BACKGROUND: The ALSYMPCA trial of α-emitter Ra-223 in symptomatic bone predominant mCRPC reported Ra-223 median overall survival (OS) of 14.9 months versus 11.3 months OS for placebo (1). Subsequently reported "real world" experience with Ra-223 in smaller mCRPC patient cohorts appeared less successful(2-3). We decided to review our own Ra-223 experience at WVU. PATIENTS: Demographic, clinical and laboratory data, and all available images were reviewed in bone predominant mCRPC treated with Ra-223 at WVU. The number of bone metastases per patient as quantified. Standard descriptive statistics were used to study IRB-exempt, de-identified patient data. The primary end-point was patient overall survival (OS) after initiating Ra-223. RESULTS: Twenty four men received 98 infusions of Ra-223; 83%of these men were referred from outside WVU. Prior to first infusion, all 24 had received a total of 73 sequential combinations of androgen deprivation therapy (ADT); 68 courses of ADT (93%) preceded the first Ra-223 infusion. Before Ra-223, 19(79%) received docetaxel and 19 (79%) received 33 courses of radiation --24 courses targeting non-prostate sites. Eleven men (46%) completed all six planned Ra-223 infusions; 13 (54%) stopped early for clinical deterioration or death. Median OS from first Ra-223 infusion to last follow-up or death was 8.3 months (range 0-44 mos.) -- nearly 50% less than the ALSYMPCA results. Compared to ALSYMPCA, more WVU patients had received bisphosphonates and docetaxel, more had ECOG PS >2, more used opiates for pain, more had greater bone metastases burden, and more had lower hemoglobin, albumin, alkaline phosphatase, and PSA levels. CONCLUSION: While the science supporting the development and clinical use of Ra-223 is compelling, optimal clinical benefit will likely require earlier referral for Ra-223, before patients have exhausted most conventional therapies. At WVU, we found that our referred patients had practically all ADT, radiation, and cytotoxic therapy before starting Ra-223. A 2019 report from McMaster University using Ra-223 in 60 men with heavily pre-treated mCRPC also found a median OS of 8.2 months with only 42% completing all six treatment cycles, results almost identical to ours(2). Other studies confirmed that men with less advanced mCRPC, receiving the full course of Ra-223, had better OS(3). Now, we offer Ra-223 to men with symptomatic bone-predominant CRPC but we highly encourage earlier referral.
Journal of nuclear medicine technology. 2020 Nov 20 [Epub ahead of print]
Ruta Arays, Zeeshan Ahmad, Lorinda Howard, Kenneth Veselicky, Joanna Kolodney, Thomas Hogan
West Virginia University, United States.
This webpage is supported through an unrestricted educational grant from Bayer. Bayer is not involved in content development and the views expressed represent those of the patient and physician contributors.
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