PSMA Imaging: A Multidisciplinary Approach

As part of GU Oncology Now’s Round the Wire series on PSMA Imaging, moderator Dr. Neeraj Agarwal and Dr. Scott Tagawa discuss the significance of a multidisciplinary approach in lutetium therapy and the importance of retaining a big picture view going into treatment. Wrapping up their discussion, Dr. Scott Tagawa shares about his multicenter trial in the setting of metastatic castration-sensitive prostate cancer.

 

Dr. Agarwal:

So it looks like these patients will need to continue to be following up with their medical oncology teams and supportive oncology teams while they’re being treated by the nuclear medicine docs or radiation oncology docs, depending upon who is administering lutetium therapy to them. Is that a fair statement that we would be seeing these patients on a regular basis in our clinics?

Dr. Tagawa:

So if you’re asking me, I think that someone or a team approach needs to be looking at the entire picture. So I think it’s possible that could be a single physician. There are, especially in Europe, but there are single physicians that do have the entire package, but I think overall, my bias is that a multidisciplinary approach is always better for individual patient and their family. So yes, we absolutely need to have the expertise to be able to administer the radionuclides safely. And in the case of a radionuclide, it does have some gamma emission. They are real, I think minor, but real potential exposures to family, etc. So it’s just something to keep in mind.

So someone needs to have that, that expertise there’s background, generally speaking, additional other therapy hormonal, but you know, we’ll see what other combinations. And as it comes to treatment choices, I don’t think just because someone has a positive PSMA PET, that’s the majority of people. So just because that they have a positive PSMA PET, PSMA target therapy is not the only option for them. So, we want to have the entire picture as we’re going in, but absolutely, as you mentioned in terms of management of the adverse offense.

Dr. Agarwal:

So it looks like this will be approved hopefully soon for patients who have had disease progression on chemotherapy in the metastatic castration-resistant prostate cancer setting. But there is no doubt these therapies may work better, especially as we have seen in the context of novel hormonal therapies, they do much better job when they move off stream to first-line CRPC or newly diagnosed metastatic castration-sensitive prostate cancer setting

Dr. Agarwal:

There is no doubt that lutetium PSMA treatment is going to move upstream, and you’re leading a multicenter trial in this setting, in the setting of metastatic castration-sensitive prostate cancer. So would you mind telling us more about the trial and how physicians can refer their patients to that trial?

Dr. Tagawa:

There are, to be inclusive in my mind, two prospective randomized trials in the setting of metastatic castration-sensitive, hormone-sensitive non castrate symptoms to me, prostate cancer. Quickly Australian trial is looking to address the question of ADT docetaxel with or without sequential deficient PSMA-617. So, it’s a phase 2randomized trial with a PSA endpoint. But just to kind of mention that and part of mentioning it because the trial that was started within the US Groups and now is an international Novartis pharmaceutical sponsored trial, initially called AFT-53, now called PSMA edition, does not include docetaxel, but is looking to address the hypothesis that PSMA is a good target in non castrate disease. There may be some modulation of both PSMA expression and probably at least as importantly, radiosensitivity with AR targeted therapy and as a randomized Phase III trial of ADT plus AR pathway inhibitor of investigator’s choice with or without lutetium PSMA-617, the primary endpoint is radiographic progression three survival.

So because of that, we were able to have crossover built-in. And I think this is patient-friendly. So hopefully, we’ll be able to prove that we push the bar with radiographic progression-free survival with early lutetium PSMA-617, but all patients that are at least still eligible following radiographic progressions, they happen to get ADT plus air pathway only initially. After confirmed radiographic progression, they will be eligible to receive lutetium PSMA-617 as part of the trial as well.

Dr. Agarwal:

So patients will be allowed to cross over to the lutetium arm regardless of whether they receive lutetium upfront or not, which is a great news. Thank you for sharing that important information.