Choosing Among The Available Radiotracer Options When Ordering PSMA-PET


Shared insight from the panel on how they typically select radiotracers when ordering PSMA-PET scans in their clinical practice.


David Albala, MD: How do you choose a radiotracer? If I’m a urologist in practice, how do I choose the radiotracer that’s available to me?

Gerald Andriole, MD: That might be the answer to your own question: What is available to you? We have availability of an F18 DCFPYL in the afternoons. The agent is produced in the mornings and therefore isn’t available to us in the mornings. If we wished to do a PSMA [prostate-specific membrane antigen] study in the morning, we would have to do a Gallium-68 PSMA 11. We schedule predominantly to perform the fluorine 18 DCFPYLs in the afternoon. Availability is the major issue. You can use any of these agents and be superior to the agents that you used previously, like CT bone scan and fluciclovine. Find the agent that you prefer working with, and you can work out a schedule that works best for you and your patients.

Ashley Ross, MD, PhD: A couple of things. As people adopt this, and I’ve been in both academic and private practice scenarios; I was in private practice when fluciclovine was getting adopted. I think there’s a couple of considerations. One, in the PET PSMA [prostate-specific membrane antigen positron emission tomography] world, where we are now, there are a lots of tracers that are FDA-approved. You don’t have to be shy about having more than one tracer that you try to get available in your institution. The bandwidth for this, as it kind of becomes our standard first-line imaging for [INAUDIBLE] recurrence, for really diverse disease is pretty high. Prostate cancer is a fairly prevalent disease. Having some backup options is necessary; I’ve certainly had patients where the F18 tracer didn’t produce well. And they said, “Well, we can get a Gallium in that day.” We’ve done that. The second thing is, and this is important, it is newer. I agree that we shouldn’t just call it new because we’ll be chasing our tail forever, but it’s newer. If you’re in private practice and onboarding this, and you’re using a remote imaging site that’s not in your institution—which is quite often the case—I think you want to talk to that institution a little bit and make sure that you’re putting in your orders the right way. I think it was either Gerry or Gary that mentioned you want to order what you want. When fluciclovine was coming up, I had a colleague that sent someone out for a PET scan of their prostate. It came back with a FDG [fluorodeoxyglucose] PET. You don’t want that to happen. You want to be very specific with what you want. You want to talk to that institution and say, “Look, this is what I’m looking for. How do I make sure, when I order it, I’m getting what I want and why?” So, it sounds like a little bit of an extra step. But I think, in these first couple of years, as we disseminate it’s an important extra step.

Gary Ulaner, MD, PhD, FACNM: I would call this one of my pet peeves: when people say, “I want to order a PET scan.” For a long time, FDG was the game. When you were ordering a PET, you were ordering an FDG PET scan. But these days, I think we really have to become cognizant that we need to say, “I want a FDG PET” or “I want a PSMA PET” or even specify which of the PSMA PETs you want to order. Versus a dotatate PET or an estrogen receptor targeted PET or any of the many additional PET agents that are now coming down the pipeline. The more PET tracers become available, the more important it’s going to be to start referring to things not as a PET scan, but as the specific PET scan that we’re referring to.

Ashley Ross, MD, PhD: We’re used to this because we don’t just order a CT for hematuria; you’re ordering a specific three-phase CT. You don’t just order an MRI for the pelvis; you order a prostate MRI or a renal MRI. It’s not a big leap, but it’s just something to think about as you do it.

David Albala, MD: Let me toss this out to the group: What do you think are the biggest logistical considerations when looking at these different agents and imaging modalities? Is it the licensing requirements? Is it the storage, staff training, preparation, the availability? What do you think is the most critical step in getting the agent to the patient? I’m a physician, I want to order my agent. What do I need to be critically thinking about when I order this to do on a patient?

Gary Ulaner, MD, PhD, FACNM: Number one is availability. If you are in southern California, or in a big metropolitan center, you probably have the option of using either the Gallium-68 or the fluorine-18 agent. But if you’re not, you need to investigate which one, or both, or neither of the agents are currently available to you. Once you have the availability of the agent, the performance of the scan, the tech training, is not so involved. One thing to keep in mind is that because we’re so used to the FDG PET [fluorodeoxyglucose positron emission tomography] being the only game in town, every patient gets an email saying, “Please fast for 4 to 6 hours prior to your PET scan. Please don’t exercise for 24 hours prior to your PET scan.” That has absolutely no applicability to PSMA [prostate-specific membrane antigen] PET scans. We need to change the instructions the patients are getting to be specific to PSMA PET scans as opposed to FDG PET scans.

Transcript edited for clarity.

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