Phillip J. Koo: Pleasure to be here.
Neha Vapiwala: Yeah, thanks for having us.
Alicia Morgans: Wonderful. So we are sort of the triad, of course, missing a urologist, but we're three of the subspecialties who engage many times with patients who are treated with radioligand therapies, nuclear medicine, radiation oncology, medical oncology. As I said, of course, urologists also involved in this process. But how at your institutions where you've practiced, how do you take this on? How do you work together? How do we all make this work together? Phil, I'd love to hear from you first as the nuclear medicine doctor.
Phillip J. Koo: Nuclear medicine, it's such a great time for nuclear medicine. Obviously, we play a pivotal role in the diagnostic piece of radioligand therapy and having that role, being able to administer these therapies and have a longitudinal relationship with patients and be able to interact with radiation oncologists and medical oncologists regarding the therapeutic care is such a great opportunity for nuc-med. And what you've seen is a growth in that and a lot of focus on being better patient-facing clinical team members.
So I think the model varies across different sites, academic centers, community centers, rural. Even within academic centers or community centers, the model's going to look very, very different. But the great news is it's multidisciplinary. We need to be flexible and we need to all work together because that's the way I think patients can get the best results.
Alicia Morgans: Absolutely. And I, for one, have been really excited to really bring nuclear medicine into the fold of prostate cancer care.
You've always been there reading bone scans, but you have a very different role today in terms of PSMA PETs and then of course administering therapy and all of the radioligands that are in process to join the ranks of our treatment opportunities for people, I think will even bring you in even more. So it's been wonderful. And to your point, this therapy administration, the multidisciplinary management is happening differently at different places. As a radiation oncologist, Neha, how is this working where you work?
Neha Vapiwala: Yeah, absolutely. I think one of the things, and I love the way you said that, Phil, it really is an opportunity for us to sort of operate at the top of our scope in terms of our training, in terms of what we've been authorized to deliver in terms of the treatments. So in that respect, nuclear medicine and radiation oncology, wherever you're practicing, there's inevitably going to be that close relationship.
And what we're finding is different regions of the country, exactly like you said, the practice setting can vary, but it might be run out of the radiation oncology department with the nuclear medicine expertise mainly on the diagnostic side. And then working with the nuclear medicine technicians or the radiation therapy technician if they're properly licensed for that treatment delivery. And then of course the follow-up, the imaging that's part of that. And then if the referring physician was not the radiation oncologist, if it was of course the medical oncologist or urologist, bringing them in the fold.
I find that it's sort of really about, okay, yes, there's one department that kind of is housing the therapy, but really it is all players at all times. And then you have other settings like where I practice where it really is nuclear medicine that is the primary home, but we have our radiation oncology expertise that we're really co-managing the patients. And in many cases, of course, the research that follows from that also is very collaborative.
Alicia Morgans: Oh, absolutely. I think this has been one of the most rewarding ways to get involved with this sort of therapeutic advance is participating in some of the studies and having access and working as a team to learn those new pathways and have those discoveries together. And in each of these settings, regardless of who's leading, some leadership is also around making sure the patient is monitored.
And I wonder, how does this happen where you've practiced or where you are now in terms of that ongoing management? I would just say where I practice, our nuclear medicine team has a few physician's assistants who are wonderful at leading that ongoing monitoring. They are looking at the mid-cycle CBCs. They are following up with those.
They are making sure that patients are scheduled out. They're adjusting the schedules if need be. They're connecting with us. If the SPECT scan was done, which these are within nuclear medicine, so they're telling us as medical oncologists, "Hey, the SPECT looks better. It looks worse. We need to kind of make some decisions here. The PSA is rising."
They are so integral and it's wonderful and different for me as a medical oncologist, I have my own PAs and MPs, but these are PAs that are within nuclear medicine. So it's great to see this expertise, but it's going to be different everywhere. How has it worked where you've been?
Phillip J. Koo: From what I've seen and based on my own experience, nuclear medicine, the physicians are the ones getting more involved. As the field grows, as RLT grows, the indications grow, the disease sites grow, I think there'll be more opportunities to be able to pay for those salaries for many of these APPs who absolutely provide an amazing service for all of our practices. And that's something I think is something that will continue to grow within nuc-med.
It really goes back to communication. And that's where I love how nuc-med is really taking on the challenge to sort of take greater ownership and look at the labs, monitor patients, and then be able to communicate with their medical oncology colleagues, their radiation oncology colleagues, urology colleagues, to make sure nothing is being missed. And there are certain things that nuc-med still can't do. When you are dealing with anemia, you need perhaps transfusions. That's where that tight communication with med-onc is obviously very, very critical. And that'll evolve and continue to grow. But in the end, again, it really comes back down to this idea of multidisciplinary care.
Neha Vapiwala: Yeah. And we have a very similar model to exactly what you described. And I would say to add to what Phil already shared, I think one of the areas where when you are looking at the follow-up imaging, when you do see certain parameters and you might be worried about persistent disease or something new, again, that's where having the radiation oncologist, there's a decision that needs to be made about ablative therapy using external beam, for example, to supplement the treatment or a decision to be made about continuing versus not continuing the cycles. Just having sort of that foundation that the APPs provide in terms of the checklist, make sure everyone is taken care of.
And I think telehealth has also really supported this because it's allowed, if you do have a slightly higher volume center, you don't want to lose track of people where they are in their cycles. That also I think helps facilitate keeping everyone on track, particularly if the blood work might delay treatment, you can do a quick check-in. And I think having that support and being able to pay for that support is absolutely critical. And I think everyone, I think, benefits from that, especially the patient.
Alicia Morgans: I would agree. And I wonder, do your practices have any sort of tips, any best practices, recommendations, something that's worked really well that might be something to think about or to share either in patient selection in terms of that ongoing monitoring, the communication back and forth? I mean, telehealth may be one of those examples.
Neha Vapiwala: Yeah. I was going to say, I think telehealth and then utilizing the electronic medical record as much as we can. And of course, depending on where the patients live and where you're licensed, sometimes you can or can't provide some of that care through telehealth. But I think having that ability and not having to bring patients in when they don't need to, or even facilitating their lab work so that's consistently in one place. And if that's closer to home, then that's okay. I think having that built in already, those templates in electronic medical record, I think have been a major facilitator, particularly when you have different physicians covering the administration and they might be coming from nuc-med one day and from rad-onc the next, that one continuity provided by often the APP is really critical there.
Phillip J. Koo: The two tips I would have would be number one, go to as many of the tumor boards as you can. Even if you're not presenting, you're not assigned, go and listen, learn, contribute. And then number two, pick up the phone. Nuc-med radiologists, we have reports, we dictate reports, but there's something different when you pick up the phone and you have a two-way dialogue regarding what you're seeing and what that means clinically. And I think patients really, the nuances are picked up in those conversations and I think better decisions can be made.
Alicia Morgans: Absolutely.
Neha Vapiwala: And I would underscore the multidisciplinary tumor boards, there'll be a case where for whatever reason, it just hasn't quite been part of the therapy up until that point. And you review the imaging and suddenly it's like, well, has anyone considered this radioligand therapy as the next step? Or altering potential path of the patient or thinking about, again, combination with external beam. So sometimes it might be the most obvious case, but just having someone there to kind of bring it up is very helpful always.
Alicia Morgans: Absolutely. And I love the idea of attending even if you're not presenting because you can certainly learn, but also provide your own expertise and perspective. It's helpful as the doc bringing the patient to the tumor board to hear just other perspectives and just make sure that you're on the right track.
One thing that I wanted to mention that has been really helpful for our practice has been engaging with the medical oncology teams who may be local to the patient. So some of our patients, I think you alluded to this, are coming from very far away distances. I have patients who come from Maine or from Northern Vermont or places where they don't have access in their local community for things like Pluvicto, as an example of a currently available radioligand therapy. And when they do need a transfusion, when they need someone to check on them in between cycles, should that happen, it's nice to have that relationship and that communication even with that local team. And it also helps bridge those practices so that the local team feels very comfortable and confident to send future patients who may need care. So that's something that's been very valuable in our practice.
Neha Vapiwala: And for administration, there's somewhat similar model of this idea of hub and spoke. So we have some radiation oncologists that are in areas where there isn't access in the community, but just having that central model and then potentially providing some of the care that doesn't have to be at the main center local to patients makes a huge difference, particularly in parts of the country where the travel to the center is really prohibitive.
Alicia Morgans: Absolutely.
Phillip J. Koo: And be nice. I think that's something that sadly a lot of people need to be reminded in it because I think that breaks down a lot of barriers. It promotes, cultivates better communication. And it really just goes a long way towards what you were talking about, practice building, because we want patients or referring physicians to feel comfortable sending their patients to you and knowing that they're in good hands.
Alicia Morgans: Well, I could not agree more. Any final words or messages you have to practices who are trying to make sure that the multidisciplinary team is as strong as it can be as it cares for patients undergoing treatment with radioligand therapy?
Phillip J. Koo: The one thing I'll say is there is no one size fits all solution. So whatever practice you're in, whatever setting you're in, you just need to find what works for you, your team locally. You could take tips from other practices and other groups, but in the end, there are certain dynamics that are just unique to that specific location. So be flexible and don't be so dogmatic about how it needs to be done.
Neha Vapiwala: And I would just add that it really is truly a team sport, right? We mentioned a lot of the physicians, of course, involved, the different specialties, the APPs. You have your pharmacist, you have your dosimetrist, again, the technicians that are there, the janitorial staff that help turn over rooms and really keep things flowing. So to say it's a team sport is an understatement. And I think just being appreciative of everyone along the path and making sure they all know why their role matters and how they contribute, I think can also always be helpful when building a new service line like this.
Alicia Morgans: Could not agree more. And to have that great communication, to be nice. I think these are all good things and to keep learning because we will keep learning. There are therapies coming into all settings of prostate cancer and perhaps even more with more opportunities to come. So we have to keep learning and keep doing all that we can for our patients and our communities. So thank you so much for your time.
Phillip J. Koo: Thank you.
Neha Vapiwala: Thank you.