The Society of Nuclear Medicine and Molecular Imaging (SNMMI) has provided standardized guidance on the selection and management of patients receiving lutetium-177–labeled PSMA-617 (LuPSMA) radionuclide therapy for metastatic castration-resistant prostate cancer, according to a new consensus statement published by Hope et al in The Journal of Nuclear Medicine. The statement also reviewed the current clinical struggles that patients and physicians may face during treatment with LuPSMA.
Background
Recently, the U.S. Food and Drug Administration approved LuPSMA for the treatment of patients with metastatic castration-resistant prostate cancer who experienced cancer progression after receiving taxane-based chemotherapy and at least one line of androgen receptor pathway inhibitors.
KEY POINTS
- PSMA PET should be performed within 3 months of treatment or since progression on prior therapy.
- Either F-18–DCFPyL or Ga-68–PSMA-11 can be used for PSMA PET imaging.
- Treatment of metastatic castration-resistant prostate cancer following chemotherapy and androgen receptor pathway inhibitors may be considered appropriate, but treatment prior to chemotherapy and following androgen receptor pathway inhibitors may be considered rarely appropriate.
Overview of the New Guidelines
In a new review, the SNMMI assembled an autonomous working group representing a multidisciplinary panel of health-care providers with substantive knowledge on the use of nuclear medicine in order to develop the patient selection criteria and determine appropriate use scenarios for LuPSMA therapy. The working group conducted a review of four prospective phase II and phase III trials that used LuPSMA to develop consensus recommendations.
The members of the working group agreed that PSMA positron-emission tomography (PET) should be performed within 3 months of treatment or since progression on the last therapy to ensure that the current disease state is represented. If disease progression or intervening therapy is evident, PSMA PET should be repeated. Either fluorine F-18–DCFPyL or gallium Ga-68–PSMA-11 can be used for PSMA PET imaging, and F-18–fluorodeoxyglucose (FDG) PET is not required as a standard patient selection tool. In addition, patients should be imaged with either contrast-enhanced computed tomography (CT) or magnetic resonance imaging (MRI) scans to identify potential PSMA-negative disease. Baseline requirements for renal and bone marrow functions were also noted.
Treatment of metastatic castration-resistant prostate cancer following chemotherapy and androgen receptor pathway inhibitors was considered appropriate, whereas treatment of metastatic castration-resistant prostate cancer following androgen receptor pathway inhibitors and prior to chemotherapy was considered rarely appropriate. Further, the working group also determined that treatment of patients with metastatic castration-sensitive prostate cancer was rarely appropriate.
The consensus statement also addressed current clinical struggles that physicians may face when administering LuPSMA radionuclide therapy—including the role of androgen receptor–targeted therapies, the role of radium-223, treatment-related toxicities, when to consider treatment cessation, exceptional responders and restarting treatment, and imaging during treatment.
Conclusions
“With the approval of [LuPSMA], a new class of therapeutics is available to patients with prostate cancer. We look forward to the potential use of PSMA radionuclide therapy in prechemotherapy [metastatic castration-resistant prostate cancer] or other settings pending the full results of ongoing trials,” concluded the statement authors.
Disclosure: For full disclosures of the statement authors, visit jnm.snmjournals.org.
