Tackling the Last Mile: A Major Component to Successfully Establish Radioligand Therapy - Ken Herrmann

June 9, 2023

Phillip Koo welcomes Ken Herrmann to discuss Herrmann’s team's latest article, "Tackling the Last Mile: A Major Component to Successfully Established Radioligand Therapy," arguing the importance of 'the last mile' of treatment delivery in nuclear medicine. Drawing parallels with the logistics industry, Herrmann emphasizes the need for flawless delivery of therapy to patients, with patient awareness and care during treatment as key considerations. Further, the conversation explores the requirement for an estimated 70-180 theranostic sites in the U.S., basing these calculations on the current setup in Germany. Lastly, Herrmann stresses the urgent need for nuclear medicine professionals to step up, focus on patient-centric treatment, and ensure the therapy reaches patients, thereby safeguarding the future of the field.


Ken Herrmann, MD, MBA, Professor and Chair of the Department of Nuclear Medicine, Universitatsklinikum Essen, Essen, Germany

Phillip J. Koo, MD, FACS Division Chief of Diagnostic Imaging at the Banner MD Anderson Cancer Center in Arizona

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Phillip Koo: Hello, my name is Phillip Koo and welcome to UroToday.

Today we have with us Dr. Ken Herrmann, who's the Chief of Nuclear Medicine at Essen in Germany, who's going to be speaking about a recent article his team published titled, Tackling the Last Mile: A Major Component to Successfully Established Radioligand Therapy.

Thank you very much for joining us, Ken.

Ken Herrmann: Thank you. I'm pleased to be here.

Phillip Koo: This title is so provocative and so relevant to what we're dealing with in nuclear medicine and in cancer in general.
Can you highlight some of the topics that you highlight that really help us make that connection in that last mile?

Ken Herrmann: We chose the title Last Mile, actually, and some of the writers did not like it at all. I still think it's highly relevant because it's, what can we learn from other industries? What can we learn from other parts? Actually, when you come talk about it, and I actually refer to it.

For example, in the logistics industry, and that's why I actually chose the example of DHL, you can see that you can do an excellent job in the first four parts of the whole thing. But if you are not at perfect game at the last mile, where you really bring logistics, bring the package to the customer, then the whole procedure is at risk.

Just looking at this what this means for us and radioligand therapies, we finally do, hopefully, have figured out supply, we have the clinical trials, we have the approval, and now we need to make sure that we get the therapy to the patients.

Of course, one thing is identifying the patients and making sure the patient's aware of the treatment. But it's also super important that once the patient is identified, when the patient should get the treatment, we make sure that the patient gets the treatment.
Apart from just getting access to the drug, it's also important that you have enough people who really are there taking care of them, bringing the therapy to the patients. I personally think that this is, not the only one, but one of the major risks of making theranostics huge success outside of just they're there.

Phillip Koo: In the article, you raise a lot of great points and you talk a lot about infrastructure. I think you quote, was it, 70 to 180 sites that are expected or needed, at least in the United States.

Can you talk a little bit about how you came to that number and is that feasible? What are your thoughts on the network of theranostic sites in the US?

Ken Herrmann: There are different ways to come to the numbers. First of all, the number I provide in the paper is actually taken from a fantastic review from Johannes Czernin and his group, but the reason I believe this number is very easy.

As you know, I work in Germany, we have 80 to 84 million people and we have quite a long time already access to Lutetium PSMA and to other theranostic therapies. We do have 40 therapy centers right now that do apply the therapy in a, let's say, quite substantial number of patients. Even there, we are not ready yet or we are not sure that we are ready for the high patient influx after the approval of Lutetium PSMA-617, But we do have a certain, let's say, the fundament of infrastructure.

If you just think that the US is 320 million, which means it's pretty much four times more than Germany, and you take the 40 centers, then you actually arrive at 160 centers. So the 160 provided by Czernin et al is a very acceptable number. If you say the US is double as efficient as Germany, also because you maybe send patients home the same day instead of keeping them for two nights, then, actually, you calculate down to 80.

So the true number is probably somewhere between 100 and 160. Depends, of course, also on the coverage of the density of people, how long patients are willing to travel. But it gives you a pretty good ballpark. We also know that no matter what, if the number's 80 or on a 120, 160, it doesn't matter. In the US, we are still not there. In many other countries in Europe we are still not there. Even in Germany, to be honest, we probably don't need 40, we probably need 60.

Phillip Koo: Great, thank you. So the physicians who deliver nuclear medicine therapies or radiopharmaceutical therapies, whatever we want to call it, that's always very variable across the globe.

From your perspective, what should the model be moving forward and how does nuclear medicine adapt to make sure we are helping to coordinate and optimize the delivery of theranostics in the future?

Ken Herrmann: It's a diplomatic way, you ask a very complicated and political question. To be fully honest, I think the overarching goal must be to deliver the therapeutic patients and this must be the underlying goal. I personally think that nuclear medicine should own and own from a way of knowledge and how we apply therapy all over the world in places.

You mentioned in some countries, and I don't want to pick a certain country, maybe we do not have enough trained people or maybe also not enough people who are willing to do this therapy. This is, of course, a very, very complicated question.

If I now take my personal head as a nuclear medicine physician, I think we now need to get ready, need to train people as much as possible. We need to motivate people to do this. I think for us in nuclear medicine, this is super, super important that we fill the need. If we don't do this, other people will do. And is it bad, adverse for the patients? Probably not. But it's not good for our field.
So coming back to the point, I believe, at least in Germany, nuclear medicine is able to deliver this therapy to patients. In the US, I urge all my colleagues and my friends to step up and make sure we train enough people to get the therapy to patients because otherwise, potential other people are highly interested with this. It's maybe not as diplomatic as it could be, but it's also not as politically aggressive, my answer, as it could be.

Phillip Koo: Sure. I think it's a great answer and I think the challenge for all of us is to be able to work to the top of our licenses and push the envelope because that's where discovery innovation occurs. If we focus on the areas that we are experts in and we continue pushing the envelope, investing in research, investing in trials, and then we find ways to work together, I think in the end, we all benefit. Clearly there're going to be those spaces where we overlap and I think we need to acknowledge that and find ways to work together.

Ken Herrmann: No, you have to do it. Overall, it's a multidisciplinary effort and the patient needs to benefit. The patients' benefit needs to be in the center of our attention.

I love to work with radiation oncology, I love to work with oncology and, of course, radiology. But I think it's still nuclear medicine; we have experience, we should really try to fill the gap as much as possible.

Phillip Koo: Agreed. I think that's something that a lot of nuclear medicine physicians, particularly in the US, have an opportunity to learn from those in the Europe, is being a little bit more patient-facing and comfortable seeing and managing patients, which I know we used to do in the past, sort of got away from a little bit when we were focused on PET. But I think it's resurging, which is a great opportunity for us to adapt.

Any last words of advice that you have for the listeners out there as we enter in this, the last mile?

Ken Herrmann: So I think it's a major issue. It's very important that we tackle this hurdle because otherwise, we risk the success of the whole field. I think it's a platform technology. But I also want to say it's absolutely rewarding; once you do see the patients and once you treat the patients, it's absolutely rewarding. Like you said, this is actually more a shoutout to everyone in our field to say, "Come on guys, let's do it together."

Phillip Koo: Wonderful. Well, thank you very much for your time and we look forward to talking to you again soon.

Ken Herrmann: Thank you very much, Phil. Thanks again for picking up this topic because I think it's really important we cover this. Well, thank you for doing this.