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Mukhtar specializes in breast and general surgery, as well as serves as an associate professor of surgery in the Division of Surgical Oncology at the University of San Francisco (UCSF), UCSF Health.

Dr. Rita Mukhtar and Dr. Joshua K. Sabari discuss the role of ctDNA to guide surgical decision-making after neoadjuvant chemo in breast cancer treatment.

Can ctDNA Help Guide Surgical Decision Making in Breast Cancer

Among patients with advanced castration-sensitive prostate cancer, health-related quality of life was not statistically different between those receiving Erleada (apalutamide) alone or in combination with Zytiga (abiraterone acetate) and prednisone compared with those receiving androgen-deprivation therapy (ADT) plus Zytiga and prednisone, according to findings in 

Health-related quality of life was evaluated using the Functional Assessment of Cancer Therapy–Prostate (FACT-P) questionnaire and its subscales. The questionnaire was completed at baseline and every four weeks until week 25. FACT-P scores range from 0 to 156, with higher scores indicating better quality of life, according to study authors.

There were no significant differences in baseline mean FACT-P total scores or subscales across the three treatment groups: ADT plus Zytiga and prednisone, 118.5; Erleada, 116.1; and Zytiga and prednisone plus Erleada, 114.9.

Health-related quality of life was maintained during the treatment period, with no statistically significant differences at 25 weeks in mean FACT-P total scores or subscales: ADT plus Zytiga and prednisone, 122.3; Erleada monotherapy, 119.5; and Zytiga and prednisone plus Erleada, 119.9.

The Erleada monotherapy and Zytiga and prednisone plus Erleada groups did not experience meaningful improvements in health-related quality of life compared with the ADT plus Zytiga and prednisone group, except in time to deterioration of the emotional well-being score. This outcome was more favorable in those who received Erleada alone, with a 63% reduction in risk compared with the ADT plus Zytiga and prednisone group, which had a 44% reduction in risk.

A prostate-specific antigen level of 0.2 nanograms per milliliter or lower at week 25 was observed in 31 of 41 patients (75.6%) in the ADT plus Zytiga and prednisone group, 24 of 40 patients (60%) in the Erleada monotherapy group and 31 of 39 patients (79.5%) in the Erleada plus Zytiga and prednisone group. The two-year overall survival rates were 92.5% for the ADT plus Zytiga and prednisone group, 87.9% for the Erleada monotherapy group and 92.7% for the Erleada plus Zytiga and prednisone arm.

Treatment-related side effects of any grade were reported in 30 of 42 patients (71.4%) in the ADT plus Zytiga and prednisone group, 34 of 42 patients (81%) in the Erleada monotherapy group and 36 of 44 patients (81.8%) in the Erleada plus Zytiga and prednisone group.

Grade 3 (severe) and 4 (life-threatening) treatment-related side effects occurred in eight of 42 patients (19%) in the ADT plus Zytiga and prednisone group, seven of 42 patients (16.7%) in the Erleada monotherapy group and 10 of 44 patients (22.7%) in the Erleada plus Zytiga and prednisone group. Lower rates of hot flashes and hypertension were reported in patients who received Erleada monotherapy.

Gynecomastia affected 23 of 42 patients (54.8%), and breast pain was reported by six of 42 patients (14.3%) in the Erleada monotherapy group, both higher than rates observed in the other two groups. No new safety signals were detected in
the study.

“Androgen Receptor Pathway Inhibitor Therapy for Advanced Prostate Cancer: Secondary Analysis of a Randomized Clinical Trial” by Dr. Diogo Assed Bastos et al., 

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In patients with advanced castration-sensitive prostate cancer, health-related quality of life (HRQOL) was similar across treatment groups receiving Erleada (apalutamide) alone, APA plus Zytiga (abiraterone acetate) and Deltasone (prednisone), or ADT plus AAP. The study, published in JAMA Network Open, found no significant differences in HRQOL scores at 25 weeks. However, the APA-alone group showed a more favorable time to deterioration in emotional well-being. PSA levels and overall survival rates were comparable, with varying side effect profiles across treatment groups.

A study found no significant HRQOL differences between Erleada-based therapies and ADT plus AAP for advanced castration-sensitive prostate cancer.

Tumor

Erleada Combo Shows Comparable Quality of Life Outcomes in Prostate Cancer

In a real-world setting, standard-of-care Carvykti (ciltacabta-gene autoleucel) has been shown to elicit responses from nearly all participating patients with relapsed/ refractory multiple myeloma (R/R MM).

Carvykti is a type of chimeric antigen receptor-T (CAR-T ) cell therapy, which, as explained by the National Cancer Institute, involves a patient’s T cells — part
of the immune system — being extracted, changed in a laboratory to attack cancer cells, grown in the laboratory and infused back into the patient.

Overall and complete response rates were 89% and 70%, respectively, in
all patients who received Carvykti, 94% and 74% in 191 patients who received conforming Carvykti and 95% and 76% in 152 patients treated with conforming Carvykti with fludarabine/ cyclophosphamide lymphodepletion.

A comforming treatment is administered according to the specifications of
the FDA’s approval, and lymphodepletion is a short course of chemotherapy administered before CAR-T cell therapy.

 for adults with R/R MM who had received at least four prior lines of treatment. In 2024, the agency approved Carvykti for patients who received at least one prior line of therapy.

, that led to the FDA’s 2022 approval of Carvykti, the overall response rate was 98%, with 83% stringent complete response, according to findings published in 2023.

Patients with R/R MM who underwent leukapheresis, or the collection of healthy white blood cells from a patient, for Carvykti manufacturing at 16 American academic medical centers were included in the study, published in Blood, with 255 patients undergoing leukapheresis and 236 receiving Carvykti.

Of the real-world patients, 54% would not have met the eligibility criteria for CARTITUDE-1.

Senior author Dr. Doris K. Hansen of Moffitt Cancer Center’s Department
of Blood and Marrow Transplant and Cellular Immunotherapy, explained in an interview with 

 why such real-world findings are significant.

“Clinical trials are invaluable because they serve as the gold standard for introducing new therapies and advancing science,” Hansen explained.

“However, clinical trials often have strict eligibility criteria. Patients must meet very specific criteria to participate — they need to have good organ function, stable blood counts and no significant comorbidities."

In contrast, Hansen said, the patients seen in day-to-day clinical practice often have a variety of health challenges, with many patients having comorbid conditions like cardiac issues or renal impairment, and with about 20% of those diagnosed with myeloma experiencing kidney problems. “Additionally,” Hansen said, “some patients may have plasma cell leukemia, amyloidosis or myeloma-related bone damage, which can lead to fractures, pain and even reduced mobility or wheelchair use. These factors often make patients ineligible for clinical trials. ... It is, therefore, very important to report on the experiences of these patients. By studying their outcomes, we can understand how treatments perform in real-world scenarios, as opposed to the controlled, ideal conditions of clinical trials.”

The eligibility criteria for CARTITUDE-1 included adequate organ function, limited comorbidities and having no prior exposure to B-cell maturation antigentargeted therapy.

Cytokine release syndrome was experienced by 75% of patients, with grade 3 (severe) or higher in 5%. Immune effector cell-associated neurotoxicity syndrome was seen in 14%, with grade 3 or higher in 4%. Delayed neurotoxicity was reported in 10% of patients.

Researchers reported a 10% nonrelapse mortality rate, mostly from infections, and noted that second primary malignancies, excluding nonmelanoma skin cancers, were seen in 5.5% of patients and myeloid malignancies/acute leukemia in 1.7%.

 such as Carvykti, as explained by the National Cancer Institute, involves a patient’s T cells, part of the immune system, being extracted, changed in a laboratory to attack cancer cells, grown in the laboratory and infused back into the patient. Carvykti is currently approved by the FDA to be administered in the second line of treatment.

Safety and Efficacy of Standard of Care Ciltacabtagene Autoleucel for Relapsed/Refractory Multiple Myeloma” by Dr. Surbhi Sidana, et al., 

Carvykti (ciltacabtagene autoleucel) demonstrates significant efficacy in real-world settings for relapsed or refractory multiple myeloma, with 89% of patients responding and 70% achieving complete response. Despite many patients not meeting clinical trial criteria, outcomes were comparable to the CARTITUDE-1 trial. At 13 months, median progression-free survival and overall survival were not reached, with 12-month estimates at 68% and 82%, respectively. Side effects included cytokine release syndrome and neurotoxicity. Carvykti, a CAR-T cell therapy, is FDA-approved for patients with multiple prior treatments.

The CAR-T cell therapy Carvykti has been shown to be effective among patients outside the confines of a clinical trial.

Carvykti Effective in Real-World Setting for Myeloma 

Among patients with stage 3 unresectable non-small cell lung cancer (NSCLC), the first participant has been dosed in the phase 2 CONVERGE study, according to a news release from biotechnology company Nanobiotix. The randomized, controlled clinical trial is evaluating the potential first-in-class radioenhancer JNJ-1900 (NBTXR3) in patients being treated with standard-of-care chemoradiation followed by consolidation Imfinzi (durvalumab).

“We believe the true value of [NBTXR3] is driven by its potential to address the unmet needs of the millions of patients each year who receive radiotherapy as part of their treatment,” said Laurent Levy, Chief Executive Officer and Chairman of the Executive Board at Nanobiotix. “With a clear path to potential registration in head and neck cancer established through NANORAY-312, the first patient dosed in the CONVERGE study in [non-small cell lung cancer] NSCLC brings us another step closer to delivering for the large number of patients [NBTXR3] is designed to serve.”

Who is Eligible For CONVERGE Study Enrollment?

According to the clinical trial page
at clinicaltrials.gov, CONVERGE is evaluating the addition of NBTXR3 to concurrent platinum-based doublet chemotherapy with radiation therapy, followed by consolidation immunotherapy, and whether this enhances the objective response rate in patients with locally advanced, unresectable stage 3 NSCLC.

To be considered eligible for enrollment, patients must be candidates for chemotherapy with radiation therapy; have a pathologically confirmed NSCLC diagnosis within three months prior to enrollment; present with unresectable stage 3IIIA or 3IIIB NSCLC; have at least one target lesion suitable for intratumoral or /intranodal injection and external beam radiation therapy; and have an ECOG performance status of 0 or 1.

Participants are considered ineligible for enrollment in the study if they have a history of primary immunodeficiency; organ transplantation requiring immunosuppression; significant cardiac events within three months before enrollment; concurrent or recent malignancies other than NSCLC; and known hypersensitivity to study drugs or components.

Patients with active bleeding diathesis or patients requiring anticoagulation or antiplatelet therapy that cannot be safely modified for procedures are also excluded.

The novel, potentially first-in-class oncology product NBTXR3 comprises functionalized hafnium oxide crystal nanoparticles administered via one-time intratumoral injection and activated by radiotherapy. The proof-of-concept for NBTXR3 was demonstrated in soft tissue sarcomas, leading to the agent receiving a European CE mark in 2019.

The agent’s mechanism of action is designed to induce substantial tumor cell death within the injected tumor when activated by radiotherapy, thereby triggering an adaptive immune response and establishing long-term anticancer memory. Consequently, the company anticipates that NBTXR3 could be applied to any solid tumor treatable with radiotherapy and be adaptable to any therapeutic combination, especially with immune checkpoint inhibitors.

The radiotherapy-activated NBTXR3 is under evaluation for multiple solid tumor indications as a stand-alone treatment and in combination with anti-PD-1 immune checkpoint inhibitors. These initiatives include the global, randomized NANORAY-312 trial, which is focused on locally advanced head and neck squamous cell carcinomas. In February 2020, the Food and Drug Administration granted fast track designation to NBTXR3 activated by radiotherapy, with or without Erbitux (cetuximab), for patients with locally advanced head and neck squamous cell carcinoma who are ineligible for platinum-based chemotherapy.

In 2019, the company entered a comprehensive clinical research partnership with The University of Texas MD Anderson Cancer Center to sponsor multiple phase 1 and 2 trials evaluating NBTXR3 across various tumor types and therapeutic combinations. Nanobiotix announced a license agreement with Janssen Pharmaceuticals, a Johnson & Johnson company, for the global co-development and commercialization of NBTXR3 in 2023.

The phase 2 CONVERGE study has commenced dosing its first participant to evaluate the radioenhancer JNJ-1900 (NBTXR3) in stage III unresectable non-small cell lung cancer (NSCLC) patients. This trial investigates the efficacy of NBTXR3 combined with standard chemoradiation and consolidation durvalumab. NBTXR3, a hafnium oxide nanoparticle, is activated by radiotherapy to induce tumor cell death and an adaptive immune response. The study aims to enhance objective response rates in NSCLC, with eligibility criteria including specific NSCLC stages and performance status, while excluding certain medical conditions.

The first participant has been dosed on the phase 2 CONVERGE study evaluating NBTXR3 in stage III, unresectable non–small cell lung cancer.

Breaking Down the CONVERGE Study of NBTXR3 in Stage 3 Unresectable NSCLC

The woman who raised me and I did not always see eye to eye. In fact, as two stubborn, opinionated characters we frequently bickered, challenged and exchanged choice words with one another. 

As I reflect on 25 years strong with Mom, here are some of my favorite words that we exchanged. We gave each other many cards over the past few years, one of which she had told me she looked for a long time searching for the right message to express her feelings. It reads:

"When you have a daughter who makes you proud, makes you laugh and, very often, makes your day ... you know what joy is. When you have a daughter who is a good person with a gracious heart and generous spirit ... you know what peace is. When you have a daughter whose beauty (inside and out) is matched only by her compassion for others ... you know what love is. Because I have you for my daughter, I know what it is to be truly blessed."

When I first read those words — as I read them now — I feel so close to my mom. Recently, I found a card with the words that expressed how I feel about her. I read this aloud to her on Christmas Day.

"Dear Mom, I'm so grateful for the way I was raised. You were never afraid to be my mother — to put your foot down, to teach me right from wrong, to make sure I did my best. You always let me know I had a mama who cared about me, who believed in me, who was there for me no matter what. Growing up with that kind of love and support made such a difference in my life; it made me who I am today."

My mother was never afraid to voice her opinion or be one to mince words, to put it lightly; but she was always pure in her intentions and true in her actions, and I feel so clearly, so humbly loved. As I go forward, I remember her strength and purity, her fierce sense of pride, her generous heart and sensitivity, her sense of humor (she once packed me a peanut-butter-jelly-and-ham sandwich because I refused to pick one of the two). 

Throughout her life and especially in her fight against lung cancer, Mom set us an example in unconditional devotion, taught our family valuable life lessons and never lost her indomitable spirit.

I know Mom is with us now and always. Goodbyes are only for those who love with their eyes, because for those who love with heart and soul there is no such thing as separation. I love you Mom, Happy New Year. Rest in peace and God bless.

For more news on cancer updates, research and education, don’t forget to

The narrative reflects on a complex yet deeply loving relationship between a daughter and her mother, characterized by mutual respect and understanding despite frequent disagreements. The daughter cherishes the heartfelt words exchanged through cards, highlighting the mother's pride, love, and unwavering support. The mother, who battled lung cancer, exemplified strength, devotion, and humor, leaving a lasting impact on her family. The daughter expresses gratitude for her upbringing and acknowledges the enduring connection with her mother, emphasizing that true love transcends physical separation.

A Tribute to Mom

Todd Greenlee first noticed a lump in his left armpit on Labor Day weekend in 2014. He didn’t think too much of it. Then, a couple of weeks later, he pressed on the lump and a bruise blossomed all the way down his left side. It hurt. Greenlee went to the doctor, and after several tests and appointments, he got the bad news: The lump was stage 4 melanoma that had spread through his lymph nodes and abdomen.

His oncologist, Joseph Clark of Loyola University Medical Center in Chicago, tried immunotherapy treatments: first a monoclonal antibody, then a clinical trial that multiplied Greenlee’s own immune T cells and trained them to fight his particular cancer. Each time, though, Greenlee’s disease would respond for a few months, then relapse. Finally, Clark tried a Hail Mary pass: very high doses of a 20-year-old treatment, one of the first immunotherapies, interleukin-2 (IL2).

Not long after beginning IL2, Greenlee started to notice white patches on his hands. Within a few months, Greenlee, a 43-year-old farm worker, had lost skin pigment over most of his body, a condition known as “vitiligo.”

That didn’t bother Greenlee too much, though, because soon after the vitiligo appeared, the spots of cancer that peppered his abdomen disappeared. More than a year later, his medical team still can find no evidence of disease.

“With regard to immune therapy, if people develop vitiligo while being treated for melanoma, that’s a good sign that treatment is working,” Clark explains.

Doctors had noticed a link between vitiligo and better melanoma outcomes as early as the 1940s, writing case studies about such patients. But no one had been able to determine whether vitiligo just happened to co-occur with good responses to treatment, or if the vitiligo actually contributed to those good responses.

In the last few years, however, a series of studies show that developing vitiligo during or after immunotherapy for melanoma, and sometimes for other skin cancers, does indeed mean that the immune system is in high gear, and is associated with a higher chance of remission or even cure.

While the exact mechanism of this phenomenon has yet to be well understood, experts say that figuring it out may lead to new immunotherapy treatments that can more effectively enlist a patient’s own immune system in fighting their cancer.

To understand how vitiligo might be related to better immune treatments, it’s good to review how the immune system works: All cells have proteins on their surfaces that act like biological bar codes, sort of like identity cards. Immune system cells — T cells, natural killer cells, white blood cells and so on &mdash; patrol the body, looking for cells that don’t have the right combination of proteins on their surface. When they find surface proteins, antigens, on cells that don’t pass the screen &mdash; that say “not-self” &mdash; the immune cells attack and kill the offenders.

An “auto-immune” disease or condition occurs when immune system cells start attacking cells that really aren’t invaders at all, but normal body cells. In the case of vitiligo, the immune cells attack “melanocytes,” the cells responsible for pigment in our eyes, hair and skin. An analysis of studies conducted over many years showed that this happens in only 3.4 percent of patients who receive immunotherapy for melanoma, but other researchers have found a much higher incidence; a 2016 study conducted in France found that 25 percent of 67 participating patients experienced vitiligo when taking the immunotherapy Keytruda (pembrolizumab) to treat their melanoma. This may be due to the fact that melanocytes and melanoma cells may share antigens that are targeted by the immune system when powerful immune-stimulating drugs are used.

When the immune system mistakenly attacks enough pigment cells, their destruction leaves behind white patches which may appear small and limited or may spread all over the body.

utside the context of cancer, vitiligo tends to appear in those between the ages of 10 and 30. And it appears to help prevent melanoma and other skin cancers in those who develop it spontaneously.

“There are a number of recent genome-wide association studies that reveal that the versions of genes that put you at risk for vitiligo are the same ones that protect you from melanoma,” explains John Harris, director of the Vitiligo Clinic and Research Center at the University of Massachusetts Medical School.

And if the vitiligo develops in response to immunotherapy for melanoma, “Studies have recently shown that those who get vitiligo have a 70 to 80 percent chance of a clinical response” to the treatment, says David Fisher, director of the Melanoma Center at Harvard’s Massachusetts General Hospital. “If they don’t get vitiligo, they have a lower chance of a major response, 20 to 30 percent.” Researchers say that stories of amazing outcomes in melanoma patients who have vitiligo, or develop it during treatment, circulate around clinics. For instance, Harris recently treated a patient who had a softball-sized melanoma in her armpit, but no metastases anywhere. “That’s incredibly unusual,” Harris says. “It’s probably the case that her vitiligo helped to protect her.”

Once it appears, whether spontaneously or because of immunotherapy, vitiligo usually does not go away. Doctors treat mild cases with topical creams such as systemic corticosteroids or topical immunomodulators, which can help with repigmentation. More widespread vitiligo may be treated with phototherapy, several sessions a week in a booth that emits ultraviolet B light, although this is considered a bad idea for people with melanoma, who are much better off avoiding any kind of tanning. If a patient stops these treatments, the vitiligo usually comes back.

Some patients, who are more bothered by the white patches, may choose to graft patches of their normal skin, or blister patches, onto small patches of vitiligo. More experimental treatments involve transplanting melanocytes from normal skin to the patches with vitiligo. These may not be options during treatment, though, because techniques such as micrografting only work on vitiligo that is inactive, points out Caroline Le Poole, who studies vitiligo and melanoma at Loyola University. In any case, she recommends not cosmetically treating vitiligo until there is absolutely no remaining evidence of melanoma tumor.

“Vitiligo is still kind of lumped into the ‘adverse events’ category,” says Mary Jo Turk, an associate professor of microbiology and immunology at Dartmouth College’s Geisel School of Medicine. “But now, people are starting to think, ‘Let’s look at vitiligo as a separate thing in this era of immunotherapy.’”

Generally, the strategies that have driven the field of immunotherapy over the last two decades have been to find therapeutic agents that target specific protein markers, antigens, on the surface of cancer cells. Or, scientists have tried to develop agents that somehow enhance the patient’s own immune system, enlisting it to help fight the cancer. For instance, if there’s normally a biological brake to regulate the immune response, an immunotherapy releases that brake so the immune system can move into motion.

For a long time, immunotherapy developers focused on “self-antigens,” protein markers that occurred on both the cancer cells and their normal counterparts, for instance cancerous melanoma cells and normal melanocytes. By appearing on cancer cells, these antigens make the aberrant cells appear normal, allowing them to hide from the immune system. More recently, the field has been exploring “tumor-specific” antigens, that is, protein markers that occur only in cancer cells.

The study that brought vitiligo into this discussion rose out of happenstance. Turk, the Dartmouth researcher, had a staffer come to her asking what to do about two cages of mice that had been on a shelf for about a year. The mice in one cage had vitiligo; the mice in the other did not. Turk decided to analyze the two populations and was shocked by what she found: The mice with vitiligo had enhanced immune T cells. The other mice did not.

Turk’s group published a 2011 paper using the data from the mice to show that, somehow, the destruction of melanocytes helped not only to keep T cells active, but to remind them to kill particular cells.

“Melanocyte destruction keeps the T cells alive for hundreds of days,” Turk says. “We were shocked to find this. This finding gave rise to other studies seeking to find out exactly what’s going on with melanoma patients who get vitiligo, and why they tend to have better outcomes. For instance, Le Poole has a grant to study autoimmune side effects of anti-tumor therapy and test measures to reverse them.

Le Poole also has a T cell receptor cloned from vitiligo skin that she’s studying to see if these cells can be used to devise new immunotherapies.

But as with so many things in cancer research, it’s not simple. “It’s not a one-to-one relationship,” Le Poole explains. For instance, not all patients who have a good response to immunotherapy will get vitiligo. Likewise, not all those who get vitiligo will go into remission. The relationship is there, but it’s not absolute.

“If you generically stimulate immune responses, one person will be very different from the other,” Le Poole says. Even in animal models, you may think they’re genetically the same, but one will develop vitiligo and one will not. So there must be something environmental, as well.”

Fisher, of Harvard, thinks that, somehow, melanoma may be changing immune cells. “These immune drugs, the immune checkpoint inhibitors, are given to lots of cancer patients. But only the patients with melanoma sometimes develop vitiligo. It’s not like the drugs are injected into the melanoma; they’re systemic. So we suspect that somehow the melanoma is educating the immune systems. It’s not just neo-antigens [produced by the tumor], but also normal melanocyte proteins at work.”

Moving forward, researchers will try to detail the mechanisms that drive auto-immune and tumor cells in vitiligo. In cases where vitiligo signals a good response to immunotherapy, which cells are helping, how and how much? Also, do other immune biomarkers, such as the protein PD-L1, make cancer cells even more susceptible to treatment if the patient has vitiligo? How much does each kind of T cell contribute to the immune response against the cancer?

“If you find T cells in a patient, that doesn’t tell you which T cells are doing the job,” explains Turk. “You could find 20 kinds of T cells. Some recognize melanocytes; some don’t. Was it all 20 [that helped the patient respond to immunotherapy]? Or was it just three? Which ones? You can answer some of these questions in mice, but it’s much more difficult in humans.” In coming years, vitiligo and melanoma researchers say they will do their best to find those answers.

Todd Greenlee's case of stage 4 melanoma, initially unresponsive to various immunotherapies, showed remarkable improvement following high-dose interleukin-2 treatment, coinciding with the development of vitiligo. This phenomenon, where vitiligo appears during melanoma immunotherapy, has been linked to better treatment outcomes, suggesting an active immune response. Studies indicate that vitiligo may signal a higher chance of remission, although the exact mechanisms remain unclear. Ongoing research aims to understand the relationship between vitiligo, immune system activity, and melanoma treatment efficacy.

 

Why is the development of vitiligo a predictor of good response in patients taking immunotherapy for melanoma, and what can scientists learn from this? 


Dr. Rita Mukhtar

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