A Urologist’s Multidisciplinary Approach to Clinical Management of the Patient Receiving Lutetium-177 - Benjamin Lowentritt

October 13, 2023

In this discussion, Phillip Koo interviews Benjamin Lowentritt about the complexities of integrating a PLUVICTO® (lutetium Lu 177 vipivotide tetraxetan) program into a large urology practice. Dr. Lowentritt emphasizes the value of patient selection, particularly for those who are post-chemotherapy. He outlines how his team manages the transition of patients from medical oncologists to their specialized clinics. The conversation also covers the role of PSMA PET scans in determining the extent of disease before initiating PLUVICTO therapy. Dr. Lowentritt discusses the collaborative relationship with medical oncology, highlighting the value of co-management and communication. He also addresses patient concerns about radiation therapy, emphasizing that most patients are eager to try a new approach given their cancer's progression.


Benjamin Lowentritt, MD, Medical Director, Prostate Cancer Program, Chesapeake Urology

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

Read the Full Video Transcript

Phillip Koo: Hi, this is Phillip Koo from UroToday. We're continuing our series looking at how you operationalize and integrate a PLUVICTO program into a large urology group practice. Today we have with us Dr. Ben Lowentritt, who's the medical director of the Prostate Cancer Program at Chesapeake Urology. Welcome, Ben.

Benjamin Lowentritt: Thank you so much. Appreciate you having me.

Phillip Koo: You guys have done a wonderful job here incorporating a radiopharmaceutical program, and you've participated in trials and are now opening up access on a commercial level for all patients who are eligible. This idea of patient selection is really important. We talked to Kara about this and sort of how the APC identifies some patients that might potentially qualify for a treatment like PLUVICTO. What do you do with that handoff from Kara's team?

Benjamin Lowentritt: It's interesting because the indication for PLUVICTO is post-chemotherapy. So by definition, these patients, at least at some point, have had a medical oncologist, and we manage that relationship. Usually we're the ones providing the novel hormonal therapy and certainly their ADT, their bone health, et cetera. So we maintain that relationship. And as you heard from Kara, that's largely done through our decentralized advanced prostate cancer clinics in many of our offices. When the patients seem to be progressing, we make sure that they have that reconnection with our advanced prostate cancer champions. So when I see the patients back at that point, they know that .... They've met me, hopefully, at some point or other. We've tried other therapies in the past with them. And many of them I see regularly throughout their therapy, as well, at different intervals, maybe once or twice a year as they're doing well. So we generally have had discussions about what else is out there, and the excitement about radioligand therapy has been going on for a number of years. So we've talked about this.

Some of them may have had another form of radiopharmaceuticals at some point in the past, too, and are looking for that next thing. But having that discussion then is about, okay, why are they now a candidate and what is it that's making them a candidate, so specifically talking about their PSMA PET findings. Some of them may not have had it, so I'm talking to them about getting it, but we'd almost presume that there's going to be something positive there. But we want to see the extent of disease, of course, before actually starting the therapy, and we need to get it before starting the therapy.

But typically, in our APC, when they progress, we'll have gotten a PSMA PET, and then I'll be talking to the patient about what's ahead of them as far as the actual process. I do tend to leave a good part of the discussion to the radiation oncologist as far as the actual details of the treatment and some of the discussion around side effects, et cetera. But I do introduce some things, especially the unique side effects related to the dry mouth, et cetera, just so that patients aren't surprised when they start to hear about it. And I also distinguish it from the chemotherapy that they've had already and let people understand that it is a different kind of therapy overall.

Phillip Koo: So when you talk about the PSMA PET, are there certain points that you like to focus on or triggers in the PSMA PET that sort of might push you towards getting PLUVICTO earlier versus later?

Benjamin Lowentritt: When we're talking about these patients who are after some of our traditional big guns, they're after chemotherapy, they're after novel hormonal therapies, the combination of PSA progression with any imaging progression, to me, is good enough. Certainly, if it's a higher risk area, like the femoral neck, then we want to probably get to it as early as possible. If a patient has a specific area where they're symptomatic, I'm also sending them and saying, "Listen, you may want to get targeted radiation to that area as well." So I think there are a series of considerations that we have as we're talking through it. But I do think the benefit here is the ability to reach the cancer throughout with the specificity and the targeting of a PSMA ligand. So I think it's an exciting time. It's an exciting option.

Phillip Koo: So you touched upon this earlier about that relationship with medical oncology and how important that is. Clearly, there are various models on how medical oncology can be incorporated into urology practice. Here, it's separate. Can you talk about how you cultivate that relationship and really optimize it so that you guys are working together and fully aligned?

Benjamin Lowentritt: I wish I could say we were perfect on that. I do think what we are seeing now is that a lot of institutions are not necessarily setting themselves up for radioligand therapy. So this is actually an interesting opportunity to re-engage with some of the medical oncology groups that tend to be more in a silo kind of environment. So we've been able to reach out and say, "Listen, we have this value add. We're already co-managing a lot of patients. We have this additional therapy. Let's make it easy for those patients." And just like we want them to allow us to continue to see these patients because of the value we think we bring to them, we certainly don't want to take the patients away from the medical oncologist if the patient's happy in that environment as well. So it's fostering a little bit, actually more communication since this has become available. But historically, I mean, we co-manage a lot of patients.

As a group that has a wider geography, there's a wide amount of variation. We've never been successful, even when we have what I would call preferred medical oncologists in certain areas. We've never been that successful in getting the patients only to see them because once again, now that's related to that institution or that group's own internal politics of how they assign referrals, et cetera. None of our community medical oncologists are truly GU medical oncologists. So we end up with a lot of variability and potential. So that's one of the reasons why I stress, and frankly, one of the reasons why we decentralized is because I do want, as much as possible, for patients to still come through our system because I feel confident that the pathways and the protocols that we've set up are going to help keep the patients moving forward as much as possible.

I'm not saying that the community medical oncologists aren't doing their best for the patients, but they're dealing with a lot of different disease states, whereas these clinics are dealing with one. So I think we've spent a long time establishing that value, and I think most of the medical oncologists understand how serious we are about treating prostate cancer. So this isn't a matter of competition. It's really almost a matter of education, of continuing to educate on our model of taking care of these patients so that they see that they want the patients to be here as well. And like I said, varying levels of success on that, but that's the goal.

Phillip Koo: I like that idea. So it's a decentralized model with standardized processes and pathways.

Benjamin Lowentritt: Yeah.

Phillip Koo: I think that's great, and it provides greater access to patients closer to where they live to make it a better patient experience.

Benjamin Lowentritt: It was never going to be practical for us to make our patients travel monthly, sometimes 30, 40 miles through a lot of different highways to get here just to see me and have me bless them once a month. And I think it was also not going to be practical for me or any other urologist to do that solely. However, it's been a really, really rewarding thing, largely through our advanced practice providers, but also through our regional champs that we call them, the physicians that are doing this as well, to elevate the care across the group. It also got a lot more buy-in from the urologists because they're still seeing the patient in the hallway. They're still seeing the patient as often as they want to in their practice, although typically the patients are happy to come in, see an APP, get the therapies they need, the labs, et cetera, and know that there's a system underneath it, making sure that everything's continuing to move forward in the right way.

Phillip Koo: Whenever a new novel therapy is introduced, and especially if it has the word radiation attached to it, it has certain connotations with patients. What advice do you have, based on your experience, for getting patients comfortable with the fact that this is radiation, it is systemic, and there are certain safety precautions that are associated with it?

Benjamin Lowentritt: Given the nature of prostate cancer, most patients or many patients have at least had a discussion about radiation at one point or another, so this isn't the first time most of them will have heard of that. But with that said, you're right, there are unique discussion points that need to go about risk to others, risk to themselves long-term, that are a little bit different from our typical treatments that we have. So I think the support that we get from our colleagues in the radiation oncology world to sort of help us and have helped educate us on some of the ways that they talk to patients. And frankly, just the long-term experience of having worked with radiation is really important. I think it's also clear to patients that this isn't the first. I mean, by definition, this isn't the first treatment that they're getting, period. So they understand that this cancer is progressing.

And so I think of it almost in a different way. This may be the first time they've actually seen the mechanism of radiation, certainly in a systemic way, and it provides us that ability to say, "Listen, we're going to hit this from a different angle." And it's one that may not have been tried before. So I think it gives us that ability to say, "Hey, we have another approach to this." The discussions around some of the unique side effects, the talking through monitoring their blood counts, monitoring for dry mouth, it's not that difficult at this point. And once again, this isn't the first therapy they're receiving. I think the comparison to chemotherapy makes it fairly easy to talk through because they've experienced it at this point. So I've not actually found that to be as challenging as I might have. Now, I hope I'm doing a good enough job, but I do feel like the patients are frankly eager to try something new. And not that they're overlooking the side effects, but they understand that these side effects are going to be monitored and are manageable.

Phillip Koo: Congratulations on opening up this great facility, and we look forward to this serving a greater number of patients in the community.

Benjamin Lowentritt: Thank you so much, and thanks for coming here and highlighting our work.