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Phillip Koo: Welcome back to the final segment for our special feature, looking at how to integrate a PLUVICTO practice into a large urology group practice. For this last segment, we're really going to focus on the multidisciplinary aspects of this program, and we're again joined by doctors Ben Lowentritt and Rob Brookland to talk about this exciting topic. Thank you, guys.

Benjamin Lowentritt: Absolutely.

Robert Brookland: Yeah.

Phillip Koo: So, Ben, I'll start with you. You see these patients; you work them up. Tell us how you make the decision to proceed with PLUVICTO and talk about that transition that you might make to Dr. Brookland.

Benjamin Lowentritt: It's actually been a great system to work in and especially given the current indication for PLUVICTO. These are patients that have been with us usually through a number of treatments, so hopefully we've had some discussion about the availability of radiopharmaceuticals. Some of them may have even been exposed to prior radiopharmaceuticals, so we have had some discussions in the past, but as they're getting to the point where they're progressing now and meeting the criteria, it's a very easy thing for me to be able to say, "Hey, I think this is the time. This is a great opportunity. This is an opportunity to get you a treatment that really can meaningfully impact the disease."

Again, hopefully they've had prior success. And in our system, it's a very easy, essentially a message through an email through the EMR for me to send the patient and say, "Hey, Rob, this patient looks like a candidate for PLUVICTO. Can you see them?" And then our system takes over and we have an approach to get the patient in to talk to them and move forward.

Phillip Koo: So when does the education occur with regards to the mechanism of action or those types of aspects of the drug? Does it occur with you or does it occur after your-

Benjamin Lowentritt: I would say I do a little bit of it, but I don't pretend to try to get to the full level of discussion that I know Rob has. But typically, the imaging will have happened in my care of the patient. So if we've seen signs of progression, we're getting an updated PSMA PET scan. And then that's showing disease in probably more progressed than a prior scan, whether it was a prior PET or not. That leads to the early part of the discussion and understanding somewhat of the mechanism. But then I really leave most of that discussion on the radiation effect to Dr. Brookland.

Phillip Koo: Great. So Dr. Brookland, you get this referral from your partner. Do you schedule a consult with the patient before you decide to move forward? How does that work?

Robert Brookland: Almost always. The reason why I said almost is because we are seeing referrals from some great distance at times. And if we have folks that we're working with medically who have done a really good job, counseling the patients upfront, I may do my consultation on the same day as getting things started because they've had that sophisticated discussion.

If the person is coming from a great distance, recently I saw someone from Tennessee, for example. So as a rule, I like to see the patients before their first dose. I want to review the records. I want to make sure not only is it appropriate for them to get this medication and almost invariably it is, but that there's not something else that we need to consider. Maybe they have some localized pain, maybe there's some imminent spinal cord compression, something that I can intervene in a very prompt way to deal with while we're gearing up to get the PLUVICTO underway.

So I'll go through the records, I'll meet and discuss with the patient what's involved, talk about all the safety considerations then so they know what we're going to expect of them to keep themselves and others safe. Talk about the procedures, the logistics. So we'll talk about all of that. And then what's the realistic expectations of benefit from the treatments? Once we've reviewed all of that, mostly they've been well versed even before they come to see me. When I'm seeing patients from sophisticated docs like Dr. Lowentritt, that makes my job so much easier.

Phillip Koo: So I'm sure there are instances in which the decision to move forward a certain treatment may not be as black and white. What is the role of tumor boards in your practice here at Chesapeake?

Robert Brookland: So if I can just answer that because I'm involved with a number of tumor boards and one of the best working tumor boards is the Chesapeake Urology Tumor Board, which is multidisciplinary. And when we get together, there's on the same conference, a number of medical oncologists, radiation oncologists, urologists, most of whom treat a lot of prostate cancer patients.

We have the radiologists and the pathologists with us and others. And so we can have a very meaningful discussion about each individual who's being presented and their pathway with this disease. And then we can really drill down to. Well, what are the right next choices? Are there clinical trials? Should we move forward with radiopharmaceuticals? And if so, which one? And it's really a great aid in patients getting optimum care.

Benjamin Lowentritt: And the structure of the tumor board is such that we don't have medical oncology within the practice. We don't have diagnostic radiology within the practice, but we invite a number of people. And especially for the radiology, we make sure that there's someone on board, but there are always two or three or four community medical oncologists that are on as well.

And we talk about more than just prostate cancer. But given the nature of our practices, it's probably about at least half of the cases that are discussed. So we do get into a rhythm and we're elevating everyone's knowledge of the different treatments that are available, period. Also, specifically what we're able to offer when it comes to PLUVICTO. It was a good opportunity for us to let people know that we were authorized and we're starting to treat.

So I think it's been a good opportunity to make sure everyone is still on board. It's always frustrating when you hear about patients that seem to be in systems that aren't being offered all of the most up-to-date care. And this has been a great way to keep with these diseases that we're so focused on, keep everyone around us aware of what we're trying to do for our patients.

Phillip Koo: So now we're going to shift a little bit towards how you like to monitor and follow these patients. And this question is for the both of you, but I'll start with you, Dr. Brookland. You're seeing these patients every six weeks for their dose. How do you like to monitor them and what are the triggers that you think about to maybe stop therapy?

Robert Brookland: The advantage that we have at Chesapeake Urology is we have nurse navigators who almost invariably reach out to the patients and check in with them even before the patient would prompt a call because of a side effect. So typically, we're monitoring them with repeated blood counts in advance of their treatment. And if they're having symptoms that need management, then we may monitor them more closely through those side effects, which fortunately aren't that common. And that's how we monitor during the course of the doses of lutetium.

Phillip Koo: And then, Ben, will you see these patients also during their potentially nine months of treatment?

Benjamin Lowentritt: Certainly, because they're getting other treatments. We don't necessarily have specific follow-ups with me for their PLUVICTO management because we work closely with Dr. Brookland and the team of the radiation team for that. But just by the nature of them, typically the patients need bone health, they need their ongoing hormonal therapy and et cetera. We are seeing them frequently and I'm checking in with them.

I also have my advanced practice providers that are checking in with them. So typically we're seeing these patients no less than about every two months for something or other. So yes, we certainly are continuing to monitor them throughout. And a lot of times the phone calls will come through to us on the urology side and we correspond and interact with the radiation team when appropriate or just handle it ourselves.

Phillip Koo: So when we look into the future, I think all of us are really excited about how RLT radioligand therapies are going to be an even bigger part of management and treatment of patients with prostate cancer. And I think we're all eagerly waiting the day when we could start using this pre-chemo. So can you give us a little glimpse into how you guys are thinking about this in the future, now that you've stood up your own radioligand therapy program here? So maybe, Ben, I'll start with you.

Benjamin Lowentritt: We've been fortunate because we've gotten a little preview through some of the trials that we've been a part of, but it immediately becomes a obvious set of criteria that we're going to be looking for. We're looking for targeted therapies for these patients now that have progressive mCRPC and whether that targeting is related to genomic or genetic markers, whether they are related to PSMA expression, we're going to have all of these different options in that space and hopefully, and probably even moving earlier.

So to me, the lutetium products will certainly work in that field very, very well to be able to offer this earlier and more systemic. One of the things that I find very interesting is with the PSMA PET, we're finding a lot of patients with nodal disease that wasn't particularly picked up before. So the ability to have something that goes systemically that gets to all the different positions where the cancer is, is such a huge advantage. It's a very easy story to tell the patient and knowing that relatively few of them have the designated genetic markers that are shown to benefit with some of the other therapies that are out there, I do think that a lot of patients are going to be moving on to this therapy as they fail novel hormonal therapies in the future.

Robert Brookland: Yeah, we need options for patients. And so we're delighted that PLUVICTO is now available and with increased availability and production capacity, patients who were waiting for this opportunity now have it. And certainly, our experience tells us that with more research, the opportunities will only increase that the eligibility criteria will only increase and that'll allow us to use certain drugs earlier when theoretically they could have even more of an impact. And when we are running out of options currently available, new ones will become available as a result of research.

Phillip Koo: So in closing, I just want to give each of you an opportunity to share with our viewers some words of advice. I think a lot of the people who are watching this are perhaps thinking or on their way to opening up their own radioligand therapy program. From the radiation oncology perspective, any words of wisdom that you'd like to share to the viewers?

Robert Brookland: Yes. I think good collaboration and communication with your colleagues is the most important part of a successful program, and it will definitely mean better service, better care for our patients.

Phillip Koo: Great. Dr. Lowentritt, last words.

Benjamin Lowentritt: I appreciate what Rob just said and what Dr. Brookland just said. Definitely collaboration is a huge important part of this. I also think that many of us have already put in a lot of the work to make sure that we're taking the best care of these patients. This is the natural evolution of that. And I don't think anything that's out there should be seen as an obstacle too. Great. This is now what we do, and we take care of these patients in our practices.

I think it is very achievable, very doable. You have to find the right partners. You have to go about the process in the way that is set up because it does require some understanding of regulations, et cetera. But truly, this is achievable, and this really will benefit your patients going forward. We know that RLTs are going to continue to grow in advanced prostate cancer. So everything that we're doing now is to help our patients for the next 10, 15, 20 years as we get more and more opportunities in this kind of field.

Phillip Koo: Well, that's great. I think I agree. It's achievable and it's beneficial, and we'll get there through strong communication. So thank you guys for joining us and we look forward to the continued growth of this program.

Benjamin Lowentritt: Thank you.

Robert Brookland: Thanks very much.