Identifying the Right Patients for Treatment with Radium-223 for mCRPC - Brenda Martone

June 22, 2022

Brenda Martone and Alicia Morgans delve into the nuanced use of Radium for treating patients with metastatic CRPC (Castration-Resistant Prostate Cancer). Dr. Martone emphasizes that Radium is not just for alleviating bone pain but can also address other symptoms like fatigue and loss of appetite. She notes that the drug can be used at any point in the treatment continuum, depending on patient needs and preferences. The conversation also explores the sequencing of Radium with other treatments, including the emerging Lutetium PSMA. Dr. Martone suggests that Radium can be safely followed by Lutetium, depending on the patient's condition and prior treatments. Both agree that informed, mutual decision-making is crucial for optimizing patient outcomes.

Brenda Martone, MSN, ANP-BC, AOCNP, Adult Nurse Practitioner at Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, Illinois

Alicia Morgans, MD, MPH, Genitourinary Medical Oncologist, Medical Director of Survivorship Program at Dana-Farber Cancer Institute, Boston, Massachusetts

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Alicia Morgans: Hi, I'm so excited to be at ASCO 2022, where I have the opportunity to speak with Brenda Martone, who's a nurse practitioner at Northwestern University. Thank you so much for being here with me today.

Brenda Martone: Thanks Alicia. It's really great to see you.

Alicia Morgans: It's great to see you too and I'm excited to talk with you about Radium because this is a drug that we actually use together when we practice together. And is one that I think is important from my perspective, at least to keep in our clinical armamentarium as a drug that both improves quality of life and also improves overall survival in patients with metastatic CRPC. One of the things that I think we need to recognize though, is that we do need to identify the right patients and that's true of any therapy that we use. In your practice, how are you thinking about identifying patients for Radium treatment?

Brenda Martone: When looking at patients for Radium treatment, the big thing is metastatic disease to bone only, just as it's indicated and approved. And we're also looking for patients who are symptomatic, who would definitely get some benefit, and that would include patients who have loss of appetite, maybe worsening fatigue. Obviously, bone pain is one of the things that come up most often, but symptomatic patients can be any sort of symptom that could require palliation because of how the Radium works. And we do know that prostate cancer when it's progressing does cause a lot of these other symptoms such as fatigue and loss of appetite. So it's not just only for bone pain.

Alicia Morgans: I think that's so important and so interesting because as we look at that overall survival benefit, which is actually similar to all of the other agents approved in this space, I think that we could get lost if we're really only looking for patients who have bone pain that we think, oh goodness, I need to give them a radio pharmaceutical to try to palliate that pain, which is what we used to do with things like [inaudible 00:01:48] and Samarium. But in this case, it sounds like it's really any symptom from the metastatic disease, so even things like fatigue or loss of appetite, which unfortunately comes with disease progression, and those are things that you're considering in your practice.

Brenda Martone: Oh, absolutely. We don't want to ever miss a treatment opportunity for a patient. We want them to be able to maximize all their options. So that's where Radium can be inserted anywhere along that continuum based on how you think your patient is doing and it's generally pretty well tolerated too. So if you do have a somewhat symptomatic patient, the balance between the risk and the benefit definitely overall favors the benefit, and we wouldn't expect to be adding too many additional toxicities if they're already having fatigue, etc., to how the patient is feeling and keep that quality of life as good or as high as possible.

Alicia Morgans: And that is so important. As I think about that, I think about sequencing all of the different options though, too that we have. Is Radium something that you typically have to use after chemotherapy, or is this something that might be used before chemotherapy, depending on the patient's preference and the disease progression?

Brenda Martone: I've actually used it both actually and it truly is the patient preference. So when you are presenting your patient with the treatment options that are available, some patients will opt for the Radium because they want to delay the chemo and it's nice that they have such a great choice between them. And then we have other patients who will say, well, I want to going to save the Radium for a little bit later and I want to do the chemo now. I think one important point to make when you're talking to patients about these treatment options is what's possible now with the Radium may not necessarily be possible in the future if their disease does spread outside the bone. But again, it's all informed mutual decision making.

Alicia Morgans: So that's an important point, that depending on how the disease progresses, you may lose the window of opportunity. And so that is absolutely something that I consider in practice as well. The final question I really want to ask is again, sort of related to sequencing. A lot of people are really excited about Lutetium PSMA and the integration of that into clinical practice. As I think about use of that drug, the question of course comes up, can patients who have had Radium before safely get Lutetium after? What are your thoughts?

Brenda Martone: Actually, based on the clinical trial and all the pre-treatments that patients had, these were heavily pretreated patients, I don't see any reason why you couldn't do Radium and then Lutetium. The Lutetium or that newest radio pharmaceutical actually does require Docetaxel, I believe, before. So this would provide opportunities for patients in terms of, if they decide to do the Radium and then maybe go to the Docetaxel, they can do the Lutetium. I think it's really going to be based on the patient's performance status, how symptomatic they are, and clinical judgment, along with informing that patient and coming to a conclusion that both the physician and the patient agree on and feel comfortable.

Alicia Morgans: Great. Well, absolutely, patients who are treated with Radium were included in VISION to your point. And so this is something that we have clear safety data that as long as those cytopenias are recovered and the patient is safe for Lutetium, prior treatment with Radium is okay, and it is certainly okay based on the label as well. So thank you so much for walking us through all of this. I always appreciate your time and your expertise.

Brenda Martone: You're very welcome. Thank you.