Phillip Koo: Hello. My name is Phillip Koo. Welcome to UroToday. Today, we're very fortunate to have with us Sam Mehr, who is the director of nuclear oncology at Nebraska Cancer Specialists. He's going to be speaking to us today about some of the logistics with regards to starting your own nuclear therapeutic practice at your facility. Thank you very much, Dr. Mehr, for being with us.

Sam Mehr: Oh, it's my pleasure, Phil. Thank you for inviting me. Nebraska Cancer Specialists is the largest community oncology practice in the Midwestern United States. In 2017, the practice made the decision to develop a formal theranostics program to be offered to our patients and the community at large. I'd like to talk to you about what we've established and how we've progressed since 2017.

We call this the "NCS/Nebraska Cancer Specialists model." The mission of the model is to provide specific targeted nuclear therapy using a patient-centered care model, which includes full integration with medical oncology. One of the things that makes our practice unique is that we are fully integrated with the medical oncology practice and are able to provide service and control our program internally.

What does one need if one wants to establish a theranostics center? Well, we need to have a radioactive materials license, an authorized user, a physician who can be licensed to administer the pharmaceuticals, a nuclear medicine technologist, and a radiopharmaceutical preparation area. Practices with current on-site PET/CT already have much of this infrastructure in place, so while it may sound daunting, it's really doable with minimal space requirements and personnel commitments.

The components of the theranostics center model consist of team members. We view our theranostics program as a team effort and a model for workflow. We have a program director. In our case, it's an oncology nurse who oversees the actual operation of the program, communicates with other parts of the oncology practice, and communicates with other practices that may refer patients to us. We have a nuclear medicine physician who serves as medical director and radiation safety officer. We have a lead medical oncologist who provides perspective from the medical oncology community. We have an operations director. We're fortunate to have a nuclear medicine advanced associate as our operations director and he oversees radiopharmaceutical acquisition, safety, decontamination, and waste issues. We have a research director because research is a strong component to what we do. The director of pharmacy is on our team because all of the radioactive drugs are contracted for and ordered through the medical oncology practice. We have a team of nuclear medicine nurses. We have nuclear medicine technologists, we have a dietician, and we have a physician liaison who works with physicians, both inside and outside of our practice.

The key player is the program director, who oversees all program components. Our program director serves as the primary point of contact for the patient during theranostics care. She assumes roles of nurse case manager and nurse navigator. She attends all patient consults and treatment appointments, collaborates with the primary oncologist before, during, and after theranostics care, and participates in education and outreach in all theranostics models.

We found this to be an increasingly important position because while the patient is undergoing theranostics care, and some theranostics care regimes can take about six months, questions arise insofar as changes in the patient due to theranostics, or are they due to the primary oncologic diagnosis? Rather than have the patient try to sort that out and decide who to call, the patient is instructed to contact the program director and the program director consults with the theranostics team and the medical oncology team to provide optimal patient care.

The nuclear physician is responsible for patient management for all therapy-related issues before, during, and after theranostics treatment. We view our theranostics patient as a patient of the nuclear medicine physician during theranostics care and the nuclear physician is responsible for patient education and communication. Because we're all part of the same medical oncology practice, it's easy to maintain ongoing contact with the referring medical oncologist regarding patient status. Our nuclear physician also identifies potential opportunities for clinical trials and research.

We have the director of pharmacy on our theranostics team and his role in acquiring radioactive drugs is the same as his role in this medical oncology practice for acquiring chemotherapy and other oncology-related non-radioactive drugs. Our pharmacy director manages pharmacy-related billing, reimbursement, and contract reviews. Also, our pharmacy director provides drug information and evidence-based recommendations to support practices improving the quality of patient care.

Because our program is new and unique, our physician liaison communicates what we do. Our physician liaison develops educational strategies for both physicians and the general public and establishes and nurtures relationships between area physicians and community oncologists. Since 2017, our theranostics center has received referrals in Nebraska from as far away as Florida and California. When we have those remote referrals, the role of physician liaison becomes critical.

We also have telehealth and remote support options and we are able to provide pretreatment consultation, authorized users willing to travel to licensed sites, qualification for continued treatment and monitoring of adverse events, side effects, and complications. We also provide post-treatment follow-up for all of our patients. We're able to remotely provide recommendations for case management, radiation safety, dietary, and promotion and support for practices just starting to develop a theranostics program.

Here is our workflow model. The medical oncologists or the medical oncologists' nurse case manager initiates communications with the theranostics program director. Also, in our practice, we are able to monitor potential patients through querying of our own medical records. The program director then communicates with the theranostics nuclear physician and schedules pre-treatment consultations. The program director, as we mentioned, is the primary contact for patients during treatment directing theranostics questions to the nuclear physician and non-theranostics questions to the medical oncology team. The nuclear physician and program director update medical oncology throughout the entire treatment regimen. Upon completion, the program director transitions the primary oncology care back to medical oncology, coordinates with medical oncology for imaging and follow-up. Following treatment, the nuclear physician monitors patients with post-treatment follow-up appointments at a predetermined regular interval and continues communication with the oncology team.

Phillip Koo: Great. Thank you very much for that very thorough and comprehensive look at how to start a theranostics program. When you started down this journey, can you talk about how long it took to bring the pieces together, and any major hurdles that you encountered as you tried to stand this up?

Sam Mehr: Well, before I joined the community oncology practice, I was a nuclear medicine physician at a university center and in a healthcare system and it was always a challenge of having to separate a patient away from the medical oncology practice, bring them into a different practice, treat them, and then return them back to that practice. Those problems went away once the medical oncology practice elected to establish its own theranostics center. We're all part of the same practice, we all have a common goal, and there's easy communication. The major problem that we had was eliminated by bringing everything under one roof.

Phillip Koo: Great. Thank you. When you are treating patients who get multiple treatments, are you, as a nuclear medicine physician, managing the adverse events, or are they seeing medical oncology at several of the follow-up visits and being managed by med onc as well?

Sam Mehr: They're generally seen by medical oncology, but if there are treatment considerations or adverse events and they're expected or not unusual or can be directly related to the theranostics care, I generally make a recommendation, communicate with the medical oncologist, and move forward from there. These can be things like transfusions that may become necessary, G-CSF if it's necessary, deciding whether or not to delay a treatment and allow for natural recovery from the radiation side effects, whether to do dose modifications. Those are all recommendations that I make and they're discussed with medical oncology as we move forward.

Phillip Koo: Great. Listening to you, Dr. Mehr, it seems like there's a great deal of professional satisfaction that you've received by shifting to this more integrated model. Can you give some words of encouragement to those people, listeners who might be sitting on the fence with regards to whether or not to implement something like this at their own practice?

Sam Mehr: Well, you're right, Phil, it's really very professionally rewarding for me as a nuclear medicine physician to have my own patients and to take responsibility for them and to see them through a course of therapy. The medical oncologists like it as well because they're comfortable with me, by training and experience, to deal with issues that relate to side effects of giving radioactive drugs, so it's really a win-win situation.

Phillip Koo: Great. Well, thank you very much, Dr. Mehr, for your time. I think for those people listening, I think it really is a really special opportunity for the field of nuclear medicine to really put ourselves on the front lines and have that patient-facing role. That adds value as well. I think we all agree with that. Well, thank you very much, Dr. Mehr, and we look forward to hearing from you in the future, especially with all the great work you're doing at Nebraska Cancer Specialists.

Sam Mehr: Thanks for inviting me.