Paul E. Oberstein, MD, is an associate professor in the Department of Medicine at New York University (NYU) Grossman School of Medicine; service chief of the Gastrointestinal Medical Oncology Program; and assistant director of the Pancreatic Cancer Center at NYU Langone Health’s Perlmutter Cancer Center

Dr Oberstein on Clinical Applications for Oncodetect in MRD Detection in Solid Tumors

“The goal [of Oncodetect] is to more accurately select patients who might have a higher risk of cancer recurrence and tell us who has a lower risk. That's where it's the most important.”

Paul E. Oberstein, MD, an associate professor in the Department of Medicine at New York University (NYU) Grossman School of Medicine; service chief of the Gastrointestinal Medical Oncology Program; and assistant director of the Pancreatic Cancer Center at NYU Langone Health’s Perlmutter Cancer Center, discussed the use of the Oncodetect test for molecular residual disease (MRD) detection in patients with solid tumors. 

Identifying circulating tumor DNA (ctDNA) in peripheral blood is technically demanding because the vast majority of cell‑free DNA originates from normal somatic turnover, Oberstein began, adding that neoplastic fragments constitute only a minute fraction of the total. Consequently, an assay must achieve extremely high analytical sensitivity and specificity todetect small amounts of ctDNA and to distinguish pathogenic alterations from background germline or clonal hematopoiesis variants, he said. The Oncodetect platform addresses this challenge by interrogating a broad panel of tumor‑associated mutations, he stated. The larger the catalogue of targetable variants, the greater the probability that at least 1 malignant signal will be captured and the lower the likelihood that benign sequences will be misclassified as tumor derived, he explained.

Oncodetect is an MRD assay, Oberstein continued. In this setting, blood is sampled after definitive therapy, which is most commonly surgical resection, according to Oberstein. Some patients will ultimately relapse, whereas others will remain disease free; ctDNA measurements may help stratify those risks, he said. A post‑operative MRD‑positive result implies a heightened probability of recurrence, whereas sustained MRD negativity suggests a lower risk, Oberstein stated. Such information could influence several aspects of disease management, including the frequency of surveillance imaging, intensity or omission of adjuvant chemotherapy, or enrollment into clinical trials, he noted. More refined risk discrimination would allow for the escalation of systemic therapy in patients with molecular persistence but spare low‑risk patients unnecessary cytotoxic exposure and attendant morbidity, he added. Reliable MRD monitoring might also become a substitute for routine CT scans or other cancer imaging modalities, provided that prospective studies confirm the clinical outcomes seen so far, he said.

Currently, most cancer centers use MRD assays as adjunctive tools: results are incorporated into risk discussions but rarely dictate definitive treatment alterations, Oberstein continued. However, enthusiasm for these assays remains high, as they may offer early warnings that can guide heightened vigilance or timely intervention. Overall, oncologists must counsel patients carefully, outlining both the prognostic utility of MRD positivity and the current evidentiary gaps that preclude routine treatment modification solely on the basis of ctDNA findings, he concluded.

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Paul E. Oberstein, MD, discusses the clinical applications of the Oncodetect test for molecular residual disease detection in patients with solid tumors. 

Dr Oberstein on Data for Pamrevlumab Plus Nab-Paclitaxel/Gemcitabine in PDAC 

“The primary finding the study is that there was no improvement in the investigational arm. The study was very exciting in that it enrolled very quickly [across] many sites and showed really positive outcomes in the standard of care arm and the ability to do a large, dynamic study like this, which hopefully will pave the way for more studies in pancreatic cancer.”

Paul E. Oberstein, MD, director, Pancreatic Cancer Center, NYU Langone Health, discusses findings from the phase 2/3 Precision Promise trial (NCT04229004), a Bayesian platform trial that evaluated pamrevlumab plus nab-paclitaxel (Abraxane) and gemcitabine compared with nab-paclitaxel plus gemcitabine alone in patients with metastatic pancreatic ductal adenocarcinoma (PDAC).

In this randomized, dynamic trial, Oberstein explains that investigators assessed the efficacy and safety of adding pamrevlumab, a connective tissue growth factor–targeted monoclonal antibody, to the chemotherapy backbone in first- and second-line metastatic PDAC.

 showed no improvement in progression-free survival (PFS) or overall survival (OS) with the addition of pamrevlumab. In the first-line cohort, median PFS was 5.3 months with concurrent nab-paclitaxel/gemcitabine (n = 23) and 5.9 months with pamrevlumab plus chemotherapy (n = 102; HR, 0.64; 95% CI, 0.36-1.14). Confirmed objective response rates (ORR) were 26.1% in the concurrent nab-paclitaxel/gemcitabine arm and 35.3% in the pamrevlumab combination arm. In the second-line setting, median PFS was 7.0 months with chemotherapy alone (n = 22) and 3.9 months with pamrevlumab plus nab-paclitaxel/gemcitabine (n = 111; HR, 1.35; 95% CI, 0.78-2.33). The ORRs were 4.5% and 9.0%, respectively.

Oberstein notes that no new safety signals were observed with the addition of pamrevlumab, and the toxicity profile was consistent with the chemotherapy backbone.

Oberstein highlights the efficiency and feasibility of the Bayesian platform design, which facilitated rapid enrollment and robust data generation. He emphasizes that although pamrevlumab did not demonstrate improved efficacy in this trial, the dynamic design of Precision Promise sets the stage for future studies in pancreatic cancer.

Oberstein concludes that continued innovation in trial design and therapeutic approaches is critical to addressing the unmet needs of patients with metastatic PDAC. Future investigations may focus on identifying subgroups most likely to benefit from targeted therapies and optimizing combination strategies in this challengingdisease.

Paul E. Oberstein, MD, discusses the efficacy and safety of pamrevlumab plus  chemotherapy in first- and second-line PDAC.

Paul E. Oberstein, MD, associate professor, Department of Medicine, director, Gastrointestinal Medical Oncology Program, assistant director, Pancreatic Cancer Center, NYU Grossman School of Medicine, NYU Langone Health’s Perlmutter Cancer Center, discusses remaining challenges in metastatic colorectal cancer (CRC).

Although targeted therapies and immunotherapy have shown favorable results, they have only been beneficial for a minority of patients, Oberstein says. Therefore, it is important to find more treatment approaches that are effective for a wider subset of patients, Oberstein explains.

Moreover, although the incidence of CRC has gone down among the overall population, the incidence of CRC is rising among adults under the age of 50 years in the United States, Oberstein continues. It is important to understand more about why this has happened, as well as how to target those patients, Oberstein says.

Paul E. Oberstein, MD, discusses remaining challenges in metastatic colorectal cancer.


Dr. Oberstein on Remaining Challenges in Metastatic CRC

Paul E. Oberstein, MD, associate professor, Department of Medicine, director, Gastrointestinal Medical Oncology Program, assistant director, Pancreatic Cancer Center, NYU Grossman School of Medicine, Perlmutter Cancer Center, NYU Langone Health, discusses the phase 2/3 CheckMate 9X8 trial (NCT03414983) in metastatic colorectal cancer (CRC).

CheckMate 9X8 evaluated standard-of-care chemotherapy plus bevacizumab (Avastin) with or without nivolumab (Opdivo) in the first-line treatment of patients with metastatic CRC.

The primary end point of the trial evaluated progression-free survival (PFS), and data did not show that there was a PFS benefit when adding nivolumab to standard-of-care chemotherapy, Oberstein says. The median PFS was identical in both groups, Oberstein explains.

Despite being a negative study due to the primary end point not being met, the 2-year overall survival data benefited the group that received nivolumab, Oberstein continued. Further research is needed to properly identify patients who could benefit from the addition of nivolumab to chemotherapy, Oberstein concludes.

Paul E. Oberstein, MD, discusses the phase 2/3 CheckMate 9X8 trial in metastatic colorectal cancer.


Dr. Oberstein on the CheckMate 9X8 Trial in Metastatic CRC

Paul E. Oberstein, MD, associate professor, Department of Medicine, director, Gastrointestinal Medical Oncology Program, assistant director, Pancreatic Cancer Center, NYU Grossman School of Medicine, Perlmutter Cancer Center, NYU Langone Health, discusses the utilization of ctDNA in metastatic colorectal cancer (CRC).

By helping detect the burden of disease, ctDNA can provide insight to how much chemotherapy a patient needs, as well as their risk of recurrence, Oberstein says. While ctDNA has shown the ability to predict risk of recurrence, it is still unknown if it can predict how a patient will respond to chemotherapy or what the best agent would be to combine with chemotherapy, Oberstein explains.

These answers can only be obtained through clinical trials, and there are multiple trials in progress aiming to find how to use information from ctDNA to decide whether to escalate or deescalate therapy, Oberstein concludes.

Paul E. Oberstein, MD, discusses the utilization of ctDNA in metastatic colorectal cancer.


Dr. Oberstein on the Utilization of CtDNA in Metastatic CRC

Paul E. Oberstein, MD, associate professor, Department of Medicine, director, Gastrointestinal Medical Oncology Program, assistant director, Pancreatic Cancer Center, NYU Grossman School of Medicine, Perlmutter Cancer Center, NYU Langone Health, discusses the current treatment landscape of colorectal cancer (CRC).

For the majority of patients with CRC, multi-agent chemotherapy is administered in both the first- and second-line settings, Oberstein says. Depending on a patient’s mutational status, targeted agents could also be deployed in these settings, Oberstein says.

For patients who progress to the third line, single-agent regorafenib (Stivarga) and TAS-102 (trifluridine/tipiracil; Lonsurf) have demonstrated efficacy in randomized trials, Oberstein explains. However, there is no standard of care beyond the third line, and enrollment on clinical trials are highly encouraged, Oberstein adds.

More patients with CRC are being classified into subsets based on genetic markers, and these subsets can receive tailored therapy in earlier settings, Oberstein continues. The increase in biomarkers has allowed for more patients with mutations to be identified, and clinical trials plus more standardized testing have changed how treatment is tailored, Oberstein concludes.

Paul E. Oberstein, MD, discusses the current treatment landscape of colorectal cancer.


Dr. Oberstein on the Current Treatment Landscape of CRC

Paul E. Oberstein, MD, assistant professor of medicine, assistant director, Pancreatic Cancer Center, director, Gastrointestinal Medical Oncology Program, NYU Langone’s Perlmutter Cancer Center, discusses the use of pegylated hyaluronidase (PEGPH20) in advanced pancreatic cancer.

PEGPH20, is an investigational agent and potential therapy for patients with advanced pancreatic cancer, says Oberstein. The mechanism of that agent breaks down hyaluronan, or hyaluronic acid, in the tumor environment. This potentially opens the tumor up to receive more chemotherapy or maybe even be able to target tumors directly.

A large phase II clinical trial showed some benefit of PEGPH20 in combination with gemcitabine and nab-paclitaxel (Abraxane). However, another trial showed no benefit of PEGPH20 in combination with an alternative chemotherapy backbone, modified FOLFIRINOX. Oberstein says that physicians need to better understand exactly who and when patients will benefit from the agent. This underscores the need for more clinical trials, observes Oberstein.

Paul E. Oberstein, MD, assistant professor of medicine, assistant director, Pancreatic Cancer Center, director, Gastrointestinal Medical Oncology Program, NYU Langone’s Perlmutter Cancer Center, discusses the use of PEGPH20 in advanced pancreatic cancer.

Paul E. Oberstein, MD

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