Uncovering the Power of Introspection to Drive Personalized Cancer Care

John L. Marshall, MD

For John L. Marshall, MD, the desire to build a career in oncology started early in his adolescence. He credits the TV show M*A*S*H with much of his passion for medicine and science. The witty yet grounded Benjamin Franklin “Hawkeye” Pierce was Marshall’s onscreen idol throughout his early years. “He was a great doctor, but he was funny and had a bite to him,” Marshall said. “I always wanted to grow up and be Hawkeye.”

However, the aspect of growing up that had the most influence on Marshall’s eventual career choices was his mother’s lymphoma diagnosis that she received when he was young. Necessities of cancer care, such as accompanying his mother to radiation therapy appointments, were baked into Marshall’s childhood and heavily influenced his interest in science and medicine. When his mother died when he was 13 years old, he became resolute to build a career in oncology.

Turn Pain into Purpose

Marshall had the drive to practice oncology, but he still needed to find his niche. No stranger to witnessing radiation oncology in practice, he chose a job as an assistant technician in a radiation oncology office to earn some money over the summer between his first and second years of medical school at the University of Louisville in Kentucky. However, “I was not all that interested in the physics and machines; I was more focused on the patient journey,” he said. Above all, he wanted to build trusting relationships with patients who he would get to see again and again as he helped them through their cancer, leading him to choose the medical oncology route.

“With each step, with each achievement...you’re influenced by what it took to get there. You’re influ- enced by what’s valuable and why,” he reflected.

In 1988, he matched at the Georgetown University School of Medicine, home to the Lombardi Comprehensive Cancer Center in Washington, DC, where he still works as a professor of medicine and oncology and the chief of hematology and oncology. At Georgetown, Marshall recognized that he wanted to contribute to an ever-evolving field. “I wanted something I could influence or be part of as it changed,” Marshall said. “The whole concept of doing better than we are has been an important theme to me for all my career.”

When he first began working at Georgetown, the institution was known for its renowned breast cancer doctors. At the time, the breast cancer research field was also more robust than that of other cancers. Although Marshall appreciated that the tide was turning for patients with breast cancer, he also recognized that much of the breast cancer science did not translate to other diseases. “What about all the other cancers out there? Why aren’t we focused on them?” he asked.

Because gastrointestinal (GI) cancers are some of the most common and fatal cancers, Marshall saw an immense need for these patients to have new and effective treatment options. Fortunately, he found mentors at Georgetown who were just as passionate about improving the field for these patients.

“These [patients] were people who needed atten- tion, needed advocacy, needed studies done, needed love...and because of great mentorship [and] some pushback against the breast cancer machine, GI cancer [became] my home,” he said.

One of the patients Marshall treated became an immense influence on his career, as well as on the whole GI cancer field. When Otto J. Ruesch died of pancreatic cancer, his family was troubled by the lack of attention on GI cancers in the oncology field. This passion for improving GI cancer outcomes inspired Marshall to establish the Ruesch Center for the Cure of Gastrointestinal Cancers in 2009.

Although people cautioned against the use of the word cure in the center’s title, Marshall vehemently disagreed, emphasizing that the goal of this center is to ultimately cure patients through research, raising awareness for the disease, and supporting patient advocacy efforts.

And the center has already had much of Marshall’s desired impact. GI cancer cure rates have improved since its inception. Furthermore, the center has been able to fund its own clinical trials and educate oncologists about GI cancer management. Overall, Marshall is proud to have participated in the creation of a place that continues to raise the bar for GI cancer outcomes.

Struggling with Professional and Personal Collisions

Amid Marshall’s drive to improve the GI cancer field, he was unexpectedly pulled back into the breast cancer realm when his wife, Liza, was diagnosed with inflammatory breast cancer. This time, the oncologist became the caregiver. “I learned just how important that caregiver role is and got a brand-new appreciation for what it is to consume cancer care,” Marshall said.

Marshall credits breast cancer research as the reason why Liza is still alive today, noting the irony in such a statement given his disdain in years past. He also notes that this time in his personal life was a turning point in both his career and the Ruesch Center as a whole. Despite the circumstances, Marshall and Liza had an overwhelmingly positive experience during her cancer treatments because the cancer center took such great care of them. This inspired Marshall to attempt to replicate that level of care for every patient who walked through the door of the Lombardi Comprehensive Cancer Center.

However, Marshall was also starting to feel the effects of cancer hitting closer to home than ever before. He was deeply upset by the notion that he might never be able to provide a level of care that he felt was enough for his patients who were suffering from their diseases. And, rattled by Liza’s run-in with cancer, his emotions ran especially high every time a patient of his would die, triggering a call to their caregiver to offer sympathy and support. The barriers that he had carefully constructed between his work and personal life began to crumble and exhaustion set in. “Once you’ve been on the other side, once you know what it feels like to hear what we say to people, then it’s really hard not to feel it,” he said.

Desperate for a break, Marshall made recent history by being the first Georgetown physician in more than 20 years to request and be approved for a yearlong sabbatical. However, taking a break was easier said than done. He recalls how patients were initially angry at him and felt he was abandoning them during pivotal points in their care, especially because many patients would likely not be alive when he returned.

During the 6 months before his sabbatical began in 2019, Marshall was able to break through the lens through which his patients saw him as more than human. They started to understand the importance of him taking time for himself so he could return energized to keep working uninterrupted.

“What we do is hard, and for me to be in the position I’m in and to publicly burn out, or at least come close to it, and needing a break...expressing this emotion has been one of the most important lessons for me,” he said. “For forever, that was just part of being a doctor; you were supposed to be able to handle that without any physical or emotional impact, and we know that’s not truly possible.”

Now when Marshall talks with patients and colleagues, he expresses the importance of being aware of the burnout that can come from living a daily life so close to cancer. Although he emphasizes to colleagues the importance of staying sensitive to patient needs and emotions, he advises them to find a unique balance that will help them regulate their own emotions as they help patients through difficult life events.

Getting Some Things 'Off His Chest'

When Marshall was growing up, his family didn’t talk much about his mother’s cancer journey. “It was a different era,” he said. Although much of the emotions surrounding those circumstances went largely unspoken, the opposite was true of Marshall’s experience with Liza’s cancer diagnosis.

During his sabbatical, Marshall and Liza went to Oxford, England, where he worked to build a global network with Indivumed Therapeutics, a global precision medicine research network that uses its vast access to biospecimens and data to provide pharmaceutical companies with packages of novel, disease-relevant targets to facilitate innovative drug development.

Around Marshall’s work with Indivumed, he and Liza wrote a book. Off Our Chests is written in alternating chapters between Marshall and Liza’s perspectives, neither of which were revealed to each other until the writing process was complete. “We enjoyed that work together, and it was very much therapy to me,” Marshall said.

Liza’s chapters focus on the timeline of her diagnosis and treatment, as well as her experience as a patient. Marshall’s chap- ters, however, dive into how his experience as a caregiver influenced his thoughts about the complicated nature of the health care system, particularly cancer medicine and clinical research.

Marshall described the moment when he shared his writing with Liza as “the hardest day of the whole process.” Each of them had filled their chapters with intense personal details, and writing those details down was much easier than witnessing someone else consume them. However, the thoughts and emotions they share in the book are a testament to all that they experienced and learned from as patient and caregiver. “Now that patients and their caregivers are reading the book in real time, they’re allowed to think some of the things we wrote,” Marshall said.

Stepping into the caregiver role also made Marshall feel the tension between the goals of the oncologist and the desires of the patient and those closest to them. Being a caregiver for a patient with cancer is akin to a full-time job, he explained. Marshall had seen how his father had tried to act normal during his mother’s battle with cancer. When Marshall found himself in the position of watching his wife struggle with her disease, his biggest desire was for her suffering to end.

He reflected that oncologists are often so focused on adding a few months to a patient’s life that they may not consider the experiences and priorities of that patient and their caregiver. Now, a few days after one of his patients dies, Marshall calls their caregiver to check-in. He recognizes that as painful as it is to die as a patient with cancer, it is also painful to be the caregiver of that patient, who now must live the rest of their life altered by the loss of their loved one. Marshall is passionate about imparting this message to colleagues so the oncology community can do everything it can to support all people involved in a patient’s cancer journey.

Carving Out Time For Rest

When Marshall meets with a new patient, one of the first questions he asks them is: “What do you do for fun?” This helps him establish a personal connection with the people in the room and lets him know some of their priorities, as well as the sacrifices they will be making as they begin their treatment course.

When Marshall himself is asked what he does for fun, he speaks fondly of “the little joys in life,” such as him and Liza enjoying dinners with their 2 children, Charlie and Emma. Marshall loves to cook and visit nice restaurants. He tests his golfing skills on the green and travels whenever he can to avoid burnout and have fun exploring new places. His busy social calendar includes attending plenty of theater and sporting events. Whether he’s savoring a glass of bourbon while cooking dinner or going to a Washington Mystics game, Marshall appreciates the full spectrum of what life has to offer so he can return to work each day with a renewed passion for driving progress in GI cancer care.

“My role is one of continuing to challenge us as a community,” he said. “We must do better. We aren’t done yet. If I can leave that anxiety and pressure behind, that would be what I would like to leave behind [so] we can make some leaps. One day, I hope we can reach an understanding of cancer to be able to say to all patients: ‘Don’t worry about that because we can cure that!’”