Moderna and Merck reported on Oct. 22 that a customized cancer vaccine for people with late-stage melanoma can reduce the risk of cancer recurrence or death over two years by 42% compared to current treatment.

The results will be presented at the European Society of Medical Oncology meeting in Madrid on Oct. 24.

The study involved more than 1,130 people with Stage 2B to Stage 4 melanoma, all of whom had their tumors surgically removed. Some were then randomly assigned to have a cancer vaccine custom-made after their tumors had been genetically sequenced. They received that vaccine, called intismeran, once every three weeks for up to nine doses, along with Keytruda, a checkpoint inhibitor, every six weeks for up to nine cycles, for about a year. Others were randomly assigned to receive a placebo vaccine and Keytruda.

Intismeran, developed jointly by Moderna and Merck, represents a new way to harness the immune system in cancer, by training immune cells to recognize 34 specific proteins on tumor cells. The mRNA coding for these proteins, or antigens, are encased in a lipid particle in a similar way to Moderna’s COVID vaccine, which used mRNA from the COVID virus’ spike protein. Using this mRNA approach, once cells start making the foreign proteins coded for by the mRNA, the immune system sees them as intruders and mounts a response against them—and the latest data show that the approach works not just against viral proteins but also against those found on tumors.

Keytruda contributes a key part of the response by removing the brakes that keep immune cells from recognizing and attacking tumor cells because they originate from normal "self" cells.

“I was surprised by the fact that the results replicated the Phase 2 [study] so closely,” says Dr. David Berman, chief development officer at Moderna, referring to an earlier stage study the companies released in June that the combination lowered the risk of cancer returning or death by 49% over five years. That study also reported that the therapy lowered the risk of the cancer spreading to other sites by 59% compared to the checkpoint inhibitor alone. “This Phase 3 [study] included a much broader population, so the hypothesis was that the treatment effect would be harder to see. There was a lot of suspicion going in that these results would not be as good as those in the Phase 2. But the fact that they reproduced almost exactly what we saw initially in the Phase 2 blew my mind.”

The companies report that the effect seems to start six months into the therapy—an important insight in understanding how immune-based approaches may work in cancer. “We think it’s because the immune system takes time to be activated,” says Berman. That includes making sure that immune cells like T cells, which are critical to recognizing and controlling cancer, have time to learn to detect tumors. Berman says these results could also help to explain why only about 30% of cancer patients respond to the checkpoint inhibitors, a powerful new tool in cancer that allows immune cells to see tumors rather than thinking they are "self" cells and therefore not foreign. “This shows us that in a significant percentage of patients, the checkpoint inhibitors are not doing anything because the immune system hasn’t even been educated to recognize the cancer cells,” he says of the potential role that the mRNA-based intismeran may play. “That’s where we now need to focus—on how to better educate the immune system. It’s a big leap, a big piece of information, that there is now another way to educate the immune system to recognize cancer.”

Data on overall survival of people on the combination therapy isn’t available yet.

Moderna and Merck are studying the intismeran-Keytruda pairing in other cancer types in nine other studies, such as pancreatic and gastric cancer, as well as in three late-stage trials of non-small cell lung cancer. They are also exploring the role of using intismeran alone in an early study in lung cancer.

Traditionally, personalized therapies have not been practical as medical treatment because of their high cost and long timeline to develop. But Berman is confident that the bespoke process of making an individualized mRNA cancer vaccine for each patient is both scalable and potentially affordable. “We have scaled down the technical footprint and have plans to scale up [the program] to look at different tumors,” he says. “The nice thing about the [mRNA] system is that it’s purely enzymatic, so no cell cultures need to be grown.” Another advantage of using mRNA is its speed—scientists at Moderna can develop a customized vaccine based on a patient’s tumor within weeks—critical for any patient with cancer.

Correction, Oct. 23

The original version of this story misstated the length of time of a study that showed a 49% reduction in recurrence of cancer. It was over five years, not over a year.

Amber Kostka, who owns The Stockpot restaurant in Hampton Roads, Va., says she has tried to do right by her employees by offering them health insurance, alongside good wages and a 401k. 

But as costs have risen—premiums have roughly tripled since the company first started offering health insurance in 2018—her employees are increasingly telling her they can’t afford health insurance. That’s even though she splits the cost of premiums with employees, which are roughly $400 a month. 

Instead, employees are dropping out of the plan and going uninsured, she says. About 35% of her eligible employees now buy the employer-sponsored health insurance, she says, down from 50% prior to COVID. She wants to warn them about the risks of going without insurance, she says, but also knows their finances are extremely tight. “It’s just a cost thing, at the end of the day,” she says. “You can’t stop paying for groceries.” 

Her employees aren’t alone. The share of working-age U.S. adults without health insurance rose to 11.2% in 2026, up from 8.9% in 2024, according to new research from the Commonwealth Fund. People don’t have health insurance because the costs of everything—including gasoline, housing, and food—are rising, and they’re deciding they can’t afford to pay for even employer-sponsored plans like Kostka’s. “The whole system just seems like a complete gamble with people’s lives,” she says. 

Some people are looking at the price of plans on the Affordable Care Act marketplace and deciding they can’t afford health insurance. Premiums on the ACA marketplaces increased by an average of 58% in 2026 after Congress decided last year not to renew expiring subsidies. 

Ironically, these uninsured Americans may be helping drive the cost of health care even higher, fueling a cycle in which health insurance gets more expensive, forcing more people to drop coverage. As hospitals field more uninsured patients, they have to pass the costs of uncompensated care onto someone. “When providers have to provide a lot of uncompensated care, how do they make themselves whole? They raise prices,” says Beth Umland, director of employer research for Marsh, the health benefits consultant company formerly known as Mercer.

Of course, having more uninsured Americans isn’t the only reason costs are rising. A Marsh survey of employers recently found that they expected total health benefit costs per employee to rise 8.2% in 2027, the highest increase since 2003. One reason was that the consolidation of health systems was leading to higher prices, as some systems had monopolies in certain markets. Another was that lower government spending for public health programs was leading to higher costs for private sector plans.

“This is starting to feel—’unsustainable’ is the word you hear,” she says.

Many of the reasons why health care costs are rising may seem minimal until you start adding them up, Umland says. For example, more doctors are using AI scribes in care, which are helping them bill for more services, making care more expensive, she says. A clause of the No Surprises Act, which was passed by Congress in 2020 to protect patients from surprise medical bills but which allows disputes to be settled by arbitration, has also added billions to costs, she says. 

There are also increasingly more treatments available for patients, and those treatments are more expensive than the ones they’re replacing, she says. One example: GLP-1s, which may save insurers money in the long run on health costs but which are expensive upfront. “That’s just a whole new category of expense that didn’t exist before,” she says. 

In its survey, Marsh found that many employers were planning to pass costs onto employees after years of trying not to do so. 

Overall, workers are paying on average about $7,471 annually towards premiums for employer-sponsored family health benefits this year, up 9% from 2025, according to a new employer health benefits survey from KFF. Workers at small firms with less than 200 employees—like Kostka’s—are especially hard hit, paying about $9,687 towards family coverage: $2,847 more than workers in larger firms. 

And even as they pay more for health care, the plans available to them are getting costlier to use. The average deductible for employer sponsored plans has increased 34% over the last 10 years, according to KFF. 

What employers are doing

Kostka says there have recently been fewer health insurers in her area to choose from. Two years ago, she switched from just buying insurance outright for her employees, which many small businesses do, to self-funding the plan. She was able to do this because her employees are relatively young and healthy, she says, making her risk of incurring big medical costs for cancer or a catastrophic illness relatively low. 

But she knows she’s just a major diagnosis away from being dropped from the self-funded plan, she says. “It’s a little bit of a gamble right now,” she says. 

There are some things employers can do to push back against high health care costs, says Jim Winkler, chief strategy of the Business Group on Health, which published its own recent survey of employers which projected health care costs to rise 9% in 2027, the highest forecast the group has ever recorded.

Some employers are dropping coverage for GLP-1s for weight loss to save money, he says. Others are trying to drive employees toward what are called Centers of Excellence—essentially hospitals or medical practices with high ratings that may save money in the long-term since employees won’t need to return again and again for care. Some employers are also telling employees to try to find cheap, legitimate medications where they can—from sites like GoodRx, for example—and reimbursing them, rather than getting medications from a pharmacy benefit manager.

“We’re just painting a really challenging picture for health care costs,” he says, “which leads employers down the path of needing to find things to do to take action to mitigate them.”

A small number of employers are deciding not to offer health care at all and are instead offering employees cash to buy their own plans through the ACA marketplace. This option, called an ICHRA (Individual Coverage Health Reimbursement Arrangement) is pushed by Republicans, Winkler says, and was introduced during the first Trump Administration. 

Small employers, though, often can only choose from available plans, and if there aren’t many, they don’t have much room to negotiate. 

It’s a problem facing Mas Torito, owner of Kokoro restaurant in Denver. He spent close to $150,000 in premium payments for his employees in 2025 and is on track to spend $200,000 in 2026. That’s about 2.7% of revenues; most restaurants only have margins of 2-3%. 

“Really since COVID, every single year feels like there are these extra pressures on us,” he says.

Kokoro has been in business for 40 years, and some of Torito’s employees have been working at the restaurant the whole time. He suspects that having an older pool of employees is part of what’s driving his health care costs up every year. 

“I think they see the number of claims and costs every year going up,” he says, “and that translates into higher premiums.”

Like Kostka, Torito is committed to offering health insurance for his employees, even as his own costs rise. And like Kostka, he’s hearing from more employees that they can’t afford it. Now, only about 40% of his employees buy the insurance, he says. 

“I get it,” he says. “The deductible keeps going up every year, the insurance keeps going up. It’s enough where people are really thinking, ‘Hey, do I want insurance or not?’”

Immune-based treatments for cancer have become the biggest new advance in tackling tumors, and the latest approval could make a big difference for some people with rectal cancer.

On Oct. 19, the U.S. Food and Drug Administration (FDA) approved dostarlimab (brand name: Jemperli) to treat a specific type of rectal cancer called microsatellite instability-high (MSI-H)/mismatch repair deficient cancer. This cancer is caused by the accumulation of certain genetic mutations that prevent rectal cells from repairing DNA damage and accounts for 5-10% of rectal cancers. In a study of 154 people with this type of rectal cancer who were treated with dostarlimab, 68% had a complete clinical response at one year, which meant doctors could not see evidence of tumors on imaging or other methods for tracking the tumors. In the study, which the drug's manufacturer, GSK, submitted to the FDA, people received nine infusions of the drug: once every three weeks for six months.

“Not only did they reach clinical complete response, but they maintained that for a year,” says Dr. Andrea Cercek, section head of colorectal cancer at Memorial Sloan Kettering Cancer Center and principal investigator of the study. (Some of the earliest patients have continued to remain tumor-free for even longer. ) “That really suggests that the response is durable and real.”

Dostarlimab is a checkpoint inhibitor, which means it releases the brakes that hold back the immune system from recognizing and attacking tumors. The drug allows immune cells to destroy cancer, making it a powerful weapon for seeking out cancer cells no matter where they spread or hide.

“We have completely leapfrogged over standard of care with a simple immunotherapy that melts the tumor away,” says Dr. Luis Diaz, head of solid tumor oncology at Memorial Sloan Kettering and one of the trial investigators.

The benefits of avoiding standard rectal-cancer treatment

Standard treatment for rectal cancer involves chemotherapy, radiation, and surgery to remove the rectum that requires patients to wear colostomy bags for the rest of their lives. The dostarlimab approval means more patients whose tumors have specific mutations could avoid those aggressive therapies altogether. “We have patients who would have lost the ability to bear children who have had children because this therapy replaced chemotherapy, radiation, and life-altering surgery in one swoop," Diaz says. "That’s a big deal.”

Kelly Spill is one of them. Diagnosed in 2020 when she was 29, shortly after having her first baby, Spill spent nearly nine months trying to figure out why she continued to have constipation and see bloody discharge in the toilet. Because she had recently given birth, doctors first attributed the symptoms to her pregnancy, and when they persisted after delivery, to internal hemorrhoids. It wasn’t until a doctor ordered a colonoscopy that they found a tumor.

“The doctor told me it was Stage III colorectal cancer, and that the treatment plan would include chemo, radiation, and surgery. And that I would never carry another baby again, and would most likely have a colostomy bag for the rest of my life,” says Spill. “It didn’t seem real until I heard the words that I was not going to carry another baby. I immediately stopped thinking about me, and started thinking about my husband and what it meant for my son. We had just started our lives together; we were supposed to have all these kids.”

Sascha Roth also faced devastating news when she was diagnosed with rectal cancer in 2019 after seeing blood in her stool. A resident of Washington, D.C., she had a friend with a similar diagnosis who had received chemotherapy, radiation, and surgery and recommended his surgeon at Memorial Sloan Kettering. Roth assumed she would follow the same strategy, but she learned that she had Stage III cancer and that she wasn’t a good candidate for surgery because the tumor was located so low in the rectum. Her tumor also had mutations that suggested it wouldn’t respond well to chemotherapy.

“It was a double whammy that threw me down,” she says. But the surgeon introduced her to Cercek, who was waiting to hear from the FDA about starting an immunotherapy trial for patients like Roth. “They told me I would be the first patient in the study, and there wasn’t scientific evidence that it would work.” Still, Roth wanted to try. She agreed to become Memorial Sloan Kettering’s first patient on the study, and then spent two months waiting for the FDA to greenlight the trial so she could begin receiving the drug. “I was calling Sloan Kettering incessantly to see if the FDA approved [the study],” she says. “The second the FDA gave its stamp of approval, Dr. Cercek’s team called me to New York to start the first round of treatment less than a week later.”

Not long after that, at Spill's first appointment at Memorial Sloan Kettering to discuss chemotherapy, she learned that the mutations on her tumor made her a good candidate for a study they had just begun. Only three patients had enrolled ahead of her (including Roth), so there was no data on whether it would actually treat her cancer. Spill, who was at the appointment with her mother, decided she had nothing to lose by joining the trial. “If it doesn’t go well, we could go back to option A,” Spill remembers her mother saying.

By her second infusion, Spill felt the tumor was shrinking because she no longer had major constipation. By the fourth infusion, scans showed the tumor had shrunk by 50%. The study originally called for patients to get chemotherapy, radiation, and surgery if needed after six months on dostarlimab. But a nurse pulled Spill’s mother aside after that appointment to tell her that the first three patients in the study did not need any additional treatments because their tumors had disappeared. Following Roth’s results, the study was revised to make chemotherapy, radiation, and surgery an option only if needed: if the tumors hadn’t gone away. It wasn’t a guarantee that Spill would have the same results as those first patients, but “it gave me hope, and all I could think about was maybe I could have another baby,” she says.

After all of her dostarlimab infusions, Spill, too, no longer had any tumor left and was declared cancer-free. Her doctors advised her to wait two years before trying to get pregnant again to ensure the cancer wouldn’t return. Once she was cleared, she got pregnant and gave birth to a girl in 2023, and later a boy in 2025. “I am now five years cancer-free, and last September got the boot from Memorial Sloan Kettering,” she says, meaning she no longer needs to follow up with her oncologists there. She now sees her primary care doctor for colonoscopies every two years.

“I see beauty in absolutely everything in life now,” Spill says.

What comes next for dostarlimab

Not only does the immunotherapy appear to work well in treating these rectal cancers, but it also comes with relatively few side effects. About 20% of those in the study reported fatigue, rash, diarrhea, and uncontrollable itching. Roth, who received her infusions during the COVID lockdown, drove from D.C. for her treatments and was able to make the roundtrip in one day. "It's just proof that you can really do the things you want to do. I didn't feel tired or sick after [the treatment], and there was never a time when I was at home recovering," she says. "I watched my mom and dad go through standard chemo and radiation and anticipated that would be what my treatment was like. It was nothing like that."

Cercek says the results point toward a potentially new model for managing some rectal cancers, which may include relying on immunotherapy like dostarlimab and monitoring patients more carefully before automatically turning to chemotherapy, radiation, or surgery. Some of the patients in the trial who were treated on dostarlimab underwent surgery after finishing their infusions if their doctors still felt there might be tumors remaining. Among them, despite the doctors’ suspicions, 80% did not turn out to have evidence of tumors in their specimens, says Cercek.

Dostarlimab is already approved to treat endometrial cancers with the same mutations and costs $10,000 to $12,000 per dose out of pocket, although GSK has a manufacturer's savings program to cover that cost for some patients.

“We still have a lot of learning about what complete clinical response means,” she says, and with immunotherapy, that might mean a more patient-centric, individualized approach that involves more time for the immune system to respond to the immunotherapy and become trained to attack the cancer. “If it looks like the tumor is responding, we need to give it more time with better techniques to determine whether or not the tumor is truly gone.”

Cercek and her team are studying the best ways to monitor how tumors respond to dostarlimab by looking at snippets of genetic information that tumors shed in the blood, or more advanced imaging to accurately capture changing tumor sizes. “We need to improve on those techniques but also to teach the oncology community that there is a very, very high chance that the tumor might disappear, even if it might not look like it at six months. We need to continue watching and waiting and giving it time.”

Wait a second. You’ve been standing in line for 20 minutes, famished and desperate to order one of the viral bagels that keep selling out—or for six hours outside a concert venue, determined to claim a spot at the barricade to see your favorite band.

And then someone strolls up and slips in line ahead of you. Apparently, the rest of you have been standing around for the ambiance.

How much of a sin are line-cutters committing? “You are ripping the fabric of society apart,” says Nick Leighton, an etiquette expert and co-host of the podcast Were You Raised by Wolves? Queue-jumpers have to live with that, he adds. “But worse, we have to live with you.”

Here’s exactly how to handle this maddening situation—including when and how best to speak up.

When to speak up about someone cutting in line

If a stranger jumping ahead of you feels strangely personal, Richard C. Larson, a professor emeritus of data, systems, and society at MIT who has studied queuing, understands why. “We only have a finite number of minutes of life on Earth,” he says. The cutter’s implied message: “A minute of my life is worth more than a minute of yours.”

Before you decide whether to confront the offender, think about what speaking up would accomplish. Are you trying to reclaim your turn or get revenge? Sometimes, the impulse is “to sort of let them know you think they’re a jerk,” says Ryan Martin, a professor of psychology and dean of the College of Arts, Humanities and Social Sciences at the University of Wisconsin–Green Bay, known online as the Anger Professor because he studies strong emotions.

Martin would speak up to help someone recognize “that what they did wasn’t OK and that I wanted them to go to the back of the line,” he says. But he’d also consider: “What is going to allow me to have the kind of night I want to have?” If you spend the concert replaying a confrontation instead of singing your happy heart out, you’ve lost more than your place in line.

Leighton's gut check for situations like these is to ask yourself: Is this the hill you want to die on? “That’s always a good etiquette question,” he says.

Consider your safety, too. If the person seems hostile or you feel uneasy approaching them, you can ask staff for help or let the cut go. “Health and safety always trumps etiquette,” Leighton says.

What to say—if you do decide to say something

Marie Helweg-Larsen, a professor of psychology at Dickinson College who studies social norms, has explored what makes line-cutting so rage-inducing. For a 2008 study, she and a colleague surveyed U2 fans waiting for prime concert-floor spots, asking how they would react to hypothetical line-cutting scenarios.

Interestingly, fans reacted just as negatively to someone cutting behind them as ahead of them—even though their own place wasn’t affected. “You have to have people follow the rules,” she says, “or your investment into the line falls apart.” Helweg-Larsen’s co-author also heard fans invoke a higher authority when someone misbehaved: “Bono wouldn’t like that!” 

You don’t need a rock star’s moral authority—or a grand speech—to point out where the line starts. Helweg-Larsen’s suggested opener: “Excuse me, but the line starts down there.” Aim for an “‘I’m just trying to be helpful’ kind of vibe,” she says.

That approach gives the person a chance to correct their mistake without having to defend their character. And you don’t have to believe it was an innocent oversight to deliver the message graciously. “Even if they’re doing it on purpose, you still need to use that tone,” Leighton says.

He’s been on the receiving end of a polite correction himself: At a deli, he once joined what he thought was the back of the line, only to discover he’d guessed wrong. He was happy for someone to point him in the right direction.

If you decide to speak up, do it promptly. “Your window of opportunity is short,” Leighton says. “As soon as it happens, that’s when you need to say something.” Waiting until you’ve spent five minutes glaring at the back of someone’s head won’t make the conversation any easier.

For a line that represents a serious investment of time, Martin suggests spelling that out: “Hey, I’m not sure you noticed, but there’s actually a really long line here, and people have been waiting all day.” You’ve identified the problem and given them an opening to say “Oops.”

Of course, some situations are murkier than a stranger breezing past the entire queue. Someone returning from a bathroom break is different from four friends arriving hours later to join the person who saved their places. Leighton is sympathetic to a water or restroom run. Holding spots all day for a last-minute entourage? “I don’t love that,” he says.

What to do if a line-cutter won’t move

Sometimes, your kind reminder won’t be met with the same level of helpfulness: They saw the line. They’re staying put. Now what?

If you feel comfortable continuing, Martin suggests a firmer follow-up: “I really think you should go back to the back of the line.” You’re making a direct request without adding an insult.

Larson advises skipping any confrontational nicknames or demands—like “What do you think you’re doing, bud?” You’re pointing someone toward the back of the line, not challenging them to a duel.

If the person still refuses to move, resist the urge to keep arguing. “We can’t control everybody,” Martin says. Continuing to push someone who’s already refused could lead to “a more significant confrontation.”

At a concert venue, amusement park, or other staffed location, you can ask an employee or security person to step in. “You can always appeal to a higher authority,” Leighton says. Whether they’ll enforce the rules is another question, but it’s an option worth trying when the cutting is particularly egregious.

If you decide to drop it, drop the parting shot, too. A sarcastic “Must be nice!” might feel irresistible, but Leighton advises against adding more rudeness to the encounter. “It will not achieve anything,” he says.

As Larson puts it, “A fight can ruin your whole day—or life.”