One of the panel sessions at UroGPO highlighted ways in which practice can maximize value. Particularly in the advanced prostate cancer space, but also in other aspects of urology, in-office dispensing can offer significant benefits to patients, physicians, and practices. In the article linked here, The University of Michigan group highlights how physician dispensing may improve patient access to life prolonging therapies such as abiraterone and enzalutamide in advanced prostate cancer. Since the publication of this paper, the indication for these treatment approaches and related ones has grown. However, uptake has lagged below what we might hope. This practice paradigm may offer a potential way forward to improve patient access.

What is theranostics? Before we try to dive deep into the clinical utility of Lutetium-PSMA for prostate cancer, let’s take a step back and sort out what we mean by theranostics. The University of Chicago has a nice explainer here (including videos) that I’ve linked. In very basic terms, theranostics couples therapies with diagnostics. Not surprisingly, then, the agents used are multi-part. In the case of Lutetium-PSMA, the radioactive Lutetium payload is the therapy which is linked (via a linker mechanism) to an antibody which targets the PSMA protein found on prostate cancer cells.

While lutetium-PSMA radioligand therapy has, so far, been approved as a late-line treatment option in monotherapy for patients who have exhausted nearly all other options for metastatic castration resistant disease (mCRPC), it is poised to move forward in our treatment paradigm rapidly. As there are established treatment approaches in first-line and second-line mCRPC (and earlier), most of these ongoing studies are assessing combination approaches. This review article, led by Oliver Sartor who was the lead author of the VISION trial, nicely summarizes future directions for radioligand therapy in prostate cancer. Notably, the upcoming ESMO meeting will give us the first look at data from PSMAfore which assesses Lu-177-PSMA in taxane naïve patients with mCRPC.

This very accessible article from Prostate Cancer UK highlights some data regarding Lutetium-PSMA therapy with a focus on the VISION trial which established Lu-177-PSMA as a treatment option in advanced prostate cancer. Importantly, this article provides a clear overview of how this treatment paradigm works, offering insights into the benefits it may offer our patients.

This short, accessible article from UCSF (one of the pioneering sites of PSMA imaging in the United States) nicely lays out the rationale and benefits of PSMA-PET imaging in prostate cancer. While this article highlights 68Ga-PSMA-11, there are numerous other tracers on the market, many of which are fluoridated which allows for a longer half-life and therefore may be more practical for use in your clinical practice. It’s important to recognise that, regardless of the tracer used diagnostically, all potential benefits of a theranostic treatment rest of on the premise established in this diagnostic paradigm of being able to accurately localize the site of prostate cancer in a way that was not feasible before this technology evolved.