Harnessing the Full Power of PSMA-PET Requires Multidisciplinary Approach

Commentary
Article

PSMA-PET imaging has successfully disrupted the prostate cancer paradigm and experts agree that unleashing the full potential of this breakthrough requires a multidisciplinary approach.

“Multidisciplinary team collaboration will be especially important for challenging cases as recognized by clinical guidelines,” Neal Shore, MD, and coauthors wrote in a recent article.

“Multidisciplinary team collaboration will be especially important for challenging cases as recognized by clinical guidelines,” Neal Shore, MD, and coauthors wrote in a recent article.10

“Recent developments in PSMA targeted diagnostic imaging and therapeutics (theranostics) promise to advance the management of primary, biochemically recurrent, and metastatic prostate cancer. In order to maximize the clinical impact of PSMA-targeted theranostics, a coordinated approach between the clinical stakeholders involved in prostate cancer management is required,” Thomas Ng, MD, PhD, a dual board-certified Diagnostic Radiology and Nuclear Medicine physician, Massachusetts General Hospital, Harvard Medical School, and coauthors wrote in a published article.1

Current State of PSMA-PET in Prostate Cancer

Emerging evidence is already associating PSMA-PET imaging with improved diagnosis and staging of prostate cancer, with many clinicians using it in addition to, or instead of, conventional imaging options.2-4

In the United States, there are several FDA-approved radioactive diagnostic agents indicated for PSMA-PET imaging.5-7 Approved populations for PSMA-PET use include patients with suspected prostate cancer metastasis who are potentially curable by definitive surgery or radiation, and patients with suspected prostate cancer recurrence based on elevated PSA levels. There is also a radiopharmaceutical cold kit8 approved by the FDA for the preparation of a radioactive diagnostic agent for PSMA-PET imaging, and a PSMA-targeted radioligand therapeutic agent approved for previously treated patients with PSMA-positive metastatic castration-resistant prostate cancer.9

Next Steps

With no shortage of PSMA-based products available, experts are now emphasizing the critical role of collaboration in taking the paradigm to the next level.

“Next-generation nuclear medicine imaging techniques, including PSMA-PET, are expected to reshape the diagnosis, staging, guidance of treatment, and response monitoring for prostate cancer. This transformation in the landscape will spur greater needs for timely critical assessments of next-generation imaging to aid multidisciplinary team clinical decision-making,” urologist Neal Shore, MD, and coauthors wrote in a recent article.10

“Collaboration among nuclear medicine specialists, radiation oncologists, urologists, medical oncologists, and pathologists is essential in assessing the clinical utility of next-generation imaging against the disadvantages (costs, radiation exposure, adverse events, false positives, over-detection) and thus mitigate these risks. Multidisciplinary team collaboration will be especially important for challenging cases as recognized by clinical guidelines,” added Shore et al.10 Shore is the US chief medical officer of Surgery and Oncology at GenesisCare USA, and the medical director of the Carolina Urologic Research Center in Myrtle Beach, South Carolina.

Scott T. Tagawa, MD, a professor of medicine and urology and medical director of the Genitourinary Oncology Research Program at Weill Cornell Medicine, adds, “We need to practice multidisciplinary care. My bias is that it should always happen for every kind of disease stage and state, from stage I through stage IV. Clearly, with the kind of onslaught [that] I hope is coming with these radiopharmaceuticals, we know that the vast majority of patients with advanced cancer are in the hands of medical oncologists or, in the case of prostate cancer, urologists. Essentially, a small handful have radioactive licenses. So, we have to work hand-in-hand with either radiation oncology, nuclear medicine, or both. And especially for the theranostics, there’s a diagnostic component in terms of patient selection.”11

Role of Urologists

PSMA-PET is increasingly becoming a standard component of clinical guidelines for the management of prostate cancer, including recommendations from the National Comprehensive Cancer Network (NCCN), the Society of Nuclear Medicine and Molecular Imaging (SNMMI), the European Association of Nuclear Medicine (EANM), the American Urological Association (AUA), and the Society of Urologic Oncology (SUO).

For urologists, this means PMSA-PET will continue to grow as a core component of their practice. As such, collaborating with their peers—radiation oncologists, nuclear medicine physicians, and medical oncologists—is crucial to maintaining momentum toward the ultimate goal of precision medicine being the true standard for all patients with prostate cancer.

Particularly important for urologists is their collaboration with radiologists. The shared expertise between these disciplines is critical to ensuring the PSMA-PET scan results are accurately interpreted. This teamwork in the clinic can lead to improved outcomes for all patients.

Not only will the urologist–radiologist relationship be important when interpreting PSMA-PET imaging results, but, as Tagawa notes, it will also be crucial to the optimal administration of PSMA-targeted therapies.

“In terms of administration of these compounds, it has to be with someone who has a license. So, most of the time, it will require a [specialist in] radiation oncology, nuclear medicine, or both. And then [urologists] will still need to see the patients, because we are the ones who have been managing the patients the longest and so we are most equipped to handle the other parts of their disease, as well as ongoing [androgen deprivation therapy], for instance, or bone health [issues],” said Tagawa.11

As so, the promise of PSMA-PET is unquestionable and if its full potential is realized, it can truly reshape the prostate cancer paradigm in the years to come. It is now up to urologists and their colleagues to ensure that this happens.

References

1. Ng TSC, Gao X, Salari K, Zlatev DV, Heidari P, Kamran SC, et al. Incorporating PSMA-Targeting Theranostics Into Personalized Prostate Cancer Treatment: a Multidisciplinary Perspective. Front Oncol. 2021;11:722277. doi: 10.3389/fonc.2021.722277

2. Hofman MS, Lawrentschuk N, Francis RJ, et al. Prostate-specific membrane antigen PET-CT in patients with high-risk prostate cancer before curative-intent surgery or radiotherapy (proPSMA): a prospective, randomized, multicentre study. Lancet. 2020;395(10231):1208-1216. Doi:10.1016/S0140-6736(20)30314-7

3. Fendler WP, Eiber M, Beheshti M, et al. PSMA PET/CT: joint EANM procedure guideline/SNMMI procedure standard for prostate cancer imaging 2.0. Eur J Nucl Med Mol Imaging. 2023;50(5):1466-1486. Doi:10.1007/s00259-022-06089-w

4. Briganti A, Abdollah F, Nini A, et al. Performance characteristics of computed tomography in detecting lymph node metastases in contemporary patients with prostate cancer treated with extended pelvic lymph node dissection. Eur Urol. 2012;61(6):1132-1138. Doi:10.1016/j.eururo.2011.11.008

5. FDA approves first PSMA-targeted PET imaging drug for men with prostate cancer. News release. FDA. December 1, 2020. Accessed October 5, 2023. https://www.fda.gov/news-events/press-announcements/fda-approves-first-psma-targeted-pet-imaging-drug-men-prostate-cancer

6. Lantheus receives U.S. FDA approval of PYLARIFY® (piflufolastat F 18) injection, the first and only commercially available PSMA PET imaging agent for prostate cancer. Published online May 27, 2021. Accessed October 5, 2023. https://investor.lantheus.com/news-releases/news-release-details/lantheus-receives-us-fda-approval-pylarifyr-piflufolastat-f-18

7. US FDA approves Blue Earth Diagnostics’ Posluma (flotufolastat F-18 injection, first radiohybrid PSMA-targeted PET imaging agent for prostate cancer. News release. Blue Earth Diagnostics. May 30, 2023. Accessed October 5, 2023. https://www.businesswire.com/news/home/20230530005180/en/U.S.-FDA-Approves-Blue-Earth-Diagnostics%E2%80%99-POSLUMA%C2%AE-Flotufolastat-F-18-Injection-First-Radiohybrid-PSMA-targeted-PET-Imaging-Agent-for-Prostate-Cancer

8. FDA approves Telix’s prostate cancer imaging product, Illuccix. Published online December 20, 2021. Accessed October 5, 2023. https://telixpharma.com/news-views/fda-approves-telixs-prostate-cancer-imaging-product-illuccix/

9. Novartis Pluvicto™ approved by FDA as first targeted radioligand therapy for treatment of progressive, PSMA positive metastatic castration-resistant prostate cancer. Press release. Novartis. March 23, 2022. Accessed October 5, 2023. https://www.novartis.com/news/media-releases/novartis-pluvictotm-approved-fda-first-targeted-radioligand-therapy-treatment-progressive-psma-positive-metastatic-castration-resistant-prostate-cancer

10. Shore, ND, Morgans, AK, El-Haddad, G. et al. Addressing Challenges and Controversies in the Management of Prostate Cancer with Multidisciplinary Teams. Targ Oncol 17, 709–725 (2022). https://doi.org/10.1007/s11523-022-00925-7

11. Interview with Scott T. Tagawa, MD. Filmed at: 2023 New York GU Interdisciplinary Prostate Cancer Congress® and Other Genitourinary Malignancies. Published online March 19, 2023. https://www.cancernetwork.com/view/multidisciplinary-care-for-prostate-cancer-should-always-happen-

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