Cancer patients often ask their doctors, “What would you do if you were me?” Here, our Curious Dr. George asks Mayo Clinic oncologist Javier Munoz, MD, MS, MBA, how he would handle his own diagnosis of mantle cell lymphoma. At the Mayo Clinic in Arizona, Dr. Munoz serves as Director of the Lymphoma Program, Co-Director of the Cellular Therapy Program, and Director of the Cancer Center Clinical Trials Office.

Curious Dr. George: Please consider this hypothetical scenario: You are a young male physician in general good health in an active practice of clinical oncology. You have recently experienced unintended weight loss of 15 pounds, loss of appetite, general malaise, and a low-grade fever with sweating at night. You consult your primary care physician who observes skin and mucous membrane pallor and palpable lymph nodes in your groin and axilla. She orders a complete blood count, which finds a hemoglobin of 11, a normal white blood cell count, mild thrombocytopenia, and relative lymphocytosis. Biopsy of an axillary lymph node results in the diagnosis of mantle cell lymphoma. How would you proceed?

Javier Munoz, MD, MS, MBA: Mantle cell lymphoma (MCL) is a rare disease with an ominous prognosis. If I were facing my own high-risk MCL, I would begin by acknowledging the shock. As oncologists, we often speak of probabilities and protocols, but when the disease becomes your own, those numbers carry a different weight. The first step would be to breathe, to process, and to gather the right team—a reminder that none of us, even physicians, should walk this path alone. High-risk disease may be defined by TP53 alterations, aggressive histological features like blastoid/pleomorphic morphology, or a high proliferation rate (e.g., Ki-67 index of 30% or greater). In this fictional case, my MCL is high-risk due to the presence of a TP53 mutation which historically heralds resistance to conventional chemotherapy agents.

After confirming pathology, morphology, and proliferation rate, I would seek enrollment in a clinical trial. MCL has long been considered incurable (outside of allogeneic stem cell transplantation), but that paradigm may soon be shifting with novel agents and cutting-edge clinical trials. The TRIANGLE and BOVen studies have introduced BTK inhibitors into the frontline management of this disease, suggesting that patients may avoid the toxicity of high-dose chemotherapy and autologous transplant. Knowing this, I would likely choose a chemo-free, novel-agent regimen rather than intensive chemotherapy for my own case of newly diagnosed TP53-mutated MCL. Outside of a clinical trial, I would choose for myself the triplet explored in the BOVen trial (zanubrutinib, obinutuzumab, and rituximab), which now appears in national cancer guidelines as an option for patients with TP53 mutations. Because of the TRIANGLE trial, I would personally shy away from accepting consolidation with autologous stem cell transplantation when achieving first complete remission in MCL.

I would continue to surround myself with positive, uplifting people and go through this journey day by day. If you have been diagnosed with cancer, there will be days that you will not know what the right way forward is. It is not a right or wrong situation, but rather what feels right to you. Find solace knowing that many have walked through this pathway before, and you do not have to walk alone. Regarding second or even third opinions, your doctor will never be upset, as we embrace collaboration and learning from you and our colleagues.

If my disease were to relapse, I would look toward CAR T-cell therapy, such as brexucabtagene autoleucel or lisocabtagene maraleucel—treatments that have yielded remarkable remissions for patients who once had no good options. CAR T-cells seem to be the great equalizers as they seem to work both for TP53-mutated and TP53 wild-type MCL. These therapies are not without risk—cytokine-release syndrome, infection, and neurologic side effects can be daunting—but I would be willing to endure the risks in exchange for the benefits of remission with a long-term horizon.

On a personal level, I imagine the greatest challenge would be relinquishing my instinct to analyze every data point and instead embracing the need to live fully in the moments between treatments. I would lean on my family, my colleagues, and my patients, whose courage has always reminded me that healing is as much about connection as it is about medicine.

For anyone newly diagnosed with MCL, my advice is simple: find a team you trust, seek second opinions, and ask about clinical trials. Revolutions in cancer care are built on hope—and in MCL, that revolution is happening right now with a quickly changing therapeutic paradigm. The future is indeed bright for MCL. By enrolling and believing in clinical trials, we can tailor such future together and ultimately cure MCL.

For publication questions, contact gdlundberg@gmail.com. For appointments with Dr. Munoz, contact ARZHEMONCNPS@mayo.edu.

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People with cancer that affects their lungs may, at some point, need to go on mechanical ventilation to help them breathe. But once they no longer need ventilation, they may struggle to regain the ability to breathe on their own. After watching his son face this challenge, Doug Evans led development of a new treatment that is like a “personal trainer” to help rebuild breathing strength more rapidly. Here, our Curious Dr. George asks Doug, who is president and CEO of Lungpacer Medical, about this approach.

Curious Dr. George: Successful respiration is essential to sustain human life. Patients with potentially lethal pulmonary malignancies may require ventilatory assistance after surgical removal of substantial lung tissue, during pulmonary infections—especially if the patient is immunocompromised, or if the patient suffers from chemo- or radiation-induced lung damage. How might your Lungpacer diaphragm pacing therapy be helpful for patients with advanced cancer who are in need of mechanical ventilation?

Doug Evans: This question is very close to my heart given my personal experience with my son, Cameron, who required mechanical ventilation during his cancer battle.

Every year, 2.5 million Americans need mechanical ventilation—up to 40% die. Diaphragm atrophy is the main reason patients struggle to be weaned off mechanical ventilation and breathe independently. Ventilator-induced diaphragm dysfunction is a big unmet clinical issue.

Cancer patients on mechanical ventilation are dealing with an especially challenging situation. Whether they’ve just undergone surgery, are fighting severe infections with compromised immune systems, or are suffering from chemo- and radiation-induced lung damage, they’re already in a weakened state when they need ventilator support.

The problem these patients face is that, when they go on mechanical ventilation, they’re sedated to keep them calm and prevent them from fighting the machine. But this sedation stops the brain from telling the diaphragm muscle to work. The diaphragm is one of the two muscles in our body that’s constantly working, and when it’s rested for just a few days, it can lose about 50% of its mass. This makes it incredibly difficult for these patients to regain independent breathing again.

Our AeroPace system addresses this by taking control of the signaling from the brain down to the diaphragm muscle. We place a neurostimulation array in blood vessels very close to the nerves that control breathing, using a catheter-based platform that clinicians already know well and use every day. The system exercises the diaphragm muscle while the patient is sedated or sleeping. It’s like going to the gym twice a day to rebuild strength. This significantly reduces the time to wean or regain independent breathing.

Perhaps the most high-profile case of this phrenic nerve stimulation technology is Christopher Reeve, an actor who was paralyzed in a horse-riding accident in 1995. About eight years after the accident, he underwent an experimental surgery to implant electrodes in his diaphragm and help him breathe again without a mechanical ventilator. Now, more than 20 years later, the same phrenic nerve stimulation technology can finally help critically ill patients everywhere—but with no surgery required.

Unlike Reeve’s implant, Lungpacer is a minimally invasive therapy that is easily inserted at bedside and later readily removed when patients are ready to breathe on their own. This is vital because many critically ill patients can’t tolerate or survive a surgical procedure.

For cancer patients specifically, this can be life changing. Our clinical data show we can reduce the time patients spend on ventilators by three days compared to standard care. We can improve muscle strength by about 50%. Most importantly, we can reduce the risk of patients needing to go back on ventilation by 46%—this durability is critical for patients whose immune systems may already be compromised.

I really wish we had this technology available for my son, Cameron, to get him off the ventilator faster. He would have been in much healthier shape. While he ultimately did wean from the ventilator, he tragically passed away several weeks later, and I believe he suffered cumulative effects from prolonged ventilation.

Our mission is to spare other families from that experience. After 70 years without innovation in this space, we’re finally giving vulnerable patients, including those fighting cancer, a real chance at faster recovery and better outcomes when they need it most.

Mr. Evans can be reached at devans@lungpacer.com.

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Copyright: This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Cancer patients often ask their doctors, “What would you do if you were me?” Here, our Curious Dr. George asks Mayo Clinic oncologist Sameer A. Parikh, MBBS, how he would handle his own diagnosis of chronic lymphocytic leukemia (CLL). Dr. Parikh is an Associate Professor of Medicine and Assistant Professor of Oncology at the Mayo Clinic in Rochester, Minnesota.

Curious Dr. George: Please imagine this hypothetical scenario: You are an active clinical and research oncologist in general good health. However, lately, you have felt less energy than usual, have been feeling fatigued at night, and have lost some weight without dieting. You decide to visit your primary care physician for a check-up. On physical examination, she notes that you are a little pale, and you have moderately enlarged lymph nodes in the axilla and groin, as well as a slightly enlarged liver and spleen. She orders several lab tests., which show that your hematocrit is 38, hemoglobin 12, WBCs 90 000 with mostly mature lymphocytes, and you have a proper number of granulocytes and normal platelets. You receive a provisional diagnosis of chronic lymphocytic leukemia. How would you proceed?

Sameer A. Parikh, MBBS: I chose to study leukemia because my maternal aunt passed away from acute myeloid leukemia at the age of 44, just three months after her diagnosis. Although chronic lymphocytic leukemia (CLL) is different, the word “leukemia” evokes feelings of helplessness and anxiety, making it difficult for anyone to process information properly. In your hypothetical scenario, although it would not be easy, I would make sure to collect my thoughts and give the diagnosis some time to process. I would also discuss the diagnosis with my close friends and family to garner all the support I would need as I navigate this period of uncertainty, with regard to outcomes following the diagnosis. I would then research the top experts in CLL and ensure I secure an appointment with a specialist. It’s crucial to consult with someone who specializes in CLL to obtain the most up-to-date information, as studies show that expertise-specific care leads to better outcomes.

Confirming a diagnosis of CLL is extremely important, and it is typically done via a peripheral blood flow cytometry study. Unlike other malignancies, patients with early-stage, asymptomatic CLL are not treated at the time of initial diagnosis, unless a few specific, well-established criteria are met (as outlined in the 2018 guidelines of the International Workshop on Chronic Lymphocytic Leukemia, iwCLL2018). This is due to decades of research demonstrating that early intervention in CLL does not lead to improved quantity or quality of life. It is essential to understand this because it challenges the common belief of “find cancers early, so you can fix them early.”

In this imaginary case, although my WBC count is high, it appears that I would not need CLL-directed treatment at this time. One of the first questions I would have for my CLL specialist is how quickly my cancer is likely to progress to the point where treatment would be necessary. To better understand the biology of the underlying CLL, we would typically obtain several genetic tests, including IGHV mutation status, serum beta-2 microglobulin, TP53 mutation status, and the CLL FISH profile. The collection of these tests would allow us to calculate the CLL international prognostic index (CLL-IPI). Based on the total score, my CLL could be classified into low risk, intermediate risk, high risk, or very high risk of disease progression requiring treatment, with a 5-year need for therapy at 20%, 50%, 70%, and 90%, respectively for the corresponding CLL-IPI risk scores.

During this active surveillance, or the so called “watch and wait” phase of the disease process, it would be important to acknowledge the anxiety or emotional distress associated with untreated malignancy (“watch and worry”). Having the support of loved ones through this journey and acknowledging that treatment may be needed in the not-too-distant future would be exceedingly important, particularly given that there may be no external signs of cancer. In addition, it would also be important to see my primary care physician on a regular basis and stay up-to-date with cancer screening measures, including undergoing a colonoscopy and prostate cancer screening as recommended. Also, I would also schedule a yearly dermatology visit for a full-body skin check, given the increased risk of skin cancers in patients with CLL. Finally, I would follow the CDC recommendations for immunization in an immunocompromised host, and stay up to date with all the vaccinations.

Once treatment is needed, I would ensure to repeat the genomic tests to confirm that nothing has changed. Currently, there is no scenario in the management of CLL where chemotherapy is indicated. Instead, treatment consists of a fixed duration (12 to 24 months) of combination therapy with pills (either Bruton tyrosine kinase inhibitors or BCL2 inhibitors) and immunotherapy infusions (such as monoclonal antibody infusions like obinutuzumab). If these treatments stop working, newer options are available, including BTK degraders, bispecific antibodies, and chimeric antigen receptor (CAR-T) therapy, in addition to an allogeneic stem cell transplant.

While we would aim to cure my CLL with the treatments available, it would be important to remember that CLL remains an incurable disease and is managed as a chronic condition. I always remind my patients that this journey is a marathon, not a sprint, and we will grow old together. My goal as an oncologist, which would also hold true in my own case, is to ensure my patients reach their average life expectancy (and hopefully beyond that) without considering CLL with a high quality of life. With the tools we have at our disposal today, I am confident that we can achieve this objective for the majority of our patients.

Dr. Parikh can be reached at Parikh.Sameer@mayo.edu

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Cancer patients often ask their doctors, “What would you do if you were me?” Here, our Curious Dr. George asks Harvard oncologist Jon Arnason, MD, how he would handle his own diagnosis of chronic lymphocytic leukemia (CLL).

Curious Dr. George:Imagine a hypothetical scenario in which, as an active clinical and research oncologist in general good health, you have lately felt less energetic than usual, have been feeling fatigued at night, and have lost some weight without dieting. You decide to visit your primary care physician for a check-up. On physical examination, she notes that you are a little pale, discovers moderately enlarged lymph nodes in the axilla and groin, and a slightly enlarged liver and spleen. She orders several lab tests. Your hematocrit is 38, hemoglobin 12, WBCs 90 000 with mostly mature lymphocytes, a proper number of granulocytes, and normal platelets. A provisional diagnosis of chronic lymphocytic leukemia (CLL) is made. How would you proceed?

Jon Arnason, MD: CLL is the most common kind of leukemia. It is a diagnosis that is often made in situations similar to the hypothetical one you present above. In addition, many patients present incidentally when laboratory testing is performed and demonstrates an incidentally elevated white blood cell count. Upon suspicion of CLL it is important to confirm the diagnosis with peripheral blood flow cytometry.

A new diagnosis of CLL can be quite distressing for patients. However, it is important to determine whether the patient is actually suffering pathology from their disease. A large percentage of patients who present with CLL will not have any active symptoms and may go for an extended period time, sometimes many years, before developing any symptoms that are attributable to their disease. In addition, a subset of CLL patients may never develop harm related to their cancer. Therefore, we do not recommend initiation of treatment if patients are asymptomatic from their CLL. Signs and symptoms that would suggest that patients require treatment include significant anemia, low platelet count, enlarged lymph nodes that are causing or about to cause symptoms, an enlarged spleen, or other systemic symptoms such as fever and weight loss that may be attributed to their disease. In addition, if the patient’s CLL-related white blood cell count doubles in less than 6 months, this suggests that the patient will imminently have symptoms and would benefit from treatment.

In the absence of the above signs or symptoms, we recommend a strategy of active surveillance. The goal of active surveillance is to identify when the patient will be about to develop symptoms and discuss treatment options at that time. At diagnosis there are number of tests that we can perform to help us predict whether a patient will have a relatively rapid progression or a more indolent course. Perhaps the most important testing to perform at diagnosis is a cytogenetic analysis. There are a number of recurrent cytogenetic abnormalities that we see with CLL. Deletion 13q is associated with a relatively good prognosis. Trisomy 12 is associated with an intermediate prognosis. Deletion 11q abnormalities are associated with large lymph nodes and a relatively more rapid progression. Finally, 17p abnormalities are associated with a poor prognosis and lack of response to traditional chemotherapeutic strategies. In addition to cytogenetic abnormalities, there is a test called IGVH mutational status. Mutations of IGVH are associated with a better prognosis than the absence of mutation.

Traditionally, CLL was treated with a combination of chemotherapeutic agents and antibody therapy. However, recent clinical studies have demonstrated that targeted therapy with oral agents and antibody treatments are more effective with less toxicity than traditional chemotherapeutic strategies. Current guidelines suggest the use of a Bruton’s tyrosine kinase inhibitor, such as acalabrutinib or zanubrutinib for continuous therapy. Alternatives include the use of the Bcl-2 inhibitor venetoclax with CD20 antibodies, potentially in addition to the use of Bruton’s tyrosine kinase inhibitors. The majority of patients will have a response to these treatments and improvement in any underlying CLL-related symptoms.

If I was diagnosed with the above findings and labs, I would not want to receive therapy. As an aging, busy clinician I am always fatigued at night, have less energy than I used to, and struggle to maintain my weight as I’m running around between clinic patients and the inpatient unit. The current data suggests that I’m not going to live any longer if I treat my CLL at diagnosis compared to at the time that I have clear symptoms. Furthermore, treatment options have significantly improved during my career, and I am hopeful that there is the potential for long term remission with some of our emerging therapies, such as CAR-T cells.

Dr. Arnason can be reached at jarnason@bidmc.harvard.edu.

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Copyright: This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

 

Artificial intelligence (AI) holds promise to transform cancer research and treatment. Here, Curious Dr. George asks our very own Director of Technology, Michael Kramer, about the powerful role Cancer Commons can play in shaping the future of AI in oncology. Having lost his son, Theo, to a rare form of brain cancer—Diffuse Intrinsic Pontine Glioma (DIPG)—Kramer is deeply committed to helping others facing similar struggles.

Michael Kramer: This year’s PMWC in Silicon Valley was a tremendous experience. It was my first time attending the conference—and I couldn’t have picked a better year. The energy was palpable. Jensen Huang, founder of NVIDIA and arguably the “Steve Jobs of the AI computing era,” gave the keynote address. His presence was symbolic: a torch has been lit. AI is no longer on the horizon. It’s here.

But if this moment sparked hope, it also exposed the deep fissures between promise and practice. I came away inspired—but also sobered. Healthcare, especially oncology, stands at a crossroads. And while AI might help us move faster, more accurately, and more personally, it will only thrive if we raise it with care—giving it the values, structure, and support systems it needs to grow into something truly beneficial.

As someone who came to this work not as a scientist or physician, but as a grieving father and a systems thinker, I’ve seen this story before—in another domain. I spent nearly two decades in the arts as a film and television composer, often building new technology to help me tell stories through music. I once believed that creativity—the essence of our humanity—would be the last frontier for AI. Surely art was safe.

I was wrong.

AI came for art first. Not because it understood the soul of the artist, but because it could mimic the product. Because in the commercial world, humanity is often less valued than efficiency. And now, healthcare is staring down the same paradox: how do we use a dehumanizing technology to become more human?

Four Key Lessons from PMWC 2025
Over the course of three days, one truth echoed across panels and disciplines: most of medicine is not ready for AI. But that’s not a reason to be cynical—it’s an invitation to get it right. And Cancer Commons is uniquely positioned to do just that.

Here are four critical insights from the conference:

1. Patient-Centric, Multimodal, Real-Time = the Future
From real-time clinical trial matching tools to AI systems that synthesize genomics, imaging, and electronic health record (EHR) data on the fly, the trend is clear: the patient must be at the center. Not data. Not the institution. Not even the technology.

Cancer Commons has always operated from this premise. We don’t provide direct care, but we educate and empower patients, families, and even the clinicians working tirelessly on their behalf. We listen, adapt, and act in real time, curating information and matching people with possibilities. In this sense, AI isn’t a disruption to our model—it’s a powerful ally. We’re modeling how to build the kind of responsive, patient-informed approach that will define the next era of medicine.

2. A Tale of Two Cultures: Big Data vs N=1
Precision medicine lives in a paradox. On one side, multi-million-dollar AI models trained on millions of data points. On the other, a child with DIPG brain cancer—a disease so rare it is invisible to those very datasets.

Most AI systems don’t know what to do with outliers. But Cancer Commons was built for outliers. Our strength lies in combining AI with “HI”—human intelligence: expert curation, personalized insight, and support for patients when the standard of care has failed them. Our small size is not a weakness; it’s a strategic advantage in a world where N=1 matters more than ever.

3. Hope Through Shared Intelligence
One of the most exciting threads at PMWC was the emergence of federated learning, synthetic data, and collaborative AI training. Again and again, we heard: no one has enough data and resources alone. Collaboration isn’t just nice—it’s necessary.

And yet, large institutions often find themselves paralyzed by competition, legal silos, and outdated business models. Cancer Commons can move nimbly where others can’t. We’re small. Agnostic. Mission-driven. And we’re building partnerships—like our collaboration with xCures—that can help overcome one of the field’s greatest obstacles: the inability to share.

4. Living on the Edge: Redefining Risk in a System That Plays It Safe
Many of the people who come to Cancer Commons are already living on the edge—medically, emotionally, and existentially. They’re facing advanced cancers, rare diagnoses, or systemic barriers that have pushed them beyond the reach of standard care. For them, risk isn’t hypothetical—it’s part of daily life.

And yet, many medical institutions are built to avoid risk, not engage with it. I saw this firsthand during my son Theo’s treatment. One day in the hospital, I found myself in a tense exchange with an anesthesiologist who hesitated to proceed because Theo had a do-not-resuscitate (DNR) order. For them, it meant “don’t engage.” For us, it meant “don’t prolong suffering”—but we were still fighting, still seeking options that balanced quality and time. Hope and realism were never in conflict. They lived side by side.

This willingness to act within uncertainty is something our clients understand deeply. It also shapes how we think about innovation.

At PMWC, Andrew Rister from Verily offered a striking metaphor: when cars first appeared, they had to share roads with horses. It was chaotic and risky, but over time, new rules emerged. The system adapted. That early turbulence wasn’t failure—it was transformation.

The same is true now. Where others see emerging technologies like AI as too risky, our unique clientele not only affords us that risk—it compels us to take it.Not carelessly, but with urgency, integrity, and care.

AI can help us act wisely in the face of uncertainty, if we’re brave enough to guide it there.

Where We Fit In
If AI is still in its infancy, Cancer Commons is uniquely positioned to raise it with care, intention, and purpose. Consider this:

• Most large institutions are not nimble enough to adopt AI. We’re small and adaptive.
• Competition prevents data sharing. We can be a neutral, open-source bridge.
• Most AI models are trained on flawed or inconsistent data. Our hand-curated patient data is small but clean.
• Protected Health Information (PHI) regulations prevent data flow. Our collaboration with partners like xCures may become a bedrock solution.
• And most importantly: our patients don’t have time to wait. My son Theo didn’t either.

For me, this isn’t theoretical. It’s personal.

When Theo was diagnosed with DIPG, we didn’t have five years to wait for perfect systems or large-scale trials. We needed real help, real insight, real options—now. That urgency is still with me. It’s why I believe Cancer Commons is not just a nonprofit—it’s a blueprint for how we all might one day learn enough to truly outsmart cancer.

What Kind of Parents Will We Be?
AI has arrived, kicking and screaming. Like any powerful new force, it’s immature, chaotic, and full of promise. The question now isn’t just how we use it—but how we raise it.

We can neglect it—feed it biased data, isolate it in silos, train it on systems we already know are broken.

Or we can nurture it—guide it with ethics, context, humility, and care. Show it the best of humanity, not just the most efficient. Teach it, like a child, how to grow into wisdom—not just intelligence.

Because at the end of the day, AI will reflect us. And if we’re brave, patient, and generous enough, it might even help us become something better than we were.

Mr. Kramer can be reached at michael.kramer@cancercommons.org.

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Copyright: This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.