what the hell is going on?
You know, the specifics first. He fired everybody at the CDC. He has hired new people at the CDC. They have not come forward with any formal vaccine recommendations. This is all about vaccines and the like.
Yesterday in clinic, a patient of mine—who would be a candidate for both flu and COVID vaccines, who could have, a month ago, walked into CVS and gotten both of those injections—now, in the state of Virginia (and I think there are about 14 other states where this is true), has to have a prescription. This came out from CVS and Walgreens—that you have to write a prescription. Physicians have to write a prescription so that patients can take it to the CVS and Walgreens to get their vaccines. Some states are not providing them at all. Some states have gone the other way, where they’ve formed collaborations—and this is those cool West Coast states: Washington, Oregon, Hawaii, California. They’ve formed a consortium to say, “We are gonna set our own policy,” because the government’s policy right now is up in the air about whether you can get access to them, whether we should be providing them. How do you get access to them? And so we’re all up in the air about what's going to happen.
And then, of course, our brilliant RFK Jr.—who, by the way, doesn’t live very far from where I’m sitting right now. There was one day I was walking through Georgetown and crossed paths with him. I was like, “Ugh.” But anyway, he doesn’t live very far from here. But he’s saying that we should kind of get rid of vaccines in general—not just COVID vaccines, but vaccines in general.
And so there is, coming out from the ACIP, a set of recommendations. And a lot of states—and I live in one, Virginia, which is over that direction—had agreed from the beginning (and I think there are seven—I don’t know, a bunch of states) that they will follow whatever the law is, they will follow whatever the ACIP says. But that was before we got this new group of people who’ve stepped in to oversee this. And so it may be that it undoes things, and we’re gonna need to put new laws in place.
We just can’t have this discussion about CDC and vaccines without saying the word “Florida.” So, Florida has a Surgeon General named Joseph Ladapo. And Joseph Ladapo is a physician—MD, PhD, incredibly well-trained. He is a professor at the University of Florida. He trained at Harvard and other really good places, and he is all about public health. That’s his thing—more on the cardiovascular side of things. But during the pandemic, he was an anti-vaxxer then. And now, of course, you all know that Florida is trying to put forward where children no longer have a vaccine requirement to go to school, etc.—that they can undo that. And these are recommendations and laws that have been in place for over 100 years. And he says, “Nope, we’re not gonna do it anymore.”
You know, my mother had polio, for goodness’ sakes. Do we want to go back to that sort of world where children are going to be getting these infections that we had solved—pretty much solved—in the past? And so, you know, we’re joking about, you know, who’s gonna want to go to Disney World. Take your children to Disney World if everybody there is unvaccinated. Maybe it’s the alternative. Maybe that’s the place to go get exposed—like you remember when we were kids? We used to be told to go over and play with the kid who has chickenpox so that we would all get chickenpox. Well, maybe we’ll all just go to Florida so we all get measles, mumps, rubella, and polio—and other things like that.
So, who knows how this well-trained person has got it in his mind that this RFK Jr. sort of “vaccines are evil” is part of his mantra, and he’s applying this across the state of Florida.
So, I am so anxious about this because I think the next step is access to medical care in general. Right? We know that there are major cuts to Medicaid about to happen—influencing the shutting down of hospitals. Even in the state of Virginia, if we apply the current Medicaid cut recommendations that the new big bill signed, seven rural hospitals will have to close. Those people will not have access to hospitals in their area. Right? Also talking about reducing Medicare support. So, okay, fine—we're gonna reduce the amount of healthcare that’s available to people out there.
But what about medicines? What’s lifesaving, and what is a hoax that causes autism? Right now, the CDC and RFK think that vaccines are a hoax that cause autism. Okay, what about immunotherapy for MSI-high patients, right? Is that a hoax, or is that amazing, life-saving therapy? And so we’re splicing and dicing all of these things to the point where we’re not gonna have access to things that we know help broad populations avoid bad infections and death.
When is that gonna start to trickle down to other healthcare access, and who’s going to be making those decisions?
I think about the HPV vaccine. Right? This is available to both boys and girls. We think—we’re pretty sure—that if everybody were to get this, cervical cancer, head and neck cancers, and others would diminish dramatically because so many of them are caused by HPV infections. Are we gonna do away with those? That’s, in essence, a cancer vaccine—a prevention-of-cancer vaccine. Is that next on the chopping block? So that now our incredible discoveries of the linkage between HPV and cancer are undone—because we can’t prevent it anymore?
So, I am very unsettled. The people around us in healthcare are very unsettled. Pharmaceutical industry is very unsettled. Healthcare providers—small hospitals, rural hospitals—are very unsettled. Yet we are being led by people who do not represent the population, who do not represent the 80–90% majority of parents that want their children to have vaccines. What these people are representing are the 5–10% of people who are convinced that vaccines don’t do anything and are crazy to give.
And so we need to figure out how to push back, how to represent the majority against these people—to stand up against these people. Both sides of the aisle are uncomfortable about this. And my fingers are crossed that if enough of us get out and scream, if enough of us go up and hold a sign over a bridge or out on a walk somewhere, that enough people will hear—and we will rise up and take back our healthcare, take back our successes so that we can at least not step backwards. More people dying. More people suffering—when we’d already figured out how to prevent it.
I am hopeful, hopeful, hopeful that the months ahead will be better than the last eight months.
John Marshall for Oncology Unscripted.
[00:13:02] Main Topic: Running Into Risk: Colon Cancer and Marathon Runners
John Marshall, MD: We have been preaching on Oncology Unscripted about the very cool new data showing that if you had a personal trainer, you had an improvement in survival in colon cancer compared to if you were just told to go exercise. Right? What an amazing abstract that was presented at ASCO this year. And so we're all wondering whether Blue Cross Blue Shield should go out there and start covering personal trainers. And maybe the answer is yes.
But follow-up data on that says—and these are things we all knew before—is that too much of a good thing can be bad. A very good friend of mine and colleague of ours, Tim Cannon, here in the Northern Virginia area, actually has been doing a study that made the big time—New York Times published work that they had been doing—showing that marathoners and ultramarathoners actually had an increased risk of colon cancer. So yeah—personal trainer a few times a week, improving your cure rate. Whereas if you go too much, you strain the body. Maybe it’s an alteration in diet, maybe it’s microbiome—we’ll talk about it. You actually can make things worse.
So, I want you to listen in to our interview together. Dr. Tim Cannon and I discuss this way cool science, with an idea of trying to figure out what the heck’s going on.
Join us for Oncology Unscripted.
[00:14:38] Interview: Running Into Risk—My Interview with Dr Timothy Cannon
John Marshall, MD: Hey, everybody out there—John Marshall for Oncology Unscripted. You're frittering away more of your time, but we've got something that is clearly worth your effort. You know what? I have run, myself, three half marathons. I hated every one of them. I did it 'cause I thought I was supposed to. I trained up for it—it took a whole season to train up for it. I didn’t hurt anything too bad, which is good. I wasn’t fast—let’s be clear. I was always glad to not be doing the other half of the marathon.
So why do you care about this? Well, there's been new evidence—it’s been building over time—and it's been really led by and championed by a very good friend and colleague of mine, Dr. Tim Cannon, where too much exercise—or too much strain on the body, maybe we should rephrase that—might, in fact, be bad for us, specifically around colorectal cancer. We already know the data—'cause we've talked about it—around a personal trainer improving your survival if you had colon cancer. But what about joining an ultramarathon team?
Dr. Tim Cannon has something to say about that. Tim, introduce yourself and tell the gang your science.
Timothy Cannon, MD: Sure. So, I'm Tim Cannon. Thank you so much for having me, John. This is a study that you cite, that we've just done in the DC area, on ultramarathoners. And I had seen, in the course of about a year, three different ultramarathoners—actually, two were ultramarathoners, one was a triathlete. They had both done dozens of those types of races. And they had stage IV cancer in their 30s.
And I thought, you know, there may be a connection here. They were all describing bleeding after they run. I had heard a lot about runner's trots, or bleeding when you run long distances. And I can see how there could be a mechanism—that this could cause cancer if you run so much that you're having repeated insults to your colon, and bleeding.
And so, we decided to start a study. We opened our Cancer Prevention Center here, and that's what we're here to talk about today. I'm really glad that you had an interest in this.
The study was of 100 long-distance runners. I would call them all extreme. They had all run at least five 26.2-mile marathons. Most of them had run ultramarathons. Many of them had run 100-mile ultramarathons. They had to be between the ages of 35 and 50, not have a known familial syndrome, and not have inflammatory bowel disease. And we screened them to see if they had precancerous polyps.
John Marshall, MD: And, as you found—they did. And some of them had an increased risk for cancer. So, fascinating work. When people were doing what they thought was gonna keep them outta trouble, they might've been getting themselves into trouble.
And I know you, you and I and others have had discussions about the “why” of this. And you just described sort of a trauma. I was always thinking like watershed—not enough blood flow, maybe hypoxia. There's also the other side that I’m, you know, obsessed with—and that's microbiome. These ultramarathoners eat all sorts of funky stuff. They do these protein gels, and they do all sorts of things that are not your classic Mediterranean diet.
If you had to put your quarter down, what do you think's the reason for it?
Timothy Cannon, MD: Yeah, and we haven’t proven anything quite yet. But I'm believing more and more that there is a connection here. And like you, I thought the watershed idea made the most sense to me initially.
Since this came out, everyone is emailing me with their own ideas about it. And some of them are pretty compelling. Microbiome, I think, may be among the most compelling. You know, I've been reading about differences in abundance in people who do endurance sports. There’s a bacteria called prevotella, for instance, that's more abundant in runners—and it may be related.
Sure, there's so much we don't know about this, but that's what we're hoping to explore in part two—analyzing the microbiome. And then, of course, there’s the lifestyle. Things that characterize long-distance runners—the goos, the... you know, I’ve worried about everything. They drink a lot of electrolyte drinks out of bottles, and maybe they have high exposure to BPA. Or maybe it’s the high-protein diet that was highlighted this week in The New York Times. Who knows? It could be any of these exposures that could cause it. It’s hard to know, hard to study. To isolate any one of these variables is tricky. But I think it’s important to try to get to the bottom of it.
John Marshall, MD: We're into prevention, right? We tell people not to smoke. We tell people to eat right. Should there be some sort of sign at the beginning of a marathon that says, “You're running at your own risk”?
Timothy Cannon, MD: Yeah, like the Surgeon General’s warning. I'm not sure we know enough quite to recommend that yet. And of course, I want to emphasize what you did first at the beginning here: that exercise is—by and large—going to be a good thing. We’ll have much bigger problems from there not being enough exercise. And I think we know fairly definitively that exercise reduces the risk of cancer recurrence. So, I want to emphasize that from the beginning.
But the question is whether there’s a dose of exercise that is too much. I believe there is. I’d like to get more evidence before we start putting signs on marathons or discouraging people too much. But I could see a future where there is something like that out there.
John Marshall, MD: Breakthrough work, in my opinion. Dr. Tim Cannon, thank you so much for, I’m sure, taking time out—when you're in The New York Times, you're much needed on the interview circuit. So, it's a real honor that you’ve taken some time to talk with us and our audience. Dr. Tim Cannon—
Timothy Cannon, MD: No way. This one means the most to me, John. Thank you.
John Marshall, MD: I love being lied to on a Wednesday. Hang in there everybody, and we'll see you next time on Oncology Unscripted.
This transcript has been edited for clarity. We have been preaching on Oncology Unscripted about the very cool new data showing that if you had a personal trainer, you had an improvement in survival in colon cancer compared to if you were just told to go exercise. Right? What an amazing abstract that was presented at ASCO this year. And so we're all wondering whether Blue Cross Blue Shield should go out there and start covering personal trainers. And maybe the answer is yes.
But follow-up data on that says—and these are things we all knew before—is that too much of a good thing can be bad. A very good friend of mine and colleague of ours, Tim Cannon, here in the Northern Virginia area, actually has been doing a study that made the big time—New York Times published work that they had been doing—showing that marathoners and ultramarathoners actually had an increased risk of colon cancer. So yeah—personal trainer a few times a week, improving your cure rate. Whereas if you go too much, you strain the body. Maybe it’s an alteration in diet, maybe it’s microbiome—we’ll talk about it. You actually can make things worse.
So, I want you to listen in to our interview together. Dr. Tim Cannon and I discuss this way cool science, with an idea of trying to figure out what the heck’s going on.
Join us for Oncology Unscripted.
[00:14:38] Interview: Running Into Risk—My Interview with Dr Timothy Cannon
John Marshall, MD: Hey, everybody out there—John Marshall for Oncology Unscripted. You're frittering away more of your time, but we've got something that is clearly worth your effort. You know what? I have run, myself, three half marathons. I hated every one of them. I did it 'cause I thought I was supposed to. I trained up for it—it took a whole season to train up for it. I didn’t hurt anything too bad, which is good. I wasn’t fast—let’s be clear. I was always glad to not be doing the other half of the marathon.
So why do you care about this? Well, there's been new evidence—it’s been building over time—and it's been really led by and championed by a very good friend and colleague of mine, Dr. Tim Cannon, where too much exercise—or too much strain on the body, maybe we should rephrase that—might, in fact, be bad for us, specifically around colorectal cancer. We already know the data—'cause we've talked about it—around a personal trainer improving your survival if you had colon cancer. But what about joining an ultramarathon team?
Dr. Tim Cannon has something to say about that. Tim, introduce yourself and tell the gang your science.
Timothy Cannon, MD: Sure. So, I'm Tim Cannon. Thank you so much for having me, John. This is a study that you cite, that we've just done in the DC area, on ultramarathoners. And I had seen, in the course of about a year, three different ultramarathoners—actually, two were ultramarathoners, one was a triathlete. They had both done dozens of those types of races. And they had stage IV cancer in their 30s.
And I thought, you know, there may be a connection here. They were all describing bleeding after they run. I had heard a lot about runner's trots, or bleeding when you run long distances. And I can see how there could be a mechanism—that this could cause cancer if you run so much that you're having repeated insults to your colon, and bleeding.
And so, we decided to start a study. We opened our Cancer Prevention Center here, and that's what we're here to talk about today. I'm really glad that you had an interest in this.
The study was of 100 long-distance runners. I would call them all extreme. They had all run at least five 26.2-mile marathons. Most of them had run ultramarathons. Many of them had run 100-mile ultramarathons. They had to be between the ages of 35 and 50, not have a known familial syndrome, and not have inflammatory bowel disease. And we screened them to see if they had precancerous polyps.
John Marshall, MD: And, as you found—they did. And some of them had an increased risk for cancer. So, fascinating work. When people were doing what they thought was gonna keep them outta trouble, they might've been getting themselves into trouble.
And I know you, you and I and others have had discussions about the “why” of this. And you just described sort of a trauma. I was always thinking like watershed—not enough blood flow, maybe hypoxia. There's also the other side that I’m, you know, obsessed with—and that's microbiome. These ultramarathoners eat all sorts of funky stuff. They do these protein gels, and they do all sorts of things that are not your classic Mediterranean diet.
If you had to put your quarter down, what do you think's the reason for it?
Timothy Cannon, MD: Yeah, and we haven’t proven anything quite yet. But I'm believing more and more that there is a connection here. And like you, I thought the watershed idea made the most sense to me initially.
Since this came out, everyone is emailing me with their own ideas about it. And some of them are pretty compelling. Microbiome, I think, may be among the most compelling. You know, I've been reading about differences in abundance in people who do endurance sports. There’s a bacteria called prevotella, for instance, that's more abundant in runners—and it may be related.
Sure, there's so much we don't know about this, but that's what we're hoping to explore in part two—analyzing the microbiome. And then, of course, there’s the lifestyle. Things that characterize long-distance runners—the goos, the... you know, I’ve worried about everything. They drink a lot of electrolyte drinks out of bottles, and maybe they have high exposure to BPA. Or maybe it’s the high-protein diet that was highlighted this week in The New York Times. Who knows? It could be any of these exposures that could cause it. It’s hard to know, hard to study. To isolate any one of these variables is tricky. But I think it’s important to try to get to the bottom of it.
John Marshall, MD: We're into prevention, right? We tell people not to smoke. We tell people to eat right. Should there be some sort of sign at the beginning of a marathon that says, “You're running at your own risk”?
Timothy Cannon, MD: Yeah, like the Surgeon General’s warning. I'm not sure we know enough quite to recommend that yet. And of course, I want to emphasize what you did first at the beginning here: that exercise is—by and large—going to be a good thing. We’ll have much bigger problems from there not being enough exercise. And I think we know fairly definitively that exercise reduces the risk of cancer recurrence. So, I want to emphasize that from the beginning.
But the question is whether there’s a dose of exercise that is too much. I believe there is. I’d like to get more evidence before we start putting signs on marathons or discouraging people too much. But I could see a future where there is something like that out there.
John Marshall, MD: Breakthrough work, in my opinion. Dr. Tim Cannon, thank you so much for, I’m sure, taking time out—when you're in The New York Times, you're much needed on the interview circuit. So, it's a real honor that you’ve taken some time to talk with us and our audience. Dr. Tim Cannon—
Timothy Cannon, MD: No way. This one means the most to me, John. Thank you.
John Marshall, MD: I love being lied to on a Wednesday. Hang in there everybody, and we'll see you next time on Oncology Unscripted.
This transcript has been edited for clarity.[00:00:05] MedBuzz: Back to Being ‘Just a Doctor’
John Marshall, MD: John Marshall for Oncology Unscripted, coming to you live from this big office. This is the biggest office because, you know, I've been the Chief of the Division here at Georgetown for 20 years. I didn't want the job when I was first offered it a long time ago. I ended up saying yes. Of course, that's a dramatic change in one's academic career—taking on administrative roles like this. You do get the big office, which is nice, but you also get a lot of other stuff. You know too much. You know who's mad at whom, you know who you need to recruit, and who you need to un-recruit—all of those things. You have the business side of a cancer business going on, and you're a doctor, and you're doing clinical research, and you're trying to educate everybody around you.
About a year or so ago, I decided in my own head that 20 years is enough. And so, as of this summer, I have officially stepped down as the Chief of the Division here at Georgetown. My colleague and much smarter friend, Dr. Steven Liu—lung cancer expert, world expert—is stepping in to be the Chief of our Division, and he's already hit the ground running. The fresh voice is honestly already a positive. You can just hear the freshness of his voice and his attitude and his energy.
You know, the Mayo Clinic actually has a structure where you can only be in a leadership position for so many years, and it has to turn over. And I really like that. It's sort of like what we hope our presidential terms will be. But who knows—that may change. But there's a limit: you do the job for a certain period of time, and then someone else steps in and gives you that fresh voice and fresh perspective. But that's not the traditional way of doing it. Most of the time, people hold on to their position as long as they can hold on to it, until they can't do it anymore or they decide to go to some other institution.
But the reason I'm sharing this is that I'm now in this sort of weird new place. I'm an ordinary staff physician. All of a sudden—yep. I have my patients, I'm doing my thing, I'm putting people on clinical trials, I'm educating the brand-new fellows who just showed up here about a month ago. Great fun having brand-new fellows 'cause they don't even know how to spell 5-FU, much less how well it works, how it works, and the side effects, etc. So, I love the first few months 'cause you're teaching people a lot of new things that they need to know. But anyway, that part's very exciting. So, I'm still doing all of that.
But what I'm gonna have to get used to is not knowing everything—also not feeling responsible for everything. And that's gonna be a change for me. So, any of you out there who've either been through that transition or who maybe wanna offer me some therapy—I'm in line for some therapy as I transition, as I begin to slow down my academic career, withdrawing as the Chief of the Division, but still doing my day-to-day job and still trying to cure cancer.
Take care of each other out there. Take care of your bosses and those leaders. It's not a great, fun job. But also, remember: those of us who are now back in the trenches—we need to take care of each other as well. John Marshall for Oncology Unscripted.
[00:03:35] Editorial: Watching Vaccine Access Collapse In Real Time
John Marshall, MD: John Marshall Oncology Unscripted. First piece of advice: don’t read the newspaper. Second piece of advice: don’t watch C-SPAN, for sure. Just yesterday on C-SPAN was the big congressional hearings. I did read the summary of it in The Washington Post, where RFK Jr. was interviewed—cross-examined for three hours by both sides of the aisle—about what he has been doing with the CDC. And I think we all, as medical professionals, need to take a big step back and a pause and sort of ask: what the hell is going on?
You know, the specifics first. He fired everybody at the CDC. He has hired new people at the CDC. They have not come forward with any formal vaccine recommendations. This is all about vaccines and the like.
Yesterday in clinic, a patient of mine—who would be a candidate for both flu and COVID vaccines, who could have, a month ago, walked into CVS and gotten both of those injections—now, in the state of Virginia (and I think there are about 14 other states where this is true), has to have a prescription. This came out from CVS and Walgreens—that you have to write a prescription. Physicians have to write a prescription so that patients can take it to the CVS and Walgreens to get their vaccines. Some states are not providing them at all. Some states have gone the other way, where they’ve formed collaborations—and this is those cool West Coast states: Washington, Oregon, Hawaii, California. They’ve formed a consortium to say, “We are gonna set our own policy,” because the government’s policy right now is up in the air about whether you can get access to them, whether we should be providing them. How do you get access to them? And so we’re all up in the air about what's going to happen.
And then, of course, our brilliant RFK Jr.—who, by the way, doesn’t live very far from where I’m sitting right now. There was one day I was walking through Georgetown and crossed paths with him. I was like, “Ugh.” But anyway, he doesn’t live very far from here. But he’s saying that we should kind of get rid of vaccines in general—not just COVID vaccines, but vaccines in general.
And so there is, coming out from the ACIP, a set of recommendations. And a lot of states—and I live in one, Virginia, which is over that direction—had agreed from the beginning (and I think there are seven—I don’t know, a bunch of states) that they will follow whatever the law is, they will follow whatever the ACIP says. But that was before we got this new group of people who’ve stepped in to oversee this. And so it may be that it undoes things, and we’re gonna need to put new laws in place.
We just can’t have this discussion about CDC and vaccines without saying the word “Florida.” So, Florida has a Surgeon General named Joseph Ladapo. And Joseph Ladapo is a physician—MD, PhD, incredibly well-trained. He is a professor at the University of Florida. He trained at Harvard and other really good places, and he is all about public health. That’s his thing—more on the cardiovascular side of things. But during the pandemic, he was an anti-vaxxer then. And now, of course, you all know that Florida is trying to put forward where children no longer have a vaccine requirement to go to school, etc.—that they can undo that. And these are recommendations and laws that have been in place for over 100 years. And he says, “Nope, we’re not gonna do it anymore.”
You know, my mother had polio, for goodness’ sakes. Do we want to go back to that sort of world where children are going to be getting these infections that we had solved—pretty much solved—in the past? And so, you know, we’re joking about, you know, who’s gonna want to go to Disney World. Take your children to Disney World if everybody there is unvaccinated. Maybe it’s the alternative. Maybe that’s the place to go get exposed—like you remember when we were kids? We used to be told to go over and play with the kid who has chickenpox so that we would all get chickenpox. Well, maybe we’ll all just go to Florida so we all get measles, mumps, rubella, and polio—and other things like that.
So, who knows how this well-trained person has got it in his mind that this RFK Jr. sort of “vaccines are evil” is part of his mantra, and he’s applying this across the state of Florida.
So, I am so anxious about this because I think the next step is access to medical care in general. Right? We know that there are major cuts to Medicaid about to happen—influencing the shutting down of hospitals. Even in the state of Virginia, if we apply the current Medicaid cut recommendations that the new big bill signed, seven rural hospitals will have to close. Those people will not have access to hospitals in their area. Right? Also talking about reducing Medicare support. So, okay, fine—we're gonna reduce the amount of healthcare that’s available to people out there.
But what about medicines? What’s lifesaving, and what is a hoax that causes autism? Right now, the CDC and RFK think that vaccines are a hoax that cause autism. Okay, what about immunotherapy for MSI-high patients, right? Is that a hoax, or is that amazing, life-saving therapy? And so we’re splicing and dicing all of these things to the point where we’re not gonna have access to things that we know help broad populations avoid bad infections and death.
When is that gonna start to trickle down to other healthcare access, and who’s going to be making those decisions?
I think about the HPV vaccine. Right? This is available to both boys and girls. We think—we’re pretty sure—that if everybody were to get this, cervical cancer, head and neck cancers, and others would diminish dramatically because so many of them are caused by HPV infections. Are we gonna do away with those? That’s, in essence, a cancer vaccine—a prevention-of-cancer vaccine. Is that next on the chopping block? So that now our incredible discoveries of the linkage between HPV and cancer are undone—because we can’t prevent it anymore?
So, I am very unsettled. The people around us in healthcare are very unsettled. Pharmaceutical industry is very unsettled. Healthcare providers—small hospitals, rural hospitals—are very unsettled. Yet we are being led by people who do not represent the population, who do not represent the 80–90% majority of parents that want their children to have vaccines. What these people are representing are the 5–10% of people who are convinced that vaccines don’t do anything and are crazy to give.
And so we need to figure out how to push back, how to represent the majority against these people—to stand up against these people. Both sides of the aisle are uncomfortable about this. And my fingers are crossed that if enough of us get out and scream, if enough of us go up and hold a sign over a bridge or out on a walk somewhere, that enough people will hear—and we will rise up and take back our healthcare, take back our successes so that we can at least not step backwards. More people dying. More people suffering—when we’d already figured out how to prevent it.
I am hopeful, hopeful, hopeful that the months ahead will be better than the last eight months.
John Marshall for Oncology Unscripted.
[00:13:02] Main Topic: Running Into Risk: Colon Cancer and Marathon Runners
John Marshall, MD: We have been preaching on Oncology Unscripted about the very cool new data showing that if you had a personal trainer, you had an improvement in survival in colon cancer compared to if you were just told to go exercise. Right? What an amazing abstract that was presented at ASCO this year. And so we're all wondering whether Blue Cross Blue Shield should go out there and start covering personal trainers. And maybe the answer is yes.
But follow-up data on that says—and these are things we all knew before—is that too much of a good thing can be bad. A very good friend of mine and colleague of ours, Tim Cannon, here in the Northern Virginia area, actually has been doing a study that made the big time—New York Times published work that they had been doing—showing that marathoners and ultramarathoners actually had an increased risk of colon cancer. So yeah—personal trainer a few times a week, improving your cure rate. Whereas if you go too much, you strain the body. Maybe it’s an alteration in diet, maybe it’s microbiome—we’ll talk about it. You actually can make things worse.
So, I want you to listen in to our interview together. Dr. Tim Cannon and I discuss this way cool science, with an idea of trying to figure out what the heck’s going on.
Join us for Oncology Unscripted.
[00:14:38] Interview: Running Into Risk—My Interview with Dr Timothy Cannon
John Marshall, MD: Hey, everybody out there—John Marshall for Oncology Unscripted. You're frittering away more of your time, but we've got something that is clearly worth your effort. You know what? I have run, myself, three half marathons. I hated every one of them. I did it 'cause I thought I was supposed to. I trained up for it—it took a whole season to train up for it. I didn’t hurt anything too bad, which is good. I wasn’t fast—let’s be clear. I was always glad to not be doing the other half of the marathon.
So why do you care about this? Well, there's been new evidence—it’s been building over time—and it's been really led by and championed by a very good friend and colleague of mine, Dr. Tim Cannon, where too much exercise—or too much strain on the body, maybe we should rephrase that—might, in fact, be bad for us, specifically around colorectal cancer. We already know the data—'cause we've talked about it—around a personal trainer improving your survival if you had colon cancer. But what about joining an ultramarathon team?
Dr. Tim Cannon has something to say about that. Tim, introduce yourself and tell the gang your science.
Timothy Cannon, MD: Sure. So, I'm Tim Cannon. Thank you so much for having me, John. This is a study that you cite, that we've just done in the DC area, on ultramarathoners. And I had seen, in the course of about a year, three different ultramarathoners—actually, two were ultramarathoners, one was a triathlete. They had both done dozens of those types of races. And they had stage IV cancer in their 30s.
And I thought, you know, there may be a connection here. They were all describing bleeding after they run. I had heard a lot about runner's trots, or bleeding when you run long distances. And I can see how there could be a mechanism—that this could cause cancer if you run so much that you're having repeated insults to your colon, and bleeding.
And so, we decided to start a study. We opened our Cancer Prevention Center here, and that's what we're here to talk about today. I'm really glad that you had an interest in this.
The study was of 100 long-distance runners. I would call them all extreme. They had all run at least five 26.2-mile marathons. Most of them had run ultramarathons. Many of them had run 100-mile ultramarathons. They had to be between the ages of 35 and 50, not have a known familial syndrome, and not have inflammatory bowel disease. And we screened them to see if they had precancerous polyps.
John Marshall, MD: And, as you found—they did. And some of them had an increased risk for cancer. So, fascinating work. When people were doing what they thought was gonna keep them outta trouble, they might've been getting themselves into trouble.
And I know you, you and I and others have had discussions about the “why” of this. And you just described sort of a trauma. I was always thinking like watershed—not enough blood flow, maybe hypoxia. There's also the other side that I’m, you know, obsessed with—and that's microbiome. These ultramarathoners eat all sorts of funky stuff. They do these protein gels, and they do all sorts of things that are not your classic Mediterranean diet.
If you had to put your quarter down, what do you think's the reason for it?
Timothy Cannon, MD: Yeah, and we haven’t proven anything quite yet. But I'm believing more and more that there is a connection here. And like you, I thought the watershed idea made the most sense to me initially.
Since this came out, everyone is emailing me with their own ideas about it. And some of them are pretty compelling. Microbiome, I think, may be among the most compelling. You know, I've been reading about differences in abundance in people who do endurance sports. There’s a bacteria called prevotella, for instance, that's more abundant in runners—and it may be related.
Sure, there's so much we don't know about this, but that's what we're hoping to explore in part two—analyzing the microbiome. And then, of course, there’s the lifestyle. Things that characterize long-distance runners—the goos, the... you know, I’ve worried about everything. They drink a lot of electrolyte drinks out of bottles, and maybe they have high exposure to BPA. Or maybe it’s the high-protein diet that was highlighted this week in The New York Times. Who knows? It could be any of these exposures that could cause it. It’s hard to know, hard to study. To isolate any one of these variables is tricky. But I think it’s important to try to get to the bottom of it.
John Marshall, MD: We're into prevention, right? We tell people not to smoke. We tell people to eat right. Should there be some sort of sign at the beginning of a marathon that says, “You're running at your own risk”?
Timothy Cannon, MD: Yeah, like the Surgeon General’s warning. I'm not sure we know enough quite to recommend that yet. And of course, I want to emphasize what you did first at the beginning here: that exercise is—by and large—going to be a good thing. We’ll have much bigger problems from there not being enough exercise. And I think we know fairly definitively that exercise reduces the risk of cancer recurrence. So, I want to emphasize that from the beginning.
But the question is whether there’s a dose of exercise that is too much. I believe there is. I’d like to get more evidence before we start putting signs on marathons or discouraging people too much. But I could see a future where there is something like that out there.
John Marshall, MD: Breakthrough work, in my opinion. Dr. Tim Cannon, thank you so much for, I’m sure, taking time out—when you're in The New York Times, you're much needed on the interview circuit. So, it's a real honor that you’ve taken some time to talk with us and our audience. Dr. Tim Cannon—
Timothy Cannon, MD: No way. This one means the most to me, John. Thank you.
John Marshall, MD: I love being lied to on a Wednesday. Hang in there everybody, and we'll see you next time on Oncology Unscripted.
This transcript has been edited for clarity.
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