Perspectives From the Ever-Changing Multidisciplinary Oncology Field

Multidisciplinary care is an often-overlooked yet integral aspect of the overarching treatment paradigm. Radiation oncologists, surgeons, and integrative care specialists work in tandem with medical oncologists to deliver optimal patient outcomes. ONCOLOGY had the opportunity to speak with 3 such experts, who provided their insights on each respective facet of multidisciplinary care.

The experts gave a broad look at the field, while also taking time to reflect on how it has changed. In tandem with the 40th anniversary of ONCOLOGY, a review of the various fields was critical to look at the components that make CancerNetwork and ONCOLOGY unique—bringing together all facets of the care team.

Integrative Oncology: “Building Bridges” With Conventional Oncology

According to the Society for Integrative Oncology, integrative oncology is “a patient-centered, evidence-informed field of cancer care that utilizes mind and body practices, natural products, and/or lifestyle modifications from different traditions alongside conventional cancer treatments. Integrative oncology aims to optimize health, quality of life, and clinical outcomes across the cancer care continuum and to empower people to prevent cancer and become active participants before, during, and beyond cancer treatment.”¹

Additionally, according to institutions such as Penn Medicine, these strategies are used to supplement, not replace, conventional medicine.² Research is being conducted to best incorporate these therapies into the treatment paradigm to optimize healing and mitigate adverse effects (AEs) from treatment.

Contextualized by a tendency among clinicians across camps to alienate integrative oncology as “alternative,” Nathan Goodyear, MD, suggested that patients are ultimately harmed by this discourse.

Furthermore, he advocated against pressure to conform in thought and reengage patients through public debate and discourse. A staunch advocate for integrative care, which has historically been othered within the cancer care continuum, Goodyear outlined a need to restore patients to the forefront of advocacy and counter their proclivity to seek out unverified information on social platforms rather than from medical specialists for their cancer care.

Goodyear, an integrative medicine physician at the Williams Cancer Institute, believes it may be worthwhile for integrative medicine to “build bridges” with conventional oncology to both restore patients’ trust in medicine and facilitate critical thinking in science. According to him, this could be accomplished by aiding in procedures they are already conducting.

“The way we do that research suggests we combine [an] intratumor approach with [a] conventional approach—doing intratumoral immunotherapy prior to surgery…by combining these neoadjuvantly, intra-arterially, we can engage the immune system,” he explained.

Specifically, many of Goodyear’s insights regarding integrative oncology are grounded in neoadjuvant strategies to bolster immune responses, thereby better conditioning patients for conventional procedures and mitigating subsequent AEs. One such modality, intravenous (IV) vitamin C, is a flagship integrative therapy that he suggested was the most misunderstood.

“[You] can give pharmacological IV vitamin C that’s directly pro-oxidative, and it is augmentative—synergistic with radiation, which, by its technique, is also pro-oxidative,” he stated. “Here’s the beauty of what it does. It is antioxidative, simultaneously, to noncancer cells.”

He further stated that, in a review of phase 1 and 3 clinical trials examining IV vitamin C in patients across a variety of disease states, it was found that it augments immune cells to protect healthy cells and enhances the destruction of tumor cells by radiation.

Specifically in pancreatic cancer, Goodyear highlighted that concurrent use of vitamin C with chemotherapy was associated with increased overall survival, citing data published in Redox Biology by a team from the University of Iowa.³

“There are studies showing that these integrative therapies can be used alongside [and] in conjunction with the targeting of tumors, the protecting of healthy cells, and improving outcomes,” he stated.

Another modality he highlighted was pulsed electric field (PEF) therapy. He explained that at his institution, it is the preferred ablative technique, as it uses nanosecond-pulsed high-voltage energy to destroy tumor tissue. This technology, which has been examined in preclinical studies, has shown promise for improving immunotherapy response and reducing the risk of recurrence or metastases when used neoadjuvantly prior to chemoimmunotherapy.

“When you look at the conventional surgery, chemotherapy, and radiation, which damages the immune system, if we engage the immune system first, then what we’re going to do is bring the immune system to the fight before we lead to potential damage with surgery, chemotherapy, and radiation,” he stated. “Now, surgery, chemotherapy, and radiation have their purpose…but if we engage the immune system first—the body’s defenses—we’re going to get better [with] lower metastasis, lower recurrence, and better outcomes.”

He concluded by emphasizing that using PEF or conventional therapy alone does not yield the same benefit as their combined use, and that their use together will best maximize positive outcomes.

Next, he highlighted a treatment modality concerning the gut microbiome, an emerging yet greatly misunderstood aspect of cancer care. Highlighting findings from the My Baby Biome study (NCT05472688), he suggested that the disappearance of Bifidobacterium from the gut microbiome in infants delivered via cesarean birth may correlate with reduced immune-priming efficacy.⁴

“Ninety-two percent of children at 2 years [who were] recruited at 3 to
7 months had significantly declining or absent Bifidobacterium [infantis, which] is a particular…species of bacteria. Now, why is that important? You can’t prime the immune system without that,” he said. “They are seeded through vaginal birth and breastfeeding, but within the 4 to 6 weeks, 90% of the gut microbiome of a child is dominated by that, and that dominates the immune priming. When you remove that, studies tell us you increase metabolic dysfunction, obesity, systemic inflammation, autoimmunity, [and] cancer.”

To address this, he suggested fecal transplantation, whereby a sample of a healthy donor’s gut microbiome is implanted into a nonresponder to engage their immune system. Describing it as a “light switch,” he explained that the receipt of fecal transplantation led to an augmentation of immunotherapy and radiotherapy responses and subsequently mitigated AEs.

“When you bring these therapeutics, as the evidence is advancing and accelerating, like the gut microbiome, like vitamin C, like intratumoral PEF…what we’re doing is we’re making what conventional oncology is doing better [and] safer, but the way we’re doing it is we’re engaging the immune system,” he concluded.

Moreover, he explained that the delivery of intratumoral immunotherapy may address an ongoing issue in conventional oncology, wherein the agent is efficacious but the delivery system is lacking. Among tumor microenvironments classified as immune-excluded or immune-desert, with an absence of immune cells or immune cells on the periphery, intratumoral delivery of these agents can bypass immune-cold environments and elicit efficacy where it had previously failed.

“These are intratumoral immunotherapeutics that are now starting to show early human data. The problem is, particularly with the CD40 inhibitors when given systemically…is not the drug, [it’s] the delivery method. It’s toxic systemically, but when you give it intratumorally, you completely bypass that,” he explained.

Lastly, Goodyear emphasized that combinatorial regimens, integrating novel integrative medicines into the treatment paradigm alongside conventional therapies, could yield better patient responses.

“The point here is, by combining these neoadjuvantly, intra-arterially, we can engage the immune system…to get a better response. It’s the integration of the hallmarks of cancer.... By looking at what combination of therapies we are going [to use] and what we’re seeing, you can see where we are and where we’re going,” he concluded.

Radiation Oncology 2025: New Indications, Streamlined Treatments, and Evolving Technologies

Following the advent of ionizing particle beams, x-rays and radium for medicinal use emerged during the turn of the 20th century.⁵ Initially plagued by poor outcomes in large part due to a lack of understanding of the properties and mechanisms of actions of this modality, newer isotopes, rays, and radiation techniques were implemented, with the introduction of the idea of fractionated dosing in the 1920s. Since then, brachytherapy and electron beam therapy emerged from the 1930s to the 1950s, proton beam therapy via computer-assisted accelerators emerged in the 1970s, and computational advances enabled the development of 3D conformal radiotherapeutic devices and adaptive radiotherapy at the turn of the millennium.

Regarding the state of the field today, ONCOLOGY called upon Sunil W. Dutta, MD, board-certified radiation oncologist and assistant professor in the Department of Radiation Oncology at Emory University School of Medicine and editorial advisory board member for the ONCOLOGY journal’s radiation oncology supplement, The RadOnc Review, to review key advances in the field in 2025, as well as future ventures that might serve to enhance care for patients.

For the first of the 2025 highlights, he spotlighted a recent readout of a randomized trial at the American Society for Radiation Oncology (ASTRO) 2025 Annual Meeting: “A sham-controlled study presented at ASTRO 2025 validated low-dose radiation therapy [LDRT] as an effective nonpharmacologic option for osteoarthritis, demonstrating significant symptom relief in [patients with] knee osteoarthritis patients.⁶ Though widely used in Europe, particularly Germany, broader clinical adoption in the US remains limited, highlighting an opportunity for increased utilization.”

According to the findings, patients treated with single-course LDRT at 3 Gy showed significant improvement in outcomes in those with mild to moderate knee osteoarthritis, establishing its potential as a conservative treatment option.

Additionally, Dutta identified 10-year findings from the phase 3 FAST-Forward trial that were presented at the European Society for Radiotherapy and Oncology (ESTRO) conference.⁷

“The 10-year FAST-Forward trial [NCT06664892] results from ESTRO 2025 confirmed ultra-hypofractionated breast radiotherapy [at] 26 Gy in 5 daily fractions as a durable, convenient standard of care, demonstrating excellent local control, comparable toxicity, and survival outcomes similar to moderate hypofractionation,” he explained.

Another trial he highlighted was the phase 3 EUROPA trial (NCT04134598), a readout of which was published in The Lancet Oncology, which suggested that radiotherapy might better preserve health-related quality of life in older patients with low-risk early breast cancer vs endocrine therapy.⁸

“[T]he EUROPA trial interim analysis showed superior quality of life outcomes with radiotherapy compared with endocrine therapy alone for women [older than] 70 [years] with low-risk luminal A breast cancer, with long-term tumor control data pending,” he stated. “Alongside axillary de-escalation data, these findings reinforce personalized, multidisciplinary approaches to early-stage breast cancer in 2026 and onward.”^9,10

Dutta further highlighted research in proton therapy, some findings of which he deemed “complex and conflicting.” On the one hand, he pointed to trials led by the University of Texas MD Anderson Cancer Center and NRG Oncology, that assessed this modality in oropharyngeal carcinoma and glioblastoma, which exhibited benefit in both survival and reduced toxicity for these groups.^11,12 However, he expressed that the data might not all be indicative of benefit with this treatment modality.

“[Data] from European studies such as the UK-based [phase 3] TORPEdO trial [NCT01893307] in oropharyngeal cancer and the Netherlands/Belgium–based SOPRANO study [NCT06180434] in glioma showed minimal or even adverse outcomes compared [with] traditional photon-based IMRT [intensity-modulated radiotherapy],” he explained.^13,14 “Lastly, the RadComp trial [NCT02603341] found equivalent patient-reported outcomes for proton vs photon therapy in breast cancer treatment. Comprehensive long-term data, with robust radiotherapy quality assurance, is needed to better define the role of proton therapy.”¹⁵

In his forward-looking perspectives, Dutta emphasized ongoing research he believes will improve patient outcomes and the treatment experience in radiation oncology. Specifically, he highlighted numerous trials initiated by NRG Oncology that could impact the radiotherapy treatment paradigm.

“NRG Oncology has activated new clinical trials addressing unmet needs beyond traditional end points,” he said. “For instance, [the phase 2 NRG-CC013 trial (NCT06532279)] investigates BMX‑001 as a radioprotector to prevent severe oral mucositis during chemoradiation for head and neck cancers, while the [phase 2 NRG‑CC015 HEAL‑ABC study (NCT06748222)] evaluates digital mindfulness training to support mental health in young breast cancer survivors.”^16,17

In the NRG-CC013 study, patients will be randomly assigned to receive BMX-001 or placebo in addition to cisplatin and image-guided IMRT. The primary end point is the incidence of oral mucositis, and secondary end points will include duration of oral mucositis, time to oral mucositis, and incidence of other toxicities.

Patients in the NRG-CC015 trial will receive primary cancer treatment consisting of surgery, radiotherapy, and/or chemotherapy, and will undergo 2 mindfulness-based interventions: one given live, delivered over Zoom and led by an instructor, and the other an app-based, self-paced version. The primary end points of the trial will be self-reported depressive symptoms in both interventions, with secondary end points including self-reported fatigue symptoms.

Finally, Dutta suggested that artificial intelligence (AI) may play a role in advancing practice in radiation oncology.

“AI tools, such as automated segmentation, are increasingly used to streamline contouring processes and enhance workflow efficiency in radiation oncology practice,” he concluded.¹⁸

The New Architecture of Surgical Oncology: Biology, Technology, and the End of the Surgery-First Era

For the better part of the last century, the playbook for a surgical oncologist was remarkably consistent: Find the tumor, cut it out, and then refer the patient over to the medical and radiation oncologists to treat what remained. According to Patrick Borgen, MD, chair of surgery at Maimonides Medical Center and a titan in the field of breast cancer surgery, that legacy default is rapidly becoming a relic of the past.

He first detailed a fundamental paradigm shift where tumor biology, rather than the surgeon’s scalpel, has taken the driver’s seat. From the emergence of “molecular interception” to the rise of AI, the current state of surgical oncology is defined by a singular goal: treating the patient based on their unique biology rather than a standardized calendar.

The most significant change in recent years has been the transition from adjuvant (postsurgical) to neoadjuvant (presurgical) therapy.

“For most of my career, surgery always came first,” Borgen explained. “We took the mass out, we took the lymph nodes out, and then we treated systemically. We are in a new era where a majority of our patients will get neoadjuvant therapy—whether it’s chemotherapy, endocrine therapy, or ablative therapy.”

To Borgen, this shift is more than just a change in timing; it is a change in the very philosophy of care. When clinicians treat the whole body first, they gain a real-time window into how the tumor responds to specific drugs. However, this transition has not been without its hurdles, particularly regarding patient perception. Many patients feel a natural urgency to have the mass removed immediately. Borgen noted that clinicians must carefully navigate these conversations, explaining that treating the systemic disease is often more critical than the local one.

Furthermore, Borgen iterated that sequencing is no longer an art left to the surgeon’s discretion; it is now a rigid clinical requirement.

“On a lot of protocols, if you do the surgery first, you don’t have access to the antibody-drug conjugate [ADC] or the checkpoint inhibitor,” stated Borgen. “We, the surgeons, can get it wrong. It’s absolutely almost black-and-white that there’s a right and a wrong way to sequence these treatments.”

This success in neoadjuvant therapy has led to the provocative watch-and-wait protocol. If imaging suggests a complete response, he questioned whether surgery would be necessary at all. Although researchers at institutions like MD Anderson are investigating the possibility of skipping surgery in favor of radiation or observation, Borgen cautions that this approach is not quite ready for prime time. The primary barrier remains the lack of perfect imaging. Although MRI with enhancement is the current gold standard, it cannot yet guarantee a pathologic complete response with 100% certainty.

Perhaps the most science fiction element of modern oncology is the use of circulating tumor DNA (ctDNA) to monitor for minimal residual disease (MRD). This involves measuring fragments of tumor DNA in the blood—a feat Borgen describes as a “technical tour de force.”

MRD monitoring allows for what Borgen dubbed “molecular interception.” Historically, clinicians waited for physical symptoms or radiographic progression before adjusting treatment. Now, the blood can inform whether the recurrence will occur months before a scan shows a single shadow. This technology is poised to de-escalate surgical intervention across the board. If a patient shows a complete erasure of ctDNA, medical oncology may soon feel comfortable shortening chemotherapy courses, avoiding extended hormone therapies, or even forgoing the standard-of-care lymphadenectomy.

Interestingly, according to Borgen, the technology could also work in the opposite direction. For patients with metastatic disease whose systemic cancer has been “sterilized” by immunotherapy but who still have a residual local tumor, surgery might become a valuable tool for local-regional control—a scenario that was almost never considered in the past.

Despite these technological leaps, Borgen showed an acute awareness of the disparities in access. Practicing in Brooklyn, New York, he highlighted a stark reality: Despite being miles from world-class academic centers and the financial epicenter of Wall Street, much of Brooklyn remains a “surgical desert.”

“Brooklyn is 3 million people. If it were a state, we would have more breast cancer than 15 US states,” he acknowledged.

Yet many of the borough’s 14 hospitals lack the resources for sophisticated next-generation sequencing, MRD testing, or immuno-oncology. The solution, according to Borgen, lies in the hub-and-spoke model, where community hospitals refer complex cases to specialized centers. Over the next 5 years, he anticipates a major shift in how urban centers manage these populations, ensuring that underinsured patients are not left behind as the technology advances.

Furthermore, technologies like fluorescence-guided surgery have materialized as surgeons look for ways to be more precise in the operating room. By using dyes that cause tumors to “glow,” surgeons can better distinguish between malignant cells and healthy tissue. Borgen suggested that while this approach is common in the resection of brain tumors like gliomas, its application in breast surgery is still evolving.

Borgen stated that the barriers are largely economic, with expensive equipment in a complex payer mix with limited resources, limiting the current justification of its widespread adoption in disease states like breast cancer. He also noted a paradox: As systemic therapies become more effective at shrinking tumors to nothing, the need for aggressive margin assessment during surgery may decrease.

Another technological advance within surgical oncology is the development of AI, and Borgen envisioned a future where AI could replace many human tasks in pathology and radiology. According to him, AI platforms can already read 3D tomosynthesis mammograms with incredible accuracy, and they learn at a rate that far outpaces human capacity.

“Matching the treatment to the type of breast cancer in front of you is going to become almost impossibly complicated,” Borgen expressed. “With over 70 different subsets of breast cancer identified, surgeons will need AI decision-analysis tools to navigate thousands of ongoing trials and genomic variables.”

Borgen concluded by highlighting one key point: The era of one-size-fits-all surgery is over. Whether it is replacing chemotherapy with ADCs or using ctDNA to intercept a recurrence, the future of surgical oncology is rooted in the deep understanding of tumor biology.

As the field moves toward more personalized, less invasive, and more technologically integrated care, the surgeon’s role is shifting from that of a primary “remover of disease” to a specialized lead in a multidisciplinary team. For patients, this means fewer unnecessary procedures, a lower risk of long-term AEs, and a treatment plan as unique as their own DNA.

“The story is evolving, and it’s a very exciting time to be part of it,” Borgen concluded.

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