Roberto Alfaro

Médico especialista en Medicina Interna y Oncología Médica.

[Dr Rishabh Jain @DrRishabhOnco]

Happy Father’s Day to the fathers of oncology.

Sidney Farber taught us cancer could be treated.

Paul Ehrlich taught us cancer could be targeted.

James Allison taught us the immune system could fight back.

Every modern oncology clinic stands on the shoulders of giants.

#FathersDay #Oncology #CancerResearch #MedTwitter
@OncoAlert @Larvol @DanaFarber

[Dr Rupam Manna MD @DrRupamOncology]

🔬 TESTICULAR GERM CELL TUMORS: KNOW YOUR TUMOR MARKERS

Serum tumor markers are more than just numbers—they guide diagnosis, staging, prognosis, treatment response, and relapse detection in testicular germ cell tumors (GCTs).

📌 AFP
✔ Elevated in yolk sac tumors, embryonal carcinoma, and mixed GCTs
✔ NEVER elevated in pure seminoma

📌 β-hCG
✔ Highest in choriocarcinoma
✔ May be mildly elevated in seminoma
✔ Can cause gynecomastia and hyperthyroidism when markedly elevated

📌 LDH
✔ Reflects tumor burden
✔ Important prognostic marker in IGCCCG risk classification

🚨 High-Yield Pearl:
Persistent elevation of tumor markers after orchiectomy suggests residual disease (Stage IS).

🧬 Future of GCT Biomarkers:
miR-371a-3p is emerging as a highly sensitive and specific marker for active germ cell tumors and may transform surveillance strategies in the coming years.

Early detection. Accurate staging. Better outcomes.

#TesticularCancer #GermCellTumor #MedicalOncology #Oncology #UroOncology #Seminoma #NSGCT #AFP #BetaHCG #LDH #CancerEducation #MedEd #FOAMed #OncologyTeaching #MedicalStudents #Residents #DrRupamManna #CancerConceptsExplained

[MV Chandrakanth @ChandrakanthMv]

OPTIMA Trial #ASCO2026

One of the most important lessons from ASCO 2026:

Clinical high risk ≠ Genomic high risk.

Among patients with clinically high-risk ER+/HER2− early breast cancer, 68% had low genomic risk (ROR ≤60).

A PAM50-guided treatment strategy substantially reduced chemotherapy use while preserving outcomes:

📊 5-year IBCFS: 90.4% vs 91.5%
📊 HR 0.99 (Non-inferior)

Key takeaway:

🧬 Biology and clinical risk are not the same.
💉 Less chemotherapy is possible for many patients.
✅ Outcomes remained preserved.

Stein et al. #ASCO2026

#BreastCancer #Oncology #PrecisionOncology #MedTwitter #MVOnco

[Matt Cooperberg @dr_coops]

Another provocative Q from @declangmurphy: does RP explain the diff across these parallel trials? #PROTEUS #ASCO26

[Yüksel Ürün @DrYukselUrun]

PROTEUS and STAMPEDE both support ARPI intensification in high-risk M0 prostate cancer, but across different designs and local treatments.
The real advance is not “which wins?”
It is “which patient, which path?”

#ASCO26
@DrChoueiri @TiansterZhang @CathyEngMD @montypal @tompowles1 @brian_rini @cdanicas @GlopesMd @PGrivasMDPhD @nataliagandur @yekeduz_emre @neerajaiims @ASCO @ONCOassist @OpenMedicineHQ @MedwatchKate @scserendipity1 @CParkMD @urotoday @OncLive @crisbergerot @urologysummit @SuyogCancer @Larvol @IMG_Oncologists @piet_ost @DrSpratticus @GGiannarini @declangmurphy @NehaVapiwala @Prof_Nick_James @AttardLab @Silke_Gillessen @APCCC_Lugano

[NEJM @NEJM]

Presented at #ASCO26:

In patients with metastatic prostate cancer with gene alterations, talazoparib–enzalutamide led to better progression-free survival outcomes than placebo–enzalutamide but with more serious adverse events. Full phase 3 TALAPRO-3 trial results: https://t.co/MFVGDGwPzc

Editorial: Precision Intensification in Metastatic Prostate Cancer https://t.co/Q7rjJJ7wJL

@ASCO

[Yüksel Ürün @DrYukselUrun]

ctDNA in adjuvant RCC is informative, but not yet directive.

KEYNOTE-564 supports its prognostic value: ctDNA positivity signals higher recurrence risk and worse outcomes.

But the limitation is critical:
low sensitivity means a negative result can miss real risk.

For now, ctDNA should refine our thinking, not replace clinical judgment.

#ASCO26
@DrChoueiri @TiansterZhang @CathyEngMD @montypal @tompowles1 @brian_rini @cdanicas @GlopesMd @PGrivasMDPhD @nataliagandur @yekeduz_emre @neerajaiims @ASCO @ONCOassist @OncoAlert @OpenMedicineHQ @MedwatchKate @scserendipity1 @CParkMD @urotoday @OncLive @crisbergerot @urologysummit @SuyogCancer @Larvol @IMG_Oncologists

[Open Medicine Insights @OpenMedInsights]

#ASCO26 through an algorithm lens
@ASCO @tompowles1
Study: EV-302 / KEYNOTE-A39
Abstract 4507 | 1L locally advanced/metastatic urothelial carcinoma
Clinical decision point:
What should be the preferred first-line systemic therapy for eligible patients with la/mUC?
Potential algorithm impact:
This update strengthens the current 1L EV+pembrolizumab pathway. With durable OS benefit at 3.5 years and no new safety signal, the algorithmic question shifts from “is this preferred?” to “who is eligible, how do we monitor toxicity, and what comes next?”

What is strengthened:
EV+P remains a high-confidence 1L option when accessible and clinically appropriate.
What remains uncertain:
Post-EV+P sequencing, treatment duration, management in frail patients, and implementation in settings where EV access is limited.

Bottom line:
The first-line mUC algorithm is increasingly shaped by EV+P — but implementation requires toxicity infrastructure, cost/access planning, and a sequencing strategy.

[Yüksel Ürün @DrYukselUrun]

Exceptional response after 2–3 cycles of Lu-PSMA?
If no PSMA uptake remains, APCCC26 favored not continuing automatically.
@drlouiseemmett @DrMHofman @ProfKHerrmann @stefanofanti4 @CigdemSoydal
@OncoAlert @APCCC_Lugano #APCCC26 @BourlonMaite @nataliagandur @Silke_Gillessen @AOmlin @OpenMedicineHQ @MedwatchKate
@Ecastromarcos @ravikanesvaran @dmukherji @scserendipity1 @CParkMD
@ZilliThomas @urotoday @Uroweb @CaPsurvivorship

[Yüksel Ürün @DrYukselUrun]

PSA alone is not enough.
Low-PSA aggressive subtypes, AVPC, and BRCA/HRR-altered mHSPC may need closer imaging.

@OncoAlert @APCCC_Lugano #APCCC26 @BourlonMaite @nataliagandur @Silke_Gillessen @AOmlin @OpenMedicineHQ @MedwatchKate @neerajaiims @AzadOncology @Ecastromarcos @ravikanesvaran @dmukherji @scserendipity1 @CParkMD @EAntonarakis

@AttardLab @ChrisSweens1 @DrRanaMcKay @mishabeltran @ZilliThomas @AarmstrongDuke @quimmateo

[Dra. María Natalia Gandur Quiroga @nataliagandur]

⭐ De-escalation in mHSPC can we safely treat less?
@OncoAlert @APCCC_Lugano #APCCC26 @Silke_Gillessen @AOmlin
Presented by Mika P. Matikainen
👏 Excellent, forward-looking presentation
🔹 Thought-provoking and clinically important talk

🔹 Key insights:
🔵 EMBARK introduces a modern de-escalation model
• PSA-guided treatment suspension
• A significant proportion remain off therapy >2 years
🔵 Current standard → continuous intensification
• De-escalation not yet standard, but rapidly evolving
🔵 Who may benefit?
• Low-volume / oligometastatic disease
• Deep PSA responders
• Favorable biology
🔵 Intermittent strategies:
• Similar OS in selected patients
• Possible trade-offs in high-volume disease

🔵 Future direction:
• Shift from empirical → biomarker-driven de-escalation
• Ongoing trials testing adaptive, response-guided strategies
🔹 Key unanswered questions:
• Optimal PSA thresholds to stop/restart
• Role of PSMA-defined disease burden
• Can ARPI monotherapy replace long-term ADT?

🔹 Take-home:
De-escalation is no longer hypothetical →
but precision selection is critical before changing practic
@ecancer @urologysummit @MedicalwatchHQ @urotoday
#ProstateCancer #UroOncology #Oncology

[Dra. María Natalia Gandur Quiroga @nataliagandur]

⭐ Molecular sub-grouping of mHSPC — who benefits from what? (PART 2)

@OncoAlert @APCCC_Lugano
#IPCS26 #APCCC26 @Silke_Gillessen @AOmlin
Presented by G. Attard

🔹 Key messages:
🔹 1. Alterations in HRR genes (especially BRCA1/2) are associated with worse overall survival
🔹 2. HRR status is not only prognostic → it is predictive for PARP inhibitor benefit
🔹 3. In AMPLITUDE, niraparib + AAP significantly improved rPFS in HRR-mutated patients
🔹 4. Genomic testing (BRCA/HRR) should be integrated early in mHSPC decision-making
🔹 5. Transcriptomic classifiers (e.g. PAM50) may help identify who benefits from docetaxel
🔹 6. Future treatment selection will rely on combined genomic + transcriptomic stratification

🔹 Take-home:
mHSPC management is shifting toward biology-driven treatment selection (ARPI vs chemo vs PARPi)
@Silke_Gillessen @JTheurillat @mishabeltran @bjartell @ChrisSweens1 @DrMHofman @ProfKHerrmann @tompowles1 @EAntonarakis @declangmurphy @VedangMurthy @KOSJ12 @LoebStacy

[Dra. María Natalia Gandur Quiroga @nataliagandur]

⭐ Neoadjuvant therapy in high-risk prostate cancer where do we stand in 2026? 🔬

@OncoAlert @APCCC_Lugano
#IPCS26 #APCCC26 @Silke_Gillessen @AOmlin

Presented by Alberto Briganti

🔹 Big picture:
🔹 1. Neoadjuvant strategies improve pathologic endpoints, but NOT survival (OS/DFS).
🔹 2. ADT ± ARPI increases response rates → but clinical benefit remains limited.

🔹 Biomarkers & response:
🔹 3. pCR, MRD and especially RCB refine response assessment → RCB strongest prognostic signal.
🔹 4. PSMA PET correlates with response → emerging non-invasive biomarker.
🔹 5. ctDNA remains limited in localized disease.

🔹 Biology of resistance:
🔹 6. Residual tumors retain AR signaling.
🔹 7. RB1 loss + TP53 alterations drive resistance and progression.
🔹 8. Distinct genomic profiles define responders (SPOP) vs non-responders.

🔹 Future direction:
🔹 9. Biomarker-driven trials (GUNS) → precision neoadjuvant strategies.
🔹 10. Pathologic response may guide escalation/de-escalation (learning from breast cancer).

@EAntonarakis @DrRanaMcKay @LoebStacy @ChrisSweens1
@fabioturco92 @UrsulaVogl @SScagliarini @Tylersbrt @neerajaiims @amerseburger @Cdanicas @AarmstrongDuke @BertrandTOMBAL @ChrisSweens1 @EAntonarakis @KOSJ12 @VedangMurthy @DrRanaMcKay @LoebStacy @stefanofanti4 @mirrorsmed @profkhermann @dr_coops @piet_ost @_ShankarSiva @DrSpratticus @scocmem @AmandaNizamMD @tompowles1 @EUplatinum @Uromigos
#ProstateCancer #UroOncology #Oncology

[Yüksel Ürün @DrYukselUrun]

1/
Obesity causes cancer. 🧵
Not "might." Not "is linked to."
10% of all new cancers in the US.
Up to 50% of endometrial and kidney cancers.
This is not a lifestyle conversation. It's oncology.
@JAMA_current

[Dr Rishabh Jain @DrRishabhOnco]

🚨 New ASCO Guidelines (2026): Well-Differentiated Thyroid Cancer

This is a major shift in how we treat RAI-refractory disease 👇

🧠 Step 1 is no longer MKI… it’s GENOMICS

👉 Test for: RET | NTRK | BRAF

If actionable → Targeted therapy FIRST
• RET → Selpercatinib (LIBRETTO-001)
• NTRK → Larotrectinib (pooled TRK trials) / Entrectinib (STARTRK)
• BRAF → Dabrafenib ± Trametinib (phase II BRAF studies)

🔥 Deep, durable responses > MKIs

📊 Signal strength
• NTRK inhibitors → ORR ~57–86%
• RET inhibitors → ORR ~79–90%

🧠 If no mutation (or not feasible)

👉 First-line MKI
• Lenvatinib (SELECT)
• Sorafenib (DECISION)

📊
SELECT → PFS 18.3 vs 3.6 mo
DECISION → PFS 10.8 vs 5.8 mo

👉 Lenvatinib preferred (higher ORR, longer PFS)

🧠 After progression

👉 Cabozantinib (COSMIC-311)
📊 PFS 11.0 vs 1.9 mo

🧠 Immunotherapy?

❌ Not upfront
👉 Consider only post-progression
Lenvatinib + Pembrolizumab (KEYNOTE-158 / ITOG study)

🧠 Chemotherapy
👉 Last-line only

🎯 Practice-changing shift
Old → Start MKI for all
New → Test → Target → Then MKI → Then Cabo

💡 Thyroid cancer is now a precision oncology disease

🔖 Save this before your next thyroid clinic

#OncoTwitter #MedTwitter #ThyroidCancer #PrecisionOncology @OncoAlert @myesmo @esmo_open @asco

[Emre Yekedüz @yekeduz_emre]

‼️❓Is trusting only PSA reasonable in metastatic prostate cancer?

🚨Post hoc analysis of ARCHES + PROSPER shows PSA can miss radiographic progression on enzalutamide.

🚨Among patients with radiological progression, 25% had no PSA rise and 60% did not meet PSA progression criteria.

‼️‼️Imaging-only progression also predicted worse OS.
👉https://t.co/poHSHZG9Id

@JCO_ASCO @ASCO @OncoAlert @APCCC_Lugano @urotoday @DrYukselUrun

[Nirmal Raut @oncologician]

🧠 Thinking Like an Elite Oncologist – Daily Checklist
🔍 1. DIAGNOSIS: “Do I truly understand this tumor?”
Histology confirmed?
Stage accurate (any missed metastasis?)
Is this typical or atypical biology?
Could this be a different primary or mixed histology?

👉 Elite move: Always question the obvious.

[Yüksel Ürün @DrYukselUrun]

In a world full of carcinogens, be TP53 for someone.
Not everything has to harm. Some things are here to protect.

[Emre Yekedüz @yekeduz_emre]

A new standard of care in the peri-op management of muscle invasive #bladdercancer ! No need chemo in this setting anymore!🚨‼️

#GU26 @ASCO @OncoAlert @MattGalsky @DrYukselUrun @OncoBellmunt @BourlonMaite @PGrivasMDPhD @drenriquegrande @shilpaonc @OncBrothers @DrChoueiri #Cancer #oncology

[Dr Rishabh Jain @DrRishabhOnco]

🚨 ASCO GU 2026 - The Precision Era of Prostate Cancer 🚨

Here are 10 practice-shaping highlights every GU oncologist should know:

1️⃣ PEACE-3
Radium-223 + Enzalutamide improved OS in bone-only mCRPC
42.3 vs 35.0 months - HR 0.69

2️⃣ PSMAddition
177Lu-PSMA-617 + ADT + ARPI improved rPFS in mHSPC
Frontline radioligand therapy has arrived

3️⃣ MEVPRO-3
Mevrometostat + Enzalutamide
49% reduction in rPFS risk post-abiraterone

4️⃣ CiPHeR
Carboplatin shows strong activity in HRR-mutated mCRPC
Genomic testing is no longer optional

5️⃣ CAPItello-281
Capivasertib + Abiraterone in PTEN-deficient mHSPC
Tolerability confirmed - AKT pathway matters

6️⃣ PEACE-2
Cabazitaxel intensification in very high-risk localized disease
Metastasis-free survival signal

7️⃣ BRCAAway
Concurrent Abi + Olaparib > sequential strategy
Timing of PARP inhibition matters

8️⃣ PAnTHA
Actinium-225 PSMA - alpha emitter strategy emerging
Potential rescue after Lu-177

9️⃣ CLIMATE
miR-371a-3p validated for MRD in stage I TGCT

🔟 Decipher GRID
Transcriptomics refines who benefits from docetaxel intensification

#ASCOGU26 #GU26 #ProstateCancer #OncTwitter #MedTwitter #PrecisionOncology
@OncoAlert @myesmo @esmo_open @asco @larvol