Alicia Morgans: Hi, I'm excited to be here at ASCO 2022, where I have the opportunity to speak with Brenda Martone, nurse practitioner at Northwestern University. Thank you for speaking with me today, Brenda,

Brenda Martone: It's a pleasure to be here.

Alicia Morgans: It's a pleasure to talk to you always, and I wanted to speak with you about something that's so important in the use of radium 223, which is really how do we practically get this treatment to patients because it does require a multidisciplinary team to communicate and deliver that treatment safely to patients. So I guess where do we start? You've chosen a patient, the patient is interested in radium. How do you begin?

Brenda Martone: So at my clinical institution, we have a process already set up and it was identified before we got radium started for our patients. Basically it's the HemOnc or the oncologist who identifies the patient. Then in our institution, we give the radium in nuclear medicine. So in other institutions, sometimes that's given in radiation oncology. The same process would still work in terms of we notify our contact person, our point person in nuclear medicine. We let that person know that we have a radium patient identified. The paperwork gets submitted that needs to be submitted. And then once that patient has been approved, we arrange with nuclear medicine setting up that first treatment. We ensure that the labs are available and the blood counts support the treatment as well as the patient's weight. Nuclear medicine then has their own physician review the information and they give the final approval. We send patients to nuclear medicine. Prior to that we go through side effects, expected management, how often counts will be monitored, but nuclear medicine really does the specific teaching in terms of radiation precautions and things after the infusion.

Alicia Morgans: That's great. It's nice, and as you said to really sort that out before the patient engages, so setting up the contact in nuclear medicine or in radiation oncology, depending on which group in your particular area is giving the medicine, is important. Communicating that information to that individual. While the insurance approval is going through, that person can be thinking about, okay, when can I fit this patient into our schedule and estimating when that approval might actually happen. And then when the approval does come through, like you said, ensuring that you have the right labs, which is really a CBC and we often would get a metabolic panel as well, just to make sure liver and kidney function is good. And of course we can have cytopenias that would put us below the threshold to be able to use the radium. So that's fantastic.

Now as the medicine is of course delivered every four weeks, in your case, nuclear medicine, in some places, radiation oncology, how do you go about communicating or getting that CBC that's due about a week before the next treatment with radium? What's your process?

Brenda Martone: We find that works the best, because we like to see our patients before each radium treatment, so we bring them in roughly seven days prior to the clinic to assess how they're doing, look at their blood counts, look at their metabolic panel, make sure that they're tolerating the treatment well. And then once that's done, it's similar to the beginning of the process. We communicate with nuclear medicine. We give them the most recent labs, the weight, that we feel the patient is safe to go ahead with treatment. And from there they go ahead and schedule the patient the following week. And we've been doing this for so long that we have such a great process and [inaudible 00:03:31] actually reaches out to us once in a while to remind us that it's getting close to timing for the blood counts, just to give us a gentle heads up. So I totally agree that communication is key. It makes the process seamless for the patients, and they're able to get their treatment without having to have multiple visits or hiccups or delays.

Alicia Morgans: And that's what's so important from a patient perspective. But I think just to your point in terms of the patient, just thinking about how often is a patient in the facility, so they're in two weeks in a row and then two weeks off, basically.

Brenda Martone: Yes.

Alicia Morgans: Because week one is often with medical oncology or it could be with urology, if urology is coordinating things to have CBC, and really to talk about tolerance of treatment. There are some patients who need additional support. Maybe they're having some nausea, maybe they're having some fatigue, they just need to talk things through, whatever it is. It's important to see them, I think, and talk about their tolerance of treatment. And then the following week they're in for their treatment. And that seems to work smoothly. So that's fantastic. One other important point when it comes to radium, obviously this is a metastatic CRPC patient population. Bone health is really important in any situation for these patients. And of course, giving monthly, up to monthly, denosumab or zoletronic acid is standard of care to prevent skeletal related events. How do you and your team work through making sure that patients are on proper bone health agents? Is that your job? Is that nuclear medicine's job? How do you think that through when you're giving radium?

Brenda Martone: It's basically the oncology team that does that. So most of these patients will have been on a bone-strengthening agent. There are some who are not. And so prior to us even starting the radium process, we encourage our patients to get their dental evaluation, to make sure that there's nothing that requires immediate intervention that would put them at increased risk for any of the toxicities associated with either denosumab or zoledronic acid. We make sure that they at least have a single dose of whichever agent, if they haven't been on that before we get started with the radium, just given the toxicity and the safety data we have showing that this is an important agent to be added to this treatment in terms of patient safety.

Alicia Morgans: That's fantastic. And it could be urology. It could be medical oncology, but I actually really use radium as sort of a check and balance because we want to already have these patients on up to monthly treatment with a bone health agent. But if for some reason they're not, this is just my mental cue, get that patient on bone health treatment. And it's really, I think, useful in that way. So any other final thoughts or words of wisdom, recommendations for listeners as they're thinking about using this treatment.

Brenda Martone: Support your patient, communication and really trying to minimize any sort of side effects or toxicities will certainly ensure your patient is successful in getting all their treatments. You really do want to get the six doses if able. And quality of life, maintaining a good quality of life while they're going through treatment is essential. And just a whole balance between the treatment, quality of life, symptom management and the entire team working together.

Alicia Morgans: Wonderful message. And thank you so much for really emphasizing that we want to try to use this drug as we can in our armamentarium and really do try to ensure that we get as many cycles in as possible. We know patients who are treated with more cycles do better, so another great point. Thank you so much for sharing your time and your expertise with us today.

Brenda Martone: You're very welcome. Thank you.