What are the barriers to rad onc doing more radiopharm?

[BobbyHeenan]

What are the supervision requirements for the Lutathera?

For Xofigo I personally push the syringe for the 60 seconds, check on patient, etc...takes me about 5 mins or so. Physics obviously more involved taking the pre and post injection measurements/activity.

For Lutathera, I know it's a ton of work, but from a physician standpoint if we give the therapy in another room over in an infusion suite, can I still be active in clinic in another room or doing computer work in my office?

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[elementaryschooleconomics]

What are the supervision requirements for the Lutathera?

For Xofigo I personally push the syringe for the 60 seconds, check on patient, etc...takes me about 5 mins or so. Physics obviously more involved taking the pre and post injection measurements/activity.

For Lutathera, I know it's a ton of work, but from a physician standpoint if we give the therapy in another room over in an infusion suite, can I still be active in clinic in another room or doing computer work in my office?

I can't speak on a state/federal level, but at my institution the Nuclear Medicine attending of record remains physically present for the initial infusion, as in, literally standing in the room for 30+ minutes. Our infusion suite where its done is far away from the NucMed department, so perhaps if that wasn't the case they could accomplish other work while still supervising?

It's an interesting question.

 

[radoncopotamus]

I can't speak on a state/federal level, but at my institution the Nuclear Medicine attending of record remains physically present for the initial infusion, as in, literally standing in the room for 30+ minutes. Our infusion suite where its done is far away from the NucMed department, so perhaps if that wasn't the case they could accomplish other work while still supervising?

It's an interesting question.

Nuc Med physicians where I trained never went to the infusion clinic for administration but their rad techs were their for the whole radiopharm infusion. I am naive as to what sort of credentialling those people have/require aside from radiation safety sign off.

 

[medgator]

Nuc Med physicians where I trained never went to the infusion clinic for administration but their rad techs were their for the whole radiopharm infusion. I am naive as to what sort of credentialling those people have/require aside from radiation safety sign off.

For xofigo or thyroids, it's pretty quick. Xofigo is a push. Lutathera is a multi hour infusion, actually multiple infusions

 

[Chartreuse Wombat]

Anyone have information on the professional wRVUs associated with these treatments?

 

[Krukenberg]

Nuc Med physicians where I trained never went to the infusion clinic for administration but their rad techs were their for the whole radiopharm infusion. I am naive as to what sort of credentialling those people have/require aside from radiation safety sign off.

At my institution the nuc med MD is just present for the initiation. Definitely doesn’t stay within eyesight at least for the whole infusion

 

[radonc17]

We are getting close to 100 responses! Thanks for all that have participated thus far!

@Krukenberg @Chartreuse Wombat @radoncopotamus @BobbyHeenan

Can I shamefully request for you to add your perspectives the survey

Radiopharmaceuticals/Unsealed Sources Survey for Radiation Oncologists

collaborate.tuftsctsi.org

 

[RickyScott]

Nucs are a loss leader for the radonc . You waste
a lot of time for small gain so that you/and radiation are more visible in the cancer center/community.

 

[RadOncDoc21]

We are getting close to 100 responses! Thanks for all that have participated thus far!

@Krukenberg @Chartreuse Wombat @radoncopotamus @BobbyHeenan

Can I shamefully request for you to add your perspectives the survey

Radiopharmaceuticals/Unsealed Sources Survey for Radiation Oncologists

collaborate.tuftsctsi.org

I provided my responses... opened up old wounds with my current turf war.

 

[medgator]

Nucs are a loss leader for the radonc . You wast
a lot of time for small gain so that you/and radiation are more visible in the cancer center/community.

Definitely won't see margins like with external beam. But that's pretty much the business of systemic therapy in the med Onc world.

Not even sure the visibility is worth it. Many times it's a service to the community if no one else is providing it

 

[Chartreuse Wombat]

We are getting close to 100 responses! Thanks for all that have participated thus far!

@Krukenberg @Chartreuse Wombat @radoncopotamus @BobbyHeenan

Can I shamefully request for you to add your perspectives the survey

Radiopharmaceuticals/Unsealed Sources Survey for Radiation Oncologists

collaborate.tuftsctsi.org

Thanks for the personal invitation but I don't complete surveys like this.

I mean no offense but I view at as doing my part to keep publications related to these surveys at a minimum (and keep medical students from adding useless additions to their CV).

Need a response rate of over 60% of the population to make any meaningful inference.

 

[radonc17]

Thanks for the personal invitation but I don't complete surveys like this.

I mean no offense but I view at as doing my part to keep publications related to these surveys at a minimum (and keep medical students from adding useless additions to their CV).

Need a response rate of over 60% of the population to make any meaningful inference.

Would it help if I tell you that 0 medical students are involved?

 

[radonc17]

I provided my responses... opened up old wounds with my current turf war.

Thank you @RadOncDoc21!

 

[FrostyHammer]

Need a response rate of over 60% of the population to make any meaningful inference.

Need any response rate of over 10% for the red journal

 

[radoncopotamus]

For xofigo or thyroids, it's pretty quick. Xofigo is a push. Lutathera is a multi hour infusion, actually multiple infusions

Xofigo is multiple infusions no?

 

[radonc17]

Xofigo is multiple infusions no?

6 injections push once every 4 weeks

just gotta check bloodwork

 

[Neuronix]

Need any response rate of over 10% for the red journal

Even 5% will do!

DEFINE_ME

PS: I did Mudit's little survey.

 

[elementaryschooleconomics]

Thanks for the personal invitation but I don't complete surveys like this.

I mean no offense but I view at as doing my part to keep publications related to these surveys at a minimum (and keep medical students from adding useless additions to their CV).

Need a response rate of over 60% of the population to make any meaningful inference.

I would normally agree that we have way too many "CV padding survey BS projects", but I think this actually has value to inform training. The ACGME seems to have somewhat arbitrarily changed graduation requirements for unsealed sources. Why? Was it data driven? Does going from 6 to 8 cases even matter or is it all hand waving?

Anecdotally, I think we're all under the impression RadOnc has handed off unsealed sources to NucMed/IR/etc. Is that true? How can we know this? If RadOncs are actually doing a lot of this, are only 8 cases enough? Should we be making the requirements more stringent?

What is the best way to answer these questions? A survey with a high response rate is probably the best way we can get this data right now. Mudit (and friends) have been super proactive about pushing this on bigger platforms (Twitter, SDN). It's not like he just grabbed the ASTRO membership emails and fired a spam request out like normal.

Believe me, I love dragging crappy research both in person and online. I hate the preponderance of survey BS. But, I don't think trying to understand RadOnc involvement with unsealed sources in America in 2021 via survey is a crappy idea. This is one of the few times I actually want to know the answers, haha. I know many of the people in my department are interested in this too. One of the normally placid faculty members WENT OFF when I told her requirements increased. It seems like a sore subject...

 

[radonc17]

Thank you @Neuronix and @elementaryschooleconomics!

Just FYI, interestingly tried to use ROHub for 1st time and they apparently have to approve your message before it can be posted. So strange

 

[Neuronix]

Just FYI, interestingly tried to use ROHub for 1st time and they apparently have to approve your message before it can be posted. So strange

They're tightly controlling the message over there... Don't say anything too controversial or question the big names or you will be kicked off. That's what happened to Simul.

 

[medgator]

Thank you @Neuronix and @elementaryschooleconomics!

Just FYI, interestingly tried to use ROHub for 1st time and they apparently have to approve your message before it can be posted. So strange

Welcome to the people's republic of ASTRO

 

[BobbyHeenan]

@radonc17

I completed the survey. Wasn't too painful

 

[OTN]

Thank you @Neuronix and @elementaryschooleconomics!

Just FYI, interestingly tried to use ROHub for 1st time and they apparently have to approve your message before it can be posted. So strange

SMDH...and academia wonders why SDN has to exist.

 

[thecarbonionangle]

They're tightly controlling the message over there... Don't say anything too controversial or question the big names or you will be kicked off. That's what happened to Simul.

yeah and meanwhile racist posts still are standing. ASTRO very woke they say, however!!!

 

[radonc17]

@radonc17

I completed the survey. Wasn't too painful

thanks @BobbyHeenan!

 

[radonc17]

Speaking of radiopharm

[177Lu]Lu-PSMA-617 vs cabazitaxel

 

[Chartreuse Wombat]

Speaking of radiopharm

[177Lu]Lu-PSMA-617 vs cabazitaxel

I will wait for the OS. Long run for a short slide

 

[RadOncDoc21]

I will wait for the OS. Long run for a short slide

I’ve seen med oncs settle for less (PFS, etc).

 

[FrostyHammer]

I’ve seen med oncs settle for less (PFS, etc).

Med oncs will settle for anything. Even zero evidence at all. Merck recently tried to get Keytruda past the FDA for neoadjuvant TNBC on the grounds of that trial looking at response rate as the primary endpoint... fortunately, the FDA wasn't having any of that.

 

[Chartreuse Wombat]

I’ve seen med oncs settle for less (PFS, etc).

Of course. Grifters gonna grift ...amirite

 

[medgator]

I’ve seen med oncs settle for less (PFS, etc).

They won't settle for losing money on giving the drug though, at least In PP....

 

[radonc17]

I will wait for the OS. Long run for a short slide

My viewpoint for this was different

for metastatic setting if you can either improve OS or improve QOL (decrease S/E) the patient will benefit

Here the study already shows decreased G3-4 side effects (53% v 33%) with radiopharm

you also decrease patient visits = more convenient?

Lu was 6 infusions q6 weeks

chemo was 10 infusions q3weeks

And then of course you still see better PSA response and PFS (19% v 3%, HR 0.63)

does trial move radiopharm to front of line? No

but it gives an excellent alternative to chemo and allows RO to stay involved

 

[Krukenberg]

Anyone know if PSMA-Lu177 infusion is as involved as lutathera?

 

[FrostyHammer]

for metastatic setting if you can either improve OS or improve QOL (decrease S/E) the patient will benefit

Nope on the QOL part. I'm not buying it. You can find prospective data supporting benefits in QOL for anything. The QOL argument is what proton people use to throw protons at everything possible. QOL is just not a robust endpoint, which explains why interventions that increase OS may not improve QOL in some cases...and it's hard to surmise that QOL is even a tink better of an endpoint than PFS in that regard. Trying to improve QOL with monstrously expensive interventions is a crapshoot when things like psychosocial support, family/house situations, spiritual care, etc are completely ignored. When you become an attending, try to convince an insurance company that you want to pursue a given intervention in a metastatic patient for the purpose of increasing QOL and see what kind of response you get

 

[radonc17]

Nope on the QOL part. I'm not buying it. You can find prospective data supporting benefits in QOL for anything. The QOL argument is what proton people use to throw protons at everything possible. QOL is just not a robust endpoint, which explains why interventions that increase OS may not improve QOL in some cases...and it's hard to surmise that QOL is even a tink better of an endpoint than PFS in that regard. Trying to improve QOL with monstrously expensive interventions is a crapshoot when things like psychosocial support, family/house situations, spiritual care, etc are completely ignored. When you become an attending, try to convince an insurance company that you want to pursue a given intervention in a metastatic patient for the purpose of increasing QOL and see what kind of response you get

I agree with you that need to take cost into account as well and perhaps Lu may price itself out of practical use

But G3-4 toxicity is nothing to sneeze at (50% of patients!) with cabazitaxel

As I said in that same post, don't think Lu moves to front of line, but there will be some subset of patients who want some treatment at that stage of their disease, but also who desire to be free of toxicity

 

[FrostyHammer]

I agree with you that need to take cost into account as well and perhaps Lu may price itself out of practical use

But G3-4 toxicity is nothing to sneeze at (50% of patients!) with cabazitaxel

As I said in that same post, don't think Lu moves to front of line, but there will be some subset of patients who want some treatment at that stage of their disease, but also who desire to be free of toxicity

Well my post above was more in a general sense rather than this specific sense. But in that sense, cabazitaxel has such high gr3-4 toxicities then maybe the best way to help QOL is not to use it and use other agents instead, or modify the regimen itself. There's a nice recent precedent for this in melanoma with combined ipi3/nivo1 changed to ipi1/nivo3, or much better to use just nivo alone.

 

[radonc17]

Well my post above was more in a general sense rather than this specific sense. But in that sense, cabazitaxel has such high gr3-4 toxicities then maybe the best way to help QOL is not to use it and use other agents instead, or modify the regimen itself. There's a nice recent precedent for this in melanoma with combined ipi3/nivo1 changed to ipi1/nivo3, or much better to use just nivo alone.

VISION Trial showing OS benefit to 177 Lu-PSMA-617 in metastatic castrate resistant prostate cancer

Novartis announces positive result of phase III study with radioligand therapy 177Lu-PSMA-617 in patients with advanced prostate cancer

www.novartis.com

 

[seper]

VISION Trial showing OS benefit to 177 Lu-PSMA-617 in metastatic castrate resistant prostate cancer

Novartis announces positive result of phase III study with radioligand therapy 177Lu-PSMA-617 in patients with advanced prostate cancer

www.novartis.com

That's nice. I wonder if OS difference is more than a few weeks tho

 

[Chartreuse Wombat]

That's nice. I wonder if OS difference is more than a few weeks tho

Can someone informed comment on the professional component of delivery?

 

[deleted941485]

Can someone informed comment on the professional component of delivery?

My guess is you’ll probably need to workout a subsidy from your hospital for delivering it if you’re a PC group.

 

[row_RO_row]

Can someone informed comment on the professional component of delivery?

~2 wRVU per administration.

 

[medgator]

Top article in my news app this evening

'Next big wave': Radiation drugs track and kill cancer cells

Doctors are reporting improved survival in men with advanced prostate cancer from an experimental drug that delivers radiation directly to tumor cells.

apnews.com

 

[ramsesthenice]

Top article in my news app this evening

'Next big wave': Radiation drugs track and kill cancer cells

Doctors are reporting improved survival in men with advanced prostate cancer from an experimental drug that delivers radiation directly to tumor cells.

apnews.com

It was presented at ASCO today. The results are pretty impressive. 4 month survival advantage that is pretty well maintained over time. Given that we know radium improves survival, this isn’t really a shock. But it’s good to see it play out.

 

[dieABRdie]

It was presented at ASCO today. The results are pretty impressive. 4 month survival advantage that is pretty well maintained over time. Given that we know radium improves survival, this isn’t really a shock. But it’s good to see it play out.

We're certainly going to look into offering it with the hospital since we already to do some of the other radionuclides. If it eventually makes a big dent in our EBRT volume by getting approved up front at least we might be able to stay involved....

 

[ramsesthenice]

If it eventually makes a big dent in our EBRT volume by getting approved up front at least we might be able to stay involved....

Don't worry about your EBRT volume. Its not going anywhere. Median PFS in the experimental arm, while double that of control, was still only 8.7 months and <20% at 2 years. This is not a cure-all. It only kicks the can down the road (at least in mCRPC). In this population, your volume may actually end up going up if they are living longer and needing more rounds of palliation. Radiopharma can both giveth and taketh away.

I do think you are wise to get in as early as possible and I wish more of us would do it if for no other reason than to be a part of interesting biology-based therapies that can help your patients. At this point, I still don't think this is much more than a negligible threat to our existence and despite what Novartis wants you to think, this is not the future of cancer care as targeted radiopharmaceuticals have the same biological hinderances that prevented most other targeted therapies (ALK, EGFR) from transforming cancer management. Only a small minority of cancers actually express unique molecular markers in sufficient volume to be targetable. Of the ones that do, you inevitably select for subclones that don't express your marker and resistance is inevitable. Look at the curves. If I had mCRPC I would absolutely take the drug and I think they are very encouraging. But we have not solved prostate cancer by any means.

 

[evilbooyaa]

If you get to these patients earlier in their course and follow them at regular intervals, might actually get to palliate their progressive symptoms later rather than hearing about the perihospice inpatient PCa patient who has had progressive back pain for 6 months and oops now has cord compression.

One of the reasons I favor following all palliative patients with some frequency unless you really trust your med-oncs to send them back when appropriate.

 

[ramsesthenice]

One of the reasons I favor following all palliative patients with some frequency unless you really trust your med-oncs to send them back when appropriate.

Trust. No one. Even the good ones. We are 100% under utilized for palliation. Its good for patient care and good for business to follow people.

 

[Radonky]

It was presented at ASCO today. The results are pretty impressive. 4 month survival advantage that is pretty well maintained over time. Given that we know radium improves survival, this isn’t really a shock. But it’s good to see it play out.

Sorry for bump, but wanted to point something out about the vision trial (https://www.nejm.org/doi/full/10.1056/NEJMoa2107322)

They did not use standard of care in the control arm, they define standard of care as "protocol permitted" standard of care, which is a shame, because they exclude chemotherapy, radium, immunotherapy etc. Maybe they can get away with not including olaparib since it was experimental at the time of trial inception. This is an open labeled study, so excluding chemo (cabazitaxel) and radium which have a proven OS benefit in these patients is not right. They have a comment "These constraints were used because of a lack of safety data on combining the investigational drug with these agents". It is not blinded, so they could absolutely use these agents in the control arm. ALSYMPCA had no restrictions in its definition of standard of care other than not allowing chemotherapy or other radionuclides concurrent with radium 223, which makes sense, and could have been done by the VISION trial.

so a big * with the vision trial. Not to mention a lot of ethical concerns I have with several employees on the author list and "vouching" for the accuracy of the data, "Four authors who are employees of Novartis vouch for the accuracy and complete-ness of the data". No one else could vouch for the accuracy and completeness of the data other than employees of the company?

 

[medgator]

Sorry for bump, but wanted to point something out about the vision trial (https://www.nejm.org/doi/full/10.1056/NEJMoa2107322)

They did not use standard of care in the control arm, they define standard of care as "protocol permitted" standard of care, which is a shame, because they exclude chemotherapy, radium, immunotherapy etc. Maybe they can get away with not including olaparib since it was experimental at the time of trial inception. This is an open labeled study, so excluding chemo (cabazitaxel) and radium which have a proven OS benefit in these patients is not right. They have a comment "These constraints were used because of a lack of safety data on combining the investigational drug with these agents". It is not blinded, so they could absolutely use these agents in the control arm. ALSYMPCA had no restrictions in its definition of standard of care other than not allowing chemotherapy or other radionuclides concurrent with radium 223, which makes sense, and could have been done by the VISION trial.

so a big * with the vision trial. Not to mention a lot of ethical concerns I have with several employees on the author list and "vouching" for the accuracy of the data, "Four authors who are employees of Novartis vouch for the accuracy and complete-ness of the data". No one else could vouch for the accuracy and completeness of the data other than employees of the company?

Don't worry, logistically this will be about as common place as provenge

 

[ramsesthenice]

Sorry for bump, but wanted to point something out about the vision trial (https://www.nejm.org/doi/full/10.1056/NEJMoa2107322)

They did not use standard of care in the control arm, they define standard of care as "protocol permitted" standard of care, which is a shame, because they exclude chemotherapy, radium, immunotherapy etc. Maybe they can get away with not including olaparib since it was experimental at the time of trial inception. This is an open labeled study, so excluding chemo (cabazitaxel) and radium which have a proven OS benefit in these patients is not right. They have a comment "These constraints were used because of a lack of safety data on combining the investigational drug with these agents". It is not blinded, so they could absolutely use these agents in the control arm. ALSYMPCA had no restrictions in its definition of standard of care other than not allowing chemotherapy or other radionuclides concurrent with radium 223, which makes sense, and could have been done by the VISION trial.

so a big * with the vision trial. Not to mention a lot of ethical concerns I have with several employees on the author list and "vouching" for the accuracy of the data, "Four authors who are employees of Novartis vouch for the accuracy and complete-ness of the data". No one else could vouch for the accuracy and completeness of the data other than employees of the company?

Your points are fair. In my neck of the woods, it’s dual ADT all the way. Chemo and radium are vastly under utilized. Which…

Don't worry, logistically this will be about as common place as provenge

bingo. We already have plenty of options with small survival benefits that are under utilized. It’s a weird space.

Like I said above, I don’t see this changing much in the grand scheme of things.