(UroToday.com) The 2024 GU ASCO annual meeting featured a prostate cancer session and a presentation by Dr. Marybeth Nedrud discussing implementation outcomes of a multidisciplinary approach for Lu177-PSMA-617 (LuPSMA) therapy. LuPSMA is a recently approved treatment for patients with metastatic castration resistant prostate cancer (mCRPC) based on results from the VISION trial.1 Importantly, successful treatment in real-world practice requires coordination between nuclear medicine, radiation safety, and medical oncology. At the 2024 GU ASCO annual meeting, Dr. Nedrud and colleagues reported outcomes from implementation of a multidisciplinary approach for LuPSMA administration at Duke University.
Dr. Nedrud’s practice prior to treatment included collaborative radiologist review of PSMA PET/CT and oncologist review of prior therapies, performance status, and baseline laboratory values to establish candidacy. For each administration, procedures included confirming IV patency, use of a shielded infusion pump, IV hydration, and standardized radiation safety recommendations. On treatment, practices included scheduled laboratory monitoring, standardized treatment holds and dose reductions, coordination of care with a dedicated advanced practitioner, and mid-treatment conventional imaging. Under this protocol, a retrospective chart review was completed for 100 mCRPC patients who received ≥1 dose of LuPSMA from June 2022 to August 2023. The interdisciplinary workflow is as follows:
Outcomes including number of treatments, dose reductions/holds, PSA, and clinical imaging responses were reviewed.
There were 98 patients included in this analysis (of note, two patients were excluded due to prior LuPSMA on clinical trial). In patients completing LuPSMA at time of data collection, the median number of treatments was 4.0 (IQR 4.0, n = 95), with 41% receiving all 6 planned treatments (n = 39/95). During treatment, 16% experienced a treatment hold (n = 16/98) with 25% ultimately completing 6 treatments (n = 4/16; median 3.0, IQR 3.25). Holds were due to worsening symptoms (44%, n = 7/16) or cytotoxicity (44%, n = 7/16). Dose reductions occurred in 8% (n = 8/98) of patients, with 38% completing 6 treatments (n = 3/8; median treatments 4.5, IQR 3.0):
Early discontinuation primarily occurred due to clinician-assessed progression (57%, n = 32/56) or cytotoxicity (25%, n = 14/56):
Of those with early discontinuation due to progression, 66% had a rising PSA at time of discontinuation and all had worsening disease on available mid-treatment imaging. For the remainder with early discontinuation due to progression, 19% had stable PSA and 9% had decreasing PSA at time of discontinuation. In those with stable or rising PSA, 75% terminated treatment due to worsening disease on available mid-treatment imaging (n = 6/8):
Dr. Nedrud concluded her presentation by discussing implementation outcomes of a multidisciplinary approach for LuPSMA therapy with the following take-home points:
- Under a multidisciplinary approach, Duke University has successfully completed LuPSMA treatment for ~100 patients over the span of 14 months. The advanced practitioner was used to assist with monitoring the patient status during treatment and to coordinate care amongst team members
- Of the 95 participants who completed LuPSMA therapy, an average number of 4.0 treatments were received and ~40% completed all 6 planned treatments. Dose reductions and holds facilitated completion of therapy in select men
- Early treatment discontinuation was most commonly second to disease progression (n=32, 57%)
- These results suggest that mid-treatment imaging may identify worsening disease in the setting of stable or decreasing PSA, underlying the importance of this practice for clinical decision making
Presented by: Marybeth Nedrud, MD, PhD, Department of Radiology, Duke University School of Medicine, Durham, NC
Written by: Zachary Klaassen, MD, MSc – Urologic Oncologist, Associate Professor of Urology, Georgia Cancer Center, Wellstar MCG Health, @zklaassen_md on Twitter during the 2024 American Society of Clinical Oncology Genitourinary (ASCO GU) Cancers Symposium, San Francisco, CA, January 25th – January 27th, 2024
References:
- Sartor O, de Bono J, Chi KN et al. Lutetium-177-PSMA-617 for Metastatic Castration-Resistant Prostate Cancer. N Engl J Med. 2021 Sep 16;385(12):1091-1103.