Select Topic:
Browse by Series:

Radium-223 in CRPC: Experience and Practical Advice

Insights From: Evan Yu, MD, University of Washington; Ulka Vaishampayan, MD, Barbara Ann Karmanos Cancer Institute ; Neeraj Agarwal, MD, Huntsman Cancer Institute
Published: Thursday, Dec 20, 2018



Transcript: 

Ulka Vaishampayan, MD:
Using radium-223 does require setup on your part and collaboration with either radiation oncology or nuclear medicine. You will have to check and make sure they have all the licensing that is required for therapeutic administration of radium-223. But once that is done, it is a very gratifying treatment for patients, mainly because the adverse event profile is much more favorable compared to chemotherapy. Typically, when you’re considering the patient for either chemotherapy or radium-223, you have a discussion regarding the multiple adverse events of chemotherapy including the risk of thrombocytopenia and neutropenia, which are fairly low with radium-223. Radium-223 shows 3% or less of severe neutropenia and thrombocytopenia, compared to chemotherapy. That does become an attractive option for metastatic castration-resistant prostate cancer patients. For the most part, in terms of sequencing, I have this discussion and patients are typically choosing to go on radium-223 and save the chemotherapy for a later date, when their disease progresses following this.

Neeraj Agarwal, MD: Radium-223 is an extremely well-tolerated drug. Patients have very limited adverse effects compared to many other therapies that are available for treatment of metastatic castrate-resistant prostate cancer. The most common sign or abnormality we see with radium-223 is anemia, thrombocytopenia, or rarely neutropenia, which can easily be handled by delaying the next dose of radium-223. If these symptoms persist, I think it is practical to delay the next dose of radium-223, but in my view that isn’t really necessarily. If patients of mine start radium-223, most of the time they finish 6 doses of radium over 6 months without any problems, unless they have been heavily pre-exposed to chemotherapy. But in patients who never used chemotherapy in the past, we rarely see myelosuppression with radium-223.

Evan Yu, MD: Radium-223 is a drug I regularly use for patients with bone-metastatic castration-resistant prostate cancer and symptoms. I tend to use it in the prechemotherapy setting if I can for somebody with metastatic castration-resistant prostate cancer. I do that for practical reasons. There are no data to show that it’s better in the pre- or the postchemotherapy setting. It certainly, in the ALSYMPCA trial, induced a survival benefit in both settings. But the reason I use it in the prechemotherapy setting is practical. In the postchemotherapy setting, patients are more apt to have myelosuppressive issues. They’re more apt to develop visceral disease because they have later stage disease or issues that might preclude me from being able to prescribe radium-223. If my goal is to get all of my patients as many life prolonging therapies as possible, I’m going to use it earlier, in the prechemotherapy setting.

There is one interesting thing about radium-223 that I think the field may not have paid as much attention to, which is the fact that it’s actually the only regulatory approved agent that incurs a survival benefit for metastatic castration-resistant prostate cancer and induces double strand DNA breaks. That’s a key fact because right now, the field is hot with all the DNA repair alterations that we’re finding, both germline and somatic, in patients with metastatic prostate cancer. Those patients might respond better to PARP [poly ADP ribose polymerase] inhibitors or anything else that induces a double strand DNA break, and that includes platinum and radium-223. We are going to be prospectively studying how well radium works in patients with homologous recombination deficiency, these DNA repair mutations, and I think that’s going to potentially be very interesting and revolutionary.


Transcript Edited for Clarity 
Slider Left
Slider Right


Transcript: 

Ulka Vaishampayan, MD:
Using radium-223 does require setup on your part and collaboration with either radiation oncology or nuclear medicine. You will have to check and make sure they have all the licensing that is required for therapeutic administration of radium-223. But once that is done, it is a very gratifying treatment for patients, mainly because the adverse event profile is much more favorable compared to chemotherapy. Typically, when you’re considering the patient for either chemotherapy or radium-223, you have a discussion regarding the multiple adverse events of chemotherapy including the risk of thrombocytopenia and neutropenia, which are fairly low with radium-223. Radium-223 shows 3% or less of severe neutropenia and thrombocytopenia, compared to chemotherapy. That does become an attractive option for metastatic castration-resistant prostate cancer patients. For the most part, in terms of sequencing, I have this discussion and patients are typically choosing to go on radium-223 and save the chemotherapy for a later date, when their disease progresses following this.

Neeraj Agarwal, MD: Radium-223 is an extremely well-tolerated drug. Patients have very limited adverse effects compared to many other therapies that are available for treatment of metastatic castrate-resistant prostate cancer. The most common sign or abnormality we see with radium-223 is anemia, thrombocytopenia, or rarely neutropenia, which can easily be handled by delaying the next dose of radium-223. If these symptoms persist, I think it is practical to delay the next dose of radium-223, but in my view that isn’t really necessarily. If patients of mine start radium-223, most of the time they finish 6 doses of radium over 6 months without any problems, unless they have been heavily pre-exposed to chemotherapy. But in patients who never used chemotherapy in the past, we rarely see myelosuppression with radium-223.

Evan Yu, MD: Radium-223 is a drug I regularly use for patients with bone-metastatic castration-resistant prostate cancer and symptoms. I tend to use it in the prechemotherapy setting if I can for somebody with metastatic castration-resistant prostate cancer. I do that for practical reasons. There are no data to show that it’s better in the pre- or the postchemotherapy setting. It certainly, in the ALSYMPCA trial, induced a survival benefit in both settings. But the reason I use it in the prechemotherapy setting is practical. In the postchemotherapy setting, patients are more apt to have myelosuppressive issues. They’re more apt to develop visceral disease because they have later stage disease or issues that might preclude me from being able to prescribe radium-223. If my goal is to get all of my patients as many life prolonging therapies as possible, I’m going to use it earlier, in the prechemotherapy setting.

There is one interesting thing about radium-223 that I think the field may not have paid as much attention to, which is the fact that it’s actually the only regulatory approved agent that incurs a survival benefit for metastatic castration-resistant prostate cancer and induces double strand DNA breaks. That’s a key fact because right now, the field is hot with all the DNA repair alterations that we’re finding, both germline and somatic, in patients with metastatic prostate cancer. Those patients might respond better to PARP [poly ADP ribose polymerase] inhibitors or anything else that induces a double strand DNA break, and that includes platinum and radium-223. We are going to be prospectively studying how well radium works in patients with homologous recombination deficiency, these DNA repair mutations, and I think that’s going to potentially be very interesting and revolutionary.


Transcript Edited for Clarity 
View Conference Coverage
Online CME Activities
TitleExpiration DateCME Credits
Community Practice Connections™: 3rd Annual International Congress on Oncology & Pathology™Aug 30, 20201.5
Community Practice Connections™: ASCO Direct™ Highlights – 2019 Official Annual Meeting ReviewAug 30, 20201.5
Publication Bottom Border
Border Publication
x